The condition known as delta phalanx (or longitudinally bracketed epiphysis) is a rare congenital anomaly first described in 1964. The deformity consists of a triangular bone with an epiphysis running along the shortened side of the phalanx in a proximal to distal direction, making longitudinal growth of the digit impossible. Isolated hallux varus congenitus due to a delta phalanx of the proximal phalanges of both great toes is extremely rare: there have been only three such cases reported, two of which were in one family--the only report of a familial occurrence of this deformity. This present report details the occurrence of isolated bilateral hallux varus congenitus in four members of one family, a father and his three eldest children. All three children show bilateral delta phalanx of the proximal phalanges of both great toes. There are associated thumb nail anomalies, but no suggestion of polydactylism

Aims. Understanding of open fracture management is skewed due to reliance on small-number lower limb, specialist unit reports and large, unfocused registry data collections. To address this, we carried out the Open Fracture Patient Evaluation Nationwide (OPEN) study, and report the demographic details and the initial steps of care for patients admitted with open fractures in the UK. Methods. Any patient admitted to hospital with an open fracture between 1 June 2021 and 30 September 2021 was included, excluding phalanges and isolated hand injuries. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture. Demographic details, injury, fracture classification, and patient dispersal were detailed. Results. In total, 1,175 patients (median age 47 years (interquartile range (IQR) 29 to 65), 61.0% male (n = 717)) were admitted across 51 sites. A total of 546 patients (47.1%) were employed, 5.4% (n = 63) were diabetic, and 28.8% (n = 335) were smokers. In total, 29.0% of patients (n = 341) had more than one injury and 4.8% (n = 56) had two or more open fractures, while 51.3% of fractures (n = 637) occurred in the lower leg. Fractures sustained in vehicle incidents and collisions are common (38.8%; n = 455) and typically seen in younger patients. A simple fall (35.0%; n = 410) is common in older people. Overall, 69.8% (n = 786) of patients were admitted directly to an orthoplastic centre, 23.0% (n = 259) were transferred to an orthoplastic centre after initial management elsewhere, and 7.2% were managed outwith specialist units (n = 81). Conclusion. This study describes the epidemiology of open fractures in the UK. For a decade, orthopaedic surgeons have been practicing in a guideline-driven, network system without understanding the patient features, injury characteristics, or dispersal processes of the wider population. This work will inform care pathways as the UK looks to the future of trauma networks and guidelines, and how to optimize care for patients with open fractures. Cite this article: Bone Jt Open 2022;3(10):746–752

Aims. The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK. Method. Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded. Results. Across 51 centres, 1,175 patients were analyzed. Antibiotics were given to 754 (69.0%) in the emergency department, 240 (22.0%) pre-hospital, and 99 (9.1%) as inpatients. Wounds were photographed in 848 (72.7%) cases. Median time to first surgery was 16 hrs 14 mins (interquartile range (IQR) 8 hrs 29 mins to 23 hrs 19 mins). Complex injuries were operated on sooner (median 12 hrs 51 mins (IQR 4 hrs 36 mins to 21 hrs 14 mins)). Of initial procedures, 1,053 (90.3%) occurred between 8am and 8pm. A consultant orthopaedic surgeon was present at 1,039 (89.2%) first procedures. In orthoplastic centres, a consultant plastic surgeon was present at 465 (45.1%) first procedures. Overall, 706 (60.8%) patients required a single operation. At primary debridement, 798 (65.0%) fractures were definitively fixed, while 734 (59.8%) fractures had fixation and coverage in one operation through direct closure or soft-tissue coverage. Negative pressure wound therapy was used in 235 (67.7%) staged procedures. Following wound closure or soft-tissue cover, 509 (47.0%) patients received antibiotics for a median of three days (IQR 1 to 7). Conclusion. OPEN provides an insight into care across the UK and different levels of hospital for open fractures. Patients are predominantly operated on promptly, in working hours, and at specialist centres. Areas for improvement include combined patient review and follow-up, scheduled operating, earlier definitive soft-tissue cover, and more robust antibiotic husbandry. Cite this article: Bone Joint J 2022;104-B(9):1073–1080

This annotation reviews current concepts on the three most common surgical approaches used for proximal interphalangeal joint arthroplasty: dorsal, volar, and lateral. Advantages and disadvantages of each are highlighted, and the outcomes are discussed.

Cite this article: Bone Joint J 2022;104-B(12):1329–1333.

Aims

The aim of this study was to develop a core outcome set of what to measure in all future clinical research on hand fractures and joint injuries in adults.

Aims

This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England.

The Trauma Triage clinic (TTC) is a Virtual Fracture clinic which permits the direct discharge of simple, isolated fractures from the Emergency Department (ED), with consultant review of the clinical notes and radiographs. This study details the outcomes of patients with such injuries over a four-year period. All TTC records between January 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and soft tissue mallet finger injuries were included. Application of the direct discharge protocol, and any deviations were noted. All records were then re-assessed at a minimum of three years after TTC triage (mean 4.5 years) to ascertain which injuries re-attended the trauma clinic, reasons for re-attendance, source of referral and any subsequent surgical procedures. 6709 patients with fractures of the radial head (1882), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and soft tissue mallet finger injures (370) were identified. 963 (14%) patients were offered in-person review after TTC, of which 45 (0.6%) underwent a surgical intervention. 299 (4%) re-attended after TTC direct discharge at a mean time after injury of 11.9 weeks and 12 (0.2%) underwent surgical intervention. Serious interventions, defined as those in which a surgical procedure may have been avoided if the patient had not undergone direct discharge, occurred in 1 patient (0.01%). Re-intervention after direct discharge of simple injuries of the elbow, hand and foot is low. Unnecessary deviations from protocol offer avenues to optimise consumption of service resources

