Introduction

The current treatment for Freiberg's osteochondrosis centres around either: simple debridement or debridement osteotomy. The main principle of the osteotomy is to rotate normal articular cartilage into the affected area. We recommend the use of CT scanning to delineate the amount of available, unaffected cartilage available to rotate into the affected space.

Introduction

Ankle fractures in the elderly are an increasing problem with our aging population. Options for treatment include non-operative and operative with a range of techniques available. Failure of treatment can lead to significant complications, morbidity and poor function. We compared the outcomes of two operative techniques, intramedullary hindfoot nailing (IMN) and fibular-pro-tibia fixation (FPT). This is the largest analysis of these techniques and there are no comparative studies published.

Aims

The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR.

Introduction

A randomized clinical trial of first metatarsophalangeal (MTP) joint hemiarthroplasty with a synthetic cartilage implant demonstrated equivalent pain, function and safety outcomes to first MTP joint arthrodesis at 2 years. The implant cohort continues to be followed under an extension of the original study and we report on prospectively determined 5+ year outcomes for subjects assessed to date.

Introduction

Total knee arthroplasty has become an established operation. Cemented fixation of the components has given satisfactory results and is accepted as the gold standard. Cement failure with aseptic loosening, however, is a possible long term complication. This is particularly important in view of the increasing number of younger patients who can benefit from this procedure. Hence the attraction of using implants fixed by direct osseointegration of bone into the implant, by passing the potential weak link of the cement.

Background

Recent publications have supported the anatomic placement of anterior cruciate grafts to optimise knee function. However, anatomic placement using the anteromedial portal has been shown to have a higher failure rate than traditional graft placement using the transtibial method. This is possibly due to it being more technically difficult and to the short femoral tunnel compromising fixation methods. It also requires the knee to be in hyper flexion. This position is not feasible during with a tourniquet in situ on the heavily muscled thighs of some athletes.

Hypothesis: That navigation can be used to place the femoral tunnel in the anatomic position via a more medial transtibial tunnel.

Approximately 20% of patients with ankle fracture sustain syndesmosis injury. This is most common in trans-syndesmotic (type B) and supra-syndesmotic (type C) fibula fractures. Intra-operative assessment of syndesmosis integrity is important because failure to treat these injuries can result in ankle instability and pain.

Our aim was to audit the documentation of intra-operative testing of syndesmosis during ankle fracture open reduction and internal fixation (ORIF). All patients who had ankle fracture ORIF between 1/1/2010 and 21/11/2011 were included. Pre-operative radiographs were reviewed and fractures were classified according to AO classification. Operation notes were reviewed for documentation of assessment of syndesmosis integrity.

153 patients, of mean age 50 years (15–93) were included. 60% (n=92) were female. In 78% of cases (n=119), an assessment of syndesmosis integrity was documented in the operation note. Of the patients with no documented syndesmosis assessment (n=35), the majority had type B fractures (n=34). One patient had a type C fracture.

We have shown that 22% of patients undergoing ankle ORIF for fracture do not have documented assessment of syndesmosis integrity. We suggest that all patients who have ankle ORIF should have intra-operative assessment and documentation of syndesmosis integrity so these injuries are identified and treated accordingly.

Locked plates confer angular stability across fusion sites, and as such are more rigid than either screws or intramedullary nails. This gives the advantage of reducing motion to enhance union rates and potentially allowing early weight bearing. The Philos plate (Synthes) is a contoured locking plate designed to fix humeral fractures but which also fits the shape of the hindfoot and provides strong low profile fixation. Its successful use for tibiotalocalcaneal (TTC) arthrodesis has been reported.

Our aim was to prospectively evaluate the use of the Philos plate in hindfoot arthrodesis Twenty-one hindfoot arthrodeses were performed using the Philos plate between Oct 2008 and Jan 2010. Patients were followed up for a minimum of 1 year and had preoperative and 6 monthly AOFAS hindfoot scores and serial radiographs until union. Overall there were 15 ankle fusions, 5 tibiotalocalcaneal fusions and 1 subtalar fusion. At 6 months there were 13 unions and 9 non-unions (4 ankle, 5 TTC) giving a non-union rate of 38% overall and 25% for ankle fusions in isolation. Mean AOFAS scores at 6 months were 74/100 for the union group and 47 for non-unions (chi squared p < 0.001). No patient in the non-union group went on to fuse within a year without further surgery. Both groups had similar case mixes including osteoarthritis, AVN of the talus and failed arthroplasty. They also had similar co-morbidities, rates of smokers and bone grafting.

