Abstract

Aims

Several studies have reported that patients presenting during the evening or weekend have poorer quality healthcare. Our objective was to examine how timely surgery for patients with severe open tibial fracture varies by day and time of presentation and by type of hospital. This cohort study included patients with severe open tibial fractures from the Trauma Audit and Research Network (TARN).

Conferences centered around surgery suffers from gender disparity with male faculty having a more dominant presence in meetings compared to female faculty. Orthopedic Surgery possibly suffers the most from this problem of all surgical specialties, and is reflective of a gender disparity in the field. The objective of this study was to investigate the prevalence of “manels”, or male-only sessions, in eight major Orthopedic Surgery meetings hosted in 2021 and to quantify the differences in location of practice, academic position, years of practice, and research qualifications between male and female faculty.

Eight Orthopedic conferences organized by major Orthopedic associations (AAOS, COA, OTA, EFORT, AAHKS, ORS, NASS, and AOSSM) from February 2021 to November 2021 were analyzed. Meeting information was retrieved from the conference agendas, and details of chairs and speakers were obtained from Linkedin, Doximity, CPSO, personal websites, and Web of Science. Primary outcomes included: one) percentage of male faculty in all included sessions and two) overall percentage of manels. Secondary outcomes included one) percentage of male speakers and chairs in all included sessions, two) overall percentage of male-chair and male-speaker only sessions. Comparisons for outcomes were made between conferences and session topics (adult reconstruction hip, adult reconstruction knee, practice management/rehabilitation, trauma, sports, general, pediatrics, upper extremity, musculoskeletal oncology, foot and ankle, spine, and miscellaneous). Mean number of sessions for male and female were compared after being stratified into quartiles based on publications, sum of times cited, and H-indexes. Data was analyzed with non-parametric analysis, chi-square tests, or independent samples t-tests using SPSS version 28.0.0.0 with a p-value of < 0 .05 being considered statistically significant.

Of 193 included sessions, 121 (62.3%) were manels and the mean percentage of included faculty that was male was 88.9% Apart from the topics of practice management/rehabilitation and musculoskeletal oncology, male representation was very high. Additionally, most included conferences had an extremely high percentage of male representation apart from meetings hosted by the COA and ORS. Non-manel sessions had a greater mean number of chairs (p=0.006), speakers (p < 0 .001), and faculty (p < 0 .001) than manel sessions. Of 1080 total included faculty members, 960 (88.9%) were male. Male faculty were more likely to be Orthopedic surgeons than female faculty (p < 0 .001) while also more likely to hold academic rank as a professor. Mean number of sessions between male and female faculty within their respective quartiles of H-indexes, sum of times cited, and number of publications did not reach statistical significance. Mean years of practice between male and female faculty was also not significantly different.

There is a high prevalence of manels and an overall lack of female representation in Orthopedic meetings. Orthopedic associations should aim to make efforts to increase gender equity in future meetings.

Knee arthroscopy with meniscectomy is the third most common Orthopaedic surgery performed after TKA and THA, comprising up to 16.6% of all procedures. The efficiency of Orthopaedic care delivery with respect to waiting times and systemic costs is extremely concerning. Canadian Orthopaedic patients experience the longest wait times of any G7 country, yet perioperative surgical care constitutes a significant portion of a hospital's budget.

In-Office Needle Arthroscopy (IONA) is an emerging technology that has been primarily studied as a diagnostic tool. Recent evidence shows that it is a cost-effective alternative to hospital- and community-based MRI with comparable accuracy. Recent procedure guides detailing IONA medial meniscectomy suggest a potential node for OR diversion. Given the high case volume of knee arthroscopy as well as the potential amenability to be diverted away from the OR to the office setting, IONA has the potential to generate considerable improvements in healthcare system efficiency with respect to throughput and cost savings. As such, the purpose of this study is to investigate the cost savings and impact on waiting times on a mid-sized Canadian community hospital if IONA is offered as an alternative to traditional operating room (OR) arthroscopy for medial meniscal tears.

