Background:
Management of complex distal humeral fractures, especially in elderly patients, represents a significant surgical challenge. Non-operative management is frequently associated with poor functional outcomes, whereas there is a high rate of complications after operative treatment whether that is open reduction and internal fixation or total elbow arthroplasty in the trauma setting.

Aim:
to examine the medium-term outcomes of distal humeral hemiarthroplasty (DHH) in patients with acute distal humeral fractures.


Methods:
All patients treated at our institute with a minimum of 24 months post-operative follow up were included. Primary outcome measure was Oxford Elbow Score(OES) at final follow up. Secondary outcomes measures included Mayo Elbow Performance Score(MEPS), range of motion ROM) and post-operative complications.

Results:
25 consecutive elbows were included for analysis at a mean follow-up of 50 months after surgery (26-87 months). 22 patients were female and the average age was 70 years(47-88). Average time from injury to surgery was 12 days. At final follow-up, mean OES was 40 (range 16-48). MEPS was 82.2 (range 50-100). Mean total arc of motion was 100 (30-130). There were 10 complications including heterotopic ossification (HO)(7 patients), dislocation(2 patients) and stiffness without HO(1 patient). 2 patients with dislocation underwent further surgery with conversion to total elbow replacement.

Conclusion:
DHH is a reliable surgical option for distal humeral fractures with satisfactory functional outcomes which are sustained at mid-term follow up in this series. This was associated with a 40% risk of complications with(8% requiring further surgery).

Introduction: To evaluate the correlation between subscapularis insufficiency and functional subacromial impingement syndrome (SAIS).
Patients and Methods: Twenty patients with nonstructural subacromial impingement with at least one positive clinical test including Neer’s,
Hawkins Kennedy, and Codman drop arm test, were recruited for this observational study. Subscapularis weakness was evaluated clinically
via Gerber lift‑off test, Bear Hug test and by Belly Press test, and by dynamometer, and its insufficiency was confirmed by evaluating changes
in muscle atrophy and fatty infiltration on magnetic resonance imaging (MRI). Subscapularis weakness was then matched with radiological
parameters of proximal migration of shoulder, namely upward migration index (UMI) and Acromiohumeral interval (AHI) on X-ray and MRI,
respectively. Results: A significant association (P < 0.05) was seen between subscapularis insufficiency and radiological parameters of SAIS,
namely UMI and AHI. Conclusion: There exists a significant positive correlation between subscapularis insufficiency and proximal migration
of humerus. Patients with clinical and radiological signs of subacromial impingement and without any evidence of structural abnormality
should be investigated for an underlying subscapularis insufficiency

Introduction: Accurately defining glenoid version is crucial to safe planning for shoulder arthroplasty. Previous studies have shown two-dimensional CT to be superior to plain radiography in determining central glenoid wear. We aimed to compare the effectiveness of plain radiography, two-dimensional axial CT and three-dimensional CT planning software to determine glenoid version. Methods:
Fifty consecutive patients undergoing elective shoulder arthroplasty who met the inclusion criteria were identified retrospectively. All patients had pre-operative plain radiography and CT scans within 6 months of each other. Exclusion criteria were absence of adequate axillary plain radiograph, revision cases and trauma cases. Glenoid version was measured on the axillary view and on two-dimensional CT using Friedman’s method. Blueprint 3D planning software was used for three-dimentional reconstructions and automated measurement of version using multiple data-points. Results: Of a total of 50 patients, there were 19 males and 31 females with a mean age of 72.9 years. There were 10 anatomic and 40 reverse total shoulder arthroplasties performed. Mean glenoid retroversion was 21.1 degrees measured on plain radiographs, 10.1 degrees on two-dimensional CT and 16 degrees on three-dimensional CT. The Pearson Correlation Coefficients were 0.80 for plain radiography/two-dimensional CT, 0.82 for two-dimensional CT/three-dimensional CT and 0.73 for plain radiography/three-dimensional CT (all with p-values <0.01). Conclusion: Plain radiography over-measures retroversion as compared to CT scanning. Using three-dimensional automated version measurements as gold standard, two-dimensional CT most accurately measures glenoid version when measured manually by an observer. We therefore recommend the routine CT scanning pre-operatively to measure glenoid version.

