[Aspiration pneumonia after spinal cord injury. Placement of PEG tubes as effective prevention]. / Aspirationspneumonie nach HWS-Verletzung. Präventiver Effekt von PEG-Sonden.

BACKGROUND: Pulmonary infections are dreaded complications in acute spinal cord injuries. The prevention of pneumonia is essential for reducing mortality and the period of hospitalization. Swallowing disorders occur frequently in patients with cervical cord injuries and are accompanied by aspiration with a high risk of pneumonia. PATIENTS AND METHODS: In this study the identification and analysis of patients with newly acquired cervical cord injuries were carried out with respect to respiratory complications, treatment and prevention. RESULTS: A total of 27 patients with a cervical cord injury (tetraplegia) were identified. Of these 20 patients (74%) were identified with a swallowing disorder and a high risk of aspiration. Of these patients 11 (PEG group) received a percutaneous feeding tube (PEG tube), 9 patients (non-PEG group) with diagnosed dysphagia were treated without PEG tube. A total of 6 patients in the non-PEG group (67%) acquired pneumonia compared to 3 patients (27%) in the PEG group. CONCLUSION: A swallowing disorder is a major risk factor for a pulmonary infection after a cervical cord injury. An early placement of a PEG tube has a preventive effect with respect to aspiration pneumonia in patients with dysphagia.

[Association between allergy to benzoyl peroxide, vitiligo and implantation of a cemented total knee joint prosthesis: Is there a connection?]. / Assoziation zwischen Benzoylperoxidallergie, Vitiligo und Implantation einer zementierten Knieprothese: Ein Zusammenhang?

Allergies against bone cement or bone cement components have been well-described. We report on a 63-year-old patient who presented with progressive vitiligo all over the body after implantation of a cemented total knee replacement. A dermatological examination was performed and an allergy to benzoyl peroxide was found. A low-grade infection was diagnosed 5 months after implantation of the total knee replacement and the prosthesis was replaced with a cement spacer. After treating the infection of the knee replacement non-cemented arthrodesis of the knee was performed. In cases of new, unknown skin efflorescence, urticaria and periprosthetic loosening of cemented joint replacement, the differential diagnosis should include not only infections but also possible allergies against bone-cement and components such as benzoyl peroxide or metal components.

[Spine fractures in patients with ankylosing spondylitis: an analysis of 129 fractures after surgical treatment]. / Wirbelsäulenfraktur bei ankylosierender Spondylitis : Eine Analyse von 129 Frakturen nach operativer Versorgung.

INTRODUCTION: The ankylosing spondylitis (AS) is a systemic rheumatic disease, which affects the skeleton, joints and internal organs. Attributed to the augmented rigidity of the spine and the concomitant impairment of compensatory mechanism minor force might cause spine fractures. Multilevel stabilization and dorsoventral instrumentation is a well - established procedure. This study was to evaluate the surgical outcome of 119 patients with AS associated spine fractures. METHODS: From 07/96 to 01/10, 119 patients with 129 spine fractures due to AS were treated in our department. Data were collected retrospectively. In all patients the operative treatment of the fracture was either performed by ventral and/or dorsal spondylodesis. RESULTS: The median age was 67 years (37-95). There were 51 cervical, 55 thoracic and 23 lumbar spine fractures. On initial presentation no fractures in 18 patients (15%) and stable fractures in 15 patients (13%) were detected, which further secondarily dislocated. Thus, in 28% of the patients the injury was assessed falsely. 47% of the fractures were preceded by a trivial trauma in domestic surrounding. 61 patients (51%) developed either an incomplete or a complete paraplegia. In 32 patients ventral instrumentation, in 82 patients dorsal and in 15 patients dorsoventral instrumentation were performed. 14% developed postoperative wound infection an in 15% revision surgery due to implant loosening or insufficient stabilization was required. CONCLUSION: Early diagnostic of AS associated spine fractures using conventional radiographs and computed tomography scans is important for the detection and adequate treatment. A great amount of spine fractures are obviously either under diagnosed or underestimated, initially. A secondary dislocation of the fracture might result in severe neurological complications up to paraplegia.

[Salvage procedures of the elbow. Alternatives to elbow arthroplasty]. / Salvage procedures am ellenbogen. Alternativen zur ellenbogenendoprothetik.

