Purpose: The purpose of this study was to assess the subjective, clinical and radiological improvement in patients with moderate to severe hallux rigidus undergoing Proximal Phalangeal Dorsomedial Closing-wedge Osteotomy with Cheilectomy.

Methods: Between March 2003 and November 2004, 17 patients (18 feet) underwent Proximal Phalangeal Dorsomedial Closing-wedge Osteotomy with Cheilectomy, 14 were available for clinical follow-up; pre and post-operative X-rays were available for all of them.

The Clinical assessment was based on modified American Orthopaedic Foot and Ankle Society’s hallux-metatarsophalangeal scale. The subjective assessment was done by a questionnaire and radiological assessment was done by using digital radiographs.

Results: Out of the 18 feet we studied, 1 was of Grade 1, 9 of Grade 2 and 8 of Grade 3. 12 out of 14 patients (85%) were satisfied with the outcome after an average follow-up period of 14 months. There was an increase in the Mean mAOFAS score of 49.6 (from a mean score of 26.2 to 75.8); the improvement in pain score was 27.4. With a mean osteotomy thickness of 1.78 mm, the proximal phalangeal length was decreased by a mean of 3.7mm. The medialization achieved in the men M1-P1 angle was 6.8 degrees. There was a highly significant gain of 25 degrees in Mean Dorsiflexion which cannot be explained by a mean increase of only 0.9 mm in the lateral dorsal joint space attributable to cheilectomy.

Conclusion: Dorsomedial Proximal Phalangeal Closing-wedge Osteotomy combined with Cheilectomy gives good subjective and clinical results regarding satisfaction, pain relief and gain in dorsiflexion; at least in the short-term. This gain in movement might be explainable by an improved EHL lever-arm resulting from dorsome-dial nature of the phalangeal osteotomy.

Interventional MRI provides a novel non-invasive method of in-vivo weight-bearing analysis of the talo-calcaneal joint. Six healthy males (mean 28.8 years) underwent static right foot weight bearing MRI imaging at 0o, 15o inversion, and eversion. Using known radiological markers the motion of the talus and calcaneum were analysed.

The calcaneum externally rotates, plantar-flexes and angulates into varus. The talus shows greater plantarflexion with similar varus angulation, with variable axial rotation. Relative talo-calcaneal motion thus involves, 6o relative talar internal rotation, 3.2o flexion and no motion in the frontal plane. Concurrently the talus moves laterally on the calcaneum, by 6.5mm, with variable translations in other planes.

The calcaneum plantar-flexes, undergoes valgus angulation, and shows variable rotation in the axial plane. The talus plantar-flexes less, externally rotates, and shifts into varus. Relative motion in the axial and saggital plane reverses rotations seen during inversion. The 8o of relative valgus talo-calcaneal angulation is achieved through considerable varus angulation of the talus, in a direction opposite to the input motion. This phenomenon has not been previously reported. From coronal MRI data, comparative talo-calcaneal motion in inversion is prevented by high bony congruity, whereas during eversion, the taut posterior tibio-talar ligament appears to prevent talar valgus angulation.

We have demonstrated that Interventional MRI scanning is a valuable tool in analysing the weight-bearing motion of the talo-calcaneal joint, whilst approaching the diagnostic accuracy of stereophotogammetry. We have also demonstrated consistent unexpected talar motion in the frontal plane. Talo-calcaneal motion is highly complex involving simultaneous rotation and translation, and hence calculations of instantaneous axes of rotation cannot effectively describe talo-calca-neal motion. We would suggest that relating individual and relative motion of the talus / calcaneum better describes subtalar kinematics.

Background: Interventional MRI provides a novel non-invasive method of in-vivo weight-bearing analysis of the subtalar joint. Preceding in-vivo experimentation with stereophotogammetry of volunteers embedded with tantalum beads has produced valuable data on relative talo-calcaneal motion (Lundberg et al. 1989). However the independent motion of each bone remains unanswered.

Materials and Methods: Six healthy males (mean 28.8 years), with no previous foot pathology, underwent static right foot weight bearing MRI imaging at 0°, 15° inversion, and 15° eversion. Using identifiable radiological markers the absolute and relative rotational and translational motion of the talus and calcaneum were analysed.

Results and Discussion: Inversion: The calcaneum externally rotates, plantar-flexes and angulates into varus. The talus shows greater plantar-flexion with similar varus angulation, with variable axial rotation. Relative talo-calcaneal motion thus involves, 6° relative talar internal rotation, 3.2° flexion and no motion in the frontal plane. Concurrently the talus moves laterally on the calcaneum, by 6.5mm, with variable translations in other planes. This results in posterior facet gapping and riding up of the talus at its posterolateral prominence. Eversion: The calcaneum plantar-flexes, undergoes valgus angulation, and shows variable rotation in the axial plane. The talus plantar-flexes less, externally rotates, and shifts into varus. Relative motion in the axial plane reverses rotations seen during inversion (2.5° talar external rotation). The 8° of relative valgus talo-calcaneal angulation is achieved consistently through considerable varus angulation of the talus, in a direction opposite to the input motion. This phenomenon has not been previously reported. From coronal MRI data, comparative talo-calcaneal motion in inversion is prevented by high bony congruity, whereas during eversion, the taut posterior tibio-talar ligament prevents talar valgus angulation.

