Arthrodesis of small joints of the feet has been used for a variety of conditions. Described initially for treatment of congenital or paralytic foot deformities, arthrodesis has now been widely accepted as treatment for a range of foot disorders from inflammatory and post traumatic arthritis to acquired flat foot. A variety of fixation devices have been used to achieve compression at the Arthrodesis site. The aim of our study is to evaluate the use of Memory compression staples in small joint fusions of the feet. The staples are made of a nickel-titanium alloy which exhibits a phenomenon called “Marmen” effect. When kept at ice-cold temperature (0–5°C), the alloy becomes plastically deformed, but, regains its original shape at body temperature. The emphasis of this study is to validate the safety of the implant for fusion of small joints of feet, as well as to determine whether the higher cost of the implant is justified by a demonstrable trend in time to fusion and period of immobilization required. Between June 2003 and June 2008, a total of 148 feet (276 joints) had Arthrodesis using memory compression staples. Data was collected retrospectively and clinical and radiological outcomes were assessed. The average period of immobilization in cast was 6.8 weeks (range, 6–12). The average time to fusion was 8 weeks (range, 6–16). The use of memory staples provides an accurate, reproducible and predictable method of achieving arthrodesis in small joints of the feet. The time to fusion is less, thereby reducing the recovery time after surgery.
The benefit of open stabilization for recurrent shoulder instability is well known, however there have been recent reports of postoperative dysfunction of the subscapularis tendon following open shoulder surgery (Habermeyer et al, Scheibel et al). We present our findings in patients who have undergone an open anterior stabilization using a subscapularis split approach. We reviewed 48 patients (49 shoulders), who were treated by the senior author (SB) from 2003–2005. They all underwent an open anterior stabilization of shoulder through a deltopectoral approach, with a subscapularis split technique, without any lateral tendon detachment. The minimum follow-up was 2 years, with average 34 months. Thirty-eight shoulders underwent an isolated anterior stabilization (1 bilateral) and 11 patients had additional procedures (8 bone grafts, 1 SLAP repair, 1 cuff repair, 1 anterior and posterior repair). There were 41 male and 7 female patients, and the mean age was 23.9 years (range 15–47 years). All patients were involved in sports and 45 had presented with recurrent dislocations. Patients were followed up using the Oxford instability score and the Rowe score questionnaires. All had a clinical examination for range of movement, stability, subscapularis muscle function, or signs of dysfunction. All had a MRI to assess the quality of the subscapularis muscle and tendon. Mean postoperative Oxford instability score was 22.5 and the Rowe score was 69.38. Two patients had redislocated following re-injury. There was no evidence clinically of subscapularis dysfunction and the muscle and tendon were normal on all MRI scans. External rotation was reduced by a mean of 15.6 degrees. There was no significant loss of flexion or abduction. 81% of patients returned to their previous level of sport. With a subscapularis split technique for anterior shoulder stabilization there is no significant postoperative dysfunction or damage to the subscapularis muscle, and most patients return to their previous level of sport.
Biologic resurfacing of the glenoid combined with surface replacement hemiarthroplasty for relatively young patients suffering from advanced glenohumeral arthritis has the advantages of both humeral head and glenoid bone preservation. The longer term results of this procedure are reported. Twenty two shoulders in 21 patients had a surface replacement hemiarthroplasty with resurfacing of the glenoid with the anterior capsule. At follow up one had died, and another was not contactable. The prosthesis was removed in one for deep infection, and the fourth patient had undergone revision to a total shoulder arthroplasty for ongoing pain. Therefore, 17 patients with 18 operated shoulders were available for clinical assessment. The average age of the patients was 54.8 years (35–78) at the time of surgery. The average length of follow-up was 4.8 years (2–10.6). The average Constant Score was 71.4 points (41–95), and the sex- and age-adjusted Constant Score was 83.9%. The mean ASES score was 74.4 points (35–100). The average arc of forward flexion was 130 degrees (100–160), and external rotation was 39 degrees (20–60). On a VAS scale of 0 to 10, the average pain score at rest was 0.5 (0–3), while pain with activity was 2.4 (0–6). Sixteen of the 17 patients (94%) had a satisfactory result, and would have the operation again. Eight of the 17 patients (47%) were able to return to their previous sporting activities. Radiographic follow-up demonstrated there were 2 mild and 2 moderate cases of superior subluxation of the humeral head. There was no subsidence or signs of loosening of any humeral prosthesis. The average glenohumeral joint space was 0.13mm (0–2). Glenoid erosion was none in one case, mild in 6 cases, moderate in 6 cases, and severe in 3 shoulders. Although the results of this procedure compare favourably with other series, the extent of glenoid erosion is concerning. A more robust tissue for interposition may give better results
