Orthopedics

Review Article Supplemental Data

Comparison of Surgical Techniques for Fixation of Terrible Triad Injuries of the Elbow: A Meta-Analysis

Lili E. Schindelar, MD, MPH; Matthew Sherman, BS; Asif M. Ilyas, MD, MBA

Abstract

Treatment of the terrible triad injury of the elbow remains a difficult problem. There are several ways to treat the radial head and coronoid fractures; controversy still exists regarding the best way to treat each. The purpose of this meta-analysis was to compare the clinical outcomes of radial head and coronoid fractures treated using current protocols. No differences in functional outcomes were found between the different surgical techniques. There is no superior current protocol for treating these injuries. Surgical treatment should be dictated by fracture type and surgeon experience. [Orthopedics. 2020;43(6):328–332.]

Abstract

Treatment of the terrible triad injury of the elbow remains a difficult problem. There are several ways to treat the radial head and coronoid fractures; controversy still exists regarding the best way to treat each. The purpose of this meta-analysis was to compare the clinical outcomes of radial head and coronoid fractures treated using current protocols. No differences in functional outcomes were found between the different surgical techniques. There is no superior current protocol for treating these injuries. Surgical treatment should be dictated by fracture type and surgeon experience. [Orthopedics. 2020;43(6):328–332.]

The terrible triad injury of the elbow, dislocation of the ulnohumeral joint with fractures of the coronoid process and radial head, is difficult to treat and has a historically poor outcome. The inherent instability of terrible triad injuries, due to disruption of the bony stabilizers of the joint as well as the lateral ulnar collateral ligament (LUCL) and anterior capsule, lends them largely to surgical management.1 The primary goal of surgery is to restore stability and permit early range of motion of the joint. This generally consists of repair or replacement of the radial head, fixation of the coronoid process, and repair of the LUCL.

Controversy still exists regarding the best way to treat the radial head and coronoid fractures involved in this complex injury. There is no consensus to the optimal surgical treatment. The past decade has seen advances in surgical technique and implant design, and the application of treatment algorithms has improved outcomes for terrible triad injuries.2–5

However, there are still multiple methods for surgically treating the radial head and coronoid fractures. Debate remains regarding when the radial head requires replacement vs fixation.1,6–14 There is also controversy regarding whether the coronoid should be fixed with suture anchors, fixed with screws, or not fixed at all.3–5,8,9,11–13,15–19 Therefore, the best surgical protocol for treating terrible triad injuries of the elbow remains unclear.

The purpose of this meta-analysis was to review the clinical outcomes of radial head fractures and coronoid fractures treated using current protocols in patients with terrible triad injuries.

Materials and Methods

A literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Cochrane, PubMed, and Google Scholar databases were searched through October 2019 using the following keywords: “terrible triad elbow”, “radial head fractures”, “coronoid fractures”, “radial head arthroplasty”, “radial head replacement”, “radial head open reduction internal fixation”, “coronoid open reduction internal fixation”, and “coronoid suture”. Literature from the past 10 years was included. Randomized controlled trials, prospective studies, and retrospective studies were included. Studies were selected based on exclusion criteria by one of the authors (L.E.S.). Initial screening was based on title; subsequent selection was based on inclusion and exclusion criteria inferred from the abstract. Included articles had to have evaluated patients with terrible triad injuries who underwent surgical repair of the radial head, coronoid, or both and had functional outcomes reported. Final screening was based on full-text review, and articles included needed to have outcomes including Disabilities of the Arm, Shoulder and Hand (DASH) score, Mayo Elbow Performance Score (MEPS), or range of motion reported for each treatment modality of the radial head or coronoid fractures.

