Objectives

Cartiva synthetic cartilage implant (SCI) is licenced for use in management of symptomatic hallux rigidus in several countries including the UK. As for now, there are no independent comparative series for treatment of hallux rigidus utilising polyvinyl alcohol implants.

Introduction

With an aging population, the prevalence of fragility ankle fractures is rising. The surgical management of these injuries is challenging and associated with high rates of complications. The incidence of fragility ankle fractures is currently estimated to be around 150 per 100,000 people annually and is anticipated to rise to around 269 per 100,000 by 2030. The aim of surgery is to restore mobility, preserve function and to prevent complications related to non-weight-bearing and the application of hind foot nail (HFN) seems to provide these advantages. This systematic review aims to investigate the role of HFN in the treatment of fragility ankle fractures. We aim to review the available evidence published on the functional recovery observed in patients following treatment with HFN and the observed complications in the literature.

Introduction

We aimed to determine whether there are differences in patient-reported quality of life (QoL) outcome between local flap versus free flap.

Introduction

Management of open fractures is challenging and requires a multidisciplinary team approach. Gustilo Anderson Type IIIB fractures reportedly have a higher infection rate (up to 52%) and up to 16% amputation rate. This study aims to evaluate outcomes of using Adjuvant Local Antibiotic Hydroxyapatite Bio-Composite in management of Open Gustilo-Anderson IIIB fractures.

Background

The viability of any surgical practice relies on the income that practice generates for the parent NHS Trust. The OPCS codes are a key determinant of an NHS trust's tariff for an admission. These contribute to the HRG codes - the means the NHS uses to determine the value of a patient's treatment, including operations. The clinical knowledge of coders may not differentiate specialist practice, including circular frames.

Introduction

The conservative management of stable Weber B fibula fractures remains variable. We thought that the current trend in our institution poses an unnecessary burden on fracture clinics.

Aim

To evaluate the clinical outcome of a new absorbable, gentamycin loaded calcium sulfate/hydroxyapatite biocomposite (CERAMENT^™/G) as cavity filler after debridement and removal of infected metalwork in chronic osteomyelitis.

Background

Reduced bone mineral density is recognised as a risk factor for hip fractures and fragility fractures in general. Vitamin D is important in maintaining healthy bone mineral levels and can therefore affect risk of hip fracture. We investigated the correlation between vitamin D levels and bone mineral density, as well as fracture type, in neck of femur fractures and also assessed the relationship of vitamin D and social deprivation.

Background

Patient reported outcomes/experience measures have been a fundamental part of the NHS since 2009. Osteotomy procedures for hallux valgus produce varied outcomes due to their subjective nature. We used PROMS2.0, a semi-automated web-based system, which allows collection and analysis of outcome data, to assess what the patient reported outcome/experience measures for scarf+/− akin osteotomy for hallux valgus are at UHSM.

Background

PROMS and PREMS are a fundamental and essential part of the NHS. Chilectomy and fusion procedures for hallux rigidus produce varied outcomes due to their subjective nature. PROMS2.0, a semi-automated web-based system, which allows collection and analysis of outcome data, to compare what PROMS/PREMS for chilectomy/fusion for hallux rigidus are at UHSM including variance across osteoarthritis grades.

Background

Patient reported outcomes measures are a fundamental part of the NHS. Since 2009, they have been used to measure quality from the patient's perspective. PROMS2.0 is a semi-automated web based system, which allows collection and analysis of outcome data. This study looks at the factors, which can influence PROMS. These include looking at general trends which affect reported outcomes such as surgeon, age and gender. We also look to assess the reasons for non-uptake in the study.

We describe a case series using calcium sulphate bio composite with antibiotics (Cerament/Stimulan) in treating infected metalwork in the lower limb.

Eight patients aged 22–74 (7 males, 1 female) presented with clinical evidence of infected limb metal work from previous orthopaedic surgery. Metal work removal with application of either cerement in 5 cases (10–20ml including 175mg–350mg gentamycin) or stimulan in 3 cases (10–20ml including either 1g vancomycin or clindamycin 1.2g or 100mg tigecycline) into the site was performed. Supplemental systemic antibiotic therapy (oral/intravenous) was instituted based on intraoperative tissue culture and sensitivity.

Four patients had infected ankle metalwork, 2 patients infected distal tibial metalwork and 2 had infected external fixators. Metal work was removed in all cases. The mean pre operative CRP was 15.8mg/l (range 1–56mg/l). The mean postoperative CRP at 1 month was 20.5mg/l (range 2–98mg/l). The mean pre op WCC was 7.9×10⁹(range 4.7–10.5 ×10⁹). Mean post op WCC at 1 month was 7.1×10⁹(range 5.0–9.2×10⁹). The organisms cultured included enterobacter, staphylococcus aureus, staphylococcus epidermidis, staphylococcus cohnii, stenotrophomonas, acinetobacter, group B streptococcus, enterococcus and escherichia coli. No additional procedures were required in any case. All surgical wounds went on to heal uneventfully. Infection control and union was achieved both clinically and radiologically in all cases.

Our results support the use of a calcium sulphate bio composite with antibiotic as an adjuvant for effective local infection control in cases with implant related bone sepsis. The technique is well tolerated with no systemic or local side effects. We believe that implant removal, debridement and local antibiotic delivery can minimise the need for prolonged systemic antibiotic therapy in such cases.

Background

Cheilectomy and arthrodesis are accepted procedures for symptomatic hallux rigidus. Although good functional outcomes have been reported, there is little data available on post-operative sporting ability for these patients.

Aim

We describe a case series using adjuvant calcium sulphate bio composites with antibiotics in treating infected metalwork in the foot and ankle.

Background

Patient reported outcome and experience measures have been a fundamental part of the NHS. We used PROMS2.0, a semi-automated web-based system, which allows collection and analysis of outcome data, to assess the patient reported outcome/experience measures for scarf+/− akin osteotomy for hallux valgus.

