Aim

The primary aim of this retrospective study was to identify the incidence of heterotopic ossification (HO) following elective and trauma elbow arthroplasty. The secondary aim was to determine clinical outcomes with respect to the formation of heterotopic ossification.

Aims

We review our experience of Coonrad-Morrey total elbow arthroplasty (TEA) for fractures of the distal humerus in non-rheumatoid patients with a minimum of ten years follow-up.

We report our experience of staged revision surgery for the treatment of infected total elbow arthroplasty (TEA). Between 1998 and 2010 a consecutive series of 33 patients (34 TEAs) underwent a first-stage procedure with the intention to proceed to second-stage procedure when the infection had been controlled. A single first-stage procedure with removal of the components and cement was undertaken for 29 TEAs (85%), followed by the insertion of antibiotic-impregnated cement beads, and five (15%) required two or more first-stage procedures. The most common organism isolated was coagulase-negative Staphylococcus in 21 TEAs (62%).

A second-stage procedure was performed for 26 TEAs (76%); seven patients (seven TEAs, 21%) had a functional resection arthroplasty with antibiotic beads in situ and had no further surgery, one had a persistent discharge preventing further surgery.

There were three recurrent infections (11.5%) in those patients who underwent a second-stage procedure. The infection presented at a mean of eight months (5 to 10) post-operatively. The mean Mayo Elbow Performance Score (MEPS) in those who underwent a second stage revision without recurrent infection was 81.1 (65 to 95).

Staged revision surgery is successful in the treatment of patients with an infected TEA and is associated with a low rate of recurrent infection. However, when infection does occur, this study would suggest that it becomes apparent within ten months of the second stage procedure.

Cite this article: Bone Joint J 2013;95-B:1681–6.

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients.

The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. The mean follow-up was of 5 years. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92.

We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed at a mean of 5 years.

We studied, ten patients (11 elbows) who had undergone 14 allograft-prosthesis composite reconstructions following failure of a previous total elbow replacement with massive structural bone loss. There were nine women and one man with a mean age of 64 years (40 to 84), who were reviewed at a mean of 75 months (24 to 213). One patient developed a deep infection after 26 months and had the allograft-prosthesis composite removed, and two patients had mild pain. The median flexion-extension arc was 100° (95% confidence interval (CI) 76° to 124°). With the exception of the patient who had the infected failure, all the patients could use their elbows comfortably without splints or braces for activities of daily living. The mean Mayo Elbow Performance Index improved from 9.5 (95% CI 4.4 to 14.7) pre-operatively to 74 (95% CI 62.4 to 84.9) at final review.

Radiologically, the rate of partial resorption was similar in the humeral and ulnar allografts (three of six and four of eight, respectively; p > 0.999). The patterns of resorption, however, were different. Union at the host-bone-allograft junction was also different between the humeral and ulnar allografts (one of six and seven of eight showing union, respectively; p = 0.03).

At medium-term follow-up, allograft-prosthesis composite reconstruction appears to be a useful salvage technique for failed elbow replacements with massive bone loss. The effects of allograft resorption and host-bone-allograft junctional union on the longevity of allograft-prosthesis composite reconstruction, however, remain unknown, and it is our view that these patients should remain under long-term regular review.

Background: Intra-articular distal humeral fractures in the elderly are difficult to treat. There is evidence in the literature to support the use of both open reduction and internal fixation (ORIF) and total elbow arthroplasty (TEA) as primary procedures, although we have been unable to find any direct comparisons of outcome.

Methods: This study reports the results of ORIF in 12 elderly patients with distal humeral fractures and compares the outcome with 12 matched patients who had undergone TEA. All procedures were performed by two Consultant elbow surgeons. The Coonrad-Morrey TEA was used in all cases of TEA and a double-plating technique was used in all ORIFs. Both groups of patients were similar with respect to fracture configuration, age, sex, comorbidity and hand dominance. The mean follow-up in both groups of patients was over 30 months.

Results: At final review, patients who had had a TEA had a mean Mayo score of 91 and a range of flexion/extension of 90 degrees. There was 1 superficial wound infection that resolved with antibiotics, 1 temporary radial nerve palsy, and 1 case of heterotrophic ossification The ORIF group had a mean Mayo score of 89 (p> 0.05) and a range of flexion/extension of 112 degrees (P=0.03). There was 1 case of heterotrophic ossification, 2 cases of ulnar nerve compression that needed decompression and 1 superficial wound infection that resolved with antibiotics. All the fractures united.

Conclusion: This study indicates that both treatment modalities can lead to excellent results. ORIF has the advantage of preserving the joint and once union has occurred has a low risk of long term complications.

