Purpose. To analyse the early results of unconstrained pyrocarbon joint replacements in patients with osteo-arthritis of the metacarpo-phalangeal joints. Background. Silicone arthroplasty, as introduced by Swanson in 1962 has remained the most popular procedure to treat arthritis of the metacarpo-phalangeal (MCP) joints. However, despite providing good pain relief, they have shown to demonstrate breakage rates up to 82% at 5 years. This is of great concern in the osteoarthritis (OA) patient group, who tend to be younger and have higher functional demands compared to their rheumatoid counterparts. The newer unconstrained pyrolytic carbon MCP joint prostheses may therefore be more suitable in OA patients whose soft tissue constraints are intact and whose hand function is strong. This study is the first to analyse the results of this implant in a cohort of OA patients only, with prospective data. Methods. 19 primary pyrocarbon metacarpo-phalangeal joint replacements, in 11 patients (5 men and 6 women) were reviewed, with prospective data collection. The diagnosis was primary osteoarthritis in all patients. The mean age at operation was 66.4 years (range 55–82 years). 2 patients underwent concomitant trapiezectomy and one underwent DIPJ fusion. All patients were right hand dominant −75% underwent surgery in their dominant hand. Eleven of the nineteen joints were performed in the index finger, with the remainder in the middle finger. Mean follow up is 22.1 months (range 11–37). Results. At the 3 month post-operative hand therapy assessment, the arc of motion had improved from a mean of 32 degrees to 45 degrees and flexion had improved from a mean of 51 degrees to 66 degrees. Grip strength improved from a mean 20 to 27Kg. DASH scores significantly improved from a mean of 40 to 10 (p=0.01). All patients were satisfied with their outcomes and would have the surgery again. Pre-operative radiographs demonstrated joint narrowing in all patients but no evidence of heterotopic ossification, cystic change or erosions. Post-operatively, there has been no radiographic evidence of joint dislocation, resorption stress-shielding, loosening, migration or heterotopic ossification. There were three intra-operative complications of phalangeal fractures that were immediately treated with a cerclage wire. In one patient there has been a fracture of the proximal phalangeal implant at 14 months which was asymptomatic. One patient has required revision for mal-rotation of the implant leading to loss of index finger supination. Conclusion. Our results demonstrate excellent early results of pyrocarbon MCP joint arthroplasty in OA patients

In some centres, serial bedside aspirations, in association with intravenous antibiotics, are still an accepted treatment for septic arthritis (Mathews, Postgraduate Medical Journal, 2008). However, there is a risk that bacterial products remain in the joint, even when the bacteria have been destroyed. We have conducted a study to ascertain whether bacterial products alone have an effect on in situ chondrocyte viability. A hip aspirate (25μl), containing Staphylococcus aureus, from a patient with septic arthritis was added to 5ml culture medium and incubated (37°C) for 48hrs. The solution was then centrifuged (3400g for 10mins) and the supernatant removed. Cartilage explants were harvested from a bovine metacarpophalangeal joint, placed into the bacterial supernatant and incubated at 37°C. Explants were removed at hourly intervals over a 6-hour period and stained with the fluorescent probes chloromethylfluorescein di-acetate (10μM) and propidium iodide (10μM) to label living chondrocytes green and dead cells red respectively. Following imaging of cartilage by confocal microscopy, the percentage cell death at each time point was obtained using Volocity 4 software. Chondrocyte death increased markedly with time: 0.04% at 2hrs, 28% at 4hrs and 39% at 6hrs. This study shows that bacterial products rapidly penetrate the cartilage matrix and have a damaging effect on in situ chondrocyte viability. Further work will clarify the contributions made by the various toxic components in the culture supernatant, but these data support the need to remove the bacteria and their products aggressively as part of the treatment of septic arthritis

