We reviewed three infants with destructive osteomyelitis involving the proximal tibial epiphysis at a follow-up of eight to 22 years. All cases showed early radiographic destructive changes in the medial or lateral aspects of the epiphysis and metaphysis. Despite the ominous early appearance of the epiphysis, all cases showed spontaneous re-ossification of the epiphysis with restoration of the tibial condyle and preservation of joint congruity. The patients, however, developed a valgus or varus deformity which was treated satisfactorily with one to three proximal tibial osteotomies. The potential for regeneration of the epiphysis following infantile osteomyelitis of the proximal tibia suggests these cases should be treated expectantly with regard to joint congruity.

This prospective five-year study analyses the impact of methicillin-resistant Staphylococcus aureus (MRSA) on an Irish orthopaedic unit. We identified 318 cases of MRSA, representing 0.76% of all admissions (41 971). A total of 240 (76%) cases were colonised with MRSA, while 120 (37.7%) were infected. Patients were admitted from home (218; 68.6%), nursing homes (72; 22.6%) and other hospitals (28; 8.8%). A total of 115 cases (36.6%) were colonised or infected on admission. Many patients were both colonised and infected at some stage. The length of hospital stay was almost trebled because of the presence of MRSA infection.

Encouragingly, overall infection rates have not risen significantly over the five years of the study despite increased prevalence of MRSA. However, the financial burden of MRSA is increasing, highlighting the need for progress in understanding how to control this resistant pathogen more effectively.

We report the survival at five years of 144 consecutive metal-on-metal resurfacings of the hip implanted between August 1997 and May 1998. Failure was defined as revision of either the acetabular or femoral component for any reason during the study period. The survival at the end of five years was 98% overall and 99% for aseptic revisions only. The mean age of the patients at implantation was 52.1 years.

Three femoral components failed during the first two years, two were infected and one fractured. A single stage revision was carried out in each case. No other revisions were performed or are impending. No patients were lost to follow-up. Four died from unrelated causes during the study period.

This study confirms that hip resurfacing using a metal-on-metal bearing of known provenance can provide a solution in the medium term for the younger more active adult who requires surgical intervention for hip disease.

Failure of total hip arthroplasty with acetabular deficiency occurred in 55 patients (60 hips) and was treated with acetabular revision using morsellised allograft and a cemented metal-backed component. A total of 50 patients (55 hips) were available for clinical and radiological evaluation at a mean follow-up of 5.8 years (3 to 9.5). No hip required further revision of the acetabular component because of aseptic loosening.

All the hips except one had complete incorporation of the allograft demonstrated on the radiographs. A complete radiolucent line of > 1 mm was noted in two hips post-operatively. A good to excellent result occurred in 50 hips (91%). With radiological evidence of aseptic loosening of the acetabular component as the end-point, the survivorship at a mean of 5.8 years after surgery was 96.4%.

The use of impacted allograft chips in combination with a cemented metal-backed acetabular component and screw fixation can achieve good medium-term results in patients with acetabular bone deficiency.

Injuries to the acromioclavicular joint are common but underdiagnosed. Sprains and minor subluxations are best managed conservatively, but there is debate concerning the treatment of complete dislocations and the more complex combined injuries in which other elements of the shoulder girdle are damaged. Confusion has been caused by existing systems for classification of these injuries, the plethora of available operative techniques and the lack of well-designed clinical trials comparing alternative methods of management. Recent advances in arthroscopic surgery have produced an even greater variety of surgical options for which, as yet, there are no objective data on outcome of high quality. We review the current concepts of the treatment of these injuries.

In this retrospective study we evaluated the method of acute shortening and distraction osteogenesis for the treatment of tibial nonunion with bone loss in 17 patients with a mean age of 36 years (10 to 58). The mean bone loss was 5.6 cm (3 to 10). In infected cases, we performed the treatment in two stages. The mean follow-up time was 43.5 months (24 to 96). The mean time in external fixation was 8.0 months (4 to 13) and the mean external fixator index was 1.4 months/cm (1.1 to 1.8). There was no recurrence of infection. The bone evaluation results were excellent in 16 patients and good in one, while functional results were excellent in 15 and good in two. The complication rate was 1.2 per patient.

We conclude that acute shortening and distraction osteogenesis is a safe, reliable and successful method for the treatment of tibial nonunion with bone loss, with a shorter period of treatment and lower rate of complication.

Revision arthroplasty after infection can often be complicated by both extensive bone loss and a relatively high rate of re-infection. Using allograft to address the bone loss in such patients is controversial because of the perceived risk of bacterial infection from the use of avascular graft material. We describe 12 two-stage revisions for infection in which segmental allografts were loaded with antibiotics using iontophoresis, a technique using an electrical potential to drive ionised antibiotics into cortical bone.

Iontophoresis produced high levels of antibiotic in the allograft, which eluted into the surrounding tissues. We postulate that this offers protection from infection in the high-risk peri-operative period. None of the 12 patients who had two-stage revision with iontophoresed allografts had further infection after a mean period of 47 months (14 to 78).

We compared the safety and outcome of one-stage bilateral total hip arthroplasty with those of a two-stage procedure during different admissions in a prospective, randomised controlled trial in an Asian population. Of 168 patients included in the study, 83 had a single- and 85 a two-stage procedure. Most of the patients (59.9%) suffered from inflammatory arthritis.

The intra-operative complications, early systemic complications, the operating time, positioning of the components, the functional score, restoration of limb length and survival rates at 96 months were similar in the two groups. The total estimated blood loss was significantly lower in patients undergoing a one-stage procedure than in patients who had a two-stage procedure, but the transfusion requirements were significantly higher in the former group (p = 0.001). The hospital stay was significantly shorter in the one-stage group, 7.25 days (sd 1.30; 5 to 20) compared with 10 days (sd 1.65; 8 to 24) in the two-stage group (p = 0.023). We believe that a one-stage procedure is safe and appropriate in our population.

We present the outcome of the treatment of chronic post-traumatic contractures of the proximal interphalangeal joint by gradual distraction correction using an external fixator. A total of 30 consecutive patients with a mean age of 34 years (17 to 54) had distraction for a mean of 16 days (10 to 22). The fixator was removed after a mean of 29 days (16 to 40). Assessment at a mean of 34 months (18 to 54) after completion of treatment showed that the mean active range of movement had significantly increased by 63° (30° to 90°; p < 0.001). The mean active extension gained was 47° (30° to 75°).

Patients aged less than 40 years fared slightly better with a mean gain in active range of movement of 65° (30° to 90°) compared with those aged more than 40 years, who had a mean gain in active range of movement of 55° (30° to 70°) but the difference was not statistically significant (p = 0.148).

The use of joint distraction to correct chronic flexion contracture of the proximal interphalangeal joint is a minimally-invasive and effective method of treatment.