A comparison of patient based outcome following knee arthrodesis for failed total knee arthroplasty and revision knee arthroplasty.

Arthrodesis of the knee is an infrequently performed operation perceived by both patient and surgeon to have a poor outcome. This study compares functional outcome of knee arthrodesis following failed primary arthroplasty with that of revision knee arthroplasty in a matched patient group. Outcome was measured using the SF12 and Oxford Knee Score. Twelve patients underwent arthrodesis, of which eight were available for functional review at a mean of 53 months. No significant difference was found between the outcome scores of the two groups, although it is recognised that the numbers involved were low. Arthrodesis of the knee may be considered as a surgical option following failed arthroplasty when factors are present that may mitigate against an optimal result following revision knee arthroplasty.

Compression of the biceps-brachialis compartment after trivial trauma.

We report a case of post-traumatic compartment syndrome of the biceps-brachialis compartment after a minor injury. The condition is well recognised after a drug overdose, but surgeons should be aware that a compartment syndrome may also be caused by apparently trivial trauma, and that it may develop in regions other than the anterior compartments of the leg and forearm.

External fixation of Colles' fractures. An anatomical study.

In a prospective, controlled study 58 patients aged under 60 years with Colles' fractures were treated either by a forearm plaster or by the application of an external fixator. In 94% of those treated by a fixator it was possible to insert the distal pins of the frame into the fracture fragment, the fixation obtained being sufficient to forgo additional splintage. The external fixator proved more effective at holding the manipulated position, and the radiological loss of position during fracture union was minimal compared with that seen in patients treated in plaster.

Arthrodesis of the knee using a custom-made intramedullary coupled device.

Nine patients underwent arthrodesis of the knee using customised coupled nail (the Mayday arthrodesis nail), five after infected arthroplasty, one following failed arthrodesis, one for intractable anterior knee pain, one for Charcot instability and one after trauma. Comparison was made with 17 arthrodeses, eight undertaken using external fixation, four with dual compression plates, and five with long Kütntscher nails. Union was achieved in all patients (100%) at a mean time of ten months using the customised implant. There were no complications despite early weight-bearing. No further procedures were required. This contrasted with a rate of union of 53% and a complication rate of 76% with alternative techniques. Of this second group, 76% required a further operative procedure. We compared the Mayday arthrodesis nail with other techniques of arthrodesis of the knee. The differences in the need for further surgery and occurrence of complications were statistically significant (p < 0.001), and differences in the rate of nonunion and inpatient stay of less than three weeks were also significant (p < 0.05) using Fisher's exact test. We conclude that a customised coupled intramedullary nail can give excellent stability allowing early weight-bearing, and results in a high rate of union with minimal postoperative complications.

The contaminated skin-knife. A surgical myth.

The scalpel blades used during 187 operations were cultured. At each procedure the knife used to incise the skin was discarded immediately and a fresh knife was used to complete the operation. The results showed that there was no difference in the bacterial growth between the two knives. From these results it would appear that the practice of changing blades after incising the skin is an unnecessary precaution in the prevention of bacterial contamination of clean wounds.

A review of wound healing following Maquet osteotomy.

Maquet osteotomy can be associated with an unacceptably high incidence of wound complications that may be as high as 37%. A consecutive series of 42 Maquet osteotomies has been performed between 1990 and 2002 by a single surgeon without a single wound problem or infection and this series is the subject of this report. The use of an anterolateral incision reduces the damage to the major lymphatics minimising the risk of wound oedema. Identification and preservation of the feeding musculocutaneous vessels on the lateral and medial sides facilitates extensive but safe mobilisation of the skin flaps permitting an easy closure over a substantially elevated tibial tubercle. The use of an anterolateral incision with knowledge of the blood supply of the leg has eliminated the wound complications associated with the standard anteromedial incision reported previously in the literature. This approach, preserving the blood supply and lymphatic drainage, avoids skin necrosis and wound dehiscence, obviates any requirement for plastic surgical procedures such as releasing incisions or skin grafts and minimises the risk of infection and osteomyelitis.

Mal-union and dysfunction in Colles' fracture.

Wrist function was assessed between one and three years after injury in patients who had suffered Colles' fractures. Both the range of wrist flexion and the strength of grip were found to be deficient. The loss of power in gripping was found to correlate with mal-union affecting the coronal and sagittal inclination of the articular surface of the radius.

