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Background: Distal biceps rupture presents with an increasing incidence and evidence suggests that although a surgical repair is not mandatory, it results in superior functional outcomes when compared to non-operative management. As implant technology has advanced, several devices have been utilised and studied in managing this pathology. We present our single-centre experience with the use of the ToggleLoc Ziploop reattachment device, a knotless cortical button implant, using a single-incision technique., Methods: Retrospective series of 70 consecutive distal biceps tendon repairs, at a mean follow-up of 45.6 months after surgery, using a standardised single implant, single-incision technique, and post-operative rehabilitation programme., Results: There was one (1.4%) re-rupture in our patient cohort. The range of motion was complete in all patients except for one patient who had symptomatic heterotopic ossification, causing limitation in pronation. Complications were minor with the commonest being transient neuropraxia of the lateral cutaneous nerve of the forearm. The mean Oxford elbow score was 46.9 out of 48, and the patient global impression of change scale was 7 out of 7 in 77% of cases., Conclusion: Our data support this technique and implant combination when dealing with acute and chronic distal biceps tendon rupture., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background: We assessed distal humeral column preservation effects on clinical, radiographic and patient reported outcomes following distal humerus hemiarthroplasty for acute unreconstructable fractures., Methods: Thirty-seven consecutive patients (mean age, 75; range, 29-93 years) with an average follow-up of 61 months (range, 24-105 months) after distal humerus hemiarthroplasty using a triceps preserving approach were studied. QuickDASH and Oxford Elbow Score assessed patient reported outcomes. Clinical and radiographic assessments comprised range of motion, grip strength, instability, implant loosening, chondral wear, heterotopic ossification and condylar union., Results: Average QuickDASH was 14.9 (range, 0-63) and Oxford Elbow Score 40.35 (range, 25-48). Mean flexion arc was 108°, extension deficit 17° and pronosupination arc 155°. Average operative sided grip strength was 31.05 kg versus 31.13 kg contralaterally. Column preservation had no statistically significant effect on QuickDASH ( p  = 0.75), Oxford Elbow Score ( p  = 0.78), flexion-extension ( p  = 0.87), pronosupination ( p  = 0.78) or grip strength ( p  = 0.87). No progressive radiographic loosening or symptomatic chondral wear occurred. All fixed columns united. Three cases of immediate post-operative laxity fully resolved on elbow mobilisation. Four post-operative complications required further surgery: one ulnar neuropathy, one heterotopic ossification, one wound breakdown and one traumatic dislocation., Conclusion: Medium-term outcome of distal humerus hemiarthroplasty for acute unreconstructable distal humeral fractures is reliable irrespective of condylar preservation., Competing Interests: Declaration of Conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2020 The British Elbow & Shoulder Society.)

Background: Total shoulder arthroplasty is an established treatment with the commonest cause of failure loosening of the glenoid component. Hydroxyapatite metal-backed glenoid components could offer better survivorship due to improved fixation. The aim of this study was to investigate periprosthetic radiolucency rates associated with an uncemented, metal-backed polyethylene glenoid component with medium-term results., Methods: A single centre retrospective study examining radiological outcomes of the Epoca metal-backed glenoid component. Radiographs were analysed for post-operative adequacy of glenoid seating and radiographs at follow-up assessed for periprosthetic lucencies and any revision procedures were recorded., Results: Forty-one patients were followed up with a mean follow-up time of 5.5 years (3-8 years). Primary indication for total shoulder arthroplasty was osteoarthritis (80%). Mean age was 69 years (53-86 years). Ninety-five per cent of glenoid components were completely seated. At follow-up six patients had undergone revision (14.6%). Thirty of the remaining patients (86%) did not demonstrate any radiolucency on follow-up radiographs. Complete glenoid seating post-operatively was associated with lower rate of subsequent radiolucency and revision (P < 0.01)., Conclusion: Low rates of radiolucency at medium-term follow-up with an uncemented metal-backed glenoid, however significant rates of revision. Complete seating of the glenoid component was associated with lower rates of radiolucency and revision., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2020 The British Elbow & Shoulder Society.)

