Elbow Stability Research Articles

Der endoprothetische Ersatz der nichtrekonstruierbaren Speichenkopffraktur mit einer bipolaren Radiuskopfprothese

Radial head arthroplasty as a treatment of non-reconstructable, comminuted fractures of the radial head in order to achieve elbow stability and to prevent secondary complications, such as valgus elbow instability and radius proximalization. In acute trauma, a radial head fracture not suitable for internal fixation without (Mason grade III) and with (Mason grade IV) concomitant destabilizing injury, Essex-Lopresti injury, sequelae following radial head resection (e.g., elbow instability or wrist pain), failed reconstruction of the radial head, and tumor-associated radial head or neck resection. General medical contraindications for surgical intervention, cobalt-chromium allergy, and osteoporosis of the proximal radius. In supine position, a lateral or posterolateral approach at the elbow was used. The annular ligament was exposed and the radial neck identified just above the bicipital tuberosity. In pronation of the forearm in order to protect the radial nerve, the medullary canal was prepared using rasps. The size of the implant was determined using trial stems. A distance of 0.5 mm between the head of the prosthesis and the capitulum humeri was recommended. After using a small bone plug, the prosthesis was cemented with respect to the anatomical radial curvature. After reconstruction of the annular ligament, the stability of the elbow was verified. In case of instability, the medial collateral ligament was reconstructed and afterwards the wound closed. Early mobilization begins the day after surgery. In case of additional injuries, the elbow was supported by an above-elbow cast for 3-4 weeks. To prevent heterotopic ossification, nonsteroidal antiinflammatory drugs were used for up to 4 weeks with gastric protection. A total of 13 patients with 15 radial head prosthesis were analyzed at a mean follow-up of 29.5±20.8 months. In all patients, the elbow was stable. Subjectively, good and excellent results were found with one exception. Compared to the pretrauma status, the subjective rate was 78±12%. Based on the Radin and Riseborough score, 6 of the results were good and 9 were fair. According to the Broberg and Morrey score, 1 result was very good, 8 were good, and 6 were fair. The mean DASH score was 9.9±9.7 points. Two temporary nerve lesions were observed. Five patients were diagnosed with heterotopic ossification stage I, while 2 patients were classified with stage II on the Brooker scale.

Comparison of Wrist and Elbow Stabilization Following Pinch Reconstruction in Tetraplegia

Individuals with spinal cord injuries resulting in tetraplegia may receive tendon transfer surgery to restore grasp and pinch function. These procedures often involve rerouting the brachioradialis (Br) and the extensor carpi radialis longus tendons volar to the flexion-extension axis of the wrist, leaving the extensor carpi radialis brevis (ECRB) muscle to provide wrist extension strength. The purpose of this study was to determine whether externally stabilizing the wrist after transfer procedures would improve the ability to activate the transferred Br and resulting pinch force, similar to the effect observed when the elbow is externally stabilized. We used a one-way repeated-measures study design to determine the effect of 3 support conditions on muscle activation and lateral pinch force magnitude in 8 individuals with tetraplegia and previous tendon transfer surgeries. Muscle activation was recorded from Br and ECRB with intramuscular electrodes and from biceps and triceps muscles with surface electrodes. We quantified pinch strength with a 6-axis force sensor and custom grip. We recorded measurements in 3 support conditions: with the arm self-stabilized, with elbow stabilization, and with elbow and wrist stabilization. Pairwise differences were tested using Wilcoxon signed-rank tests. Maximum effort pinch force magnitude and Br activation were significantly increased in both supported conditions compared with the self-supported trials. The addition of wrist stabilization had no significant effect compared with elbow stabilization alone. A strong ECRB has adequate strength to extend the wrist, even after multiple transfers that contribute an additional flexion moment from strong activation of donor muscles. Anatomical and functional differences between the wrist and elbow musculature are important determinants for self-stabilizing joints proximal to the tendon transfer. The ability to increase Br activation and resulting pinch force may be determined, in part, by the individual's ability to develop new coordination strategies.