Indication for weight relief and containment in the treatment of perthes' disease.

Fifty-four cases of Perthes' disease each suffering from total involvement of the femoral head were investigated to establish the relative merits of total weight relief and containment in management. It was found that using Catterall's criteria, once the femoral head is "at risk", containment is the only treatment of value; but when the head is "not at risk" a combination of containment and total weight relief produces a near perfect result in every case.

Skier's thumb--a method of prevention.

Skiing is increasingly popular among people of all ages and as the number of enthusiasts grows so does the incidence of ski-related injuries. Injuries to the thumb, which account for up to 17 per cent of skiing injuries, are associated with considerable morbidity. The cause of these injuries is discussed and a simple method of prevention is proposed.

External fixation and recovery of function following fractures of the distal radius in young adults.

The functional recovery from Colles' fracture was studied prospectively over a 1-year period in 106 patients randomized to treatment by plaster or external fixation. Although external fixation allows immediate mobilization of the wrist and leads to a much better anatomical result, these factors did not permit any improvement in the wrist's early functional recovery. One year following injury the grip strength of the fixator-treated group was significantly superior to that of the plaster-treated patients.

Vibration analysis in the assessment of conservatively managed tibial fractures.

A simple and quantitative method for the assessment of fracture healing has been developed. this method depends on a technique of vibration analysis evolved from a study of 30 intact human tibiae and has been applied to the study of 22 tibial fractures. Real time vibration analysis will allow quantitative comparisons of different methods of non-operative fracture management, and, in addition to providing a uniquely powerful research tool, may have value in aiding clinical management decisions.

New problems in old bones: closed nailing of the shaft of the femur.

Closed medullary nailing is now established as a routine treatment of fractures of the shaft of the femur. However, the quality of the bone in elderly patients is such that serious technical difficulties may arise during the operation. Three typical cases illustrate the problems that may occur and point the lesson that closed nailing in the elderly ought not to be undertaken by the inexperienced surgeon.

Irreducible dislocation of the distal radioulnar joint.

Although dislocation of the distal radioulnar joint is commonplace in association with fractures of the radial shaft, irreducible dislocation has previously been considered to be rare. In the only three previously reported cases the tendon of the extensor carpi ulnaris blocked reduction of the distal radioulnar joint in Galeazzi injuries. The cases presented in this report show that other tendons may be involved, and that the injury may occur even when the ulna is broken. It is likely that the injury described is more common than is realized and is usually overlooked.

Compartment pressure monitoring--current UK orthopaedic practice.

Debate continues over the use of compartment pressure monitoring devices in the diagnosis of compartment syndrome. We present the results of a survey that was designed to explore this issue. The majority of UK trauma and orthopaedic surgeons surveyed advocate making the diagnosis of compartment syndrome by a combination of clinical acumen and compartment pressure measurements. Less than half of the trauma centres surveyed had pressure monitoring equipment available. There is marked variation in opinion regarding the threshold level for surgery when monitoring is applied.

Abdominal girth: an unreliable measure of intra-abdominal bleeding.

The measurement of abdominal girth in an attempt to detect intra-abdominal bleeding may be dangerously misleading. It is an inaccurate measure of intra-abdominal collection of fluid. The results show that measurements are heavily biased by the expectations of observers, with the result that a considerable change in girth is likely to be ignored. The error caused by observer bias is much greater than the distension which actually occurs when fluid collects in the abdomen over a short period.

Vibration analysis of human tibia: the effect of soft tissue on the output from skin-mounted accelerometers.

The vibration response of bone can be recorded from a skin-mounted accelerometer, but only if it is sufficiently preloaded to overcome the damping effect of the interposed soft tissue. Excessive preload results in distortion of the recorded signal by a high-frequency component which probably originates in the supporting apparatus of the accelerometer. The required preload is proportional to the soft tissue thickness, but for any given soft tissue thickness, the range of allowable preload is fairly wide.

Direct and indirect determination of tibial natural frequency--a comparison of frequency domain analysis and fast Fourier transform.

The natural frequency of in vivo mechanical systems has been derived in the past by signal conditioning techniques. For the living tibia the accuracy of this derived method was not validated. In addition the use of Fast Fourier Transform is time consuming, tedious and expensive. Direct measurement yields results which are more accurate, more easily obtained, and more clinically applicable.