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Gupta R, Kapoor A. Management of Elderly Elbow Fractures. Indian J Orthop 2025; 59:358-367. [PMID: 40201913 PMCID: PMC11973029 DOI: 10.1007/s43465-024-01331-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2024] [Accepted: 12/27/2024] [Indexed: 04/10/2025]
Abstract
Background Elbow fractures are common in elderly patients with osteoporotic bones, typically resulting from falls on the elbow. Common fracture types include distal humerus, olecranon, and radial head fractures. Occasionally, a combination of these fractures occurs, creating complex injuries such as terrible triad injuries. Accurate evaluation using X-rays and CT scans is essential for optimal treatment planning. Careful preoperative planning, including the decision between non-operative and operative treatment and selecting appropriate surgical implants, is critical for achieving successful outcomes. Objective This chapter focuses on common elbow fractures in elderly patients and explores the available treatment options. Given the lack of clear consensus on managing elbow fractures in osteoporotic bones, we address the associated complications and highlight various treatment approaches. Current Knowledge Numerous treatment methods have been proposed for osteoporotic elbow fractures, including various fixation techniques, arthroplasty, and excisions. Despite the availability of multiple treatment options, no method has emerged as superior. Each method has distinct advantages and disadvantages. This chapter aims to compile and compare these options, outlining their respective pros and cons. Conclusions Elbow fractures in osteoporotic bones present significant challenges for surgeons. Although elderly patients with osteoporotic bones generally have lower functional demands compared to younger individuals, they still require adequate, pain-free elbow function for daily activities. Advances in surgical techniques and implant technology have expanded treatment options for these fractures. Achieving successful outcomes requires selecting the appropriate implant, meticulous preoperative planning, and expert surgical execution tailored to the specific fracture characteristics.
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Affiliation(s)
- Ravi Gupta
- Paras Hospital Panchkula, Nana Sahib, Haryana India
| | - Anil Kapoor
- Paras Hospital Panchkula, Nana Sahib, Haryana India
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Larwa J, Buchanan TR, Janke RL, Burns MQ, Wright L, Hao KA, Cueto RJ, Hones KM, Aibinder WR, Wright TW, Schoch BS, King JJ. Characteristics of rehabilitation protocols following operative treatment of terrible triad elbow injuries and the influence of early motion: A systematic review and meta-analysis. Shoulder Elbow 2024:17585732241269807. [PMID: 39552691 PMCID: PMC11562217 DOI: 10.1177/17585732241269807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 05/22/2024] [Accepted: 07/20/2024] [Indexed: 11/19/2024]
Abstract
Background As no consensus exists on the optimal postoperative rehabilitation protocol in terrible triad injuries, we sought to characterize the reported protocols and relate them to postoperative range of motion (ROM) measures and Mayo Elbow Performance Score (MEPS). Methods A systematic review was performed by searching PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles on the operative treatment of terrible triad injuries reporting postoperative rehabilitation protocols were included. Included studies were descriptively summarized. Methodologic quality was assessed using the Methodological Index for Non-randomized Studies criteria. Meta-analysis compared postoperative ROM measures and the MEPS between patients initiating passive ROM exercises at ≤7 days vs. >7 days. Results Our review included 36 articles with 1123 elbows (66% male, mean age: 43 years, follow-up: 27 months). Of the studies reporting physical therapy protocols, it was most commonly initiated at 7 days postoperatively (6/36, 17%), passive ROM exercises at 7 days (3/25, 12%), and active ROM at 21 days (4/26, 15%). On meta-analysis, early passive ROM initiation was not associated with improved elbow ROM or MEPS. Discussion While rehabilitation protocols commonly advised passive ROM at one week post-operatively, meta-analysis did not support functional benefits of early passive ROM. Study design Systematic Review; Level of evidence, 4.
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Affiliation(s)
- Joseph Larwa
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Jacksonville, FL, USA
| | | | - Rachel L Janke
- College of Health and Human Performance, University of Florida, Gainesville, FL, USA
| | - Madison Q Burns
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Logan Wright
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Robert J Cueto
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Keegan M Hones
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - William R Aibinder
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Thomas W Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
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Le GAT, To K, Dang NT, Nguyen VT, Phan TN, Nguyen VT, Ton TTT, Vo TT. The anconeus-triceps lateral flap approach in terrible triad of the elbow: good outcome in a series of ten cases. Ann Med Surg (Lond) 2024; 86:4352-4357. [PMID: 39118682 PMCID: PMC11305737 DOI: 10.1097/ms9.0000000000002211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/14/2024] [Indexed: 08/10/2024] Open
Abstract
Introduction Standard surgical management for the terrible triad of the elbow (TTE) has been established since 2004, yet postoperative complications are common and consensus on optimal management is absent. Different surgical algorithms for treating TTE and their efficacy have been reported worldwide, yet evidence from Vietnam remains limited. Methods Ten cases diagnosed with TTE admitted to the Hospital of Traumatology and Orthopedics, a tertiary orthopedic center in Ho Chi Minh City, were presented to demonstrate the effectiveness and rate of postoperative complications following our stepwise surgical procedures using the anconeus-triceps lateral flap approach. The intraoperative "drop sign", quantitative assessment of pain and level of upper arm disability (via VAS and QuickDASH score) was mentioned to assess the algorithm's benefit. All patients' information was retrieved from medical records from August 2022 to January 2024. Results All 10 cases required repair of the lateral ligament complex and underwent surgery within 2 days of hospitalization. Immediate postoperative imaging revealed no drop sign, and none of the patients experienced elbow dislocation nor the need for repeated surgery, and a full range of elbow motion was demonstrated at 3-6 months follow-up. Conclusion TTE is a challenging injury that almost always obligates surgical correction. The anconeus-triceps lateral flap approach, with its advantages of better visualization and preservation of certain essential stabilizing muscles of the elbow, was demonstrated to yield a high success rate and low postoperative complication rate.
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Affiliation(s)
- Gia Anh Thy Le
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Kha To
- School of Medicine, Vietnam National University Ho Chi Minh City
- Trauma and Orthopedics Department, Thong Nhat Hospital
- Division of Surgery and Interventional Science
- Institute of Sport, Exercise and Health, University College London, London, UK
| | - Nghia Thanh Dang
- School of Medicine, Vietnam National University Ho Chi Minh City
| | - Viet Tan Nguyen
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Tri Nguyen Phan
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Van Thai Nguyen
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
- Department of Orthopaedics and Trauma, Pham Ngoc Thach Medical University, Ho Chi Minh City, Vietnam
| | - Thi Thanh Thao Ton
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Thanh Toan Vo
- Trauma and Orthopedics Department, Thong Nhat Hospital
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Cueto RJ, Kakalecik J, Burns MQ, Janke RL, Hones KM, Hao KA, Wright LT, Buchanan TR, Aibinder WR, Patrick MR, Schoch BS, King JJ. Reported outcome measures in complex fracture elbow dislocations: a systematic review. J Shoulder Elbow Surg 2024; 33:1709-1723. [PMID: 38609003 DOI: 10.1016/j.jse.2024.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/04/2024] [Accepted: 02/17/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Complex elbow fracture dislocations, dislocation with fracture of one or several surrounding bony stabilizers, are difficult to manage and associated with poor outcomes. While many studies have explored treatment strategies but a lack of standardization of patient-reported outcome measures (PROMs) makes cross-study comparison difficult. In this systematic review, we aim to describe what injury patterns, measured outcomes, and associated complications are reported in the complex elbow fracture dislocation literature to provide outcome reporting recommendations that will facilitate improved future cross-study comparison. METHODS A systematic review was performed per Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles published between 2010 and 2022 reporting on adult patients who had a complex elbow fracture dislocation. Pathologic fractures were excluded. A bias assessment using the methodological index for nonrandomized studies criteria was conducted. For each article, patient demographics, injury pattern, outcome measures, and complications were recorded. RESULTS Ninety-one studies reporting on 3664 elbows (3654 patients) with an elbow fracture and dislocation (weighted mean age 44 years, follow-up of 30 months, 41% female) were evaluated. Of these, the injury pattern was described in 3378 elbows and included 2951 (87%) terrible triad injuries and 72 (2%) transolecranon fracture-dislocations. The three most commonly reported classification systems were: Mason classification for radial head fractures, Regan and Morrey coronoid classification for coronoid fractures, and O'Driscoll classification for coronoid fractures. Range of motion was reported in 87 (96%) studies with most reporting flexion (n = 70), extension (n = 62), pronation (n = 68), or supination (n = 67). Strength was reported in 11 (12%) studies. PROMs were reported in 83 (91%) studies with an average of 2.6 outcomes per study. There were 14 outcome scores including the Mayo Elbow Performance Score (n = 69 [83%]), the Disabilities of Arm, Shoulder and Hand (DASH) score (n = 28 [34%]), the visual analog scale for pain (n = 27 [33%]), QuickDASH score (n = 13 [15.7%]), and Oxford Elbow score (n = 5 [6.0%]). No significance was found between the number of PROMs used per article and the year of publication (P = .313), study type (P = .689), complex fracture pattern (P = .211), or number of elbows included (P = .152). CONCLUSION There is great heterogeneity in reported PROMs in the complex elbow fracture dislocation literature. Although there is no gold standard PROM for assessing complex elbow fracture dislocations, we recommend the use of at least the Mayo Elbow Performance Score and DASH outcomes measures as well as visual analog scale pain rating scale in future studies to facilitate cross-study comparisons.
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Affiliation(s)
- Robert J Cueto
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jaquelyn Kakalecik
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Madison Q Burns
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Rachel L Janke
- College of Health and Human Performance, University of Florida, Gainesville, FL, USA
| | - Keegan M Hones
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Logan T Wright
- College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - William R Aibinder
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Matthew R Patrick
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Bradley S Schoch
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA.
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Yang F, Wang Z, Yuan T, Qin J. Treatment of Ulnar Coronoid Process Fracture Using the Anterior Neurovascular Interval Approach: A Retrospective Clinical Study with Short- to Mid-term Follow-up. Orthop Surg 2024; 16:1732-1743. [PMID: 38828840 PMCID: PMC11216846 DOI: 10.1111/os.14123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/09/2024] [Accepted: 05/15/2024] [Indexed: 06/05/2024] Open
Abstract
OBJECTIVE Numerous surgical techniques for addressing ulnar coronoid process fractures are available; however, a consensus on the optimal approach remains elusive. This study aimed to use the anterior neurovascular interval approach for the surgical management of ulnar coronoid process fractures and to evaluate its clinical outcomes over short- to mid-term follow-up. METHODS This retrospective clinical study included 20 patients with ulnar coronoid process fractures who were treated using the anterior neurovascular interval approach between January 2018 and December 2022. Participants comprised 16 males and four females, aged between 20 and 64 years (mean, 34.3 ± 12.44 years). Clinical and radiological evaluations were based on elbow joint range of motion (ROM), Visual analogue scale (VAS), and Mayo elbow performance score (MEPS). A paired t-test was used to compare the pre-operative and final follow-up VAS and MEPS scores. RESULTS The follow-up duration for all patients was at least 12 months (average, 12.65 ± 1.60 months). At the final follow-up, measurements of elbow ROM included a mean extension of 2.85 ± 3.17°, mean flexion of 135 ± 7.25°, mean pronation of 86.4 ± 4.56°, and mean supination of 84.85 ± 5.54°. All participants reached their target MEPS, with an average score of 97.25 ± 4.72 points, and the final mean VAS score was 0.2 ± 0.52 points. The VAS score was significantly lower and MEPS score was higher at the final follow-up than those before surgery (p < 0.05). Throughout the follow-up period, all the fractures united, and the stability of the affected elbows was satisfactory. CONCLUSION Employing the anterior neurovascular interval approach for open reduction and internal fixation to manage coronoid process fractures effectively facilitates anatomical restoration and robust fixation of ulnar coronoid process fractures.
