Single-staged Treatment Using a Standardized Protocol Results in Functional Motion in the Majority of Patients With a Terrible Triad Elbow Injury

Abstract

Background Terrible triad injuries of the elbow, defined as elbow dislocation with associated fractures to the radial head and coronoid, are associated with stiffness, pain, and loss of motion. Studies to date have consisted of small sample sizes and used heterogeneous surgical techniques, which render comparisons difficult and unreliable. Questions/purposes In a group of patients treated under a standard surgical protocol, we sought to determine the early dislocation rate, the range of motion in those not undergoing secondary procedures, the frequency and types of secondary surgical interventions required, the difference in motion between those undergoing secondary surgery and those who did not, and the frequency of heterotopic ossification and patient-reported stiffness. Methods Patients underwent a surgical protocol that involved fixing the coronoid, fixing the radial head if possible, otherwise performing radial head arthroplasty, and repairing the lateral ligamentous structures. Patients were excluded if ipsilateral upper extremity fractures from the humerus to the distal forearm were present. Fifty-two patients had a minimum followup of 6 weeks and were included for the early dislocation rate, and 34 of these (65%) had a minimum of 6 months followup and were included for the rest of the data. Eighteen of the 52 (35%) were considered lost to followup because they were seen for less than 6 months postsurgically and were excluded from further analysis. Chart review was performed to determine the presence of early dislocation within the first 6 weeks after surgery, range of motion in patients not requiring a secondary procedure, the frequency and types of secondary procedures required, the range of motion before and after a secondary procedure if it was required, and postoperative stiffness. Postoperative radiographs were analyzed to determine the presence and severity of heterotopic ossification. Results One of 52 patients sustained a dislocation within the first weeks of surgery (1.9%). Those not undergoing a secondary procedure were able to achieve a flexion arc of 110°and a supination-pronation arc of 148°. Nine of 34 patients (26%) underwent a secondary surgical procedure with stiffness, heterotopic ossification, and ulnar neuropathy being the most common surgical indications. Before secondary surgical procedures, patients had a flexion arc of 57°a nd a supination-pronation arc of 55°, which was less than those only requiring primary surgery alone (p \ 0.001). After secondary surgery, patients were able to achieve a flexion arc of 96°and a supination-pronation arc of 124°, which was not different from those who did not undergo reoperation (p = 0.09 and p = 0.08, respectively). Twentyeight of 34 patients demonstrated evidence of heterotopic ossification on radiographs, whereas 20 patients, including all nine undergoing secondary procedures, reported stiffness at the elbow.

Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach

“…The functional outcomes of this current series were similar to the findings reported in previous studies, with a mean flexion–extension arc of 100° to 127°, a mean supination–pronation arc of 126° to 156°, and a mean MEPS of 81 to 96 points. 2 – 8 , 27 – 32 However, the rate of secondary surgery was lower in this current series than that reported by others, with only three patients requiring secondary procedures in this series. 2 – 8 , 27 – 32 …”

Comparative analysis of surgical options for medial collateral ligament repair in terrible triad injury of the elbow

“…An organized treatment protocol of terrible triad injury has been developed to improve clinical outcomes including symptoms and elbow function. 9 , 10 In contrast, several studies indicated considerable problems such as instability, contracture, reoperation, and/or progression to arthrosis still remains even after this surgical approach. 11 , 14 Thus, within the framework of this systematic protocol, some authors investigated further into its surgical options in detail; indication of radial head prosthesis despite the ORIF, 11 , 12 validity to repair coracoid fractures, 13 necessity to treat the medial side after restoring other components, 6 , 14 , 15 and so on.…”

“… 4 , 5 Recently, a systematic protocol for surgical treatment was advocated based on the anatomical and biomechanical knowledge. 6-8 Although this algorithmic approach could lead to improve the outcomes in terms of elbow pain and its function, 9 , 10 there remain some problems postoperatively including contracture, heterotopic ossification and arthrosis. 11 …”

Lateral Approach Versus Combined Lateral and Anteromedial Approach for Surgical Treatment of Terrible Triad of Elbow: A Meta-Analysis

“…Various approaches have been described for the same. The posteromedial approach can give access to both medial and lateral aspect of elbow joint, but has the disadvantages of long incision, extensive dissection, subcutaneous hematoma and risk of flap necrosis, so it has been obsoleted gradually [10][11][12][13]. Pugh et al, [14] showed good results with lateral approach in TTE.…”