Intra-articular distal humeral fractures in the elderly are difficult to treat. There is evidence in the literature to support the use of both Open Reduction and Internal Fixation (ORIF) and Total Elbow Arthroplasty (TEA) as primary procedures, although we have been unable to find any direct comparisons of outcome.

This study reports the results of ORIF in 12 elderly patients with distal humeral fractures and compares the outcome with 12 matched patients who had undergone TEA.

All procedures were performed by two experienced Consultant Surgeons. The Coonrad-Morrey TEA was used in all cases of TEA and a double-plating technique was used in all ORIFs.

Both groups of patients were similar with respect to fracture configuration, age, sex, co-morbidity and hand dominance. The mean follow-up in both groups of patients was over 30 months.

At final review, patients who had had a TEA had a mean Mayo score of 91 and a range of flexion/extension of 90 degrees. There was 1 superficial wound infection that resolved with antibiotics, 1 temporary radial nerve palsy, and 1 case of heterotrophic ossification The ORIF group had a mean Mayo score of 89 (p> 0.05) and a range of flexion/extension of 112 degrees (P=0.03). There was 1 case of heterotrophic ossification, 2 cases of ulnar nerve compression that needed decompression and 1 superficial wound infection that resolved with antibiotics. All the fractures united.

This study indicates that both treatment modalities can lead to excellent results. ORIF has the advantage of preserving the joint and once union has occurred has a low risk of long term complications.

MRI arthography (MRA) is commonly used in the investigation of shoulder instability. However many surgeons are now using CT arthography (CTA) as their primary radiological investigative modality. They argue that CTA is cheaper, and give satisfactory soft tissue images in the “soft tissue window” mode. They believe that CTA give superior images when looking at bone loss and bony defects, and as such is more useful in deciding whether a patient requires an open procedure or not.

In this study we aimed to compare the results of MRA and CTA in the investigation of shoulder instability.

We reviewed the operative and arthographic findings in all patients who had surgery for shoulder instability in our unit over a 4 year period. We compared the results of the arthograms with the definitive findings found at the time of surgery. All arthograms were performed by standard techniques and were reported by musculoskeletal radiology consultants. All surgery was performed by experienced consultant shoulder surgeons.

In total 48 CTAs and 50 MRAs were performed. We found that there was no significant difference between the two wrt sensitivity (p=0.1) and specificity (p=0.4) when looking at labral pathology. However CTA was more sensitive at picking up bony lesions (p< 0.05).

This study supports the view that CT arthography is the superior radiological modality in identifying pathology when investigating patients with shoulder instability. It is cheaper and better tolerated by patients than MRA and gives useful information on whether a patient needs an open or arthroscopic stabilisation procedure.

Between September 1993 and September 1996, we performed 34 Kudo 5 total elbow replacements in 31 rheumatoid patients. All 22 surviving patients were reviewed at a mean of 11.9 years (10 to 14). Their mean age was 56 years (37 to 78) at the time of operation. All had Larsen grade IV or V rheumatoid changes on X-ray. Nine (three bilateral replacements and six unilateral) had died from unrelated causes. One who had died before ten years underwent revision for dislocation.

Of the 22 total elbow replacements reviewed six had required revision, four for aseptic loosening (one humeral and three ulnar) and two for infection. Post-operatively, one patient had neuropraxia of the ulnar nerve and one of the radial nerve. Two patients had valgus tilting of the ulnar component.

With revision as the endpoint, the mean survival time for the prosthesis was 11.3 years (95% confidence interval (10 to 13) and the estimated survival of the prosthesis at 12 years according to Kaplan-Meier survival analysis was 74% (95% confidence interval 0.53 to 0.91).

Of the 16 surviving implants, ten were free from pain, four had mild pain and two moderate. The mean arc of flexion/extension of the elbow was 106° (65° to 130°) with pronation/supination of 90° (30° to 150°) with the joint at 90° of flexion. The mean Mayo elbow performance score was 82 (60 to 100) with five excellent, ten good and one fair result.

Good long-term results can be expected using the Kudo 5 total elbow replacement in patients with rheumatoid disease, with a low incidence of loosening of the components.

