单一外侧入路治疗肘部损伤"三联征"的修复技巧及疗效分析

目的 探讨采用单一肘关节外侧入路治疗肘部损伤"三联征"的手术扩大显露、修复技巧及临床疗效.方法 对2007年5月至2010年3月收治的6例肘部损伤"三联征"患者采用单一肘关节外侧入路,由深至浅依次修复下列结构:冠状突骨折、桡骨头骨折、外侧副韧带、伸肌总腱起点.并用自创的方法对冠状突骨折进行扩大显露,直视下复位与牢靠固定,对肘关节外侧结构的撕裂进行有效修复.本组患者均未做肘关节内侧副韧带的探查与修复.随访时采用Mayo肘关节功能评分(MEPS)对患者肘关节功能进行评价.结果 本组患者随访3～24个月,平均11个月.所有患者骨折均获骨性愈合,肘部屈伸活动度105°～135°,平均120.0°;前臂旋转活动度150°～170°,平均168.3°;MEPS评分93～95分,平均93.3分,均为优.所有患者均无伤口感染,伤口一期愈合.结论 单一肘关节外侧入路结合相应手术技巧的改进,解决了肘部损伤"三联征"中冠状突骨折复位与固定的疑难问题,对肘关节外侧结构的修复也更加简单、牢靠,是一种临床可行且疗效满意的手术方式.     

Unstable Simple Elbow Dislocation Treated with the Repair of Lateral Collateral Ligament Complex

Background

Unstable simple elbow dislocation (USED) repair is challenged by the maintenance of joint reduction; hence, primary repair or reconstruction of disrupted ligaments is required to maintain the congruency and allow early motion of the elbow. We evaluated the effectiveness and the outcome of lateral collateral ligament (LCL) complex repair with additional medial collateral ligament (MCL) repair in cases of USED.

Methods

We retrospectively reviewed 21 cases of diagnosed USED without fractures around the elbow that were treated with primary ligament repair. In all cases, anatomical repair of LCL complex with or without common extensor origin was performed using suture anchor and the bone tunnel method. Next, the instability and congruency of elbow for a full range of motion were evaluated under the image intensifier. MCL was repaired only if unstable or incongruent elbow was observed. Clinical outcomes were evaluated using the Mayo elbow performance score (MEPS) and radiographic outcomes on last follow-up images.

Results

All cases achieved a stable elbow on radiographic and clinical results. LCL complex repair alone was sufficient to obtain the stable elbow in 17 of 21 cases. Four cases required additional MCL repair after restoration of the LCL complex. The overall mean MEPS was 91 (range, 70 to 100): excellent in 12 cases, good in 7 cases, and fair in 2 cases. All 17 cases with LCL complex repair only and 2 of 4 cases with additional MCL repair had excellent or good results by MEPS.

Conclusions

USED requires surgical treatment to achieve a congruent and stable joint. If the repair of lateral stabilizer such as LCL complex acquires enough joint stability to maintain a full range of motion, it may not be necessary to repair the medial stabilizer in all cases of USED.     

Elbow dislocation with irreparable fracture radial head

Background:

Treatment of elbow dislocation with irreparable radial head fracture needs replacement of radial head to achieve stability of elbow. An alternate method in cases of elbow dislocation with radial head fracture can be resection of radial head with repair of medial collateral ligament. We report a retrospective analysis of cases of elbow dislocation with irreparable radial head treated by excision head of radius and repair of MCL.

Materials and Methods:

Nine patients of elbow dislocation with associated irreparable fractures of the head of the radius were included in this analysis (6 F:3 M, Age: 35-47 years). Radial head excision was done through the lateral approach and MCL was sutured using no 3 Ethibond using medial approach. Above elbow plaster was given for 6 weeks and gradual mobilization was done thereafter. All patients were assessed at final followup using Mayo elbow performance score (MEPS).