Radiocapitellar stability: the effect of soft tissue integrity on bipolar versus monopolar radial head prostheses

Radiocapitellar stability depends, in part, on concavity-compression mechanics. This studywas conducted to examine the effects of the soft tissues on radiocapitellar stability with radial head prostheses. Monopolar radial head implants are more effective in stabilizing the radiocapitellar joint than bipolar radial head prostheses, with the soft tissues intact or repaired. Twelve fresh frozen elbow specimens were used to evaluate radiocapitellar stability with monopolar and bipolar radial heads. The study variables focused on varying soft tissue conditions and examined the mean peak subluxation forces put forth by each prosthesis design. With the soft tissues intact, the mean peak force resisting posterior subluxation depended significantly on the radial head used (P = .03). Peak force was greatest for the native radial head (32 ± 7 N) and least with the bipolar prosthesis (12 ± 3 N), with the monopolar prosthesis falling in between (21 ± 4 N). The presence of soft tissues significantly affected the bipolar implant's ability to resist subluxation, though it did not significantly impact the native or monopolar radial heads. This study reveals the dependence of radiocapitellar stability on soft tissue integrity, particularly for bipolar prostheses. Overall, monopolar prostheses have a better capacity to resist radiocapitellar subluxation. From a biomechanical perspective, the enhancement of elbow stability with a monopolar radial head prosthesis is superior to that with a bipolar design. This is especially true when the integrity of the soft tissues has been compromised, such as in trauma.

Pediatric Complex Divergent Elbow Dislocation

A divergent dislocation of the elbow is a very rare injury, and only a few cases have been described in the literature. It is characterized as a dorsal dislocation of the ulnohumeral joint combined with a lateral dislocation of the proximal radius. All three articulations of the elbow joint are involved. Like in our case, it can be accompanied by an avulsion fracture of the coronoid and a distal radius fracture. For correct understanding of the injury, proper radiographic studies are imperative. In contrast to some earlier reports that advise a conservative approach, we performed a very aggressive operative treatment. To ensure anatomic reconstruction of the elbow, surgical exposure of the various injuries was performed first. After gross reduction of the joint dislocation, definitive osteosynthesis of the distal radius fracture was performed. Subsequently, the coronoid process and lateral collateral ligament could be repaired anatomically, improving the stability of the elbow. An uneventful recovery with excellent elbow motion and stability was achieved.

New Technique of Reconstruction for Medial Elbow Instability

This study reports a new substitution technique as a choice to repair both acute and chronic injuries of the ulnar collateral ligament of the elbow. Different researchers have described different techniques to reconstruct the medial ligament complex with similar results (with the use of grafts). There is a shared variable in the latest reports, the interpretation of the anterior bundle as the most important structure, for medial elbow stability and the only structure to be repaired as well. The approach to the medial structures of the elbow is similar to most of the surgical techniques. It consists of an incision on the medial aspect of the elbow, centered on the epicondyle, of length 4 inches. The reconstruction uses a strip of the aponeurosis of the flexor carpi ulnaris (FCU) reinforced with Kracow stitches. The graft is harvested using the strong aponeurosis of the FCU, a vascularized structure, a viable option and with sufficient resistance to bear the tension of the inner aspect of the elbow. The surgical morbidity is also reduced as the graft is not taken from other zones. As the distal insertion of the neo-ligament, the proximal fixation of the FCU is used in the sublime tubercle, inverting the direction of the fibers of this strip from distal to proximal. The proximal fixation of this ligament is an osseous tunnel in the epitroclea secured with an interference screw. Common complications are those resulting from the approach and the ulnar nerve manipulation. Owing to the satisfactory stability outcome achieved by this technique, early rehabilitation may start without inconveniences.

