Complex regional pain syndrome type 1 (CRPS-I) is a devastating complication that can occur after limb extremity injuries. The effectiveness of vitamin C in preventing CRPS-I incidence is debatable. Therefore, we conducted a systematic review and meta-analysis to assess the role of vitamin C in CRPS-I prevention and its effect on pain score, functional outcomes and complications rate after wrist, ankle, and foot fractures. We searched Medline, Embase, the Cochrane Library, . Clinicaltrial.gov. , and Google Scholar from infinity to May 2021 for relevant studies comparing the incidence of CRPS-I with administration of perioperative vitamin C versus placebo after wrist, ankle, and foot fractures. Continuous data such as functional outcomes and pain scores were pooled as mean differences (MD), whist dichotomous variables such as the incidence of CRPS-I and complications were pooled as odds ratios (OR), with 95% confidence interval (CI). Data analyses was done using R software (meta package, version 4.9-0) for Windows. Eight studies, including two quasi-experimental studies, were included. The timeframe for vitamin C administration ranged from 42 to 50 days post-injury and/or surgical fixation and the dosage was either 500 mg or 1000 mg. The results showed that vitamin C was associated with a lower rate of CRPS-I relative to a placebo (OR 0.33, 95% CI [0.17, 0.63]). No significant difference was found between vitamin C and placebo in terms of complications (OR 1.90, 95% CI [0.99, 3.65]), functional outcomes (MD 6.37, 95% CI [-1.40, 14.15]), and pain scores (MD -0.14, 95% CI [-1.07, 0.79]). The findings demonstrate that when compared to placebo, at least 42 days of vitamin C prophylaxis is associated with prevention of CRPS-I following wrist, ankle, and foot fractures, irrespective of vitamin C dosage or fracture type. No significant differences were found with secondary outcomes

Reflex sympathetic dystrophy is a syndrome characterised by pain and hyperaesthesia associated with swelling, vasomotor instability and dystrophic changes of the skin. It is rare in children, can occur without any previous history of significant trauma and may be recurrent and migratory. We reported 13 new cases of RSD in children and emphasised the role of a multidisciplinary team approach in management. A review of the literature was included. 13 children (3 boys and 10 girls) with reflex sympathetic dystrophy were presented. They were aged between 8 and 17 years. Mean age at onset was 13 years 4 months. All of them had RSD involving the lower limbs. Thermography was performed in 10 cases. The average time to correct diagnosis was 4 months. Five ankles, 4 knees and 5 hips were involved (14 joints in 13 cases). Psychological assessments revealed abnormalities in all cases. Pain (visual analogue score) and function were assessed before and after treatment. The most common therapy in children is progressive mobilisation supported by analgesic drugs, psychological and physical therapy. We individualised the therapy for each child. A team-care approach with the physiotherapist, psychologist and pain-care team co-ordinated by the Orthopaedic Consultant was the essence of our management. All children received physical therapy including a wide variety of non-standarised approaches involving analgesics and hydrotherapy. 5 patients received guanithidine blocks. Individual therapy was monitored with set achievable goals and weekly assessment of progression of mobility and joint motion. Time from the first RSD episode to resolution averaged 6 months in our series [it was mean 10 weeks in the non-adolescent cases (8 cases) and 7 months in the adolescent one (5 cases)]. The pain and function scores improved remarkably in all patients. RSD in children is not a widely recognised condition. There is often a delay in diagnosis in view of the rarity of the condition as well as the fact that specific diagnostic modalities are not readily available in all centres. Psychological factors should not be underestimated. Early diagnosis with an aggressive, multidisciplinary, monitored, ‘goal-oriented’ team approach should be the basis of management in these cases

