Aims

The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA).

Operative management of clavicle fractures is increasingly common. In the context of explaining the risks and benefits of surgery, understanding the impact of incisional numbness as it relates to the patient experience is key to shared decision making. This study aims to determine the prevalence, extent, and recovery of sensory changes associated with supraclavicular nerve injury after open reduction and plate internal fixation of middle or lateral clavicle shaft fractures. Eighty-six patients were identified retrospectively and completed a patient experience survey assessing sensory symptoms, perceived post-operative function, and satisfaction. Correlations between demographic factors and outcomes, as well as subgroup analyses were completed to identify factors impacting patient satisfaction. Ninety percent of patients experienced sensory changes post-operatively. Numbness was the most common symptom (64%) and complete resolution occurred in 32% of patients over an average of 19 months. Patients who experienced burning were less satisfied overall with the outcome of their surgery whereas those who were informed of the risk of sensory changes pre-operatively were more satisfied overall. Post-operative sensory disturbance is common. While most patients improve, some symptoms persist in the majority of patients without significant negative effects on satisfaction. Patients should always be advised of the risk of persistent sensory alterations around the surgical site to increase the likelihood of their satisfaction post-operatively

A Morel-Lavallee lesion (MLL) is a benign cystic lesion that occurs due to injury to the soft-tissue envelope's perforating vascular and lymphatic systems, resulting in a distinctive hemolymphatic fluid accumulation between the tissue layers. The MLL has the potential to make a significant impact on the treatment of orthopaedic injuries. A 79-year-old male patient community ambulatory with assisting aid (cane) known case of Diabetes mellitus, hypertension, bronchial asthma and ischemic heart disease. He was brought to the Emergency, complaining of right hip discomfort and burning sensation for the last 5 days with no history of recent trauma at all. Patient had history of right trochanteric femur fracture 3 years ago, treated with DHS in a privet service. Clinical and Radiological assessment showed that the patient mostly has acute MLL due to lag screw cut out. We offered the patient the surgical intervention, but he refused despite explaining the risks of complications if not treated and preferred to receive the conservative treatment. Compression therapy management explained to him including biker's shorts (instructed to be worn full-time a day) and regular follow up in clinic. Symptom's improvement was reported by the patient in the subsequent visits. In the polytrauma patient, a delayed diagnosis of these lesions is conceivable due to the presence of more visible injuries. It's located over the greater trochanter more commonly, but sometimes in other areas such as the lower lumbar region, the thigh, or the calf. Incorrect or delayed diagnosis and care can have unfavorable outcomes such as infection, pseudocyst development, and cosmetologically deformity. Magnetic resonance imaging (MRI) and ultrasound will aid in MLL diagnosis. However, the effectiveness of MLL therapy remains debatable. We strongly believe that the MLL caused due to tangential shear forces applied to the soft tissue leads to accumulation of the blood and/or lymph between the subcutaneous and overlying fascia and it often misdiagnosed due to other distracting injuries. Nontheless, in our case we reported MLL occur due to internal pressure on the fascia caused by cut out of DHS lag screw

