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Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_14 | Pages 12 - 12
1 Dec 2015
Berwin J Burton T Taylor J McGregor A Roche A
Full Access

Background

The current ‘gold standard’ method for enabling weightbearing during non-invasive lower limb immobilisation is to use a Patella Tendon-Bearing (PTB) or Sarmiento cast. The Beagle Böhler Walker™ is a non-invasive frame that fits onto a standard below knee plaster cast. It is designed to achieve a reduction in force across the foot and ankle.

Our objective was to measure loading forces through the foot to examine how different types of casts affect load distribution. We aimed to determine whether the Beagle Böhler Walker™ is as effective or better, at reducing load distribution during full weightbearing.

Methods

We applied force sensors to the 1st and 5th metatarsal heads and the plantar surface of the calcaneum of 14 healthy volunteers. Force measurements were taken without a cast applied and then with a Sarmiento Cast, a below knee cast, and a below knee cast with Böhler Walker™ fitted.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 50 - 50
1 Sep 2012
Roche A Selvaratnam V Mukhopadhaya S Unnikrishnan N Abiddin Z Narayan B Giotakis N Aniq H Nayagam S
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Introduction

The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis.

Methods

A retrospective review of cases treated consecutively from 2006 to 2010 was undertaken. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology and microbiology. The Cierney-Mader system was used to classify. Treatment involved removal of implants (if any), intramedullary debridement and local resection (if needed), lavage and instillation of the gentamicin carrier, supplemented with systemic antibiotics. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip) and general health outcome (SF36).


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 68 - 68
1 Sep 2012
Deol R Roche A Calder J
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Introduction

Lisfranc joint injuries are increasingly recognised in elite soccer and rugby players. Currently no evidence-based guidelines exist on timeframes for return to training and competition following surgical treatment. This study aimed to see whether return to full competition following surgery for Lisfranc injuries was possible in these groups and to assess times to training, playing and possible related factors.

Material/Methods

Over 46-months, a consecutive series of fifteen professional soccer (6) and rugby(9) players in the English Premierships/Championship, was assessed using prospectively collected data. All were isolated injuries, sustained during competitive matches. Each had clinical and radiological evidence of injury and was treated surgically within thirty-one days. A standardised postoperative regime was used.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIV | Pages 17 - 17
1 Jul 2012
Roche A Selvaratnam V Mukhopadhaya S Unnikrishnan N Abiddin Z Narayan B Giotakis N Aniq H Nayagam S
Full Access

The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis.

A retrospective review of cases treated consecutively from 2006 to 2010 in the Royal Liverpool University Hospital was undertaken. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology and microbiology. The Cierney-Mader system was used to classify. Treatment involved removal of implants (if any), intramedullary debridement and local resection (if needed), lavage and instillation of the gentamicin carrier, supplemented with systemic antibiotics. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip) and general health outcome (SF36).

There were 31 patients (22 male, 9 female). The mean age was 47 years (20-67). Twenty-five cases were post-surgery (6 open fractures) and 6 were haematogenous in origin. The median duration of osteomyelitis was 1.6yrs. The bones affected were 42% femur, 45% tibia, 3% radius and 10% humerus. 11 cases had diffuse as well as intramedullary involvement. 9 cases underwent segment resection and bone transport. We identified Staphylococcus Aureus in 16 and Coagulase Negative Staphylococcus in 6 cases. The median follow-up was 1.7 years (0.5-5.6). The median scores attained were: AOFAS-78, DASH-32, IOWA-71, Oxford-32. There were two recurrences.

Dead space management of intramedullary infections is difficult. We describe a method for delivery of local antibiotics and provide early evidence to its efficacy. The treatment success to date is 93%.

Bioabsorbable carriers of antibiotics are efficacious adjuncts to surgical treatment of intramedullary osteomyelitis.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXII | Pages 29 - 29
1 May 2012
Roche A Bennett S Fischer B Molloy A
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NHS governance demands that services provided are clinically effective and safe. In the current financial climate and threats over public sector spending cuts, services offered by health care providers should also be cost-effective and profitable. Surgical specialties are often perceived as expensive with high implant costs. The aim of this audit was to cost the profit margin for foot/ankle surgery and test the accuracy of coding data collected.

Materials and Methods

Theatre data between January-April 2010 was retrospectively reviewed. Equipment inventories, operation notes and radiographs were reviewed for implants used. Clinical coding data was analysed and coded separately by the surgeon for comparison. Theatre expenses were calculated and accuracy estimated. Tariff generated and patient expenses were calculated and a final profit margin revealed. Wilcoxon matched-pair testing compared hospital recorded and surgeon calculated data.

Results

95 cases were included (51 forefoot, 5 midfoot, 6 arthroscopy, 12 hindfoot, 21 other), 65 female and 30 male patients. Theatre inventories were correct in 11% of cases. Mean inventory costs recorded were £90 and following surgeon analysis, £319. Total actual inventory cost was £30,306.23 but £8548.58 was recorded (p<0.0001). OPCS codes were deemed correct in 43% and incorrect in 57% of cases. Operation profit margin, including theatre, ward and salary costs was recorded as £158,229 but corrected profit margin with d inventories and OPCS codes was £121,584 (p=0.001).


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 9 - 9
1 Jan 2011
Roche A Hunter L Pocock N Brown D
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To test the knowledge of clinicians in Orthopaedic clinics and Emergency departments of the surface anatomical landmarks that should be examined during assessment of foot and ankle injuries. Specifically trained assessors observed 109 clinicians examining 6 anatomical landmarks on uninjured subjects. Each landmark was chosen for their relevance in assessment of foot and ankle injuries. The landmarks were the medial malleolus, lateral malleolus, fibula head, navicular, base of the 5th metatarsal and the anterior talo-fibular ligament (ATFL).

