Aims. The aim of this study was to investigate the potentially increased risk of dislocation in patients with neurological disease who sustain a femoral neck fracture, as it is unclear whether they should undergo total hip arthroplasty (THA) or hemiarthroplasty (HA). A secondary aim was to investgate whether dual-mobility components confer a reduced risk of dislocation in these patients. Methods. We undertook a longitudinal cohort study linking the Swedish Hip Arthroplasty Register with the National Patient Register, including patients with a neurological disease presenting with a femoral neck fracture and treated with HA, a conventional THA (cTHA) with femoral head size of ≤ 32 mm, or a dual-mobility component THA (DMC-THA) between 2005 and 2014. The dislocation rate at one- and three-year revision, reoperation, and mortality rates were recorded. Cox multivariate regression models were fitted to calculate adjusted hazard ratios (HRs). Results. A total of 9,638 patients with a neurological disease who also underwent unilateral arthroplasty for a femoral neck fracture were included in the study. The one-year dislocation rate was 3.7% after HA, 8.8% after cTHA < 32 mm), 5.9% after cTHA (= 32 mm), and 2.7% after DMC-THA. A higher risk of dislocation was associated with cTHA (< 32 mm) compared with HA (HR 1.90 (95% confidence interval (CI) 1.26 to 2.86); p = 0.002). There was no difference in the risk of dislocation with DMC-THA (HR 0.68 (95% CI 0.26 to 1.84); p = 0.451) or cTHA (= 32 mm) (HR 1.54 (95% CI 0.94 to 2.51); p = 0.083). There were no differences in the rate of reoperation and revision-free survival between the different types of prosthesis and sizes of femoral head. Conclusion. Patients with a neurological disease who sustain a femoral neck fracture have similar rates of dislocation after undergoing HA or DMC-THA. Most patients with a neurological disease are not eligible for THA and should thus undergo HA, whereas those eligible for THA could benefit from a DMC-THA. Cite this article: Bone Joint J 2022;104-B(1):134–141

Introduction. We aim to assess whether radiographic characteristics of the greater tuberosity fragment can predict rotator cuff tears inpatients with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity. Methods. A retrospective single-centre case series of 61 consecutive patients that presented with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity between January 2018 and July 2022. Inclusion criteria: patients with atraumatic anterior shoulder dislocation associated with an isolated fracture of the greater tuberosity with a minimum follow-up of 3-months. Exclusion criteria: patients with other fractures of the proximal humerus or glenoid. Rotator cuff tears were diagnosed using magnetic resonance or ultrasound imaging. Greater tuberosity fragment size and displacement was calculated on plain radiographs using validated methods. Results. The case series was composed of 22 men and 39 women with a mean age of 65 years (29 - 91 years). The mean follow-up was 15months and median follow up 8.5 months (3 – 60 months). A rotator cuff tear was diagnosed in 14 patients (16%) and involved the supraspinatus (13), infraspinatus (4) and subscapularis (2). Full-thickness tears occurred in 6 patients and partial-thickness tears in 8patients. The mean time from initial injury to rotator cuff tear diagnosis was 5 months (2 – 22 months). The mean greater tuberosity fragment length was 23.4 mm in rotator cuff tear patients versus 32.6 mm in those without a tear (p = 0.006, CI: -15 - -2). The mean greater tuberosity. fragment width was 11.1 mm in rotator cuff tear patients versus 17.8 mm in those without a tear (p = 0.0004, CI: -10 - -2). There was no significant difference in the super inferior and anteroposterior fragment displacement between the two groups. Conclusion. In patients with shoulder dislocations combined with an isolated fracture of the greater tuberosity, rotator cuff tears are associated with a smaller sized greater tuberosity fragment

In a group of 25 patients with traumatic dislocation of the knee, four, all of whom had similar ligament and medial soft-tissue injuries, also had associated lateral patellar dislocation. In all four reconstruction was delayed because of their other serious injuries. Having encountered the combination of knee dislocation and lateral patellar dislocation in 16% of our patients, we believe that it may be less rare than is commonly believed. We think that it is important to maintain a high index of suspicion of possible patellar dislocation when medial structures have been severely damaged. Early recognition and immobilisation in extension can prevent fixed lateral dislocation of the patella