Purpose The purpose of this study aimed to evaluate the efcacy of local injection of allogeneic platelet-derived growth factors in treatment of patients with tennis elbow.Patients and methods This study included 120 tennis elbow patients randomly divided into two groups. The patients were locally injected with allogeneic growth factors (treatment group) or with normal saline (control group). The outcomes were assessed using Patient-Related Tennis Elbow Evaluation (PRTEE) and quick Disabilities of the Arm, Shoulder and Hand (qDASH) scales. The clinical outcomes were accordingly classifed as excellent, good and poor. The patient’s satisfaction and adverse efects were also recorded.Results There was no statistically signifcant diference between the two groups regarding the age, gender, dominant arm or the pre-injection scores. At three month follow-up, the reductions in the mean PRTEE and qDASH scores were 88.7% and 70.6% in the treatment group versus 21.8% and 14.9% in the control group, respectively. At the last follow-up, the outcomes in the treatment group were excellent in 85% of patients and good in 15%, versus 8% and 32% in the control group. Overall, 95% were satisfed in the treatment group compared to 25% in control group. Forty patients in the treatment group experienced mild transient post-injection pain.Conclusion This study strongly suggests that local injection of allogeneic platelet-derived growth factors could be a promising safe treatment option for tennis elbow with signifcant pain relief, functional improvement and patient’s satisfaction. Yet, additional larger studies are needed to assess the durability of these outcomes.

Introduction: The Constant score is a universally recognized assessment tool for patients with shoulder pain and disability. However, it has been proven to have poor interobserver reliability for some of its aspects and is not suitable for remote assessment. The aim of this study is to develop an automatic Constant-Murley shoulder joint function evaluation system and to verify its reliability. Methods: The subjective score was reported by electronic scales. The range of motion aspect was recorded by movement images of patients. Then, these images were analyzed through a pose estimation algorithm and graded by machine learning classifiers. The shoulder strength score was evaluated through the data recorded by the built-in inertial sensors in the mobile phone, and graded by machine learning classifiers. To assess the reliability of the proposed method, the results of this automatic system were compared to the results concluded by experienced human raters. Results: Data from 68 patients with shoulder pain and disability were collected. In the evaluation of the joint range of motion, the mean difference between the proposed method and human raters was 0.34 ±4.22, and the ICC was 0.920 (95% CI: 0.865-0.953). As for the shoulder abduction strength, the accuracy of the classifier was 76.12%. Conclusion: This automatic Constant-Murley system method could be used to evaluate shoulder joint function by utilizing the movement images of patients and the data collected by the built-in sensor in mobile phones. The results indicated that this method has good reliability.

Introduction: Adhesive capsulitis is a debilitating condition. Treatment options include physiotherapy, capsular release, intra-articular injections and hydrodistension. This study aimed to 1) assess the effectiveness of hydrodistension, and 2) evaluate any influence the presence of diabetes, insulin and HbA1c may have on treatment effectiveness. Methods: Data was retrospectively collected at two NHS trusts offering hydrodistension as a treatment for adhesive capsulitis. Minimum follow-up was 18 months. The primary outcome was re-intervention rate (either in the form of a subsequent steroid injection, capsular release or repeat hydrodistension). Patient’s diabetic status, insulin usage and HbA1c was recorded. Chi-squared statistical analysis was used. Results: 309 patients underwent hydrodistension between 2018-2021 (114 male, 195 female). Mean age was 54.5 (range 22-83). Mean duration of symptoms was 14.5 months (range 1-120). 81.5% (251/308) of patients had physiotherapy prior to hydrodistension. 77.0% (238/309) of patients required no further intervention. Diabetes was recorded in 28.5% (88/309) of patients. Of these, 36.4% (32/88) were on insulin. There were statistically significant higher rates of re-intervention in diabetics compared to non-diabetics (33.0% vs 19.1%, p = 0.009). Re-intervention rates were higher in patients who took insulin (28.1% vs 22.4%, p = 0.465) and in those with a HbA1c of ≥48 (30.6% vs 22.9%, p = 0.200) but this was not statistically significant. Conclusion: Hydrodistension is a successful treatment for adhesive capsulitis with the majority of patients requiring no further intervention. Patients with diabetes are more likely to require further treatment. We plan a multi-centre study to investigate this further.

Introduction: The aim of this study was to evaluate the thoracohumeral (TH) and glenohumeral (GH) motion with muscle activity after latissimus dorsi transfer (LDT) in a massive irreparable posterosuperior rotator cuff tear (MIRT) and pseudoparalytic shoulder compared to the asymptomatic contralateral shoulder (ACS).
Methods: Thirteen patients were recruited and evaluated after LDT with a preoperative clinical pseudoparalysis and MIRT. 3D electromagnetic tracking was used to assess maximal active elevation of the shoulder (MAES) in both the LDT and the ACS. Surface electromyography (EMG) tracked activation of the latissimus dorsi (LD) and deltoid muscles during shoulder motion.
Results: In MEAS the TH motion of the LDT shoulder was not significantly different to that of the ACS, F(1,12) = 1.174, p=0.300, but the GH contribution was found to be significantly lower in the LDT shoulder for all motions, F(1,12) =11.230, p=0.006. External rotation (LDT 26+/-10, ACS 42+/-11; P < 0.001) was significantly more in the ACS.
LD % EMG max showed no significant difference between LDT and ACS during MAES F(1,11) = 0.005, p= 0.946. During maximal active external rotation in the shoulder, the LDT showed a higher % EMG max in the LDT than ACS (LDT 3.0%+/- 2.9, ACS 1.2%+/-2.0; P=0.006).
Conclusions: TH motion improved after LDT in a pseudoparalytic MIRT and was not different to the ACS. However, GH motion was significantly lower after LDT than in the ACS in active elevation ROM. The LD was active after LDT but not more than in the ACS.

