Introduction: Recent studies have compared open versus arthroscopic release for lateral epicondylitis. However, there are lacunae in the literature comparing patients receiving an arthroscopic release of CEO and lateral condyle decortication (ARD) with continued intensive conservative (CIC) management. Methods: A retrospective observational study comparing 23 patients receiving CIC in group 1 to 24 patients receiving ARD in group 2 was conducted with a minimum follow-up of 3.5 years. Return to work (RTW) at the same intensity, or lower level and any change in previous work were compared between the two groups. Objective grip strength, patient-reported outcome measures like the post-intervention satisfaction level (on a scale of 0-100) and VAS score for residual elbow pain were also compared. Results: RTW was significantly earlier in group 2 than in group 1 and a greater number of patients returned to the same or at a lower level of work in group 2. Patient satisfaction and VAS for residual elbow pain were also clinically better in the ARD group, although it was not statistically significant. The grip strength was comparable in the bilateral upper extremities when the affected sides were compared to the unaffected side and among both groups of patients. Conclusion: ARD for RTE suggests a significantly better and earlier RTW at the same or lower intensity level than standard CIC therapy protocol. Although the study suggests better and relatively improved patient satisfaction and residual elbow pain among patients receiving ARD compared to CIC, it was not statistically significant at a mid-term review.

Introduction: Supracondylar humerus fractures with pink pulseless hands occasionally require exploration of the brachial artery. We retrospectively analysed paediatric supracondylar humerus fracture patients who underwent surgical exploration of the brachial artery for mid-term functional outcome. Materials and Methods: Total of 12 male patients with Gartland type III fractures operated from 2014-2019 were included. 8 left and 4 right side injuries. Average age was 8 years (Range 2-12). Closed reduction and pinning was attempted in 10 patients. After procedure, observation for 30 min by palpation and doppler and SpO2 monitoring of fingers was done. 2 cases required open reduction along with vessel exploration. Average time of presentation was 8 hours (3-24 hours) and ischaemia time was 11.8 hours (6-25 hours). Injury was RTA-2, fall in stairs-2, fall from cycle-1 and fall while playing-7 cases. Brachial artery tethering to fracture in 4 cases where kink release was done, thrombus in radial artery in 6 cases where thrombectomy and end to end microvascular repair was done and 2 cases of arterial spasm where lignocaine was sprayed on the vessels and flow returned. One case with 24 hour delayed presentation required primary fasciotomy. Results: All patients had good outcomes. Average of 5 year follow-up showed good vessel flow on USG and hand function. Conclusion: All pulseless supracondylar humerus fractures must have attempted closed reduction and observation. After 30 min of no pulse on doppler or SpO2 monitoring, it is better to explore and release or repair the brachial artery early for good functional outcomes.

Objective: Isolated greater tuberosity fractures account for 20% of all proximal humerus
fractures. Operative means of management for displaced fracture patterns provides optimal
patient outcomes. Multiple modalities of fixation have been described. We aim to investigate the clinical and radiological outcomes for patients undergoing greater tuberosity
fractures utilising a uni-cortical suture tension button (Arthrex Pec Button®).

Methods: A retrospective case series was carried out at our local trauma unit. Inclusion criteria included patients undergoing greater tuberosity fixation via a uni-cortical suture tension button (Arthrex Pec Button®). Exclusion criteria included those patients who did not
consent to research or those with concomitant injuries. Patient demographics and clinical data was extrapolated from clinical records following ethical approval. Radiological
measurements were identified on PACS system. The DASH and Oxford shoulder scores (OSS)
were utilised to ascertain clinical outcome following surgery. Fracture reduction was assessed on standard postoperative AP, lateral and scapular Y plain film radiographs.

Results: Eleven patients were identified to have had fixation of greater tuberosity fracture
with a uni-cortical suture tension button. The mean age of the patients identified was 52.
The mean DASH score was 11.94 +/- 20.57. The mean OSS was 40.56 +/- 14.94. Mean follow up time
from date of fixation 20.9 months.

Conclusion: Clinical and radiological patterns for patients undergoing pec button fixation shows satisfactory outcomes. We recommend that the pec button be considered as a fixation method for GT fractures.