Data Extraction and Statistical Analysis

Data were extracted by one of the authors (L.E.S.) during full-text review. The following information was collected from each study: study title, first author, year of publication, study design, study group and treatment type, number of patients in each group, patients' age and sex, mean follow-up, Mason type, Regan-Morrey type, if the LUCL was repaired, if the medial collateral ligament was repaired, DASH scores, MEPS, range of motion, and complications. The data were then organized based on treatment type into the following groups: radial head arthroplasty, radial head open reduction and internal fixation (ORIF), radial head resection, no fixation of the radial head, coronoid ORIF, coronoid suture repair, and no fixation of the coronoid. Primary outcomes were DASH score, MEPS, and range of motion. Data for each treatment group were pooled. Analysis of variance or t testing was used for continuous data and proportions testing was used for categorical data to calculate P values. All statistical analyses were done using R Studio, version 3.6.1, software.

Results

The initial search identified 161 articles through database query. Based on title, 101 records were excluded for being irrelevant to the topic, not being in English, or being published prior to 2009. Sixty records were screened based on abstract, and 26 were excluded for not including primary outcome data. Thirty-four full-text articles were assessed for final eligibility; 2 were excluded for not reporting primary outcomes for each treatment group or not separating the coronoid fracture treatment group into separate functional outcomes. Ultimately, 18 articles were included in this meta-analysis (Figure 1).

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) search and selection process.

Figure 1:

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) search and selection process.

A total of 589 patients were included in this study. The mean age was 42.3 years, and the mean follow-up was 30.4 months.

One hundred seven patients received radial head arthroplasty, 174 patients underwent ORIF of the radial head, 35 patients had their radial head resected, and 19 patients had no treatment of the radial head (Table 1). The coronoid was treated with ORIF in 83 patients, 137 patients underwent suture fixation of the coronoid, and 63 patients had no treatment of the coronoid fracture (Table 2). There was no significant difference in demographics between the groups (Tables 12).

Radial Head Fracture Treatment

Table 1:

Radial Head Fracture Treatment

Coronoid Fracture Treatment

Table 2:

Coronoid Fracture Treatment

There were no significant differences in outcomes assessed by DASH score, MEPS, or range of motion for radial head fracture treatments. Mean DASH scores were 27.9 for arthroplasty, 8.0 for no fixation, 11.4 for ORIF, and 10.4 for resection (P=.58). Mean MEPS had less variability, with arthroplasty being 72.0, no fixation being 74.8, ORIF being 85.0, and resection being 87.2 (P=.66). Mean range of motion flexion arc was 110.0° for arthroplasty, 89.2° for no fixation, 112.0° for ORIF, and 120.0° for resection (P=.09). Mean supination-pronation range of motion arc was 126.0° with arthroplasty, 142.0° in the no fixation group, 127.0° with ORIF, and 124.0° with resection (P=.70) (Table 1).

There were no significant differences in outcomes assessed by DASH score, MEPS, or range of motion for coronoid fracture treatments. Mean DASH scores were 11.7 for no fixation of the coronoid, 15.9 for ORIF, and 17.7 for suture fixation (P=.33). Mean MEPS were 85.8 for no fixation, 79.9 for ORIF, and 90.5 for suture fixation (P=.29). Mean range of motion flexion arc was 116.0° for no fixation, 105.0° for ORIF, and 111.0° for suture fixation (P=.37). Mean supination-pronation range of motion arc was 141.0° for no fixation, 130.0° for ORIF, and 129.0° for suture fixation (P=.63) (Table 2).

When subgroup analysis was performed comparing radial head arthroplasty with radial head ORIF, there was no significant difference in DASH score, MEPS, or range of motion outcomes. Mean DASH score was 11.4 for ORIF compared with 27.9 for arthroplasty (P=.30). Mean MEPS was 85.0 for ORIF vs 72.0 for arthroplasty (P=.41). Mean flexion range of motion arc and supination-pronation arc were similar for both groups at 112.0° for ORIF vs 110.0° for arthroplasty and 127.0° for ORIF vs 126.0° for arthroplasty, respectively (P=.77 and P=.92, respectively).

