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Use of suture anchors for coronoid fractures in the terrible triad of the elbow

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To report outcomes in 6 patients with the terrible triad of the elbow treated with our modified protocol. 6 men aged 26 to 54 years underwent surgery for the terrible triad of the elbow by a single surgeon. All the patients had a displaced comminuted fracture of the radius, posterior dislocation of the elbow, and Morrey type-I fracture of the coronoid. They all underwent replacement of the radial head and repair of the lateral collateral ligament to the isometric part of the lateral condyle using suture anchors. Five had an additional capsular fixation to the anterior coronoid using suture anchors; in patient 6 the coronoid was not repaired because it was stable. Functional outcomes were evaluated using the Hospital for Special Surgery (HSS) elbow assessment score. Bone union, implant loosening, heterotopic ossification, and degenerative changes were assessed using anteroposterior and lateral radiographs. After a mean follow-up of 2.2 (range, 1-3) years, the mean arc of flexion-extension was 116 degrees and the mean flexion contracture was 15 degrees. All patients maintained a concentric reduction of both the ulnotrochlear and the radiocapitellar articulation, with isometric fixation of the lateral collateral ligament. No patient had dislocation of the radial-head prosthesis. All had good-to-excellent HSS elbow scores, and none required re-operation. Patient 2 had neuropraxia of the radial nerve, which recovered within 3 months. Patient 4 had a range of movement of only 20 to 100 degrees, but was satisfied with the outcome. Repair of the articular capsule using suture anchors in addition to replacement of the radial head and repair of the lateral collateral ligament achieves favourable outcome in patients with the terible triad of the elbow.

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									Journal of Orthopaedic Surgery 2009;17(1):31-5




Use of suture anchors for coronoid fractures in
the terrible triad of the elbow
V Pai,1 V Pai2
	 Gisborne	Hospital,	New	Zealand
1

	 Alfred	hospital,	Melbourne,	Australia
2




                                                           years, the mean arc of flexion-extension was 116
                                                           degrees and the mean flexion contracture was 15
ABSTRACT                                                   degrees. All patients maintained a concentric reduction
                                                           of both the ulnotrochlear and the radiocapitellar
Purpose. To report outcomes in 6 patients with the         articulation, with isometric fixation of the lateral
terrible triad of the elbow treated with our modified      collateral ligament. No patient had dislocation of
protocol.                                                  the radial-head prosthesis. All had good-to-excellent
Methods. 6 men aged 26 to 54 years underwent               HSS elbow scores, and none required re-operation.
surgery for the terrible triad of the elbow by a single    Patient 2 had neuropraxia of the radial nerve, which
surgeon. All the patients had a displaced comminuted       recovered within 3 months. Patient 4 had a range of
fracture of the radius, posterior dislocation of the       movement of only 20 to 100 degrees, but was satisfied
elbow, and Morrey type-I fracture of the coronoid.         with the outcome.
They all underwent replacement of the radial head          Conclusion. Repair of the articular capsule using
and repair of the lateral collateral ligament to the       suture anchors in addition to replacement of the
isometric part of the lateral condyle using suture         radial head and repair of the lateral collateral ligament
anchors. Five had an additional capsular fixation to       achieves favourable outcome in patients with the
the anterior coronoid using suture anchors; in patient     terible triad of the elbow.
6 the coronoid was not repaired because it was stable.
Functional outcomes were evaluated using the               Key words: elbow joint; radius fractures; suture anchors
Hospital for Special Surgery (HSS) elbow assessment
score. Bone union, implant loosening, heterotopic
ossification, and degenerative changes were assessed       INTRODUCTION
using anteroposterior and lateral radiographs.
Results. After a mean follow-up of 2.2 (range, 1–3)        The terrible triad of the elbow is an incapacitating



Address	correspondence	and	reprint	requests	to:	Dr	Vasu	Pai,	Gisborne	Hospital,	Ormond	Road,	Gisborne,	New	Zealand.	
E-mail:	vasuchitra@gmail.com
32	    V	Pai	and	V	Pai	                                                                           Journal of Orthopaedic Surgery



 (a)                         (b)                                                         (c)




Figure 1 Patient	1:	radiological	images	showing	(a)	a	posterior	dislocation	and	comminuted	fracture	of	the	radial	head,	(b)	
a	type-I	coronoid	fracture	and	a	grossly	comminuted	fracture	of	the	radial	head	after	closed	reduction,	and	(c)	a	concentric	
reduction	using	suture	anchors	following	coronoid	fixation	and	radial	head	replacement.




 (a)                                        (b)                                         (c)




Figure 2 Intra-operative	photographs	showing	(a)	ter
								
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