Introduction

The aim of this study was to identify the effects of first MTPJ arthritis, ankle arthritis and hallux valgus on patient reported outcomes, and to assess the efficacy of surgery.

During surgical reduction of ankle injuries with syndesmotic instability surgeons often use the anteroposterior (AP) and mortise radiographs to assess reduction. Current literature predicts 50% are malreduced mainly in the sagittal plane. Our aim was to develop a radiographic measure based on the lateral view to assess both the normal and abnormal fibula/tibia relationship after simulated syndesmotic malreduction and to evaluate the effect on commonly used AP and mortise measurements.

Nine fresh-frozen cadaveric specimens were dissected to the level of the syndesmosis. AP, mortise and talar dome lateral radiographs were obtained before and following syndesmosis division and posterior fibula displacement. On the lateral radiograph a line was drawn (Orthoview) from the anterior border of the fibula bisecting a line drawn from the anterior to posterior lips of the distal tibia. The ratio of the anterior-posterior segments was calculated. Also a line was drawn from the posterior border of the fibula and the distance was measured to the posterior lip of the tibia.

At 0, 2, 4 and 6mm of displacement the ratio measured 1.3±0.2, 1.1±0.2, 0.9±0.2 and 0.7±0.2 respectively with all pairwise comparisons being significantly different. Inter- and intra-observer variability varied from substantial to perfect. The only significant medial clear space (MCS) difference was on the mortise view between 0mm (2.0±0.3mm) and 6mm (2.4±0.4mm) displacement.

Our new measure of syndesmotic reduction is reproducible and can detect from 2mm of saggital fibular displacement. At maximum fibular displacement the increase in MCS was less than 1mm. This demonstrates standard mortise radiographs are poor at detecting syndesmotic reduction. An interesting observation was in all specimens prior to any displacement, the posterior fibular line always bisected the posterior lip of the tibia or lay just anterior to it, never posterior. This could serve as a useful adjunct for surgeons when assessing syndesmotic reduction intra-operatively.

The aim of this project was to look at time taken to achieve clinical resolution of diabetic charcot neuroarthropathy (CN) and to see if there was a correlation with location within the foot and overall outcomes.

A retrospective analysis of newly presenting acute CN patients between 2007 & 2012 was performed. Clinic records were examined to determine the site of the CN; total time treated in a TCC or other removable offloading devices; the presence of co-morbidities.

Fifty CN cases presented during this time. The mean age was 62.5±11.7 (SD) years. Eleven patients had type 1 diabetes mellitus (T1DM). The mean duration of diabetes was 29.7±12.9 years for T1DM, and 14.4±10.7 years for type 2 diabetics. All had palpable foot pulses & peripheral neuropathy at diagnosis. 82% had retinopathy; 34% had CKD stage 3–4. For the 42 patients who completed treatment, the mean duration was 53.9±28.0 weeks, of which a mean of 30.2±25.0 weeks was spent in a TCC. 23.7±16.2 weeks were spent in other offloading devices. Mean duration of treatment for forefoot, mid-foot & hind-foot was 47.2±22.6, 55.9±30.6 & 51.8±23.1 weeks respectively. Thirty-six patients were treated with TCC & other removable offloading devices, 6 were treated with one modality. Fourteen of the 36 (38.9%) required re-casting. Eight patients did not complete treatment: 4 underwent below knee amputation, 2 died, 2 were still undergoing treatment.

In our cohort the mean length of treatment is dependent on the position of the CN. The mean time to resolution is just over 1 year. However, a high percentage (38.9%) deteriorated after coming out of a TCC. This study highlights the need to develop more precise measures to help manage acute CN.

Introduction

The aim of this study is to better understand the anatomy of the forefoot to minimise surgical complications following minimally invasive forefoot surgery.

Introduction

Surgical approaches to the dorsum of the foot are common for management of midfoot fracture dislocations and arthritis. The anatomy can be difficult to identify and neurovascular injury can be a serious complication.

Extensor hallucis brevis (EHB) is a consistent and easily identifiable structure encountered in these approaches. This study assesses the close relationship of the EHB musculotendinous junction to the neurovascular bundle for use as a reliable landmark.

Introduction

Medial column insufficiency in patients with painful acquired flatfoot can be difficult to appreciate. The reverse Coleman block test is used in this study to predict medial column instability.

Introduction

Osteochondral defects of the talus are usually a consequence of trauma. They can cause chronic pain and serious disability. Various interventions, non-surgical and surgical, have been used for treating these defects. The objective of this Cochrane systematic review of randomised control trials is to determine the benefits and harms of the interventions used for treating osteochondral defects of the talus in adults.

Introduction

Medial column insufficiency in patients with painful acquired flatfoot can be difficult to appreciate. The reverse Coleman block test (as described and published by Mr E Wood in 2009) is used in this study to predict medial column instability.

Patella instability is a common problem with many surgical options. We prospectively evaluated the results of medial patella femoral ligament (MPFL) reconstruction with an autogenous gracilis or semitendinous graft. With a minimum follow up of one year patients were reviewed using the Kujala scoring system.