Aims. This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation. Patients and Methods. Of 3326 consecutive patients treated with hemiarthroplasty for fractured neck of femur, 46 (1.4%) sustained dislocations. Of the 46 dislocations, there were 37 female patients (80.4%) and nine male patients (19.6%) with a mean age of 83.8 years (66 to 100). Operative intervention for each, and subsequent dislocations, were recorded. The following outcome measures were recorded: dislocation; mortality up to one-year post-injury; additional surgery; residential status; mobility; and pain score at one year. Results. Of 43 dislocations, 30 (70%) occurred within one month and 42 (98%) occurred within three months of hip fracture surgery. Seven (16%) of these patients were treated with a single closed reduction and sustained no further dislocations. Four (9%) were treated with open reduction and experienced no further dislocations. Three (7%) hips were left dislocated and the remaining 32 (74%) patients required additional surgery of further closed reduction, revision, or excision arthroplasty. The one-year mortality rates for patients treated with two or fewer reductions (open or closed), successful revision arthroplasty, and excision arthroplasty were 3/14 (21%), 1/7 (14%), and 8/14 (57%) respectively. The only statistically significant difference in mortality was the difference between patients who did not sustain a dislocation and those who did and were treated by excision arthroplasty (p = 0.03). Patients treated by excision arthroplasty had the greatest reduction in mobility scores and highest pain scores. The excision arthroplasty group also included the greatest proportion of patients not able to mobilize and the smallest proportion of patients remaining in their own home. Conclusion. Most dislocations of hemiarthroplasties of the hip occur within one month of surgery. Closed reduction is generally unsuccessful. For those patients with unsuccessful closed reduction, revision arthroplasty should be considered when possible, as this results in a better functional outcome with a lower mortality than excision arthroplasty

Dual mobility significantly reduces the risk of prosthetic instability. This mechanical complication occurs when the prosthetic head moves out from the retentive polyethylene liner, such phenomenon called intra-prosthetic dislocation reports a ten-year incidence of 2% in the literature. We prospectively analysed all intra-prosthetic dislocations having occurred since 1985 in our department in order to investigate patient- and implant-related risk factors. 91 intra-prosthetic dislocations occurred with NOVAE (SERF) cups in 85 patients of mean age 50.7 years. Intra-prosthetic dislocation occurred after a mean period of 8.8 years. A PRO (SERF) stem was implanted in 56 cases and a PF (SERF) stem in 35. The stems were different from one another in their neck diameter and material: 13 mm titanium neck and 16 mm stainless steel neck respectively. When taking both prosthetic features into account, no significant difference could be established regarding the time between implantation and dislocation. Comparison between these two prosthetic features was performed by means of two continuous homogeneous series which included 240 patients implanted with PF stems and 382 patients with PRO stems. At a mean 15-year follow-up, the two series reported a non-statistically different intra-prosthetic dislocation rate of 4%. In both series, young age and large diameter cups were considered predisposing factors for intra-prosthetic dislocation. Therefore, unlike suggested by several authors, prosthetic neck material and diameter do not appear as the main predictors for intra-prosthetic dislocation which is highly promoted by patient-related features

Total Hip Arthroplasty (THA) is one of the most successful and cost-effective treatments available for painful hip arthritis. Unfortunately, dislocation following primary THA is one of the most common complications, occurring in approximately 0.50–10percnt; cases. However, there is little literature that investigates the effects that dislocation has on the patient's overall function and satisfaction. We reviewed 229 THA patients that had sustained dislocation from a prospective database, consisting 156 single dislocations and 73 with two or more. Patient outcomes were compared with a matched control group of 196 patients without dislocation in the same follow-up period. Harris Hip Score (HHS) and patient satisfaction were recorded pre-operatively and at one, five and ten years post-operatively. Mann-Whitney test compared HHS between control and dislocation groups, Chi-Square test compared patient satisfaction and implant survival. Total HHS and functional component were significantly lower in the dislocation group at one, five and ten years (p<0.05). HHS Pain component revealed a significant difference but only at one and three years (p<0.05). Patient satisfaction only showed a significant difference at one-year review. Dislocation rates were significantly higher in females. Implant survivorship was significantly lower in the dislocation group at 15-years. Hip-function and implant survival is significantly reduced following prosthesis dislocation, however patient satisfaction and pain levels appear unaffected at long-term follow-up