Background: Total shoulder arthroplasty has shown good clinical efficacy in treating primary and secondary degenerative conditions of the glenohumeral joint. Glenoid loosening, however, remains the commonest cause of failure. The purpose of this study was to investigate the rate of radiographic periprosthetic lucency associated with the use of an uncemented, pegged, metal-backed polyethylene glenoid component., Materials and Methods: A retrospective, single-centre study using the Epoca (Synthes, Paoli, Pennsylvania) metal-backed glenoid component. Operations were performed by two experienced consultant upper limb surgeons. Radiographs were analysed for immediate post-operative component seating and periprosthetic radiolucent lines at predefined regular post-operative intervals. Intra- and inter-observer reliability was assessed to improve validity of results., Results: Mean age and follow-up was 72 (48-91) years and 2.5 years (2-5), respectively. Main indications for total shoulder arthroplasty were primary osteoarthritis, rheumatoid arthritis, revision for failed hemi-arthroplasty and acute fracture. Ninety-six per cent of components were completely seated post-operatively. Fifty-four (95%) of the 57 shoulders had no periprosthetic radiolucent lines at most recent follow-up. Complete post-operative glenoid seating was significantly associated with the absence of later periprosthetic radiolucency (p < 0.01)., Conclusion: This study reports low early radiolucency rates with the pegged, uncemented, metal-backed polyethylene glenoid prosthesis used. Excellent post-operative glenoid seating is associated with a significantly lower rate of radiolucency. Longer follow-up data are required to confirm these early promising results. Level of evidence: Therapeutic, level IV., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2018 The British Elbow & Shoulder Society.)

Background: We report functional outcomes at six years in patients with varying degrees of fatty infiltration and atrophy of the rotator cuff muscles who have undergone anatomic total shoulder replacement., Methods: A retrospective analysis of case notes and magnetic resonance imaging scans of patients undergoing total shoulder replacement for primary glenohumeral arthritis was performed. Patients were grouped based upon their pre-operative magnetic resonance imaging findings for fatty infiltration, muscle area and tendinopathy. Post-operative functional outcomes were assessed using the Oxford Shoulder Score and Quick Disabilities of the Arm, Shoulder and Hand score. Post-operative measurements were made for active shoulder movements., Results: Thirty-two patients were reviewed at a mean of 67 months following surgery. All patients demonstrated fatty infiltration on their pre-operative magnetic resonance imaging scan. Muscle atrophy was shown in 22 patients and 12 had tendinopathy. Multiple regression analysis showed no correlation between the Oxford Shoulder Score (p = 0.443), the Quick Disabilities of the Arm, Shoulder and Hand score (p = 0.419), forward flexion (p = 0.170), external rotation (p = 0.755) and any of the pre-operative independent variables., Discussion: The degree of fatty infiltration, muscle atrophy and tendinopathy of the rotator cuff muscle on pre-operative magnetic resonance imaging scanning is not associated with functional outcome score or functional movement at medium-term follow-up following total shoulder replacement., Level of Evidence: IV., (© 2018 The British Elbow & Shoulder Society.)