Twenty MPFL reconstructions were performed on seventeen patients over a two year period, from January 2004 to December 2005. There were 13 females and 4 males. Three patients had bilateral involvement. Thirteen patients had a lateral release with their MPFL reconstruction and three had a distal realignment procedure as well to correct their patella instability.

The mean follow up was 17 months (range 12 to 26 months). The average age was 25 years old at operation (range 13 to 47) and the average age of their first dislocation was 16 (range 0-35). Nine patients had previous surgical treatment for patella instability. The average hypermobility score in the patients was 5/9 and six patients scored 9/9.

At follow up 18 out of 20 patients (90%) had stable tracking with no further subluxations/dislocations. Of the two with unstable tracking, one had a stable patella before falling several times onto her knee. An MRI confirmed the ligament was intact but a type 2 trochlear dysplasia was present and a Bereiter trochleoplasty was subsequently performed. The other patient described no frank dislocation but instead subluxations.

Eighteen of the twenty reconstructions (90%) achieved a stable patella. Overall Kujala scores increased by a third.

The ITS volar radial plate (Implant Technology Systems, Graz/Austria) is a fixation device that allows for the distal locking screws to be fixed at variable angles (70°-110°). This occurs by the different material properties, with the screws (titanium alloy) cutting a thread through the plate holes (titanium). We present our experience with the ITS plate.

We retrospectively studied 26 patients who underwent ITS plate fixation for unstable multifragmentary distal radial fractures (AO types A3, B2, B3, C2, C3). The surgery was performed either by a consultant orthopaedic hand surgeon or senior registrar. A volar approach was used every time and 10 cases required synthetic bone grafting. Post-operatively they were immobilised for an average of 2.5 weeks.

The 26 patients had a mean age of 58 and the dominant side was affected in 46% of cases. 5 cases were open fractures and 10 cases followed failed manipulation under general anaesthesia. The average interval between injury and surgery was 7 days. Union was achieved in all cases. No implant infections, failure or tendon rupture/irritation occurred. There were two fractures which loss reduction, of which one required revision surgery. There was one case of CRPS. The six month average DASH score was 27.5.

We consider the ITS plate a technically easy plate to use and a reliable implant at early follow-up. We value the versatility of its variable angle screw fixation ability for complex intra-articular distal radial fractures.

This study was performed to compare the clinical outcomes and radiographic changes between patients with cruciate retaining (CR) and cruciate substituting (CS) total knee replacements (TKR) where the PCL was cut in both groups.

From 1997 to 2001, 114 patients (79 females and 35 males) were enrolled in this study. Patients were blindly randomized into two groups, group 1 having a CR TKR and group 2 having a CS TKR. After surgery patients were followed up at six weeks, one year and at five years. The evaluation parameters at the 5 year assessment included the Oxford Knee Questionnaire, American Knee Society scoring system, SF-12 questionnaire and weight bearing radiographs of the knee, with anteroposterior and lateral views.

There were 80 patients at the time of five year follow up. Of the other patients, 26 had died and 10 were either too ill to attend or did not respond to a follow up request. The average patient follow up was for 77 months (ranging from 51 to 96 months). There was no statistical difference between the two groups in the Oxford Knee Questionnaire, American Knee Society scoring system or the SF-12. Radiological assessment showed no statistical difference in radiolucent lines in either group. At five year follow up, one knee in the CS group had been revised for deep infection. The patient required a two stage revision procedure.

Our study has shown no statistical difference in the five year results for a CR TKR or CS TKR. This suggests that a non-functioning PCL does not affect the performance of a CR TKR.

Introduction: The management of total hip replacement (THR) dislocations is variable after closed reduction. This study was performed to look at the differences in immediate management of THR dislocations after reduction under anaesthesia.

Method: A questionnaire was sent to all members of the British Hip Society asking them about their management of THR dislocations after closed reduction.

Results: 62 orthopaedic consultants completed the questionnaire. A 34% return rate for our postal survey to the 2004 members of the British Hip Society.

For first time dislocations with a stable EUA 8% always used an abduction brace and 50% never used one. 20% were managed with a period of bed rest. For an unstable EUA, 40% always used a brace and 23% never used one. 31% were managed with a period of bed rest. When a brace was used, the majority (75%) used it for 6 weeks (range 2 to 12 weeks).

For recurrent dislocations, with a stable EUA, 65% used a brace for at least 6 weeks. For an unstable EUA 74% used a brace for at least 6 weeks and 15% managed with a brace permanently or until revision.

50% asked the patient to wear the brace 24 hours a day including whilst asleep, the only exception being for washing. The others were varying from 12 to 16 hours a day.

The commonest criteria for revision surgery were recurrent dislocation (seen as more than three), component malposition, aseptic loosening and instability at EUA. The questionnaire was answered by orthopaedic surgeons who all had experience in revision surgery, the majority having performed over 100 revision THR in the past 5 years.

Discussion: The management of dislocated THR is varied between units. There does not appear to be a pattern of management amongst BHS members. The popularity and efficacy of abduction braces remains unknown.