The optimal method for the management of neglected traumatic bifacetal dislocation of the subaxial cervical spine has not been established. We treated four patients in whom the mean delay between injury and presentation was four months (1 to 5). There were two dislocations at the C5-6 level and one each at C4-5 and C3-4. The mean age of the patients was 48.2 years (27 to 60). Each patient presented with neck pain and restricted movement of the cervical spine. Three of the four had a myelopathy. We carried out a two-stage procedure under the same anaesthetic. First, a posterior soft-tissue release and partial facetectomy were undertaken. This allowed partial reduction of the dislocation which was then supplemented by interspinous wiring and corticocancellous graft. Next, through an anterior approach, discectomy, tricortical bone grafting and anterior cervical plating were carried out. All the patients achieved a nearly anatomical reduction and sagittal alignment. The mean follow-up was 2.6 years (1 to 4). The myelopathy settled completely in the three patients who had a pre-operative neurological deficit. There was no graft dislodgement or graft-related problems. Bony fusion occurred in all patients and a satisfactory reduction was maintained. The posteroanterior procedure for neglected traumatic bifacetal dislocation of the subaxial cervical spine is a good method of achieving sagittal alignment with less risk of iatrogenic neurological injury, a reduced operating time, decreased blood loss, and a shorter hospital stay compared with other procedures

BACKGROUND & AIM. Most previous studies found that the rate of dislocation following primary THA was 2 to 3 % on average. It is expected that minimally invasive (MI) THA has fewer dislocations after surgery because it causes less muscle damage. To ascertain the risk factors of dislocation, we conducted a retrospective study of the occurrence of dislocation after MI-THA in Japanese patients. METHODS. From June 2003 when we began MI-THA to August 2010 primary MI-THAs were performed on 2,042 hips; 1,997 hips with mini-posterior approach (a mean incision of 7 cm) with the repair of posterior soft tissues and 45 hips with other approaches. The dislocation after MI-THA was studied with respect to age, sex, body mass index, the use of navigation system, femoral head size, cup size and approaches. The period of follow-up was from six weeks to seven years. RESULTS. The numbers of dislocation after MI-THA were 13 hips (0.6%). The numbers of posterior and anterior dislocation after MI-THA were nine and four hips, respectively. In the patients undergoing MI-THA, there was a significant difference between non-dislocated hips and dislocated hips, with respect to the average age (57 years vs. 66 years, p<0.017), the numbers of male patients (181 cases (9%) vs. 4 cases (31%), p<0.024), cup size (50 mm vs. 53 mm, p<0.007) and the numbers of cases which used navigation system (1,932 hips (95%) vs. 10 hips (77%), p<0.023). Whereas there was no significant difference between non-dislocated hips and dislocated hips with respect to the body mass index, femoral head size and approaches. DISCUSSION. Several risk factors of the dislocation after primary THA have been reported. In this study we found that MI-THA had fewer risk of dislocation as compared with historic controls. It is suggested that less soft tissue damage can decrease the risk of the dislocation after surgery. The incidence of dislocation was fewer in the younger and female patients undergoing MI-THA with the navigation system than in the older and male patients undergoing MI-THA without the navigation system. The posterior approach combined with the repair of posterior soft tissues did not increase the risk of dislocation after surgery as compared with other approaches. The position of implants is important to prevent dislocation after surgery, and the navigation system can help to obtain a good position of implants. CONCLUSIONS. We conclude that MI-THA can decrease the risk of dislocation after primary THA. Furthermore the combination of MI-THA and the navigation system is very useful to reduce the incidence of dislocation because the use of the navigation system during surgery can be helpful to acquire the precise position of implants

Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9). Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports. Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis

