Case Series of All-Arthroscopic Treatment for Terrible

Triad of the Elbow: Indications and Clinical Outcomes

Sung Hyun Lee, M.D., Kyeong Hoon Lim, M.D., and Jeong Woo Kim, M.D., Ph.D.

Purpose: To evaluate the results of all-arthroscopic treatment of the terrible triad of the elbow, a combination of elbow
dislocation, radial head dislocation, and coronoid process fracture, and its complications. Methods: We performed a
retrospective review of consecutive patients with terrible triad who underwent all-arthroscopic treatment between January
2011 and December 2016. All-arthroscopic treatment was performed in the unstable elbows after manual reduction. Clinical
evaluation was performed at least 2 years postoperatively. Patients with another fracture in the upper extremity and previous
fracture of the affected elbow were excluded. A radial head fracture that was stable enough to reduce or involved less than
25% of the articular surface for partial excision and Regan-Morrey classification type I and type II coronoid process fractures
were treated arthroscopically. Range of motion, radiologic outcomes, surgical complications, and the Mayo Elbow Perfor-
mance Score were evaluated at the final follow-up. The Mann-Whitney test was used for statistical analysis. Results: A total
of 24 patients met the inclusion criteria, and the average age was 47.6 years. Coronoid process fractures were fixed in all
patients, by use of Kirschner wires in 15 (62.5%) and pullout sutures in 9 (37.5%). Radial head fractures were treated using
screw or K-wire fixation in 4 patients (16.7%); only the fragment of the fracture was resected in 11 patients (45.8%). In all 24
cases (100%), the lateral collateral ligaments were repaired. At the final follow-up, the mean flexion contracture angle was
4.8
 1.1
and the mean flexion angle was 132.5
 6.3
. Clinical scores were satisfactory, with a mean Mayo Elbow Per-
formance Score of 93 points. However, nonunion of coronoid fractures was observed in 4 patients (16.7%). There was 1 case
of pin-site irritation. Conclusions: All-arthroscopic treatment for the terrible triad can provide an excellent safety profile
without the need for a large incision if the indications are met. Level of Evidence: Level IV, therapeutic case series.

E lbow arthroscopy has historically been considered

a challenging procedure given the relatively
confined joint space and proximity of surrounding
neurovascular structures.1 However, with advance-
ments in experience, technique, and instrumentation,
elbow arthroscopy has emerged as a safe and effective
means of treating a wide range of acute and chronic
elbow pathologies.1-3 Several types of elbow fractures
are amenable to arthroscopic treatment, including
coronoid fracture, radial head fracture, and lateral
collateral complex injury.2-6 Therefore, depending on
From the Department of Orthopedic Surgery, Wonkwang University Hos-
pital, Iksan, Republic of Korea.
The authors report the following potential conflicts of interest or sources of
funding: This study was supported by a Wonkwang University research grant
in 2019. Full ICMJE author disclosure forms are available for this article
online, as supplementary material.
Received February 24, 2019; accepted September 2, 2019.
Address correspondence to Jeong Woo Kim, M.D., Ph.D., Department of
Orthopedic Surgery, Wonkwang University Hospital, 344-2 Shinyong-dong,
Iksan, Jeollabuk-do, Republic of Korea. E-mail: serina@wonkwang.ac.kr
Ó 2019 by the Arthroscopy Association of North America
0749-8063/19235/$36.00
https://doi.org/10.1016/j.arthro.2019.09.014
the type of fracture, arthroscopic surgery may be per-
formed even for severe fractures such as the terrible
triad.
The term “terrible triad of the elbow” (TTE) joint was
coined by Hotchkiss7 because of the greater difficulty in
managing this entity and the poor results obtained,
particularly compared with simple dislocation of the
elbow, and has been used in the literature since then.8,9
Furthermore, stiffness is a frequent complication,
ranging from capsular fibrosis to heterotopic ossification
with a bony block to motion.10,11 Attempting to avoid
these complications, previous studies have supposed
that applied algorithmic approaches to manage each
injury in the triad have shown more promising
results.8,10-12 In addition, previous studies have sug-
gested that arthroscopic management of some types of
elbow fractures has several advantages, including
improved visualization, better wound healing, and
preservation of critical soft-tissue structures.1-4 How-
ever, only a few studies have investigated the clinical
outcomes of arthroscopic treatment of TTE.1-4
The purpose of this study was to evaluate the results
of all-arthroscopic treatment of TTE and its complica-
tions. We hypothesized that all-arthroscopic treatment

