Terrible Triad Injuries of the Elbow -...

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CURRENT CONCEPTS Terrible Triad Injuries of the Elbow Neal C. Chen, MD, * David Ring, MD, PhD* The treatment of terrible triad injuries of the elbow continues to evolve. Radial head xation and arthroplasty, coronoid process xation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. In the elbow with persistent instability after repair of these elements, application of a static external xation, hinged external xation, ulnohumeral joint pinning, or an internal hinge may be needed. In patients who undergo treatment after the acute injury period, the coronoid may require reconstruction using radial head autograft, iliac crest autograft, olecranon autograft, or allograft. (J Hand Surg Am. 2015;40(11):2297e2303. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Terrible, triad, elbow, fracture, instability. T HE TERRIBLE TRIAD OF THE ELBOW is posterior or posterolateral dislocation of the ulnohumeral joint with fractures of the radial head and coronoid process. The origins of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) complexes avulse from the epicondyles and the anterior capsule fails with a transverse fracture of the coronoid tip. The treatment of terrible triad injuries has evolved over the last decade. There is a consensus that the radial head injury and the LCL injury should be addressed, but there are differing opinions as to whether the radial head should be repaired or replaced, when the coro- noid fracture should be addressed, or if the MCL re- quires repair. In addition, there has been an evolution in the late treatment of terrible triad injuries. This current concepts article focuses on these 2 areas of development. CLINICAL PICTURE In general, terrible triad injuries are the result of a fall onto an outstretched hand. It is postulated that there is a posterolateral load upon the elbow during the fall, which results in tension failure of the LCL and the MCL, and a compressive load that fractures the radial head. Some circumstantial evidence supports this concept. Patients generally present with pain, swelling, and limited range of motion of the elbow. Patients may or may not describe a subluxation or dislocation event. Although neurovascular injuries are uncommon after this injury, ulnar neuropathy and radial nerve palsy have been described after surgical treatment of these injuries. DIAGNOSIS Radiographs of terrible triad injuries can be deceptive. In some cases, the elbow is reduced and there are small fragments of bone anterior to the ulnohumeral joint on a lateral radiograph and a radial head/neck fracture is noted on the anteroposterior view. The small triangular anterior fragment is a piece of the fractured coronoid tip and is a sign that a more sub- stantial injury has occurred. Computed tomography scans are helpful for preoperative planning, especially for understanding the complexity of the radial head/ neck fracture and the size of the coronoid fracture. TREATMENT AND OUTCOMES Upon presentation, if the ulnohumeral joint is dis- located, it should be reduced. In cases in which the elbow is unstable and re-dislocates easily, surgery is From the *Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA. Received for publication April 8, 2015; accepted in revised form April 25, 2015. D.R. reports receiving grants from Skeletal Dynamics; royalties from Wright Medical; personal fees from Biomet, Acumed, universities and hospitals, and lawers; stock options from Illuminos; speaking honoraria from other universities and hospitals; and personal fees from being a deputy editor for Journal of Hand Surgery and Clinical Orthopaedics and Related Research. Corresponding author: David Ring, MD, PhD, Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, 55 Fruit St., Yawkey 2C, Boston, MA 02114; e-mail: [email protected]. 0363-5023/15/4011-0033$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.04.039 Ó 2015 ASSH r Published by Elsevier, Inc. All rights reserved. r 2297 Current Concepts

Transcript of Terrible Triad Injuries of the Elbow -...

From the *Department of Orthopaedic Surgery, Hand and UppMassachusetts General Hospital, Boston, MA.

Received for publication April 8, 2015; accepted in revised form A

D.R. reports receiving grants from Skeletal Dynamics; royalties fpersonal fees from Biomet, Acumed, universities and hospitals, andfrom Illuminos; speaking honoraria from other universities and hofees from being a deputy editor for Journal of Hand Surgery and ClinRelated Research.

Corresponding author: David Ring, MD, PhD, Department of Orthoand Upper Extremity Service, Massachusetts General Hospital, 55Boston, MA 02114; e-mail: [email protected].