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Affiliation(s)
- Fei Yang
- Department of Orthopedics, Sir Run Run HospitalNanjing Medical UniversityNanjingChina
| | - Zeyong Wang
- Department of Orthopedics, Sir Run Run HospitalNanjing Medical UniversityNanjingChina
| | - Tangbo Yuan
- Department of Orthopedics, Sir Run Run HospitalNanjing Medical UniversityNanjingChina
| | - Jian Qin
- Department of Orthopedics, Sir Run Run HospitalNanjing Medical UniversityNanjingChina
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Baker M, Eyre-Brook A, Gokaraju K, Jones V, Thyagarajan D, Ali A, Booker S. Non-operative management of terrible triad injuries of the elbow; not so terrible? Shoulder Elbow 2024; 16:200-205. [PMID: 38655413 PMCID: PMC11034474 DOI: 10.1177/17585732231190599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 07/04/2023] [Accepted: 07/09/2023] [Indexed: 04/26/2024]
Abstract
Introduction Terrible triad injuries (TTIs) of the elbow have traditionally been reported to have poor outcomes, hence requiring surgical stabilisation. We identified and reviewed patients with TTIs treated non-operatively within our department. Methods We retrospectively reviewed patients with TTI treated non-operatively with standardised elbow-instability rehabilitation from 2010 to 2020. We used Mason and Morrey classifications for radial head and coronoid fractures, respectively. Non-operative indications included a congruent joint on CT, significant co-morbidities pre-disposing to high-risk surgery and/or patient preference. Outcomes included Oxford Elbow Score (OES), ROM and complications. Results Nineteen patients were included (mean age 49; 37% female). At an average of 6 years (range 2-11 years) post-treatment, mean OES was 46 ± 7. At last clinic review, mean 6 months (2-15), average ROM was 131 ± 11° flexion, 8 ± 10° extension, 85 ± 12° supination and 85 ± 13° pronation. One patient required arthrolysis and another had an incongruent ulnohumeral joint which developed clicking with a functional ROM. Conclusion Our report suggests non-operatively managed and appropriately rehabilitated TTI injuries can achieve good function and ROM. We recommend conservative management as a viable option in cases with joint congruency and no mechanical block in patients with significant co-morbidities or those refusing surgery but patients must be assessed on a case-by-case basis.
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Affiliation(s)
- Megan Baker
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Alistair Eyre-Brook
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Kishan Gokaraju
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Valerie Jones
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - David Thyagarajan
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Amjid Ali
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Simon Booker
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
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Ahmed Kamel S, Shepherd J, Al-Shahwani A, Abourisha E, Maduka D, Singh H. Postoperative mobilization after terrible triad injury: systematic review and single-arm meta-analysis. J Shoulder Elbow Surg 2024; 33:e116-e125. [PMID: 38036253 DOI: 10.1016/j.jse.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/30/2023] [Accepted: 10/18/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Terrible triad injury is a complex injury of the elbow, involving elbow dislocation with associated fracture of the radial head, avulsion or tear of the lateral ulnar collateral ligament, and fracture of the coronoid. These injuries are commonly managed surgically with fixation or replacement of the radial head and repair of the collateral ligaments with or without fixation of the coronoid. Postoperative mobilization is a significant factor that may affect patient outcomes; however, the optimal postoperative mobilization protocol is unclear. This study aimed to systematically review the available literature regarding postoperative rehabilitation of terrible triad injuries to aid clinical decision making. METHODS We systematically reviewed the PubMed, Embase, Cochrane, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The inclusion criteria were studies with populations aged ≥16 years with terrible triad injury in which operative treatment was performed, a clear postoperative mobilization protocol was defined, and the Mayo Elbow Performance Score (MEPS) was reported. Secondary outcomes were pain, instability, and range of motion (ROM). Postoperative mobilization was classified as either "early," defined as active ROM commencement before or up to 14 days, or "late," defined as active ROM commencement after 14 days. RESULTS A total of 119 articles were identified from the initial search, of which 11 (301 patients) were included in the final review. The most common protocols (6 studies) favored early mobilization, whereas 5 studies undertook late mobilization. Meta-regression analysis including mobilization as a covariate showed an estimated mean difference in the pooled mean MEPS between early and late mobilization of 6.1 (95% confidence interval, 0.2-12) with a higher pooled mean MEPS for early mobilization (MEPS, 91.2) than for late mobilization (MEPS, 85; P = .041). Rates of instability reported ranged from 4.5% to 19% (8%-11.5% for early mobilization and 4.5%-19% for late mobilization). CONCLUSION Our findings suggest that early postoperative mobilization may confer a benefit in terms of functional outcomes following surgical management of terrible triad injuries without appearing to confer an increased instability risk. Further research in the form of randomized controlled trials between early and late mobilization is advised to provide a higher level of evidence.
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Affiliation(s)
- Sherif Ahmed Kamel
- University Hospitals of Leicester NHS Trust, Leicester, UK; Ain Shams University, Cairo, Egypt.
| | - Jenna Shepherd
- University Hospitals of Leicester NHS Trust, Leicester, UK; University of Leicester, Leicester, UK; Integrated Academic Clinical Training Pathway, Academic Foundation Programme, National Institute for Health and Care Research, UK
| | | | | | | | - Harvinder Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK; University of Leicester, Leicester, UK
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Ma SB, Lee SK, An YS, Choi HG, Choy WS. Is the 'safe zone' identified in preoperative computed tomography helpful for choosing optimal implant for fixation of radial head fracture? Acta Orthop Belg 2023; 89:709-717. [PMID: 38205765 DOI: 10.52628/89.4.11188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
The purpose of this study is to assess the clinical significance of the radiologic safe zone based on computed tomography and to compare the outcomes of three different implants for fixation of isolated radial head fractures. We retrospectively reviewed 367 patients who underwent internal fixation for isolated radial head fractures. We newly defined two subtypes of Mason type II fractures associated with the radiographic safe zone (IIA, two-part fracture allowing for safe fixation of plate; IIB, two-part fracture not allowing for safe fixation). 170 patients (CCS group, n = 82; HCS group, n = 31; plate group, n = 57) were investigated with no significant differences in demographics. The range of pronation and supination at 1 month postoperatively (P = 0.04 and P = 0.04) and the range of supination at 6 and 12 months postoperatively (P = 0.03 and P = 0.03) were significantly smaller in the plate group. In Mason type IIB fractures, the average MEPS was higher in the CCS and HSC groups than in the plate group (P = 0.01 and P = 0.02). And the average DASH score was lower in the CCS and HCS groups (P < 0.01 and P < 0.01). Evaluation of the radiologic safe zone is potentially helpful in selecting better surgical fixation option. For type III fractures, 2.3-mm cortical screws would be a better option than Acutrak screws. Plates would not be suitable for type IIB radial head fractures.
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Corbet C, Boudissa M, Dao Lena S, Ruatti S, Corcella D, Tonetti J. Surgical treatment of terrible triad of the elbow: Retrospective continuous 50-patient series at 2 years' follow-up. Orthop Traumatol Surg Res 2023; 109:103057. [PMID: 34536597 DOI: 10.1016/j.otsr.2021.103057] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 10/02/2020] [Accepted: 12/31/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Terrible triad (TT) of the elbow is an association at high risk of instability. Treatment aims to restore joint stability. Lateral collateral ligament (LCL) repair is systematic, whereas medial collateral ligament (MCL) repair is only exceptionally necessary. The main aim of the present study was to assess clinical results in TT surgery. The secondary objective was to compare clinical progression with versus without MCL repair. MATERIAL AND METHODS A retrospective study included 50 TTs operated on via an isolated lateral or combined medial-lateral approach. Clinical assessment comprised MEPS, QuickDASH, VAS, flexion-extension and pronation-supination, and return to work and sport. Subgroup analysis was made according to associated MCL repair. RESULTS Fifty patients (19 female, 31 male) were operated on between January 2006 and January 2017. Mean follow-up was 24 months. At last follow-up, mean MEPS was 89.1, VAS 0.7, QuickDASH 16, flexion-extension 114°, and pronation-supination 137°. Only MEPS was significantly improved by MCL repair (p=0.02), with no significant difference in complications. DISCUSSION TT surgery with immediate mobilization gave good long-term functional results, not significantly improved by MCL repair. The lateral approach should be adopted in first line, with the medial approach in second line in case of persistent instability after lateral osteo-ligamentous repair. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
- Clémentine Corbet
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France.
| | - Mehdi Boudissa
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | | | - Sébastien Ruatti
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | - Denis Corcella
- Service de Chirurgie de la Main et des Brûlés, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | - Jérôme Tonetti
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
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Abstract
Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.
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Affiliation(s)
- Naoko Onizuka
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Julie Switzer
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Chad Myeroff
- TRIA Orthopedic Center, 155 Radio Drive, Woodbury, MN 55125, USA.
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Rhyou IH, Lee JH, Cho CH, Park SG, Lee JH, Kim KC. Patterns of injury mechanism observed in terrible triad. J Shoulder Elbow Surg 2021; 30:e583-e593. [PMID: 33545337 DOI: 10.1016/j.jse.2020.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The purpose of this study was to classify the injury mechanism of terrible triad (TT) and suggest a treatment method according to the mechanism. MATERIALS AND METHODS Forty TTs with magnetic resonance imaging (MRI) scans and 3-dimensional computed tomography (3D CT) were enrolled. 3D CT scans of coronoid fractures were used for classifying into O'Driscoll type representing injury mechanisms and measuring sizes. In MRI scans, lateral collateral ligament complex (LCLC) injuries were classified into distraction (D) type caused by varus force and stripping (S) type caused by forearm external rotation force. Using these findings, possible injury mechanisms were speculated and classified into groups. Characteristic soft tissue injury patterns of collateral ligaments and overlying muscles, direction of dislocation in simple radiographs, and the amount of involvement of radial head fracture were investigated. Ulnar- and radial-side instabilities of soft tissues were newly defined and investigated. RESULTS There were 29 (73%) cases by posterolateral external rotation (PLER), 5 (13%) cases by posteromedial external rotation (PMER), and 6 (14%) cases by posteromedial internal rotation (PMIR). Simple radiographs showed all posterolateral dislocations in PLER TT compared to posteromedial or pure posterior dislocations in PMER or PMIR TT. Regarding LCLC and overlying extensor muscle, they were all completely torn with D type in all PLER compared to D type in PMER or PMIR. The ulnar collateral ligament was spared in 5 (17%) cases among 29 PLER in contrast to complete rupture in all PMER and PMIR. In PLER, PMER, and PMIR, involvement ratios of radial head fracture were 82% (range, 27%-100%), 61% (range, 25%-100%), and 61% (range, 25%-100%), respectively, and sizes of coronoid fractures were 7 mm (range, 1-14 mm), 6 mm (range, 2-11 mm), and 10 mm (range, 2-16 mm), respectively. In PLER, PMER, and PMIR, percentages of ulnar-side instabilities were 17%, 20%, and 17%, respectively, and those of radial-side instabilities were 59%, 60%, and 83%, respectively. CONCLUSIONS TT is caused by at least 3 mechanisms (PLER, PMER, and PMIR) with characteristic soft tissue injuries and fracture patterns. PLER is the main mechanism of injury. It is always observed in the form of posterolateral dislocation on simple radiographs compared with pure posterior or posteromedial dislocation of PMER or PMIR. It should be managed individually based on injury mechanisms presenting different instability patterns.
