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.

The N-brace trial: Does arm position during immobilisation of proximal humerus fractures influence outcome - A preliminary study.

Background: Traditional initial management of proximal humerus fractures (PHF) involves arm immobilisation in a simple sling (SS) in an internally rotated position. We believe this risks fracture displacement and imbalance of soft tissues, encouraging malunion and stiffness. A neutral-rotation brace (NRB) maintains an arm position which may prevent this, leading to quicker and superior recovery. Methods: We randomised patients with two- to four-part PHF into 4 weeks of immobilisation with either a SS or NRB, independent of surgery. Range of motion (ROM), subjective shoulder value (SSV), DASH, Constant-Murley (CMS) and Oxford Shoulder (OSS) scores were assessed at 6-weeks, 3-months and 1-year post-injury. Results: The SS group included 11 patients vs 9 in the NRB group. At final follow-up, the SS and NRB groups had mean DASH scores of 42 vs 35, OSS 42 vs 46, CMS 71 vs 86, SSV 84% vs 92%, respectively. ROM was superior with the NRB (elevation 159°, ER 47° and IR score 8 vs 140°, 37° and 7 with SS). Conclusions: Despite being a small series, our results demonstrate a trend towards NRB providing better outcomes. This feasibility study supports the need for a larger multi-centre randomised controlled trial comparing these immobilisation methods for PHF.

Long-term Outcomes After the Open Latarjet Procedure for the Surgical Management of Humeral Avulsion of the Glenohumeral Ligament Lesions.

BACKGROUND: Recurrent anterior glenohumeral instability caused by a humeral avulsion of the glenohumeral ligament (HAGL) lesion has been studied, but very limited long-term evidence is available. PURPOSE: To retrospectively review patients with a HAGL lesion who underwent an open Latarjet procedure for recurrent anterior shoulder instability. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 16 patients with complete clinical and radiological data were available for a review. Clinical outcomes were assessed by range of motion, apprehension testing, the visual analog scale for pain, the Walch-Duplay score, the Rowe score, the Constant-Murley score, the Subjective Shoulder Value, and return to sports. Radiographs were reviewed for osteoarthritis and complications. RESULTS: The median age of patients at the time of surgery was 28 years (range, 18-42 years). All patients were male with no hyperlaxity. The median follow-up time was 10 years (range, 2.8-15 years). Postoperative range of motion showed recovered forward elevation (median, 175°), external rotation (median, 62°), and internal rotation (median, 9 points). Overall, 87% returned to sports, with 68% to the same level and 93% satisfied or very satisfied. Median clinical outcomes were the following: visual analog scale score, 1 (range, 0-2); Walch-Duplay score, 86 (range, 75-100); Rowe score, 95 (range, 90-100); Constant-Murley score, 77 (range, 74-79); and Subjective Shoulder Value, 88% (range, 80%-95%). There were no recurrent dislocations or subluxations. One patient described mild long-term pain, and 1 patient had persistent stiffness. Other complications included 12% with subjective apprehension, 1 patient with a wound infection, and another patient with delayed bone graft union. Additionally, 56% of cases had mild postoperative arthritis at the final follow-up. There were no reoperations. CONCLUSION: The open Latarjet procedure provided good outcomes with acceptable complication rates in the long term for patients with HAGL lesions. It is an effective treatment option and a safe alternative to arthroscopic or open HAGL repair.

A comparative study of 6-week and 12-week Radiographic Union Scores for HUmeral fractures (RUSHU) as a predictor of humeral shaft non-union.

Background: Non-union in non-operatively managed humeral shaft fractures are associated with significant morbidity. Hence, developing a robust system that could help with early diagnosis is important. We aimed to evaluate the validity of the Radiographic Union Score for HUmeral fractures (RUSHU) at 6 weeks (RUSHU-6) and test whether a RUSHU at 12 weeks (RUSHU-12) would be a better predictor of non-union. Methods: We retrospectively reviewed all non-operatively managed humeral diaphyseal fractures from 2012 to 2018. Statistical analysis was used to determine the cut-off RUSHU-12 and evaluate the effect of RUSHU-6 and RUSHU-12 on non-union prediction. Results: In sum, 32 patients had radiographs at 6 weeks post-injury, 27 of which also had radiographs at 12 weeks. A RUSHU cut-off of 9 was the best predictor of non-union at 12 weeks. Only RUSHU-12 had a statistically significant influence predicting non-union (P = 0.011) and there was a significant correlation (P = 0.003) between score progression from RUSHU-6 to RUSHU-12 and the development of non-union. Discussion: A RUSHU-12 of <9 and a low score progression between 6 and 12 weeks suggest superior predictive value in determining the likelihood of non-union. Further validation in the form of a large multicentred study is however required.

