Symptomatic flexion deformity of proximal interpahalangeal joint (PIPJ) is one of the most common foot deformities and usually treated with arthrodesis. In general, percutaneous K-wires are used to stabilize the joint after excision of cartilage. K-wires projecting out of the toe need special care and can occasionally be dislodged accidentally. Furthermore issues such as cellulitis, pin tract infections, rarely osteomyelitis and need for removal make alternative fixation methods desirable. Smart toe is an intra-osseous titanium memory implant, which is stored frozen. It expands on insertion and does not require removal.

18 consecutive K-wire PIPJ arthrodesis were compared with 18 Smart toe PIP fusions with a mean follow up of 6 months. Post operative forefoot scores and complications were documented.

Patient satisfaction was higher and complications were lower with Smart toe fusions than with K-wire arthrodesis. Fusion of PIP joints with smart toe is an effective and safer alternative to using K-wires. Although more expensive, higher patient satisfaction and lower complication rate may offset the extra cost of the implant.

Background

Symptomatic flexion deformity of proximal interpahalangeal joint (PIPJ) is one of the most common foot deformities and usually treated with arthrodesis. In general, percutaneous K-wires are used to stabilize the joint after excision of cartilage. K-wires projecting out of the toe need special care and can occasionally be dislodged accidentally. Furthermore issues such as cellulitis, pin tract infections, rarely osteomyelitis and need for removal make alternative fixation methods desirable. Smart toe is an intra-osseous titanium memory implant, which is stored frozen. It expands on insertion and does not require removal.

Reduction and K-wiring is the most popular form of treating displaced supracondylar fractures of the humerus. Complications including redisplacement of the fracture, cubitus varus, iatrogenic nerve injuries and pin tract infection have been reported following surgery. For successful outcome with K-wiring of supracondylar fractures, strict adherence to protocols and surgical expertise are necessary. We have treated these fractures in straight arm traction since 1995, and the purpose of this study was to audit our practice.

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus, without neurovascular deficit, were managed by straight arm traction for a mean duration of 22 days. Final outcome was assessed using clinical (flex-ion-extension arc, carrying angle and residual rotational deformity) and radiographical (metaphyseal-diaphyseal angle and Humero-Capitellar angle) criteria. Our outcomes were compared with those of the recent large studies reporting results of surgical treatment.

71 (63%) patients had excellent, 33 (29%) patients good, 5 (4.4%) patients fair, and 3 (2.6%) patients poor outcome. All patients with fair or poor outcomes were older than 10 years.

Elevated straight-arm traction is safe and effective in children younger than 10 years. It can be effectively used in an environment that has provision of paediatric medical care and general orthopaedic expertise with outcomes comparable to those fractures treated surgically in specialist centres.

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus without vascular deficit, were managed by elevated, straight-arm traction for a mean of 22 days. The final outcome was assessed using clinical (flexion-extension arc, carrying angle and residual rotational deformity) and radiographic (metaphyseal-diaphyseal angle and humerocapitellar angle) criteria. Excellent results were achieved in 71 (63%) patients, 33 (29%) had good results, 5 (4.4%) fair, and 3 (2.6%) poor. All patients with fair or poor outcomes were older than ten years of age.

Elevated, straight-arm traction is safe and effective in children younger than ten years. It can be effectively used in an environment that can provide ordinary paediatric medical care and general orthopaedic expertise. The outcomes compare with supracondylar fractures treated surgically in specialist centres.

Objective The hypothesis of this study is that the flexibility of idiopathic scoliosis curves as measured by traction radiography performed under general anaesthetic (TUA) will be superior to supine bending radiography. Subsequently, this may aid in determining the surgical approach, sparing patients anterior release surgery, and show greater correlation with the postoperative result. This is a new technique, not previously reported in the literature.

Design A prospective comparison between TUA and supine bending radiography to determine curve flexibility, and examine their relationship with anterior release surgery and postoperative correction.

Subjects This study was based on 21 patients with a diagnosis of idiopathic scoliosis, admitted for corrective surgery at our unit.