In order to develop a comprehensive understanding and accurate representation of the quantifiable operations involved in the current state for medial meniscus tear care, process mapping was performed that describes the journey of a patient from when they present with knee pain to their general practitioner until case resolution. This technique was then repeated to create a second process map describing the hypothetical proposed state whereby OR diversion may be conducted utilizing IONA. Once the respective process maps for each state were determined, each process map was translated into a Dupont decision tree. In order to accurately determine the total number of patients which would be eligible for this care pathway at our institution, the OR booking scheduling for arthroscopy and meniscectomy/repair over a four year time period (2016-2020) were reviewed. A sensitivity analysis was performed to examine the effect of the number of patients who select IONA over meniscectomy and the number of revision meniscectomies after IONA on 1) the profit and profit margin determined by the MCS-Dupont financial model and 2) the throughput (percentage and number) determined by the MCS-throughput model.

Based on historic data at our institution, an average of 198 patients (SD 31) underwent either a meniscectomy or repair from years 2016-2020. Revenue for both states was similar (p = .22), with the current state revenue being $ 248,555.99 (standard deviation $ 39,005.43) and proposed state of $ 249,223.86 (SD $ 39,188.73). However, the reduction in expenses was significant (p < .0001) at 5.15%, with expenses in the current state being $ 281,415.23 (SD $ 44,157.80) and proposed state of $ 266,912.68 (SD $ 42,093.19), representing $14,502.95 in savings. Accordingly, profit improvement was also significant (p < .0001) at 46.2%, with current state profit being $ (32,859.24) (SD $ 5,153.49) and proposed state being $ (17,678.82) (SD $ 2,921.28). The addition of IONA into the care pathway of the proposed state produced an average improvement in throughput of 42 patients (SD 7), representing a 21.2% reduction in the number of patients that require an OR procedure. Financial sensitivity analysis revealed that the proposed state profit was higher than the current state profit if as few as 10% of patients select IONA, with the maximum revision rate needing to remain below 40% to achieve improved profits.

The most important finding from this study is that IONA is a cost-effective alternative to traditional surgical arthroscopy for medial meniscus meniscectomy. Importantly, IONA can also be used as a diagnostic procedure. It is shown to be a cost-effective alternative to MRI with similar diagnostic accuracy. The role of IONA as a joint diagnostic-therapeutic tool could positively impact MRI waiting times and MRI/MRA costs, and further reduce indirect costs to society. Given the well-established benefit of early meniscus treatment, accelerating both diagnosis and therapy is bound to result in positive effects.

The 2020-2021 Canadian Residency Matching Service (CaRMS) match year was altered on an unprecedented scale. Visiting electives were cancelled at a national level, and the CaRMS interview tour was moved to a virtual model. These changes posed a significant challenge to both prospective students and program directors (PDs), requiring each party to employ alternative strategies to distinguish themselves throughout the match process. For a variety of reasons, including a decline in applicant interest secondary to reduced job prospects, the field of orthopaedic surgery was identified as vulnerable to many of these changes, creating a window of opportunity to evaluate their impacts on students and recruiting residency programs.

This longitudinal survey study was disseminated to match-year medical students (3rd and 4th year) with an interest in orthopaedic surgery, as well as orthopaedic surgery program directors. Responses to the survey were collected using an electronic form designed in Qualtrics (Qualtrics, 2021, Provo, Utah, USA). Students were contacted through social media posts, as well as by snowball sampling methods through appropriate medical student leadership intermediates. The survey was disseminated to all 17 orthopedic surgery program directors in Canada.