Our conclusion is that the high non-union rates are probably due to the lack of compression conferred across the join by the Philos plate as there is no compression hole and we did not supplement the fixation with a lag screw. We recommend using locked plates for hindfoot arthrodesis only with additional compression.

Introduction

Growing evidence in the literature suggests better clinical and functional outcomes and lower re-rupture rates with repair compared to non-operative treatment of ruptured Achilles tendon. There are however, concerns of wound infection, nerve injury and scar tenderness with the standard open and percutaneous techniques of repair. We aim to evaluate clinical and functional outcomes and complications in patients treated with minimally invasive Achillon device.

Introduction

Medial calcaneal displacement osteotomy with an FDL tendon transfer is a common method of correcting pes planus deformity secondary to grade II tibialis posterior dysfunction. There is currently no evidence that calcaneal displacement alters the centre of pressure in the foot from a medial to a more central position as the normal shape is reconstituted.

There have been mixed reports of the contribution of the anterior cruciate ligament (ACL) to the overall envelope of tibial rotational stability. The effect of single bundle ACL reconstruction on the separate components of internal and external rotational stability respectively is also unclear.

We determined the internal and external rotation, and antero-posterior movement of the knee before and after single bundle computer assisted reconstruction of the anterior cruciate ligament (ACL) in 57 patients. The Orthopilot^® ACL (v2) software (BBraun, Aesculap) was used.

The mean overall range of tibial rotation was also significantly reduced from 30.5 degrees to 16 degrees (p< 0.0001). The mean internal rotation was significantly reduced from 16 degrees to 8 degrees (p< 0.0001). Mean external rotation was also significantly reduced from 15 degrees to 8 degrees (p< 0.0001). Unlike previous studies we did not find a greater reduction of internal rotation compared with external rotation. The mean antero-posterior movement of the tibia was significantly reduced from 12mm to 4mm (p< 0.0001).

The results of this study seem to indicate that computer assisted single bundle ACL reconstruction results in a significant intraoperative improvement in both internal and external rotatory stability as well as a significant improvement in antero-posterior stability.

Uncemented total knee arthroplasty (TKA) implants were designed as an alternative to cemented implants. However, critical studies revealed a unique set of complications. At the same time, cemented prostheses continue to yield excellent results. To address some of the issues with uncemented implants, porous coatings were introduced. This follow-up study reports the early results of Plasmapore^® coating in Navigated uncemented rotating platform TKA.

277 patients who had consecutively undergone a Navigated TKA procedure with the e.motion knee endoprostheses were followed up at the Bluespot Knee Clinic in Blackpool, UK. Of these 277 patients, 91 received an uncemented TKA between May 2005 and September 2007. The prosthesis is coated with a 350μm plasma-sprayed titanium layer. All procedures were carried out by the senior author (SACS). The Orthopilot navigation system was used to accurately restore the axial alignment of the implants.

Men comprised 51% and women 49%. The mean age was 69 years and the mean BMI was 30. There were 50 right and 41 left knees. The mean operating time was 59 minutes. Of the 91 patients who received an uncemented e.motion TKA, 84 patients had at least 1 follow-up assessment. The average follow-up period for these 84 cases was 7 months. The integrated Knee Society Score (KSS) defined as the sum of functional and clinical KSS, was recorded for all 91 patients preoperatively and had a mean of 78. The KSS had increased to 182 after 4 months, 193 after 1 year and 198 after 2 years. Oxford score was recorded for 87 of the 91 patients preoperatively. The average preoperative score was 44. It had decreased to 18 after 4 months, and 16 after 1 year and 13 after 2 years.

Radiological examination showed no evidence of periprosthetic lucency and no subsidence.

There were 5 DVTs with 2 pulmonary embolisms, 2 cases of reflex sympathetic dystrophy, 2 stitch abscesses, 2 haematomas, and 9 cases of wound erythema. These preliminary findings compare favourably with published series of cemented TKAs. They have prompted a more detailed review which is in progress.

