Restoration of normal anatomy following a distal radial fracture is an important factor in determining functional recovery. However, current methods of assessing dorsal tilt and displacement require ‘true’ lateral radiographs, and important reference points are often obscured by metalwork.

Aims: To investigate if an easily identifiable and predictable relationship exists in the normal wrist between the distal radius and lunate; and if so, to compare fractured wrists (pre and postoperatively)using conventional and new assessment methods.

Methods: 22 patients with displaced distal radial fractures treated by ORIF, were included. Patients had pre and postoperative radiographs taken of the injured and uninjured wrists. From true lateral radiographs, measurements were performed using the PACS system. A line was superimposed upon the dorsal radial cortex at least 2cm proximal to the wrist and extending distally. The following measurements were performed: lunate height, distance from the ‘line’ to the superior and inferior poles of the lunate, and conventional measurements of dorsal tilt and angulation.

Results: Uninjured wrist: Most noticeably the dorsal radial line always passed superior to the lunate, mean distance of 3.27mm (1.75–6.6mm). As a ratio, the distance from the line to the superior pole of the lunate divided by the distance to the inferior pole (‘lunate ratio’) had a mean of 0.16 (0.11–0.19).

Fractured wrist, PreORIF: Using conventional methods, the mean fracture displacement was 2.64mm (0–5.1mm) and the mean dorsal tilt was 23.3 degrees(4 degrees volar tilt to 43 degrees dorsal tilt). Using the dorsal reference ‘line’, in all cases the lunate was either above or transected by the line; mean lunate ratio of 1.61 (0.54–8.05). The mean height of the lunate projecting dorsal to the line was 9.5mm (6.1–16.1mm).

Fractured wrist, PostORIF: Apart from one radiograph, the ‘line’ passed superior to the lunate; mean distance of 2.64mm (0–3.9mm), with a mean lunate ratio of 1.13 (0.61–2.74). These measurements correlated well with measurements of dorsal tilt and displacement.

Discussion: Our study suggests that there is a strong relationship between the distal radius and the lunate that could be used to assess fracture displacement and quality of reduction. Its main advantages are simplicity and ease of use despite the presence of metalwork.

Aim: To assess the ability of volar locking plates to maintain fracture reduction when used to treat dorsally displaced extra and intra-articular distal radial fractures.

Methods: This prospective study was conducted over a 12 month period. Consenting patients who had sustained a closed, dorsally displaced distal radial fracture, treated by open reduction and internal fixation using a volar distal radial locking plate, were included in the study. Radial inclination, volar tilt and ulnar variance were measured from radiographs taken at least 3 months after surgery and compared with radiographs of the uninjured side. Only two of the eight participating surgeons have a specialist interest in upper limb surgery.

Results: Thirty-three patients were included in the study. There were 23 females and 10 males. The mean age was 49.5 years, range 26–82 years. According to the OTA classification there were 19 Type A, 1 Type B and 13 Type C fractures. The mean restoration of volar tilt was 1° of under-correction, median 1.1° under-correction with a range of 7.3° of under-correction to 3.7° of over-correction, when compared with the uninjured side. The mean restoration of radial inclination was 1.9° of under-correction, median 1.6° under-correction with a range of 10° of under-correction to 8.4° of over-correction. As a group the mean ulnar variance was 0mm with a range of 2mm of relative ulnar shortening to 3.5mm of ulnar prominence when compared with the uninjured side.

Conclusion: In the hands of general trauma surgeons, the volar approach combined with the application of a suitable volar locking plate is a good treatment for restoring and maintaining the anatomy of dorsally displaced intra and extra-articular distal radial fractures.

Aims: In recent years, volar locking plates have increased in popularity for the treatment of displaced distal radial fractures. The angular stability of the screws help maintain reduction permitting early mobilisation. The aim of this study was to assess functional outcome using both subjective and objective methods.

Methods: The study was a prospective cohort study. Over a 2 year period 110 patients with closed, displaced distal radial fractures were considered suitable for treatment with the distal radius volar locking plate. Of these, 51 patients were followed up for a full 12 months. One year post-operatively all patients were reviewed and both subjective and objective measurements made:

Subjective:

Pain – visual analogue scale (VAS) (0 = no pain, 10 = worst pain ever).