Objective: The eversion technique for carotid endarterectomy (eCEA) offers an alternative to longitudinal arteriotomy and patch closure (pCEA) for open carotid revascularization. In some reports, eCEA has been associated with a higher rate of >50% restenosis of the internal carotid when it is defined as peak systolic velocity (PSV) >125 cm/s by duplex imaging. Because the conformation of the carotid bifurcation may differ after eCEA compared with native carotid arteries, it was hypothesized that standard duplex criteria might not accurately reflect the presence of restenosis after eCEA., Methods: In a case-control study, the outcomes of all patients undergoing carotid endarterectomy by one surgeon during the last 10 years were analyzed retrospectively, with a primary end point of PSV >125 cm/s. Duplex flow velocities were compared with luminal diameter measurements for any carotid computed tomography arteriography or magnetic resonance angiography study obtained within 2 months of duplex imaging, with the degree of stenosis calculated by the methodology used in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) as well as cross-sectional area (CSA) reduction. Simulations were generated and analyzed by computational model simulations of the eCEA and pCEA arteries., Results: Eversion and longitudinal arteriotomy with patch techniques were used in 118 and 177 carotid arteries, respectively. Duplex follow-up was available in 90 eCEA arteries at a median of 16 (range, 2-136) months and in 150 pCEA arteries at a median of 41 (range, 3-115) months postoperatively. PSV >125 cm/s was present at some time during follow-up in 31% of eCEA and pCEA carotid arteries, each, and in the most recent duplex examination in 7% after eCEA and 21% after pCEA (P = .003), with no eCEA and two pCEA arteries occluding completely during follow-up (P = .29). In 19 carotid arteries with PSV >125 cm/s after angle correction (median, 160 cm/s; interquartile range, 146-432 cm/s) after eCEA that were subsequently examined by axial imaging, the mean percentage stenosis was 8% ± 11% by NASCET, 11% ± 5% by ECST, and 20% ± 9% by CSA criteria. For eight pCEA arteries with PSV >125 cm/s (median velocity, 148 cm/s; interquartile range, 139-242 cm/s), the corresponding NASCET, ECST, and CSA stenoses were 8% ± 35%, 26% ± 32%, and 25% ± 33%, respectively. NASCET internal carotid diameter reduction of at least 50% was noted by axial imaging after two of the eight pCEAs, and the PSV exceeded 200 cm/s in each case., Conclusions: The presence of hemodynamically significant carotid artery restenosis may be overestimated by standard duplex criteria after eCEA and perhaps after pCEA. Insufficient information currently exists to determine what PSV does correspond to hemodynamically significant restenosis., (Published by Elsevier Inc.)

Introduction: Total shoulder replacement (TSR) is a reliable treatment for glenohumeral osteoarthritis. In addition to proper component orientation, successful arthroplasty requires accurate restoration of soft tissues forces around the joint to maximize function. We hypothesized that pathological changes within the rotator cuff on preoperative magnetic resonance imaging (MRI) adversely affect the functional outcome following TSR., Materials and Methods: A retrospective analysis of case notes and MRI of patients undergoing TSR for primary glenohumeral osteoarthritis over a 4-year period was performed. Patients were divided into three groups based upon their preoperative MRI findings: (1) normal rotator cuff, (2) the presence of tendonopathy within the rotator cuff, or (3) the presence of a partial thickness rotator cuff tear. Intra-operatively tendonopathy was addressed with debridement and partial thickness tears with repair. Functional outcome was assessed with the Oxford Shoulder Score (OSS), and quick disabilities of the arm, shoulder and hand score (quick-DASH)., Results: We had a full dataset of complete case-notes, PACS images, and patient reported outcome measures available for 43 patients, 15 in group 1, 14 in group 2, and 14 in group 3. Quick-DASH and OSS were calculated at a minimum of 24 months following surgery. There was no statistically significant difference between the results obtained between the three groups of either the OSS (P = 0.45), or quick-DASH (P = 0.46)., Conclusions: TSR is an efficacious treatment option for patients with primary glenohumeral osteoarthritis in the medium term, even in the presence of rotator cuff tendonopathy or partial tearing. Minor changes within the cuff do not significantly affect functional outcome following TSR.

