The aim of our study was to compare the clinical versus radiological diagnosis of patients suffering from a Morton's neuroma. Clinical assessments and pre operative radiological imaging of patients who underwent operative procedures for an excision of a Morton's neuroma were retrospectively compared. This review included 43 excised Morton's neuromas from 36 different patients over a period of 68 months, performed by one surgical team.

The commonest clinical symptoms were those of pain or tingling on the plantar aspect of the affected webspace on direct palpation (100%), pain of weight bearing (91%) which was relieved by rest (81%) and pain on stretching the toes (79%). The most sensitive clinical sign was a Mulder's click.

Our results showed that clinical assessment was the most sensitive method of diagnosing these neuromas (98%). All of our patients had at least one mode of radiological investigation. Ultrasonography was the commonest requested single imaging modality in our series. It was found to have a sensitivity of 90% (28/31). This imaging technique has the disadvantage of being operator dependant, as highlighted by the fact that one of our patients had a correct radiological diagnosis after a repeat ultrasound to the affected area was requested. Magnetic Resonance Image scan is a more expensive technique as it has the advantage of producing static reproducible images. As a single imaging modality, it was found to have a sensitivity of 92% (12/13) in our series. 3 patients had both imaging modalities; initial ultrasound failed to convincingly diagnose a neuroma in 2 cases and in the other case, the initial MRI did not show any pathology. In all these cases, the repeat imaging techniques confirmed the clinical diagnosis.

We conclude that there is no absolute requirement for ultrasonography or magnetic resonance imaging in patients who clinically are suspected to have a Morton's neuroma, as the clinical examination was found to be the most sensitive method of diagnosis. We suggest that the two main indications for performing some form of imaging is (a) an unclear clinical assessment and (b) cases when more than one webspace appears to be affected. An ultrasound of the webspaces should be the radiological investigation of choice, followed by a magnetic resonance scanning if any uncertainty still remains.

Akins original description of his osteotomy did not describe the use of any metal work. Today the osteotomy is most commonly held and fixed with either a staple or screw. We describe the results obtained with a simple suture technique. Methods Data was collected prospectively on 125 patients undergoing an Akin osteotomy. Hallux valgus (HV) and intermetatarsal (IM) angles pre and postoperatively were recorded. Patients were reviewed at 6 week follow up. Cost analysis was also performed comparing different fixation types.

111 of the patients were female and 14 male. The average age at time of surgery was 49 years. 104 cases were in conjunction with hallux valgus correction while 21 cases were for hallux interphalangeus. The mean preoperative HV angle was 33.3 degrees (range 22 to 53), and the IM angle 13.3 degrees (range 9 to 25). At the 6 week follow up all patients had shown signs of radiological union. The postoperative HV angle was 12.4 degrees (range 7 to 17) and the IM angle 6.4 degrees (range 5 to 11). All patients maintained their correction. There were no complications, infections or fixation problems. All patients were satisfied with their surgery and would have it repeated again. The suture technique was the most cost effective method.

We describe a quick, easy, implant free method of fixing the Akin osteotomy. There is no need for metalwork removal and in today's world of austerity and the current climate of widespread budget constraints we describe a cost effective method which is clinically just as effective as methods requiring a staple or screw.

Introduction

Freiberg's disease is an uncommon condition of anterior metatarsalgia that involves the head of metatarsals. Avascular necrosis of the metatarsal head is thought to arise during puberty. Treatment is usually conservative and operative treatment reserved for cases that do not respond to these measures.

Aims: Firm bandaging of the knee following knee replacement may prevent bleeding into the joint by a tamponade effect, but the presence of a tight bandage around the knee may obstruct venous return and lead to thromboembolic complications. We have studied the pressure required, and then compared clinically the use of a compression bandaging with the use of either a drain, or a standard crepe bandage. Method: Transducers were used to measure the pressure achieved on the surface of the knee under different bandages, and within the knee following release of tourniquet. Three series of 50 patients have been compared: with compression bandaging from toes to mid-thigh, with crepe alone, or with suction drain and crepe. Results: The pressure within the joint at which tamponade occurs is 52–57 mm Hg. The pressure on the skin under a properly applied compression bandage is between 28 and 32 mmHg and this controls bleeding within the joint. Patients treated with compression bandaging recovered quicker from the operation had a shorter hospital stay and a greater range of ßexion on discharge. They had no swelling of the limb, rarely suffered a tense haemarthrosis and had fewer complications. Conclusions: The use of compression bandage incorporating the foot and calf following knee replacement surgery confers speciþc advantages over the use of crepe bandage alone.

Surgibone (Unilab R) is a dry bone graft substitute prepared from Canadian bovine bone. It contains hydroxyapatite and 20–29% protein. The manufacturer claims that it is biocompatible; does not lead to foreign body reaction and does not produce pyrogenic effects.

We have used Surgibone routinely in revision joint replacement surgery over a 6-year period, to augment autograft in filling osseous defects in the acetabulum and proximal femur. 27 patients who received Surgibone have been reviewed to assess the degree of graft incorporation, any evidence of graft rejection or immunogenic reaction. One patient died and 2 were excluded from the study for early fixation failure. The remaining 24 were studied 6 months to 5 years post surgery.

In 17 patients (71%) there was radiological appearance of complete incorporation of the bone graft within 6 months. In 3 of these patients the graft incorporated as early as 3 months. There were 7 failures (29%). 3 patients have no radiological evidence of graft incorporation up to 3 years post surgery, although 2 have a satisfactory clinical result. Another 3 patients appeared to have graft rejection, and at revision were found to have sterile pus around the graft. These patients had negative responses to skin patch test for allergy to Surgibone. The seventh patient suffered an MRSA deep infection of the prosthesis that resulted in removal of the implants 4 weeks post operatively.

We conclude that the use of xenograft Surgibone in revision hip surgery leads to unacceptable incidence of failure. Although in the majority of cases good incorporation of the graft was observed, there has been a substantial incidence of graft rejection.