Open Reduction and Internal Fixation Versus Resection of the Radial Head to Treat Terrible Triad Injury of the Elbow: What if Radial Head Replacement is not Possible?

Abstract

Background:

Terrible triad of elbow injury (TTI) has great potential for joint instability with a relatively poor prognosis. Different surgical methods have been introduced for radial head fractures. In this study, we aimed to evaluate the results of treatment of radial head fractures with open reduction and internal fixation (ORIF) and resection in TTI patients when radius head replacement was not attainable.

Materials and Methods:

In this retrospective study, 48 patients with TTI who underwent radial head fracture surgery with ORIF (n = 33) or resection (n = 15) were included. During follow-up, patients were evaluated for elbow range of motion (ROM), pain score, complications, need for reoperation, and Mayo Elbow Performance Score (MEPS). ORIF and resection groups were followed for 49.47 ± 28.58 and 52.79 ± 23.57 months, respectively.

Results:

Compared to the resection group, the ORIF group had significantly better ROM in extension and pronation and lower supination, although, when compared with a subgroup of mason type III fractures, the resection group had substantially better ROM in extension, pronation, and supination and better MEPS. The resection group had lower rates of pain score, instability, arthritis, heterotopic ossification, and need for reoperation compared to ORIF and its subgroup; however, the difference was not significant.

Conclusion:

Compared to resection of radial head fractures in TTI, ORIF had significantly better ROM overall, but resection efficacy was better than ORIF when comparing the Mason type III fractures.

INTRODUCTION

TTI of the elbow is described as posterior dislocation combined with fractures of the radial head and the coronoid process of the ulna.[1] Improper treatment of TTI can result in subsequent joint instability with a relatively poor prognosis and is a challenge even for experienced orthopedic surgeons.[2,3]

TTI has unfavorable complications such as joint stiffness, instability, pain, ulnar nerve complications, post-traumatic arthritis, and heterotopic ossification.[4,5] Surgery is the treatment of choice for TTI. Anatomical reduction and early mobilization could potentially reduce subsequent complications.[5,6] Radial head fixation or radial head resection and arthroplasty, fixation of the coronoid process of ulna, and lateral collateral ligament repair constitute the three principles of the surgery.[1]

The radial head fracture treatment options are arthroplasty, open reduction, and internal fixation (ORIF) with screws, ORIF with site-specific plates, or excision. In the isolated fractures of the radial head, ORIF demonstrated superior results compared to radial head excision.[7]

The treatment of choice for the comminuted radial head fracture in TTI is resectioning the bone fragments and replacing them with a prosthesis; however, on occasions, a radial head prosthesis is not always available, especially in resource-poor settings. Considering a relatively high prevalence of TTIs, other treatment options should be addressed in conditions when a radial head prosthesis is not readily available. Few studies have compared the efficacy of methods other than arthroplasty to treat TTI patients with comminuted radial head fractures. This study aimed to compare the results of ORIF and radial head resection in patients with TTI in settings where arthroplasty might not be available.

MATERIALS AND METHODS

Patients

Forty-eight patients with TTI were included in this study. All patients underwent surgery in a tertiary trauma center between September 2015 and November 2017. Patients with prior elbow surgery, cutaneous pre-elbow infection, history of rheumatologic disease, history of pre-operative reduced elbow range of motion (ROM), and progressive degenerative joint disorders were excluded. We also excluded patients with incomplete medical records and follow-up data. The ethics committee of our institute approved the study protocol. All patients had a minimum of 2 years of follow-up.

Pre-operative roentgenograms and computerized tomographic (CT) scans with three-dimensional reconstructions of the elbows were thoroughly reviewed by two orthopedic surgeons (two of the authors). The fractures of the radial head were classified per Mason’s classification as modified by Johnston, which divides the fractures into three types: type I: marginal fractures without displacement, type II: marginal sector fractures with displacement, and type III: comminuted fractures involving the whole head of the radius. Coronoid fractures were also classified according to the Regan and Morrey fracture classification, including type I: coronoid tip avulsion, type II: impairment of up to 50% of the coronoid height, and type III: involving over 50% of the coronoid height.[8]

Surgical procedure

All the patients underwent surgery under general anesthesia by one senior surgeon (one of the authors) within 6–48 hours after the initial injury. The patients were placed in the supine position with a high-arm pneumatic tourniquet, and asepsis was performed. The surgical procedure always began laterally via the Kocher approach, between the extensor carpi ulnaris and the anconeus muscles. The coronoid fractures were dealt with first, and then the radial head was approached. For type I of Regan and Morrey fracture classification, the coronoid was fixed with transosseous sutures, and types II and III were treated with mini-plates and screws.

The lateral ulnar collateral ligament was repaired in all cases. Repair or reconstruction of the medial collateral ligament was done through a separate medial skin incision and approach when necessary. After repairing all the structures, the elbow is taken through the arc of flexion and extension in supination, pronation, and neutral position for evaluating the elbow stability. A dynamic elbow external fixator was applied if there was any remaining instability under clinical and fluoroscopic examinations(incongruent joint).