Destructive changes of the elbow joint represent a challenge for both patient and surgeon. Resection arthroplasty is associated with postoperative instability and loss of power and is a rarely performed procedure. Interpositional arthroplasty remains a useful option for healthy active patients with severe post-traumatic elbow arthrosis and is one of the oldest methods used to reconstruct the elbow. The principle of interpositional arthroplasty is based on a sparing resection of the destroyed joint surface and on creating a congruent elbow joint with human tissue. Nowadays, autogenous dermis, fascia lata or Achilles allograft are used. A preoperatively stable elbow is required to prevent instability following interpositional arthroplasty. The use of total elbow arthroplasty is limited due to the contraindications and in such cases the only remaining options are salvage procedures of the elbow. In general, arthrodesis should be performed in patients with painful osteoarthritis of the elbow with high demands on the upper extremities. Historically, tuberculosis was the most common indication for elbow arthrodesis and various methods of elbow arthrodesis have been described. However, most attention has been given to the position in which the elbow joint should be fixed and should be decided depending on the individual characteristics of the patient. Sufficient bone stock is crucial for a successful elbow arthrodesis and in cases with massive bone loss reconstruction of the elbow using an allograft can be performed to restore bone quality. However, the high complication rate of this procedure limits the scope of its use. Nevertheless, allograft procedures can restore pain-free joint function for several years.

[Operative treatment of pediatric open fractures of the lower limb using the Taylor spatial frame fixator]. / Versorgung der kindlichen offenen Unterschenkelfraktur mit dem Taylor-spatial-frame-Fixateur.

The operative management of open fractures of the lower limb requires a consistent treatment to avoid soft tissue complications. Acute angular shortening of the fracture enabling primary soft tissue closure is still an uncommon operative technique because of difficulties in correcting the secondary deformity. The case of a pediatric open fracture of the lower limb (Gustilo type IIIa) is described, which was treated with acute angular shortening followed by gradual correction using the Taylor spatial frame (TSF).

[Blunt force injuries due to martial arts in children--a diagnostic problem? Delayed diagnosis of an infected hematoma]. / Stumpfe Verletzungen im Kampfsport bei Kindern--ein diagnostisches Problem? Verzögerte Diagnose eines infizierten Hämatoms.

INTRODUCTION: Blunt force injuries in martial arts occur frequently but isolated hematoma of muscles in the extremities is rare. Even minor trauma of the lower extremities due to throwing techniques in judo and other forms of Asian martial arts can lead to major pathologies. METHODS: A 9-year-old girl presented with an unclear swelling and soreness of the calf muscle. The patient could not remember an obvious traumatic event. She was admitted 4 days later because of increased swelling, pain and erythema. The parents reported a minor trauma at judo training 1 week ago. Further investigation was performed with MRI and confirmed a massive hematoma much greater than previously shown by sonography. RESULTS: Histologic and microbiologic evaluation demonstrated florid inflammation and proof of Staphylococcus aureus was found intra-operatively. DISCUSSION: The diagnosis of blunt force injuries due to martial arts is difficult in childhood because often children do not remember a traumatic event. Therefore, it is important to obtain a thorough history from caregivers. Because sonography depends highly on the experience of the investigator MRI is considered to be a better diagnostic modality to diagnose and guide treatment in this age group.

Studies on the biocompatibility and the interaction of silver nanoparticles with human mesenchymal stem cells (hMSCs).

