This prospective study explores the outcomes of the Forth Valley Protocol (FVP) for the management of acute Achilles tendon ruptures. The protocol uses ultrasound as the primary mechanism to guide treatment.

All patients presenting with acute tendoachilles rupture over a three-year period were included. Patients under 18 years of age, chronic ruptures, or prior surgery to the Achilles tendon were excluded. Patients with a gap ≤2cm had conservative management following an Early Rehabilitation Protocol (ERP) and >2cm underwent surgery (if an appropriate surgical candidate). Achilles Tendon Rupture Scores (ATRS) were obtained retrospectively. Fischer's exact test was used to determine statistical significance.

158 patients were included with a mean age of 53 (range 20–89). Ultrasound scans were obtained for 121 patients (76.5%), demonstrating a mean tendon gap of 1.61cm. 143 patients managed conservatively and 15 surgically. The overall re-rupture rate was 3.8% (n=6). All the re-ruptures occurred in patients treated conservatively, but this was not found to be statistically significant (n=6, P=1.0). The overall complication rate (excluding re-ruptures) was 1.9%. ATRS was comparable between both treatment modalities (P=0.382, 0.422), with a mean score of 86.6 in the conservative group and 81.4 in the surgical group.

The FVP demonstrates low re-rupture and complication rates in line with other published studies. Patients with gaps ≤2.0cm on the ultrasound can be successfully treated conservatively with an ERP. This has potential benefits in terms improved patient outcomes, satisfaction, and preservation of resources.

Data was collected for patients referred to the orthopaedic department at Forth Valley Royal Hospital with metatarsalgia who subsequently received an ultrasound. Patients found to have a Morton's neuroma were divided into groups based on its size.

A total of 90 patients received an ultrasound scan and neuroma was confirmed in 58 with an alternative diagnosis found in 32 patients and a total of 42 were included in the final analysis.

All 14 patients with neuroma < 6mm reported resolution of symptoms. 4 (28.5%) underwent surgical excision as first line, 1 (7%) received a single corticosteroid injection and 9 (64%) were treated with metatarsal bars.

There were 27 patients with neuroma > 6mm; 8 (29.6%) underwent surgical excision as first line treatment, 5 (18.5%) received metatarsal bars and 14 (51.9%) received injections. 7 (25.9%) patients reported resolution of symptoms after 1 injection, 1 (3.7%) patient required 2 injections and 1 (3.7%) patient required 3 injections to achieve resolution. 5 (18.5%) patients required surgical excision following ongoing symptoms despite non-surgical treatment. 9 (33.3%) reported resolution of symptoms following injection. 5 (18.5%) reported resolution of symptoms following use of metatarsal bars.

A total of 71% of patients with a neuroma measuring < 6mm reported full resolution of symptoms with non-surgical treatment. For patients with neuroma >6mm, 64.3% had resolution of symptoms with injections alone and 18.5% required surgical excision despite injection.

In conclusion, there is a benefit to offering non-surgical treatment as first line in patients with a neuroma regardless of size.

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is the most reliable surgical option, for hallux rigidus from end-stage osteoarthritis. The aim of the study was to compare the functional outcomes of memory nickel-titanium staples versus a compression plate with a cross screw construct for first MTPJ arthrodesis using the Manchester–Oxford Foot Questionnaire (MOXFQ).

Patients who underwent MTPJ arthrodesis using either memory nickel-titanium staples or a compression plate with a cross screw construct were identified from the surgical lists of two orthopaedic consultants. Pre and post-operative MOXFQ questionnaire, a validated patient-reported outcome measure, was administered, and responses were analysed to derive the MOXFQ summary index.

The study included 38 patients (staple group N=12 and plate and cross screw group N=26). 23 patients were female and 15 were male. Mean age was 64.8 years (SD 9.02; 40 to 82). Initial analysis showed no significant difference in preoperative MOXFQ scores between the groups (p = 0.04). Postoperatively, the staple group exhibited a mean improvement of 36.17, surpassing the plate group's mean improvement of 23. Paired t-test analysis revealed a statistically significant difference (t-score= 2.5, p = 0.008), favouring the use of staples.

The findings indicate that the use of staples in MTPJ arthrodesis resulted in a significantly greater improvement in MOXFQ scores compared to plates. Further research is needed to explore the underlying factors contributing to this difference and to evaluate long-term effects on patient outcomes.