Introduction: Total shoulder resurfacing (TSR) provides a reliable solution for the treatment of glenohumeral arthritis. It confers a number of advantages over traditional joint replacement with stemmed humeral components, in terms of bone preservation and improved joint kinematics. This study aimed to determine if humeral reaming instruments produce a thermal insult to subchondral bone during TSR., Patients and Methods: This was tested in vivo on 13 patients (8 with rheumatoid arthritis and 5 with osteoarthritis) with a single reaming system and in vitro with three different humeral reaming systems on saw bone models. Real-time infrared thermal video imaging was used to assess the temperatures generated., Results: Synthes (Epoca) instruments generated average temperatures of 40.7°C (SD 0.9°C) in the rheumatoid group and 56.5°C (SD 0.87°C) in the osteoarthritis group (P = 0.001). Irrigation with room temperature saline cooled the humeral head to 30°C (SD 1.2°C). Saw bone analysis generated temperatures of 58.2°C (SD 0.79°C) in the Synthes (Epoca) 59.9°C (SD 0.81°C) in Biomet (Copeland) and 58.4°C (SD 0.88°C) in the Depuy Conservative Anatomic Prosthesis (CAP) reamers (P = 0.12)., Conclusion: Humeral reaming with power driven instruments generates considerable temperatures both in vivo and in vitro. This paper demonstrates that a significant thermal effect beyond the 47°C threshold needed to induce osteonecrosis is observed with humeral reamers, with little variation seen between manufacturers. Irrigation with room temperature saline cools the reamed bone to physiological levels and should be performed regularly during this step in TSR.

A series of 49 pilon fractures in a tertiary referral centre treated definitively by open reduction and internal fixation have been assessed and the complications of such injuries examined. A retrospective analysis of case notes, radiographs and computerised tomographs over a seven-year period from 1999-2006 was performed. Infection was the most common postoperative problem. There were seven cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case). The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Rüedi and Allgöwer in Injury 2:92-99, 1969) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to access the tibia via the "direct approach" which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe that open reduction and internal fixation of pilon fractures via the direct approach to be a safe technique in the treatment of such devastating injuries.

Penile injuries are relatively uncommon. The crush injury mediated by entrapment of the skin between the teeth and fastener of a zipper mechanism has been described. It is seen more commonly in uncircumcised children than adults. A number of treatment methods have been mentioned in the literature. An adult case presentation and novel method of management using two small needle holders is illustrated.

Germination and outgrowth of spores of Streptomyces alboniger, Streptomyces scabies, and Streptomyces violaceus-ruber in the presence of intercalating dyes resulted in a high frequency (2 to 20%) of occurrence of aerial mycelium-negative (Amy-) isolates. Coincident with the appearance of the Amy- trait was the loss of several differentiated functions, including the characteristic pigments and earthy odor of the wild types. All S. alboniger, 27% of S. scabies, and 39% of the S. violaceus-ruber Amy- isolates were arginine auxotrophs. The missing enzyme step was identified as argininosuccinate synthetase by using a sensitive microassay for estimation of enzyme activity. The remainder of the S. scabies and S. violaceus-ruber isolates were prototrophs. In addition, S. alboniger Amy- isolates failed to produce or respond to the stimulator of aerial mycelium formation isolated from the wild type. The Amy- isolates did not revert to either Amy+ of Arg+. The lack of any detectable reversion, coupled with the high frequency of curing, supports the idea that a deletion of genetic material, possibly a plasmid, has occurred.

When Streptomyces alboniger spores were grown in Hickey-Tresner broth containing 5 muM ethidium bromide, a high frequency of permanently cured aerial mycelia-negative (am-) colonies was recovered. The appearance an am- colonies was time dependent: a very low frequency (0.3%) at zero time, a maximum (9 to 21%) after 2 to 5 days of growth, and a decline again to low frequencies later in the growth cycle. On agar, cured am- colonies of S. alboniger still produced puromycin. The development of aerial mycelia in S. alboniger, S. scabies, and S. coelicolor was also sensitive to glucose repression. Colonies grown on Hickey-Tresner agar containing 2% glucose remained phenotypically am- throughout the observation period. Adenine (2.5 mM or greater), and to a lesser extent adenosine and guanosine, specifically reversed the repression. The accumulation of undissociated organic acids appears to be involved in glucose repression of aerial mycelia formation. However, this does not appear to be the case with puromycin production in S. alboniger; glucose repression was observed over the pH range 5.0 to 7.5.