The management and outcome of treatment in 42 patients (49 shoulders) with an infected shoulder prosthesis was reviewed in a retrospective multicentre study of 2343 prostheses. The factors which were analysed included the primary diagnosis, the delay between the diagnosis of infection and treatment and the type of treatment. Treatment was considered to be successful in 30 patients (71%). Previous surgery and radiotherapy were identified as risk factors for the development of infection. All patients with an infected prosthesis had pain and limitation of movement and 88% showed radiological loosening. In 50% of the shoulders, the antibiotics chosen and the length of treatment were considered not to be optimal. The mean follow-up was 34 months. Antibiotics or debridement alone were ineffective. In acute infection, immediate revision with excision of all infected tissue and exchange of the prosthesis with appropriate antibiotic therapy gave the best results. Multidisciplinary collaboration is recommended

We have reviewed 15 patients with infected total knee replacements after removal of the prosthesis, rigorous debridement, antibiotic irrigation, and prolonged systemic antibiotics. Infection was permanently eradicated in all patients; they were left with a functioning limb, on which they could walk with either a caliper (8 patients), a simple splint (3), crutches, or sticks. Three were disappointed because of residual pain. We believe that, if exchange arthroplasty is inappropriate, this procedure is preferable to arthrodesis or amputation for persistent and disabling infection, particularly where constrained artificial joints have been used

Crushing of the radial side of the hand results in a wide spectrum of injuries varying from contusion of muscles to total loss. The main problem concerns the function of the thumb. The results of such injuries in 161 hands were reviewed. Those with mild injuries treated conservatively or by debridement alone had good results. When skin flaps were required for wound coverage, the results were still satisfactory. However, when bones and joints were injured, the results were poor. In certain patients opponensplasty through scarred tissue proved to be a good procedure to improve the function of the thumb

We describe a technique for arthroscopy of the wrist which is carried out without traction and with the arm lying horizontally on the operating table. The wrist is not immobilised, which makes it possible to assess the extent of instability after a ligamentous tear. In a prospective study of 30 patients we compared this technique with conventional wrist arthroscopy, performing the new method first followed by conventional arthroscopy. The advantages are that the horizontal position of the arm allows the surgeon to proceed directly from arthroscopic diagnosis to treatment, and that no change of position is required for fluoroscopy. In terms of diagnostic sensitivity, we found our technique matched that of conventional arthroscopy. We had no difficulty in carrying out minor surgical procedures such as debridement and suturing

Aims

Currently, periprosthetic fractures are excluded from the American Society for Bone and Mineral Research (ASBMR) definition of atypical femoral fracture (AFFs). This study aims to report on a series of periprosthetic femoral fractures (PFFs) that otherwise meet the criteria for AFFs. Secondary aims were to identify predictors of periprosthetic atypical femoral fractures (PAFFs) and quantify the complications of treatment.

Inversion injuries of the ankle are common and most are managed adequately by functional treatment. A significant number will, however, remain symptomatic. Synovial impingement is one cause of continuing pain. This condition is often difficult to diagnose because the physical signs and investigations are non-specific. If the diagnosis is made, treatment by arthroscopic debridement has been shown to be highly effective. Our aim was to describe a new physical sign to help in the diagnosis of anterolateral synovial impingement in the ankle. A cadaver dissection demonstrated the anatomical basis for the physical sign and a prospective clinical study involving 73 patients showed that the lateral synovial impingement test had a sensitivity of 94.8% and a specificity of 88%. We describe the test and conclude that this physical sign will be of use to practitioners treating patients with chronic pain in the ankle after injury

We treated 37 patients with chronic osteomyelitis of the tibia (25), femur (9), radius (2) and humerus (1) by a two-stage technique, comprising radical debridement of all infected bone and soft tissue with the provision of soft-tissue cover, and delayed autogenous bone grafting when necessary. All patients were reviewed at an average of 49 months (12 to 121). Infection-free bone union was achieved in 34. No patient required amputation. Wide excision of all compromised tissue and the closure of bone within a healthy vascularised soft-tissue envelope are essential if infection is to be eradicated. The combined assessment and management of such patients by an orthopaedic surgeon and a plastic surgeon are advocated

Degenerative arthritis of the elbow is a poorly recognised condition, usually seen in a middle-aged man with an occupation or activity which involves the repetitive use of his dominant arm. Flexion contracture and pain at terminal extension are common presenting features. Fifteen patients were reviewed at a mean of 33 months after debridement by ulnohumeral arthroplasty. Fourteen had good relief of pain, elbow extension had improved by an average of 11 degrees and elbow flexion by 10 degrees. On an objective scale 12 of the 15 patients had good or excellent results and 13 (87%) felt that they were improved by the operation

Although the incidence of infection associated with hip and knee prostheses is low, with the increasing number of arthroplasties being carried out, the total number of such cases is increasing. The pattern of infecting organisms after total joint arthroplasty has changed and gentamicin-resistant organisms are becoming increasingly common. In conjunction with surgical debridement, vancomycin added to a bone-cement carrier can be very effective in the treatment of infection caused by such organisms. We report the results of its use in proven deep infection in 26 hip and seven knee arthroplasties. After a mean follow-up of 67 months, 32 patients remained clinically and radiologically free from infection. There was one recurrence and positive second-stage cultures of uncertain significance in three other patients. Vancomycin is potentially very useful in the management of deep infection after arthroplasty

Aims

The increasing infection burden after total hip arthroplasty (THA) has seen a rise in the use of two-stage exchange arthroplasty and the use of increasingly powerful antibiotics at the time of this procedure. As a result, there has been an increase in the number of failed two-stage revisions during the past decade. The aim of this study was to clarify the outcome of repeat two-stage revision THA following a failed two-stage exchange due to recurrent prosthetic joint infection (PJI).

