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Introduction: The terrible triad injury of the elbow (TTIE) remains challenging to manage and has been associated with high complication rates and poor outcomes. There is a trend towards performing radial head replacement (REP) in preference to radial head reconstruction (REC) as arthroplasty provides early stability and may allow mobilisation sooner, potentially resulting in a better functional outcome. This systematic review compares the outcome of patients with TTIE treated with either REC or REP.Materials and Methods: MEDLINE, Embase, and CINAHL were searched for studies published in English involving at least ten patients exclusively with a TTIE managed operatively, including both patients with either REC or REP. Data collection was in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis protocol. The outcomes of interest were Mayo Elbow Performance Score (MEPS) and range of motion (ROM). Post-operative complications were also compared.Results: 9 studies involving 210 patients were included (98 REPs and 112 RECs). There was no statistically significant difference (p = 0.51) demonstrated between in the mean MEPS of the REP group (mean 88.6) and REC group (mean 88.5). Similarly, there was no statistically significant difference demonstrated between the REP and REC groups in terms of ROM. The risk of re-operation was high in both the REP (18.4%) and REC (17.9%) group. The overall complication rate of all patients included in the study was high (65%).Conclusions: Comparable results with good outcomes in terms of functional scores and ROM can be achieved with both REP and REC when treating TTIE, although the re-operation rate for both remains relatively high. Given there is no apparent clear advantage between the two treatment groups, we would suggest that REC should be performed when a satisfactory fixation can be achieved as the longevity of REP in young patients with a TTIE is currently uncertain. [ABSTRACT FROM AUTHOR]