Proximal inter-phalangeal joint (PIPJ) arthrodesis is a commonly performed procedure as a part of hammer and claw-toe correction. Conventional K-wire stabilisation has the potential disadvantages of infection; violation of DIP joint; external protrusion or the wire and necessity of removal.

Newer intra-medullary stabilisation devices are also available, though tend to incur addition costs. We present our technique and results of using a single, buried 1.6 mm K-wire for proximal inter-phalangeal joint fusion

Our objectives were to assess union rates and patient satisfaction following intra-medullary K wires for PIP joint fusion. This involved reviewing 26 consecutive patients (34 toes) who had undergone hammer or claw toe correction. Case notes and radiographs were reviewed to establish results and complications and the need for revision surgery. Initial Radiographs taken at 6 weeks and a telephone survey was undertaken to assess patient satisfaction (16–44 weeks).

Our findings were that of the twenty-one women and five men underwent surgery, with a mean age of 59 years (24–77), stable union was achieved in 33 of 36 toes. No patients had superficial or deep infection and no patient required wire removal or a revision procedure.

In conclusion, PIPJ Arthrodesis with buried K Wires has excellent clinical outcome and high patient satisfaction.

Bone bruising of the scaphoid is a common term reported, when MRI imaging is carried out for continued pain, within the anatomical snuff box. Is this significant? Our aim was to ascertain if bone bruising lead to continued symptoms, and resulted in delayed fracture detection- an occult fracture. This was a prospective study looking at 170 patients with scaphoid injuries. Of the 170 scaphoid injuries identified there were 120 scaphoid fractures seen on scaphoid view radiographs. The remaining 50 had no fracture on radiographs, however were clinically symptomatic and had MRI scaphoid imaging which demonstrated various grades of bone bruising. All were treated in a scaphoid plaster and re-examined at 8 weeks. There 4 were patients that remained symptomatic, MRI scan were performed which revealed 3 with resolving scaphoid bone bruising and 1 with a scaphoid fracture (p-value=0.05). Two further weeks of immobilisation resolved the symptoms of those 4 patients. Therefore occult scaphoid fractures demonstrating only bone bruising may take up to 8 weeks to declare itself as a fracture. Immobilisation in a scaphoid cast should be the mainstay of treatment for a minimum period of 8 weeks.

Mid-shaft humeral fractures in adults are common these days and often present with a management dilemma between operative and non-operative treatment. This study evaluates the outcome of such fractures treated non-operatively over a span of 10 years.

In this retrospective study, a review of case notes and radiographs of patients whose mid-shaft humerus fractures were treated non-operatively between 1994 and 2004 was done. Those younger than 16 years and/or who had surgery primarily were excluded. Various factors including patient demographics, mechanism of injury, AO fracture classification and time to union were studied. Mean patient follow-up was 4 years and 6 months. The Oxford shoulder score was used for functional assessment.

There was a total of 43 patients, mostly men with involvement of the dominant arm. 5 patients required open reduction and internal fixation with bone grafting for non-union. The average Oxford shoulder score was 18. The majority of patients could resume their jobs and the average time to union was 9 weeks.

We conclude from this study that there is a high union rate in the mid-shaft humeral fractures in adults treated non-operatively, with an acceptable functional outcome.

Introduction: Ankle fractures are common in trauma practice. Traditional teaching has been to use two screws for medial malleolar fixation to achieve better rotational control. However, the evidence for this is limited. This study compares the outcome following either one or two screws for medial malleolar fracture fixation.

Materials and Methods: Retrospective analysis of case notes and x-rays of all medial malleolar fracture fixations performed between 2002 to 2007. Two groups were formed (group-I and group-II) depending upon the use of either one or two screws, respectively.

Both groups were age and sex matched. Besides patient demographics, fracture pattern according to Dennis–Webber classification, orientation of the medial malleolar fracture, position of screw in relation to fracture, post-operative fracture displacement and union (bony and clinical) were assessed. Patients were also contacted to assess whether they had returned to their pre-injury level of activities.

Results: There were total of 76 patients (group-I had 37 and group-II had 39 patients). The majority were females with age range between 19 and 84 years with involvement of the right ankle mostly.

