A common step to revision surgery for infected total knee replacement (TKR) is a thorough debridement. Whilst surgical and mechanical debridement are established as the gold standard, we investigate a novel adjuvant chemical debridement using an Acetic Acid (AA) soak that seeks to create a hostile environment for organisms, further degradation of biofilm and death of the bacteria.

We report the first orthopaedic in vivo series using AA soak as an intra-operative chemical debridement agent for treating infected TKR's. We also investigate the in vitro efficacy of AA against bacteria isolated from infected TKR's.

A prospective single surgeon consecutive series of patients with infected TKR were treated according to a standard debridement protocol. Patients in the series received sequential debridement of surgical, mechanical and finally chemical debridement with a 10 minute 3% AA soak.

In parallel, we isolated, cultured and identified bacteria from infected TKR's and assessed the in vitro efficacy of AA. Susceptibility testing was performed with AA solutions of different concentrations as well as with a control of a gentamicin sulphate disc. The effect of AA on the pH of tryptone soya was also monitored in an attempt to understand its potential mechanism of action.

Physiological responses during the AA soak were unremarkable. Intraoperatively, there were no tachycardic or arrythmic responses, any increase in respiratory rate or changes in blood pressure. This was also the case when the tourniquet was released. In addition, during the post-operative period no increase in analgesic requirements or wound complications was noted. Wound and soft tissue healing was excellent and there have not been any early recurrent infections at mean of 18 months follow up.

In vitro, zones of inhibition were formed on less than 40% of the organisms, demonstrating that AA was not directly bactericidal against the majority of the clinical isolates. However, when cultured in a bacterial suspension, AA completely inhibited the growth of the isolates at concentrations as low as 0.19%v/v.

This study has shown that the use of 3% AA soak, as part of a debridement protocol, is safe. Whilst the exact mechanism of action of acetic acid is yet to be determined, we have demonstrated that concentrations as low as 0.19%v/v in solution in vitro is sufficient to completely inhibit bacterial growth from infected TKR's.

Aims: To treat posttraumatic stiffness of elbow by distraction arthrodiastasis and mobilisation. Standard operative procedures were combined for 4 patients with bony blocks due to myositis ossiþcans. Methods: We reviewed 8 patients, 5:M, 3:F aged 20–42 years. 3 x 2.5mm k-wires were passed in lower-third humerus from lateral to medial side and 3 x 2.5mm k-wires in proximal ulna. Distractors were applied on anterior and posterior aspect of elbow and hinge-joint at the level of elbow-joint. Elbow was gradually distracted to achieve arthro-diastatic state of joint. Maintaining arthrodiastatic state now elbow deformity is gradually corrected by distracting anterior distractors. Than distractors and hinge are locked for tissue reaction to subside over 2–3 weeks followed by dynamic mobilization. Movement gradually improves over 2–3weeks (sometimes prolonged in severe cases). Than þxator is removed and appropriate dynamic splint is applied to maintain correction while allowing mobility. In 4cases bone block was removed surgically and followed by distraction arthrodiastatic procedure. No steroid in any form was used in any stage of treatment. Results: Average follow-up: 2years (maximum 4years). All elbows were stable and extension increased by 30û and ßexion increased by 50û. One case had minor pin-tract infection, responded to basic treatment. No neurovascular deþcit was not seen post procedure in any patients. Conclusion: This technique may be considered before arthrolysis is undertaken for stiff elbow.

Aims: Osteotomy of ulna with fractional distraction maintains ulnar length and reduced position of radial head via interrosseous membrane. Methods: We reviewed 9patients, 5:M, 4:F, aged 2Ð14years. Interval between injury and surgery ranged 2–36months. All had elbow deformity with radial head prominence. Restricted movement in 6patients. 3 had pain on movements. 2x2mm k-wires each, proximal and distal to ulnar osteotomy. Distal k-wires transþxed in radius in supination (during distraction of ulna, radius is pulled down). ÔZñ/ÔTransverseñ osteotomy performed subperiosteally Ulna lengthened by fractional distraction. Axial k-wire in ulna in selected patients to prevent angular deformity, developing at osteotomy site during distraction. Latency period: 7days, Distraction rate: 0.8mm/day. Radial head position monitored by weekly x-rays. Static þxator time: 2x(distraction time), for consolidation of new-bone. Total þxator time: 6weeks followed by þxator removal. Brace for 2weeks with elbow-joint physiotherapy. Results: Distraction corrected ulnar deformity, restored ulnar length and radial head in anatomical position. Average ulnar length gain: 14mm. Duration of distraction: 17days. Average follow-up: 2years (1.5 Ð 4years). We achieved full, painless, stable elbow ßexion, extension, pronation and supination movements in eight but one patient. Pronosupination movement did not deteriorate over four years of study. No patient developed myositis ossiþcans or neurodeþcit. 2patients had minor pin-tract infection, subsided on treatment. Conclusion: Safe, effective and fully controlled method. This technique may be considered before open procedures for radial head.