Aim: There are more than 50 methods for the treatment of Reflex Sympathetic Dystrophy Our aim is to test how effective is the treatment of patients with Reflex Sympathetic Dystrophy with guanethidine. Method: 15 patients (F=12, M=3, Mean age 59.9) were seen in the chronic pain clinic with Reflex Sympathetic Dystrophy. 13 patients had sustained a Colles fracture and 11 of them had a closed reduction and application of POP and 2 had an external fixation. 1 had an operation for release of median nerve and 1 amputation of 3 fingers due to trauma. There were first seen in the Pain Clinic 12–16 weeks after the initial injury. Main symptoms were pain and stiffness. On examination all of them had oedema of the hand, stiffness and discoloration. Allodynia was present in 8. Patsy osteoporosis was evident on the x-rays. Palmar elytritis with atrophy in 6. The treatment was intravenous sympathetic block with 20 mg guanethidine plus 2ml 2% lignocaine and N/Saline up to 20 ml. The second block was repeated after 3 days and the following depending on the response to pain. Physiotherapy session followed each block. Results: 2 patients needed 5 blocks, 7 patients 4 blocks, 5 patients 3 blocks and 1 patient 2 blocks. In the end there was complete regression of the pain, oedema and restoration of the movement. Conclusion: The sympathetic block with I.V. administration of guanethidine in combination with physiotherapy seems to be a safe and simple treatment of choice, well tolerated and with good results

Introduction Reflex sympathetic dystrophy (RSD) as a complication of total knee arthroplasty (TKR) is rarely mentioned. The literature has been limited to 58 cases of RSD in TKR, a prevalence of 0.8% of all TKR done. No previous reports give a clear understanding as what to expect in the long term after the diagnosis of RSD post TKR has been made nor do they report the struggle that patients undergo to achieve their result. Methods We report on 11 cases of RSD diagnosed post TKR, operated on by one of us from 1991 to 2001. All patients met diagnostic criteria for Complex Regional Pain Syndrome, Type 1. Specifically they exhibited slow post-operative recovery and delayed return of normal function. Flexion was limited and cutaneous hypersensitivity was present along with temperature changes in the limb. These patients were evaluated using general and disease specific outcome tools previously validated in the literature, the SF-36 and WOMAC scores. In addition they were evaluated clinically at minimum two years following resolution of symptoms. Results We found that once appropriate treatment had been instituted, which in our case was manipulation under anaesthetic in the painfree phase of CRPS-I, the majority of our patients reported higher scores on the bodily pain section of SF-36 however these were still lower than age matched controls of pre-operative osteoarthritic patients as determined by WOMAC scores. In general, though patients had poorer SF-36 and WOMAC scores than primary uncomplicated TKR, they did significantly better than primary osteoarthritics without surgery. Conclusions This would suggest that when appropriately managed, RSD after TKR does not hold the dire prognostic consequences as previously thought

Complex regional pain syndrome (CRPS) is a devastating complication that is very difficult to treat. Whilst uncommon, the condition is frequently encountered by extremity surgeons. The author has considerable experience of dealing with CRPS and, with three clinical cases, will describe how the condition is diagnosed and treated. The very real clinical situation of timing for surgery in patients who have suffered from CRPS is also to be discussed

Diagnosis of complex regional pain syndrome (CRPS) can be challenging. We explore the role of fracture clinic in diagnosis and management with a closed-loop audit of new guidelines. We retrospectively reviewed patients with CRPS over 3.5 years. We determined the delay from injury to commencement of treatment and monitored symptoms. New guidelines were introduced to fracture clinic in January 2013. The Budapest Criteria aids diagnosis. GAD-7 and PHQ-9 patient questionnaires grade symptoms. Orthopaedic surgeons prescribe nortriptylline or pregabalin, refer to physiotherapy and review patients after six weeks. We re-audited prospectively after implementing these guidelines. The first audit cycle found 11 patients in 3.5 years. The mean delay to anti-neuropathic medication from injury was 4.7 months. Two patients required psychotherapy, one intravenous pamidronate, three inpatient physiotherapy under nerve blocks and two spinal cord stimulators. After implementing guidelines, there were 14 patients with CRPS in 9 months. All but two patients received anti-neuropathic medication on the day of diagnosis. All patients treated appropriately improved markedly within 4–12 weeks. No patients required escalation of treatment. Our guidelines increased pick-up rates of CRPS, diagnoses were made earlier and treatment started sooner. Physiotherapy modalities remained varied, however, early anti-neuropathic treatment led to a rapid improvement in all cases