The objective of this study was to investigate how a new customizable light-curable osteosynthesis method (AdFix) compared to traditional metal hardware when loaded in torsion in an ovine phalanx model. Twenty-one ovine proximal phalanges were given a 3mm transverse osteotomy and four 1.5mm cortex screws were inserted bicortically on either side of the gap. The light-curable polymer composite was then applied using the method developed by Hutchinson [1] to create osteosyntheses in two groups, having either a narrow (6mm, N=9) or a wide (10mm, N=9) fixation patch. A final group (N=3) was fixated with conventional metal plates. The constructs were loaded in torsion at a rate of 6°/second until failure or 45° of rotation was reached. Torque and angular displacement were measured, torsional stiffness was calculated as the slope of the Torque-Displacement curve, and maximum torque was queried for each specimen. The torsional stiffnesses of the narrow, wide, and metal plate constructs were 39.1 ± 6.2, 54.4 ± 6.3, and 16.2 ± 3.0 Nmm/° respectively. All groups were statistically different from each other (p<0.001). The maximum torques of the narrow, wide, and metal plate constructs were 424 ± 72, 600 ± 120, and 579 ± 20 Nmm respectively. The narrow constructs were statistically different from the other two (p<0.05), while the wide and metal constructs were not statistically different from each other (p=0.76). This work demonstrated that the torsional performance of the novel solution is comparable to metal fixators. As a measure of the functional range, the torsional stiffness in the AdhFix exceeded that of the metal plate. Furthermore, the wide patches were able to sustain a similar maximum toque as the metal plates. These results suggest AdhFix to be a viable, customizable alternative to metal implants for fracture fixation in the hand

Introduction. Enchondromas located in the phalangeal bones may be more cellular than non-digital locations necessitating clinical and radiological correlation to determine diagnosis. Atypical enchondromas have increased cellularity and atypia relative to simple enchondromas but no evidence of permeation. Chondrosarcomas of the phalanges are thought to have a more indolent course than chondrosarcomas in other locations. The aim of the study was to determine the outcome of atypical enchondromas and grade 1 chondrosarcomas of the phalanges treated surgically. Methods. Data was collected prospectively on patients with a cartilage lesion of the phalanges. Typical enchondromas, grade 2 or 3 chondrosarcomas and patients with Ollier's disease were excluded. Results. There were twenty two cases of atypical enchondroma or grade 1 chondrosarcoma. Ten of the patients were female and twelve male with a mean age of 41. There were fourteen atypical enchondromas and eight grade 1 chondrosarcomas. Sixteen of the lesions were in the hand and six were in the foot. Seventeen tumours, including four cases of grade 1 chondrosarcoma, were treated with extended curettage utilising a high speed burr. Five cases were managed by digital amputation as the degree of bone loss precluded retention of the phalanx. At a mean follow up of 30 months there has been one case of local recurrence occurring in an atypical enchondroma of the foot. There have been no cases of local recurrence in the four cases of grade 1 chondrosarcoma treated by curettage. There have been no cases of distant metastasis. All patients remain under long term clinical review. Discussion. There are few published results on the treatment of atypical enchondromata and low-grade chondrosarcomas of the phalanges. In selected cases extended curettage has a low recurrence rate in the treatment of atypical enchondromata and grade 1 chondrosarcomas of the phalanges

Purpose of the study: Duplication of the thumb is the most common congenital anomaly of the first ray. The characteristic feature of type IV is the diversity of the clinical forms and the presence of certain complex forms particularly difficult to treat (Hung IVD). We propose a new procedure for reconstruction of IVD type thumb duplication. Material and method: This new procedure was used for thumb reconstruction in two boys with type IVD thumb duplication. Mean age at surgery was 10 months. Surgical technique. The future incisions were traced with a central skin resection removing the most hypoplastic nail entirely (generally the radial nail). At the bone level, a longitudinal osteotomy of the proximal phalanges was made over the entire length to remove the central part and obtain a width for the first phalanx comparable to that of the contralateral thumb. An oblique osteotomy was cut in the base of the distal phalanx of the ulnar hemithumb with resection of a radial corner. The same type of osteotomy was performed at the base of the distal phalanx of the radial hemithumb, but with preservation of the radial corner and resection of the rest of the radial thumb. The proximal hemiphalanges were sutured as were the bases of the distal phalanges. This produced automatic realignment and stabilisation of the interphalangeal joint without an ungueal intervention. Results: The three children were reviewed at 24, 18 and 12 months. The Horii score was good in all cases. Discussion: Type IVD duplications of the thumb are difficult to treat and may leave serious sequelae. Our technique is based on the principle of a central resection of the proximal phalanges associated with partial resection of the base of the distal phalanges. This enables realignment and stabilisation of the interphalangeal joint while avoiding the problem of ungueal dystrophy since only one nail is preserved. Our preliminary results are encouraging but must be confirmed with a longer term study

Suture anchors have changed the practice of repair of tendons in modern Orthopaedics. The purpose of the study was to identify the ideal suture anchor length for anchoring flexor digitorum profundus tendon to the distal phalanx. We dissected 395 distal phalanges from 80 embalmed hands. Phalanges from two little fingers and three thumbs were damaged, hence were excluded from the study. We measured the Anteroposterior and Lateral dimensions at three fixed points on the distal phalanges of all 395 fingers using a Vernier’s Callipers with 0.1mm accuracy. The mean value of the Anteroposterior width of the distal phalanx at the insertion of the FDP was found to be 3.4mm for the little finger; 3.9mm for the ring finger; 4.3mm for the middle finger; 4.0mm for the index finger and 5.0mm for the thumb respectively. The commonly available anchors and drill bits were found to be too long when used for anchoring the flexor digitorum profundus tendon in certain distal phalanges. Our findings may be a reason for poor outcome of FDP repair to distal phalanx using suture anchors. New designs for tissue anchors for distal phalanges may be necessary

1. A seven-generation family is described which presented an autosomal dominant hereditary disorder characterised by brachydactyly, hypoplastic nails from the index to the little fingers, normal toe nails, absent middle phalanges in the fingers and lateral four toes, variable degrees of hypoplasia of the distal phalanges in the fingers with normal thumbs and normal big toes. 2. Less frequently syndactyly between middle and ring fingers on the left and narrowing of the proximal phalanges of the ring and little fingers are also found. 3. This disorder seems to represent a new hereditary syndrome

