We report the functional outcome and survivorship of the Hintegra Total Ankle Replacement (TAR), in consecutive cases by multiple surgeons in a single UK institution. Between 2010–2014 the Hintegra TAR held 7.1% UK market share and surgeons should be aware of failure mechanisms. We conducted a retrospective review of prospectively collected data for 70 consecutive Hintegra TAR cases in a single institution between 2010–2014. Data collected included patient demographics, complications, reoperations, patient reported outcome measures (PROMS: AOS, MOX-FQ, pain VAS) and patient satisfaction.Introduction
Methods
When ankle arthroplasty fails the options are revision to arthrodesis or revision to arthroplasty. We report early outcomes of revision procedures for failed total replacement. Retrospective review of prospectively collected data including post-operative complications, union, survivorship and PROMS scores to compare revision to arthrodesis and revision to arthroplasty.Introduction
Methods
Lateral approach open calcaneal osteotomy is the described gold standard procedure in the management of hindfoot deformity. With development of minimally invasive surgery, a MIS approach has been described, citing fewer wound complications and lower risk of sural nerve injury. This audit compares MIS to the traditional procedure. A retrospective review of all patients undergoing calcaneal osteotomy in Northumbria Trust in the past 5 years was performed. A total of 105 osteotomies were performed in 97 patients; 28 (13M:15F) in MIS group and 77 (40M:37F) had an open approach. The average age was 52.1 (range 16–83) for MIS and 51.5 (range 18–83) in the open group. All patients were followed up for development of wound complication, nerve injury and fusion rate. Wound complications were similar (10.7% in MIS group vs 10.3% in Open group) with no significant difference (p=0.48). Patients were treated for infection in 3(3.8%) cases in the open group and 2(7.1%) in the MIS group. This difference was not significant (p=0.43). 4 (14.3%) patients in the MIS group had evidence of sural nerve dysfunction post-operatively (managed expectantly), compared to 12(15.5%) patients in the open group (p=0.44). Of these, 2 went on to undergo neuroma exploration. There was no difference in nerve dysfunction in varus or valgus correction. Mean translation in the open group was measured as 7.3mm(SD=1.91;3 to 13mm) and 7.5mm(SD=1.25;5 to 10mm) in the MIS group. Translation was similar in varus or valgus correction. Non-union occurred in 2 patients in the MIS group and none in the open group (p= 0.06). MIS calcaneal osteotomy is a safe technique, that works as effectively as osteotomy performed through an open approach. There were lower rates of nerve injury, wound complication and infection, but this was not significantly different comparing groups. There was a higher risk of non-union in MIS technique.
Day Case Surgery (defined as same day discharge) is a priority within the National Health Service and has been shown to provide beneficial outcomes for patients and hospitals. We report our experience developing a Day Case Programme for Total Ankle Replacement (TAR). Prior to the introduction of a Day Case Programme, average length of stay following TAR in our unit was 3.5 days. Stakeholders were consulted about ways in which same day discharge could be facilitated. Patients' post-operative pain charts were reviewed prior to the introduction of this programme. Inclusion criteria included non-complex surgery (anticipated tourniquet < 2hrs), friend or relative support and pre-operative walking-aid assessment. An enhanced recovery protocol included long-acting popliteal block and dexamethasone. Patients were discharged with opiate analgesia and written pain instructions. Patients were asked to complete a pain and satisfaction questionnaire. Patient Reported Outcome Measures (PROMs) were recorded.Introduction
Methods
The use of a knotless TightRope for the stabilisation of a syndesmotic injury is a well-recognised mode of fixation. It has been described that the device can be inserted using a “closed” technique. This presents a risk of saphenous nerve entrapment and post-operative pain. We aimed to establish the actual risk of injury to the Saphenous Nerve using a “closed” technique for the insertion of a TightRope.Background
Aim
Traditionally, the extended lateral approach (ELA) was the favoured approch for calcaneal fractures, but has been reported to have high incidence of wound complications. There has been a move amongst surgeons in the United Kingdom towards the sinus tarsi approach (STA) due to its minimally invasive nature, attempting to reduce such complications. To evaluate outcomes of ELA and STA for all consecutive calcaneal fracture fixation in our institution over a 10yr period.Background
Aims
First Metatarsophalangeal joint fusion has been successfully used to treat Hallux rigidus. We have attempted to evaluate commonly used methods of fixation and joint preparation. To the best of our knowledge, this is the single largest comparative study on first MTPJ fusion. We aimed to evaluate the radiological union and revision rates. We included 409 consecutive MTPJ fusions performed in 385 patients. We collected demographic, comorbidities and complication data. We evaluated the radiographs for the status of the union. Logistic regression was used to calculate the Odds ratio (OR) of non-union for the collected variables. Our union rate was 91.4% (34/409). 29.4% of our non-unions were symptomatic (10/34). Hallux valgus showed a statistically significant relation to non-union (Odds ratio 9.33, p-value 0.017). Other potential contributing factors like sex (OR1.9, p-value 0.44), diabetes (OR 0, p-value 0.99), steroid use (OR 2.07, p-value 0.44), inflammatory arthritis (OR 0, p-value 0.99) and smoking (OR 2.69, p-value 0.34) did not attain statistical significance. Further, the methods of fixation like solid screws (OR 0, p-value 0.99), plate (OR 3.6, p-value 0.187) or cannulated screws (OR 0.09, p-value 0.06) showed no correlation with non-union. We compared two techniques of joint preparation and found no significant difference in union rates (Chi-Square 1.0426, p-value 0.30). Our crude cost comparison showed the average saving to the trust per year could be 33,442.50£ by choosing screws over plate. Only Hallux Valgus had a statistically significant relation to non-union. Solid screw could be economically the most viable option and a valid alternative.