Two participants failed to identify a single landmark. Of 109 assessed, 27% correctly identified all 6 landmarks. The average correctly identified by each clinician was 4.1 with a standard deviation of 1.5 and range of 0–6. One hundred and seven clinicians correctly identified the lateral malleolus, the most consistently identified. The most poorly identified landmark was the ATFL, by 45%.

The knowledge of surface anatomy overall by junior Orthopaedic and Emergency clinicians was found to be poor and only seems to significantly improve once higher specialty training is reached. Despite the potential for subjectivity and bias the authors believe the methodology is sufficient to demonstrate a lacking in anatomical knowledge amongst clinicians. Poor anatomical knowledge leads to inaccurate examination. This can lead to incorrect diagnoses or even mal-treatment of patients. Clinicians are becoming more reliant on potentially unnecessary and expensive imaging investigations. They have neglected the basic art of physical examination based on sound knowledge of human anatomy. At present, the authors believe that the anatomical teaching in undergraduate medicine is inadequate.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 11 | Pages 1586 - 1588
1 Nov 2010
Perry DC Tawfiq SM Roche A Shariff R Garg NK James LA Sampath J Bruce CE

The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia.

This study supports selective ultrasound screening of hips in infants with CTEV.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 532 - 532
1 Oct 2010
Wharton D Roche A Scott S
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Background: Mini-incision surgery (MIS) for total hip replacement (THR) typically uses incisions of 10cm or less and therefore may offer a better cosmetic appearance. Reported advantages of MIS include decreased blood loss, less tissue trauma and decreased pain, all of which are equivocal by six weeks post-surgery, when compared with standard incisions. The aim of this study was to compare patient scar satisfaction and identify potential long-term benefits of this incision when used in the posterior approach for THR.

Methods: Two groups of patients who underwent primary THR were reviewed. Group 1 consisted of 43 patients who underwent THR via a mini-incision, with a mean incision length of 9.44cm. Group 2 consisted of 51 patients who had a posterior standard incision, with a mean length of 15.3cm. The average length of follow-up was 12.8 months (range 2 – 48 months). There were no wound complications in either group. Scars were assessed using the validated Manchester Scar Proforma (MSP) and Visual Analogue Scales (VAS), and patients completed a Patient Scar Assessment Scale.

Results: The mean combined MSP and VAS scores for Group 1 and Group 2 were 7.2 and 7.1 respectively. The mean Patient Scar Assessment Scale score was 8.8 in group 1, and 10.4 in Group 2. The single parameter that scored highest in the Patient Scar Assessment Scale was the colour of the scar. This did not vary between the two groups of patients. There was no statistical significance in any of the parameters measured.

Conclusion: There does not appear to be any cosmetic benefit from MIS, when performing THR via the posterior approach. The length of wound was of little concern to patients, while the colour of the scar was the highest-scoring factor in the Patient Scar Assessment Scale. We therefore conclude that there is no long-term benefit from mini-incision surgery for THR via the posterior approach.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 243 - 243
1 Mar 2010
Roche A Hunter L Pocock N Brown D
Full Access

Aim: To test the knowledge of clinicians in orthopaedic clinics and emergency departments of the surface anatomical landmarks, that should be examined during assessment of foot and ankle injuries.

Methods: Specifically trained assessors observed 109 clinicians examining 6 anatomical landmarks on uninjured subjects. Each landmark was chosen for its relevance to assessment of foot and ankle injuries. The landmarks were the medial malleolus, lateral malleolus, fibula head, navicular, base of the 5th metatarsal and the anterior talofibular ligament (ATFL).

Results: 2 participants failed to identify a single landmark. Of 109 assessed, 27% correctly identified all 6 landmarks. The average correctly identified by each clinician was 4.1 (sd: 1.5 and range: 0–6). 107 correctly identified the lateral malleolus, the most consistently identified. The most poorly identified landmark was the ATFL, by 44%.

Discussion: The knowledge of surface anatomy of junior orthopaedic and emergency clinicians was found to be poor and only seems to significantly improve once higher specialty training is reached. Despite the potential for subjectivity and bias the authors believe the methodology is sufficient to demonstrate a lack of anatomical knowledge amongst clinicians. Poor anatomical knowledge leads to inaccurate examination. This can lead to incorrect diagnoses or even maltreatment of patients. Clinicians are becoming more reliant on unnecessary and expensive imaging investigations. They have neglected the basic art of physical examination based on sound knowledge of human anatomy. At present, the authors believe that the anatomical teaching in undergraduate medicine is inadequate.


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_III | Pages 250 - 250
1 Mar 2003
Dhukaram V Roche A Walsh H
Full Access

A retrospective analysis was done on 20 cases of interphalangeal joint fusion of the great toe utilizing longitudinal cortical screw fixation. The purpose of this study was to present a series of interphalangeal joint fusion great toe done in both paediatric and adult patients using 3.5mm cortical screws. Most of the patients had interphalangeal joint fusion along with Jones transfer and other associated procedures with a mean follow up period of 19 months. Arthrodesis was successfully achieved in all the patients. No one had pain at the interphalangeal joint of the great toe. A literature review on interphalangeal joint arthrodesis was done and advantages of cortical screw fixation over other techniques have also been presented.