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.

We investigated the association of Dupuytren’s contracture with smoking and with alcohol by a case-control study in which 222 patients having an operation for this condition were matched for age, operation date and gender with control patients having other orthopaedic operations. Fifty of the cases were also each matched with four community controls. Data were collected by postal questionnaire.

Dupuytren’s contracture needing operation was strongly associated with current cigarette smoking (adjusted odds ratio 2.8 (95% confidence interval (CI) 1.5 to 5.2)). The mean lifetime cigarette consumption was 16.7 pack-years for the cases compared with 12.0 pack-years for the controls (p = 0.016). Dupuytren’s contracture was also associated with an Alcohol Use Disorders Test score greater than 7 (adjusted odds ratio 1.9 (95% CI 1.02 to 3.57)). Mean weekly alcohol consumption was 7.3 units for cases and 5.4 units for controls (p = 0.016). The excess risk associated with alcohol did not appear to be due to a confounding effect of smoking, or vice versa.

Smoking increases the risk of developing Dupuytren’s contracture and may contribute to its prevalence in alcoholics, who tend to smoke heavily.

We reviewed 25 patients with rheumatoid arthritis who had failure of 26 primary total elbow arthroplasties causing pain and loss of function. Most revision cases required special custom implants to treat varying bone loss and soft-tissue disruption. Assessment showed satisfactory functional results in the patients treated by revision at a mean follow-up period of 35 months. Our review suggests that revision surgery produces short- to medium-term painfree function, and is the treatment of choice for a failed total elbow arthroplasty in the absence of infection.

We reviewed 32 ankles in 30 patients at an average of five years after a Watson-Jones tenodesis. All but one patient had had ankle pain before operation and 19 had had clicking, catching, or locking of the ankle. Eleven of these had an ankle arthrotomy at the time of ligament reconstruction for intraarticular pathology. At review seven of 23 ankles had a significant decrease in ankle motion, and five in subtalar motion, but only two were unstable on examination. Twenty-one ankles, however, caused some pain on activity and nine were tender on palpation. These findings indicate intra-articular degeneration or injury rather than simple instability. Radiographs of 16 ankles showed good varus and anterior-drawer stability. Seven had talocrural osteoarthritis, but only four showed grade-1 subtalar osteoarthritis. We found no correlation between follow-up time and long-term results. The Watson-Jones tenodesis provides good rotational and lateral ankle instability and does not appear to lead to subtalar degeneration.