Introduction:

PREMS and PROMS are part of the national initiative of the DoH. They measure quality from patient perspective and also help patient choice. We present our pioneering experience of PROMS 2.0 which is a semi automated web based system to collect and analyse outcome data in real time.

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. Its effect on sesamoid function and the pathomechanics of this joint have not been described.

Fresh frozen cadaveric specimens without evidence of forefoot deformity were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in various positions of dorsiflexion and plantarflexion using a MicroScribe, enabling quantitative analyses in a virtual 3D environment.

In 75% of specimens, there was some degree of chondral loss within the metatarsosesamoid articulation. The metatarsal surface was more commonly affected. These changes most frequently involved the tibial metatarsosesamoid joint.

The tibial sesamoid had an average excursion of 14.2 mm in the sagittal plane when the 1st MTP joint was moved from 10 degrees of plantarflexion to 60 degrees of dorsiflexion; the average excursion of the fibular sesamoid was 8.7 mm. The sesamoids also move in a medial to lateral fashion when the joint was dorsiflexed. The excursion of the tibial sesamoid was 2.8 mm when the joint was maximally dorsiflexed while that of the fibular sesamoid was 3.2 mm.

There appears to be differential tracking of the hallucal sesamoids. The tibial sesamoid has comparatively increased longitudinal excursion whilst the fibular sesamoid has comparatively greater lateral excursion.

This greater excursion of the tibial sesamoid could explain the higher incidence of sesamoiditis in this bone. The differential excursion of the 2 metatarsosesamoid articulations is also a factor that should be considered in the design and mechanics of an effective hallux MTP joint arthroplasty.

Introduction

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints.

Plantar fasciitis is thought to be a self limiting condition best treated by conservative measures, but despite this many patients have a prolonged duration of symptoms and for some surgery may be indicated. Partial plantar fascial release is reported to have a short term success rate of up 80%, but anecdotally this was not thought to represent local experience.

An audit of long term patient reported outcomes following surgery was performed. A total of 26 patients (29 feet) were identified retrospectively and case notes were reviewed for each patient. Patients were contacted by letter and invited to complete two validated patient reported outcome score questionnaires (foot and ankle visual analogue scale (VAS) and MOXFQ).

The average age of the patients was 42.4(range 28–61) for males and 46.2 (range 33–60) for female patients, with a female:male ratio of 2.7:1. Preoperative treatments included orthotics (29), steroid injections (23), physiotherapy (21) and cast immobilisation (11). The average duration of treatment prior to surgical intervention was 3.1 years (range 1–5). All patients were reviewed post operatively and discharged from follow up at an average of 31 weeks, at which time 38% remained symptomatic.

We conclude that the results from open partial plantar fascial release are poor and it is a technique of dubious clinical value.

Introduction

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints.

Introduction

Peroneal tendon subluxation & dislocation is a rare phenomenon. It is a commonly misdiagnosed cause of lateral ankle pain and instability.

Introduction

The exact action of the Peroneus Longus muscle on the foot is not fully understood. It is involved in a number of pathological processes like tendonitis, tenosynovitis, chronic rupture and neurological conditions. It is described as having a consistent insertion to the base of the first metatarsal, but there have also been reports of significant variations and additional slips. Our aim was to further clarify the anatomy of the main insertion of the Peroneus Longus tendon and to describe the site and frequency of other variable insertion slips.

The patella is a complex sesamoid bone within the quadriceps enhancing mechanical advantage of the extensor mechanism. Depending on activity, the patella magnifies either force or displacement; behaving as a lever, by redirecting quadriceps force it also acts as a pulley.

Peroneal tendon subluxation although rare, is a commonly misdiagnosed cause of lateral ankle pain and instability. The orientation and depth of the lateral retromalleolar groove is a major contributor to peroneal stability, but is little understood. We attempt to quantify the groove using three directional mapping techniques.

Eight age and sex matched embalmed cadaveric feet were dissected to expose the peroneal tendons and the retromalleolar groove. A hand held digitiser was used to map the version and inclination of the groove in a 3D virtual environment. The length and depth of the groove and its orientation were calculated using the cartilage boundary and the centroid of the curved surface.

Four male and four female specimens (mean age 80 Yrs) were studied. The groove was noted to be concave in 62%, flat in 25 % and concave in 12.5 %. Flatter groove were more commonly noted in (2/4) females. There was a significant difference in length and width of the groove between male and female feet. The mean length of the groove in male specimens was 6.2cm (5.4–6.7cm), and in female specimens 5.5cm (4.4–5.9cm). The mean width in males was 5.3mm (5.0–6.1mm) and in females 4.5mm (3.7–5.3mm). There was no significant difference noted in the depth of the groove between male and female feet. The mean depth in males was 2.3mm (0.8–3.1) and in female 2.2mm (0–2.4mm).

Knowledge of peroneal groove geometry in treatment of peroneal tendon instability is important. There appears to be a consistent difference in the anatomy of the groove between the sexes. Although men have longer and wider grooves than woman, the depth is the same in both sexes.

Introduction

There is a need for a standardised guideline to assist in optimal decision-making in diabetics who have acquired an ankle fracture. Through a critical analysis of the literature, a diagnostic and management algorithm that incorporates a quantitative scoring system is proposed and presented for consideration.

Our unit has pursued a policy of using donor nerves from the same limb for grafting. Nerves which have already been affected by the primary injury are selected where possible, thus avoiding any new sensory deficit.

36 of the 41 brachial plexus repairs were available for outcome data collected prospectively over 2 years. Over a nine year period, donor nerves used for the 41 brachial plexus repairs included the lateral cutaneous nerve of the forearm, superficial radial, medial cutaneous of the forearm, ulnar and sural nerves. Patients were grouped into having injured nerve grafts only (A), injured and uninjured nerve grafts (B) and uninjured nerve grafts. The repaired brachial plexus nerves were assessed by measuring the MRC grading of the power of movement of the muscle innervated by that nerve (i.e. elbow flexion for musculocutaneous nerve). These were graded as good (MRC grading 3 or better), fair (MRC grade 1 or 2), or poor (MRC 0).

