Introduction: Haemorrhagic Epithelioid and Spindle Cell Haemangioma (HESCH) is a new entity that was first described by Rosenberg in 1999. We report the first instance of this tumour occurring in pelvis along with literature review.

Case Report: A 65 year-old man presented with complains of pain in left hip radiating to leg of 5 months duration. X-ray & MRI scan (Fig 1, 2, 3) of his pelvis showed lytic destructive lesion in the left inferior pubic rami. Trucut biopsy showed it as a HESCH with no evidence of malignancy (Fig. 4). He successfully underwent pre op. embolization and excision of the tumour including the ischium. His symptoms started to subside within 4 weeks of surgery and he is remaining pain free at one year follow up.

Discussion: Although endovascular tumours are relatively common in soft tissues, for them to be present in the bone is very rare. This is the first reported case of HESCH occurring in the pelvis, as previous cases tend to occur in the small bones of the hands and feet and were thought to be confined to the distal extremities. The age of this patient is also a point of interest, as he is over 2 decades older than the oldest, previously reported case. Histologicaly, a mixture of both epithelioid and spindle cells are seen which grow in a lobular pattern. As the tumour grows, it can lead to destruction of bone. It is important to note that this is a benign tumour with good prognosis.

Conclusion: This case report highlights the good prognosis associated with this form of benign tumour and that embolisation and curettage are the most effective treatment methods.

Introduction: The cause for Subungual Exostosis remains unknown, although relationships with trauma, infection and irritation have all been suggested. We report the case of a 23 year old female who developed this condition after Zadek’s procedure done for an in growing toe nail.

Case Report: A 23-year-old woman presented to us with an infected ingrowing great toenail of 1 month duration. An X-ray was performed to rule out osteomyelitis (Figures 1a and 2a), and the patient was put on oral antibiotics to control infection. 12 weeks later, the patient underwent a Zadek’s procedure with uneventful post op. recovery. However, 4 months later the patient came back with increasing pain and swelling in the operated toe. Clinically, there was a shiny nodule measuring 0.5 x 0.5cm over the dorso-medial aspect of the nail bed which was tender to touch, hard in consistency and appeared to be arising from the bone. X-ray’s confirmed it as Subungual Exostosis (Figures 1b and 2b). She successfully underwent excision of the tumour and was symptom free with no signs of recurrence at six-month follow up

Discussion: Our case highlights the fact that Subungual Exostosis may be triggered off by damage to the nail bed during surgeries for ingrowing toe nails and that extreme care must be taken during nail removal to avoid injury to the nail bed. This complication is more pronounced in the presence of pre-existing infection. Excision appears to be the treatment of choice and a biopsy report is always needed for confirmation before discharging the patient from the clinic.

Conclusion: Careful handling of nail bed is necessary during surgery and this unusual complication can be included when taking consent for Zadek’s procedure.

Background: Whether to cross match or simply group and save for a primary THR is still a matter of debate. The argument in favour of cross match being immediate availability of blood and against it being wastage of resources, underutilization of cross matched samples etc.

Patients & Methods: We retrospectively analyzed the records of 136 patients who underwent primary THR at Manchester Royal Infirmary in 2004.

Result: Of the 136 patients, 104 had 220 units of blood cross matched. The average blood loss was 520 mls. The average pre op. Hb level was 12.8 g/dl while the average post op. Hb levels at 1, 3 & 5 days were 9.4, 9.9 & 10.1 gms/dl resply. Blood loss in patients on pre op. anticoagulant treatment (n = 44) was 596 mls while in the rest, it was 502 mls. The drop in Hb levels between the 2 groups was 3.6 gms/dl and 3.1 gms/dl resply. Patients with drain had an average drop in Hb level of 3.5 gms while it was 3.1 gms in others. The overall transfusion rate was 43.7 %. The most common reason for transfusion was asymptomatic low Hb (< 8 g/dl). Out of the 220 cross matched units, 99 (44.8 %) were transfused. Various probabilities like Cross-match to Transfusion ratio, Transfusion Probability & Transfusion Index were used to find out whether the cross matched units are used effectively.

Discussion: The only factor which influenced the transfusion rate was pre-op. Hb value. 79 %of patients required transfusion when pre op. Hb level was < 12 gm/dl.

Conclusion: 1. Group & Save is a safe policy for primary THR’s 2. Cross match only for patients with Hb of < 12gms/ dl. 3. Consider oral/IV iron therapy, autologous blood transfusion and retransfusion drain 4. Use of Aprotinin and transanamic acid reduces bleeding during surgery.

The mortality following surgery in patients with a recent MI is high. Standard advice is to wait for a minimum of 6 months. In urgent situations, this may not be possible. From Jan 2003 to Aug 2004, 10 patients were admitted with fracture neck of femur and a recent MI proven by ECG changes or raised troponin. There were 7 females. The mean age was 79.5 yrs (59–95yrs). The premorbid mobility and co-morbidities were noted. Echocardiography was done in all patients preoperatively to assess the cardiac function. All patients were seen by physicians and anaesthetist pre-operatively. The mean time from infarction to operation was 11.5 days (3–23 days). The patients underwent either Thompsons hemiarthroplasty or DHS. The anaesthetic was performed by a consultant. Most patients received spinal anaesthesia (7/9). The anaesthetic records could not be found for 1 patient. 6 patients died within a month and 1 patient died within 6 month of operation. Despite thorough preoperative work-up and consultant anaesthesia, the mortality following surgery for proximal femur fractures in patients with recent myocardial infarction is 70% at 6 months. To our knowledge, there are no published mortality figures for this situation. This is much higher than the reported mortality following proximal femur fracture.

Purpose: To investigate the outcome of tibiotalocalcaneal (TCC) fusion using the retrograde intramedullary nail (IMN).

Methods and results: We reviewed clinical and radiological outcome of 42 patients who underwent TTC fusion with a retrograde IMN in a single health region from 1996 to 2003. Out of 42 patients, four patients died of unrelated causes and two patients were lost to follow up. Finally, 36 patients (20 males, 16 females) were followed up. Mean age was 63 years and the follow up averaged 10 months. Degenerative arthritis (primary and post traumatic) and rheumatoid arthritis made up the majority of the preoperative diagnoses. Clinical outcome was assessed using the AOFAS hindfoot score and three independent observers reviewing radiographs.

Radiologically 22 ankles fused, three probably fused whilst 11 (30%) had evidence of non-union. The majority of subtalar joints failed to unite, reflected by the high rate of distal screw breakage. Primary bone grafting appeared to aid union however smoking, age and the use of an open approach did not seem to be significant factors. Other than non-union complications included two nail fatigue fractures, two deep infections, seven screw breakages, six wound problems and one fractured tibia. Post operatively the mean AOFAS score was 51, 25 patients were satisfied (of these 20% had radiological non-union) and 19 would undergo the same procedure again.

Conclusion: Despite a high rate of ankle and subtalar non-union most of the patients were satisfied with the procedure and would undergo the same operation again. Technical errors apart, the high rate of complications and non-union probably reflected the advanced nature of the disease process and deformity in this group of patients. Although IMN TTC fusion remains a viable option in the management of concurrent ankle and sub-talar joint arthritis, patients should be warned of the potential for non-union and high complication rates.