Introduction Terrible triad injuries (TTIs) of the elbow have traditionally been reported to have poor outcomes, hence requiring surgical stabilisation. We identified and reviewed patients with TTIs treated non-operatively within our department. Methods We retrospectively reviewed patients with TTI treated non-operatively with standardised elbow-instability rehabilitation from 2010 to 2020. We used Mason and Morrey classifications for radial head and coronoid fractures, respectively. Non-operative indications included a congruent joint on CT, significant co-morbidities pre-disposing to high-risk surgery and/or patient preference. Outcomes included Oxford Elbow Score (OES), ROM and complications. Results Nineteen patients were included (mean age 49; 37% female). At an average of 6 years (range 2–11 years) post-treatment, mean OES was 46 ± 7. At last clinic review, mean 6 months (2–15), average ROM was 131 ± 11° flexion, 8 ± 10° extension, 85 ± 12° supination and 85 ± 13° pronation. One patient required arthrolysis and another had an incongruent ulnohumeral joint which developed clicking with a functional ROM. Conclusion Our report suggests non-operatively managed and appropriately rehabilitated TTI injuries can achieve good function and ROM. We recommend conservative management as a viable option in cases with joint congruency and no mechanical block in patients with significant co-morbidities or those refusing surgery but patients must be assessed on a case-by-case basis.

Background:Radial head fractures represent 1-4% of all adult fractures and 1/3rd of elbow fractures (Kaas et al., 2010). Radial head is an important secondary stabilier of the elbow. The aim of the treatment of radial head fractures is to achieve stability and good functional outcome. Radial head replacement (RHR) is indicated when robust reconstruction and fixation of the fracture fragments is not possible. Methods:This article explores history and evolution, anatomical considerations, biomechanics, implant designs, indications, surgical outcomes and controversies in radial head replacement based on current evidence. Results:There is a wide range of RHR designs available without conclusive evidence to support the superiority of one design over the other. Ranges of motion, functional outcomes and complication were comparable among different designs with a high incidence of complications reported in many studies. Conclusion:RHR remains a good option in unreconstructible radial head fractures, with potential to regain excellent function. It is imperative to continue with the quest to innovate and improve on current designs, to reduce complications in the long term.

Background: Revisions of total elbow arthroplasties (TEAs) are commonly performed because of prosthetic loosening. UK National Joint Registry data show that TEA revisions are becoming increasingly common, with 123 TEA revisions performed in 2018 and 76 performed in 2017. TEA radiologic assessment is based on subjective interpretation with no published criteria. We defined TEA loosening by the presence of at least one of the following criteria: (1) progressive widening of the bone-cement, bone-prosthesis, or cement prosthesis interface; (2) fragmentation or fracture of cement; (3) prosthetic component migration; and (4) bead shedding in porous coated prostheses. Using this definition, we looked at interobserver and intraobserver agreement on radiologic loosening and compared this assessment with intraoperative findings. Methods: In our tertiary care center, we conducted a retrospective review to identify TEA revisions performed between November 2008 and July 2018. Radiologic implant loosening was independently assessed by 5 orthopedic surgeons. Interobserver agreement (kappa coefficient) was calculated. The majority's view of radiologic loosening was compared with intraoperative findings. Results: We identified 93 sets of radiographs with implant stability clearly documented in their operative notes. The kappa coefficient between assessors for humeral implant loosening was 0.87 (almost perfect). The kappa coefficient for ulnar loosening was 0.75 (substantial). The kappa coefficients for radiologic and intraoperative findings of humeral loosening and ulnar loosening were 0.67 and 0.71 (substantial), respectively. Intraobserver reliability was almost perfect for humeral loosening (K = 0.86) and substantial for ulnar loosening (K = 0.74). Conclusion: Our definition of loosening provides reproducible interobserver and intraobserver agreement on radiographic component loosening. In our center's experience, radiologic findings may not translate to intraoperative findings, and we would advise that surgical strategies for TEA revision include the possibility of needing to perform a dual-implant exchange. Level of evidence: Level IV; Case-Control Design; Diagnosis Study Crown Copyright (c) 2021 All rights reserved.

