An Imperfect Peace: Trends In Paramilitary Related Violence 20 Years After The Northern Ireland Ceasefires.

BACKGROUND: The 1994 Northern Ireland ceasefire heralded a new beginning for the region after 30-years of violence. In the 20-years following the cessation of hostilities, paramilitary punishment attacks continue to occur in breach of the ceasefire. The aim of this study was to review trends in these attacks over the 20-years and their impact on orthopaedic services. METHODS: We conducted a retrospective review of patients admitted under orthopaedic services following paramilitary assault across Northern Ireland over the last 20-years. The frequency of assaults, demographics of the victim population, injury pattern and weapons used was determined. Data on the total number of attacks was obtained from the Police Service for Northern Ireland (PSNI). RESULTS: 3691 paramilitary style attacks occurred between 1994 and 2014 despite bilateral ceasefires. The overwhelming majority of attacks are on males, however females and children as young as 12 have been victims. Prior to 1994, penetrating trauma predominated (62% vs 38%), with blunt trauma more common post ceasefire (60% vs 40%). 33% of those injured required orthopaedic treatment. The type of weapon used in these assaults has changed primarily from ballistic to non-ballistic devices. CONCLUSIONS: We present data of paramilitary related trauma presenting to orthopaedic services across Northern Ireland in the 20-years since the conclusion of hostilities following the negotiated 1994 ceasefire. Many assaults continue to occur despite being in breach of the ceasefire. The frequency of these assaults is however, declining. The type of weapons used has changed resulting in less ballistic trauma and more blunt trauma. The injury pattern associated with blunt trauma has significant long-term morbidity and potentially a greater financial burden on the health service. IMPLICATIONS: 20-years of peace in Northern Ireland has had a hugely positive impact on the political and financial stability of the region. Unfortunately, continued violence represents a significant burden on the health service resources and causes potential long-term changes to victim's lives.

Factitious lymphoedema as a psychiatric condition mimicking reflex sympathetic dystrophy: a case report.

INTRODUCTION: Reflex sympathetic dystrophy can result in severe disability with only one in five patients able to fully resume prior activities. Therefore, it is important to diagnose this condition early and begin appropriate treatment. Factitious lymphoedema can mimic reflex sympathetic dystrophy and is caused by self-inflicted tourniquets, blows to the arm or repeated skin irritation. Patients with factitious lymphoedema have an underlying psychiatric disorder but usually present to emergency or orthopaedics departments. Factitious lymphoedema can then be misdiagnosed as reflex sympathetic dystrophy. The treatment for factitious lymphoedema is dealing with the underlying psychiatric condition. CASE PRESENTATION: We share our experience of treating a 33-year-old man, who presented with factitious lymphoedema, initially diagnosed as reflex sympathetic dystrophy. CONCLUSION: Awareness of this very similar differential diagnosis allows early appropriate treatment to be administered.

Dislocation of the rotating platform after low contact stress total knee arthroplasty.

From a one-surgeon series of 2485 patients, we report on 10 patients with rotating platform dislocation after primary Low Contact Stress total knee arthroplasty. All dislocations occurred within 2 years of the index procedure. Of the 10 patients, nine required open reduction. Five of these patients also had exchange of the original insert. One patient was treated by closed reduction. All knees were immobilized in a cast for 8 weeks. Eight of the 10 patients had no additional dislocation and at followup (average, 35 months; range, 12 months-5 years), had a stable functional joint. Two patients had recurrent spinout of the rotating platform develop. One patient had arthrodesis whereas the other patient had the insert cemented to the tibial tray as a salvage procedure. Increasing age, a preoperative valgus deformity, and prior patellectomy were significantly associated with rotating platform spinout. Surgical experience and an improved understanding of the soft tissue constraints, particularly in the valgus knee, are important in minimizing this complication.

Migration of intrapelvic cement after total hip arthroplasty.

Intrapelvic extrusion of cement during total hip arthroplasty is a frequent occurrence. We report a case in which the intrapelvic cement mass broke free 3 years after the primary procedure and migrated proximally to lie against the posterior abdominal wall, resulting in intractable groin pain. The patient was relieved of pain after removal of the cement mass.