Introduction. Angular deformities of the distal femur can be corrected by opening, closing and neutral wedge techniques. Opening wedge (OW) and closing wedge (CW) are popular and well described in the literature. CW and OW techniques lead to leg length difference whereas the advantage of neutral wedge (NW) technique has several unique advantages. NW technique maintains limb length, wedge taken from the closing side is utilised on the opening side and since the angular correction is only half of the measured wedge on either side, translation of distal fragment is minimum. Leg lengths are not altered with this technique hence a useful technique in large deformities. We found no reports of clinical outcomes using NW technique. We present a technique of performing external fixator assisted NW correction of large valgus and varus deformities of distal femur and dual plating and discuss the results. Materials & Methods. We have treated 20 (22 limbs – 2 patients requiring staged bilateral corrections) patients for distal femoral varus and valgus deformities with CWDFO between 2019 and 2022. Out of these 4 patients (5 limbs) requiring large corrections of distal femoral angular deformities were treated with Neutral Wedge (NW) technique. 3 patients (four limbs) had distal femoral valgus deformity and one distal femoral varus deformity. Indication for NW technique is an angular deformity (varus or valgus of distal femur) requiring > 12 mm opening/closing wedge correction. We approached the closing side first and marked out the half of the calculated wedge with K – wires in a uniplanar fashion. Then an external fixator with two Schanz screws is applied on the opposite side, inserting the distal screw parallel to the articular surface and the proximal screw 6–7 cm proximal to the first pin and at right angles to the femoral shaft mechanical axis. Then the measured wedge is removed and carefully saved. External fixator is now used to close the wedge and over correct, creating an appropriate opening wedge on the opposite side. A Tomofix (Depuoy Synthes) plate is applied on the closing side with two screws proximal to osteotomy and two distally (to be completed later). Next the osteotomy on the opposite side is exposed, the graft is inserted. mLDFA is measured under image intensifier to confirm satisfactory correction. Closing wedge side fixation is then completed followed by fixation of opposite side with a Tomofix or a locking plate. Results. 3 patients (4 limbs) had genu valgum due to constitutional causes and one was a case of distal femoral varus from a fracture. Preoperative mLDFA ranged from 70–75° and in one case of varus deformity it was 103°. We achieved satisfactory correction of mLDFA in (85–90°) in 4 limbs and one measured 91°. Femoral length was not altered. JLCA was not affected post correction. Patients were allowed to weight bear for transfers for the first six weeks and full weight bearing was allowed at six weeks with crutches until healing of osteotomy. All osteotomies healed at 16–18 weeks (average 16.8 weeks). Patients regained full range of movement. We routinely recommend removal of metal work to facilitate future knee replacement if one is needed. Follow up ranged from 4 months to 2 yrs. Irritation from metal work was noted in 2 patients and resolved after removing the plates at 9 months post-surgery. Conclusions. NWDFO is a good option for large corrections. We describe a technique that facilitates accurate correction of deformity in these complex cases. Osteotomy heals predictably with uniplanar osteotomy and dual plate fixation. Metal work might cause irritation like other osteotomy and plating techniques in this location

