Using an Internal Joint Stabilizer Through a Single Posterior Approach for Elderly Patients With Terrible Triad Injury

Abstract

Introduction

Treating a terrible triad injury of the elbow remains a challenge for orthopedic surgeons, especially in elderly patients due to the poor quality of the surrounding soft tissue and bony structures. In the present study, we propose a treatment protocol using an internal joint stabilizer through a single posterior approach and analyze the clinical results.

Materials and Methods

We retrospectively reviewed 15 elderly patients with terrible triad injuries of the elbow who underwent our treatment protocol from January 2015 to December 2020. The surgery involved a posterior approach, identification of the ulnar nerve, bone and ligament reconstruction, and the application of the internal joint stabilizer. A rehabilitation program was initiated immediately after the operation. Surgery-related complications, elbow range of motion (ROM), and functional outcomes were evaluated.

Results

The mean follow-up period was 21.7 months (range, 16-36 months). ROM at the final follow-up was 130° in extension to flexion and 164° in pronation to supination. The mean Mayo Elbow Performance Score was 94 at the final follow-up. Major complications included breaking of the internal joint stabilizer in 2 patients, transient numbness over the ulnar nerve territory in one, and local infection due to irritation of the internal joint stabilizer in one.

Conclusions

Although the current study involved only a small number of patients and the protocol comprised two stages of operation, we believe that such a technique may be a valuable alternative for the treatment of these difficult cases.

Level of Clinical Evidence

4.

Introduction

Terrible triad injury is a type of complex elbow fracture-dislocation which is comprised of damage to the soft tissue and bone structure simultaneously. Management of this difficult injury remains a challenge for orthopedic surgeons, even with advancements in medicine. Significant morbidities, such as chronic instability, joint stiffness, post-traumatic arthrosis, and poor functional outcomes, may occur even after treatment.^1,2 The majority of patients require surgical treatment which currently tends to be reconstruction of the bone and ligament structures followed by rehabilitation as soon as possible to prevent joint stiffness.^2,3 Sufficient bony and soft tissue stability, which allows an immediate rehabilitation program, is crucial for achieving a good prognosis. However, it is difficult to ensure adequate stability in elderly patients due to the poor quality of the surrounding bone and ligaments.^4,5 Hence, prolong immobilization is often required to prevent loss of fixation, delaying post-operative physiotherapy and affecting patient outcomes.

Orbay et al designed an internal joint stabilizer (IJS) using a bent Steinmann pin placed through the axis of the ulnohumeral joint which was then attached to the proximal ulna with screws.⁶ This IJS could restore elbow stability and permit a good range of motion; potentially being a promising treatment option for patients with severe elbow instability. Although a commercial IJS had been developed based on this idea,⁷ this device remains unavailable in our country. Furthermore, hand-made IJSs are much cheaper compared to their commercial counterparts. Hence, using a hand-made IJS is still a reasonable choice.

We developed a treatment protocol which included bone reconstruction, soft tissue repair, and applying an IJS to facilitate elbow stability through a single posterior approach. The treatment protocol focused on using an IJS to ensure sufficient elbow stability and allowing immediate postoperative physiotherapy. In the present retrospective study, we aimed to analyze the outcomes of 15 geriatric patients with terrible triad injuries of the elbow who underwent treatment according to our newly introduced protocol.

Methods

From January 2015 to December 2020, 15 consecutive cases with terrible triad injuries of the elbow in patients age over 65 years were treated using the described technique by a single surgeon (CHM) (Table 1). A minimum of 1 year of follow-up (range, 16-36 months) was fulfilled for all cases. There were eight men and seven women with a mean age of 70.6 years (range, 66-78 years). The mechanism of injury was falls (9 patients) and traffic accidents (6 patients). The study was approved by the institutional review board (EMRP-109-157), and informed consent was obtained from each patient.

Table 1.

Patients’ Demographic Data.