The greatest success for nerve grafting was elbow flexion with good results in 22 out of 27 assessments. Using Mann-Whitney test, Group A had significantly better results (p=0.025) than group C. However, ignoring the poorer results of shoulder abduction there was no significant difference between all 3 groups of patients.

We conclude that using injured nerve grafts taken distal to the lesion in the brachial plexus is as effective as using nerve material from an uninjured limb.

Our unit has pursued a policy of using donor nerves from the same limb for grafting. Nerves which have already been affected by the primary injury are selected where possible, thus avoiding any new sensory deficit.

The exact action of the Peroneus Longus muscle on the foot is not fully understood. It is involved in a number of pathological processes like tendonitis, tenosynovitis, chronic rupture and neurological conditions. It is described as having a consistent insertion to the base of the first metatarsal, but there have also been reports of significant variations and additional slips.

Our aim was to further clarify the anatomy of the main insertion of the Peroneus Longus tendon and to describe the site and frequency of other variable insertion slips.

The course of the distal peroneus longus tendon and its variable insertion was dissected in 20 embalmed, cadaveric specimens. The surface area of the main insertion footprint was measured using an Immersion Digital Microscibe and 3D mapping software. The site and frequency of the other variable insertion slips is presented.

There was a consistent, main insertion to the infero-lateral aspect of the first metatarsal in all specimens. The surface area of this insertion was found to be proportional to the length of the foot. The insertion in males was found to be significantly larger than females. The most frequent additional slip was to the medial cuneiform. Other less frequent insertion slips were present to the lesser metatarsals.

The main footprint of the Peroneus Longus tendon is on the first metatarsal. There appears to an additional slip to the medial cuneiform frequently. Although we are unsure about the significance of these additional slips, we hope it will lead to a better understanding of the mechanism of action of this muscle and its role both in the normal and pathological foot.

Regional anaesthetic for foot surgery has been discussed as a method of post operative analgesia. Ankle block as the sole anaesthetic for foot surgery has not been extensively reviewed in the literature. We aimed to describe our experience of forefoot surgery under ankle block.

Sixty-six consecutive forefoot procedures (59 patients) were carried out under ankle block. Patients were contacted post operatively and completed a standardised questionnaire including an incremental pain assessment ranging from 0-10 (0 no pain, 10 severe pain).

Forty nine female and 10 male patients (age range 20-85y) were included. Procedures included 33 first metatarsal osteotomies, 15 cheilectomies, 3 first MTP joint replacements, 5 fusions, 4 excision of neuroma and 6 other procedures. 22 patients (33% of cases) reported discomfort during the block procedure (average pain score 1.5). 6 patients reported pain during their operation(s), average score 0.26. Average pain scores at 6, 12, 24 and 48 hours following surgery were 2.0, 3.2, 2.7 and 2.1 respectively. All patients were discharged home and walking on the same day. There were no readmissions. Each patient confirmed they would have surgery under regional block rather than general anaesthesia and would recommend this technique to family and friends.

There are many advantages in being able to perform these relatively small procedures under regional anaesthesia. The anaesthesia obtained permits the majority of forefoot procedures and provides lasting post-operative analgesia. Combined with intra-operative sedation, use of ankle tourniquet and same day discharge; it has very high patient acceptance and satisfaction.

Background

Talar neck fractures occur infrequently and are associated with high complication rates. Anatomical restoration of articular congruity is important. Adequate exposure and stable internal fixation of these fractures are challenging.

Regional anaesthetic for foot surgery has been discussed as a method of post operative analgesia. Ankle block as the sole anaesthetic for foot surgery has not been extensively reviewed in the literature.

Advantages of arthroscopic surgery in orthopaedic practice are well documented. The use and scope of ankle arthroscopy has evolved in the last decade. Its role in both the evaluation and treatment of chronic ankle pain has become more important with identification of newer pathologies. We aimed to identify the indications and complications of ankle arthroscopy in chronic ankle pain and to correlate the arthroscopic findings with pre-operative MRI/CT.

A retrospective analysis of all procedures done in our unit from 2005-2009. Patient records, X- rays and scans were reviewed. 77 patients were included in the study (46 male/31 female). The commonest age group was the 4^th decade. There was a male preponderance in the younger age group (<50y), and a female preponderance in the older age groups (>50y). The commonest indication was impingement syndrome (44%/mean age 38y), followed by osteochondral lesions of the talus (23%/mean age 36y) and Osteoarthritis (22%/mean age56y). Other pathology included synovitis, Rheumatoid Arthritis, instability, AVN and combined pathologies. Pre-op MRI scans correlated with arthroscopic findings in 59%. The pathology most missed by MRI was impingement. 1 patient developed wound infection and another iatrogenic tendon rupture. 78% reported improvement in their symptoms following the procedure.

Ankle arthroscopy is a safe and effective procedure. It is particularly useful in the diagnosis and treatment of impingement syndromes and osteochondral lesions. Although there are serious recognised complications, their incidence is low. Patients with chronic symptoms and normal MRI/CT may have treatable pathology on arthroscopy.

Bizarre parosteal osteochondromatous proliferation (BPOP) is a benign lesion of bone originally described by Nora et al in 1983. To date there are no UK-based case series in the literature. Here we present the Scottish Bone Tumour Registry (SBTR) experience of this rare lesion.

A retrospective analysis of SBTR records was performed. Histological specimens were re-examined by a consultant musculoskeletal oncology pathologist. Radiographs were re-reported by a consultant musculoskeletal radiologist. From 1983-2009, 13 cases were identified; 6 male, 7 female. Age ranged from 13-65. All patients presented with localised swelling. Pain was present in 5 and trauma in 2. 9 lesions affected the hand, 3 the foot, and 1 the tibial tuberosity. 12 lesions were excised and 1 curetted. There were 7 recurrences of which 6 were excised. 1 patients' recurrence was not treated. 1 lesion recurred a second time. This was excised. There were no metastases. Radiographs typically showed densely mineralised lesions contiguous with an uninvolved cortex. Cortical breakthrough was present in 1 case and scalloping in another. Histology characteristically showed hypercellular cartilage with pleomorphism and calcification/ossification without atypia; bone undergoing maturation; and a spindle-cell stroma.

