Fine wire frame arthrodesis for the salvage of severe ankle pathology.

Ankle arthrodesis is an accepted method of treatment for severe ankle pathology, but no single method of treatment is universally successful. Compression is usually applied across the ankle joint and maintained with either internal or external fixation; both are associated with complications such as infection, non-union and pain. We present our experience of 13 difficult cases managed by fine wire external frames, and describe the surgical technique used.A sound arthrodesis was achieved in 12 out of 13 cases, though one case required a repeat procedure, giving a union rate of 92% of cases or 86% of procedures. The mean period of fixation was 24 weeks (range 12-82), followed by a mean period of cast immobilisation of 7 weeks (range 0-10). Using Mazur's functional ankle score there were seven good results, four fair, one poor and one failure, which resulted in a below knee amputation. We believe this method represents a significant improvement on previously published results, but accept that it requires considerable experience and should not be considered for primary ankle arthrodesis. We would recommend its usage for the salvage of failed arthrodesis or severe fracture non-union, particularly in the presence of infection.

What is the best way of assessing outcome after total knee replacement?

Variable definitions of outcome have been used in the past to assess the results after total joint replacement surgery. These differ in their approach to the measurement of outcome but all must be valid (they measure what they are designed to measure), reliable (they consistently produce the same score), and responsive (able to detect changes that may occur during a period). Responsiveness is crucial to distinguish those patients who benefit from a procedure from those who do not, and a more responsive test will theoretically be able to identify more subtle changes in patient status. The responsiveness of 6 different scoring systems was compared. The results are based on a cohort of 71 patients undergoing total knee arthroplasty in a 7-month period. Responsiveness was determined by performing a paired t test among each patient's scores at 0, 3, and 6 months. The size of the resulting t value represented the comparative responsiveness of the 6 tests. The highest value achieved was with the Western Ontario and McMaster Universities osteoarthritis index and the Knee Society clinical rating scale. The worst scores were achieved by Short Form-36 and time trade off, a utility method of measurement. If small differences between groups of patients are to be shown, measures of outcome that are more responsive to patient change should be used.

Comparison of two conservative methods of treating an isolated fracture of the lateral malleolus.

We compared two conservative methods of treating Weber B1 (Lauge-Hansen supination-eversion 2) isolated fractures of the lateral malleolus in 65 patients. Treatment by immediate weight-bearing and mobilisation resulted in earlier rehabilitation than immobilisation for four weeks in a plaster cast. There was no significant difference in the amount of pain experienced or in the requirement for analgesics and early mobilisation was not associated with any complications. We therefore advocate early mobilisation for these stable ankle fractures.

Systemic release of cobalt and chromium after uncemented total hip replacement.

We measured the levels of cobalt and chromium in the serum in three groups of patients after uncemented porous-coated arthroplasty. Group 1 consisted of 14 consecutive patients undergoing revision for aseptic loosening. Group 2 comprised 14 matched patients in whom the arthroplasty was stable and group 3 was 14 similarly matched patients with arthritis awaiting hip replacement. Specimens were analysed using atomic absorption spectrophotometry. Aseptic loosening of a component resulted in a significant elevation of serum cobalt (p < 0.05), but not of serum chromium. The relative risk of a component being loose, if the patient had a serum cobalt greater than 9.0 nmol/l, was 2.8.

Circular frames in the management of infected tibial non-union: a modification of the Papineau technique.

We have treated five patients with an infected non-union of the tibia by a modification of the Papineau technique, consisting of a wound microenvironment chamber and bone stabilization with a circular frame. In all cases bone union and elimination of infection was achieved.