Previous studies of osteoarthritic knees have examined the relationship between the variables body mass index (BMI) and weight on the one hand and coronal plane deformity on the other. There is a consensus that weight and BMI are positively correlated to the degree and progression of a varus deformity. However, there does not appear to be a consensus on the effect of these variables on knees with a valgus deformity. Indeed, the view has been expressed that in knees with a severe deformity a relationship might not exist. A review of these studies reveals that in all cases, the alignment of the lower limb was obtained from a standing antero-posterior long leg radiograph. In no cases was the deformity in the sagittal plane measured. This study analyses the relationship between BMI, weight, deformity in the sagittal plane and valgus deformity.

The study group consisted of 73 patients with osteoarthritis and valgus knees. All of them had failed conservative treatment for their symptoms and were listed for navigated TKA. Their weight and height were measured two weeks preoperatively and the BMI calculated. At operation the coronal and sagittal deformities were measured using the Orthopilot^® navigation system (BBraun Aesculap, Tuttlingen). The results were analysed using SPSS 15.

Regression analysis showed a significant relationship (p< 0.05) with a negative correlation between valgus deformity and weight. the correlation coefficient for flexed knees (−0.59) showed a moderately strong relationship whereas that for extended knees (−0.38) showed a relatively weak relationship.

It is acknowledged that there is an increased force on the lateral compartment with increased valgus deformity. a larger deformity causes a larger moment arm about the centre of the knee. this study has shown that at the time of surgery, individuals with lower weights have larger valgus deformities. we postulate, therefore, that when the moment due to the weight of the individual and the length of the moment arm exceeds a certain value, a symptomatic threshold is crossed. in the presence of a fixed flexion deformity, the force on the patella-femoral joint is increased, contributing further to the onset of discomfort.

Further investigation into the subsets of valgus knees appears to be warranted.

Purpose of Study: To examine if and when patients return to sporting activity following surgery, and how their subjective assessment of ability to perform activities was affected by their injury and surgery. We also wished to examine if there was any difference in the timing of return to sport between different sporting activities and by graft (hamstring or bone, patella tendon, bone (BTB)) used for ACL reconstruction.

Method and Results: 252 ACL reconstructions were followed up for 2.5 years post surgery. They were evaluated pre and post surgery with Mohtadi activity scores evaluating their function for their primary and secondary sporting activities. They were also evaluated regards exactly when they got back if at all to their primary and secondary activities. 84.2% returned to activity1 at a mean of 9.3 months 87.2% returned to activity 2 at a mean of 8.5 months. 60.7% of patients who returned to activity 1 returned at the same level as prior to their injury. 69.8% of those who returned to activity 2 returned at the same level as prior to their injury. There was no significant difference in timing of return to sport between hamstring and BTB graft.

Discussion: We can conclude from this study that the mean time to return to sport following ACL reconstruction is close to what most surgeons) are telling their patients (i.e. 6 to 9 months). However there is wide variation between subjects with a number of complex factors affecting when a person returns to their activity. It is probably wrong for us to give the expectation to all patients that they will be back to their preferred activities at 6 to 9 months.

Lateral sided hip pain frequently presents to the orthopaedic clinic. The most frequent cause of this pain is trochanteric bursitis. This usually improves with conservative treatment. In a few cases it doesn’t settle and warrants further investigation and treatment. Between July 2006 and February 2008, 28 patients underwent MRI scanning for such pain, 16 were found to have a tear of their abductors. All 16 underwent surgical repair using multiple soft tissue anchors inserted into the greater trochanter of the hip to reattach the abductors.

There were 15 females and 1 male. They had a mean age of 62. All patients completed a self-administered questionnaire pre-operatively and 1 year postoperatively. Data collected included: A visual analogue score for hip pain, Charnley modification of the Merle D’Aubigne and Postel hip score, Oxford hip score, Kuhfuss score of Trendelenburg and SF36 scores.