Bone allograft use in trauma and orthopaedic surgery is limited by the potential for cross infection due to inadequate acceptable decontamination methods. Current methods for allograft decontamination either put the recipient at risk of potentially pathogenic organisms or markedly reduce the mechanical strength and biological properties of bone. This study developed a technique of sterilization of donor bone which also maintains its mechanical properties. Whole mature rat femurs were studied, as analogous to strut allograft. Bones were inoculated by vortexing in a solution of pathogens likely to cause cross infection in the human bone graft situation. Inoculated bones were subjected to supercritical carbon dioxide at 250 bar pressure at 35 degrees celsius for different experimental time periods until a set of conditions for sterilization was achieved. Decontamination was assessed by vortexing the treated bone in culture broth and plating this on suitable culture medium for 24 hours. The broth was also subcultured. Controls were untreated-, gamma irradiated- and dehydrated bone. Mechanical testing of the bones by precision three-point bending to failure was performed and the dimensions and cross-section digitally assessed so values could be expressed in terms of stress. Mechanical testing revealed bone treated with supercritical carbon dioxide was consistently significantly stronger than that subjected to gamma irradiation and bones having no treatment (due to the minor dehydrating effect of the carbon dioxide). Terminal sterilization of bone is achieved using supercritical carbon dioxide and this method maintains the mechanical properties. The new technique greatly enhances potential for bone allograft in orthopaedic surgery.
The satisfaction of patients at both sites was analysed using a number of factors- the care provided was 79% before the move and 82% afterwards, their understanding of a nurse led service was rated as 73% and 85% respectively. Evaluation of the quality of information demonstrated that their questions had been answered well 78% and 75% respectively and the confidence and trust in the person providing the care was 91% and 89%. Failure by the IT department in delivering effective links to hospital computer system resulted in the LBOS data not being completed in the period following the move with logistical difficulties in clinic organisation.
This study demonstrates that the NP documentation follows the guidelines identified by the RCGP, conversely it was not possible to assess from the GP documentation if all the steps had been followed. The mean average LBOS in the NP patients was slightly higher than those in the GP group, was this because these patients were having guideline applied care as opposed to “usual care”? Evaluation of the patient recall of information shows the NP sent five patients for X-ray even though this did not occur and is not recommended in guidelines. Conversely twenty-three patients can remember being given the “Back Book” by the GP but this was only documented in three cases. We believe that patient recall demonstrates an ineffective way to measure outcome and funding allocation for back pain management and needs to more accurately reflect the evidence.
The aim of this study was to compare implementation of RCGP guidelines in patients in Primary Care with acute low back pain between GP and Nurse Practitioner. This report presents preliminary results. The intention was to recruit 200 patients presenting to GP with new episode of back pain. 50% randomised to NP care, 50% to GP care. Outcome measured by documentation audit and patient feedback. Individuals complete a questionnaire which includes a Low Back Outcome Score (LBOS) at 14 weeks, 6,12 and 24 months. All patients in NP arm given back book and advised against bed rest.
Initial results suggest no significant difference in outcome between GP and Nurse Practitioner patients. Of interest is that 10% and 13% of patients failed to recall important features of management. This implies that audit of healthcare processes by patient questionnaire may be unsatisfactory.
After having had a standard decompression for anterior compartment syndrome, five patients presented with persistent symptoms and pressure values above normal. A repeat procedure combined with fasciectomy relieved their pain; postoperative pressure values were normal.
A cortical bone graft on a muscle pedicle was taken from the ulna and transferred to bridge a complete defect of the radius in 16 dogs. In 14 control dogs a free graft was used, that is, one without a muscle pedicle. Union in the group with pedicle grafts was far superior to that in the group with free grafts, mainly because in those with pedicle grafts there was good subperiosteal new bone formation from active viable periosteum. In six of the pedicle grafts the viability of some osteocytes was retained over a 12-week period and in five the graft was almost completely replaced by new bone.
We present three cases of a previously undescribed condition characterised by unilateral tibia vara associated with an area of focal fibrocartilaginous dysplasia in the medial aspect of the proximal tibia. The three children affected were aged 9, 15 and 27 months respectively. Two required tibial osteotomy, but in one the deformity resolved without treatment. The pathogenesis of the focal lesion remains conjectural; the most likely explanation is that the mesenchymal anlage of the tibial metaphysis has, for unknown reasons, developed abnormally at the insertion of the pes anserinus.