Background

Plantar fasciitis is a frequently chronic and disabling cause of foot pain in adults. This prospective study aims to evaluate the analgesic effect of ultrasound guided dry needling in patients with chronic plantar fasciitis, refractory to conservative treatment.

Massive, irreparable rotator cuff tears occur in about 15% of patients with ruptures of the rotator cuff tendons. There is no consistently agreed management for irreparable rotator cuff tears, however, latissimus dorsi tendon transfer is a recognised technique. We aimed to review the functional outcome of patients undergoing this operation at a single tertiary referral centre.

Fourteen latissimus dorsi transfer procedures in thirteen patients from May 2007 to May 2008 were retrospectively reviewed. The mean age of patients undergoing the procedure was fifty nine years. All patients were confirmed to have massive, irreparable (>5cm) rotator cuff tears as determined by MRI or ultrasound. Modified Constant scores (assessing shoulder pain, functional activity and movement) determined pre-operatively and post latissmus dorsi transfer were compared. The mean duration of follow up was 12 months.

The mean Modified Constant Score (maximum = 75) improved from 23 points pre-operaively to 52 points post latissimus dorsi transfer (p < 0.05). All patients had improvement in shoulder pain following the operation. There was a trend for younger patients to have greater improvement in functional activity and shoulder movement.

From our series, latissimus dorsi transfer is effective at improving functional outcomes in patients with massive, irreparable rotator cuff tears, especially in younger age groups.

Guidelines for cervical trauma x-rays highlight the necessity for visualization of the C7-T1 junction. However, despite 15% of thoracolumbar fractures involving the T12 vertebra, less emphasis has been placed on ensuring the thoracolumbar junction or T12 vertebra is included on lumbar trauma radiographs. This may be due to an assumption that the lower thoracic spine will routinely be seen on lumbar x-rays.

We aimed to determine the proportion of lumbar trauma x-rays that allowed adequate visualisation for fracture diagnosis. We retrospectively reviewed all lumbar spine radiographs for patients presenting with blunt trauma to the Victoria Infirmary, Glasgow from January 2007 to January 2009. Our criteria for an appropriate lumbar trauma x-ray were that the whole lumbar spine should be visualized as well as the whole T12 vertebra.

From 583 lumbar radiographs reviewed, 61 (10%) did not fulfill the criteria for an acceptable lumbar trauma x-ray. 3% did not include the lumbrosacral junction and 7% did not include the T12 vertebra. One patient had a delayed diagnosis of a T12 fracture due to incomplete visualisation of the T12 vertebra on initial lumbar radiographs.

A significant proportion of lumbar spine x-rays performed for trauma patients (up to 10%) may not allow adequate visualisation for fracture diagnosis. These x-rays may give false reassurance that no fracture is present and, in turn, may lead to potentially disabling consequences. Spinal imaging for trauma patients should be interpreted closely with clinical findings. In cases where there is difficulty visualising the lumbar spine appropriately with radiographs, a CT scan should be considered.

Introduction: Though Cutaneous nerve injury following ACL reconstruction is a recognized complication, we identified an undescribed pattern of numbness involving the entire shin from the knee to the ankle.

Methods: A review of 143 Hamstrings ACL reconstructions performed between 1999 and 2004 was done. Mean age was 34.8 years (17–57) and the follow-up was 40.2 months (9–80).

Results: The patterns of numbness were classified into non-scar related and scar related. 76 patients (53 %) had non-scar related numbness. Among this 7 (5%) had numbness of the entire shin from the knee to the ankle. This pattern of numbness is significant considering the large area involved. 38 patients (27%) had scar related numbness.

Non-scar related numbness corresponded to the innervation of the branches of the Saphenous nerve. Only 39% of patients with non-scar related numbness and 47% with scar related numbness recovered completely. None of the patients who had numbness of the entire shin recovered. Interestingly only 3 patients reported that this numbness bothered them.

Conclusion: Anatomical studies have shown that it is difficult to identify a safe zone for tendon harvest. Efforts should be made to minimize the risk of such nerve damage, by making the incision more horizontal and keeping the knee in flexion while harvesting the graft. Patients should be warned of this complication while taking consent.

Lumps of the foot present relatively infrequently to the orthopaedic service. There have been very few published studies looking at presenting characteristics or the differential diagnosis of such lesions. We report our experience of foot lumps treated surgically looking at the patient demographics, presenting characteristics, diagnoses encountered and the diagnostic accuracy of the surgeon. All patients who underwent excision or biopsy of a foot lump over a period of 4 years were studied; 101 patients were identified. Average age was 47.3 years (range 14–79); there was a significant female preponderance with 73 females and 28 males (p< 0.0001). Pain was the single most common presenting complaint followed by footwear problems. Only three patients attended because of cosmetic reasons and neurological symptoms were very rare with only one patient complaining of paraesthesia. Certain lesions were more commonly encountered in specific zones of the foot. 32 different histological types were identified, ganglion cysts were the most commonly encountered lesions and there was only one malignant lesion encountered in this study. Only 58 out of the l01 lumps were correctly diagnosed prior to surgery.