SBTR records indicate that BPOP is a rare lesion with no sex predilection that affects patients over a wide age range. Minor antecedent trauma was present in only 2 cases. In agreement with Nora et al. we feel that trauma is unlikely to represent an aetiological factor. Recurrence was over 50% in this series. Although this is similar to that found in other reports, it may indicate that more extensive resection is required for this aggressive lesion. Finally, although radiological/histological findings are often bizarre there have been no reported metastases and so it is important that BPOP is not mistaken for, or treated as, a malignant process such as chondrosarcoma.

Regional anaesthetic for foot surgery has been discussed as a method of post operative analgesia. Ankle block as the sole anaesthetic for foot surgery has not been extensively reviewed in the literature.

We aimed to describe our experience of forefoot surgery under ankle block alone. 21 consecutive forefoot procedures (18 patients) were carried out under ankle block. The blocks were performed by the senior authors. A mixture of 10ml 2% Lidocaine with 10ml 0.5 % Bupivacaine was administered to the superficial peroneal, deep peroneal, sural and saphenous nerves. Ankle tourniquet was employed in all procedures. The patients were contacted post operatively and completed a standardised questionnaire including an incremented pain assessment ranging from 0-10 (0 no pain, 10 severe pain). 17 female and 1 male patients were contacted (age range 33-67y). Procedures included 13 first metatarsal osteotomies, 3 cheilectomies, 2 first MTP joint replacements, and 5 fusions. 14 patients requested a short acting sedative (midazolam). 5 patients (27 %) reported some discomfort during the block procedure (average pain score 1.2). No patients reported any pain during their operation(s). 4 patients (22%) required supplementation of the block. Average pain score at 6, 12, 24 and 48 hours following surgery were 0.66, 2.9, 2.4 and 1.3 respectively. All patients were discharged home and walking on the same day. None complained of nausea or required parenteral analgesia; there were no readmissions. Each patient confirmed they would have surgery under local block rather than general anaesthesia and would recommend this technique to family and friends.

Forefoot surgery under ankle block alone is safe and effective. Anaesthesia obtained permits the majority of forefoot procedures and provides lasting post-operative analgesia. Combined with intraoperative sedation, use of ankle tourniquet and same day discharge, it has very high patient acceptance and satisfaction.

The extended lateral approach offers a safe surgical approach in the fixation of calcaneal fractures. Lateral plating of the calcaneum could put structures on the medial side at risk. The aim was to identify structures at risk on the medial side of the calcaneum from wires, drills or screws passed from lateral to medial.

Ten embalmed cadaveric feet were dissected. A standard extended lateral approach was performed. The DePuy perimeter plate was first applied and 2mm K-wires were drilled through each of the holes. The medial side was now examined to determine the structures at risk through each hole. The process was repeated with the Stryker plate. The calcaneum was divided into 6 zones, by two vertical lines, from the margins of the posterior facet and a transverse line along the axis of the bone through the highest point of the peroneal tubercle.

The DePuy and the Stryker plates have 12 screw positions, 5 of which are common. With both systems, screw positions in zone 1 risk injury to the medial plantar nerve and zone 3 the lateral plantar nerve. A screw through zone 2 compromises the medial plantar in both. Screws through zone 4 risk the lateral plantar nerve with the DePuy plate. Screws through zone 5 of the DePuy plate risk the medial calcaneal nerve. Zone 5 of the Stryker plate and Zone 6 of both are safe.

There is significant risk to medial structures from laterally placed wires, drills or screws. Subtalar screws have the highest risk and have to be carefully measured and placed. The Stryker plating system is relatively safer than the DePuy perimeter plate with three safe zones out of six.

The role of digital radiography has evolved in recent years. In many hospitals, radiographs have been completely digitised and moved to Picture Archiving and Communications System (PACS). Pre-operative templating for arthroplasty has been a major problem as a result.

We investigate the accuracy of Orthoview™ software in templating for hip and knee arthroplasty. A retrospective review of 20 Stryker-Exter hip and 20 Biomet-Vanguard knee arthroplasties was conducted. Anonymised preoperative radiographs were reviewed by experienced orthopaedic surgeons. Templated component sizes were compared with actual implanted component sizes. All radiographs were digitised on Kodak Carestream PACS. Five surgeons were asked to separately review the radiographs to avoid intra-observer error.

In templating for hip arthroplasty, Orthoview™ was 80% accurate in predicting the femoral stem size within one size of the actual component used. It predicted the offset with 100% accuracy. In 90% of patients, the actual head implant was within one size of the templated head. The system was able to predict the acetabular component size in only 30%. In knee arthroplasty, Orthoview™ was 80% accurate within one size of the actual component used for the femur and 90% for the tibia.

Orthoview™ enables the flexibility of digitised films to be used for pre-operative templating. It is reasonably accurate in prediction of femoral sizing in both hip and knee arthroplasty and tibial size in knee arthroplasty. It is considerably less useful for acetabular sizing. Surgeons should keep this variability in mind until more accurate systems are available.

A consensus regarding management of calcaneal fractures eludes orthopaedic surgeons. While operative treatment has gained more acceptance, surgical morbidity remains high. We undertook a retrospective review of early complications and radiological outcomes following internal fixation of calcaneal fractures in our unit over 15 months.

A consecutive series of 33 patients who underwent fixation of the Calcaneus was selected. Patient records, X-rays and scans were reviewed.

