Reverse Shoulder Arthroplasty (RSA) has been widely accepted for the treatment of rotator cuff arthropathy. There are a number of other shoulder pathologies where the reverse shoulder prosthesis can salvage previously untreatable shoulder conditions and restore function to the shoulder. This is a series of cases where RSA has been used to treat shoulder fractures.

Crosby and Colleagues described 24 scapula fractures in 400 reverse shoulder arthroplasties and classified scapula fractures after reverse shoulder arthroplasty into 3 types.

Type 1 – true avulsion fracture of acromion related to a thinned out acromion (post-acromioplaty or cuff arthropathy). A small bone fragment dislodges during reduction of RSA.

Type 2 – Acromial fracture due to Acromio-clavicular (AC) joint arthrosis. They feel the lack of movement at the AC joint leads to stresses across the acromion and cause it to fracture. They recommend AC joint resection and ORIF of acromion, if the acromion is unstable.

Type 3 – true scapula spine fracture caused by the superior screw acting as a stress riser. This fracture occurs about 8 months after the arthroplasty and is a true stress fracture requiring open reduction and internal fixation.

Of 123 reverse shoulder arthroplasties performed from Jan 2003 to Feb 2011, a total of 6 scapula fractures were encountered post-surgery. Three were acromial fractures and three were scapula spine fractures all related to trauma. The fractures of the spine occurred between 6 months and 4 years post arthroplasty. We feel the fractures were traumatic but did occur through the posterior or superior screws from the metaglen. where stress risers developed for a fracture to occur.

We found that using a sliding osteotomy of the spine of the scapula to bridge the defect of the scapula and a double-plating technique using two plates at 90 degrees to each other provides a satisfactory outcome after 3–6 months where patients can start actively elevating again. This method of treatment will be presented.

With the advent of locked volar radial plates there has been a wave of enthusiasm in the fixation of distal radial fractures with these devices. This study was designed to look at potential complications and pitfalls of this treatment modality.

80 consecutive cases treated by the author with locked volar radial plates were analysed. Complications were divided into major and minor groups and recorded exhaustively.

Major complications included 6 patients requiring further wrist related surgery, 1 patient with an iatrogenic radial artery injury, 1 patient with an iatrogenic palmer branch of median nerve partial injury, 1 patient with a complex regional pain syndrome and 6 patients with a less than adequate return of range of movement. ^ minor complications were recorded.

With attention to detail and by avoiding several recurring pitfalls volar locked plating is a safe and effective procedure.

This study was designed to investigate distal radial osteotomy performed from a volar approach for dorsal deformity. In the past conventional dorsal approaches have led to extensor tendon synovitis and a volar approach was thus appealing.

A prospective analysis of 8 consecutive patients with distal radial malunions with residual dorsal angulation was performed. In each case a volar approach was used and a locked distal radial plate was applied. Laic crest bone graft was used.

In each case an acceptable correction was obtained. Union occurred in 6–8 weeks. Pain and grip strength were improved in all 8 cases.

The author concludes that a volar approach and locked plate fixation is useful for the correction of dorsal deformity in distal radial malunions. Implant problems with this approach.

We have undertaken a prospective clinical and radiological analysis of 124 shoulder arthroplasties (113 patients) carried out for osteoarthritis. The clinical results showed improvement in the absolute Constant score and the American Shoulder and Elbow Surgeons score of 22 and 43, respectively. Both were statistically significant (p < 0.001). There was no significant difference in the scores after hemiarthroplasty and total arthroplasty in those patients with an intact rotator cuff.

When revision was used as the end-point for survival at ten years, survival of 86%, or 90% if glenoid components made of Hylamer sterilised in air were omitted, was obtained in primary osteoarthritis. The most common cause for revision in the hemiarthroplasty group was glenoid pain at a mean of 1.5 years; in the total arthroplasty group it was loosening of the glenoid at a mean of 4.5 years. Analysis of pre-operative factors showed that the risk of gross loosening of the glenoid increased threefold when there was evidence of erosion of the glenoid at operation. Shoulder arthroplasty should not be delayed once symptomatic osteoarthritis has been established and should be undertaken before failure of the cuff or erosion of the glenoid are present.

Introduction and Aims: The purpose of this study was to investigate the effectiveness of a specifically designed titanium wrist fusion plate for use in wrist arthrodesis. The possibility of no or minimal casting post-operatively was considered and an early return to function was another proposed benefit.

