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.

We reviewed 158 hip replacements performed using the Exeter® stem between 1992 and 1996. The operations were performed using third generation cementation and the majority using medium viscosity Simplex cement via a posterior approach. Per-operative complications [shaft fracture etc] were not seen.

Using stem revision as an endpoint, only one stem has been revised [0.6%] for aseptic loosening, and one for sepsis. Aseptic asymptomatic loosening was observed in a further 4 patients [2.5%]. Stem subsidence was seen in the majority [81%], but none greater than 3mm [mean 1.4mm]. Other complications were rare.

This medium term review confirms that the Exeter® stem is a prosthesis with excellent results. This is one of the first series published outside Exeter to confirm their reported results.

39 consecutive patients (40 hips) undergoing femoral impaction grafting were retrospectively reviewed to assess our mid-term results and analyse them for any factors that could influence outcome. 36 revisions were for aseptic loosening, 3 for infection and 1 following a periprosthetic fracture. Those hips revised for infection were revised in 2 stages. In 37 cases, the Exeter X-Change bone impaction technique was used, implanting an Exeter stem with Simplex cement through a posterior approach. A Charnley stem was implanted in the 3 others.

Each surviving patient was assessed using the Harris hip score, AP pelvis and lateral hip radiographs. Potential prognostic factors were analysed using the Spearman’s rank correlation test.

The patients were reviewed after a mean follow-up of 5 years. 1 patient didn’t wish to attend review but was asymptomatic. Complications included 4 intraoperative femoral fractures during cement removal, 2 postoperative femoral fractures, 2 dislocations, 1 femoral component fracture and 1 deep infection. There were 3 re-revisions and 1 Girdlestones procedure.

The median Harris hip score of those implants still in-situ was 78.5. Those patients who had previously undergone a revision had a significantly worse Harris hip score (p< 0.05). The patients age, reason for revision, preoperative bone loss, surgeon, simultaneous acetabular revision, simultaneous bone grafting to acetabulum, loose acetabular component on radiographs, femoral subsidence, presence of trabeculae in the graft, any radiolucency, a complete cement mantle and ectopic bone formation had no significant correlation to the Harris hip score.

In this series, previous revision was found to be the only significant risk factor for a poor Harris hip score after femoral impaction grafting. Postoperative radiographic changes in this group correlated poorly with function and could not predict outcome. Further study is required to assess other factors such as bone graft and soft tissue quality that may also predict outcome.