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

Abstract. Objective. There is no specific framework for the clinical management of sports related brachial plexus injuries. Necessarily, rehabilitation is based on injury presentation and clinical diagnostics but it is unclear what the underlying evidence base to inform rehabilitative management. Methods. A systematic review of the literature was undertaken in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We applied the PEO criteria to inform our search strategy to find articles that reported the rehabilitative management of brachial plexus injuries sustained while playing contact sports. An electronic search of Medline, CINAHL, SPORTDiscus and Web of Science from inception to 3rd November 2022 was conducted. MESH terms and Boolean operators were employed. We applied an English language restriction but no other filters. Manual searches of Google Scholar and citation searching of included manuscripts were also completed. All study types were considered for inclusion provided they were published as peer-reviewed primary research articles and contained relevant information. Two investigators independently carried out the searches, screened by title, abstract and full text. Two researchers independently extracted the data from included articles. Data was cross-checked by a third researcher to ensure consistency. To assess internal validity and risk of bias, the Joanna Briggs Institute (JBI) critical appraisal tools were utilised. Results. The search generated 88 articles. Following removal of duplicates, 43 papers were evaluated against the eligibility criteria. Nine were eligible for full text review, with the majority of exclusions being expert opinion articles. Eight case reports were included. One article reported three individuals, resulting in data for ten athletes. The mean age was 19.8 years (±4.09). Injuries occurred in five American football players, two wrestlers, two rugby players, and a basketball player. No two studies applied the same diagnostic terminology and the severity of injury varied widely. Burning pain and altered sensation was the most commonly reported symptom, alongside motor weakness in the upper limb. Clinical presentation and management differed by injury pattern. Traction injuries caused biceps motor weakness and atrophy of the deltoid region, whereas compression injuries led to rotator cuff weakness. In all cases treatment was separated into acute and rehabilitative management phases, however the time frames related to these differed. Acute interventions varied but essentially entailed soft tissue inflammation management. Rehabilitation approaches variously included strengthening of shoulder complex and cervical musculature. Return-to-play criteria was opaque. The methodological quality of the case reports was acceptable. Four met all nine of the JBI evaluation criteria, and a further three met at least 75% of items. Conclusion(s). There is a distinct lack of evidence supporting rehabilitation management of sports related brachial plexus injury. Through systematic review we found only eight reports, representing ten individual case studies. No trials, cohort studies, or even retrospective registry-based studies are available to inform clinical management, which, necessarily, is driven by expert opinion and application of basic rehabilitation principles. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Endoprosthetic reconstruction for pathologic acetabular fractures is associated with a high risk of periprosthetic joint infection. In this setting, bone defect reconstruction utilising co-delivery of a synthetic bone substitute with an antibiotic, is an attractive treatment option from both, therapeutic and prophylactic perspective. We wished to address some concerns that remain regarding the possible presence of potentially wear inducing particles in the periprosthetic joint space subsequent to this procedure. We analysed a drain fluid sample from an endoprosthetic reconstruction of a pathologic acetabular fracture with implantation of a gentamicin eluting, biphasic bone graft substitute, consisting of 40% hydroxyapatite (HA) and 60% calcium sulphate (CERAMENT G), into the residual peri-acetabular bone defect. This sample was divided into two 1.5ml subsamples, to one of which 100mg HA particles were added as control before burning off all organic substance at very high temperature. These heat treated samples were then examined with scanning electron microscopy (SEM) and energy dispersive x-ray analysis (EDAX) and compared to a reference sample consisting of HA particles only. On SEM, hydroxyapatite particles were readily recognisable in the control and reference samples, whereas only very few particles over 2μm were apparent in the ”pure” drain sample. EDAX revealed that very large amounts of salts were present in both drainage samples. The pure drainage sample however, contained markedly lower amounts of calcium and phosphate compared to reference and control samples. No HA particles as such, were seen in the pure sample, however their presence cannot be excluded with absolute certainty, as some particles might have been hidden within the large salt conglomerates. We could not find clear evidence that the drain fluid really contained HA particles. More thorough investigations are needed and future analyses with prior removal of the high salt content would likely yield more conclusive results

Aim. To determine if the location and pattern of knee pain as described by the patients using the knee pain map was comparable with the intra articular pathology found on arthroscopy as well as to facilitate diagnosis based on pain. Methods. There were fifty five consecutive patients with acute and chronic knee pain participating in the study and they subsequently underwent arthroscopy of the knee joint as therapeutic or diagnostic procedure in day surgery. Those patients with extra articular pathologies, referred pain hip, back and foot were excluded from the study. All the participants were consented for the study; subjective data was recorded on the standardised knee pain map that included visual analogue pain scale preoperatively on the day of admission for arthroscopy. The findings of the arthroscopy including EUA were recorded on the on standard arthroscopy forms used in our department by the operating surgeon. Results. Patients on the knee pain map most often recorded sharp/stabbing pain (72%), followed by diffuse dull pain (14.5%), mixed dull and sharp pain (10 %) and burning pain (3.5%). 82% of the localising pain pattern recorded on the knee pain map by the patients corresponded to the intra articular lesion found during knee arthroscopy. 18 % of the pain mapping location and pattern was not very specific to the intrarticular arthroscopic lesions. Conclusions. The results from our study indicate, majority of the patients could map the knee pain location and pattern correlating to the knee arthroscopic findings. Furthermore, the knee pain mapping can be used as a reliable tool to assist the clinician to determine the specific knee pain patterns correlating with intra-articular lesion

