Non-operative management of terrible triad injuries of the elbow; not so terrible?

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.

A Comparison of Fibula Pro-Tibia Fixation Versus Hindfoot Nailing for Unstable Fractures of the Ankle in Those Older Than 60 Years.

BACKGROUND: Ankle fractures in the elderly are an increasing problem, with poor outcomes reported. Operative options for patients with suspected osteoporosis and needing to bear weight to ambulate can include hindfoot intramedullary nail (IMN) or fibula pro-tibia fixation (FPT). FPT involves passing 2 or more screws through a lateral fibula plate, crossing the fibular into the tibia, with 1 or more screws proximal to the incisura. We compared the outcomes of these 2 techniques. METHOD: A retrospective review identified 68 patients aged over 60 years with unstable ankle fractures, treated with IMN or FPT. Primary outcome was surgical reoperation/revision rate, secondary outcomes included complications, length of stay, and functional status. Results: There were no significant differences in demographics between IMN and FPT. Revision rates were higher in IMN compared with FPT (P < .0001). IMN patients postoperatively had longer hospital stays (P = .02), longer follow-up times (P = .008), and higher rates of delayed wound healing (P = .03) and nonunion (P = .001). Multivariate analysis identified fixation and age to affect revision rates. CONCLUSION: Outcomes were worse in the IMN group compared with FPT. We believe both techniques have a role in the management of elderly ankle fractures, but patient selection is key. We suggest that FPT should be the first-choice technique when soft tissues permit. LEVELS OF EVIDENCE: Level III.

A Systematic Review of the Utility of Intraoperative Navigation During Total Shoulder Arthroplasty.

Total shoulder arthroplasty (TSA) has been demonstrated to successfully recover function to shoulders impaired by arthrosis and rotator cuff insufficiency. Long-term survival depends on the correct positioning of glenoid components and secure bone fixation. Computed tomography (CT)-based intraoperative navigation has proven to be an effective technique for successful TSA procedures. This paper presents a review of CT-based intraoperative navigation considering its advantages and disadvantages. The crucial factors that contribute to the success of this technique are glenoid component positioning, operative duration, and screw selection, which are detailed in this review.

Reliability analysis of radiologic and intraoperative loosening in total elbow arthroplasty.

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 (κ 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 κ coefficient between assessors for humeral implant loosening was 0.87 (almost perfect). The κ coefficient for ulnar loosening was 0.75 (substantial). The κ 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 (κ = 0.86) and substantial for ulnar loosening (κ = 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.

Revision total elbow arthroplasty: Is it safe to perform a single-stage revision for presumed aseptic loosening based on clinical assessment, normal inflammatory markers, and a negative aspiration?

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%). χ2 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.

Increased precision of coronal plane outcomes in robotic-assisted total knee arthroplasty: A systematic review and meta-analysis.

BACKGROUND: Inaccuracy of component alignment in total knee arthroplasty adversely impacts outcomes. Robotic systems improve translation of pre-operative planning to intra-operative steps, theoretically resulting in greater accuracy and precision. In this study we systematically review literature data of alignment outcomes and apply meta-analysis methods to assess whether robotic-assisted knee arthroplasty provides superior outcomes when compared to conventional knee prostheses. METHODS: A PRISMA compliant search comparing alignment outcomes in robotic vs conventional knee arthroplasty was performed. Primary outcome measures were; number of three degree outliers and mean deviation from a neutral post-operative mechanical axis. RESULTS: In total, from five studies reporting upon 402 knees, a post-operative mechanical axis malalignment of >3° occurred in 1/181 (0.006%) of robotic knees, and 42/159 (26.4%) of conventional knees with a meta-analysis odds ratio of 0.04 (95% CI 0.01-0.14), p < 0.00001 favouring robotic-assisted instrumentation. Meta-analysis also demonstrated weighted mean differences of post-operative mechanical axis alignment to be significantly more accurate in the robotic knee group: mean difference -0.63 (95% CI: -1.18,-0.08), z = 2.25, p = 0.02. Sensitivity analysis with inclusion of only Level 1 studies showed similar findings. CONCLUSIONS: This systematic review and meta-analysis demonstrates clear evidence of increased accuracy of alignment in robotic-assisted knee arthroplasty with specific regard to reconstituting a neutral mechanical axis and minimising number of outliers in the coronal plane. Further studies and long term data is required in order to conclude on survivorship and functional outcomes.

Iselin's Disease: A Systematic Review.

Iselin's disease was first described in 1912. It is a condition affecting the tuberosity of the base of the fifth metatarsal. It has been described as a traction apophysitis predominately affecting adolescents, in particular those who partake in regular sporting activity. The condition is rarely reported and likely to remain undiagnosed, possibly mistaken for a fracture. The present report reviewed the available published data to highlight this condition as a differential diagnosis in patients with fifth metatarsal pain. Investigations, treatments and outcomes into this condition are described, to support the management and diagnosis of this condition.

Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction.

BACKGROUND: This paper reports the outcomes of patients undergoing ACL reconstruction using a TransLateral single bundle, all-inside hamstring technique at a minimum of two year follow-up. METHODS: The semitendinosus alone is harvested, quadrupled and attached in series to two adjustable suspensory fixation devices. Femoral and tibial sockets are produced using a retrograde drill. The graft is deployed, fixed and tensioned on both tibia and femur. Patients were evaluated preoperatively using the KOOS, Lysholm and Tegner scores and at six, 12 and 24months postoperatively. Objective assessment of knee laxity was performed using the KT-1000 along with goniometric measurement of range or motion. RESULTS: One hundred and eight patients, mean age 30.9years (range 15 to 61) were included. Mean follow-up 49.8months (range 30-66). The mean increase in KOOS at two years was 30.3 points; Lysholm, 33.1 points; Tegner Activity scale, 2.0 levels. These were all statistically significant (p<0.001). Range of motion in the reconstructed knee approximated the uninjured knee by 12months and was restored by two years. KT-1000 showed significant reduction in side-side difference to no more than 2.4mm at all postoperative time points (p<0.001). Re-rupture rate in this series was 6.5%, all following episodes of significant additional postoperative trauma to the knee. CONCLUSIONS: TransLateral all-inside ACL reconstruction demonstrates good medium term subjective and objective outcomes with a low complication and failure rate.