Background: Revision total elbow arthroplasty (TEA) is a challenging procedure that is becoming increasingly common. In our unit, we regard it as essential to exclude infection as the underlying cause of TEA loosening. In all patients with arthroplasty loosening, we undertake a careful history and examination, perform radiographs, monitor inflammatory markers, and undertake a joint aspiration. If any investigation suggests infection as the etiology, then a 2-stage revision is undertaken. Open biopsies are not routinely performed. The aim was to ascertain from our outcomes whether it is safe to perform a single-stage revision for presumed aseptic loosening using these criteria. Methods: A retrospective review of a consecutive series of revision TEAs was performed in our unit over a 10-year period (2008-2018). Single-stage revisions performed for presumed aseptic loosening were identified. Case notes, radiographs, bloods, aspiration results, and microbiology of tissue samples taken at revision were reviewed. Results: A total of 123 revision elbow arthroplasty cases were performed in the study period. Sixty cases were revised for preoperatively proven infection, instability, or implant failure and were excluded from this study. In 63 cases, aseptic loosening was diagnosed based on history, clinical examination, blood markers, and aspiration. There were 21 dual-component and 42 single-component revisions. In the dual-component revision group, tissue samples taken at the time of revision were positive in only 1 case (5%). In the single-component revision group, positive culture samples were present in 3 cases (7%). chi(2) analysis showed no significant difference between single- and dual-component revisions (P = .76). No cases with positive culture samples from either group have required subsequent revision surgery. Conclusion: Given the results of this study, we conclude that is safe to perform single-stage revision arthroplasty for implant loosening based on history, examination, normal inflammatory markers, and negative aspiration results without the need for open biopsy. (C) 2020 All rights reserved.

Total Elbow Replacements are indicated for pain and disability in patients with rheumatoid and osteoarthritis of the elbow. The quality of the cementation has been specifically studied and shown to...

Osteochondral lesions (OCL) of the talus occur in 38% of the patients with supination external rotation type IV ankle fractures and 6 % of ankle sprains. Osteoarthritis is reported subsequently in 8–48% of the ankles. Several marrow stimulation methods have been used to treat the symptomatic lesion, including arthroscopic debridement and micro fracture. Encouraging midterm results have been reported, but longterm outcome is unknown in relation to more invasive treatments such as transfer of autologous osteoarticular tissue from the knee or talus (OATS), autologous chondrocyte implantation (ACI), frozen and fresh allograft transplantation.AimThe aim of our study was to review our long term results of arthroscopic treatment of osteochondral lesions of the talus.Materials and methods65 patients underwent arthroscopic treatment of the OCL between 1993 and 2000. There were 46(71%) men and 19(29%) women. The mean age at surgery was 34.2 years. The right side was affected in 43 patients and the left side in 22 p...

AIMS Glenoid bone loss can be a challenging problem when revising a shoulder arthroplasty. Precise pre-operative planning based on plain radiographs or CT scans is essential. We have investigated a new radiological classification system to describe the degree of medialisation of the bony glenoid and that will indicate the amount of bone potentially available for supporting a glenoid component. It depends on the relationship between the most medial part of the articular surface of the glenoid with the base of the coracoid process and the spinoglenoid notch: it classifies the degree of bone loss into three types. It also attempts to predict the type of glenoid reconstruction that may be possible (impaction bone grafting, structural grafting or simple non-augmented arthroplasty) and gives guidance about whether a pre-operative CT scan is indicated. PATIENTS AND METHODS Inter-method reliability between plain radiographs and CT scans was assessed retrospectively by three independent observers using data from 39 randomly selected patients. Inter-observer reliability and test-retest reliability was tested on the same cohort using Cohen's kappa statistics. Correlation of the type of glenoid with the Constant score and its pain component was analysed using the Kruskal-Wallis method on data from 128 patients. Anatomical studies of the scapula were reviewed to explain the findings. RESULTS Excellent inter-method reliability, inter-observer and test-retest reliability were seen. The system did not correlate with the Constant score, but correlated well with its pain component. TAKE HOME MESSAGE Our system of classification is a helpful guide to the degree of glenoid bone loss when embarking on revision shoulder arthroplasty.

Dislocations of the sternoclavicular joint (SCJ) occur with relative infrequency and can be classified into anterior and posterior dislocation, with the former being more common. The SCJ is inherently unstable due to its lack of articular contact and therefore relies on stability from surrounding ligamentous structures, such as the costoclavicular, interclavicular and capsular ligaments. The posterior capsule has been shown in several studies to be the most important structure in determining stability irrespective of the direction of injury. Posterior dislocation of the SCJ can be associated with life threatening complications such as neurovascular, tracheal and oesophageal injuries. Due to the high mortality associated with such complications, these injuries need to be recognised acutely and managed promptly. Investigations such as X-ray imaging are poor at delineating anatomy at the level of the mediastinum and therefore CT imaging has become the investigation of choice. Due to its rarity, the current guidance on how to manage acute and chronic dislocations is debatable. This analysis of historical and recent literature aims to determine guidance on current thinking regarding SCJ instability, including the use of the Stanmore triangle. The described methods of reduction for both anterior and posterior dislocations and the various surgical reconstructive techniques are also discussed.

