This study investigates the concerns of 50 patients with ganglia and their reasons for primary care consultation and referral to a hand unit. Although a minority of patients sought advice and treatment because of pain, more (38%) were concerned about the cosmetic appearance and a significant number (28%) were concerned that their ganglion was a malignant growth. The general practitioners referred 70% of patients to the hand clinic for "excision of the ganglion" and 30% for further "advice and treatment". However, 74% of patients were satisfied with aspiration of the ganglion and general advice.

This randomized prospective study assessed whether multiple puncture of the ganglion wall improves the results of simple ganglion aspiration. We found that 32% of ganglia resolved after aspiration alone in comparison with 22% after aspiration and multiple puncture. This difference was not significant. However, only 18% of patients requested formal surgical excision, suggesting that aspiration allays fears of malignancy and allows the patient to accept a minor cosmetic embarrassment.

No abstract

Osteoporosis poses a significant orthopaedic problem of epidemic proportions. Clear guidelines for the management of osteoporosis presenting early or late are still being debated. Several recommendations, however, are now generally accepted. Measurements of BMD should be taken if the diagnosis is in doubt or as an adjunct to encourage patient compliance with treatment. Those with multiple risk factors and who are under the age of 65 years would benefit from a scan. Those with previous fractures and no obvious risk factors should also be sent for DXA assessment. The elderly with fractures and multiple risk factors do not need scanning and can normally be started on treatment. Mass population screening is not cost-effective. Prevention strategies should be targeted at high-risk patients and not offered to everyone. In the perimenopausal woman HRT is the first line of treatment and prevention, along with changes in lifestyle. Tibolone may be an option for those who find cyclical bleeding unacceptable. In the elderly, institutionalised patient, calcium and vitamin-D supplements should be considered to replace depleted levels, particularly for secondary prevention. Postmenopausal women with multiple risk factors and at least one insufficiency fracture should be treated. The most likely pharmacological agent will be a bisphosphonate with supplemental calcium if indicated. Each hospital should have a recognised link person through whom referrals can be channelled, either a clinical nurse specialist or physician. A protocol for treatment should be agreed locally and publicised among the primary health-care groups. The first step of identification of high-risk patients is most often in fracture clinics. Standardised letters attached to the clinic note to general practitioners are an easy way of 'getting these patients into the system'.

Arterial pseudoaneurysm formation of the genicular vessels following orthopaedic surgery to the knee is an extremely rare occurrence. Here we report the successful management of two cases as a complication of total knee arthroplasty and a tibial interlocking nail, utilising coil embolisation by interventional radiological techniques and negating the need for further surgery. To our knowledge this is one of the few reported cases of pseudoaneurysms of the descending genicular artery secondary to drain placement and only the second following tibial interlocking nail placement.