0363-5023/15/4011-0033$36.00/0http://dx.doi.org/10.1016/j.jhsa.2015.04.039

CURRENT CONCEPTS

Terrible Triad Injuries of the Elbow

Neal C. Chen, MD,* David Ring, MD, PhD*

The treatment of terrible triad injuries of the elbow continues to evolve. Radial head fixationand arthroplasty, coronoid process fixation, and repair of the lateral collateral ligamentcontinue to be the mainstays of treatment. In the elbow with persistent instability after repair ofthese elements, application of a static external fixation, hinged external fixation, ulnohumeraljoint pinning, or an internal hinge may be needed. In patients who undergo treatment after theacute injury period, the coronoid may require reconstruction using radial head autograft, iliaccrest autograft, olecranon autograft, or allograft. (J Hand Surg Am. 2015;40(11):2297e2303.Copyright � 2015 by the American Society for Surgery of the Hand. All rights reserved.)Key words Terrible, triad, elbow, fracture, instability.

T HE TERRIBLE TRIAD OF THE ELBOW is posterior orposterolateral dislocation of the ulnohumeraljoint with fractures of the radial head and

coronoid process. The origins of the medial collateralligament (MCL) and lateral collateral ligament (LCL)complexes avulse from the epicondyles and theanterior capsule fails with a transverse fracture of thecoronoid tip.

The treatment of terrible triad injuries has evolvedover the last decade. There is a consensus that the radialhead injury and the LCL injury should be addressed,but there are differing opinions as to whether the radialhead should be repaired or replaced, when the coro-noid fracture should be addressed, or if the MCL re-quires repair. In addition, there has been an evolutionin the late treatment of terrible triad injuries. Thiscurrent concepts article focuses on these 2 areas ofdevelopment.

er Extremity Service,

pril 25, 2015.

rom Wright Medical;lawers; stock optionsspitals; and personalical Orthopaedics and

paedic Surgery, HandFruit St., Yawkey 2C,

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CLINICAL PICTUREIn general, terrible triad injuries are the result of a fallonto an outstretched hand. It is postulated that there is aposterolateral load upon the elbowduring the fall,whichresults in tension failure of the LCL and theMCL, and acompressive load that fractures the radial head. Somecircumstantial evidence supports this concept.

Patients generally present with pain, swelling, andlimited range of motion of the elbow. Patients may ormay not describe a subluxation or dislocation event.Although neurovascular injuries are uncommon afterthis injury, ulnar neuropathy and radial nerve palsyhave been described after surgical treatment of theseinjuries.

DIAGNOSISRadiographs of terrible triad injuries can be deceptive.In some cases, the elbow is reduced and there aresmall fragments of bone anterior to the ulnohumeraljoint on a lateral radiograph and a radial head/neckfracture is noted on the anteroposterior view. Thesmall triangular anterior fragment is a piece of thefractured coronoid tip and is a sign that a more sub-stantial injury has occurred. Computed tomographyscans are helpful for preoperative planning, especiallyfor understanding the complexity of the radial head/neck fracture and the size of the coronoid fracture.

TREATMENT AND OUTCOMESUpon presentation, if the ulnohumeral joint is dis-located, it should be reduced. In cases in which theelbow is unstable and re-dislocates easily, surgery is

015 ASSH r Published by Elsevier, Inc. All rights reserved. r 2297

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recommended to maintain a congruent elbow joint. Incases in which the elbow joint stays grossly congruentafter reduction, operative intervention can maximizeelbow function and prevent residual instability. Pa-tients with a stable elbow after reduction may beconsidered for nonsurgical treatment, but stability andfinal elbow function after nonsurgical treatment maynot be predictable. The residual instability resultsbecause the malunited radial head does not provide anadequate buttress to the elbow; subsequently, the softtissues heal at a different length.

