Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. All had a minimum of 5 years follow-up. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed for at least 5 years

Aim: Stainsby and Briggs described a procedure for the correction of þxed claw toes. We studied the results of the Stainsby procedure in non-rheumatoid þxed claw-toes performed between March 1995 and January 2000. Method: All procedures were reviewed independently by the junior authors. The outcome was measured using the American Orthopaedic Foot and Ankle Society lesser toe scale (Kitaoka 1994). Patients were asked about overall satisfaction and whether they would recommend the operation to a family member. Results: Thirty-seven patients were operated on, four of whom died and one moved away, leaving 32 patients (38 feet, 88 toes) for study. The median age of the study patients was 59.5years (16–80 years) and median follow-up was 37 months (12–60 months). Twenty-two patients had hallux valgus, 7 pes cavus and 6 underwent salvage surgery for previous failed forefoot surgery. The median AOFAS score at follow-up was 80 (37–95). Thirty-four feet (89%) were satisfactory and 25 patients (78%) would recommend the operation. Wound problems occurred in 11 feet (29%) and transient paraesthesiae in 9 (24%). Dissatisfaction was usually due to the ßoppiness of the toe. Conclusion: The Stainsby procedure is a good salvage procedure for severe claws toes with good patient perception and function

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients. The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. The mean follow-up was of 5 years. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed at a mean of 5 years

Claw toes are treated by a variety of soft tissue and bony proceduresbased on the severity of the deformity. We evaluated the results of Stainsby procedure for claw toes. This is a retrospective analysis of the results of Stainsby procedure for claw toes of the foot done by a single surgeon over a 10 year period. All patients who had claw toes,secondary to Rheumatoid and Non rheumatoid causes and treated by this procedure were included in the study. All the patients operated between Jan 1995 -Dec 2004 and who had minimum follow-up of 6 months after surgery were included in the study. Follow up evaluation was by clinical examination, review of case notes and telephone conversation. 42 patients underwent this procedure of which 38 were available for evaluation. Average follow-up was 43.5 months (6–110months). 26 rheumatoid and 21 non-rheumatoid feet were evaluated based on the AOFAS score. The mean AOFAS score was 76.5. The scores for the Rheumatoid and Non-Rheumatoid groups were 81.5 and 72.6 respectively.81% were satisfied with the result of the operation and 83% would recommend this surgery for friends and relatives. Six patients had superficial infection, 2 had broken k-wires, 2 had DVT, and 2 had recurrence of deformity. We conclude that Stainsby procedure for claw toes is a procedure which has good results in the long term and can be taken up as a procedure of choice for severe claw toes

Claw toes are treated by a variety of soft tissue and bony proceduresbased on the severity of the deformity. We evaluated the results of Stainsby procedure for claw toes. This is a retrospective analysis of the results of Stainsby procedure for claw toes of the foot done by a single surgeon over a 10 year period. All patients who had claw toes, secondary to Rheumatoid and Non rheumatoid causes and treated by this procedure were included in the study. All the patients operated between Jan 1995 -Dec 2004 and who had minimum follow-up of 6 months after surgery were included in the study. Follow up evaluation was by clinical examination, review of case notes and telephone conversation. 42 patients underwent this procedure of which 38 were available for evaluation. Average follow-up was 43.5 months (6–110months). 26 rheumatoid and 21 non-rheumatoid feet were evaluated based on the AOFAS score. The mean AOFAS score was 76.5. The scores for the Rheumatoid and Non-Rheumatoid groups were 81.5 and 72.6 respectively.81% were satisfied with the result of the operation and 83% would recommend this surgery for friends and relatives. Six patients had superficial infection, 2 had broken k-wires, 2 had DVT, and 2 had recurrence of deformity. We conclude that Stainsby procedure for claw toes is a procedure which has good results in the long term and can be taken up as a procedure of choice for severe claw toes

