Complications of a simple procedure: de Quervain's disease revisited.

We reviewed the results of 22 operations performed on 21 patients for the relief of de Quervain's disease over the last six years. At a mean follow-up of 34 months (range 4-78 months), 18 of 22 wrists had complete relief of their original symptoms. One patient required reoperation because of inadequate decompression, and two others await further surgery. Most operations (14 out of 22) were performed under local anaesthesia, and 17 out of 22 used a longitudinal incision. The use of a longitudinal incision was associated with a significant risk of complications: four patients had a poor cosmetic result, and six showed evidence of superficial radial nerve injury. Two patients had a wound infection, and one developed reflex sympathetic dystrophy. Although surgical decompression for de Quervain's disease is effective in curing the symptoms in most patients, using a longitudinal incision is associated with poor wound healing and damage to the terminal branches of the radial nerve.

Kinematics of the wrist. Evidence for two types of movement.

We enrolled 34 normal volunteers to test the hypothesis that there were two types of movement of the wrist. On lateral radiographs two distinct patterns of movement emerged. Some volunteers showed extensive rotation of the lunate with a mean range of dorsiflexion of 65 degrees, while others had a mean range of 50 degrees. The extensive rotators were associated with a greater excursion of the centre of articulation of the wrist. It is suggested that dynamic external fixation of a fracture of the distal radius carries with it the risk of stretching the ligaments or causing volar displacement at the site of the fracture.

How long should patients be followed-up after total hip replacement? Current practice in the UK.

Some 1000 postcard questionnaires were sent to Fellows of the British Orthopaedic Association (BOA) to establish current follow-up practice of primary total hip replacement (THR) patients. For cemented THRs, 50% of surgeons saw their patients for under 1 year, 78% under 5 years with indefinite follow-up being performed by 14%. There was significantly more follow-up of uncemented and hybrid prostheses with the proportions being 25%, 56% and 30% respectively (chi 2, P < 0.0001). This study has revealed a wide variation in practice between individual surgeons and has shown over one-third of surgeons feel they are prevented from performing as much follow-up as they would wish by the availability of clinic resources. Higher follow-up rates of uncemented components may reflect a lack of confidence in their long-term performance.

An association between scapho-trapezio-trapezoid osteoarthritis and static dorsal intercalated segment instability.

A relationship between scapho-trapezio-trapezoid (STT) osteoarthritis and static dorsal intercalated segment instability (DISI) was suspected. The radiographs of 697 wrists in patients over 50 years were surveyed. In 63 wrists STT osteoarthritis was found in isolation, and isolated DISI was found in four wrists. A combination was found in 16 wrists. This was statistically significant (0.02 < P < 0.05). It is likely that the static DISI occurs as a consequence the STT osteoarthritis.

Airport metal detectors and orthopedic implants. The responses of arch and hand-held devices.

8 subjects with a variety of orthopedic implants were examined by the security staff at an international airport using arch and hand-held metal detectors. None of the subjects caused activation of the alarm on the arch, although the presence of metal was registered in 2 at a level below the alarm threshold. The hand-held detectors alarmed over the larger superficial implants. A substantial tissue screening effect was noted.

Colles' fractures: the use of the metacarpal index as a prognostic indicator investigated.

The radiographs of 25 patients who presented to the Whittington Hospital with Colles' fractures were studied. Measurements of dorsal angulation and radial shortening were made on radiographs taken at presentation, following reduction (where performed) and 5 weeks after injury. The presence, and degree, of osteoporosis was assessed using the metacarpal index. There was a strong correlation between the degree of osteoporosis and age. There was no correlation between the degree of osteoporosis, as determined by the metacarpal index, and either the severity of the injury or the final result. Thus, the metacarpal index is not a useful prognostic indicator as to the radiological outcome of Colles' fractures. The single most important factor influencing the radiological result was the quality of the initial reduction.

Congenital hypoplasia of the medial meniscus: a report of two cases.

Congenital abnormalities of the medial meniscus are extremely rare. We present two cases of hypoplasia and demonstrate the arthroscopic and radiological features.

Radiological study of alignment after total knee replacement. Short radiographs or long radiographs?

The axial alignment on short and long radiographs was measured in 50 knees in 34 patients who had undergone posteriorly stabilised (Insall-Burstein) condylar knee arthroplasty. A mean difference of 1.6 degrees was found when the tibiofemoral angles were compared on short and long radiographs. Short radiographs are probably adequate for routine assessment of knee replacements in a busy out-patient clinic, but for accurate scientific studies the long radiographs are preferable.