Introduction. Coronal malalignment and leg length discrepancies (LLD) are frequently associated. Temporary hemiepiphysiodesis (tHED) is commonly employed for the correction of limb malalignment in skeletally immature patients. For treatment of LLD greater than 2 cm, lengthening with intramedullary legnthening nails is a safe and reliable technique. However, the combined application of these approaches in skeletally immature patients has not yet been investigated. Materials & Methods. Retrospective radiological and clinical analysis of 25 patients (14 females, 11 males) who underwent intramedullary femoral lengthening with an antegrade PRECICE® lengthening nail as well as tHED of the distal femur and / or proximal tibia between 2014 and 2019. tHED was conducted by implantation of flexible staples (FlexTack™) either prior (n = 11), simultaneously (n = 10), or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4). Results. The median initial LLD was 39.0 mm (35.0–45.0). 21 patients (84%) presented valgus and 4 (16%) showed varus malalignment. Leg length equalization was achieved in 13 patients at skeletal maturity (62%). The median LLD of patients with a residual LLD > 10 mm was 15.5 mm (12.8–21.8). Limb realignment was obtained in nine of seventeen skeletally mature patients (53%) in the valgus group, and in one of four patients (25%) in the varus group. Conclusions. The combination of antegrade femoral lengthening and tHED can efficiently correct LLD and coronal limb malalignment in skeletally immature patients. Nevertheless, achieving limb length equalization and realignment may render difficult in cases of severe LLD and angular deformity. Furthermore, the reported techniques ought to be thoroughly planned and executed and require regular clinical and radiological examinations until skeletal maturity to avoid - or timely detect and manage - adverse events such as overcorrection and rebound of deformity

Introduction. Angular deformity in the lower extremities can result in pain, gait disturbance, deformity and joint degeneration. Guided growth modulation uses the tension band principle with the goal of treatment being to normalise the mechanical axis. To assess the success of this procedure we reviewed our results in an attempt to identify patients who may not benefit from this simple and elegant procedure. Materials and Methods. We reviewed the surgical records and imaging in our tertiary children's hospital to identify all patients who had guided growth surgery since 2007. We noted the patient demographics, diagnosis, peri-operative experience and outcome. All patients were followed until skeletal maturity or until metalwork was removed. Results. 173 patients with 192 legs were assessed for eligibility. Six were excluded due to inadequate follow-up or loss of records. Of the 186 treated legs meeting criteria for final assessment 19.8% were unsuccessful, the other 80.2% were deemed successful at final follow up. Complications included infection and metal-work failure. Those with a pre-treatment diagnosis of idiopathic genu valgum/ varum had a success rate of 83.6%. Conclusions. In our hands, guided growth had an 80-percent success rate when all diagnosis were considered. Those procedures that were unlikely to be successful included growth disturbances due to mucopolysaccharide storage disease, Blounts disease and achondroplasia. Excluding those three diagnoses, success rate was 85.4%. We continue to advocate the use of guided growth as a successful treatment option for skeletally immature patients with limb deformity

Introduction. The purpose of our study was to retrospectively analyze our patients who were treated for FH and PFFD by means of guided growth temporary Hemiepiphysiodesis. We sought to determine the effectiveness of the procedure, as well as its success rates, complications, and rebound phenomena. Materials and Methods. We retrospectively reviewed the medical records and all routine preoperative and post operative long standing radiograph of all the FH and PFFD patients that were operated in our institute using guided growth hemiepiphysiodesis technique of distal femur or proximal tibia between 2007 to 2017. Results. 42 patients (28/FH, 14/PFFD) with 55 involved physis were included in the study. The mean duration of follow-up was 51.11 ± 27.56 months after the first operation. The average age at first plate insertion was 11.7 years and 50% of patients reached puberty by the time of data collection. 32 physes (21 FH, 11 PFFD) were operated due to pathological mLDFA with a mean angle correction of 6.24° for the FH group and 6° for the PFFD group and time-to-correction of 14.07 months and 11.56 months, respectively. 23 physes (14 FH, 9 PFFD) were operated due to pathological mMPTA with a mean angle correction of 4.43° for the FH group and 6.22° for the PFFD group with time-to-correction of 17.95 months and 20.35 months respectively. 40% (12/30) of patients, whose metalwork was removed, had a recurrence of the deformity, 7/21 [33.3%] in the FH group and 5/9 [55%] in the PFFD group. All required a second hemiepiphysiodesis operation. 2. nd. rebound was recorded in 3/21 (14%) FH patients and 2/9 (22%) PFFD patients. Conclusions. Temporary hemiepiphysiodesis is an effective treatment of angular deformities around the knees of FH and PFFD patients. With low complication rate and high risk of rebound phenomenon