Complex Regional Pain Syndrome (CRPS) is regarded as an uncommon clinical complication to orthopaedic surgery. Few have looked into its prevalence in foot and ankle surgery. This is a retrospective cohort study of all patients undergoing foot and ankle surgery, operated on by the foot and ankle team in our department in 2009. The objectives of this study was to determine the prevalence CRPS in these patients post-operatively and to examine the associated factors. 17 patients from 390 (4.4%) were identified as meeting the IASP (International Association for the Study of Pain) criteria for the diagnosis of CRPS. Of these, the majority were female (n = 14, 82.4%) and the average age was 47.2 (SD 9.7). All were elective patients. The majority involved operating on the forefoot (n = 9, 52.9%), followed by the hindfoot and ankle (3 cases each, 17.6%). Most of these patients had new onset CRPS (n = 12, 70.6%), with no previous history of the condition. 3 patients (17.6%) had documented nerve damage and therefore suffered from CRPS Type 2. Blood results were available for 14 (82.4%) patients at a minimum of 3 months post-operatively, and none had elevated inflammatory markers. 5 of the patients (29.4%) were smokers and 8 (47.1%) had a pre-existing diagnosis of anxiety or depression. At present, based on our findings, we recommend that middle-aged women, with a history of anxiety or depression, undergoing elective foot surgery be specifically counselled on the risk of developing CRPS at consenting. We recommend similar studies to be undertaken in other West of Scotland orthopaedic units

Introduction: Although well-recognized in adults, RSD is rarely diagnosed in children. Management is still controversial and includes, mobilization and physical therapy, spinal cord stimulation, transcutaneous electrical nerve stimulation, steroids, tricyclic antidepressants, anticonvulsants, non-steroidal anti-inflammatory drugs, injections of calcitonin, vasodilators and calcium channel blocker or alpha-sympathetic blocker. In this study, we describe the treatment of RSD in children using Iloprost, a pros-tacyclin analog that mimics sympathicolysis. We report our treatment regime, the clinical course, complications and the outcome in our first seven patients. Patients and Methods: Seven female patients with a mean age of 9 years (6 to 11 years) suffering from reflex sympathetic dystrophy (RSD) stage II were included in this prospective study. Inclusion criteria were RSD stage II – III, an age between 4 to 12 years, no previous operative procedures and duration of symptoms for a minimum of 6 months. Diagnosis of RSD was based on the presence of neuropathic pain, such as burning, dysaesthesia, paresthesia, and hypalgesia to cold, and physical signs of autonomic dysfunction such as skin cyanosis, mottling, hyperhidrosis, edema and coldness of the extremity. Treatment regime consisted of two infusions of Iloprost (IlomedinÒ, Schering AG, Germany) administered over 6 hours on two consecutive days. Additionally, all patients underwent physiotherapy as part of their inpatient treatment and were offered psychological counselling. Results: One day after the last infusion, all seven patients were free of pain and full weight-bearing was possible. The side-effects of Iloprost were a headache in all patients and vomiting in two patients. Two patients relapsed, one 3 months and one 5 months after primary treatment. These two patients received a second series of infusions and were again free of pain within two days. During a mean follow-up period of 30 months all patients remained asymptomatic. Conclusion: These preliminary results indicate that the treatment of RSD with Iloprost in combination with psychological counselling is a safe and effective treatment regime. Infusion therapy is a non-frightening procedure which may be an important factor considering the possible psychogenic etiology of RSD in children. Additional psychological counselling helps patients and their parents to develop coping strategies which may help to avoid relapses

