Rev. bras. ortop. vol.49 número4

w w w . r b o . o r g . b r

Original

Article

Terrible

triad

of

the

elbow:

influence

of

radial

head

treatment

夽

,

夽夽

Lucas

Braga

Jaques

Gonc¸alves

_,

_Jorge

_de

_Almeida

_e

_Silva

_Neto

_,

Mario

Roberto

Chaves

Correa

Filho

_,

_Ronaldo

_Percope

_de

_Andrade

_,

Marco

Antônio

Percope

de

Andrade

_,

_Anderson

_Humberto

_Gomes

_,

José

Carlos

Souza

Vilela

a_{Servic¸odeOmbroeCotovelo,HospitalMadreTeresa,BeloHorizonte,MG,Brazil}

b_{Servic¸odeOrtopedia,HospitaldasClínicas,UniversidadeFederaldeMinasGerais(UFMG),BeloHorizonte,MG,Brazil}

c_{Servic¸odeOrtopediaeMedicinadoEsporte,HospitalUnimed,BeloHorizonte,MG,Brazil}

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Articlehistory:

Received16May2013 Accepted30August2013 Availableonline11July2014

Keywords:

Dislocations Elbowjoint Radialfractures

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b

s

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Objective:totestthenullhypothesisthatpatientswiththeterribletriadoftheelbow

(dislo-cationtogetherwithfracturesoftheradialheadandcoronoidprocess)whoaretreatedwith openreductionandinternalfixationoftheradialheadhavefinalresultsthatarecomparable withthoseofpatientstreatedwitharthroplastyorpartialresectionoftheradialhead.

Methods:twenty-sixpatientswiththeterribletriadoftheelbowwhowereoperatedbya

singlesurgeonwereevaluatedonaverage23monthsafterthesurgery(range:16–36months). Therewere17menandninewomenofmeanage41±13.4years.Thefracturesoftheradial headweretreatedbymeansofosteosynthesis(12patients),arthroplasty(nine)orresection ofasmallfragmentornotreatment(five).Fixationofthecoronoidprocess/anteriorcapsule wasperformedin21patients.Thelateralligamentcomplex(LLC)wasrepairedinallthe patients,whilethemedialligamentcomplex(MLC)wasrepairedinthreepatientswhose elbowsremainedunstableaftertreatmentfortheradialheadandLLC,butwithoutfixation ofthecoronoidprocess.

Results:themeanfinalrangeofflexionandextensionwas112◦_{.Themeanpronationwas}

70◦_{andsupination,6}◦_{.ThemeanDASHscore(DisabilitiesoftheArm,Shoulder&Hand)} was12andmeanMEPI(MayoElbowPerformanceIndex)was87.AccordingtotheMEPI scores,21patients(80%)hadgoodandexcellentresults.Therewasnostatisticallysignificant differenceintheresultsbetweenthepatientswhounderwentfixationoftheradialhead andthosewhounderwentarthroplastyorresectionofasmallfragment.

Conclusion:therewasnodifferencebetweenthepatientstreatedwitharthroplastyofthe

radialheadandthosetreatedwithothertechniques.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

夽

Pleasecitethisarticleas:Gonc¸alvesLBJ,NetoJAS,CorreaFilhoMRC,deAndradeRP,deAndradeMAP,GomesAH,etal.Tríadeterrível docotovelo:ainfluênciadotratamentodacabec¸adorádio.RevBrasOrtop.2014;49:328–333.

夽夽

WorkperformedatHospitalMadreTeresaandHospitalUnimed,BeloHorizonte,MG,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](J.C.S.Vilela). http://dx.doi.org/10.1016/j.rboe.2014.07.001

Tríade

terrível

do

cotovelo:

a

influência

do

tratamento

da

cabec¸a

do

rádio

Palavras-chave:

Luxac¸ões

Articulac¸ãodocotovelo Fraturasdorádio

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e

s

u

m

o

Objetivo:testarahipótesenuladequeospacientescomatríadeterríveldocotovelo(luxac¸ão

associadaa fraturasdacabec¸adorádioedoprocessocoronoide)tratadoscomreduc¸ão abertaefixac¸ãointernadacabec¸adorádiotêmresultadofinalcomparávelaospacientes tratadoscomartroplastiaouressecc¸ãoparcialdacabec¸adorádio.