A pre-match and post-match iteration of this survey were designed to identify whether expectations differed from reality regarding the effect of the COVID-19 pandemic on the CaRMS match 2020-2021 process. A similar package was disseminated to Canadian orthopaedic surgery program directors pre-match, with an option to opt-in for a post-match survey follow-up. This survey had a focus on program directors’ opinions of various novel communication, recruitment, and assessment strategies, in the wake of the COVID-19 pandemic.

Students’ responses to the loss of visiting electives were negative. Despite a reduction in financial stress associated with reduced need to travel (p=0.001), this was identified as a core component of the clerkship experience. In the case of virtual interviews, students’ initial trepidation pre-CaRMS turned into a positive outlook post-CaRMS (significant improvement, p=0.009) indicating an overall satisfaction with the virtual interview format, despite some concerns about a reduction in their capacity to network. Program directors and selection committee faculty also felt positively about the virtual interview format. Both students and program directors were overwhelmingly positive about virtual events put on by both school programs and student-led initiatives to complement the CaRMS tour.

CaRMS was initially developed to facilitate the matching process for both students and programs alike. We hope to continue this tradition of student-led and student-informed change by providing three evidence-based recommendations. First, visiting electives should not be discontinued in future iterations of CaRMS if at all possible. Second, virtual interviews should be considered as an alternative approach to the CaRMS interview tour moving forward. And third, ongoing virtual events should be associated with a centralized platform from which programs can easily communicate virtual sessions to their target audience.

In the current healthcare environment, cost containment has become more important than ever. Perioperative services are often scrutinized as they consume more than 30% of North American hospitals’ budgets. The procurement, processing, and use of sterile surgical inventory is a major component of the perioperative care budget and has been recognized as an area of operational inefficiency. Although a recent systematic review supported the optimization of surgical inventory reprocessing as a means to increase efficiency and eliminate waste, there is a paucity of data on how to actually implement this change. A well-studied and established approach to implementing organizational change is Kotter's Change Model (KCM). The KCM process posits that organizational change can be facilitated by a dynamic 8-step approach and has been increasingly applied to the healthcare setting to facilitate the implementation of quality improvement (QI) interventions. We performed an inventory optimization (IO) to improve inventory and instrument reprocessing efficiency for the purpose of cost containment using the KCM framework. The purpose of this quality improvement (QI) project was to implement the IO using KCM, overcome organizational barriers to change, and measure key outcome metrics related to surgical inventory and corresponding clinician satisfaction. We hypothesized that the KCM would be an effective method of implementing the IO.

This study was conducted at a tertiary academic hospital across the four highest-volume surgical services - Orthopedics, Otolaryngology, General Surgery, and Gynecology. The IO was implemented using the steps outlined by KCM (Figure 1): 1) create coalition, 2) create vision for change, 3) establish urgency, 4) communicate the vision, 5) empower broad based action, 6) generate general short term wins, 7) consolidate gains, and 8) anchor change. This process was evaluated using inventory metrics - total inventory reduction and depreciation cost savings; operational efficiency metrics - reprocessing labor efficiency and case cancellation rate; and clinician satisfaction.

The implementation of KCM is described in Table 1. Total inventory was reduced by 37.7% with an average tray size reduction of 18.0%. This led to a total reprocessing time savings of 1333 hours per annum and labour cost savings of $39 995 per annum. Depreciation cost savings was $64 320 per annum. Case cancellation rate due to instrument-related errors decreased from 3.9% to 0.2%. The proportion of staff completely satisfied with the inventory was 1.7% pre-IO and 80% post-IO.

This was the first study to show the success of applying KCM to facilitate change in the perioperative setting with respect to surgical inventory. We have outlined the important organizational obstacles faced when making changes to surgical inventory. The same KCM protocol can be followed for optimization processes for disposable versus reusable surgical device purchasing or perioperative scheduling. Although increasing efforts are being dedicated to quality improvement and efficiency, institutions will need an organized and systematic approach such as the KCM to successfully enact changes.

For any figures or tables, please contact the authors directly.

Aims

This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England.

