The aim of this study was to examine the incidence of obesity in patients undergoing primary total shoulder replacement (TSR) (stemmed and reverse) for osteoarthritis (OA) in Australia compared to the incidence of obesity in the general population.

A 2017–18 cohort of 2,621 patients from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) who underwent TSR, were compared with matched controls from the Australian Bureau of Statistics (ABS) National Health Survey from the same period. The two groups were analysed according to BMI category, sex and age.

According to the 2017–18 National Health Survey, 35.6% of Australian adults are overweight and 31.3% are obese. Of the primary TSR cases performed, 34.2% were overweight and 28.6% were obese. The relative risk of requiring TSR for OA increased with increasing BMI category. Class-3 obese females, aged 55–64, were 8.9 times more likely to require TSR compared to normal weight counterparts. Males in the same age and BMI category were 2.5 times more likely. Class-3 obese patients underwent TSR 4 years (female) and 7 years (male) sooner than their normal weight counterparts.

Our findings suggest that the obese population is at risk for early and more frequent TSR for OA. Previous studies demonstrate that obese patients undergoing TSR also exhibit increased risks of longer operative times, higher superficial infection rates, higher periprosthetic fracture rates, significantly reduced post-operative forward flexion range and greater revision rates.

Obesity significantly increases the risk of requiring TSR. To our knowledge this is the first study to publish data pertaining to age and BMI stratification of TSR Societal efforts are vital to diminish the prevalence and burden of obesity related TSR.

There may well be reversible pathophysiology in the obese population to address prior to surgery (adipokines, leptin, NMDA receptor upregulation). Surgery occurs due to recalcitrant or increased pain despite non-op Mx.

Aims

Hereditary haemochromatosis is a genetic disorder that is caused by several known mutations in the human homeostatic iron regulator protein (HFE) gene. Abnormal accumulation of iron causes a joint disease that resembles osteoarthritis (OA), but appears at a relatively younger age and is accompanied by cirrhosis, diabetes, and injury to other organs. Increased serum transferrin saturation and ferritin levels are known markers of haemochromatosis with high positive predictive values.

Open cheilectomy is an established surgical treatment for hallux rigidus. Cheilectomy is now being performed using minimally invasive (MIS) techniques. In this prospective study we report the outcome of minimally invasive cheilectomy comparing the results with a matched group who had cheilectomy using standard open procedure

Introduction

Trends in hallux valgus surgery continue to evolve. Basal metatarsal osteotomy theoretically provides the greatest correction, but is under-represented in the literature. This paper reports our early experience with a plate-fixed, opening- wedge basal osteotomy, combined with a new form of distal soft tissue correction (in preference to Akin phalangeal osteotomy).

Background

Short term results of silastic implant of first MTPJ are successful. However reservations exist regarding long term results. The aim of this study is to evaluate long term outcome of silastic implant prosthesis in treatment of hallus rigidus.

We reviewed 108 feet in 83 patients who were operated on between 1988 and 2003. Mean age at operation = 55(SD 8.1). Mean follow up = 8.31 years (SD 3.3). Patients were assessed using the American Orthopaedic Foot and Ankle Scoring system (AOFAS). Passive and active arc of motion were measured. To assess patients' satisfaction they are asked if they would repeat the procedure and also using a visual analogue scale (VAS) to express their overall satisfaction with the outcome. All the patients had anteroposterior and oblique views. Radiographs were assessed for loosening and osteolysis.

Introduction

Symptomatic hallux valgus is a common clinical problem, current trends is towards minimally invasive procedures. The goal of this study is to evaluate the outcome of minimally invasive chevron ostoetomy, comparing it with a matched group who had open chevron osteotomy.

Open cheilectomy is an established surgical treatment for hallux rigidus. Cheilectomy is now being performed using minimally invasive(MIS) techniques. In this prospective study we report the outcome of minimally invasive cheilectomy comparing the results with a matched group who had cheilectomy using standard open procedure.