Introduction: The aim of the study was to identify which shoulder muscles and what timing of muscle recruitment are responsible for the increased ST contribution and shoulder elevation after LDT for a massive irreparable posterosuperior rotator cuff tear (MIRT).

Methods: Thirteen patients with a preoperative pseudoparalysis and MIRT were recruited after LDT with a minimum follow-up of 1 year. 3D electromagnetic tracking was used to assess maximum active elevation of the shoulder (MAES) in both the LDT and the asymptomatic contralateral shoulder (ACS). Surface electromyography (EMG) tracked activation (% EMG max) and activation timing of the latissimus dorsi (LD), deltoid, teres major, trapezius (upper, middle and lower) and serratus anterior muscles.

Results
The LD %EMG max did not differ between the LDT and ACS in MAES. A higher % EMG max was found for the deltoid F(1,12)=17.241, P=0.001, and upper trapezius F(1,10)=13.612, P=0.004 in the LDT shoulder during MAES. The middle trapezius only showed a higher significant difference in % EMG max for scapular abduction, P =0.020 (LDT 52.3+/-19.4, ACS 38.1+/-19.7).

Conclusion
After LDT in patients with a MIRT and preoperative pseudoparalysis, the LD muscle did not alter its % EMG max during MAES when compared to the ACS. The cranial transfer of the LD tendon with its native %EMG max, together with the increased %EMG max of the deltoid, middle and upper trapezius muscles could be responsible for the increased ST contribution.

The Wide-Awake local anesthesia technique (WALA)has been used in many orthopedic surgeries. Combined with the clavipectoral fascia Block (CPB) in selected patients, can offer good outcomes during surgery in patients with acute midshaft clavicle fractures.
A prospective study of a series of 221 selected Patients with ASA I-II scores, between 19 and 42 years old, was performed from February 2016 to December 2022.
All patients who underwent midshaft clavicle osteosynthesis under general anesthesia during the same period (62 patients) were also evaluated.
A preparation of 2% Lidocaine (15ml) + 0.5% Bupivacaine (10ml) + 20 ml of 0.9% saline solution is infiltrated directly into the fracture focus, soft tissues adjacent to the fracture, subcutaneous infiltration in the surgical approach area, plus infiltration of the inferior surface of the clavicle.
Results: WALA Combined Group (WAG):
220 patients had(FES 0) during the procedure and good operative and postoperative analgesia(VAS 0-2).
The mean total surgical time (ST) was 1 hour 10 minutes and the length of stay in the hospital (LSH)was 0.7 days on average.
General Anesthesia Group (GAG):
All patients had FES 0, VAS 0.
In the postoperative 18 patients reported VAS 3, 30( VAS 4), and 14( VAS 6).
The ST was 2 hours and 15 minutes, and LSH was 1.5 days.
Conclusions:
WALA combined with the CPB provides good analgesia during the surgery in acute midshaft clavicle fractures osteosynthesis and better postoperative analgesia.
Additionally, the time in the operating room and the length of hospital stay are reduced.

Reverse shoulder arthroplasty (RSA) is being increasingly used for complex fractures of proximal humerus fracture (PHF). The goal of our study is to evaluate the functional and radiographic results after RSA of three or four-part PHF in elderly patients .
Methods: 70 consecutive patients with a recent three- or four-part PHF were treated with RSA. There were 41 women and 29 men, with a mean age of 76 years (range 65 to 87). The dominant arm was involved in 42 patients (60%). Displaced three-part PHF sustained in 16 patients, 24 fracture dislocation and 30 four-part PHF described by Neer. Patients were followed up for a mean of 26 months (range 10 to 36).
Results: The mean postoperative Oxford Shoulder Score at the end of the follow-up period was 32.4 (range 16 to 42). The
mean DASH score was 44.3 (range 10 to 92). Tuberosity non-union occurred in 18 patients (12.6%), malunion occurred in 7
patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching observed in one patient. In this study
anatomical reconstruction was achieved in 25 patients (17.5%) but the influence of greater tuberosity healing on shoulder
function could not be demonstrated. Heterotopic ossification seems to affect the OSS and QDASH, we found statistically
significant relation between HO and clinical outcomes. Patients with HO had significantly lower
postoperative scores on DASH and OSS (P = .0527).
Conclusion: Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was
irrespective of healing of the tuberosities.

