JSES - 2026-05-26 - Journal Article
Has the Internal Joint Stabilizer Altered the Need for a Medial Approach in Triad Injuries?
Phillips T, Casanova C, Fiedler B, Phan E, Morrow B, Mitchell S
Topics
Key Takeaway
Introduction of the internal joint stabilizer (IJS) into the terrible triad treatment algorithm reduced the medial approach rate to 3.9% versus a historical mean of 38.3% (RR 0.10, p<0.001).
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Summary
This study asked whether IJS use reduces the need for supplemental medial approaches in terrible triad injuries. A retrospective case series of 51 patients treated at a single high-volume institution (October 2018–July 2025) was compared against a meta-analytic historical baseline; 70.6% received the IJS and only 3.9% required a medial approach. The risk ratio for medial approach in the post-IJS cohort versus historical controls was 0.10 (p<0.001), with historical rates ranging 18.2–53.3% (mean 38.3%).
Key Limitation
The retrospective, non-randomized design with a historically derived comparator cannot exclude selection bias, as surgeons may have preferentially used the IJS in less severe injuries or avoided it in patterns already planned for a medial approach.
Original Abstract
BACKGROUND
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.
METHODS
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 internal joint stabilizer (IJS) and/or external fixation. Coronoid fractures were classified based on CT 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.
RESULTS
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 < 0.001).
CONCLUSIONS
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.
LEVEL OF EVIDENCE
Level IV, Case Series, Treatment Study.