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Affiliation(s)
- In Hyeok Rhyou
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea.
| | - Jung Hyun Lee
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea
| | - Chul-Hyun Cho
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Sam-Guk Park
- Department of Orthopedic Surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Ji-Ho Lee
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea
| | - Kyung Chul Kim
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea
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Abstract
BACKGROUND Complex fracture-dislocations of the elbow, including terrible triad of the elbow, are serious injuries with guarded outcomes in adults. Although described extensively in adults, little is known about similar complex fracture-dislocations of the elbow in the pediatric population. The purpose of this study was to describe patterns of elbow dislocations with associated fractures in children and report the outcomes of these injuries. METHODS This was a retrospective review of patients who presented to a level I trauma center from 2007 to 2019 with an elbow dislocation and at least 2 associated fractures. Demographic data, fracture locations, and treatment modality were recorded. Operative reports and radiographs were reviewed to determine clinical outcomes and complications. RESULTS A total of 26 patients (mean age, 9.8 y) were identified. The majority of patients sustained an elbow dislocation and a medial epicondyle fracture (n=16). The most common third fractures involved the lateral condyle (n=8) or radial neck (n=7). At mean 6.03±3.11 months follow-up, 3 patients lacked ≥10 degrees of extension, and 2 patients lacked ≥15 degrees of flexion. Most patients had a Flynn score of "excellent" (n=20, 76.9%) or "good" (n=2, 7.7%). One patient with significant residual stiffness (>30 degrees flexion contracture) eventually underwent open contracture release. CONCLUSIONS The most common complex elbow fracture-dislocation pattern in this series was an elbow dislocation with fracture of the medial epicondyle and lateral condyle or radial neck. In contrast to adult terrible triad injuries, most patients had a favorable clinical outcome, with nearly 80% excellent results and a low rate of complications. LEVEL OF EVIDENCE Therapeutic Level IV-case series.
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Antoni M, Mereb T, Ginot G, Meyer N, Clavert P. Prognostic factors for traumatic elbow osteoarthritis after terrible triad surgery, and functional impact. Orthop Traumatol Surg Res 2021; 107:102826. [PMID: 33516892 DOI: 10.1016/j.otsr.2021.102826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Terrible triad (TT) of the elbow almost always requires surgery to prevent progression to chronic instability and more or less inevitable osteoarthritis. Progression toward osteoarthritis after well-conducted surgery and associated risk factors have been little reported. We performed a retrospective study: (1) to assess rates of post-traumatic elbow osteoarthritis after surgical treatment of TT; (2) to assess functional impact; and (3) to identify prognostic factors. HYPOTHESIS Prevalence of osteoarthritis after surgical treatment of TT is high, impairing functional results. MATERIAL AND METHOD A single-center retrospective study included 53 patients, with a mean age of 50±17.8 years (range, 21-84 years), undergoing surgery for acute TT in our department. All received clinical examination with ranges of motion and Mayo Elbow Performance Index (MEPI) and radiographic assessment at a minimum 1 year's follow-up. Osteoarthritis at last follow-up was assessed on elbow X-ray in the humero-ulnar and radio-condylar compartments on the Broberg-Morrey classification. Functional impact on range of motion and MEPI and prognostic factors were assessed on Student test or ANOVA and Chi2 or Fisher test. RESULTS Prevalence of Broberg-Morrey grade 2 or 3 osteoarthritis was 45.3% (24/53) in the humero-ulnar compartment and 50% (25/50) in the radio-condylar compartment. Humero-ulnar osteoarthritis impaired MEPI (76.3 points with versus 88.4 points without; p=0.003), flexion-extension (102.3° versus 115.2°; p=0.043) and pronation-supination (138.8° versus 159.3°; p=0.006). Radio-condylar osteoarthritis had no significant impact on MEPI (81.4 points with and 84.4 points without; p=0.47), flexion-extension (104.8° and 113°; p=0.23) or pronation-supination (141.8° and 156.4°; p=0.2). Humero-ulnar osteoarthritis at last follow-up was associated with dislocation or subluxation on immediate postoperative lateral view (45.8% with versus 10.3% without; p=0.004) and at last follow-up (20.8% versus 3.4%; p=0.047) and with postoperative complications (54.2% and 27.6%; p=0.049). Radio-condylar osteoarthritis at last follow-up was associated with radial head replacement rather than internal fixation (respectively, 92% and 48%; p=0.0007) and excessively high radial head implant positioning (47.8% versus 0%; p=0.023). CONCLUSION Prevalence of traumatic osteoarthritis after TT surgery was high, at 45.3% in the humero-ulnar compartment and 50% in the radio-condylar compartment, with clinical impact in humero-ulnar involvement. LEVEL OF EVIDENCE IV; cohort study without control group.
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Affiliation(s)
- Maxime Antoni
- Pôle de chirurgie orthopédique et de traumatologie, service de chirurgie du membre supérieur, CHU de Strasbourg, Hôpital Hautepierre 2, avenue Molière, 67000 Strasbourg, France.
| | - Thomas Mereb
- Pôle de chirurgie orthopédique et de traumatologie, service de chirurgie du membre supérieur, CHU de Strasbourg, Hôpital Hautepierre 2, avenue Molière, 67000 Strasbourg, France
| | - Geoffrey Ginot
- Pôle de chirurgie orthopédique et de traumatologie, service de chirurgie du membre supérieur, CHU de Strasbourg, Hôpital Hautepierre 2, avenue Molière, 67000 Strasbourg, France
| | - Nicolas Meyer
- Pôle de santé publique, secteur méthodologie et biostatistiques, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - Philippe Clavert
- Pôle de chirurgie orthopédique et de traumatologie, service de chirurgie du membre supérieur, CHU de Strasbourg, Hôpital Hautepierre 2, avenue Molière, 67000 Strasbourg, France
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Ni Q, Yang X, Pan Z, Wang J. The pronator teres and the flexor carpi radialis interval approach for operative fixation of ulna coronoid process fractures. Orthop Traumatol Surg Res 2021; 107:102610. [PMID: 32418740 DOI: 10.1016/j.otsr.2020.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/15/2020] [Accepted: 04/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The optimal approach for the fixation of coronoid process fractures is unknown. We present the advantages and the clinical effect of the pronator teres and the flexor carpi radialis interval approach for the treatment of ulna coronoid process fractures. METHODS The patients, who had operative treatment of closed ulna coronoid process fracture by the pronator teres and the flexor carpi radialis interval approach between January 2011 to December 2016, were studied retrospectively. Seventeen consecutive patients had received surgical fixation by screws or a mini-plate through the above approach, of whom were 16 males and one female with an average age of 36.7 years (range, 21-58 years). There were 11 cases of type II and 6 cases of type III according to the O'Driscoll classification, of which, 6 patients had combined elbow dislocation, 2 patients showed elbow instability after fixation, and one had another incision to repair the lateral collateral ligament, and received a hinged external fixator. The other patient only received a hinged external fixator for 4 weeks. Mayo Elbow Performance Score (MEPS) was used to assess the function of elbow for each patient at the final follow-up. RESULTS Mean follow-up was 28.7 months (range, 24-38 months). Fracture union was achieved in each patient; the average time to radiologic union was 14.2 weeks (range, 12-16 weeks). At the final follow-up, the elbow extension degree of the affected side was (3.88±2.96°), reaching 98.1% of the normal side, and the flexion degree was (131.59±4.93°), reaching 98.16% of the normal side. The forearm pronation was (82.94±3.86°), reaching 94.31% of the normal side, and the supination activity was (82.12±3.82°), reaching 93% of the normal side. According to the MEPS, the functional recovery of the injured arm was assessed as excellent in 16 cases, and good in one. None of the patients showed any neurovascular or deep infections and no heterotopic ossification was found. CONCLUSIONS The pronator teres and the flexor carpi radialis interval approach has the advantages of simplicity, safety, minimal invasion, excellent exposure, and good postoperative function recovery for ulna coronoid process fracture.
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Affiliation(s)
- Qubo Ni
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuchang District, Wuhan 430071, China
| | - Xu Yang
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuchang District, Wuhan 430071, China
| | - Zhengqi Pan
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuchang District, Wuhan 430071, China
| | - Jianping Wang
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuchang District, Wuhan 430071, China.
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Hou F, Liang X, Fan W, Zhao F, Li D. Analysis of twenty-five cases of terrible triad injury of the elbow surgically treated with a single lateral approach. INTERNATIONAL ORTHOPAEDICS 2020; 45:241-246. [PMID: 33230605 DOI: 10.1007/s00264-020-04891-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The objective was to analyze the long-term clinical outcome of terrible triad injury of the elbow following surgical intervention with a single lateral approach. METHOD We treated twenty-five patients with terrible triad injury of the elbow from July 1, 2017, to June 30, 2020, and performed post hoc analysis. All patients underwent standardized surgery which entailed: plate fixation for the ulnar coronoid process, fixation or replacement of the radial head, and repair of the lateral ligament but not the medial collateral ligament. RESULTS We followed up each patient for an average of 22.9 months (range, 12 to 36 months) after surgery. Patients had an average angle scope of elbow flexion and extension that ranged from 8° to 120°. Average pronation of the elbow was 75° (range, 10°-85°), and average supination was 72° (range, 25°-80°). Patient-reported outcome measures were excellent: the DASH and Mayo elbow performance score (MEPS) were 96%. We were unable to follow-up one patient (4%). Among the remaining 24 patients, one patient (4%) presented with heterotopic ossification and stiffness following arthrolysis in the elbow one year after the initial surgery. We did not observe any joint dislocation, subluxation, or joint instability in the elbow after surgery. DISCUSSION The single lateral approach, a sequential surgery for terrible triad injury of the elbow, can improve initial stability of the elbow. Patients are able to perform rehabilitative exercises sooner in their recovery, which helps to reduce stiffness. Heterotopic ossification is also reduced.
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Affiliation(s)
- Fushan Hou
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan, 030001, Shanxi, People's Republic of China
| | - Xiao Liang
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan, 030001, Shanxi, People's Republic of China
| | - Wei Fan
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan, 030001, Shanxi, People's Republic of China
| | - Feng Zhao
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan, 030001, Shanxi, People's Republic of China
| | - Dong Li
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan, 030001, Shanxi, People's Republic of China.