Case	Sex/Age	Mechanism	Classification and Treatment		Associated Injury	Comorbidity
			Radial Head	Coronoid
1	F/68	Fall	Type I-ORIF	Type I		DM
2	F/67	Traffic accident	Type III-PR	Type II-ORIF		HTN, CAD
3	M/70	Traffic accident	Type II-ORIF	Type III-ORIF	Intracranial hemorrhage
4	F/66	Traffic accident	Type III-ORIF	Type I		Liver cirrhosis, child A
5	M/78	Fall	Type III-PR	Type I
6	M/72	Fall	Type II-ORIF	Type II-ORIF	Ipsilateral distal radial fracture
7	F/78	Fall	Type II-ORIF	Type I		ESRD, DM, HTN
8	M/70	Fall	Type II-ORIF	Type III-ORIF
9	M/71	Traffic accident	Type III-ORIF	Type II-ORIF	Epidural hemorrhage	DM
10	M/73	Fall	Type I-ORIF	Type I
11	M/69	Fall	Type II-ORIF	Type I
12	F/74	Traffic accident	Type III-PR	Type II-ORIF	Ipsilateral clavicle fracture
13	F/66	Fall	Type III-PR	Type I
14	F/70	Traffic accident	Type II-ORIF	Type I		Rheumatoid arthritis
15	M/68	Fall	Type II-ORIF	Type I		DM, HTN

F, female; M, male; ORIF, open reduction internal fixation; PR, prothesis radius; DM, diabetes mellitus; CAD, cardiovascular disease.

Plain radiography and computed tomography (CT) were performed to evaluate osseous abnormalities in all patients preoperatively (Figure 1(A)), and plain radiographic exams in two views were arranged at each post-surgery visit (Figure 1(B) and 1(C)). The Regan-Morrey classification was used to classify coronoid fractures based on the results of CT scans preoperatively.⁸ Radial head fractures were classified according to the original Mason classification.⁹

Figure 1.

(A1) Preoperative three-dimensional computed tomography (CT) reconstruction, (A2) lateral radiograph of a 67-year-old woman who sustained a right “terrible triad injury” with a type II coronoid fracture. (B1) Anteroposterior and (B2) lateral radiographs of the patient status post open reduction of the elbow joint, fixation of the coronoid process with screws, radial head arthroplasty, lateral collateral ligament repair, and internal joint stabilizer implantation. (C1) Anteroposterior and (C2) lateral radiographs of the patient showing a stable elbow joint after removing the internal joint stabilizer. Functional range of motion observed at the 1-year follow-up showing (D1) extension, (D2) flexion, (D3) pronation, and (D4) supination.

Surgical Techniques

Patients were placed in the lateral decubitus position. A tourniquet was used in all cases. The elbow was exposed via a posterior incision, and a global approach was followed. The ulnar nerve was routinely identified, released from the tunnel, and protected. Broad medial and lateral full-thickness soft tissue flaps were elevated, and the elbow joint was exposed. The coronoid process fracture was addressed first, according to the Regan-Morrey classification.⁸ Fixation of the coronoid process was performed for type II and III fractures, while type I coronoid tip fractures did not require fixation. The radial head fracture was then repaired or replaced with an artificial implant according to the fracture pattern and bone quality.

Once bony reconstruction was complete, we used a Kirschner-wire (K-wire) to drill a tunnel under the guidance of an aim-device (cruciate ligament reconstruction guide) from the lateral aspect into the distal humerus along the rotation axis of the ulnohumeral joint. The rotation axis could be determined by direct visualizing of the anatomic center of the capitellum and the origin of the medial collateral ligament (MCL). After the tunnel was created, the lateral collateral ligament (LCL) complex injury was repaired by direct suture or reattached to the lateral epicondyle. Most LCL injuries presented as an avulsion fracture over the lateral epicondyle. Anatomical fixation of the LCL could be fulfilled through reattaching the avulsion fragment back to the fracture site using one or two anchor sutures. The MCL complex was not repaired whether residual elbow instability existed or not.

