Cut and cure: surgical therapy of synovitis.

Surgical management for synovitis has undergone radical change in the last few years with the evolution of DMARDs and advanced Interventional Radiology techniques. Here we present areas where surgical therapy may still be the most effective option, either alone or in conjunction with non-surgical measures.

Anatomic, diagnostic and management challenges in paediatric pelvic injuries: a review.

Pelvic injuries have an incidence of 1: 100 000 children per year in the UK, of which 10% are unstable. A literature review was conducted. Clinical examination alone in a stable patient precludes the need for imaging. Imaging options in the acute pelvic injury are critically reviewed. Where appropriate Judet views or limited exposure computed tomography scan remain of diagnostic benefit. Displacement greater than 1 cm should be reduced and held with an appropriate method. Closed reduction and external fixation for rotationally unstable fractures, and closed or open reduction with internal fixation of two columns should be considered for rotationally and vertically unstable fractures.

Tibial tunnel defect size as a risk factor in growth arrest following paediatric transphyseal anterior cruciate ligament reconstruction: an anatomical study.

BACKGROUND: There is ongoing controversy regarding growth disturbances in younger patients undergoing anterior cruciate ligament reconstructions. Animal models have shown that an injury of 7-9% of the physeal area is a risk factor for growth disturbances. METHODS: A total of 39 magnetic resonance imaging studies of the knee were examined. The proximal tibial physeal area was determined using a calibrated 'region of interest' ligature encompassing the tibial physis in the axial plane. The potential defect left by commonly used drill sizes was calculated as a percentage of the physeal area. RESULTS: A 7-mm drill leaves a mean defect of 1.45% physeal area (range: 1.11-1.89%, SD: 0.28, 95% CI: ±0.09), 8-mm drill leaves a 1.84% mean defect (range: 1.43-2.49%, SD: 0.38, 95% CI: ±0.12) and a 9-mm drill leaves a 2.30% mean defect (range: 1.83-3.19%, SD: 0.58, 95% CI: ±0.17). At 55°, 7-mm drill leaves a mean defect of 1.96% (range: 1.32-2.28%, SD: 0.37, 95% CI: ±0.12), 8-mm drill leaves a mean defect of 2.19% (range: 1.71-2.95%, SD: 0.46, 95% CI: ±0.14) and a 9-mm drill leaves a mean defect of 2.76% (range: 2.16-3.73%, SD: 0.58, 95% CI: ±0.18). There was a statistically significant difference in the tunnel area with a change of drill angle (7-mm drill P = 0.005, 8-mm drill P = 0.001, 9-mm drill P = 0.001). CONCLUSION: On the basis of this study in the context of animal model and observational evidence, the area of physeal injury using drill tunnels for anterior cruciate ligament reconstruction would not appear to contribute to potential growth disturbances.

Experimental model for controlling shear using the Ilizarov frame.

OBJECTIVE: This study has been designed to ascertain whether a standard configuration Ilizarov tibial frame can control shear motion at the fracture site of an oblique fracture within acceptable limits for axial micro-motion, and therefore promote bony union. If not, are there simple modifications to the frame design that can achieve this? METHODS: Four Ilizarov frame designs were tested on a load test rig. Fracture site shear displacement was measured using a clip gauge attached to an automated data recording system. FINDINGS: The standard Ilizarov frame allowed 4mm of fracture site displacement at 340N of load. Our fourth frame design, the locked olive frame, allowed a maximum of 0.61mm displacement at 700N. INTERPRETATION: This is one of only two studies to look at circular frame fracture site control in oblique fractures. This is the only study to characterise Ilizarov frame stiffness in oblique fractures. We have shown that the standard Ilizarov frame design is inadequate for control of oblique fractures in this mechanical model. Our data show that with the application of simple principles, the Ilizarov frame can be modified to provide better fracture site control. These frame designs can be applied clinically to reduce fracture site shear motion in oblique fractures, resulting in improved union rates.

Patellar reconstruction using posterior femoral condyle: a 5-year follow-up.

A patient with rheumatoid arthritis presented to clinic with an increasingly painful knee. The patient had undergone patellectomy for patellofemoral arthritis 10 years previously. After knee arthroscopy showing extensive arthritic changes, it was decided to offer primary arthroplasty of the knee with patellar reconstruction using posterior lateral femoral condyle graft taken at the time of arthroplasty. The positive outcome from this case is encouraging and constitutes a further option in patients with prior patellectomy undergoing knee arthroplasty.