Results:

Mean followup was 19.55 ± 7.12 months (range 14-36 months). There was no extension deficit when compared to opposite side with mean range of flexion of 138.8° ± 6.97° (range 130 -145°). Mean pronation was 87.7° ± 4.4° (range 80-90°) and mean supination was 87.7 ± 4.62° (range 80-90°). The mean MEPS was 98.8 ± 3.33 (range 90-100). No patient had pain, sensory complaints, subluxation or redislocation. All were able to carry out their daily activities without disability.

Conclusion:

Radial head excision with MCL repair is an acceptable option for treatment of patients with elbow dislocation and irreparable radial head fracture.     

外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效

 目的 探讨采用外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效。方法 回顾性分析2008年7月至2011年1月,采用外侧入路联合前内侧入路治疗23例肘关节“恐怖三联征”患者,其中21例获得完整随访资料,男17例,女4例;年龄17~63岁,平均38.4岁;坠落伤15例,运动损伤4例,交通伤2例;受伤至手术时间为2~8 d,平均4 d。尺骨冠突骨折O’Driscoll分型：A1型5例,A2型12例,B2型4例;桡骨头骨折Mason分型：Ⅰ型2例,Ⅱ型12例,Ⅲ型7例;软组织损伤仲飙等分型：Ⅰ型6例,Ⅱ型12例,Ⅲ型3例。先采用Kocher入路内固定或人工桡骨小头置换治疗桡骨小头骨折,暂时修补外侧副韧带复合体,而后通过前内侧入路固定冠突骨折并修补内侧副韧带损伤;术后采用铰链式外固定支具辅助固定。术后分别采用Mayo肘关节评分（Mayo elbow performence score, MEPS）和Broberg-Morrey分级评估患者肘关节功能及创伤性关节炎程度。结果 21例患者均获得随访,随访时间24~48个月,平均32个月。末次随访时,患者肘关节屈伸及前臂旋转平均活动度分别为126°（范围,115°~135°）和139°（范围,125°~145°）;MEPS评分为85~100分,平均95分,其中19例评定为优,2例为良,优良率为100%,无一例发生肘关节复发不稳定。术后1周,1例发生伤口浅表感染,经清创及静脉使用抗生素治疗后愈合;术后3个月,发生异位骨化症2例,桡骨头骨折骨不连1例,尺神经麻痹1例,均未行手术处理。结论 采用外侧入路联合前内侧入路治肘关节“恐怖三联征”具有一期同时重建骨结构和恢复软组织稳定性的优势,术后患者能早期进行功能锻炼,利于肘关节功能恢复。     

人工桡骨头置换在肘关节恐怖三联征中的应用

 目的 观察人工桡骨头置换治疗肘关节恐怖三联征的近期疗效。方法 2011年6月至2012年6月采用人工桡骨头置换治疗肘关节恐怖三联征6例,男4例,女2例;年龄23~50岁,平均39岁。新鲜肘关节骨折脱位5例,陈旧性骨折1例。桡骨头骨折MasonⅡ型2例,MasonⅢ型4例。对肘关节恐怖三联征进行切开复位,尺骨冠突骨折固定（螺钉固定1例、不可吸收缝线固定4例）、人工桡骨头置换、外侧韧带复合体修复及环状韧带修复或重建（修复环状韧带1例、掌长肌腱重建环状韧带2例）。术后第5至7天逐步开始肘关节功能锻炼。术后复查肘关节正侧位X线片,术后3个月复查肘关节三维CT,并采用Myao肘关节功能评分（Myao elbow performance score,MEPS）评价肘关节功能。结果 6例均获得随访,随访时间10~24个月,平均16.8个月。术后3个月肘关节MEPS评分85~95分,平均91.7分;优5例,良1例。肘关节活动度（采用标准中立位0度法测量）：屈82°~95°,平均87°;伸15°~32°,平均21°;旋前82°~90°,平均86°;旋后45°~80°,平均56°。随访期间未出现肘关节不稳、脱位或半脱位、创伤性关节炎及感染。1例因桡骨头假体位置欠佳使肱骨与桡骨头假体间隙变窄而影响肘关节屈曲活动度。2例出现未影响肘关节功能的Hahi 1级异位骨化。结论 采用人工桡骨头置换治疗伴有桡骨头粉碎性骨折的肘关节恐怖三联征能恢复肘关节稳定性,减少肘关节僵硬、脱位及半脱位等并发症的发生。     

