The swollen, painful hand is a familiar sight in the emergency department (ED), and often is seen in the context of alcohol intake, following a fight or in association with multiple trauma, all of which can make accurate assessment challenging. We report a case of complete dorsal dislocation of the four ulnar metacarpals and highlight the importance of early diagnosis and treatment for this unusual injury.

BACKGROUND:There are little data available on complication rates following primary total hip arthroplasty (THA) surgery in Ireland.AIMS:To determine self-reported complication rates and national data for primary THA.METHODS:A postal questionnaire surveyed Irish orthopaedic association consultant members. Additional data were obtained from the economic and social research institute (ESRI).RESULTS:We achieved an 83% response rate. 5,424 THAs were self-reported. Mean dislocation rates were 1%, but higher using a posterior surgical approach (p < 0.05). Mean deep infection rates were 0.4%. 29% were MRSA. No reduction was reported from additional barrier prophylaxes. Mean venous thrombo-embolism (VTE) rates were 3.5%. No reduction was reported from commencing prophylaxis preoperatively or extending treatment duration. National rates for dislocation, deep infection and VTE were 25.7, 0.87, and <0.1%, respectively.CONCLUSIONS:The creation of a National Hip Register is strongly recommended. A register would improve surgical practices and patient outcomes, and provide significant healthcare savings.

AIM:To evaluate the use of rapid prototyping in the assessment, classification and preoperative planning of acetabular fractures.INTRODUCTION:The complex three-dimensional anatomy of the pelvis and acetabulum make assessment, classification and treatment of fractures of these structures notoriously difficult. Conventional imaging only provides two-dimensional images of these fractures. While interpretation of traditional imaging techniques becomes better with experience, novel techniques may assist in the understanding of these complex injuries.METHODS:Twenty patients with acetabular fractures were studied. Life size three-dimensional models were manufactured from standardised CT scans, using the rapid prototyping process, selective laser sintering. Each model was presented to the operating surgeon prior to surgery. The surgeons found that the models greatly assisted in their understanding of the personality of the fracture. Three consultant orthopaedic surgeons and three senior trainees were asked to classify each fracture using conventional radiographs (AP pelvis, Judet views and CT scans) and then using the model. The kappa statistic was used to evaluate inter- and intraobserver agreement.RESULTS:Interobserver agreement was not absolute using either conventional radiographs or the models. For the consultants the kappa statistic using conventional radiographs was 0.61 while the kappa value using the model was 0.76 (p<0.05). For the trainees the kappa value was 0.42, using conventional radiographs and 0.71 using the model (p<0.01).CONCLUSION:Full sized models of acetabular fractures greatly assisted surgeons understand the personality of complex fractures prior to surgery and have been shown in this study to significantly reduced the degree of interobserver variability in fracture classification. This effect is particularly evident for less experienced surgeons. This technique is available and relatively inexpensive. The use of these models should prove invaluable as a tool to aid clinical practice.

Primary total hip replacement (THR) surgery is the most commonly performed and successful reconstructive procedure in orthopaedic surgery. We performed a survey of Irish Orthopaedic consultants to elucidate current practices of primary THR in elderly and young patients and identify changing trends. There was an 83% response rate. Most respondents use a cemented THR in elderly patients. 69% use a different THR in younger patients compared to older patients. 9% refer younger patients to hip replacement specialist consultant colleagues. 70% report changing to a new implant or new technique in younger patients and 45% use a hybrid THR, 15% an uncemented THR, 15% perform hip resurfacing and 47% use different bearing surfaces. Only 17% use the Charnley hip prosthesis in younger patients. Young and active patients will place high demands on a new THR and newer techniques, implants and bearing surfaces are being adopted in the hope of better outcomes.

A total of 69 patients undergoing revision hip arthroplasty using a transtrochanteric approach who all had at least 1 previous transtrochanteric surgical approach. In 6 patients, it was the third time the trochanter was taken down, and in 2 patients, it was the fourth time. We believe this is the first review of trochanteric union in such a subgroup of patients. The mean age was 66 years (range, 46-82 years). Before revision, 49 of 69 patients (71%) had a united trochanter, whereas 20 of 69 (29%) had a pseudarthrosis. The overall pseudarthrosis rate decreased from 20 patients (29%) to 10 patients (14%) after revision surgery. The mean Harris hip score was 86 (range, 29-100). Repeated transtrochanteric osteotomy was not associated with any significant morbidity and did not affect the clinical outcome.