37 fractures in 33 patients underwent fixation. 81 % were male. Mean age at surgery was 37yrs (19 -59yrs). 35 % were operated within 1 wk of injury and 13% after 2 wks of injury. 43% were Sanders' type III, 18% type II and 13% tuberosity avulsion fractures. 63% had a reversed/zero Bohler's angle. Mean post-op Bohler's angle was 32 degrees. Overall complication rate was 32%, with a combined deep infection rate of 8%. All patients with infection were male, and 70% were smokers. 86% were above 40yrs of age (mean 47yrs). The deep infection rate for intra-articular fractures was 3% and for tuberosity avulsion fractures 40%. Majority of patients with wound complications had been operated within 7 days of injury.

Males over 40yrs and smokers seem to be at most risk of wound complications. Time to surgery/delay in surgery up to 2 wks did not seem to have any adverse consequences. Complications increase with fracture complexity and avulsion fractures have highest risk of wound breakdown. Near anatomical restoration of the articular surface is possible in most.

Talar neck fractures are associated with high complication rates with significant associated morbidity. Adequate exposure and stable internal fixation remains challenging. We investigated the anterior extensile approach for exposure of these fractures and their fixation by screws introduced through the talo-navicular articulation. We also compared the quality and quantity of exposure of the talar neck obtained by this approach, with the classically described medial/lateral approaches.

An anterior approach to the talus between the tibialis anterior and the extensor hallucis tendons protecting both the superficial and deep peroneal nerves was performed on 5 fresh frozen cadaveric ankles . The surface area of talar neck accessible was measured using an Immersion Digital Microscribe and analysed with Rhinoceros 3D graphics package. Standard antero-medial and antero –lateral approaches were also carried out on the same ankles, and similar measurements taken. Seven talar neck fractures underwent operative fixation using the anterior approach with parallel cannulated screws inserted through the talo-navicular joint.

3D mapping demonstrated that the talar surface area visible by the anterior approach (mean 1200sqmm) is consistently superior to that visible by either the medial or lateral approaches in isolation or in combination. Medial malleolar osteotomy does not offer any additional visualisation of the talar neck. 3D reconstruction of the area visualised by the three approaches confirms that the anterior approach provides superior access to the entirety of the talar neck. 5 male and 2 female patients were reviewed. All had anatomical articular restoration, and no wound problems. None developed non union or AVN.

The anterior extensile approach offers superior visualisation of the talar neck in comparison to other approaches for anatomical articular restoration. We argue that this approach is safe, adequate and causes less vascular disruption.

Background: The role of digital radiography has evolved consistently over the last decade. In many European hospitals, radiographs have been completely digitised and have moved to Picture Archiving and Communications System (PACS). Pre-operative templating for arthroplasty has been a major problem with using the system.

Aims: We investigate the accuracy of the OrthoviewTM software in templating for hip and knee arthroplasty.

Methods: A retrospective review of 20 Stryker-Exter hip and 20 Biomet- Vanguard knee arthroplasties were carried out. Anonymised preoperative radiographs were reviewed by experienced orthopaedic surgeons blinded to the purpose of the study. Templated component sizes were compared with actual implant sizes used at surgery. All radiographs were digitised on Kodak Car-estream PACS. Five surgeons were asked to separately review the radiographs to avoid intra-observer error.

Results: In templating for hip arthroplasty, Orthoview TM was 80% accurate in predicting the femoral stem size within one size of the actual component used. It also predicted the offset with 100% accuracy. In 90% of the patients, the actual head implant was within one size of the templated head. The system was able to predict the acetabular component size in only 30%. In knee arthroplasty, OrthoviewTM was 80% accurate within one size of the actual component used for the femur and 90% for the tibia.

Discussion: Digital radiographs have several well documented advantages over traditional radiographs. Orthoview TM enables the flexibility of digitised films to be used for pre-operative templating. It is reasonably accurate in prediction of femoral component size in both hip and knee arthroplasty and tibial size in knee arthroplasty. It is considerably less useful for acetabular sizing. Surgeons have to keep this variability in mind until more accurate systems are available.

Background: The Calcaneus is the largest of the tarsal bones. 2% of all adult and 60 % of all tarsal fractures involve the Calcaneus. A true consensus regarding the management of these fractures still eludes orthopaedic surgeons. While operative treatment for displaced fractures has gained more acceptance in the last decade, surgical morbidity still remains high.

Aim: A retrospective review of the early complications and radiological outcomes following open reduction and internal fixation of displaced calcaneal fractures in our unit over the last 15 months.

Methods: A consecutive series of 33 patients who underwent surgical fixation of the Calcaneus was selected. Patient records, X rays and scans were reviewed. Mode and nature of injury, life style factors, surgical complications and Bohler’s angles were analysed.

Results: 37 fractures in 33 patients underwent operative fixation. 81 % were male. Mean age at surgery was 37yrs (range19–59). 35 % were operated within 1 week of the injury and 13% after 2 weeks of injury. 43% were Sanders’ type III, 18% type II and 13% tuberosity avulsion fractures. 63% of patients had a reversed or zero Bohler’s angle. Mean post-op Bohler’s angle was 32 degrees. Overall complication rate was 32%, with a combined deep infection rate of 8%. All patients with infection were male, and 70% were smokers. 86% were above 40yrs of age (mean 47yrs). The deep infection rate for intra-articular fractures was 3% and for tuberosity avulsion fractures 40%. Majority of patients with wound complications had been operated within 7 days of injury. 4 patients had persisting pain requiring removal of metal work.

Discussion: Our study highlights that there are significant risks associated with operative management of calcaneal fractures. Male patients over the age of 40yrs who are smokers seem to be at most risk of wound complications. Time to surgery or delay in surgery up to 2 weeks did not seem to have any adverse consequences. Complications increase with fracture complexity, and avulsion fractures have a high risk of wound breakdown. Near anatomical restoration of the articular surface is possible in most cases.

Introduction: Bizarre parosteal osteochondromatous proliferation(BPOP) is a benign lesion of bone originally described by Nora et al in 1983. To date there are no UK-based case series in the literature. Here we present the Scottish Bone Tumour Registry(SBTR) experience of this rare lesion.

