Background

Lack of ankle dorsiflexion secondary to a tight gastrocnemius-soleus complex is believed to be a contributing factor in forefoot pain particularly metatarsalgia. It is believed that by lengthening the gastroc-soleus complex weight is distributed more evenly over the foot reducing symptoms. However lengthening any tendon, especially using a percutaneous method carries risks of over-lengthening. In the summer of 2008 we started to see some patients who complained of significant weakness in their Achilles tendons following the 3 cut percutaneous tenotomy procedure.

The aim of this study was to determine the accuracy of Magnetic Resonance Imaging (MRI) scanning compared to arthroscopic findings in patients presenting with chronic ankle pain and/or instability. We reviewed all patients who underwent arthroscopy of the ankle between December 2005 to July 2008 in our institution.

A total of 105 patients underwent arthroscopy for chronic ankle pain and/or instability. Twenty-four patients underwent MRI prior to the procedure. We compared the MRI findings with arthroscopic findings. We specifically examined for the anterior talofibular ligament (ATFL), calcaneofibular cigament (CFL) and osteochondral lesions(OCD). Arthroscopic findings were considered as a gold standard. There were 12 female and 12 male patients with an average age 39 years (11–65). The time interval between the MRI scan and arthroscopy was 7 months (2–18). In our study MRI had 100% specificity for the diagnosis of ATFL and CFL tears and osteochondral lesions. However sensitivity was low particularly for CFL tears. The accuracy of MRI in detecting ATFL tear was 91.7%, CFL tear was 87.5% and osteochondral lesion was 83.3%.

We conclude that MRI scanning has a very high specificity and positive predictive value in diagnosing tears of ATFT, CFL and osteochondral lesions. However sensitivity was low with MRI. In a symptomatic patient negative results on MRI must be viewed with caution and an arthroscopy is advisable for a definitive diagnosis and treatment.

Introduction: We found some unusually long delays and repeated canellations in patients on warfarin and associated proximal femur fractures. Aim of our study was to find the safe INR levels at which the patients can be subjected to surgery and if possible determine the approximate time when patients would reach the safe levels based on INR results at admission. Generally an INR level of less than 2.0 is considered safe and there is no set policy within hospitals on advance booking of these patients.

Methods: We identified all proximal femur fractures in a one year period in our hospital who were on warfarin, determined the reason for which they were on warfarin. Checked INR, LFTS and Renal function on admission. Patients had daily INR levels done at 6’oclock in morning to determine the suitability for theatre.

Results: There were 23 patients of total 437 patients with proximal femur fractures on warfarin. Single most important reason for treatment on warfarin was atrial fibrillation(in 18 patients),other reasons were thromboembolic disease, recurrent pulmonary embolism and heart valve replacement. The INR on admission ranged 1.6–4.0 with a mean of 2.6.We found that most patients with an INR less than 3.0 on admission had acceptable levels within three days of admission whilst those with an INR greater than 3.1 had an acceptable levels within four days. In patients with raised LFTS or renal function impairment took longer time to settle.

Conclusion: We recommend that patients with an INR less than 3.0 can be provisionally booked for theatre 3 days from admission while those with an INR 3.1–4.0 can be listed for theatre 4 days from admission except where there is a grossly altered renal or liver function. By listing patients in above method, unexpected cancellations and the practice of keeping the patients fasted on a daily basis can be avoided.