A retrospective review of 51 consecutive patients undergoing fixation of Scaphoid fractures by two surgeons in a single institution was conducted. Twenty-four patients were treated with a Herbert screw and twenty-seven with an Acutrak screw. This included six patients who underwent acute fixation, three in each group. The remaining cases were for the treatment of non-union and delayed union.

There were no significant differences between the two groups in terms of age, side of injury, and mechanism of injury. Fractures were classified as proximal, middle and distal thirds of the Scaphoid and there was no significant difference between the groups regarding the types of fractures treated. The only significant difference between the groups was the time from injury to fixation when considering the cases of delayed union and non union which was greater in the Herbert screw group (7.5 months vs 4 months p=<0.05).

There was no significant difference in outcome between the two methods of fixation. Union rates for all cases were 79% for Herbert screws and 81% for Acutrak screws and 82% and 83% respectively when only considering the delayed union/non-union procedures. There was no difference in terms of time to union, further surgery or clinical outcome between the two groups. The Acutrak screw required removal in five patients and the Herbert screw in two due to symptoms from screw prominence. This was not statistically significant.

In conclusion there is no significant difference in surgical outcome between these two methods of fixation for Scaphoid fractures. The authors feel that this supports the view that biological factors are more important than the method of fixation in obtaining union of Scaphoid fractures.

Aggressive digital papillary adenocarcinoma (ADPACa) is a rare skin adnexal tumour, which has a predilection for the digits. We report a case with this tumour in a 51 year old insulin dependent diabetic man, who presented as a paronychia of right index finger. After histopathological confirmation as an ADPACa partial amputation was performed. This case emphasizes the presentation of this tumour as a simple nail bed infection occasionally.

Aim: To review results and complications of revision knee replacements.

Materials and Methods: We retrospectively reviewed 41 cases of cemented revision knee arthroplasty in 39 patients (15 male, 24 female) performed between 1993 and 2003. Data regarding clinical and functional outcomes and complications was recorded.

Results: Mean age at index (revision) operation was 67.8 years (32 to 86) and mean follow-up was 6.8 years (1.5 to 12). Average time to revision was 80 months (9 months to 23 years).

The indication for revision was aseptic loosening in 16 cases, and deep sepsis in 13 cases, (12 were done in 2 stages). Others included polyethylene wear in 4 knees, instability in 2, and 1 each of peri-prosthetic fracture, implant breakage and pain of undetermined origin. 3 revisions were performed for failed Link Lubinus patello-femoral replacement. Mean interval between staged procedures for sepsis was 2 months.

Reconstruction was performed using the Kinemax Revision system with the use of augments and stems. The modular rotating hinge was used in 4 cases. Surgical exposure included additional lateral release in 7 cases, tibial tubercle osteotomy in 4 and quadriceps snip in one.

Complications: Included 1 post-operative death due to haematemesis and 2 non-fatal cardiac complications. 1 patient was re-revised for aseptic loosening at 3.5 years, 1 needed an above knee amputation for intractable sepsis after multiple failed reconstructions and 1 is awaiting patellar revision.

At latest review, 7 patients had died due to unrelated causes with a pain free functioning knee prosthesis. Of the remaining 31, 26 patients had none or minimal pain. 21 were independently mobile with a satisfactory range of motion.10 patients needed a walking stick.

Conclusion: Revision total knee replacement can give satisfactory results in the short to medium term, although the complication rate can be significant. The procedure should be performed in specialist units. Revision in 2 stages for sepsis resulted in satisfactory control of infection in our study.

The AO, Frykman, Mayo and Fernandez classification system for distal radius fractures were evaluated for interobserver reliability and intraobserver reproducibility using plain radiographs. Five orthopaedic consultants, five orthopaedic registras and five orthopaedic senior house officers classified 20 sets of distal radius fractures on two seperate occasions. There were 2400 induvidual observations. Kappa statistics were used to establish a relative level of agreement between observers for the two readings and between seperate readings by the same observer. Our results for intraobserver reproducibility showed Fernandez Kappa value of 0.49, Frykman 0.47, Mayo 0.45 and AO 0.33. A 0.4 result shows good consistecy accorcing to well reconised staistical boundries and is significant. That is reproducibility happened at a level greater than by chance. Interobserver Kappa values were poor in all classification systems. We also sought to look at varibles within grade of surgeon and developed Kappa values for these also.

Purpose: To evaluate the objective outcomes in patients who had undergone hardware removal after ORIF of calcaneus fractures.

Materials and Methods: Between 1994 and 2002, 31 cases of hardware removal was performed in 30 patients (25 male, 5 female) with an average age at operation of 47 years (31 to 65 years) were reviewed. Patients’ demographic details were recorded including smoking habit. Fracture patterns were graded according to the Sanders’ classification with preoperative CT scans. The clinical result was assessed using Bristol hind foot scoring system. Serial radiographs assessments were also recorded.

Results: Average follow-up was 4.5 years. Average delay from time of injury to surgery was 12.4 days (range 5 to 24 days). 7 (23%)fractures were Sanders’ type 2A, 8 (26%)fractures were type 2B, 6 (19%)fractures were type 2C, 2 (6%) fractures were type 3AB and 8 (26%) fractures were type 3AC. Average time from surgery to hardware removal was 27 months (range 11 to 45 months). There were 16 smokers and 14 non-smokers. There were 5 deep infections and 3 superficial wound infections after ORIF of calcaneus fractures. 84% of the patients shown objective improvement following hardware removal at the latest follow-up. 2 patients had unsuccessful hardware removal due to dense scarring. No wound infections were recorded. Smoking habit had no significant bearing on the objective outcome improvement following hardware removal (p= 0.891), time from surgery to hardware removal (p=0.53) and wound morbidity (p= 0.4882). Objective improvement showed a statistically significant improvement in the Sanders’ type 2 compared with Sanders’ type 3 (p=0.015).

Conclusion: Removal of hardware is justified in symptomatic patients following ORIF calcaneus fractures. It results in an improved objective outcome and has a low complication rate. Hardware removal may be considered in cases of Sanders’ type 2 calcaneus fractures which are refractory to improvement.

Introduction: The lower limb deformities in relation to hip dysplasia and genu valgum seen in Hurler’s Syndrome are well recognised. Bone marrow transplantation has improved the survival of patients with Hurler’s Syndrome, reversing many of the clinical features associated with it. This is of increasing importance because the musculoskeletal manifestations do not appear to be affected.

Methods: Between 1990 and 2003, 18 patients have been successfully engrafted and have been followed up for a mean of 6.8 years (range 18 months to 15 years) at Royal Manchester Children’s Hospital. We describe the lower limb problems and their management in these patients. We report on their skeletal development following successful transplant. Radiographic analysis was done using the following measurements where possible – acetabular index, centre-edge angle, migration percentage, femoral neck-shaft angle and tibio-femoral shaft angle.

Results: Of the 18 patients, one has had bilateral staged shelf acetabuloplasty and bilateral staged medial epiphyseal stapling (MES) of the upper tibia. The second patient has had bilateral upper tibial MES.

Discussion: There is very little in the literature on the long-term natural history of the orthopaedic manifestations of Hurler’s Syndrome after bone marrow transplantation. Presently there is no consensus as to the best management of the lower limb problems in this disorder. Well conducted long-term follow up is essential.