Of the 16 patients who underwent surgery 5 had a failure of surgical treatment. There were 4 re ruptures, 3 of which were revised and 1 deep infection which required debridement. In the remaining 11 patients there were statistically significant (p< 0.05) improvements in hip symptoms. The mean change in visual analogue score was 5 out of 10. The mean change of Oxford hip score was 20.5. The mean improvement in SF-36 PCS was 8.5 and MCS 13.7. 6 patients who had a Trendelenberg gait pre-surgery had normal gait 1 year following surgery.

We conclude that hip abductor mechanism tear is a frequent cause of recalcitrant trochanteric pain that should be further investigated with MRI scanning. Surgical repair is a successful operation for reduction of pain and improvement of function. However there is a relatively high failure rate.

Introduction: Achilles tendinopathy (AT) is the most common over use syndrome of the lower limb. One of the simple operations performed for this condition is “Multiple longitudinal tenotomies”. This can be performed by either percutaneous or open methods. We compared the outcome of percutaneous versus open method of multiple longitudinal tenotomies for this condition.

Methods and materials: It is a retrospective study of patients operated for AT in our hospital from 1997 to 2008. Total of 43 patients. Twenty had percutaneous and 23 had open tenotomies. All of them had a trial of non-operative treatment prior to surgery, in the form of analgesia, physiotherapy, heel inserts, and ultrasound therapy. Data was collected from patient records and by telephonic questionnaire of the patients. Data collected includes pre and postoperative pain scores on a scale of 0–10, duration of symptoms, patient satisfaction scores (0–10) and complications. This questionnaire also included limitation to walk, run, going up/down the stairs, work and sporting activities.

Results: In the percutaneous group the mean pre and postoperative pain scores were 8.79 and 2.07 (p value 0.000). In the open group the values were 8.65 and 1.75 (p value 0.000). The mean satisfaction scores in the percutaneous and open groups were 8.25 (range 3–10) and 8.14(range2–10) respectively. The patient satisfaction scores were not significantly different between the two groups (p value 0.942). In the percutaneous group there was one recurrence and in one patient there was no symptomatic relief. In the open group there were 2 superficial infections, which settled with antibiotics and a wound breakdown, which in addition required debridement and eventually healed by secondary intension.

Conclusions: Both percutaneous and open methods of longitudinal tenotomies resulted in significant symptomatic relief and good patient satisfaction scores. Although the outcomes of both groups were comparable the percutanous method has an added advantage of less complications and simplicity of the procedure.

Purpose: To examine if and when patients return to sporting activity following surgery and how their subjective assessment of ability to perform activities was affected by their injury and surgery. We also wished to examine if there was any difference in the timing of return to sport between different sporting activities and by graft (hamstring or bone, patella tendon, bone (BTB)) used for ACL reconstruction.

Method and Results: 252 ACL reconstructions were followed up for 2.5 years post surgery. Theyere evaluated pre and post surgery with Mohtadi activity scores evaluating their function for their primary and secondary sporting activities. They were also evaluated regards exactly when they got back if at all to their primary and secondary activities. 84.2% returned to activity1 at a mean of 9.3 months 87.2% returned to activity 2 at a mean of 8.5 months. 60.7% of patients who returned to activity 1 returned at the same level as prior to their injury. 69.8% of those who returned to activity 2 returned at the same level as prior to their injury. There was no significant difference in timing of return to sport between hamstring or BTB graft.

Discussion: We can conclude from this study that the mean time to return to sport following ACL reconstruction is close to what most surgeons) are telling their patients (i.e. 6 to 9 months). However there is wide variation between subjects with a number of complex factors affecting when a person returns to their activity. It is probably wrong for us to give the expectation to all patients that they will be back to their preferred activities at 6 to 9 months.

We report the results of cementless total hip arthroplasty using the Bi-metric titanium femoral stem at a minimum follow up of 10 years and a mean of 12.2 years (range 10–17).

64 hips (43 male/21 female) were implanted consecutively into 54 patients between 1988 and 1995. The mean age at operation was 54.3 years (range 42–65). All patients had a Bi-metric uncemented stem (Biomet UK). The first 13 patients received a metal backed screw in acetabular cup (TTAP-ST, Biomet UK) with the remainder receiving metal backed pressfit cups (Universal, Biomet UK).

All patients were followed up annually and assessed using the Hip Society Score (HSS; max 40 points) to record pain, function and mobility. Survivorship was calculated using the Kaplan-Meier method.