Delayed sciatic nerve palsy following total hip arthroplasty.

Peripheral neuropathy, following total hip arthroplasty, has a reported incidence of 0.7%. However, delayed sciatic nerve palsy has only been reported twice in the literature. We report on two further cases, both of whom developed clinical sciatic nerve palsy at 72 hours after surgery.

A quantitative study of the tissue reaction and its relationship to debris production from a joint implant.

An attempt has been made to refine the quantitative evaluation of the tissue response to a prosthesis using the goat hip as an experimental model. Total joint replacement was performed in six goats; in three the cup was made of conventional ultrahigh molecular weight polyethylene and in three a new silane cross-linked ultrahigh molecular weight polyethylene was used. The pseudocapsule of the hips was examined histologically at 15, 19 and 24 months following surgery. Small and large polyethylene debris were visualized using semi-crossed polars and were counted. Giant cells were counted after staining with toluidine blue as were macrophages which were identified by dense staining after the acid phosphatase reaction. The amount of small birefringent debris was closely related to the number of macrophages in the pseudocapsule. This method of assessment may be helpful in comparing the tissue reaction of different polymers.

Congenital snapping knee. Habitual anterior subluxation of the tibia in extension.

We describe a rare form of congenital snapping knee. In six knees in four children, the tibia subluxed anteriorly on the femur when the knee was extended and reduced spontaneously on flexion. The abnormal movements were seen and felt as sudden snaps or clunks at about 30 degrees of flexion. All six knees showed similar dysplastic features, although the patients had different clinical syndromes. The mechanism of the subluxation and its management are discussed.

Morphology of the femur in proximal femoral fractures.

We studied the morphology of the contralateral femur in 10 patients with subcapital fractures, 10 with trochanteric fractures and 10 with unilateral osteoarthritis. We found that the patients with trochanteric fractures had a significantly shorter femoral neck (4.5 +/- 0.5 cm) than patients with subcapital fractures or osteoarthritis (5.4 +/- 0.4 cm). It may be that this difference in femoral neck length is related to the site at which a proximal femoral fracture occurs.

Coracoid process transfer for acromioclavicular dislocations. A report of 20 cases.

Twenty patients with acromioclavicular dislocations treated by transfer of the coracoid process to the clavicle were reviewed and were compared to a previous study. Surgery was performed for acute dislocations in seven cases and for chronic dislocations in 13 cases. At the follow-up examination (5.6 +/- 3.5 years for acute and 4.0 +/- 3.6 years for chronic dislocations), all patients had some relief of their symptoms. Nine patients had residual aching in the joint, and this was associated with an older age at injury (40 years as opposed to 25 years for chronic dislocations). Complications included superficial wound infections in two patients, transient stiffness of the shoulder in two patients, loss of range of movement in one patient, and subjective weakness in one patient. In general, satisfactory results were achieved in younger patients, but as the results of conservative treatment of these injuries are comparable, the operation is indicated only in patients with symptomatic chronic acromioclavicular dislocations.

Axillary aneurysm after shoulder injury. A report of 2 cases.

Two cases of false aneurysm of the axillary artery occurred after closed shoulder injuries. One was a dislocation of the shoulder, and the other was a fracture of the lesser tuberosity. In both cases the diagnosis was delayed, and only became apparent after excessive bruising was seen.

To stitch or not to stitch the fat?

A total of 22 patients having hip replacements were studied to determine biochemically whether or not fat stitches cause fat necrosis. We found that fat necrosis, as measured by the triglyceride concentration of the drainage fluid, occurred in all wounds. The use of a fat stitch did not increase the amount of fat necrosis, but significantly reduced the amount of fluid drained (P less than 0.001; Student's t test). This retention of triglycerides is probably undesirable as they can act as a substrate for prostaglandin synthesis.

Brace treatment of Colles' fracture.

Twenty patients with Colles' fractures were treated with a functional brace that allows wrist motion. The result was compared with a similar group of patients treated with a plaster cast. Dorsal displacement of the fracture was less and wrist function was better in the brace group. Swelling of the hand during the early stages was observed in the brace group; and because this may necessitate brace adjustment, increased medical supervision is necessary for this period.