Normal digital flexion relies on flexor tendon pulleys to transmit linear muscular force to angular digital motion. Despite the critical role these pulleys play, there is a growing trend among surgeons to partially sacrifice or “vent” them during flexor tendon repair to improve surgical exposure. Although this new practice is reported to improve outcomes after flexor tendon repair, there is concern for the long-term effects of bowstringing, reduced finger range of motion (ROM) and altered tendon biomechanics. The objective of this study was to examine the effects of the application of a thermoplastic ring, acting as an “external” pulley, on flexor tendon biomechanics and finger ROM. We hypothesized that the application of an external thermoplastic ring would produce a centripetal force over the tendon to reduce bowstringing, improve finger ROM, and restore tendon loads following pulley venting. Twelve digits comprised of the index, long, and ring fingers from four cadaveric specimens were tested using a novel in-vitro active finger motion simulator. Servo-motors were used to generate motion. Loads induced by flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP), and joint range of motion were measured with each sequential sectioning of the A2, A3, and A4 flexor pulley, in comparison to a native healthy finger condition. At each finger condition, A2 and A4 external thermoplastic pulley rings were applied over the proximal phalanx and middle phalanx, respectively, to recreate A2 and A4 function. Results were recorded and analyzed using a one way repeated-measures ANOVA. Following venting of the A2, A3 and A4 pulley, proximal interphalangeal joint (PIPJ) ROM significantly decreased by 17.02 ± 8.42 degrees and distal interphalangeal joint (DIPJ) range of motion decreased by 17.25 ± 8.68 degrees compared to intact pulleys. Application of the external rings restored range of motion to within 8.14 ± 8.17 degrees at the PIPJ and to within 7.72 ± 8.95 degrees at the DIPJ. Similarly, pulley venting resulted in a 36% reduction in FDS load and 50% in FDP load compared to intact pulleys. Following application of the external rings, loads were almost restored to normal at 7% reduction for FDS load and 13% reduction for FDP load. Venting of flexor tendon pulleys significantly alters flexor tendon biomechanics and digit range of motion. The application of thermoplastic rings acting as external pulleys over the proximal and middle phalanges is an effective, inexpensive, non-invasive and reproducible therapeutic method to restore flexor tendon biomechanics and digit range of motion

Fractures of metacarpals and phalanges are common in hand injuries. The goal of treatment is the immediate mobilization of the fingers and restoration of the hand anatomy thus avoiding contractures of the metacarpo-phalangeal and phalangophalangeal joints and hand dysfunction. The aim of this study is the comparison between two methods of fixation of these fractures. Between 2000–2007, 74 patients who suffered meta-carpophalangeal fractures were treated by K-wires and 62 patients were treated by mini external fixation. Parameters recorded were the operating time, postoperative range of motion, cost and complications. The surgical time was lesser with the use of K-wires, the operative technique much simple and the cost minimum as compared to mini external fixators. The postoperative range of motion was inferior with the external fixation. However, there was no statistical difference between the two groups. 2 patients with the external fixation and 1 patient with K-wires developed pin-track infection. There were 3 failures of fixation in the external fixator group but no failure occurred with the use of K-wires. The majority of the fractures healed within 6 weeks. K-wires seem to be the ideal method of treatment considering the fractures of metacarpals and phalanges. The use of mini external fixation presents many disadvantages and probably is restricted to the treatment of the open and comminuted hand fractures

1. A review of intra-articular and peri-articular fractures of the phalanges has been carried out, and the late results of such injuries have been examined. 2. These fractures usually unite by bone. 3. The results of conservative treatment by immobilisation are satisfactory in the case of mallet fractures, hyperextension sprain fractures and collateral avulsion fractures of the proximal phalanges. 4. The less satisfactory results after collateral avulsion fractures of the interphalangeal joints and avulsion fractures complicating dislocations are discussed

Introduction: During the design of minimally invasive surgeries (MIS) carried out on the third toe of the foot, it is important to know the position of the nutrient foramen in the third metatarsal shaft and/or proximal phalanx to prevent complications such as avascular necrosis or delays in consolidation further to corrective osteotomies carried out to treat certain conditions that affect the third toe in toe-to-hand surgical transposition. Our aim was to determine the location of the main nutrient foramen of the third metatarsal and/or proximal phalange providing a mathematical method to accurately locate it prior to surgery. Materials and methods: We studied 70 third metatarsals and proximal phalanges of the third toe from surgically amputated lower limbs. We established the position of the nutrient foramen in both normal feet and those with forefoot pathological conditions by means of the nutrient index and the distance from the nutrient foramen to the base and the distal cartilage border and, for the third metatarsal, also to the dorsal aspect. Results: The most frequent location of the nutrient foramen was the middle third of the shaft on the plantar aspect of both bones, and in the majority it was the only location. The distance from the nutrient foramina to each base was significantly correlated with their total length and physiology; we provide the corresponding predictive equations with regression lines. Conclusions: We propose predictive equations of the distance of the NF from the base of both bones based on their total lengths. This distance can be determined by somatic measurement or by means of conventional dorso-plantar x-rays without contrast medium

Introduction: Dorsally angulated metaphyseal fractures of the proximal phalanges usually occur in the middle aged or elderly and are common. Reduction is difficult to maintain with non-operative treatment, due the action of the intrinsic muscles. Most techniques advocated in the literature suggest a transmetacarpal K-wire fixation. We present the results of a simple method of stabilisation using intramedullary K-wires without violating the articular surface. Methods: Over a three-year period, sixty patients with these fractures were treated in this way. A single wire is inserted through the rim of the proximal phalangeal base with MCPJ fully flexed, avoiding transfixion of the collateral ligament. The wire is passed up the medullary canal, across the fracture and up either to subchondral bone or to engage the opposite cortex. The metacar-pophalangeal joints were immobilised with a thermoplastic splint in full flexion and interphalangeal joints mobilised under supervision by the hand therapists. The wire was removed at three weeks. Results: Most patients achieved a full range of movement at 6 weeks follow-up. There were no pin site infections. Conclusion: Dorsally angulated metaphyseal fractures of the proximal phalanges fractures are difficult to treat by non-operative means. If the fracture heals in an angulated position the altered line of pull of the intrinsics will result in loss of flexion at the MCPJ and of power grip. This method is straightforward and gives satisfactory results. It avoids damage to the articular surface of the MCPJ, allows mobilisation of the entire digit and reliably controls the fracture

