Abstract

Abstract

The Cobb Stainsby forefoot arthroplasty for claw and hammer toes combines excision arthroplasty (Stainsby) with extensor tendon transfer to the metatarsal head (Cobb). We present a retrospective, three surgeon case series of 218 toes in 128 patients over four years. Clinical notes were reviewed for all patients and 77 could be contacted for a telephone survey. Follow up ranged from 12–82 months.

All patients presented with pain and shoe wear problems from dislocated metatarsophalangeal joints either from arthritis, hallux valgus, Freiberg's disease or neurological disorders. Ipsilateral foot procedures were performed simultaneously in 24 (30%) patients. Seventy-two patients (94%) were satisfied, 72 (94%) reported pain relief, 55 (71%) were happy with toe control, 61 (79%) were pleased with cosmesis, 59 (77%) returned to normal footwear and 56 (73%) reported unlimited daily activities. Minor complications occurred in 17 (13%) and 3 (2%) developed complex regional pain syndrome. Four (5%) developed recurrent clawing.

The Stainsby procedure permits relocation of the plantar plate under the metatarsal head for cushioned weight-bearing but can create a floppy, unsightly toe. By combining this with the Cobb procedure, our case series demonstrates improved outcomes from either procedure alone with benefits over alternatives such as the Weil's osteotomy.

Oxford Level 4 evidence – retrospective case series.

We present 2 year results of a prospective natural history study of Type III Acromioclaviclular joint dislocation (ACJD) treated non-operatively. Previous natural history studies are compromised by inconsistent definitions of the grade of injury and non-validated scoring tools; they do not identify which patients will have ongoing symptoms. This trial documents the strength and subjective recovery over time, and identifies risk factors for poor outcome and need for surgery.

Patients with Rockwood Type III ACJD received a standardised rehabilitation protocol (6 sessions of physiotherapy). Clinical assessment was performed at presentation, 3, 6, 12 and 24 months after injury, including isometric strength testing, pain (VAS/10) and subjective scores – Subjective percentage of normal (SPON), American Shoulder and Elbow (ASES), Oxford Shoulder Score (OSS) and Quick Disabilities of Arm Shoulder and Hand (qDASH).

28 male patients were recruited, 26 reached 12, and 9 to 24 months follow up. Two required surgery and one emigrated. The mean age was 39 (15 to 67). Initial mean pain was 3/10, SPON 51% (6–95) and strength was 76% of the other side. By 3 months mean subjective recovery was 70% and strength 90%. Strength recovered to 99% of normal by 12 months but subjective scores remained at mean 90%; by 24 months subjective scores were mean 94%. 2 patients had subjective scores <80%.

There was a wide range of initial subjective scores and weakness after Type III ACJD. 95% of strength had recovered by 6 months and subjective scores recovered to 94% of normal by 24 months. 4 patients (14%) did poorly with 2 requiring surgery. Low initial subjective score and inability to abduct the arm at presentation were risk factors for a poor outcome.

Thromboembolic complications following lower limb arthroplasty are reported to be high. The aim of this of this study is to ascertain the incidence of symptomatic venous thromboembolic disease following lower limb arthroplasty without Pharmacological thrombo prophylaxis.

Retrospective review was undertaken of 752 patients following total hip or total knee replacement between January 1^st 2002 and June 30^th 2005.

Fifty one patients were considered high risk and received thrombopharmacologal prophylaxis with Clexane and Warfarin. Information on all patients was obtained from medical records, computerised information system, general practitioners and patients themselves to produce a complete picture of the three months immediately following the index arthroplasty. All patients who presented with calf symptoms suggestive of venous thrombosis, respiratory distress or died in that three months were investigated.

Two patients were lost to follow up. All others had full documentation. Twenty-nine patients presented with calf related symptoms and after ultrasound investigation nine (five THR, four TKR) were confirmed to have venous thrombosis and were treated. One of these patients developed tense haemarthrosis while on treatment. Twelve other patients presented with respiratory symptoms. Eight (six THR two TKR) were confirmed to have pulmonary embolism on either VQ scan or spiral CT. Four of these on VQ scan were low probability. All patients were treated for thromboembolic disease and while on treatment one patient developed persistent wound discharge and infection. Of the 51 patients treated with pharmacological prophylaxis one developed a DVT and five developed wound problems, one of which was major. Two patients died during the three month period, but neither was related to thromboembolic disease.

From the 699 patients the symptomatic DVT rate was 1.1%. Symptomatic pulmonary embolism rate was 1.5% including the low probability of VQ scans. There was no mortality from thromboembolism in this study. These results compare favourably with the recent literature. Our department has a policy to select patients for thromboembolic prophylaxis based on high risk factors. All other patients are fully informed of this risk and are treated with elevation, avoidance of swelling, early supervised and regular mobilisation. Our result from this study substantiate our policy for selection of patients for thromboembolic prophylaxis.