PURPOSE: Silver nanoparticles (Ag-NPs) are widely used in different areas, e.g., in the food, electronic, or clothing industry due to well-known slow-release antiseptic activities. Despite the widespread use of nanosilver, there is a serious lack of information concerning the biological activities of nanosilver on human tissue cells. MATERIALS AND METHODS: In this study, the influence of spherical Ag-NPs (diameter about 100 nm) on the biological functions (proliferation, cytokine release, and chemotaxis) of human mesenchymal stem cells (hMSCs) was analyzed. RESULTS: The results showed a concentration-dependent activation of hMSCs at nanosilver levels of 2.5 microg mL(-1), and cytotoxic cell reactions occurred at Ag-NPs concentrations above 5 microg mL(-1). Cell proliferation and the chemotaxis of hMSC both decreased with increasing Ag-NPs concentrations. Different effects on the cytokine release from hMSCs were observed in the presence of Ag-NPs and Ag(+) ions. The release of IL-8 was significantly increased at high but noncytotoxic concentrations of Ag-NPs (2.5 microg mL(-1)). In contrast, the levels of IL-6 and VEGF were concomitantly decreased compared to the control group. The synthesis of IL-11 was not affected at different Ag-NP concentrations. The agglomeration tendency of Ag-NPs in different biological media increased with a high electrolyte content, e.g., in RPMI. However, complexation with fetal calf serum in the cell culture media stabilized the Ag-NPs against agglomeration. CONCLUSION: In summary, the results showed that Ag-NPs exert cytotoxic effects on hMSCs at high concentrations but also induce cell activation (as analyzed by the release of IL-8) at high but nontoxic concentrations of nanosilver.

Systemic inflammatory mediators in post-traumatic complex regional pain syndrome (CRPS I) - longitudinal investigations and differences to control groups.

OBJECTIVES: The Complex Regional Pain Syndrome I (CRPS I) is a disease that might affect an extremity after trauma or operation. The pathogenesis remains yet unclear. It has clinical signs of severe local inflammation as a result of an exaggerated inflammatory response but neurogenic dysregulation also contributes to it. Some studies investigated the role inflammatory mediators and cytokines; however, few longitudinal studies exist and control groups except healthy controls were not investigated yet. METHODS: To get further insights into the role of systemic inflammatory mediators in CRPS I, we investigated a variety of pro-, anti-, or neuro-inflammatory mediators such as C-Reactive Protein (CRP), White Blood Cell Count (WBC), Interleukins 4, 6, 8, 10, 11, 12 (p70), Interferon gamma, Tumor-Necrosis-Factor alpha (TNF-a) and its soluble Receptors I/II, soluble Selectins (E,L,P), Substance-P (SP), and Calcitonin Gene-Related Peptide (CGRP) at different time points in venous blood from patients with acute (AC) and chronic (CC) CRPS I, patients with forearm fractures (FR), with neuralgia (NE), and from healthy volunteers (C). RESULTS: No significant changes for serum parameters investigated in CRPS compared to control groups were found except for CC/C (CGRP p = 0.007), FR/C (CGRP p = 0.048) and AC/CC (IL-12 p = 0.02; TNFRI/II p = 0.01; SP p = 0.049). High interindividual variations were observed. No intra- or interindividual correlation of parameters with clinical course (e.g. chronification) or outcome was detectable. CONCLUSION: Although clinically appearing as inflammation in acute stages, local rather than systemic inflammatory responses seem to be relevant in CRPS. Variable results from different studies might be explained by unpredictable intermittent release of mediators from local inflammatory processes into the blood combined with high interindividual variabilities. A clinically relevant difference to various control groups was not notable in this pilot study. Determination of systemic inflammatory parameters is not yet helpful in diagnostic and follow-up of CRPS I.

[Early-onset infection after hemiarthroplasty of the hip: an algorithm for surgical therapy]. / Die früh infizierte Duokopfprothese: Ein Behandlungsalgorithmus.

BACKGROUND: In a retrospective study, we compared the results of different surgical therapies in 30 patients who had an early-onset infection after implantation of a hip hemiarthroplasty. MATERIAL AND METHODS: Patients were divided into two groups: In group 1 (n=16, deep infection), we changed the polyethylene inlay as well as the femoral head. In group 2 (n=14, deep infection), an acetabular component was also implanted. RESULTS: In group 1, successful treatment was achieved in 37.5% of patients 6 months after the last operation, compared with 71.4% in group 2 (p=0.019). All patients were supported with antibiotics. In group 1, three patients died from septic multiorgan failure. Two patients in group 1 and one patient in group 2 received a Girdlestone operation. CONCLUSIONS: These results suggest that aggressive surgical treatment with soft tissue revision, lavage, and implantation of an acetabular component in combination with antibiotics is a useful technique for treating early-onset infection.

[Tuberculous rice body synovitis of the shoulder joint]. / Tuberkulöse Reiskornsynovitis des Schultergelenks.

The clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.

[Solitary fibrous tumor of the pelvis: a rare extrathoracic manifestation]. / Solitärer fibröser Tumor des kleinen Beckens: Eine seltene extrathorakale Manifestation.

Solitary fibrous tumors (SFT) are rare spindle cell neoplasms. To date only very few cases of pelvic SFT have been reported in the literature. SFT are characterized by unique microscopic and immunohistochemical findings. Complete local resection is the treatment of choice. Recurrence and metastasis may be related to infrequent malignant histological features, but histology is not always a reliable predictor for prognosis. Therefore long-term follow-up is necessary.We report about a male patient with a malignant pelvic SFT. After complete resection the tumor recurred after a short period of 6 months posterior to the original location in the pelvis. The differential diagnoses and the therapy options are discussed with a review of the present literature.

[Delayed gadolinium enhanced MRI of cartilage (dGEMRIC): molecular MRI of hip joint cartilage]. / "Delayed Gadolinium Enhanced MRI of Cartilage" (dGEMRIC): Molekulare MRT-Bildgebung des Hüftgelenkknorpels.

Factors such as instability and impingement lead to early cartilage damage and osteoarthritis of the hip joint. The surgical outcome of joint-preserving surgery about the hip joint depends on the preoperative quality of joint cartilage.For in vivo evaluation of cartilage quality, different biochemically sensitive magnetic resonance imaging (MRI) procedures have been tested, some of which have the potential of inducing a paradigm shift in the evaluation and treatment of cartilage damage and early osteoarthritis.Instead of reacting to late sequelae in a palliative way, physicians could assess cartilage damage early on, and the treatment intensity could be adequate and based on the disease stage. Furthermore, the efficiency of different therapeutic interventions could be evaluated and monitored.This article reviews the recent application of delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) and discusses its use for assessing cartilage quality in the hip joint. dGEMRIC is more sensitive to early cartilage changes in osteoarthritis than are radiographic measures and might be a helpful tool for assessing cartilage quality.

[The Taylor spatial frame fixator. Soft-tissue distraction for post-traumatic varus deformities of the hindfoot]. / Der Taylor-spatial-frame-Fixateur. Weichteildistraktion bei posttraumatischer Varusdeformität des Rückfusses.

Despite adequate primary treatment many ankle fractures result in post-traumatic deformities and arthrosis. Revision mostly requires a multidirectional correction whereas internal fixation procedures are often not applicable due to soft tissue damage and the extent of deformity. The Taylor spatial frame enables simultaneous correction of multidirectional deformities through a virtual hinge using the same ideas of distraction osteogenesis as the Ilizarov fixator. The presented case demonstrates minimally invasive correction of a complex deformity of the ankle with the Taylor spatial frame fixator. Orthogonal alignment was achieved and a stabilizing tibiotalar arthrodesis was performed achieving a good functional and pain-free result.

[Posttraumatic tracheal stenosis after complex fracture of the upper cervical spine: a rare complication]. / Posttraumatische Trachealstenose nach komplexer HWS-Fraktur: Eine seltene Komplikation.

Combined injuries of the upper cervical spine are rare and can lead to life-threatening positional changes of the respiratory tract. Hence, it is very important to recognize tracheal and soft tissue injuries and to treat these adequately. We report on the clinical course and outcome of a case with a delayed high-grade tracheal stenosis after cervical spine injury, which could only be treated by emergency tracheotomy and partial transverse trachea resection.The 25-year-old female suffered a complex dislocated upper cervical spine fracture with a Jefferson fracture, an odontoid fracture and a dislocated C6/7 luxation fracture after a motor vehicle accident. Immediately after trauma inspiratory stridor was reported. Postoperatively, the tracheal stenosis increased and the histological examination of tissue collected during emergency bronchoscopy showed granulation tissue.Even if fractures of cervical spine injuries are treated successfully, soft tissue and tracheal injuries cannot be precluded. Therefore, it is most important that such patients are followed-up closely to classify the problem and to determine the ideal time for surgical treatment of tracheal injuries and stenoses.

Hepatic failure after injury - a common pathogenesis with sclerosing cholangitis?

OBJECTIVE: Hepatic failure after trauma occurs in about 5 - 10 % of multiple injured patients. Mortality rate remains high and liver dysfunction might deteriorate to complete liver failure and contribute to multi organ failure (MOF). Pathogenesis is multifactorial and distinct mechanisms are unknown. METHODS: To get further knowledge about pathogenesis of posttraumatic liver failure we investigated clinical course, inflammatory mediators, ERCP and histologic findings in 7 patients [6 male, 1 female, mean age 45.7 +/- 12.1 years, mean ISS 38.4 +/- 10.8 pts. (range 25-58 pts.)] that evolved hepatic failure after major trauma. Mortality rate was 14 %. RESULTS: All patients presented with a prolonged shock period after trauma and severe respiratory failure requiring differentiated ventilatory support and prone positioning. Onset of significant bilirubinemia (> 2.0 mg/dl) was day 3 to 16 days (median 11 days) after trauma. Past medical history did not reveal any underlying liver disease in all patients. Pro-and anti-inflammatory parameters like WBC, Procalcitonin, IL-4, IL-10, IL-11, IL-12, and IL-18 remained close to healthy control values. CRP was elevated but did not correlate with Bilirubin. Transaminases (ALT, AST) remained close to normal values but increased during the further course, whereas alkaline phosphatase (aP) and gamma-glutamyl transpeptidase (gGT) were already significantly elevated even before Bilirubin (gammaGT: 394 +/- 317 U/l; controls: < 56 U/l; aP 557 +/- 311 U/l; controls: < 127 U/l). Although no cholestasis was proven in ultrasound and CT investigations, all patients underwent ERCP and liver biopsy. Here, all patients presented uniform signs of multiple strictures of the intrahepatic bile ducts and sclerosing cholangitis. CONCLUSIONS: Our data provide evidence that sclerosing cholangitis contributes to liver failure after trauma. The pathomorphologic picture can not distinguish between shock liver and sclerosing cholangitis. Ischemia during posttraumatic shock might be an early trigger of hepatic failure, supported by further contributing factors such as catecholamines, parenteral nutrition, and bacterial translocation. As specific therapy for sclerosing cholangitis does not exist yet, prevention of triggers is central to avoid progressive hepatic failure in those patients. Further prospective studies have to prove whether sclerosing cholangitis is commonly involved in the pathogenesis of liver failure after trauma and shock. If so, one might speculate that early therapy with ursodeoxycholic acid might be effective thus reducing incidence and/or severity of hepatic failure in the future.

Aging skin is functionally anaerobic: importance of coenzyme Q10 for anti aging skin care.

The functional loss of mitochondria represents an inherent part in modern theories trying to explain the cutaneous aging process. The present study shows significant age-dependent differences in mitochondrial function of keratinocytes isolated from skin biopsies of young and old donors. Our data let us postulate that energy metabolism shifts to a predominantly non-mitochondrial pathway and is therefore functionally anaerobic with advancing age. CoQ10 positively influences the age-affected cellular metabolism and enables to combat signs of aging starting at the cellular level. As a consequence topical application of CoQ10 is beneficial for human skin as it rapidly improves mitochondrial function in skin in vivo.

Transmission of methicillin-resistant Staphylococcus aureus among hospital staff in a German trauma centre: a problem without a current solution?

Between October 2001 and February 2002, 324 healthcare workers were screened for methicillin-resistant Staphylococcus aureus (MRSA) by nose and throat swabs. A positive finding led to activation of a standardised control programme for the affected person who was immediately excluded from work. Family members of those who were MRSA-positive were offered screening free of charge. An eradication programme was carried out in the permanent carriers. MRSA was found in 17 (5.3%) healthcare workers, 11 of whom proved to be permanent carriers, and six temporarily colonised. Three children of a positive healthcare worker showed nasopharyngeal MRSA, the acquisition of which occurred within the hospital. The standardised eradication programme for carriers was successful in most cases but failed in two individuals, whereupon systemic antibiotics were used successfully. The decolonised carriers, observed for more than one year, remained MRSA negative. Isolation precautions in hospitals do not always prevent hospital staff and their families from acquiring MRSA. The identification of affected employees is difficult because in most cases only asymptomatic colonisation occurs. Screening and eradication can be complicated and costly, and for the affected employees the occupational consequences can be far-reaching as they have no guaranteed legal protection.