Complex regional pain syndrome (type 1) (CRPS) is a chronically painful and disabling condition commonly encountered following trauma and surgery to an extremity. The condition comprises of a combination of pain, swelling, sensory impairment, joint stiffness, trophic changes, motor abnormalities and vasomotor instability. Post-traumatic CRPS is a significant clinical problem presenting to the orthopaedic surgeon and pain specialist. A clear understanding of the condition has been hampered by a lack of uniformity of diagnostic criteria (. Van de Beek W-JT, et al . Neurology. 2002. ;. 58. :. 522. –526. ). Pain therapists use the International Association of Pain (IASP) criteria (. Bruehl S et al . Pain. 1999. ;. 81. :. 147. –154. ) and orthopaedic surgeons the Atkins criteria (. J Bone Joint Surg. 1990. ;. 72B. :. 105. –110. ). Breuhl’s criteria use a combination of symptoms and signs from 4 distinct groups (hypersensitivity; vasomotor; swelling and sudomotor; motor and trophic). Atkins’ criteria require the finding of vasomotor instability symptoms, abnormal finger dolorimetry and abnormal finger range of movements. We have compared these different criteria on a series of 262 patients with distal radial fracture. The incidence of CRPS was similar using either criteria (Bruehl 20.61% vs. Atkins 22.52%). Using the Bruehl criteria as a gold standard, there was strong diagnostic agreement (Kappa = 0.79, sensitivity = 0.87, specificity = 0.94). The main difference between the two methods was in pain assessment. 16 patients had vasomotor instability, swelling and motor changes but 12 did not complain of hypersensitivity although the dolorimetry ratio was lowered. These cases have CRPS by the Atkins criteria but not the Bruehl. In contrast 4 of these cases had normal finger dolorimetry but abnormal forearm hypersensitivity and therefore had CRPS by the Bruehl criteria and not the Atkins. These finding show that the Bruehl and Atkins criteria are basically concordant. The differences reflect only minor variations in the assessment of pain. Agreement between researchers in the orthopaedic and pain therapy communities will allow improved understanding of the pathophysiology, possible prevention and future methods of managing CRPS

Purpose of the study: The pathophysiology of reflex dystrophy or type I complex regional pain syndrome remains poorly understood, but the cost is considerable in terms of public health expenditures both for programmed and emergency orthopedic surgery. We present a historical cohort assessed to evaluate the usefulness of vitamin C for the prevention of reflex dystrophy in programmed foot and ankle surgery. Material and methods: The study included two groups of patients treated in two successive periods: July 2002 to June 2003 and July 2003 to June 2004. All patients underwent foot and ankle surgery performed by the same senior surgeon. Diabetic feet were excluded. The first group (185 feet, 177 patients) was not given any particular preventive treatment. The second group (235 feet, 215 patients) was given one gram vitamin C for 45 days. The diagnosis of reflex dystrophy was retained on the basis of clinical and radiological arguments noted at follow-up visits with the operator. Several factors were studied: gender, age, type of disease condition, history of reflex dystrophy, psychological context, duration of tourniquet, cast immobilization. Results: Reflex dystrophy occurred in 18 feet in group. 1 (9.6%) and in 4 (1.7%) in group 2. The difference was significant. Presence of a history of dystrophy was significantly associated with development of dystrophy (RR=10.4). A psychological context appeared to increase the risk of dystrophy (RR 2.6) but did not reach significance. There was no statistical relationship with age, gender, duration of tourniquet, type of disease condition, or surgical procedure performed. Discussion: Vitamin C has been found to be effective in the prevention of reflex dystrophy after wrist fractures. Data in the literature is scarce on dystrophy of the foot and ankle. Our study provided objective evidence of the usefulness of vitamin C for the prevention of reflex dystrophy in foot and ankle surgery patients, a complication frequently observed in our control group (9.6%). The psychological context and history of dystrophy increase the risk of dystrophy. Conclusion: Vitamin C is associated with a lower risk of reflex dystrophy in the postoperative period after foot and ankle surgery. We advocate preventive treatment with vitamin C

Aim: We present a review on RSD in children and emphasise the role of multidisciplinary team approach in the management of 13 children. Method: 3 boys and 10 girls with a mean age of 13 years and 4 months were reviewed before and after treatment. They were assessed for pain (visual analogue score) and function. A team-care approach was utilised and co-ordinated by the Orthopaedic Surgeon. Other members included a physiotherapist, clinical psychologist and the pain care team. Results: All the patients received physical therapy (land and hydrotherapy). 5 patients received guanethidine blocks and 10 required psychological support. The time to diagnosis ranged from 2 to 11 months. All the patients improved over a period of 2.5–7 months. Conclusion: Early diagnosis with aggressive multidisciplinary goal oriented team approach should form the basis of management in children with RSD.

