Introduction

The concept of a predetermined first patient on the following days trauma list (the golden patient) was introduced to our hospital in April 2009. The golden patient (GP) should already have been seen by an anaesthetist and be ready to be sent for by theatres early. The aim was to improve theatre start times following disappointing results from a previous in-hospital study. It has been shown by others to improve operation start times and could be used to improve trauma services and meet clinical targets more readily.

Introduction

The concept of the golden patient (GP) was introduced to our busy teaching district general hospital, in April 2009, to improve trauma theatre start times following disappointing results from a previous in-hospital study. The GP is a pre-selected first patient on the following day trauma list who is medically fit with a clear surgical plan. The GP should have already been seen by an anaesthetist and be ready to be sent for by theatres early. It has been shown by others to improve operation start times and could be used to improve trauma services and meet clinical targets more readily.

Introduction: Lesser metatarsophalangeal instability is a common cause of forefoot pain. Previous studies were small and there is little data comparing surgical with non-surgical treatment.

Patients and Methods: Metatarsophalangeal instability was diagnosed and staged with the draw test. We recorded the clinical presentation, involved toes, severity of instability, presence of toe deformity and management. Patients were followed-up in clinic or by telephone interview with visual analogue pain and satisfaction scores and AOFAS lesser metatarsophalangeal scores. Outcomes were assessed by an independent observer.

Results: We studied 154 patients: 127 (82%) female and 27 (18%) male. The median age was 56 years (range 33–85). One foot was affected in 107 patients (69%) and both feet in 47 (31%). The second toe only was affected in 99 patients (64%) and multiple toes in 52 (34%). Seventy-three patients (47%) had a complaint of generalised forefoot pain. Sixty-eight (44%) had pain and deformity localised to the second toe. Thirteen patients (8%) had toe deformity with significant MTPJ instability. 150 toes (52%) had grade 1 instability, 108 (37%) grade 2 instability and 21 (7%) grade 3 instability. Twelve toes (4%) presented dislocated with a history of instability. Ninety-nine patients (64%) were treated conservatively, using functional taping, shoe modifications, insoles and injections. Fifty-five patients (36%) had surgery, including lesser toe straightening, flexor-extensor transfer, plantar plate repair, Weil and Stainsby procedures. 79% of patients were reviewed at a mean of 65 months (range 14 to 138). Mean pain score was 31mm ± 23.7mm for the conservative group and 23mm ± 24.1mm in the surgical group. Mean AOFAS score was 69 ± 16.3 for the conservative group and 67 ± 17.8 in the surgical group. 39 (52%) conservatively treated patients were either satisfied or very satisfied compared to 31 (66%) surgically treated patients. No differences were statistically significant.

Templating of preoperative radiographs is routinely recommended prior to knee arthroplasty. We performed this study to assess the reproducibility and accuracy of the templates for three commonly used knee implants (PFC, Kinemax, Scorpio). Six lower limb surgeons templated 10 patients for each of the three designs. The inter and intra-observer reliability and accuracy was calculated. There was marked variation in the reliability of the templating with the tibial insert scoring better than the femoral and the Kinemax being the most reproducible of the three. In general, the intra-observer scores (κ= 0.57–0.81) were better than the inter-observer ones (κ= 0.21–0.60). The Scorpio was the most accurately templated of the three implants, with the percentage correlating with what was actually implanted ranging from 55–62% for the femur and 72–75% for the tibia, with no templated sizes more than 1 size different from the actual implant. The other implants ranged from 38–42% for the femur and 53–58% for the tibia with both having up to 3% more than 1 size difference from the actual implant. We believe that the use of templating in total knee arthroplasty should be interpreted with caution and we urge the development of more accurate prosthesis sizing techniques.