Similarly, there were no significant differences in DASH score, MEPS, or range of motion outcomes when coronoid ORIF was compared with coronoid suture repair. Mean DASH scores were 15.9 for ORIF and 17.7 for suture repair (P=.76). Mean MEPS was 79.9 for ORIF vs 90.5 for suture (P=.15). Mean range of motion flexion arc was 105.0° vs 111.0° for ORIF vs suture (P=.43). Mean supinationpronation range of motion was 130.0° vs 129.0° for ORIF vs suture (P=.99).

Finally, when coronoid suture repair and ORIF were combined, and compared with no fixation of the coronoid, there were no significant differences in outcome scores. Mean DASH score for coronoid suture/ORIF was 17 compared with 11.7 for no fixation (P=.05). Mean MEPS for suture/ORIF was 85.2 vs 85.8 for no fixation (P=.93). Mean range of motion flexion arc was 108° for suture/ORIF vs 116° for no fixation (P=.18). Mean range of motion supination-pronation arc was 20.2° for suture/ORIF vs 15.4° for no fixation (P=.39).

There was a significant difference between total complications in the radial head fracture treatment group. In the no fixation group, there was a 50% total complication rate, compared with 35% for ORIF, 25% for arthroplasty, and 15% for resection (P=.04). However, there was no difference in complications when radial head arthroplasty was compared with ORIF alone: 24% vs 35% (P=.15). Coronoid fracture fixation had no significant difference in total complication rates, at 27%, 36%, and 28% in the no fixation, ORIF, and suture fixation groups, respectively (P=.51).

Discussion

This meta-analysis analyzed all relevant and current literature on the repair of radial head fractures and coronoid fractures in patients who had terrible triad injuries of the elbow. Eighteen studies with a total of 589 patients were included in this review.

Studies assessing the treatment of the radial head fracture had variable outcomes (Table A, available in the online version of the article). Yan et al6 compared radial head arthroplasty with ORIF and found that MEPS, flexion arc, and supinationpronation arc were significantly better in the arthroplasty group. Two other studies found no difference in range of motion between arthroplasty and ORIF.1,14 Leigh and Ball14 reported worse DASH scores with arthroplasty and a higher complication rate with ORIF. Interestingly, Mazhar et al10 compared radial head resection with arthroplasty and found that there was no difference in range of motion, DASH score, MEPS, or complications. Additionally, Chan et al19 showed that not fixing the radial head in select cases led to stable range of motion and a DASH score of 8 and a MEPS of 94. The results of the current meta-analysis demonstrate that there is no superior treatment for the radial head fracture in terrible triad injuries. Radial head arthroplasty comes with a learning curve to avoid complications (eg, prosthesis overstuffing).6 Longer-term outcomes are needed to determine if there are late complications to arthroplasty, as data are limited.

Demographics and Functional Outcomes of Included Studies: Radial Head Fracture TreatmentDemographics and Functional Outcomes of Included Studies: Radial Head Fracture TreatmentDemographics and Functional Outcomes of Included Studies: Radial Head Fracture Treatment

Table A:

Demographics and Functional Outcomes of Included Studies: Radial Head Fracture Treatment

Literature on the management of the coronoid fracture also showed little differences in outcomes (Table B, available in the online version of the article). Data on not fixing the coronoid fracture indicated functional range of motion, excellent MEPS (94) and DASH scores (14 and 8), and low complication rates.17,19 Garrigues et al3 compared suture fixation with ORIF of the coronoid, finding that the suture technique led to a stable elbow and had fewer complications than ORIF, with comparable range of motion and DASH scores. Novel techniques on suturing the coronoid fracture have shown promising results, with low complication rates, acceptable and stable range of motion, moderate disability (DASH score of 21), and good function (MEPS of 85).15,18

Demographics and Functional Outcomes of Included Studies: Coronoid Fracture TreatmentDemographics and Functional Outcomes of Included Studies: Coronoid Fracture TreatmentDemographics and Functional Outcomes of Included Studies: Coronoid Fracture Treatment

