Radial head replacement or repair for the terrible triad of the elbow: which procedure is better? Mingming Yan, Jiangdong Ni, Deye Song, Muliang Ding, Tang Liu and Jun Huang Department of Orthopaedic Surgery, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
Key words elbow, fracture, radial head replacement, terrible triad. Correspondence Dr Jiangdong Ni, Department of Orthopeadic Surgery, Second Xiangya Hospital, Central South University, 139 Renmin Road, Changsha, Hunan 410011, China. Email: [email protected]
M. Yan MD, PhD; J. Ni MD, PhD; D. Song MD, PhD; M. Ding MD, PhD; T. Liu MD, PhD; J. Huang MD, PhD. Accepted for publication 12 February 2015. doi: 10.1111/ans.13060
Abstract Background: The terrible triad of the elbow comprises an ulnar coronoid process fracture, a radial head (RH) fracture and posterior dislocation of the elbow. It is considered severe by many clinicians because it is difficult to repair and has a poor prognosis; therefore, it deserves more attention. Methods: Thirty-nine patients with terrible triad of the elbow characterized by a Mason type-III RH fracture were randomly divided into either an RH repair group (n = 19) or an RH replacement group (n = 20). The complication rates, radiological outcomes, Mayo Elbow Performance Score and range of motion of the elbow were analysed. Results: Follow-up demonstrated no subluxation or recurrent dislocation of the elbow. Differences in surgery duration between the groups were significant (P < 0.001). The outcomes in terms of Mayo Elbow Performance Score (P = 0.009), flexion–extension arc (P = 0.01) and pronation–supination arc (P = 0.04) were significantly better in the RH replacement group. In addition, patients in the RH replacement group displayed significantly fewer post-surgery complications than those in the RH repair group (P = 0.04). Conclusion: Treating Mason type-III RH fracture in a terrible triad of the elbow with a metal RH prosthesis resulted in better clinical outcomes and fewer post-surgery complications than treating a terrible triad of the elbow by repairing it with screws or plates. RH replacement might be a more effective approach to better managing a terrible triad of the elbow.
Introduction The injury pattern of a terrible triad of the elbow is a type of severe fracture–dislocation injury that comprises an ulnar coronoid process fracture, a radial head (RH) fracture and posterior dislocation of the elbow.1,2 The outcome of this complicated injury is poor because it usually results in a high incidence of stiffness, pain, instability, arthritis and unsatisfactory arc of motion of the elbow. Recently, surgical intervention has been strongly advocated to achieve two purposes: to restore elbow stability by reconstructing bony and ligamentous structures; and to allow early elbow mobilization.3,4 Cumulative biomechanical knowledge on this type of injury emphasizes the importance of more closely addressing an RH fracture. Currently, surgical management is not recommended in a Mason type-I RH fracture in a terrible triad of the elbow. Mason type-II RH fracture in a terrible triad of the elbow is usually managed well by treating with open reduction and internal fixation (ORIF); however, ANZ J Surg 85 (2015) 644–648
ORIF in an unstable and multifragmented Mason type-III RH fracture in a terrible triad of the elbow often renders unsatisfactory results. This barrier has confounded many clinicians and has led to many controversial surgical protocols. This retrospective study reviewed 39 patients with a terrible triad fracture who underwent either RH replacement or repair. Clinical and radiological data were analysed to compare the outcomes of a terrible triad from either RH replacement or repair.
Methods Data on patients Eighteen male and 21 female patients with a terrible triad of the elbow were enrolled in the study between June 2005 and June 2008 in our hospital (Table 1). According to the Mason classification system,5 all RH fractures were categorized as either type IV because © 2015 Royal Australasian College of Surgeons
Radial head replacement or repair?
of dislocation; otherwise, all of RH fractures were type-III. Coronoid fractures were categorized based on the Regan and Morrey classification system6 into seven type-I, 26 type-II and six type-III fractures. Surgical procedures on all patients were performed by the same senior surgeon. Inclusion criteria were as follows: closed fracture, terrible triad of the elbow, fresh fracture (injury within 3 weeks), Mason type-III RH fracture, ulnar proximal fracture (including ulnar olecranon fracture), or medial or lateral ligament injury. Exclusion criteria were as follows: open fracture, paediatric fracture, pathological fracture, old fracture (more than 3 weeks), Mason type-I or type-II RH fracture, or RH fracture or coronoid fracture alone.