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Kim BS, Kim DH, Byun SH, Cho CH. Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? Mid-Term Postoperative Outcomes Following a Standardized Protocol. J Clin Med 2020; 9:E3500. [PMID: 33138199 PMCID: PMC7693719 DOI: 10.3390/jcm9113500] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to investigate mid-term outcomes and complications after operative treatment according to a standardized protocol for terrible triad injuries. Twenty-four patients that were treated by a single surgeon with a standardized surgical protocol were retrospectively reviewed. After the complete reconstruction of radial head and/or lateral collateral ligament (LCL) complex through a lateral approach, coronoid process, and/or medial collateral ligament (MCL) complex through a medial approach were fixed if the elbow is unstable. For coronoid fractures, only type III were fixed in four cases (16.7%). Twenty-two LCL (91.7%) and five MCL (20.8%) complexes were repaired. At the final follow-up, the mean MEPS and Quick-DASH score were 91.5 and 17.3, respectively. There was no recurrent instability after operation in all cases. This study revealed that operative treatment that was based on our standardized protocol for terrible triad injuries yielded satisfactory mid-term clinical and radiographic outcomes without any recurrent instability. These results suggest that Type I and II coronoid fractures in terrible triad injuries do not need to be fixed if the radial head and ligamentous complex are completely reconstructed.
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Affiliation(s)
| | | | | | - Chul-Hyun Cho
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1035 Dalgubeol-daero, Dalseo-gu, Daegu 42601, Korea; (B.-S.K.); (D.-H.K.); (S.-H.B.)
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17
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Pasternack JB, Ciminero ML, Choueka J, Kang KK. Patient outcomes for the Internal Joint Stabilizer of the Elbow (IJS-E). J Shoulder Elbow Surg 2020; 29:e238-e244. [PMID: 32147333 DOI: 10.1016/j.jse.2019.12.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/22/2019] [Accepted: 12/10/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recently, the Internal Joint Stabilizer of the Elbow (IJS-E) was developed as an internal dynamic fixator for use in the setting of traumatic elbow instability. This study reviews the patients who had an IJS-E placed at our institution. Specifically, postoperative complications, postoperative functional outcomes, and need for subsequent procedures were reviewed. METHODS A retrospective chart review was conducted of patients in whom the IJS-E was implanted from June 2016 to July 2018. Indications for use, range of motion at final follow-up, and the need for subsequent procedures were reviewed. Disabilities of the Arm, Shoulder, and Hand (DASH) and Broberg-Morrey scores were also obtained. RESULTS Ten IJS-E devices were implanted into 10 patients. Average length of follow-up was 13.4 months. Average flexion-extension and pronation-supination motion arcs at final follow-up were 106° and 141°, respectively. Seventy-eight percent of patients achieved >100° arcs of both flexion-extension and pronation-supination. Average DASH and Broberg-Morrey scores were 28.7 and 68.2, respectively. Four subsequent procedures were required in 4 patients: 2 contracture releases, 1 medial collateral ligament reconstruction, and 1 total elbow arthroplasty. There were no postoperative infections or nerve injuries. DISCUSSION The IJS-E has replaced the use of external hinged fixation at our institution. Final range of motion was consistent with that reported for terrible triad and complex elbow dislocation injuries. The IJS-E is a good option for use in patients with traumatic elbow instability, as it restores motion and function without immediate postoperative complication. However, it does not eliminate the potential for future operative intervention in these complex injuries.
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Affiliation(s)
- Jordan B Pasternack
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA.
| | - Matthew L Ciminero
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Jack Choueka
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Kevin K Kang
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
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Antegrade Reduction and Fixation of Coronoid Fractures: A New Arthroscopic Technique. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2020. [DOI: 10.1097/bte.0000000000000185] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Antoni M, Eichler D, Kempf JF, Clavert P. Anterior capsule re-attachment in terrible triad elbow injury with coronoid tip fracture. Orthop Traumatol Surg Res 2019; 105:1575-1583. [PMID: 31732394 DOI: 10.1016/j.otsr.2019.09.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 08/09/2019] [Accepted: 09/16/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND During the surgical treatment of terrible triad elbow injury (TTEI), the usefulness of re-attaching the anterior joint capsule when the coronoid tip is fractured remains unclear. The primary objective of this study was to assess potential benefits during surgery for TTEI of re-attaching the joint capsule when the coronoid tip is fractured. HYPOTHESIS Re-attaching the anterior joint capsule in TTEI with a fractured coronoid tip improves clinical and radiological outcomes and decreases the complication and revision rates. MATERIALS AND METHODS This single-centre retrospective study included patients who underwent surgery at the acute phase of TTEI with a fractured coronoid tip. In all patients, a physical examination and elbow radiographs were performed at least 1year after surgery. A statistical analysis was done to compare the groups with vs. without re-attachment of the anterior capsule and coronoid tip. RESULTS The study included 30 patients, 16 females and 14 males, with a mean age of 51years (range: 21-84years). Among them, 11 did and 19 did not undergo re-attachment. The two groups were comparable regarding demographic features and follow-up duration. No significant differences were found at last follow-up for flexion-extension motion arc (p=0.75), pronation-supination motion arc (p=0.3051), or the Mayo Elbow Performance Score (p=0.19). Radiographic evidence of humero-radial osteoarthritis was significantly more common in the absence of re-attachment (p=0.04), whereas no differences were evidenced regarding humero-ulnar osteoarthritis (p=0.73), the occurrence of subluxation or dislocation (p=0.43), or loosening of the radial head implant (p=0.47). The complication and revision rates were similar in the two groups. CONCLUSION In our experience, re-attaching the anterior capsule during the surgical treatment of TTEI with a coronoid tip fracture did not improve the clinical or radiographic outcomes after a mean follow-up of 54months. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Maxime Antoni
- Service de chirurgie du membre supérieur, hôpital de Hautepierre 2, CHU Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France.
| | - David Eichler
- Service de chirurgie du membre supérieur, hôpital de Hautepierre 2, CHU Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - Jean-François Kempf
- Service de chirurgie du membre supérieur, hôpital de Hautepierre 2, CHU Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - Philippe Clavert
- Service de chirurgie du membre supérieur, hôpital de Hautepierre 2, CHU Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
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Radial head replacement versus reconstruction for the treatment of the terrible triad injury of the elbow: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2019; 139:507-517. [PMID: 30656475 PMCID: PMC6420892 DOI: 10.1007/s00402-019-03111-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The terrible triad injury of the elbow (TTIE) remains challenging to manage and has been associated with high complication rates and poor outcomes. There is a trend towards performing radial head replacement (REP) in preference to radial head reconstruction (REC) as arthroplasty provides early stability and may allow mobilisation sooner, potentially resulting in a better functional outcome. This systematic review compares the outcome of patients with TTIE treated with either REC or REP. MATERIALS AND METHODS MEDLINE, Embase, and CINAHL were searched for studies published in English involving at least ten patients exclusively with a TTIE managed operatively, including both patients with either REC or REP. Data collection was in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis protocol. The outcomes of interest were Mayo Elbow Performance Score (MEPS) and range of motion (ROM). Post-operative complications were also compared. RESULTS 9 studies involving 210 patients were included (98 REPs and 112 RECs). There was no statistically significant difference (p = 0.51) demonstrated between in the mean MEPS of the REP group (mean 88.6) and REC group (mean 88.5). Similarly, there was no statistically significant difference demonstrated between the REP and REC groups in terms of ROM. The risk of re-operation was high in both the REP (18.4%) and REC (17.9%) group. The overall complication rate of all patients included in the study was high (65%). CONCLUSIONS Comparable results with good outcomes in terms of functional scores and ROM can be achieved with both REP and REC when treating TTIE, although the re-operation rate for both remains relatively high. Given there is no apparent clear advantage between the two treatment groups, we would suggest that REC should be performed when a satisfactory fixation can be achieved as the longevity of REP in young patients with a TTIE is currently uncertain.
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Mazhar FN, Ebrahimi H, Jafari D, Mirzaei A. Radial head resection versus prosthetic arthroplasty in terrible triad injury: a retrospective comparative cohort study. Bone Joint J 2018; 100-B:1499-1505. [DOI: 10.1302/0301-620x.100b11.bjj-2018-0293.r1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Aims The crucial role of the radial head in the stability of the elbow in terrible triad injury is acknowledged. This retrospective study aims to compare the results of resection of a severely comminuted radial head with or without prosthetic arthroplasty as part of the reconstruction for this injury. Patients and Methods The outcome of radial head resection was compared with prosthetic arthroplasty in 29 and 15 patients with terrible triad injuries, respectively. There were ten female patients (34.5%) in the resection group and six female patients (40%) in the prosthesis group. The mean age was 40.7 years (sd 13.6) in the resection group and 36 years (sd 9.4) in the prosthesis group. The mean follow-up of the patients was 24.4 months (sd 12) in the resection group and 45.8 months (sd 6.8) in the prosthesis group. Outcome measures included visual analogue scale (VAS) for pain, Mayo Elbow Performance Score (MEPS), Disabilities of Arm, Shoulder and Hand (DASH) Score, and range of movement. Postoperative radiological complications were also recorded. Results The mean ranges of extension, flexion, supination, and pronation were not significantly different between the two study groups (p = 0.75, p = 0.65, p = 0.82, and p = 0.68, respectively). The mean VAS score, DASH score, and MEPS of the two groups were also not statistically significantly different (p = 0.93, p = 0.19, and p = 0.32, respectively). At the final visit, the elbow was stable in all patients. No patient was found to have developed an Essex–Lopresti injury. Osteoarthritis grade I and II was observed in five and three patients of the resection group, respectively, and four and one patients of the arthroplasty group, respectively. Conclusion The outcome of patients undergoing treatment for terrible triad injuries is similar whether the patient’s radial head was excised or replaced. Cite this article: Bone Joint J 2018;100-B:1499–505.
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Affiliation(s)
- F. Najd Mazhar
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - H. Ebrahimi
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - D. Jafari
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - A. Mirzaei
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
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Galbiatti JA, Cardoso FL, Ferro JAS, Godoy RCG, Belluci SDOB, Palacio EP. Tríade terrível do cotovelo. Avaliação do tratamento cirúrgico. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2017.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Domos P, Griffiths E, White A. Outcomes following surgical management of complex terrible triad injuries of the elbow: a single surgeon case series. Shoulder Elbow 2018; 10:216-222. [PMID: 29796110 PMCID: PMC5960872 DOI: 10.1177/1758573217713694] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 05/08/2017] [Accepted: 05/08/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Terrible triad injuries of the elbow are complex injuries to treat and we report our outcomes following surgical management. METHODS Twenty-two consecutive patients who underwent fixation of terrible triad injuries between 2007 and 2012 were identified. Clinical outcomes were assessed by examination, visual analogue scores (VAS), Oxford Elbow Score (OES), Mayo Elbow Performance Index (MEPI) and QuickDash score (QD). RESULTS The mean age of patients was 47 years, with a mean follow-up of 32 months. All patients underwent lateral ligament repair, with additional medial ligament repair in four cases. Thirteen patients required repair of the coronoid and 18 patients required surgery to the radial head. The mean flexion-extension arc was 113°, with mean prono-supination of 136°. The functional elbow scores revealed good outcomes in the majority (mean OES of 37, MEPI of 79 and QD of 21). The overall complication rate was 41%. In total, 23% required reoperation, with one patient requiring fasciotomy for acute compartment syndrome and four requiring subsequent removal of metalwork as a result of stiffness. CONCLUSIONS Recognition of this complex injury pattern and appropriate restoration of the joint stability are the prerequisites. Systematic surgical approach is effective and can provide both stability and good function, in most cases.