Table B:

Demographics and Functional Outcomes of Included Studies: Coronoid Fracture Treatment

Multiple studies focusing on a systemic approach to the terrible triad injury indicate that recent developments in better understanding of the biomechanics of the elbow, alterations to surgical approach, and improved fixation technique have led to good to excellent functional outcome scores and functional range of motion with stability and low complication rates, as compared with historical outcomes.2,8,9,11–13

A limitation of this study was the type of studies included in this systematic review: retrospective studies with level III and IV evidence. Only one randomized controlled trial was included. Some studies did not include specific data on the complications being reported, or did not report complications. Thus, the outcomes for complications may have been misrepresented. Also, not all studies included had complete functional outcome data (range of motion, DASH score, MEPS). Finally, arthroplasty techniques of the radial head require longer-term follow-up data to determine true functional outcomes and complications.

Conclusion

This meta-analysis indicated that there is no difference in functional outcomes between different surgical techniques for a fractured radial head and coronoid process in patients with terrible triad injuries. This would suggest that there is no superior current protocol for treating these injuries, and that surgical treatment should be dictated by fracture type and surgeon experience.

References

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  2. Fitzgibbons PG, Louie D, Dyer GSM, Blazar P, Earp B. Functional outcomes after fixation of “terrible triad” elbow fracture dislocations. Orthopedics. 2014;37(4):e373–e376. doi:10.3928/01477447-20140401-59 [CrossRef]. PMID:24762843
  3. Garrigues GE, Wray WH III, Lindenhovius ALC, Ring DC, Ruch DS. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am. 2011;93(20):1873–1881. doi:10.2106/JBJS.I.01673 [CrossRef]. PMID:22012524
  4. Liu G, Hu J, Ma W, Li M, Xu R, Pan Z. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach. J Int Med Res. 2018;46(8):3053–3064. doi:10.1177/0300060518771263 [CrossRef]. PMID:30027783
  5. Chen HW, Liu GD, Ou S, et al. Operative treatment of terrible triad of the elbow via posterolateral and anteromedial approaches. PLoS One. 2015;10(4):e0124821. doi:10.1371/journal.pone.0124821 [CrossRef]. PMID:25910196
  6. Yan M, Ni J, Song D, Ding M, Liu T, Huang J. Radial head replacement or repair for the terrible triad of the elbow: which procedure is better?ANZ J Surg.2015;85(9): 644–648. doi:10.1111/ans.13060 [CrossRef] PMID:25827024
  7. Chen HW, Wang ZY, Wu X, et al. Evaluation of a combined posterior lateral and anteromedial approach in the treatment of terrible triad of the elbow: a retrospective study. Medicine (Baltimore). 2017;96(22):e6819. doi:10.1097/MD.0000000000006819 [CrossRef]. PMID:28562532
  8. Liu G, Ma W, Li M, Feng J, Xu R, Pan Z. Operative treatment of terrible triad of the elbow with a modified Pugh standard protocol: retrospective analysis of a prospective cohort. Medicine (Baltimore). 2018;97(16):e0523. doi:10.1097/MD.0000000000010523 [CrossRef] PMID:29668642
  9. Galbiatti JA, Cardoso FL, Ferro JAS, Godoy RCG, Belluci SOB, Palacio EP. Terrible triad of the elbow: evaluation of surgical treatment. Rev Bras Ortop. 2018;53(4):460–466. doi:10.1016/j.rboe.2018.05.012 [CrossRef]. PMID:30027079
  10. Mazhar FN, Ebrahimi H, Jafari D, Mirzaei A. Radial head resection versus prosthetic arthroplasty in terrible triad injury: a retrospective comparative cohort study. Bone Joint J. 2018;100-B(11):1499–1505. doi:10.1302/0301-620X.100B11.BJJ-2018-0293.R1 [CrossRef] PMID:30418065
  11. Ikemoto RY, Murachovsky J, Bueno RS, Nascimento LGP, Carmargo AB, Corrêa VE. Terrible triad of the elbow: functional results of surgical treatment. Acta Ortop Bras. 2017;25(6):283–286. doi:10.1590/1413-785220172506168821 [CrossRef]. PMID:29375261
  12. Naoki Miyazaki A, Santos Checchia C, Fagotti L, et al. Evaluation of the results from surgical treatment of the terrible triad of the elbow. Rev Bras Ortop. 2014;49(3):271–278. doi:10.1016/j.rboe.2014.03.006 [CrossRef]. PMID:26229812
  13. Pierrart J, Bégué T, Mansat PGEEC. Terrible triad of the elbow: treatment protocol and outcome in a series of eighteen cases. Injury. 2015;46(suppl 1):S8–S12. doi:10.1016/S0020-1383(15)70004-5 [CrossRef]. PMID:26528938
  14. Leigh WB, Ball CM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg. 2012;21(10):1336–1341. doi:10.1016/j.jse.2012.03.005 [CrossRef]. PMID:22705316
  15. Zhang J, Tan M, Kwek EBK. Outcomes of coronoid-first repair in terrible triad injuries of the elbow. Arch Orthop Trauma Surg. 2017;137(9):1239–1245. doi:10.1007/s00402-017-2733-8 [CrossRef]. PMID:28634742
  16. Shi Y, Wang G-F, Mei K, et al. Use of mother-child screws in the treatment of coronoid fractures in terrible triad injury of the elbow. Acta Chir Orthop Traumatol Cech. 2018;85(2):102–108. PMID:30295595
  17. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. Terrible triad injuries of the elbow: does the coronoid always need to be fixed?Clin Orthop Relat Res.2014;472(7):2084–2091. doi:10.1007/s11999-014-3471-7 [CrossRef] PMID:24474322
  18. Pai V, Pai V. Use of suture anchors for coronoid fractures in the terrible triad of the elbow. J Orthop Surg (Hong Kong). 2009;17(1):31–35. doi:10.1177/230949900901700108 [CrossRef]. PMID:19398790
  19. Chan K, MacDermid JC, Faber KJ, King GJW, Athwal GS. Can we treat select terrible triad injuries nonoperatively?Clin Orthop Relat Res.2014;472(7):2092–2099. doi:10.1007/s11999-014-3518-9%20 [CrossRef] PMID:24549776