At our institution between 1994 and 2003 a total of 36 revision total elbow Arthroplasties were performed in 34 patients. We clinically reviewed 25 patients and reviewed the notes and x-rays of all of them. Of eleven who were not reviewed clinically seven had died from an unrelated cause and four were unable to attend because of illness but we were able to include them as sufficient data were available in the notes. There were 24 female and 12 male, Average age was 67 years and twelve had elbow Arthroplasty in a non-dominant side. The average follow up was 6 years (range 5–13 years). The mean period between the primary and revision surgery was sixty three months (range 3–240 months). The indication for surgery was mainly for aseptic loosening in 15 cases, followed by septic loosening in twelve. All cases of septic loosening had two stage revisions. Other reasons for revision in this series include unstable elbows, implant fracture and peri-prosthetic fractures. Twelve of these revisions had a further revision for a variety of reasons at an average period of twenty eight months. Seven patients had thirteen complications in this series, two radial nerve palsies (one recovered), one distal humeral fracture, five cortical perforations and five triceps weakness. Most of the patients are satisfied with their elbows. The mean Mayo elbow Performance Score was 79 points. We conclude that revision Elbow Arthroplasty is a specialized surgery which is technically demanding, with high risk of complications and high re-revision rate and therefore, should be done in a specialised centres.

Total elbow arthroplasty (TEA), as a primary procedure and open reduction and internal fixation (ORIF) have been used to treat complex intra-articular distal humeral fractures in elderly patients. The failure rate after ORIF is high and TEA has often been used as a salvage procedure. Although satisfactory results have been reported after TEA as a primary procedure, there are no publications reporting the results of TEA after failed internal fixation (FIF). In this study we compared the results of patients that had TEA after FIF with those that had had primary arthroplasty (PA). We reviewed the results of 9 consecutive patients who had FIF with 12 patients who had PA. All the operations were performed by one surgeon using the same technique and same prosthesis. Both groups of patients were similar with respect to ages, sex, co-morbidity and hand dominance. The mean follow-up for both groups of patients was 5 years. At final review, patients who had had FIF had a mean Mayo score of 68 and a range of flexion/extension of 90 degrees, there was 1 infection and 1 case of loosening. The PA group had a mean Mayo score of 88 and a range of flexion/extension of 96 degrees, there were no cases of infection or loosening. This study shows the results of TEA are satisfactory either as a PA or after FIF, however the results after PA are significantly better than after FIF.

The aim of this study was to compare the results of physical examination and magnetic resonance arthrography (MRA) in the diagnosis of superior labrum anterior posterior (SLAP) lesions of the shoulder. A review of all patients seen in 2005–2006 with an arthroscopically confirmed SLAP lesion was undertaken (n =22). Prior to surgery all patients had been examined prospectively by an upper limb physiotherapy practitioner and had then undergone MRA. All scans were undertaken and reported upon by an experienced consultant radiologist, specialising in musculo-skeletal conditions. A combination of 4 clinical tests were used to diagnose a SLAP lesion, these being O’Brien’s, pain provocation, bicep load and the crank test. To confirm a SLAP lesion a minimum of 2 of the above tests had to be positive. The sensitivity of each test in isolation and in combination and MRA sensitivity was determined and values statistically analysed for significance. The sensitivity of each isolated test was as follows: O’Brien’s = 82%, pain provocation = 86%, bicep load = 55% and the crank test = 68%. Using a combination of 2 or more positive tests was 95% sensitive, whereas MRA had a sensitivity of 64%. Using the McNemar test there was a statistically significant assosciation between positive clinical testing and negative MRA findings in the same patient (p< 0.05). The results would suggest that it may be advantageous to use a combination of physical tests rather than 1 test in isolation when examining a patient with a suspected SLAP lesion. The study would also suggest that even in the absence of radiological findings, in patients with a relevant history and strongly positive clinical signs, arthroscopic assessment may be indicated.

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. All had a minimum of 5 years follow-up. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed for at least 5 years.

A significant number of patients return with persistent symptoms following surgical release of the posterior interosseous nerve for radial tunnel syndrome. The aim of this study was to attempt to explain this fact in anatomical terms by defining the anatomy of the posterior interosseous nerve and its branches in relation to the supinator muscle and arcade of Frohse. Using standard dissection tools 20 preserved cadaveric upper limbs were dissected. The radial nerve and all its branches within the radial tunnel were exposed and a digital calliper was used to measure distances. The bifurcation of the radial nerve to posterior interosseous nerve and superficial sensory branch occurred at a median distance of 4.35mm proximal to the elbow joint-line. The bifurcation was proximal to the joint-line in 11 cases, at the level of the joint-line in one case and distal in eight cases. There was a range of 0–5 branches to the supinator originating proximal to the entry point of the posterior interosseous nerve under the arcade of Frohse at a median distance of 10.27mm (medial branches) or 11.11mm (lateral branches) distal to the elbow join-line. These branches either passed under the arcade of Frohse or entered through the proximal edge of the superficial belly of the supinator. In 10 limbs there was a variable number of branches to the supinator originating under its superficial belly and in five limbs multiple perforating posterior interosseous nerve branches within the muscle were identified. This variation in anatomy we believe may explain the persistence of symptoms following surgical release of the posterior interosseous nerve for radial tunnel syndrome and suggests that careful exploration of all the nerve branches during surgical decompression should be routinely performed.