Métodos: foramavaliados,emmédiaaos23meses(16a36)apósacirurgia,26pacientes

coma tríadeterríveldocotovelooperados por umúnicocirurgião.Eram17 homense novemulheres,commédiadeidadede41anos(±13,4).Asfraturasdacabec¸adorádio foramtratadascomosteossíntese(12pacientes),ouartroplastia(nove),ouressecc¸ãodeum fragmentopequenoounenhumtratamento(cinco).Fixac¸ãodoprocessocoronoide/cápsula anteriorfoifeitaem21pacientes.Ocomplexoligamentarlateral(LCL)foireparadoem todosospacientes,enquantoqueocomplexoligamentarmedial(LCM)foireparadoemtrês pacientescujoscotovelospersistiaminstáveisapósotratamentodacabec¸adorádioedo LCL,massemfixac¸ãodoprocessocoronoide.

Resultados: oarcofinalmédiodeflexãoeextensãofoide112◦_{.Apronac¸ãomédiafoide}

70◦_{easupinac¸ão,de6}◦_{.OescoreDash(DisabilitiesofArm,Shoulder&Hand)médiofoi} de12eoMepi(MayoElbowPerformanceIndex)médiofoide87.DeacordocomoMepi,21 pacientes(80%)tiverambonseexcelentesresultados.Nãohouvediferenc¸aestatisticamente significativaentreosresultadosdospacientessubmetidosafixac¸ãodacabec¸adorádioe aquelessubmetidosaartroplastiaouressecc¸ãodeumfragmentopequeno.

Conclusão: nãohádiferenc¸aentreospacientestratadoscomaartroplastiadacabec¸ado

rádiodaquelestratadoscomoutrastécnicas.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Injuriesthatinvolvedislocationoftheelbowinassociation withfracturingoftheradialheadandfracturingofthe coro-noidprocessarereferredtoastheterribletriadoftheelbow.1 Historically,theseinjurieshavebeendifficulttodealwithand theresultsfrom treatmenthavebeenunsatisfactorydueto instability,arthrosisand/orstiffnessoftheelbow.2,3_The diffi-cultyintreatingthisinjurypatternhasbeenascribedtolackof knowledgeregardingtheanatomicalfactorsinvolvedinelbow stabilization andthe appropriatesurgicaltechniques. Pugh andMcKee4,5_{describedasystematizedapproachforsurgical} treatmentoftheterribletriadofthe elbow,whichincluded osteosynthesisor arthroplasty ofthe radialhead, repairof thecoronoidwhenpossibleand/orrepairofthejointcapsule, andrepairofthelateralligamentcomplex(LLC)oftheelbow. Theyreportedthat80%oftheirpatientspresentedgoodor excellentresultsandalsothattherevisionratewas15–25%. Sincethen,severalauthorshavepresentedgoodand excel-lentresults(77–100%)fromsurgicaltreatmentoftheterrible triadoftheelbow,inaccordancewiththeprotocolpresented byPughetal.6–14

Thisstudyhadtheobjectiveofevaluatingtheclinicaland radiographicresultsfrom patientswiththeterribletriadof theelbowwho were operatedinaccordancewiththis pro-tocol.Ourhypothesiswasthatthepatientswhounderwent arthroplastyoftheradialheadwouldhaveresultsthatwere comparabletothoseoftheotherpatients.

Methods

Between March 2007and December 2009,32 patients with theterribletriadoftheelbowwerediagnosedandunderwent surgicaltreatmentperformedbythesamesurgeon(LBJG)at HospitalMadreTeresa(HMT)and“RisoletaTolentinoNeves” UniversityHospital(HURTN).Sixpatientswereexcluded:four whocouldnotbefoundandtwowhodidnotadheretothe postoperativefollow-up.Thus,26patientsremainedfor eval-uation(17menandninewomen),withameanageof41years (±13.4). Three were left-handedand 23 were right-handed. Theinjurymechanismswerefallsfromaheightin13cases, motorcycleaccidentsin10casesandbeingrunover,falling offabicycleandbeinginacaraccidentinonecaseeach.The elbowswereoperated,onaverage,ninedays(±5.93)afterthe initialtrauma.Theleftsidewasaffectedin17patients(65%) andrightsideinseven(35%).