Radial head repair versus arthroplasty

For terrible triad injuries, repair or replacement of theradial head helps prevent re-dislocation by restoringradiocapitellar contact. Radial head fracture fixationversus replacement is dictated in part by the numberand character of the fracture fragments.1 Fixation ofradial head fractures with more than 3 parts (shaft and2 articular fragments) is prone to early failure offixation, nonunion, and limited forearm rotation whenthe fracture heals.1

If secure and stable fixation of the radial headcannot be achieved, the radial head should bereplaced with a prosthesis. This determination is amatter of judgment. There is variation of opinionamong surgeons in determining how many fracturefragments are present when utilizing 3-dimensionalcomputed tomography2 scan and even after operativevisualization of the fracture.3 Although surgeonsoften dread discarding intact radial head in the settingof partial articular fractures, some partial radial headfractures have small fragments and comminution atthe fracture margin that can difficult to repair.4 Inaddition, partial articular fractures tend to involve theanterolateral part of the radial head that is critical toelbow stability.5 Failure of radial head fixation withindays risks subluxation or dislocation of the elbow. Ifthe fixation is adequate for 3 to 4 weeks, the repairedradial head may serve as a biological spacer that canbe excised later if it becomes symptomatic.

Watters et al6 compared 39 patients with terribletriad injuries who were treated with either openreduction internal fixation (ORIF) of the radial heador radial head arthroplasty. Three of 9 patients whounderwent ORIF had instability of the elbow 18months after surgery compared with 1 of 30 patientswho had radial head arthroplasty. In a retrospectivecomparison, Leigh and Ball7 found that patients withterrible triad injuries who underwent radial headarthroplasty had slightly, but significantly, higheraverage Disabilities of the Arm, Shoulder, and Handscores indicating more disability than patients who

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underwent ORIF (10.3 vs 9.2), a difference unlikelyto be clinically meaningful and possibly due to se-lection bias.

Fixed monopolar, fixed bipolar, and loose smoothmonopolar spacer prosthetic radial head designs areavailable. There are some biomechanical data sug-gesting that bipolar arthroplasty provides less ulno-humeral stability than the other designs.8 In the nativeradial head or monopolar arthroplasty, as the radiusbegins to displace posteriorly with respect to thecapitellum, there is an increased resistance to poste-rior ulnohumeral subluxation; however, in bipolararthroplasties, posterior displacement of the radius isassociated with decreased resistance to ulnohumeralsubluxation. Bipolar arthroplasties are associatedwith osteolysis around the stem.9 Monopolar spacerarthroplasties with an unfixed stem are associatedwith radial neck lucency and capitellar changes,10

although these radiographic findings do not corre-late with symptoms. Fixed monopolar arthroplastiesare associated with stress shielding around the radialneck of well-fixed stems, although—again—thesefindings are not associated with symptoms.11

When resources are limited, a loose monoblockprosthesis can be fashioned from methylmethacrylatecement. Sometimes, a screw is used to help make theneck of the prosthesis. Cement is inexpensive and acement spacer helps stabilize the elbow as well as ametal spacer.

The major issue with all radial head arthroplastydesigns is a prosthesis that is too long: so-called“overstuffing” of the radiocapitellar joint. A pros-thesis that is too long can be painful. The abnormallength increases radiocapitellar joint pressures,erosion of the capitellum, subluxation of the ulno-humeral joint, and loss of elbow flexion.12 Doornberget al13 have suggested that the lateral edge of thecoronoid is a useful reference point for sizing of theradial head, and in general, the prosthesis should notlie more than 1 mm proximal to this landmark.Rowland and colleagues14 found that a lateral portionof ulnohumeral joint space that is not parallel onanteroposterior postoperative radiographs was not agood indicator of overstuffing. A nonparallel medialjoint space was a better indicator of overstuffing, butimperfect. It seems that overstuffing of the radial headmay not be radiographically apparent until over-lengthening is greater than 6 mm.15

Coronoid fixation

Relevant biomechanics: Studies of the in vitro effect ofcombined injuries to the elbow on rotatory stress and theinfluence of repair or reconstruction of specific injury

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components on elbow stability support the followingconcepts:

1. Medial collateral ligament repair may be able tocompensate for small coronoid deficiency.

Beingessner et al16 evaluated Regan and Morrey typeI coronoid fractures (small fractures of the tip) andMCL insufficiency in an elbow with a prostheticradial head and a competent LCL. In cadavers,repair of a small coronoid fracture did not improvekinematics during valgus gravity loading, and theauthors concluded that MCL repair was a betteroption for adding more stability than repairing asmall coronoid fracture in the treatment of terribletriad injuries.

