Background

Masses are not uncommon in the foot and ankle. Most of these masses are benign, often leading clinicians to underestimate their potential for malignancy.

Introduction

Primary ankle arthroplasty (TAR) is increasingly used to treat end-stage ankle arthritis. Reported revision rates of TAR vary from 8.5% to 11.1% at 9 years. Revision surgery remains technically challenging with options ranging from simple joint debridement to tibio-talar-calcaneal fusion. The efficacy of these procedures remains unclear and there is no consensus on optimal revision options.

Background

Open or arthroscopic ankle fusion (AAF) is a successful operative treatment for end-stage ankle arthritis. Evidence suggest that AAFs have better outcomes. In addition to the operative technique other patient-factors can influence outcomes. The most significant complication of ankle fusion is a non-union. To better understand the risk factors related to this we undertook a retrospective investigation of primary AAFs.

Tendinopathy can commonly occur around the foot and ankle resulting in isolated rupture, debilitating pain and degenerative foot deformity. The pathophysiology and key cells involved are not fully understood. This is partly because the dense collagen matrix that surrounds relatively few resident cells limits the ability of previous techniques to identify and target those cells of interest. In this study, we apply novel single cell RNA sequencing (CITE-Seq) techniques to healthy and tendinopathic foot/ankle tendons. For the first time we have identified multiple sub-populations of cells in human tendons. These findings challenge the view that there is a single principal tendon cell type and open new avenues for further study. Healthy tendon samples were obtained from patients undergoing tendon transfer procedures; including tibialis posterior and FHL. Diseased tendon samples were obtained during debridement of intractable Achilles and peroneal tendinopathy, and during fusion of degenerative joints. Single cell RNA sequencing with surface proteomic analysis identified 10 sub-populations of human tendon derived cells. These included groups expressing genes associated with fibro-adipogenic progenitors (FAPs) as well as ITGA7+VCAM1- recently described in mouse muscle but, as yet, not human tendon. In addition we have identified previously unrecognised sub-classes of collagen type 1 associated tendon cells. Each sub-class expresses a different set of extra-cellular matrix genes suggesting they each play a unique role in maintaining the structural integrity of normal tendon. Diseased tendon harboured a greater proportion of macrophages and cytotoxic lymphocytes than healthy tendon. This inflammatory response is potentially driven by resident tendon fibroblasts which show increased expression of pro-inflammatory cytokines. Finally, identification of a previously unknown sub-population of cells found predominantly in tendinopathic tissue offers new insight into the underlying pathophysiology. Further work aims to identify novel proteins targets for possible therapeutic pathways.

Aims

Periprosthetic joint infection (PJI) is a debilitating condition with a substantial socioeconomic burden. A novel autologous blood glue (ABG) has been developed, which can be prepared during surgery and sprayed onto prostheses at the time of implantation. The ABG can potentially provide an antimicrobial coating which will be effective in preventing PJI, not only by providing a physical barrier but also by eluting a well-known antibiotic. Hence, this study aimed to assess the antimicrobial effectiveness of ABG when impregnated with gentamicin and stem cells.

Aims

For cementless implants, stability is initially attained by an interference fit into the bone and osteo-integration may be encouraged by coating the implant with bioactive substances. Blood based autologous glue provides an easy, cost-effective way of obtaining high concentrations of growth factors for tissue healing and regeneration with the intention of spraying it onto the implant surface during surgery. The aim of this study was to incorporate nucleated cells from autologous bone marrow (BM) aspirate into gels made from the patient’s own blood, and to investigate the effects of incorporating three different concentrations of platelet rich plasma (PRP) on the proliferation and viability of the cells in the gel.

Introduction:

In April 2012 National Trauma Networks were introduced in England to optimise the management of major trauma. All patients with an ISS of ≥ 16 should be transferred to the regional Major Trauma Centre (level 1). Our hypothesis was that severe foot and ankle injuries would no longer be managed in Trauma Units (level 2).

Painful foot and ankle joints are often pointed out as an impeding factor for lack of mobility and weight reduction. There is an assumption that weight loss will occur after their surgery due to increased mobility. The current study aimed to evaluate the effect of surgery on post-operative body mass index (BMI) in patients who underwent mid-foot or hind-foot arthrodesis. Our secondary aim was to look at the effect of sex, pre-operative obesity and good pain relief (AOFAS> 80) on post-operative BMI.