We treated 35 brachymetatarsal rays of 18 feet in 12 patients by one-stage lengthening with interpositional bone grafts or by gradual lengthening with callotasis combined with shortening of the adjacent metatarsals and phalanges. Definition of the two parabolas which connect the metatarsal heads and the tips of the toes, and recognition of three patterns of metatarsal length, were helpful guides in treatment. In total, 36 excisions of the phalanges and/or the metatarsals were undertaken. The mean shortening was 8 mm. The radiological results were satisfactory. The mean values were as follows: one-stage lengthening, length gain, 1.3 cm; healing index, 1.3 months/cm; percentage increase, 30%; gradual lengthening, length gain, 2.0 cm; healing index, 2.0 months/cm; percentage increase, 50%. Associated shortening of an adjacent bone can avoid the disadvantages of one-stage lengthening which may not achieve target length and can result in neurovascular complications. Reduction of the target length enables the surgeon to carry out one-stage instead of gradual lengthening. It also shortens the length of treatment in the group undergoing callotasis and improves cosmesis

Extensor tendon attachment to the dorsum of the proximal phalanx may fully extend the finger metacarpal phalangeal joint (MPJ). 15 fresh-frozen cadaveric hands were axially loaded in the line of pull to the extensor digitorum comunis of the index, middle, ring and small finger at the level just proximal to the MPJ. We measured force of extension at the MP joint in 3 groups: 1) native specimen, 2) extensor tendon release at the proximal interphalangeal (PIP) joint with release of lumbricals/lateral bands, 3) extensor tendon release at the PIP joint and dorsal proximal phalanx and lumbrical/lateral band release. Degree change of extension was calculated using arctan function with height change of the distal aspect of the proximal phalanx, and the length of the proximal phalanx. We used Student T-test to determine significant decrease in the extension of the phalanges. Extension of all fingers decreased slightly when the extensor tendon were severed at the PIP joint with release of the lateral bands/lumbricals (8deg+/−2deg). After this release, the finger no longer extended. Slight loss of extension was not statistically significant (p >.05) between group 1 and group 2. Groups 1 and 2 were significantly different compared to group 3. In summary, distal extensor tendon transection and release of lateral bands/lumbricals resulted in little change in force and degree of finger extension. The distal insertion of the extensor, released when exposing the PIP joint dorsally, may not need to be repaired to the base of the middle phalanx

The purpose of this prospective clinical study was to identify the true incidence, pattern, and location of the injury and nature of fracture following hand injuries in different paediatric age groups attending a hand unit. Three hundred and sixty children (237 boys and 123 girls) under 16 years of age who presented with hand injuries between 1st April 2000 and 30th September 2000 were included in the study. Bony injuries accounted for 65.5% (236 injuries), 33.3% (120 injuries) were soft tissue injuries. The projected annual incidence rate for skeletal injuries was 418/100,000 children/year. Incidence was low in toddlers (34/100,000), more than doubled in pre-school children (73/100,000) and steeply increased to around 20 fold after the 10th year (663/100,000). Girls had a higher incidence of hand injuries among toddlers and pre-school children. Crushing was the most common cause of hand injury (64%) and most injuries were sustained at home (45%). Toddlers sustained soft tissue injuries predominantly (86%) and older children sustained more bony injuries (77%). Sport was the cause of injures commonly in the older children. There was a higher incidence of fracture in little finger (52%) followed by the thumb (23%). The proximal phalanx was the most frequently fractured bone (67%) among the phalanges. Diaphyseal fractures (46%) were more common in the metacarpal and basal fractures (51%) were common in the phalanges. At discharge more than 80% of the patients felt that they were cured or significantly better. This paper highlights the changing pattern and the different varieties of hand injuries in different paediatric age groups

Aims

The metabolic variations between the cartilage of osteoarthritis (OA) and Kashin-Beck disease (KBD) remain largely unknown. Our study aimed to address this by conducting a comparative analysis of the metabolic profiles present in the cartilage of KBD and OA.

The August 2023 Foot & Ankle Roundup³⁶⁰ looks at: Achilles tendon rupture: surgery or conservative treatment for the high-demand patient?; First ray amputation in diabetic patients; Survival of ankle arthroplasty in the UK; First metatarsophalangeal joint fusion and flat foot correction; Intra-articular corticosteroid injections with or without hyaluronic acid in the management of subtalar osteoarthritis; Factors associated with nonunion of post-traumatic subtalar arthrodesis; The Mayo Prosthetic Joint Infection Risk Score for total ankle arthroplasty.

Aims

In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs.

Aims

Previous studies have suggested that selenium as a trace element is involved in bone health, but findings related to the specific effect of selenium on bone health remain inconclusive. Thus, we performed a meta-analysis by including all the relevant studies to elucidate the association between selenium status (dietary intake or serum selenium) and bone health indicators (bone mineral density (BMD), osteoporosis (OP), or fracture).

1. Four cases of epidermal cysts of the terminal phalanges of the fingers are reported. 2. The literature is reviewed and the etiological factors discussed

1. Delta phalanx is a rare congenital abnormality not to be confused with other forms of angular deformity of the phalanges. 2. The deformity needs radical treatment by repeated surgery because there is no tendency to spontaneous correction and growth of the phalanx is prevented by the epiphysial deformity

A minority of cases of osteopetrosis show in addition syndactyly and distal phalangeal anomalies. The seven cases that have been reported with this combination have had an unusual degree of density and thickening of the skull vault, face and mandible, and of the shafts of the metacarpals, metatarsals, proximal phalanges and clavicles. It is submitted that these features constitute a distinct morphological variety of osteopetrosis

1. Rotational deformity of a finger caused by malunion of a phalangeal fracture has been corrected by metacarpal osteotomy. 2. Because of the anatomical arrangement of the metacarpo-phalangeal joint this method gives good control of the distal phalanges. 3. Division through the metacarpal rather than through the phalanx avoids adhesions in the flexor and extensor mechanisms and in the joints of the fingers, allows early mobilisation and is an easier procedure

