Where Are We Now?
It has been a pleasure to review the landmark article of Ostergaard et al. , which is a valuable report of 114 patients whom the authors attempted to follow after reconstructive operations for terrible triad injuries (TTIs) of the elbow from January 2000 to June 2017. Despite losing 46% (52 of 114) of these patients to a formal follow-up review, this is still a valuable study because, to my knowledge, it is the largest series of primary operations in patients with TTIs that has been published to date. In a meta-analysis of published studies on TTIs, Chen et al.  identified only four other large series with a total of 115 surgically treated patients [5, 7, 13, 14]. In Ostergaard et al.’s study , reoperations were performed in 47% (26 of 55) of patients who underwent radial head arthroplasty, two of three patients who underwent radial head excision, and none of four patients who underwent open reduction and internal fixation of the radial head, indicating that there is a high complication rate after the primary procedure for TTIs. Chen et al.  indicated that patients with TTIs who underwent radial head arthroplasty had better functional outcomes as assessed by objective scoring systems, including the DASH and Mayo Elbow Performance Score, and fewer postoperative complications than those treated with open reduction and internal fixation did. They concluded that radial head arthroplasty might be a more-effective treatment approach with good clinical outcomes for patients with a TTI of the elbow.
It is refreshing that the authors of the paper accompanying this CORR Insights®  concentrated not on what was correctly done during the primary operation and the good results they obtained with these operations but, more constructively, they focused on what did not go right with the first operation and how to adjust surgical treatment in the future to obtain even better outcomes. Their findings are important because they identified four different problems that created symptoms and resulted in a revision operation: difficulty establishing anatomic reconstruction of the radial head and neck to ensure bony stability of the lateral column, ulnar neuropathy that is associated with excessive handling or traction on the ulnar nerve, postoperative elbow stiffness, and symptomatic hardware.
Ostergaard et al.  made little comment about reconstructing the coronoid process, possibly because, as Papatheodorou et al.  observed, “terrible triad injuries with Type I and II coronoid process fractures can be effectively treated without fixation of coronoid fractures when repair or replacement of the radial head fracture and reconstruction of the lateral ulnar collateral ligament complex sufficiently restores intraoperative stability of the elbow through a functional range of motion.” Ostergaard et al.  have stimulated all surgeons to focus on improving their own results by improving stability of the radial side of the elbow with either better fixation or better prosthetic replacement, protecting the ulnar nerve, avoiding elbow stiffness by encouraging early mobilization, and using low-profile internal fixation that will reduce postoperative symptoms.
Where Do We Need To Go?
Accurate and stable reconstruction of the radial head and neck is important. Good stability is needed to allow early movement. Ostergaard et al.  did not discuss the use of acute radial head replacement because different designs of radial head prostheses (loose fitting with a smooth stem, press fit, or cemented) were introduced and discarded while their study was performed. We know from recent publications that radial head prostheses have a high failure rate [4, 12]. Even with anatomically improved radial head prosthetic designs, there are still problems with implanting them accurately and at the correct length . Future studies need to explore better-shaped prosthesis that have reliable fixation to bone and are reliably implanted at the correct length and rotation.
The ulnar nerve should be respected and protected, but it is often difficult to do this correctly during the surgical treatment of TTIs. Jupiter et al.  and Blonna and O’Driscoll  emphasized the importance of wide exposure and release of the ulnar nerve during the primary operation, and we should consider their advice in order to reduce this complication. Investigations into whether identifying the ulnar nerve earlier using nerve stimulators together with exploring more gentle methods of releasing the nerve are required.
Postoperative elbow stiffness can be reduced or eliminated by early mobilization from Day 1 after surgery. The evidence over the past 10 years is that this is best achieved by ensuring that full ROM is demonstrated at the end of the reconstruction procedure and that the reconstruction is sufficiently strong to allow ROM exercises to start on Day 1. However, stiffness because of progressive radiocapitellar arthritis and instability has been less appreciated and is associated with radial head prostheses. Stiffness continues to be a challenging problem, but it is less likely to occur if the native radial head remains in place. Liu et al.  performed a study of 22 patients who underwent surgical treatment of TTIs of the elbow. Fracture union and concentric reduction of the ulnotrochlear and radiocapitellar articulations were achieved in all patients. However, at the follow-up interval, radiographic signs of post-traumatic arthritis were seen in six patients. We now need to explore whether biological methods to aid healing of the capitellar articular surface can be introduced at the time of the primary surgery.
Another issue is symptomatic hardware. The designs of plates and screws have been transformed over the past 20 years to allow us to use screws with heads that can be placed flush with the underlying bone and low profile plates that protrude minimally from the overlying bone. When wires are used, their knots should always be buried, if possible, into bone. Sometimes a compromise must be made intraoperatively and the surgeon might realize that the implants are too prominent and will require early removal, but this should be avoided if at all possible. We now all have a responsibility to provide feedback to implant manufacturers about how they can improve their products so that we can avoid post-implant symptoms, and some of us should collaborate with the manufacturers in designing better implants.