Prospective study of 47 patients. 22 patients had MIS cheilectomy between March 2009 and September 2010. We compared the outcome with a matched group (25 patients) who had open cheilectomy. Functional outcome was assessed using the Manchester Oxford Foot and ankle questionnaire (MOXFQ). The MOXFQ is a validated 16-item, patient-generated questionnaire designed to be self-completed and used as an outcome measure for foot surgery. It comprises three domains foot pain, walking and standing problems and social interaction. Total score ranges from 0 (best score) to 64 (worst score). Patients completed preoperative and postoperative questionnaires. Patients’ satisfaction and complications were recorded.

In the MIS group, the median follow up was 11 months (4–23. The median preoperative MOXFQ score was 34/64(23) and the median postoperative score was 19/64 (p value <0.02) In the open group the median follow up was 17 months (9–27). The median preoperative MOXFQ score was 35/64 and the median postoperative score was 7.5/64 and this difference was statistically significant (<0.0001). There were three failures in the open group (Fusion) compared to none in the MIS.

MIS cheilectomy is an effective alternative procedure with satisfactory functional outcome and high patient satisfaction. Results are comparable to the standard open cheilectomy with a lower apparent failure rate. The results of our randomised controlled trial comparing MIS cheilectomy to open cheilectomy are awaited.

Introduction

Second ray problems are common, especially chronic MTP joint dislocation, and intractable metatarsalgia caused by a relatively long second ray we describe a new extra-articular technique that allows considerable shortening

Introduction: We present the results of the Ankle Evolution System (AES) total ankle replacements with a minimum follow up of four years.

Methods: Forty-five consecutive patients who had AES ankle replacement were included in the study. The mean age at operation was 64.6 (50–77). Pain and function were assessed using the AOFAS score. Patients had standardised AP and lateral weight bearing radiographs and were assessed for loosening and alignment. Patients’ satisfaction and complications were recorded. The survival of the implant was constructed using the Kaplan-Meier survival curve.

Results: The mean follow up for our patients who were alive and available for follow up at the final clinical review (40 patients) was 57.8 months (48–80). A total of 2 patients were revised (One patient sustained talar fracture and was converted to arthrodesis at three years postoperatively. The second patient had revision of the tibial component because of aseptic loosening at 4 years postoperatively). The mean total AOFAS score was 88.1 (53–100). For pain the mean score was 35.8 (20–40). Nine patients showed osteolysis only 2 were considered as significant. Those patients had minimal symptoms that were not progressing and further surgery was not justified. Ten patients presented with edge loading of which nine had corrective surgery. Our cohort showed high patients’ satisfaction. Our cumulative survival rate at 6 years was 94.7% with revision or decision to revise as the endpoint

Conclusion: The medium term results of the mobile AES total ankle replacement in terms of survivorship, functional outcome and patients’ satisfaction are satisfactory but we have our concerns about the high rate of osteolysis. The long-term benefit of this procedure has yet to be determined.

Background: Local blocks, as the sole means of anaesthesia, in forefoot surgery have previously been described. This technique is not widely practised in the UK but we have routinely used such blocks for many years. Our aim was to assess how well patients tolerated this technique.

Methods: 64 consecutive day cases of fore-foot surgery were recruited prospectively for local anaesthetic block. A range of operations were performed including basal osteotomy of 1st metatarsal and MTPJ arthrodesis. No patients declined to be included. Peripheral nerve blockade was performed by the orthopaedic surgeon or his registrar. Efficacy of block was assessed intra-operatively with a visual analogue score (VAS) of 0 to 10 (10 being worst pain imaginable and 0 being no pain). Overall satisfaction with the anaesthetic procedure was assessed on a 5 point scale (from 1 = very unsatisfied to 5 = very satisfied) at 2 weeks.

