This novel modification of the posterior approach allows a low hazard exposure and easier surgery to the radial head.

Methods and Materials: The most commonly used approaches are from the lateral aspect. The limitations of this approach in particular for radial head replacement is that it is a tight exposure, there is a risk of damage to the posterior interosseous nerve and there is always a difficulty in dislocation due to the presence of the interosseous membrane. The posterolateral approach to the proximal radius and ulna was described by Boyd, Gordon and Thompson. This approach avoids damage to the posterior interosseous nerve but the annular ligament requires incision and repair.

Approach: Position the forearm in pronation aligning the ulnar styloid with lateral epicondyle of the humerus. A tencentimetre long incision is then made on the lateral border of the ulna exposing deep fascia. Following this a 1cm flap of fascia is left on the ulna and anconeus is lifted off the bone. This exposes underlying radial head, annular ligament and interosseous membrane. After identifying the ulnar insertion of annular ligament a 0.5 cm bone is osteotomised with annular ligament attached from the supinator tuberosity. The radial head osteotomy is performed with the radial head in pronation to align it with shaft of radius using specially designed jig. Osteotomy of the radial head has to be at right angles to the axis of the forearm. This is a line between centre of the radial neck to the ulnar styloid process. Radial head can now be subluxed out of the wound and preparing for a replacement. The trial prosthetic radial head is then inserted and reduced. The bone fragment with annular ligament attachment is then reduced back into the original slot. This allows one to judge the size of prosthetic radial head if ligament is too tight a small diameter implant is required. The bone fragment is reattached using especially devised washer with, wire holes and a 2mm AO screw.

Results: This approach is easier, safer and reproducible. When compared to lateral approach it provides an easier access and excellent stability in radial head replacement. We recommend this approach for radial head replacements and difficult trauma cases.

Ulnar drift is a common deformity in the hands of patients with rheumatoid arthritis. There is little in the literature regarding the value of crossed intrinsic transfer with MCPJ arthroplasty (Hellum 1968, Stothard et al 1991). In addition the significance of recurrent ulnar drift on hand function is unknown. The aim of this study is to assess if the addition of crossed intrinsic transfer to metacarpophalangeal arthroplasty has an effect on the recurrence of ulnar drift and to overall hand function.

This is a retrospective comparative study. 73 hands in patients with rheumatoid arthritis undergoing primary 2nd to 5th metacarpophalangeal joint (MCPJ) replacements were studied. In 28 hands a crossed intrinsic transfer was performed and in 45 hands it was not . A similar splintage and rehabilitation programme was followed in each group. Mean follow up was 50 months.

Ulnar drift and active range range of motion, Sequential Occupational Dexterity Assessment (SODA) functional score, patient satisfaction , grip strength.

The two groups had similar preoperative ulnar drift (crossed intrinsic transfer group mean 27 degrees, comparative group 29 degrees, p=0.44). At follow up the crossed intrinsic transfer group had statistically less ulnar drift (crossed intrinsic transfer group mean 6 degrees, comparative group 14 degrees, p=0.01). There was no difference at follow up in active flexion, extensor lag, SODA score, grip strength and patient satisfaction (both groups had 70% improved function).

The natural history of scapholunate ligament injury is unknown. In fact, as far as we can tell, there has been no study examining the long-term natural history of this condition. It has, however, been assumed that the long-term progression of this injury leads to secondary osteoarthritis – scapholunate advanced collapse (the so-called SLAC wrist). In this study, we evaluated the clinical condition of 11 patients with proven scapholunate ligament injuries that had declined further treatment in an attempt to quantify any long-term disability. Whilst there was on-going pain and functional limitation in the injured wrist, there was no rapid progression of the osteoarthritis or SLAC wrist deformity.

We reviewed 25 patients with rheumatoid arthritis who had failure of 26 primary total elbow arthroplasties causing pain and loss of function. Most revision cases required special custom implants to treat varying bone loss and soft-tissue disruption. Assessment showed satisfactory functional results in the patients treated by revision at a mean follow-up period of 35 months. Our review suggests that revision surgery produces short- to medium-term painfree function, and is the treatment of choice for a failed total elbow arthroplasty in the absence of infection.

We studied prospectively the relationship between serum lipids and Dupuytren's disease of the hand in 85 patients, 65 men and 20 women. The Dupuytren patients had significantly higher fasting serum cholesterol and triglyceride levels than did the controls (p < 0.001). The raised levels of serum lipids appeared to be associated with the pathogenesis of Dupuytren's disease, and this may help to explain the high incidence of Dupuytren's disease in alcoholic, diabetic and epileptic patients, since these conditions are also associated with raised serum lipid levels.

A review of seventy-one children with sacral anomalies is presented. The aetiology is discussed and a classification of sacral anomalies is suggested, with three groups of patients: agenetic, dysgenetic and dysraphic. The clinical presentation of each group is discussed and the high incidence of congenital visceral and skeletal abnormalities is indicated in the dysgenetic group. The need for constant urological assessment is emphasised, particularly in the agenetic and dysraphic children.