We have shown that there are a wide variety of potential diagnoses, which have to be considered when examining a patient with a foot lump. There is a low diagnostic accuracy for foot lumps and therefore surgical excision and histological diagnosis should be sought if there is any uncertainty.

This study assessed whether spinal fusion surgery could be performed safely in patients with Duchenne’s muscular dystrophy (DMD) and a low (less than 30%) predicted forced vital capacity (PFVC).

Patients were identified with a diagnosis of scoliosis secondary to DMD who underwent spinal fusion procedures at the Royal National Orthopaedic Hospital, Stanmore between January 1990 and December 1999. Their notes and radiographs were reviewed and a standardised data collection form was completed.

Thirty patients with a mean age of 14 years 8 months at surgery underwent posterior spinal fusions. All were discharged from hospital alive and self-ventilating on average 22 days post-operatively (range 13–62 days). Thirteen patients had a PFVC less than 30%. The mean pre-operative curve was 61 degrees (range 30 to 90) and the mean number of levels fused was 15 (i.e. T3 to sacrum). The mean correction was 36 degrees (range 16 to 61). Two patients required temporary tracheotomies, one with a PFVC of 34% and one with a PFVC of 20%. Both were removed successfully after 39 days and 27 days respectively. There was no association between PFVC and operative time, blood loss, length of time on ventilatory support, time intubated, incidence of complications or length of admission.

Historically, only curves of greater than 20–35 degrees have been considered suitable for surgery, as the progression of the curve is associated with a marked decline in respiratory function. Considering the currently used criteria for surgery, the group of 13 with low PFVCs normally would have been denied surgery.

We conclude that spinal fusion surgery can be safely performed in DMD patients with a low PFVC.

Introduction and Aims: This study is to assess whether spinal fusion surgery can be performed safely in patients with Duchenne’s muscular dystrophy (DMD) and a low (less than 30%) predicted forced vital capacity (PFVC).

Method: Patients were identified with a diagnosis of scoliosis secondary to DMD who underwent spinal fusion procedures at the Royal National Orthopaedic Hospital, Stanmore between January 1990 and December 1999. Their notes and radiographs were reviewed and a standardised data collection form was completed.

Results: Thirty patients with a mean age of 14 years 8 months at surgery underwent posterior spinal fusions. All were discharged from hospital alive and self-ventilating on average 22 days post-operatively (range 13–62 days). Thirteen patients had a PFVC less than 30%. The mean pre-operative curve was 61 degrees (range 30–90) and the mean number of levels fused was 15 (i.e. T3 to sacrum). The mean correction was 36 degrees (range 16–61). Two patients required temporary tracheotomies, one with a PFVC of 34% and one with a PFVC of 20%. Both were removed successfully after 39 days and 27 days respectively. There was no association between PFVC and operative time, blood loss, length of time on ventilatory support, time intubated, incidence of complications or length of admission.

Conclusion: Historically, only curves of greater than 20–350 have been considered suitable for surgery, as the progression of the curve is associated with a marked decline in respiratory function. Considering the currently used criteria for surgery, the group of 13 with low PFVCs normally would have been denied surgery. We conclude that spinal fusion surgery can be safely performed in DMD patients with a low PFVC.

Aim: This study is to assess whether spinal fusion surgery can be performed safely in patients with Duchenne’s muscular dystrophy (DMD) and a low (less than 30%) predicted forced vital capacity (PFVC).

Patients- Methods: Patients were identified with a diagnosis of scoliosis secondary to DMD who underwent spinal fusion procedures at the Royal National Orthopaedic Hospital, Stanmore between January 1990 and December 1999. Their notes and radiographs were reviewed and a standardised data collection form was completed.

Results: Thirty patients with a mean age of 14 years 8 months at surgery underwent posterior spinal fusions. All were discharged from hospital alive and self-ventilating on average 22 days postoperatively (range 13–62 days). Thirteen patients had a PFVC less than 30%. The mean preoperative curve was 61 degrees (range 30 to 90) and the mean number of levels fused was 15 (i.e. T3 to sacrum). The mean correction was 36 degrees (range 16 to 61). Two patients required temporary tracheotomies, one with a PFVC of 34% and one with a PFVC of 20%. Both were removed successfully after 39 days and 27 days respectively. There was no association between PFVC and operative time, blood loss, length of time on ventilatory support, time intubated, incidence of complications or length of admission.