Repairing the annular ligament is not necessary in the operation of Mason type 2, 3 isolated radial head fractures if the lateral collateral ligament is intact: Minimum 5 years follow-up

Introduction

The repair of annular ligament after open reduction and internal fixation of radial head fracture could produce the irritation or crepitation during range of motion exercise. The purpose of this study is to evaluate the significance of unrepaired annular ligament during fixation of isolated radial head fractures.

Materials and methods

Retrospectively we reviewed the twenty-five patients who underwent surgical fixation with a plate for Mason type 2, 3 isolated radial head fracture without annular ligament repair. All the radial head fracture did not have the associated injuries which could cause the elbow instabilities. The average length of follow-up was 6.9 years. The outcomes were evaluated clinically (range of motions, instabilities, pain VAS, Broberg & Murrey functional rating score, DASH score) and radiographically (bony union, arthritic change, lateral translation of the radial head, humero-ulnar angle with maximum varus stress of elbow, ulnar variance).

Results

The range of motions between affected and contralateral side were not significantly different at last follow-up. No one showed the instabilities of elbow. The mean pain VAS, Broberg & Murrey functional rating score, and DASH score were 2.7 ± 0.5, 95.3 ± 2.5, and 14.8 ± 5.3 points respectively. Bony union was observed for all cases. There was no significant difference in the lateral translation of the radial head, humero-ulnar angle with maximum varus stress of elbow, and ulnar variance between the affected and the contralateral arm.

Conclusion

The isolated role of the annular ligament seems overestimated. We scrutinize that the annular ligament repair is not essential in the operative treatment of isolated radial head fractures if the lateral collateral ligament is intact.     

肘关节三联征的治疗进展

肘关节三联征这类损伤因为其周围解剖的复杂性,生物力学研究有限,治疗相当困难,预后较差,选择治疗方案仍存在争议,本文通过检索大量参考文献对肘关节周围解剖、损伤机制、手术治疗方法及预后情况进行归纳总结。目前肘关节三联征的手术治疗方案多样,但由于个体差异的存在,临床疗效大多不确切。肘关节三联征的治疗,多数骨科医生仍然选择外侧手术入路,固定冠状突骨折,桡骨头修复或者置换,常规修复外侧副韧带,大多数学者不建议修复内侧副韧带,故仍有待商榷。     

Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament

PURPOSE: To determine the effectiveness of a protocol for the treatment of fracture-dislocations of the elbow based on the concept that, if dislocation of the elbow with associated fractures can be made to resemble a simple elbow dislocation by repairing or reconstructing the fractured structures, repair of the medial collateral ligament (MCL) will not be necessary. METHODS: Over a 5-year period, a single surgeon operated on 34 patients with a posterior dislocation of the elbow associated with one or more intra-articular fractures. The mean age of these 19 men and 15 women was 48 years. Associated fractures included the capitellum, trochlea, and lateral epicondyle in 3 patients; the olecranon in 1 patient; and the radial head in 30 patients (with concomitant fracture of the coronoid process-the so-called "terrible triad" of the elbow-in 22 patients, and concomitant fracture of the coronoid and olecranon in 1 patient). Operative treatment consisted of open reduction internal fixation (ORIF) or prosthetic replacement of all fractures and reattachment of the origin of the lateral collateral ligament (LCL) complex to the lateral epicondyle. The MCL was not repaired. RESULTS: Two patients (1 with a terrible triad injury and 1 with fracture of the capitellum and trochlea) had postoperative instability related to noncompliance, had reconstructive procedures, and were considered failures. An average of 32 months after injury, the remaining 32 patients regained an average of 120 degrees ulnohumeral motion and 142 degrees forearm rotation. Twenty-five of 34 patients (74%) had good or excellent results according to the system of Broberg and Morrey. Patients with terrible triad injuries had an average of 117 degrees ulnohumeral motion and 137 degrees forearm rotation, and 17 of 22 patients (77%) had good or excellent results. CONCLUSIONS: MCL repair is unnecessary in the treatment of dislocation of the elbow with associated intra-articular fractures, provided that the articular fractures and the LCL are repaired or reconstructed.     