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2019: pp 1-10 1
2 S. H. LEE ET AL.

of TTE, for which arthroscopic procedures are indicated,
would present satisfactory clinical results with low rates
of complications.
Methods
This study was approved by our institutional review
board (No. WKUHIRB 208-03-013).
Patient Selection
We performed a retrospective review of consecutive
patients with terrible triad who underwent all-
arthroscopic treatment between January 2011 and
December 2016. The inclusion criteria were as follows:
(1) terrible triad with elbow instability after manual
reduction (positive drop sign),13,14 (2) treatment with
all-arthroscopic surgery, and (3) clinical assessment at a
minimum of 2 years postoperatively. The exclusion
criteria were as follows: (1) another fracture in the
ipsilateral and contralateral upper extremity, (2) open
reductioneinternal fixation (ORIF) of fractures of the
radial head or coronoid process if not amenable to
arthroscopic management, and (3) previous fracture of
the affected elbow.
Surgical Algorithm and Technique for All-Arthroscopic
Treatment
All surgical procedures were performed by 1 senior
surgeon (J.W.K.) within 1 week after the onset of
trauma. The surgical treatment algorithm of open
treatment of TTE has been established in recently

Fig 1. Treatment algorithm and indications for all-arthroscopic treatment in patients with terrible triad of elbow. (LUCL, lateral
ulnar collateral ligament; OR/IF, open reductioneinternal fixation; Tx, treatment.)
 ARTHROSCOPY FOR TERRIBLE TRIAD OF ELBOW
Fig 2. Arthroscopic partial exci-
sion for radial head fracture fixa-
tion (right elbow). (A)
Arthroscopic view of radial head
fracture. (B) View after excision
of fracture fragment.
published studies.10-12 However, the surgical proced-
ures were performed step by step with a different
sequence for all-arthroscopic surgery. Arthroscopic
fixation or partial excision of radial head fractures was
performed as the first step, fixation of coronoid process
fractures or anterior capsular repair was performed as
the second step, and lateral collateral ligament (LCL)
complex repair was performed as the third step. The
management of radial head fractures, coronoid process
fractures, and ligament injuries was based on the
intraoperative findings. The surgical algorithm and in-
dications for all-arthroscopic treatment of TTE are pre-
sented in Figure 1.
Radial Head Fracture
As arthroscopic reduction of a radial head fracture
was performed using a probe via the lever-arm method,
a completely displaced fracture that was not able to be
reduced was treated with open surgery (when the
fracture fragment involved >25% of the articular sur-
face) or arthroscopic fracture fragment excision (when
the fracture fragment involved <25% of the articular
surface) (Figs 2 and 3). When the fracture fragment of
the radial head was reducible using a probe, radial head
fractures were fixed using headless screws or smooth
Kirschner wires. When the radial head fracture was
stable and the displacement of the articular surface was
less than 2 mm, an operation was not performed for the
radial head fracture.
Coronoid Process Fracture
For patients with coronoid process fractures,
arthroscopy-assisted fixation was performed using 1
of 2 techniques: K-wire fixation or suture repair2,3
(Figs 4 and 5). Coronoid fractures were fixed using a
K-wire when the fracture fragment was large enough
to penetrate using such a K-wire. To prevent iatrogenic
cartilage injury, 1.6-mm K-wires were inserted from
the posterior aspect of the ulna in an anterior direction
to the radial head. With this K-wire used as a guide, an
3
additional K-wire was inserted 0.5 cm distally and 1 cm
medially to guide the wire in a parallel direction. Two
or three K-wires were then used, depending on the size
of the fragment. Thereafter, the K-wire was advanced
and passed through the fragment while the fragment
was held using a grasper and the reduction was main-
tained. Otherwise, coronoid fractures were fixed via
suture repair. FiberWire (Arthrex, Naples, FL) was used
as a fixation suture because of the small fragment of the
fracture. Reduction was performed arthroscopically by