The fractures ofthe radialhead were classified astype 4,inaccordance withMason’sclassificationasmodifiedby Johnston.15_{Insixfractures,onlyonefragmentwasidentified} and,infourofthese,therewasananteriorfragment account-ingforlessthan20%ofthejointsurface,whichwasextremely comminuted,withoutthepossibilityoffixation.Fivefractures hadtwofragments,sevenfractureshadthreeandeight frac-tureshadmorethanthree.

Fig.1–A56-year-oldwomanwhosufferedafallfromastandingposition.(A)Lateralandanteroposteriorradiographsprior toreduction,showingposteriordislocationoftheelbowandtype2fracturingoftheradialhead,withacomminuted anteriorfragment.(B)Lateralandanteroposteriorradiographsaftersurgicaltreatment,showingconcentricreductionofthe elbow,despiteresectionoftheanteriorfragmentoftheradialhead.

intothreemaintypes.Type1consistsoffracturesofthetop ofthecoronoidprocess:1Awithfragmentsupto2mmand1B withfragmentslargerthan2mm.Type2fracturesare antero-medialandtype3are atthe baseofthe coronoidprocess. Type1Afracturesofthecoronoidprocesswereidentifiedin 19 patients, and type 1B fractures in the remaining seven patients.

Inall thepatients, injuriestothe lateral ligament com-plexdietoavulsionatitsorigininthelateral condylewere identified. Reinsertion was performed bymeans of a tran-sosseoussutureora4.0metalanchor(HexagonInd.eCom. de AparelhosOrtopédicos Ltda., Campinas, SP)using Ethi-bondno.2thread(Johnson&JohnsondoBrasilLtda.,SãoJosé dosCampos,SP).Reinsertionofthemedialligamentcomplex wasperformedinonlythreepatients,bymeansof4.0metal anchorsandEthibondno.2thread.Thesepatientspresented residualinstabilityaftertreatmentofthefractureoftheradial headandthelateralligamentcomplex.Inthesethreecases, thecoronoidprocess/anteriorcapsulewasnotfixedbecause, duringthepreoperativeassessment,thesurgeonconsidered thesetobeseparateinjuriesthatdidnotcontributetoward theelbowinstability.

Sevenpatientspresentedotherfracturesintheipsilateral upperlimb:twofractures inthe distalradius,onefracture intheulnarstyloid,onefractureinthelateralcondyle,one Stennerinjuryinthethumb,onefractureofthemetacarpal andonerotatorcuffinjuryintheshoulder.Withthe excep-tionoftherotatorcuffinjury,alltheotherswerefixedduring thesameoperation,inordertoaccelerateelbowrehabilitation duringthepostoperativeperiod.

Inall the patients, auniversal posteriorincision inthe elbowwas made,withlateral subcutaneouspushback until theelbowwascompletelyexposedlaterally.TheKocher inter-val was exploredusing the spacing alreadydefined bythe lateralligamentinjury,inordertoobtainaccesstotheelbow joint.After the joint had been exposed, the coronoid pro-cesswasdealtwithfirst.In12patients,transosseoussuturing ofpull-outtypewasperformed,whichincludedtheanterior jointcapsule andthe fragmentofthe coronoidprocess.In onepatient, thesuturingwasperformedbymeans ofa4.0 metalanchorthatwasinsertedintotheproximalulna.Ineight patientswhoallhadtype1Bfracturesofthecoronoidprocess,

osteosynthesisofthefracturedbonefragmentofthecoronoid processwasperformedusingacannulatedscrewaloneintwo cases, cannulatedscrew and Kirschnerwiresin twocases, cannulatedscrewandtransosseoussuturingofthecapsule inonecase,Kirschnerwiresandtransosseoussuturingintwo casesandKirschnerwiresaloneinonecase.Infivepatients, norepairtothecoronoidprocesswasperformed,because dur-ingthepreoperativeassessment,thesurgeonconsideredthat thesewereseparateinjuriesthatdidnotcontributetoward theelbowinstability.