Background. Correct positioning of the femoral component in resurfacing hip arthroplasty (RHA) is an important factor in successful long-term outcomes. The purpose of computer-assisted navigation (CAS) in resurfacing is to insert the femoral neck guide wire with greater accuracy and to help size the femoral component, thus reducing the risk of notching at the head and neck junction. Several recent studies reported satisfactory precision and accuracy of CAS. However, there is little evidence that CAS is useful in the presence of anatomical deformities of the proximal femur, which is frequently observed in young patients with secondary degenerative joint disease. Aim. The purpose of this in vitro study was to determine the accuracy of an image-free RHA navigation system in the presence of angular deformity of the neck, pistol grip deformity of the head and neck junction and slipped upper femoral epiphysis deformity. Methods. An artificial phantom leg was used. Implant-shaft angles for the guide wire of the femoral component reamer were calculated, in frontal and lateral planes, with the computer navigation system and an electronic caliper combined with micro-CT. Results. With both normal anatomy and angular deformity we found close agreement between the CAS system and our measurement system. There was a consistent disagreement on both planes for the pistol grip deformity. In the presence of the slipped upper femoral epiphysis deformity, close agreement was found only on the frontal plane but calculation of the femoral head size was inaccurate. Conclusion. This is the first study designed to assess the accuracy of a femoral navigation system for RHA in the presence of anatomical deformity of the proximal femoral head and neck segment. Our data suggests CAS technology should not be used to expand the range of utilisation of resurfacing surgery to these cases but rather to improve the surgical outcome in those with suitable anatomy

Osteomyelitis and septic arthritis are common pathologies in young children. Because of their skeletal immaturity, children are particularly vulnerable to orthopaedic complications, including limb-length discrepancies, angular deformities, chondrolysis, etc. The primary objective of this study was to review the clinical follow up and outcomes of paediatric patients diagnosed with osteoarticular infections. The secondary purpose was to look for significant differences in the clinical characteristics between the one with and without complications. Patients' medical charts, hospitalised between 2010 and 2016, were retrospectively reviewed. The inclusion criteria were: patients (1) aged of less than 10 years old (2) treated and followed for osteomyelitis of long bones of upper and lower extremities and/or septic arthritis (3) with at least one year of radiological follow up. The exclusion criterion was: (1) any concomitant chronic diseases. The information collected included demographic and clinical data. A late sequela was defined as a limb-length discrepancy superior to 5 mm or an abnormal articular angulation of more than 5°, or a symptomatic chondropathy. Patients were separated in two groups: with and without complications. Chi-square tests were used for categorical variables and Mann-Whitney U tests for continuous data in order to establish significant differences between both groups. Of the 401 patients with osteomyelitis and/or septic arthritis treated in our tertiary paediatric hospital over 7 years, 50 met the inclusion criteria. There were 24 girls and 26 boys. The etiological agent was identified in 56% of the cases. Staphylococcus aureus was the predominant causal pathogen (50%), followed by Kingella kingae (19.2%). The mean follow up was 780 days. Six out of 50 (12%) patients had physeal or chondrolytic complications at the latest follow-up. The only significant difference between the 2 groups was the delay between onset of symptoms and initiation of antibiotic therapy (P = 0.039). Only 12.5% of the patients were followed up at least one year. In the population of 50 skeletally immature patients without comorbidities, 12% had a sequela. The delay in initiating antibiotic treatment was significantly longer in the group with the presence of sequelae. The results of this study reveal that there were low rates of outpatient follow-up reaching more than a year after an osteoarticular infection, thus raising the question about the importance of a follow up after such a diagnosis. Twelve percent of the patients had a growth or chondrolysis complication and this might be related to the delay before initiating antibiotic treatment

