The Fixion expandable nailing system provides an intramedullary fracture fixation solution without the need for locking screws. Proponents of this system have demonstrated shorter surgery times with rapid fracture healing, but several centres have reported suboptimal results with loss of fixation. This is the largest comparative series to be reported to date.

We compared outcomes between 50 consecutive diaphyseal tibial fractures treated with a Fixion device at our institution to an age, sex and fracture configuration matched series of 57 fractures at a neighbouring hospital treated with a conventional interlocked intramedullary nail. Minimum follow up time was 2 years.

Operating time was significantly reduced in the Fixion group (mean 61 minutes, range 20–99) compared to the interlocked group (88 minutes, 52–93), p< 0.00001. The union rate was no different between the Fixion group (93.9%) and the interlocked group (96.5%), p=0.527. Time to clinical and radiological union was significantly faster in the Fixion group (median 85 days, range 42–243) compared to the interlocked group (119, 70–362), p< 0.0001. The overall reoperation rate was lower in the Fixion series (24.5% vs 38.6%, p=0.121), although the majority of reoperations in the interlocked group were more minor, for screw removal. 3 Fixion nails were revised for fixation failure and 2 manipulations were required for rotational deformities after falls; all of these patients were non-compliant with post-operative instructions. There were no fixation failures in the interlocked group. 3 fractures were noted to propagate during inflation of Fixion nails.

The Fixion nail is faster to implant and allows more physiological loading of the fracture, with a faster union time. However, these advantages are offset by a reduction in construct stability. Our results have demonstrated a learning curve with a reduction in complications as our indications were narrowed, avoiding osteoporotic, multifragmentary, unstable fractures and non-compliant patients

Introduction

PIPJ replacement has become increasingly popular however, there is very little clinical data available apart from small studies and those from the originators of the prostheses. We present a review of our initial experience with the Acension^(c) Pyro-carbon PIP joint.

A systematic search of the literature published between January 1985 and February 2006 identified 62 studies which reported the results of arthroscopic procedures for chronic anterior shoulder instability or comparisons between arthroscopic and open surgery. These studies were classified by surgical technique and research methodology, and when appropriate, were included in a meta-analysis.

The failure rate of arthroscopic shoulder stabilisation using staples or transglenoid suture techniques appeared to be significantly higher than that of either open surgery or arthroscopic stabilisation using suture anchors or bio-absorbable tacks. Arthroscopic anterior stabilisation using the most effective techniques has a similar rate of failure to open stabilisation after two years.

Introduction and Aims: The management of diaphyseal tibial fractures remains controversial. This paper looks at the use of an innovative, unlocked, inflatable intra-medullary nail (Fixion, Disc-O-Tech). The study aim is to assess the performance of this nail relative to a traditional locked nail.

Method: This study compares a prospectively recruited cohort of patients treated with the fixion nail to a consecutive series of patients treated with the Russel Taylor locked nail prior to the introduction of the new device. All the fractures were classified using the AO system. Operating time and the x-ray screening time were recorded, along with any peri or post-operative complications, and need for secondary procedures. Follow-up x-rays were assessed for time to radiological union.

Results: Thirty-six patients were identified, 17 undergoing fixion tibial nailing and 19 having locked Russell Taylor nails. AO classification of fractures ranged from 42-A1 to 42-C3 and was similar in the two groups. In the Fixion group were 15 males and two females with an age range of 15 to 76 years. Two cases required secondary procedures. In the locked nail group were 19 cases, 16 males and three females. Eleven of the cases required secondary procedures, principally removal of locking screws for dynamisation of the nail in cases of delayed bone union and four patients had the nail removed.

The mean operating time for the fixion nail was 58 minutes and 89 minutes for the locked Russell Taylor nail, a statistically significant difference (p< 0.002, unpaired t-test). There was also a significant difference in the need for secondary procedures with at least one further procedure in 11/18 Russel Taylor nails and only 2/17 Fixion nails (p< 0.006, Fisher’s exact test). There was no significant difference in image intensifier screening time between the two groups. There was a trend to reduced time to bone union with the Fixion nail which did not reach statistical significance in this small cohort (p = 0.06), but may do so as a larger number of patients are studied.

Conclusions: Our results show that operative time was significantly less with the fixion nail, there were many fewer secondary procedures and all fractures went on to union. Our study demonstrates that an unlocked, inflatable nail compares favourably with a locked nail and should be considered in tibial diaphyseal fractures.