Conslusion: Historically, only curves of greater than 20–350 have been considered suitable for surgery, as the progression of the curve is associated with a marked decline in respiratory function. Considering the currently used criteria for surgery, the group of 13 with low PFVCs normally would have been denied surgery. We conclude that spinal fusion surgery can be safely performed in DMD patients with a low PFVC.

Aim. This study was performed to evaluate the efficacy of a balanced interscalene and general anaesthetic and its potential for use in increasing the provision of day case shoulder surgery.

Patients and Methods. 104 patients undergoing shoulder surgery were audited using a questionnaire immediately postoperatively, and at 6, 12 and 48 hours. Pain scores were recorded using a visual analogue scale. Operative details including operation time, postoperative stay and complications have also been recorded. At 48 hours patients were asked about having their operation as a day case and their pain control was assessed.

Results. 52 males and 52 females mean age 49 years (range 18–85) completed the questionnaire. 90 responded to a 48-hour interview. 75 arthroscopic decompressions, 15 arthroscopically assisted mini open cuff repairs, 9 open glenohumeral stabilisations and 5 open Mumford procedures were performed. Mean operation time was 47 minutes (range 25–90) and 101 patients were discharged after one (86 patients) or two (15 patients) postoperative nights. 97 patients had no pain immediately postoperatively, 76 were pain free at 6 hours and 39 were pain free at 12 hours. Mean pain scores at 6 and 12 hours were 3 and 4. 101 patients said that their pain was well controlled throughout the first 48 hours with simple oral analgesics. 83% of patients expressing an opinion on day case treatment (69 out of 83) could have been managed as day cases provided that they were adequately counseled about the procedure. 6 patients showed signs of Horner’s syndrome that resolved fully by 12 hours. No other complications related to the inter-scalene block occurred.

Conclusion. This study has shown that interscalene anaesthesia is a safe procedure providing sustained and adequate pain relief. In association with oral analgesia and patient counselling it allows a high percentage of patients undergoing shoulder surgery to be discharged home on the day of surgery.

Aim: A prospective study designed to assess and evaluate the results of arthroscopic acromioclavicular joint (ACJ) minimal excision arthroplasty.

Patients and Methods: Twenty-two patients with ACJ arthropathy underwent an arthroscopic limited excision of the ACJ preserving the superior ligamentous complex. The patients were assessed pre and post operatively using the Constant score. The average time from surgery to review was five months (three to nineteen months). A self assessment questionnaire was also used, evaluating outcome measures such as activities of daily living, shoulder function and patients satisfaction.

Results: The mean preoperative Constant score was 28 and postoperative score was 71 with an improvement in pain from 15% to 80% and the range of motion from 37% to 84%. The preoperative self assessment score was 25.9 and postoperative score was 83 with an improvement in activities of daily living from 28% to 79%, and shoulder function from 34% to 87%.Twenty patients were very satisfied, one was moderately satisfied and one patient was dissatisfied although his shoulder function increased from 20 to 60%.

Discussion: This study suggests that this technique is well accepted by the patients and results in a good improvement in shoulder function. The results are comparable with those reported in the literature concerning the standard ACJ arthroplasty. We therefore believe that a limited excision of the ACJ is adequate and a reliable alternative to conventional techniques.

Aim. The purpose of this study was to assess the outcome of arthroscopic shoulder surgery by evaluating the pre- and postoperative shoulder function using a simple self-assessment questionnaire filled in by the patient.

Patients and Methods. In this study 89 patients were studied who underwent arthroscopic subacromial decompression. Shoulder function was assessed preoperatively and at 3 to 6 months following surgery according to a self-assessment questionnaire, which was developed in our Shoulder Unit. It allows for a maximum score of hundred, with 30 points for pain, 20 for power and 50 points for work, recreation and 8 activities of daily living.

Results. All patients reported improvement in shoulder function with an average total shoulder score increase from 33.4% preoperatively to 87.8% post-surgery. The pain score increased from 21% to 83%, power from 30% to 89% and activities of daily living from 42% to 90%. Detailed analysis of ADL’s showed substantial improvement in all functions.

Conclusion. This study has shown that minimal invasive surgery to the shoulder in the form of arthroscopic procedure, results in satisfactory improvement of all outcome measures in the majority of the patients. Together with low morbidity and early functional recovery, shoulder arthroscopy appears to be the procedure of choice in current surgical practice.

We believe that the self-assessment questionnaire represents a useful outcome measure and reflects the improvement in shoulder function as perceived by the patient.