Three-dimensional (3D) printing has become more frequently used in surgical specialties in recent years. Orthopaedic surgery is particularly well-suited to 3D printing applications, and thus has seen a variety of uses for this technology. These uses include pre-operative planning, patient-specific instrumentation (PSI), and patient-specific implant production. As with any new technology, it is important to assess the clinical impact, if any, of three-dimensional printing.

The purpose of this review was to answer the following questions:

What are the current clinical uses of 3D printing in orthopaedic surgery?

Four electronic databases (Embase, MEDLINE, PubMed, Web of Science) were searched for Articles discussing clinical applications of 3D printing in orthopaedics up to November 13, 2018. Titles, abstracts, and full texts were screened in duplicate and data was abstracted. Descriptive analysis was performed for all studies. A meta-analysis was performed among eligible studies to compare estimated blood loss (EBL), operative time, and fluoroscopy use between 3D printing cases and controls. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria for non-randomized studies and the Cochrane Risk of Bias Tool for randomized controlled trials (RCTs). This review was prospectively registered on PROSPERO (Registration ID: CRD42018099144).

One-hundred and eight studies were included, published between 2012 and 2018. A total of 2328 patients were included in these studies, and 1558 patients were treated using 3D printing technology. The mean age of patients, where reported, was 47 years old (range 3 to 90). Three-dimensional printing was most commonly reported in trauma (N = 41) and oncology (N = 22). Pre-operative planning was the most common use of 3D printing (N = 63), followed by final implants (N = 32) and PSI (N = 22). Titanium was the most commonly used 3D printing material (16 studies, 27.1%). A wide range of costs were reported for 3D printing applications, ranging from “less than $10” to $20,000. The mean MINORS score for non-randomized studies was 8.3/16 for non-comparative studies (N = 78), and 17.7/24 for non-randomized comparative studies (N = 19). Among RCTs, the most commonly identified sources of bias were for performance and detection biases. Three-dimensional printing resulted in a statistically significant decrease in mean operative time (−15.6 mins, p < .00001), mean EBL (−35.9 mL, p<.00001), and mean fluoroscopy shots (−3.5 shots, p < .00001) in 3D printing patients compared to controls.

The uses of 3D printing in orthopaedic surgery are growing rapidly, with its use being most common in trauma and oncology. Pre-operative planning is the most common use of 3D printing in orthopaedics. The use of 3D printing significantly reduces EBL, operative time, and fluoroscopy use compared to controls. Future research is needed to confirm and clarify the magnitude of these effects.

To assess the current literature on suture anchor placement for the purpose of identifying factors that lead to suture anchor perforation and techniques that reduce the likelihood of complications.

Three databases (PubMed, Ovid MEDLINE, EMBASE) were searched, and two reviewers independently screened the resulting literature. Methodological quality of all included papers was assessed using Methodological Index for Non-Randomized Studies criteria and the Cochrane Risk of Bias Assessment tool. Results are presented in a narrative summary fashion using descriptive statistics.

Fourteen studies were included in this review. Four case series (491 patients, 56.6% female, mean age 33.9 years), nine controlled cadaveric/laboratory studies (111 cadaveric hips and 12 sawbones, 42.2% female, mean age 60.0 years), and one randomized controlled trial (37 hips, 55.6% female, mean age 34.2 years) were included. Anterior cortical perforation by suture anchors led to pain and impingement of pelvic neurovascular structures. The anterior acetabular positions (three to four o'clock) had the thinnest bone, smallest rim angles, and highest incidence of articular perforation. Drilling angles from 10° to 20° measured off the coronal plane were acceptable. The mid-anterior (MA) and distal anterolateral (DALA) portals were used successfully, with some studies reporting difficulty placing anchors at anterior locations via the DALA portal. Small-diameter (< 1 .8-mm) suture anchors had a lower in vivo incidence of articular perforation with similar stability and pull-out strength in biomechanical studies.