Use of metal proximal radial endoprostheses for treatment of non-traumatic disorders

We have reviewed five adult patients treated with endoprosthetic reconstruction of the proximal radius following resection of non-traumatic lesions. The patients had a mean age of 33.4 years (20 to 60) at the time of surgery and the mean follow-up was 7.6 years (0.8 to 16). Following surgery, all elbows were clinically stable and there was 100% survivorship of the prosthesis. Evaluation of function was assessed clinically and by the Mayo Elbow Performance Score, achieving a mean of 86% (70 to 100). Results at medium-term follow-up are encouraging with regards to elbow stability, implant survivorship and functional outcome.

Is a Silastic Radial Head Still a Reasonable Option?

The importance of the radial head to elbow function and stability is increasingly apparent. Although preservation of the native radial head is preferred, severely comminuted fractures may necessitate resection or arthroplasty. Silastic radial head arthroplasty has been condemned on the basis of several sporadic reports of silicone synovitis. However, problems of "overstuffing," cartilage wear, and motion loss are becoming apparent with metal prostheses, indicating this also is not an ideal solution. Thus, the choices remain controversial. We asked whether intact or reconstructed primary elbow stabilizers permit use of silastic radial head implants without fragmentation, failure, and silicone synovitis. We retrospectively reviewed 23 patients with unreconstructable radial head fractures who were treated with silastic radial head arthroplasty and concomitant repair and/or reconstruction of the medial ulnar collateral ligament and/or lateral ulnar collateral ligament. Analysis included range of motion, pain, stability, and radiographic assessments; Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire; and Mayo Elbow Performance Score (MEPS). The minimum followup was 16 months (average, 69.6 months; range, 16-165 months). At last followup, the mean elbow flexion was 145°, extension 11°, supination 80°, and pronation 83°. The mean MEPS score was 88.9. The mean DASH score was 11.8. There were eight reoperations, none resulting from failure of the radial head implants. These results demonstrate silastic radial heads can be used with low complication rates and without evidence of synovitis when concomitant elbow ligament repair or reconstruction is performed. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Reconstruction of deficient coronoid for treatment of chronic elbow dislocation

Objective To report clinical results of reconstruction of the deficient coronoid to improve the elbow stability for the treatment of chronic elbow dislocation. Methods From July 2008 to January 2010, we preformed coronoid reconstruction with autogenous olecranon or radial head after arthrolysis for 6 patients with chronic elbow dislocation complicated with deficient coronoid. All the 6 patients were male, withan average age of 30.5 years (18 to 42 years) at the time of surgery. Four right and 2 left elbows were affected. The average time from injury to surgery was 5 months (2 to 11 months) . All the primary injuries were terrible triad. The average range of elbow motion before operation was 13.3° (0 to 35°), and the average range of forearm rotation before operation was 62.5° (10° to 140°) . Through a standard posterior skin inci sion, the elbow joint was dislocated posteriorly in extension after arthrolysis to reconstruct the coronoid with autogenous olecranon or radial head. After fixation with screws or k-wires, the Stryker hinged external fixator was used for protection. Exercise began the first day after operation, Indomethacin was administered to prevent ectopic ossification. The external fixator was removed after 8 weeks. Results The mean follow-up time was 12 months (3 to 21 months) . The average range of elbow motion after operation was 120.0° ( 100° to 140°), and the average range of forearm rotation after operation was 141.7° (110°to 170°) . The average Mayo elbow performance score increased from 51.7 (50 to 55) before operation to 97.5 (85 to 100) after operation. All the 6 elbows were stable in extension after coronoid reconstruction. Conclusion Since coronoid reconstruction with autogenous olecranon or radial head can substantially improve the elbow stability,it is a good treatment for chronic elbow dislocation complicated with deficient coronoid. Key words: Elbow joints; Dislocation; Wounds and injuries; Recovery of function

Outcome of Ulnar Collateral Ligament Reconstruction of the Elbow in 1281 Athletes

