Introduction

Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to perform major foot/ankle operations as day-case. This could have significant impact on length of stay, saving resources and is in keeping with government policy. However, there are theoretical concerns about complications and low patient satisfaction due to pain.

Alcohol-based cutaneous disinfectant use is well established in the surgical environment. However, during scrubbing, volatile alcohols are inspired into the pulmonary system. With the recent reduction in the national drink driving limit, even low levels of detected breath alcohol can have legal implications. This study aimed to determine the extent to which passive inhalation of alcohol-based surgical hand disinfectant affects estimated percentage blood alcohol concentration (%BAC) on breathalyser testing.

Over a one week period (September 2015), 24 theatre team members (13 surgeons, 6 scrub staff and 5 anaesthetists) were prospectively recruited. The mean cohort age was 43.7 years (50% female). Participants were instructed to scrub for 90 seconds with an alcohol-based hand disinfectant comprising of the active ingredients (per 100g): propan-1-ol 30.0g, propan-2-ol 45.0g and mecetroniumetilsulphate 0.2g. Estimated %BAC was recorded immediately before and after scrubbing, and every five minutes thereafter until levels returned to 0.00%BAC. Results ≥ 0.05%BAC were deemed above the Scottish legal driving limit.

All participants exceeded the 0.05%BAC threshold on immediate post scrub testing. The mean peak %BAC was 0.12% (± 0.05) with a maximum BAC documented at ≥0.20% in four subjects. In all participants, the %BAC descended to zero over a period ranging from 10–30 minutes with a mean time to zero of 16.7 (± 4.8) minutes.

Following the use of alcohol-based surgical hand disinfectant, estimated blood alcohol concentrations detected on breath sampling can rise up to four times the Scottish driving limit which may have legal and professional ramifications.

This study reports the first 10-year clinical and radiological follow-up data for the Sigma PFC. The DuPuy Sigma total knee arthroplasty (TKA) is a modification of the well established Press Fit Condylar (PFC) TKA and is used extensively in the UK and worldwide. It is the most commonly used TKA in England and Wales, where it accounts for 34% of all primary TKA.

A total of 235 consecutive Sigma TKAs were performed in 203 patients between October 1998 and October 1999, in our unit. Patients were seen at a specialist nurse led clinic 7 to 10 days before admission and at 6 months, 18 months, 3 years, 5 years and 7-10 years after surgery. Data was recorded prospectively at each clinic visit. Radiographs were obtained at the 5 year and 8-10 year follow-up appointment.

Of 235 knees 171 (147 patients) were alive at 10 years. Twelve were lost to follow up. Nine knees (3.8%) were revised; five for infection and four underwent change of polyethylene insert. Ten-year survival with and end point of revision for any reason was 95.9%, and with and endpoint of revision for aseptic failure was 98.7%. The mean American Knee Society score was 62 at 8-10 years compared with 31 out of 100 pre-operatively. Of 109 radiographs, 47 knees had radiolucent lines but none showed radiological evidence of loosening.

Our results show that the PFC Sigma knee arthroplasty performs well over the first 10 years post implantation.

The DuPuy Sigma total knee arthroplasty (TKA) is a modification of the well-established Press Fit Condylar (PFC) TKA and is used extensively in the UK and worldwide. This study reports the first 10-year clinical and radiological follow-up data for the Sigma PFC.

A total of 235 consecutive Sigma TKAs were performed in 203 patients between October 1998 and October 1999, in our unit. Patients were seen at a specialist nurse-led clinic 1 week before admission and at 6 months, 18 months, 3 years, 5 years and 7-10 years after surgery. Data was recorded prospectively at each clinic visit.

Of 235 knees, 171 (147 patients) were alive at 10 years. Twelve were lost to follow up. Eight knees (3.4%) were revised; four for infection and four underwent isolated change of polyethylene insert. Ten-year survival with an end point of revision for any reason was 95.9%, and with an endpoint of revision for aseptic failure was 98.7%. The mean American Knee Society score was 62 at 8-10 years compared with 31 out of 100 pre-operatively.

Our results show that the PFC Sigma knee arthroplasty performs well over the first 10 years post-implantation.

Current health economics forces the clinician to consider the cost of treatment. Currently in Fife Hospitals, all lower limb injuries likely to require operative treatment are admitted from the Accident and Emergency department on the day of injury. The aim of this investigation was to see if non-emergency trauma cases could be managed pre-operatively as outpatients to reduce costs.

We prospectively recorded all patients admitted with lower limb trauma excluding neck of femur fractures, requiring operative treatment over an eleven-week period. The senior author reviewed all patients and a clinical judgment was made as to whether the patient could have been safely managed as an outpatient pre-operatively.

61 patients met the inclusion criteria. Average age 41.8 (Range 8-66). The three most common fractures were 23(38%) ankle fractures, 15(25%) tibial fractures and 8(13%) femoral shaft fractures. 28(46%) fractures were deemed safe to have been managed preoperatively on an outpatient basis. 14/23(61%) ankle fractures were deemed safe to be discharged home. The average pre-operative stay was 1.38 nights (Range 1-4 nights).