Between 1997 and 2005, 10 patients with chronic instability of the elbow underwent surgical stabilisation. There were 5 men and 6 women with a mean age of 41 years (16 to 58). All patients had initially dislocated the elbow at a mean of 5.6 years (6 months to 25 years) prior to surgical reconstruction. There were 8 chronic lateral and 2 medial reconstructions performed. The presenting symptoms, findings on clinical examination and methods of surgical reconstruction are defined. Two patients underwent reconstruction using an artificial ligament (Corin) as they had evidence of ligamentous laxity and at the time of assessment all the other patients had been treated using autografts. At a mean follow up of 3 years (1 to 6 years) all patients except one reported no symptoms of pain or instability and had been able to return to their normal work and social activity. The one patient with persisting elbow instability had Ehlers-Danlos syndrome and underwent a second revision procedure again using an artificial ligament (Corin). This review represents our surgical experience and functional outcomes with this rare form of ligamentous elbow injury.

Between 1993 and 1996, 35 Kudo unlinked total elbow replacements were performed in a consecutive series of 33 rheumatoid patients. All patients had radiological changes of Larsen grade IV or grade V and met the diagnostic criteria of the American Rheumatism Association. The indication for surgery was intractable pain leading to loss of function. There were 6 men and 27 women with a mean age of 60 years (37 to 79) at the time of surgery. A total of 23 patients were reviewed at a mean follow up of 12 years (10 to 13). Ten patients (11 replacements) had died from unrelated causes prior to the review period. Function was assessed with regards to activities of daily living with the Mayo Clinic Performance Index and DASH scoring. Seven patients had undergone revision surgery after the index procedure with conversion of the Kudo replacement to a Coonrad-Morrey prosthesis. The mean time to revision was 6 years (1 to 11). The indications for revision were periprosthetic fracture (n=1), infection (n=2) and aseptic loosening (n=5). This review represents the longest follow up of the Kudo implant outside of the design unit and includes a detailed assessment of the failed arthroplasties.

We present a case of idiopathic osteonecrosis of the humeral capitellum in a 44-year-old female in the absence of any associated risk factors. Arthroscopy was undertaken to remove the loose bodies and debride the capitellum, with a satisfactory outcome.

Sixteen patients who underwent a revision operation for nonunion of fractures of the distal humerus following previous internal fixation were reviewed at a mean follow-up of 39 months (8 to 69).

The Mayo elbow performance score was excellent in 11, good in two, fair in two and poor in one. In 15 patients union was achieved and in one with an infected nonunion a subsequent bone graft was necessary in order to obtain union.

Age, gender, a history of smoking, mechanism of the injury and the AO classification of the initial fracture did not correlate with the development of nonunion. In 12 patients (75%), the initial fixation was assessed as being suboptimal. The primary surgery was regarded as adequate in only three patients. Our findings suggest that the most important determinant of nonunion of a distal humeral fracture after surgery is the adequacy of fixation.

Despite the literature reporting a high complication rate tension band wiring remains a common technique for the fixation of olecranon fractures.

In our unit 44 patients who underwent tension band wiring of olecranon fractures between May 1998 and May 2002 were reviewed specifically with regards factors that might be responsible for a poor outcome. The patient’s age at the time of injury, mode of injury and fracture configuration were recorded. In addition the adequacy of reduction was assessed and the position of the k-wires (parallel/non-parrallel, anterior cortex fixing/intramedullary) length of wire beyond the fracture line and number of circlage wire twists noted.

All patients had a minimum follow-up of 12 months. 22 patients (50%) had complications following the index procedure of which 8 had wire back out, 7 had pain and discomfort requiring removal of the metalwork and 4 had wound infections. Fixation of the radius occurred in 1 patient and 2 patients developed a non-union. In all further surgery was needed in 18 patients (41%).

No common features were identified in patients developing complications and in particular no statistical difference was found when k-wire position (P=0.35) length of k-wire beyond the fracture line (P=0.34) and number of circlage wire twists (P=0.33) were analysed.

Using Kaplan-Meier analysis the patients who required wire removal were likely to undergo their surgery within 6 months of fracture fixation.

The high complication rate begs the question: Is this an appropriate modern method of fracture fixation?

This paper reports our experience of revision open reduction, internal fixation and bone grafting of distal humeral fracture non-unions and in addition looks specifically at factors that may predispose to the development of non-union.

Between 1993 and 2003 18 patients with distal humeral fracture non-unions underwent revision surgery with bone grafting and rigid internal fixation. Two patients were lost to follow-up leaving a study group of 16 patients.

