We present 2 year results of a prospective natural history study of Type III Acromioclaviclular joint dislocation (ACJD) treated non-operatively. Previous natural history studies are compromised by inconsistent definitions of the grade of injury and non-validated scoring tools; they do not identify which patients will have ongoing symptoms. This trial documents the strength and subjective recovery over time, and identifies risk factors for poor outcome and need for surgery.

Patients with Rockwood Type III ACJD received a standardised rehabilitation protocol (6 sessions of physiotherapy). Clinical assessment was performed at presentation, 3, 6, 12 and 24 months after injury, including isometric strength testing, pain (VAS/10) and subjective scores – Subjective percentage of normal (SPON), American Shoulder and Elbow (ASES), Oxford Shoulder Score (OSS) and Quick Disabilities of Arm Shoulder and Hand (qDASH).

28 male patients were recruited, 26 reached 12, and 9 to 24 months follow up. Two required surgery and one emigrated. The mean age was 39 (15 to 67). Initial mean pain was 3/10, SPON 51% (6–95) and strength was 76% of the other side. By 3 months mean subjective recovery was 70% and strength 90%. Strength recovered to 99% of normal by 12 months but subjective scores remained at mean 90%; by 24 months subjective scores were mean 94%. 2 patients had subjective scores <80%.

There was a wide range of initial subjective scores and weakness after Type III ACJD. 95% of strength had recovered by 6 months and subjective scores recovered to 94% of normal by 24 months. 4 patients (14%) did poorly with 2 requiring surgery. Low initial subjective score and inability to abduct the arm at presentation were risk factors for a poor outcome.

Despite a large body of literature the optimal choice of bearing surface for total hip arthoplasty (THA) remains controversial. To avoid the brittleness and squeaking noted with ceramic-on-ceramic and the metal ion release associated with metal-on-metal (MOM) articulations, a novel hybrid coupling of ceramic-on-metal (COM) has been introduced. The purpose of this study was to compare changes in serum metal ion levels and the functional performance of COM and MOM bearing combinations.

Eighty-six patients (86 hips) undergoing THA between April 2009 and October 2010 were randomized to COM or MOM bearing couplings. All received identical uncemented acetabular shells and femoral components from two experienced surgeons using the same operative technique.

Demographic and peri-operative data were recorded. Serum cobalt and chromium levels, renal function and disease specific outcome scores (Oxford Hip, Harris Hip, UCLA activity) were assessed at baseline, 6 and 12 months post-operatively. Patients and outcome assessors remained blinded.

Mean age of the total cohort was 62.5 years. Randomization successfully matched groups for age, Body Mass Index, baseline serum Cobalt and Chromium levels, and pre-operative functional performance scores. One-year data is currently available for 25 of 44 COM and 26 of 42 MOM patients. No significant difference in serum cobalt (P value = 0.81) and chromium (P value = 0.66) levels between groups was noted. Improvements in outcome scores (Oxford Hip, Harris Hip, UCLA activity) were equivalent (P values 0.16 – 0.46).

At 1-year, COM and MOM hip arthroplasty articulations appear equivalent in terms of function and serum metal ion levels. Data collection out to 5-years post-surgery continues.

This study reviews the early results of Distal Humeral Hemiarthroplasty(DHH) for distal humeral fracture and proposed a treatment algorithm incorporating the use of this technique in the overall management of distal humeral fractures.

DHH was performed on 30 patients (mean 65 years; 29-91) for unreconstructable fractures of the distal humerus or salvage of failed internal fixation. A triceps on approach was used in six and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Latitude (Tornier) in 16. Clinical review at a mean of 25 months (3–88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment.

At follow up of 28 patients mean flexion deformity was 25 degrees, flexion 128 degrees, range of pronosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re- operation was required in 16 patients (53%); two revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and four ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, four had laxity and mild pain on loading (two with prosthesis or pin loosening), four had laxity associated with column fractures (two symptomatic) and 10 had asymptomatic mild laxity only. The triceps on approach had worse instability and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and seven had lucencies >1 mm; one was loose but acceptable. Five prostheses were in slight varus. Two elbows had early degenerative changes and 15 developed a medial spur on the trochlea.

This is the largest reported experience of DHH. Early results of DHH show good outcomes after complex distal humeral fractures, despite a technically demanding procedure. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy. As a result of this experience anatomical and clinical pre-requisites and advise on technique are outlined. An algorithm for use of DHH in relation to total elbow arthroplasty and ORIF for the treatment of complex intra-articular distal humeral fractures with or without column fractures is proposed.

Introduction

The Stanmore Percentage of Normal Shoulder Assessment (SPONSA) is a simple, fast and reproducible measure of the subjective state of a shoulder. It has been invaluable in our busy clinical practice. This study validates the SPONSA score against the Oxford Shoulder and Constant score and demonstrates a greater sensitivity to change.