Objective of the study. To determine if the location and pattern of knee pain as described by the patients using the knee pain map was comparable with the intra articular pathology found on arthroscopy as well as to facilitate diagnosis based on pain. Methods. There were Sixty consecutive patients with acute and chronic knee pain participating in the study and they subsequently underwent arthroscopy of the knee joint as therapeutic or diagnostic procedure in day surgery. Those patients with extra articular pathologies, referred pain hip, back and foot were excluded from the study. All the participants were consented for the study; subjective data was recorded on the standardised knee pain map that included visual analogue pain scale preoperatively on the day of admission for arthroscopy. The findings of the arthroscopy including EUA were recorded on the on standard arthroscopy forms used in our department by the operating surgeon. Results. Patients on the knee pain map most often recorded sharp/stabbing pain (72%), followed by diffuse dull pain (14.5%), mixed dull and sharp pain (10 %) and burning pain (3.5%). 78 % of the localising pain pattern recorded on the knee pain map by the patients corresponded to the intra articular lesion found during knee arthroscopy. 18 % of the pain mapping location and pattern were not very specific to the intrarticular arthroscopic lesions and the rest were non specific. Conclusions. The majority of the patients could map the knee pain location and pattern correlating to the knee arthroscopic findings. The results from our study indicate that knee pain mapping can be used as a reliable tool to assist the clinician to determine the specific knee pain patterns correlating with discrete pathologic findings knee intra articular lesion

Introduction. Patients who present with atypical foot pain in a non specific sensory distribution may benefit from having nerve conduction studies (NCS). The aim of this study was to confirm whether NCS is a useful tool. Methods. Between July 2005 and March 2011, 78 patients had NCS to investigate foot pain. The management following NCS was compared with the initial management plan. Results. Complete data was available for 60 patients, of whom 31 were male. The mean age at presentation was 54.4 years (range 18–89.7). Eighteen patients had bilateral symptoms. The predominant symptom was pain in 47 patients. Aching, burning, throbbing, shooting, pins and needles, proximal/distal radiation, numbness, and paraesthesia were also described in 23 patients. Twenty patients had a history of trauma and five developed symptoms following elective lower limb surgery. Eight patients had a cavovarus foot. There were 22 normal results. The NCS diagnosed peripheral nerve (13)/nerve root (8) pathology, Charcot-Marie-Tooth (1), amyotrophic lateral sclerosis (1), tarsal tunnel syndrome (3), and nonspecific neuropathy (12). Surgery was initially considered for 9 patients. Following a normal result, 4 out of 7 had surgery. One patient with an abnormal result proceeded to surgery. The NCS was abnormal in 70.1% (36/51) of patients who were for nonoperative management, 4 of whom proceeded to have surgery. None of the patients who had a normal NCS had an operation. Conclusion. NCS provided a diagnosis for 63.3% of the patients. Following NCS, the management plan changed in 44% of patients who were initially considered for surgery (4/9) and in 7.8% of patients who were initially considered for nonoperative management (4/51). This investigation is a useful adjunct in guiding the management of patients who present with atypical non specific foot pain

Introduction and Aims: The Lateral Femoral Cutaneous Nerve is placed at risk of iatrogenic injury in the dual incision minimally invasive approach THA. A number of trials have indicated rates of injury up to 30%. This clinical and cadaver study examined the morphology of the nerve in 101 cadaver specimens and in 78 dual incision THA patients. Method: One hundred and one lateral femoral cutaneous nerves of the thigh were dissected in fresh and formalin embalmed specimens. Dissection was limited to the anterior thigh and the branch pattern of the LFCN recorded. Dual incision patients were followed prospectively and examined with regard to LFCN paraesthesia. Results: Despite the variability of the nerve, three basic morphologic patterns emerged. Approximately 55% had a major medial trunk and smaller lateral branch, 30% involved two distinct large branches and 15% had a trifurcation or other pattern. In our clinical series, over 30% of patients experienced paraesthesia and some experienced a burning dysaesthesia in the distribution of the LFCN. Conclusion: Iatrogenic injury to the LFCN is relatively common in the dual incision minimally invasive THA and patients must be informed of such a risk. Based on this study we have slightly modified our incision and approach

Aims

Mendelian randomization (MR) is considered to overcome the bias of observational studies, but there is no current meta-analysis of MR studies on rheumatoid arthritis (RA). The purpose of this study was to summarize the relationship between potential pathogenic factors and RA risk based on existing MR studies.