Subsequently, an IJS, as described by Orbay et al, was prepared.⁶ The IJS was created from a 2.4 mm K-wire with a figure-of-eight formed first on the blunt end to accept two 3.5 mm screws and washers for attachment to the ulna. The axis portion was established by making a sharp bend at the proper location and then cut to the appropriate length. The IJS was applied and attached to the proximal ulna with two 3.5 mm screws and washers while the elbow was in 90 flexion with an anatomic concentric reduction position. Restoration of elbow flexion/extension, pronation/supination, and stability in all directions were assessed under fluoroscopic guidance before wound closure.

Postoperative Follow-Up and Evaluation of Joint Function

Post-surgery, regular aseptic wound care and pain control were initiated. All patients underwent upper limb peripheral nerve blockage for pain control in order to facilitate physiotherapy. A range of motion (ROM) exercise and rehabilitation program supervised by a physical therapist was allowed immediately. Patients were able to be discharged if the wound condition was stable, then regular follow-up at the outpatient clinic was arranged. The IJS was removed 6 weeks to 3 months after surgery when the soft tissue was expected to have healed enough to maintain elbow stability. Physiotherapy was continued and performed by an experienced therapist to achieve maximum ROM.

All patients were followed up clinically and radiographically for at least 1 year after the index operation. ROM (Figure 1(D)), pain, and complications were assessed. Radiographic exams were used to identify the recovery of bone, synostosis, heterotopic ossification (HO), and joint congruency. Functional outcomes based on the Mayo Elbow Performance Score (MEPS) were determined for each patient at the final clinic visit.

Results

Patients were followed up for a mean duration of 21.7 months (range 16-36 months) (Table 2). ROM at final follow-up was 130° in extension to flexion and 164° in pronation to supination. The majority of patients reported an average pain level <2 on the visual analog scale (VAS); 4 patients had a VAS pain score of 2 which could be controlled by taking oral pain killers occasionally. The mean MEPS was 94 (range 80-100 points) at the final follow-up, with excellent and good results in 12 and 3 patients, respectively.

Table 2.

Results.

Case	Follow-Up (months)	Pain (VAS)	Range of Motion		MEPS	Complications
			F-E	P/S
1	24	1	5-135	90/80	95	Ulnar nerve symptom
2	18	1	0-130	80/80	100
3	24	1	5-130	80/75	90
4	18	1	0-135	90/80	100
5	24	1	0-140	90/85	100	IJS broken, heterotopic ossification
6	16	2	5-130	70/70	85
7	22	2	5-125	80/85	80
8	18	2	15-135	75/70	85	Local infection
9	36	1	10-140	80/75	95
10	24	1	0-140	85/90	100	Heterotopic ossification
11	18	1	5-135	90/90	100
12	18	1	0-130	85/85	90
13	24	1	0-140	80/90	100	IJS broken
14	24	2	15-130	75/80	90
15	18	1	5-140	80/90	100

VAS, visual analog scale; F-E, flexion-extension; P/S, pronation/supination; MEPS, mayo elbow performance; IJS, internal joint stabilizer.

Postoperative radiographic follow-up for all cases showed concentric, anatomic restoration without objective signs of instability. A broken IJS without elbow joint instability was noted in two patients at week 6 of the follow-up. Slight heterotopic ossification was evident in 2 patients, but neither required additional surgery. A superficial wound infection due to irritation by the IJS occurred in one case, which healed after antibiotic therapy and removal of the IJS. Transient ulnar nerve symptoms developed postoperatively in one patient and resolved within 3 months. None of the patients required additional surgery.