Radial Head Fracture Treatment

ParameterArthroplastyNo FixationORIFResectionP
Demographics for radial head fracture treatment
  Patients, No.1071917435
  Male47.4%60.0%60.0%64.7%.66
  Age, mean (SD), y41.2 (5.36)49.1 (9.99)40.7 (5.18)42.6 (7.67).32
  Follow-up, mean (SD), mo31.6 (15.5)30.5 (7.78)32.2 (19.6)43.8 (27.5).85
Functional outcomes for radial head fracture treatment
  DASH score, mean (SD)27.9 (31.4)8.0 (0)11.4 (3.37)10.4 (1.27).58
  MEPS, mean (SD)72.0 (32.0)74.8 (22.3)85.0 (5.93)87.2 (15.5).66
  ROM arc, mean (SD)110.0° (10.8°)89.2° (39.0°)112.0° (9.73°)120.0° (10.7°).09
  ROM flexion, mean (SD)130.0° (8.16°)112.0° (31.1°)130.0° (6.75°)129.0° (9.12°).18
  ROM flexion contracture, mean (SD)19.7° (6.84°)23.0° (24.0°)17.8° (5.03°)9.1° (8.11°).17
  ROM supination-pronation arc, mean (SD)126.0° (17.3°)142.0° (35.8°)127.0° (13.8°)124.0° (28.9°).70
  ROM supination, mean (SD)63.7° (8.19°)78.5° (4.95°)65.1° (8.29°)61.0° (11.3°).17
  ROM pronation, mean (SD)63.3° (13.0°)83.5° (4.95°)66.2° (8.15°)63.4° (18.0°).22
  Complications24.6%50.0%35.1%15.2%.04