肘关节“恐怖三联征”的手术治疗-改良手术技术及初步结果报道

目的总结肱尺关节后脱位合并桡骨头和尺骨冠状突骨折的手术治疗体会。方法回顾5例典型肘关节“恐怖三联征”的手术治疗结果。手术方法包括：经肘关节外侧入路予桡骨头骨折内固定、修补外侧副韧带及伸肌总腱止点。经肘关节内侧径路固定尺骨冠状突,修复肘关节周围关节囊和内外侧副韧带损伤。最后使用肘关节铰链式外固定支架固定肱尺关节脱位．恢复肘关节同心圆稳定性。于术后1、3、6个月及随访结束时,进行影像学和临床检查评估。结果5例平均手术时间为76min（60．150min）。平均随访时间8．8个月（3～13个月）。外固定支架拆除时间6周（4—9周）。至随访末患者肘关节活动度平均为（127±25）°。按照Mayo肘关节评分平均为87分（80～95分）,优2例,良3例。无浅表或深部感染、皮肤无坏死、无骨化性肌炎等并发症。结论通过手术内固定或修补肘关节稳定结构结合外固定支架维持肘关节同心圆解剖关系可以明显改善肘关节“恐怖三联征”患者肘关节的功能及预后．对此类损伤建议采用内固定结合外固定治疗。     

前内侧入路结合外侧入路内固定治疗肘关节三联征

目的：探讨前内侧入路结合外侧入路治疗肘关节三联征的临床疗效。方法：2009年11月至2013年3月,采用前内侧入路结合外侧入路治疗肘关节三联征17例,男11例,女6例;年龄22~68岁,平均36.6岁;左侧10例,右侧7例。术中前内侧入路采用肘关节前内侧切口桡侧腕屈肌和掌长肌之间劈开指浅屈肌入路对冠状突骨折进行复位内固定,外侧入路采用肘关节外侧Kocher入路,沿肱骨外上髁在肱三头肌和肱桡肌间隙切开,向下在后侧的肘肌和尺侧腕伸肌间隙切开,显露外侧副韧带、关节囊和桡骨小头,采用微型钢板及螺钉固定桡骨小头,用带线锚钉修复外侧副韧带复合体。术后根据Mayo肘关节功能评分评价肘关节功能。结果：所有患者获得随访,时间13~24个月,平均12.4个月。所有患者术后末次随访时肘关节平均屈曲（134.0±8.8）°,平均伸直受限（6.4±2.3）°。末次随访时Mayo肘关节功能评分：疼痛42.4±5.9,屈伸活动17.6±2.6,关节稳定性9.7±1.2,日常生活功能22.1±2.5,总分91.8±7.9;优13例,良4例。术后2例出现一过性尺神经麻痹症状,异位骨化1例,无感染、骨折不愈合、肘关节不稳、脱位及僵硬等并发症发生。结论：前内侧入路结合外侧入路治疗肘关节三联征疗效可靠,术中能充分显露骨折部位,利于内固定植入,带线锚钉修复韧带可使关节获得充分稳定性,利于早期功能锻炼。     

Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures

Objective

The objective of this study was to compare treatment results and complication rates between lateral and posterior approaches in surgical treatment of extra-articular distal humeral shaft fractures.