Management of open tibial fractures remains controversial. We hypothesised that unreamed intramedullary nail offers inherent advantages of nail as well as external fixation. We undertook a prospective randomised study to compare the results of management of open tibial fractures with either an external fixator or an undreamed intramedullary nail until fracture union or failure. Our study included 30 consecutive open tibial fractures (Gustilo I, II & IIIA) between 4 cm distal to knee and 4 cm proximal to ankle in skeletally mature adults, who presented to a level-1 trauma centre. Alternate patients were treated by either external fixation and unreamed nailing i.e. 15 in each group. Standard protocol for debridement and fixation was followed in all cases. All external fixators were removed at 6 weeks. All cases were followed up until fracture union, the main outcome measurement. 26 (87%) were males and 4 (13%) females; age range was 20-60 years (average 33.8). All fractures in both groups united. Time to union averaged 7.9 months for both groups. Incidence of wound problems, infection, hardware failure and delayed union were comparable. However, there was higher incidence of angular deformities and stiffness of knee and ankle in external fixation group, although not statistically significant. We found no statistically significant difference between unreamed intramedullary nailing and external fixation for the management of open tibial diaphyseal fractures, although ease of weight bearing as well as absence of angular deformities and joint stiffness were distinct advantages in the nail group. Therefore we recommend unreamed nail for Gustilo I, II and IIIA open tibial fractures

First generation condylar knee replacements suffered from 2 prominent observations: Difficulty in stair climbing and Limited range of motion. Improved understanding of knee kinematics, the importance of femoral rollback, and enhanced stability in flexion led to 2 differing schools of thought: posterior cruciate ligament retention or posterior cruciate substitution. The advantages of posterior cruciate substitution include predictable CAM-post engagement leading to rollback, predictable ROM, stability during stair climbing, ease of knee balancing regardless of degree of angular deformity, and avoidance of issues such as PCL tightness / laxity at time of index procedure, as well as late ligament disruption leading to late instability. Evolution has shown that human appendages that no longer served a purpose, slowly shrivel up. As we have seen with the appendix, the coccyx, and the erector pili muscles, these vestigial organs no longer are necessary for daily function and are destined for obsolescence. I submit: the PCL in knee arthroplasty IS THE VESTIGIAL ORGAN: not the posterior stabilizing mechanism!

Limb deformity is common in patients presenting for knee arthroplasty, either related to asymmetrical wear patterns from the underlying arthritic process (intra-articular malalignment) or less often major extra-articular deformity due to prior fracture malunion, childhood physical injury, old osteotomy, or developmental or metabolic disorders such as Blount's disease or hypophosphatemic rickets. Angular deformity that is above the epicondyles or below the fibular neck may not be easily correctable by adjusted bone cuts as the amount of bone resection may make soft tissue balancing impossible or may disrupt completely the collateral ligament attachments. Development of a treatment plan begins with careful assessment of the malalignment which may be mainly coronal, sagittal, rotational or some combination. Translation can also complicate the reconstruction as this has effects directly on location of the mechanical axis. Most intra-articular deformities are due to the arthritic process alone, but may occasionally be the result of intra-articular fracture, periarticular osteotomy or from prior revision surgery effects. While intra-articular deformity can almost always be managed with adjusted bone cuts it is important to have available revision type implants to enhance fixation (stems) or increase constraint when ligament balancing or ligament laxity is a problem. Extra-articular deformities may be correctable with adjusted bone cuts and altered implant positioning when the deformity is smaller, or located a longer distance from the joint. The effect of a deformity is proportional to its distance from the joint. The closer the deformity is to the joint, the greater the impact the same degree angular deformity will have. In general deformities in the plane of knee are better tolerated than sagittal plane (varus/valgus) deformity. Careful pre-operative planning is required for cases with significant extra-articular deformity with a focus on location and plane of the apex of the deformity, identification of the mechanical axis location relative to the deformed limb, distance of the deformity from the joint, and determination of the intra-articular effect on bone cuts and implant position absent osteotomy. In the course of pre-operative planning, osteotomy is suggested when there is inability to correct the mechanical axis to neutral without excessive bone cuts which compromise ligament or patellar tendon attachment sites, or alternatively when adequate adjustment of cuts will likely lead to excessive joint line obliquity which can compromise ability to balance the soft tissues. When chosen, adjunctive osteotomy can be done in one-stage at the time of TKA or the procedures can be done separately in two stages. When simultaneous with TKA, osteotomy fixation options include long stems added to the femoral (or tibial) component for intramedullary fixation, adjunctive plate and screw fixation, and antegrade (usually locked) nailing for some femoral osteotomies. Choice of fixation method is often influenced by specific deformity size location, bone quality and amount, and surgeon preference. Surgical navigation, or intra-operative x-ray imaging methods (or both) have both been used to facilitate accurate correction of deformity in these complex cases. When faced with major deformity of the femur or tibia, with careful planning combined osteotomy and TKA can result in excellent outcomes and durable implant fixation with less constraint, less bone loss, and better joint kinematics than is possible with modified TKA alone