Our knowledge of primary bone marrow edema (BME) of the knee is still limited. A major contributing factor is that it shares several radiological findings with a number of vascular, traumatic, and inflammatory conditions having different histopathological features and etiologies. BME can be primary or secondary. The most commonly associated conditions are osteonecrosis, osteochondritis dissecans, complex regional pain syndrome, mechanical strain such as bone contusion/bruising, micro-fracture, stress fracture, osteoarthritis, and tumor. The etiology and pathogenesis of primary BME are unclear. Conservative treatment includes analgesics, non-steroidal anti-inflammatory drugs, weight-bearing limitations, physiotherapy, pulsed electromagnetic fields, prostacyclin, and bisphosphonates. Surgical treatment, with simple perforation, fragment stabilization, combined scraping and perforation, and eventually osteochondral or chondrocyte transplant, is reserved for the late stages. This retrospective study of a cohort of patients with primary BME of the knee was undertaken to describe their clinical and demographic characteristics, identify possible risk factors, and assess treatment outcomes. We reviewed the records of 48 patients with primary BME of the knee diagnosed on MRI by two radiologists and two orthopedists. History, medications, pain type, leisure activities, smoking habits, allergies, and environmental factors were examined. Analysis of patients’ characteristics highlighted that slightly overweight middle-aged female smokers with a sedentary lifestyle are the typical patients with primary BME of the knee. In all patients, the chief symptom was intractable day and night pain (mean value, 8.5/10 on the numerical rating scale) with active as well as passive movement, regardless of BME extent. Half of the patients suffered from thyroid disorders; indeed, the probability of having a thyroid disorder was higher in our patients than in two unselected groups of patients, one referred to our orthopedic center (odds ratio, 18.5) and another suffering from no knee conditions (odds ratio, 9.8). Before pain onset, 56.3% of our cohort had experienced a stressful event (mourning, dismissal from work, concern related to the COVID-19 pandemic). After conservative treatment, despite the clinical improvement and edema resolution on MRI, 93.8% of patients described two new symptoms: a burning sensation in the region of the former edema and a reduced ipsilateral patellar reflex. These data suggest that even though the primary BME did resolve on MRI, the knee did not achieve full healing

The primary aim was to determine the rate of complications and re-intervention rate in a consecutive series of operatively managed distal radius fractures. Data was retrospectively collected on 304 adult distal radius fractures treated at our institution in a year. Acute unstable displaced distal radius fractures surgically managed within 28 days of injury were included. Demographic and injury data, as well as details of complications and their subsequent management were recorded. There were 304 fractures in 297 patients. The mean age was 57yrs and 74% were female. Most patients were managed with open reduction and internal fixation (ORIF) (n=278, 91%), with 6% (n=17) managed with manipulation and Kirschner wires and 3% (n=9) with bridging external fixation. Twenty-seven percent (n=81) encountered a post-operative complication. Complex regional pain syndrome was most common (5%, n=14), followed by loss of reduction (4%). Ten patients (3%) had a superficial wound infection managed with oral antibiotics. Deep infection occurred in one patient. Fourteen percent (n=42) required re-operation. The most common indication was removal of metalwork (n=27), followed by carpal tunnel decompression (n=4) and revision ORIF (n=4). Increasing age (p=0.02), male gender (p=0.02) and high energy mechanism of injury (p<0.001) were associated with developing a complication. High energy mechanism was the only factor associated with re-operation (p<0.001). This study has documented the complication and re-intervention rates following distal radius fracture fixation. Given the increased risk of complications and the positive outcomes reported in the literature, non-operative management of displaced fractures should be considered in older patients

The April 2012 Wrist & Hand Roundup. 360 . looks at releasing the trigger finger, function in the osteoarthritic hand, complex regional pain syndrome, arthroscopic ligamentoplasty for the injured scapholunate ligament, self-concept and upper limb deformities in children, wrist arthroscopy in children, internal or external fixation for the fractured distal radius, nerve grafting, splinting the PIPJ contracture, and finding the stalk of a dorsal wrist ganglion

