Glenoid bone grafting in reverse total shoulder arthroplasty (RTSA) has emerged as an effective method of restoring bone stock in the presence of complex glenoid bone loss, yet there is limited published evidence on efficacy. The aim of this study was to conduct an analysis of clinical and radiographic outcomes associated with glenoid bone grafting in primary RTSA.

Patients who underwent a primary RTSA with glenoid bone grafting were retrospectively identified from the databases of two senior shoulder surgeons. Inclusion criteria included minimum of 12 months clinical and/or radiographical follow up. Patients underwent preoperative clinical and radiographic assessment. Graft characteristics (source, type, preparation), range of movement (ROM), patient-reported outcome measures (Oxford Shoulder Scores [OSS]), and complications were recorded. Radiographic imaging was used to analyse implant stability, graft incorporation, and notching by two independent reviewers.

Between 2013 and 2021, a total of 53 primary RTSA procedures (48 patients) with glenoid bone grafting were identified. Humeral head autograft was used in 51 (96%) of cases. Femoral head allograft was utilised in two cases. Depending on the morphology of glenoid bone loss, a combination of structural (corticocancellous) and non-structural (cancellous) grafts were used to restore glenoid bone stock and the joint line. All grafts were incorporated at review. The mean post-operative OSS was significantly higher than the pre-operative OSS (40 vs. 22, p < 0.001). ROM was significantly improved post-operatively. One patient is being investigated for residual activity-related shoulder pain. This patient also experienced scapular notching resulting in the fracturing of the inferior screw. One patient experienced recurrent dislocations but was not revised.

Overall, at short term follow up, glenoid bone grafting was effective in addressing glenoid bone loss with excellent functional and clinical outcomes when used for complex bone loss in primary RTSA. The graft incorporation rate was high, with an associated low complication rate.

Scapho-lunate Dissociation is an uncommon carpal instability, but produces significant functional loss and early post-traumatic arthritis. Traditional soft tissue reconstructions have a mixed history of success, and are associated with significant loss of range of motion making sport difficult. This study reports use of modified Brunelli reconstruction that allows return to professional contact sport

The Brunelli reconstruction tethers proximally from the lunate attachment of the FCR graft. The modification anchors the tendon graft from the lunate to the capitate across the stretched mid-carpal capsule, and ensures better correction of the DISI deformity and good range of motion.

A cohort of 8 AFL level footballers was treated with this reconstruction, and retrospectively reviewed.

The modified Brunelli reconstruction was used in all cases. Interestingly, 3 of the 8 cases were delayed by over 12 months, and had already suffered loss of cartilage over the scaphoid proximal pole dorsally. The same operation was performed despite this relative contra-indication. This was protected by a specific translation manouvre to lift the dorsal scaphoid away from the dorsal ridge of the radius whilst the wires holding the reduction were in situ.

All players returned to professional level Australian Rules Football. Follow up examination revealed excellent maintenance of dorsiflexion and good retention of palmar flexion post reconstruction. No players complained of arthritic pain, and no further procedures were performed.

This procedure is an excellent alternative to partial carpal fusion which is promoted in the literature as the only reliable treatment option for symptomatic scapho-lunate instability.

There has been concern over the safety of the upright position for shoulder surgery from anaesthetists uncomfortable with the risk of reduced cerebral blood flow (CBF). Because there are no studies documenting what happens to CBF during upright surgery we aimed to measure CBF through an indirect and non-invasive method using recently available Ultrasound monitoring equipment.

This study randomised patients into awake (interscalene block alone) and GA with block, and indirectly measured the CBF by using a validated Doppler technique on carotid flow both before and during the shoulder procedure. Non-invasive and invasive measurements of mean arterial pressure were made throughout the procedure, together with doppler measurement of carotid flow following preoperative measurement of carotid contribution to cerebral flow in the radiology department by an experienced sonographer. All measurements recorded in real time and charted independently.

This study has shown that CBF in both groups were consistent with the expected values, and CBF remained proportionate in supine to upright. CBF values in the block alone group were generally lower than the GA group. In the GA group the MAP dropped lower, requiring use of adrenergic drugs to bring the pressure up. Despite the significant drop in MAP, the CBF was still high. This could signify cerebral autoregulation is a significant factor in the upright position.

We have shown the feasibility of use of DOppler to indirectly measure CBF during upright surgery. Despite the predicted drop in MAP in this position with GA, we could NOT show a concurrent drop in CBF, demonstrating that much more complex factors regulate the CBF in these patients. Clearly, monitoring is the key to safe administration of anaesthetic in the upright position.

Proximal humeral fractures may be treated by joint replacement or internal fixation. We have been concerned by the unpredictable results of hemiarthroplasty in the trauma situation. At The Alfred hospital, we have used the ACE proximal humeral plate over the last three years. This is a retrospective study of 55 cases, looking at the outcome of internal fixation, the incidence of avascular necrosis, and the functional results. The results were very favourable when compared with the results of other series that have been published in the literature. Our conclusion is that it is better to internally-fix these fractures whenever possible.