All patients who underwent mid-foot and hind-foot arthrodesis between April 2005 and November 2006 were identified from the operating theatre records. Each patient’s BMI recorded pre-operatively was compared with that recorded at a minimum of 6 months postoperatively using the paired Student’s t-test.

There were 35 eligible patients. 3 patients were excluded because of multiple trauma and 1 patient died during the period of study. We had 31 patients with 33 procedures with a mean age of 61 years (range 41–80). There were 18 females and 13 males. It was found that there was a mean increase of BMI by 0.25 (95%CI of −.95 to.44; p-value=0.47). It was noted that BMI of patients in obese group (BMI> 30) increased post-operatively by 0.07 (95%CI of −1.52 to 1.66; p-value=0.92).

This study highlights the fact that there is no significant effect on BMI in obese patients after successful fusion surgery. The post-operative BMI is neither significantly affected by sex nor quality of pain relief.

Introduction: Obesity has become a major public health epidemic, with recent reports citing that 22% of English men and 24% of women are clinically obese. Painful foot and ankle joints are often pointed out as an impeding factor for lack of mobility and weight reduction. There is an assumption that weight loss will occur after their surgery due to increased mobility.

The current study aimed to evaluate the effect of surgery on post operative body mass index (BMI) in patients who underwent mid-foot or hind-foot arthrodesis.

Patients and Method: All patients who underwent mid-foot and hind-foot arthrodesis under the care of senior author from April 2005 to Nov. 2006 were identified from the operating theatre records. In total 33 procedures were done in 31 patients. Each patient’s BMI recorded pre-operatively was compared with that recorded at a minimum of 6 months postoperatively using the paired Student’s t-test. Analysis of the data was also conducted by stratifying pre-operative BMI, good pain relief (i.e AOFAS> 80), sex and fusion site.

Results: It was found that there was a mean increase of BMI by 0.25 (95% CI of −0.95 to 0.44) with p-value of 0.47.

It was noted that BMI of patients in obese group increased post-operatively by 0.07 (95% confidence interval of −1.52 to 1.66) with p-value of 0.9.

Discussion: This study highlights the fact that there is no significant effect on BMI in obese patients despite significant increase in mobility and pain levels after mid-foot and hind-foot arthrodesis. The change in BMI after fusion surgery is not significantly effected by sex nor quality of pain relief.

Background: Traumatic femoral head osteonecrosis in adolescents has a poor prognosis due to collapse and subsequent degenerative change. There are currently no satisfactory treatments available for this condition. Bisphosphonate therapy has improved outcome in animal models of osteonecrosis. We have evaluated bisphosphonate therapy as a novel strategy for adolescent traumatic osteonecrosis.

Methods: We established a protocol of identification of adolescents with osteonecrosis utilizing bone scans immediately after surgical treatment for hips at risk of osteonecrosis after trauma. Of a consecutive group of twenty-eight patients with either unstable slipped capital femoral epiphyses (SCFE) (22), femoral neck fracture (4) or hip dislocation (2), seventeen patients with osteonecrosis were identified. These patients (13 boys and 4 girls, mean age 12.6 years) and their families consented for treatment with intravenous bisphosphonates based on animal experimental evidence. Of the patients with osteonecrosis, twelve had presented with unstable SCFE, four with femoral neck fractures and one following traumatic hip dislocation. The average length of bisphosphonate treatment was 20.3 months (range 7 to 39). All patients were followed for at least 2 years.

Results: At mean follow-up of 38.7 months, fourteen patients (82%) were pain free. Clinically, all patients had a good to excellent outcome. The mean Harris Hip Score was 91.1, the Iowa Hip Rating was 92.1 and the Global PODCI score was 91.5. On radiographs, nine patients (53%) were rated as Stulberg I–II, six (35%) as Stulberg III, and two (12%) as Stulberg V.

Conclusion: Bisphosphonates therapy may play an adjunctive role in the treatment of adolescents with traumatic osteonecrosis.