Material and methods

Between June 2008 and May 2012, a total of 68 patients with extra-articular distal humeral shaft fractures were treated by lateral and posterior approaches. Of the patients, 30 were operated by a lateral approach (group I) and 26 patients were operated by a posterior approach (group II). There was no statistical significance between the two groups in sex distribution, age, the mechanism of the injury, injured arms, AO/ASIF (Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation) classification, and the time from injury to surgery (P > 0.05). Operation time, intraoperative bleeding volume, hospitalisation, clinical outcomes, and complications were compared between the two groups. The elbow functional results were evaluated by the Mayo Elbow Performance Score (MEPS).

Results

All patients were followed up. The average of follow-up in group I was 15.53 ± 2.636 months (range, 12–22 months), and was 16.12 ± 2.889 months (range, 12–22 months) in group II. There was no significant difference in the operation time, intraoperative bleeding time, and hospitalisation between the two groups (P > 0.05). In group I, the mean time of bone union was 12.87 ± 1.852 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 139.20° ± 3.274° (range, 134–146°), the mean degrees of elbow extension was 4.77° ± 1.906° (range, 0–8°), and the mean points of MEPS was 87.00 ± 7.724 (range, 70–100 points). In group II, the mean time of bone union was 12.96 ± 2.218 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 137.85° ± 4.076° (range, 130–145°), the mean degrees of elbow extension was 5.15° ± 2.327° (range, 0–9°), and the mean points of MEPS was 86.15 ± 7.656 (range, 70–100 points). There was no significant difference in the bone union, range of elbow flexion, range of elbow extension and MEPS between the two groups (P > 0.05). The overall complication rate in group I was lower than that in group II (P = 0.041).

Conclusions

Both lateral and posterior surgical approaches acquired satisfied treatment results in the management of extra-articular distal humeral shaft fractures, and there was a lower complication rate using the lateral approach.     

肘关节“恐怖三联征”中内侧副韧带及合并损伤的治疗策略

目的 探讨肘关节“恐怖三联征”中内侧副韧带及合并损伤的治疗策略.方法 回顾性分析2010年2月至2012年4月治疗的21例肘关节“恐怖三联征”患者病历资料,男17例,女4例;年龄16～57岁,平均37.6岁;左侧12例,右侧9例.术前常规行MR检查并根据其结果制定内侧副韧带及合并损伤的治疗策略.对于MRI提示没有损伤或部分撕裂但内侧副韧带前束完整的患者,术中并不常规探查修补;对于MRI提示内侧副韧带前束起、止点撕脱或体部断裂者,则常规采用前内侧入路探查修补,对于起、止点撕脱者采用锚钉予以缝合,对于体部断裂者则采用“8”字缝合,合并屈肌-旋前圆肌复合体损伤者也同时予以缝合修补.术后予以可屈性支具固定,无一例患者采用外固定支架固定.结果 术后随访平均12.4个月(6～26个月)°所有患者术后末次随访时肘关节平均屈伸活动度为135.2°±10.2°,平均伸直受限6.7°±2.2°,平均屈曲142°±11.0°.Mayo肘关节功能评分平均为92分(85～100分),17例患者功能为优,4例为良.术后并发症包括一过性尺神经麻痹3例、异位骨化2例、迟发性尺神经炎1例,无肘关节残留不稳定、脱位、肘关节僵硬等并发症.结论 对于内侧副韧带前束起、止点撕脱或体部断裂者应常规采用内侧入路探查修补,有利于恢复肘关节即刻稳定性.     

Total elbow replacement with the Coonrad-Morrey prosthesis: our medium to long-term results

INTRODUCTION

Semiconstrained total elbow replacement is now a well recognised and reliable surgical option for advanced elbow disease, mainly rheumatoid arthritis.

