Aims

Distal third clavicle (DTC) fractures are increasing in incidence. Due to their instability and nonunion risk, they prove difficult to treat. Several different operative options for DTC fixation are reported but current evidence suggests variability in operative fixation. Given the lack of consensus, our objective was to determine the current epidemiological trends in DTC as well as their management within the UK.

Aims

Is it feasible to conduct a definitive multicentre trial in community settings of corticosteroid injections (CSI) and hydrodilation (HD) compared to CSI for patients with frozen shoulder? An adequately powered definitive randomized controlled trial (RCT) delivered in primary care will inform clinicians and the public whether hydrodilation is a clinically and cost-effective intervention. In this study, prior to a full RCT, we propose a feasibility trial to evaluate recruitment and retention by patient and clinician willingness of randomization; rates of withdrawal, crossover and attrition; and feasibility of outcome data collection from routine primary and secondary care data.

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The open Latarjet procedure is a widely used treatment for recurrent anterior instability of the shoulder. Although satisfactory outcomes are reported, factors which influence a patient’s experience are poorly quantified. The aim of this study was to evaluate the effect of a range of demographic factors and measures of the severity of instability on patient-reported outcome measures in patients who underwent an open Latarjet procedure at a minimum follow-up of two years.

The December 2022 Research Roundup³⁶⁰ looks at: Halicin is effective against Staphylococcus aureus biofilms in vitro; Synovial fluid and serum neutrophil-to-lymphocyte ratio: useful in septic arthritis?; Transcutaneous oximetry and wound healing; Orthopaedic surgery causes gut microbiome dysbiosis and intestinal barrier dysfunction; Mortality in alcohol-related cirrhosis: a nationwide population-based cohort study; Self-reported resistance training is associated with better bone microarchitecture in vegan people.

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Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters.

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The use of fluoroscopy in orthopaedic surgery creates risk of radiation exposure to surgeons. Appropriate personal protective equipment (PPE) can help mitigate this. The primary aim of this study was to assess if current radiation protection in orthopaedic trauma is safe. The secondary aims were to describe normative data of radiation exposure during common orthopaedic procedures, evaluate ways to improve any deficits in protection, and validate the use of electronic personal dosimeters (EPDs) in assessing radiation dose in orthopaedic surgery.

Aims. Displaced fractures of the lateral condyle of the humerus are frequently managed surgically with the aim of avoiding nonunion, malunion, disturbances of growth and later arthritis. The ideal method of fixation is however not known, and treatment varies between surgeons and hospitals. The aim of this study was to compare the outcome of two well-established forms of surgical treatment, Kirschner wire (K-wire) and screw fixation. Patients and Methods. A retrospective cohort study of children who underwent surgical treatment for a fracture of the lateral condyle of the humerus between January 2005 and December 2014 at two centres was undertaken. Pre, intraoperative and postoperative characteristics were evaluated. A total of 336 children were included in the study. Their mean age at the time of injury was 5.8 years (0 to 15) with a male:female patient ratio of 3:2. A total of 243 (72%) had a Milch II fracture and the fracture was displaced by > 2 mm in 228 (68%). In all, 235 patients underwent K-wire fixation and 101 had screw fixation. . Results. There was a higher rate of nonunion with K-wire fixation (p = 0.02). There was no difference in Baumann’s angle, carrying angle or the rate of major complications between the two groups. No benefit was obtained by immobilizing the elbow for more than four weeks in either group. No short-term complications were seen when fixation crossed the lateral ossific nucleus. Conclusions. Fixation of lateral condylar humeral fractures in children using either K-wires or screws gives satisfactory results. Proponents of both techniques may find justification of their methods in our data, but prospective, randomized trials with long-term follow-up are required to confirm the findings, which suggest a higher rate of nonunion with K-wire fixation. Cite this article: Bone Joint J 2018;100-B:387–95

Aims

There is a considerable challenge in treating bone infections and orthopaedic device-associated infection (ODAI), partly due to impaired penetration of systemically administrated antibiotics at the site of infection. This may be circumvented by local drug administration. Knowledge of the release kinetics from any carrier material is essential for proper application. Ceftriaxone shows a particular constant release from calcium sulphate (CaSO₄) in vitro, and is particularly effective against streptococci and a large portion of Gram-negative bacteria. We present the clinical release kinetics of ceftriaxone-loaded CaSO₄ applied locally to treat ODAI.