Background. Acute anterior dislocation of the glenohumeral joint may be complicated by injury to neighboring structures. These injuries are best considered a spectrum of injury ranging from an isolated dislocation (unifocal injury), through injuries associated with either nerve or osteoligamentous injury (bifocal injury), to injuries where there is evidence of both nerve and osteoligamentous injury. The latter combination has previously been described as the “terrible triad,” although we prefer the term “trifocal,” recognizing that this is the more severe end of an injury spectrum and avoiding confusion with the terrible triad of the elbow. We evaluated the prevalence and risk factors for nerve and osteoligamentous injuries associated with an acute anterior glenohumeral dislocation in a large consecutive series of patients treated in our Unit. Materials and Methods. 3626 consecutive adults (mean age 48yrs) with primary traumatic anterior shoulder dislocation treated at our unit were included. All patients were interviewed and examined by an orthopaedic trauma surgeon and underwent radiological assessment within a week of injury. Where rotator cuff injury or radiologically-occult greater tuberosity fracture was suspected, urgent ultrasonography was used. Deficits in neurovascular function were assessed clinically, with electrophysiological testing reserved for equivocal cases. Results. Unifocal injuries occurred in 2228 (61.4%) of patients. There was a bimodal distribution in the prevalence of these injuries, with peaks in the 20–29 age cohort (34.4% patients) and after the age of 60 years (23.0% patients). Of the 1120 (30.9%) patients with bifocal dislocations, 920 (82.1%) patients had an associated osteotendinous injury and 200 (17.9%) patients had an associated nerve injury. Trifocal injuries occurred in 278 (7.7%) of cases. In bifocal and trifocal injuries, rotator cuff tears and fractures of the greater tuberosity or glenoid were the most frequent osteotendinous injuries. The axillary nerve was most frequently injured neurological structure. We were unable to elicit any significant statistical differences between bifocal and trifocal injuries with regards to patient demographics. However, when compared with unifocal injuries, bifocal or trifocal injuries were more likely to occur in older, female patients resulting from low energy falls (p<0.05). Conclusions. We present the largest series reporting the epidemiology of injury patterns related to traumatic anterior shoulder dislocation. Increased understanding and awareness of these injuries among clinicians will improve diagnosis and facilitate appropriate treatment

Of 545 consecutive patients with anterior shoulder dislocations, 108 (20%) were aged 60 years or more at the time of injury. We reviewed and radiographed 95 of these elderly patients after a mean follow-up of 7.1 years. Axillary nerve injuries were seen in 9.3% of the 108 patients, but all recovered completely in 3 to 12 months. There were single or multiple recurrences of dislocation in 21 patients (22.1%), but within this group age had no influence on the tendency to redislocate. Tears of the rotator-cuff were diagnosed by imaging studies or clinically in 58 patients (61%), including all who had redislocations. Sixteen patients required surgery. Eight with a single dislocation and a cuff tear had only repair of the torn cuff. Of the eight patients with multiple dislocations requiring operation, five also had a torn cuff and needed either a stabilising procedure and a cuff repair or repair of the cuff only. All patients who were operated on had a satisfactory result, with the exception of those with multiple redislocations and a cuff tear who had repair of the cuff only. Anterior shoulder dislocation in elderly subjects is more common than is generally believed; 20% suffer redislocation and 60% have a cuff tear. Operation may be needed to repair a torn cuff or to stabilise the shoulder. Patients with multiple redislocations will probably require both procedures

Introduction. Dislocation following total hip arthroplasty THA is a major short term complication not infrequently resulting in revision arthroplasty. Malposition of the acetabular component in THA results in a higher rate of dislocation as well as increased wear and osteolysis. The aim of this study was to assess the effect of mode of fixation on positioning of the acetabular component. Patients, materials and methods. For all THAs performed at our hospital in 2008, angle of acetabular inclination was measured using PACS by two independent observers. Interobserver and intraobserver reliability were assessed (Pearson's correlation coefficient, r). We determined whether the number of acetabular components outside the target angle range (eg:45±5°) was significantly different between cemented and cementless THA (chi squared test). An enquiry was made to the National Joint Registry (NJR) in respect to incidence of revision for dislocation of THA using cemented and cementless acetabular components, 2004–2009. Results. During 2008 126 THA were performed, 80 cemented and 46 cementless. There was good reliability of angle measurement (interobserver: r=0.89; intraobserver: r=0.87 and 0.97). More cemented acetabular components were within target angle range compared to cementless (cemented 32/80, cementless 29/46; chi squared=6.39, p<0.05). Using data from NJR comparing the number of primary hip replacement operations with number of revisions due to dislocation found a higher rate for cementless THA, 0.381% (266/69,822) than for cemented, 0.282% (262/92,928) (Odds ratio: 1.35 (95% CI 1.14–1.60; P<0.05). Conclusion. Positioning of the acetabular component is more difficult when using cementless systems as implant position is determined by orientation of reaming whereas with cement there is potential for fine implant position adjustment on insertion. The choice of a cementless acetabular component significantly increases the incidence of dislocation post THA. Acetabular component malposition is likely to be a factor in this increased incidence

