Summary Statement

This study assesses the service provision of viscosupplementation within an NHS (British National Health System) hospital. The results of this study show long term efficacy of the treatment, when provided by a dedicated, orthopaedic unit.

Aim: To see the efficacy of white cell scan in the diagnosis of prosthetic joint infections.

Materials and methods: A retrospective study was done from Jan 2001 to Dec 2003 on patients with suspected joint infections after prosthetic joint surgery that had white cell scans. 109 patients were identified. We excluded 13 patients due to lack of proper documentation. The case notes for clinical details, laboratory investigations, radiological investigations were reviewed for this purpose. All the patients who did not have intervention were followed for a year for signs of infection.

Results: After exclusion, of 13 patients, 96 patients were taken into the study. Of these, 44 were males and 52 were females. The age range was from 53 years to 91 years with an average of 76 years. We identified 30 total hip replacements, 61 total knee replacements, 3 shoulder replacements and 2 hemi-arthroplasties. 77 of these were cemented and 19 uncemented. The scan was done on an average of 23 months, with a range of 4 months to 16 years after the surgery. The chief complaint was persistant pain at rest and walking in all patients.11 patients had swelling, 7 had redness. None of the patients had discharge. White cells were raised in 6, ESR was raised in 28, and CRP was raised in 15 patients. Antibiotics were started on clinical grounds in 10 patients of which 4 patients showed no response. Plain X-Rays suggested infection in 5 patients. White cell scan suggested infection in 26 patients. Irrespective of scan report, 28 patients were operated for symptoms. There was surgical evidence of infection in 11 patients and 17 had aseptic loosening. Of the 11 surgically confirmed cases of infection, white cell scan showed infection only in 7 patients.

Infection +ve Infection –ve

Positive White Cell Scan 7 19

Negative White Cell Scan 5 65

The specificity of the WCS is 0.77 and sensitivity is 0.58. The positive predictive value is 0.36, and negative predictive value is 0.92.

Conclusion: White cell scan has a good predictive value for exclusion of prosthetic joint infections it has high false positive rate. However caution must be excised in interpreting the negative scans. Persistent symptoms should not be ignored. We recognise that the limitation of our study is our small sample size.

We present a retrospective study on the outcome of Clayton’s forefoot arthroplasty in 23 patients with rheumatoid arthritis.

The average age at surgery was 51.2 years (range 26–88). Pre-operative symptoms were pain, deformity, and footwear problems. Hallux valgus, lesser toe deformities and callosities were the common signs. One surgeon performed all procedures. All patients were assessed radiologically and clinically using American Orthopaedic Foot and Ankle Society (AOFAS) rating system.

Thirteen patients had bilateral correction, and 10 had single foot surgery, providing a total of 36 feet for analysis. Complications included eight wound infections, two toe tip ulceration, two ischaemic toes and two painful feet.

The AOFAS average score was under 45 before surgery and it improved to 83 (range 47–100) for hallux and 79 (range 40–100) for the lesser toes. Overall 91% patients were pleased with the procedure. Our results suggest that Clayton’s forefoot arthroplasty is a procedure, which provides predictable comfort and immediate, functional improvement in advanced rheumatoid arthritis.

Aim To assess the outcome of ankle fractures in diabetic patients.

Method The case notes and X-rays of 39 patients with diabetes, who had sustained ankle fractures between 1994–2003, were retrospectively analysed.

Results There were 23 females and 16 males with mean age of 66 years in females and 51 years in males. The fracture was the result of a twisting injury in 37 of 39 patients. The average duration of diabetes prior to the fracture was 9.6 years. Thirty per cent of patients had systemic complications. Twenty patients had insulin dependent and 19 had non-insulin dependent diabetes. Fractures were on the left side in 21 patients. One patient had a Gustilo grade 2 fracture. Two had a single malleolar fracture, 28 had bi-malleolar fractures and the remaining nine had tri-malleolar fractures. Talus shift was present in 26 cases. The average time to surgery is 3.8 days. The mean ASA grade is 2.3. Twenty-one patients were managed operatively, of which seven had an infection. One patient underwent amputation. One had post-operative myocardial infarction. Nineteen were managed conservatively and in this group, four patients had infected pressure sores from the plaster, of which two needed plastic surgery care. One was managed with external fixator and developed osteomyelitis, and persistent talus shift and non-union.

Three patients died within 2 years of fracture due to diabetes-related complications. Union was achieved in 36 cases and 30 of the patients walked independently after union.

Conclusion There is a high complication rate following surgery for fractures of the ankle in diabetic patients, but conservative treatment also carries a significant risk because poor skin condition can lead to pressure sores while in plaster and these may need major plastic interventions.