The primary aim was to assess the reliability of ultrasound in the assessment of humeral shaft fracture healing. The secondary aim was to estimate the accuracy of ultrasound assessment in predicting humeral shaft nonunion. Twelve patients (mean age 54yrs [20–81], 58% [n=7/12] female) with a non-operatively managed humeral diaphyseal fracture were prospectively recruited and underwent ultrasound scanning at six and 12wks post-injury. Scans were reviewed by seven blinded observers to evaluate the presence of sonographic callus. Intra- and inter-observer reliability were determined using the weighted kappa and intraclass correlation coefficient (ICC). Accuracy of ultrasound assessment in nonunion prediction was estimated by comparing scans for patients that united (n=10/12) with those that developed a nonunion (n=2/12). At both six and 12wks, sonographic callus was present in 11 patients (10 united, one developed a nonunion) and sonographic bridging callus (SBC) was present in seven patients (all united). Ultrasound assessment demonstrated substantial intra- (6wk kappa 0.75, 95% CI 0.47-1.03; 12wk kappa 0.75, 95% CI 0.46-1.04) and inter-observer reliability (6wk ICC 0.60, 95% CI 0.38-0.83; 12wk ICC 0.76, 95% CI 0.58-0.91). Absence of sonographic callus demonstrated a sensitivity of 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (accuracy 92%). Absence of SBC demonstrated a sensitivity of 100%, specificity 70%, PPV 40% and NPV 100% (accuracy 75%). Of three patients at risk of nonunion based on reduced radiographic callus formation (Radiographic Union Score for HUmeral fractures <8), one had SBC on 6wk ultrasound (and united) and the other two had non-bridging or absent sonographic callus (both developed a nonunion). Ultrasound assessment of humeral shaft fracture healing was reliable and predictive of nonunion, and may be a useful tool in defining the risk of nonunion among patients with reduced radiographic callus formation

Helical plates are preferably used for proximal humeral shaft fracture fixation and potentially avoid radial nerve irritation as compared to straight plates. Aims:(1) to investigate the safety of applying different long plate designs (straight, 45°-, 90°-helical and ALPS) in MIPO-technique to the humerus. (2) to assess and compare their distances to adjacent anatomical structures at risk. MIPO was performed in 16 human cadaveric humeri using either a straight plate (group1), a 45°-helical (group2), a 90°-helical (group3) or an ALPS (group4). Using CT-angiography, distances between brachial arteries and plates were evaluated. Following, all specimens were dissected, and distances to the axillary, radial and musculocutaneous nerve were evaluated. None of the specimens demonstrated injuries of the anatomical structures at risk after MIPO with all investigated plate designs. Closest overall distance (mm(range)) between each plate and the radial nerve was 1(1-3) in group1, 7(2-11) in group2, 14(7-25) in group3 and 6(3-8) in group4. It was significantly longer in group3 and significantly shorter in group1 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the musculocutaneous nerve was 16(8-28) in group1, 11(7-18) in group2, 3(2-4) in group3 and 6(3-8) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the brachial artery was 21(18-23) in group1, 7(6-7) in group2, 4(3-5) in group3 and 7(6-7) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.021. MIPO with 45°- and 90°-helical plates as well as ALPS is safely feasible and showed a significant greater distance to the radial nerve compared to straight plates. However, distances remain low, and attention must be paid to the musculocutaneous nerve and the brachial artery when MIPO is used with ALPS, 45°- and 90°-helical implants. Anterior parts of the deltoid insertion will be detached using 90°-helical and ALPS implants in MIPO-technique