Conclusion: We have demonstrated that Interventional MRI scanning is a valuable tool to analysing the weight bearing motion of the talo-calcaneal joint, whilst approaching the diagnostic accuracy of stereophoto-gammetry. We have also demonstrated consistent unexpected talar motion in the frontal plane. Talo-calcaneal motion is highly complex involving simultaneous rotation and translation, and hence calculations of instantaneous axes of rotation cannot effectively describe talo-calcaneal motion. We would suggest that relating individual and relative motion of the talus / calcaneum better describes subtalar kinematics.

Aims: To study whether re-transfusion of autologus blood from solcotrans drains reduced banked blood transfusion requirement in primary total knee arthroplasty (TKR). Methods: 195 patients with unilateral primary TKR using the same surgical technique and implants were prospectively reviewed. Group 1: In 120 cases, solcotrans drain system used for postoperative blood salvage and reinfusion. Group 2: 75 cases had standard redivac drains. Homologous blood transfusions used if post-operative haemoglobin < 9 gm. Factors like weight and height, and pre-operative haemoglobin levels were also studied. Results: Group 1: Average blood loss: 598 ml. 88 cases (71%) had reinfusion of autologous salvaged blood, average re-transfusion: 271 ml (range: 200 Ð 1160 ml). In 29% (32 cases), there was not enough blood in solcotrans drains for re-transfusion. 29 patients (23%) required banked blood transfusion in whom average blood loss was 720 ml, average number of units transfused: 1.6. In 10 of the 29 cases, there was not enough blood in solcotrans drains for re-transfusion. Group 2: Average blood loss: 588 ml. 20 cases (26%) required banked blood transfusion in whom average blood loss was 758 ml. Average number of units transfused: 1.9. Conclusions: In our study, solcotrans system did not reduce the requirement of banked blood transfusion signiþcantly in TKR. In both groups, low levels of preop-erative haemoglobin, low weight and amount of blood loss inßuenced banked blood requirement (p< 0.05).

Aims: To study functional outcome and survivorship of custom designed knee implants for primary and revision TKR where off-the-shelf prostheses were unsuitable. Methods: Clinical and radiological results of twenty-three custom-designed total knee prosthesis in twenty patients were prospectively reviewed. The indications were bone loss following multiple revisions of total knee prosthesis and debridement for infection, periprosthetic fractures, bone deformity with rickets and small bones with juvenile chronic arthritis. All implants designed and manufactured at Centre for Biomedical Engineering, Stanmore, U.K. Four different designs of knee prosthesis used: Condylar knee of miniature size, CAD-CAM knee, Superstabiliser and Rotating Hinges. Hospital for Special Surgery (HSS) score taken preoperatively, at 3 months, and yearly by an independent research physiotherapist. Duration of follow up: 62.5 months (28–126 months) Results: Average HSS score improved from 13.5 points (range 0–48) pre-operatively to 86.5 points postoperatively (range 62–96) (p=0.025). Average maximum flexion post operatively: 86.4° (range 60°–122°). Sixteen knees had excellent, five good and two poor results. Extension lag of 15°–25° in three patients. One patient with juvenile chronic arthritis needed revision at five years after index arthroplasty. Conclusions: Clinical and radiological results for custom designed prostheses compare favourably with standard knee prosthesis for similar indications. Our results support the use of a custom designed knee implant as salvage prosthesis and also as an alternative to arthrodesis or amputation.

Clinical investigations and tests need to be validated by studying their inter-observer and intra-observer errors, but there has been no documentation of such verification in diagnostic knee arthroscopy. We performed a prospective study to find out to what extent the findings in knee arthroscopy differ between two different surgeons.

Two senior specialist registrars (M.S. and A.J.) who took part in this study worked with the senior author (ACW) for a period of eight and seven months respectively. A total of 78 knee arthroscopies admitted from routine waiting list were studied. The specialist registrar first performed arthroscopy when the supervising consultant stayed away from the operating room. His findings were recorded on a proforma by an independent third person before the consultant returned to the operating room and repeated the EUA and arthroscopy without prior knowledge of the trainee findings. Findings from the consultant arthroscopy were then recorded separately on the same proforma.

The following findings were recorded:

Examination under anaesthesia

The inter-observer variations in diagnostic knee arthroscopy were found to be high. Given the seniority and experience of the two trainee senior registrars involved in the study, and allowing for the Hawthorne effect, the results of the study cast doubt on this procedure being performed un-supervised. It also questions the validity of any therapeutic intervention based on the findings of un-supervised arthroscopies.

We carried out a prospective study in order to establish to what extent the intra-articular evaluation undertaken during arthroscopy of the knee differed between surgeons. Two senior specialist registrars and a consultant orthopaedic surgeon with a special interest in knee surgery were involved. A total of 78 knee arthroscopies (78 patients) was studied. Arthroscopy was first carried out by the trainee and then by the senior author (ACWH). The intra-articular evaluation during the arthroscopy was recorded independently by a third person in the operating theatre. Data were collected to record variations in examination under anaesthesia, the morphology and pathology of the menisci and anterior cruciate ligament and the state of the articular surfaces.

The overall interobserver variation was 20% in all categories. We question the published results of intra-articular evaluation during knee arthroscopy when surgeons of different levels of experience are involved in a single study.