We report on the first clinical cases of the Arthrex Ankle Syndesmosis TightRope (winner of 2003 BOA Technological Achievement Award and 2004 Cutlers' Prize), which has recently been licensed for use where classically a syndesmosis screw would be used.

Twelve patients with Weber C ankle fractures treated with Arthrex TightRope syndesmosis fixation have a minimum of six months follow-up. The syndesmosis was fixed with the ankle in plantarflexion to aid reduction. Patient demographics, including fracture classification and mode of injury were obtained. Parameters measured at follow-up included ankle range of motion, maintenance of reduction and fibular length, and AOFAS ankle outcome score.

The patient cohort showed a typical bimodal distribution of age. Age over 65 years was associated with a poorer outcome. Five patients had ankle fracture-dislocations, which was a factor for a poorer outcome. Nine patients had fibular plate fixation in addition to syndesmosis fixation, whilst three patients with Maisonneuve injuries had syndesmosis fixation only. There were no major complications, loss of reduction, wound problems, implant loosening or osteolysis. Ankle dorsiflexion was not restricted and mean total ankle range of motion was comparable to the uninjured side. No patient required secondary surgery for any reason, including hardware removal.

Arthrex TightRope fixation is a simple, safe and effective method of ankle syndesmosis fixation, which allows physiological micromotion. Fixation in plantarflexion provides optimum syndesmosis compression for reduction, and does not compromise ankle range of motion. The Arthrex Ankle Syndesmosis TightRope may become the treatment of choice in Weber C ankle fractures.

A new apparatus and technique of syndesmosis fixation is tested in a prospective clinical study. Buttons on both sides of the ankle anchor a strong suture under tension following syndesmosis reduction. This syndesmosis suture acts like a tightrope when under tension. Implantation is simple with a minimally invasive technique, as the medial side is not opened. It allows physiological micromotion whilst resisting diastasis, does not require routine removal, and allows patients to weight-bear earlier.

Sixteen patients with Weber C ankle fractures with a syndesmosis diastasis underwent suture-button fixation and the results compared to 16 consecutive patients with syndesmosis screw fixation. Patients were, in effect, quasi-randomised according to surgeon preference. Mean A,O,F,A,S, ankle scores were significantly better in the suture-button group at three months post-op (91 vs 80, p=0.01, unpaired t-test) and at twelve months (93 vs 83, p=0.04, unpaired t-test). Return to work was also significantly faster (2.6 months vs 4.6 months, p=0.02, unpaired t-test). No suture-buttons required implant removal. Axial CT scanning at three months showed implants to be intact with maintenance of reduction, as compared to the uninjured contralateral side.

Suture-button syndesmosis fixation is simple, safe and effective. It has shown improved outcomes and faster rehabilitation, without needing routine removal. Although the apparatus design may undergo further refinement, we believe this technique will become the treatment of choice in Weber C ankle fractures with a syndesmosis injury.

Aim: The literature suggests that the incidence of osteomyelitis in the paediatric population has changed. We undertook to examine changes in incidence, causative organisms and treatment regimes over a 13 year period.

Methods: Patients admitted with a diagnosis of osteomyelitis between January 1991 and January 2004 were identified from hospital records and data collected from their medical and laboratory records.

Results: A total of 362 patients were admitted over the study period with a mean age of 5.9 years. A significant decrease in the number of patients presenting over the study period with osteomyelitis was noted, from a peak of 77 cases in 1991 to 12 cases in 2003 (p< 0.05). There was no significant difference in patient age or length of hospital stay over the study period. The majority of cases involved the lower appendicular skeleton with Staphylcoccus Aureus being the commonest organism cultured (accounting for 60% of positive cultures). All cases were initially treated empirically with intravenous Flucloxicillin and oral Fusidic acid. Surgical debridement/decompression was required in 11% of cases.

Conclusion: Osteomyelitis now appears to be a rare condition in children with a marked decrease in the incidence being noted over the study period. This correlates with the introduction of the Haemophilus Influenzae B vaccination in Ireland and may partly explain the decrease in incidence. The majority of cases settled on a course of non-operative management.

Introduction: Recent data from the UK suggests that the incidence of osteomyelitis in the paediatric population is declining. However, the incidence in the Scandic countries has risen in the late eighties and nineties. We undertook to examine the epidemiology of osteomyelitis presenting to a paediatric teaching hospital in an Irish urban setting.

Patients and Methods: We undertook a retrospective review to identify patients admitted over a twenty-five year period with a diagnosis of osteomyelitis. Patients were identified from hospital records, theatre log-books and a departmental database. Demographic data was collected, as were details of the infected bony structure, treatment required and organism cultured.