Outcomes following revision of the revision total elbow arthroplasty.

BACKGROUND: There is very little information in the literature on the outcomes of revision of revision total elbow arthroplasty (RRTEA). Our aim was to report the outcomes of this rarely performed procedure. METHODS: We retrospectively identified all patients who had undergone RRTEA between 2007 and 2016. Outcomes were assessed clinically using a number of validated systems, and radiographs were reviewed for prosthesis alignment, cementation by Morrey grading, and heterotopic ossification. RESULTS: We identified 22 patients who underwent RRTEA. Of these patients, 14 were available for assessment (2 died of unrelated causes, 2 could not be contacted, 2 declined to participate because of travel difficulties, and 2 had incomplete data). At the final review, the median age was 73 years (range, 57-83 years), with a median follow-up period of 4.5 years (range, 2-7 years) since the last surgical procedure. The median number of previous revision arthroplasty procedures per patient was 3 (range, 2-6). The indications for RRTEA were aseptic loosening (60%), bushing wear (16%), fracture (14%), and infection (10%). Of the patients, 30% required extra-long or custom-made implants and 50% needed allograft augmentation. At final clinical assessment, 56% of patients had triceps insufficiency, the median flexion-extension arc was 90°, and the median prono-supination arc was 95°. The functional elbow scores revealed good outcomes in the majority of patients (median visual analog scale score, 5; median Oxford Elbow Score, 22; median Mayo Elbow Performance Index score, 55; and median QuickDASH [short version of Disabilities of the Arm, Shoulder and Hand questionnaire] score, 63). Eighty-one percent of patients were satisfied with their RRTEAs. Complications included infection in 2 patients (1 superficial and 1 deep), symptomatic aseptic humeral component loosening in 1, sensory ulnar nerve symptoms in 2, and radial nerve injury in 1. One patient required ulnar nerve release. Radiologic review revealed asymptomatic loosening in 1 patient (humeral component), and overall prosthesis alignment with cementation was adequate in 81%. Heterotopic ossification was present in 38% of cases. CONCLUSIONS: RRTEA is a satisfactory treatment option in these complex cases, with good short- to mid-term survival rates but a relatively high complication rate.

Mid-term outcomes of surgical management of complex, isolated radial head fractures: a multicentre collaboration.

OBJECTIVES: The available literature discussing optimal surgical management of Mason II and III radial head (RH) fractures without concomitant bone or ligamentous injuries is limited. We aim to help determine the appropriate management of these functionally significant injuries. DESIGN: We present our retrospective cohort study of outcomes of surgically managed isolated, displaced RH fractures SETTING: Study from three trauma centres. PATIENTS/PARTICIPANTS: Adults who underwent surgical treatment for isolated displaced RH fractures. INTERVENTION: RH open reduction internal fixation (ORIF), replacement or excision MAIN OUTCOME MEASUREMENTS: Elbow range of motion (ROM), pain and function using Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), Patient-Rated Elbow Evaluation (PREE) and QuickDASH (QD). RESULTS: Of 46 patients included (mean age 47 years and mean follow-up 48 months), 12 type II fractures were treated with ORIF and 34 type III injuries had ORIF (16), replacement (12) or resection (6). ROM was comparable in all groups, with mean arcs of flexion-extension of 131° and pronation-supination of 147°. Mean visual analogue score for pain was 1.3 in those treated with ORIF compared to 1.9 with arthroplasty and 2.5 with excision. Mean functional scores were 41, 92, 14 and 14 for OES, MEPS, PREE and QD, respectively. Complication rates were 39% for ORIF, 33% for arthroplasty and 33% for resection. Overall re-operation rate was 13%. CONCLUSIONS: Functional outcome is similar in all groups of surgically treated patients with isolated, displaced RH fractures. Complication rates are higher than that reported previously in the literature but with low re-operation rates. LEVEL OF EVIDENCE: IV.

Axillary artery pseudoaneurysm resulting in brachial plexus injury in a patient taking new oral anticoagulants.

We discuss the case of an independent 80-year-old Caucasian woman, being treated with new oral anticoagulants for a previous deep vein thrombosis, who had fallen on her right shoulder. She made a delayed presentation to the emergency department with a wrist drop in her right dominant hand. She had right arm bruising with good distal pulses but had a global neurological deficit in the hand. Plain radiographs of the shoulder, humerus, elbow, forearm and wrist demonstrated no fractures. MRI showed a significant right axillary lesion distorting the surrounding soft tissues, including the brachial plexus, and CT with contrast confirmed this to be a large axillary pseudoaneurysm. This was treated with an endovascular stent resulting in slightly improved motor function, but the significant residual deficit required subsequent rehabilitation to improve right upper limb function.