During revision hip surgery, damage to the sciatic nerve is due most commonly to excessive tension. While the nerve is strong in tension and is able to tolerate this remarkably, it is sensitive to lateral compression against angled structures and it is likely that tension causes injury by such pressure. In a personal series of 441 revision hip procedures, sciatic nerve injury occurred in 9 recognised cases:. 2 were complete with no useful recovery. 2 were severe with some incomplete recovery. 3 were predominantly lateral popliteal with incomplete recovery. 2 were transient and clinically fully recovered. In only two of these were the cause and the time of injury identifiable. In these cases, pain was not a serious feature but in eight separate medico-legal cases, burning pain of variable distribution has been the most serious complaint. Medical negligence has been successfully sustained on the grounds of res ipsa locitur. Regrettably, patients must be given informed consent with yet another potential hazard being listed. We have found that in normal individuals the range of straight leg raising varies between 30 and 90 degrees. Towards the limit of this range the nerve is tight and a crude cadaveric test indicated a tension force of 40 newtons! In an athlete this may be extreme and yet the nerve does not complain. Excluding direct compression (e.g. by a retractor) and thermal injury, we suggest that the tension developed during unguarded straight leg raising while the patient is still anaesthetised is a serious risk factor. After even conservative lengthening, the tension rises alarmingly during such action. It is possible that pre-existing lumbar degenerative disk disease can contribute to the hazard and be source of pain

Femoral nerve block is a reliable and effective method of providing anaesthesia and analgesia in the peri-operative period but there remains a small but serious risk of neurological complication. We aimed to determine incidence and outcome of neurological complications following femoral nerve block in patients who had major knee surgery. During the period January 2003 to August 2008, medical records of all patients undergoing knee surgery by Dr Myles Coolican and Dr David Parker, who had been administered femoral block for peri-operative analgesia, were evaluated. Patients with a neurological complication were invited take part in the study. A detailed physical examination including sensory responses, motor response and reflexes in both limbs was performed by an independent orthopaedic surgeon. Subjective outcome and pain specific questionnaires as well as clinical measurements were also collected. Out of 1393 patients administered with femoral nerve block anaesthesia during this period, 28 subjects (M:F= 5:23) were identified on the basis of persistent symptoms (more than three months) of femoral nerve dysfunction. All the patients had sensory dysfunction in the autonomous zone of femoral nerve sensory distribution. The incidence of neurological complications was 2.01%. One patient was deceased of unrelated causes and five patients declined to participate in the study. 14 patients out of the 22 have been examined so far. Nine cases had a one shot nerve block and five had continuous peripheral nerve block catheter. Areas of hypoesthesia/anaesthesia involving femoral nerve distribution occurred in 7 subjects and hyperaesthesia/paresthesia occurred in four. One subject had a combination of hypoesthesia and hyperesthesia in different areas of the femoral nerve distribution. Three subjects had bilateral symptoms following bilateral simultaneous nerve blocks. Dysesthesias in the affected dermatomes were found in seven cases and paresthesias were found in eight cases. Douleur Neuropathique en 4 questions (DN4) score of ï. 3. 4 was found in all the patients (average value: 5.55). The average scores for tingling, pins and needles and burning sensation (in a scale from 0 to 10) are 3.8, 3.1 and 2.9 respectively. The incidence of persistent neurological complication after femoral nerve block in our series is much higher compared to the reported incidence in the contemporary literature (Auroy Y. et al. Major complications of regional anesthesia in France: Anesthesiology 2002; 97:1274 80). The symptoms significantly influence the quality of life in the affected cases and question the value of the femoral nerve block in knee surgery

