The treatment of dorsal fracture-dislocation of the proximal interphalangeal joint by closed reduction and Kirschner wire fixation: a 16-year follow up.

Ten patients who had sustained 11 unstable dorsal fracture-dislocations of finger proximal interphalangeal joints were reviewed at a mean follow-up of 16 years. All had been treated acutely by closed reduction and transarticular Kirschner wire fixation of the proximal interphalangeal joint, without any attempt at reduction of the fracture of the base of the middle phalanx, which probably involved 30-60% of the articular surface. Seven of the ten patients complained of no finger pain or stiffness, and none complained of severe pain. There was a mean fixed flexion deformity of 8 degrees at the proximal interphalangeal joint, which had a mean arc of movement of 85 degrees. Although subchondral sclerosis and mild joint space narrowing were observed in some instances, there were no severe degenerative changes. These results confirm that this technique is a reliable treatment method for these injuries, and produces satisfactory long-term results.

Children's proximal phalangeal neck fractures with 180 degrees rotational deformity.

Five patients under 4 years of age with 180 degrees rotational deformity of a proximal phalangeal neck fracture are described. All cases resulted from a direct shear force to the bone coupled with a sharp withdrawal reaction of the hand. All of the children were successfully treated with open reduction and internal fixation but only after fruitless attempts at closed manipulation and an initial lack of recognition of the severity of the fracture. Each child achieved a full functional recovery of the finger with clinical and radiological union at 4 weeks.

The versatility of the free fibula flap in the management of traumatic long bone defects.

The free fibula flap has been used to treat ten patients with important long bone defects (mean length 14 cm) following severe trauma. Defects in all the long bones of the limbs have been treated by this technique. Five free osseous and five osteocutaneous flaps were performed. Primary skeletal union occurred at 17 bone junctions (85 per cent) within 5 months. No secondary grafting procedures were required. The mean delay in referral was 17 months and eight patients had already undergone three or more unsuccessful surgical procedures to promote union. The versatility of the vascularized free fibula flap is presented as a one-stage reconstruction for large bony and soft tissue defects, stressing the importance of prompt referral and recognition of cases. A combined orthopaedic and plastic surgical approach to these patients is advisable from the onset.

Groin wound infection after arterial surgery.

Fifty-six patients, 30 with superficial and 19 with deep groin wound infections, and seven with lymph fistulae with positive cultures within 30 days of arterial surgery, were identified after 661 operations (873 groins at risk) between September 1984 and August 1988. The commonest infecting organisms were Staphylococcus aureus, Pseudomonas aeruginosa and Proteus spp. In 33 patients the infection settled completely after treatment with culture specific antibiotics. These were given intravenously then orally for up to 6 weeks. Sixteen patients required debridement and excision of necrotic wound edges, including one who had an antibiotic infusion into the wound. Graft excision was performed in seven patients of whom five received an extra anatomic bypass. The need for graft excision was much greater (six versus one) for Dacron and/or polytetrafluoroethylene than for vein. In two lymph fistulae sartorius transposition and wound resuture were used. All groins healed, though three extremities were ischaemic following occlusion of the bypass. There were two deaths, one from myocardial infarction and one from pulmonary embolism and no major amputations. These results suggest that most infective groin problems may be successfully managed conservatively and that radical graft excision is only necessary for a few intractable cases.

Primary total hip replacement in patients over 80 years of age.

We have reviewed 107 patients of 80 years or over who underwent primary total hip replacement. They had many more complications than younger patients. Thus, acute dislocation occurred in 15%, and became chronic in 9%; there were femoral shaft fractures in 4.6% and these, with shaft perforation gave universally poor results. Nevertheless, 75% of patients had a satisfactory outcome, with worthwhile relief of pain. It would seem sensible to warn elderly patients and their relatives of the increased risks in this age group.