Method: Ten consecutive patients with pathology requiring wrist arthrodeses were subjected to wrist fusion by means of a titanium wrist fusion plate. In all 10 cases, a similar technique was used securing the plate to the third metacarpal and the radius. In all cases, autologous bone graft was harvested from the patient’s iliac crest. Time to union, time of immobilisation and overall functional results were looked at. Patient satisfaction with the procedure was also documented.

Results: In all 10 patients, solid radiological union was documented between eight and 12 weeks. The pre-contoured plates produce a satisfactory and consistent position of fusion when correctly applied. Six of the 10 patients were managed with a light cast for six weeks post-operatively. The other four patients were treated with no immobilisation at all. There was no failure of fixation in this small series. One patient with a pre-existing transverse scar on the dorsum of the wrist, a small area of skin necrosis occurred. This healed by secondary intention over a four-week period.

Conclusion: The titanium arthrodesis plate provides a reliable good method for wrist fusion. Although the longitudinal scar is longer than necessary in some other techniques described, and the carpometacarpal joint is included in the fusion, the overall level of patient satisfaction is high.

Introduction and Aims: The ‘Boxer’s fracture’ is a common injury. Often these fractures are treated conservatively with acceptable functional results, leaving the patient with a residual deformity. A minimally invasive technique of treating these fractures was investigated.

Method: Twenty-three consecutive patients with a fractured neck of the fifth metacarpal with a volar angulation exceeding 40 degrees were offered treatment with a prograde intramedullary K-wire. All 23 patients accepted this treatment with informed consent. A 1.6 mm pre-bent K-wire was inserted via the base of the fifth metacarpal in each case. Time to regaining full function, time to union and final functional and radiological outcome were looked at.

Results: All 23 patients went on to full clinical and radiological union within six weeks. In 18 patients the reduction was anatomical with no residual angulation. In five, the residual angulation ranged from five to 15 degrees with an average of eight degrees. Two patients suffered a transient sensory neuropraxia.

Conclusion: The presented technique is a simple, cost-effective and reliable method of treating a ‘Boxer’s fracture’. Although this type of injury can often be treated without surgery, this procedure ensures a rapid return to full function with little or no residual deformity.

Introduction and Aims: Acromioclavicular dislocations and fractures of the distal clavicle present a challenging problem for the treating surgeon. The use of a new specifically designed implant was investigated. A hooked-shaped plate with fixation to the distal clavicle and ‘hook’ placement under the posterior acromion was used.

Method: The procedure was carried out on eight patients. In five patients the injury was a fractured distal clavicle. In three cases an acromioclavicular dislocation was treated. In all cases the time to returning to a functional capacity was analysed. The eventual functional result was indexed from the time of fracture union or complete stabilisation of the dislocations.

Results: All five fractures went on to anatomical union. The three dislocations were all stabilised with no instability or subluxation. In two cases patients complained of impingement symptoms with decreased overhead functional capacity. In both cases the patients regained a full and pain-free range of movement after removal of the implant.

Conclusion: This new implant provides an acceptable alternative in the management of distal clavicle fractures and acromioclavicular dislocations. The complication of impingement is encountered, but this appears to be treatable by removal of the implant after fracture union or joint stabilisation.

Following up seven consecutive patients for a minimum of 3 years, we assessed the clinical outcome and level of patient satisfaction after distal ulnar head replacement.

In one patient the procedure was done because of a tumour. In the rest the pathology was predominantly OA and RA.

At follow-up, all patients had almost full pronation and supination. Grip strength was better than it was preoperatively, but generally not as good as in the non-pathological hand. In one patient instability was a problem, but overall patient satisfaction was high.

Although our study was of a small group and follow-up has been relatively short, early indications are that distal ulnar head replacement is a reliable and effective way of managing selected patients with problems that are otherwise difficult to treat.

This study of 10 consecutive patients analysed the benefit of percutaneous scaphoid fixation in minimally or non-displaced scaphoid fractures, looking at time to union, range of movement and strength. In all but one patient, who had an associated distal radius fracture, early mobilisation was the goal. Fixation was by canulated compression screw in all cases.

Clinical and radiological union took place in a mean time of 7 weeks. Mobilisation was possible from 2 weeks postoperatively in nine of the 10 patients. By the time of union, there was minimal loss of mobility. Patient satisfaction was high. There was no need for prolonged immobilisation in a cast.

Introduction and Aims: With the prevalence of gunshot injuries in our society a new approach to the treatment of gunshot radius and/or ulna was analysed. These fractures are often very comminuted and surgical exposure of the fracture site may render many previously viable bone fragments devoid of a blood supply. It was decided to look at a minimally invasive method of plating these fractures.