Intra-articular corticosteroid injections are frequently utilised in patients with glenohumeral arthritis. It is debated whether these injections increase the risk of infection following subsequent shoulder arthroplasty. Purpose: to evaluate the relationship between prior corticosteroid injection and infection following shoulder arthroplasty. A computerised search was performed, using the databases Medline, EMBASE and CINAHL, with supplementation from Google Scholar. Studies with comparative data of post-arthroplasty infection following previous corticosteroid injection versus controls were included. Data were extracted and quality assessment performed by two reviewers. Quantitative analysis was performed where possible. Results: Six studies fulfilled the inclusion criteria (one prospective and five retrospective studies), with 71,043 patients in total. On pooled analysis, a previous steroid injection did not increase the risk of infection (relative risk 1.11, 95% CI 0.91-1.35, p=0.30). It did, however, confer an increased risk of revision surgery (all cause) (relative risk 1.52, 95% CI 1.32-1.75, p<0.001). On subgroup analysis, injections given within 3 months of arthroplasty conferred a greater risk of infection that no injection (relative risk 3.39, 95% CI 1.02-11.24, p<0.05) or one given at 3-12 months before arthroplasty (relative risk 3.32, 95% CI 1.43-7.72, p=0.005). An injection at 3-12 months before arthroplasty did not increase the risk of infection over controls (relative risk 0.89, 95% CI 0.63-1.25, p=0.50). conclusion: There to be a time-dependent relationship between prior corticosteroid injection and infection post-arthroplasty, with an increased risk at a gap of less than three months. Thus, an interval of at least three months is recommended between injection and arthroplasty.

Unstable distal clavicle fractures associated with lesions of the CC ligaments demonstrate a high symptomatic nonunion rate if treated conservatively. A wide variety of surgical techniques have been described. Many of these techniques were associated with high failure rates and hardware-related complications. We have adopted a surgical technique that aims at stabilization of the CC ligaments in combination with osteosynthesis of the clavicle.

We questioned: (i) Loss of reduction or loosening of the CC ligaments, (ii) The clinical function, (iii) Return to work, (iv) Return to sports.

A retrospective single-centre case series. Between 2015 and 2019, patients who had a lateral clavicular fracture associated with a CC ligament lesion and underwent stabilization of the CC ligaments by FiberWire® and osteosynthesis by low-profile plating. Thirteen patients, with an average age of 48 years, had a clinical and/or radiological average follow-up of 3 years.

Only one of the patients showed loosening of more than 5 mm of the CC ligaments. No loss of reduction was determined.
The clinical function at an average of 38 months showed a complete recovery in 10 of the patients. The average OSS was 47 out of 48, the average ASES 99, and the VAS 0.

Stabilization of the CC ligaments in combination with osteosynthesis of the lateral clavicle using low profile plating provides a surgical treatment option with complication rates consistent with the current literature, a very satisfactory clinical outcome, as well as early return to work and sports.

Background: Fixation of radial head fractures is still controversial, as there is uncertainty about when the surgery is indicated as well as what type of surgical intervention is the best
Aim: To assess the clinical, radiological and functional outcomes of arthroscopic assisted fixation of radial head fractures in adults.
Methods: A prospective analytic study was conducted following approval of our Ethical and Research Committee, including 35 patients with Mason type II radial head fractures. We presented the mid-to-long-term results of an arthroscopic technique for reduction and percutaneous fixation of radial head fractures. The functional evaluation was carried out using the Disabilities of Arm, Shoulder and Hand Questionnaire (DASH), Mayo Elbow Performance Index (MEPI) and the Oxford Elbow Score (OES).
Results: There was a significant gradual decrease in the DASH score between different follow-up points post-operatively (p<0.001). Mayo score at 6 months (98.14 ± 2.73) was significantly higher than their score at both 3 months (92.0 ±4.41) and 6 weeks (85.71 ±5.16) (p<0.001). The Oxford score of the patients at 6 months (47.34 ± 0.99) was significantly higher than their score at both 3 months (44.51 ± 2.40) and 6 weeks (41.20 ±2.85) (p<0.001). The flexion angle of the patients at 6 months (143.03 ± 2.95) was significantly higher than their score at both 3 months (138.71 ± 3.28) and 6 weeks (134.23 ± 4.56) (p<0.001).
Conclusion: Arthroscopic assisted radial head fixation is safe and reliable. It achieves good outcomes in patients with Mason type II fractures of the radial head.