Results: A total of 291 patients were admitted over a twenty-four year period, from 1977 to 2000.

A marked reduction in osteomyelitis was noted over the twenty-four year incidence of the study. In addition, a shift in the causative organism was noted from an incidence of H Influenzae in the 70’s of up to 30%, to less than 5% in the 90’s. The treatment regime changed markedly over the course of the study period, with a significantly reduced duration of hospital stay reflecting the move away from protracted periods of hospitalisation.

Conclusion: A marked fall in osteomyelitis has occurred in the paediatric population. This may be due to improved living conditions and the introduction of H Influenzae vaccinations. The duration of hospital stay has declined markedly and the introduction of newer imaging modalities has aided diagnosis, allowing early aggressive intervention. However, as osteomyelitis is becoming increasingly rare, a higher index of suspicion is required, particularly from non-specialists who are more likely to be the first to encounter these patients.

Introduction: Histamine is an integral mediator following traumatic injury. Histamine-2 receptors have previously been identified on lymphocytes and monocytes.

Materials and methods: Two rodent models (1) Bilateral femoral fracture and intramedullary nailing, with resulting indirect lung injury (n=30). (2) In vivo model of orthopaedic implant contaminated by Staphylococcus epidermidis (n=36). Animals were randomised to receive ranitidine or placebo (saline).

Results: Markers of lung injury (MPO activity, BAL proteins and wet:dry ratios) increased 24 hours following bilateral femoral fracture, but were reduced if ranitidine was administered systemically after the injury. Production of Th-1 cytokines was blocked by ranitidine, whilst Th-2 cytokine production remained unaffected by ranitidine. These suggest an anti-inflammatory effect of ranitidine, blocking the early (Th-1) pro-inflammatory response following major injury.

Ranitidine’s effect on implant infection rates showed higher rates (44% versus 17%, relative risk 1.8 (95% CI 1.0 to 3.3)) when systemic ranitidine was delivered peri-operatively, suggesting an immunosuppressive effect.

Conclusions: The findings highlight the complex balance in vivo, a double-edged sword: the risk of increasing implant infection versus reducing indirect lung injury following major injury. The administration of ranitidine in major trauma patients with severe pro-inflammatory responses may block and reduce early multi-organ dysfunction and improve survival. However, owing to infection, the peri-operative administration of ranitidine should be avoided in elective cases.

Introduction A new technique of ankle syndesmosis fixation is proposed. Buttons are placed on both sides of the ankle, connected by a strong non-absorbable suture. The technique is simple and minimally invasive: a medial incision is not required. It resists diastasis whilst allowing physiological micromotion and does not require routine removal.

Methods The technique was tested on a cadaver model of a Maisonneuve injury under increasing torque loads. Sixteen embalmed cadaver legs were randomised to receive suture-button fixation or four-cortical 4.5 mm syndesmosis screw fixation. A prospective clinical study involving 16 patients with Weber C fractures and syndesmosis diastasis is presented. They underwent suture-button fixation and the results were compared to 16 consecutive patients with syndesmosis screw fixation.

Results In the cadaver study, both groups had similar rates of diastasis following torque loading. However, the suture-button did give a more consistent performance: standard deviations were significantly lower (p=0.001) than the screw group. In the clinical study, both groups were evenly matched as regards patient age, male: female ratio, and fracture patterns. Mean AOFAS ankle outcome scores at three months were significantly better in the suture-button group (91 versus 82, p=0.01). No suture-button patients required implant removal. They had a faster return to work compared to the screw group (three months versus five months). Axial CT scanning performed at three months post-op showed all implants to be intact with no loss of reduction.

Conclusions Suture-button syndesmosis fixation is simple, safe, effective and physiological. It has shown improved outcomes and faster rehabilitation, without needing routine removal. It may become the treatment of choice in Weber C ankle fractures with a syndesmosis diastasis.

In relation to the conduct of this study, one or more the authors have received, or are likely to receive direct material benefits.

Aims: A new technique of syndesmosis fixation is proposed; placing buttons on both sides of the ankle, without opening the medial side, connected by a strong non-absorbable suture. We tested this against syndesmosis screw fixation in a cadaver model of a Maisonneuve injury and subsequently in a prospective clinical study. Methods: 16 cadaver legs were randomised to have suture-button or syndesmosis screw fixation and tested under torque loading. In the clinical study, 16 patients with a syndesmosis diastasis underwent suturebutton fixation and the results compared to 16 patients with syndesmosis screw fixation. Results: In the cadaver study, both groups had similar rates of diastasis, although the suture-button did give a more consistent performance: standard deviations were significantly lower (p=0.001). In the clinical study, mean A.O.F.A.S. scores at 3 months were significantly better in the suturebutton group (91 vs 82, p=0.01). No suture-button implants required removal, compared to 13/16 of the screw group (p=0.001). Conclusions: Suture-button syndesmosis fixation is simple, safe and physiological. Biomechanically it performs at least as well as screw fixation. Clinically it has shown improved outcomes, without needing routine removal. It may become the treatment of choice in syndesmosis injuries.