METHODS

We report a retrospective analysis of 31 primary total elbow replacements in 28 patients with a mean follow-up duration of 55 months. The mean age of the patients was 65 years. The indications included 27 cases of rheumatoid arthritis, 3 fractures and 1 case of osteoarthritis. Twenty-one elbows in nineteen patients were assessed using the Mayo elbow performance score (MEPS) in a special follow-up clinic. In the other nine patients (ten elbows), the assessment was carried out with case notes and x-rays.

RESULTS

The mean pre-operative MEPS in the 21 elbows recalled was 40. This improved to 89 post-operatively (range: 55-100). Sixteen of the twenty-one elbows were considered excellent, two good, two fair and one poor. The range of movement was recorded in eight of the other ten elbows and the mean was 98°. At the last follow-up visit, x-rays were normal in 23 elbows although the ulnar component was loose in 3, the humeral component loose in 2. There were also two cases of nonunion of the medial epicondyle and one patient had mild heterotopic ossification. Complications included one infection, which needed irrigation and debridement with a satisfactory final result, and two cases of ulnar nerve palsy/neurapraxia. Two elbows were considered failures due to severe pain caused by prosthetic loosening. These were referred for revision surgery.

CONCLUSIONS

Excellent pain relief and good function can be achieved in the medium and long term with the Coonrad-Morrey semiconstrained total elbow replacement prosthesis in patients with severe destructive elbow arthropathy.     

Appropriate excision time of heterotopic ossification in elbow caused by trauma

Objective

The aim of this study was to investigate the optimal timing for the resection of heterotopic ossification (HO) of the elbow.

肘关节"可怕三联征"的诊断与治疗

目的 探讨肘关节"可怕三联征"的诊断要点、手术治疗原则及效果.方法 回顾性分析自2005年3月至2008年1月收治的27例肘关节"可怕三联征"患者的病历资料及随访结果,男19例,女8例;平均年龄38(14～72)岁.所有患者均采取手术治疗,23例采用单纯外侧入路,3例采用外侧加内侧入路,1例采用肘后正中入路.所有患者平均随访17.5(6～33)个月,随访内容包括:病情主诉、肘关节屈伸活动度、前臂旋转活动度、腕关节活动度、双侧握力以及X线片情况.用MEPS(Mayo Elbow Perfof-mance Score)和Broberg & Morrey评分对肘关节功能进行评分;用Morrey等提出的"5%"校正值对主力侧和非主力侧的握力标准化后进行比较.结果 所有患者在未次随访时患侧肘关节均没有明显疼痛及不稳定.患侧肘关节伸屈活动范围平均为107°(30°～150°).患侧前臂旋前-旋后活动范围平均为147°(0°～220°).患肢握力较健侧平均减少13.7%.MEPS评分平均为93.4(72～100)分,优良率92.6%.Broberg＆Morrey评分平均为91.2(68～100)分,优良率88.9%.结论 对肘关节"可怕三联征"的诊断要紧扣其定义,且须与肘关节其它损伤相鉴别.对肘关节"可怕三联征"应采用手术治疗,大多采用单纯外侧入路即可完成,必要时可加用内侧入路.治疗原则为重建肘关节同心圆性中心复位及可靠的稳定性、对桡骨头、冠状突骨折尽量进行复位内固定并重视对软组织的处理.     

Surgical management of medial and lateral elbow instability secondary to acute atypical complex elbow dislocation: Case report and literature review