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Affiliation(s)
- Peter Domos
- Department of Trauma and Orthopaedics, Royal Free NHS Foundation Hospital, London, UK,Peter Domos, Royal Free NHS Foundation Hospital, Pond Street, London NW3 2QG, UK.
| | | | - Andrew White
- Department of Trauma and Orthopaedics, Peterborough City Hospital, Peterborough, UK
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Galbiatti JA, Cardoso FL, Ferro JAS, Godoy RCG, Belluci SDOB, Palacio EP. Terrible triad of the elbow: evaluation of surgical treatment. Rev Bras Ortop 2018; 53:460-466. [PMID: 30027079 PMCID: PMC6052181 DOI: 10.1016/j.rboe.2018.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/19/2017] [Indexed: 10/31/2022] Open
Abstract
Objective This study aims at analyzing retrospectively the clinical-functional and radiographic results of surgical treatment of the terrible elbow triad, with at least 12 months of postoperative follow-up evaluating elbow function. Methods A group of patients for retrospective analysis from 2004 to 2015 was defined, in which 12 patients were studied. They underwent surgery due to fracture of the radial head, coronoid fracture, and elbow dislocation; they were evaluated by the Disabilities of the Arm, Shoulder and Hand (DASH) score, the degree of patient satisfaction, the degree of trauma energy, radiographic images, range of motion, and complications. Results There was a higher incidence of Regan and Morrey type II coronoid process fractures; in relation to the injuries, nine patients had deinsertion of the brachialis. Half of the patients suffered a fall from their own height as the mechanism of trauma. The extent of elbow flexion and extension averaged 126.6 and 24.1 degrees, respectively; the averages for pronation and supination were 64.1 and 62.0 degrees, respectively. All patients presented muscle strength of grade IV or V. The mean DASH score was 14.3, the mean pain score was 2.5, and a majority of the patients were satisfied with the treatment. Conclusion Despite the total loss of range of motion of the elbow, especially in extension, the treatment was satisfactory for most patients.
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Liu G, Ma W, Li M, Feng J, Xu R, Pan Z. Operative treatment of terrible triad of the elbow with a modified Pugh standard protocol: Retrospective analysis of a prospective cohort. Medicine (Baltimore) 2018; 97:e0523. [PMID: 29668642 PMCID: PMC5916669 DOI: 10.1097/md.0000000000010523] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of the present study was to investigate the efficacy of the surgical treatment of terrible triad injuries of the elbow using a modified standard surgical approach, and treatment determined by the mode and mechanism of injury, and intraoperative findings.The study was a retrospective analysis of a prospective cohort of patients presenting with terrible triad injuries of the elbow, who underwent surgical treatment between July 2009 and January 2014. All patients were treated surgically according to a modified Pugh standard protocol. Elbow functional status and range of movements were evaluated at 3 months, 6 months, 1 year, and 2 years or more after surgery. Radiographic signs of post-traumatic arthritis were rated according to the Broberg and Morrey system.Our series included a final cohort of 29 males and 13 females with a mean age of 48.23 ± 10.95 years at the time of injury. The mean follow-up period was 30.47 ± 7.65 months. The mean flexion-extension arc was 107° ± 22°, and the average forearm rotation arc was 145° ± 14°. The mean Mayo Elbow Performance Score was 88 ± 10 points (range 55 to 100 points), with excellent results in 24 elbows, good results in 16, and poor results in 2. Functional results of the elbow improved significantly from 3 months postoperatively (P < .05), but tended to plateau from 1 year after surgery. Thirteen patients had radiographic signs of arthrosis (9 grade 1, 4 grade 2). Postoperative complications were local infection around the incision (n = 1), transient postoperative median nerve paralysis (n = 1), and postoperative posterior interosseous nerve paralysis (n = 1). Four patients required further surgery. Five patients had evidence of heterotopic ossification.Overall, we show that slight modifications to Pugh standard protocol for the surgical treatment of terrible triad injuries can lead to good to excellent results, although there were a good number of complications. The ideal surgical approach and treatment should be based on the mode and mechanism of injury, and intraoperative findings, and modifying the standard surgical treatment approach for terrible triad elbow injuries may be beneficial.
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Affiliation(s)
- Guanyi Liu
- Department of Orthopedics, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou
- Department of Orthopedics, Ningbo 6th Hospital, Ningbo, Zhejiang, P.R. China
| | - Weihu Ma
- Department of Orthopedics, Ningbo 6th Hospital, Ningbo, Zhejiang, P.R. China
| | - Ming Li
- Department of Orthopedics, Ningbo 6th Hospital, Ningbo, Zhejiang, P.R. China
| | - Jianxiang Feng
- Department of Orthopedics, Ningbo 6th Hospital, Ningbo, Zhejiang, P.R. China
| | - Rongming Xu
- Department of Orthopedics, Ningbo 6th Hospital, Ningbo, Zhejiang, P.R. China
| | - Zhijun Pan
- Department of Orthopedics, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou
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Comparison of a single approach versus double approaches for the treatment of terrible traid of elbow—A retrospective study. Int J Surg 2018; 51:49-55. [DOI: 10.1016/j.ijsu.2018.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 01/13/2018] [Indexed: 11/18/2022]
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Kachooei AR, Baradaran A, Ebrahimzadeh MH, van Dijk CN, Chen N. The Rate of Radial Head Prosthesis Removal or Revision: A Systematic Review and Meta-Analysis. J Hand Surg Am 2018; 43:39-53.e1. [PMID: 29054353 DOI: 10.1016/j.jhsa.2017.08.031] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/25/2017] [Accepted: 08/30/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE We conducted a meta-analysis and systematic review with the primary objective to determine the overall incidence of radial head prosthesis removal or revision. Our secondary objectives addressed the incidence of removal or revision based on the type of prosthesis fixation (cemented, uncemented smooth stem, uncemented press-fit), material (metal, Vitallium, titanium, pyrocarbon), and design (short vs long stem and monopolar vs bipolar), and the reasons for prosthetic removal or revision. METHODS We included 30 studies with a total of 1,017 patients out of whom 77 prostheses were removed and 45 prostheses were revised. RESULTS The pooled rate of radial head prosthesis removal or revision was 10.0% (95% confidence interval, 7.3%-13.6%) with a mean follow-up of 38 months. Subgroup analysis showed that the incidence of removal/revision was lowest with the cemented fixation, longer-stem, Vitallium material, and bipolar prosthesis. More than half of the prostheses were removed/revised for excision of the heterotopic ossification (47%) and for the treatment of stiffness and limitation of motion (42%). Other reasons recorded were pain (19%), loosening (16%), overstuffing (13%), instability (12%), infection (8%), and prosthesis disassembly (4%). CONCLUSIONS The current data show that the highest incidence of removal/revision occurred within 2 years after implantation. There was no major difference in the incidence of removal/revision among different designs and materials. Implant removal was often performed as part of a procedure to manage elbow stiffness and heterotopic ossification at the surgeon's preference, not necessarily because the implant was malfunctioning. It appears that most radial head arthroplasties have an acceptable and comparable mid-term longevity; however, it is unclear whether long-term longevity will differ between devices. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Affiliation(s)
- Amir R Kachooei
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Aslan Baradaran
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - C Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Neal Chen
- Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Jones ADR, Jordan RW. Complex Elbow Dislocations and the "Terrible Triad" Injury. Open Orthop J 2017; 11:1394-1404. [PMID: 29290879 PMCID: PMC5721343 DOI: 10.2174/1874325001711011394] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 07/12/2017] [Accepted: 07/18/2017] [Indexed: 02/08/2023] Open
Abstract
Background: The elbow is the second most commonly dislocated joint in adults and up to 20% of dislocations are associated with a fracture. These injuries can be categorised into groups according to their mechanism and the structures injured. Methods: This review includes a literature search of the current evidence and personal experiences of the authors in managing these injuries. Results: All injuries are initially managed with closed reduction of the ulno-humeral joint and splinting before clinical examination and radiological evaluation. Dislocations with radial head fractures should be treated by restoring stability, with treatment choice depending on the type and size of radial head fracture. Terrible triad injuries necessitate operative treatment in almost all cases. Traditionally the LCL, MCL, coronoid and radial head were reconstructed, but there is recent evidence to support repairing of the coronoid and MCL only if the elbow is unstable after reconstruction of lateral structures. Surgical treatment of terrible triad injuries carries a high risk of complications with an average reoperation rate of 22%. Varus posteromedial rotational instability fracture-dislocations have only recently been described as having the potential to cause severe long-term problems. Cadaveric studies have reinforced the need to obtain post-reduction CT scans as the size of the coronoid fragment influences the long-term stability of the elbow. Anterior dislocation with olecranon fracture has the same treatment aims as other complex dislocations with the added need to restore the extensor mechanism. Conclusion: Complex elbow dislocations are injuries with significant risk of long-term disability. There are several case-series in the literature but few studies with sufficient patient numbers to provide evidence over level IV.
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Affiliation(s)
- Alistair D R Jones
- Department of Trauma and Orthopaedics, Worcestershire Royal Hospital, Charles Hastings Way, WR5, Worcester, 1DD, UK
| | - Robert W Jordan
- Coventry and Warwickshire Shoulder and Elbow Unit, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
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Yang X, Chang W, Chen W, Liu S, Zhu Y, Zhang Y. A novel anterior approach for the fixation of ulnar coronoid process fractures. Orthop Traumatol Surg Res 2017; 103:899-904. [PMID: 28655630 DOI: 10.1016/j.otsr.2017.05.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 04/16/2017] [Accepted: 05/02/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is no universally accepted approach to the elbow for the fixation of coronoid process fractures. This study aims to introduce a novel anterior surgical approach for the fixation of the ulnar coronoid fracture, with minimal surgical dissection damage and excellent visualization for reduction and internal fixation. HYPOTHESIS The anterior approach can facilitate satisfactory outcomes for coronoid process fractures. MATERIAL AND METHODS From February 2010 to July 2014, 12 patients (8 males and 4 females; range 14-62years; mean age 31years) with a closed fracture of the coronoid process of the ulna were included in this study. According to Adams classification, we included 5 type II, 3 type III, 3 type IV AM, and 1 type IV AL. The fractures were treated operatively via an anterior approach between nerves and blood vessels. The anatomical reduction and fixation with cannulated screws or a mini plate was easily performed. One elbow showed significant joint instability, necessitating, another incision to repair the lateral collateral ligament, and a subsequent operation with a hinged external fixator was required. The remaining patients received a splint for 2 weeks followed by functional exercises. RESULTS Mean follow-up was 21 months (13-36). Fracture union was achieved in each patient. The arc of elbow flexion and extension were (135±15)°, and forearm pronation/supination were restored to (165±15)°. When compared with the normal side, there was no significant difference in the functional outcome (P>0.05). According to Morrey' scale, the functional recovery of the injured arms was assessed as excellent in eleven patients and good in one. Mild heterotopic ossification was found in one case, which had not impaired the elbow function. No other complications were noted. CONCLUSIONS The anterior approach has the benefits of simplicity, safety, minimal invasion, excellent exposure, and satisfactory prognosis for coronoid process fractures. LEVEL OF EVIDENCE Prospective study, Level IV.