In a varus posteromedial rotatory instability model,Pollock et al17 evaluated subtypes of anteromedialcoronoid facet fractures exposed to varus and valgusstress. Some anteromedial facet fractures involvethe coronoid tip; with loss of 5 mm of the tip and themedial rim of the coronoid, repair of the LCL couldnot restore elbow stability when exposed to valgusstress. These data might apply to terrible triad in-juries in that coronoid tip injuries greater than 5 mmin size with a repaired or restored radial head andrepaired MCL and LCL complexes may not bestable to valgus forces, whereas fractures less than 5mm could potentially be managed by repair of boththe MCL and LCL in lieu of coronoid fixation.

2. There may be a threshold coronoid deficiency thatresults in instability that cannot be compensatedby radial head arthroplasty and collateral ligamentrepair alone.

Schneeberger et al18 evaluated posterolateral rotatoryinstability resulting from isolated or combinedinjuries of the radial head or coronoid. Removal ofthe radial head in the setting of intact collateralligaments resulted in posterolateral laxity. If 30%of the coronoid was then excised, the elbow dis-located consistently at 60� of elbow flexion, butstability could be restored with implantation of aradial head prosthesis. However, if 50% of thecoronoid was excised, radial head replacement didnot prevent dislocation. When the coronoid wasrepaired and the radial head was replaced, theelbow did not dislocate. Fern et al have also foundthat, with loss of 75% of the coronoid, LCL repairand radial head arthroplasty without repair of thecoronoid do not restore valgus stability.19

Types of coronoid fixation: Fixation of the coronoid tipfracture helps stabilize the elbow and prevent itssubluxation or dislocation. But the fixation techniqueis unfamiliar to some and difficult to perform and the

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need for routine repair of the coronoid fracture isdebated. Papatheodorou et al20 reported on a series of14 terrible triad injuries treated without coronoidrepair. No patients had residual instability, the meanDisabilities of the Arm, Shoulder, and Hand scorewas 14 (range, 0e38), and the mean Broberg-MorreyScore was 90 (range, 70e100), which is consideredan excellent result.

Conversely, this injury pattern acquired its namefrom a predisposition for subluxation and dislocationafter operative treatment, and fixation of the coronoidmay enhance elbow stability and helps minimizethese problems.21,22 It is not currently possible topredict which terrible triad injuries will be problem-atic. Furthermore, the repair sequence should be frominside out: coronoid, radial head, and LCL complex.If the latter 2 alone prove inadequate, then either therepairs need to be taken down to get at the coronoid, aseparate medial exposure will be needed to addresseither the MCL or the coronoid fragment, or theelbow will have to be immobilized with a fixator orcross pins. Based on this rationale, we and othersroutinely repair the coronoid tip fracture.21e23

A number of techniques have been described forcoronoid fixation ranging from transosseous suturefixation (the so-called “lasso” technique), suture an-chor fixation, and screw fixation. Garrigues et al24

compared these 3 techniques and found that trans-osseous suture fixation had the lowest incidence ofsubluxation or dislocation of the elbow among pa-tients evaluated an average of 18 months after sur-gery. Three of 5 patients treated with screw fixationof the coronoid had implant failure and the other 2patients had nonunion.

In situations in which there is a partial articularfracture of the radial head, arthroscopic repair of thecoronoid may be reasonable as lateral access to thecoronoid is limited. Hausman et al25 and Adamset al26 have described arthroscopic coronoid repairusing screws, Steinmann pins, or suture fixationlooped around the ulna. These techniques are stillunder development, but there is some hope that theymay help patients in these situations avoid a medialincision for coronoid repair and allow for earlier re-covery (Figs. 1e5).

Ligament repair

There is consensus that the LCL origin should bereattached to the lateral epicondyle in all elbow in-juries; however, there continues to be somedebate as towhether or not the MCL should be reattached to themedial epicondyle. Forthman et al21 describe 22 pa-tients with terrible triad injuries successfully treated

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FIGURE 1: Radiographs of a 40-year-old man who fell while skiing and sustained a terrible triad injury with coronoid fracture andpartial articular radial head fracture. Arrow 1 points to the coronoid fragment and arrow 2 points to the marginal radial head fracture. ALateral radiograph. B Anteroposterior radiograph.