Introduction: Although RTSA outcomes are influenced by wide range of surgical variables, subjective assessments of pain and function are the determinants of patients satisfaction. Following RTSA, it is possible to anticipate improvements in flexion and abduction. However, shoulder's fIR is reduced or completely lost. This study aims to determine the influence of an implant-related parameter, the glenosphere size, on the progress of fIR after RTSA. Methods: 238 primary RTSA were included in our retrospective case series with at least two years follow-up. A single senior surgeon implanted the same onlay type prosthesis with a neck-shaft angle of 145° for irreparable rotator cuff tear, rotator cuff arthropathy, and primary arthritis. A 36mm diameter glenosphere was used in 111 patients (47%), a 39mm sphere was used in 114 patients (48%), and 13 patients (5%) with a 42mm sphere. We evaluated the progress of fIR as follows; type I internal rotation with the hand blocked to buttock, type II with lumbar sliding, and type III with smoth motion. We classified type I as non-functional internal rotation, while types II and III are functional internal rotation. We also used SSV and CS to evaluate the preoperative and postoperative ROM. Results: Glenosphere diameter and fIR do not significantly correlate. A mean postoperative level of L5 (type II internal rotation) was attained by the three groups when comparing 36 mm, 39mm, and 42 mm glenospheres. Conclusion: Overall, CS and SSV improved after RTSA. While there is no significant impact between different glenosphere sizes and postoperative fIR.

Elbow dislocation with radial head and coronoid fractures has been referred to as the “terrible triad injury” which represents a pattern of complex elbow instability that has historically been associated with a very poor prognosis and challenging in its management. We prospectively followed up 23 patients who are surgically managed at our unit by the same surgical protocol. At the end of follow up, all patients had satisfactory results and good range of motion with minimal complications. We concluded that implementation of this surgical protocol has transformed “ terrible triad injury” into a historical term.

Introduction: Recently, surgical treatment of diaphyseal humeral fractures has gained importance worldwide. Although, ORIF with a plate, still remains as the gold standard, however there have been increasingly concerns with the dissection of soft tissues. The anterior bridge plating (MIPO) technique for the treatment of these fractures has gained remarkable popularity amidst orthopedic surgeons, globally.Materials & methods: Prospective study of 43 adult patients, with a humeral diaphyseal fracture, treated by anterior bridge plating (MIPO) technique. Patients with closed, displaced diaphyseal fracture of the humerus, between 25 to 65 years, were included in this study. Patients were followed clinically and radiographically.Results:Out of 40 patients, union was observed in 38 (95%) fractures. Two fractures did not unite at 6 months follow up, and required bone grafting as a secondary procedure for union. The time taken for radiographic union was found to be less than 12 weeks in 3 fractures, between 12-16 weeks in 33fractures, and higher than 16 weeks in 2fractures. On determining the final shoulder functional outcome, 33 patients had excellent result, and 7 patients had good shoulder function, on UCLA score. With regard to the final elbow function, 31 patients had an excellent outcome, 6 patients had a good outcome, 2 patients had a fair outcome, and 1 patient had a poor outcome.Conclusion: Anterior humeral bride plating using MIPO technique yields high rates of union, minimal biological disruption of the soft tissue envelope, and better cosmesis, along with a fast and good functional recovery of patients with humeral shaft fractures.

Introduction: Lateral clavicle fractures are complex injuries that involve disruption of the coracoclavicular (CC) ligaments and result in significant functional impairment. Advances in surgical techniques have contributed to better outcomes for patients. This review aims to compare patient reported outcome measures (PROMs) and complications following different treatment options. PROSPERO:CRD42021297393.

Methods: A systematic electronic search of: Medline, Embase, CINAHL, and Cochrane CENTRAL databases was conducted on 8th March 2023. All surgical comparative studies in adults sustaining acute fractures with a minimum follow up period of 12-months were included. The Cochrane RoB-2 and ROBINS-I tools were used to evaluate the included studies. A pairwise meta-analysis of the most reported PROMs was conducted.

Results: Twenty-five studies, totalling 1216 patients and featuring twelve interventions were included. Hook plate fixation yielded the worst PROMs compared to all other common methods of fixation. Locking plate fixation had significantly worse PROMs compared to: locking plate augmented with CC-tape and CC-endobutton fixations, and standalone CC-endobutton fixation. Standalone CC-fixation showed significantly better PROMs compared to standalone plates. Plate (hook/locking) augmented CC-fixation consistently yielded better PROMs compared to standalone plate fixation. Postoperative complication rates were low. Transacromial pinning had the highest incidence of wound infection whilst conservative management had the highest incidence of non-union.

Conclusion: Hook plate fixation is associated with worse PROMs and should be used with caution. Plate augmented CC-fixation should be the favourable management option. Further research in the form of a randomised control trial is needed to compare standalone CC-fixation against locking plate augmented with CC-fixation.