First generation condylar knee replacements suffered from two prominent observations: 1) Difficulty in stair climbing, 2) Limited range of motion (ROM). Improved understanding of knee kinematics, the importance of femoral rollback, and enhanced stability in flexion led to 2 differing schools of thought: Posterior Cruciate ligament retention vs. Posterior Cruciate substitution. The advantages of posterior cruciate substitution include predictable cam-post engagement leading to rollback, predictable ROM, stability during stair climbing, ease of knee balancing regardless of degree of angular deformity, and avoidance of issues such as PCL tightness / laxity at time of index procedure, as well as late ligament disruption leading to late instability. Evolution has shown that human appendages that no longer served a purpose, slowly shrivel up. As we have seen with the appendix, the coccyx, and the erector pili muscles, these vestigial organs no longer are necessary for daily function and are destined for obsolescence. I submit: the PCL in knee arthroplasty IS THE VESTIGIAL ORGAN: not the posterior stabilizing mechanism!

Aim. Simultaneous use of Ilizarov techniques with transfer of free muscle flaps is not current standard practice. This may be due to concerns about duration of surgery, clearance of infection, potential flap failure or coordination of surgical teams. We investigated this combined technique in a consecutive series of complex tibial infections. Method. A single centre, consecutive series of 45 patients (mean age 48 years; range 19–85) were treated with a single stage operation to apply an Ilizarov frame for bone reconstruction and a free muscle flap for soft-tissue cover. All patients had a segmental bone defect in the tibia, after excision of infected bone and soft-tissue defects which could not be closed directly or with local flaps. We recorded comorbidities, Cierny-Mader and Weber-Cech classification, the Ilizarov method used, flap type, follow-up duration, time to union and complications. Results. 26 patients had osteomyelitis and 19 had infected non-union. Staphylococci were cultured in 25 cases and 17 had polymicrobial infections. Ilizarov monofocal compression was used in 14, monofocal distraction in 15, bifocal compression/distraction in 8, and bone transport in 8. 8/45 had an additional ankle fusion, 7/45 had an angular deformity corrected at the same time and 24 also had local antibiotic carriers inserted. Median time in frame was 5 months (3–14). 38 gracilis, 7 latissimus dorsi and 1 rectus abdominus flaps were used. One flap failed within 48 hours and was revised (flap failure rate 2.17%). There were no later flap complications. Flaps were not affected by distraction or bone transport. Mean follow-up was 23 months (10–89). 44/45 (97.8%) achieved bony union. Recurrence of infection occurred in 3 patients (6.7%). Secondary surgery was required to secure union with good alignment in 8 patients (17.8%; docking site surgery in 6, IM nailing in 2) and in 3 patients for infection recurrence. All were infection free at final follow-up. Conclusions. Simultaneous Ilizarov reconstruction with free muscle flap transfer is safe and effective in treating segmental infected tibial defects, and is not associated with an increased flap failure rate. It shortens overall time spent in treatment, with fewer operations per patient. However, initial theatre time is long and a committed multidisciplinary team is required to achieve good results

Aims

As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach.