suturing the surrounding anterior capsule of the coro-
noid. Moreover, a 2.7-mm drill bit was used to create 2
holes in the ulna toward the coronoid process. These
holes passed through the fracture site and the Fiber-
Wire to create an interosseous suture on the ulna.
When anterior capsular repair was performed, suture
fixation of the coronoid process was followed by repair
of the lateral ulnar collateral ligament (LUCL).
LCL Complex Repair
Arthroscopic LCL complex repair was performed us-
ing a previously described technique2 (Fig 6). Mason-
Allen sutures were passed via a shuttle technique, and
the lateral epicondyle was then fixed with a knotless
anchor (PopLok; Linvatec, Largo, FL). A spinal needle
was passed through the radial head portal to penetrate
the LCL complex stump at the joint capsule. A poly-
dioxanone suture (PDS; Ethicon, Somerville, NJ) was
passed through the spinal needle and pulled out
through the proximal anterolateral portal using a
grasper (Fig 6 A and B). A shuttle relay was performed
by connecting the PDS with a high-strength nonab-
sorbable suture and was then pulled out through the
proximal anterolateral portal. A second PDS was passed
through the proximal anterolateral portal from the
radial head portal, and the nonabsorbable suture was
connected with the second PDS. The nonabsorbable
suture was then moved back to the radial head portal
(Fig 6C). One more sequence was repeated with a
10-mm gap left between it and the previous stitches.
4 S. H. LEE ET AL.
Both paired strands of the nonabsorbable suture were
knotted using the modified Mason-Allen method
(Fig 6D). An anterolateral portal was created using a
spinal needle, and the nonabsorbable suture was then
transferred from the radial head portal to this portal for
fixation at the LCL complex footprint. The footprint of
the humeral attachment of the LCL complex was gently
decorticated using a burr or shaver. A predrilled hole
directed slightly upward was created using a 4.5-mm
drill bit before anchor fixation. The transferred nonab-
sorbable sutures were fixed using 1 knotless suture
anchor on the articular side of the LCL complex
footprint of the humeral attachment, with the elbow
in a valgus position, through the anterolateral portal
(Fig 6 E and F).
Postoperative Management
Initially, the elbow was immobilized in a posterior
splint while flexed at 90
for 2 to 3 days. Patients were
instructed to perform passive range-of-motion (ROM)
exercises, using a hinged brace with a 30
extension
block, approximately 3 times a day for 4 weeks after
surgery. The exercises involved full passive ROM after 4
weeks. At 6 weeks postoperatively, strengthening
exercises were initiated, and patients returned to
full activity typically at 3 months. The K-wires were
Fig 3. Arthroscopic technique for
radial head fracture fixation with
headless screw (left elbow). (A)
Arthroscopic view of radial head
fracture. (B) View after reduction
of fracture using probe. (C, D) The
radial head fracture was fixed
with a headless screw.
removed at an average of 8 to 12 weeks postoperatively
when bone union was identified on radiography in the
clinic with patients under local anesthesia.
Clinical Evaluation
ROM, surgical complications, and the Mayo Elbow
Performance Score were evaluated at the final follow-
up by 2 surgeons (S.H.L. and K.H.L.). Delayed union
or nonunion was measured at the outpatient follow-up
via radiography. The anatomic integrity after LCL
complex repair was evaluated via magnetic resonance
imaging 6 months after surgery and followed up yearly
by ultrasonography.
Statistical Analysis
Statistical analysis was conducted using SPSS for
Windows (version 12.0; IBM, Armonk, NY). The
Mann-Whitney test was used to assess the significance
of differences in ROM and clinical scores compared
with the contralateral elbow at the final follow-up.
A power analysis was performed to evaluate the
power of group comparisons of the clinical outcomes
between the affected and contralateral elbows;
this study achieved a power of 0.75 for detecting
differences with an actual a value of .05. G*Power
software (version 3.1.9.2; Heinrich-Heine-Universität
 ARTHROSCOPY FOR TERRIBLE TRIAD OF ELBOW 5