Method: A retrospective analysis of SBTR records was performed.

Histological specimens were re-examined by a consultant musculoskeletal oncology pathologist. Radiographs were re-reported by a consultant musculoskeletal radiologist.

Results: From 1983–2009, 13 cases were identified; 6 male, 7 female. Age ranged from 13–65.

All patients presented with localised swelling. Pain was present in 5 and trauma in 2.

9 lesions affected the hand, 3 the foot, and 1 the tibial tuberosity.

12 lesions were excised and 1 curetted. There were 7 recurrences of which 6 were excised. 1 patients’ recurrence was not treated. 1 lesion recurred a second time. This was excised. There were no metastases.

Radiographs typically showed densely mineralised lesions contiguous with an uninvolved cortex. Cortical breakthrough was present in 1 case and scalloping in another.

Histology characteristically showed: hypercellular cartilage with pleomorphism and alcification/ossification without atypia; bone undergoing maturation; and a spindle-cell stroma.

Discussion: SBTR records indicate that BPOP is a rare lesion with no sex predilection that affects patients over a wide age range.

Minor antecedent trauma was present in only 2 cases. In agreement with Nora et al. we feel that trauma is unlikely to represent an aetiological factor.

Recurrence was over 50% in this series. Although this is similar to that found in other reports, it may indicate that more extensive resection is required for this aggressive lesion.

Finally, although radiological/histological findings are often bizarre there have been no reported metastases and so it is important that BPOP is not mistaken for, or treated as, a malignant process such as chondrosarcoma.

Background: Selective ultrasound screening of neonatal hips with risk factors has been undertaken in Lanarkshire from 2001. Referral reasons included family history, breech, clicky hip and instability. Patients are examined by an orthopaedic surgeon with a special interest and scanned by static Graf technique. Our experience with selective screening and its effect on late DDH is presented.

Methods: All ultrasound screening data was collected prospectively and entered into a database. Late presenters were identified at the tertiary centre by case note and X ray review. Population data was obtained from the Scottish registry.

Results: Between 2001–2005, there were 30,824 live-births. 405 babies (910 hips) were identified as being at risk. 5(1.2%) were identified as Graf III/IV. Three responded to splinting, 1 required closed reduction and 1 open reduction. 11 who had initially normal scans were noted to have abnormal acetabular index (> 30) at 6 months. 2 required open reduction, 1 closed reduction and the rest eventually normalised with follow up. True late presentation was identified (> 3 months) in 11 children. Mean age at diagnosis was 14.7m (4–29 mts). 7(64%) did not have any identifiable risk factors. 4 had risk factors, but had escaped screening. 8 underwent open and 3 closed reduction. 7 derotation osteotomies and 1 pelvic osteotomy were additionally performed.

Discussion: The identifiable incidence of DDH in Lanarkshire is 0.87/1000. The incidence of true late presenting DDH in the same population was 0.35/1000. If all hips with risk factors had been successfully screened it would reduce to 0.22/1000. Selective screenings can minimise the incidence of late presenting DDH if rigorously implemented. Majority of late presenters do not have risk factors and are likely to escape detection with a selective screening programme. This suggests a different natural history in late presenting cases.

Background: DDH represents a spectrum of anatomical abnormalities in which the femoral head and the acetabulum are either in improper alignment or grow abnormally. Although screening leads to earlier identification, 60–80% of abnormal hips of newborns identified by physical examination resolve spontaneously by 2–8 weeks and 90% of the hips of newborns with mild dysplasia identified by ultrasound resolve spontaneously between 6 weeks and 6 months.

Aims: To assesses accuracy of ultrasound screening of neonatal hip by the static technique of Graf. We attempt to answer the question whether routine radiological follow up of these children are indicated.

Methods: Since 2001, we have performed selective ultrasound screening of over 600 neonates (1200 hips). The reasons for referral included, breech presentation, clicky hip, unstable hip, dislocation, foot deformity and family history of DDH. Clinical examination, followed by serial ultrasound examinations at presentation, 6 weeks and 3 months of age were carried out. A radiological examination and measurement of the acetabular index was performed at 6 months of age. Hips were classified according to the 4 Graf types. We compared the ultrasound findings with the acetabular index (AI) for individual patients.

Results: All children were followed up prospectively from presentation to discharge. For neonates without any family history of DDH and normal clinical examination (symmetrical skin creases, equal limb lengths, unrestricted abduction and no instability demonstrated on the Ortolani and Barlow manoeuvres) the ultrasound classification according to Graf co-related with the acetabular index on 6 month radiographs. 100% of hips with normal scan (Graf I) both at 6 weeks and at 3 months of age had a normal AI.

Discussion: The static technique of Graf is an accurate and reliable method of assessment of neonatal hips. In children with normal clinical examination, and no family history of dysplasia, scan findings are a good predictor of the AI. Routine radiological follow up in such patients is not necessary.

Background: Hip fracture is a serious injury mainly affecting the elderly population. The injury has a high mortality of 30% at 1 year and also has a major impact on the quality of life of the survivors. The Scottish Hip Fracture Audit has identified significant difference in the level of care provided in hip fractures between different hospitals and regions. The study aims to assess the impact of the experience of the operating surgeon on the long term outcome of hip fractures taking a cemented bipolar hip arthroplasty as an index procedure.

Materials and Methods: All patients who had the index procedure carried out over an eight year period at the Dumfries and Galloway Royal Infirmary were included in the study. Their preoperative mobility and health status along with the experience of the surgeon performing the procedure were determined. The outcome assessment was carried out using a modified Harris hip score.

Results: 46 patients were followed up at a mean of 45 months (range 16 to 109). One patient required a revision for aseptic loosening. Of the remaining, 18 procedures were carried out by consultant surgeons and 27 by trainees unsupervised. There was no statistical difference in the age, sex, ASA grade, preoperative mobility level or duration of follow up between the two groups of patients. The mean hip score at the time of follow up for the consultant group was 67.2 and 52.6 for the trainee group. This was statistically significant with a P value < 0.05.