The LockDown device (previously called Surgilig) is a braided polyester mesh which is mostly used to reconstruct the dislocated acromioclavicular joint. More than 11,000 have been implanted worldwide. Little is known about the tissue reaction to the device nor to its wear products when implanted in an extra-articular site in humans. This is of importance as an adverse immunological reaction could result in osteolysis or damage to the local tissues, thereby affecting the longevity of the implant. We analysed the histology of five LockDown implants retrieved from five patients over the last seven years by one of the senior authors. Routine analysis was carried out in all five cases and immunohistochemistry in one. The LockDown device acts as a scaffold for connective tissue which forms an investing fibrous pseudoligament. The immunological response at the histological level seems favourable with a limited histiocytic and giant cell response to micron-sized wear particles. The connective tissue envelope around the implant is less organised than a native ligament.

We report on a rare case of myositis ossificans of the humeral insertion of pectoralis major muscle following a single episode of trauma which, to our knowledge, has not previously been documented.

We present the first ever case report of a floating clavicle with a unique combination of a posterior sternoclavicular joint dislocation and an associated grade III acromioclavicular joint dislocation. We treated this injury surgically by stabilizing both ends of clavicle using a polyester surgical mesh device (LockDown™; Mandaco 569 Limited, Redditch, UK; previously called the Nottingham Surgilig).

AIM:The aim of our study was to review our experience of the extended lateral approach to the hind foot in treatment of non-traumatic foot disorders with particular reference to wound complications.MATERIALS AND METHODS:We retrospectively reviewed 51 consecutive patients who under went extended lateral approach to the hind foot for treatment of various non traumatic foot disorders. We documented the indication for surgery, co-morbidity, quality of wound healing and other wound related problems.RESULTS:The mean age was 47.9. There were three superficial wound infections (5.8%). One had slight sensory loss close to the scar, one developed hypersensitivity over the scar. There was no wound break down or any deep infection. No sural nerve deficit was noted. Six patients had the calcaneal screw removed due to prominent metal work (11.7%).CONCLUSION:The extended lateral approach to hind foot is safe in the surgical treatment of a wide variety of non-traumatic foot conditions. Despite the larger deep dissection, the arterial anatomy ensures reliable wound healing and a low incidence of wound complications.

In a prospective study we assessed 440 patients, sequentially admitted to the trauma unit with hip fracture. The superficial infection rate was 7.7% and the deep infection was 1.8%. The commonest organism responsible for surgical site infection was MRSA (47.6%). 45.2% of the patients with SSI and 50 % of the patients with MRSA wound infection were admitted from institutional care or other hospital. The high prevalence of MRSA wound infection and increased mortality rate in this subgroup highlights the need for a good surveillance programme in place, to monitor trends and identify risk factors with an emphasize on minimising infection rates. Using the National Hip Fracture Database (NHFD) to make surveillance for surgical site infection a routine part of hip fracture care would be best practice in monitoring the trend and comparing care and outcomes against national benchmarks and quality standards. We recommend a close surveillance of wound in this vulnerable group.

We retrospectively evaluated 51 patients (17 in each of three groups) with mid shaft clavicle fractures. Group 1 underwent intramedullary stabilization using clavicle pins. Group 2 underwent open reduction and internal fixation using plates and group 3 underwent non operative treatment with a sling. Group1 patients progressed to union within 8 to 12 weeks. In Group 2, six patients had scar related pain and two had prominent metal work and discomfort and in group 3, three patients developed non union and one had symptomatic malunion. Our results suggest that the displaced and shortened midshaft clavicle fractures require operative fixation and the techniques of clavicle pinning resulted in less complications, short hospital stay and good functional outcome.

In a prospective study we assessed 440 patients, sequentially admitted to the trauma unit with hip fracture. Of the 403 who had a swab on admission, 5.2% (21/403) were found to be colonised with MRSA. Fifty two percent of MRSA colonised patients were admitted from their own home, 29% from residential homes and 19% from nursing homes. MRSA colonisation was found in 3.6% of patients admitted from their own home, 10.9% of residential home patients, and 17.4% of nursing home patients. A high proportion (80.9%) of colonised patients had been admitted to a hospital within the previous one year, and the high prevalence of previous hospitalisation among people from institutional care may explain the higher rates of MRSA carriage among these individuals.When a patient gives a history of hospitalisation within the previous year, it is clearly sensible to consider the use of an agent such as teicoplanin for perioperative prophylaxis.