The choice of treatment for radial head fracture, either with resection or ORIF, depended on each patient’s pre-operative planning and intraoperative findings and was made by the surgeon. Thirty-three patients were treated using ORIF [Figure 1], and 15 patients underwent radial head resection [Figure 2]. In all the patients, the Kocher approach was used. Subsequently, in the ORIF group (n = 33), the fractured fragments were reduced and stabilized with pointed reduction clamps and 1.6 mm Kirschner wires and then fixed with 2.4 mm titanium mini-screws. In the resection group (n = 15), the comminuted fragments were removed, and the radial head was resected using an oscillating bone saw close to the surgical neck of the radius. Patients with probable intraosseous ligament or triangular fibrocartilage complex injury (checked by surgeon intraoperatively) were omitted. The surgical wound was closed in a standard manner. All the patients were discharged 48 hours after the operation with no oral antibiotics and indomethacin 25 mg three times a day. The early postoperative period was uneventful for all the patients.

Figure 1.

ORIF

Figure 2.

surgical resection of the radial head

After surgery, early assisted ROM exercises were started depending on the patient’s tolerance of pain, in order to avoid elbow stiffness due to joint immobilization. The patients were followed at one month, three months, six months, one year, and two years postoperatively.

Patients’ clinical outcomes were assessed by the Mayo Elbow Performance Score (MEPS). The MEPS rates pain, ROM, stability, and function, and the results are graded as excellent (90–100 points), good (75–89 points), fair (60–74 points), or poor (<60 points). The visual analog scale (VAS) was used to quantify the pain status. A goniometer was used to measure the elbow’s range of motion in flexion, extension, and rotation.

Control radiographs were obtained in each follow-up visit and evaluated for post-traumatic osteoarthritis and the presence of periarticular ossification. The need for reoperation was also recorded.

Statistical analysis

All statistical tests were performed using SPSS software version 19 (IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY). The Student’s t-test was used to compare the continuous variables, whereas nominal categorical data between the study groups were compared using the chi-square test or Fisher’s exact test as appropriate. P values of less than 0.05 were considered statistically significant.

RESULTS

In this study, 48 patients diagnosed with terrible triad injury of the elbow were studied for outcomes of two different surgical methods. Thirty-five patients were male (72.9%), and 13 patients were female (27.1%) with a mean (SD) age of 37.52 (±13.03) years. Thirty-three patients (68.8%) underwent radial head fracture surgery with ORIF, and 15 patients (31.2%) were treated with radial head resection. Comparing the two study groups shows that there were more males in the ORIF group compared to the resection group, and more Mason’s type III radial head fracture was treated by resection [Table 1].

Table 1.

Baseline findings between groups

Variables	Variables	ORIF group	Resection group	P
Age (years)		39.03±14.95	34.20±6.48	0.23
Gender	Male	28 (84.8%)	7 (46.7%)	0.01*
	Female	5 (15.2%)	8 (53.3%)
The time-lapse between trauma and surgery		42.39±18.73	40.00±15.87	0.67
Trauma mechanism	Simple fall	27 (81.8%)	7 (46.7%)	0.01*
	Height fall	4 (12.1%)	6 (40%)
	Vehicle accident	2 (6.1%)	3 (13.3%)
Mason classification of radial head fracture	Type I	3 (9.1%)	0	0.001*
	Type II	16 (48.5%)	0
	Type III	14 (42.4%)	15 (100%)
Regan and Morrey Classification of coronoid fractures	Type I	26 (78.8%)	11 (73.3%)	0.4
	Type II	5 (15.2%)	4 (26.7%)
	Type III	2 (6.1%)	0

*P is two-sided significant

Table 2 summarizes the obtained postoperative outcomes between the two groups. Although pain, instability, post-traumatic arthritis, heterotopic ossification, and the need for reoperation were higher in the ORIF group, the disparities were not statistically significant (P > 0.05). Three patients underwent reoperation in the ORIF group because of the malposition of screws.

Table 2.

Postsurgery outcome between groups

	Resection group	ORIF group	P
Pain+	1 (6.7%)	9 (27.3%)	0.14
Instability	1 (6.7%)	3 (9.1%)	0.77
Arthritis	1 (6.7%)	7 (21.2%)	0.4
Heterotopic ossification	0	5 (15.2%)	0.16
Reoperation	0	3 (9.1%)	0.54
MCL restoration	11 (73.3%)	2 (6.1%)	<0.001*
Flexion range	135.2±7.76	133.94±8.58	0.59
Extension range	12.67±7.76	20.15±8.82	0.007*
Supination range	78.00±9.15	65.15±13.02	0.001*
Pronation range	75.33±9.15	59.7±14.78	<0.001*
MEPS	85.67±9.03	79.39±13.79	0.11
Mean follow-up (months)	49.47±28.58	52.79±23.57	0.67

*P-value is two-sided significant. + visual analog scale of more than 5. MCL=medial collateral ligament. MEPS=Mayo Elbow Performance Score

However, there were significantly more cases of medial collateral ligament (MCL) restoration in the resection group (P < 0.05). Considering the elbow’s range of motion at 24-month follow-up, the patients in the ORIF group had significantly better ROM in elbow extension and pronation but lower supination with no difference in flexion compared to the resection group. In a subgroup analysis of patients with Mason type III fractures, the resection group had significantly better ROM than the ORIF group. Although not statistically significant, there was a lower rate of complications. No cases of distal radioulnar joint instability was found pre-or postoperative in either group.

