Introduction: The purpose of this study was to assess the effect of lateral release surgery in our middle aged to elderly population with advanced isolated patellofemoral osteoarthritis while the weight bearing part of the joint is well preserved. We hypothesized that lateral release is a helpful procedure in improving function and relieving pain and hence deferring the need for arthroplasty.

Material and Methods: This is a prospective study performed in patients with patellofemoral pain recalcitrant to conservative management. 57 Knees (11 Bilateral) had arthroscopic lateral retinacular release from October 1999 to Jan 2007. All patients had pain secondary to Patellofemoral osteoarthritis or ELPS (Excessive Lateral Pressure Syndrome) and had through arthroscopic evaluation of the knee prior to the lateral retinacular release. Decision was made after assessing the patella tracking from the superolateral portal using a 70 degree arthroscope. There were forty two females and 15 males with a mean age of 63 years (41 – 84 years). Thirty five procedures were done on the left knee and 22 on the right. The average body weight was 12.9 stone (9.7 – 16.5). The mean follow-up was 72 months (36 – 130). Clinical assessment tools used were the IKDC, Tegner, WOMAC and Knee Society Scores. Visual analogue pain scale and the need for reoperation were also recorded. All but one patient, who died of other medical reason, were asked to fill out questionnaires based on the above outcome measures.

Results: One patient developed swelling in the calf postoperatively. Doppler study ruled out deep vein thrombosis. No other complication (hemarthrosis or infection) was noted.

Mean pre and post operative functional score were compared. Tegner Activity scale was unchanged. Lysholm score was improved from 48(13 – 80) to 87(60–100) (p < 0.004). Post op IKDC Subjective knee score was 60(32–82). Post op WOMAC score was 42 (26–77), while The Knee Society and Functional scores were 86(63–100) and 86(45–100) respectively. Finally Visual analogue pain scale was 6(4–10) pre-op which improved to 2(0–6). At the final follow-up (mean 72 weeks), only seven patients (12%) require arthroplasty. Four patients require Total knee replacement while three patients required patellofemoral replacement at an average of 21 months (8–32) post op.

Conclusion: This procedure appears to improve function and provide significant relief of pain. The need for arthroplasty can be deferred in successful cases. Only 12 percent of our patients required arthroplasty at an average of seventy two months follow up.

Thus this confirms our hypothesis. With a low failure rate and morbidity, we do recommend this procedure in middle aged to elderly patients who has patellofemoral osteoarthritis.

Introduction: We present preliminary short term results of medial opening wedge high tibial osteotomy with hemicallotasis using a monolateral external fixator, combined with microfracturing, in younger active patients with established Grade IV medial compartment osteoarthritis.

Methods: Prospectively collected data was analysed for 28 consecutive knees in 27 patients undergoing this procedure. Mean age was 47 years (range 28 to 64); follow up was 23 months (range 7 to 61).

Results: Mean Lysholm scores improved from 63.6 before surgery (range 42 to 85) to 81.6 at latest follow-up (range 46.5–100) (p< 0.001). Similarly, the mean Tegner activity scale improved from 1.7 (range 1–4) to 3.3 (range 1–6) (p< 0.001). Average IKDC score at last follow-up was 68 (range 35.6–100). Mean pain score (visual analogue scale 0 to 10) improved from 5.5 pre-operatively (range 1–9), to 3.5 at latest follow-up (range 0–8) (p< 0.001). All but 4 patients reported improved pain scores, one of whom had patellofemoral pain. Superficial pin site infection occurred in 6 patients (21.4%) and settled with oral antibiotics in all cases.

Discussion: The use of hemicallotasis for high tibial osteotomy in association with extensive microfracturing of medial compartment provides a viable, minimally invasive method for management of the young active patient with medial compartment osteoarthritis, without the risk of serious complications. In the short term even with advanced full thickness damage, this provides effective pain relief, helps put off more major arthroplasty alternatives and allows patients an improved activity level. The external fixator provides a very stable functional stabilization, superior to other available methods of internal fixation.

Background: Postoperative pain following forefoot surgery can be difficult to control with oral analgesia so regional analgesic methods have become more prominent.

Aim: It is the aim of this study to evaluate the efficacy of a combination of popliteal and ankle blocks and decide if they give significantly better postoperative analgesia than ankle block alone in forefoot surgery.

