Has the internal joint stabilizer altered the need for a medial approach in triad injuries?

Surgeons historically repair terrible triad injuries of the elbow with a laterally based approach, adding a secondary medial approach when adequate stability is not achieved with lateral repair alone. The internal joint stabilizer (IJS) (Skeletal Dynamics, Inc. Miami, Florida, USA) may improve joint stability from the standard lateral approach, potentially decreasing the need for a secondary medial approach or supplementary procedures. The purpose of this study was to determine the effect of the introduction of internal joint stabilization on the rate of supplemental medial approaches in the treatment of terrible triad injuries.

This study utilized a retrospective case series comparing data from a high-volume academic institution in the post-IJS era to historical data from pre-IJS years. A review was conducted of all terrible triad cases treated from a single institution from October 2018 to July 2025. Medical records were reviewed to extract patient demographics, injury characteristics, surgical approaches and procedures utilized, and use of the IJS and/or external fixation. Coronoid fractures were classified based on computed tomography imaging using the O'Driscoll and Regan-Morrey systems. A meta-analysis literature review was conducted to determine historical rates of medial approach for terrible triad injuries prior to IJS use. Risk ratio calculations were used to compare pre-IJS medial approach rate to post-IJS medial approach rate.

In the post-IJS cohort, 36 of 51 patients received the IJS (70.6%), with 2 of 51 (3.9%) patients requiring a supplemental medial approach. Literature review shows historical rates of medial approach pre-IJS ranging from 18.2-53.3% (mean 38.3%). The risk ratio for medial approach in the post-IJS cohort relative to historical findings is 0.10 (P < .001).

The present study found that the incorporation of the IJS into the treatment algorithm of terrible triad injuries of the elbow is associated with a decreased need for medial-sided approaches. While some fracture and injury patterns will continue to necessitate a medial approach, the IJS adds a valuable tool to the arsenal in the treatment of unstable elbow fracture-dislocations and should be regularly considered in the treatment algorithm.