The patients’ age, sex, mechanism of injury, AO classification of the initial fracture and the primary treatment method were analysed with respect to possible factors predisposing to non-union.

All revision procedures were performed by the senior author. The non-union site was debrided, bone grafted and rigidly internally fixed.

Clinical assessment was performed using the Mayo Elbow Performance Score and radiographs were reviewed for evidence of bony union.

The Mayo elbow performance scores were excellent in 11, good in 2, fair in 2 and poor in 1.

Our results indicate that age, sex and mechanism of injury are not important in the development of non-union. Twelve patients (75%) however were considered to have undergone inadequate management of the original fracture.

Our experience would suggest that to reduce the risk of non-union following distal humeral fractures appropriate consideration must be given to the established and well proven surgical techniques.

If adequate fixation is considered beyond the experience of the treating surgeon we would strongly advise referral to a specialist unit.

Aims: The purposes of this study were to design a more useful fracture classiþcation system for distal humeral fractures and to validate it by exactly reproducing methodology from a previous study. Methods: We designed a new fracture classiþcation system based upon our experience of managing these fractures. We tested its validity by reproducing methodology from a study performed in Oxford. Using the same radiographs, we asked 9 independent assessors to classify the fractures, on two separate occasions, according to the Riseborough and Radin, Jupiter and Mehne and AO classiþcation systems as well as our own Ð The Shefþeld Classiþcation. The assessors were unaware that the new system was produced for the purposes of the study. Using the Kappa statistic, the level of interobserver and intraobserver agreement was determined. Results: Amongst all observers, The Shefþeld Classiþcation is a moderately reliable (k=0.603) but substantially reproducible (k=0.713) classiþcation system. The system improves to become substantially reliable (k=0.643) amongst orthopaedic surgeons. The proportion of fractures unclassiþable by the new system is similar to the AO classiþcation (3.7%). Conclusions: By reproducing previous methodology, we have a unique study that validates The Shefþeld Classiþcation. We believe that it can be used in a management algorithm for these complex fractures.

Although it is generally accepted that revision total elbow replacement may be necessary for loosening, instability, peri-prosthetic fracture and infection there is less agreement as to whether surgery should be performed as a one or two stage procedure. This can be of vital importance since the soft tissues around the elbow are often relatively poor making a single operation desirable. However, a one stage procedure in the presence of undetected low grade infection will result in joint failure with early loosening.

In our unit we have found the use of a preliminary aspiration/drill biopsy prior to revision surgery helpful in evaluating whether a one or two stage procedure should be performed.

Over an 8 year period 18 revision total elbow replacements have been undertaken. 9 patients were revised for aseptic loosening, 4 for proven infection, 3 for instability of an unlinked implant and 2 for peri-prosthetic fracture.

With this experience we have devised the following management plan: Early instability of an unlinked implant is due to either poor implant positioning or soft tissue balancing and is suitable for a one stage revision without the need for aspiration/drill biopsy. Late instability is due to implant wear or low grade infection. In this situation we regard an aspiration/drill biopsy as necessary. A negative result allows a one stage revision whereas a positive aspiration indicates the need for a two stage revision.

In a peri-prosthetic fracture if the bone cement mantle is intact a one stage revision without aspiration/ drill biopsy can be performed. If however, there is bone cement lucency we would advise an aspiration/ drill biopsy.

We have found the aspiration/drill biopsy helpful prior to revision total elbow replacement and we have used it to guide us as to whether a one or two stage procedure should be performed.

The Copeland shoulder arthroplasty has been reported to give good results over a 5 to 10 year follow-up period. In this series all the humeral implants were inserted without cement. There was evidence of radiolucency in 30% of the humeral components.

In our unit since 1995 we have implanted the Copeland shoulder hemiarthroplasty using cement around the stem of the prosthesis. We radiologically reviewed 40 patients with a mean radiological follow-up of 4.5 years. There was radiological evidence of loosening in 5%.

Of this group, twenty-five patients had a minimum follow-up of 5 years, with a radiological loosening rate of 8%.

We would suggest that the use of a small amount of cement around the stem of the humeral component is beneficial in reducing the rate of loosening.

We also feel that, as the amount of cement is small and only around the stem, if revision is required it can be undertaken without the difficulties usually associated with cemented prostheses.

The purpose of this study was to design a clinically useful classification for distal humeral fractures that would provide guidance to the surgeon with regard to surgical approach and operative management.