Outcome measures The amount of correction achieved by each of the two methods on the preoperative curve was examined using a paired t-test. The influence of the TUA on the decision for anterior release surgery was noted, along with the correlation of each method with postoperative correction.

Results On statistical analysis with a paired t-test, TUA showed significantly greater curve flexibility than that shown by supine bending radiographs (p< 0.001) irrespective of curve classification or magnitude. Of the 11 patients planned for anterior release surgery with posterior fusion, the use of TUA obviated this in 9 (82%) by demonstrating greater preoperative curve flexibility. Excluding thoracolumbar curves, TUA showed significantly greater postoperative correlation than supine bending radiography (R=0.79, R=0.61 respectively).

Conclusion In our unit, traction radiography performed under general anaesthetic is superior to supine bending radiography in assessing curve mobility prior to surgery. Performing TUA has significant benefits to patients in avoiding unnecessary anterior release surgery, and has greater correlation with postoperative correction. In studying fulcrum bending radiographs, Cheung1 showed similar benefits in avoiding anterior release and we therefore recommend the use of these methods by other institutions.

Sublaminar wiring with posterior instrumentation is one of the methods used when long fusions involving 10 to 12 thoracolumbar levels are required. Classically wires are used at every consecutive level to make the construct as rigid as possible although complications like dural tears, CSF leak, and neurological deficiet have been reported during their passage.

We compared the mechanical stability of five specimens of each of the three construct designs by static and fatigue testing to torsional strain on Electro-servo-hydraulic testing machine. In construct A, a contoured Hartshill rectangle was used from T2 to L2, with sub-laminar wires passed at every level. In construct B, every alternate level was wired. In construct C, every alternate level was wired except at the proximal end two consecutive levels were wired. Industrially fabricated spine models were used to prepare these constructs. The intervertebral motion within the construct was measured using FASTRAK magnetic field sensor device.

On static testing, no statistically significant difference was found in the rotational displacement of the three construct designs. On fatigue testing, all samples of construct B consistently failed with breakage of the wire at the most proximal level on the left side. But on adding additional wires to the next level (Construct C), all five samples withstood fatigue testing at 300 Newton load to 3 million cycles.

Wiring alternate levels instead of every level, does not compromise the stability of the construct provided the most proximal two levels are consecutively wired. This practise would minimise the risk of dural tears and cord damage during wire passage and reduce surgical time, not to mention the economical benefit.

Purpose of the study: To study clinical, radiological and pathological features of this rare condition and to observe the effect of surgery on the relief of presenting symptoms.

Materials, Methods and Results: between February 1989 to May 1999, more than 200 spinal operations were carried out at Oswestry, amongst which we found 11 patients with 13 symptomatic lumbar synovial cysts. Nine patients were female and 2 were male. Among the symptoms produced, sciatica was present in 10 out of 11 patients, neurologic claudication was present in 6 patients and only one patient had neurologic deficit. All the patients suffered with back pain, which was either of facetal origin or mechanical back pain.

Radiological investigations revealed that all patients had evidence of facet arthrosis. Seven patients had degenerative spondylolisthesis. Degenerative disc disease was also seen in 7 patients.

The contents of the cysts varied from serous fluid to chalky white material to gelatinous grey material. One cyst contained calcium pyrophosphate crystals. Another cyst contained hydroxyapatite crystals. Seven cysts which contained deposition of bone debris in the cyst wall also revealed an (giant cell and macrophage) inflammatory reaction to this bone debris. In all patients complete resolution of sciatica, neurologic claudication and neurologic deficit was observed after surgery. However, after a minimum follow up of two years the back pain persisted in all but one patient.

Conclusion: Lumbar synovial cyst is a rare condition, more common in females, elderly, and occurs most commonly in association with degenerative disease of the spine, although it can also be caused by other conditions like trauma, or rheumatoid arthritis. When they cause compression of the dura or nerve roots, they present with symptoms like sciatica and neurologic claudication, which resolve promptly after surgery. However, patients also have a long history of back pain from the associated degenerative spinal disease which usually does not resolve unless it is addressed separately and patients need to be warned regarding this.