Discussion

Most patients with a terrible triad injury require surgical management, and various operative methods had been reported in the literature.^1–3,10 The surgical goal is to obtain and maintain concentric reduction of the elbow joint.¹¹ The current surgical principles for these patients includes (1) fixation or replacement of the radial head, (2) fixation of the coronoid fragment or suturing of the anterior capsule and bone to the anterior ulna, (3) repair of the LCL complex, and (4) repair of the MCL complex, and/or application of a hinged external fixator for patients who demonstrate residual instability.^1–3,10,11 Post-surgery, physiotherapy should be initiated as soon as possible to prevent joint stiffness and ensure a good prognosis. Post-operative functional outcomes are varied, and the complications of chronic instability, traumatic arthritis, and joint stiffness can occur after surgical management.¹² There remains no standard treatment for these challenging patients. In our treatment protocol, we took into account the current treatment aims. The only difference being the use of a IJS to replace a hinged external fixator. For geriatric patients, the MCL repair may be unreliable due to poor soft tissue quality. Hence, we did not repair the MCL and simply applied the IJS in these patients.

In 2020, people aged 65 years and above accounted for 16% of total population in Taiwan. It is estimated that Taiwan will progress to become a super-aged society by 2025.¹³ With this aging population, managing musculoskeletal injuries in elderly patients has become an important health issue. Although elbow injuries only account for around 4.1% of all fractures in the elderly,¹⁴ treating a geriatric fracture dislocation around the elbow remains a challenge for orthopedic surgeons due to preexisting conditions related to aging. The high incidence of multiple co-morbidities can increase the risk of surgery and difficulty in peri-operative care, as well as affecting treatment decisions. The quality of bone and soft tissue are usually poor in the elderly^4,5; therefore, the strength of fracture fixation and soft tissue reconstruction may be insufficient for early mobilization. Prolonged bracing or even fixation with a temporary external fixation may be required to protect the repaired structure, which can result in joint stiffness.¹⁵

As well as the radial head, the coronoid also plays an important role in posterolateral rotatory stability. Hence, fixation of coronoid fractures for terrible triad injuries, especially for Regan-Morrey type II or III fractures, is recommended by most surgeons.¹⁶ However, there is still debate in the management of type I coronoid fractures. Although some authors suggest that this type of fracture does not lead to elbow instability and repairing or fixation of this lesion is unnecessary, most surgeons still prefer to synthesize the fragment as it could affect the anterior capsule and cause instability in the anterior posterior plane.¹⁷ However, the fragment is usually too small to be fixed with screws or a buttress plate. Therefore, repair of the anterior capsule and coronoid-brachialis capsular-ligamentous complex using harpoon or transosseous Lasso type sutures had been proposed.^16,18 Ligament repair of an unstable elbow joint requires experience and a skilled technique. Over-tightening or malpositioning of the ligaments beyond the isometric point may contribute to stiffness and instability.¹⁹ Furthermore, ligamentous repair or reattachment may not be sufficient to stabilize the elbow for immediate active movement, especially in geriatric patients with poor quality bone and soft tissue.

According to recent data published in the literature, using a hinged external fixator for cases of complex elbow fracture-dislocation can eliminate the need of fixation for coronoid tip fracture, anterior capsule repair, and ligament reconstruction. This could reduce surgical time and intra-operative soft tissue manipulation.^19,20 The hinged external fixator stabilizes the elbow and protects it against valgus and varus stress and allows adequate early ROM. Theoretically, this allows the ligaments to heal in a physiologic position without additional reconstruction procedures.^19,20 However, there are some drawbacks of hinged external fixators which include a cumbersome frame, pin-tract infections, broken or loose pins, fractures, and nerve injury.²¹ As long lever arms of hinged external fixators are required to attempt to avoiding radial nerve injury and extraarticular placement of the pins, any error in the placement of the hinged center could be magnified and result in motion restriction. Hence, it is technically demanding to place the hinged center along with the rotation axis of elbow joint precisely.²² Furthermore, this implant may be unavailable in some hospitals.