Suture anchors at anterior acetabular rim positions (3–4 o'clock) should be inserted with caution. Large-diameter (>2.3-mm) suture anchors increase the likelihood of articular perforation without increasing labral stability. Inserting small-diameter (< 1 .8-mm) all-suture suture anchors (ASAs) from 10° to 20° using curved suture anchor drill guides, may increase safe insertion angles from all cutaneous portals. Direct arthroscopic visualization, use of fluoroscopy, distal-proximal insertion, and the use of nitinol wire can help prevent articular violation.

Introduction

Polyetheretherketone (PEEK) has been proposed as an implant material for femoral total knee arthroplasty (TKA) components. Potential clinical advantages of PEEK over standard cobalt chrome alloys include modulus of elasticity and subsequently reduced stress shielding potentially eliminating osteolysis, thermal conduction properties allowing for a more natural soft tissue environment, and reduced weight enabling quicker quadriceps recovery. Manufacturing advantages include reduced manufacturing and sterilization time, lower cost, and improved quality control. Currently, no PEEK TKA implants exist on the market. Therefore, evaluation of mechanical properties in a pre-clinical phase is required to minimize patient risk.

The objectives of this study include evaluation of implant fixation and determination of the potential for reduced stress shielding using the PEEK femoral TKA component.

INTRODUCTION

In patients presenting with significant ligamentous instability/insufficiency and/or significant varus/valgus deformity of the knee, reproduction of knee alignment and soft tissue stability continues to be a difficult task to achieve. These complex primary total knee arthroplasty (TKA) candidates generally require TKA systems incorporating increasing levels of constraint due to the soft-tissue and/or bone deficiencies. In addition, achievement of “normal” gap symmetry through physiologic kinematics is challenging due to the complexity of the overall correction. Advancements in TKA design have not fully addressed the negative consequences of the increased forces between the degree of component constraint, the femoral box, and the tibial post. The purpose of this early feasibility study was to introduce the design characteristics of a primary TKA system that incorporates progressive constraint kinematics using a low profile trapezoidal femoral box, and to assess the short-term clinical and radiographic results of this patient cohort.

Introduction

Fungi are a rare and devastating cause of Periprosthetic Joint Infection (PJI). Diagnosis and treatment is a challenge as there are currently no specific guidelines. A recently published review identified 75 case reports of fungal PJI.

Aims

Infection following total hip or knee arthroplasty is a serious complication. We noted an increase in post-operative infection in cases carried out in temporary operating theatres. We therefore compared those cases performed in standard and temporary operating theatres and examined the deep periprosthetic infection rates.

Infection following total hip or knee arthroplasty is a serious complication. We noted an increase in post-operative infection in cases carried out in a temporary operating theatre. We therefore compared those cases performed in standard and temporary operating theatres and examined the deep periprosthetic infection rates.

A total of 1233 primary hip and knee arthroplasties were performed between August 2012 and June 2013. 44% were performed in temporary theatres. The two groups were matched for age, sex, BMI and ASA grade.

The deep infection rate for standard operating theatres was 0/684 (0%); for temporary theatres it was 8/539 (1.5%); p=0.001.

Use of a temporary operating theatre for primary hip and knee arthroplasty was associated with an unacceptable increase in deep infection. We do not advocate the use of these theatres for primary joint arthroplasty.

Aim

To determine the influence of tendo achilles (TA) rupture gap distance and location on clinical outcome managed with accelerated functional rehabilitation.

Introduction

One of the important criteria of the success of TKR is achievement of the Flexion ROM. Various factors responsible to achieve flexion are technique, Implant and patient related. Creation of the Posterior condylar offset is one such important factor to achieve satisfactory flexion.

Introduction

Fixed flexion isolated or along with varus / valgus is a common deformity for patients undergoing TKR. For a satisfactory outcome and normal gait post op FFD needs to be corrected completely. An additional distal femoral resection may be necessary to equalize the extension gape to correct Gr 2 FFDs.