Purpose. To determine, in skeletally immature children with acceptably angulated (< = 15 degrees deformity at presentation) distal radius fractures, if a pre-fabricated wrist splint is at least as effective as a cast. Methods. A randomised controlled, non-inferiority, single blinded, single-centre trial was performed. The primary outcome was physical function at six weeks. Secondary outcomes included angulation, wrist range of motion, strength, pain, and patient preferences. Results. 93 of 97 randomised patients completed full follow-up. ASK scores at six weeks were 92.8 in the splint group and 91.4 in the cast group. Among patients treated in a cast, the average angular deformity at follow-up was 11.0 degrees, compared with an average of 6.6 degrees angulation among patients treated in a splint (p=0.02, t-test). Complications did not differ between groups, nor did range of motion. Conclusion. Splinting was not inferior to casting, and in fact may be superior to casting, for maintaining the position of a minimally displaced distal radial metaphyseal fracture. Significance. The benefits of splinting over casting have been previously established for undisplaced distal radius and ulnar fractures (Plint), this is the first study which extends the benefits of splinting to the large group of children with minimally displaced distal radius fractures

Aims

Distraction osteogenesis with intramedullary lengthening devices has undergone rapid development in the past decade with implant enhancement. In this first single-centre matched-pair analysis we focus on the comparison of treatment with the PRECICE and STRYDE intramedullary lengthening devices and aim to clarify any clinical and radiological differences.

Background. Tension band epiphysiodesis for lower limb length discrepancy in children Planned physeal growth arrest (epiphysiodesis) for the treatment of limb length discrepancy (LLD) in growing children is a well described treatment modality in the literature. We describe our experience of temporary epiphysiodesis using a tension band technique with the “8-plate” in the treatment of LLD in growing children. Aim. The main objective of this study was to confirm whether bilateral 8-plates achieve an epiphysiodesis or not?. Methods and results. This is a prospective study of 27 patients who were treated with 8-plate epiphysiodesis for limb length discrepancy with a mean follow up of 28 months. Perthes disease was the most common underlying pathology for the LLD. The average preoperative LLD was 25.9 mm (15–49 mm). 17 patients successfully corrected to < 15 mm LLD, 5 patients corrected to between 15–20 mm and 5 patients did not correct to with in 15 mm LLD (22.2%). In those patients whom have corrected, the average correction length was 25.6 months with an average correction rate of 1.52 mm per month. There was a trend for insufficient equalisation if the procedure was performed < 1.5 years prior to skeletal maturity. The was also a trend for insufficient equalisation if performed at single physis only (femur or tibia). Complications included one superficial infection and one deep infection following plate removal at the end of treatment. Screw breakage was noticed in one patient. No long term complications were reported. No angular deformity was reported. Conclusion. This study has confirmed that bilateral 8 plates produce an epiphysiodesis. Failures are mainly due to late insertion or single physis usage. Future application depends on demonstrating reversibility when applied to younger children

Introduction. Fracture of the proximal femur frequently occur in children with osteogenesis imperfecta(O.I.) or fibrous dysplasia and may lead to progressive coxa vara and a “shepherds crook” deformity. In adults, these changes introduce difficulties that are not ordinarily encountered with routine osteosynthesis. There is minimal literature on this topic and the cases reported are few in number. Objective. The purpose of this case report was to describe a intertrochanteric fracture in a elderly woman with O.I. successfully treated by 115 degrees hip osteotomy plate and cannulated screws. Methods. We present a case of a 82-year-old female who was injured by falling. She had O.I. type â�£ A according to Sillence. Radiographs showed a intertrochanteric fracture of the femur with severe deformity. The femoral shaft had 25 degrees angular deformity and moderate rotation at the proximal. The angle between femoral neck and shaft was 105 degrees (severe coxa vara) and the proximal femur had a “shepherds crook” deformity (See Figure 1). She had presented 70 years previously ipsilateral fractures of the femur which had healed. These mal-united fracture involved anatomical changes such as medicalization of the femoral canal and intramedullary remodeling and sclerosis (See Figure 2). Recognizing the anatomical changes before and during surgery, standard dynamic hip screw or AO angled blade plate could not fit the femur and not provide stability. Using 115 degrees hip osteotomy plate and cannulated screws, osteosynthesis was performed (See Figure 3). Results. Twelve months postoperatively, the fracture united without complications and the patient felt comfortable and satisfied with gait. Conclusion. An unusual case was presented in which a 82-year-old woman was successfully treated with 115 degrees hip osteotomy plate and cannulated screws for a intertrochanteric fracture of the femur with osteogenesis imperfecta. Standard plate osteosynthesis was unlikely to provide sufficient stable fixation in this case