There are two types of pain, mechanical and non-mechanical. Mechanical pain hurts with movement/use, is not constant and is helped by morphine-type products. Non-mechanical pain is different. It is present 24 hours a day, often worse at night, and except for the pain of infection, is not relieved by morphine-type products. If the cause of mechanical pain can be determined, it can be corrected by an operation. The usual cause of postoperative mechanical knee pain nowadays is multifactorial, i.e. a combination of minor errors, none of which on their own would require revision. Non-mechanical pain, other than infection, is much more difficult to handle. The commonest cause is not really a pain complaint, it is disappointment due to a failure of expectation. It does not matter how often you tell patients, some patients still think they should step in a drive away. A lot of these failures of expectations become much more realistic by the end of year one. There are several other categories. Incipient osteoarthritis or sensitive people (The Princess and the Pea). If the pain complaints were severe with minimal arthritis, an operation is not likely to help. The patient on disability for no clear reason is unlikely to get a good result and Workmen's Compensation Board and motor vehicle accident patients are also a very bad prognostic sign and will often produce the postoperative painful knee. Preoperative use of large doses of morphine is also a very bad sign. It is not clear if it is the morphine, which influences the patient or the patient, who influences the morphine. There are several pain syndromes, some of which are purely psychiatric such as Conversion Disorders and Somatoform Pain Disorders. Treatment of purely psychiatric conditions should be a referral to a psychiatrist is in order. Complex regional pain syndrome is an organic pain disorder. Type 2 is causalgia or an actual nerve injury. This is unusual following knee replacement other than the odd drop foot, which even after recovery, leaves an area of dysaethesia on the dorsum of the foot. Type 1 used to be called reflex sympathetic dystrophy. This is not uncommon after total knee replacement. I managed to collect more than 40 cases. One problem is that the diagnosis to some extent is a diagnosis of exclusion. If the diagnosis can be made, then treatment is available including Cymbalta, Lyrica or Gabapentin. I have found most success with lumbar sympathetic blocks, but it is difficult to find someone, who can do these. Some patients have been treated with implantable electrical spinal stimulators with variable results. The current flavour of the month pain syndrome is called central sensitization. The theory is that if someone has pain for more than six months, then there will be changes in the brain, which will remain after the original pain goes away, hence, the title the pain in the brain syndrome. If this theory were correct, then we as arthroplasty surgeons have been collectively wasting our time for the last 40 years as no patient would have recovered. The likelihood, therefore, of this theory having any basis in reality is pretty remote. Fortunately, by the end of year one, the vast majority of our knee replacement patients are reasonably content with the procedure

Limb preserving surgery following segmental resection of the distal end of the radius and its articular surface presents a major challenge. We have studied 11 consecutive patients with aggressive tumours located in the distal radius that required segmental resection of the distal radius and its articular surface to evaluate the clinical and functional outcome of reconstruction of such defects. The mean age at the time of diagnosis was 33 years (7–60). Follow up ranged from 12 to 306 months (median 56). Histological diagnosis was osteosarcoma in 4 patients, chondrosarcoma in 2, giant cell tumour in 5 and meta-static carcinoma in 1 patient. Four patients received chemotherapy. The length of excised bone ranged from 6 to 14cm. Reconstruction was performed with non-vascularised proximal fibula strut graft in 6 patients, ulna transposition in 3 and custom made endoprosthesis in 2 patients. The wrist joint was arthrodesed in 5 patients. At the time of review 2 patients had died of disease, one was alive with disease and 8 were alive and free of disease. Non-union of the graft occurred in one patient, reflex sympathetic dystrophy in 2 and prosthetic dislocation in one. One patient had local recurrence. Four patients required further surgery including one patient who needed an amputation for severe reflex sympathetic dystrophy, one graft revision for non-union, one secondary wrist arthrodesis and one closed reduction of dislocated endoprosthesis. Patients without arthrodesis often had clinical and radiological signs of wrist instability. The majority of the patients achieved satisfactory function with little or no discomfort and ability to perform activities of daily living. We conclude that limb salvage surgery is worthwhile in patients with resectable tumours of the distal radius