Platelet rich plasma has been advocated for the treatment of plantar fasciitis but there are few good quality clinical trials to support its use. We report a pilot double blind randomised controlled trial of platelet rich plasma versus normal saline. Patients with more than 6 months of MRI proven plantar fasciitis who had failed conservative management were invited to participate in this study. Patients were block randomised to either platelet rich plasma injection (intervention) or equivalent volume of normal saline (control). The techniques used for the injection and rehabilitation were standardised for both groups. The patient and independent assessor were blinded. Visual analogue scale for pain (VAS) and painDETECT were recorded pre-op and at 6 months. Twenty-eight patients (19 females, mean age 50 years) were recruited, with 14 randomised to each arm. At 6 month follow-up, 8 patients (28.6%) were lost to follow-up. There was a significant change in VAS score from baseline to follow-up in both intervention (mean change 37.2, p = 0.008) and control (mean change 42.2, p = 0.003) groups. However there was no difference between the arms in terms of the change in VAS score from baseline to follow-up (p = 0.183). There was no correlation between pre-op PainDETECT score and change in VAS.Methods
Results
The surgical treatment of intractable metatarsalgia has been traditionally been an intra-articular Weil's type of metatarsal osteotomy. In such cases, we adopted the option of performing a minimally invasive distal metaphyseal metatarsal ostetomy (DMMO) to decompress the affected ray. The meta-tarsophalangeal joint was not jeopardised. We present our outcomes of Minimally Invasive Surgery for metatarsalgia performed at our teaching hospital. This is a multi-surgeon consecutive series of all the thirty patients who underwent DMMO. The sex ratio was M: F- 13:17. Average age of patients was 60 yrs. More than one metatarsal osteotomy was done in all cases. The aim was to try and decompress the affected rays but at the same time, restore the metatarsal parabola. It was performed under image-intensifier guidance, using burrs inserted via stab incisions. Patients were encouraged to walk on operated foot straight after the operation; the rationale being that the metatarsal length sets automatically upon weight bearing on the foot. Outcome was measured with Manchester-Oxford Foot Questionnaire's (MOXFQ's) and visual analogue pain score (VAS). Minimum follow up was for six months.Introduction:
Material and methods:
Ankle sprains are one of the most common sports injuries. Around 10–20 % of the acute ankle sprains may lead to the sequelae of chronic ankle instability. Around 15–35% of the patients have residual pain following successful lateral ligament reconstruction. One of the reasons suggested for the persistent symptoms following lateral ligament reconstruction has been the presence of intra-articular pathology. We performed ankle arthroscopy on all patients undergoing the modified Brostrom repair and compared patients with associated intra-articular pathology to those without any intra-articular pathology.Aim:
Methods and materials:
Postoperative pain following the 3 component ankle arthroplasty (AA) (Mobility™) is a recognised problem without any apparent cause. This study aimed to determine pattern of postoperative pain following Total Ankle Arthroplasty (TAA) and its management options. In prospective observational study 167 patients who had (AA) and minimum follow-up of 24 months were included. FAOS ankle score, patients' satisfaction, SF36 and diagrammatic mapping of postoperative pain among other parameters were collected preoperatively and postoperatively at 3 months, 6 months and the annually. 20 Patients (12%) had moderate to severe postoperative ankle pain following the ankle arthroplasty.Introduction
Materials and methods
A prospective cohort of patients undergoing total ankle arthroplasrty for arthritis following pilon fractures was included in the present study. This group of patients generally have poor soft tissue envelope and have had previous surgical interventions prior to the ankle arthroplasty, making the arthroplasty more difficult as well as prone to complications. The data collected included patient demographics, American Orthopaedic Foot and Ankle Score (AOFAS) and patient reported outcomes (FAOS, SF-36, patient satisfaction) The data was collected preoperatively and at 1 & 2 years postoperatively. The minimum follow-up period was 2 years post-operatively.Aim
Methods
The purpose of this study was to investigate the effects of plaster/splint immobilisation of the knee/ankle on driving performance in healthy individuals. Twenty-three healthy drivers performed a series of emergency brake tests in a driving simulator having applied above knee plaster casts, below knee plaster casts, or a knee brace with increasing restriction.Aim
Methods & Materials
