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.

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.

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.

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.

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 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.

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 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.

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.

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.