Reamed intramedullary nailing was carried out on 57 Gustilo grade-IIIB tibial fractures in 55 patients. After debridement, there was substantial bone loss in 28 fractures (49%). The mean time to union was 43 weeks (14 to 94). When there was no bone loss, the mean time to union was 32 weeks; it was 45 weeks if there was bone loss. Fractures complicated by infection took a mean of 53 weeks to heal. Revision nailing was necessary in 13 fractures (23%) and bone grafting in 15 (26%). In ten fractures (17.5%) infection developed, in four within six weeks of injury and in six more than four months later. Of these, nine were treated successfully, but one patient required an amputation because of osteomyelitis. Our results indicate that reamed intramedullary nailing is a satisfactory treatment for Gustilo grade-III tibial fractures

We treated 52 patients with impingement of the anterolateral soft tissues of the ankle by arthroscopic debridement. All had a history of single or multiple inversion injuries, without instability. One half had negative stress radiographs (stable group), while the others were positive (unstable group). Their mean age was 31 years and there were 35 men and 17 women. The results were assessed at a mean follow-up of 30 months. Three patients (6%) had a fair result, while 49 (94%) had an excellent or good outcome. No difference was found in the final results between the two groups (p > 0.05). We conclude that anterolateral impingement of the ankle should be considered in a patient with chronic anterolateral pain after an injury, regardless of the stability of the ankle

We reviewed 13 patients with congenital insensitivity to pain. A quantitative sweat test was carried out in five and an intradermal histamine test in ten. DNA examination showed specific mutations in four patients. There were three clinical presentations: type A, in which multiple infections occurred (five patients); type B, with fractures, growth disturbances and avascular necrosis (three patients); and type C, with Charcot arthropathies and joint dislocations, as well as fractures and infections (five patients, four with mental retardation). Patient education, shoeware and periods of non-weight-bearing are important in the prevention and early treatment of decubitus ulcers. The differentiation between fractures and infections should be based on aspiration and cultures to prevent unnecessary surgery. Established infections should be treated by wide surgical debridement. Deformities can be managed by corrective osteotomies, and shortening by shoe raises or epiphysiodesis. Joint dislocations are best treated conservatively

Nineteen patients with thoracic or thoracolumbar spinal tuberculosis and neurological deficits were treated by anterior debridement, decompression and vascularised rib grafting, followed, either during the same procedure or 14 days later, by multilevel posterior osteotomies, instrumentation and fusion. Surgery was performed under cover of four-drug antituberculosis chemotherapy, given for 12 months. The average pre-operative kyphotic angulation of 56 degrees was reduced to 27 degrees postoperatively and 30 degrees at the latest follow-up (3 degrees loss of correction). Radiological fusion between the vascularised rib graft and the vertebrae was seen after an average of 3.3 months. Eighteen patients (95%) had normal neurological function at 14 months, and the other could walk with the aid of crutches

In order to define the predisposing factors and outcome of infected arthroplasty of the knee, a retrospective analysis of a consecutive series of 471 knee arthroplasties was performed. There were 23 cases of superficial wound infection and 25 of deep infection. Superficial wound infection alone resulted in a painfree gait, with little limitation of movement. Rheumatoid arthritis, the use of constrained prostheses and the presence of a superficial wound infection, all predisposed to deep infection. Deep infection was eradicated by long-term antibiotics in only two patients in whom skin cover was successfully provided by a gastrocnemius musculocutaneous flap. Excision of a sinus track, wound debridement and exchange arthroplasty were universally unsuccessful. Arthrodesis, however, in 11 out of 12 cases, provided the painfree gait these patients desire

Aims

The Bundled Payments for Care Improvement (BPCI) initiative has identified pathways for improving the value of care. However, patient-specific modifiable and non-modifiable risk factors may increase costs beyond the target payment. We sought to identify risk factors for exceeding our institution’s target payment, the so-called ‘bundle busters’.

Of 37 consecutive patients suffering from tuberculosis of the lumbosacral spine, 26 were reviewed after an average follow-up of 20 years. Those presenting at under 10 years of age usually had a discharging sinus or a pointing abscess and a visible kyphosis. In older patients, low back pain was the predominant presenting symptom. Neurological involvement was uncommon. Both operative and conservative treatment had resulted in fusion but all patients treated conservatively ended up with a kyphosis associated with trunk shortening. They had a higher incidence of back pain and more complications in pregnancy. Anterior debridement and fusion with a strut graft can reduce the incidence and size of kyphosis, but is technically demanding. Treatment remains difficult and requires individual consideration

Aims

The aim of this study was to describe the use of 3D-printed sacral endoprostheses to reconstruct the pelvic ring and re-establish spinopelvic stability after total en bloc sacrectomy (TES) and to review its outcome.