Open fractures are uncommon in the UK sporting population, however because of their morbidity then are a significant patient group. Currently there is very little in the literature describing the epidemiology of open fracture in sport. We describe the epidemiology of sport related open fractures from one centre's adult patient population. Retrospective analysis of a prospectively collected database recording all sport related open fracture s over a 15 year period in a standard population. Over the 15 year period, there were 85 fractures in 84 patients. The mean age was 29.2 years (range 15–67). 70 (83%) were male and fourteen female (17%). The six most common sports were football (n=19, 22%), rugby (n=9, 11%), cycling (n=8, 9%), hockey (n=8, 9%); horse riding (n=6, 7%) and skiing (n=6, 7%). The top five anatomical locations were fingers phalanges, 35%; tibia-fibula 23%; foreman 14%; ankle 11% and metacarpals 5%. The mean injury severity score was 7.02. Forty five patients were grade 1; 28 patients were grade 2; 8 patients were grade 3a; and 4 were grade 3b according to the Gustilo-Anderson classification system. Seven patients (8%) required plastic surgical intervention for the treatment of these fractures. The types of flaps used were split skin graft (n=4), fasciocutaneous flaps (n=2); and adipofascial flap (n=1). We looked at the epidemiology open fractures secondary to sport in one centre over a 15 year period. Football was the most common sport (22%) and within football, the most common site was the tibia and fibula. In contrast, within the cohort a whole the majority of fractures were upper limb, with the hand being the most common site. Whilst not common in sport, when they are sustained they are frequently occur on muddy sport fields or forest tracks and must be treated appropriately. A good understanding of the range and variety of injuries commonly sustained in different sports is important for clinicians and sports therapists

We report a case of multicentric massive osteolysis. A 52-year-old woman presented with a three-year history of progressive deformities of the hands. She had osteolytic lesions of the metacarpals and metatarsals, and resorption of the terminal phalanges. During follow-up over four years osteolysis spread to affect the ribs, clavicles, mandible, and long bones. There was no family history of any bone disorder and renal function was normal. Death resulted from resorption of the rib cage and post-mortem studies failed to reveal the cause of the osteolysis

EH of bone is a rare vascular neoplasm, subtype of hemangioendothelioma, characterized by mesenchimal cells that have an epithelioid endothelial appearance. There are different kinds of EH: the benign epithelioid hemangioma, and the malignant epithelioid angiosarcoma. This tumors can occurs in soft tissue, lung, liver and bones and often are multicentric. EH generally involve the bone of the spine and lower limb and is very rare in the upper limb and the hands. The main symptom is pain; pathological fracture may occur in aggressive lesions. Radiographically the EH is a ostelytic lesion with variable peripheral sclerosis, cortical destruction and periosteal new bone. Treatment of EH is curettage and local adjuvants in benign lesion, en bloc resection in the low-grade forms and wide or radical surgery in the high-grade forms. Radiation therapy is suggest in inoperable situations. In the present report we describe the clinical features, the oncological treatment and the reconstructive solutions of two cases of EH of the hand treated in the Orthopedic Oncological Center of Gaetano Pini Institute of Milan. Both cases had multiple locations in the carpus, metacarpus and phalanges. The involvement of more joints caused a delayed diagnosis (> 1 year). Exer-esi and reconstruction of several segments of the wrist and hand has led to considerable technical difficulties resolved with the collaboration of the microsurgeon and plastic surgeon

1. A new piece of equipment, the quantitative colour television image analyser, has been introduced as providing a superior method for measuring bone density. 2. This method produces not only a numerical result but also a pattern of density distribution in the form of a seven colour contour map. 3. The changes in twenty rheumatoid hands at an interval of one year have been measured. The metacarpals and proximal phalanges always lose bone, but the metacarpo-phalangeal joint may gain in density if the disease process is far advanced. Some areas can lose 50 per cent of bone in one year

1. Bone changes in the haemoglobinopathies are caused by either (a) chronic haemolysis with marrow hyperplasia, or (b) infarction, when Hb S is present in the red cells in amounts sufficient to allow sickling (and therefore vascular occlusion) in vivo. 2. Marrow hyperplasia produces osteoporosis, widening of the medulla, and thinning of the cortex; it may lead to spontaneous fractures and disturbances of growth. Enlargement of the foramina of the nutrient arteries may be seen especially in the phalanges. Infarcts leading to aseptic necrosis occur in the long bones, and may become infected with Salmonella organisms. The range of radiological lesions caused by these processes is illustrated

The purpose of this study was to retrospectively review the outcomes of percutaneous flexor tenotomies of diabetic claw toes with ulcers or pending ulcers. A retrospective chart review between January 1999 and June 2005 was performed to identify those patients that had undergone a percutaneous flexor tenotomy for diabetic claw toe deformities. Thirty-four toes in fourteen patients were identified. Twenty-four toes had ulcerations at the terminal aspect and three of these had radiographic evidence of osteomyelitis of the terminal phalange. All patients had palpable pulses and good capillary refill. A percutaneous flexor tenotomy was performed in an outpatient clinic on all toes, patients with a rigid flexor contracture at the proximal interphalangeal (PIP) joint underwent an osteoclaysis to correct a portion of the deformity. The average follow-up was thrirteen months, all patients with ulcers healed and there were no significant complications. Those without osteomyelitis healed within an average of three weeks and those with osteomyelitis healed within an average of eight weeks. A Percutaneous flexor tenotomy with osteoclasis of the PIP joint performed in an outpatient clinic is a safe and effective method to off-load the tip of the toe such that ulcer healing can occur. The presence of osteomyelitis is not a contraindication for this technique; however, an increased healing time can be expected

1. Frostbite in a child may be severe enough to destroy the cartilage cells of the epiphysial plate of a digit, and produce clinical deformity. 2. Both the direct effect of the freezing itself and the vascular changes secondary to such frostbite appear to cause necrosis of the growing epiphysis with destruction of the epiphysis and disappearance of the epiphysial line or plate. The disappearance of the epiphysial plate is obvious, but whether the epiphysis itself is actually destroyed and disappears or simply fuses with the metaphysis is a question now being studied. 3. It is suggested that the deformities may be helped by interphalangeal fusion of severely involved joints in the position of function, and phalanges that become angled into varus or valgus may be improved by open wedge osteotomy or epiphysiodesis of the side of the epiphysis still functioning