Proximal humeral shaft fractures are commonly treated with long straight plates or intramedullary nails. Helical plates might overcome the downsides of these techniques as they are able to avoid the radial nerve distally. The aim of this study was to investigate in an artificial bone model: (1) the biomechanical competence of different plate designs and (2) to compare them against the alternative treatment option of intramedullary nails. Twenty-four artificial humeri were assigned in 4 groups and instrumented as follows: group1 (straight 10-hole-PHILOS), group2 (MULTILOCK-nail), group3 (45°-helical-PHILOS) and group4 (90°-helical-PHILOS). An unstable proximal humeral shaft fracture was simulated. Specimens were tested under quasi-static loading in axial compression, internal/external rotation and bending in 4 directions monitored by optical motion tracking. Axial displacement (mm) was significantly lower in group2 (0.1±0.1) compared to all other groups (1: 3.7±0.6; 3: 3.8±0.8; 4: 3.5±0.4), p<0.001. Varus stiffness in group2 (0.8±0.1) was significantly higher compared to groups1+3, p≤0.013 (1: 0.7±0.1; 3: 0.7±0.1; 4: 0.8±0.1). Varus bending (°) was significantly lower in group2 compared to all other groups (p<0.001) and group4 to group1, p=0.022. Flexion stiffness in group1 was significantly higher compared to groups2+4 (p≤0,03) and group4 to group1, p≤0,029 (1: 0.8±0.1; 2: 0.7±0.1; 3: 0.7±0.1; 4: 0.6±0.1). Flexion bending (°) in group4 was higher compared to all other groups (p≤0.024) and lower in group2 compared to groups1+4, p≤0.024. Torsional stiffness remained non significantly different, p≥0.086. Torsional deformation in group2 was significantly higher compared to all other groups, p≤0.017. Shear displacement remained non significantly different, p≥0.112. From a biomechanical perspective, helical plating with 45° and 90° may be considered as a valid alternative fixation technique to standard straight plating of proximal third humeral fractures. Intramedullary nails demonstrated higher axial and bending stiffness as well as lower fracture gap movements during axial loading compared to all plate designs. However, despite similar torsional stiffness they were associated with higher torsional movements during internal/external rotation as compared to all investigated plate designs

Proximal humeral shaft fractures are commonly treated with long straight locking plates endangering the radial nerve distally. The aim of this study was to investigate the biomechanical competence in a human cadaveric bone model of 90°-helical PHILOS plates versus conventional straight PHILOS plates in proximal third comminuted humeral shaft fractures. Eight pairs of humeral cadaveric humeri were instrumented using either a long 90°-helical plate (group1) or a straight long PHILOS plate (group2). An unstable proximal humeral shaft fracture was simulated by means of an osteotomy maintaining a gap of 5cm. All specimens were tested under quasi-static loading in axial compression, internal and external rotation as well as bending in 4 directions. Subsequently, progressively increasing internal rotational loading until failure was applied and interfragmentary movements were monitored by means of optical motion tracking. Flexion/extension deformation (°) in group1 was (2.00±1.77) and (0.88±1.12) in group2, p=0.003. Varus/valgus deformation (°) was (6.14±1.58) in group1 and (6.16±0.73) in group2, p=0.976. Shear (mm) and displacement (°) under torsional load were (1.40±0.63 and 8.96±0.46) in group1 and (1.12±0.61 and 9.02±0.48) in group2, p≥0.390. However, during cyclic testing shear and torsional displacements and torsion were both significantly higher in group 1, p≤0.038. Cycles to catastrophic failure were (9960±1967) in group1 and (9234±1566) in group2, p=0.24. Although 90°-helical plating was associated with improved resistance against varus/valgus deformation, it demonstrated lower resistance to flexion/extension and internal rotation as well as higher flexion/extension, torsional and shear movements compared to straight plates. From a biomechanical perspective, 90°-helical plates performed inferior compared to straight plates and alternative helical plate designs with lower twist should be investigated in future paired cadaveric studies

