Freiberg's Infraction; osteonecrosis of the metatarsal head, is the fourth most common intra-articular osteonecrosis in the body. Surgical intervention is usually reserved for late stage of the disease process (III-V) or failure of conservative management. We evaluated the outcomes of patients treated with primary Interpositional Arthroplasty technique using periosteum and fat for adequate surfacing and as a spacer for Freiberg's Disease. Twenty-three cases (21 patients) were performed from February 2009 – March 2016 (18 women, 5 men). Mean age at surgery was 51.1 years (range 19 – 70.5 years) with 91% affecting the second metatarsal. Twenty-one cases were primary and two cases were revision. Five cases were stage III, 10 were in stage IV and 8 were stage V. All patients underwent Interpositional Arthroplasty using periosteum and fat graft from affected metatarsal inserted as joint spacer and secured with sutures. Patients were followed up by postal questionnaires using two validated questionnaires; MOXFQ and AOFAS. Mean follow-up was 3.7 years (0.6 – 7.6 years). Paired two-tailed student t tests were used to assess clinical significance. The left and right foot was affected in 12 and 11 cases respectively. There were no postoperative infections, non-unions or transfer metatarsalgia. Surgery allowed 8 patients to wear normal footwear, 9 wearing fashion shoes, 5 wearing dress shoes and 5 patients returned to sporting activities. Mean pre-operative and post-operative VAS pain scores were 6.7 (range 4–10) and 3.2 (range 0–0) (p< 0.05). Mean peri-operative AOFAS scores were 43.8 (range 14–14) and 71.3 (range 10–10) (p< 0.05). Mean peri-operative MOXFQ scores were 62.9 (range 23–23) and 31.8 (range 0–0) (p< 0.05). We recommend our novel Interpositional Arthroplasty using periosteum and fat spacer for late stage Freiberg's disease as it can result in significant improvement in pain, prevents donor site morbidity and produces significant functional improvement and patient satisfaction.
The ODEP (Orthopaedic Data Evaluation Panel) rating system should offer a surgeon and patient extra information when making a choice on which implant to use. However, in the current economic environment, ratings may also influence implant choice by contracting bodies. Our aim was to determine the performance of commonly used Acetabular and femoral components in our unit and compare these to their published ODEP ratings (or absence of rating). We analysed all of the following primary THR components (12,792) for revision for any reason, using same date ranges as ODEP where more than 100 implantations had occurred. Hip components: Trinity (3A in 2013), Trilogy (10A* in 2016), Atlas (10A in 2013), Trilogy TMT (10A 2010) Durom (not rated), BHR (10A, 2010), ACCIS (not rated); Femoral components: Taperfit (10A in 2013), Taperloc (10A* in 2016), Metafix (3A in 2013), CPT (10A in 2012), Ecofit (not Rated), ESOP (not rated), Minihip (3A 2013), Durom (not rated), BHR (10A 2010), ACCIS (not rated). Analysis of Kaplan Meier survival curves was undertaken for all components. The rated components and non-rated components were compared using HR and logrank tests for all time groups when ratings were introduced. No statistical difference was observed in any group except for the Trinity cup which had a 98.2% (1344 cups) survival at 6 years. Component survival in our unit was better than ODEP suggested failure for A category of not more than 1% per year, for all components. Whilst we applaud the intention to improve data available for prostheses, the present ODEP system does not distinguish between performances of different implants in our unit. We therefore recommend care when relying upon ODEP ratings to make clinical or contracting decisions.
To determine the efficacy and safety of the Magec system in early onset scoliosis (EOS). In 2011, 6 males and 2 females had Magec rods, with an average age of 8.5 years (2.9–12.7 years), 7 patients had dual rods, and 1 had single. The main cause of EOS was idiopathic scoliosis (n=6), followed by Congenital (n=1), and Syndromic (n=1). Average follow up was 19.4 months (14–26 months). 4 of these patients had their previous Paediatric Isola growing rods exchanged to Magec, and 1 patient had an exchange from single to Dual Magec rods.Aim:
Methods:
Despite the suggestion by Virchow in 1856 that thrombosis was the result of venous stasis, endothelial dysfunction and hypercoagulability there are some fundamental questions which remain to be answered. The published studies fail to provide specific details such as cast type and anatomical location of the thrombosis, but instead focus on the incidence of VTE and which chemical thromboprophylaxis is most effective. Previous studies of VTE in trauma patients have involved small numbers of patients and have not look at the risk medium to long term risk. Most importantly they have not looked at the site of the VTE. This makes interpretation of the link between cast and VTE even more complex. We analysed 1479 consecutive trauma cast applications and the incidence of symptomatic VTE in the six months following the injury. The diagonosis, cast type and site of the VTE was recorded.Background
Methodology
Approximately 20% of patients with ankle fracture sustain syndesmosis injury. This is most common in trans-syndesmotic (type B) and supra-syndesmotic (type C) fibula fractures. Intra-operative assessment of syndesmosis integrity is important because failure to treat these injuries can result in ankle instability and pain. Our aim was to audit the documentation of intra-operative testing of syndesmosis during ankle fracture open reduction and internal fixation (ORIF). All patients who had ankle fracture ORIF between 1/1/2010 and 21/11/2011 were included. Pre-operative radiographs were reviewed and fractures were classified according to AO classification. Operation notes were reviewed for documentation of assessment of syndesmosis integrity. 153 patients, of mean age 50 years (15–93) were included. 60% (n=92) were female. In 78% of cases (n=119), an assessment of syndesmosis integrity was documented in the operation note. Of the patients with no documented syndesmosis assessment (n=35), the majority had type B fractures (n=34). One patient had a type C fracture. We have shown that 22% of patients undergoing ankle ORIF for fracture do not have documented assessment of syndesmosis integrity. We suggest that all patients who have ankle ORIF should have intra-operative assessment and documentation of syndesmosis integrity so these injuries are identified and treated accordingly.