In years past, the most common reason for revision following knee replacement was polyethylene wear. A more recent study indicates that polyethylene wear is relatively uncommon as a cause for total knee revision counting for only 10% or fewer of revisions. The most common reason for revision currently is aseptic loosening followed closely by instability and infection. The time to revision was surprisingly short. In a recent series only 30% of knees were greater than 5 years from surgery at the time of revision. The most common time interval was less than 2 years. This is likely because of the higher incidence of infection and instability that occurs most commonly at a relatively early time frame. Evaluation of a painful total knee should take into account these findings. All total knees that are painful within 5 years of surgery should be assumed to be infected until proven otherwise. Therefore, virtually all should be aspirated for cell count, differential, and culture. Alpha-defensin is also available in cases in which a patient may have been on antibiotics within a month or less, as well as cases in which diagnosis is a challenge for some reason. Instability can be diagnosed with physical exam focusing on mid-flexion instability which can be usually determined with the patient seated and the knee in mid-flexion, with the foot flat on the floor at which point sagittal plane laxity can be discerned. This is also frequently associated with symptoms of giving way and recurring effusions and difficulty descending stairs. A new phenomenon of tibial de-bonding has been described, which can be a challenge to diagnose. Radiographs can appear normal when loosening occurs between the implant and the cement mantle. This seems to be more common with the use of higher viscosity cement. Obviously this is technique dependent since good results have been reported with the use of high viscosity cement. Component malposition can cause stiffness and pain and relatively good results have been reported by component revision when malrotation has been confirmed with CT scan. When infection, instability and loosening are not present, extra-articular causes should be ruled out including lumbar spine, vascular compromise, complex regional pain syndromes and fibromyalgia, and peri-articular causes such as bursitis, tendonitis, tendon impingement among others. One of the most common causes of pain following total knee is unrealistic patient expectations. Performing total knee replacement in early stages of arthritis with only mild to moderate symptoms and radiographic changes has been associated with persistent pain and dissatisfaction. It may be prudent to obtain the immediate preoperative x-rays to determine if early intervention was undertaken and patients have otherwise normal appearing total knee x-rays and a negative work up. A recent study indicated that this was likely a cause or a major contributing factor to persistent pain following otherwise a well performed knee replacement. A national multicenter study of the appropriateness of indications for TKA also indicated that early intervention was a major cause of persistent pain, dissatisfaction, and failure to improve following total knee replacement

Aims

It is not clear which type of casting provides the best initial treatment in adults with a distal radial fracture. Given that between 32% and 64% of adequately reduced fractures redisplace during immobilization in a cast, preventing redisplacement and a disabling malunion or secondary surgery is an aim of treatment. In this study, we investigated whether circumferential casting leads to fewer fracture redisplacements and better one-year outcomes compared to plaster splinting.

Aims

The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality.

The Cobb Stainsby forefoot arthroplasty for claw and hammer toes combines excision arthroplasty (Stainsby) with extensor tendon transfer to the metatarsal head (Cobb). We present a retrospective, three surgeon case series of 218 toes in 128 patients over four years. Clinical notes were reviewed for all patients and 77 could be contacted for a telephone survey. Follow up ranged from 12–82 months. All patients presented with pain and shoe wear problems from dislocated metatarsophalangeal joints either from arthritis, hallux valgus, Freiberg's disease or neurological disorders. Ipsilateral foot procedures were performed simultaneously in 24 (30%) patients. Seventy-two patients (94%) were satisfied, 72 (94%) reported pain relief, 55 (71%) were happy with toe control, 61 (79%) were pleased with cosmesis, 59 (77%) returned to normal footwear and 56 (73%) reported unlimited daily activities. Minor complications occurred in 17 (13%) and 3 (2%) developed complex regional pain syndrome. Four (5%) developed recurrent clawing. The Stainsby procedure permits relocation of the plantar plate under the metatarsal head for cushioned weight-bearing but can create a floppy, unsightly toe. By combining this with the Cobb procedure, our case series demonstrates improved outcomes from either procedure alone with benefits over alternatives such as the Weil's osteotomy. Oxford Level 4 evidence – retrospective case series