Fig 4. Arthroscopic technique for

coronoid fracture fixation using
K-wire (left elbow). (A) Arthro-
scopic view of coronoid fracture.
(B) Reduction of fracture using
probe or grasper under arthro-
scopic view. (C, D) The use of 3 to
4 K-wires will add stability to
fracture fixation.

Düsseldorf, Düsseldorf, Germany) was used for the post
hoc power analysis.
Results
We initially identified 42 patients who underwent
surgery for terrible triad between 2011 and 2016. Of
these patients, 18 were excluded in accordance with the
following exclusion criteria: combined upper-extremity
fractures (n ¼ 4), open surgery of radial fractures
(n ¼ 9), ORIF of coronoid process fractures (n ¼ 2), and
unavailability for a minimum of 2 years of follow-up
(n ¼ 3). Consequently, 18 men and 6 women with a
mean age of 47.6 years (range, 20-73 years) were
finally included, and the mean follow-up period was
29.8 months (range, 24-50 months). The mean opera-
tion time was 151 minutes (range, 95-270 minutes),

Fig 5. Arthroscopic technique for coronoid fracture treatment using FiberWire (right elbow). (A) Arthroscopic view of coronoid
fracture. By use of the arthroscope, the soft tissue is sutured around the fracture fragment. (B) With a 2.7-mm drill bit, 2 holes are
created in the coronoid process that pass through the fracture site. (C) The FiberWire is inserted through the drill hole to place an
interosseous suture on the ulna.
6 S. H. LEE ET AL.

Fig 6. Illustrations and arthroscopic views of arthroscopic lateral collateral ligament (LCL) complex repair (right elbow). (A)
Ruptured LCL complex with posterior arthroscopic soft-spot portal established as viewing portal for LCL complex repair. (C, LCL
complex footprint of humeral attachment; L, LCL complex stump; P, probe.) (B) A spinal needle is passed through the radial head
(RH) portal to penetrate the LCL complex stump and joint capsule. Polydioxanone suture (PDS) is then passed through the spinal
needle and moved outside of the proximal anterolateral (PAL) portal using a grasper. (C) The high-strength nonabsorbable
suture is moved back to the RH portal. (D) One more sequence is repeated with a 10-mm gap left between it and the previous
stitches. Both paired strands of the nonabsorbable suture are knotted using the modified Mason-Allen method. First, 1 limb of
the nonabsorbable suture is passed by a shuttle relay through the ligament. Then, the suture limb is passed in the opposite
direction at about 1 cm from the first passage. A horizontal loop is made. For the third passage, suture limb is passed just medial
to the horizontal strand and forms a modified Mason-Allen stitch. Thereafter, the non-passed limb of suture is passed near the
third passage point of the previously passed limb. (E) An anterolateral portal is made using a spinal needle, and the nonab-
sorbable suture is then transferred from the RH portal to the anterolateral portal for fixation at the LCL complex footprint. The
transferred nonabsorbable sutures are fixed using 1 knotless suture anchor on the articular side of the LCL complex footprint of
the humeral attachment through the anterolateral portal. (F) Complete arthroscopic LCL complex repair and stable elbow joint.

