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// ──────────────────────────────────────────
// COL 1 — BACKGROUND + CASE PRESENTATION
// ──────────────────────────────────────────
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  { text: "11-28%", options: { bold: true, color: TEAL } },
  { text: " of all elbow injuries and represent the second most common major joint dislocation in adults, after the shoulder (Campbell's Operative Orthopaedics, 15th Ed., 2026).", options: {} },
  { text: "\n\n", options: {} },
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  { text: "fibrosis, capsular contracture, heterotopic ossification,", options: { bold: true } },
  { text: " and shortening of the triceps-collateral ligament complex transform the joint into a surgically complex problem.", options: {} },
  { text: "\n\n", options: {} },
  { text: "The altered relationship of the bony triangular landmarks (olecranon, medial and lateral epicondyles) is the hallmark clinical sign of unreduced posterior dislocation.", options: {} }
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slide.addText("Patient: 70-year-old female  |  Injury: Left elbow  |  Duration: 3 months post-fall", {
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  { text: "Clinical Findings:", options: { bold: true, color: TEAL, breakLine: true } },
  { text: "• Elbow held at 90° flexion with marked swelling", options: { breakLine: true } },
  { text: "• ROM restricted to ~20° flexion-extension arc", options: { breakLine: true } },
  { text: "• Tenderness over the olecranon region", options: { breakLine: true } },
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  { text: "• Previous management: Above-elbow slab × 6 weeks (elsewhere)", options: { breakLine: true } },
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  { text: "\n", options: {} },
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  { text: "• Open reduction with complete soft-tissue release", options: { breakLine: true } },
  { text: "• Bell-Tawse annular ligament reconstruction (radial head stabilisation)", options: { breakLine: true } },
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  { text: "• Early supervised physiotherapy initiated post-op", options: { breakLine: true } },
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// ──────────────────────────────────────────
// COL 2 — DISCUSSION (full height)
// ──────────────────────────────────────────
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  { text: "Chronicity and Pathological Changes", options: { bold: true, color: NAVY, breakLine: true } },
  { text: "Neglected elbow dislocations are defined as dislocations unreduced beyond 3 weeks. With time, the distal humerus becomes embedded in dense fibrous scar tissue. Shortening of the triceps muscle-tendon unit, contracted medial and lateral collateral ligaments, and heterotopic callus in the olecranon fossa render closed reduction hazardous and potentially damaging to articular surfaces (Campbell's Operative Orthopaedics, 15th Ed., 2026, Ch.66).", options: { breakLine: true } },
  { text: "\n", options: {} },
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  { text: "Open reduction is the definitive treatment. The procedure requires: (i) complete subperiosteal release of contracted muscles from the distal humerus, (ii) excision of fibrous tissue from the olecranon fossa, (iii) V-Y lengthening of the triceps (Speed technique), and (iv) ulnar nerve decompression with low threshold for transposition. Concentric reduction of the ulnohumeral joint must be confirmed intraoperatively (Rockwood & Green's Fractures in Adults, 10th Ed., 2025).", options: { breakLine: true } },
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  { text: "\n", options: {} },
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  { text: "The medial ulnar collateral ligament (UCL) is the primary stabiliser against valgus stress at the elbow. Repair or reconstruction of the anterior bundle of the UCL (Tommy John procedure) restores medial stability. After chronic dislocation, the UCL may be attenuated or scarred, necessitating formal repair with suture anchors or graft augmentation to achieve durable joint stability (Campbell's Operative Orthopaedics, 15th Ed., 2026, Ch.38).", options: { breakLine: true } },
  { text: "\n", options: {} },
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  { text: "Due to an approximately 30% redislocation rate following ligamentous repair alone, adjuncts such as hinged external fixation or Internal Joint Stabilisation (IJS) devices are recommended to protect the repair and permit early range of motion. Early mobilisation is paramount to prevent recurrent stiffness (Campbell's Operative Orthopaedics, 15th Ed., 2026).", options: { breakLine: true } },
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  { text: "The most common complications include persistent stiffness, loss of terminal extension, heterotopic ossification, and neurovascular injury — particularly to the ulnar nerve given its proximity. Neurovascular examination before and after reduction is mandatory (Campbell's Operative Orthopaedics, 15th Ed., 2026).", options: {} }
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// ──────────────────────────────────────────
// COL 3 — CONCLUSION + KEY POINTS + REFERENCES
// ──────────────────────────────────────────
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  { text: "Altered bony triangle is pathognomonic of unreduced posterior dislocation", options: { breakLine: true } },
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slide.addText([
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  { text: "Azar FM, Beaty JH, Canale ST. Campbell's Operative Orthopaedics, 15th Ed. Philadelphia: Elsevier; 2026. Ch.38 (Elbow), Ch.66 (Chronic Dislocations).", options: { breakLine: true } },
  { text: "2. ", options: { bold: true, color: TEAL } },
  { text: "Rockwood CA, Green DP. Rockwood and Green's Fractures in Adults, 10th Ed. Philadelphia: Wolters Kluwer; 2025. Simple Elbow Dislocation (Ch.38).", options: { breakLine: true } },
  { text: "3. ", options: { bold: true, color: TEAL } },
  { text: "Arafiles RP. Neglected posterior dislocation of the elbow: a reconstruction operation. J Bone Joint Surg Br. 1987;69(2):199-202.", options: { breakLine: true } },
  { text: "4. ", options: { bold: true, color: TEAL } },
  { text: "Donohue KW, Mehlhoff TL. Chronic elbow dislocation: evaluation and management. J Am Acad Orthop Surg. 2016;24(1):15-23.", options: { breakLine: true } },
  { text: "5. ", options: { bold: true, color: TEAL } },
  { text: "Elzohairy MM. Neglected posterior dislocation of the elbow. Injury. 2009;40(2):197-200.", options: { breakLine: true } },
  { text: "6. ", options: { bold: true, color: TEAL } },
  { text: "Lyons RP, Armstrong A. Chronically unreduced elbow dislocations. Hand Clin. 2008;24(1):91-103.", options: {} }
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// ─── WRITE ───────────────────────────────────────────────────
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Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/elbow-poster/poster.js'