For the purpose of this analysis, the fractures were divided into intra- and extra-articular fracture patterns based on the initial pre-operative X-rays.

Results: The mean age was 55 years (28 – 83), 36 were female and 15 male. Of the fractures, 26 were extra-articular and 25 intra-articular. 28 of the 51 patients had a period of physiotherapy post-operatively. 23 patients were either not referred to physiotherapy or failed to attend.

Subjectively 75% of patients had an excellent result with a pain VAS score of 0–1/10 (mean 0.9 for extra-articular and 1.2 for intra-articular) and an overall function VAS score of 9–10/10 (mean 92% for extra-articular and 86% for intra-articular).

Objective outcome measures were also very good. The results for the extra-articular group showed a mean grip strength of 85%, a mean pinch grip of 91%, a mean flexion of 82%, a mean extension of 88%, a mean pronation of 98% and a mean supination of 98%. The results for intra-articular fractures showed a mean grip strength of 80%, a mean pinch grip of 88%, a mean flexion of 78%, a mean extension of 83%, a mean pronation of 94% and a mean supination of 93%.

Conclusions: Overall patients made an excellent recovery. The majority of patients had little or no pain and almost complete return to function at 12 months post-operatively. Interestingly, individual patient demographics (age, sex, fracture type, physiotherapy) did not make a statistically significant difference to the outcome measures.

This study confirmed excellent functional results comparable with other methods of fixation for extra-articular fractures, but it also showed good results with the more complex intra-articular fractures.

Restoration of normal anatomy following a distal radial fracture is an important factor in determining functional recovery. However, current methods of assessing dorsal tilt and displacement require ‘true’ lateral radiographs, and important reference points are often obscured by metalwork.

Aims: to investigate if an easily identifiable and predictable relationship exists in the normal wrist between the distal radius and lunate; and if so,to compare fractured wrists (pre and postoperatively)using conventional and new assessment methods.

22 patients with displaced distal radial fractures treated by ORIF, were included. Patients had pre and postoperative radiographs taken of the injured and uninjured wrists. From lateral radiographs, measurements were performed using the PACS system. A line was superimposed upon the dorsal radial cortex 2cm proximal to the wrist passing distally. The following measurements were performed: lunate height, distance from the ‘line’ to the superior and inferior poles of the lunate, and conventional measurements of dorsal tilt and angulation.

Uninjured wrist: Most noticeably the dorsal radial line always passed superior to the lunate, mean distance of 3.27mm (1.75-6.6mm). As a ratio, the distance from the line to the superior pole of the lunate divided by the distance to the inferior pole (‘lunate ratio’) had a mean of 0.16 (0.11-0.19).

Fractured wrist, PreORIF: Using conventional methods, the mean fracture displacement was 2.64mm (0-5.1mm) and the mean dorsal tilt was 23.3 degrees(4 degrees volar tilt to 43 degrees dorsal tilt). Using the dorsal reference ‘line’, in all cases the lunate was either above or transected by the line; mean lunate ratio of 1.61 (0.54-8.05). The mean height of the lunate projecting dorsal to the line was 9.5mm (6.1-16.1mm).

Fractured wrist, PostORIF: Apart from one radiograph, the ‘line’ passed superior to the lunate; mean distance of 2.64mm (0-3.9mm), with a mean lunate ratio of 1.13 (0.61-2.74). These measurements correlated well with measurements of dorsal tilt and displacement.

Our study suggests that there is a strong relationship between the distal radius and the lunate that could be used to assess fracture displacement and quality of reduction. Its main advantages are simplicity and ease of use despite the presence of metalwork.

Introduction: For years traditional intramedullary nails (IMNs) have been used with great success to treat long bone fractures, however, based upon our clinical observations, we hypothesise that design changes incorporated into newer femoral IMNs reduces fracture stability resulting is a higher incidence of non-union.

AIMS: To biomechanically test the factors that may reduce fracture stability.