This classification was assessed using the original radiographs from a study comparing distal humeral fracture classifications previously undertaken in Oxford, and validated using the exact methodology of that study. Nine independent assessors (3 orthopaedic consultants, 3 orthopaedic registrars and 3 musculoskeletal radiologists) were asked to classify 33 sets of radiographs on two separate occasions using the Riseborough and Radin, Jupiter and Mehne, and AO classifications as well as the new classification system. The assessors were unaware of the origin of the new system as this had been given a fictitious name. Using the Kappa statistic, the level of inter-observer and intra-observer agreement was determined and interpreted using the Landis and Koch criteria.

Amongst all observers, the new classification is both a substantially reliable (k=0.664) and reproducible (k=0.732) classification system. The new classification achieved superior inter- and intra-observer agreement compared to the other three classification systems with a low proportion of unclassifiable fractures comparable to the AO method (3.7%).

In reproducing materials and methodology from an independent study, we have been able to validate this new fracture classification system. Used in conjunction with a management algorithm, we believe the new classification aids the surgical decision-making process for these complex fractures.

Between 1993 and 1996, we undertook 35 Kudo 5 total elbow replacements in a consecutive series of 31 rheumatoid patients. A total of 25 patients (29 procedures) was evaluated at a mean follow-up of six years (5 to 7.5) using the Mayo Clinic performance index. In addition, all patients were assessed for loosening using standard anteroposterior and lateral radiographs.

At review, 19 elbows (65%) had either no pain or mild pain, ten (35%) had moderate pain and none had severe pain. The mean arc of flexion/extension was 94° (35 to 130) and supination/pronation was 128° (30 to 165).

A fracture of the medial epicondyle occurred during surgery in one patient. This was successfully treated with a single AO screw and a standard Kudo 5 implant was inserted. Postoperatively, there were no infections. One patient had a dislocation which was treated by closed reduction and five had neurapraxia of the ulnar nerve.

Radiologically, there was no evidence of loosening of the humeral component, but two ulnar components had progressive radiolucent lines suggestive of loosening. Two other ulnar components had incomplete and non-progressive radiolucent lines. With definite radiological loosening as the endpoint, the probability of survival of the Kudo 5 prosthesis at five years using the Kaplan-Meier method was 89%.

Between 1990 and 1996 we performed 20 consecutive ulnohumeral arthroplasties for primary osteoarthritis of the elbow.

The outcome was assessed using the Disabilities of Arm, Shoulder and Hand Score (DASH) and the Mayo Elbow Performance Score (MEPS) at a mean follow-up of 75 months (58 to 132). There were excellent or good results in 17 elbows (85%) using the DASH score and in 13 (65%) with the MEPS (correlation coefficient 0.79). The mean fixed flexion deformity had improved by 10° and the range of flexion by a mean of 20°.

In 16 elbows (80%) the benefits of surgery had been maintained, and of 16 patients working at the time of operation, 12 (75%) had returned to the same job.

There was no correlation between radiological recurrence of degenerative changes and the amount of fixed flexion deformity, the flexion arc, or the elbow scores.

We undertook a prospective, controlled trial which compared two rehabilitation programmes for 86 patients who sustained two-part fractures of the proximal humerus. Patients were randomised either to receive immediate physiotherapy within one week (group A) or delayed physiotherapy after three weeks of immobilisation in a collar and cuff sling (group B).

At 16 weeks after the fracture, patients in group A had less pain (p < 0.01) and had greater shoulder function (p < 0.001) than those in group B. At 52 weeks, the differences between the groups had reduced. Although group A still had greater shoulder function and less pain, there was no statistical difference when compared with group B. By analysis of the area under the curve, an overall measure up to the 52-week period, group A experienced less pain as measured by the SF36 general health questionnaire and had improved shoulder function.

Our results show that patients with two-part fractures of the proximal humerus who begin immediate physiotherapy, experience less pain. The gains in shoulder function persist at 52 weeks which suggests that patients do not benefit from immobilisation before beginning physiotherapy.

Aim: To study the long term results of rotator cuff repair in patients over the age of 65.

Introduction: Although some patients with rotator cuff tears are asymptomatic, the majority have a combination of pain, weakness and restricted function. Whilst this affects the lifestyle of all patients, in the elderly these symptoms can make the difference between independent living and the need for assistance or sheltered accommodation.

Method: The present study has looked at a consecutive series of 24 patients all of them over 65 years, who underwent rotator cuff surgery between 1993 and 1997. Outcome has been assessed using two validated scoring systems – the Oxford Shoulder Score (OSS) and the DASH questionnaire. All patients had an open subacromial decompression of their shoulders at the time of cuff repair. Two patients could not be contacted for follow up and were therefore excluded. One patient who had a hemiarthroplasty of the shoulder 3 years after rotator cuff repair was excluded as well.