Method: A consecutive series of nine patients with a diaphyseal gunshot of the radius or ulna or both was subjected to a ‘percutaneous plating’ procedure. This form of fixation acts as an internal form of ‘external fixator.’ Two surgeons performed the procedures.

Results: At the time of submission of this abstract five of the six patients had gone on to complete clinical and radiological union. The sixth patient is still under follow-up. The average time to full union was 12 weeks. The average pronation obtained was 60 degrees (20–80) and the average supination 50 degrees (10–70). In all patients full elbow and wrist movement was preserved.

Conclusion: Although this is a very limited series of patients it would appear that this method of treating gunshot injuries of forearm bones produces good results in injuries that are sometimes difficult to treat. The long-term effect on wrist function is difficult to predict. To date, we have had no serious complications in this small series, with no incidence of nerve injury, no sepsis and no radio-ulna synostosis.

The purpose of this study was to analyse the reason for failure of shoulder arthroplasties performed for osteoarthritis, looking specifically at factors associated with either hemi or total shoulder replacement.

Over an eight-year period over 80 consecutive patients undergoing a Global hemi-arthroplasty or total shoulder arthroplasty were looked at. All patients underwent at least two years of follow up. All patients were assessed pre and post operatively using the Constant and ASES scoring systems. A bio-engineer or physiotherapist performed these evaluations. X-rays were analysed for demarcation, loosening and glenoid erosion. Failure was defined as the need for revision surgery. Reasons for revision were predominately pain, loosening and instability. In these instances the differences between hemi and total joint arthroplasty were recorded. A distinct pattern was present with several early revisions being performed for continuing pain in the patient group who underwent hemi-arthroplasty.

In conclusion, this study supports total shoulder replacement as the operation of choice, in suitable patients, as compared to hemi-arthroplasty. This would appear to reduce the risk of the need for early revision on account of pain. This must be weighed against the potential for late glenoid loosening.

Between 1992 and 2000, 120 shoulder arthroplasties have been inserted in patients with osteoarthritis at this hospital. Shoulder function was assessed using the ASES patient self-evaluation form and the Constant-Murley clinical index as well as evaluation including routine measurements of shoulder motion and pain. The mean follow-up was 4.4years (2 to 10years).

Movement, pain and both shoulder function scores significantly improved after operation with t-test values significant at P< 0.001 level. Three sub-groups of primary osteoarthritis (OA), avascular necrosis (AVN) and post traumatic arthritis (PTA) were analysed separately. Although each group was significantly improved after arthroplasty the AVN and PTA patients had significantly poorer results than OA patients for pain and the functional scores, except the AVN group for the Constant Murley score. General linear model analysis indicated that both Constant-Murley and ASES shoulder function scores were shown to be sensitive to change after treatment and that improvement was maintained for up to 8 years post-operation.

Kaplan-Meier analysis showed a significant difference in survival between the 3 sub-groups of OA, PTA and AVN with 5 of 16 PTA operations needing revision. This was reflected in function measurement with PTA values 20 points lower in both clinical (P=0.014) and self assessed functional status (P=0.004).

At each visit a true AP radiograph was taken. Radiological lucency was graded using the method of Matsen. The humeral components were inserted without cement and there were no signs of loosening. Just four components had lucency at one of 7 zones. There was a noticeably higher incidence of glenoid lucency, Proportional hazards analysis was used to model the hazard rate of glenoids at risk. A hazard model for the glenoid components consisted of only one variable – presence or absence of glenoid erosion noted at operation. The model is significant (P= 0.02) with erosion having a hazard rate 6 times greater than that if not eroded.

Gunshot injuries to large joints are increasing in South Africa. If the bullet is in contact with the synovial fluid of the joint, it must be removed to prevent a foreign body effect and lead poisoning.

We devised a new extra-articular approach to removing the bullet from the joint. We used a reamer to make a tract in the bone towards the joint, and then removed the bullet and irrigated the joint through the same tract. Postoperatively patients were mobilised immediately. At follow-up they had good functional outcome.

Where reconstruction is deemed impossible, excision of the radial head has been the mainstay of treatment for shattered radial head and neck fractures. While some patients seem to do well after the procedure, some develop progressive instability and pain because of proximal translocation of the radius. We looked at a new procedure in which a metal radial head is inserted to provide greater stability after the excision. Historically silicone prostheses have been used, but these were found to fail dramatically after a time.

