Purpose: Tension band wiring is the most common surgical procedure for fixation of fractures of the Olecranon, but it is associated with high rate of metal work complications and implant failure leading to re-operation.

Method: We present a new fixation technique for olecranon fractures that avoids reoperation to remove hardware as compared with the standard fixation technique with Kirschner wires and tension band wiring as advocated by the AO technique. We describe fixation of displaced transverse and oblique olecranon fractures with anchor sutures, each of which has two pairs of suture strands. Prior to the insertion of the anchor sutures, the fracture is reduced through a standard open approach

Results: Twelve patients have been treated with this technique so far, with a mean follow-up of 6 months. The mean age of the patients was 46.7 years (range 14–75 yrs). We have followed all these patients till union of the fractures. No immediate complications have been noted. Radiographic results are good, with no loss of reduction.

Conclusion: This technique avoids the need for reop-eration for hardware removal without compromising the quality of reduction. It may be argued that anchor sutures may cost more than tension band wiring which is a very low cost procedure. At the same time, we should also consider the future cost involved because of reoperation rate and morbidity. Our newly described technique would be particularly useful in dealing with olecranon fractures in children where it is undesirable to cross the physeal plate by metal work. It would also be of great value in dealing with intra articular distal humeral fractures where fixation is planned initially but conversion to total elbow replacement becomes essential intra-operatively. In such cases an olecranon osteotomy can be fixed by this technique, even in presence of a total elbow replacement.

Complex primary total knee replacements have been poorly reported in the literature We review all complex primary total knee replacement procedures at Stepping Hill Hospital. Patients underwent knee examination, knee scores, notes review and pre- and post-operative radiograph review. There were 29 patients with 36 knees that had a complex primary total knee replacement. Most frequent indications for surgery were osteoarthritis, rheumatoid arthritis or following trauma. Mean age at surgery 70 years. The prosthesis used were : 3 Stryker Kinemax; 32 De Puy PFC and one rotating hinge. Complex Primary Oxford knee score; preoperative mean 45 (range 33 to 57); postoperative mean 26 (range 14 to 53). NJR Total Knee Replacement Oxford knee score postoperative mean 30. Mean visual analogue scores; pain in the knee, mean 19; knee function, mean 77; outcome of the operation 76; satisfaction with the surgery 87. Mean length of hospital stay 13 days.

Using the Knee Society Radiographic Scoring System, there were no signs that need to be monitored or signify failure. Seven patients were transfused postoperatively, four patients had minor wound problems, three required further surgery, two to washout the knee and exchange the polyethylene liner, one femoral plating to stabilise an osteotomy site. Long term complications : one above knee amputation for infection, one foot drop.

Revision implants can be used in complex primary knee replacements, and pose technical difficulties but address various pathologies. The surgery is associated with an increased risk of complications and transfusion. Clinical scores at least match scores for routine total knee replacements, patient satisfaction is excellent.

We present our results in 89 consecutive patients (138 feet), minimum FU of 24/12.

Methods: Typical indications were IM angles > 13 degrees, incongruent MTP1 joints.

Contraindications included abnormal DMMA, significant 1st MTP arthritis, hypermobility of 1st MTC joint, revision surgery.

All patients underwent a 3-in-1 procedure with soft tissue release in 1stwebspace, medial bunionectomy with capsulorraphy and basal crescentic osteotomy.

A 25 mm blade on oscillating driver was used. Fixation was staples(70%),screws(20%),K- wires(10%).

Post op, PWB, progressing to FWB at 3/52.

AOFAS forefoot scores at pre-op, 6/12, 12/12 and 24/12.

Weight bearing radiographs obtained at pre-op, 3/12, 12/12.

Results:

M:F=19:70

Age 31–79 (Mean 64)

89 patients, 138 feet

AOFAS scores improved from average 42/100 preop to 76/100 at 6/12.

Radiographic correction excellent in78% of patients.

74 % of patients extremely satisfied,15 %satisfied,11 %unsatisfied with outcome.

Complications:

Nonunion=2

Infection=2 superficial,1 deep

Recurrence of deformity at 6/12 = 2

12/12 = 2

Transfer metatarsalgia M2 due to overriding of distal M1=3

Conclusions: Basal Dome Osteotomy with soft tissue correction is powerful and reproducible for the correction of moderate and severe Hallux Valgus. There is an initial learning curve. Much less soft tissue dissection required compared to the SCARF procedure. Results are very satisfactory.

Subtalar joint stiffness is an under recognized complication of ankle fractures. We set out to objectively measure its prevalence and impact on Activities of Daily Living (ADL).

Method:

60 ankle fractures included in study. All patients had contralateral normal ankle.

M:F=21:39

Average age: 36 (19 – 84)

Weber: A B C

21 27 12

27 patients underwent ORIF (12C + 15B)

39 patients had plaster casts for between 2 and 6 weeks. (27B + 12C)

Postop regimes included early mobilization and POP application (AO recommendation)

Weber A (21) treated symptomatically.

Examinations for study at 3/12 and 6/12 post injury.

Subtalar and ankle movements were assessed by the same examiner (as per Hoppenfeld)

Subjective questions about subtalar stiffness and their impact on ADL were asked.

Results:

At 3/12, 56 patients (17A + 27B + 12C) had subjective and clinical impairment of subtalar movement.

32 patients (2A + 20B + 10C) had moderate to severe impairment (> 30%)

At 6/12, 42 patients (9A + 23B + 10C) had subjective symptoms and clinical impairment of subtalar function. Of these, 26 (0A + 18B + 8C) had > 30% impairment vs. controls.

Conclusions: Symptomatic subtalar joint stiffness with limitation of ADL is a significant sequel of ankle fractures and results in long term morbidity. This has implications in assessing functional outcome of these common injuries.

We present our results with a modified Mann-Thompson procedure in 47 patients (86 feet). Minimum follow up was 24 months.

All patients had moderate to advanced forefoot deformities.

Methods:

M:F=12:35

43/47 bilateral

Simultaneous procedures in bilateral cases.

Popliteal block analgesia used routinely.

Technique:

Medial incision centered on MTP1 joint. Minimal bony and soft tissue resection. Fixation carried out with staples (78 feet),K-wires (8 feet)

Transverse incision centered on the lesser MTP joints made. Combination of soft tissue release, lesser MT head resection in cascade fashion from dorsal distal to proximal plantar performed. Lesser toe deformities treated by a combination of closed osteoclasis, soft tissue release and bony resection. Transarticular K-wire fixation then performed for all lesser toes.

Bulky postop dressing and post op shoes used.

Immediate FWB permitted.

Transarticular K-wires removed at 4/52.

Results:

AOFAS Forefoot Scores assessed at preop,6/12,12/ 12,and24/12.

Subjective patient assessment of procedure requested.

Average AOFAS scores improved from 37to72(67 – 84)

40 patients extremely pleased with the results. 5 patients pleased with reservations and 2 patients disappointed with the outcome.

Complications:

3 superficial wound infections

2 metal work related problems

2 early loss of lesser toe correction

3 late deformities of lesser metatarsals requiring surgery

Conclusion: This procedure offers excellent, reproducible biomechanical correction with high rates of patient satisfaction.