The radial head was dealt with next. For four patients whopresentedananteriorfragmentaccountingforlessthan 20%ofthejointsurface,whichwascomminutedanddidnot present any possibilityofreconstruction, it wasdecidedto performsimpleresectionofthefragments,sincetherewas noimpairmentofelbowstabilization(Fig.1).Insixfractures, osteosynthesisusingHerbertscrewswasperformed.Infour cases,KirschnerwireswereusedinadditiontoHerbertscrews. Intwopatients,screwsandplateswereused.Ineightpatients, uncementedarthroplastyoftheradialheadwasperformed usingamonoblockprosthesis(MetaBioIndustrialLtda.,Rio Claro,SP),withthreepossiblesizes,relatingtonecklengthsof 9,12and19mm.Inonepatient,arthroplastywasperformed usingamethylmethacrylatemoldedprosthesis,whichwas removed eight weeks later. In one patient who presented onlyslightdisplacement,thefracture wasnotsubjectedto osteosynthesis.

Lastly,thelateralligamentcomplexoftheelbowwas rein-sertedatitsisometricpoint,eitherbymeansofmetalanchors or by means oftransosseous suturing.The stabilityof the elbowwastestedthroughfullpassiveextensionoftheelbow inneutralorientation.Followingthis,assistedpassiveflexion of the elbowwas performed, with the aimof testing con-centric stability over the entirerange of motion(ROM). In threepatients,residualposteriorsubluxationwasobserved:in thesecases,themedialligamentcomplexwasrepairedusing a4.0anchorandEthibondno.2thread,andjointstabilitywas reestablishedovertheentireROM.Therewasnoneedforan articulatedexternalfixatorinanypatient.

Afterthesurgery,theelbowwasimmobilizedforoneweek at90◦_{offlexionandinpronation,usingaplaster-castsplint.}

Fig.2–A54-year-oldwomanwhosufferedafallfromastandingposition.(A)Lateralradiographpriortoreduction, showingposteriordislocationoftheelbowandfracturingoftheradialhead.(B)Lateralradiographafterreduction,showing comminutivefracturingoftheradialheadandfracturingofthecoronoid.C1andC2:lateralandanteroposteriorradiographs showingconcentricreductionoftheelbow,theradialheadprosthesisandthelateralmetalanchor.D1,D2,D3andD4: clinicalresultsfromfinalfollow-up.

advised to start a home-based program for early gains in ROM,whichconsistedofactiveflexionandextensionofthe elbow(extensionwiththeelbowpronated),alongwith pas-sivepronation-supinationofthe elbowwhileflexedat90◦_.

Thisprogramwascontinuedforsixweeksand,duringthis period,thepatientswereinstructednottoperformabduction oftheshouldergreaterthan60◦_{,orabductionwiththe}

shoul-derflexedat90◦_{,inordertoavoidvarusstressontheligament}

reconstruction, asrecommended byDuckworthet al.17 _Six weekslater,thepatientswerereferredforphysiotherapyand rehabilitationoftheoperatedlimbwasstartedunder super-vision.

Postoperativecontrolswereconductedinthe1st,2ndand 6th weeksand inthe 3rd, 6th and 12th months.Pain was assessed using a visual analog scale,ROM by means of a goniometer and stability through clinical tests (pivot shift and drawer) and radiograph imaging, in terms of concen-tricreductionsobservedinanteroposterior (AP)and lateral views.Theconsolidationofthefracturesandpresenceof het-erotopicossificationanddegenerative alterationswere also assessed.

Thefinalevaluationonthepatientswasmadebyaproperly trainedshoulderandelbowsurgeryspecialistandconsisted of application of the DASH18 _{and MEPI}19 _{questionnaires,} measurementoftheROM,assessmentofjointstability, inves-tigationofcomplicationsandothersurgicalproceduresinthe sameelbow,andevaluationofAPandlateral-viewradiographs inordertoinvestigatecalcificationaroundtheligament inser-tions,heterotopicossificationanddegenerativealterationsof theelbow.Thesealterationswereclassifiedinaccordancewith thecriteriaofBrobergandMorrey19_{:grade0(absence;i.e.} nor-malelbow);grade1(mild;jointnarrowingaloneandminimal formationofosteophytes);grade2(moderate;moderatejoint

narrowingandmoderateformationofosteophytes);grade3 (severe;severenarrowingandjointdestruction).