Multiple myeloma presenting with acute bony spinal cord compression and mechanical instability successfully managed nonoperatively.

BACKGROUND CONTEXT: Multiple myeloma (MM) with spinal involvement may present with spinal cord or cauda equina compression, with or without neurological impairment. This occurs when a soft-tissue myelomatous mass extends into the epidural space (Barron et al., 1959 [1]). The mainstay of management for such lesions in patients with normal neurology is chemotherapy and radiotherapy or radiotherapy alone, but those with neurological compromise require surgical decompression with adjuvant therapy (Patchell et al., 2005 [2]). Infrequently, patients with MM present with spinal cord compression and neurological impairment due to bony encroachment from vertebral translation and kyphosis where significant lytic bone disease has rendered the spine mechanically unstable. The standard management for these patients is surgical decompression and internal fixation. PURPOSE: This study aimed to report a high-risk myeloma patient with a mechanically unstable spine, acute spinal cord compression, and neurologic deficit that was treated successfully using nonoperative means. STUDY DESIGN: Case report. METHODS: A 37-year-old male patient with MM was referred to our tertiary referral spinal unit with acute bony spinal cord compression and neurological impairment. Computer tomography revealed lytic lesions of T2 and T3 and anterolisthesis of T1 on T2 producing mechanical instability and magnetic resonance imaging confirmed extension of disease into the epidural space and cord compression. This was successfully managed with nonoperative treatment using a brace. RESULTS: Management in a brace restored clinical and radiological stability and normal neurological function. CONCLUSION: Certain high-risk myeloma patients with a mechanically unstable spine, acute spinal cord compression and neurologic deficit can be treated effectively in an appropriate brace when managed by a tertiary referral spinal unit.

Changing the consultant on calls from a daily to weekly rotation system reduces time to theater for patients with hip fracture to improve quality of care: a retrospective study of 2 cohorts of patients presenting with hip fracture.

OBJECTIVE: To determine whether changing the consultant on-call schedule resulted in a reduction in time to theater for patients presenting with a hip fracture. SUMMARY BACKGROUND DATA: Guidelines in the United Kingdom state that patients presenting with a neck of femur fracture should ideally be operated on the day of or the day after admission. However, there is a best practice tariff in the United Kingdom persuading trusts to operate on elderly patients with hip fracture within 36 hours of admission. Differing formats of daily trauma operating lists and varying consultant on-call schedules have the potential to affect a trusts ability to successfully meet such demands. METHODS: This study retrospectively analyzed whether changing the on-call schedule from a system where the on-call consultant is changed on a daily basis to one which changes weekly resulted in a reduction in time to theater for such patients and an increase in best practice tariffs paid. RESULTS: With the initial rotation system, the average time to theater for a fractured neck of femur was 44 hours 46 minutes, with 44.7% of patients having a time to surgery of less than 36 hours. Patients in the modified system underwent surgery with an average time to theater of 32 hours 19 minutes. In 71.7% of these patients, time to surgery was less than 36 hours. CONCLUSION: This study demonstrates that changing the schedule to permit a consultant to have a 7-day period of trauma on call at a time instead of only 1 day dramatically reduced the time to theater for patients with hip fracture. This significantly reduced the number of these cases done outside 36 hours and increased trust financial reward.

Use of endoprosthetic diaphyseal replacement: a novel approach to management of extensive metastatic tumor of the midshaft radius.

We report the first use of an endoprosthetic diaphyseal replacement after the excision of a midshaft radial tumor. We present a rare case of a solitary midshaft radial metastasis in a 72-year-old gentleman who was treated 8 years earlier for primary renal cell carcinoma by radical nephrectomy. Follow-up for this patient was 25 months after implant insertion and at the latest review was pain-free. Functional scores for the elbow (using the Mayo Elbow Performance Score) and the wrist (using the Mayo Wrist Score) were 80 and 60, respectively, both out of 100. Use of a midshaft radial endoprosthesis provides a good functional outcome and symptom relief after extensive tumor resection, with regard to functional outcome and symptom relief.

Use of a distal radius endoprosthesis following resection of a bone tumour: a case report.

Limited literature is available on the reconstruction of the distal radius using prosthetic replacement following resection of a bone tumour. We present the first reported case, in the English literature, of the use of an entirely metal endoprosthesis for the reconstruction of the distal radius. This case involves a 66-year-old male who was treated for giant cell tumour of the distal radius with surgical excision of the lesion and replacement of the defect using a predominantly titanium endoprosthesis. He was followed-up for 56 months following surgery and had a good functional outcome with no associated pain or complications. We propose that the use of a primarily titanium endoprosthesis for the reconstruction of a bone defect of the distal radius is a suitable alternative, providing good function of the forearm with satisfactory range of movement at the wrist and adequate pain relief.