Materials and methods: The fracture fixation model consisted of custom made stainless steel IMNs of different wall thicknesses and outer diameters, cylinders manufactured from stainless steel, aluminium or HDPE of differing inner diameters and wall thicknesses, and 5mm rods made from stainless steel or titanium. The dimensions of the cylinders were chosen to resemble those commonly observed in the distal femur. The test nails and cylinders were connected using a single rod. Axial loading was undertaken up to 2KN (constant rate of 0.5KN/sec) and repeated a minimum of three times. The effects of various factors such as IM nail wall thickness and outer diameter, the alloy from which the rods were manufactured, and, the diameter, wall thickness and material properties of the cylinders were studied.

Results: The factors that most affected stability were the diameter, wall thickness and the material properties of the cylinders, with the least stable configuration being a HDPE cylinder with a diameter of 75mm and a wall thickness of 3mm. By reducing the diameter of the cylinder to 50mm combined with increasing the wall thickness to 5mm, stability increased considerably even when HDPE was used. The stability of each fracture fixation system was further reduced by using titanium rods.

Discussion: In clinical practice, new femoral IMNs permit longer cross screws to be inserted in the distal femur where the diameter is greatest and the cortical bone is thinnest. Since cancellous bone offers little resistance, screws effectively span from one cortex to the other gaining limited purchase in the bone. As a result, the newer IMN systems are more likely to displace regardless of the direction and force applied. This effect is exaggerated by using titanium. Overall the combination of screw length, choice of alloy and cortical thickness could easily explain our unsatisfactory clinical observations.

Introduction: The knee meniscus is prone to injury and has limited intrinsic healing potential despite surgical repair. Methods to enhance fibrochondrocyte function and augment meniscal repair would be invaluable in the treatment of meniscal injuries. Ultraviolet Ozone (UVO) modified surfaces have been characterised chemically and topographically. These surfaces have been shown to promote the function of certain cell types. This study investigated the attachment, proliferation and extracellular matrix production of fibrochondrocytes cultured on UVO modified polystyrene surfaces. Interest was paid to the integrins, a group of transmembrane extracellular matrix attachment glycoproteins. In particular the subunits alpha2 and alpha5, as they specifically bind to the ligands Collagen Type I and Fibronectin, major components in the human meniscus.

Methods: Tissue samples from adult human medial meniscal tears were obtained at knee arthroscopy. Fibrochondrocytes were isolated by standard cell culture techniques and cultured to 100% confluence before seeding onto UVO modified polystyrene surfaces. The untreated polystyrene surfaces of culture dishes were oxidatively modified with an ultraviolet ozone treater. The response of fibrochondrocytes to various surface oxygen concentrations was investigated. Untreated, hydrophobic surfaces acted as controls. Images of cells in culture were obtained with a Leica digital camera mounted on a microscope. Cells were counted at 24, 48, 72 and 96 hours. After 48 and 96 hours of culture standard wet transfer Western Blots were undertaken using antibodies to the alpha2 and aalpha5 integrin subunits (Santa Cruz Biotechnology). To evaluate potential extracellular matrix production total protein assays were undertaken at 1, 2, 3, 4, 6, 8 and 10 days of culture (Bio-Rad Laboratories).

Results: Fibrochondrocytes attached preferentially to the UVO treated surfaces. They proliferated steadily until they reached confluence at 96 hours. Western Blot analysis showed the integrin subunit a5 to be present in the cell lysate after both 48 and 96 hours of culture. The a2 subunit was not detected at these times. There was no increase in total protein concentration on surfaces after fibrochondrocytes had reached confluence. Discussion: UVO modified surfaces promote the attachment and proliferation of human fibrochondrocytes. The alpha2 subunit was not detected in the cell lysate of these surfaces after culture for 96 hours. Whether this is due to defective or absent Collagen Type I at this stage of culture remains to be answered. The presence of the alpha5 subunit suggests that Fibronectin may be involved in the process of fibrochondrocyte attachment to UVO modified polystyrene surfaces. It is suggested that there is little or no extracellular matrix production after 4 days as there is no increase in total surface protein concentration after confluence is reached. The increase in total surface protein concentration up to this point most likely reflects cell proliferation.