RH prosthesis and internal fixation A metal monopolar anatomic prosthesis with a smooth stem (Waldemar LINK GmbH & Co. KG, Hamburg, Germany) was used in replacement surgery, and the Synthes Modular Hand System comprising screws and plates (Synthes Holding AG, Solothurn, Switzerland) was used in repair surgery.
Operative techniques In a supine position and under general anaesthesia, a tourniquet on the proximal arm was used. RH replacement was performed by a lateral incision (Kocher approach). All coronoid fractures characterized as Regan–Morrey II and Regan–Morrey III were fixed securely first. After deciding to replace RH, it was removed, and concentric reduction and fixation of the coronoid process from the lateral space were performed. A standard medial approach was preferred to fix the coronoid fracture if repair to RH was random or if satisfactory exposure of the medial facet of coronoid fracture was difficult. Coronoid fixation was performed with a non-absorbable suture lasso device or lag screws inserted through drilled holes. When the fragments were characterized as Regan–Morrey III, dorsal plates were used. In the RH repair group, internal fixation of the RH fracture was performed with screws or plates by lateral approach if the RH neck was fractured. The fragments of RH were assembled on the
operating table to assess the required size of the prosthesis. The position where the radial neck was cut was in accordance with the relative position of the prosthesis and the capitulum humerus, taking care to avoid lengthening or shortening the radiocapitellar joint by more than 2.5 mm after the prosthesis was implanted. An RH prosthesis was implanted without bone cement to make any needed revisions easier. Annular ligaments, if ruptured, were carefully repaired in both groups. Finally, the lateral–collateral ligament complex (LCL) was tied to the lateral epicondyle with non-absorbable sutures or anchor sutures through holes drilled into the lateral epicondyle. A C-arm was used to confirm the concentric reduction and stability for full range of elbow motion. The medial–collateral ligament was not repaired because all cases gained stability with the elbow at >45° flexion. Braces were used in patients with the elbow at 70° flexion, forearm in slight pronation and wrist in the neutral position. Within 5 or 7 days post-surgery, passive flexion–extension exercises were initiated and were to be performed for the first 3 weeks under supervision. The pronation–supination exercises were forbidden until 3 weeks post-surgery. All patients were gradually allowed active elbow motion under rehabilitation protocols if there was no pain, fatigue or swelling. The brace was removed 6 weeks post-surgery and weight bearing on the elbow was gradually allowed.
Follow-up All patients participated in the follow-up for 3 years, and MEPS was used to assess elbow function. The flexion and extension of the elbow were tested as well as pronation and supination of the forearm (Fig. 1). Plain radiographs were taken of the anteroposterior and profile views (Fig. 2).
Statistical analyses Statistical analyses were performed using SPSS 16.0 (SPSS, Inc., Chicago, IL, USA). The Fisher’s exact test and independent sample Student’s t-test were used to compare the differences between the two groups. A level of P < 0.05 was considered a significant statistical difference and preferred to the two-sided probability.
Table 1 Data and results of patients with terrible triad of elbow in repaired and replaced group Variables Male Female Age (years) Duration of surgery (min) Surgery after injury (days) MEPS Flexion (degree) Extension (degree) Flexion/extension arc (degree) Pronation (degree) Supination (degree) Pronation/supination arc (degree) MEPS, Mayo Elbow Performance Score.
© 2015 Royal Australasian College of Surgeons
Repair group (n = 19)
Replacement group (n = 20)
7 12 35.51 ± 6.28 (22–48) 231.74 ± 29.97 (180–300) 11.95 ± 1.8 (9–16) 77.91 ± 13.86 (55–95) 114.63 ± 6.94 (98–126) 22.21 ± 4.16 (15–30) 92.42 ± 9.06 (75–103) 56.74 ± 13.74 (39–76) 49.53 ± 9.58 (30–69) 103.12 ± 19.47 (72–122)
11 9 36.54 ± 6.58 (23–51) 193.2 ± 15.53 (160–220) 12.25 ± 1.52 (10–16) 85.80 ± 7.51 (60–95) 117.40 ± 9.12 (101–130) 17.00 ± 4.35 (11–28) 101.40 ± 11.35 (82–115) 63.00 ± 9.98 (47–81) 51.10 ± 5.48 (40–61) 114.10 ± 13.56 (94–142)