The role of total ankle replacements remains unproven within orthopaedic literature. We present a prospective series of patients who underwent a SALTO TAR (Tornier) between October 2006 and January 2014. A cohort of 53 TAR (50 patients) were prospectively followed up and assessed clinically, radiologically and asked to complete FAOS, VAS and Modified AOFAS scores. Four patients had bilateral procedures. The mean age was 71 years old (range 42–92). The mean follow up was 55 months (range 6–92). Nineteen TARs (19 patients) have a follow up of more than 60 months.Introduction:
Methods:
Open reduction and internal fixation of displaced intra-articular calcaneal fractures is susceptible to a high incidence of wound complications. Displaced fractures create abnormal contact characteristics at the subtalar joint, resulting in poor functional outcome and arthritis. We present the functional outcomes of 32 fractures (Sanders 2 and 3) at an average follow up of two years. Over a 57 month period, 32 fractures (29 patients) underwent this technique in a London level 1 trauma centre. Open fractures were excluded. The previously described technique with sinus tarsi portals was used. Pre and post-operative radiographs and functional outcomes were assessed.Introduction:
Methods:
The aim of our study was to compare the clinical versus radiological diagnosis of patients suffering from a Morton's neuroma. Clinical assessments and pre operative radiological imaging of patients who underwent operative procedures for an excision of a Morton's neuroma were retrospectively compared. This review included 43 excised Morton's neuromas from 36 different patients over a period of 68 months, performed by one surgical team. The commonest clinical symptoms were those of pain or tingling on the plantar aspect of the affected webspace on direct palpation (100%), pain of weight bearing (91%) which was relieved by rest (81%) and pain on stretching the toes (79%). The most sensitive clinical sign was a Mulder's click. Our results showed that clinical assessment was the most sensitive method of diagnosing these neuromas (98%). All of our patients had at least one mode of radiological investigation. Ultrasonography was the commonest requested single imaging modality in our series. It was found to have a sensitivity of 90% (28/31). This imaging technique has the disadvantage of being operator dependant, as highlighted by the fact that one of our patients had a correct radiological diagnosis after a repeat ultrasound to the affected area was requested. Magnetic Resonance Image scan is a more expensive technique as it has the advantage of producing static reproducible images. As a single imaging modality, it was found to have a sensitivity of 92% (12/13) in our series. 3 patients had both imaging modalities; initial ultrasound failed to convincingly diagnose a neuroma in 2 cases and in the other case, the initial MRI did not show any pathology. In all these cases, the repeat imaging techniques confirmed the clinical diagnosis. We conclude that there is no absolute requirement for ultrasonography or magnetic resonance imaging in patients who clinically are suspected to have a Morton's neuroma, as the clinical examination was found to be the most sensitive method of diagnosis. We suggest that the two main indications for performing some form of imaging is (a) an unclear clinical assessment and (b) cases when more than one webspace appears to be affected. An ultrasound of the webspaces should be the radiological investigation of choice, followed by a magnetic resonance scanning if any uncertainty still remains.
Freiberg's disease is an uncommon condition of anterior metatarsalgia that involves the head of metatarsals. Avascular necrosis of the metatarsal head is thought to arise during puberty. Treatment is usually conservative and operative treatment reserved for cases that do not respond to these measures. We retrospectively reviewed a consecutive series of ten patients who presented to our institution who did not respond to conservative methods. These patients were treated surgically with a previously undescribed operative technique involving microfracture of the metatarsal heads and reattachment of the cartilage flap.Introduction
Materials and Methods
The main purpose of preoperative blood tests is to provide information to reduce the possible harm or increase the benefit to patients by altering their clinical management if necessary. This information may help clinicians assess the risk to the patient, predict postoperative complications and establish a baseline measurement for later reference. National Institute of Clinical Excellence (NICE) has issued guidelines around the need for pre-operative blood tests related to the age of the patient, comorbidities and the complexity of the procedure they will undergo. We decided to retrospectively review the pre-operative blood requests for patients under the age of 65 who were admitted at our institution over a 2 month period for open reduction and internal fixation of the ankle or tibial plateau and manipulation under anaesthesia of the lower limb. Patients were divided into 2 groups, under the age of 40 and between 40-65 years old. Patients under the age of 18 were excluded. These surgical procedures were classified as ‘intermediate complexity’. Admission clerkings of our 63 patient cohort were reviewed to ascertain if any patients had a significant co-morbidity or past medical history. The pre operative blood tests requested for each patient were audited against the NICE recommendations. None of the patients under the age of 40 had any significant comorbidites, whilst 8 patients above the age of 40 suffered with hypertension. 95% of patients had at least one blood test carried out. All patients over the age of 40 had at least one blood test. Tests requested included full blood count (91%), urea and electrolytes (91%), coagulation (66%), liver function tests (67%), group and save (69%), CRP (70%), ESR (2%), thyroid function tests (5%) and CK (2%). Only 5 patients (5%) followed the guidelines correctly. The clinical value of testing healthy individuals before an operation is debatable. The possible benefits of routine preoperative investigations include identification of unsuspected conditions that may require treatment before surgery or a change in surgical or anaesthetic management. The American Society of Anaesthesiologists has stated that ‘routine preoperative tests (i.e. tests intended to discover a disease or disorder in an asymptomatic patient) do not make an important contribution to the process of perioperative assessment and management of the patient by the anaesthesiologist.’ The overzealous requesting of preoperative blood tests also has a financial burden upon individual institutions. Our study also showed that some blood tests, such as inflammatory markers and thyroid function tests, were inappropriately requested. Adherence to the NICE guidelines would have resulted in a significant financial saving. This review has shown that adopting the NICE guidelines may result in a decrease in the amount of unnecessary blood tests patients undergo when they attend hospital for routine, minor or intermediate surgical procedures. If these guidelines were implemented for all surgical procedures, this would undoubtedly result in a significant financial saving for the institution and the NHS as a whole. At our institution we have implemented surgical and anaesthetic team awareness and education around these guidelines in a bid to reduce the use of unnecessary testing.
