The results of revision knee arthroplasty with and without retention of secure cemented femoral components.

We have compared the survival of 67 revision arthroplasties of the knee undertaken for aseptic loosening with and without the retention of a secure, cemented femoral component. All the patients had undergone a single primary procedure at a mean of nine years previously. In group I (25 knees) the original femoral component was secure and was retained. There were no abrasions or osteolysis. The knees were stable, normally aligned, with minimal bone loss. In group 1142 knees did not fulfil these criteria and underwent revision of both components. The mean follow-up was four years. Re-revision for loosening was required in seven knees (28%) in group I and three (7%) in group II (p < 0.01). The remaining knees function well with Knee Society scores averaging 84/69 and no radiological evidence of osteolysis. When revising cemented implants, retention of a secure femoral component cannot be recommended even when conditions appear to be suitable.

Which primary shoulder and elbow replacement? A review of the results of prostheses available in the UK.

To assist surgeons select a suitable prosthesis, we have undertaken a detailed review of all shoulder and elbow replacements currently marketed in the UK. Twenty shoulder and 8 elbow implants, manufactured by 16 companies, have been identified. Twelve of the shoulder and one of the elbow implants have been introduced or modified in the last 8 years and have no clinical results published in peer-reviewed journals. Only the Biomodular, Bipolar, Copeland, Isoelastic, Neer hemi, Neer II, Roper-Day and Select shoulders accounting for less than 40% of the UK shoulder market, possess published results. The Capitello-condylar, Coonrad-Morrey, GSB III, Kudo, Liverpool, Roper-Tuke and Souter-Strathclyde elbows all have published results. These account for over 95% of all UK elbow replacements. The implications of these findings in an era of evidence-based medicine is discussed. Reviewing the clinical results should be of primary importance in the selection of a suitable prosthesis. Implants with a proven long-term record must represent the 'gold standard'. New or modified implants should only be used if they are part of a properly conducted clinical trial.

Audit of deep wound infection following hip fracture surgery.

An audit of 171 consecutive hip fractures treated surgically showed a deep wound infection rate of 3.6%. Several shortcomings in the implementation of the infection policy were identified and recommendations to eliminate them introduced. Review of the subsequent 186 patients gave a deep infection rate of 1.1%. Attention to detail and good practice are essential to maintain low wound infection rates.

Variational Gaussian process classifiers.

Gaussian processes are a promising nonlinear regression tool, but it is not straightforward to solve classification problems with them. In this paper the variational methods of Jaakkola and Jordan are applied to Gaussian processes to produce an efficient Bayesian binary classifier.

Dorsal wedge osteotomy in the treatment of hallux rigidus.

The results of 18 dorsal wedge osteotomies in the treatment of hallux rigidus are presented. Patients were retrospectively interviewed and examined, and an assessment was made in a number of key functional areas. Good or excellent results were obtained in 14 or 18 cases at a mean follow-up time of 4 years with only one patient requiring further surgery. Pain (p = 0.00014), activity levels (p = 0.0019), footwear difficulties (p = 0.0016), and joint range of motion (p = 0.0001) were all significantly improved; tiptoeing was the only activity assessed (p = 0.23) for which the improvement was not significant. These results compare well with other published series. We recommend dorsal wedge osteotomy as a useful alternative in the treatment of hallux rigidus.

Unilateral fenestration in the treatment of lumbar spinal stenosis.

The results of decompression by fenestration restricted to the clinically relevant level and side in 50 cases of spinal stenosis are presented. Forty-two patients underwent unilateral and 37 single level procedures. The mean follow-up time was 32 months. Patient assessment of outcome was: 32% excellent, 28% good, 28% fair, 4% marginal and 8% poor. This is comparable to published series. Two patients developed contralateral leg symptoms during the study. MRI showed neither case to be due to progressive stenosis. It is proposed that fenestration type surgery restricted to the clinically relevant level and side provides adequate spinal decompression whilst minimizing the extent of the surgical intervention.

The role of cheilectomy in the treatment of hallux rigidus.

The aim of this study was to evaluate and compare the outcome of cheilectomy for patients with grades 1, 2, and 3 hallux rigidus according to Regnauld's classification. We evaluated 39 patients at a mean of 3.8 years after surgery for pre- versus postoperative changes in pain, activity level, difficulties with footwear, tiptoe walking, and metatarsophalangeal joint range of motion. We used Wilcoxon paired rank tests to compare outcomes for each grade of hallux rigidus. There was significant improvement (p < 0.05) in pain, activity level, tiptoe walking, and range of motion for all three grades of hallux rigidus. Footwear selection was significantly improved in Grades 1 and 2 patients but not in patients with Grade 3 hallux rigidus.

The early morbidity of varicose vein surgery.

The early outcome and morbidity associated with varicose vein surgery were assessed at six months post operation by postal questionnaire. Most cases underwent sapheno-femoral ligation, above-knee stripping of the long saphenous vein and multiple stab avulsions. A 73.8% response rate resulted in 155 replies, and revealed a high incidence (65.8%) of perceived complications within the first two weeks after surgery. The commonest of these were bruising, pain and numbness. Over a third of patients consulted their general practitioner (GP) postoperatively. Half of these required further management or treatment and the rest, reassurance alone. At six months 79.4% were satisfied with the outcome of their surgery, although some still claimed problems with residual veins, skin discoloration, numbness, and ankle or foot discoloration. Eleven percent were referred to hospital for further opinion, mostly because of perceived residual varicose veins. The difference between residual and recurrent varicose veins is discussed. No patient felt that the standard 2.5 day admission was too long, and 12.9% thought it too short. Day case surgery is not a popular option in this population group. Despite high satisfaction rates, there is a considerable morbidity attached to varicose vein surgery. We believe that good pre- and perioperative communication, augmented by a comprehensive information sheet, is important to prepare patients for those postoperative problems and thus reduces their perceived importance.

Caffeine and caffeinism.

Caffeine is a widely ingested and generally beneficial drug. However, when taken in excess, anxiety related symptoms become increasingly apparent. A case of caffeinism, which presented as a paranoid delusion, is reported as an extreme example of this. A study of 60 hospital inpatients revealed that about 40% of them consumed sufficient caffeine to produce symptoms of caffeinism. It is thus recommended that all patients should be questioned on their caffeine intake. Also, caffeinism should be considered as a differential diagnosis of anxiety states.