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Affiliation(s)
- X Yang
- Second division of department of orthopedic surgery, affiliated hospital of Chengde medical college, 067000 Chengde, P.R. China
| | - W Chang
- Department of orthopedic surgery, the third hospital of hebei medical university, NO.139 Ziqiang road, 050051 Shijiazhuang, P.R. China
| | - W Chen
- Department of orthopedic surgery, the third hospital of hebei medical university, NO.139 Ziqiang road, 050051 Shijiazhuang, P.R. China
| | - S Liu
- Department of orthopedic surgery, the third hospital of hebei medical university, NO.139 Ziqiang road, 050051 Shijiazhuang, P.R. China
| | - Y Zhu
- Department of orthopedic surgery, the third hospital of hebei medical university, NO.139 Ziqiang road, 050051 Shijiazhuang, P.R. China
| | - Y Zhang
- Department of orthopedic surgery, the third hospital of hebei medical university, NO.139 Ziqiang road, 050051 Shijiazhuang, P.R. China.
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Chen HW, Wang ZY, Wei GS. Evaluation of the therapeutic effects of lateral approach combined with anteromedial approach in the treatment of terrible triad of the elbow. Biomed Pharmacother 2017; 91:748-754. [PMID: 28499246 DOI: 10.1016/j.biopha.2017.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 03/24/2017] [Accepted: 04/03/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study aims to evaluate the therapeutic effects of the lateral approach combined with anteromedial approach in the treatment of terrible triad of the elbow. METHODS Between June 2010 and January 2015, 334 patients suffering from terrible triad of the elbow, amongst whom 105 cases underwent lateral approaches combined with anteromedial approaches, 112 cases underwent lateral approaches, and 117 cases underwent anteromedial approaches were included in the study. The serum levels of C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-α (TNF-α) were detected using enzyme-linked immunosorbent assay (ELISA) before operation and at 7 days and 3 months after operation. X-ray imaging was employed to examine the recovery condition of the elbow, and the joint motion and the forearm rotation of elbow were evaluated before and after the operation. RESULTS Excellent rate was obtained in accordance with the Mayo Elbow Performance Score (MEPS). The serum levels of CRP, IL-6, IL-8 and TNF-α gradually decreased to normal levels after the operation, and recovery was faster in patients undergoing lateral approach combined with anteromedial approach in comparison to those undergoing lateral and anteromedial approaches. The X-ray images showed good recovery of elbows in all patients, but the range of joint motion, forearm rotation degree, and MEPS were higher in patients undergoing lateral approach combined with anteromedial approach compared to those undergoing lateral and anteromedial approaches independently. CONCLUSION Taken together, these findings demonstrate lateral approach combined with anteromedial approach reveals better therapeutic effect than lateral approach and anteromedial approach in the treatment of terrible triad of the elbow.
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Affiliation(s)
- Hong-Wei Chen
- Department of Orthopedics, Yiwu Hospital of Wenzhou Medical University, Yiwu 322000, PR China.
| | - Zi-Yang Wang
- Department of Orthopedics, Yiwu Hospital of Wenzhou Medical University, Yiwu 322000, PR China
| | - Geng-Sheng Wei
- Department of Orthopedics, Beijing Haidian Section of Peking University Third Hospital, Beijing 100080, PR China
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Shen L, Yu X, Zhong B, Ding J. A figure-eight suture loop with Kirschner wires for fixation of anteromedial coronoid process fractures: A case series. Int J Surg Case Rep 2017; 33:130-134. [PMID: 28315817 PMCID: PMC5358819 DOI: 10.1016/j.ijscr.2017.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 02/10/2017] [Accepted: 02/10/2017] [Indexed: 11/25/2022] Open
Abstract
Eleven cases with a fracture of the anterior or anteromedial facet of the coronoid process were treated by coronoid fixation using a figure-eight suture loop. All 11 fractures were united at final follow-up with no joint incongruity, dislocation, or subluxation of the injured elbow. The figure-eight suture pattern technique is an easy and effective technique to fix anterior or anteromedial facet fractures of the coronoid process. Purpose Sufficient fixation of an anterior or anteromedial facet fracture of the coronoid process in fracture-dislocation of elbow is important to maintain joint stability. The purpose of this study was to report our experience with 11 patients who were managed with an original fixation technique using a “figure-eight” suture loop. Methods From February 2010 to March 2011, 11 cases with a fracture of the anterior or anteromedial facet of the coronoid process were treated by coronoid fixation using a figure-eight suture loop. For cases with comminuted fractures, to prevent a suture from sliding into the fracture line, a 3- or 4-hole phalanx plate was enclosed in the suture loop to compress multiple fragments. Accompanying injuries, such as a radial head fracture or olecranon fracture, were fixed with repair of lateral collateral ligament injuries. Results On final evaluations at an average of 18 months after injury, the mean elbow arc of motion was 125.5° and the mean forearm rotation arc of 124.1°. All fractures were united with an average postoperative score according to the Mayo Elbow Performance Index of 91 points. All patients achieved satisfactory scores (seven excellent, four good). All 11 fractures were united at final follow-up with no joint incongruity, dislocation, or subluxation of the injured elbow. Conclusions The figure-eight suture loop technique is an easy and effective technique to fix anterior or anteromedial facet fractures of the coronoid process.
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Affiliation(s)
- Longxiang Shen
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, PR China
| | - Xingang Yu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, PR China
| | - Biao Zhong
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, PR China
| | - Jian Ding
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, PR China.
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Chen HW, Bi Q. Surgical Outcomes and Complications in Treatment of Terrible Triad of the Elbow: Comparisons of 3 Surgical Approaches. Med Sci Monit 2016; 22:4354-4362. [PMID: 27841255 PMCID: PMC5111572 DOI: 10.12659/msm.897297] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND This study compared the efficacy of combined lateral and medial approach, lateral approach, and anterior medial approach in treatment of terrible triad of the elbow (TTE). MATERIAL AND METHODS Thirty-eight TTE patients hospitalized in our center were retrospectively analyzed, among which 14 patients were arranged for combined lateral and medial approach, 12 for lateral approach, and 12 for anterior medial approach. All included patients underwent open reduction, collateral ligament repair, and postoperative function exercise. Follow-up was conducted for 13~22 months. The elbow motion, excellent and good rate, healing time, and complication rate were recorded and compared. RESULTS These 3 approaches significantly improved the postoperative elbow motion, MEPS, VAS, excellent and good rate, and open reduction (all P<0.05). The VAS score for lateral approach was evidently higher than that for combined lateral and medial approach (P<0.05). Combined lateral and medial approach and anterior medial approach had better performance on elbow motion, MEPS, and excellent and good rate than lateral approach (both P<0.05). Lateral approach and anterior medial approach had a significantly reduced healing time compared with combined lateral and medial approach (both P<0.05), while anterior medial approach had a higher complication rate compared with anterior medial approach and lateral approach (both P<0.05). CONCLUSIONS Lateral combined medial surgery approach contributes to wide surgical exposure, facture stability, and decreased complication rate, and thus has superior efficacy than the other 2 surgical approaches.
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Affiliation(s)
- Hong-Wei Chen
- Department of Orthopedic Surgery, Yiwu Central Hospital, Affiliated Hospital of Wenzhou Medical University, Yiwu, Zhejiang, China (mainland)
| | - Qing Bi
- Department of Orthopedics and Joint Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, China (mainland)
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Shimura H, Nimura A, Nasu H, Fujishiro H, Imatani J, Okawa A, Akita K. Joint capsule attachment to the coronoid process of the ulna: an anatomic study with implications regarding the type 1 fractures of the coronoid process of the O'Driscoll classification. J Shoulder Elbow Surg 2016; 25:1517-22. [PMID: 27039672 DOI: 10.1016/j.jse.2016.01.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 01/16/2016] [Accepted: 01/22/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The attachment of the anterior joint capsule on the ulnar coronoid process is not yet completely understood. The purpose of this study was to clarify the anatomic relationship between the anterior capsule of the elbow joint and the tip of the coronoid process. METHODS Seventeen embalmed elbows were used for this anatomic study. The anterior capsule of the elbow joint was reflected, and the attachment of the capsule on the coronoid process was exposed. The attachment of the joint capsule on the coronoid process was macroscopically and histologically observed, its relationship to the coronoid tip was assessed, and the length of the attachment of the joint capsule was measured. RESULTS The length of the capsule attachment at the radial side of the coronoid (11.9 mm) was greater than that at the ulnar side (6.1 mm). The bone thickness on the coronoid tip from the proximal edge of the joint capsule attachment was 1.9 mm; together, the cartilage and bone thickness was 4.7 mm. At the radial side of the coronoid, the thickness of the joint capsule at the proximal aspect of the attachment of 2 samples was 0.6 mm and 0.3 mm, and that at the tip of the coronoid was 2.6 mm and 1.7 mm, respectively. CONCLUSIONS The anterior capsule of the elbow joint had a substantial attachment on the radial side of the coronoid process. The subtype 2 tip fractures of the O'Driscoll classification included the joint capsule attachment, joint cartilage, and subchondral bone.
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Affiliation(s)
- Haruhiko Shimura
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan; Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akimoto Nimura
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Hisayo Nasu
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hitomi Fujishiro
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junya Imatani
- Department of Orthopaedic Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keiichi Akita
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Poglia P, Wehrli L, Steinmetz S, Zermatten P. Radial nerve palsy after the use of an adjuvant hinged external fixator in a complex fracture-dislocation of the elbow: a case report and review of the literature. J Med Case Rep 2016; 10:121. [PMID: 27170152 PMCID: PMC4866299 DOI: 10.1186/s13256-016-0904-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 04/19/2016] [Indexed: 11/13/2022] Open
Abstract
Background The combination of an elbow dislocation, a radial head fracture, and a coronoid process fracture is known as “terrible triad” injury of the elbow. This injury is one of the most challenging injuries of the musculoskeletal system and almost always causes instability of the elbow. The use of an adjuvant hinged external fixator in such injuries is still debated. Case presentation In this case report we present a case of radial nerve palsy after setting up an adjuvant hinged external fixator in a complex fracture–dislocation of the elbow. The patient was a 39-year-old white man. A revision of his radial nerve was undertaken at 7 weeks. A radial nerve injury at two levels facing the humeral apex pins was found intraoperatively; the pins were carefully removed and partial nerve grafts done. The functional outcome at 18 months was excellent. Conclusion This case report highlights that the use of an adjuvant hinged external fixator in complex fracture –dislocation of the elbow is technically demanding and not without risk.
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Affiliation(s)
- Pietro Poglia
- Department of Surgery, Division of Orthopaedic Surgery and Traumatology, Centre Hospitalier du Centre du Valais, avenue Gd-Champsec 80, 1950, Sion, Switzerland
| | - Laurent Wehrli
- Department of Surgery, Division of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois, University of Lausanne, rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Sylvain Steinmetz
- Department of Surgery, Division of Orthopaedic Surgery and Traumatology, Centre Hospitalier du Centre du Valais, avenue Gd-Champsec 80, 1950, Sion, Switzerland
| | - Philippe Zermatten
- Department of Surgery, Division of Orthopaedic Surgery and Traumatology, Centre Hospitalier du Centre du Valais, avenue Gd-Champsec 80, 1950, Sion, Switzerland.
