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Fixation Versus Replacement of Radial Head in Terrible Triad: Is There a Difference in Elbow Stability and Prognosis?

  • Symposium: Traumatic Elbow Instability and its Sequelae
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Surgical treatment for terrible triad injuries of the elbow (defined as elbow dislocations with concomitant fractures of the radial head and coronoid) remains a challenging clinical problem. Specifically, the question of whether to repair or replace the radial head remains controversial.

Questions/purposes

We compared patients with terrible triad injuries of the elbow whose radial head fracture was treated with either internal fixation and internal fixation (ORIF) or radial head arthroplasty in terms of (1) clinical outcome measures (DASH and Broberg-Morrey scores, ROM), (2) elbow stability and radiographic signs of arthrosis, and (3) complications and reoperation rates.

Methods

Retrospective review identified 39 patients with terrible triad injuries and minimum 18-month complete clinical and radiographic followup (mean, 24 months; range, 18–53 months). Patients were managed with a standard algorithm consisting of (1) repair (n = 9) or replacement (n = 30) of the radial head, (2) repair of the lateral ulnar collateral ligament, and (3) repair of the coronoid fracture. During the study period, the radial head generally was internally fixed when there were fewer than four articular fragments; otherwise, it was replaced. Evaluation included the DASH score, the Broberg-Morrey index, measurements of elbow stability and motion, and radiographic assessment for signs of arthrosis; chart review was performed for complications and reoperations. Complete followup was available on 87% (39 of 45 patients).

Results

There were no differences between groups in terms of ROM or elbow scores. All patients who underwent radial head arthroplasty at the index procedure had a stable elbow at final followup whereas three of nine patients who underwent ORIF were unstable (p = 0.009). However, 11 patients who underwent arthroplasty demonstrated radiographic signs of arthrosis compared to none in the ORIF group (p = 0.04). Eleven patients (28%) underwent reoperation (seven arthroplasty, four ORIF) for various reasons. With the numbers available, there was no difference in reoperation rate between groups (p = 0.45).

Conclusions

For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to ORIF. As these injuries commonly occur in younger patients, longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening.

Level of Evidence

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

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References

  1. Birkedal JP, Deal DN, Ruch DS. Loss of flexion after radial head replacement. J Shoulder Elbow Surg. 2004;13:208–213.

    Article  PubMed  Google Scholar 

  2. Coonrad RW, Roush TF, Major NM, Basamania CJ. The drop sign, a radiographic warning sign of elbow instability. J Shoulder Elbow Surg. 2005;14:312–317.

    Article  PubMed  Google Scholar 

  3. Doornberg JN, Linzel DS, Zurakowski D, Ring D. Reference points for radial head prosthesis size. J Hand Surg Am. 2006;31:53–57.

    Article  PubMed  Google Scholar 

  4. Egol KA, Immerman I, Paksima N, Tejwani N, Koval KJ. Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Bull NYU Hosp Jt Dis. 2007;65:263–270.

    PubMed  Google Scholar 

  5. Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg Am. 2007;32:1200–1209.

    Article  PubMed  Google Scholar 

  6. Frank SG, Grewal R, Johnson J, Faber KJ, King GJ, Athwal GS. Determination of correct implant size in radial head arthroplasty to avoid overlengthening. J Bone Joint Surg Am. 2009;91:1738–1746.

    Article  PubMed  Google Scholar 

  7. Garrigues GE, Wray WH 3rd, Lindenhovius AL, Ring DC, Ruch DS. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am. 2011;93:1873–1881.

    Article  PubMed  Google Scholar 

  8. Harrington IJ, Sekyi-Otu A, Barrington TW, Evans DC, Tuli V. The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review. J Trauma. 2001;50:46–52.

    Article  CAS  PubMed  Google Scholar 

  9. Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults. 4th ed. Philadelphia, PA: Lippincott-Raven; 1996:980–981.

    Google Scholar 

  10. Johnston GW. A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Ulster Med J. 1962;31:51–56.

    CAS  PubMed Central  PubMed  Google Scholar 

  11. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Dislocations of the elbow and intraarticular fractures. Clin Orthop Relat Res. 1989;246:126–130.

    PubMed  Google Scholar 

  12. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68:647–659.

    CAS  PubMed  Google Scholar 

  13. Leigh WB, Ball CM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg. 2012;21:1336–1341.

    Article  PubMed  Google Scholar 

  14. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. 1954;42:123–132.

    Article  CAS  PubMed  Google Scholar 

  15. McKee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures: surgical technique. J Bone Joint Surg Am. 2005;87:22–32.

    Article  PubMed  Google Scholar 

  16. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am. 2001;83:1201–1211.

    PubMed  Google Scholar 

  17. O’Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect. 2003;52:113–134.

    PubMed  Google Scholar 

  18. O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF. The unstable elbow. Instr Course Lect. 2001;50:89–102.

    PubMed  Google Scholar 

  19. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004;86:1122–1130.

    PubMed  Google Scholar 

  20. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am. 1989;71:1348–1354.

    CAS  PubMed  Google Scholar 

  21. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002;84:547–551.

    PubMed  Google Scholar 

  22. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am. 2002;84:1811–1815.

    PubMed  Google Scholar 

  23. Van Glabbeek F, Van Riet RP, Baumfeld JA, Neale PG, O’Driscoll SW, Morrey BF, An KN. Detrimental effects of overstuffing or understuffing with a radial head replacement in the medial collateral-ligament deficient elbow. J Bone Joint Surg Am. 2004;86:2629–2635.

    PubMed  Google Scholar 

  24. Zeiders GJ, Patel MK. Management of unstable elbows following complex fracture-dislocations—the “terrible triad” injury. J Bone Joint Surg Am. 2008;90:75–84.

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors thank Sandra Stinnett DrPH for the statistical analysis in this manuscript.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Duke University Medical Center, DUMC 3000, Durham, NC, 27710, USA

    Tyler Steven Watters MD, Grant E. Garrigues MD & David S. Ruch MD

  2. Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA

    David Ring MD, PhD

Authors
  1. Tyler Steven Watters MD
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  2. Grant E. Garrigues MD
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  3. David Ring MD, PhD
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  4. David S. Ruch MD
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Corresponding author

Correspondence to Tyler Steven Watters MD.

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Each author certifies that he, or a member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

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Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at Duke University Medical Center, Durham, NC, USA.

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Watters, T.S., Garrigues, G.E., Ring, D. et al. Fixation Versus Replacement of Radial Head in Terrible Triad: Is There a Difference in Elbow Stability and Prognosis?. Clin Orthop Relat Res 472, 2128–2135 (2014). https://doi.org/10.1007/s11999-013-3331-x

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  • DOI: https://doi.org/10.1007/s11999-013-3331-x

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