Abstract. Objectives. Operative management of distal humerus fractures is challenging. In the past, plates were manually contoured intraoperatively, however this was associated with high rates of fixation failure, nonunion and metalwork removal. Anatomically pre-contoured distal humerus locking plates have since been developed. Owing to the rarity of distal humeral fractures, literature regarding outcomes of anatomically pre-contoured locking plates is lacking and patient numbers are often small. The purpose of this study is to investigate the outcomes of these patients. Methods. We retrospectively identified patients with distal humeral fractures treated at our institution from 2009–2018. Inclusion criteria were patients with a distal humeral fracture, who underwent two-column plate fixation with anatomically pre-contoured locking plates. Clinical records and radiographs were reviewed to elicit outcome measures, including range of motion, complications and reoperation rate. Results. We identified 50 patients with mean age of 55 years (range 17–96 years). Mean length of follow up was 5.2 years. AO fracture classification Type A occurred most frequently (46%), followed by Type B (22%) and Type C (32%). Low energy mechanisms of injury predominated in 72% of patients. Mean time from injury to fixation was seven days. Mean range of motion at the elbow was 13–123o postoperatively. The overall reoperation rate was 22%, the majority of which required subsequent removal of prominent metalwork (18%). The incidence of nonunion, heterotopic ossification, deep infection and neuropathy requiring decompression was 2% each. Fixation failure occurred in only one patient however the fracture went on to heal. Conclusions. Previously reported reoperation rates with manually contoured plates were as high as 44%, which is twice our reported rate. Modern locking plates are no longer subject to implant failure (previously 27% reported metalwork failure rate). Likewise, heterotopic ossification and non-union have also reduced, highlighting that modern plates have significantly improved overall patient outcomes. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Standard fixation for intra-articular distal humerus fracture is open reduction and internal fixation (ORIF). However, high energy fractures of the distal humerus are often accompanied with soft tissue injuries and or vascular injuries which limits the use of internal fixation. In our report, we describe a highly complex distal humerus fracture that showed promising healing via a ring external fixator. A 26-year-old man sustained a Gustillo Anderson Grade IIIB intra-articular distal humerus fracture of the non-dominant limb with bone loss at the lateral column. The injury was managed with aggressive wound debridement and cross elbow stabilization via a hinged ring external fixator. Post operative wound managed with foam dressing. Post-operatively, early controlled mobilization of elbow commenced. Fracture union achieved by 9 weeks and frame removed once fracture united. No surgical site infection or non-union observed throughout follow up. At 2 years follow up, flexion - extension of elbow is 20°- 100°, forearm supination 65°, forearm pronation 60° with no significant valgus or varus deformity. The extent of normal anatomic restoration in elbow fracture fixation determines the quality of elbow function with most common complication being elbow stiffness. Ring fixator is a non-invasive external device which provides firm stabilization of fracture while allowing for adequate soft tissue management. It provides continuous axial micro-movements in the frame which promotes callus formation while avoiding translation or angulation between the fragments. In appropriate frame design, they allow for early rehabilitation of joint where normal range of motion can be allowed in controlled manner immediately post-fixation. Functional outcome of elbow fracture from ring external fixation is comparable to ORIF due to better rehabilitation and lower complications. Ring external fixator in our patient achieved acceptable functional outcome and fracture alignment meanwhile the fracture was not complicated with common complications seen in ORIF. In conclusion, ring external fixator is as effective as ORIF in treating complex distal humeral fractures and should be considered for definitive fixation in such fractures

Abstract. Background/Objectives. The incidence of reverse total shoulder replacement (rTSR) implantation is increasing globally, but apprehension exists regarding complications and associated challenges. We retrospectively analysed the senior author's series of rTSR from a tertiary centre using the VAIOS shoulder system, a modular 4th generation implant. We hypothesised that the revision rTSR cohort would have less favourable outcomes and more complications. Methods. 114 patients underwent rTSR with the VAIOS system, over 7 years. The primary outcome was implant survival. Secondary outcomes were Oxford shoulder scores (OSS), radiographic analysis (scapular notching, tuberosity osteolysis, and periprosthetic radiolucent lines) and complications. Results. There were 55 Primary rTSR, 31 Revision rTSR and 28 Trauma rTSR. Implant survival: Primary rTSR- 0 revisions, average 3.35-year follow-up. Revision rTSR-1 revision (4.17%), average 3.52-year follow-up. Trauma rTSR- 1 revision (3.57%), average 4.56-year follow-up OSS: Average OSS improved from 15.39 to 33.8 (Primary rTSR) and from 15.11 to 29.1 (Revision rTSR). Average post-operative OSS for the Trauma rTSR was 31.4 Radiological analysis and complications: Low incidence of scapular notching One hairline fracture below the tip of stem, noted incidentally, which required no treatment. One periprosthetic fracture after alcohol related fall. Treated non-surgically One joint infection requiring two-stage revision to rTSR. One dislocation noted at 2 year follow up. This patient had undergone nerve grafting within 6 months of rTSR for axillary nerve injury sustained during the original fracture dislocation. One acromial fracture with tibial and distal humeral fracture after a fall. Conclusions. The 4th generation modular VAIOS implant is a reliable option for various indications. The revision rTSR cohort had favourable outcomes with low complication rates. In this series, early-to-medium term results suggest lower revision rates and good functional outcomes when compared to published reports. We plan to monitor long-term implant survivorship and patient reported outcomes. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