1. In a series of seventy-one patients with wringer injuries of the hand three basic types of lesion were observed: a) denuding of part of or the entire hand, usually accompanied by avulsion of the distal phalanges; b) small lacerated wounds with wide detachment of surrounding skin and frequent fractures; c) multiple cut injuries of digits or the entire hand with skin avulsions. 2. Treatment was guided by the following principles: a) improvement of blood supply in regions of impaired nourishment; b) stable primary fixation of bones with Kirschner wires; c) primary wound closure through free skin grafting with maximal utilisation of available flaps. 3. Surgical technique as applied in various typical cases is outlined

Introduction. Hand tumors are usually rare and there is not much literature about series of cases. We have studied a series of 110 cases. Hand tumors do consists of both benign and malignant cases. Methods. We studied series of 110 cases at Karnataka Institute of Medical Sciences, Hubli and Mysore Medical College & Research Institute, Mysore. We retrospectively reviewed the records of 110 patients who underwent double ray amputations at our center over few years: few had amputations of the fourth and fifth rays and others amputation of the second and third rays. Mean age at surgery was 34 years (range, 10–45 years), and minimum follow up was 64 months (mean, 98 months; range, 64–136 months). Some patients had high-grade soft tissue sarcomas of the hand, synovial sarcomas, malignant peripheral nerve sheath tumors, and undifferentiated sarcoma. No patients had detectable metastases at surgery. Results. All patients were completely disease-free at latest follow up. One patient was alive with lung metastases detected 32 months after surgery. No patients developed local tumor recurrence. Functional assessment showed a mean Musculoskeletal Tumor Society score of 24 (range, 19–28) and mean grip strength 24% of the contra lateral side (range, 17%–35%). Conclusions. The majority of osseous tumors of the hand are benign. The surgeon who evaluates and treats osseous tumors of the hand has to be familiar with limb anatomy, tumor biology, various presentations of the tumors and the range of treatment possibilities and their limitations. Lesions in the hand more often present earlier in their course than those at other sites, just because they are more likely to superficial and easily noticed. Ganglion cyst is the most frequently encountered comprising 50–70% of benign tumors of hand. Enchondroma was the next common benign bone tumour followed by osteoid osteoma, osteoblastoma, aneurismal bone cyst, giant cell tumor, epidermoid cyst, and osteochondroma. Although malignant neoplasms in the hand that arise from tissues other than the skin are very rare, the hand may be the site of distant breast, lung, kidney, esophagus, or colon adenocarcinoma metastases, most of which have a predilection for the distal phalanges. Malignant tumours of the hand are rare, although there remain many instances in which marginal excisions are performed for unsuspected malignant hand lesions. Suboptimal biopsy incisions and inadvertent contamination during these excisions may result in larger resections or amputations being necessary to ensure complete removal of the tumour with negative margins

Summary Statement. An alternative way to assess three dimensional skin motion artefacts of kinematic models is presented and applied to a novel kinematic foot model. Largest skin motion is measured in the tarsal region. Introduction. Motion capture systems are being used in daily clinical practise for gait analysis. Last decade several kinematic foot models have been presented to gain more insight in joint movement in various foot pathologies. No method is known to directly measure bone movement in a clinical setting. Current golden standard is based on measurement of motion of skin markers and translation to joint kinematics. Rigid body assumptions and skin motion artefacts can seriously influence the outcome of this approach and rigorous validation is required before clinical application is feasible. Validation of kinematic models is currently done via comparison with bone pin studies. However, these studies can only assess major bones in a highly invasive way; another problem is the non-synchronous measurement of skin markers and bone pins. Recently the Glasgow Maastricht kinematic foot model, which comprises all 26 foot segments, has been presented. To validate the model we propose a novel non-invasive method for the assessment of skin motion artefact, involving loaded CT data. Patients & Methods. 25 subjects (healthy and pathological feet) have undertaken CT scans. These CT-scans have been obtained in 1 unloaded and 3 varying loading conditions. CT-slices are 3D reconstructed and segmented. The principal axes of the segmented bones were derived from the surface points of the bones. These principal axes are used to compute bone orientation. Subsequently, coordinate systems of bones in the different loading conditions were matched. Markers were translated and rotated to orientations of their corresponding bones. Maximal distance between markers is calculated per subject to asses the influence of skin motion. Results. Preliminary results of 9 subjects show largest positional differences for markers associated with the cuneiform lateralis (5.7 ± 3.2 mm) and cuneiform intermedium (7.7 ± 3.7 mm). Smallest positional differences are found on the hallux proximalis (0.9 ± 0.34mm). Spatial resolution is too small to accurately calculate orientation of smaller bones, therefor distal phalanges 2–5 are not taken into account in the analysis. Discussion/Conclusion. Skin motion is a major cause of inaccuracy in gait analysis. This is the first study presenting an automated non-invasive method to calculate the 3D orientation of skin markers with respect to the coordinate system of the corresponding bone(s). Largest skin motion is measured in the tarsal region. Future work will be in calculation of the effect of skin motion in the accuracy of joint angle calculation

We performed one-stage lengthening using intercalary autogenous bone graft in 34 metatarsals and seven proximal phalanges in 21 patients with congenitally short metatarsals. At operation, in order to decrease the tension in the surrounding soft tissues, we gradually distracted the osteotomies of the affected bones for 20 to 30 minutes. The patients, all women, were followed up for a mean period of 2.1 years (1 to 6.5). The average gain in length for the 34 metatarsal procedures was 14 mm (6 to 21), equivalent to an increase of 32% (11 to 51), and for the seven proximal phalangeal lengthenings 8 mm (5 to 11), an increase of 54% (47 to 65). There was no evidence of neurovascular impairment. The technique of gradual distraction during operation is simple and effective. It overcomes the disadvantages of one-stage lengthening such as a small gain in length and neurovascular damage

