Which is the optimal surgical strategy for the terrible triad of the elbow?

To compare and rank the clinical outcomes of commonly used surgical strategies for the terrible triad of the elbow (TTE) using a network meta-analysis (NMA).

Major databases were searched from inception to September 2025 for comparative studies evaluating different surgical approaches for TTE. Primary outcomes were the Mayo Elbow Performance Score (MEPS) excellent-good rate and complication incidence. Secondary outcomes included elbow flexion-extension range of motion (ROM), forearm rotation ROM, and fracture healing time. A frequentist NMA framework was applied to estimate comparative effects and rank strategies.

Fourteen studies involving 866 patients were included. The Lateral + Anteromedial (L + AM) approach demonstrated a higher probability of achieving favorable MEPS outcomes and lower complication rates. The Anterolateral (AL) and Anteromedial (AM) approaches ranked more favorably in restoring flexion-extension and forearm rotation ROM. No significant differences in fracture healing time were observed across strategies. Overall heterogeneity and inconsistency were low.

The L + AM approach appears to offer a favorable balance between functional outcomes and complication risk, whereas AL and AM approaches may provide advantages in postoperative mobility. As all included studies were retrospective and heterogeneous in design, these findings should be interpreted with caution. High-quality prospective studies are required to validate these results.