Conclusion: Ultraviolet Ozone modified surfaces enhance certain aspects of fibrochondrocyte function and therefore have a potential role in the development of novel therapies for meniscal repair.

Background: There is a huge controversy regarding the period of immobilization after Bankart stabilisation. This ranges from 2 days to 5 weeks for open repair and from 3 to 6 weeks for arthroscopic Bankart repair. We believe it is inappropriate to immobilise the operated shoulder after Bankart repair. In our study all the patients were allowed to use their arm, the same day, pain permitting. No restrictions were imposed for the type and range of movement for those who had open repair. With arthroscopic repair they were asked to limit their shoulder abduction upto 45-degreee and external rotation to neutral.

Method: In this retrospective study (1998–2003) we have analyzed the outcome of mobilisation of operated shoulder on the same day.43 primary stabilisations were performed by the senior author.one patient was uncontactble. We reviewed the records of 42 patients. Subsequently the General Practitioners were contacted to collect information about these patients and the patients were contacted, if needed. Out of 42 patients 34 were males and 8 females. 35 patients had an average of 7 episodes of anterior shoulder dislocations (range 2–25), 7 had unstable shoulder pre-operatively.30 had open repair, 12 had arthroscopic stabilisation. The average follow-up is 3.5years(1–6 years).

Result: 41 patients did hot have any further episode of frank anterior shoulder dislocation and they had returned to their previous level of activities. Only one patient injured his operated shoulder year later while playing football. He underwent arthroscopic capsular shrinkage for traumatic deformation of the capsular and inferior glenohumeral ligament.

Conclusion: In primary straightforward Bankart stabilisation, same day mobilisation does not increase the risk of anterior shoulder dislocation

Introduction and Aims: To assess the effects of the various stages of intra-medullary (IM) nailing of the tibia upon intra-compartmental pressure (ICP) measurements, with particular emphasis on factors which reduce the pressure.

Method: Using sensitive transducer-tipped pressure monitors, the anterior compartment pressure was recorded throughout IM nailing of tibial shaft fractures in 34 consenting patients.

Results: Significant peaks in ICP, up to 140mmHg, occurred during reaming and nail insertion, with a sustained elevated pressure phase seen following nail insertion (p< 0.01). In those patients with no fracture distraction visible on fluoroscopy following nail insertion, this pressure was relieved by the release of traction (mean reduction 16.79mmHg, p< 0.01). However, in those with a visible fracture gap, traction release was not sufficient, and impaction of the fracture after distal cross-screw insertion was required to achieve baseline levels in this group (mean reduction 15.29mmHg; p< 0.01).

Conclusions: Using the various pressure criteria for diagnosing ACS, some of our patients either had, or were at considerable risk of developing ACS post-operatively. Furthermore, if fracture impaction had not been performed where necessary, the subsequent sustained increase in ICP would have resulted in additional patients fulfilling the diagnostic criteria for ACS. Clearly, this observation may explain the tendency for some distracted fractures to fail to unite as a result of ischaemia, but of greater significance is the potential for ACS to occur in the post-operative period, leading to significant long-term complications. We recommend that, if traction is used, it is released as early as possible following nail insertion, and that the fracture should be impacted following distal cross-screw insertion if there is visible distraction of the bone ends on fluoroscopy following nail insertion.

Introduction and Aims: There has been a lack of studies investigating the effect of cytokines on human meniscal cartilage. We investigated the regenerative potential of meniscal cartilage at different zones of human and sheep menisci under the effect of platelet-derived growth factor AB (PDGF-AB), insulin-like growth factor I (IGF-I), and basic fibroblast growth factor (bFGF) in a dose-dependent manner.

Method: Monolayer cell cultures were prepared from the inner (avascular), middle, and outer (vascular) zones of human and sheep lateral menisci. Fibrochondrocytes were exposed to various concentrations of each of the three growth factors. To assess cell proliferation, 3H-Thymidine uptake assay was used. For assessment of matrix formation, radioactive 35S uptake assay and Blyscan assay were used to assess newly formed glycosaminoglycans (GAGs), 14C-Proline uptake assay and ELISA were used to assess newly formed collagen.