57 hips were followed up for a minimum of ten years. There were 4 deaths (6 hips) before completion of follow up and 1 patient was lost to follow up.

Using revision for any reason as the end point of the study; survivorship for the total hips at 10 years was 89.5% (95% confidence interval: 78.1–96.1%) with a mean Hip Society Score of 34.9 (range 20–40) compared to 14.5 (range 8–24) pre-operatively (p< 0.01 student t test).

Survivorship for the femoral stem in isolation was 100% at 10 years (95% CI 93.7–100%) and there continues to be no revisions to date at a mean follow up of 12.2 years.

The screw fix cup performed poorly with 3 acetabular revisions (including 1 liner change) before the 10 year follow up, a failure rate of 23.1%. There has sub-sequently been a further 4 acetabular revisions.

Ten year survivorship for the pressfit cup is 93.5% (95% CI 82.0–98.8%) with 3 revisions (including 2 liner changes) at ten years. There has subsequently been one further acetabular revision and 9 further liner changes (29.5% failure rate).

There have been no recorded infections and no instances of thigh pain.

Radiographs at ten years showed all the femoral stems were stable with no evidence of migration. Two stems had small radiolucent lines at the bone-implant interface but no signs of loosening. One stem had an area of osteolysis in Gruen zone 7 but didn’t require revision. Rates of osteolysis were extremely low given the large amounts of particulate debris in the hip from the worn acetabular liners.

In conclusion, although neither cup has proved to be particularly successful the Bi-metric stem has performed well at 10 year follow up and continues to do so. This is inspite of the fact they were implanted into a young and active group of patients.

Navigated Total Knee Arthroplasty (TKA) is a new technique in our hospital. Any new procedure can be associated with both technical difficulties and difficulties due to patient and theatre staff expectations. The aim of this study was to demonstrate our learning curve and assess patient and staff acceptance. We highlight common technical problems unique to navigation and offer our solutions.

A prospective study of 231 consecutive Emotion TKA were implanted over a 30 month period with Orthopilot version 4.2 Navigation system using soft tissue management (BBraun Aesculap, Tutlingen). They were done by a single knee surgeon previously experienced only in non-navigated TKA. Patient height and weight were measured preoperatively and the BMI calculated. Tourniquet times were recorded digitally with fixed timing criteria. Informed consent was obtained.

Our results showed a significant decrease of tourniquet time with experience (p=< 0.0001) with other possible factors being preoperative deformity and BMI. There was full patient acceptance with the exception of the first patient. The surgical team had to modify patient positioning on the operating table, setup of the theatre and navigation equipment, placement of the scrub staff and delegation of tasks.

Navigated Emotion TKA with Orthopilot software provided a comfortable learning curve. It was readily acceptable to patients and staff and has been adopted as our standard practice. The discussion of problems and the introduction of solutions had a positive effect on building our team. Further investigation is needed to elucidate other variables that affect the tourniquet time.

Valgus knees present a surgically demanding challenge. Dissimilar bone and soft-tissue deformities compared to varus knees complicate restoration of proper alignment, positioning of components, and attainment of joint stability. Our study examined the relationship between tourniquet time and valgus deformity.

A prospective study of all valgus knees were implanted over a 30 month period with Emotion Ortho-pilot version 4.2 Navigation system (BBraun Aesculap, Tutlingen). They were done by a single knee surgeon. Tourniquet times (TT) were recorded digitally with fixed timing criteria. The software recorded all pre- and post-operative deformities. We performed the lateral parapatella approach for all valgus knees. No patella resurfacing was done but all tibiae were cemented.

There were a total of 56 valgus knees (1° to 22°, Mean 5.9°, SD 4.9). The TT varied from 42 min to 121 min (mean 72 min, SD 17.4). There was a statistically significant relationship between TT and Valgus deformity. Tourniquet Time = 59.6 + 2.1 * Pre-operative Valgus (p= < 0.0001, R² = 36.4%)

Thirty six percent of the observations were explained by this analysis. Other factors will need to be considered in future studies. This equation can be used as a guide in the allocation of theatre time. It applies to a specific surgical team and we would expect different teams to have different coefficients. This may be useful in comparisons of different teams.