Introduction

Various implant designs and bearing surfaces are used in TKR. The use of All Poly Tibia and poly moulded on Tibial metal base plate has been in practice since long. Recently due to the reports on wear and osteolysis in modular articulations, these components have generated significant interest.

Introduction:

One of the important criteria of the success of TKR is achievement of the Flexion ROM. Various factors responsible to achieve flexion are technique, Implant and patient related. Creation of the Posterior condylar offset is one of the important factors to achieve satisfactory flexion.

Introduction:

During TKR it is mandatory to achieve perfect soft tissue balance and component alignment. As knee is covered in front by quadriceps mechanism, there is some manipulation of this structure while approaching knee for an arthroplasty. This alteration in Quadriceps mechanism can affect outcome of the surgery.

Aim

Following successful adoption of the Ponseti method for clubfoot treatment, a team of physiotherapists and orthotists and one surgeon in Jalalabad, Afghanistan have begun to treat Congenital Vertical Talus (CVT) by the technique described by Dodds et al, adapted to locally available resources. We have reviewed the outcome.

Introduction

Negative remodelling of the femoral cortex in the form of calcar resorption due to stress shielding and cortical hypertrophy at the level of the tip of the implant, due to distal load transfer, is frequently noted following cemented total hip replacement, most commonly with composite beam implants, but also with polished double tapers. The C-stem polished femoral component was designed with a third taper running from lateral to medial across and along the entire length of the implant, with the aim of achieving more proximal and therefore more natural loading of the femur. The hoop stresses generated in the cement mantle are transferred to the proximal bone starting at the calcar, which should theoretically minimise stress-shielding and calcar resorption, as well as reducing distal load transfer, as signified by the development of distal femoral cortical hypertrophy.

Introduction

Traditionally the use of small diameter femoral head (22mm) with the posterior approach has been perceived as an increased risk of dislocation. We present this prospective study of 400 consecutive total hip replacements performed using a 22mm femoral head and the posterior approach.

Introduction

Success of TKR depends upon soft tissue balance and component alignment. The alteration of quadriceps mechanism while approaching knee for TKR can affect outcome of the surgery.

Introduction

Fixed Flexion deformity (FFD) is a common deformity amongst patients due to undergo TKR. For their correction surgical algorithm is documented. Resection of distal femur and clearing off posterior recess are two essential steps. In balancing these knees it is suggested to resect extra distal Femur to gain extension space.

Introduction

The aim of the study was to whether the bone grafting techniques used affected the long term stability of the acetabular implant.

There is conflicting information regarding the recommendations of bracing, physical therapy and cessation of sports for young athletes with symptomatic spondylolysis. The purpose of this study was to identify factors affecting the prognosis and to find the optimal method of non-operative treatment.

The patients in our study were athletes who visited our children's hospital for low back pain with lumbar spondylolysis and were treated non-operatively from 1990 to 2002. Clinical and radiological outcomes were reviewed retrospectively. The effects of bracing, physical therapy, cessation of sports, duration of symptoms before the first hospital visit, lateralisation of spondylolysis, age, gender, onset of low back pain after lumbar trauma during sports, bone scan uptake, vertebral level of the lesion, associated scoliosis or spina bifida and radiological bony healing were analysed using univariate and multivariate analysis with logistic regression. The mean age of patients was 13 years (range 7 to 18 years). The mean follow-up was 4.2 years (range 1.2 to 12 years).

Of 132 patients, 48 patients had excellent results with no pain during sports, 76 good, 6 fair, and 4 poor. Cessation of sports, early non-operative intervention, and a unilateral spondylolysis appeared to be factors associated with excellent outcomes. However, bracing, physical therapy, age, gender, level of lesion, history of trauma, increased uptake on bone scan, or associated scoliosis or spina bifida were not factors. Bony healing was not related to the clinical outcome. The non-operative treatment of spondylolysis in children can yield excellent clinical outcomes, and the absence of bony healing has no influence on clinical outcome. Factors in this study found to correlate with an excellent outcome include unilateral spondylolysis, acute spondylolysis, and treatment with cessation of sports for 12 weeks.

