Purpose

This study evaluated the acceptability of performing manipulations with intranasal diamorphine and inhaled Entonox to parents of children presenting to our Emergency Department.

Joint aspiration is a useful tool during preoperative workup in suspected periprosthetic infection. The aim of this study was to review efficacy of joint aspiration in our unit and compare results with the published literature.

We undertook a retrospective review of 153 consecutive patients who underwent joint aspirations for suspected periprosthetic infection between 03/2011 and 10/2012 who were identified from the hospital electronic database. As per protocol, joint fluid was sent in an EDTA tube for cell count, Paediatric blood culture bottle and the remainder in a specimen pot.

105 (69%) were TKRs and 48 (31%) were THRs. Intraoperative samples were sent as per protocol in only 40 (26%) cases. The hit rate of positive cultures was 11/153 (7%) and specimens sent in paediatric culture bottles identified more positives than if it was omitted (10.5 Vs 5.5%).

In conclusion, the hit rate of positive cultures is low in this study compared to the literature (7% Vs 33%) and this is likely due to blanket aspiration of all patients who are undergoing revision. In addition, specimens sent in paediatric culture bottles seem to identify more positives. We recommend cases are selected for aspiration according to AAOS guidelines.

Medical and Health care products Regulatory Agency (MHRA) released an alert in 2010 regarding metal on metal (MoM) bearings in hip arthroplasty owing to soft tissue reactions to Metal debris. Following this, we adopted a targeted screening protocol to review patients with this bearing couple.

218 Patients (252 hips), mean age 53.2 (25–71) years were assessed clinically using Oxford hip score (OHS) and X-ray examination. The mean follow up was 44.5 (12–71) months. Patients were considered at higher risk (118 patients/133 hips) if they had deterioration of OHS (50 hips), Small sized heads <50mm (114 hips), acetabular inclination >500 (37 hips), neck thinning (17 hips). These patients (107/118), (120/133 hips) were further investigated through measuring metal ion levels and magnetic resonance imaging (MRI).

The mean blood levels of cobalt and chromium in this group were 6.7, 8.62 ug/L respectively. Metal ions increased significantly with high acetabular inclination angles (p=0.01, 0.004 respectively), but was not affected by the size of the head (p=0.13). MRI showed periprosthetic lesions around 28 hips (26 fluid collections, 2 pseudotumours).

The screening protocol detected all patients who subsequently required elective revision. We believe that this protocol was beneficial in detecting problematic MoM hip replacements.

Scarf osteotomy for correction of painful hallux valgus is an effective technique, giving a predictable correction of the deformity. However, some patients remain less than fully satisfied, despite normalisation of the usual radiographic parameters. This study examines whether lateral soft tissue release can cause late splaying of the forefoot.

A series of 32 feet in 29 consecutive patients in a single centre, operated on by a single surgeon, over a 12 month period were studied. After pre-operative weight-bearing x-rays and consenting, a standardised ‘Barouk-technique’ Scarf procedure was undertaken with on-table assessment for lateral soft tissue release and phalangeal varisation. Post-operatively, patients were kept heel weight-bearing without cast for 6 weeks, with use of a fabric splint after removal of bandages at 2 weeks.

HVA and IMA were measured pre-operatively, at 6 weeks, and at 6-12 month follow-up. Distance from the mid-points of the 1st to the 5th metatarsal heads and distance from lateral sesamoid to 2nd metatarsal shaft were also recorded by blinded observers. AOFAS Foot Scores were collected prospectively. Student's t-test for single-tailed paired data was applied and p-values calculated. There were 22 female and 10 male feet; in patients aged 27 to 74 (mean 58).

Average HVA improved from 34° to 17° and was maintained at 16°. IMA improved from 14° to 7°, but then increased significantly to 10°. Overall inter-metatarsal width reduced from 76mm to 65mm but then significantly increased to 71mm. Sesamoid distance was also reduced and later increased, but not significantly. Mean foot scores improved from 52 to 85 at late follow-up. Complication rate was low.

Late widening occurred more in those feet with bigger original HVA, which were likely to have had more extensive soft tissue release (deep inter-metatarsal ligament). We recommend cautious release; and pre-operatively counselling specifically regarding eventual overall foot-width.