The muscles of the leg collectively comprise the calf pump, however the action of each muscle group on calf pump function is not known. Patients with foot or ankle injury or surgery are often advised to perform foot and ankle movements to help prevent deep venous thrombosis. Our aim was to determine which foot and ankle movements were most effective in stimulating the calf pump. Method: Nine healthy participants were enrolled in this research and ethics approved prospective study. Participants with a previous history of peripheral vascular disease, varicose veins, deep venous thrombosis or previous foot and ankle surgery were excluded. Each participant followed a standardized protocol of foot and ankle movements, starting with foot in neutral position and the baseline and movement peak systolic velocity within the popliteal vein was measured during each movement. The movements tested were toe dorsiflexion, toe plantar flexion, ankle dorsiflexion, ankle plantar flexion. The mean patient age was 34 years (range 28–58), the majority were female (n = 6). All movements resulted in statistically significant changes in peak systolic velocity (p = <0.05). In order of decreasing peak velocity the exercises which had greatest effect on calf pump function were: Ankle dorsiflexion (101cm/s), Ankle plantarflexion (84cm/s), Toe dorsiflexion (63cm/s), Toe plantarflexion (59cm/s). We have shown that all four exercises significantly increased calf pump function. The greatest effect was seen with ankle movements.Introduction
Results
The incidence of deep venous thrombosis (DVT) in patients with lower limb cast immobilization occurs in up to 20% of patients. This may result from altered calf pump function causing venous stasis. Our aim was to determine the effects of below knee cast on calf pump function. Nine healthy participants were enrolled in this research and ethics approved prospective study. Four foot and ankle movements (toe dorsiflexion, toe plantar flexion, ankle dorsiflexion, ankle plantar flexion) and weight bearing were performed pre and post application of a below knee cast. Baseline and peak systolic velocity within the popliteal vein was measured during each movement. Participants with peripheral vascular disease, varicose veins, deep venous thrombosis or previous foot and ankle surgery were excluded.Introduction
Method
Patients with hip fracture are at high risk of venous thromboembolism (VTE). Chemical thromboprophylaxis with low molecular weight heparin (LMWH) is associated with a risk of major bleeding in certain patient groups, such as those with renal failure. In these patients, unfractionated heparin should be used. Our aim was to determine the practice of VTE risk assessment in patients admitted with hip fracture against the national guidance, which states that all should have VTE risk assessment on admission. We also assessed the impact of introducing the VTE risk assessment form on prescribing practice of chemical thromboprophylaxis in patients with renal failure. Prospective audit of patients of 50 patients admitted with hip fracture from 4/8/10 with re-audit of 50 patients admitted from 17/2/2011 after introducing the VTE risk assessment form into the hip fracture admissions proforma. Retrospective analysis was undertaken to determine chemical thromboprophylaxis prescribing in patients with eGFR <30ml/min/1.73m2. Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). There were similar numbers of patients with eGFR <30ml/min/1.73m2 in both audit loops with 8% (n=4) in the initial audit, and 10% (n=5) in the re-audit. Frequency of VTE risk assessment significantly increased from 16% to 86% after including the VTE risk assessment form in the hip fracture proforma ( Documentation of VTE risk assessment in patients admitted with hip fracture can be improved by simple measures such as inclusion of the VTE risk assessment form in the admissions proforma. However, this did not result in a reduction of LMWH prescribed in patients with significant renal failure and risk of major bleeding.
To review the Five year survivorship of Kinnemax TKA performed at the NHS Treatment Cantre, Weston-Super-Mare (WSM), and compare it to a similar cohort from our institution. As part of the government's initiative to reduce waiting times for major joint surgery in Wales, the Cardiff and Vale NHS Trust (CAVOC) sent 224 patients (258 knees) to the NHS Treatment Centre in Weston-Super-Mare (WSM) for total knee arthroplasty. Controversy remains as to the unexpectedly high revision rates previously seen.Purpose
Introduction
Cognitive impairment is common in patients with hip fracture both on admission and may develop later on. Reduced cognitive function is a risk factor for development of delirium, correlates with poor rehabilitation, and is an independent predictor of increased mortality. Despite its commonplace and potential for serious morbidity, cognitive dysfunction is often poorly assessed & diagnosed. Our aims were to 1) assess the practice of cognitive assessment on admission for hip fracture patients according to local guidelines and 2) ascertain whether it can be improved by the formal introduction of Abbreviated Mental Test Score (AMTS) & Clock Drawing Test (CDT) in the hip fracture admission proforma. A prospective audit was undertaken of cognitive assessment by either AMTS or CDT for 50 consecutive patients admitted with hip fracture from 4/8/2010. Subsequently, the hip fracture admission proforma was amended to include both the AMTS & CDT. A re-audit was performed on 50 consecutive patients admitted from 17/2/2011 to determine the change in practice. Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). Cognitive assessment by either AMTS or CDT significant increased from 28% (n=14) to 86% (n=43) in the re-audit ( The assessment of cognitive function can be greatly improved by inclusion of both the AMTS & CDT to the hip fracture admission proforma, allowing the most appropriate multi-disciplinary care to be planned for the patient. Whilst both CDT and AMTS are good screening tools for cognitive impairment, many are unfamiliar with CDT & more training is needed.