FIGURE 2: Computed tomography of the same patient demon-strates coronoid fracture.

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with coronoid fixation, radial head repair or replace-ment, LCL reattachment, but no MCL repair. Pughet al22 described an algorithm used in 34 patients inwhich the MCL was repaired if there was residualinstability after addressing the coronoid, radial head,and lateral collateral ligament. Instability was definedas posterior or posterolateral subluxation when theelbow was moved through a range of 20� to 130� ofextension and flexion with the forearm in neutralrotation. Six patients hadMCL repair and, of those 6, 2had external fixation as well. In the series by Papa-theodorou et al,20 the coronoid was not repaired and noattempt was made to repair the MCL or apply anyadjunctive fixation.

Persistent subluxation or dislocation

In patients with persistent subluxation or dislocationafter repairs, adjunct fixation is recommended. Dur-ing surgery, once the injured structures are repaired,the elbow is supported at the upper arm to allowgravity extension of the elbow with the forearm inneutral. Subluxation in this position merits consid-eration of additional treatment: either reattachment ofthe MCL to the epicondyle, hinged external fixation,static external fixation, ulnohumeral joint pinning,or—experimentally–an internal hinge mechanism.The complications of external fixation—including pinbreakage, pin infection, and radial nerve injury—limit its appeal. Concerns about pin breakage, jointinfection, and joint damage limit the appeal of cross-pinning. The incidence of complications is higherwhen external fixation is used than when ulno-humeral joint pinning is used.27

Orbay and Mijares28 described using a temporarySteinmann pin bent and placed through the axis of the

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ulnohumeral joint then attached to the proximal ulnaas an internal hinge device to treat persistent insta-bility of the elbow. An average of 14 months aftersurgery, all 10 patients treated with this technique didnot have subluxation or dislocation. Some mightconsider this technique an alternative to repair of thecoronoid process, but additional research is needed.

COMPLICATIONSComplications of terrible triad surgical treatment in-clude heterotopic ossification, stiffness, nerve injury,and recurrent subluxation or dislocation of the elbow.Because case series are relatively small, it is difficultto estimate the incidence of complications. The most

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FIGURE 3: Arthroscopy-assisted coronoid fixation using cannulated screws and a suture passed through the screws to secure thecoronoid fragment. A The base of the fracture has been prepared, and an external aiming guide is visible in anticipation of guidewireplacement. B Threaded guidewires have been passed into the fracture base. C The coronoid fragment is reduced, and the guidewires areadvanced. D After placement of cannulated screws over the guidewire, a nonresorbable suture has been passed through the cannulatedscrews for additional fixation. After the coronoid was repaired, an open incision was made to repair the partial articular radial headfracture and the lateral collateral ligament.

FIGURE 4: Postoperative radiographs demonstrate this joint congruency. A Lateral radiograph. B Anteroposterior radiograph.

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challenging of these problems is recurrent subluxationor dislocation.

In patients who are treated longer than 2 weeksafter injury, standard repairs are often insufficient tolimit the risk of recurrent dislocation or subluxation.As time elapses, there can be soft tissue changes or

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bony erosion that further limit stability. Patients whoundergo treatment before 6 weeks have better func-tional scores than those patients who undergo treat-ment after 6 weeks.29

The approach to treatment uses similar principlesas in the acute terrible triad injury; however, the main

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FIGURE 5: Clinical images at the 6-week postoperative visit show satisfactory elbow and forearm range of motion. A Elbow flexion. BElbow extension. C Supination. D Pronation.