Hind foot arthrodesis through traditional lateral approach in patient with severe valgus deformity carries a significant risk of wound breakdowns, infection and the risk of sural nerve damage. It is also difficult to fully correct a severe valgus deformity through the lateral approach. To overcome some these problems a medial approach has been recommended. Few authors have reported good results in a small series of cases.

We present a retrospective review of 18 consecutive patients with valgus hind foot deformity who underwent hind foot arthrodesis via a medial approach. There were 10 male and 8 female with an average age of 55 years (range 28–75years). The indications included osteoarthritis in 13; post traumatic OA in 3 and rheumatoid arthritis in 2. The mean pre-op subtalar valgus angle was 32o (range 12 – 49) and mean post op valgus angle was 17 (range 10 – 25). All the wounds healed primarily and there were no incidence of wound breakdown or infection. None of the patients developed neuro-vascular complications. The average time for fusion was 5.6 months (range 3–9). Two patients needed further surgical intervention, one for FHL tethering at the fusion site and one for non-union of subtalar joint in a chronic smoker.

The medial approach not only allows a safe and fantastic access to subtalar joint making correction of valgus deformity easier but is also extendable to include talo- navicular and naviculo-cunieform fusion and FDL transfer as additional procedures through the same approach as and when indicated

In conclusion we recommend the medial approach for performing subtalar arthrodesis in valgus hind foot deformities

We undertook this study to evaluate our results of Arthroscopic Capsular Shrinkage as a treatment of Multi Directional Instability of the shoulder. Patients with symptomatic multidirectional instability (MDI) have excess capsular laxity. Arthroscopic capsular shrinkage is a fairly new procedure, to treat laxity with variable results in the reported literature. We analysed the records of patients who under went 20 (10 males, nine females) arthroscopic thermal capsular shrinkage procedures for MDI of the shoulder, which were performed by the senior author between 2000 and 2004. The mean age was 28.3 years (median 29.4, range 18 to 46 years) and the mean follow up was 44.5 months (median 43, range 20 to 69 months). All patients had undergone specialist shoulder physiotherapy for four months or more prior to surgery. The type of shoulder instability was subcategorised (based upon the predominant symptomatology as perceived by the patient) as follows: dislocation (seven), subluxation +/− pain (nine), and impingement (four). The procedure and postoperative regimen were standardised. Clinical outcome measures were: patient satisfaction, pain and instability. Sixteen shoulders (80%) were symptom free and fully satisfied at last follow up. One patient (5%) had some pain but a stable shoulder. Three patients (15%) [two dislocators and one subluxator] had recurrent instability between six to eight months post operatively and underwent further surgery. The less the instability, the more likely it was, that the procedure would succeed. We conclude that out results are encouraging particularly in patients with less severe instability despite the small size (20) of our cohort of patients. We think that careful patient selection may be important for success from this surgery.

Fracture of the lateral process of the talus (FLPT) is one of the common, yet frequently missed, fractures in snow boarders and can cause severe long-term disability if not treated properly. This fracture has been thought to result from dorsiflexion and inversion combined with axial loading. This assumption is based on injury mechanism reported by patients and anatomical studies and has not been supported by experimental data. We have to understand the mechanism of fracture generation in order to identify potential preventive strategies in equipment design or snowboarding techniques.

In order to understand the pathomechanics of FLPT generation we conducted dynamic impact tests on 19 fresh cadaver lower limbs. A test apparatus was constructed to deliver a pure inversion or eversion moment to the foot and ankle along the centre of rotation of the subtalar joint. An axial load of 2.5 kN was applied to all the legs. The legs were tested in four configurations: inversion with and without dorsiflexion, and eversion with and without dorsiflexion. All the specimens underwent post-test radiographic examination and a necropsy.

Necropsy revealed various injuries including ligamental injuries, malleolar fractures, osteochondral fractures of the talus and joint subluxations. In this study, ten cadaveric leg specimens were subjected to inversion or eversion of an axially loaded and dorsiflexion ankle. Inversion failed to produce any LPT fractures in three injured specimens. However, all six specimens subjected to eversion sustained an LPT fracture. Eversion of an axially loaded and dorsiflexion ankle may be an important injury mechanism for LPT fracture in snowboarders.