Purpose. A review of the role of external fixators in paediatric trauma at The Royal London Hospital Trauma and Orthopaedic Department. Methods. Retrospective study between 2004 and 2010 reviewing traumatic bone injuries that required initial management with an external fixator. Information was collected through the patients' medical documents and radiographs. Results. In total twenty-seven patients (15 male:12 female, mean age 11, age range 7-15) were initially treated with external fixators over the six year period. The injured bones included 18 tibias, 5 femurs, 2 humeri, 2 radius/ulna, 2 phalanges and 1 wrist. Three patients had two fractures requiring external fixators. Four patients had associated head injuries. Indications included twenty –one open fractures (3 Gustilo type 2, 6 Gustilo type 3A, 12 Gustilo type 3B), seven closed fractures in poly-trauma patients and two closed severely comminuted fractures. Ten fractures were treated with the external fixator as the definitive treatment, fourteen had application of cast following removal of the external fixator and six were converted to internal fixation. Twenty-eight Linear frames were applied (23 Hoffman IIs, 5 Compact Hoffmans) and two circular frames. Mean duration of frame stabilisation was 8 weeks (range 1-16 weeks). Complications included 2 pin site infections successfully treated with antibiotics, 2 patients with hypertrophic scars, 2 leg length discrepancies secondary to bone loss, 2 patients had delayed union and 2 patients had a lower limb deformity requiring intervention, one for adjustment of frame and the other for correction osteotomy with circular frame. Conclusion. The use of external fixators has an important role to play in the management of open fractures and poly-trauma paediatric patients

A 14-year-old girl with a congenitally deformed and shortened right leg and foot is described. The patient could not bear weight on the deformed limb and had to hop on the left leg. The deformed foot faced backwards and had nine toes. The right leg was shorter than the left by 26 centimetres. Radiologically, the lower end of the right femur was ill-developed and there was no knee joint. There were two fibulae and the tibia and the patella were absent. A through-knee disarticulation was done and a prosthesis fitted later. The amputated leg and foot were dissected. Many of the muscles in the leg and foot were duplicated. There were two calcanei, one talus, one navicular, two cuboids and four cuneiforms. Ther were nine metatarsals, and all the toes had three phalanges except for one which had two

Objectives: Nowadays estimating paediatric bone age is done using methods based on standards from the 50’s and 70’s. These methods are often difficult to perform, they require experience in the analysis of multiple bones and are based on subjective measures. Many times, the age calculated stands within a wide range of age interval. We investigate a new method based on AP foot X-rays. Material and Methods: 971 radiographs taken from 220 paediatric patients (0–18 years old) were analyzed. 34 different ratios were designed by measuring ossification centres of the bones of the first and second foot rays. These ratios were statistically studied searching for the relation with variables as gender, laterality, foot pathology and forefoot formulae. Finally, regression lines and curves from each ratio were calculated as well as their correlation with chronological age. Results: The best suited correlations are obtained with the ratios calculated from the epiphysis of the proximal phalange of the first and second toes. With them, multiple regression analysis is able to establish an equation that estimates bone age, with a chronological age correlation of 0,86 for general population, 0,85 for boys and 0,90 for girls (p< 0,01). It is applicable for either feet, and valid for every forefoot formula or pathologic feet. Conclusions: This new method is designed to estimate bone age in children using either plain radiographs or digital images. The method is objective, precise, universal and easy to calculate. It proves a good correlation in children between 1 and 13 years old. It is based on a modern population and adjusted with lineal regression equations to both genders

Malunion of digital fractures can be difficult to correct especially for rotational phalangeal malunion. We describe the simple closed corrective technique. Materials/Methods: Patients whose phalangeal fractures were treated closed (mobilised or POP +/− K wires) and malunited, typically with mal-rotation. The technique is performed under LA. The bone is cut by percutaneous passage of a 1.1 mm K wire multiple times until the bone is fractured. The malunion is corrected and held with one longitudinal 1.1 mm K wire. The osteotomies are supported for 6 weeks in POP/splint and the wire(s) removed. Results: 11 patients with 12 post fracture malunion–All metaphyseal osteotomies healed within 6 weeks with correction of malrotation and no significant angular deformity. The one diaphyseal osteotomy united late healing only partially (inadequately) corrected and requires revision. Apart from the malunion there were no major complications albeit short-term PIP joint stiffness. Conclusion: This is a safe and reliable technique that avoids most of the complications of more challenging open techniques in the phalanges or the compromises of distant techniques e.g. metacarpal correction of phalangeal malrotation. It does however require immobilisation precluding any major simultaneous soft tissue releases. It appears unsuited to diaphyseal correction

Introduction: In clinical practice The Cascade sign is widely used to assess the rotational deformity of the fingers associated with metacarpal and phalangeal fractures. We carried out a scientific study on thirty volunteers to evaluate the validity or otherwise of this standard sign. Material and Methods: Metal pointers were attached to the dorsum of the fingers, flexed at MCP and PIP joints. These pointers represented the mid longitudinal axis of the phalanges. Standardised AP radiographs of the closed fist were taken in all cases with the wrist placed in neutral position, in a custom made jig. The radiographs were assessed by two different observers using Picture Archiving and Communication System, software version VA42B, to determine the convergence of the metal pointers towards the scaphoid tubercle, as described in the cascade sign and Lister method. Statistics: Power of the study was determined with an assumption of a type-2 error of 0.05 and a two sided test. Descriptive statistics and confidence limits were calculated using SPSS 11 software. Results: We observed that the metal pointers did not equivocally converge towards the scaphoid tubercle. The persistent pattern of convergence was within a 2–3cm radius of the scaphoid tubercle. The statistical analysis, two tailed paired t-test of this pattern showed strong association with this latter finding. (p< 0.003). Conclusion: Our study suggests that the cascade sign is sensitive but not specific to access the rotational deformity of the fingers. Radiological there is significant scatter about the scaphoid tubercle

Aim. Assess the oncological and clinical outcomes associated with intralesional curettage, phenol and bone grafting of the lesions. Method. A retrospective study was performed using data from the Leiden University Medical Center. Ninety patients with low grade central chondrosarcoma of long bones and small tubular bones were treated using phenol and ethanol as adjuvant therapy after intralesional curettage. Standard clinical follow-up contained regular visits to the orthopaedic department, physical examination and radiological follow-up with plain X-rays and dynamic Gadolineum-enhanced MRI scans. Results. Between 1994 and 2005 thirty-three males and fifty-seven females with a mean age of 47 years (range 5.6-73.1) were treated in our clinic. Mean follow-up 6.5 years (range 0.2-14.1). Location of chondrosarcoma. Femur (43%), humerus (32%), tibia (10%), fibula (6%), metacarpalia (4%), radius (2%), ulna (1%), phalanx (1%). Average tumour volume of all lesions, including metacarpals and phalanges, was 22 cm3 (range 1-104). With a mean follow up of 6.5 years, 86% of the patients are free of tumour on plain X-ray and dynamic Gd-MRI. Two femoral fractures occurred within 6 weeks after surgery, treated by ORIF. 14% of the patients had re-intervention(s) due to suspected recurrence or residual tumour on dynamic Gd-MRI (7 recurettage, 6 RFA). Histology: Grade I Chondrosarcoma (7), no recurrence (2), non conclusive (4). Overall, there were no cases of metastases. Conclusion. This study presents a large number of patients included, all with same diagnosis and uniform treatment for lowgrade central chondrosarcoma. Periodically clinical and radiological follow-up by dynamic Gd-MRI only showed 8% histological proven recurrences, no upgrading of tumour or occurrence of metastases were seen. Compared to other studies, the complication rates and impairment for the patients are low. Intralesional treatment of low-grade central chondrosarcoma, followed by phenol and ethanol is an effective and safe method with low morbidity for these patients