There are only a limited number of long term studies of total knee arthroplasty and few with a minimum fifteen year survivorship of a modular fixed bearing posterior cruciate-retaining prosthesis. This consecutive series of 139 total knee arthroplasties (109 patients), using the non-conforming posterior cruciate-retaining Press Fit Condylar (PFC®) system was followed for a minimum of 15 years (range 15.0 to 16.9 years). The patella were resurfaced with an all-polyethylene component in 83% of knees. The tibial component was always cemented, while a porous-coated femoral component was used in 84% of knees. Fifty-nine knees (45 patients) were followed up for a minimum of 15 years. Fifty-seven patients (70 knees) had died and five (8 knees) were too ill to assess. Survivorship of the prosthesis was confirmed for 98.6% of the prosthesis, as only two patients (2 knees) were lost to follow-up.

The mean Knee Society Score and Function Score were 96 and 78 respectively. The total incidence of radiolucent lines was 13%, with 2% around the femur, 11% around the tibia, and 0% around the patella. None of these lines were of any clinical relevance. There was no evidence of progressive radiolucent lines or component loosening, and one case of zone 4 femoral osteolysis.

There were five re-operations for any indication, of which four were for polyethylene insert wear. There was also one loose cemented femoral component after more than 15 years. The survival without need for revision for any reason was 99% at 10 years and 95.6% (worst-case scenario of 94.2%) at 15 years.

This single-surgeon series with a minimum 15 year follow-up shows that the modular fixed bearing posterior cruciate retaining total knee arthroplasty of the PFC system can provide excellent and predictable long term results in tri-compartmental arthritis of the knee.

Traumatic osteonecrosis of the femoral head in adolescents has a poor prognosis due to collapse and degenerative change. We hypothesised that early bisphosphonate treatment to reduce osteoclast activity could allow revascularisation and repair with maintenance of joint congruity.

Nine patients with documented osteonecrosis were treated with intermittent intravenous pamidronate (Aredia, Novartis) commencing within a mean 1 month of diagnosis (range, 5 to 91days). The dosing protocol has evolved over two years with the current dose being 9 mg/kg/year for 18 months. Mean follow up is 19.8 months (range, 13 to 30 months) with all patients followed for more than one year. There were 6 patients, who presented after unstable SCFE. Of these the index procedure had failed in three, requiring multiple early operations. The other three patients had sustained an inter-trochanteric fracture with a pelvic fracture, a traumatic hip dislocation and a femoral neck fracture respectively.

Eight of the patients are painfree. Six have been instructed to fully weight bear, while two can partial weight bear and one is non-weight bearing. Seven of 9 patients do not show significant resorption of the femoral heads at the most recent follow up. Of the two patients with significant resorption, one patient began to resorb after his medication was ceased, so it was recommenced. He has subsequently undergone a realignment procedure. The other patient had resorption of a section of the femoral head, which had not re-vascularised by 18 months, and this was elevated and bone grafted. These two hips are considered functional in the short term as they are currently pain free, but their deformity is expected to bring about early osteoarthritis in adult life.

This early experience lays the foundation for prospective clinical trials of bisphosphonate therapy in adolescents with osteonecrosis. It appears that bisphosphonate treatment protocols for adolescents will need to be prolonged. Our current practice is for a duration of around 18 months with normalisation of uptake on bone scan as the end point for therapy.

A consecutive series of 139 total knee arthroplasties (109 patients, average age 67 years), using a non-conforming posterior cruciate-retaining prosthesis was followed for 15 years (range, 15.0 to 16.9 years).

Forty-five patients (59 knees) were clinically and radiographically evaluated, 57 (70 knees) had died, five patients (8 knees) were too ill to assess, two patients (2 knees) were considered lost to follow-up. Survivorship analysis was performed using worst case scenario analysis and failure defined as re-operation for any reason.

Results: In this series there were five re-operations for any indication, four of which were for polyethylene insert wear. One loose cemented femoral component was revised at 15 years. The survival without revision or need for any re-operation was 92.6% at 15 years. The mean Knee Society Score and Function Score at 15 year follow-up are 96 and 78 respectively. The prevalence of radiolucent lines was 13%. None of these lines were clinically relevant. There was no evidence of progressive radiolucent lines, and one case of asymptomatic femoral osteolysis.

Conclusions: This single-surgeon series with a minimum 15 year follow-up shows good clinical and radiological results with excellent survivorship of a modular fixed bearing posterior cruciate retaining total knee arthroplasty system.

Introduction There are only a limited number of long term studies of total knee arthroplasty but none with a minimum 15 year survivorship of a modular fixed bearing posterior cruciate-retaining prosthesis.