How Do We Get There?
Because there are insufficient numbers of TTIs to design a prospective randomized trial, we need to focus on improving what we currently do not do well.
More-innovative ways of enhancing bone stability of the lateral column of the elbow are required. Are innovative devices, such as an expanding intramedullary implant that could improve fixation of the radius (expanding foams are now used in the building industry), being developed? Is there a biologically appropriate human solution that is better than the current bone-graft pastes?
A new technique of reproducing the proximal radius is by three dimensional printing a mirror image of the opposite radius; is this possible in the future to replace the proximal radius?
Better ways of strengthening repair of the lateral collateral ligament complex are required, and polyester devices to facilitate this have been developed and are already in use.
Are there better ways of tracking the ulnar nerve, perhaps using ultrasound, so that we are less likely to injure it? Additionally, having tracked the nerve, can we use better instruments such as lasers designed to reduce the risk of nerve injury during surgical release?
Regarding stiffness, I thought continuous passive motion was going to improve management, but it has been disappointing. We need to explore whether smartphone applications that help with rehabilitation can be used to encourage our patients to maximize their postoperative elbow mobilization; these applications have already been developed. We need to biologically enhance articular cartilage healing, particularly for the capitellum, and this is currently being investigated in biolaboratories.
Finally, how can we better fix bone with lower-profile implants? One day someone is going to design a biologically compatible Chinese finger trap (Fig. 1) device that will encircle, compress, and stabilize the bone fragments after application in a very low profile way. I would love to be the inventor of such a device.
Before starting treatment, patients need to be warned that this injury is associated with a high complication rate and that one-third of those treated surgically later undergo further operations. Later operations include removal of heterotopic ossification and coronoid reconstruction using a radial head autograft, iliac crest autograft, olecranon autograft, allograft, or prosthetic replacement .
Finally, we should address the surgical team performing the surgery. If an upper limb surgeon sees a TTI and decides that reconstruction should be performed, is this surgeon the right person for the job? If a surgeon identifies radial head and neck injuries and coronoid fractures on radiographs or ligament injuries on MRI and his or her reaction is, “this is the worst injury I have ever seen or treated,” perhaps this is not the operation for this particular surgeon to take on. If the surgeon refers the patient to a team with more experience, it is likely that the patient will be eternally grateful and the surgeon will not lose sleep at night worrying about the outcome of a procedure that became too challenging while performing the operation.
1. Bellato E, O'Driscoll SW. Management of the posttraumatic coronoid-deficient elbow. J Hand Surg Am. 2019;1:400-410.
2. Blonna D, O'Driscoll SW. Delayed-onset ulnar neuritis after release of elbow contracture: preventive strategies derived from a study of 563 cases. Arthoscopy. 2014;1:947-956.
3. Chen H, Shao Y, Li S. Replacement or repair of terrible triad of the elbow: a systematic review and meta-analysis. Medicine. 2019;98:e13054.
4. Cristofaro CD, Carter TH, Wickramasinghe NR, McQueen MM, White TO, Duckworth AD. High risk of further surgery after radial head replacement for unstable fractures: longer-term outcomes at a minimum follow-up of 8 years. Clin Orthop Relat Res. 2019;477:2531-2540.
5. Jeong WK, Oh JK, Hwang JH, Hwang SM, Lee WS. Results of terrible triads in the elbow: the advantage of primary restoration of medial structure. J Orthop Sci. 2010;15:612-619.
6. Jupiter JB, O'Driscoll SW, Cohen MS. The assessment and management of the stiff elbow. Instr Course Lect. 2003;1:93-111.
7. Leigh WB, Ball CM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg. 2012;21:1336-1341.
8. Liu G, Hu J, Ma W, Li M, Xu R, Pan Z. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach. J Int Med Res. 2018;46:3053-3064.
9. Ostergaard PJ, Tarabochia MA, Hall MJ, Dyer G, Earp BE, Blazar P, Zhang D. What factors are associated with reoperation after operative treatment of terrible triad injuries? Clin Orthop Relat Res. 2021;479:119-125.
10. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Clin Orthop Relat Res. 2014;472:2084-2091.
11. Shukla DR, Vanhees MKD, Fitzsimmons JS, An KN, O'Driscoll SW. Validation of a simple overlay device to assess radial head implant length. J Hand Surg Am. 2018;1:1135.e1-1135.e8.
12. Somerson JS, Matsen FA 3rd. Timely recognition of total elbow and radial head arthroplasty adverse events: an analysis of reports to the US Food and Drug Administration. J Shoulder Elbow Surg. 2019;28:510-519.
13. Watters TS, Garrigues GE, Ring D, Ruch DS. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Clin Orthop Relat Res. 2014;472:2128-2135.
14. Yan M, Ni J, Song D, Ding M, Liu T, Huang J. Radial head replacement or repair for the terrible triad of the elbow: which procedure is better? ANZ J Surg. 2015;85:644-648.