Surgical treatment of terrible triad of the elbow: Retrospective continuous 50-patient series at 2 years' follow-up.

INTRODUCTION: Terrible triad (TT) of the elbow is an association at high risk of instability. Treatment aims to restore joint stability. Lateral collateral ligament (LCL) repair is systematic, whereas medial collateral ligament (MCL) repair is only exceptionally necessary. The main aim of the present study was to assess clinical results in TT surgery. The secondary objective was to compare clinical progression with versus without MCL repair. MATERIAL AND METHODS: A retrospective study included 50 TTs operated on via an isolated lateral or combined medial-lateral approach. Clinical assessment comprised MEPS, QuickDASH, VAS, flexion-extension and pronation-supination, and return to work and sport. Subgroup analysis was made according to associated MCL repair. RESULTS: Fifty patients (19 female, 31 male) were operated on between January 2006 and January 2017. Mean follow-up was 24 months. At last follow-up, mean MEPS was 89.1, VAS 0.7, QuickDASH 16, flexion-extension 114°, and pronation-supination 137°. Only MEPS was significantly improved by MCL repair (p=0.02), with no significant difference in complications. DISCUSSION: TT surgery with immediate mobilization gave good long-term functional results, not significantly improved by MCL repair. The lateral approach should be adopted in first line, with the medial approach in second line in case of persistent instability after lateral osteo-ligamentous repair. LEVEL OF EVIDENCE: IV; retrospective study.

Complications and outcomes in 69 consecutive patients with floating hip.

BACKGROUND: Floating hip is a rare and potentially serious injury. The objective of this study was to evaluate our management strategy for patients with floating hip. HYPOTHESIS: A standardized strategy with specialised multidisciplinary management is associated with a low mortality rate. METHODS: Consecutive patients who had surgery to treat floating hip between January 2010 and December 2019 were included in this single-centre retrospective study. Epidemiological, clinical, and radiological data were collected and analysed. Patients were managed according to a standardised strategy adapted to the haemodynamic status and type of floating hip (type A, femoral and pelvic ring fractures; type B, femoral and acetabular fractures; and type C, femoral, acetabular, and pelvic ring fractures). The clinical outcome at last follow-up was determined by a telephone interview, based on the Majeed and Oxford scores, sports resumption, and work resumption. To assess the radiological outcomes, we applied Matta's criteria for the acetabulum and Tornetta's criteria for the pelvic ring. RESULTS: We included 69 patients with a mean age of 38.5 years. Among them, 39 (57%) had haemodynamic instability requiring embolisation (n=15, 22%) or multiple blood transfusions (n=24, 35%). Type A injuries predominated (n=57, 83%). The need for multiple blood transfusions was significantly associated with type C floating hip, underlining the risk of heavy bleeding with this injury. Two (3%) patients died. When management was complete, the reduction was anatomical or satisfactory for 76% (13/17) of the acetabula according to Matta's criteria (maximum residual displacement <3mm) and for 85% (56/66) of the pelvic rings according to Tornetta's criteria (maximum residual displacement <10mm). One or more complications occurred in 45 (65%) patients. After a mean follow-up of 5 years, the mean Oxford Hip Score in patients with acetabular fractures was 35.5 and the mean Majeed score in patients with pelvic ring fractures was 71.5. Only 30% of patients were able to resume physical activities at the former level and to return to their former professional activities. CONCLUSION: Type C floating hip, which combines fractures of the pelvic ring and acetabulum, carries a high risk of bleeding. Special attention should be directed to the reduction of pelvic ring fractures, to avoid malunion. Acetabular fractures that are complex in the Letournel classification carry a risk of imperfect reduction. The results of this study confirm the severity of these rare injuries and the need for specialised multidisciplinary management according to a standardised strategy that is appropriate for the haemodynamic status and type of floating hip (A, B, or C). LEVEL OF EVIDENCE: IV; retrospective study.

Total Talar Prosthesis Replacement after Talar Extrusion.

Dislocation of the talus is a serious and extremely rare injury, with 86 cases reported in the published data in 20 years. The reference standard for case management involves replacement of the dislocated talus to restore the height and function of the tibiotalar joint. The risk of avascular necrosis remains very high, and the standard treatment in such cases is tibiotalar arthrodesis. We report the case of total dislocation of the talus, which was treated with the insertion of a custom total talar prosthesis affixed directly to the tibial cartilage at 6 months after injury. At the 2-year follow-up point, the preliminary results were rather encouraging, with well-functioning activity and an improved American Orthopaedic Foot and Ankle Society foot function scale score increasing from 11 to 77 of 100 and a Short-Form 36-item Health Survey score increasing from 17 to 82. Much longer follow-up periods are necessary to evaluate longer term trends.