Babst R, Schraner C, Beeres F J P
Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, 6000, Luzern, Schweiz.
Oper Orthop Traumatol. 2017 Apr;29(2):125-137. doi: 10.1007/s00064-017-0489-5. Epub 2017 Mar 17.
Reconstruction of the most important ligamentous and osseus structures of the elbow after terrible triad injury via the radial head to the lateral collateral ligament complex (LCL) and if necessary beginning at the coronoid process. The aim is a stable concentrically guided elbow with early functional follow-up treatment. The approach depends on the intraoperatively tested stability.
Osteoligamentous terrible triad injury pattern with or without subluxation position following reduction and temporary immobilization.
Inoperable due to comorbidities. Concentric elbow with radial head fracture without impairment of pronation/supination, coronoid fragment <50% and stable range of motion up to 30°.
Lateral access according to Kaplan or Kocher in order to address the anterior capsule/coronoid tip. Stabilization of the radial head with mini fragment screws and plates or radial head prosthesis. Osseous reinsertion of the LCL at its origin with transosseous sutures/bone anchors on the radial epicondyle of the humerus. In cases of persisting instability (hanging arm test) treatment with lateral movement fixation and/or the medial collateral ligaments from medial.
FOLLOW-UP TREATMENT: Immobilization in upper arm plaster cast in the first postoperative days, active assistive pain-adapted movement therapy in the cast from postoperative day 1 and after 6-8 weeks resistive therapy in the whole elbow.
Control of 15 terrible triad patients (mean age 45.9 years, range 20-87 years) after 9.6 months (range 2.6-31.6 months), extent of movement flexion/extension 131/14/0°, pronation/supination 78/0/67°. Arthrolysis after an average of 38 weeks in 4 patients, signs of joint arthrosis in 8, heterotopic ossification in 7 and neuropathic complaints in the region of the ulnar nerve in 1 patient. Early functional therapy with reproducible results by stabilization of osteoligamentous structures.
通过桡骨头至外侧副韧带复合体（LCL）修复严重三联征损伤后肘部最重要的韧带和骨结构，必要时从冠突开始修复。目的是获得一个稳定的、同心引导的肘部，并进行早期功能随访治疗。手术入路取决于术中测试的稳定性。
复位及临时固定后出现或未出现半脱位的骨韧带严重三联征损伤模式。
因合并症无法手术。桡骨头骨折的同心肘部，旋前/旋后功能未受损，冠突碎片<50%，活动范围稳定至30°。
根据卡普兰或科赫尔方法进行外侧入路，以处理前侧关节囊/冠突尖。用微型碎片螺钉和钢板或桡骨头假体稳定桡骨头。通过经骨缝线/骨锚将LCL在其起点重新固定于肱骨桡侧髁。对于持续不稳定（垂臂试验）的病例，采用外侧移动固定和/或从内侧修复内侧副韧带。
术后头几天用上臂石膏固定，术后第1天开始在石膏内进行主动辅助的疼痛适应性运动治疗，6-8周后对整个肘部进行抗阻治疗。
对15例严重三联征患者（平均年龄45.9岁，范围20-87岁）随访9.6个月（范围2.6-31.6个月），屈伸活动范围为131/14/0°，旋前/旋后为：78/0/67°。4例患者平均38周后进行了关节松解术，8例有关节关节炎体征，7例有异位骨化，1例患者尺神经区域有神经病变主诉。通过稳定骨韧带结构进行早期功能治疗，结果可重复。