Introduction: The literature regarding the functional outcome following C1–C2 surgeries for non-rheumatoid C1–C2 pathologies following selective arthrodesis is sparse. Aim: To determine the long term correlation between functional outcome and radiological determinants following C1–C2 fusion for conditions other than RA. Methods: All C1–C2 surgeris performed between 1988–2002 for non-RA etiologies were reviewed retrospectively. Selective C1–C2 fusion performed in 32 pts with a min f/u of 5 yrs formed the study group. The mean age at surgery was 57.2 yrs (r 22–84yrs). The etiologies were trauma (15), non-union (6), congenital AAD (2), C1–C2 deg. arthropathy (2), os odontoideum (2), tumours (4) and instability due to TB (1). Neurodeficit were present in 7 pts. Transarticular (TA) screws supplemented with posterior wiring was performed in 27 & posterior wiring alone in 5 pts respectively. A monocortical H-shaped autograft from iliac crest was used in all cases. There were two deaths & two pts were lost for F/U. The mean F/U was 7.8 yrs (r 5–13 yrs). Disability & pain using NDI & VAS and subjective satisfaction were recorded in all pts. We measured 1) C1/2 fixation angle, 2) Inclination of C1, 3) Anterior shift of C2 and 4) C2–7 lordosis on pre and final F/U lateral x-rays. Results: Optimal TA screw placement was seen in 78.5% of pts. The mean improvement in NDI & VAS were from 55.4% to 19.6% and 8.4 to 1.6 respectively and was better in younger pts. Fusion was seen radiologically in 82.1% of pts at 12 mo post surgery. Segmental stability and resolution of symptoms was seen in all patients despite implant failure in 4 and incomplete fusion 5 cases respectively. Two wound dehiscences needed debridement of which one elderly pt died of MRSA sepsis 2 mo post-op. The C1–C2 segmental lordosis was significantly increased by surgery (−4.2 0 vs. −11.80; P=0.016). The subaxial cervical spine became less lordotic in initial few months post-op but eventually regained more lordosis as time progressed. The C1 inclination came into more extended position w.r.t horizontal line post-op with minimal loss of inclination subsequently. C1–C2 fixation angle and anterior shift of C2 did not have significant correlation with long term functional outcome i.e. NDI and VAS (r=0.35, p=0.17). Conclusion: The functional outcome following C1–C2 arthrodesis is usually good despite metalwork issues and incomplete fusion in these selective group of non-rheumatoid arthritis pathologies

Introduction We report the experience of a district general hospital foot and ankle service, in performing a modified excision arthroplasty and tendon transfer to the metatarsophalangeal (MTP) joints of the lesser toes in both rheumatoid and non-rheumatoid patients. The procedure was carried out on 114 toes, in 58 feet of 55 patients over a 5-year period. Background Historically, partial proximal phalangectomy was complicated by recurrence of the extension deformity. . Stainsby (1990). described a technique of 7/8ths phalangectomy, repositioning of the plantar plate, extensor to flexor attachment and K-wire stabilisation to treat dislocated MTP joints of the lesser toes. However, it is recognised that the use of K-wires can be complicated by infection or premature removal. Angel reported the re-routing of the extensor tendon through a drill hole in the metatarsal head for MTP joint instability; this technique was attributed to Nigel Cobb. We have utilised the Stainsby technique and combined it with a Cobb tendon transfer to impart immediate stability to the toe, allowing K-wire fixation to be discarded. Technique Following a percutaneous proximal extensor tenotomy, a radical partial proximal phalangectomy (via a dorsal incision) reduces a dislocated MTP joint and the plantar plate is repositioned beneath a mobilised metatarsal head. A drill hole is then placed in the metatarsal head and the extensor tendon is re-routed from a plantar to dorsal direction. This maintains the reduction of the toe and provides interposition between the cut end of the proximal phalanx and the metatarsal head. Conclusion We believe that this modified combined technique is a reproducible alternative to the Stainsby procedure but, in addition, provides immediate stability of the MTP joint without the need for K-wire fixation