ThevariableswereanalyzedusingFisher’stestandvalues wereconsideredtobesignificantwhenp<0.05.

Results

Thefinalevaluationwasmadeafteranaveragepostoperative periodof23months(range:12–36).Thefinalmeanflexed con-tracturewas20◦_(±13.70◦_{),witharangefrom0}◦_to40◦_(Fig.2).

Thefinalmeanflexionwas132◦_(±13.20◦_{),witharangefrom}

90◦_to150◦_{.ThefinalmeanROMwas112}◦_(±24.29◦_).Themean

pronationwas70◦_(±18.34◦_{),witharangefrom0}◦_to80◦_.The

meansupinationwas63◦ _(±19.92◦_{),witharangefrom0}◦ _to

80◦_.

Themean DASHwas12(±15.36),witharangefrom0to 44.ThemeanMEPIwas87(±14.34),witharangefrom50to 100.TheindividualMEPIanalysisshowedthattherewere12 excellent,ninegood,fourfairandonepoorresult,i.e.80%of thepatientspresentedsatisfactoryresults.Theradiographic evaluationshowedthattherewerenodegenerativealterations in14 patients(54%),whilenine patientspresentedgrade1 alterations,onegrade2andnonegrade3.Inthecasesoftwo patients,noupdatedradiographicassessmentwaspossible.

Amongtheeightpatientswhoreceivedaradialhead pros-thesis,four(50%)presentedaflexion-extensionrangeofless than100◦_{.Inthegroupof17patientswhoseradialheadswere}

reconstructed,onlythree(17%)hadaflexion-extensionrange oflessthan100◦_{.However,thesevalueswerenotstatistically}

osteosynthesis.However,thesevalueswerenotstatistically significant (p=0.208). In this evaluation, the patient who underwent arthroplasty ofthe radial head using a methyl methacrylate molded prosthesis, which was subsequently removed, was excluded from the comparative analysis, despitepresentingMEPIof85◦_{andaflexion-extensionrange}

of150◦_.

Complications

Noneofthepatientspresentedanyinfections,dehiscenceof theoperativewoundorneurovascularlesions.Fivepatients hadcomplicationsthatrequiredsurgicaltreatment.One pre-sented avascularnecrosis and pseudarthrosisof the radial head and underwent removal of the synthesis material togetherwiththebonefragmentsfromtheradialhead,three monthsaftertheindexsurgery.Fourpatientsdevelopedelbow jointstiffness.Ofthese,twopresentedanteriorheterotopic ossificationandthreehadundergoneradialheadarthroplasty. Allofthemunderwentsurgicalreleaseoftheelbowin asso-ciationwith removaloftheradialhead prosthesisand the heterotopic ossification, in the cases in which these were present. In one patient, two osteocapsular releases of the elbowwereperformed.Oneofthepatientsdeveloped proxi-malradioulnarsynostosisafterremovaloftheprosthesis,and subsequentlyunderwenttheKaminemi–Morreyprocedure,20 buttherewasnogaininpronation-supination,becauseofthe neoformationofsynostosis.Thispatientrefusednewsurgery.

Discussion

Historically,publishedpapersontreatmentoftheterribletriad weresparse,presentedsmallcaseseriesandhaddifferent sur-gicalorconservativeapproaches.Allofthempresentedpoor resultsfromtreatmentsforthistypeofinjury.2,3,19

