P. J. Gregg

Intra-articular fractures of the calcaneum treated operatively or conservatively : a prospective study

We report a prospective trial of 66 patients with intraarticular fractures of the calcaneum. All fractures were assessed by CT. Patients with displaced fractures were randomised to receive either conservative (n = 31) or operative treatment (n = 25). Undisplaced fractures (n = 10) were treated conservatively. Operation involved open reduction of the posterior subtalar joint, and fixation with Kirschner wires. All 66 patients were reviewed at a minimum of one year (mean 23 months). After conservative treatment the undisplaced fractures had slightly better results than the displaced fractures. There was no significant difference in outcome between the operatively and the conservatively treated displaced fractures. We have also documented prospectively the natural history of the injury, which is of use in assessing prognosis for both clinical and medicolegal purposes.

Suspected scaphoid fractures. The value of radiographs

Twenty observers reported independently on the presence or absence of a fracture of the scaphoid on 60 sets of radiographs; these included initial and 2- to 3-week views in patients in whom the outcome was known, normal scaphoids and random copies of these. Analysis of variance of the accuracy of observations revealed that the 2- to 3-week radiographs did not improve diagnostic ability and that this was independent of the experience or seniority of the observer. For normal radiographs, 20% of the observations reported a fracture. Reproducibility of opinion improved with experience but this did not help with accuracy. Radiographs without accurate clinical observation should not determine the management of the suspected scaphoid fracture.

UNIPOLAR OR BIPOLAR PROSTHESIS FOR DISPLACED INTRACAPSULAR HIP FRACTURE IN OCTOGENARIANS: A RANDOMISED PROSPECTIVE STUDY

We performed a randomised prospective trial to compare a cemented unipolar prosthesis (Thompson) with a cemented bipolar prosthesis (Monk) in the treatment of displaced intracapsular fractures of the hip in patients over 80 years of age. Patients with a mental test score of less than 5/13 were excluded but the mortality was still about 30% at one year in both groups. We therefore feel that subjective criteria such as the level of pain and the return to the preinjury state are of paramount importance. Two years after operation there was no statistical difference between the rate of complications in the two groups. After adjusting for confounding factors such as differences in the level of function before injury between the groups, the degree of return to the preinjury state was significantly greater (p = 0.04) when using the unipolar prosthesis, which is one-quarter of the price of the bipolar. We cannot therefore justify the use of an expensive bipolar prosthesis in patients over 80 years of age.

Femoral head blood flow in femoral neck fractures. An analysis using intra-osseous pressure measurement

We studied 50 patients with fractures of the femoral neck, 33 intracapsular and 17 extracapsular. Intraosseous pressure was measured by a transducer within the bone to quantify blood flow, and intracapsular pressure by a needle introduced into the joint space. The mean intracapsular pressure was lower in the extracapsular fractures. In these, the mean intraosseous pressure in the femoral head was unchanged by aspiration of the joint. However in the intracapsular fractures aspiration produced a significant decrease in intra-osseous pressure and an increase in pulse pressure within the femoral head. The results suggest that aspiration of intracapsular haematoma produced an increase in femoral head blood flow by relieving tamponade.

The management of the painful first metatarsophalangeal joint in the older patient. Arthrodesis or Keller's arthroplasty?

We report a prospective randomised trial comparing Kellers arthroplasty and arthrodesis of the first metatarsophalangeal joint for the management of symptomatic hallux valgus and hallux rigidus in the older patient. In 81 patients (110 feet), with a minimum of two years follow-up, both procedures gave a similar degree of patient satisfaction and symptom relief. The incidence of metatarsalgia was also similar. As there were no obvious advantages to arthrodesis, and since six out of 50 arthrodesed toes required revision, we suggest that Kellers arthroplasty is the better operation in these patients.

Plasma viscosity and C-reactive protein after total hip and knee arthroplasty

We studied the changes in plasma viscosity and C-reactive protein to establish normal values after total hip or knee arthroplasty. Viscosity decreased from 1.68 (+/- 0.017) to 1.57 (+/- 0.014) on the first postoperative day and thereafter rose to 1.60 (+/- 0.019), 1.75 (+/- 0.015), and 1.74 (+/- 0.011) on the third, seventh and fourteenth days respectively. Six to eight weeks after operation it had returned to pre-operative levels. A viscosity above the upper limit of the laboratory range, obtained more than two months after operation, may be considered as abnormal. The C-reactive protein level increased significantly on the first postoperative day and then decreased from a peak on the second day, attaining nearly normal levels at six to eight weeks after operation. It may be a more sensitive indicator of deep postoperative infection than plasma viscosity.

Acromioclavicular joint injuries in sport. Recommendations for treatment.

SummaryDislocation of the acromioclavicular joint is a common joint injury in sport, especially those in which there is the risk of falling on to the point of the shoulder. There is controversy regarding the early management of such a dislocation but recent literature strongly favours a conservative approach, because no single surgical procedure has produced results which are consistently better than those achieved following conservative management. In addition the few studies which document late results suggest that in most instances the outcome following conservative treatment is very satisfactory with good power and movement of the shoulder.

The treatment of hallux valgus with overriding second toe

effusion in either child (Fig. 2) but needle aspirations subsequently demonstrated intracapsular blood under pressure . Following decompression, hip movements became much freer and the hips were radiographically reduced (Fig. lb). Discussion. Plain radiographs have been shown to be less accurate than ultrasound examination in the detection of hip effusion (Peck 1986); thus it has been suggested that they are redundant in the routine investigation of irritable hip. However, in our two cases tense effusions were not detected by ultrasound examinations whilst radiographic changes were clearly present. How can this come about? With a tense effusion, extrusion of the femoral head may tighten the anterior capsule across the front ofthe femoral neck, displacing intracapsular fluid into the acetabulum. A given volume of intracapsular fluid is therefore accommodated at lower pressure but at the expense of subluxation. In this way, with the flattening of the iliofemoral ligament against the femoral neck, the ultrasonic sign of effusion is masked. This previously unrecognised phenomenon therefore requires that subluxation is excluded by radiography before ultrasound examination can be considered reliable. Conclusion. If a significant hip effusion is suspected on clinical grounds, both a radiograph and an ultrasound examination should be performed. Neither one in isolation can exclude an effusion.