The primary goal of treatment of an ankle fracture is to obtain a stable anatomic fixation to facilitate early mobilisation and good functional recovery. However, the need for open reduction and internal fixation must be weighed against poor bone quality, compromised soft tissues, patient co-morbidities and potential wound-healing complications. We reviewed two matched groups of 18 patients each, who underwent fixation for unstable Weber-B ankle fractures with intramedullary fibular nail (Group 1) and Standard AO semi-tubular plate osteo-synthesis technique (Group 2) to achieve fracture control and early mobilisation. Clinical and radiological fracture union time, and the time at mobilisation with full weight bearing on the ankle were used as outcome measures.Introduction
Materials and Methods
The incidence of hip fractures is rising worldwide. Hip fracture patients with a cardiac murmur have an echocardiogram pre-operatively in our unit. We assessed the impact of obtaining a pre-operative echocardiogram on treatment of such patients, using National Confidential Enquiry into Patient Outcome and death (NCEPOD) report 2001 as gold standard. We undertook a retrospective audit of hip fracture patients (N=349) between 01/06/08 and 01/06/09. 29 patients had pre-operative echocardiogram (echo group). A computer generated randomised sample of 40 patients was generated from N, ‘non-echo’ group. Data was obtained from medical records and the Hospital Information Support System. The groups were compared using Student's t test. Age and gender distribution were similar in both groups. 29 patients had pre-operative echo. The indication for requesting an echocardiogram pre-operatively was an acute cardiac abnormality in 4 cases. 25 patients had echocardiogram for no new cardiac problem. In the latter group, the reason for requesting an echo was a cardiac murmur in 23 patients and extensive cardiac history in 2 cases. A specialist input from the cardiologist was sought in 5 cases. Most patients with aortic valve abnormality had surgery under general anaesthetic. No patient required cardiac surgery or balloon angioplasty pre-operatively. There was a significant delay to surgery in the patients who had a pre-operative echo (average 2.7 days, range 0–6 days) compared to ‘non-echo’ group (average 1.1 days, range 0–3 days), (P< 0.001). There was no significant difference in length of stay and mortality at 28 days between the two groups. We are now developing departmental guidelines for requesting echo in hip fracture patients with cardiac murmur to prevent unnecessary avoidable delay. We are developing a link with the cardiology department to expedite echocardiogram requests in hip fracture patients.
Retrospective study to assess the outcomes of ulnar shortening for TFCC tear and distal radial malunion. Retrospective note and x-ray review of all patients undergoing ulnar shortening over a ten year period along with a clinic assessment and scoring to date. The ulnar shortening was performed using the Stanley Jigs (Osteotec). A 5–6 holed DCP was used to stabilize the osteotomy site. Physiotherapy was commenced immediately following the surgery to promote prono-supination and wrist exercises.Objective
Method
The cause of elbow tendinosis is most likely a combination of mechanical overloading and abnormal microvascular responses. Numerous methods of treatment have been advocated. In this study, we evaluated the use of platelet-rich plasma (PRP) as a treatment for resistant epicondylitis. The rationale for using platelets is that they participate predominantly in the early inflammation phases and degranulation. They constitute a reservoir of critical growth factors and cytokines which when placed directly into the damaged tissue, may govern and regulate the tissue healing process. We looked at 25 patients (19 with lateral and 6 with medial) who failed to improve after physiotherapy, cortisone injections and application of epicondylar clasps and assessed the efficacy of platelet-rich plasma injections using Gravitational platelet separation system (GPS). The cohort of patients included over a period of three years had physiotherapy, stretches, epicondylar clasp and an average of 2.9steroid injections (1–6) before having a PRP injection. The mean patient age was 43 years ranging between 24 and 54. There were 11 men and 14 women. The study included 19 patients with lateral epicondylitis and 6 patients with symptoms on the medial side. The ratio between dominant and nondominant side was according to the literature: 76%. The quick DASH scores imroved by 14% on an average in the first 3 months and further 26% in the following 9 months. 4 patients needed reintervention, 3 lateral and 1 medial and had surgical release between 6 and 12 months. 2 of them had reinjections before surgery. No local infections except mild inflammation and no systemic effects were noted. Within the limitations of being a case series and limited follow-up PRP injections provided a safe and progressive benefit over a period of 1 year in refractory cases, providing a good nonoperative alternative.