Introduction. The reduction of intraoperative blood loss during total knee arthroplasty (TKA) and total hip arthroplasty (THA) and even organ resection is an important factor for surgeons as well as the patient. In order to cauterize blood vessels to stop bleeding diathermy is commonly used and involves the use of high frequency and induces localized tissue damage and burning. Saline-coupled bipolar sealing RFE technology however has been shown to reduce tissue carbonization, however the dosage effects of RFE are not well known for both bone and soft tissue. This study examined sealing progression of blood vessels using a range of energy levels of saline-coupled bipolar RFE on bone and various soft tissues in a non-survival animal study. Materials and Methods. Following institutional ethical approval, three mature sheep were used to examine the cancellous bone of the femoral trochlear groove and soft tissue (liver, kidney, lung, pancreas and mesentry peritoneum) subjected to the following treatment regime varying by watts and time: (1) untreated control, (2) 50 W for 1 sec, 2 sec, 3 sec and 5 sec, (3) 140 W for 1 sec, 2 sec, 3 sec and 5 sec and (4) 170 W for 1 sec, 2 sec, 3 sec and 5 sec. The Aquamantys™ System Generator and hand piece (Salient Surgical Technologies, Inc, Portsmouth, NH) coupled to a saline (0.9% NaCl) drip was used to apply RFE to the various tissues. Two clinical diathermy settings were used as controls. Tissues were immediately harvested, fixed in 10% buffered formalin and prepared for routine paraffin histology. Stained sections were evaluated in a blinded fashion for the acute in vivo response. Result. Soft tissue histology treated with the Aquamantys System revealed varying degrees of coagulation and blood vessel sealing. Initial observations were indicative of hemostasis. Once RFE and saline were applied to the tissues, the blood vessels constricted and platelets were observed along the blood vessels to provide a seal to cover the break in the vessel wall. No smoke or char formation was evident when this system was placed in contact with the tissues. Higher frequency revealed an increased cluster of platelets along the vessel wall. Saline-coupled bipolar RFE application on bone demonstrated blood vessel sealing and clumping of bone marrow. With increased frequency and time red blood cells clumped together however the most significant observation was that the surrounding bone remained normal and no damage was evident. Diathermy however demonstrated a complete disruption of the collagen fibres. Conclusions. Saline-coupled bipolar RFE can provide many clinical benefits not just during orthopaedic reconstruction but also during spine surgery and clinical oncology. The use of high frequencies for longer periods of time enables complete sealing of blood vessels without damage to the tissue or bone

Thermal capsular shrinkage presents the prospect of reducing redundant capsule, and therefore may be a suitable method of treating capsular-type instability. A prospective study of fifty-four consecutive patients (58 shoulders) treated exclusively with radiofrequency capsular shrinkage for atraumatic instability. The mean Rowe score improved from 33.1 to 74.1 points at followup of up to 48 months. Twenty of the fifty-eight shoulders had recurrence instability. Recurrent instability was related to the type of instability: 76.9% for voluntary instability, 30.3% for involuntary instability and none of 12 shoulders for instability/impingement pain. Recurrence was related as well to previous instability surgery (70%). The outcome was not related to the direction of instability, type of radiofrequency probe used, age of patient or ligamentous laxity. Twenty-two (57.9%) of thirty-eight patients returned to their pre-instability level of sporting activity. By using repeated RF treatments for the failed thermal shrinkage cases the failure rate was reduced from (20/58) 34.5% to (13/58) 22.4% and cumulative changes were seen on electron microscopy. These results are comparable to some of the results for open inferior capsular shift for patients with multidirectional instability with substantial less morbidity. The application of the minimal effective energy is controlled according to the tissue response without any charring or burning effect to the tissue. No scar was seen in repeated arthroscopies, or in electron microscopy studies. Thermal shrinkage does not negatively affect a later open stabilisation, but rather may provide better conditions for secure open surgery. We have found significant improvement in proprioception following thermal shrinkage treatment. We believe that by re-tensioning the proprioceptors they begin to fire off at lesser degrees of movement, and that there is a greater dynamic muscular contribution to shoulder stability. When using the correct technique for the right indications, Radiofrequency thermal shrinkage is a viable alternative to open inferior capsular shift in patients with capsular type of instability

