Terrible triad injury of the elbow: a historical perspective.

PURPOSE: The aims of this study are to summarize (1) the history of terrible triad injury (TTi) treatment and (2) the clinical and biomechanical data that engendered its evolution. METHODS: A literature search was performed using five electronic databases. Results were discussed as a chronologic review of the relevant literature between 1920 and 2022. RESULTS: In 1962, Osborne was the first to describe a link between elbow dislocation, radial head fracture, and lateral collateral ligament complex injury via a novel mechanism: posterolateral rotatory instability (PLRI). Given that untreated elbow instability leads to post-traumatic osteoarthritis (PTOA), there has been increasing interest in elbow biomechanics since the 1980s. Data from studies in that period revolutionized the approach to elbow instability. The authors demonstrated that TTi could occur via a PLRI mechanism with a disruption of the lateral collateral ulnar ligament and a functionally competent anterior medial collateral ligament (aMCL). Since the 1990s, due to the difficulty in identifying its pathoanatomic features, some began to speculate about a sequence of injuries and mechanisms leading to TTi. However, the clinical literature has largely been unable to reproduce in vitro findings describing the pathomechanics of TTi. Some aspects of treatment remain controversial including systematic coronoid and aMCL repair. CONCLUSION: Despite a growing body of biomechanics data, there is no widely accepted surgical protocol for the treatment of TTi. Functional outcomes among patients have greatly improved. Better diagnosis and treatment of infra-clinical instability after a TTi may be an important stepping stone to prevent the onset of moderate/severe PTOA.

The human costal cartilage: Anatomical and radiological study of macro-vascularization and micro-vascularization and its clinical relevance regarding vascularized chondrocostal free flap surgery.

INTRODUCTION: Cartilage repair usually involves in non-vascularized osteochondral or chondral grafts with some drawbacks potentially linked to the lack of vascular supply in those grafts. The aim of this study was to describe a surgical approach for harvesting a vascularized chondrocostal graft, to study the vascular supply to the perichondrium and finally to describe the perichondrium micro-vascularization in order to know how such grafts could be used in cartilage repair surgery. MATERIALS AND METHODS: We harvested and studied 18 costal cartilages harvested from 12 fresh anatomical subjects. The anatomic pieces were injected with a radio-opaque tracer, analyzed macroscopically, then a plain X-rays and CT scan analysis with three-dimensional rendering was performed in order to evaluate the characteristics of the different patterns of their vascularization. RESULTS: The surgical approach to harvest a vascularized 5th chondrocostal graft is explained in detail. All of the cartilages were vascularized by the internal thoracic artery and harvested with a pedicle of an average length of 34mm and diameter of 2.14mm. In all specimens, perichondrium vascularization arises from both superior and inferior intercostal branches. Anastomoses between inferior and superior intercostal branches are always found in all specimens at the level of the epichondrium. CONCLUSIONS: The anatomic approach for harvesting a vascularized chondrocostal graft is simple and only slightly differs from the approach described for harvesting a non-vascularized chondrocostal graft. The vascular supply to the perichondrium of such a vascularized chondrocostal graft is sustained by the internal thoracic vessels which have a sufficient diameter and length to allow easy micro-anastomosis. The organization of the micro-vasculature within the perichondrium allows the graft to be tailored to a large cartilage defects and also to small bipolar cartilage defects.