Aims

The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs.

Shoulder rotator cuff tears can be very debilitating and painful. Whilst massive tears may defy attempts at surgical repair due to the size of the defect, various biological materials have been proposed to reinforce tenuous repairs; initial results have been promising. It has been suggested that these materials may be used to bridge defects in the rotator cuff as a ‘patch’ or ‘interposition implant’ to provide pain relief and even offer some hope of functional recovery. A porcine dermal collagen implant (Permacol ©) has been engineered and introduced for the repair and reconstruction of soft tissues in the human body. In orthopaedics, it has been successfully used in the reinforcement and augmentation of rotator cuff repairs by suturing it over the repaired tendon. Proper et al reported good short term results in using this implant to bridge defects in massive rotator cuff tears and suggested it was good solution for this group of patients, reporting improvement in all aspects of the Constant Score. We have used Permacol © to reinforce cuff repairs with satisfactory results and thus considered its use as a salvage procedure to bridge massive rotator cuff defects, both of traumatic and degenerate origins. Unfortunately, we have seen with great concern that our results have been less than satisfactory. In a cohort of 20 patients who underwent Permacol © interposition / rotator cuff repair, 4 of these have failed, despite a promising initial recovery phase with good pain relief. We believe that use of this and similar implants to bridge a defect in the cuff is not indicated; MRI and dynamic ultrasound examination showed an inflammatory response in the shoulder, and resulting weakness/failure of the implant. We present clinical, radiographic, and histological findings of our experience and a discussion as to the probable cause for the failure of this implant in this particular group of patients.

To investigate the incidence of complications arising from clavicle fractures in children and the need for multiple review in fracture clinic.

Retrospective analysis of 200 children with isolated clavicle fractures. The number of clinic visits was documented along with the mechanism of injury and any complications attributable to the fracture. Plain radiographs allowed classification of the fractures both in terms of site and type of fracture.

Retrospective review failed to provide any evidence of long term complications from isolated clavicle fractures. Two patients complained of a non-specific tingling in the arm which had settled within 2 weeks. No intervention other than rest in a broad arm sling was deemed necessary in any of the 200 children. Despite this, the average number of clinic appointments was 2.8.

In the prospective study there were no complications arising from an isolated clavicle fracture. Two patients returned (one at 6 weeks and one at 12 weeks) with concerns about the cosmetic appearance of the fracture site - both patients were reassured and discharged. All patients were satisfied with the cosmetic appearance and function of their shoulder when reviewed at a mean of 7.3 months post injury (range 6–10 months). All patients and/or guardians were satisfied with the patient information sheet.

Isolated clavicle fractures in children are rarely complicated by injuries such as skin necrosis or a neuro-vascular deficit. Despite this, children are commonly reviewed many times by juniors in a busy fracture clinic. We suggest that such review is unnecessary and that uncomplicated fractures may be safely discharged with a patient information sheet after the first clinic appointment.

Three cases of posterior dislocation of the Kinemax Posterior- Stabilized total knee replacement are reported, and predisposing factors, including operative technique and prosthesis design, are discussed.

All three patients underwent posterior-stabilised knee replacement surgery at the Avon Orthopaedic Centre for osteoarthritis, between 1984 and 2000. In all cases the patient represented to the Emergency Department of a local hospital with posterior dislocation, at between 9 months and 6 years postoperatively. The mechanism for dislocation was hyperflexion of the knee.

The dislocations could not be reduced under sedation because of obstruction by the protruding tibial insert, and required general anaesthesia to disengage the components. In all cases posterior dislocation became recurrent problem, and further surgery was required to address the instability. Two of the three patients underwent exchange of their stabilised tibial inserts for thicker versions of the same design, in order to reduce the excessive laxity present in flexion. The third patient underwent exploratory surgery and it was found that his patellar button had separated from the underlying bone. The patella was therefore resurfaced, restoring the integrity of his extensor mechanism. No further dislocations have occurred in any of the three patients.

The causes of posterior dislocation of posterior-stabilized total knee replacements are multifactorial. They include malrotation of the tibial component, although this was not found to be the case in the three patients reported here. The design of the prosthesis may also contribute, and the upsloping and relatively shallow tibial spine of the Kinemax prosthesis (Howmedica) appears to be less forgiving than others. This is particularly the case if soft tissue lateral release or excessive resection of the posterior condyles has produced an increased flexiongap and therefore excessive flexion laxity. Our cases demonstrate the pitfalls that can produce this uncommon but serious complication, some of which can be predicted preoperatively, particularly in the patient with a valgus knee or deficiency of the extensor mechanism.