Aims: This is a prospective study that evaluates the impact of psychological disturbance upon symptoms, self-reported disability and surgical outcome in patients with carpal tunnel syndrome. Methods: We recruited a consecutive series of 84 patients with a clinical diagnosis of carpal tunnel syndrome. Symptom severity and disability were assessed using the Boston carpal tunnel questionnaire (Levine et al 1993). Psychological distress was assessed using the Hospital Anxiety and Depression Scale (Zigmond & Snaith 1983). Questionnaires were administered before and six-weeks after open carpal tunnel decompression. Complete pre and postoperative data were available for 69/84 patients (82%). A statistical correlation of psychological distress with symptoms, self reported disability and surgical outcome was performed. Results: There was a signiþcant correlation between the psychological disturbance (the HAD score) and the pre-operative symptom severity (correlation coefþcient = 0.37, p < 0.04) and function scales (correlation coefþcient = 0.55, p < 0.0001) of the Boston carpal tunnel score. Self reported symptoms improved following surgery in 65/69 patients (94%). The mean symptom score improved from 3.01 pre-op to 1.69 post-op (p < 0.0001). Function and psychological distress improved signiþcantly following surgery. Conclusions: There was no signiþcant correlation between pre-operative psychological distress and the outcome of carpal tunnel decompression though there was signiþcant correlation with symptom severity.

The use of musculo-skeletal MRI is increasing at spectacular rate, however there have been few rigorous evaluations of its’ clinical effectiveness. This study was conducted to assess the impact of MRI of the wrist on clinical diagnosis and patient management.

A controlled observational study was performed, in which referring clinicians completed questionnaires on diagnosis and intended management before and after wrist MRI. We analysed 118 consecutive patients referred for MRI of the wrist, to the magnetic resonance imaging units at a regional teaching hospital and a large district general hospital. We assessed: changes in clinicians’ leading and subsidiary diagnoses after MRI; their certainty of these diagnoses; and changes in intended patient management.

Five patients had incorrectly completed requests, ten cancelled their appointments and two could not tolerate the MR examination. Complete follow up data is available for 98/101 patients with correctly completed request forms who were examined. The clinical diagnosis changed in 55 of 98 patients (56%). Diagnostic certainty increased in 23 of the remaining 43 patients (53%). Clinicians reported that MRI had substantially improved their understanding of the patients’ disease in 67/98 (68%) patients. There was a change in management in 46/98 (47%) patients, with a shift away from operative treatment. 28 out of 98 (29%) patients were discharged without further investigation. MRI was similarly effective in a regional teaching centre and a district general hospital.

Magnetic resonance imaging of the wrist influences clinicians’ diagnoses and management plans. These results demonstrate the clinical effectiveness of MRI of the wrist in both a regional teaching centre and a district general hospital.

This study investigated the relationship between histological, clinical and radiological features of aseptically loose total joint replacements (TJRs) and synovial fluid levels of interleukin (IL)-1b, IL-6, IL-8 and IL-10.

Tissue and synovial fluid samples were retrieved from patients undergoing primary (hip; n=15: knee; n=13), or revision of aseptically loose TJRs (hip; n=14: knee; n=9). The presence of inflammatory cells, blood vessels and wear debris in the tissue were assessed on a relative scale. Revision TJRs were assessed for sepsis, migration of the implant, gross loosening and the degree of radiolucency. Cytokine levels in the synovial fluid samples were determined by ELISA.

All cytokines were increased in synovial fluid from revision TJRs compared to primary replacements, as were the degree of macrophage and giant cell infiltration (p< 0.01). There was a significant positive correlation between the presence of macrophages and giant cells with the levels of IL-1b, IL-8 and IL-10 (p< 0.05) but not IL-6.

The amount of wear debris was related to the presence of macrophages and giant cells (p< 0.01) but not to any of the cytokines.

There were no relationships between any of the clinical parameters and the presence of wear debris or the levels of any cytokine with the exception of IL-6 and gross loosening (p< 0.01). Similarly there were no differences between hips and knees for any of the parameters except IL-6, for which higher levels were found in hips (p< 0.05).

The results suggest that macrophages and giant cells are responsible for the majority of IL-1b, IL-8 and IL-10 production but another cell type is contributing to IL-6 production. Furthermore, IL-6 does not fit the pattern of the other cytokines as it is upregulated in hip joints compared to knees and correlates with the presence of gross loosening. This may suggest a unique role for IL-6 that requires further investigation.