The goal of arthrodesis around the ankle or of triple (hind foot) arthrodesis is a painless, plantigrade, and stable foot. Stress fracture is a differential diagnosis for pain following an ankle/subtalar arthrodesis. Management of stress fractures following sound ankle/subtalar fusion is extremely difficult as the entire movement tends to occur at the fracture site, hence hampering healing. 33 patients underwent ankle/subtalar arthrodesis at our institute from 2000-2008. The average age of the patients was 69 years and the male: female ratio was 2:1. The minimum follow-up was for one year. Although there were some variations in technique, all the arthrodesis were performed by removal of articular cartilage, bone grafting of any defects and rigid internal fixation.Introduction
Methods and materials
Spinal disc infection is associated with a significant morbidity and mortality in the acute setting. On long term review it leads to significant moribidity due to the deformity and secondary osteoarthritic changes in the surrounding vertebral segments. Prospective collection of data of 21 patients suffering from discitis was collected over the span of last 10 years. The age group ranged between 21 -67 yrs. The male: female ratio was 1.2:1. The minimum delay in presentation since the onset of symptoms was 8 weeks. The detection of the micro-organism was either by needle/open biopsy or indirectly via blood cultures. Serial records were maintained of inflammatory markers. All patients received plain radiographs, gadolinium-enhanced magnetic resonance imaging scans, and bone/gallium radionuclide studies Operative decompression was performed in 7 patients. Infection elsewhere was the most common predisposing factor. Leukocyte counts were elevated in 54% of spondylodiscitis cases. The erythrocyte sedimentation rate and CRP were elevated in all cases of epidural abscess. The most common organism was Staph Aureus. Antibiotics were administered for duration of at least 6 weeks. On long term, all patients developed deformity at the level of the infection, with half of them being symptomatic. Spinal infections are extremely morbid conditions demanding prompt diagnosis and urgent treatment to prevent complications. Ethics approval: Audit Committee Interest statement: No conflict of interest
Lumbar decompression-fusion surgery involves extensive surgery in prone position and is associated with significant post-op ileus. We compared the post-operative oral intake regimes of our two spinal firms over a 6 months period. The post operative oral intake was commenced as soon as the bowel sounds started in one firm. In the other firm, the oral intake was started only after the patient passed wind. There were 28 patients in the first group (bowel sounds) and 27 patients in the second group (passage of wind). The two groups were comparable for age and sex distribution. The average age was 69 yrs, and the male: female ratio was 1.2:1. The bowel sounds were found to start on an average of 8.5 hours (6-16 hours) post-operatively. The average time between the operation and the patient passing wind was 26 hours (18-73 hours). The patients who were on Patient Controlled Analgesia (PCA) were found to have a delayed passage of wind. There was no significant correlation between the number of fusion levels or the operative time and commencement of bowel sounds/ passage of wind The patient satisfaction rate was much better when the oral intake was commenced as soon as the bowel sounds start. The incidence of nausea/vomiting was significantly less in the group in which the oral intake was commenced following patient passing wind. The bloating of the abdomen was found in the first group. Audit Committee Interest statement: No conflict of interest
The purpose of this study was to investigate the effects of right leg restriction at the knee, ankle or both, on a driver’s braking times. Previous studies have not investigated the effects of knee restriction on braking performance. A total of 23 healthy drivers performed a series of emergency braking tests in a driving simulator in either an above-knee plaster cast, a below-knee cast, or in a knee brace with an increasing range of restriction. The study showed that total braking reaction time was significantly longer when wearing an above-knee plaster cast, a below-knee plaster cast or a knee brace fixed at 0°, compared with braking normally (p <
0.001). Increases in the time taken to move the foot from the accelerator to the brake accounted for some of the increase in the total braking reaction time. Unexpectedly, thinking time also increased with the level of restriction (p <
0.001). The increase in braking time with an above-knee plaster cast in this study would increase the stopping distance at 30 miles per hour by almost 3 m. These results suggest that all patients wearing any lower-limb plaster cast or knee brace are significantly impaired in their ability to perform an emergency stop. We suggest changes to the legislation to prevent patients from driving with lower-limb plaster casts or knee braces.