Introduction and importanceElbow dislocation is common in adults, and complex elbow dislocations are generally associated with bone fractures. Anteromedial coronoid fracture, in association with lateral collateral ligament (LCL) disruption, often results from varus posteromedial forces. “Terrible triad” injuries are more likely to result from valgus posterolateral forces. However, our case presentation has combined medial and lateral elbow instability in addition to “terrible triad” injury of the elbow with no radial head injury.Case presentationThe patient was a 38-year-old man with an atypical complex elbow dislocation. He was successfully treated by stabilizing the medial epicondyle and coronoid anterolateral facet fractures, in addition to LCL repair and medial collateral ligament (MCL) reconstruction. A radial head fracture was unnoted. The procedure yielded satisfactory functional outcome, with a stable and painless full elbow range of motion.Clinical discussionMulti-ligament injuries with coronoid fractures result in highly unstable elbow joints, forming a variant of the “terrible triad” injury. Surgical options vary according to the surgeon’s experience and equipment availability. In this case, direct LCL repair and MCL reconstruction were performed and were well tolerated. Elbow stability improved and the patient experienced improved functionality with minimal pain. However, it may be premature to report a definite outcome in this case because of short follow-up time postoperatively.ConclusionThe injury described in this case has a unique presentation as a multi-ligamentous injury will make the elbow very unstable. Thus, careful clinical judgment, knowledge, and experience are needed to identify the underlying injury and for optimal management.     

肘关节“三联征”的诊治分析

目的:探讨肘关节"三联征"的诊疗要点及治疗效果。方法:回顾性分析2001年6月至2009年6月7例肘关节"三联征"的临床资料及随访结果。男6例,女1例;年龄20～68岁,平均36.5岁;均为新鲜骨折。全部病例住院后先行手法复位肘关节脱位,石膏固定,7～10d后手术治疗。均采用外侧切口入路,依次从深层至浅层修复冠状突骨折、前方关节囊、桡骨头骨折、外侧副韧带、伸肌总腱起点,冠状突骨折和桡骨头骨折复位后根据骨块大小采用不同方法固定。疗效按Mayo肘关节功能评分(Mayoelbowperformancescore,MEPS)评定。结果:本组平均随访16.3个月(5～36个月),骨折平均愈合时间4.5个月(3～6个月),异位骨化4例。肘关节活动度-20°～130°,平均106.5°;前臂旋转度70°～140°,平均121°。本组疗效优2例,良0例,一般4例,差1例。1例桡骨头切除,冠状突骨折复位后克氏针自后向前固定,术后拍X线片示冠状突骨折块发生分离移位,肘关节呈半脱位状态,随访时肘关节仍不稳定,关节功能差。结论:肘关节"三联征"应积极手术治疗,骨与软组织损伤并重处理,结合术后早期功能练习是获得良好疗效的关键。     

Arthrolysis combined with reconstruction for treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention

Introduction

The treatment of terrible triad injury with a poor outcome after intervention has not been successful thus far. The purpose of this study was to evaluate the efficacy of arthrolysis and reconstruction in the treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention.

Materials and methods

Twelve patients (12 elbows) with the diagnosis of terrible triad injury were respectively reviewed. All the 12 patients had elbow dysfunction after conservative and surgical treatment of the terrible triad injury. Preoperatively, the flexion arc and forearm rotation were 36.7° ± 28.5° and 51.3° ± 43.4°, respectively, and the Mayo Elbow Performance Score was 56.3 points. The mean interval between the primary injury and our surgical treatment was 6.6 months. Our surgical intervention included elbow arthrolysis, ulnar nerve transposition, radial head replacement, coronoid process and ligament repair, and hinged external fixation. Patients were encouraged to participate in rehabilitation training 24 h after surgery.

Results

The mean follow-up duration was 20.1 months; the flexion arc and forearm rotation were 122° ± 18° and 140° ± 20°, respectively, and the mean Mayo Elbow Performance Score was 94.6 points (9 excellent, 3 good). Concentric stability was restored in all elbows. Complications included superficial pin tract infection (1), heterotopic ossification (3), and ulnar nerve palsy (1); the ulnar nerve symptoms had improved at the last follow-up.

Conclusions

The combination of open arthrolysis and reconstruction performed at a mean interval of 6-month posttrauma can restore functional mobility in cases of terrible triad injury with a poor outcome after surgical as well as conservative intervention. Thus, it may be an effective alternative for the treatment of the poor outcome terrible triad injury. We recommend early functional rehabilitation with adherence to the guidelines for hinged external fixation.