A review of the classification of Dupuytren's disease.

Although much has been published about the treatment of Dupuytren's disease, there is no clear consensus regarding the most effective form of treatment. Part of this uncertainty may result from the absence of a universal method of assessing this condition. We undertook a review of the literature in order to summarize the various methods by which Dupuytren's disease has been measured and quantified. We included all articles that offered a classification or assessment system for the disease. We excluded articles that dealt solely with surgical technique (although inevitably there was some overlap). We conclude that there are many methods of assessment, but that none of them is perfect and that further work is needed in the field.

A three-step technique to correctly identify the trapezium without the need for fluoroscopic imaging.

Thumb pain secondary to degenerative arthritis of the carpometacarpal joint of the thumb is a common disabling condition. The key principles of successful basal joint arthroplasty involve trapezial excision, which is required for pain relief, with or without some form of ligament reconstruction. The majority of basal joint reconstructive procedures include partial or complete trapeziectomy, with and without some types of tendon transfer and ligament reconstruction and with or without tendon interposition and/or temporary wire stabilisation. When performing a trapeziectomy, it is important to identify the trapezium correctly before excising it. Excision of the incorrect bone during trapeziectomy for basal joint arthritis of the thumb has been reported within the NHS Litigation Authority database. We describe the senior author's routinely used three-step technique to confirm the identity of the trapezium before excision. This technique has been reliably used in over 300 cases with successful excision of the trapezium without intraoperative fluoroscopy.

Rapidly destructive osteoarthritis of the hip joint: a case series.

BACKGROUND: Rapidly destructive arthrosis of the hip is a rare and incompletely understood disorder with scarce literature about variations in natural history within a population. METHODS: A series of cases from North Wales with rapid progressive joint destruction and extensive subchondral bone loss in the femoral head and acetabulum are presented. Radiographic findings mimicked those of other disorders such as septic arthritis, rheumatoid and seronegative arthritis, primary osteonecrosis with secondary osteoarthritis, or neuropathic osteoarthropathy, but none of the patients had clinical, pathologic, or laboratory evidence of these entities. RESULTS: Rapid progression of hip pain and disability was a consistent clinical feature. The average duration of symptoms was 1.4 years. Radiographs obtained at various intervals before surgery (average 14 months) in 18 patients documented rapid hip destruction, involvement being unilateral in 13 cases. All patients underwent total hip arthroplasty, and osteoarthritis was confirmed at pathologic examination. CONCLUSION: The authors postulate that these cases represent an uncommon subset of osteoarthritis and regular review, both clinically and radiologically, are required to assess speed of progression and prevent rapid loss of bone stock without the surgeon being aware. These cases are unsuitable for being placed on long waiting list due to technical difficulties in delayed surgery and compromised outcome following surgery.

Distal radius fracture management in the emergency departments in UK: are we doing enough?

The objective of this study was to ascertain knowledge of the normal anatomy and appreciation of components of an 'adequate' or 'acceptable' reduction by the medical staff responsible for management of distal radius fractures in the emergency departments (A&E) in UK. A nationwide structured questionnaire survey based on literature review was performed on 138 doctors. Of the 100 (72%) respondents, only 40% could cite the correct values for volar tilt, radial inclination and ulnar variance, there being a significant difference between orthopaedic, n = 16 (64%) and A&E staff, n = 24 (32%); p = 0.031; chi(2) = 12.17. Only 18% respondents were aware of the acceptable ranges of adequate reduction; with orthopaedic staff, n = 12 (48%) being more aware than A&E staff, n = 6 (8%); p = 0.002; chi(2) = 6.38. Only 19% formally measure the key parameters before decision making (52% orthopaedic vs. 8% A&E staff; p = 0.018; chi(2) = 7.31). Only 14% of respondents from hospitals equipped with picture archive navigation system stated that they used the angle measurement function.A lack of knowledge of the normal anatomical values and implementation of generally accepted measurement criteria predictive of fractures unlikely to benefit from repeat manipulations is evident. It is important to emphasise the influence of factors reported to affect stability such as age, functional demands of the patient and extent of initial fracture displacement in decision making. The introduction of a set of guidelines and further education of the medical staff could reduce the number of inappropriately treated distal radial fractures in the A&E setting with significant economic implications.

Novel method of closing a tracheo-oesophageal fistula using a de-epithelialized deltopectoral flap.

The authors describe a novel use of a de-epithelialized deltopectoral flap for the closure of tracheo-oesophageal fistulae, which have been resistant to other methods of closure.