By initiating a simple policy of allowing uncomplicated ankle fracture patients to wait at home and return on the morning of surgery it is possible to reduce inpatient occupancy by 64 nights per year in our department. At a cost of £518 per patient per night, this could result in a saving of around £33,000 in unnecessary overnight inpatient stays. In order to achieve this, clear clinical guidance for admitting doctors is necessary and further prospective research should be conducted into the risk/benefit of implementing this policy.

The exact action of the Peroneus Longus muscle on the foot is not fully understood. It is involved in a number of pathological processes like tendonitis, tenosynovitis, chronic rupture and neurological conditions. It is described as having a consistent insertion to the base of the first metatarsal, but there have also been reports of significant variations and additional slips.

Our aim was to further clarify the anatomy of the main insertion of the Peroneus Longus tendon and to describe the site and frequency of other variable insertion slips.

The course of the distal peroneus longus tendon and its variable insertion was dissected in 20 embalmed, cadaveric specimens. The surface area of the main insertion footprint was measured using an Immersion Digital Microscibe and 3D mapping software. The site and frequency of the other variable insertion slips is presented.

There was a consistent, main insertion to the infero-lateral aspect of the first metatarsal in all specimens. The surface area of this insertion was found to be proportional to the length of the foot. The insertion in males was found to be significantly larger than females. The most frequent additional slip was to the medial cuneiform. Other less frequent insertion slips were present to the lesser metatarsals.

The main footprint of the Peroneus Longus tendon is on the first metatarsal. There appears to an additional slip to the medial cuneiform frequently. Although we are unsure about the significance of these additional slips, we hope it will lead to a better understanding of the mechanism of action of this muscle and its role both in the normal and pathological foot.

Aim

To compare the results of total knee replacement in a consecutive series of morbidly obese patients (body mass index (BMI) > 40 kg/m²) with a matched group of non-obese (BMI< 30 kg/m²) patients.

Pre-operative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA).

We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives. We also had data on pre-operative age, sex and body mass index (BMI).

There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P<0.001).

Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P<0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 - 21.7 with a cardiac history compared to 4.8 - 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, nor did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA.

The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history.

This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors.

Aim

To investigate the incidence, types and trends in diagnosis of venous thromboembolic events (VTE) in patients undergoing total knee arthroplasty (TKA) over a ten-year period.

Introduction: Tarsometatarsal joint (TMTJ) arthrodesis is traditionally performed through a dorsal approach and is associated with higher incidence of cutaneous nerve damage, prominent metalware and high non-union rates. It is postulated that applying fixation to the plantar (tension) side, rather than the dorsal (compression) side would create a more stable construct with higher union rates. A suitable surgical approach has not previously been described. The aim of this study is to define a plantar surgical approach to the TMTJ’s.

Methods: We dissected 10 cadaveric feet, identifying nerves, vessels, muscles and their innervation on the plantar aspect of the 1st and 2nd TMTJ’s.

Results: We found that in all specimens a plane of dissection could be created between the two terminal divisions of the medial plantar nerve between flexor digitorum brevis and abductor hallucis. Although exposure of the 1st TMTJ was relatively easy, access to the 2nd TMTJ was difficult due to its location at the apex of the transverse metatarsal arch and the overlying peroneus longus insertion. We found that the peroneus longus tendon had a variable insertion not only at the base of the 1st metatarsal but also at the medial cuneiform and the base of the 2nd metatarsal.

Discussion: This is a new surgical approach, following an internervous dissection plane. The feasibility of making an incision over the convex side of the rocker bottom deformity and the biomechanical advantage of a plantarly applied fixation device may make this an attractive surgical approach.

Introduction: The sural nerve is commonly encountered in many operations on the lateral part of the foot and ankle, such as fixation of distal fibula, 5th metatarsal and calcaneal fractures, and fusion of the subtalar or calcaneo-cuboid joints. However there is no consensus and quantitative description of the branches of sural nerve distal to the ankle in the reviewed literature. This study aims to describe these branches and quantify their relations.

Methods: The distal course of the sural nerve was dissected in 30 embalmed cadaveric limbs.

Results: A fibular branch was found in close proximity to the tip of the distal fibula in 63% of specimens. A dorsal branch at the level of the cuboid was found in 80% of specimens, however, its point of departure from the main nerve varied considerably. More distally a series of plantar branches of varying number, and at varying distances to each other was found. These branches were then described in relation to the following bony landmarks: the tip of the distal fibula, the calcaneo-cuboid joint, the tuberosity of the base the 5th metatarsal, the shaft of the metatarsal and the 5th metatarso-phalangeal joint. The distances between these landmarks were quantified using digital analysis.