Introduction: The treatment with epidural steroids and local anaesthetic for radicular pain arising from nerve root compression is a commonly utilised and recognised treatment. The aim of this study is to determine the efficacy of CT-guided injection of epidural steroids without anaesthetic for radicular pain but without clinical neurology in the presence of a degenerative of lytic spondylolisthesis and concomitant foraminal narrowing. Method: The study subjects, 21 in total, were selected over a 1-year period by the surgeon. All patients had either degenerative or lytic spondylolisthesis as determined by CT, MRI and plain film and were suffering from radicular pain – sharp, shooting and burning in the L5 or S1 dermatome. For inclusion, there had to be no associated evidence of nerve root compression. All patients completed, prior to epidural therapy, a pain diagram, visual analogue scale (VAS) of pain severity on a scale of 1 to 10 and Oswestry Disability Index (ODI). The MRI and clinical pain picture were correlated. The level of the spondylolithesis was determined. Highly selective CT-guided epidural steroid injection was then carried out at the level of spondylolithesis by an experienced interventional radiologist. The pain diagram, VAS of pain severity and ODI were all completed again by the subjects themselves or by telephone at 1 and 3 months after injection in the presence of an independent assessor (nurse) and then reviewed and discussed with the treating doctor. All subjects were also asked to complete a functional questionnaire. Results: One month after injection 86% of those treated had greater than 50% radicular pain relief and from this group 72% had radicular pain reduction of greater than 80%. All had improvement in function. All of the above, confirmed that their quality of life had certainly improved. Three months after injection 76% of those treated still had a reduction in their radicular pain of greater than 50% (92% of these still had pain reduction of over 80%). Again all reported continued functional improvement. Discussion: Despite the small sample size, this study highlights the short-term Benefit of CT-guided steroid epidural injections with symptomatic lumbosacral spondylolisthesis and spondylolysis with radicular pain. Pain can be relieved without anaesthesia. The mechanisms of pain relief are speculative

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

Purpose: To document the incidence of neurological lesions and functional outcome following displaced acetabular fractures. Patients and Methods: Prospective review of patients who underwent stabilisation of acetabular fractures in a University Hospital trauma centre. From December 1994 to November 2000 136 patients were identified with acetabular fractures. The open reduction and internal fixation of the acetabular fixation was performed by standard operative techniques. The time from the initial injury to the operation ranged from 24 hours to I4days. Patients with sciatic nerve injuries were prospectively followed up and long-term outcome recorded. Weakness or absence of dorsiflexion or plantar flexion was graded according to the standard Medical Research Council. Abnormalities of sensation, including absent or diminished sensation to light touch and pinprick as well as dysesthesia or hyperesthesia of the dorsal and plantar aspects of the foot were recorded. None of the patients had an injury of the spinal cord. Intra-operative monitoring was performed in most cases, and routine electromyography and nerve -conduction studies were done post-operatively and at least on one more occasion to record the level and severity of the lesion and to monitor progress of recovery. All the patients were followed up clinically in the trauma clinics and functional improvement was routinely assessed. The mean follow up of the patients was 3.4 years (range 1.5–6 years). Results: Out of 136 patients who underwent stabilisation of acetabular fractures there were 27 (19.8 %) cases of neurological lesions. In 12 cases the femoral head was dislocated posteriorly. Twenty were men and eight were woman. The mean age was 33.8 (range 16–66). 15 patients had associated injuries. The mean ISS was 12.6 (range 9–34). At initial presentation there were 13 patients with a complete dropped foot lesion, 10 patients with foot weakness and 4 patients with burning pain and altered sensation over the dorsum of the foot. Intra-operative monitoring was performed in 16 cases. All the patients had EMG studies for neurophysiological assessment of the lesion. EMG studies revealed sciatic nerve lesions in all the cases but in nine patients with a dropped foot there was evidence of a proximal (sciatic) and distal (neck of fibula) lesion, “double crush syndrome”. Only in 3 of these cases there was documentation of an ipsilateral knee injury. In two patients there was deterioration of foot function after surgery due to iatrogenic damage. At final follow-up, clinical examination and associated EMG studies revealed full recovery in 5 cases with initial muscle weakness (mean time 4.2 years (2–5)) and complete resolution of sensory symptoms (burning pain and hyposthesia) in 4 cases (mean time 3 years (2–4)). There was improvement of functional capacity (motor and sensory) in two cases with initially complete drop foot and in 4 cases with muscle foot weakness (mean time 3.6 years (range 2–6). In 11 of the cases with dropped foot (all nine with “double crush”) at presentation, there was no improvement in function, (mean time 3.9 years (range 2–6). Conclusion: Acetabulum fractures associated with sciatic nerve injuries continue to be a significant cause of long-term morbidity in trauma patients. In cases where there is evidence of “double crush lesions” the prospect of functional recovery is low as seen in this group of patients. Single lesions appear to be associated with a more favourable prognosis