and the mean tourniquet time was 107 minutes (range,
55-210 minutes).
Coronoid process fractures were fixed in all 24
patients, by use of K-wires in 15 (62.5%) and ante-
rior capsular repair including coronoid fracture
fragments in 9 (37.5%). Radial head fractures were
treated via screw fixation in 4 patients (16.7%), only
the fragment of the fracture was resected in 11
(45.8%), and nonoperative treatment was provided
in 9 (37.5%). In the analysis of the collateral liga-
ments, 20 cases (83.3%) of medial collateral ligament
(MCL) injury and 24 cases (100%) of LCL injury
were found on magnetic resonance imaging. In all
patients with MCL and LCL injuries, stability was
obtained via only LCL repair. Patient characteristics,
comorbidities, and mechanisms of injury are
described in Table 1.
At the final follow-up assessment, all 24 patients
showed complete resolution of their elbow instability
and a negative result for the lateral pivot-shift test.
Clinical scores and ROM showed no significant differ-
ence between the affected and contralateral elbows.
According to the validated Mayo Elbow Performance
Score, the elbow performance was rated excellent in 15
patients and good in 9. Clinical scores and ROM are
described in Table 2.
 ARTHROSCOPY FOR TERRIBLE TRIAD OF ELBOW
Complications
No complications of the neurovascular structures
were observed. However, nonunion of coronoid
fractures was observed in 4 patients (16.7%), without
instability and clinical symptoms. In addition, mild
widening of the radiocapitellar joint space with
incomplete healing on the 3-month follow-up magnetic
resonance image was observed in 1 patient, without
instability symptoms. Another patient had ROM
limitations (extension-flexion, 5
-110
). However, the
clinical score was good, and the patient did not want to
undergo additional surgical procedures, such as
arthroscopic debridement. In addition, there was 1 case
of pin-site irritation, which was a complication of
arthroscopic fixation of coronoid fractures and
completely resolved after pin removal.
Discussion
The most important finding of this study was that all-
arthroscopic treatment of TTE could restore stability
enough to permit early rehabilitation. In addition,
satisfactory clinical scores and ROM with no recurrent
instability and low rates of complications were
observed. Thus, our primary hypothesis was supported:
All-arthroscopic treatment of TTE presented satisfactory
clinical results with low rates of complications.
Many fractures of the elbow can be treated with
arthroscopic assistance, including fractures of the
coronoid and radial head.1 The most important
advantage of arthroscopy is that it offers a good view of
the articular surface, which leads to a better under-
standing of the morphology of the fracture lines and
fragments. This facilitates more precise fracture reduc-
tion control.15-17 Another important advantage is better
evaluation of associated lesions than with other tech-
niques.15,17,18 Minimal additional tissue damage with
early mobilization, as well as the removal of hemarth-
rosis and articular debris, decreases the risk of adher-
ence and creates circumstances that allow a better
functional outcome.17,18 However, the techniques are
challenging and have potential complications.1 The
available evidence to support the use of elbow
arthroscopy in the management of intra-articular elbow
fractures is of poor quality.19 Most current clinical
research findings on these techniques have been
reported from small case series, and more research is
