Introduction:

There are concerns with the use of the Shannon burr in calcaneal osteotomies entered from the lateral side, with the medial structures possibly at risk when performing the osteotomy of the medial calcaneal wall. Our aims with this study were to investigate the neurovascular relationships with the calcaneal osteotomy performed using a Shannon burr.

Introduction

The aim of this study was to assess whether routine X-Rays at six weeks altered the subsequent management of patients who underwent a Scarf osteotomy.

Introduction: Physical challenges and a long term treatment for Perthes disease can affect patients’ behaviour in their adolescence. We carried out a study to assess the long term psychosocial development of children treated non-operatively using abduction cast and brace.

Methodology: 104 patients treated for Perthes disease between 1992 and 2001 were recruited for a retrospective study. Besides clinical review, patients and their main carers were asked to fill in Strengths and Difficulties Questionnaires (SDQ). SDQ included scores for total difficulties, emotional symptoms, conduct problems, hyperactivity, peer problems, social behaviour and total impact. 70 controls, matched for age and sex, attending the clinics for other unrelated pathology were requested to fill in the same questionnaires along with their main carers.

Results: Data from 91 patients was available for assessment. Age at diagnosis was 1.9 to 7.3 years (median 3.9 years). Follow-up duration was 5.6 to 15.1 years (median 8.7 years). The age of subjects at final follow up was 8.9 to 20.4 years (median 15.3 years). The mean duration of treatment in abduction cast or brace was 2.4 years.

57 controls and 69 subjects were found to be low risk for emotional disorder (p> 0.05).

Similarly 58 control and 74 subjects were predicted to be low risk for behavioural disorder. 16 controls and 18 subjects had medium or high risk for hyperactivity or concentration disorder (p> 0.05; student t test). There was no significant difference between the self report and parent questionnaires for difficulties or their impact.

Conclusion: Perthes disease and the resultant restricted physical activities in early childhood does not affect the emotional and mental well being of patients in a long term.

Introduction: Complex fractures and singular acute orthopaedic admissions in an individual hospital form only a small proportion of admissions. An average orthopaedic surgeon does not gain and maintain enough experience to provide proficient care. Referral with in the department to a sub-specialist for that anatomical region is forming a norm. We studied the practice in our department to assess how much specialist care we provide.

Materials & Methods: Prospective study over four month’s period with specialist referrals reported by teams and Trauma Fellow. We observed the time spent before making the referrals and that taken by specialists in carrying out management. The spectrum of investigations by various specialist teams was also noted. Number of referrals made to each sub speciality was observed.

Results: Of a total of 836 acute admissions in the department over this four months period, 98 (11.7%) were referred to sub-specialists. Referrals were made on an average of 1.8 days after admission and were seen by the specialist after another 2.1 days. Average time to surgery was 4.7 days after referral. Special Imaging investigations were performed in 84 (86%) patients of whom 31 had been organised before the referral was made. 81 (82%) patients were operated by the specialist teams while rest underwent conservative treatment.

Discussion: With the changing structure and decreasing duration of higher specialist training, expertise in complex trauma is expected to be limited to the anatomical region of surgeons’ interest. Specialist management provides better patient care with improved satisfaction.

Conclusion: In the modern orthopaedic practice with intensive but limited expertise, specialist referrals are the acceptable solution both to the patient and the provider. This should be encouraged. Specialists should provide appropriate investigation and referral protocols.

Introduction: The transverse metatarsal arch is the subject of some controversy as there isn’t a clear consensus as to whether there is a transverse arch (TMA) in stance phase. The current treatment options of forefoot pathology focus on the need to harmonise the TMA by the use of osteotomies such as the Weil osteotomy.

Materials and Methods: A retrospective study of 75 feet (62 patients) with a mean follow up of 19 months. Patients underwent clinical, pedobarographic and radiological assessment. ‘Metatarsal skyline Views’ (MSV) were procured to assess the plantar profile of the TMA following Weil osteotomy. The feet were assessed using AOFAS, Foot Function Index, SF-36 and Manchester-Oxford Foot Questionnaires.