Results: The growth factors under investigation stimulated the fibrochondrocytes isolated from all meniscal zones in a similar dose-dependent fashion. In human meniscal cells, PDGF-AB at a concentration of 200 ng/ml stimulated proliferation by up to four-fold and GAGs synthesis by up to 12-fold (p < 0.001). IGF-I and to a lesser extent bFGF, at concentrations of 100 and 200 ng/ml, also stimulated both cell proliferation and matrix formation in all three meniscal zones (p < 0.001). PDGF and to a lesser degree IGF at concentrations of 100 and 200 ng/ml have stimulated collagen type I synthesis by up to two-fold.

Conclusion: The results of this study indicate that fibro-chondrocytes originating from the avascular zone of the meniscus have the ability to proliferate and to regenerate their surrounding extracellular matrix when exposed to growth factors. This is an encouraging observation that will form the basis for in vivo research, aimed at enhancing meniscal repair, even within the avascular zone, following surgical repair.

Aims: To assess the effects of the various stages of intramedullary (IM) nailing of the tibia upon intracompartmental pressure (ICP) measurements, including new factors such as fracture impaction. Methods: Anterior compartment pressure monitoring was performed on 25 consenting patients undergoing IM nailing for tibial shaft fractures, using a sensitive transducer-tipped pressure monitor. Results: Signiþcant peaks in ICP, up to 130mmHg, occurred during reaming and nail insertion. Although the ICPs recorded post-operatively (32.79mmHg; range 10 to 68mmHg) were higher than the initial recordings (25.83mmHg; range 8 to 61mmHg), the change was not statistically signiþcant. Reduction of ICP was achieved through release of the traction, but the greatest drop in ICP followed impaction of the fracture after distal cross screw insertion (mean drop 21.75mmHg; range 5 to 58mmHg; p< 0.01). Conclusions: Using the various criteria for diagnosing acute compartment syndrome (ACS), some of our patients either had, or were at considerable risk of developing ACS postoperatively. Furthermore, if fracture impaction had not been performed where necessary, the subsequent sustained increase in ICP would have resulted in additional patients fulþlling the diagnostic criteria for ACS. Clearly, this observation may explain the tendency for some distracted fractures to fail to unite as a result of ischaemia, but of greater signiþcance is the potential for ACS to occur in the postoperative period, leading to signiþcant long term complications.

Aims: This study investigated the regenerative potential of different parts of human and sheep menisci when exposed to PDGF-AB, IGF-I, and bFGF in a dose dependent manner. Methods: Monolayer cell cultures were prepared from inner, middle, and outer zones of the lateral menisci of sheep and from humans obtained following total knee replacement and partial meniscectomy. Various concentrations of each of the three growth factors were used in addition to control samples. Wemeasured the incorporation of Radio-labelled thymidine to assess cell proliferation and radioactive sulphate and radio-labelled proline to assess matrix formation. Results: Both PDGF-AB and IGF-I have a signiþcant effect in promoting both þbrochondrocyte proliferation and matrix formation in the all meniscal zone zones at 100 and 200 ng/ml (p< 0.001). However, cells isolated from the inner avascu-lar zone of the meniscus showed a higher response than those isolated from the outer vascular zone. bFGF has also stimulated both cell proliferation and matrix formation, but to a lower degree in comparison to PDGF-AB and bFGF, in all meniscal zones of sheep meniscus (p< 0.05). Whereas, in humans, bFGF stimulated only cell isolated form the inner zone of the meniscus (p< 0.05). Conclusions: These results indicate that the meniscal tissue in the avascular zone has the ability to regenerate when exposed to growth factors such as PDGF, IGF-I, and bFGF. This could improve the therapeutic methods to treat meniscal injuries and, ultimately, reduce the incidence of osteoarthritis of the knee.

We discuss the role of primary knee arthroplasty in supracondylar and intercondylar fractures of the femur in elderly patients with reference to 13 cases. This method of treatment is shown to be effective and to have good results. It is recommended for all type C and some type A supracondylar fractures in old people.