Methods We present a consecutive series of 139 total knee arthroplasties (109 patients, average age 67 years), using a non-conforming posterior cruciate-retaining prosthesis, followed for a minimum of 15 years (range, 15.0 to 16.9 years). The patella was resurfaced with an all-polyethylene component in 83% of knees. The tibial component was always cemented, while a porous coated femoral component was used in 84% of knees. Fortyfive patients (59 knees) were followed-up for a minimum of 15 years, 57 (70 knees) had died, five patients (8 knees) were too ill to assess, two patients (two knees) were considered lost to follow-up.

Results In this series there were five re-operations, four of which were for polyethylene insert wear. At two of these, the patella was exchanged for early surface wear and one patella was resurfaced for the first time. There was one loose cemented femoral component after more than 15 years. The survival without revision or need for revision for any reason was 99% at 10 years and 95.6% (worst case scenario of 94.2%) at 15 years. The mean Knee Society Score and Function Score at 15 year follow-up was 96 and 78 respectively. The total incidence of radiolucent lines was 13%, with two percent around the femur, 11% around the tibia and zero percent around the patella. None of these lines were of any clinical relevance. There was no evidence of progressive radiolucent lines or component loosening, and one case of zone four femoral osteolysis.

Conclusions This single-surgeon series with a minimum 15 year follow-up, and excellent clinical, radiological and survivorship results provides a benchmark upon which other long term studies of modular fixed bearing posterior cruciate retaining total knee arthroplasty can be compared.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.

Introduction Traumatic osteonecrosis of the femoral head in adolescents has a poor prognosis due to femoral head collapse and degenerative change. We hypothesised that early bisphosphonate treatment to reduce osteoclast activity could allow revascularisation and repair with maintenance of joint congruity.

Methods Nine patients with documented osteonecrosis are presented. There were six patients, who presented after unstable SCFE. Of these the index procedure had failed in three, requiring multiple early operations. The other three patients had sustained an inter-trochanteric fracture with a pelvic fracture, a traumatic hip dislocation and a femoral neck fracture respectively. They were treated with intermittent intravenous pamidronate (Aredia, Novartis) commencing within a mean one month of diagnosis (range 5 to 91 days). The dosing protocol has evolved over two years with the current dose being 9 mg/kg/year for 18 months. Mean follow-up is 19.8 months (range 13 to 30 months) with all patients followed for more than one year.

Results Eight of the patients are painfree. Six have been instructed to fully weight bear, while two can partial weight bear and one is non-weight bearing. Seven of nine patients do not show significant resorption of the femoral heads at the most recent follow-up. Of the two patients with significant resorption, one patient began to resorb after his medication was ceased, so it was recommenced. He has subsequently undergone a realignment procedure. The other patient had resorption of a section of the femoral head, which had not re-vascularised by 18 months, and this was elevated and bone grafted. These two hips were considered functional in the short term as they were pain free, but their deformity was expected to bring about early osteoarthritis in adult life.

Conclusions This early experience lays the foundation for prospective clinical trials of bisphosphonate therapy in adolescents with osteonecrosis. It appears that bisphosphonate treatment protocols for adolescents will need to be prolonged. Our current practice is for a duration of around 18 months with normalisation of uptake on bone scan as the end point for therapy.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.

Introduction: Hip fractures are usually evident on plain radiographs. Some are not obvious and require further investigation. A review of the pertinent literature reveals different treatment algorithms for such patients but MRI is recommended as the investigation of choice. Little is stated about the clinical findings in patients with an occult fracture of the hip.

Aims: To investigate any correlation between clinical findings and the presence of fracture on MRI in occult fracture of the hip and use this as a means of speeding the diagnosis of such patients.

Methods: We report a prospective, multi-centre trial. 22 patients admitted with a suspected occult fracture of the hip were assessed clinically for evidence of resting deformity, ecchymosis, point tenderness, hip pain on heel percussion or pistoning and ability to straight leg raise (SLR). The same features were assessed in the contralateral limb. All patients were alert and orientated as to comply with examination. Plain radiograph and MRI findings of both hips were recorded in each case.

Results: Of 22 patients, 17 were unable to perform SLR on the affected side, 5 were able to do so. Of the 18 patients, all had a fracture of either the acetabulum or proximal femur on MRI. Of the group of 5, 2 had normal MRI scans, 1 had a pubic ramus fracture, 1 had bone marrow oedema secondary to osteoarthritis and 1 patient had a six week old valgus impaction fracture. All patients could SLR and had normal MRI of the contralateral hip.