Total hip arthroplasty (THA) has been efficacious for treating hip fractures. However, in these patients with fractures a widely variable prevalence of dislocation has been reported, partly because of varying durations of follow-up for this specific end-point. The purpose of the present study was to determine the risk of dislocation as a function of time after total hip arthroplasty in these patients with fractures and to investigate if constrained liners influence the cumulative risk of dislocation. Between 2000 and 2005, 425 patients with neck fracture underwent primary THA using a constrained acetabular liner (Cemented retentive cup, Groupe lépine, Genay, France). The results of these 425 constrained acetabular liners were compared with 380 THA without constrained liners performed for neck fractures between 1994 and 1999 in the same hospital. All patients were followed for a minimum of 5 years for radiographic evidence of implant failure. The patients were followed at routine intervals and were specifically queried about dislocation. The cumulative risk of dislocation was calculated with use of the Kaplan-Meier method. Results. For patients without constrained liners, the cumulative risk of a first-time dislocation was 5% at one month and 12% at one year and then rose at a constant rate of approximately 2% every five years to 17% at five years, 19% at ten years, 21% at 15 years for patients who were alive and had not had a revision by that time. For patients with constrained liners, the cumulative risk of a first-time dislocation was 1% at one month, 2% at one year and then did not changed at 5 years and at 10 years for patients who were alive and had not had a revision by that time. Multivariate analysis revealed that the relative risk of dislocation for female patients (as compared with male patients) was 2.1 and that the relative risk for patients who were 80 years old or more (as compared with those who were less than 80 years old) was 1.5. Two underlying diagnoses - cognitively impaired patients or neurologic desease—were also associated with a significantly greater risk of dislocation. At minimum 7 year follow up (range 5 10 yrs), there were 8 radiographic failures (dislocations) of the 425 constrained liners (2%), and no loosenings were noted. Conclusions. The cumulative long-term risk of dislocation for patients with hip fractures is considerably greater than has been reported in short-term studies. The incidence of dislocation is highest in the first year after arthroplasty and then continues at a relatively constant rate for the life of the arthroplasty. Patients at highest risk are old female patients and those with a diagnosis of neurologic desease. Constrained liners in these patients is an efffective technique to prevent post operative hip dislocation

Simultaneous bilateral posterior dislocation of the hip is very uncommon and most cases are caused by road accidents. Simultaneous bilateral posterior dislocation of the hip due to convulsions is extremely rare. We report the case of a man who was diagnosed late and operated on 15 weeks after the injury. We discuss the treatment of chronic dislocation of the hip and review the literature

The posterior approach to the hip avoids violating abductors and has presumed functional advantages. The anterolateral approach risks abductor damage, but has reportedly lower dislocation rate. To determine effects of surgical approach on function and dislocation after primary and revision THR 3274 primary THRs and 66 first time revision THRs were investigated from the arthroplasty database (2000–2008). 2682 (82%) primary THRs were via anterolateral approach, 592 (18%) by posterior. Post primary dislocation rate was 50/2682 (1.9%) for anterolateral and 26/592 (4.4%) for posterior. Posterior approach had significantly better Harris Hip Scores: 91 vs 88 (P = 0.000) and function: 40 vs 37 (P = 0.000). Of the 66 revisions THRs, 30 were anterolateral and 36 posterior. Dislocation rates were 2/30 (6.7%) and 4/36 (11.1%) respectively. There was no significant difference in Harris Hip Score or Harris Hip Function 1 year after revision based on revision surgery approach. However there was a significant difference in Harris Hip Function 1 year after revision based on the approach for primary surgery (Anterolateral 30 vs Posterior 37, P=0.008) and a similar trend in Harris Hip Score (Anterolateral 79 vs Posterior 85, P = 0.198) and patients who had posterior approach for both primary and revision had the best scores overall. The clinical relevance of the modest, but statistically significant difference in Harris hip score after primary THR is unclear. That primary approach has an impact on function after revision suggests the posterior approach should be considered in younger patients likely to require revision in the future

