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

Following the publication of our original survey in 2000 (Eur. Sp. J. 11(6):515-8 2002) we have sought to re-evaluate the perceptions and attitudes towards spinal surgery of the current UK orthopaedic Specialist Registrars (SpRs), and to identify factors influencing an interest in spinal surgery. At that time 175 orthopaedic spinal surgeons in the UK needed to increase by 25% to satisfy parity with other European countries.

Introduction

This study investigates the effect of somatisation on results of lumbar surgery.

Introduction: Fractures of the neck of femurs in amputees have been reported sporadically in literature. We reviewed a series of 19 amputees who presented with a fracture neck of femur to analyse their mobility and pain scores at the end of one year and compared them with other patients presenting with the same condition.

Methods: We retrospectively analysed prospectively collected data for fractures of the proximal femur on all patients with amputations of the lower limb. Details on admission of all consecutive admission to one hospital were recorded from 1989 onwards including age, sex, type of amputation, fracture type, mechanism of injury, peri-operative mobility and rehabilitative status up to 1 year post operatively.

Results: Nineteen (19) patients with 22 amputations, sustaining 20 fractures of the neck of femurs were treated among approximately 6500 neck of femur fractures in our hip fracture database. Of these 7 were male and 12 were female. The mean age was 79 years with a range of 50–89 years. 17 patients had undergone below knee amputations (BKA) and 5 above knee amputations (AKA). Thirteen patients came from their own homes with thirteen patients being mobile pre-operatively while 6 were bed bound. All patients were alert and scored well on mental test scores. Intracapsular fractures were the most common type with AO Screw fixation being the most common operative management. Hospital stay was an average of 7 days with a range of 1–90 days. Thirteen of our cohort of patients survived more than a year after the fracture operation. Post operative mobility scoring revealed that most of our patients returned to their preoperative mobility level except for those that did not survive for the first year.

Discussion: Fractures of the neck of femurs have an increasing incidence in an expanding aging population with nearly 60000 fractures treated in the United Kingdom every year. Amputees suffer from accelerated bone density loss and are at an increased risk for osteoporosis and fragility fractures in the hip. The future prospect with an increasing population of amputees with fracture neck of femurs must be addressed so that appropriate management plans can be implemented to allow such patients to return to full mobility and active lifestyle. This also decreases other co-morbidities such as pressure sores and infection.

Approximately one third of our patients survived between 1 to 4 years and another third survived between 5 to 10 years with one patient surviving over 10 years with nearly returning to their pre-injury status. We suggest that satisfactory post operative function is achievable with either internal fixation or hemiarthroplasty.

We conclude that these fractures should be treated with the same urgency and expertise as similar fractures in non-amputees as long term survival and good quality of life can be expected.

Introduction: Leg length discrepancy (LLD) following total hip replacement (THR) is not uncommon. Some patients are symptomatic, with problems such as gait imbalance or back pain. LLD is a potential cause of litigation following THR.

We have observed that some patients perceive their LLD to be much greater than the true LLD. A large LLD is sometimes reported by therapists, despite only a small true LLD.

We have found that abduction tightness is a potent cause of apparent LLD, and report our investigations into this phenomenon.

Method: We have identified a series of patients with abductor tightness and a significant apparent LLD. The LLD becomes apparent when the operated leg is adducted to the midline (or when the patient stands with their ankles together). This causes the contralateral pelvis to elevate and the un-operated leg to “shorten”.

Clinical photographs and videos have been produced to demonstrate this phenomenon.

A 2-dimensional model has been made to demonstrate how the degree of abduction, offset and over-lengthening affect this phenomenon.

A computer model has been used to quantify these effects.

Results: An abduction contracture after THR will cause the un-operated leg to be apparently and functionally short, even in the absence of a true discrepancy.

Even with only minor abductor tightness, increasing the true length will disproportionately increase the apparent LLD.

Conclusion: An abduction contracture is a potent cause of apparent LLD. Even a small degree of true over lengthening will be greatly magnified by this phenomenon. We recommend careful clinical assessment for abductor tightness when examining patients complaining of a LLD after THR.

Introduction: This study investigates the effect of soma-tisation on results of lumbar surgery.

Methods: Pre- and postoperative data of all primary discectomies and posterior lumbar decompressions was prospectively collected. Pain using the Visual Analogue Score (VAS) and disability using the Oswestry Disability Index (ODI) were measured. Psychological assessment used the Distress Risk Assessment Method (DRAM). Follow-up was at 1 year.

Results: There were a total of 320 patients (average age 49.7 years). Preoperatively there were 61 Somatising and 75 psychologically Normal patients. 47 of the pre-operative Somatisers were available for follow-up.

All pre-operative parameters were significantly higher compared with the Normal group (back pain VAS 6.3 and 3.8; leg pain VAS 7 and 4.7; ODI 61 and 34.4 respectively).

At 1 year follow-up, 23% of the somatising patients became psychologically Normal; 36% became At Risk; 11% became Distressed Depressed; and 30% remained Distressed Somatisers.

The postoperative VAS for back and leg pain of the 11 patients who had become psychologically Normal was 3.4 (pre-op 6.8) and 3.2 (pre-op 6.6) respectively. In the 14 patients who remained Distressed Somatisers the corresponding figures were 5.6 (pre-op 7.8) and 6.7 (pre-op 7.0).

The postoperative ODI of the 11 patients who had become psychologically Normal was 26.4 (pre-op 55.5).

In the 14 patients who remained Distressed Somatisers the corresponding figures were 56.7 (pre-op 61.7).

These differences are statistically significant.

Discussion: Patients with features of somatisation are severely functionally impaired preoperatively. One year following lumbar spine surgery, 60%(28) had improved psychologically, 23%(11) were defined as psychologically normal. This was associated with a significant improvement in function and back and leg pain. The 14(30%) patients who did not improve psychologically and remained somatisers had a poor functional outcome. Our results demonstrate that psychological distress is not an absolute contraindication to lumbar spinal decompressive surgery.

Introduction: Following the publication of our original survey in 2000 (Eur. Sp. J.11(6):515–8 2002) we have sought to re-evaluate the perceptions and attitudes towards spinal surgery of the current UK orthopaedic Specialist Registrars (SpR’s), and to identify factors influencing an interest in spinal surgery. At that time 175 orthopaedic spinal surgeons in the UK needed to increase by 25% to satisfy parity with other European countries.

Methods: A postal questionnaire was sent to all 950 SpR’s. The questionnaire sought to identify perceptions in spinal surgery, levels of current training and practice, and intentions to pursue a career in spinal surgery.

Results: As before, a 70% response rate has confirmed that 74% of trainees intend to avoid spinal surgery (69% in 2000). However 10% are committed to become a Specialist Spinal Surgeon (9% in 2000). Their perceptions were wide ranging but most concluded that the intellectual challenge and opportunities for research are widely recognised. However enthusiasm is dampened by poor perceptions of outcomes from surgery, negative somatization and depression associations, complications and the fear of litigation. In some areas there is inadequate exposure to spinal surgery during the first 4 years of training.

Conclusions: Spinal surgery remains a career choice for 10% of surgical trainees (up 1% since 2000). With a large SpR expansion (578 to 950 SpRs in the last 5 years) an average of 16 new spinal surgeons annually will be produced over the next six years. This has improved on the figure of 8.6 per year from 2000 and represents a 200% increase in numbers per year. These figures suggest that by 2011 and allowing for retirement, there should be enough spinal surgeons to meet the desired UK/Europe ratio.