Surgical strategies for coronoid fixation in terrible triad elbow injuries: A comparative analysis of Tight-Rope and screw fixation

BACKGROUND: The terrible triad of the elbow describes a complex injury pattern characterized by elbow subluxation or dislocation, rupture of the lateral ulnar collateral ligament (LUCL), and concomitant fractures of the radial head and coronoid process. This study aimed to evaluate and compare the clinical outcomes of patients with terrible triad injuries treated surgically at our institution, in whom coronoid fractures were managed using either screw fixation or the Tight-Rope technique.
METHODS: This retrospective cohort study included patients who underwent surgical treatment for terrible triad injuries between January 2017 and December 2023. Patients with Regan–Morrey type 2 or 3 coronoid fractures treated using the Tight-Rope technique were assigned to the Tight-Rope group, whereas those treated with screw fixation comprised the Screw group. Demographic characteristics, range of motion (ROM), visual analog scale (VAS) scores, and QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) scores at 3, 6, and 12 months postoperatively were analyzed. Patients with type 1 fractures, medial collateral ligament (MCL) injuries, follow-up <12 months, or a history of systemic infection were excluded.
RESULTS: Twenty-nine patients were included (11 in the Tight-Rope group and 18 in the Screw group). No significant differences were observed between the groups in terms of ROM or VAS and QuickDASH scores at 3, 6, and 12 months. After excluding cases requiring LUCL reconstruction and analyzing only patients who underwent LUCL repair (8 Tight-Rope, 13 Screw), the only statistically significant difference was a lower 12-month QuickDASH score in the Screw group. Complications included superficial cellulitis (1 Tight-Rope, 2 Screw) and heterotopic ossification (2 Tight-Rope, 3 Screw), all of which were managed conservatively. Post hoc power analysis based on 12-month QuickDASH scores, VAS scores, and elbow ROM (effect size d=0.77, α=0.05) demonstrated power of 77%, 71%, and 74%, respectively.
CONCLUSION: Functional outcomes were largely comparable between Tight-Rope and screw fixation techniques. These findings align with emerging evidence questioning the routine necessity of coronoid fixation and underscore the importance of individualized surgical decision-making.

Keywords: Terrible triad, coronoid fracture, Tight-Rope, screw fixation, LUCL

Dirsek terrible triad yaralanmalarýnda koronoid fiksasyonuna yönelik cerrahi stratejiler: Tight-rope ve vida fiksasyonunun karþýlaþtýrmalý analizi

AMAÇ: Dirseðin “terrible triad” yaralanmasý; dirsek subluksasyonu veya dislokasyonu, lateral ulnar kollateral ligament (LUCL) yýrtýðý ve eþlik eden radius baþý ile koronoid kýrýklarýný içeren kompleks bir yaralanma paternini ifade eder. Bu çalýþma, kliniðimizde cerrahi olarak tedavi edilen terrible triad yaralanmalý hastalarda, koronoid kýrýklarýnýn vida fiksasyonu veya tight-rope tekniði ile tedavi edildiði hastalarýn klinik sonuçlarýný deðerlendir-meyi ve karþýlaþtýrmayý amaçlamaktadýr.
GEREÇ VE YÖNTEM: Bu geriye dönük kohort çalýþmasýna, Ocak 2017 ile Aralýk 2023 tarihleri arasýnda “terrible triad” yaralanmasý nedeniyle cerrahi tedavi uygulanan hastalar dâhil edilmiþtir. Regan–Morrey tip 2 veya 3 koronoid kýrýðý bulunan ve Tight-Rope tekniðiyle tedavi edilen hastalar Tight-Rope grubuna, vida fiksasyonu ile tedavi edilenler ise Vida grubuna ayrýlmýþtýr. Demografik özellikler ile birlikte 3., 6. ve 12. aylarda ölçülen ha-reket açýklýðý (ROM), görsel analog skala (VAS) ve QuickDASH skorlarý analiz edilmiþtir. Tip 1 kýrýðý olanlar, medial kollateral bað (MCL) yaralanmasý bulunanlar, 12 aydan kýsa takip süresi olanlar ve sistemik enfeksiyon öyküsü bulunan hastalar çalýþma dýþý býrakýlmýþtýr.
BULGULAR: Yirmi dokuz hasta çalýþmaya dâhil edildi (11 Tight-Rope, 18 Vida). Üç, altý ve on iki aylýk deðerlendirmelerde iki grup arasýnda Qu-ickDASH, ROM ve VAS skorlarý açýsýndan anlamlý bir fark saptanmadý. LUCL rekonstrüksiyonlarý dýþlanýp yalnýzca LUCL tamiri yapýlan hastalar incelendiðinde (8 Tight-Rope, 13 Vida), istatistiksel olarak anlamlý tek bulgu, vida grubunda 12. ay QuickDASH skorunun daha düþük olmasýydý. Komplikasyonlar arasýnda yüzeyel selülit (1 Tight-Rope, 2 Vida) ve heterotopik ossifikasyon (2 Tight-Rope, 3 Vida) yer aldý; tümü konservatif olarak tedavi edildi. Post-hoc güç analizi, 12. ay QuickDASH, VAS ve dirsek ROM deðerlerine göre (etki büyüklüðü d=0.77 ve α=0.05), sýrasýyla %77, %71 ve %74 güç gösterdiði görülmüþtür.
SONUÇ: Bu çalýþmanýn bulgularý, her iki tekniðin genel fonksiyonel sonuçlarýnýn benzer olduðunu göstermektedir. Elde edilen sonuçlar, koronoid fiksasyonunun rutin olarak uygulanmasýnýn gerekliliðini sorgulayan güncel literatürle uyumludur ve hasta bazlý, patolojiye özgü cerrahi karar verme süreçlerinin önemini vurgulamaktadýr.

Anahtar Kelimeler: Terrible Triad, Koronoid kýrýðý, Tight-Rope, Vida fiksasyonu, LUCL