Background The anterior bundle of the ulnar collateral ligament (UCL) is the primary anatomical structure providing elbow stability in overhead sports, particularly baseball. Injury to the UCL in overhead athletes often leads to symptomatic valgus instability that requires surgical treatment. Hypothesis Ulnar collateral ligament reconstruction with a free tendon graft, known as Tommy John surgery, will allow return to the same competitive level of sports participation in the majority of athletes. Study Design Case series; Level of evidence, 4. Methods Ulnar collateral reconstruction (1266) or repair (15) was performed in 1281 patients over a 19-year period (1988—2006) using a modification of the Jobe technique. Data were collected prospectively and patients were surveyed retrospectively with a telephone questionnaire to determine outcomes and return to performance at a minimum of 2 years after surgery. Results Nine hundred forty-two patients were available for a minimum 2-year follow-up (average, 38.4 months; range, 24-130 months). Seven hundred forty-three patients (79%) were contacted for follow-up evaluation and/or completed a questionnaire at an average of 37 months postoperatively. Six hundred seventeen patients (83%) returned to the previous level of competition or higher, including 610 (83%) after reconstruction. The average time from surgery to the initiation of throwing was 4.4 months (range, 2.8-12 months) and the average time to full competition was 11.6 months (range, 3-72 months) after reconstruction. Complications occurred in 148 patients (20%), including 16% considered minor and 4% considered major. Conclusion Ulnar collateral ligament reconstruction with subcutaneous ulnar nerve transposition was found to be effective in correcting valgus elbow instability in the overhead athlete and allowed most athletes (83%) to return to previous or higher level of competition in less than 1 year.

Anticipatory postural adjustments in a bimanual load‐lifting task in children with developmental coordination disorder

Postural control is a fundamental component of action in which deficits have been shown to contribute to motor difficulties in children with developmental coordination disorder (DCD). The purpose of this study was to examine anticipatory postural adjustments (APAs) in children with DCD in a bimanual load-lifting task. Sixteen children with reported motor problems (two females, 14 males; mean age 9 y; SD 2 y) and 16 typically developing, age-matched children (six females, 10 males; mean age 9 y; SD 2 y) took part in the study. The task required the children to maintain a stable elbow angle, despite imposed or voluntary unloading of the forearm. APAs were assessed using electromyography and kinematics analysis. Although children with DCD could compensate for the consequences of unloading, the results demonstrated that APAs were less efficient in children with DCD than in typically developing children. A positive and significant coefficient of regression between the flexor inhibition latency and the postural stabilization was only found in typically developing children. The impaired fine-tuning of the muscle contribution and the poor stabilization performances demonstrate poor predictive modelling in DCD.

Arthrolysis and a hinged external fixator for posttraumatic elbow stiffness

Objective To study the clinic results of arthrulysis and a hinged external fixator for treatment of posttraumatic elbow stiffness. Methods From February 2006 to April 2008,we treated 16patients,10 males and 6 females with an average age of 30.5 years(16 to 42 years),with open arthrolysis and a hinged external fixator.Flexion deformity was observed in 11 patients.The mean interval between trauma and arthrolysis was 13 months.After radiological examination,the lateral Kocher incision was used in 11 patients.the medial incision in 4 and the medial and lateral incision in one.The operation was to eliminate all the factors affecting the joint movement and to restore the range of motion(ROM)of the elbow.Early rehabilitation was encouraged after a hinged external fixator Was applied. Results After an average followup peried of 16 months,the mean ROM improved from preoperative 34°±26°to postoperative 92°±14° (P<0.05).The Mayo elbow performance score(MEPS)improved from preoperative 42 ±11 to postoperatire 84±16(t=4.351,P<0.05).No such complications as iatrogenic elbow instability and incision infection were discovered. Conclusion Arthrolysis and a hinged external fixator can keep stability of the elbow and its specific position,allowing early rehabilitation to promote functional recovery of the elbow. Key words: Elbow ioint; wounds and injuries; External fixator; Stiffness; Arthrolysis