Introduction: Deep infection continues to be the first most important early complication in knee arthroplasty. It is usual to apply standard prophylaxis to all patients, but it is not usual to use special measures in those of them who present a higher risk. Moreover, sometimes these patients are even not identified. Purpose: To analyse statistically significant risk factors for deep infection in patients with a knee arthroplasty. Patients and Methods:. Design: Case-control study. Observational and retrospective comparison of incidence or prevalence of all risk factors described in the literature. These factors have been classified according to the period of risk in: epidemiologic; pre, intra and postoperative; and distant infections. Case series: 32 consecutive patients with a deeply infected knee arthroplasty operated in the same Department of a University General Hospital. Control series: 100 randomly selected patients, operated in the same hospital and period of time, with no deep infection in their knee arthroplasty along follow-up. Pearson was used for comparison of qualitative variables and ANOVA for quantitative ones. Results: The following risk factors were significantly more frequent (p< 0.05) in the patients with an infected knee arthroplasty:. Preoperative conditions: previous surgery in the same knee (25% vs 9%), chronic therapy with glucocorticoids (19% vs 4%), immunosuppressive treatments (16% vs 3%), and non-rheumatoid inflammatory arthritis (13% vs 0%). Patients in this case-control did not present a significant difference in the prevalence of rheumatoid arthritis, diabetes, obesity (BMI> 30), chronic liver diseases, or alcohol addiction. Intraoperative facts: a prolonged surgical time (149 min vs 108 min) and intraoperative fractures. Differences were not found in the amount of bleeding or need for transfusion. Postoperative events: secretion of the wound longer than 10 days (48% vs 0%), wound haematoma (36% vs 6%), new surgery in the knee (30% vs 0%), and deep venous thrombosis in lower limbs (10% vs 1%). Distant infections (risk for haematogenous seeding): deep cutaneous (27% vs 3%), generalized sepsis (7% vs 0%), upper and lower urinary tract (27% vs 5%), pneumonias and bronchopneumonias (27% vs 5%), and diverse abdominal focus (17% vs 1%). On the contrary, significant differences were not found in the prevalence of severe oral or dental infections. Epidemiologic characteristics: significant differences were not found in gender or in the prevalence of any aetiology. Conclusion: To identify significative risk factors for deep infection in knee arthroplasty is important:. to control and minimize these risk factors when present. when this is not possible not possible, to implement additional prophylactic measures

Pre-revision detection of infection in failed total joint replacements (TJR) is essential to allow appropriate management planning. Unfortunately, low-grade infection is often difficult to detect. The use of molecular biology may offer increased sensitivity in this setting. We have analysed the use of the Polymerase Chain Reaction (PCR) to diagnose infection in pre-operative aspirates in a group of patients undergoing revision arthroplasty. We prospectively tested 50 aspirates in 50 patients with failed TJR (34 hips and 16 knees). Antibiotics were omitted for 2 weeks prior to aspiration. The aspirate was sent for microbiological culture in aerobic and anaerobic conditions. An aliquot was retained for PCR analysis which involved DNA extraction then amplification of an 882 base pair segment of the Universal 16S RNA gene. In 33 patients who subsequently underwent revision arthroplasty multiple specimens were taken from around the joint for microbiological and histological examination and the presence or absence of pus was noted. The patient was deemed to be infected if one of these criteria was found: 2 or more intra-operative cultures positive for the same organism; an acute inflammatory response on histology; pus in the joint at revision . 1. . PCR was positive in 29 cases. Aspiration microbiology was positive in 13 cases. Of the 33 cases revised, 15 patients were deemed to be infected using the previously established criteria, described above. Compared to preoperative aspiration microbiology PCR had a sensitivity of 92% and specificity of 54%. Compared to the published criteria for infection, PCR was 93% sensitive and 61% specific. If rheumatoid cases are excluded the specificity improves to 71%. It was concluded that PCR has the ability to amplify very small amounts of target DNA. The apparently high false positive rate compared to aspiration microbiology may indicate that PCR is picking up DNA from contaminating or non-viable organisms (treated or phagocytosed), giving poor specificity. However, microbiology is known to have poor sensitivity on pre-operative aspiration samples, and some of the microbiology results may be false negative. Compared to the criteria for infection after revision our results for PCR are more encouraging, especially for non-rheumatoid patients. These patients are part of an ongoing study to identify the most reliable criteria for pre-operative diagnosis of infection in total joint replacement

The February 2014 Wrist & Hand Roundup³⁶⁰ looks at: simple debridement and ulnar-sided wrist pain; needle fasciotomy or collagenase injection; joint replacement in osteoarthritic knuckles; the Mannerfelt arthrodesis; scaphoid union rates with conservative treatment; the benefits of atorvastatin for muscle re-innervation after sciatic nerve transection; and complications of trapeziectomy.