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difference is reconstruction rather than repair of thecoronoid. In patients in whom the distal humerus issubluxated over the coronoid base, there may beimpaction or loss of bone, making simple repair ofthe coronoid insufficient. In these cases, coronoidreconstruction with bone graft can be considered.Radial head is a preferred graft option if available,30

but in revision cases, radial head may not be availableto be used for repair. Papandrea et al31 have reporteda series of 9 bone allografts, but noted that manyallografts undergo resorption on radiographic follow-up. Olecranon autograft has also been described as agraft by Moritomo et al.32 The harvested autograftshould be less than 50% of the olecranon, and cautionshould be exercised not to disrupt the triceps tendonattachment.

In all late reconstructions of terrible triad injuries,it is almost universally recommended that adjunctfixation using a static external fixator, hinged externalfixator, joint pinning, or internal hinge mechanismshould be utilized.

DISCUSSIONOur understanding of terrible triad injuries is incom-plete. Further biomechanical studies may be helpful inelucidating the relationship between the MCL and thecoronoid in providing stability to the elbow. Futurestudies of in vitro varus loading of the elbow afterterrible triad repair may refine our understanding ofhow to rehabilitate these injuries. In addition, we donot clearly know when radial head fractures can befixed and preserved.

Continued improvement of arthroscopic techniquesto repair the coronoid process may be beneficial intreating injuries with partial articular fractures ofthe radial head as well as patients with posteromedial

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varus rotatory instability. Arthroscopic repair mayallow us to retain the radial head more frequently. Inaddition, with the development of an internal hingedstabilizer, it may be possible to neutralize forces onthe radial head to prevent fixation failure.

Study of the long-term outcomes of these injurieswill be beneficial. Clinical manifestations of osteol-ysis and capitellar wear after radial head arthroplastymay become more prevalent with extended follow-up.

REFERENCES

1. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixationof fractures of the radial head. J Bone Joint Surg Am. 2002;84(10):1811e1815.

2. Guitton TG, Ring D, Science of Variation Group. Interobserverreliability of radial head fracture classification: two-dimensionalcompared with three-dimensional CT. J Bone Joint Surg Am.2011;93(21):2015e2021.

3. Guitton TG, Brouwer K, Lindenhovius AL, et al. Diagnostic accuracyof two-dimensional and three-dimensional imaging and modeling ofradial head fractures. J Hand Microsurg. 2014;6(1):13e17.

4. Guitton TG, van der Werf HJ, Ring D. Quantitative three-dimensional computed tomography measurement of radial headfractures. J Shoulder Elbow Surg. 2010;19(7):973e977.

5. van Leeuwen DH, Guitton TG, Lambers K, Ring D. Quantitativemeasurement of radial head fracture location. J Shoulder Elbow Surg.2012;21(8):1013e1017.

6. Watters TS, Garrigues GE, Ring D, Ruch DS. Fixation versusreplacement of radial head in terrible triad: is there a difference inelbow stability and prognosis? Clin Orthop Relat Res. 2014;472(7):2128e2135.

7. Leigh WB, Ball CM. Radial head reconstruction versus replacementin the treatment of terrible triad injuries of the elbow. J ShoulderElbow Surg. 2012;21(10):1336e1341.

8. Moon JG, Berglund LJ, Zachary D, An KN, O’Driscoll SW. Radi-ocapitellar joint stability with bipolar versus monopolar radial headprostheses. J Shoulder Elbow Surg. 2009;18(5):779e784.

9. Popovic N, Lemaire R, Georis P, Gillet P. Midterm results with abipolar radial head prosthesis: radiographic evidence of loosening atthe bone-cement interface. J Bone Joint Surg Am. 2007;89(11):2469e2476.

10. Shore BJ, Mozzon JB, MacDermid JC, Faber KJ, King GJ. Chronicposttraumatic elbow disorders treated with metallic radial headarthroplasty. J Bone Joint Surg Am. 2008;90(2):271e280.

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11. Chanlalit C, Shukla DR, Fitzsimmons JS, An KN, O’Driscoll SW.Stress shielding around radial head prostheses. J Hand Surg Am.2012;37(10):2118e2125.

12. Birkedal JP, Deal DN, Ruch DS. Loss of flexion after radial headreplacement. J Shoulder Elbow Surg. 2004;13(2):208e213.

13. Doornberg JN, Linzel DS, Zurakowski D, Ring D. Reference pointsfor radial head prosthesis size. J Hand Surg Am. 2006;31(1):53e57.