needed to evaluate the efficacy compared with other
treatments.14 In addition, no study has evaluated the
clinical outcomes of all-arthroscopic treatment of TTE
yet. Our study suggests the indications for and possi-
bility of all-arthroscopic treatment of TTE. We observed
a low rate of complications with no complications from
neurovascular damage.
Radial head fractures have been treated conserva-
tively, with ORIF, with arthroscopic fixation, with
open or arthroscopic excision, or with radial head
7
replacement.4,17 For displaced type II fractures, Rolla
et al.17 performed fixation arthroscopically without
short-term complications. Excision of the radial head
remains controversial with respect to indications.15 A
previous study suggested that excision is indicated for
comminuted fractures or for small fragments involving
less than 25% of the articular surface in low-demand
patients with no concomitant elbow or forearm disor-
der.20 Another previous study reported that satisfactory
clinical outcomes and ROM could be obtained via
arthroscopic resection of the anterior three-quarters of
the radial head.4 In our study, arthroscopic reduction
with fixation and partial excision were performed in 4
patients (16.7%) and 11 patients (45.8%), respectively,
who achieved satisfactory clinical outcomes and ROM.
The ulnar coronoid process plays a major role in
stabilizing the elbow joint.8,21-23 O’Driscoll et al.24,25
and Doornberg and Ring22 reported that elbow joint
instability may result from a small fracture, such as
Regan-Morrey types I and II. Such fractures may be
more complex than previously imagined, and when
they are associated with ulnar collateral ligament or
radial collateral ligament damage, they may conse-
quently lead to elbow instability. Regan-Morrey type III
fractures and O’Driscoll anteromedial facet fractures
can cause severe elbow instability; moreover, on the
basis of the extent of bone injury rather than ligament
injury, surgeons usually opt for the safer and more
reliable open fixation.22,24-28 However, the other types
of fractures may often be ignored during treatment,
which makes the outcomes more difficult to predict
than those of type III fractures. Open reduction for
small coronoid process fractures can be technically
challenging because it requires extensive exposure of
the fracture site and may result in the dissociation of the
attached residual anterior capsule.8,29 The damage to
the integrity of the anterior capsule would impair the
function as a stabilizer. Using arthroscopy can help
obtain intra-articular control of fracture reduction,
which enables perfect visualization to prevent damage
to the capsules and protect the blood supply.30,31 In our
study, all coronoid process fractures were treated with
arthroscopy. There were 4 cases of nonunion, which
did not influence the clinical outcomes. We believe that
nonunion (including fibrous union) did not impact
outcomes because restoration of the anterior capsular
attachment and anterior bony buttress is far more
important than articular incongruity in this area.
Savoie et al.18 compared arthroscopic repair or plica-
tion of the LUCL in 24 patients versus open repair,
plication, or reconstruction in 30 patients. They
reported significant improvements in Andrews-Carson
scores in each group, with no significant difference
between groups. In addition, Spahn et al.32 performed
electrothermal shrinkage of the LUCL in 21 patients
and reported significant improvements in clinical
 8
Table 1. Data of Patients Who Underwent All-Arthroscopic Treatment for Terrible Triad