Enchondromatosis is a non-hereditary disease, characterised by the presence of multiple enchondromas. While Ollier Disease is typified by multiple enchondromas, in Maffucci Syndrome they are combined with haemangioma. Due to the rarity of these diseases, systematic studies on clinical behaviour providing information how to treat patients are lacking. This study intends to answer the following questions: What are predictive factors for developing chondrosarcoma? When is extensive surgery necessary? How often patients die due to dedifferentiation or metastasis?. Twelve institutes in eight countries participated in this descriptive retrospective EMSOS-study. 118 Patients with Ollier Disease and 15 patients with Maffucci Syndrome were included. Unilateral localization of disease was found in 60% of Ollier patients and 40% of patients with Maffucci Syndrome. One of the predictive factors for developing chondrosarcoma is the location of the enchondromas; the risk increases especially when enchondromas are located in the scapula (33%), humerus (18%), pelvis (26%) or femur (15%). For the phalanges, this risk is 14% in the hand and 16% in the feet. The decision whether or not to perform extensive surgery is difficult, especially in patients who suffer multiple chondrosarcomas. Malignant transformation was found in fourty-four patients with Ollier Disease (37%) and eight patients with Maffucci Syndrome (53%). Multiple synchronous or metachronous chondrosarcomas were found in 15 patients. Nine patients died (range 21–54 yrs). Seven of them died disease related due to pulmonary metastasis (2 humerus, 2 pelvis, 3 femur). Two patients died from glioma of the brain. In conclusion, one important predictive factor for developing chondrosarcoma is the location of the enchondromas; interestingly, only patients with chondrosarcoma outside the small bones died of their disease. In this series, no dedifferentiation of chondrosarcoma was seen. A first design flow-chart how to approach chondrosarcoma in patients with Ollier Disease and Maffucci Syndrome is in preparation

Nineteen chondrosarcomas are reported arising in proximal phalanges or metacarpal bones of the hand mainly in elderly patients, predominantly women. The usual clinical presentation was of a progressively painful large tumour, often arising in a dormant lesion near the metacarpo-phalangeal joint. Radiologically most showed some bone expansion with a poorly defined area of destruction and a considerable soft-tissue swelling. Histologically, malignancy was usually obvious, but confusion might arise from the inclusion of bland areas of chondromatous tissue that probably represented the original lesion. Four tumours, initially curetted and grafted, recurred locally and necessitated amputation of the digit or ray. Amputation was the primary treatment for fourteen other tumours and was curative except in one patient who eventually needed amputation through the forearm for a large second recurrence. One tumour was satisfactorily controlled by excision of the affected phalanx. None of these nineteen tumours is known to have metastasised. Correct treatment implies a carefully considered balance between conservation of function and complete removal of all tumour tissue

We retrospectively reviewed 27 patients who underwent an uncemented total Moje ceramic arthroplasty of hallux rigidus. Out of 33 patients who had the above procedure, 27 were available for review. Clinical and functional outcome were assessed using the American orthopaedic foot and ankle society (AOFAS) fore-foot score, and the SF-36 health assessment score. All patients had an antero-posterior and a lateral weight bearing radiograph. The primary pathology was oesteo-arthritis (Hallux Rigidus). All procedures were performed by the senior author or under his supervision. All patients were female with an average age at surgery of 52.6 years (range 45.8–64.7). The average follow up was 39.5 months (range 14–46). The average post-operative AOFAS forefoot score was 80/100 (range 40–100). The average subscore for pain was 29.39/40 (range 10–40). Twenty five patients 92.5% were satisfied with the outcome, and 22 (81%) were able to wear high heel foot wear. The functional outcome as assessed using the SF-36 health score was compatible with an age matched population. The alignments of component were measured in relation to the shaft of the metatarsal and to the proximal phalange. There was no statistical correlation between the alignment and the functional scores. Although, arthrodesis remains the gold standard procedure, total ceramic first MTP joint arthroplasty has a place in the management of some cases of advanced but not end stage hallux rigidus. Careful patient selection is essential to achieve a favourite outcome

We retrospectively reviewed 27 patients who underwent an uncemented total Moje ceramic arthroplasty of hallux rigidus. Out of 33 patients who had the above procedure, 27 were available for review. Clinical and functional outcome were assessed using the American orthopaedic foot and ankle society (AOFAS) fore-foot score, and the SF-36 health assessment score. All patients had an anteroposterior and a lateral weight bearing radiograph. The primary pathology was oesteo-arthritis (Hallux Rigidus). All procedures were performed by the senior author or under his supervision. All patients were female with an average age at surgery of 52.6 years (range 45.8–64.7). The average follow up was 39.5 months (range 14–46). The average post-operative AOFAS forefoot score was 80/100 (range 40–100). The average subscore for pain was 29.39/40 (range 10–40). Twenty five patients 92.5% were satisfied with the outcome, and 22 (81%) were able to wear high heel foot wear. The functional outcome as assessed using the SF-36 health score was compatible with an age matched population. The alignments of component were measured in relation to the shaft of the metatarsal and to the proximal phalange. There was no statistical correlation between the alignment and the functional scores. Although, arthrodesis remains the gold standard procedure, total ceramic first MTP joint arthroplasty has a place in the management of some cases of advanced but not end stage hallux rigidus. Careful patient selection is essential to achieve a favourite outcome