Results: 69 feet showed good to excellent results with a normal MSV plantar profile. 6 feet had recurrent meta-tarsalgia with callosities and abnormal MSV profiles. These results correlated well with pedobarography.

Discussion: The angle of Weil osteotomy is usually referenced relative to the floor irrespective of the plantar angulation of metatarsal. As different metatarsals had varying plantar angulations, the weight bearing metatarsal skyline view was used to ascertain the plantar profile of the metatarsals before, during and after surgery. This was also used to determine the amount of dorsal displacement required in addition to shortening in order to harmonise both length and plantar profile.

Conclusion: The use of the Metatarsal skyline view has significantly improved our planning of the angles of the Weil osteotomy.We suggest that the reference for the osteotomy should be the plantar angulation of the metatarsal rather than the floor. It has made the intra-operative assessment of the osteotomy easier and has improved our understanding of the osteotomy and its influence on the forefoot plantar profile.

Introduction: The transverse metatarsal arch is the subject of some controversy as there isn’t a clear consensus as to whether there is a transverse arch (TMA) in stance phase. The current treatment options of forefoot pathology focus on the need to harmonise the TMA by the use of osteotomies such as the Weil’s.

Materials and Methods: A retrospective study of 75 feet (62 patients) with mean follow up of 19 months. Patients underwent clinical, pedobarographic and radiological assessment. ‘Metatarsal skyline Views’ (MSV) were procured to assess the plantar profile of the TMA following Weil osteotomy. The feet were assessed using AOFAS, Foot Function Index, SF-36 and Manchester-Oxford Foot Questionnaires.

Results: 69 feet showed good to excellent results with a normal MSV plantar profile. 6 feet had recurrent metatarsalgia with callosities and abnormal MSV profiles. These results correlated well with pedobarography.

Discussion: The angle of Weil osteotomy is usually referenced relative to the floor irrespective of the plantar angulation of metatarsal. As different metatarsals had varying plantar angulations, the weight bearing metatarsal skyline view was used to ascertain the plantar profile of the metatarsals before, during and after surgery. This was also used to determine the amount of dorsal displacement required in addition to shortening in order to harmonise both length and plantar profile.

Conclusion: The use of the Metatarsal skyline view has significantly improved our planning of the angles of the Weil osteotomy. We suggest that the reference for the osteotomy should be the plantar angulation of the metatarsal rather than the floor. It has made the intraoperative assessment of the osteotomy easier and has improved our understanding of the osteotomy and its influence on the forefoot plantar profile.

To compare the intrinsic foot function and pliability of the foot in shoe and non shoe wearing population, measurement on the right foot of 100 randomly selected non-shoe wearing (Indians) and 100 shoe-wearing (British) population was carried out. They had normal body-mass index, age between 25 to 35 years and no previous injury or disability to the lower extremities.

Using a force gauge, force of extension and flexion at 1st metatarsophalyngeal joint, abduction at 5th meta-tarsophalyngeal joint and adduction between 1st and 2nd toe was measured. Pliability Ratio was calculated as follows:

Maximum weight bearing foot length X maximum weight bearing foot length

Maximum non-weight bearing foot length X maximum non-weight bearing foot length.

Using the student test at 95% confidence interval, there was no statistically significant difference in the intrinsic foot function. Multivariate regression analysis showed that after adjustment for other variables like gender and ethnicity, the shoe condition is significant on the pliability ratio. This study shows that although shoe-wearing does not affect the intrinsic foot function it definitely results in stiffer feet. This difference is more marked in women (p=0.0171).