In 1990 an estimated 1.3 million hip fractures occurred worldwide. Clostridium difficile diarrhoea has emerged as a healthcare associated infection of great clinical and economic significance especially in the frail and vulnerable group of fracture neck of femur patients. The major risk factor is peri-operative antibiotic exposure especially cephalosporins. A retrospective audit was performed to study the effect of C. Difficile in operated fracture neck of femur patients. All the patients who were diagnosed with C. Difficile infection after an operated fracture neck of femur at the District general hospital from April 2004 till March 2007 were included in the present study. All patients received the routine peri-operative antibiotic prophylaxis of three doses of intravenous cefuroxime. Data collected included age, sex, duration between operation and the onset of diarrhoea, length of stay and associated mortality. A total of 1023 patients underwent surgery for fracture neck of femur during the three years of study period. The average age of the patients was 81 years. 80% of the patients were females. A total of 62 patients suffered from C. Difficile diarrhoea (6%) after the arthroplasty procedure, and within this cohort, 29 patients died during the same admission to the hospital (47%). The average length of stay for a patient with fracture neck of femur was increased from 23.4 to 60 days in those affected with C. Difficile. The patients with fracture neck of femur are generally elderly with poor body reserves. C.difficile infection in such patients not only adds to the morbidity, but also causes significant increase in the mortality rate. Propagation of simple infection control measures such as hand-washing and isolation and change of peri-operative antibiotic protocol led to a statistically significant reduction in the incidence of C.Difficile infections after fracture neck of femur surgery.
One of the many challenges in revision hip arthroplasty is massive bone loss. Subsidence of the collarless stem with impaction allografting has been reported by several authors. Impaction grafting has emerged as a useful technique in the armamentarium of the revision total hip arthroplasty surgeon. The original technique proposed by Ling has been associated with complications, including femoral shaft fractures, recurrent dislocations, and uncontrolled component subsidence. Modifications in that technique seem to be associated with a reduction in complications. The aim of this study was to assess the functional outcome of radial impaction grafting in femoral bone defects and the use of collared long stem prosthesis. A total of 107 patients underwent radial impaction allografting and collared long stem prosthesis during revision THA between 1997 and 2005. The patients with Paprosky type II, IIIA and IIIB defects were included in this study. Average duration between the primary and revision surgery was 9.4 years (Range 6–23 years). Assessment was done using Oxford Hip Score, Harris Hip Score and with plain X-rays. Three patients were lost to follow-up and three patients died due to unrelated causes. The follow-up period lasted between 12 to 114 months (average – 68.8 months). Three patients who sustained post-operative peri-prosthetic fracture had standard stem inserted in them. None of the patients with long stem sustained peri-prosthetic fracture. Four patients had infection and underwent revision procedure. In this study, using revision for any cause as the end-point, survival of the femoral stem was 93.8%. Subsidence was not recorded in any of the patients in this study. Oxford Hip Score improved from mean pre-operative value of 41.2 to 19.2 post-operatively. Mean Harris Hip Score improved from 40.8 pre-operatively to 83.4 post-operatively. Subsidence of the prosthesis is commonly encountered with collarless stems and this was not a problem in this study. The risk of peri-prosthetic fracture can be reduced by using long stem prosthesis which bypasses the existing cement mantle by at least two femoral diameters. The radial impaction grafting technique permits the use of revision femoral components with variable stem lengths, neck lengths, and neck offsets. We conclude that radial imaction graftind along with collared long stem prosthesis is a good solution for massive femoral bone defects while performing total hip arthroplasty.
Clostridium difficile associated diarrhoea (CDAD) has emerged as a healthcare associated infection of great clinical and economic significance especially in the frail and vulnerable group of fracture neck of femur patients. A major risk factor for the development of CDAD in patients who undergo operation for fracture neck of femur is the perioperative antibiotic exposure, with cephalosporins being particularly implicated. The type ‘027’ strains of C. Difficile are multi-resistant and cause severe morbidity and mortality. A retrospective audit was performed to study the effect of C. Difficile infection in operated fracture neck of femur patients.
One elderly patient with a fatal intracerebral bleed was found to have justified an early CT scan on the criteria of more than one vomiting episode and a history of unconsiousness.
The total of 41 patients were divided into two groups depending on the duration between the primary hemiarthroplasty procedure and its revision to total hip arthroplasty – (1) Less than one year (16 patients) and (2) More than one year (25 patients). The data collected included: age, sex, classification of the fracture, date of primary operation, surgical approach, inflammatory markers, indication and date of revision to total hip arthroplasty, and the final outcome.