Aim: To assess the functional outcome following internal fixation with the PHILOS (proximal humeral interlocking system) for displaced proximal humeral fractures. Patients and Methods: We reviewed 30 consecutive patients treated surgically with the proximal humeral locking plate for a displaced proximal humeral fracture. Functional outcome was determined using the American Shoulder and Elbow Society (ASES) score and Constant Murley score. Results: Average age of the patients was 58 years (range, 19-92 years). The average overall ASES score was 66.5. The average overall Constant score was 57.5. Conclusion: Our results show that good fracture stability was achieved, and the functional outcome was very good in younger patients and it declined with increasing age. Early mobilization of the shoulder can be achieved without compromising fracture union.

Traditionally midshaft clavicle fractures have been treated conservatively. It is recognized that displaced and shortened fractures may be better treated operatively. In particular, patients with greater than 20 mm of shortening and 100 percent displacement have a symptomatic non union rate of 30 percent. The standard technique used previously has been via plate fixation with LC-DCP or DCP. However in the last 5 years intramedullary fixation has been popularized. “Rockwood intramedulary clavicular pin” remedies the past treatment issues including poor blood supply, painful prominent hardware and stress raiser related to removal of metal work. Aim: The aim of this study was to assess the functional outcome following intramedullary fixation of clavicle using Rockwood pin. Method: We retrospectively evaluated 17 patients with displaced and shortened mid-shaft clavicular fractures who underwent intramedullary pinning using Rock-wood pins. Each patient was assessed using the ASES, Constant and SF36 scoring system. A physical examination was performed and individual radiographs were assessed to determine union. Results: The mean age of the patients was 28 (range 15–56). All patients went into union within 2 to 4 months. They had a shorter stay in hospital, earlier mobilization and no scar related paraesthesia. The average ASES score 98.2 (range 92–100) and constant 95.3 (range 89–100). Summary: Displaced and shortened mid clavicular fractures require operative fixation. Plates and screws on the clavicle requires significant soft tissue stripping leading to compromised blood supply to the bone and multiple bi-cortical screws act as stress raisers. Previous intra-medullary devices presented with the problem of pin migration. Rockwood pins are designed with a differential pitch which leads to compression at the fracture site and prevent pin migration. From this study we now recommend the use of the Rockwood Pin for the management of displaced mid-shaft clavicle fractures.

Aim: To assess the functional outcome following internal fixation with the PHILOS® plating system for displaced proximal humeral fractures by using the ASES and Constant scoring system. Background: Controversy exists with regards to the management of displaced proximal humeral fractures and many methods of treatment have been proposed over the years. In particular, the role of surgery has not been clearly defined. The current trend is toward limited dissection of the soft tissues with the use of minimal amounts of hardware to gain stability. Methods: We performed a retrospective analysis of 30 consecutive patients treated surgically with the PHILOS ® plate for a displaced proximal humeral fracture between February 2002 and October 2003. Patients were assessed clinically and radio graphically at an average follow-up time of 9 months. Functional outcome was determined utilising the American Shoulder and Elbow Society score (ASES) and Constant Murley score. The injury was classified using Neer’s 4 part classification. Results: Average age of the patients was 58 years (19 to 92). There were 6 two part, 14 three part and 10 four part fractures. All the fractures were radio graphically united by 10 weeks. The average overall ASES score is 66.5%. The average overall Constant score is 55%. The average external rotation at 90 of abduction for the ages 15–55 was 55°–64° and the ages 56–95 was 25°–34°. The average forward elevation for the ages 15–55 was 85°–95° and the ages 76–95 was 55°–64°. The most difficult movement for the older subgroup of patients was internal rotation which was up to the sacrum. Conclusion: Our results show that good fracture stability and functional outcome can be obtained from the use of the PHILOS® plate. Early mobilisation of the shoulder can be achieved without compromising fracture union. We would recommend the use of the PHILOS® plate for the management of displaced fractures of the proximal humerus.

Confectionery may require reclamation or reworking for a number of reasons; when high speed production lines stop because of a problem downstream, such as a fault in coating machines or a breakdown in the packing line. Equally, sweets may be rejected as being mis-shapen. Ingredients produced on a continuous basis were often diverted into scrap bins until the line was running again, as stopping production may be difficult and costly. The reclamation of confectionery waste can be difficult, which in the past has resulted in product simply being scrapped. However, the high cost of raw materials such as sugar and cocoa means that it was increasingly important to try to reclaim and rework “off-spec” product. To prevent and reduce this rework process in one product preparation in a centre filled candy confectionery unit certain cost effective conventional strategies like prevention of leakers, dustiness, striping and cracking were applied and the rework time were reduced greatly by fifty percentage.