Results: Average time to perform the block was 6 minutes (range 3 to 12 mins). Mean VAS for knife to skin was 0.38 (95% confidence ± 0.31) and for ankle tourniquet was 1.44 (95% confidence ± 0.51). At follow up mean satisfaction at 2 weeks was 4.2 out of 5 (95% confidence ± 0.30) with only 9 patients lost to follow up (86% of patients followed up). No complications were reported.

Conclusion: Our experience is that these blocks are quick and easy to perform in the hands of orthopaedic surgeons. They are well tolerated and effective. They result in a considerable cost saving in terms of theatre efficiency and anaesthetist and ODP resources. These savings are still being evaluated.

Introduction: Postoperative pain management following shoulder arthroscopy procedures is important, especially if they are to be performed as a day case surgeries. A variety of techniques are currently used to reduce postoperative pain such as patient controlled infusion pump and Interscalene block

Aim: In this study we evaluate the effect of Baxter elastomeric continuous infusion pump in managing pain following shoulder arthroscopy procedures.

Methods & Materials: We prospectively reviewed thirty four patients who had shoulder arthroscopy procedures between January and July 2007. All patients had arthroscopic subacromial decompression. Baxter elastomeric infusion pump was used in all patients to provide postoperative pain relief. All patients had 10ml of 0.5% Marcaine as a bolus followed by 5ml/hr for 10 hours through the infusion pump.

Visual analogue scale (VAS) was assessed at 4, 6,8 and 24 hours postoperatively. Discharge time and patients’ satisfaction were also assessed

Results: The Baxter elastomer pump provided effective pain relief postoperatively with median VAS(IQR) of 2.5(1.5–4.5), 2.5(1–5), 3(2–6), 6 (2–8) at 4, 6, 8 and 24 hours respectively. Our cohort had short hospital stay postoperatively with median (IQR) discharge time of 4.6 hours (3.5–5.3).Majority of patients reported that they are either very satisfied or satisfied with the pump.

Conclusion: We conclude that Baxter Infusion Elastomer pump is effective in managing pain postoperatively following shoulder arthroscopy with a high patients’ satisfaction which resulted in a short hospital stay. It is simple to insert under direct visualisation ensuring adequate placement, simple to use and doesn’t require skilled nursing care. Also it has got less morbidity compared to other means which are used to provide postoperative pain relief such as interscalene block.

Introduction: We present the results of 35 patients following Ankle Evolution System (AES) total ankle replacements (TAR) with a minimum follow up of four years.

Methods: We retrospectively reviewed 39 consecutive total ankle replacements. Two patients died, and two emigrated. Thirty-five patients were available for clinical and radiological assessment. All patients underwent standardised radiographs. Complications and failures were recorded. Patient satisfaction and functional outcome of all patients was determined using the American orthopaedic foot and ankle society (AOFAS) score.

Results: All ankles were examined at a mean of 4.7 years postoperatively. The mean age at operation was 64 years. In 18 ankles the indication for the operation was primary osteoarthritis (OA), in 13 ankles post-traumatic OA, in three ankles rheumatoid arthritis and in one ankle psoriatic arthropathy. One patient had revision of the tibial component because of loosening. Sixteen patients recorded their satisfaction as excellent postoperatively, 15 patients as much better, three as better and only one patient recorded that he was worse off. The mean AOFAS score was 88.9 (confidence interval 85.7–92.1). The mean walking distance for our cohort is two miles. Thirteen ankles had radiological osteolysis; in two ankles this was more that 2cms.

Conclusion: The medium term results after implantation of the AES ankle prosthesis are encouraging. With the correct indication, a high rate of pain reduction and patient satisfaction can be achieved. The long-term benefit of this procedure has yet to be determined. The rate of osteolysis is of some concern.

Multiple treatments of Sacro-iliac joint (SIJ) dysfunction have been adopted by various disciplines that treat low back pain. The aim of this audit is to evaluate the effect of steroids and Local anaesthetic injection (LA) in the management of SIJ dysfunction and to determine the relation between road traffic accident and low back pain (LBP).