DISCUSSION

“Terrible” triad, not just by name, is one of the worst traumatic injuries of the elbow joint with a high rate of complications and poor prognosis. Surgical intervention is the treatment of choice to lessen complications and improve joint stability.[1] Radial head fracture morphology and its treatment are essential parts of TTI surgery. Surgeons either fix or replace the fractured radial head, depending on the extent of comminution, the number of fragments, and the surgeon’s experience.[9] Although arthroplasty is the treatment of choice for highly comminuted radial head fractures in TTI, the prosthesis might not always be readily available, as is generally the case in settings with limited resources. In such circumstances, the treatment options subside to resection or internal fixation of the radial head.

In this study, we evaluated 48 cases of TTI treated with ORIF or resection of the radial head and observed that ORIF cases had less fragmented fractures. In the previous studies, it has been reported that ORIF for radial head fractures with more than three separate fragments accompanies unsatisfactory results.[10] Therefore, fewer cases with Mason type III radial head fracture are expected to undergo fixation rather than resection when a prosthesis is unavailable.

In our study, the ORIF group showed a significantly better range of motion of the elbow in extension and pronation but a lower supination range with no difference in flexion compared to the radial head resection group. In a subgroup of patients with Mason type III fractures, ROM was significantly better in the resection group, indicating superior ORIF results in lower grades of Mason classification. Similar to our findings, Ikeda et al.[11] reported lower ROM in flexion, extension, pronation, and supination for patients that underwent radial head resection. Zarattini et al.[12] also reported better ROM postsurgery for the ORIF group than resection. Of note, both studies evaluated patients with Mason type II radial head fractures, while the main challenge is the management of type III fractures. Unlike our findings, Akman et al.[13] reported no significant difference in ROM between ORIF and resection in patients with Mason type III radial head fractures.

Lindenhovius et al.[14] found no difference in ROM between ORIF and resection groups in their study. Similarly, Goncavse et al.[15] also found no difference in the outcomes of three methods of replacement, fixation, and resection of the radial head. These differences could be attributed to the small sample size in these studies.

We also observed a higher, albeit the non-significant rate of pain, instability, arthritis, heterotopic ossification, and a need for reoperation in the ORIF group and subgroup of Mason type III fractures compared to the resection group. Other studies have reported a higher rate of some complications for resection of the head of the radius. Zarattini and colleagues[12] reported significantly higher osteoarthritis and degenerative changes among resection patients. Shetty et al.[7] reported that in patients with Mason type II and type III radial head fractures, ORIF has a better outcome and lower complications compared to resection. In another study, Akman et al.[13] reported no significant difference in pain and MEPS between ORIF and resection in patients with Mason type III radial head fractures. Still, there is no high-quality evidence regarding the complication rate between ORIF and resection of the radial head methods.

We also observed no significant difference in MEPS between the two groups, but the subgroup of Mason type III fractures had a significantly lower score. Similarly, Lindenhovius et al.[14] found no significant difference in MEPS between groups, while Ikeda et al.[11] reported higher scores for ORIF compared to resection, and Akman et al.[13] reported no significant difference between groups of patients with Mason type III fractures. Further studies are needed to clarify the exact outcomes of these two methods in radial head fracture.

It should be noted that we evaluated the outcome of radial head fracture surgery in patients with TTI, which is a very severe injury with multiple domains. Similar studies in this regard are scarce. It is possible that the magnitude of the severity of this type of injury and associated fractures could affect the outcomes.

This study had some clear limitations. First, it was a retrospective observational study. Second, the small sample size in each study arm, especially resection, could limit our interpretation of the results. Third, we are aware that the patients undergoing radial head resection have more comminuted fracture patterns and, therefore, a more severe injury, which could result in a biased interpretation of the findings. Further randomized controlled trials are required to evaluate these results better.

CONCLUSION

Although arthroplasty is the treatment of choice in comminuted radial head fractures in TTIs, there might be conditions where a radial head prosthesis is not feasible. The present study showed that, whenever possible, open reduction and internal fixation of Mason type I and II radial head fractures result in a significantly better ROM than resection in the radial in TTI patients. However, when comparing the Mason type III fractures, the efficacy of resection was more than ORIF in restoring elbow ROM.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.