Conclusions: Under the conditions of this study straight leg raise test is 95% sensitive and 95% specific for predicting the presence of fracture in either the acetabulum or proximal femur. We recommend that this simple test can be used to help speed up the diagnosis of and further management of occult fractures of the hip

To establish whether postoperative x-rays were of sufficient quality compared to those at the first outpatients’ appointment, uncomplicated primary total knee replacements performed by one surgeon were reviewed retrospectively. Measurements were made from these X-rays. Rotation was also assessed.

Forty-eight knee replacements were reviewed. Postoperative films showed the tibial tray to be tilted an average of 5. 04 degrees and a femoral valgus angle of 1. 56 degrees. First outpatients’ X-rays showed the tibial tray to be tilted an average of 1. 16 degrees and the femoral valgus angle to be an average 5. 16 degrees. 15 of 25 postoperative films were found to be rotated compared to 1 of 25 in the outpatients’ group.

Immediate postoperative films are of variable and often poor quality. Films at the first outpatients’ appointment were of superior quality.

Phosgene has been deployed as a CW and is also widely used in the chemical industry. Following exposure, acute lung injury (ALI) occurs after a latency period of 6 – 12 h, with pulmonary oedema ensuing. Death may occur 6–24 h after exposure. There is no specific therapy.

Conventional ventilation strategies (VS) for the treatment of ALI and ARDS utilise tidal volumes of 10 – 12 ml.Kg⁻¹ with variable PEEP. A recent multinational clinical trial advocates a protective VS (PVS) combining reduced tidal volume and increased PEEP, which resulted in a significant reduction in mortality.

The purpose of this study is to determine if a similar strategy is beneficial in the treatment of PIALI.

Twenty female pigs were anaesthetised and instrumented for the collection of physiological and biochemical data. Following surgery the animals equilibrated for 1 hour, and exposed to air (Control) or Phosgene (10 min). At 30 minutes post exposure, ventilation was initiated and the animals further divided into treatment groups prior to monitoring for up to 24 hours.

Preliminary results show that, utilising a PVS, there is an increase in oxygenation together with reduced mortality at 24 hour post exposure. Post mortem showed a decrease in severity of pathology and lung wet weight/ body weight ratio.

These results would indicate that in a clinical situation this strategy would be of benefit in the treatment of PIALI.

The aim of the study was to review the role of Magnetic Resonance Imaging of the spine in discitis in the toddler age group (one to three years).

Discitis presents differently in different age groups of children. It is most difficult to diagnose in the uncommunicative non-compliant toddler. The clinical features are often non-specific and laboratory and microbiological tests can be unhelpful. A highly sensitive test is required to aid in making the diagnosis. Although MR Imaging has been used in discitis for several years, we reviewed its actual effectiveness in this specific difficult age group.

At a mean of 21 months at follow-up (range 10 to 40), MR imaging of the disc was variable, with partial recovery after 15 months and complete recovery after 34 months. Routine follow-up MR imaging was not recommended.

We reviewed the role of Magnetic Resonance Imaging in eleven consecutive cases, both at presentation and at a follow-up clinic.

MR imaging was diagnostic in all cases, reduced the diagnostic delay, and often avoided a disc biopsy. It demonstrated any paravertebral inflammatory collection, which helped in determining the duration of the oral therapy given after the initial intravenous antibiotics.

Discitis is uncommon in children and presents in different ways at different ages. It is most difficult to diagnose in the uncommunicative toddler of one to three years of age. We present 11 consecutive cases. The non-specific clinical features included refusal to walk (63%), back pain (27%), inability to flex the lower back (50%) and a loss of lumbar lordosis (40%). Laboratory tests were unhelpful and cultures of blood and disc tissue were negative.

MRI reduces the diagnostic delay and may help to avoid the requirement for a biopsy. In 75% of cases it demonstrated a paravertebral inflammatory mass, which helped to determine the duration of the oral therapy given after initial intravenous antibiotics.

At a mean follow-up of 21 months (10 to 40), all the spines were mobile and the patients free from pain. Radiological fusion occurred in 20% and was predictable after two years. At follow-up, MRI showed variable appearances: changes in the vertebral body usually resolved at 24 months and recovery of the disc was seen after 34 months.