In group-I, 15 patients had bi-malleolar Dennis-Webber type B fractures, 9 had bi-malleolar Dennis-Webber type C and 10 had tri-malleolar fractures. 3 had uni-malleolar fracture.

In group-II, 20 patients had bi-malleolar Dennis-Webber type B fractures, 9 had bi-malleolar Dennis-Webber type C fractures and there were 5 tri-malleolar fractures. 5 had uni-malleolar fracture.

The fracture orientation in both the groups was mostly horizontal than oblique and the screw placement was at an angle to the fracture in the majority of cases in both of them.

There was no significant difference between the two groups, in terms of clinical union, post-operative fracture displacement and return of patients to their pre-injury level of activity.

Conclusion: Medial malleolar fractures can be efficiently fixed with one screw only, which does not increase the risk of post-operative fracture fragment displacement, compared to using two screws.

Introduction: Hallux valgus is a common presentation at the elective orthopaedic clinics. Patients complain of pain and deformity of the big toe. Treatment is aimed at improving the cosmesis and alleviating pain in the fore foot.

This study assesses the pre and post-operative pedal pressures during stance phase of dynamic gait cycle to identify objective biomechanical factors which influence the final outcome.

Materials and Methods: This is a prospective study, approved by the local research and ethics committee, in which 17 feet were assessed with moderate to severe hallux valgus. Distal-L and Scarf osteotomies were performed for moderate and severe deformities, respectively.

Pedobarography was performed before and 8 months after surgery, on an average. Sole was divided into eight segments i.e. heel, midfoot, lateral forefoot, central forefoot, medial forefoot, II–V toes, hallux and total sole area. Variables compared were contact area, peak pressure, mean pressure and contact time. Manchester-Oxford foot questionnaire (MOXFQ) was used to assess the clinical disability. The inter-metatarsal and metatarso-phalengeal angles were measured radiographically. Both clinical and radiological assessments were performed pre and post-operatively.

Results: 11 had distal-L and 6 had Scarf osteotomies. There were significant improvements in all the three domains of the subjective MOXFQ questionnaire i.e. walking/standing (p 0.013), pain (p 0.001) and social limitation (p 0.002).

The inter-metatarsal angle reduced from 15 to 7 (p 0.001) and the metatarso-phalengeal angle reduced from 32 to 9 (p 0.001).

There was significant reduction in heel contact area (p 0.002), the medial forefoot (p 0.030) and II – V toes (p 0.048) contact time.

Conclusion: Both distal-L and Scarf osteotomies resulted in significant improvements in clinical and radiographic outcome. Although there was reduction in heel contact area and medial forefoot contact time, there were no significant changes in pedal pressures at 8 months postoperatively.

Introduction: Distal Radius Fractures (DRF) and Hip Fractures are considered as fragility fractures. The purpose of this study was to assess whether DRF precedes hip fracture or not. This retrospective analysis was carried out in a group of patients who sustained bilateral non contemporary hip fractures.

Materials and Methods: Retrospective analysis of radiographs and notes of all the patients requiring surgery for bilateral neck of femur fractures, from January 1994 to June 2005 at a district general hospital. Data included ages at the first and second fractures, mechanisms of injury, types of fracture and implants used. Time interval between the two fractures was also noted.

These were analyzed for presence of any Distal Radius Fractures (DRF) prior to first admission for hip fracture and time period between first and second admission. It was also analyzed whether a DRF was sustained between these two episodes.

Results: Ninety five patients had bilateral neck of femur fractures during the study period with an average age of 76 years at the first fracture. There were eighty-three females and twelve males. The time interval between bilateral non contemporary hip fracture was 2.5 years.

Out of these ninety five patients a small minority of patients had a DRF preceding their first hip fracture. Those sustaining DRF prior to their second hip fracture was also studied and statistical methods were employed to predict the presence of DRF prior to hip fractures

Conclusion: This study shows that there is no correlation between sustaining two fragility fractures i.e DRF & Hip Fracture and DRF may not necessarily precede a Hip Fracture.

INTRODUCTION: Median Nerve has small vessel on the volar aspect of the nerve which is filled with blood and results in so called ‘ BLUSHING’ of the nerve once it has been decompressed. It was thought that the nerve which didnot blush meant an inadequate decompression was carried out.

PURPOSE: To evaluate whether ‘Blushing’ of the Median Nerve is correlated with adequate decompression and level of recovery in Carpal Tunnel Syndrome through Mini Palmar Incision.