Osteosynthesis of Intercondylar Humerus Fracture Using Bryan and Morrey Approach

Acute respiratory distress syndrome (ARDS) is an acute hypoxic respiratory failure due to non-cardiogenic pulmonary edema with diverse etiologies and high mortality. This study has been conducted to assess etiologies, physiological variables, mortality and its predictors in the ICU. A prospective cross-sectional study was carried out with all the patients more than 14 years of age admitted to ICU of a general hospital that fulfilled the criteria of American-European Consensus Conference criteria for ARDS were included in the study. Out of total 42 patients, main etiologies were sepsis (30.7%), polytrauma (25%), fat embolism syndrome (25%), acute severe pancreatitis (5.7%) pneumonia (5.7%) and others (8.3%). Non-survivors had significantly lower pH, PaO2/FiO2 on day 3 and higher SOFA score. Hospital mortality was 38.9%. The causes of death were MOF (57.1%), septic shock (21.4%) and refractory hypoxaemia (21.4%). Factors significantly associated with mortality were PaO2/FiO2 on day 3, pH and SOFA score; and SOFA score of 13 or above was predictive of death. MOF was the most common cause of death. Sepsis was the most common etiology. ARDS was associated with high but comparable mortality. The non-survivors had significantly lower oxygenation, pH, and higher SOFA scores.

Fracturas conminutas de la cabeza radial: estudio comparativo entre resección y fijación interna

Introduction The treatment of radial head fractures continues to be controversial. The open reduction and internal fixation (ORIF) method is expanding due to improvements in the techniques and the implants. However, it can be very demanding technically and is not free of complications. On the other hand, resection shows satisfactory results in the long term in stable elbows, although it is also associated with complications. We compared resection and ORIF in comminuted fractures of the radial head. Material and Method A total of 23 patients with type III Mason fractures were included, of which 11 were subjected to resection of the radial head (Group A), and 12 to internal fixation of their fracture (Group B). The mean age was 54 and 45 years, respectively. The fractures were clinically and radiologically evaluated, with a mean follow-up of 80 months in Group A and 76 months in Group B. Results The flexion-extension movement range was 121°–(−11°) in Group A and 131°–0° in Group B. The functional results obtained according the Broberg and Morrey scale were: 82 points in Group A and 90.9 points in Group B. Discussion Patients with comminuted fractures of the radial head subjected to open reduction and internal fixation have a satisfactory movement range, with greater strength, and therefore, better function. We recommend open reduction and internal fixation in the treatment of these fractures, particularly in young patients.

Effects of bone defects on elbow stability in olecranon fractures

Objective To investigate effects of different bone defects on stability of the elbow in the olecranon fracture. Methods Ten fresh cadavers with 20 upper extremities were used in the present study. Different models of bone defects in the middle olecranon were created by cutting the bone from 10 mm below the olecranon process. The 20 specimens were randomly made into intact, 3 mm defect, 6 mm defect and 9 mm defect groups. After osteotomy fixations were applied with the tension band wire. Changes in the range of motion of the elbow joint were measured. When the elbow was flexed at 30°, 60°, 90°, and 120°, a and the varus angulations in the varus test position, and observe the changes in relationship to the humeroulnar joint. Results Extension of the elbow was limited when the defect was 3 mm. X-ray showed that the extension of the elbow was obviously limited when the defect was 6 mm, with the humeroulnar joint moving resistantly, the olecranon process completely touching the surface of the trochlear and the interspace between the humeroulnar joint increasing. When the defect was up to 9 mm, the humeroulnar joint was subluxated obviously,with the trochlear notch nearly disappearing. Given the same degree of elbow flexion, the valgus angulation increased with the defect, especially when the defect was beyond6 mm (P ＜0.05). Conclusions When the bone defect at the middle olecranon reaches 6 mm, the trochlear notch radian will change, leading to an unstable elbow joint. Consequently, comminuted fractures of the middle olecranon can be treated with fixation if the defect is less than 6 mm: Otherwise bone grafting may be necessary to recover the trochlear notch radian and reduce the risk of traumatic osteoarthritis. Key words: Ulna; Fracture; Osteotomy; Elbow joint

