We present nine patients (five men and four women) who underwent surgical excision of clinically significant heterotopic ossification at the elbow. They also received perioperative radiation therapy using total doses between 600 and 1000 cGy. Five received fractionated radiotherapy, with two fractions of 500 cGy applied on the first two postoperative days, and the remaining four were irradiated with single doses of 600 and 700 cGy.

After a mean period of observation of 7.7 months (6 to 13) none had radiological recurrence of heterotopic ossification and eight showed clinical improvement. Assessment of the functional outcome showed a mean improvement in the Morrey score from 33.3 to 84.5 points indicating a high therapeutic efficacy of prophylactic irradiation.

We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive. At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side. Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid

We investigated the incidence of and risk factors for venous thromboembolism (VTE) following surgery of the shoulder and elbow and assessed the role of thromboprophylaxis in upper limb surgery. All papers describing VTE after shoulder and elbow surgery published in the English language literature before 31 March 2012 were reviewed. A total of 14 papers were available for analysis, most of which were retrospective studies and case series. The incidence of VTE was 0.038% from 92 440 shoulder arthroscopic procedures, 0.52% from 42 261 shoulder replacements, and 0.64% from 4833 procedures for fractures of the proximal humerus (open reduction and internal fixation or hemiarthroplasty). The incidence following replacement of the elbow was 0.26% from 2701 procedures. Diabetes mellitus, rheumatoid arthritis and ischaemic heart disease were identified as the major risk factors.

The evidence that exists on thromboprophylaxis is based on level III and IV studies, and we therefore cannot make any recommendations on prophylaxis based on the current evidence. It seems reasonable to adopt a multimodal approach that involves all patients receiving mechanical prophylaxis, with chemical prophylaxis reserved for those who are at high risk for VTE.

Cite this article: Bone Joint J 2013;95-B:70–4.

In light of the growing number of elderly osteopenic patients with distal humeral fractures, we discuss the history of their management and current trends. Under most circumstances operative fixation and early mobilisation is the treatment of choice, as it gives the best results. The relative indications for and results of total elbow replacement versus internal fixation are discussed.

The purpose of this study was to assess the long-term results (more than ten years) of two types of cemented ulnar component with type-5 Kudo total elbow arthroplasty in a consecutive series of 56 patients (60 elbows) with rheumatoid arthritis, and to compare the results in elbows above and below a Larsen grade IV.

There was no radiolucency around the humeral component. Patients in whom a metal-backed ulnar component and a porous-coated stem were used had better clinical results and significantly less progression of radiolucent line formation around the ulnar component. They also had a significantly better long-term survival than patients with an all-polyethylene ulnar component. The clinical results of arthroplasty using all-polyethylene ulnar components were inferior, regardless of the degree of joint destruction.

We conclude that the type-5 Kudo total elbow arthroplasty with cementless fixation of the porous-coated humeral component and cemented fixation of a metal-backed ulnar component is acceptable and well-tolerated by rheumatoid patients.

Fractures of the proximal humerus can lead to malalignment of the humeral head, necrosis and post-traumatic osteoarthritis. In such cases surface replacement might be a promising option.

A total of 28 shoulders with glenohumeral arthritis subsequent to a fracture underwent surface replacement arthroplasty of the humeral head in patients with a mean age of 60 years (35 to 83). On the basis of the inclination of the impacted head, post-traumatic arthritis was divided into three types: type 1, an impacted fracture of the head in an anatomical position (seven cases); type 2, a valgus impacted fracture (13 cases); type 3, a varus impacted fracture (eight cases). The outcome was measured by means of the Constant score.

According to the Boileau classification of the sequelae of fractures of the proximal humerus, all 28 patients had a final result of intra-capsular category 1. The mean Constant score for the 28 shoulders increased from 23.2 points (2 to 45) pre-operatively to 55.1 points (20 to 89) at a mean of 31 months (24 to 66) post-operatively. Valgus impacted fractures had significantly better results (p < 0.039).

Surface replacement arthroplasty can provide good results for patients with post-traumatic osteoarthritis of the shoulder. Their use avoids post-operative complications of the humeral shaft, such as peri-prosthetic fractures. Further surgery can be undertaken more easily as the bone stock is preserved.

We retrospectively compared wrist arthrodesis using the Mannerfelt technique in 19 or an AO-plate in 23 patients with long-standing rheumatoid arthritis. The mean follow-up was for 76 months.

Compared with the Mannerfelt fusion group, patients in the AO-plate group reported greater satisfaction with their wrist function (74% vs 37%, p = 0.015). Complications were reported in six wrists in the AO-plate group and two wrists in the Mannerfelt fusion group (p = 0.258). At final follow-up, 95% of patients (41) reported either no pain or only mild pain. There was improvement in flexion of the finger joints in both groups but no significant improvement in the extension lag in either group.

Both methods relieve pain and improve function. Overall, the activities of daily living scores and the patients’ subjective assessment of outcome tended to be higher in the AO-plate group than in the Mannerfelt fusion group, although the difference was not statistically significant. Similarly, although more postoperative complications occurred in the AO-plate group, the difference between the two groups was not statistically significant.

There are few reports in the literature of the diagnosis and treatment of the infected shoulder arthroplasty. Most deal with resection arthroplasty and two-stage exchange surgery. We present our results of one-stage exchange operation as treatment for the infected shoulder arthroplasty.

Our group comprised 16 patients (ten men, six women) with 16 infected arthroplasties. By the time of follow-up, two patients had died (mean 5.8 years), two could not be located and three had already undergone revision surgery. Nine patients were thus available for clinical examination and assessment.

The infections were largely caused by staphylococci, Propionibacterium species and streptococci. Two were early infections (within three months of surgery) and 14 were late infections. The mean follow-up was 5.8 years (13 months to 13.25 years) when the mean Constant-Murley score was 33.6 points and the mean University College of Los Angeles score 18.3 points.

Further revision was performed in three patients. One sustained a peri-prosthetic humeral fracture, another developed an acromial pseudarthrosis after transacromial surgery and the third suffered recurrent dislocations. No patient had a recurrence of infection.

A one-stage exchange procedure using antibiotic-loaded bone cement eradicated infection in all our patients and we suggest that such a procedure is at least as successful as either a resection arthroplasty or a two-stage exchange in the management of the infected shoulder arthroplasty.