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Background The internal joint stabilizer of the elbow (IJS-E) adds to techniques for maintaining reduction of elbow fracture-dislocations while allowing early motion. Literature on this device is limited to small case series. Methods Retrospective comparison of function, motion and complications in patients who sustained elbow fracture-dislocations reconstructed with (30 patients) and without (34 patients) an IJS-E by a single surgeon. The minimum follow up was 10 weeks. Results The mean follow up was 16 ± 17 months. The mean final flexion arc did not differ between the two groups, however patients without an IJS achieved greater pronation. There were no differences in mean Mayo Elbow Performance, Quick-DASH and pain scores. Five patients (17%) underwent IJS-E removal. The rates of capsular releases for stiffness after 12 weeks and recurrent instability were similar. Conclusions The use of an IJS-E to supplement traditional repair of elbow fracture-dislocations does not appear to affect final function or motion, and appears to be effective in reducing the risk of recurrent instability in a group of patients deemed high risk. However, its use is weighed against a 17% rate of removal at early follow up and possibly inferior forearm rotation. Level of Evidence Retrospective Cohort study, Level 3

BackgroundAggressive acceptance of liver allografts has driven utilization of marginal allografts. Our aim was to assess the impact of the aggressive phenotype on transplant center outcomes over time.MethodsWe used a cohort of 148 361 candidates from the Organ Procurement and Transplantation Network for liver transplantation between 2002 and 2016 in 134 centers. Using the Discard Risk Index, we designated high probability discard allografts by the top 10th percentile for likelihood of discard. Aggressive phenotype was defined by usage of high probability discard (HPD) allografts (top 10th percentile). Our analysis of survival on waitlist and graft survival after transplantation included a comprehensive list of center level covariates across three equal time periods (2002‐2006, 2007‐2011, and 2012‐2016).ResultsAfter adjusting for recipient and center‐level factors, aggressive centers had improving graft survival over time. Aggressive vs non‐aggressive centers: 2002‐2006 HR 1.12 (1.05‐1.19), 2007‐2011 HR 1.13 (1.05‐1.22), 2012‐2016 HR 0.99 (0.89‐1.10). Aggressive centers had improved waitlist survival compared with non‐aggressive centers after adjusting for allograft disparity.ConclusionsAggressive phenotype had a positive impact on waitlist survival, and graft survival in aggressive centers have improved to benchmark levels over time. These findings serve as justification for aggressive utilization of allografts.

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Case: A 31-year-old man with recurrent instability after treatment of a terrible triad elbow fracture-dislocation that was reconstructed with revision coronoid fixation and a novel use of a medially applied internal joint stabilizer (IJS). Conclusion: A medially applied IJS is an option to supplement coronoid fixation in cases with tenuous repair because of comminution or relative coronoid insufficiency. This location may be more protective for this instability pattern and, in revision settings, can avoid a second lateral incision.