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/elbow-poster/poster.js'

const pptxgen = require("pptxgenjs");

let pres = new pptxgen();
pres.layout = 'LAYOUT_WIDE'; // 13.3" x 7.5" — landscape poster

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// ─── HELPER ──────────────────────────────────────────────────────
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// ═══════════════════════════════════════════════════════════════
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// Col 2: x=4.2   w=4.7
// Col 3: x=9.05  w=4.1
// ═══════════════════════════════════════════════════════════════
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// ──────────────────────────────────────────
// COL 1 — BACKGROUND + CASE PRESENTATION
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  { text: "\n\n", options: {} },
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slide.addText("70-year-old female  |  Left elbow  |  3 months post-fall", {
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  { text: "• Elbow held in 90° flexion with swelling", options: { breakLine: true } },
  { text: "• ROM restricted to ~20° flexion-extension arc", options: { breakLine: true } },
  { text: "• Tenderness over olecranon; disrupted bony triangle", options: { breakLine: true } },
  { text: "• Prior treatment: Above-elbow slab × 6 weeks (elsewhere)", options: { breakLine: true } },
  { text: "• X-ray confirmed neglected posterior dislocation", options: { breakLine: true } },
  { text: "\n", options: {} },

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  { text: "2. Posterior triceps-sparing approach", options: { breakLine: true } },
  { text: "3. Medial and lateral flaps elevated; ulnar nerve released", options: { breakLine: true } },
  { text: "4. Extensive soft tissue release performed", options: { breakLine: true } },
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  { text: "• Marked pain relief and restored independence in ADLs", options: {} }
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// ──────────────────────────────────────────
// COL 2 — DISCUSSION (flowing prose)
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  "Neglected elbow dislocations, defined as those unreduced beyond three weeks, present a formidable surgical challenge. Over time, the distal humerus becomes encased in dense fibrous scar tissue, the triceps muscle-tendon unit undergoes progressive shortening, the medial and lateral collateral ligaments contract, and heterotopic callus fills the olecranon fossa. These changes collectively render closed reduction hazardous, with a real risk of articular surface damage or fracture — making open surgical reconstruction the only viable definitive option (Campbell's Operative Orthopaedics, 15th Ed., 2026).\n\nOpen reduction requires meticulous subperiosteal release of all contracted muscles from the distal humerus, complete excision of fibrous tissue from the olecranon fossa, and V-Y lengthening of the triceps using the Speed technique to achieve reduction without excessive force. Ulnar nerve decompression is mandatory in all cases given the nerve's proximity to the operative field, with a low threshold for anterior transposition if under tension. Concentric reduction of the ulnohumeral joint must be confirmed intraoperatively under C-arm fluoroscopy (Rockwood & Green's Fractures in Adults, 10th Ed., 2025).\n\nThe Bell-Tawse annular ligament reconstruction addresses chronic radial head instability by fashioning a strip of local fascia or periosteum to encircle the radial neck, recreating the annular ligament and restoring the radiocapitellar relationship. This prevents proximal radial migration and is essential when the native annular ligament has failed to heal or is irreparably attenuated following chronic dislocation (Campbell's, 2026).