Coronoid Fracture Treatment

ParameterNo FixationORIFSuture FixationP
Demographics for coronoid fracture treatment
  Patients, No.6383137
  Male54.4%67.1%65.0%.33
  Age, mean (SD), y48.7 (6.09)40.8 (8.64)40.6 (6.81).21
  Follow-up, mean (SD), mo31.0 (21.0)16.8 (9.03)30.7 (19.7).44
Functional outcomes for coronoid fracture treatment
  DASH score, mean (SD)11.7 (2.60)15.9 (10.8)17.7 (2.53).33
  MEPS, mean (SD)85.8 (8.68)79.9 (12.7)90.5 (7.52).29
  ROM arc, mean (SD)116.0° (9.75°)105.0° (20.3°)111.0° (12.5°).37
  ROM flexion, mean (SD)131.0° (4.53°)127.0° (12.2°)126.0° (14.2°).67
  ROM flexion contracture, mean (SD)15.4° (6.43°)22.8° (9.60°)18.1° (8.65°).27
  ROM supination-pronation arc, mean (SD)141.0° (24.2°)130.0° (25.5°)129.0° (14.0°).63
  ROM supination, mean (SD)70.7° (12.5°)62.6° (11.6°)67.2° (9.08°).50
  ROM pronation, mean (SD)70.3° (15.2°)67.0° (14.0°)65.3° (9.51°).83
  Complications26.7%35.9%28.5%.51

Demographics and Functional Outcomes of Included Studies: Radial Head Fracture Treatment

Demographics and Outcomes of Included Studies: Radial Head Treatment
InterventionFirst Author (Year)DesignNo. of SubjectsMean Age, yMean Followup, moDASHMEPSROM Flexion ArcROM FlexionROM Flexion ContractureROM Supination-Pronation ArcROM SupinationROM PronationComplications
Radial Head ArthroplastyYan (2015)RCT2036.536.0.85.8101.4117.417.0114.151.163.04
Watters (2013)Retrospective30..16.1.118.0137.020.0...3
Liu (3, 2018)Retrospective448.029.5.92.5115.0135.020.0142.570.072.50
Galbiatti (2018)Retrospective10.6.014.8.100.5126.526.0126.062.064.0.
Mazhar (2018)Retrospective1536.045.813.988.7112.3131.319.0120.061.558.510
Ikemoto (2017)Retrospective1040.1.84.015.795.0119.024.0104.562.542.0.
Pierrart (2015)Retrospective7...77.1112.1138.626.4....
Leigh (2012)Retrospective1145.540.710.9.128.0135.05.0150.075.080.0.
Total10741.231.627.972.0110.0130.019.7126.063.763.317
Radial Head No FixationChen (2017)Retrospective738.3..50.489.5..101.2...
Liu (3, 2018)Retrospective158.025.0.80.050.090.040.0155.075.080.01
Chan (2014)Retrospective1151.036.08.094.0128.0134.06.0169.082.087.05
Total1949.130.58.074.889.2112.023.0142.078.583.56
Radial Head ORIFYan (2015)RCT1935.536.0.77.992.4114.622.2103.149.556.79
Shi (2018)Prospective1847.217.67.192.0130.0137.07.0148.069.079.05
Watters (2013)Retrospective9..15.7.106.0130.024.0...5
Chen (2017)Retrospective3737.5..89.9116.5..125.5...
Liu (3, 2018)Retrospective3748.030.7.88.5108.4128.119.7142.970.372.610
Galbiatti (2018)Retrospective2.6.011. 9.112.5127.515.0127.562.565.0.
Ikemoto (2017)Retrospective1036.5.13.283.0105.5126.020.5125.568.057.7.
Miyazaki (2013)Retrospective1137.862.7..115.9133.617.7123.661.462.34
Pierrart (2015)Retrospective18...79.0115.0134.019.0....
Leigh (2012)Retrospective1342.240.59.2.115.0135.015.0120.075.070.0.
Total17440.732.211. 485.0112.0130.017.8127.065.166.233
Radial Head ResectionMazhar (2018)Retrospective2940.724.49.591.7115.8133.617.8117.060.656.45
Ikemoto (2017)Retrospective136.0.11.3100.0135.0140.05.0100.050.050.0.
Miyazaki (2013)Retrospective451.063.3..110.0123.813.8156.372.583.80
Pierrart (2015)Retrospective1...70.0120.0120.00.0....
Total3542.643.810. 487.2120.0129.09.2124.061.063.45