The aim of management of an adult distal humeral fracture is to restore mobility, stability and pain-free elbow function. Good results are usually achieved in the majority of fractures treated with ORIF, but the management of comminuted fractures in elderly, frail patients with osteoporotic bone remains controversial. The literature focuses on elbow replacement if stable internal fixation cannot be achieved, with “bag-of-bones” management now rarely discussed eg. key-note paper - 10 successful cases reported by Brown RF & Morgan RG in 1971 (JBJS 53-B(3):425-428). We present the experience in two units in which conservative management has been actively adopted in selected cases by consultants with a subspecialty interest in the elbow. All patients over the age of 60 with distal humeral fractures (2007 – 2009) who had been treated conservatively were reviewed clinically and radiologically. Duration of follow-up and outcome, including the Oxford and quick DASH scores, were recorded, with the fractures classified using the AO system. There were 25 patients, 19 female and 6 male. 19/25 patients have been successfully treated conservatively with a mean Range Of Movement: Extension/Flexion: 45/125, Pronation/Supination 74/70. Only 5 underwent subsequent total elbow replacement and one delayed ORIF. There is a significant complication rate following surgical treatment with ORIF or elbow replacement in elderly, frail patients, including infection, painful non-union and/or stiffness. We believe that there is a role for initial conservative treatment in selected patients with low, displaced, comminuted humeral fractures in osteoporotic bone. Initial early mobilisation as pain allows can give good functional results without the risks of operation. It does not preclude future surgery if conservative treatment fails, but this is not required in the majority of cases

Cubitus varus following paediatric supra-condylar humeral fracture represents a complex three-dimensional malunion. This affects cosmesis, function and subsequent distal humeral fracture risk. Operative correction is however difficult with high complication rates. We present the 40-year Yorkhill experience of managing this deformity. From a total of 3220 supracondylar humeral fractures, 40 cases of post-traumatic cubitus varus were identified. There were ten undisplaced fractures, treated in cast, and thirty displaced fractures. Five were treated in cast, thirteen manipulated (MUA), four MUA+k-wires, seven ORIF (six k-wire, one steinman pin) and one in skeletal-traction. Sixteen malunions were treated operatively. The mean pre-operative varus was 19°. All had cosmetic concerns, three mild pain, one paraesthesia/weakness and three reduced movement (ROM). The operative indication was cosmetic in fifteen and functional in one (concern about instability). Twelve patients had lateral closing-wedge osteotomies; three complex/3D osteotomies (dome, unspecified rotational, antero-lateral wedge) and two had attempted 8-plate guided-growth correction. Complications occurred in eight patients (50 %): Fixation was lost in three (two staples, one k-wiring), incomplete correction in six (both 8-plates, both staples, two standard plates) and one early wound infection requiring metalwork removal resulting in deformity recurrence. One patient underwent revision lateral wedge osteotomy with full deformity correction but marked ROM restriction (20–100°) secondary to loose bodies. Those without complications were satisfied (50 %). All patients with residual deformity were unsatisfied. 1 patient with keloid scarring was unsatisfied despite deformity correction. Varus malunion is uncommon (1 %) but needs to be guarded against. It tended to occur in displaced fractures treated with MUA and cast alone. We therefore recommend additional pin fixation in all displaced fractures. Deformity correction should only be attempted in those with significant symptomatic deformity due to the high complication/dissatisfaction rates. Staple osteotomy fixation and 8-plate guided growth correction are not recommended

Arthritis of the glenohumeral joint accompanied by an irreparable tear of the rotator cuff can cause severe pain, disability and loss of function, particularly in the elderly population. Anatomical shoulder arthroplasty requires a functioning rotator cuff, however, reverse shoulder arthroplasty is capable of addressing both rotator cuff disorders and glenohumeral deficiencies. The Aequalis Reversed Shoulder Prosthesis design is based on two bio-mechanical principles by Grammont; a medialized center of rotation located inside the glenoid bone surface and second, a 155 degree angle of inclination. Combined, they increase the deltoid lever arm by distalizing the humerus and make the prosthesis inherently stable. 24 consecutive primary reverse total shoulder arthroplasties were performed by a single surgeon for arthritis with rotator cuff compromise and 1 as a revision for a failed primary total shoulder replacement between December 2009 and October 2012. Patients were assessed postoperatively with the use of the DASH score, Oxford shoulder score, range of shoulder motion and plain radiography with Sirveaux score for scapular notching. Mean age at the time of surgery was 72.5 years (range 59 to 86). Average follow up time was 19.4 months (range 4 to 38). Functional outcome scores from our series were comparable with patients from other follow up studies of similar prosthesis design. All patients showed improvement in range of shoulder movement postoperatively. Complications included one dislocation, one acromion fracture and one humeral shaft fracture. No cases of deep infection were recorded. Overall, the short-term clinical results were promising for this series of patients and indicate reverse shoulder arthroplasty as an appropriate treatment for this group of patients