Introduction: An osteotomy in the proximal first metatarsal corrects the metatarsal head position with much less movement of the fragment than an equivalent distal osteotomy. Most described techniques are technically demanding and reported complications including non-union, mal-union and transfer pain. We present our results of an opening wedge osteotomy with a medial wedge plate. We also present the pitfalls and tips to avoid complications.

Materials and Methods: Thirty-four procedures in 30 patients were performed using the Arthrex wedge plate. Demographic and clinical data, AOFAS scores and radiological measurements of standardised radiographs were collected for all the patients.

Results: All patients were females. The average age was 52 years. Twenty-seven were primary procedures and 7 patients had had previous, failed 1st ray surgery. No bone graft was used. Thirty-two feet showed clinical and radiological signs of union. Four complications occurred and one was treated with metatarsophalangeal joint fusion. One had an infection. Two patients had broken screws. The average hallux valgus angle and inter-metatarsal angle corrections were 200 and 90 respectively. Average increase in AOFAS scores: preoperative 47 to postoperative 81.

Discussion: The spacer in the plate acts as a pillar and obviates the need for a bony strut. Keeping an intact lateral cortex and preventing any shaft displacement was important in avoiding transfer pain. 4.5mm or smaller plates appear to have fewer problems and better scores, al though this was statistically unproven. Screw breakage in the absence of infection had no bearing on overall outcome. Some patients with poor fixation may benefit from non-weight bearing for the first 6 weeks.

Conclusion: The wedge plate osteotomy is a powerful tool to correct moderate to severe hallux valgus. It does not need additional bone graft and has a favorable clinical and radiological outcome. The prelude to optimum result was meticulous technique avoiding the discussed pit falls.

Introduction: Diagnosis of syndesmotic injuries is primarily based upon the assessment of ankle radiographs. Earlier studies examining normal radiographs are limited by small sample size and methodological issues.

Materials and Methods: One thousand four hundred and fifteen consecutive patients with ankle radiographs were reviewed. 1023 patients were excluded as a result of a history of ankle/hindfoot pain, trauma, or surgery; or radiographic evidence of ankle/hindfoot pathology. 392 patients (218 females, 174 males) with normal ankle radiographs were included. 83 of 392 patients had bilateral normal radiographs. All radiographs were reviewed independently by a fellowship-trained foot and ankle surgeon and a fellowship-trained musculoskeletal radiologist. Tibiofibular overlap and tibiofibular clear space were measured on anteroposterior (AP) and mortise radiographs. These four measurements were analyzed.

Results: Mean AP overlap was 8.3 mm (±2.5). Mean mortise overlap was 3.5 mm (±2.1), 7.7% patients had < 1 mm overlap and 4.9% of patients had < 0 mm overlap. Mean AP clear space was 4.6 mm (±1.1), 7.1% patients had > 6 mm clear space. Mean mortise clear space was 4.3 mm (±1.0), 4.3% patients had > 6 mm clear space. All measurements were significantly different between females and males (p < 0.001). Mortise clear space is the most accurate measure when obtaining contralateral radiographs. Intraobserver and interobserver reliabilities of all measurements were high (intra-class correlation coefficient range 0.820–0.983).

Discussion and Conclusion: Our data unequivocally demonstrates that basing treatment of syndesmotic injuries on previously reported radiographic criteria can lead to unnecessary operative intervention or failure to treat. Lack of overlap on the mortise view can represent a normal variant, which has not been definitively reported in prior investigations. Our data forms the basis for new radiographic criteria to evaluate syndesmotic disruption.

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.