Demographics and Functional Outcomes of Included Studies: Coronoid Fracture Treatment

Demographics and Outcomes of Included Studies: Coronoid Treatment
InterventionFirst Author (Year)DesignNo. of SubjectsMean Age, yMean Follow up, moDASHMEPSROM Flexion ArcROM FlexionROM Flexion ContractureROM Supination-Pronation ArcROM SupinationROM PronationComplications
Coronoid No FixationPapatheodorou (2014)Prospective1452.024.014.0.123.0134.011.0145.064.082.01
Galbiatti (2018)Retrospective2.7.012.8.102.5125.022.5117.557.560.0.
Ikemoto (2017)Retrospective1639.6.11.986.6107.5126.318.8114.464.150.3.
Miyazaki (2013)Retrospective552.257.0..121.0134.013.0158.086.072.02
Chan (2014)Retrospective1151.036.08.094.0128.0134.06.0169.082.087.05
Pierrart (2015)Retrospective15...76.7114.3135.321.0....
Total6348.731.011.785.8116.0131.015.4141.070.770.38
Coronoid ORIFShi (2018)Prospective1847.217.67.192.0130.0137.07.0148.069.079.05
Garrigues (2011)Retrospective5..11.0.116.0138.022.0...7
Liu (2018)Retrospective15...86.7112.4129.717.3137.768.069.7.
Liu (3, 2018)Retrospective2949.228.0.85.7104.0124.720.7140.968.572.48
Chen (2015)Retrospective1233.615.5..105.0125.020.0126.060.066.03
Galbiatti (2018)Retrospective1.6.014.0.110.0135.025.0145.070.075.0.
Ikemoto (2017)Retrospective133.0.31.660.060.0100.040.080.040.040.0.
Pierrart (2015)Retrospective2...75.0100.0130.030.0....
Total8340.816.815.979.9105.0127.022.8130.062.667.023
Coronoid SutureZhang (2017)Prospective1346.427.721.185.0105.090.015.0114.9..4
Watters (2013)Retrospective3948.024.016.0.115.0.....0
Garrigues (2011)Retrospective28..16.0.118.0136.018.0...10
Garrigues (2011)Retrospective7..19.0.103.0133.030.0...12
Liu (2018)Retrospective7...91.4110.2128.818.6145.872.972.9.
Liu (3, 2018)Retrospective1346.035.0.95.0115.8135.019.2148.174.773.53
Galbiatti (2018)Retrospective9.5.814.7.101.7126.124.4126.162.263.9.
Pai (2009)Retrospective633.726.0..114.2124.210.0...2
Ikemoto (2017)Retrospective434.0.19.581.390.0117.527.5122.572.550.0.
Miyazaki (2013)Retrospective1035.865.8..111.0129.518.5119.553.566.02
Pierrart (2015)Retrospective1...100.0140.0140.00.0....
Total13740.630.717.790.5111.0126.018.1129.067.265.333
Authors

The authors are from the Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Asif M. Ilyas, MD, MBA, Rothman Institute at Thomas Jefferson University, 925 Chestnut St, Philadelphia, PA 19107 ( asif.ilyas@rothmanortho.com).

Received: April 03, 2020
Accepted: May 18, 2020
Posted Online: October 01, 2020

10.3928/01477447-20200923-04

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