METHODS & MATERIALS: Retrospective analysis of a Single Surgeon practise where it was documented in operation notes whether the nerve was seen to ‘Blushed’ at the time of surgery.They were assessed postoperatively from notes for complete resolution of symptoms and whether there was any recurrence of symptoms.

RESULTS: n=330 Carpal Tunnel Decompressions were reviewed. It was noted that those who had complete resolution of symptoms had ‘Blushing’ noted at the time of surgery compared to those who had partial or incomplete resolution of symptoms wher ‘No BUSHING’ was noticed. Average time of follow up = 6 weeks. Blushing Noted at the time of decompression 192, Recovery/ improvement of symptoms 189, Blushing not noted at the time of surgery 38, NO documentation about Blushing in 100

CONCLUSION: Blushing of Median Nerve intraoperatively is a reliable sign for complete decompression of the nerve and is correalted with good final outcome.

Introduction: Management of acute rupture of the Achilles tendon is controversial. Conservative treatment has a higher re-rupture rate while surgery has complications like infection and wound breakdown. We devised a protocol in our hospital to decide between the surgical or non-surgical options

At our institution, a well-documented and structured program of non-operative or opeartive management of Achilles tendon rupture with use of either casts or operation has been devised based on Ultrasound findings of the ‘Gap/distance between the two ends of the Tear’.

PURPOSE: The purpose of this study was to compare the incidence of Re-rupture in those treated by cast immobilization where the ends were approximating at ultrasound examination at our institution.

METHODS: This study Prospectively assessed the results in 50 consecutive patients with a complete rupture of the Achilles tendon who had been treated with our regimen depending on the findings of the ultrasound examination, between 2003 and 2006. All ruptured Tendoachilles had ultrasound done in Full Equinus position to assess whether the ends are approximating or not. If ends were approximating they were treated in an equinus cast. Patients were evaluated on the basis of the subjective results and functional outcome measure, along with validated visual analogue scores. Re-rupture rates were measured at 06 months after injury. There were 35 Male and 13 females. This was followed by a final questionnaire to assess their return to pre-injury activities. Two patients were lost to follow-up as they moved out of the area.

RESULTS: All the 48 re-ruptures available for analysis had their ultrasound done on initial presentation. 25 were treated non-operatively and 23 underwent surgery. The overall complication rate for Non Operative was minimal, with NO re-rupture or documented deep vein thromboses. In operative group there were 2 re-ruptures, 5 postoperative infection and discharge.

CONCLUSION: The results of our non-operative treatment were better overall than published results of non operative & operative repair of acute Achilles tendon rupture. In this study the ends are approximating, confirmed on ultrasound before being assigned to Cast Immobilization.

SIGNIFICANCE: The previous studies have not assigned patients into operative or non-operative groups based on whether the ends are approximating in full equines position. By assigning only those in whom the ends are approximating, to cast immobilization, re-rupture rates are less, thus resulting in better and stronger healing of TAs’ and avoiding risks of surgery.

Introduction: Supracondylar fracture of the humerus is a common upper limb fracture in children. Treatment is controversial and often technically difficult; complications are common. Cubitus varus is the most common problem with a mean incidence of 30%. A variety of methods of treatment for displaced fractures have been recommended.

Materials & Method: We reviewed 20 cases of severely displaced grade III supracondylar fractures of the humerus in children. There was marked swelling and distorted local anatomy in all these cases. These fractures were managed conservatively with straight – arm lateral traction. The patients were treated in skin traction for 2 weeks. They commenced physiotherapy after that. The traction was applied with arm in 90 degrees of abduction and forearm in supination.

Results: None of the patients developed any complication. All had full range of movements. None had cubitus varus deformity and none of these patients required resurgery. There was a complete patient and parent satisfaction.

Discussion: Open or closed reduction with internal fixation is the most common method of treating these injuries. In some cases this can be very difficult and dangerous. The local anatomy and swelling may not permit this; hence non-operative measures have to be adopted.

Conclusion: We conclude that straight – arm lateral traction is a safe and effective method of treating these fractures especially when the local anatomy is disturbed and the swelling is making operative intervention more risky and difficult. Moreover this method is also appropriate in areas where access to specialised centres in treating these injuries is either difficult or delaying.