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Bonnevialle N. Radial head replacement in adults with recent fractures. Orthop Traumatol Surg Res 2016; 102:S69-79. [PMID: 26796996 DOI: 10.1016/j.otsr.2015.06.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/22/2015] [Accepted: 06/03/2015] [Indexed: 02/02/2023]
Abstract
Radial head fractures are fairly common (20% of all traumatic elbow injuries). Non-operative treatment is indicated in non-displaced fractures, and direct stable internal fixation allowing early elbow mobilisation in most other cases. For severely comminuted fractures precluding stable fixation, replacement of the radial head was introduced in the 1970s as a better alternative to simple radial head resection, which can induce instability of the elbow and/or forearm, most notably in patients who have complex fractures with concomitant lesions to other structures. With contemporary implants (modular or monoblock, with or without a mobile cup), mechanical stability is close to that provided by the native radial head, although appropriate treatment of concomitant lesions remains crucial (e.g., re-attachment of the radial collateral ligament, or distal radio-ulnar stabilisation in patients with Essex-Lopresti fracture). The key technical points are selection of implant size and determination of the optimal implantation height. The two most common complications are capitellar overloading due to excessively high implantation of the prosthetic head, which causes stiffness and pain, and loosening of the stem. These complications may require removal of the implant at a distance from the injury. Studies have demonstrated satisfactory clinical outcomes in 60% to 80% of cases.
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Affiliation(s)
- N Bonnevialle
- Service d'orthopédie et de traumatologie, hôpital Riquet, place Baylac, 31059 Toulouse cedex 09, France.
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Ozel O, Demircay E. Review of management of unstable elbow fractures. World J Orthop 2016; 7:50-54. [PMID: 26807356 PMCID: PMC4716571 DOI: 10.5312/wjo.v7.i1.50] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/12/2015] [Accepted: 11/04/2015] [Indexed: 02/06/2023] Open
Abstract
Stable and painless elbow motion is essential for activities of daily living. The elbow joint is the second most commonly dislocated joint in adults. The goals of treatment are to perform a stable fixation of all fractures, to achieve concentric and stable reduction of the elbow and to provide early motion. The treatment modality for complex elbow instability is almost always surgical. The treatment objectives are anatomic reduction, stable fixation, and early rehabilitation of the elbow. The common complications of these unstable fractures include recurrent instability, stiffness, myositis ossifications, heterotopic calcification, and neurovascular dysfunction. We analyzed the management of complex elbow fractures and instabilities on the basis of recent literature and suggested possible guidelines for the treatment in this paper. In conclusion, recognition of the injury pattern and restoration of the joint stability are the prerequisites for any successful treatment of an unstable elbow injury.
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Abstract
BACKGROUND Terrible triad injury (TTI), one of the main patterns of complex elbow instability, is difficult to treat and yields conflicting surgical results. We analyzed prospectively a series of patient affected by TTI and treated according to the current diagnostic and surgical protocols to investigate whether their application allow to obtain more predictable outcomes. MATERIAL AND METHODS We analyzed 26 patients with a mean age of 52 years. Preoperative X-rays and CT were performed; all patients were operated by the same elbow surgeon and underwent the same surgical and rehabilitation treatment. Final functional outcome was assessed by the Mayo Elbow Performance Score (MEPS), Quick-Disability of the Arm Shoulder and Hand-score (Q-DASH) and the modified-American Shoulder and Elbow Surgeons score (m-Ases). A radiographic evaluation was also performed. RESULTS Mean follow-up was 31 months. At final evaluation, mean flexion, extension, supination and pronation were 137°, 10°, 77° and 79°, respectively; mean MEPS, m-ASES and Q-DASH scores were respectively 96, 91 and 8 points. Complications observed after first surgery were: elbow stiffness in 5 cases, mild posterolateral instability in 3 cases, chronic subluxation in 1 case. Radiographic evaluation showed secondary arthritis in 9 cases, symptomatic HO in 3 cases and late hardware displacement in 2 cases. Six out of 26 patient underwent reoperation with final satisfactory results. CONCLUSION The current diagnostic and therapeutic protocols allow obtaining satisfactory clinical outcomes in majority of cases but a high number of major and minor unpredictable complications persist yet. In this series, low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery. On the other hand, the strict application of current algorithms by an expert elbow surgeon appears to improve clinical results by reducing the influence of other avoidable negative prognostic factors well known in current literature, such as the incomplete recognition of injuries, delayed treatment, inadequate treatment of bony and ligamentous injuries, prolonged immobilization and, last but not least, the surgeon's inexperience. LEVEL OF EVIDENCE Level IV, Case series, Treatment study.
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Affiliation(s)
- Giuseppe Giannicola
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy.
| | - Piergiorgio Calella
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Andrea Piccioli
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Marco Scacchi
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Stefano Gumina
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
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38
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Yan M, Ni J, Song D, Ding M, Liu T, Huang J. Radial head replacement or repair for the terrible triad of the elbow: which procedure is better? ANZ J Surg 2015; 85:644-8. [PMID: 25827024 DOI: 10.1111/ans.13060] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Mingming Yan
- Department of Orthopaedic Surgery; Second Xiangya Hospital; Central South University; Changsha Hunan China
| | - Jiangdong Ni
- Department of Orthopaedic Surgery; Second Xiangya Hospital; Central South University; Changsha Hunan China
| | - Deye Song
- Department of Orthopaedic Surgery; Second Xiangya Hospital; Central South University; Changsha Hunan China
| | - Muliang Ding
- Department of Orthopaedic Surgery; Second Xiangya Hospital; Central South University; Changsha Hunan China
| | - Tang Liu
- Department of Orthopaedic Surgery; Second Xiangya Hospital; Central South University; Changsha Hunan China
| | - Jun Huang
- Department of Orthopaedic Surgery; Second Xiangya Hospital; Central South University; Changsha Hunan China
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Delclaux S, Lebon J, Faraud A, Toulemonde J, Bonnevialle N, Coulet B, Mansat P. Complications of radial head prostheses. INTERNATIONAL ORTHOPAEDICS 2015; 39:907-13. [PMID: 25655903 DOI: 10.1007/s00264-015-2689-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 01/20/2015] [Indexed: 11/27/2022]
Abstract
Radial head prostheses are indicated for treatment of complex radial head fractures not amenable for fixation. After the initial experience with silastic implants, metallic or pyrocarbon arthroplasty have been used for 20 years. Little is known about complications related to these implants. Main complications are related to loosening whether they are cemented or not cemented. Hypotheses have been proposed like inadequate stem design, insufficient cement technique, stress shielding, and foreign body reactions secondary to polyethylene wear. Pain and stiffness are other common complications often related to oversized radial head component or overstuffing of the joint with excessive lengthening of the radius. Instability can be another complication in the context of more complex trauma with lateral collateral ligament complex lesion and coronoid fracture. Fixation of the coronoid fracture, reinsertion of the lateral collateral ligament complex, and the use of monobloc radial head prosthesis are recommended to stabilize the joint. Finally, osteoarthritis is common with follow-up.
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Affiliation(s)
- Stéphanie Delclaux
- Orthopaedic and Traumatology Department, University Hospital of Toulouse Riquet Hospital, CHU Purpan, Place du Dr Baylac, 31059, Toulouse, France
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40
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Abstract
The terrible triad is an uncommon injury, which includes an elbow posterior dislocation with fractures of the radial head and coronoid process of the ulna. In addition there is rupture of the lateral and medial collateral ligaments. The short-term and long term results are historically poor, with a high rate of complications. The main objective of this study is to report the results of a multicentre study of patients who sustained the terrible triad injury focusing on surgical treatment in order to offer a standardized surgical protocol. We retrospectively review the results of surgical treatment of eighteen terrible triads from a multicentre study of 226 elbow dislocations. At an average follow up of 31.5 months postoperatively, all eighteen patients returned for clinical examination, functional evaluation, and radiographs. The mean MEPS score value was 78 (25-100), which correspond to three excellent results, ten good results, three fair results, and two poor results. Five early and three late complications were reported. This particular case of elbow dislocation is very unstable and leads to many complications. The surgeon should attempt to restore stability by preserving the radial head whenever possible or replacing it with prosthesis otherwise, by repairing the lateral collateral ligament and performing fixation of the coronoid fracture. If after anatomical restoration of stability elements, the elbow remains unstable, options include repair of the medial collateral ligament or stabilization assumed by hinged external fixator.
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Affiliation(s)
- Jérôme Pierrart
- Department of Orthopaedics and Trauma Surgery, Hôpital Avicenne, AP-HP, Univ Paris XIII, 125 rue de Stalingrad, 93909 Bobigny, France
| | - Thierry Bégué
- Department of Orthopaedics and Trauma Surgery, Antoine Béclère Hospital, AP-HP, Univ Paris-Sud, 157 rue de la Porte de Trivaux, 92140 Clamart, France.
| | - Pierre Mansat
- Department of Orthopaedics and Trauma Surgery, C.H.U. Toulouse/Purpan - Place du Dr Baylac, 31059 Toulouse, France
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Niéto H, Billaud A, Rochet S, Lavoinne N, Loubignac F, Pietu G, Baroan C, Espie A, Bonnevialle P, Fabre T. Proximal ulnar fractures in adults: a review of 163 cases. Injury 2015; 46 Suppl 1:S18-23. [PMID: 26528935 DOI: 10.1016/s0020-1383(15)70006-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The aim of this study was to report the epidemiological characteristics and the experience of 5 departments of trauma, in France, in the management of fractures of the proximal ulna. 163 patients with fractures of the proximal ulna with a mean age of 49.9 years (range 16-97) were managed. The most common mode of injury was a motor vehicle collision (48%). 18% sustained associated injuries to the ipsilateral limb. Open fractures were present in 42 patients (25%). A total of 109 patients had a fracture of the olecranon, with the Mayo 2A and B types most frequently seen (66%). The patients were invited for clinical examination at a mean duration of 16 months, retrospectively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Index (MEPI) and the Broberg and Morrey score were evaluated. All patients had follow-up radiographs. The mean arc of elbow motion was 130° (70-150°). The mean MEPI was 91 (20-100) with good results in 23% and excellent results in 52% of the patients. The mean Broberg and Morrey score was 90 after isolated olecranon fracture, and decreased with the complexity of the lesion. 117 fractures (72%) healed with ulnohumeral congruity. 9 fracture non-unions occurred (6%). Although the fracture of the proximal ulna can be described in several classifications, none of them accommodate it satisfactorily, because of the complexity of the lesion. The coronoid process is the keystone for the stability of the elbow. It forms the anterior buttress with the radial head. Tension band wire fixation is by far the commonest technique of internal fixation used for the treatment of non-comminuted olecranon fractures. Dorsal plate fixation is a useful option by providing improved fixation of complex comminuted fractures and fracture-dislocations. The radiocapitellar joint has to be restored appropriately, preserving the radial head when possible and replacing it with a prosthesis otherwise. The lateral collateral ligament complex is commonly disrupted and usually can be reattached to its origin from the lateral epicondyle. In addition, a brief period of hinged external fixation should be considered.