There is a high rate of forearm deformity in patients with hereditary multiple exostoses (HME), and a quarter of patients acquire a dislocated radial head due to disproportionate ulnar shortening. One-hundred and six patients with HME aged 15 years or older were identified from a prospective database. Flexion and extension of the elbow and wrist, and supination and pronation of the forearm was measured. The number of exostoses affecting the proximal and distal radius and ulna were recorded. Proportional ulna length was calculated as a percentage of the patients measured height ([ulna length/height] × 100). More than 70% of patients were affected by exostoses of the forearm, of which the distal radius was the commonest site to be affected (73%). One in seven patients had a dislocated radial head, which was associated with proportional ulna shortening (p<0.001). Both radial head dislocation (p<0.001) and proportional ulna shortening (p<0.001) were confirmed to be independent predictors of forearm motion on multivariable regression analysis. In conjunction with other predictors these could be used to calculate ROM of the forearm. In addition proportional ulna length was also an independent predictor of radial head dislocation (p<0.001). Proportional ulna length could be used as a tool to identify patients at risk of diminished forearm motion and radial head dislocation during childhood, who could be monitored clinically and radiographically, and surgical intervention could be offered before deterioration in function and dislocation of the radial head occurs

First-time anterior dislocation of the shoulder is associated with the development of recurrent instability. It is recognised that patients with recurrent instability often have osseous defects. Using 3D computerised tomography (3DCT) it is possible to quantify these defects. Whether these defects are present after the primary dislocation or occur progressively from multiple dislocations is unclear. We correlated the presence of Hill-Sachs lesions and anterior glenoid bone loss with evidence of recurrent dislocation and clinical outcomes. 78 patients were followed up for two years. All underwent a 3DCT within a week of injury. Standardised images of the humeral head and glenoid were produced. Using standardised digital techniques bone loss was measured. 39% of the patients developed further instability. Average Hill-Sachs circumferential length = 15.23%. Average Hill-Sachs surface area = 5.53%. The length and surface area of the Hill-Sachs lesions were significantly associated with further instability. (p=0.019 and p=0.003). Average en face glenoid surface area loss=1.30% with no association to instability (p=0.685). There was poor correlation between the size of the glenoid lesion and the size of the Hill-Sachs lesion. Results showed that age and increasing size of the Hill-Sachs lesions result in a higher rate of instability. Interestingly glenoid bone loss was relatively low and did not predict recurrent instability. The size of the Hill-Sachs lesion does not have a linear relationship with glenoid bone loss. Further work defining the morphology of the Hill-Sachs lesion and its engagement with a glenoid defect is required

We retrospectively analysed the clinical results of 30 patients with injuries of the sternoclavicular joint at a minimum of 12 months’ follow-up. A closed reduction was attempted in 14 cases. It was successful in only five of ten dislocations, and failed in all four epiphyseal disruptions. A total of 25 patients underwent surgical reduction, in 18 cases in conjunction with a stabilisation procedure. At a mean follow-up of 60 months, four patients were lost to follow-up. The functional results in the remainder were satisfactory, and 18 patients were able to resume their usual sports activity at the same level. There was no statistically significant difference between epiphyseal disruption and sternoclavicular dislocation (p > 0.05), but the functional scores (Simple Shoulder Test, Disability of Arm, Shoulder, Hand, and Constant scores) were better when an associated stabilisation procedure had been performed rather than reduction alone (p = 0.05, p = 0.04 and p = 0.07, respectively). We recommend meticulous pre-operative clinical assessment with CT scans. In sternoclavicular dislocation managed within the first 48 hours and with no sign of mediastinal complication, a closed reduction can be attempted, although this was unsuccessful in half of our cases. A control CT scan is mandatory. In all other cases, and particularly if epiphyseal disruption is suspected, we recommend open reduction with a stabilisation procedure by costaclavicular cerclage or tenodesis. The use of a Kirschner wire should be avoided