Coronoid Fracture Radial Head Fracture Ligament Injury

Case Sex/Age, Regan-Morrey Mason LCL Complex MCL Duration of Injury
No. yr Classification OP Method Classification OP Method Injury Injury OP Method Follow-Up, mo Mechanism Complication
1 M/31 II K-wire fixation I Conservative Tx Yes No LUCL repair 50 Fall from height None
2 F/67 I Suture repair II Fixation Yes Yes LUCL repair 24 Slip None
3 M/55 II K-wire fixation II Partial excision Yes Yes LUCL repair 24 Slip None
4 F/62 II K-wire fixation I Conservative Tx Yes Yes LUCL repair 24 Slip None
5 F/61 II K-wire fixation II Partial excision Yes Yes LUCL repair 35 Slip None
6 M/41 II Suture repair III Fixation Yes Yes LUCL repair 32 Fall from height Nonunion
7 M/25 II K-wire fixation I Conservative Tx Yes Yes LUCL repair 29 Slip Nonunion
8 F/42 I Suture repair II Fixation Yes Yes LUCL repair 50 Slip ROM limitation
9 M/73 II K-wire fixation I Conservative Tx Yes Yes LUCL repair 27 Slip Incomplete LCL

S. H. LEE ET AL.
complex healing
10 M/72 II K-wire fixation I Conservative Tx Yes No LUCL repair 30 Slip None
11 M/56 I Suture repair II Partial excision Yes Yes LUCL repair 24 Fall from height None
12 M/20 I Suture repair I Conservative Tx Yes Yes LUCL repair 26 Fall from height None
13 M/39 II K-wire fixation II Fixation Yes Yes LUCL repair 28 Fall from height None
14 M/40 II K-wire fixation II Partial excision Yes Yes LUCL repair 27 Passenger traffic None
accident
15 F/61 II K-wire fixation II Partial excision Yes Yes LUCL repair 32 Slip Nonunion
16 M/72 II K-wire fixation II Partial excision Yes Yes LUCL repair 26 Passenger traffic Pin-site irritation
accident
17 F/67 I Suture repair I Conservative Tx Yes Yes LUCL repair 24 Slip None
18 M/28 II K-wire fixation I Partial excision Yes No LUCL repair 36 Slip None
19 M/22 II K-wire fixation II Partial excision Yes No LUCL repair 36 Slip None
20 M/45 II K-wire fixation III Partial excision Yes Yes LUCL repair 26 Fall from height None
21 M/46 I Suture repair II Partial excision Yes Yes LUCL repair 27 Passenger traffic None
accident
22 M/47 II K-wire fixation I Conservative Tx Yes Yes LUCL repair 26 Fall from height Nonunion
23 M/20 II Suture repair I Conservative Tx Yes Yes LUCL repair 26 Slip None
24 M/51 I Suture repair II Partial excision Yes Yes LUCL repair 26 Fall from height None
F, female; LCL, lateral collateral ligament; LUCL, lateral ulnar collateral ligament; M, male; MCL, medial collateral ligament; OP, operative; ROM, range of motion; Tx, treatment.
 ARTHROSCOPY FOR TERRIBLE TRIAD OF ELBOW
Table 2. Clinical Scores and ROM at Final Follow-Up
Affected Elbow Contralateral Elbow
MEPS, points 93 (75-100) 100
ROM,

Extension 4.8  1.1 0  0.3
Flexion 132.5  6.3 140  2.4
Supination 85  5.2 90  1.8
Pronation 81.5  4.8 90  1.5
NOTE. Data are presented as mean  standard deviation or mean
(range).
MEPS, Mayo Elbow Performance Score; ROM, range of motion.
outcomes. Recently, O’Brien et al.33 reported that acute
and subacute arthroscopic repairs of the radial ulno-
humeral ligament are safe and effective procedures for
patients with simple elbow dislocation. In our study,
only 1 patient had mild widening of the radiocapitellar
joint space with incomplete healing. No patient com-
plained of postoperative instability.
Considering the MCL’s role as the primary stabilizer
of the elbow joint, surgical management to repair the
torn MCL seems warranted.34,35 Nevertheless, a previ-
ous study on simple elbow dislocations showed no
significant differences in clinical outcomes between
patients who underwent surgical repair and those who
did not.34 Regarding the terrible-triad injury, Forthman
et al.11 concluded that MCL repair was unnecessary to
obtain satisfactory outcomes with surgical treatment.
Toros et al.36 reported no differences in functional
scores between a group with MCL repair and a group
without it. In addition, Hatta et al.37 supposed that the
effect of MCL repair on elbow motion and function
might be small when comparing patients who under-
went MCL repair for TTE and those who did not. Our
results support these previous findings; postoperative
elbow function was not necessarily affected by the
supplementation of MCL repair in the systematic
treatment of the terrible-triad injury. We found
20 cases (83.3%) of MCL injury and 24 cases (100%) of
LCL injury. In all patients with MCL and LCL injuries,
stability was obtained via only LCL repair.
We cautiously suggest that stability could be obtained
without MCL repair if coronoid process fixation
and LCL complex repair are securely performed
arthroscopically.
Limitations
The most significant limitation of this study is the
relatively low number of surgical interventions per-
formed for each indication. The second limitation is
that this study presents an analysis of patients treated
by a single surgeon experienced in elbow arthroscopy.
Elbow arthroscopy is a technically challenging pro-
cedure with a steep learning curve and may not be
suitable for occasional use in the treatment of elbow
pathology. Other limitations are the retrospective and
9
nonrandomized nature of the study, which can lead to
selection bias. To prevent bias from the learning curve,
P Value
arthroscopic surgery was performed for fractures after
.31
elbow arthroscopic surgery had been performed in
.24 more than 20 cases.
.34
.41
.28 Conclusions
All-arthroscopic treatment for the terrible triad can
provide an excellent safety profile without the need for
a large incision if the indications are met.
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