We recruited 11 patients requiring radial head replacements. Their ages ranged from 26 to 54 years. In five patients the dominant arm was affected. The radial head was deemed non-reconstructable in all patients, and the alternative method of treatment would have been radial head excision. In one patient, radial head replacement was performed 14 years after previous radial head excision. A standardised procedure was performed, replacing the radial head with an Evolve modular radial head prosthesis.

At follow-up, we assessed patient satisfaction, range of movement, overall stability of the prostheses, grip strength and return to full activity. The postoperative range of movement was assessed at three and six weeks, and the outcome in terms of mobility at six months. Supination ranged between 40( and 90( and pronation between 40( and 85(. Elbow extension ranged between -5( and -30 and flexion between 100( and 150(.

We concede that the follow-up period has been short, but early results suggest that radial head replacement may be a good option in patients in whom radial head reconstruction is not possible.

Conservative treatment of the ‘boxer’s fracture’ gives acceptable functional results but often leaves the patient with a residual deformity.

Using a prograde intramedullary K-wire, we treated 23 consecutive patients with a fractured neck of the fifth metacarpal. Volar angulation exceeded 40°. A 1.6-mm pre-bent K-wire was inserted via the base of the fifth metacarpal in each case. Time to regaining full function, time to union and final functional and radiological outcome were recorded.

All 23 patients went on to full clinical and radiological union within six weeks. In 18 patients, the reduction was anatomical with no residual angulation. In five the residual angulation ranged from 5° to 15°, with a mean of 8°. There was a transient sensory neuropraxia in two patients.

This minimally invasive technique is a simple, cost-effective and reliable method of treating a ‘boxer’s fracture’ and ensures a rapid return to full function with little or no residual deformity.

Treating 10 consecutive patients requiring wrist arthrodesis, we assessed the effectiveness of a titanium plate specifically designed by Hill Hastings for wrist arthrodesis. It appeared to call for little or no postoperative casting and to promise an early return to functionality.

We secured the plate to the third metacarpal and the radius and used autologous bone graft taken from their iliac crest. Length of time immobilisation, time to union, overall functional results and patient satisfaction were recorded.

In all 10 patients clinical and radiological union occurred in 8 to 12 weeks. Four patients had no postoperative immobilisation and six had a Litecast. Correctly applied, the pre-contured plate produced a consistently satisfactory position of fusion. One patient had a small area of wound skin necrosis in a pre-existing transverse scar over the dorsum of the wrist, but this healed.

The carpometacarpal joint is included in this fusion, which requires a longer longitudinal incision than some other wrist fusion techniques. However, patient satisfaction was high.

Acromioclavicular (AC) joint dislocations and fractures of the distal clavicle present challenging problems for the treating surgeon. We treated eight patients using a hook-shaped plate fixed to the distal clavicle and ‘hooked’ under the posterior acromion.

In five patients the injury was a fractured distal clavicle and in three an AC joint dislocation. We analysed the time taken to achieve a functional capacity. The eventual functional result was indexed from the time of fracture union or complete stabilisation of the dislocations.

All five fractures went on to anatomical union. The three dislocations were all stabilised with no instability or sub-luxation. Two patients complained of impingement symptoms and decreased overhead functional capacity. After the implant was removed, both patients regained a full range of pain-free movement.

This is a small study with limited follow-up. However, the results suggest that this new implant provides an acceptable alternative in the management of distal clavicle fractures and AC joint dislocations. The complication of impingement can be treated by removal of the implant after union or stabilisation has been achieved.

Radial and/or ulnar fractures caused by gunshots are common in our society. These fractures are often very comminuted, and surgical exposure of the fracture site may deprive previously viable bone fragments of a blood supply. We looked at a minimally invasive method of plating these fractures.

Two surgeons performed a percutaneous plating procedure on six consecutive patients with a diaphyseal gunshot of the radius and/or ulna. This type of fixation acts as an internal form of ‘external fixator’.

When this paper was prepared, five of the six patients had gone on to complete clinical and radiological union and the sixth was still under follow-up. The mean time to full union was 12 weeks. Mean pronation was 60° (20° to 80°) and mean supination 50° (10° to 70°). In all patients, full elbow and wrist movement was preserved. To date we have had no complications of nerve injury, sepsis or radioulnar synostosis.

This is a very limited series of patients, but it seems this method of treating gunshot injuries of forearm bones produces good results. The long-term effect on wrist function is difficult to predict.