Aim

Surgical options for management of a failed ankle arthroplasty are currently limited; typically conversion to fusion is recommended with only a few patients being considered for revision replacement surgery. This paper presents our experience of revision ankle replacements in a cohort of patients with failed primary replacements.

Deficiency in the gluteus medius and minimus abductor muscles is a well-recognised cause of hip pain and considerable disability. These patients present a management challenge, with no established consensus for surgical intervention. Whiteside in 2012 described a surgical technique for gluteus maximus tendon transfer, with successful outcomes reported. This study is the largest known case series to date of patients undergoing gluteus maximus tendon transfer with clinical and patient reported outcomes measured.

13 consecutive patients were included in the study. All patients had clinical evidence of abductor dysfunction together with MRI evidence of gluteal atrophy and fat infiltration. All patients underwent gluteus maximus transfer with surgery performed according to the procedure described by Whiteside. Patients were followed up with both clinical assessment and patient questionnaires conducted.

Mean age was 69 (range 54–82) with 9 patients (69%) having previous Hardinge approach to the affected hip. 6 patients (46%) reported they were satisfied overall with the procedure and 5 patients (38%) were unsatisfied. 7 patients (54%) had improvements in visual analogue scale of pain and 5 patients (54%) reported overall improvements in function. Mean Oxford Hip Score on follow up was 20/48 (range 5–48) and trendelenberg test was positive in 11 patients (85%). No differentiating variable could be identified between patients with positive and negative outcomes (Assessed Variables: Age, sex, BMI, aetiology and gluteus maximus muscle thickness).

Clinical outcomes were varied following gluteus maximus tendon transfer for chronic hip abductor dysfunction. Results are considerably less promising than pre-existing studies would suggest.

Local infiltration analgesia is a relatively novel technique developed for effective pain control following total knee replacement, reducing requirements of epidural or parenteral post-operative analgesia. The study aimed to investigate the anatomical spread of Local Infiltration Analgesia (LIA) used intra-operatively in total knee arthroplasty (TKA) and identify the nerve structures reached by the injected fluid.

Six fresh-frozen cadaveric lower limbs were injected with 180ml of a solution of latex and India ink to enable visualisation. Injections were done according to our standardised LIA technique. Wounds were closed and limbs were placed flat in a freezer at −20°C for two weeks. Limbs were then either sliced or dissected to identify solution locations.

Injected solution was found from the proximal thigh to the middle of the lower leg. The main areas of concentration were the popliteal fossa, the anterior aspect of the femur and the subcutaneous tissue of the anterior aspect of the knee. There was less solution in the lower popliteal fossa. The solution was found to reach the majority of the terminal branches of the tibial, fibular and obturator nerves.

Overall, there was good infiltration of nerves supplying the knee. The lack of infiltration into the lower popliteal fossa suggests more fluid or a different injection point could be used. The solution that travelled distally to the extensor muscles of the lower leg probably has no beneficial analgesic effect for a TKA patient. This LIA technique reached most nerves that innervate the knee joint which supports the positive clinical results from this LIA technique. However, there may be scope to optimise the injection sites.

In this study we aimed to identify which anatomical site was the most effective for methicillin resistant staphylococcus aureus (MRSA) detection within an elective orthopaedic setting. A retrospective review was performed of 13,373 elective orthopaedic patients from pre-assessment and admission screening swabs taken over a five year period (2005-2010). Swabs were taken from the nose, the axilla and either the groin or perineum. MRSA was identified in 136(1.02%) of patients. The nose was found to be positive for MRSA in 89.6% of cases identified. Therefore only 10.4% of the MRSA carriers (0.1% of all admissions) would not have been identified had a single nasal swab been taken. There was no additional benefit in swabbing the axilla. We believe that for the majority of orthopaedic elective admissions a single nasal swab should be sufficient. In hip arthroplasty patients it may be beneficial to additionally swab the groin given the close proximity of the surgical wound.