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Affiliation(s)
- H Niéto
- Department of Trauma and Orthopaedics, Niort, France
| | - A Billaud
- Department of Trauma and Orthopaedics, Pau, France
| | - S Rochet
- University Hospital of Besançon, France
| | - N Lavoinne
- Department of Trauma and Orthopaedics, Saint Jean de Luz, France
| | - F Loubignac
- Department of Trauma and Orthopaedics, Toulon, France
| | - G Pietu
- University Hospital of Nantes, France
| | - C Baroan
- Department of Trauma and Orthopaedics, Niort, France
| | - A Espie
- Department of Trauma and Orthopaedics, Albi, France
| | | | - T Fabre
- University Hospital of Bordeaux, France
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42
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Bohn K, Ipaktchi K, Livermore M, Cao J, Banegas R. Current treatment concepts for "terrible triad" injuries of the elbow. Orthopedics 2014; 37:831-7. [PMID: 25437075 DOI: 10.3928/01477447-20141124-06] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Elbow fracture-dislocations destabilize the elbow, preventing functional rehabilitation. If left untreated, they commonly result in functional compromise and poor outcomes. The "terrible triad" injury is classically described as a combination of a coronoid process and radial head fractures, as well as a posterolateral elbow dislocation. Surgical treatment to restore stable elbow range of motion has evolved in the past few decades based on increased understanding of elbow biomechanics and the anatomy of these injuries. This article highlights current concepts in the treatment of these complicated injuries.
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43
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Abstract
Traumatic injuries to the extremities are common in athletic competitions. The practitioner providing coverage of sporting events must be prepared to diagnose and provide initial treatment of these injuries. A thorough history and physical examination should result in a provisional diagnosis. Many injuries will require subsequent radiographs or orthopedic consultation. Limb threatening emergencies are rare but must be promptly recognized and referred to a hospital. Early treatment can protect athletes from further injury and may hasten their return to competition. Some athletes with extremity trauma can return to the contest, but this decision must be made on an individual basis.
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Affiliation(s)
- Daniel C Wascher
- Department of Orthopaedics and Rehabilitation, University of New Mexico, MSC 10 5600, 1 University of New Mexico, Albuquerque, NM, 87131-0001, USA,
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Gonçalves LBJ, Neto JDAES, Correa Filho MRC, de Andrade RP, de Andrade MAP, Gomes AH, Vilela JCS. Terrible triad of the elbow: influence of radial head treatment. Rev Bras Ortop 2014; 49:328-33. [PMID: 26229822 PMCID: PMC4511605 DOI: 10.1016/j.rboe.2014.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 08/30/2013] [Indexed: 11/19/2022] Open
Abstract
Objective to test the null hypothesis that patients with the terrible triad of the elbow (dislocation together with fractures of the radial head and coronoid process) who are treated with open reduction and internal fixation of the radial head have final results that are comparable with those of patients treated with arthroplasty or partial resection of the radial head. Methods twenty-six patients with the terrible triad of the elbow who were operated by a single surgeon were evaluated on average 23 months after the surgery (range: 16–36 months). There were 17 men and nine women of mean age 41 ± 13.4 years. The fractures of the radial head were treated by means of osteosynthesis (12 patients), arthroplasty (nine) or resection of a small fragment or no treatment (five). Fixation of the coronoid process/anterior capsule was performed in 21 patients. The lateral ligament complex (LLC) was repaired in all the patients, while the medial ligament complex (MLC) was repaired in three patients whose elbows remained unstable after treatment for the radial head and LLC, but without fixation of the coronoid process. Results the mean final range of flexion and extension was 112°. The mean pronation was 70° and supination, 6°. The mean DASH score (Disabilities of the Arm, Shoulder & Hand) was 12 and mean MEPI (Mayo Elbow Performance Index) was 87. According to the MEPI scores, 21 patients (80%) had good and excellent results. There was no statistically significant difference in the results between the patients who underwent fixation of the radial head and those who underwent arthroplasty or resection of a small fragment. Conclusion there was no difference between the patients treated with arthroplasty of the radial head and those treated with other techniques.
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Affiliation(s)
| | | | | | | | | | | | - José Carlos Souza Vilela
- Serviço de Ortopedia e Medicina do Esporte, Hospital Unimed, Belo Horizonte, MG, Brazil
- Corresponding author.
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45
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Gonçalves LBJ, Neto JDAES, Correa Filho MRC, de Andrade RP, de Andrade MAP, Gomes AH, Machado TL, Vilela JCS. Tríade terrível do cotovelo: a influência do tratamento da cabeça do rádio. Rev Bras Ortop 2014. [DOI: 10.1016/j.rbo.2013.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Complications of treating terrible triad injury of the elbow: a systematic review. PLoS One 2014; 9:e97476. [PMID: 24832627 PMCID: PMC4022574 DOI: 10.1371/journal.pone.0097476] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 04/19/2014] [Indexed: 11/22/2022] Open
Abstract
Objective Terrible triad injury of the elbow (TTIE), comprising elbow dislocation with radial head and coronoid process fracture, is notoriously challenging to treat and has typically been associated with complications and poor outcomes. The objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications following surgical management of TTIE. Methods Medline, EMBASE, Cochrane Library, and Google Scholar were searched to identify relevant studies, which were included if they were retrospective or prospective in design, involved participants who had TTIE, and were published in English. Outcomes of interest were functional outcomes and complications. Results Sixteen studies, involving 312 patients, were included in the systematic review. Mean follow up after surgery was typically 25 to 30 months. Mean Mayo elbow performance scores ranged from 78 to 95. Mean Broberg-Morrey scores ranged from 76 to 90. Mean DASH scores ranged from 9 to 31. The proportion of patients who required reoperation due to complications ranged from 0 to 54.5% (overall = 70/312 [22.4%]). Most of these complications were related to hardware fixation problems, joint stiffness, joint instability, and ulnar neuropathy. The most common complications that did not require reoperation were heterotopic ossification (39/312 [12.5%] patients) and arthrosis (35/312 [11.2%] patients). Conclusions The results of this systematic review indicate that functional outcomes after surgery for TTIE are generally satisfactory and that complications are common. Further research is warranted to determine which surgical techniques optimize functional outcomes and reduce the risk of complications.
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47
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Naoki Miyazaki A, Santos Checchia C, Fagotti L, Fregoneze M, Doneux Santos P, da Silva LA, do Val Sella G, Luiz Checchia S. Avaliação dos resultados do tratamento cirúrgico da tríade terrível do cotovelo. Rev Bras Ortop 2014. [DOI: 10.1016/j.rbo.2014.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Fitzgibbons PG, Louie D, Dyer GSM, Blazar P, Earp B. Functional outcomes after fixation of "terrible triad" elbow fracture dislocations. Orthopedics 2014; 37:e373-6. [PMID: 24762843 DOI: 10.3928/01477447-20140401-59] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 11/08/2013] [Indexed: 02/03/2023]
Abstract
Historically, the published literature on "terrible triad" injuries has shown a high rate of unacceptable results. The use of systematic treatment protocols may improve functional outcome. The authors performed a retrospective study of all patients aged 18 years or older who underwent surgical treatment for "terrible triad" elbow fracture dislocation at their institution over a period 7 years. Surgical treatment involved fixation or replacement of the radial head, repair of the anterior capsule or coronoid fracture in most cases, and repair of the lateral collateral ligament. Outcomes included grip strength, range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, and a visual analog score for pain as well as radiographic assessment of arthritis, maintenance of reduction, and development of heterotopic ossification. Eighteen patients were identified and 11 enrolled. Seven patients had suture fixation of the coronoid fragment and anterior capsule, 2 had screw fixation, and 2 had no repair of the coronoid. The radial head was replaced in 9 patients and repaired in 1, and a fracture fragment was excised in another. The average follow-up was 38 months. The average arc of motion of the injured elbow was 112° and that of the contralateral elbow was 142°. The average DASH score was 19.7 (scale, 0-100). The average visual analog score for pain was 2.2 (scale, 0-10). No patients had recurrent elbow instability. Three patients underwent further surgical procedures, all for loss of motion. The authors concluded that a systematic approach to the fixation of "terrible triad" elbow fracture dislocations can provide predictable elbow stability and functional range of motion in the medium term.
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49
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Evaluation of the results from surgical treatment of the terrible triad of the elbow. Rev Bras Ortop 2014; 49:271-8. [PMID: 26229812 PMCID: PMC4511680 DOI: 10.1016/j.rboe.2014.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 06/11/2013] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE to evaluate the results from surgical treatment of the terrible triad of the elbow (fracture of the radial head, fracture of the coronoid process and elbow dislocation) and its complications. METHODS between August 2002 and August 2010, 15 patients (15 elbows) with the terrible triad were treated by the Shoulder and Elbow Group of the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo. Nine (60%) were male and six (40%) were female; their ages ranged from 21 to 66 years, with a mean of 41 years. With the exception of one case that underwent arthroscopic surgery, all the patients underwent open surgery. The fracture of the coronoid process was fixed in 10 patients (66.7%). The fracture of the radial head was treated by means of internal osteosynthesis in 11 cases (73.3%); in three cases (20%), the radial head was resected; and in one case, only the fragment of the fracture was resected. The collateral ligaments, except for one case, were repaired whenever they were found to be injured; ten cases (66.7%) of medial collateral injury and 15 (100%) of lateral collateral injury were found. The mean length of the postoperative follow-up was 62 months, with a minimum of 12 months. The postoperative evaluation was done by means of the Bruce score. RESULTS more than 80% of the patients recovered their functional ranges of motion but, according to the Bruce score, only 26% of the patients achieved results that were considered satisfactory. CONCLUSION despite the unsatisfactory results, the functional ranges of motion and elbow function could be restored.
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50
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Arthrolysis combined with reconstruction for treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention. Arch Orthop Trauma Surg 2014; 134:325-31. [PMID: 24474612 DOI: 10.1007/s00402-014-1923-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The treatment of terrible triad injury with a poor outcome after intervention has not been successful thus far. The purpose of this study was to evaluate the efficacy of arthrolysis and reconstruction in the treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention. MATERIALS AND METHODS Twelve patients (12 elbows) with the diagnosis of terrible triad injury were respectively reviewed. All the 12 patients had elbow dysfunction after conservative and surgical treatment of the terrible triad injury. Preoperatively, the flexion arc and forearm rotation were 36.7° ± 28.5° and 51.3° ± 43.4°, respectively, and the Mayo Elbow Performance Score was 56.3 points. The mean interval between the primary injury and our surgical treatment was 6.6 months. Our surgical intervention included elbow arthrolysis, ulnar nerve transposition, radial head replacement, coronoid process and ligament repair, and hinged external fixation. Patients were encouraged to participate in rehabilitation training 24 h after surgery. RESULTS The mean follow-up duration was 20.1 months; the flexion arc and forearm rotation were 122° ± 18° and 140° ± 20°, respectively, and the mean Mayo Elbow Performance Score was 94.6 points (9 excellent, 3 good). Concentric stability was restored in all elbows. Complications included superficial pin tract infection (1), heterotopic ossification (3), and ulnar nerve palsy (1); the ulnar nerve symptoms had improved at the last follow-up. CONCLUSIONS The combination of open arthrolysis and reconstruction performed at a mean interval of 6-month posttrauma can restore functional mobility in cases of terrible triad injury with a poor outcome after surgical as well as conservative intervention. Thus, it may be an effective alternative for the treatment of the poor outcome terrible triad injury. We recommend early functional rehabilitation with adherence to the guidelines for hinged external fixation.
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