Conclusion: The sural nerve has a number of previously undescribed but potentially important branches distal to lateral malleolus in the foot. Identifying these branches during surgery with relation to the various bony structures should minimise the risk of nerve injury.

The Depuy Sigma Total Knee Arthroplasty (TKA) was introduced in 1997 as a modification of the Pressed Fit Condylar (PFC) TKA. It is the most commonly used TKA in England and Wales, accounting for 34.9% of all primary TKAs performed in 2006. The PFC has reported 10-year survival rates of 90–95%. This study reports the first clinical and radiological outcomes at 7–9 years following TKA using the PFC Sigma prosthesis.

Three hundred and eighteen consecutive Sigma TKAs were performed in 275 patients between October 1998 and March 2000. Patients were prospectively followed up in a specialist nurse-led clinic. Final review was performed in December 2007 or January 2008, i.e. 7–9 years post surgery. Outcome measures included American Knee Society Scores, Radiographic Scores and Oxford Knee Scores. Survival analysis was performed using the life table method.

Of 318 Sigma knees, 225 (193 patients) were alive at 7–9 years. 6 knees in 5 patients were lost to follow up. 7 knees (2.2%) were revised: 6 for infection within the first two years and 1 at 59 months who underwent isolated change of polyethylene insert. The 9-year survival was 97.7% with revision for any reason as endpoint and 99.6% with revision for aseptic failure as endpoint. The mean American Knee Society Knee score was 84/100 at 7–9 years compared with 33/100 pre-operatively. 0f 140 radiographs, 48 knees had radiolucent lines but no knee showed radiological evidence of loosening.

These results suggest that the Sigma TKA gives excellent clinical results up to 9-years.

Outcomes following total ankle replacement (TAR) have been less favorable than hip and knee arthroplasty. The Mobility TAR is a newly introduced mobile bearing ankle prosthesis which, unlike its predecessor the Agility, does not require fusion of the tibiofibular syndesmosis which in theory should reduce the rate of early failure. No studies have been published yet reporting follow-up longer than 1 year after surgery with this prosthesis.

From June 2006 to May 2008, 50 Mobility TARs were performed in our unit. Data have been collected prospectively on all 50 patients and all have been reviewed annually since surgery. Follow up ranges from one to three years.

The mean age was 65 (range 35–79). 20 patients (40%) were male. 10 underwent additional concurrent procedures (six calcaneal osteotomies, one 1st metatarsal osteotomy, two lateral ligament reconstructions, one subtalar arthrodesis). There was one early wound breakdown which subsequently healed without causing deep infection. There were no malleolar fractures. In two prostheses the talar component has subsided over two years resulting in painful loosening. Interestingly both these patients had postraumatic osteoarthritis with a fibular malunion. Both have been listed for revision to arthrodesis. One further patient has a loose talar component without subsidence and is awaiting exploration with a view to revision. There was one deep infection presenting at 18 months. One further patient reports continued hindfoot pain, thought to be from the subtalar joint and is being worked up for arthrodesis. The mean American Orthopaedic Foot and Ankle Society scores (scale 10–100) increased from 30 to 69 scores following surgery.

TAR using the Mobility prosthesis gives good early clinical results. Further follow-up studies are required to see if this performance is maintained in the long term.

Preoperative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA). We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives.

We also had data on preoperative age, sex and body mass index (BMI).

There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P< 0.001).

Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P< 0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 – 21.7 with a cardiac history compared to 4.8 – 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, as did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA.

The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history.

This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors.

Introduction: The Depuy Pressed Fit Condylar (PFC) total knee arthroplasty (TKA) is well established with reported 10-year survival rates of 93–97%. The PFC was modified, leading to the introduction of the Sigma TKA in 1997. The theoretical advantages of the Sigma system include increased contact area between the femoral component and the tibial insert. We report the first 5-year clinical and radiographic follow-up data for the Sigma TKA.

Methods: Over a ten-month period, 211 Sigma TKAs were performed in 179 patients. Patients were seen at a specialist nurse-led clinic at admission and at 6 months, 18 months, 3 years and 5 years after surgery. Data were recorded prospectively at each visit. Radiographs were obtained at the 5-year follow-up appointment.

Results: Of 211 knees, 187 (150 patients) were alive at 5 years. 5 were lost to follow up. 5 knees (2.4%) were revised: 4 for infection and 1 underwent change of polyethylene insert at 4.9 years. 5-year survival with an endpoint of revision for any reason was 97.4%; with an endpoint of revision for aseptic loosening it was 99.5%. The median American Knee Society score was 93/100 at 5 years compared with 25/100 at admission. Of 145 radiographs, 17 (11.7%) showed radiolucent lines. None showed radiographic loosening of either component. 28 (19.3%) had alignment outside the range of 7±3° valgus.

Discussion: These results suggest that the Sigma TKA gives excellent clinical results after five years. Further follow-up studies are required to see if this performance is maintained in the long term.