The lateral ligament complex is the primary constraint to posterolateral rotatory laxity of the elbow, and if it is disrupted during surgery, posterolateral instability may ensue. The Wrightington approach to the head of the radius involves osteotomising the ulnar insertion of this ligament, rather than incising through it as in the classic posterolateral (Kocher) approach. In this biomechanical study of 17 human cadaver elbows, we demonstrate that the surgical approach to the head can influence posterolateral laxity, with the Wrightington approach producing less posterolateral rotatory laxity than the posterolateral approach

This is a retrospective review of the results of the Acclaim total elbow replacement in 11 older patients aged ≥ 65 years with primary osteoarthritis of the elbow, with a mean follow-up of 57.6 months (30 to 86.4). Significant reductions in pain and improvement in range of movement and function were recorded. Radiological review revealed two patients with 1 mm lucencies in a single zone, and one patient with 1 mm lucencies in two zones. No components required revision. There were no deep infections, dislocations or mechanical failures. Complications included one intra-operative medial condylar fracture and one post-operative transient ulnar neuropathy, which resolved. This study demonstrates that the Acclaim prosthesis provides good symptomatic relief and improvement of function in patients with primary osteoarthritis, with low rates of loosening or other complications. This prosthesis can therefore be considered for patients aged ≥ 65 years with primary osteoarthritis of the elbow

Aims. The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years. Patients and Methods. Patients were randomised to either non-operative management or operative management with either tension-band wiring or fixation with a plate. They were reviewed at six weeks, three and six months and one year after the injury. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at one year. Results. A total of 19 patients were randomised to non-operative (n = 8) or operative (n = 11; tension-band wiring (n = 9), plate (n = 2)) management. The trial was stopped prematurely as the rate of complications (nine out of 11, 81.8%) in the operative group was considered to be unacceptable. There was, however, no difference in the mean DASH scores between the groups at all times. The mean score was 23 (0 to 59.6) in the non-operative group and 22 (2.5 to 57.8) in the operative group, one year after the injury (p = 0.763). There was no significant difference between groups in the secondary outcome measures of the Broberg and Morrey Score or the Mayo Elbow Score at any time during the one year following injury (all p ≥ 0.05). . Conclusion. These data further support the role of primary non-operative management of isolated displaced fractures of the olecranon in the elderly. However, the non-inferiority of non-operative management cannot be proved as the trial was stopped prematurely. Cite this article: Bone Joint J 2017;99-B:964–72

We retrospectively studied the possibility that direct trauma to the biceps muscle might be the cause of poor elbow flexion and supination in 18 consecutive children with birth lesions of the brachial plexus who had delayed or impaired biceps recovery despite neurophysiological evidence of reinnervation. All had good shoulder and hand function at three months of age. Eight recovered a strong biceps after six months, but nine required a pectoralis minor to biceps transfer to augment elbow flexion and supination. One had a delayed but good recovery of the biceps after microsurgical reconstruction of the plexus. All had a clinical ‘pseudotumour’ in the biceps muscle, which was biopsied during pectoralis minor transfer in two patients and showed rupture and degeneration of muscle fibres with a fibro-fatty infiltrate, suggesting previous muscle trauma. Direct muscle trauma is an uncommon but important cause of delayed or impaired biceps recovery after brachial plexus birth injuries. Surgery to reinnervate the biceps muscle will not work if substantial muscle damage is present when a suitable muscle transfer should be considered

We studied, ten patients (11 elbows) who had undergone 14 allograft-prosthesis composite reconstructions following failure of a previous total elbow replacement with massive structural bone loss. There were nine women and one man with a mean age of 64 years (40 to 84), who were reviewed at a mean of 75 months (24 to 213). One patient developed a deep infection after 26 months and had the allograft-prosthesis composite removed, and two patients had mild pain. The median flexion-extension arc was 100° (95% confidence interval (CI) 76° to 124°). With the exception of the patient who had the infected failure, all the patients could use their elbows comfortably without splints or braces for activities of daily living. The mean Mayo Elbow Performance Index improved from 9.5 (95% CI 4.4 to 14.7) pre-operatively to 74 (95% CI 62.4 to 84.9) at final review. Radiologically, the rate of partial resorption was similar in the humeral and ulnar allografts (three of six and four of eight, respectively; p > 0.999). The patterns of resorption, however, were different. Union at the host-bone-allograft junction was also different between the humeral and ulnar allografts (one of six and seven of eight showing union, respectively; p = 0.03). At medium-term follow-up, allograft-prosthesis composite reconstruction appears to be a useful salvage technique for failed elbow replacements with massive bone loss. The effects of allograft resorption and host-bone-allograft junctional union on the longevity of allograft-prosthesis composite reconstruction, however, remain unknown, and it is our view that these patients should remain under long-term regular review