Orbay et al described the use of a bent Steinmann pin placed through the axis of the ulnohumeral joint and attached to the proximal ulna as a IJS to treat persistent instability of the elbow.⁶ In contrast to hinged external fixator, the shorter lever arm of the IJS make it much easier to reproduce the rotation axis. This idea was further developed into a new device as an internal hinged fixator of the elbow.⁷ The function of this simple internal device is similar to a hinged external fixator that is able to maintain concentric reduction, against valgus and varus stress, prevent re-dislocation, and permit functional motion during the healing period, as well as avoiding problems inherent to external fixators.⁶ It had been widely used to treat elbow instability and good results had been reported in the literature.^6,7,23 Salazar et al²³ even used this type of device to augment surgical fixation in the treatment of elbow instability for patients with advanced age, obesity, and cognitive dysfunction. In our case series, we used an IJS as an augmentation after the repair of bone and ligaments. The IJS was used to protect the repaired bone and ligaments, thus immediate physiotherapy was allowed post-operatively.

In our surgical protocol, we used a global posterior approach through a single incision which can provide adequate exposure to identify soft tissue and bony lesions. Moreover, the technique also allows protection of the ulnar nerve, reduction or re-alignment of the elbow joint, convenient repair of the bone and ligament structures, and application of the IJS. We repaired the LCL complex injuries and radial head fractures in every patient. Type I coronoid tip fractures and medial collateral ligaments did not require repair; instead, we maintained concentric reduction of the elbow joint with the IJS that allowed the coronoid-brachialis capsular-ligamentous complex and medial collateral ligament complex to heal under physiological tension.

Rehabilitation programs are important for regaining elbow motion, restoring muscle strength, and achieving a good functional outcome; therefore, programs should be started immediately and continued until no further improvements are noticed.²⁴ There is currently no standard rehabilitation protocol for terrible triad injuries of the elbow. The presence of pain can be a significant obstacle during early rehabilitation. In the current study, an upper extremity nerve block was used routinely to facilitate physiotherapy. Under the protection of the IJS, early and progressive joint ROM exercise was allowed. This treatment protocol represents a systematic approach to re-establish stability and functional motion using a simplified surgical procedure, by which we achieved very encouraging functional recovery with an acceptable complication rate.

There are several advantages of using the proposed treatment protocol. First, the IJS can provide good stability of the elbow joint, which allows patients to perform functional exercises immediately after surgery with little possibility of reduction or fixation failure. Second, the surgery can be accomplished through a single posterior approach instead of traditional double incisions over the medial and lateral elbow. This is crucial to decrease the wound complication rate as severe swelling of the surrounding soft tissue is noted in almost all patients with terrible triad injuries. Third, this IJS is low-profile, easy-to-apply, and provides higher levels of patient comfort, with no pin tract infection, in comparison with the use of traditional external hinged stabilizers. Fourth, it can decrease the need for complete ligament reconstruction, reducing surgical time and unnecessary soft tissue dissection. For the reasons above, using our treatment protocol with an IJS could be a valuable alternative for the management of elderly patients with terrible triad injuries of the elbow.

Although good clinical outcomes can be achieved through our method, there are some drawbacks to our study. First, there is no randomization due to the nature of a retrospective study. Hence, enrolling patients who received different treatment methods for subsequent comparison of clinical outcomes is impossible. Second, there were only 15 elderly patients enrolled, thus, the sample size is too small to prove it’s efficacy. Third, we enrolled patients with a diverse type of radial head and coronoid process fractures. The analysis may be affected due to the broad inclusion criteria. Fourth, some elderly patients in our study had comorbidities such as hypertension, diabetes mellitus, liver cirrhosis, and rheumatoid arthritis. These comorbidities were not taken into consideration, which may influence the analysis. Finally, the bone quality of each patient was unknown because we did not carry out dual-energy X-ray absorptiometry exams routinely. Due to the reasons mentioned above, further prospective randomized studies are required to prove the efficacy of our proposed treatment protocol.

Conclusions

Although only a few cases were enrolled in our study and a 2-stage operation was required in our treatment protocol, we believe that the proposed method may be a valuable alternative to treat elderly patients with terrible triad injuries. More biomechanical studies and prospective clinical trials are required to evaluate the validity of the use of an IJS through a single posterior approach for treating this challenging injury.

ORCID iD

Ching-Hou Ma https://orcid.org/0000-0001-6918-8812