Conclusion: The proportion of hip fracture surgeries done by, or under the direct supervision of a consultant orthopaedic surgeon vary widely between various Scottish hospitals (20% to 90%). The significant difference in long term out come of the procedure based on the surgeon’s experience calls for greater supervision and training of juniors.

Background: After Jules-Emile Pean and Neer, unconstrained prosthetic arthroplasty of the shoulder is widely used for glenohumeral osteoarthritis (OA), rheumatoid arthritis (RA) and trauma. While the debate continues over whether humeral head replacement (HHR) or total shoulder arthroplasty (TSR) is better for OA and RA, hemiarthroplasty is preferred in the trauma situation.

Aims: A retrospective review (1993–2000) of 54 patients with the DePuy Global second generation modular shoulder hemiarthroplasty is presented. We highlight the various complications encountered in the longer term and attempt to use our experience to rationalize treatment choice.

Methods: 49 shoulders in 41 patients were available for review. Case records and radiographs were reviewed and clinical assessment carried out. Functional assessment was done using the Constant (CM) and the American Shoulder and Elbow Society systems (ASES). Patients were also asked to complete a shoulder self assessment questionnaire (Insalata, Hospital for Special Surgery).

Results: The pre-op diagnosis was 20 RA, 12 OA, 11 trauma. The mean age was 63.4Yrs. The mean follow up was 6.8Yrs (4–11 Yrs). The mean Constant scores for the 3 groups were 48.1 RA, 46.3 OA, and 56.6 trauma. The mean ASES functional scores were 39.6 RA, 37.5 OA and 32.9 trauma. Active elevation in the RA group was a mean of 83.5°, and 69.5° for OA and 79° for the trauma group. 65% of the RA group was completely pain free compared to 50% and 54% in the OA and trauma groups respectively. Patient satisfaction was high in the RA and OA groups but poor in the trauma group. 90% of RA patients had evidence of superior migration of the prosthesis (ASM), with the majority of them developing cuff dysfunction. 36% of trauma patients had tuberosity escape/nonunion. 100% of OA patients developed late glenoid erosion. Presence of secondary glenoid arthrosis and ASM co-related with poor function (r =0.5, p< 0.05).

Discussion. Second generation prosthesis can prejudice the shoulder biomechanics. Over-tensioning the joint can lead to both glenoid wear and cuff rupture.

In OA patients, satisfaction was highest, but function was poor. Patients with out cuff tear pre-operatively did not develop it later. They may thus benefit from a TSR compared to HHR. RA patients had the least pain, best function and high satisfaction. Most had evidence of either primary or secondary cuff dysfunction. In them patients HHR may be the preferred option. Trauma patients did poorly in all respects. More anatomical reconstruction and greater emphasis on salvage of the humeral head is required in this group.

Introduction: Frozen shoulder is a general term denoting all causes of motion loss in the shoulder. As the syndrome is very common, many patients do not undergo detailed imaging studies before treatment.

Objectives: A series of 15 patients with primary neoplasms of the shoulder girdle mimicking frozen shoulder syndrome is presented.

Results: There were 6 male and 9 female patients. The common presentation was pain and stiffness of the shoulder joint. Mean age at diagnosis was 46.63Yrs (range 23 “ 71 Yrs). 73% were less than 50 Yrs of age. Only 2 gave history of trauma. Most received local steroids and physiotherapy before diagnosis. There were 10(66.6%) proximal humeral lesions and 5(33.3%) scapular lesions. Humeral lesions included chondrosarcoma (2), Ewing’s (2), lymphoma (2), chondroma (2) and osteoblastoma (1). Scapular lesions included chondrosarcoma (3), lymphoma (1) and fibromatosis (1). Scapular tumors involved older individuals. The mean delay in diagnosis after onset of symptoms was 15.8 mts (range 2 weeks- 48 months). All patients had X rays and CT / MRI. Treatment included a combination of surgery, chemotherapy and radiation. 3 patients with humeral lesions died at a mean of 20.6 mts, and 3 patients with scapular lesions died at a mean of 4.3 mts after diagnosis. The common cause of death was pulmonary metastasis.

Discussion: Many so called frozen shoulders are joints inhibited by pain rather than by true contracture. The commonest lesion to mimic a frozen shoulder is a slow growing low/middle grade chondrosarcoma. Young patients presenting with persistent pain or night pain must be examined for this possibility. Consideration should be given for further investigation before instituting treatment. Delay in diagnosis adversely affects survival. Surgeons are reminded that although rare, a tumor should be suspected when clinical presentations are unusual.

Introduction Ewing’s sarcoma family of tumors was first described by James Ewing in 1921. It is a rare tumor and no one center can hope to accrue sufficient numbers over a reasonable period of time to accurately review them.

Objectives A retrospective analysis of all Ewing’s sarcomas of the upper limb from the Scottish Bone Tumor registry (1940–2000), is presented. Attempts have been made to elaborate on prognostic factors, and to document improvements in survival with trends in local therapy over the study period.

Results The registry included 23 patients with Ewing’s sarcoma of the upper limb bones. Age at diagnosis ranged from 7–58 Yrs (mean −21.6 Yrs). 48% of lesions occurred in the second decade and 26 % in the third decade. Male: Female ratio was 2.8: 1. The commonest site involved was the proximal humerus (30%), followed by scapula (21%), radius (17%) and hand bones (13%).Resectable lesions underwent excision and adjuvant radio/chemo therapy. Cumulative 5 year survival for the series was 52%. Forearm and hand lesions which achieved complete excision had best results (75% five year survival). Proximal humeral lesions had 57 % survival. Scapular lesions had the worst prognosis (20% survival). Death was usually due to metastatic disease (diagnosed mean 12mts after initial presentation). Lesions presenting with pathological fractures, or having metastasis at diagnosis had extremely poor survival. There was an increasing use of surgery, and changes to chemotherapy (Euro-Ewing protocol) during the latter part of the study period. There were no toxic deaths reported.