Shoe-wearing can affect the transmission of forces during locomotion especially if the muscles acting across the foot are normal but the joints across which they act are stiff. Shoes have an inbuilt medial arch support and narrow toe boxes. This result in incomplete movement of the transverse and longitudinal arches of the foot leading to stiffer feet and can affect the biomechanics of shod feet.

Aim: To compare and assess the quality of nursing care provided to acute trauma patients that have been admitted to trauma wards and non-trauma outlying wards.

Design: Multi-centre comparison, questionnaire study undertaken in three large hospitals in South Wales. The study compares the knowledge of qualified trauma nurses, based on trauma wards and non-trauma nurses, based on outlying wards.

Method: 100 qualified trauma nurses and 170 qualified non-trauma nurses were asked to independently complete a questionnaire. The questions included the nursing management of common fractures and post operative conditions. The completed questionnaires were marked and the results analysed.

Results: 100% of the questionnaires were completed and returned. The trauma nurses conveyed the importance of ice (85%) and elevation (97%) in the initial management of limb fractures. This compares with ice (10%) and elevation (50%) on the outlying wards. Trauma nurses correctly monitor for potentially devastating post operative complications and compartment syndrome 87% of the time compared with 42% on outlying wards. Spinal injuries are managed appropriately 88% of the time on trauma wards compared with 36% on outlying wards.

Conclusion: Trauma patients receive optimum nursing care when admitted to a trauma ward and are nursed by trauma nurses. They probably have a shorter hospital stay. Many of the out-lying wards provide sub-optimal trauma nursing care and a few are positively dangerous.

Recommendations: We believe that hospital trusts should train nurses to confidently and competently be able to nurse outlying patients. Until that time, we recommend that trauma patients should not be nursed by non-trauma nurses.

Aims: To assess the difference in muscle function and pliability between shoe wearing and non shoe-wearing feet. Methods: Using a basic force gauge, force of extension and ßexion at 1st metatarsophalyngeal joint, abduction at 5th metatarsophalyngeal joint and adduction between 1st and 2nd toe was measured on the right foot of 100 (50 male and 50 female) randomly selected human population. They had normal body-mass index and age between 25 to 35 years. People with previous injury or disability to the right lower extremity were excluded. Measurement on non-shoe wearing population was carried out on Indian population. Measurements on shoe-wearing population were carried out on the British population. Maximum length and breadth of full weight bearing and non-weight bearing foot was measured. Pliability Ratio of weight bearing length and breadth of the foot by the non-weight bearing length and breadth of the foot was calculated. Results: There was no statistically different muscle force in the small joints of the feet. Pliability ratio showed that the shoe wearing feet were stiffer than non-shoe shoe wearing feet. Conclusions: Shoe wearing does not affect the intrinsic foot function. It may result in slightly stiffer feet. This can result in improper distribution of force while weight bearing Pediatric hip

The aim of this study was to demonstrate the benefits of a simple blood transfusion protocol in Primary Total Knee Replacement.

Patients undergoing TKR in the UK usually have either blood cross matched or have an auto transfusion of drained blood postoperatively. Audit of blood requirements of patients undergoing TKR showed that a large amount of blood was wasted. A CT ratio (Ratio of number of units of blood cross matched to number of units transfused) of 4.86 was obtained. Range recommended by the blood transfusion society is 2: 1 to 3: 1. A protocol was then made to Group and Save and Antibody Screen for all patients having a primary TKR, except patients with haemoglobin less than 12.5 gm/dl pre operatively and those patients with multiple red cell antibodies in their blood.

A further study involving 50 patients was carried out using the new protocol. Two units of blood was cross matched for each of 5 patients (3 with Hb < 12 gm/dl and 2 with red cell antibodies). Post operatively the 3 patients with Hb < 12 gm/dl required blood transfusion of 2 units each, reducing the CT ratio to 1.7: 1.

The benefits from above protocol are : a). Patient safety as risks of transfusion are avoided and b). Cost saving for trust on haematology technician time and on transfusion sets which cost around £70 each.