The surgical treatment of chronic Achilles tendon ruptures is essential to restore the normal gait pattern. There are a variety of surgical techniques described, including primary repair, augmentation with tendon transfers, augmentation with aponeurosis flaps and bridging techniques. In recent times augmentation with tendon transfers or aponeurosis flaps are the most commonly performed procedures. Our study examined the biomechanical effect of using the flexor hallicus longus in an augmented chronic Achilles tendon repair on gait pattern and forefoot loading distribution using pedobaragraphical analysis.

We, pedobarographically examined the gait patterns of 10 patients who had undergone augmented chronic Achilles tendon repair using the flexor hallicus longus tendon. The mean age at the time of injury was 59 years of age (range 46–70). The mean follow-up time was 38 months. All patients reported good to excellent results. The mean AOFAS ankle score was 96.25 (range 90–100). There was no statistically significant difference between the loading distributions of the operated foot relative to the contralateral side.

While there is no comparative study examining the outcomes of the varying surgical techniques for chronic Achilles tendon repair, the use of the flexor hallicus longus tendon in augmented chronic Achilles tendon repair has been proven as an effective repair to restore normal function while not compromising the biomechanics of the 1st ray or the loading distribution of the forefoot.

Introduction: Fractures of the distal radius are amongst the most commonly encountered injuries in orthopaedic trauma. Treatment options include closed manipulation, percutaneous fixing using K wires and external fixation. Restoration of the volar tilt and radial length are proven to have a positive correlation with a good functional outcome.

A randomised prospective study has been performed to compare the effectiveness of percutaneous stabilisation using K wires inserted in the traditional transcortical fashion with K wires inserted using a novel intramedullary spring loaded technique. The treatments were compared for their ability to restore normal anatomy, carpal alignment and function of the hand after unstable fractures of the distal radius.

Patients and Methods: Between October 2001 and February 2002, 46 patients with unstable fractures of the distal radius were entered into the study. There were 37 females and 9 males, mean age of 58 years (range 17–87). Fractures were classified using the AO system. Patients were randomly allocated using closed envelopes into one of two groups. All fractures were reduced, and three 1.6mm K wires were inserted using one of two techniques. Group I (24 pts) had the wires engaged into the opposite cortex and driven down the medullary canal (spring-loaded). All patients were followed up for a minimum of 6 weeks. Radiological and functional evaluation was performed.

Results: Immediate post operative radiographs showed a mean dorsal angle of –3° in Group I (ie 3 degrees volar tilt) and –7.5° in Group II. Restoration of radial length was similar in both groups. By 6 weeks, the mean dorsal angle for Group I was −1.9°, and –10.6° in Group II. The mean loss of radial length was similar in both groups (1.2mm in Group I; 1.3mm in Group II). Functional outcome was assessed using the Wrist Function Score², and was similar in both groups at 6 weeks. There were 2 early fixation failures, both in Group I, and both class C3 fractures (AO).

Conclusion: ‘Spring loaded’ percutaneous K wiring of distal radius fractures results a significantly superior restoration of volar tilt post operatively and at 6 weeks when compared against the transcortical technique. The ‘spring’ translates into a dynamic force reducing the fracture. We estimate that these radiological results will result in a superior functional outcome in the longer term.

We have compared the rates of infection and resistance in an animal model of an orthopaedic procedure which was contaminated with a low-dose inoculum of Staphylococcus epidermidis. We randomised 44 Sprague-Dawley rats to have bone cement implanted subcutaneously containing either gentamicin or saline (control). The wound was inoculated with a dilute solution of gentamicin-sensitive Staphylococcus epidermidis. At two weeks the cement was retrieved and microbiologically tested. A lower overall rate of infection was seen in the gentamicin-loaded cement group, but there was a significantly higher rate of gentamicin-resistant infection in this group (Fisher’s exact test, p < 0.01). Antibiotic-impregnated cement has an optimum surface for colonisation and prolonged exposure to antibiotic allows mutational resistance to occur. Gentamicin-loaded cement may not be appropriate for revision surgery if it has been used already in previous surgery.