14. Rowland AS, Athwal GS, MacDermid JC, King GJ. Lateral ulno-humeral joint space widening is not diagnostic of radial headarthroplasty overstuffing. J Hand Surg Am. 2007;32(5):637e641.

15. Shors HC, Gannon C, Miller MC, Schmidt CC, Baratz ME. Plainradiographs are inadequate to identify overlengthening with a radialhead prosthesis. J Hand Surg Am. 2008;33(3):335e339.

16. Beingessner DM, Stacpoole RA, Dunning CE, Johnson JA, King GJ.The effect of suture fixation of type I coronoid fractures on the ki-nematics and stability of the elbow with and without medial collateralligament repair. J Shoulder Elbow Surg. 2007;16(2):213e217.

17. Pollock JW, Brownhill J, Ferreira L, McDonald CP, Johnson J,King G. The effect of anteromedial facet fractures of the coronoidand lateral collateral ligament injury on elbow stability and kine-matics. J Bone Joint Surg Am. 2009;91(6):1448e1458.

18. Schneeberger AG, Sadowski MM, Jacob HA. Coronoid process andradial head as posterolateral rotatory stabilizers of the elbow. J BoneJoint Surg Am. 2004;86(5):975e982.

19. Fern SE, Owen JR, Ordyna NJ, Wayne JS, Boardman ND III. Com-plex varus elbow instability. J Shoulder Elbow Surg. 2009;18(2):269e274.

20. PapatheodorouLK,Rubright JH,HeimKA,WeiserRW,SotereanosDG.Terrible triad injuries of the elbow: does the coronoid always need tobe fixed? Clin Orthop Relat Res. 2014;472(7):2084e2091.

21. Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of operative treatment without repairof the medial collateral ligament. J Hand Surg Am. 2007;32(8):1200e1209.

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22. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD.Standard surgical protocol to treat elbow dislocations with radialhead and coronoid fractures. J Bone Joint Surg Am. 2004;86(6):1122e1130.

23. Gupta A, Barei D, Khwaja A, Beingessner D. Single-staged treatmentusing a standardized protocol results in functional motion in themajority of patients with a terrible triad elbow injury. Clin OrthopRelat Res. 2014;472(7):2075e2083.

24. Garrigues GE, Wray WH III, Lindenhovius AL, Ring DC, Ruch DS.Fixation of the coronoid process in elbow fracture-dislocations.J Bone Joint Surg Am. 2011;93(20):1873e1881.

25. Hausman MR, Klug RA, Qureshi S, Goldstein R, Parsons BO.Arthroscopically assisted coronoid fixation: A preliminary report.Clin Orthop Relat Res. 2008;466(12):3147e3152.

26. Adams JE, Merten SM, Steinmann SP. Arthroscopic-assisted treat-ment of coronoid fractures. Arthroscopy. 2007;23(10):1060e1065.

27. Ring D, Bruinsma WE, Jupiter JB. Complications of hinged externalfixation compared with cross-pinning of the elbow for acute andsubacute instability. Clin Orthop Relat Res. 2014;472(7):2044e2048.

28. Orbay JL, Mijares MR. The management of elbow instability usingan internal joint stabilizer: preliminary results. Clin Orthop Relat Res.2014;472(7):2049e2060.

29. Ruch DS, Triepel CR. Hinged elbow fixation for recurrent instabilityfollowing fracture dislocation. Injury. 2001;32(suppl 4):SD70eSD78.

30. Ring D, Guss D, Jupiter JB. Reconstruction of the coronoid processusing a fragment of discarded radial head. JHand Surg Am. 2012;37(3):570e574.

31. Papandrea RF, Morrey BF, O’Driscoll SW. Reconstruction forpersistent instability of the elbow after coronoid fracture-dislocation.J Shoulder Elbow Surg. 2007;16(1):68e77.

32. Moritomo H, Tada K, Yoshida T, Kawatsu N. Reconstruction of thecoronoid for chronic dislocation of the elbow. Use of a graft from theolecranon in two cases. J Bone Joint Surg Br. 1998;80(3):490e492.

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