The average follow up period was 6 years (range 4.5 – 9 years). The Oxford Shoulder Score revealed that 72% had good to excellent results, 16% remained unchanged and 12% were worse than prior to surgery. The corresponding DASH scores were 28% excellent, 40% good, 16% fair and 16% poor respectively. In addition 81% of patients were independent with daily activities, with 48% of them living alone and the remaining 33% living with their partners. Only 19% of patients needed significant help with their activities of daily living. These results were irrespective of whether surgery was performed on the dominant or non-dominant shoulder.

Conclusion: We would suggest that age itself should not be considered a contraindication to rotator cuff repair.

Between 1993 and 2002 7 allografts/joint replacement combinations have been used to treat massive bone loss at the elbow.

The original 4 procedures (2 humeral and 2 ulna allografts) used a standard Stanmore total elbow replacement. Of these the 2 humeral allografts failed and revision surgery was necessary. The 2 grafts on the ulna side of the joint remain in situ (average 6 years after surgery) with one of the patients subsequently having a primary joint replacement on the contra-lateral side.

More recently a further humeral and a further ulna allograft/joint replacement have been performed together with one patient having humeral and ulna allografts on both sides of the joint for extensive bone loss. In these cases the Coonrad-Morrey total elbow arthroplasty was used as the joint implant.

The philosophy behind the use of allografts is discussed and the management principles outlined. The possible reasons for failure of the early humerus allograft/joint replacement combinations is addressed and future developments considered.

The long term results of the ulnohumeral arthroplasty have not previously been reported using a recognised elbow scoring system.

Kashiwagi reported his results in 1986 but no validated scoring system was used in the publication. Morrey in 1992 evaluated his results using the Mayo Elbow Performance Score but the mean follow-up interval was only 33 months.

Between 1990 and 1996 twenty consecutive ulnohumeral arthroplasties were performed for primary degenerative disease of the elbow.

Outcome assessment using the DASH questionnaire and the Mayo Elbow Performance Score was taken at a mean follow-up of 75 months (range 58 to 132). Excellent or good results were identified in 85% (17/20) using the DASH questionnaire, and 65% (13/20) on assessment with the Mayo Elbow Performance Score (correlation coefficient 0.79).

Eighty percent (16/20) felt that the benefits of surgery had been maintained, and of those working at the time of surgery, 75% (12/16) were still employed in the same vocation.

There was no correlation between radiographic recurrence and the degree of fixed flexion deformity, flexion arc or elbow scores.

Although total elbow arthroplasty is undertaken in far smaller numbers than total hip and knee arthroplasty a recent review of the world literature indicated that aseptic loosening radiologically occurred in 17.2% whilst clinical loosening was present in 6.4%. In addition, infections were noted in 8.1%

With both aseptic and septic loosening bone loss can be a major problem and must be addressed if revision surgery is contemplated Options for treating bone loss include:

Revision with standard implant

When considering revision surgery it is essential to ascertain whether or not implant loosening is aseptic or septic. To this end screening blood tests including white blood count, ESR and CRP should be performed. A bone scan may also be helpful. In addition, it is my practice to perform an aspiration biopsy prior to revision surgery. A sample of fluid from the elbow joint is looked at microscopically and cultured for organism sensitivity.

If infection is present surgery is undertaken as a two-stage procedure. The first stage involves removal of the implant and bone cement together with the insertion of antibiotic beads specially prepared with added antibiotics appropriate to the sensitivity of the infectiong organism.

If infection is not present then a one-stage revision is performed.

Between 1995 and 2000, 19 consecutive patients with fractures of the distal humerus were treated by primary total elbow replacement using the Coonrad-Morrey prosthesis. No patient had inflammatory or degenerative arthritis of the elbow. The mean age at the time of injury was 73 years (61 to 95). According to the AO classification, 11 patients had suffered a C3 injury, two a B3 and two an A3. One fracture was unclassified. Two patients died from unrelated causes and one was unable to be assessed because of concurrent illness.

The mean time to follow-up was three years (1 to 5.5). At follow-up 11 patients (68%) reported no pain, four (25%) had mild pain with activity and one had mild pain at rest. The mean flexion arc was 24° to 125°. The mean supination was 90° (70 to 100) and pronation 70° (50 to 110). No elbow was unstable. The mean Disabilities of the Arm, Shoulder and Hand score was 23 (0.92 to 63.3) and the mean Mayo elbow performance score was 93 (80 to 100). Of the 16 patients, 15 were satisfied with the outcome.

Radiological evaluation revealed only one patient with a radiolucent line at the cement-bone interface. It was between 1 and 2 mm in length, was present on the initial postoperative radiograph and was non-progressive at the time of follow-up.