To consider bilateral simultaneous knee replacement, both knees must have significant structural damage. It is best if the patient can't decide which knee is more bothersome. In borderline cases, ask the patient to pretend that the worse knee is normal and if so, would they be seeing you for consideration of knee replacement on the less involved side. If the answer to this question is “yes,” consider the patient a potential candidate for bilateral knee replacement. If the answer is “no,” recommend operating only on the worse knee, and expect that the operation on the second knee can probably be delayed for a considerable period of time. Strong indications for bilateral simultaneous TKA are bilateral severe angular deformity, bilateral severe flexion contracture, and anesthesia difficulties, i.e., patients who are anatomically or medically difficult to anesthetise, such as some adult or juvenile rheumatoid arthritis patients or patients with severe ankylosing spondylitis. Relative indications for bilateral simultaneous TKA include the need for multiple additional surgical procedures to achieve satisfactory function and financial or social considerations for the patient. Contraindications to bilateral TKA include medical infirmity (especially cardiac), a reluctant patient, and a patient with a very low pain threshold. When performing bilateral simultaneous TKA, both limbs are prepped and draped at the same time. An initial dose of an intravenous antibiotic is given (usually 1g of a cephalosporin) before inflation of the tourniquet. Surgery begins on the more symptomatic side or on either side if neither knee is significantly worse than the other. The reason for starting on the more symptomatic side is in case surgery has to be discontinued after only one procedure owing to anesthetic considerations. After the components have been implanted on the first side, the tourniquet is deflated and a second dose of intravenous antibiotic is administered (usually 500mg of a cephalosporin). After the joint capsule is closed and flexion against gravity is measured, one team completes the subcutaneous and skin closure on the first side while the other team inflates the second tourniquet and begins the exposure of the second side. When the second tourniquet is deflated, a third dose of antibiotic is given (usually 500mg of a cephalosporin for a total dose of 2g for both knees). Because of concern about the potential for cross-contamination of the knee wounds when instruments used during the final stages of skin closure on the first knee are maintained on the field and used on the second knee, they should probably be handed off the field and outer surgical gloves changed. Most patients will report after their complete recovery that they are glad they did both knees at the same time. A patient who has any uncertainty about proceeding with bilateral surgery should have only one knee done at a time. In many cases, the second side receives a “reprieve,” becoming more tolerable after the first side has been operated on

Twenty-four replacements were performed in 19 patients (13 female: 6 male), with average age of 33 years (18-40). All had severe polyarticular rheumatoid arthritis. Pre-operatively 12 ankles had no angular deformity, 9 were in valgus and 3 in varus. All had associated hindfoot disease. Some of these patients are part of two larger studies of the Scandinavian Total Ankle Replacement (STAR) and the Buechel-Pappas (BP) replacement. In this group there were 20 STAR and 4 BP replacements. Average follow-up was 62 months (36 to 120). Twenty-one replacements had good pain relief and function. The AOFAS hindfoot score for pain improved from 0 to 36 (max 40) and for function from 25 to 35 (max 60). Three have failed. One ankle had a 25-degree valgus deformity pre-operatively and this recurred and caused failure at 11 months. The second failed at 34 months due to aseptic loosening of the talar component. Both of these were converted to tibio-talo-calcaneal fusions with an intra-medullary nail. The third failure had never provided satisfactory pain relief in spite of appearing satisfactory on clinical and radiological examination. Exploratory surgery was carried out at 36 months but failed to produce an improvement and at 61 months the decision was made to revise the replacement to a fusion. However, due to concurrent health problems, this has not yet been done. We offer replacement to patients with severe polyarticular rheumatoid disease especially if there is a stiff but well aligned hindfoot. In the light of increased experience, we now consider valgus or varus deformity of greater than 20 degrees to be a contra-indication to replacement. This is because the deformity tends to recur leading to pain, loosening and failure

