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.

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.

Bronchodilator reversibility, exercise performance and breathlessness in stable chronic obstructive pulmonary disease

Partial bronchodilator reversibility can be demonstrated in many patients with stable chronic obstructive pulmonary disease (COPD), but its relevance to exercise capacity and symptoms is uncertain. Previous data suggest that anticholinergic bronchodilators do not improve exercise tolerance in such patients. We studied 32 patients with stable COPD, mean age 65 yrs, in a double-blind, placebo-controlled, cross-over trial of the inhaled anticholinergic drug, oxitropium bromide. From the within and between day placebo spirometry, we derived the spontaneous variation in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) of this population (FEV1 140 ml; FVC 390 ml) and considered responses beyond this to be significant. Oxitropium bromide increased baseline FEV1 from 0.70 (0.28) l (mean (SD)) to 0.88 (0.36) l. The 6 min walking distance increased by 7% compared with placebo, whilst resting breathlessness scores fell from 2.0 to 1.23 at rest and 4.09 to 3.28 at the end of exercise after the active drug. Improvements in walking distances and symptoms were unrelated to changes in either FEV1 or FVC, indicating that routine reversibility testing is not a good predictor of symptomatic benefit in these patients.

Bronchodilator reversibility, exercise performance and breathlessness in stable chronic obstructive pulmonary disease

Partial bronchodilator reversibility can be demonstrated in many patients with stable chronic obstructive pulmonary disease (COPD), but its relevance to exercise capacity and symptoms is uncertain. Previous data suggest that anticholinergic bronchodilators do not improve exercise tolerance in such patients. We studied 32 patients with stable COPD, mean age 65 yrs, in a double-blind, placebo-controlled, cross-over trial of the inhaled anticholinergic drug, oxitropium bromide. From the within and between day placebo spirometry, we derived the spontaneous variation in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) of this population (FEV1 140 ml; FVC 390 ml) and considered responses beyond this to be significant. Oxitropium bromide increased baseline FEV1 from 0.70 (0.28) l (mean (SD)) to 0.88 (0.36) l. The 6 min walking distance increased by 7% compared with placebo, whilst resting breathlessness scores fell from 2.0 to 1.23 at rest and 4.09 to 3.28 at the end of exercise after the active drug. Improvements in walking distances and symptoms were unrelated to changes in either FEV1 or FVC, indicating that routine reversibility testing is not a good predictor of symptomatic benefit in these patients.

Effect of four-week treatment with oxitropium bromide on lung mucociliary clearance in patients with chronic bronchitis or asthma

The effect of oxitropium bromide on lung mucociliary clearance, pulmonary function and viscoelastic properties of sputum was investigated in 10 asthmatics and 10 chronic bronchitics. A controlled, double-blind, crossover study was performed. Following a baseline (B) measurement the patients were, in a random order, allocated placebo (P) or oxitropium bromide (O; 0.1 mg/puff), administered from metered dose inhalers, which they used for 4 weeks at a dose of 2 puffs t.d.s. This test medication was used in conjunction with their normal medication. At the end of the treatment period the patients were assessed, the treatments were then crossed over and a final assessment made 4 weeks later. The administration of oxitropium bromide resulted in (1) small but statistically significant increases in pulmonary function (less than 10% vs. placebo); (2) increased penetrance of radioaerosol into the lungs (mean +/- SEM alveolar deposition: 35 +/- 3, 26 +/- 3 and 24 +/- 3% for the O, P and B runs respectively; p less than 0.025); (3) no significant change in particle clearance rate from the lungs despite their deeper penetration (mean +/- SEM area under the tracheobronchial clearance curves between 0 and 6 h: 317 +/- 26, 324 +/- 25 and 287 +/- 25%.h for the O, P and B runs respectively; p greater than 0.1); (4) no alteration in sputum production, and (5) no significant changes in apparent viscosity (mean +/- SEM: 640 +/- 162, 446 +/- 79 and 557 +/- 115 mPa.s for the O, P and B runs, respectively; p greater than 0.1) and elasticity (mean +/- SEM: 3,682 +/- 1,383, 1,779 +/- 353 and 2,061 +/- 366 mPa for the O, P and B runs, respectively; p greater than 0.1) of sputum. When the two groups, i.e. the chronic bronchitics and asthmatics, were studied separately, no significant differences in any parameter measured (other than radioaerosol penetrance which was significantly enhanced on oxitropium bromide in chronic bronchitics) were noted between the three assessments.

Posterior dislocation of the shoulder

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