Recently,severalstudiesandinvestigationshaveprovided better understanding ofthe biomechanics and stability of theelbowandoftheinteractionsbetweenthesefactors21–28 and have contributed toward publication ofbetter surgical resultsfrom this injury. Pugh et al.4,5 _{described a} system-atizedapproachforsurgicaltreatmentoftheterribletriadof theelbow,whichincludedosteosynthesisorarthroplastyof theradialhead,repairofthecoronoidifpossibleand/orthe jointcapsule,andrepairofthelateral ligamentcomplexof theelbow,alongwithmakingrepairstothemedialcollateral ligamentandusingexternalfixatorsfortheelbowinselected cases.Theseauthorsdemonstratedgoodandexcellentresults inmostoftheirpatientsandalsopresentedarevisionrate of15–25%.Subsequently,severalstudiespresentedconsistent andreproducibleresultsthroughusingthesamesystematized approach,withproportionsofgoodandexcellentresultsof 77–84%.6,9,13

Our study confirms the results from these morerecent studies and reinforces the reproducibility of satisfactory resultsamongpatientswhoundergotheapproachproposed byPughetal.Amongourpatients,80%presentedgoodand excellentresults,withameanMEPIof87pointsandamean DASH of 12. Nonetheless, 38% presented some degree of degenerative alterations, even though most of these were

mild,whichsupportsthenotionthatasubtledegreeofjoint instabilitypersists.Thiswouldgiverisetopoorfunctioning of the joint,witha consequent early start to degenerative alterationsinsomeoftheseelbows.Alongerfollow-upperiod wouldbeneededtoevaluatetheprogressionofthese degen-erativealterationsandtheirpossibleclinicalrepercussions.

Our null hypothesiswas corroborated.Although several papers have emphasized the importance oftrying to con-stitute the radiocapitellar joint anatomically or as closeto thisaspossible,therearenostudiesthathavecomparedthe resultsfromarthroplastyoftheradialheadwithother tech-niquesfortreatingtheterribletriad.VanGlabbeeketetal.29 describedtheimportanceofrestoringthelengthoftheradius afterarthroplastyoftheradialhead,inelbowswithinjuriesto themedialcollateralligament.Theseauthorsrecommended thatreplacementoftheradialheadshouldbedonewiththe sameaccuracyandreproducibilityregardingthepositionsof thecomponentsasinanyotherarthroplasty.Charalambouset et al.30 _{suggestedthatosteosynthesis oftheradialheadin} patients withmedialcollateral ligament injuriespresented resultsthatweresuperiortothoseofarthroplastyand exci-sionoftheradialhead,withregardtothevarusstabilityof theelbow.Theradialheadprosthesisthatwehadavailableto uswasmodular,withjustthreesizepossibilities,allrelated tothenecklength:9mm,12mmand19mm.Therewereno variationsinthesizeoftheradialhead,thenailorthe bipo-larity.Thus,thisprosthesishastheprimaryfunctionofacting asaspacerandenablingadequatehealingofthesofttissues after the operation. We imagined that although this pros-thesiswouldbeunabletoreestablishtheradiocapitellarand proximalradioulnarjointsmoreprecisely,patients undergo-ingarthroplastyoftheradialheadwouldhaveresultssimilar tothosewhounderwentothertreatments.Incomparingthese groups, wedid notfindany statisticallysignificant results. Thus,webelievethatiftreatmentoftheradialheadis cho-sen, theresected radialhead shouldbereplacedbyarigid spacer, whichcould beametalprosthesisoraradialhead moldedfrommethylmethacrylate,aswasdoneinoneofour patients,untiladequatehealingofthesofttissueshasbeen achieved. Clearly, this isa conclusionfrom ashort follow-up andwithasmall groupofpatients, whichweakens the statisticalanalysis.Alongerfollow-upisnecessaryinorder demonstratewhetherthe“non-anatomical”reconstructionof theradialheadmighthaveconsequencesfortheelbow.

Thisstudypresentssomelimitations.Itwasa retrospec-tiveobservationalstudy withashortaveragefollow-up (23 months).Thisshortfollow-upmadeitimpossibletocorrectly assesstheincidence,progressionandclinicalrepercussions of secondary degenerative osteoarthrosis, which is one of themostfearedanddifficult-to-treatlatecomplications.The smallnumberofpatientsineachgroupevaluatedalso weak-enedthefinalanalysisofourhypothesis.

Conclusion

withosteosynthesisoftheradialheadandthosetreatedwith arthroplastyoftheradialheadorresectionofafragment.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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