We retrospectively reviewed 31 patients who were diagnosed as having SIJ dysfunction. All patients had steroids and LA injection under x-ray control. Based on previous history of road traffic accident patients were divided into RTA and non-RTA group. Through a postal questionnaire the severity of LBP and leg pain (pre and post injection) were assessed using visual analogue scale (VAS). Functional level was evaluated through the Oswestery disability Index (ODI).

All patients showed improvements in LBP and leg pain post injection with mean improvement in VAS of 2.95 (SD 3.0, p-value < .0001) for LBP and mean improvement of 3.3 (SD 3.3, p-value < 0.001) for leg pain. Similarly the ODI showed mean improvement of 15.0 (SD 17.0, p-value < 0.0001). Patients in the RTA group showed greater improvement than the non RTA group, however this did not reach statistical significance.

We conclude that steroids and LA injection is an effective method in management of SIJ dysfunction. Also our study suggests that RTA can be a potential cause of back pain by causing SIJ dysfunction. We accept that our sample size is small and needed to be confirmed through a prospective randomised controlled trial which is currently taking place in our institution.

Sarcoidosis is a multisystem syndrome characterized by the development of non-caseating granulomata. The lesion disrupts the architecture and function of the tissue in which they reside.

Sarcoidosis in and around the spine is very rare affecting less than 1% of patients with the disease. It can affect various parts of the craniospinal axis: intramedullary, intradural, extramedullary, intraspinal epidural spaces and in vertebral bodies. In this report we present a rare case of sarcoidosis in the intervertebral disc causing diagnostic dilemma. To our knowledge this has never been reported before.

Our patient has had aggressive systemic sracoidosis, however the first presentation of the disease was in his spine in the form of intractable low back and leg pain resistant to treatment. X-ray and MRI showed Listhesis at L4/5. Posterior Fusion was performed. Pain became worse and accordingly anterior fusion was attempted, which was aborted because of excessive bleeding. Patient then developed subcutaneous nodules. Biopsy from the nodules showed features of non-caseating granulomatous lesion. In view of the persistence of his symptoms biopsy from L4/5 disc was performed and showed similar histological features. CT chest and abdomen confirmed the diagnosis of sarcoidosis. The patient was commenced on steroids and Methotrexate.

In this report we highlight the approach to diagnosis and management and present a review of the literature. Our main aim is to make the clinicians more aware of this rare condition and raise the index of suspicion, particularly if the first presentation of this multi-system granulomatous disorder is in the spine.

Restoration of the mechanical axis is thought to be a critical factor in determining the Outcome of knee replacement surgery. There is strong theoretical evidence that reproduction of this axis improves mechanical loading and hence longevity of the implant. Clinical studies are small in number.

Per-operative use of intra-and-extra-medullary alignment jigs help to determine the distal femoral and proximal tibial cuts. Studies have shown large margins of error using the standard jigs provided with most total knee replacement systems. On this basis computer assisted guidance systems are being introduced such as Orthopilot and BrainLab. These systems allow more accurate placement of the bony cuts and hence improve overall lower limb alignment.

No study has shown conclusively that accurately reproducing the mechanical axis of the lower limb improves survivorship of the implant. Prior to investing in these systems we felt it would be prudent to investigate how critical reproduction of the mechanical axis was in the primary total knee replacement.

We assessed 100 primary kinematic total knee replacements performed in 1990. All case notes were reviewed looking for basic demographics, pathology and clinical outcome.

All cases had a long leg film weight-bearing alignment film taken post-operatively. These were digitised and then analysed using Design CAD 97 software and from this the mechanical axis calculated.

Using these data the patients were divided into two groups. The first were within 3 degrees varus/valgus of the mechanical axis. The second were outside this range. These two groups were then correlated to clinical outcome.

Conclusions: Our results suggest that accurate reproduction of the lower limb alignment and the mechanical axis improves clinical outcome and survivorship of the implant using revision as an endpoint. Our data would support the introduction and use of intra operative computer aided guidance systems.