D-1 Elbow Joint Laxity and Stability Analysis Using Image Based Method

D-1 Elbow Joint Laxity and Stability Analysis Using Image Based Method

Reconstruction of the medial collateral ligament plus radial head resection in the treatment of terrible triad of the elbow for young patients

Objective To observe the results of medial collateral ligament reconstruction plus radial head resection in the treatment of terrible triad of the elbow for young patients. Methods From November 2005 to October 2009,3 cases of terrible triad of the elbow were treated in our hospital. The radial head fractures were classified in type Ⅲ according to Mason classification. All patients underwent coronoid fixation, collateral ligament and joint capsule repair, medial collateral ligament reconstruction and radial head resection. Postoperatively Kirschner wire and the plaster was applied for elbow stabilization for 3 weeks after operation, in position with elbow flexion in 90 degrees and forearm rotation in neutral, and then removal of Kirschner wire and the plaster. Then physical exercise and rehabilitation program were carried out. Results 3 patients were followed up for more than 1 year with fracture healing. The functional outcome in 3 cases was excellent in 2 and good in 1 according to Broberg and Morrey Elbow Score. Conclusion It is exceptionally important of the reconstruction of collateral ligaments and joint capsule in the treatment of elbow terrible triad associated with radial head comminuted fracture for young patients. Radial head replacement should be cautious. Radial head resection under the premise of satisfactory ligament reconstruction does not cause significant elbow dysfunction. Key words: Terrible triad of the elbow; Reconstruction of the medial collateral ligament; Radial head resection

Effect of coronal shear fractures of the distal humerus on elbow kinematics and stability

Coronal shear fractures of the distal humerus can include some or all of the cartilaginous and bony surface. Fixation is preferred, but severe comminution, nonunion, and avascular necrosis may mandate excision. The amount of distal humerus that is safe to excise is unknown. This study examined the effect of excision of the capitellum and trochlea on elbow kinematics and stability with intact collateral ligaments. Eight cadaveric arms were mounted in an upper extremity joint testing system. Electromagnetic receivers on the radius and ulna enabled quantification of ulnohumeral and radiocapitellar kinematics. The distal humeral articular surface was sequentially excised to replicate clinically relevant coronal shear fractures, leaving the collateral ligaments undisturbed. The arms underwent simulated active flexion in vertical and valgus-loaded positions, and passive forearm rotation in the vertical position. In the vertical position, sequential excision of the articular surface increased valgus angulation during active flexion (P < or = .04), and excision of the entire articular surface increased ulnar external rotation compared to the intact elbow (P < or = .02). In the valgus position, excisions involving the trochlea increased valgus angulation for active flexion (P < or = .04). The radial head moved distal, posterior, and medial on the capitellum with some or all of the trochlea excised (P < or = .02). While the capitellum alone does not contribute to elbow stability, the trochlea has an important role. Excision of the trochlea resulted in multiplanar instability of the ulnohumeral and radiocapitellar joints. Therefore, excision of an irreparable capitellum fracture may be considered if collateral ligaments are intact, while excision of some or all of the trochlea may not.