Three-dimensional spiral CT scanning is now becoming a common investigation in children who have a history of acute torticollis. In the last year, 21 consecutive children who came to our unit with a history of acute torticollis were assessed using standard plain radiographs and a 3-dimensional spiral CT scan. Ten patients had a history of recent trauma. Spiral CT scanning revealed that 13 children had atlanto-axial rotatory subluxation (AARS). Plain radiographs had only a sensitivity of 33% and specificity of 71% in detecting AARS. Sixteen children were treated using a Halter traction. Four failed to resolve clinically and were put on a halo traction after 3-dimensional CT scanning again confirmed residual AARS. Two children remained symptomatic after halo traction, with persisting rotatory and anterior subluxation on repeat spiral CT. They both underwent a posterior in-situ fusion, with no attempt at open reduction. Plain radiography is limited in investigating acute torticollis in children. Spiral 3-dimensional CT reconstruction has an important role to play in both the investigation and management of children who present with acute torticollis.

Orthopaedic surgeons in many major arthroplasty centres advocate the use of a prolonged surgical hand-scrub prior to total joint replacement. In this study we evaluated the antimicrobial efficacy of a 5 compared with a 10 min scrub before both long (>90 min) and short (< 90 min) operations for total hip arthroplasty. Surgical hand disinfection was performed on one occasion for 5 min and on a second for 10 mm by 41 surgeons and theatre nurses using 4% chlorhexidine gluconate as a detergent formulation (‘Hibiscrub’, ICI Pharmaceuticals). None of the subjects had previously scrubbed on the day of each test. Bacterial colony counts on the fingers were measured using the method described by Rotter (vide infra) before scrubbing, immediately after scrubbing, and at the end of each operation. Our results showed that for arthroplasty procedures lasting less than 90 min (35 operations) a 5 min hand-scrub was equally as effective as one of 10 min. However, following longer procedures (36 operations) colony counts were significantly higher on subjects who had scrubbed for 10 min than on those who only scrubbed for 5 (P < 0·05, Mann-Whitney U-Test). This study suggests that the practice of a prolonged scrub before total joint replacement does not have a scientific basis and that such a policy should be discontinued where it is still practised.

243,901), but an understanding of its role in control of airway function in health and disease has been difficult because of the lack of specific antagonists.It was the purpose of this study to synthetise analogues of NKA and to test them for pharmacological antagonism of NKA-induced contraction of guinea-pig tracheal smooth muscle.We have previously reported that NKA analogue in which glycine 8 was replaced by aminoisobutyric acid (Aib) is an antagonist of NKA, but not Substance P, activity on tracheal smooth muscle from guinea-pig (Abu Shanab et al, Biochem.Soc.Trans.1990: 18, 286).We now report the effect on biological activity of deletions at the N-terminus.NKA was purchased from Biosyn Ltd. (Belfast, N. Ireland) and the peptides [Ala s, Aib s, Leu 1~ NKA (4-10), [Ala ~, Aib 8, Leu 1~ NKA (2-10) and [Ala s, Aib s, Leu 1~ NkA, hereafter referred to as peptides 1, 2 and 3 respectively, were synthetised by solid phase methods.Isometric contraction of isolated guinea-pig tracheal rings in response to exogenous NKA (10 -1~ to lO-6M) was recorded as described previously (Abu Shanab et al, Biochem.Soc.Trans.1990: 18, 286) and the effect of the peptide analogues on the NKA doseresponse relationship examined.In the presence of peptide 3 (10 -8 to 10-6M) NKA evoked contractions were reduced at all doses producing acharacteristic shift in the NKA dose-response curve suggestive of classical non-competitive antagonism, although contractions to substance P (SP; 10 -8 to 10-6M) were unaltered by analogue.In contrast, peptide 2 (104 to 1 ff6M) caused a dose-dependent shift to the right of the NKA doseresponse curve with no depression of the maximum NKA response.Peptide 2 showed no pharmaclogical antagonism to SP.A schild regression plot for peptide 2 antagonism of NKA evoked contractions yielded a straight line of slope -0.4 with an interscept (PA2) of 7.7 on the abscissa.Unlike peptides 2 and 3, peptide 1 (10-6M) itself caused contraction of the tracheal preparation.In conclusion, peptide analogues that selectively antagonise the activity of NKA on tracheal smooth muscle have been produced by replacement of Gly s in a NKA ,,~icgue that also had the substitutions Ala s and Leu 1~ Removal G~ the N-terminal residue did not abolish this selectivity although the nature of the antagonism was altered.Removal of a further two amino acid residues from the Nterminus resulted in the generation of agonist activity.