Staphylococcus aureus is a highly virulent pathogen and is implicated in approximately 50% of cases of septic arthritis. Studies investigating other S. aureus-related infections have suggested that alpha (Hla), beta (Hlb) and gamma (Hlg) toxins are key virulence factors. In particular, the ‘pore-forming’ alpha toxin is believed to be most potent. In this study, we have assessed the influence of alpha toxin on in situ chondrocyte viability. Osteochondral explants were harvested from the metacarpophalangeal joints of 3-year-old cows and placed into flasks containing Dulbecco's Modified Eagle's Medium. The flasks were then inoculated with the following isogenic ‘knockout’ strains of S. aureus: DU5946 (Hla+Hlb-Hlg-) or DU1090 (Hla-Hlb+Hlg+). The explants were incubated (37°C) and stained after 18, 24 and 40hrs with chloromethylfluorescein di-acetate and propidium iodide, labelling living chondrocytes green and dead cells red, respectively. Axial sections were imaged by confocal microscopy and the percentage cell death obtained using Volocity 4 software. The alpha toxin-producing S. aureus caused rapid cell death, with 24.8+/−3.7% at 18hrs and 44.6+/−7.2% at 24hrs. At 40hrs, there was significantly more chondrocyte death (87.4+/−3.6%; p<0.001) compared to the alpha toxin knockout strain (4.1+/−1.7%; means +/− SEM; n=4). In situ chondrocyte viability was significantly compromised by alpha toxin, with beta and gamma toxins having minimal effect. Further work will clarify the exact mechanism through which this important toxin induces chondrocyte death. Thereafter, it is hoped that targeted treatments can be developed to reduce the extent of cartilage destruction during, and after, an episode of septic arthritis

Hand fasciotomy is a rarely performed procedure which should be considered by military surgeons, and performed where necessary. Maximising hand function is vital in all military patients, but is even more significant in those who have lost multiple limbs and require maximal function from remaining hands, which are commonly injured too. It is vital that compartments are decompressed expediently to minimize muscle ischaemia. Cases were identified from the JTTR from March 2003. Data were collected prospectively from Aug 2009 to Feb 2010. Patient notes were analysed and the following recorded –demographics, mechanism of injury (MOI), associated injuries, echelon of care at which fasciotomy was performed, indication recorded by operating surgeon, and specialty of operating surgeon. 9 patients were identified, median age was 23, MOI was IED in 8/9 and mine in 1/9/. All were multiply injured. 4/9 (44%) were performed at R3 and 5/9 (56%) at R4. All fasciotomies at R4 were performed at the first debridement, intrinsic muscles were found to be necrotic in 1 case. At R3 3/4 were performed by orthopaedic surgeons and 1/4 by a plastic surgeon, at R4 all were performed by hand surgeons, either orthopaedic or plastic. All fasciotomies performed at R4 were at the first debridement, and 1 revealed necrotic intrinsic muscles. This implies that some of these patients may have benefited from earlier procedures. In upper limb injury where it is not possible to passively flex the metacarpophalangeal joints to 90 degrees, decompressing the hand should be considered

Aims

Outcome measures quantifying aspects of health in a precise, efficient, and user-friendly manner are in demand. Computer adaptive tests (CATs) may overcome the limitations of established fixed scales and be more adept at measuring outcomes in trauma. The primary objective of this review was to gain a comprehensive understanding of the psychometric properties of CATs compared with fixed-length scales in the assessment of outcome in patients who have suffered trauma of the upper limb. Study designs, outcome measures and methodological quality are defined, along with trends in investigation.

We studied prospectively the regional inflammatory response to a unilateral distal radial fracture in 114 patients at eight to nine weeks after injury and again at one year. Our aim was to identify patients at risk for a delayed recovery and particularly those likely to develop complex regional pain syndrome. In order to quantify clinically the inflammatory response, a regional inflammatory score was developed. In addition, blood samples were collected from the antecubital veins of both arms for comparative biochemical and blood-gas analysis.

The severity of the inflammatory response was related to the type of treatment (Kruskal-Wallis test, p = 0.002). A highly significantly-positive correlation was found between the regional inflammatory score and the length of time to full recovery (r² = 0.92, p = 0.01, linear regession). A regional inflammatory score of 5 points with a sensitivity of 100% but a specificity of only 16% also identified patients at risk of complex regional pain syndrome. None of the biochemical parameters studied correlated with regional inflammatory score or predicted the development of complex regional pain syndrome.

Our study suggests that patients with a distal radial fracture and a regional inflammatory score of 5 points or more at eight to nine weeks after injury should be considered for specific anti-inflammatory treatment.