Background

A recent Cochrane review has shown that total shoulder arthroplasty (TSA) seems to offer an advantage in terms of shoulder function over hemiarthroplasty, with no other obvious clinical benefits. This is the first study to compare complication rates on a national scale.

Fixation of comminuted olecranon and proximal ulna fractures can be a challenge. The goal of surgery is for stable fixation to encourage union and allow early elbow movement.

Over a 3 year period, a low profile titanium, precon-toured olecranon plate (Acumed LLC, Hillsboro, Portland, Oregon) was used in 16 patients with comminuted olecranon and proximal ulna fractures, using a standard universal posterior approach to the olecranon with the patient in a lateral position and active flexion/extension of the elbow was started 48 hours postoperatively. Functional outcomes were measured during follow-up (FU), including range of movement (ROM), Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow Performance Score (MEPS).

There were 9 isolated olecranon fractures, including one open fracture in a multiple injured patient and one an infected non-union and 7 with associated ipsilateral upper limb injuries. Mean age was 52 years (13 to 84) and mean FU was 12.8 months (3 to 33). All had achieved radiological union at 3 months. Overall mean ROM for both groups was 19.3 to 130.7 degrees flexion, 71.8 degrees pronation and 72.1 degrees supination. DASH was 19.1 and MEPS was 87.7.

When comparing the 2 groups, there was no significant difference in supination or pronation but all other mean outcomes measurements showed statistical significance in favour of isolated, comminuted olecranon fractures. Extension 9.4 versus 35.0 degrees (p< 0.005), Flexion 140.6 versus 117.5 (p< 0.05), DASH 7.5 versus 34.7 (p=0.0007) and MEPS 96.3 (excellent) versus 78.3 (good) (p< 0.05). There were no infections or failure of metalwork, but two patients had the metalwork removed after union as they required further surgery to their elbows.

We demonstrate this is a safe and reliable method of fixation and can expect excellent results when treating isolated comminuted olecranon/proximal ulna fractures and good results when there are associated ipsilateral injuries.

Purpose: To compare the incidence of avascular necrosis, and radiological outcomes between groups treated by closed reduction, open reduction, and open reduction + femoral shortening, under the care of a single surgeon, with open reductions performed through an anterior approach, uninfluenced by the appearance of the ossific nucleus.

Methods: Between Sept 1991 and Dec 2003 we retrospectively studied 66 patients (3 bilateral; 10 males, 53 females) who had undergone reduction under anaesthesia. Of these 34 hips were reduced closed with adductor release (average 0.7 yrs, range 0.2–1.7), 11 reduced open (average age 1.0; 0.4–3.3) and 24 reduced open with femoral shortening (average age 2.4; 0.9–7.8).

Follow up radiographs were graded for the presence of AVN by the Bucholz and Ogden method. Radiological outcome was graded by the Severin score. Average follow up was up to the age of 6.6 years (SD 2.9) for the closed reduction group, open reduction group 8.0 (SD 3.6) and femoral shortening group 9.0 (SD 3.9)

Results:

AVN scores

Closed Reduction (n=34) : Grade 1 : 5.

Conclusions: The group with the highest incidence of AVN & worse Severin grades was the group (average age-1.0) who had open reduction without femoral shortening. The open reduction & shortening group had a higher proportion of good radiological results despite treatment being given at a older age. Concentric closed reduction, where possible, gave the best results.

Significance: Any child presenting with DDH at walking age (over 1) who requires open reduction should also have a femoral shortening. This gives the best chance of avoiding high grade AVN and achieving a good radiological result. Results might improve if open reductions without shortening were discontinued.

Introduction: The threshold for internal fixation of thoracolumbar junction fractures is controversial. Most authorities would agree that indications would include neurological deficit and severe deformity. The definition of severe deformity many would regard as a kyphus angle of 20° or more and/or compression of more than 50% of the anterior body height. Patients are only assessed on supine films alone. The aim of this study was to ascertain whether weight-bearing films altered the deformity and if so did this subsequently alter management.

Methods: A prospective study of patients who had suffered a fracture of the thoracolumbar junction (T11- L2). All patients who had a neurological deficit or a kyphus angle of greater than 20° and/or greater than 50% anterior body collapse were excluded. Only patients with a deformity less than the above were entered into the study. These patients then had weight-bearing views (standing or sitting) as soon as they had developed trunk control. A kyphus angle of greater than 20° or more than 50% body collapse were used as a criteria for fixation.

Results: 16 patients were entered into the study over a one year period. Five (31% ) of the 16 patients had a significant increase in their deformity on weight-bearing films that caused them to pass the threshold for fixation, and subsequently had surgery .

Conclusion: The authors recommend that weight-bearing views should always be taken on fractures of the thoracolumbar spine if conservative treatment is being considered.

Thirty patients who had 34 Bio-Action Great Toe Implants (four bilateral replacements) for symptomatic advanced degenerative changes in the first metatarso-phalangeal joint (MTPJ) were followed prospectively for an average period of 20. 7 months (range 8–32 months).

The age range of patients was between 38 and 72 years with mean age 55. 8 years. Majority of patients had either a Hallux rigidus (19/34 replacements, 56%) or hallux valgus with severe degenerative changes in first MTP joint (9/34 replacements, 26%). The scoring system designed by Kitaoka et al for the American Foot and Ankle Society, was adopted to assess the functional results. Patient satisfaction, length of stay, time to return to routine activities, footwear problems, x-ray appearances and complications were all assessed.

There was a statistically significant improvement in the range of motion achieved and Hallux MTP scale after the operation. (Paired samples test was significant at 5 percent level). There was a positive correlation between the patients’ satisfaction and Hallux MTP scale. However, there was no correlation between patients’ age and patients’ satisfaction. Similarly, there was no correlation between patients’ age and post operative Hallux MTP scale score. (Pearson’s correlation coefficients). There is statistically significant improvement in life style, foot wear requirements and functional abilities after the operation. The complications includedmetatarsal fracture during operation (l/34 replacements) in one case, four cases of superficial infection which resolved completely with a course of antibiotic and one case of aseptic loosening of the implant which was revised to a cemented implant. Two out of 34 replacements reported sustained transference metatarsalgia beyond 6 months post operatively. 72% of patients (24/34 replacements) considered the result of the operation to be excellent or good. Overall, the early functional results of this total joint system appeared to be satisfactory.