Background. Proximal phalangeal fractures are caused by an injury to the dorsum of the hand. This usually causes volar angulation which is unstable when reduced. K-wiring or external fixation can damage the soft tissue envelope, can introduce infection and can loosen or displace. Traction splinting is not well described for these fractures. Objectives. Functional and radiographic assessment of all patients with proximal phalangeal fractures treated with traction splinting. Methods. Theatre records were examined for relevant injuries over a 2 year period. These patients were then assessed using a QuickDASH score, a questionnaire specific to traction splinting and with pre-op, intra-op, post-op and follow-up radiographs. Results. A total of 7 patients were treated with traction splinting, all by the senior author (FJS). Clinical follow was 16 months (range12-20). QuickDASH scores were 0, 0, 0, 0, 0, 2.5, 25/100. With regard to work (n=6), all patients but one scored 0/100 for disability with one patient describing mild work related difficulties. Those participating in sports/performing arts (n=6) scored 0/100. There were no finger-tip pain or numbness issues. Finger length perception was satisfactory in all patients. The splint slipped in 3 patients, secondary to horse riding, showering and through scratching. Two patients reported having a measurable loss of motion in the affected digit (follow-up 18 and 20 months), both with mild functional deficit. Radiographic outcomes showed that traction achieved acceptable length restoration, with no angular deformities. Finger length was maintained in all but one patient who had a shortening of 3.2mm. Conclusions. Traction splinting is a non-invasive, safe and inexpensive method of treating proximal phalangeal fractures. Results of our follow-up study show excellent functional and radiographic outcomes with minimal long term morbidity for this treatment option

Late presentation and rapid progression of Dupuytren's contracture significantly increases operating time, complications and likelihood of incomplete correction; however, surgical timing is usually more a function of waiting list length than of clinical criteria. We sought to measure the rate of progress of Dupuytren's contracture. All patients with Dupuytren's contracture referred to the sole Consultant Hand Surgeon for Highland Region between June 1997 and February 2003 were prospectively included. Fixed flexion deformities at each finger joint and thumb-index angle to the point of firm resistance to extension were recorded by a single observer (QGNC) at presentation and immediately pre-operatively. Of 151 participants 37% had a family history. There was a male predominance of 5:1, with bilaterality in 77% at presentation. Five percent had diabetes, 3% had epilepsy, 52% acknowledged tobacco habits and 24% regular alcohol in excess of recommended limits. Angular deterioration was observed in 52% of digits, over one quarter of this occurred at the small finger joints, where 58% of PIPJs progressed. Mean delay from presentation to surgery was 11 months (2-55.5). Mean age at presentation of 62 (16-86) years did not correlate with angular deformity at presentation or with velocity of deterioration or with manual/non-manual employment. Mean severity of deformity at presentation for manual (34°) was double non-manual workers (17°) although angular deterioration was faster in the non-manual group (3.8 cf 0.7°/month respectively). Similar speeds of deterioration were seen at MCPJ and PIPJ, speed of deterioration was 2.2°/month for each of the three ulnar digits. Speed of deterioration correlated (r=0.7) with severity of deformity at presentation for ring and small fingers. This study offers the first quantification of rate of deterioration in Dupuytren's contracture. This could be used as a waiting list tool to predict the delay before a digit is likely to pose increased surgical risk