Aims: In reconstruction of brachydactyly, either post-traumatic or congenital, we present our method of skeletal lengthening by distraction. Methods: We treated 32 short digits in 15 patients. Posttraumatic: 10patients and Congenital shortening: 5patients (Average age 5years (3.4 – 7.7 years) in congenital group). For traumatic amputation duration between injury and surgery: average 14weeks (10–19.5weeks). Concerned phalanx exposed through dorsal approach. Transfixing k-wires passed perpendicular to phalangeal shaft above and below proposed osteotomy and connected on either side to a distractor. Latency period: 5days. Distraction rate: 0.8 mm/day. Serial x-rays at 3weekly intervals. In 6patients with deficient new bone, bone grafting was done using iliac crest graft. Fixator left in situ till radiological evidence of bony healing than wires removed under local anaesthesia and patients were started on vigorous physiotherapy for gaining range of movements. 8patients required deepening of the web space in addition to above-mentioned procedures. This procedure was required in cases having more than one short digit. Results: Average length gained: 18mm. Average duration of distraction: 42.26days. Fixator in situ: average 92days (80–136days). Initial stiffness of digits was seen in 50% of cases, which eventually responded to physiotherapy, & all patients had an excellent range of motion. Conclusions: This method provides patients with good function and cosmetic hand. Any surgeon not familiar with microvascular surgery can use this technique.

Aims: To correct cubitus varus deformity by wedge resection and compression by external þxator for rapid osteogenesis. Methods: We treated 6patients with cubitus varus deformity secondary to malunited supra-condylar fracture of humerus. 4:M, 2:F aged between 8–14years. Duration between injury and surgery averaged 20months (1.4–2.4years). Preoperative humeroulna angle on x-ray averaged Ð18.5¡ (−12¡ to −28¡) and on contralateral limb averaged 12.4¡ (8¡−18¡). All patients had full elbow movements preoperatively. 2x2mm k-wires passed in lower humeral metaphysis parallel to joint line and 2x2mm k-wires passed in lower diaphysis perpendicular to humeral shaft. Laterally based bone wedge equivalent to preoperatively calculated template including 5¡ of over-correction was removed in between the wires. A compression distraction rod was applied to close the wedge by compression. Elbow was mobilized after postoperative pain relief in þrst week with dynamic elastic sling. Fixator was removed at 6weeks. Results: All patients achieved full elbow movements and complete cosmetic correction. Osteotomy united faster under compression. No neurovascular complication was seen. One patient had minor pin tract infection, subsided on treatment. Conclusions: Any residual corrections postoperatively are fully adjustable. Literature reports poor results of up to 30% due to loss off or inadequate correction. Stability achieved by þxator allowed early postoperative elbow mobilization. Extremely reliable, ßexible and fully controlled method.

Osteotomy of ulna with fractional distraction maintains ulnar length and reduced position of radial head via interrosseous membrane.

We reviewed 9 patients, 5:M, 4:F, aged 2–14 years. Interval between injury and surgery ranged 2–36months but in seven patients the repositioning was performed within 6 months. All had elbow deformity with radial head prominence. 6 patients had restricted movements of elbow. 3 had pain on movements.

2 x 2mm k-wires each, proximal and distal to ulnar osteotomy. Distal k-wires were transfixed in radius in complete supination (during distraction of ulna, radius is pulled down). ‘Z’/‘Transverse’ osteotomy was then performed subperiosteally. Ulna lengthened by fractional distraction. Axial k-wire in ulna was used in selected patients to prevent any angular deformity from developing at osteotomy site during distraction. Latency period was 7 days, Distraction rate was 0.8mm/day. Radial head position was monitored by weekly x-rays. Static fixator time was 2 x (distraction time) so as to allow time for consolidation of new-bone. Total fixator time was 6weeks followed by fixator removal and brace for 2weeks with elbow-joint physiotherapy.

Distraction corrected ulnar deformity, restored ulnar length and repositioned radial head in anatomical position. Average ulnar length gained was 14mm. Duration of distraction was 17 days. Average follow-up was 2 years (1.5 – 4years). We achieved full, painless, stable elbow flexion, extension, pronation and supination movements in eight but one patient. Pronosupination movement did not deteriorate over four years of our study. No patient developed myositis ossificans or neurodeficit. 2 patients had minor pin-tract infection, which responded to basic treatment.

Safe, effective and fully controlled method. This technique may be considered before open procedures for radial head is undertaken.