title: Terrible triad of the elbow: is it still a troublesome injury?
abstract: BACKGROUND
  Terrible triad injury (TTI), one of the main patterns of complex elbow instability, is difficult to treat and yields conflicting surgical results. We analyzed prospectively a series of patient affected by TTI and treated according to the current diagnostic and surgical protocols to investigate whether their application allow to obtain more predictable outcomes.
  
  
  METHODS
  We analyzed 26 patients with a mean age of 52 years. Preoperative X-rays and CT were performed; all patients were operated by the same elbow surgeon and underwent the same surgical and rehabilitation treatment. Final functional outcome was assessed by the Mayo Elbow Performance Score (MEPS), Quick-Disability of the Arm Shoulder and Hand-score (Q-DASH) and the modified-American Shoulder and Elbow Surgeons score (m-Ases). A radiographic evaluation was also performed.
  
  
  RESULTS
  Mean follow-up was 31 months. At final evaluation, mean flexion, extension, supination and pronation were 137°, 10°, 77° and 79°, respectively; mean MEPS, m-ASES and Q-DASH scores were respectively 96, 91 and 8 points. Complications observed after first surgery were: elbow stiffness in 5 cases, mild posterolateral instability in 3 cases, chronic subluxation in 1 case. Radiographic evaluation showed secondary arthritis in 9 cases, symptomatic HO in 3 cases and late hardware displacement in 2 cases. Six out of 26 patient underwent reoperation with final satisfactory results.
  
  
  CONCLUSIONS
  The current diagnostic and therapeutic protocols allow obtaining satisfactory clinical outcomes in majority of cases but a high number of major and minor unpredictable complications persist yet. In this series, low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery. On the other hand, the strict application of current algorithms by an expert elbow surgeon appears to improve clinical results by reducing the influence of other avoidable negative prognostic factors well known in current literature, such as the incomplete recognition of injuries, delayed treatment, inadequate treatment of bony and ligamentous injuries, prolonged immobilization and, last but not least, the surgeon's inexperience.
  
  
  METHODS
  Level IV, Case series, Treatment study.
authors.affiliation: Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy. Electronic address: giannicola.giuseppe@gmail.com.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Giannicola
authors.affiliation: Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Piergiorgio
authors.initials: P
authors.lastname: Calella
authors.affiliation: Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Piccioli
authors.affiliation: Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Scacchi
authors.affiliation: Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Gumina
mesh_terms: D057929:Arthroplasty, Replacement, Elbow; D001696:Biomechanical Phenomena; D017885:Collateral Ligaments / Q000503:physiopathology*; D004551:Elbow Joint / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods*; D006801:Humans; D004204:Joint Dislocations / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery; D007593:Joint Instability / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011885:Radius Fractures / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery; D016059:Range of Motion, Articular; D020127:Recovery of Function; D016896:Treatment Outcome
keywords: collateral ligaments; complex elbow instability; coronoid; elbow; fractures; fractures-dislocations; radial head; terrible triad