Postoperative mobilization after terrible triad injury: systematic review and single-arm meta-analysis

Abstract

Background: Terrible triad is a complex injury of the elbow, involving elbow dislocation with associated fracture of the radial head, avulsion or tear of the lateral ulnar collateral ligament and fracture of the coronoid. These injuries are commonly managed surgically with fixation or replacement of the radial head, repair of collateral ligaments, with or without fixation of the coronoid. Postoperative mobilization is a significant factor that may affect patient outcomes; however the optimal postoperative mobilization protocol is unclear. This study aims to systematically review the available literature regarding postoperative rehabilitation of terrible triad injuries to aid clinical decision-making. Methods: We systematically reviewed PubMed, Embase, Cochrane and CINAHL in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were studies with populations aged 16 years or over with terrible triad injury, underwent operative treatment, defined a clear postoperative mobilization protocol and reported the Mayo Elbow Performance Score (MEPS). Secondary outcomes were pain, instability, and range of motion (ROM). Postoperative mobilization was classified as 'early', defined as active ROM commenced up to 14 days, or 'late', defined as active ROM commenced after 14 days. Results: A total of 119 articles were identified from the initial search, of which 11 (301 patients) were included in the final review. The most common protocols (6 studies) favored early mobilization, whilst 5 studies undertook late mobilization. Meta-regression analysis including mobilization as covariate showed an estimated mean difference of pooled mean MEPS between early and late mobilization of 6.1 points (95% CI 0.2 - 12) with higher pooled mean MEPS in early mobilization (MEPS 91.2) compared to late mobilization (MEPS 85), p = 0.041. Rate of instability reported ranged from 4.5 - 19%, (8-11.5% early mobilization, 4.5-19% late mobilization). Conclusion: Our findings suggest that early postoperative mobilization may confer a benefit in terms of functional outcome following surgical management of terrible triad injuries, without appearing to confer an increased instability risk. Further research in the form of randomized controlled trials between early and late mobilization is advised to provide a higher level of evidence.