Methods: This is a prospective, randomised, controlled and single blind study. The total number of patients is 80 with 40 patients in the ankle block only group (control) and 40 patients in the ankle and popliteal block group. All patients underwent forefoot surgery. Postoperative pain was evaluated in the form of a visual analogue scale and verbal response form. Evaluations took place four times for each patient: in the recovery room, 6 hours postoperatively, 24 hours postoperatively and on discharge. The pain assessor, who helped the patient complete the pain evaluation forms, was blinded to the number of blocks used. The amount of opiate analgesia required whilst an inpatient was also recorded. On discharge the patient was asked to rate their satisfaction with the pain experienced during their hospital stay. Results were analysed using Mann-Whitney tests.

Results: Results show that pain is significantly less in recovery (p=0.044) and after 24 hours (p=0.0012) for those patients with combined blocks. Satisfaction with pain relief is also higher for these patients. No complications were found as a consequence of having two peripheral nerve blocks.

Conclusions: A popliteal block in conjunction with an ankle block does reduce postoperative pain significantly more than ankle block alone after forefoot surgery.

Total hip arthroplasty has improved the quality of life for many patients with osteoarthritis. Infection is a serious complication, difficult to treat and often requires removal of the prosthesis to eradicate the infection.

An analysis of the surgical management, risk factors, complications and outcome of infected total hip replacements. Thirty one consecutive patients underwent revision hip arthroplasty for infection between 1997 and 2003. Risk factors, co-morbidity, clinical presentation, biochemical profiles, microbiology, management and radiology were recorded. Outcome and complications following surgery are reviewed. Classification of infection after total hip arthroplasty was based on their clinical presentation—early postoperative, late chronic, or acute hematogenous infection, and positive intraoperative cultures.

All patients underwent resection arthroplasty, 26 had a two-stage revision, 1 had a three stage, 4 did not have a re-implantation. Staph Aureus was the most common organism identified. 16 patients were classified as late chronic insidious, 8 early post operative infection, 6 acute haematogenous and 1 occult intraoperative. Average total blood loss was 5 litres, average replacement was 7 units. 1 patient had a persistent infection. 3 underwent further surgery for dislocation, stem perforation or fracture. 5 patients had a persistent limp.

In infected revisions the bone stock is usually adequate, the soft tissues are very poor. Bivalving the femur allows for optimal cement removal. Blood loss can be significant with average replacement of 7 units. Meticulous removal of infected components, cement and tissue is essential for good long-term results.

There are numerous ankle and hindfoot scores in existence, which have been devised and used to assess surgical interventions. All have in common that there has been little or no work done to demonstrate their validity, reliability or sensitivity to change. Which score one chooses to use for the assessment of outcome will at present depend largely on personal preference.

We have undertaken a study to assess four of the most commonly used scores, those of Mazur (1978), Takakura (1990), AOFAS (1994) and Kofoed (1995) as well as a little used but well designed score, The Foot Function Index (1991).

A cohort of twenty patients who had undergone a unilateral total ankle replacement (STAR) for rheumatoid or osteoarthritis were assessed by a single observer. The time following operation ranged from six to 48 months. All completed the above scores as well as a SF36 questionnaire. Using the SF36 as a “Gold standard” the scores were compared, both in terms of their overall results and also more specifically in terms of subsections such as pain and function.

Our results, though not to be interpreted as validation, do give some rational basis for the choice of score to use in assessing total ankle replacements.

Abstract: The early stages of ankle arthroplasty were complicated by unsatisfactory surgical results and poor patient satisfaction. This paper reveals far greater patient satisfaction and excellent surgical results achieved from the STAR uncemented ankle replacement.

Materials and Methods: We reviewed the first 29 STAR ankle replacements carried out by the senior author. Patients were reviewed clinically and radiographically according to the AAOS hind-foot score. Failure was deemed to be revision of the implant. Reason for surgery was rheumatoid arthritis in twelve patients and primary or secondary osteoarthritis in seventeen patients.

Results: One patient required revision surgery. This was an osteopoenic rheumatoid patient and the revision was for component subsidence. Three patients from the initial stages required minor soft tissue and bony resection at a second procedure with retention of the prosthesis. Patient satisfaction was high. Clinically, the average ROM was 5deg dorsiflexion and 12 deg plantarflexion. Patient satisfaction was extremely high. While the AAOS score does not give a grading, we also applied the Kofoed scale and 28 of our patients achieved a good or excellent result.

Conclusion: We conclude that the STAR uncemented ankle replacement achieves very good clinical results and excellent patient satisfaction.