Is there any purpose in classifying subtrochanteric fractures? The reproducibility of four classification systems.

INTRODUCTION: Classification systems are used for communication, planning treatment options, predicting outcomes and research purposes. The majority of subtrochanteric fractures are now treated with intramedullary nails and therefore questioning the need for classification. OBJECTIVES: To assess the intra- and inter-observer reproducibility of the Seinsheimer, AO and Russell-Taylor (RT) classification systems and to assess a new simple system (MCG). MATERIALS AND METHODS: The MCG system was developed to alert the surgeon to potential hazards: type 1-subtrochanteric fracture (ST#) with intact trochanters, type 2-ST# involving greater trochanter (entry point for nailing difficult), and type 3-ST# involving lesser trochanter (most unstable). Thirty-two anteroposterior and lateral radiographs of subtrochanteric fractures were classified independently for each of the 4 classification systems by 4 observers on 2 separate occasions. RESULTS: The intra- and inter-observer variation was poor in all systems (highest Kappa 0.35). MCG had the best reproducibility followed by RT, then AO and Seinsheimer. The data were re-analysed to determine whether the findings were due to the presence of too many subgroups and whether the observers could more accurately identify important individual subclassifications: Seinsheimer 3a, AO31-A3.1, RT 1 or 2, RT a or b, and MCG3. The MCG3 had the narrowest ranges for intra- and inter-observer reproducibility. CONCLUSIONS: The classification systems analysed in this study have poor reproducibility and seem to be of little value in predicting the outcome of intramedullary nailing as all of the fractures achieved union. The MCG system may be of some use in alerting the surgeon to potential problems.

Management of hyperextension of the metacarpophalangeal joint in association with trapeziometacarpal joint osteoarthritis.

This study investigates the management of metacarpophalangeal joint (MCP) hyperextension in patients undergoing trapeziectomy for thumb base osteoarthritis. A total of 297 thumbs with painful trapeziometacarpal osteoarthritis were assessed on pain and thumb key and tip pinch preoperatively and at 1 year. Before surgery 101 had no MCP hyperextension, 168 had hyperextension ≤ 30° and 28 had hyperextension ≥ 35°. Of these 157 hyperextension deformities ≤ 30° and eight ≥ 35° were not treated. The others were treated by temporary insertion of a Kirschner wire (n = 9), MCP fusion (n = 6), sesamoid bone tethering to the MC head (n = 5) and palmar capsulodesis using a bone anchor (n = 11). Untreated MCP hyperextension deformities < 30° did not influence the outcome of trapeziectomy. MCP hyperextension deformities ≥ 35° can be improved by capsulodesis or MCP fusion but this may not improve the clinical outcome.

Skimboarding: a new danger in the surf?

Skimboarding is an increasingly popular activity on the beach. Over a six week period we saw 10 patients with fractures or dislocations, half of whom required operative intervention. The majority (80%) were of the lower limb, some of which were severe.

A case of dissociation of polyethylene from its metal baseplate in a "one piece" compression-moulded AGC tibial component.

The Anatomic Graduated Component (AGC) total knee arthroplasty is a commonly used prosthesis with good long-term results. This longevity is thought to be due to the technique of manufacture of the polyethylene and its "one piece" design reducing backside wear. Despite the perception of the AGC tibial component being a monobloc, we report a case of dissociation of the polyethylene from the baseplate.