We report the results of performing a pronating osteotomy of the radius, coupled with other soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic patients with supination contractures. In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109). Pre-operatively, passive movement ranged from a mean of 19.2° pronation (−70° to 80°) to 95.8° supination (80° to 140°). A pronating osteotomy of the radius was then performed with release of the interosseous membrane. Extension of the elbow was restored postoperatively in 11 patients, with key-pinch reconstruction in nine. At the final follow-up every patient could stabilise their hand in pronation, with a mean active range of movement of 79.6° (60° to 90°) in pronation and 50.4° (0° to 90°) in supination. No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to 3) MRC grading. Pronating osteotomy stabilises the hand in pronation while preserving supination, if a complete release of the interosseous membrane is also performed. This technique fits well into surgical programmes for enhancing upper limb function

We aim to explore the potential technologies for monitoring and assessment of patients undergoing arthroplasty by examining selected literature focusing on the technology currently available and reflecting on possible future development and application. The reviewed literature indicates a large variety of different hardware and software, widely available and used in a limited manner, to assess patients’ performance. There are extensive opportunities to enhance and integrate the systems which are already in existence to develop patient-specific pathways for rehabilitation.

Cite this article: Bone Joint J 2022;104-B(10):1104–1109.

Aims

There remains a lack of consensus regarding the management of chronic anterior sternoclavicular joint (SCJ) instability. This study aimed to assess whether a standardized treatment algorithm (incorporating physiotherapy and surgery and based on the presence of trauma) could successfully guide management and reduce the number needing surgery.

We reviewed the clinical and radiological results of six patients who had sustained traumatic separation of the distal epiphysis of the humerus at birth. The correct diagnosis was made from plain radiographs and often supplemented with ultrasonography, MRI and arthrography. An orthopaedic surgeon saw two patients within two days of birth, and the other four were seen at between nine and 30 days. The two neonates underwent unsuccessful attempts at closed reduction. In the remaining patients, seen after the age of eight days, no attempt at reduction was made. All six displaced fractures were immobilised in a cast with the elbow at 90° of flexion and the forearm pronated. When seen at a mean of 58 months (16 to 120) after injury, the clinical and radiological results were excellent in five patients, with complete realignment of the injury. In one patient the forearm lay in slightly reduced valgus with the elbow in full extension. Traumatic separation of the distal epiphysis of the humerus may be missed on the maternity wards and not diagnosed until after discharge from hospital. However, even when no attempt is made to reduce the displaced epiphysis, a good clinical result can be expected

Using an osteotomy of the olecranon as a model of a transverse fracture in 22 cadaver elbows we determined the ability of three different types of suture and stainless steel wire to maintain reduction when using a tension-band technique to stabilise the bone. Physiological cyclical loading simulating passive elbow movement (15 N) and using the arms to push up from a chair (450 N) were applied using an Instron materials testing machine whilst monitoring the osteotomy site with a video extensometer. Each osteotomy was repaired by one of four materials, namely, Stainless Steel Wire (7), No 2 Ethibond (3), No 5 Ethibond (5), or No 2 FiberWire (7). There were no failures (movement of > 2 mm) with stainless steel wire or FiberWire and no significant difference in the movements measured across the site of the osteotomy (p = 0.99). The No. 2 Ethibond failed at 450 N and two of the five of No. 5 Ethibond sutures had a separation of > 2 mm at 450 N. FiberWire as the tension band in this model held the reduction as effectively as stainless steel wire and may reduce the incidence of discomfort from the hardware. On the basis of our findings we suggest that a clinical trial should be undertaken

Aims

Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier.