The governance of overseas surgical collaborations - BFIRST/BSSH.

Clinical governance is the structured approach to maintaining and improving the quality of patient care and is a vital part of global surgery. BFIRST and BSSH closely collaborate with local doctors on a number of overseas projects, seeking to strengthen and develop local knowledge and skills, aiming for an independent local practice in reconstructive and upper limb surgery. Thoughts on essential requirements, improvements and pitfalls in the ethical approach to global collaboratives are presented.

Isolated lesser trochanter fractures in elderly--a case for prophylactic DHS fixation. A case series.

Isolated lesser trochanter fractures are a rare presentation of hip fractures in the elderly. Classically, lesser trochanter fractures in adults are associated with tumours and result from little or no trauma. We present three elderly osteoporotic ladies who sustained isolated fractures of the lesser trochanter secondary to a definite history of trauma. Radiologically, none of them showed any evidence of pathological lesions or intertrochanteric fracture at presentation. Two patients subsequently developed displaced intertrochanteric fractures, which necessitated internal fixation. In the third patient, a dynamic hip screw (DHS) was inserted before mobilisation. Based on this experience, we recommend careful observation and follow-up of such cases and suggest that isolated lesser trochanteric fractures in the elderly osteoporotic population may be an indication for prophylactic DHS fixation.

An approach to the diagnosis of chronic wrist pain.

A clinical algorithm was developed to help to establish a diagnosis in patients with chronic wrist pain. The accuracy of the algorithm was examined in a prospective blind study of 40 patients presenting to the Hand Unit with undiagnosed wrist pain and compared with the later findings at arthroscopy, which were believed to be as accurate as currently possible. Using simple examination techniques and conventional radiographs, an accurate diagnosis was made in 80% of cases. Examination techniques including the scapholunate shear test and the presence of local tenderness or pseudostability were found to be particularly accurate.

An approach to the diagnosis of chronic wrist pain.

A clinical algorithm was developed to help establish a diagnosis in patients with chronic wrist pain. The accuracy of the algorithm was examined in a prospective blind study of 40 patients presenting to the Hand Unit with undiagnosed wrist pain and compared with the later findings at arthroscopy, which were believed to be as accurate as currently possible. Using simple examination techniques and conventional radiographs, an accurate diagnosis was made in 80% of cases. Examination techniques including the scapho-lunate shear test and the presence of local tenderness or pseudostability were found to be particularly accurate.

Capitellocondylar total elbow replacement for rheumatoid arthritis.

In all, 23 capitellocondylar total elbow replacements were performed in 18 patients with rheumatoid arthritis. Follow-up was for a mean (range) of 3 (1.5-5) years. Pain relief was achieved in all patients and the postoperative range of movement showed an improvement in all directions. No evidence of radiological loosening has been seen. Complications consisted of a transient ulnar nerve palsy in 15 elbows (65%) and a permanent ulnar nerve palsy in one elbow (4%). In two elbows there was delayed wound healing.

Removal of Moore's pins.

We reviewed 37 consecutive patients who have had Moore's pins removed from the hip as an elective procedure. Ten cases were bilateral giving a total of 47 hips from which pins were removed. Complications were encountered in 19 hips (40%). The most common complication was pin breakage.

Ten-year experience of bone and joint tuberculosis in Blackburn 1978-1987.

A retrospective review of 70 cases of bone and joint tuberculosis seen between 1978 and 1987 is reported. Forty-nine of the cases were patients of Indian subcontinent ethnic origin. There was a wide range of sites affected. Pain, swelling or sinus formation were the commonest presenting features. Delay in diagnosis from the first hospital visit was significantly longer in the Caucasian population (mean delay; Caucasian 17.6 weeks, Indian subcontinent 2.8 weeks). Drug treatment was used in all cases, combined with biopsy in 21 cases and more radical surgery in 28 cases. The results of treatment were good with low morbidity and mortality, long-term problems have been few, and no relapses have occurred. Nine months of chemotherapy and the joint system of orthopaedic and medical management employed locally are strongly recommended.

The Wrightington classification of rheumatoid wrist X-rays: a guide to surgical management.

We have reviewed the pre-operative radiological appearances, the type of operation performed and the results of surgery of 234 wrists in 179 patients with rheumatoid arthritis. Based on this, a classification of X-rays of the rheumatoid wrist is described. It is designed to provide practical guidance to the surgeon who is planning surgery in a patient with rheumatoid disease. The surgical choices at each stage of the disease are briefly discussed.