\n\nThe medial ulnar collateral ligament (UCL), specifically its anterior bundle, is the primary stabiliser against valgus stress at the elbow. After chronic dislocation, the UCL becomes stretched, scarred, or functionally incompetent. The Tommy John repair restores this medial constraint using suture anchor fixation or graft augmentation, providing durable valgus stability essential for a functional, pain-free elbow (Campbell's, 2026, Ch.38).\n\nPost-reduction instability is a recognised concern, with a reported redislocation rate of approximately 30% after ligamentous repair alone. Adjuncts such as hinged external fixation or the Internal Joint Stabilisation (IJS) device allow early protected range of motion while protecting the repair. Early mobilisation is paramount — immobilisation risks recurrent stiffness and defeats the surgical goal. Anderson et al. reported 97% good-to-excellent outcomes (Mayo Elbow Performance Index) in 32 chronic dislocation patients treated with open reduction and soft-tissue release, regardless of patient age or duration of dislocation, affirming that chronicity is not a contraindication to reconstruction (Campbell's, 2026).",
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// ──────────────────────────────────────────
// COL 3 — CONCLUSION + KEY POINTS + REFERENCES
// ──────────────────────────────────────────
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// --- CONCLUSION ---
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  "This case demonstrates that open reduction with Bell-Tawse and Tommy John reconstruction can achieve excellent functional outcomes even beyond three months post-injury. Chronicity alone is not a contraindication — surgical technique and early rehabilitation determine recovery.",
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// --- KEY LEARNING POINTS ---
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  { text: "01  ", options: { bold: true, color: GOLD } },
  { text: "Altered bony triangle is pathognomonic of posterior dislocation", options: { breakLine: true } },
  { text: "02  ", options: { bold: true, color: GOLD } },
  { text: "Closed reduction is hazardous after 3 weeks; open reduction required", options: { breakLine: true } },
  { text: "03  ", options: { bold: true, color: GOLD } },
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// --- REFERENCES ---
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  { text: "1. ", options: { bold: true, color: TEAL } },
  { text: "Azar FM, Beaty JH, Canale ST. Campbell's Operative Orthopaedics, 15th Ed. Elsevier; 2026. Ch.38, Ch.66.", options: { breakLine: true } },
  { text: "2. ", options: { bold: true, color: TEAL } },
  { text: "Rockwood CA, Green DP. Rockwood and Green's Fractures in Adults, 10th Ed. Wolters Kluwer; 2025.", options: { breakLine: true } },
  { text: "3. ", options: { bold: true, color: TEAL } },
  { text: "Arafiles RP. Neglected posterior dislocation of the elbow: a reconstruction operation. J Bone Joint Surg Br. 1987;69(2):199-202.", options: { breakLine: true } },
  { text: "4. ", options: { bold: true, color: TEAL } },
  { text: "Donohue KW, Mehlhoff TL. Chronic elbow dislocation: evaluation and management. J Am Acad Orthop Surg. 2016;24(1):15-23.", options: { breakLine: true } },
  { text: "5. ", options: { bold: true, color: TEAL } },
  { text: "Elzohairy MM. Neglected posterior dislocation of the elbow. Injury. 2009;40(2):197-200.", options: { breakLine: true } },
  { text: "6. ", options: { bold: true, color: TEAL } },
  { text: "Lyons RP, Armstrong A. Chronically unreduced elbow dislocations. Hand Clin. 2008;24(1):91-103.", options: {} }
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// ═══════════════════════════════════════════════════════════════
// FOOTER
// ═══════════════════════════════════════════════════════════════
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// ─── WRITE ───────────────────────────────────────────────────
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