[The dorsal spondylodesis of rotationally unstable thoracic fractures. Is additional ventral stabilization necessary?]. / Dorsale Spondylodese rotationsinstabiler Frakturen der Brustwirbelsäule. Bedarf sie einer ventralen Gegenstabilisierung?

METHODS: A total of 60 patients with solely dorsally reconstructed type C fractures of the thoracic spine admitted between January 2000 and December 2003 were retrospectively evaluated. Stability was determined by measuring kyphosis of the vertebral body, the operated segments and of lateral bending on the basis of plain films and computed tomography immediately postoperatively and after 2 and 19 months. RESULTS: There were 48% C2, 38% C1 and 13% C3 fractures. Of the injuries, 28% were caused by motorbike accidents, 25% by car accidents, 23% by falling from a height, 13% by suicidal jumps, 3% by ski accidents and 3% for other reasons. A total of 92% of the patients had severe thoracic trauma as attendant injuries, 42% further vertebral fractures, 35% a head injury, 30% an extremity fracture, 15% a clavicle fracture, 8% an abdominal trauma and 7% a fractured pelvis. At 19+/-12 months postoperatively, the angle of the operated segments increased by 4.7 degrees +/-4.0 degrees and that of lateral bending of the operated segments by 0.7 degrees +/-1.8 degrees compared to the immediate postoperative values. CONCLUSION: In spite of the high instability of the injured spine, the collective examined had no relevant postoperative loss of correction and no increase in lateral bending. Therefore, a solely dorsal reconstruction is sufficient, reasonable and economical.

Cytokine release of mononuclear leukocytes (PBMC) after contact to a carbonated calcium phosphate bone cement.

Human leukocytes (peripheral blood mononuclear cells, PBMC) were overlaid on calcium phosphate bone cement (CBC, Norian SRS) and allowed to settle for 1 h under cell culture conditions. Subsequently, the cells were either left unstimulated (i.e. sham stimulation using cell culture medium), or stimulated with toxic shock syndrome toxin-1 (TSST-1, 10 ng/mL), staphylococcal enterotoxin B (SEB, 10 ng/mL), or concanavalin A (ConA, 2 microg/mL) for further 24 h using cell culture conditions. Supernatants were then analyzed for cytokine content (interleukin-1 receptor antagonist, IL-1ra; IL-2; IL-6; IL-10; IL-12) by enzyme-linked immunosorbent assay. While the spontaneous generation of cytokines was not influenced, the IL-2 release from stimulated PBMC was significantly decreased in contrast to other analyzed cytokines after contact to the curing CBC compared to control incubations without CBC. This decrease in IL-2 release was not due to known inhibitors of IL-2 synthesis platelet factor-4 (PF-4), IL-10, TGF-beta, or elevated calcium ion concentrations.

The undiagnosed Essex-Lopresti injury.

The Essex-Lopresti injury is rare. It consists of fracture of the head of the radius, rupture of the interosseous membrane and disruption of the distal radioulnar joint. The injury is often missed because attention is directed towards the fracture of the head of the radius. We present a series of 12 patients with a mean age of 44.9 years (26 to 54), 11 of whom were treated surgically at a mean of 4.6 months (1 to 16) after injury and the other after 18 years. They were followed up for a mean of 29.2 months (2 to 69). Ten patients had additional injuries to the forearm or wrist, which made diagnosis more difficult. Replacement of the head of the radius was carried out in ten patients and the Sauve-Kapandji procedure in three. Patients were assessed using standard outcome scores. The mean post-operative Disabilities of the Arm, Shoulder and Hand score was 55 (37 to 83), the mean Morrey Elbow Performance score was 72.2 (39 to 92) and the mean Mayo wrist score was 61.3 (35 to 80). The mean grip strength was 68.5% (39.6% to 91.3%) of the unaffected wrist. Most of the patients (10 of 12) were satisfied with their operation and in 11 the pain was relieved. When treating the chronic Essex-Lopresti injury, we recommend accurate realignment of the radius and ulna and replacement of the head of the radius. If this fails a Sauve-Kapandji procedure to arthrodese the distal radioulnar joint should be undertaken to stabilise the forearm while maintaining mobility.