Management of complex elbow instability

Complex elbow instability is a challenging injury even for expert elbow surgeons. The preoperative radiographs should be carefully evaluated to recognize all lesions that may occur in complex elbow instabilities. Recognizing all the possible lesions is critical to achieve an optimal outcome. The most common types of injuries are as follows: (1) radial head fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation); (2) Coronoid fractures and lateral collateral ligament lesion (with or without elbow dislocation); (3) Terrible Triad; (4) Transolecranon fracture-dislocation; (5) Monteggia-like-lesions; and (6) Humeral Shear fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation). A correct evaluation includes X-rays, CT scan with 2D and 3D reconstruction and stability test under fluoroscopy. The treatment is always surgical and is challenging, and outcomes are not predictable. The goals of treatment are (1) to perform a stable osteosynthesis of all fractures, (2) to obtain concentric and stable reduction of the elbow and (3) to allow early motion. The proximal ulna must be anatomically reduced and fixed; the radial head must be repaired or replaced, and the coronoid fractures must be repaired or reconstructed. With respect of soft tissue lesions, the LUCL must be reattached with suture anchors or trans-osseous suture. The next critical step is the intra-operative assessment of elbow stability. If the elbow remains unstable, MCL repair and/or application of hinged external fixator must be considered. The most recent clinical and experimental studies have significantly expanded our knowledge of elbow instability and its management. Definite treatment protocols may improve the clinical results of such complex injuries.

Contribution of the Olecranon to Elbow Stability

The amount of the olecranon that can be removed without substantially affecting the kinematics and stability of the elbow is controversial. The purpose of this study was to determine the effect of serial resections of the olecranon on elbow kinematics and stability. Eight fresh, previously frozen cadaver arms were mounted in an in vitro motion simulator, and kinematic data were obtained with use of an electromagnetic tracking system for active and passive motion. Flexion was studied in the varus, valgus, horizontal, and dependent positions. Custom-written three-dimensional computer navigation software was utilized to guide serial resection of the olecranon in 12.5% increments from 0% to 100%. A traditional triceps advancement repair was performed following each resection. Flexion angle, amount of olecranon resection, and active and passive motion measurements were compared. Serial resection of the olecranon resulted in a significant increase in varus-valgus angulation with the arm in the varus (p < 0.04) and valgus (p = 0.01) orientations. Ulnohumeral rotation significantly increased in the varus (p < 0.001) and valgus (p < 0.007) orientations. Angular (p = 0.02) and rotational (p < 0.001) kinematics were greater with passive compared with active motion. There was no difference in elbow kinematics following olecranon resection with the arm positioned in the horizontal and dependent positions. Valgus-varus angulation and ulnohumeral rotation progressively increase with sequential excision of up to 75% of the olecranon. Elbow stability is progressively lost with sequential excision, with gross instability noted at resection of > or = 87.5% of the olecranon.

Terrible triad injury of the elbow: How to improve outcomes?

Dislocation of the elbow joint combined with fractures of the radial head and ulnar coronoid process is referred to as Terrible Triad Injury (TTI). The purpose of this study is to report our experience in the management of this specific injury and to validate the therapeutic choices of our treatment.Between 1996 and 2006, 23 TTI in 22 patients were treated in our department. Fifteen males and seven females of mean age 46 years were included in this series.Internal fixation of the radial head was performed in 13 cases and arthroplasty in four. Fractures of the coronoid process were managed by surgical fixation in 10 cases. All torn ligaments were reconstructed which include 19 lateral and six medial ligament reconstructions.Thirteen patients (14 elbows) were reviewed at a mean follow-up of 63 months, four patients at a mean follow-up of 11 month (range, 6 to 18 months), and five patients were lost to follow-up. All patients had stable elbow joint and in 90% of the cases, patients reported mild or no elbow pain. The arc of extension-flexion ranged from 18 to 127 grades, while the average arc of pronation-supination was 134 grades. The mean Mayo Elbow Performance Score was 87. Only one patient suffered from osteoarthritis 8 years after trauma and all elbows were centred on X-rays. Negative prognosis factor was associated with Mason type 3 radial head fractures.The principle of the surgical management is based on two main objectives: restoration of bony stabilizing structures (radial head and coronoid process) and lateral collateral ligament reconstruction. A medial surgical approach is recommended in the case of persistent posterolateral instability following lateral collateral ligament reconstruction or when fixation of a large coronoid process fragment is indicated. The use of an external fixator is only advocated in case of persistent instability following the reconstruction of bony and ligamentous structures.Level IV: Retrospective study.