Introduction. Chronic radial head dislocation in children after trauma is a serious condition. Often the dislocation is overseen initially and is a part of the Monteggia fracture complex with anterior bowing of the ulna. Typical complaints are pain, decreased ROM and cubitus valgus. Radial head dysplasia often occurs. The treatment of this condition is debated. Only few series of patients treated with open reduction and ulnar osteotomy exists with long-term follow up. We present a group of rare patients with long-time follow-up treated by only two surgeons through a period of 16 years. Materials and Methods. All 16 patients had anterior radial head dislocation (Bado type 1). Mean age at the time of traumatic dislocation was 6 years ranging from 2 to 9. We found a mean delay of 17 (range 1–83) months before open reduction and ulnar open wedge osteotomy. In 8 cases reconstruction of the annular ligament was performed and in 6 patients temporary transarticular fixation of the radial head with a k-wire was performed. Follow-up time was 8 (range 3–17) years postoperatively. Patients were investigated with bilateral x-ray, arthrosis status, congruency of the radiocapitellar joint, Oxford Elbow Score, force measurements and range of motion. Results. There were no major complications to surgery such as infection, nerve palsies or pseudarthrosis. Radiological results showed 9/16 with reduction of the radial head and with no arthrosis, 4/16 with arthrosis or subluxation, and 2/16 with a dislocated radial head. We found a significant correlation between radiological outcome and delay to ulnar osteotomy (p = 0.03). At follow up the mean Function score was 92 (SD 9), Social/psychological score 83 (SD 14) and Pain score was 88 (SD 15). None of the patients with fully reduced radial head had progressed in increased valgus deformity. In contrast, one of two patients with postoperative secondary dislocation of the radial head had an increase in carrying angle on 25 degrees. Typical clinical findings were a small but significant extension deficit and median loss of supination on 10 grades ranging from 0–90 (p = 0.008). Five patients had subsequent surgery, of which one had an excision of the radial head 8 years after primary surgery. Ligament reconstruction or transfixation of the radial head did not influence the radiological or clinical outcome. Discussion and Conclusion. Case reports of similar patients treated conservatively demonstrate high morbidity and therefore open reduction and ulnar osteotomy is justified given the good clinical longterm outcome in the present study. However, this study underlines the importance of minimising the delay between trauma and open reduction. If surgery is performed before 40 months after trauma good to fair longterm radiological results can be obtained. After 40 months there is a high risk of recurrent luxation of the radial head

This study describes the long term clinical and patient reported outcomes following simple dislocation of the elbow. We identified all adult patients treated at our trauma centre for a simple dislocation of the elbow over 10 years. 140 patients were identified and 110 (79%) patients were reviewed at a mean of 88 (95% CI 80–96) months after injury. This included clinical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, an Oxford Elbow questionnaire and a patient satisfaction questionnaire. Patients reported long-term residual deficits in range of movement. The mean DASH score was 6.5 (95% CI 4 to 9). The mean Oxford Elbow score was 43.5 (95% CI 42.2 to 44.8). The mean satisfaction score was 85.6 (95% CI 82.2 to 89). Sixty-two patients (56%) reported persistent subjective stiffness of the elbow. Nine (8%) reported subjective instability and 68 (62%) complained of continued pain. The DASH, Oxford Elbow and satisfaction scores all showed good correlation with absolute range of movement in the injured elbow. After multivariate analysis, a larger elbow flexion contracture and female gender were both independent predictors of worse DASH scores. Poorer Oxford Elbow scores and overall satisfaction ratings were predicted by reduced flexion-extension arc of movement. Patients report good long term functional outcomes after simple dislocations of the elbow. These are not entirely benign injuries. There is a high rate of residual pain and stiffness. Functional instability is less common and does not often limit activities