Discussion Ewing’s sarcoma is a rare lesion. Any of the upper limb bones can be involved. Majority of lesions occur within the first 3 decades of life (87%). Survival is highly dependent on initial presentation. The key prognostic factor is the presence of detectable metastasis at diagnosis. Increased use of surgery and newer chemotherapeutic agents have decreased the local relapse rate over the period of study.

Background Osteosarcoma is the most common bone sarcoma, and the 3rd most common malignancy in children and adolescents. It accounts for 20% of primary malignant bone tumors.

Methods A retrospective review of osteosarcomas from the Scottish National Bone Tumor Registry (1940–2000) involving the upperlimb bones is presented. Patient demography, type and location of lesions, treatment options, recurrence and survival rates, and metastasis have been analysed.

Results 75 cases were identified from the registry. Sex incidence showed a slight male preponderance with male: female ratio 1.14: 1.Age at presentation ranged from 4–88 Yrs (mean 28.44 Yrs). 46.7% sarcomas occurred in the second decade (11–20 Yrs). The humerus was the bone most frequently involved (78.6% of lesions), and the proximal humerus the commonest site (60%). The scapula was involved in 9.3% and the forearm in 8%.A rare solitary lesion of the clavicle was encountered.17% presented with pathological fractures at diagnosis. Patients typically present with dull aching pain of weeks to months. All patients underwent radiological studies and diagnostic biopsy. Treatment modalities included amputation, limb-sparing surgery, adjuvant/neoadjuvant chemotherapy and radiotherapy. The cumulative 5 year survival for the series was 32%.Death was usually due to pulmonary and skeletal metastasis, and the mean survival in such patients was 21.5 mts. Patients presenting with metastatic pulmonary disease had poor prognosis. Limb-sparing surgery with wide margins does not compromise survival. Results with custom endoprosthesis are encouraging.

Discussion Osteosarcomas require a multidisciplinary approach to diagnosis and treatment to optimise survival. During the first half of the study period amputation was the mainstay of treatment with high incidence of mortality due to metastatic disease. Recent advances in neoadjuvant/adjuvant chemotherapy have improved the ability to perform limb –sparing resections, and disease free and overall survival rates have improved. Regular, long follow-up is indicated in these patients.

Introduction: Frozen shoulder is a general term denoting all causes of motion loss in the shoulder. As the syndrome is very common, many patients do not undergo detailed imaging studies before treatment. Some patients are managed by their GPs for long periods before being referred to a hospital.

Objectives: A series of 15 patients with primary neoplasms of the shoulder girdle mimicking frozen shoulder syndrome is presented.

Methods: A retrospective review of the Scottish bone tumor registry.

Results: There were 6 male and 9 female patients. The common presentation was pain and stiffness of the shoulder joint. Mean age at diagnosis was 46.63Yrs (range 23 – 71 Yrs). 73% were less than 50 Yrs of age. Only 2 gave history of trauma. Most received local steroids and physiotherapy before diagnosis. There were 10(66.6%) proximal humeral lesions and 5(33.3%) scapular lesions. Humeral lesions included chondrosarcoma (2), Ewing’s (2), lymphoma (2), chondroma (2) and osteoblastoma (1). Scapular lesions included chondrosarcoma (3), lymphoma (1) and fibromatosis (1).Scapular tumors involved older individuals. The mean delay in diagnosis after onset of symptoms was 15.8 mts (range 2 weeks- 48 months). All patients had X rays and CT/MRI. Treatment included a combination of surgery, chemotherapy and radiation. 3 patients with humeral lesions died at a mean of 20.6 mts, and 3 patients with scapular lesions died at a mean of 4.3 mts after diagnosis. The common cause of death was pulmonary metastasis.

Discussion: Many so called frozen shoulders are joints inhibited by pain rather than by true contracture. The commonest lesion to mimic a frozen shoulder is a slow growing low/middle grade chondrosarcoma. Young patients presenting with persistent pain or night pain must be examined for this possibility. Consideration should be given for further investigation before instituting treatment. Delay in diagnosis adversely affects survival. Surgeons are reminded that although rare, a tumor should be suspected when clinical presentations are unusual.

Background: The late effect of ionizing radiation on the development of sarcomas within the field of radiation is referred to as Post Irradiation Sarcoma (PRS).

Methods: A retrospective study from the Scottish Bone Tumor Registry (1940–2000) of PRS of the upper limb. The diagnostic criterion of Cahan was strictly followed and all patients followed up for 5 years.

Results: 11 female patients with previous history of radiotherapy (XRT) for carcinoma breast were identified as having PRS. The mean age at diagnosis was 68.7 years (51–80y). The latent period between irradiation and diagnosis ranged from 8 to 36 years (mean 15.6 y). All lesions occurred on the same side as breast malignancy. 6 lesions involved the proximal humerus and 5 the scapula. Histologically there were 7 osteosarcomas (65%), 1 chondrosarcoma, 1 spindlecell sarcoma and 2 dedifferentiated sarcomas. 2 humeral lesions underwent forequarter amputation, 2 excisions and endoprosthesis and 2 chemotherapy. Cumulative 5 year survival for humeral lesions was 33%. Survival was better with patients who achieved complete surgical margins. Majority of scapular lesions presented with either pulmonary/chest wall secondaries and were unresectable. Cumulative survival was poor ranging from 1 to 12 months (mean 6.2 months). De-differentiated lesions had the worst prognosis. Both orthovoltage and megavoltage XRT were implicated. It was not possible to analyze the relationship between total irradiation dose, individual fraction dose and incidence of PRS.

Discussion: PRS is an uncommon tumor with an incidence less than 1%, for patients who survive 5 years after XRT. Delay in diagnosis, aggressive nature, truncal location making extirpative surgery difficult and elderly patients all make the prognosis worse than that of primary sarcomas. As treatment of carcinoma of the breast evolves towards greater breast conservation it will be important to monitor the frequency of this complication more closely.