Primary total elbow arthroplasty is an acceptable option for the management of comminuted fractures of the distal humerus in elderly patients when the configuration of the fracture and the quality of the bone make reconstruction difficult.

Three and four part fractures of the proximal humerus can prove difficult to treat and results are generally poor. We used a Polarus Nail technique to treat seven consecutive patients who had sustained an isolated fracture to the proximal humerus. According to Neers classification, four patients had sustained a three-part fracture and three patients a four-part fracture. One patient had a fracture dislocation.

At review, six of the seven patients were assessed using the Constant and Dash scoring systems. One patient had died, but at last review had been discharged with a satisfactory result.

The average age of the patients reviewed was 62 years (range 48–79). The dominant hand was affected in 2 patients.

All six patients were followed up to fracture union and were happy with the result of treatment. All patients had mild or no pain. The average Constant score was 83 (range 59–98) and average Dash score was 131 (range 8–300)

When comparing our results to other methods of treatment already described, we found that fixation using a Polarus nail provided a satisfactory alternative method. In fact, our patients appeared to have less pain and a higher score to all elements of the Constant score.

We conclude therefore that the use of the Polarus Nail should be considered as a treatment option in this group of patients.

Cobb and Morrey (1997) reported the use of Total Elbow Replacement (TER) for patients with distal humerus fractures. In this paper, 48% of the patients had a previous history of inflammatory arthropathy. Our aim was to determine the role of TER as treatment for complex distal humeral fractures in elderly patients with no previous history of inflammatory arthropathy. These patients have greater functional demands.

The complexity of the original injury was graded according to the AO Mullers’ classification of supracondylar humeral fractures. All patients were reviewed clinically and radiographically. Their daily activities and general post-operative quality of life was estimated with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The Mayo elbow performance score was used for functional evaluation. Implant survivorship was assessed.

Fourteen patients (11 female and three male) underwent a Coonrad-Morrey TER via a standard posterior approach for humeral fractures. Their mean age was 73 years (range 61–84 years) at the time of injury. Ten patients had suffered a C3 injury, two a B3 and two an A3 according to the AO classification. The mean time to surgery after their injury was 8 days (range: 1–21 days). Complications: one myocardial infarct and one superficial wound infection.

Mean time to follow-up was three years and two months (range: 9–66 months). Nine (64%) reported no pain, four (29%) had mild pain with activity and one had mild pain at rest. The mean arc of extension-flexion movement was 24°–125°. Supination: mean = 90° (range: 70°–100°). Pronation: mean = 70° (range: 50°–110°). No elbow was unstable. The mean DASH score was 22.6 (range: 0.92–63.3). Zero reflects no disability, 100 reflects most severe disability. The mean Mayo elbow performance score was 90 (range: 80–100). X-rays revealed that all implants were well fixed with no evidence of loosening. One patient had severe hypertrophic bone.

We describe a posterior approach to the elbow which combines the advantages of both splitting and reflecting the triceps. It gives protection to the ulnar nerve and its blood supply during the operation while providing excellent exposure of the distal humerus. During closure, the triceps muscle can be tensioned, thereby improving stability of the elbow. This approach has particular relevance to unlinked total elbow arthroplasty allowing early rehabilitation of the joint.

We have reviewed 12 fractures of the coracoid process. In two of these patients the fracture extended into the body of the scapula and resulted in displacement of the glenoid. In some cases, there were associated acromioclavicular and glenohumeral dislocations or fractures of the clavicle and the acromion. Two patients required internal fixation to restore congruence of the glenoid; the others were treated conservatively with success. We present a new classification of coracoid fractures which helps in their management.

A method of treating Freiberg's disease of the metatarsal head by shortening the metatarsal bone is described. This operation has been performed in 15 patients (16 feet). Excellent relief of pain was obtained, although most patients had persistent stiffness of the metatarsophalangeal joint.

In a prospective study of 100 knee arthroplasties in patients with rheumatoid arthritis, simultaneous bilateral surgery was compared with staged bilateral replacements. All patients had improved function following their operations but those who had staged surgery only achieved maximum benefit after the second knee had been replaced. The complication rate was no greater for simultaneous surgery and we therefore advocate the method for those patients who require bilateral replacements.

A consecutive series of 150 patients with clavicular fractures is presented. In 81% detailed information regarding the mechanism of the injury was available and, of these, 94% had fractured their clavicle from a direct blow on the shoulder; only 6% had fallen on the outstretched hand. This finding, at variance with commonly held views regarding the mechanism of this injury, was further investigated by biomechanical analysis of the forces involved in clavicular fractures. The biomechanical model supported the clinical findings.