Background: Several hospitals within the NHS now run specialist teams that look after assisted discharge plans for patients following elective surgeries. Joint replacements form a significant segment of elective majors in orthopaedics. In the second half of the last year alone, the National Joint Registry estimated that there were over 100,000 joint replacements carried out within England and Wales. Such schemes are designed to: 1. Enable patients to be discharged to their home as quickly and safely as possible, to maximise recovery and rehabilitation. 2. Ensure the most effective use of acute orthopaedic beds. 3. Reduce risks of hospital acquired infection 4. Streamline inpatient care so as to positively impact upon inpatient and outpatient waiting times. There is scarce information available about the experience of NHS hospitals with such schemes.

Aims And Objectives: 1. Investigate patient expectations of and satisfaction with discharge planning on the early discharge scheme. 2. Assess areas of concern to the patient and difficulties encountered by the patient in the home environment. 3. Improve our understanding of patient requirements, functional recovery and planning of discharge. 4. Investigate whether our lengths of stay compare with others in the NHS/literature and what factors are influencing the figures. 5. Investigate overall success of the scheme.

Patient And Methods: The study identified 100 consecutive patients who have had joint replacement surgery after August 2003 and have been discharged under the scheme. A Patient Satisfaction Questionnaire was used and the patients completed different sections at discharge and then at about six. Notes were reviewed for any complications or problems.

Conclusions: The scheme to discharge patients early is highly successful and well received by staff and patients. All consultants now use the service and the initial aims have been met, saving approximately 335 bed days in the first six months. The average inpatient stay has been reduced by half in the last 18 months. 98% of patients stated that the scheme met their needs. The majority of comments were positive. Only two patients needed readmission within the first fortnight from discharge, one with a dislocated hip and the other was a knee with wound infection. There were two complaints, which were deemed serious enough for a mention.

Total Knee Replacement (TKR) is one of the commonest and successful orthopaedic operations performed in the UK with good long term results. The Natural knee (Sulzer – Centerpulse ) is one of the various types of prostheses available. This implant is unique because of the trochlear notch over the anterior surface of the femoral prosthesis that allows natural tracking of the patella and an asymmetric anatomical tibial component. To our knowledge there are no studies reviewing outcome of Natural Knee Replacement from the UK.

We reviewed 177 consecutive TKRs in 147 patients including 30 bilateral simultaneous or staged procedures using Natural Total Knee prosthesis performed during 1994 to 1998, with a minimum of five years follow up. All these surgeries were performed at a single NHS District General Hospital by different grades of surgeons including consultants and trainees.

12 patients died and 10 were lost to follow up. 155 knees were available for final follow up and evaluation. We carried out an outcome related to patient satisfaction using Oxford Knee questionnaire system. We compared the preoperative and post operative scoring using the questionnaire and found an improvement of the score after the procedure. The average improvement in scores before and after surgery was 30 (20 pre op to 50 post op). Out of 155 knees evaluated, 143 knees (92%) were happy with the results while the rest did not have satisfaction with surgery. Complications included anterior knee pain in 12, DVT in 40 , non fatal pulmonary embolism in 2, wound infection in 3, stiffness in 8 of which 5 needed manipulation under anaesthesia, there were 2 revisions of which one knee was done for infection and one for a loose femoral component.

Our results suggest that the five year follow-up results of this prosthesis are at par with other commonly used knee replacement prostheses in the UK.

We reviewed retrospectively 94 patients who had undergone soft-tissue release to correct flexion contracture of the knee to determine the incidence of postoperative hypertension. The cause of contracture in most patients was cerebral palsy (45) or old poliomyelitis (39). Twenty patients developed persistent hypertension. Two of them were symptomatic, one developing hypertensive encephalopathy. Patients who had had poliomyelitis were at a higher risk than those with cerebral palsy; the risk increased with bilateral procedures. The amount of correction achieved had no influence on the incidence of hypertension.