Zha Y J, Jiang X Y, Gong M Q
Department of Orthopaedic Trauma, Beijing Jishuitan Hospital, Beijing 100035, China.
Beijing Da Xue Xue Bao Yi Xue Ban. 2016 Apr 18;48(2):224-9.
To introduce the surgical techniques and treating results of the old "terrible triad" of the elbow.
A retrospective analysis of 11 cases of old "terrible triad" of the elbow treated by the author from March 2009 to February 2014 were performed, with 9 males and 2 females; mean age was (31.82±8.66) years (17-45 years). The average time after injury was (6.36±2.50) weeks (4-12 weeks), with 7 cases on the left and 4 right. The combined injury included 2 cases with distal radius fractures, 1 with ankle fractures, fractures of the distal radius and the head injury (minor epidural hematoma, no surgery), and 1 with Pilon fractures and L4 fractures (fixed at local hospital). All the patients had elbow stiffness and joint dislocation, and 2 patients had symptoms of ulnar nerve. Mason classification of radial head fractures: 2 cases were type I, 5 were type II, 4 were type III. Classification of the coronoid process: Regan & Morrey: 1 was type I, 10 were type II; according to O'Driscoll classification, all the fractures were tip fracture, one was the first subtype, 10 were the second subtype. The elbow were released, the coronoid process were fixed by lasso suture combined with Kirschner wires. Radial head fractures were resected in 1 case, and replaced in 1 case, 3 cases with no treatment, 6 cases with osteotomy and 3.0 mm headless compression screw (HCS) fixation. The lateral collateral ligament complex and the common extensor tendon were repaired to the humeral lateral epicondyles, No.2 Ethibon was used in 2 cases through bone holes, and suture anchorsin the other 9 cases. All the patients were fixed by Stryker DJD II hinged external fixator to protect the bone and soft tissue.
The average follow-up time was (38.36±21.92) months (19-77 months). All the patients had no obvious pain, instability and ulnar nerve symptoms in the last follow-up. The average elbow flexion was 134.09°±12.41° (100°-140°), average extension was -15.91°±14.46 ° (-40°-0°), range of flexion and extension was 118.18°±23.80° (70°-140°). Average pronation was 70.91°±26.63° (20°-90°), supination was 70.91°±26.63° (20°-100 °). The range of motion (ROM) of forearm rotation was 150.91°±43.00° (40°-180°). Average Mayo elbow performance score (MEPS) was 96.36±5.04 (85- 100).X-ray showed that no degenerative changes. Five patients had heterotopic ossifications, according to Hastings and Graham grading: 1 case was grade I, 3 cases were grade IIA, 1 case was IIB.
The old "terrible triad" of elbow with no operative history is difficult to treat. The elbow's functions and stabilization can be recovered by thorough elbow release, repair of coronoid process and anterior capsule, radial head fractures, lateral collateral ligament and the common extensor tendon insertion, combined with hinged external fixator. Joint stiffness and heterotopic ossification are common complications.
介绍陈旧性肘关节“恐怖三联征”的手术技术及治疗效果。
回顾性分析2009年3月至2014年2月作者收治的11例陈旧性肘关节“恐怖三联征”患者，其中男性9例，女性2例；平均年龄（31.82±8.66）岁（17 - 45岁）。伤后平均时间为（6.36±2.50）周（4 - 12周），左侧7例，右侧4例。合并损伤包括2例桡骨远端骨折，1例踝关节骨折，桡骨远端骨折合并头部损伤（轻度硬膜外血肿，未手术），1例Pilon骨折合并L4骨折（在当地医院固定）。所有患者均有肘关节僵硬及关节脱位，2例有尺神经症状。桡骨头骨折Mason分型：Ⅰ型2例，Ⅱ型5例，Ⅲ型4例。冠突骨折分类：Regan & Morrey分型：Ⅰ型1例，Ⅱ型10例；按O'Driscoll分类，均为尖端骨折，其中1例为第一亚型，10例为第二亚型。松解肘关节，采用套索缝线联合克氏针固定冠突。1例桡骨头骨折行切除术，1例行置换术，3例未处理，6例行截骨术并用3.0 mm无头加压螺钉（HCS）固定。外侧副韧带复合体及伸肌总腱修复至肱骨外上髁，2例通过骨孔用2号Ethibon缝线，其余9例用缝合锚钉。所有患者均采用史赛克DJD II型铰链式外固定器固定以保护骨与软组织。
平均随访时间为（38.36±21.92）个月（19 - 77个月）。末次随访时所有患者均无明显疼痛、不稳定及尺神经症状。肘关节平均屈曲角度为134.09°±12.41°（100° - 140°），平均伸展角度为 - 15.91°±14.46°（ - 40° - 0°），屈伸活动度为118.18°±23.80°（70° - 140°）。平均旋前角度为70.91°±26.63°（20° - 90°），旋后角度为70.91°±26.63°（20° - 100°）。前臂旋转活动度（ROM）为150.91°±43.00°（40° - 180°）。平均Mayo肘关节功能评分（MEPS）为96.36±5.04（85 - 100）。X线显示无退变改变。5例患者有异位骨化，根据Hastings和Graham分级：Ⅰ级1例，ⅡA级3例，ⅡB级1例。
无手术史的陈旧性肘关节“恐怖三联征”治疗困难。通过彻底松解肘关节、修复冠突及前关节囊、处理桡骨头骨折、修复外侧副韧带及伸肌总腱附着点，并结合铰链式外固定器，可恢复肘关节功能及稳定性。关节僵硬和异位骨化是常见并发症。