Introduction: The study aimed to interpret the long-term outcome of bicortical refixation techniques. The major focus of this study was to verify the importance of anatomical correct tendon repair for an ideal postoperative outcome.
Methods: Patients following surgical treatment of the distal biceps tendon rupture between 2001 - 2016 were matched retrospectively. Inclusion criteria of this single center study included a bicortical technique and a minimum follow-up of 4 years. The radiological outcome as well as all adverse events were recorded. Objective criteria were functional parameters (ROM, flexion- and supination-strength) as well as radiological and clinical parameters (MEPS, OES, qDASH, SANE). Descriptive analysis and two tailed unpaired t-tests {p=0.05} form the basis for data interpretation. An additional subgroup analysis with focus on anatomic vs. non-anatomic as well as single-incision vs. double-incision repair was implemented.
Results: Sixty-five patients were included. The average follow-up period was 7,5 years. Anatomic repair showed significant performance advantages in flexion- (p=0,041) and supination strength (p=0,002) compared with non-anatomic refixation of the tendon. The localization of insertion had no effect on range of motion. There were only good to excellent results in patient reported outcome measures (MEPS: 99,9, OES: 47,6, qDASH: 10,6, SANE: 94,8). We found a total complication rate of 18,5%.
Conclusion: This study confirms the excellent outcome of distal biceps tendon repair. Surgical procedure provides optimal functional performance as well as high patient satisfaction.
The importance of correct anatomical refixation must be considered, resulting in a significant advantage in flexion and supination strength.

Introduction: Complication rates for the treatment of acute/chronic complicated fracture-dislocation of the elbow are substantial. To optimise and enhance our outcomes, the Modified Internal Joint Stabilizer of the Elbow (IJSE) device seems to be a viable solution. Case series of five patients treated in LGH, Lahore with modified IJS-E System (with T-plate) from January 2022 full filling the inclusion criteria.
Results: The mean final postoperative MEP score was 80 points, the postoperative DASH score was 11.78 points (4.2---20.6) with final arc of motion of 130◦with a range of flexion between 120◦and 140◦and a mean lack of extension of 12◦(5◦---20◦), with a complete arc of pronosupination.
Conclusions: In place of external fixation or K-wire (ulno-humeral) handling, the modified IJS-E device looks to be a successful substitute. Instead of the traditional IJS-E implant which is too costly, consider the T-plate as it is cheap and easily available.

Background: Proximal humeral fractures are common injuries. Treatment options like conservative treatment, percutaneous fixation, open reduction internal fixation and joint replacement. The objective was to compare the results of two different options of percutaneous fixation; multiple k- wires and modified Minimally Invasive Reduction Osteosynthesis System (MIROS).Methods: Between January 2020 and June 2022 at Zagazig University hospital ,36 patients, 12 patients had two part, 14 patients had three part and 10 patients had four-part fractures according to Neer's classification, Divided into two equal groups: group A treated with closed reduction and pinning with multiple k-wires and group B treated with modified MIROS
Results: The mean CS for the entire series, at the end of the follow-up period, was 76.3±11.40 in the k-wires group, 4 patients had excellent results, 6 patients had good results, 6 patients had fair results and 2 patients had poor results. In the Modified MIROS group, the mean CS was 83.5±17.62, 8 patients had excellent results, 7 patients had good results,1 patient had fair result. Regarding Constant Score, the results in the modified MIROS group were better than the multiple K-wires group with shorter time of union and fewer complications. Conclusion: Percutaneous pinning is a good treatment option for fixation of proximal humeral fractures and adding an external Ilizarov cubes and intramedullary elastic nails in modified MIROS technique resulted in better clinical results than multiple K-wires and minimizes the complications of multiple k- wires alone even in osteoporotic patients.

Aim to evaluate clinical outcomes of all arthroscopic stabilisation of acute acromioclavicular joint(ACJ) disruption using the Dogbone Button™
Methods: A single unit series of 64 patients with acute ACJ disruption were treated using the Dogbone Button suspensory device; two arthroscopically implantable metal buttons connected by 2 loops of Fibertape™.
Results The injury was grade lll in 10 patients and V in 54 patients. Mean time to surgery was 11 days (range 2-20). Of the 64 patients 43 were male. Mean age was 33 (range 20 to 39). Intra-operative fluoroscopy demonstrated anatomical reduction of the ACJ in all patients. Mean follow-up was 12 months (range 6-18). At final follow-up the mean Subjective Shoulder Value was 82%±12, mean Constant Score was 80±5 and mean Oxford Shoulder Score was 42±5. There were complications seen in 10 patients (12%). Repair failure was seen in 8 patients. There was early cut out of the clavicle button in 2 patients which required revision. Further to this, in 5 patients (9%) who had not undergone failure, we saw significant clavicle tunnel erosion at 1.5 and 6 months post-operatively by a mean of 87.5% (p0.001).
ConclusionsEarly results of acute ACJ repair using the Dogbone in isolation indicate a high complication rate and clavicle erosion. These problems have been seen previously with other suspensory devices. We advise this device is use in conjunction with a repair of the acromioclavicular ligaments. Despite the high complication rate the early outcome scores were not affected