Introduction

Despite costing up to 5X more than a one-third tubular plate (TTP) and no absolute indications, distal fibula locking plates (DFLP) are becoming increasingly popular in the fixation of ankle fractures, particularly in the elderly. We reviewed all our distal fibula fracture fixations, over the course of one year, in order to rationalise DFLP use.

Limited forefoot amputation in diabetic patients with osteomyelitis is frequently required. We retrospectively reviewed diabetic patients with osteomyelitis, an unhealed ulcer and blood pressure in the toe of > 45 mmHg who underwent limited amputation of the foot with primary wound closure. Between 2006 and 2012, 74 consecutive patients with a mean age of 67 years (29 to 93), and a median follow-up of 31 months, were included. All the wounds healed primarily at a median of 37 days (13 to 210; mean 48). At a median of 6 months (1.5 to 18; mean 353 days), 23 patients (31%) suffered a further ulceration. Of these, 12 patients (16% of the total) required a further amputation.

We conclude that primary wound closure following limited amputation of the foot in patients with diabetes is a safe and effective technique when associated with appropriate antibiotic treatment.

Cite this article: Bone Joint J 2013;95-B:1083–7.

Purpose

To highlight the cardiovascular responses of a trainee and supervising consultant while performing Total Knee Arthroplasty (TKA) and to demonstrate the impact that supervision has on both their responses.

Introduction: Serial reamers of incremental diameter are used in the preparation of the acetabulum in Total Hip Arthroplasty. If the reamer is blunt then the size of the reamed acetabulum may not accurately represent the size of the last reamer used. This inaccuracy may then adversely affect implant selection or implantation.

Methods: Traditional debris-retaining cheese grater ace-tabular reamers were used to create a cavity in a foam block, following a standardised technique. A casting was then made of the cavity, the diameter of the cast measured and compared to that of the reamer. Accuracy was defined as the difference between the observed and expected diameters. Measurements were collected for five different hip systems (78 reamers in total)

Results: Sixty-four out of the seventy-eight reamer tested were inaccurate. There was a significant difference between groups. Only reamers from one of the five systems tested consistently created cavities which accurately matched their stated size. Two systems consistently produced a cavity that was at least 1mm smaller than intended. In the majority of cases the mid-range reamers, sizes (46–52mm) were the most inaccurate.

Discussion: The majority of acetabular reamers in our study were inaccurate. If this is unintentional, it suggests reamers may become increasingly blunt with use and should be calibrated, sharpened or replaced.

Background: A subcuticular suture is an ideal closure method of a surgical wound, in patients undergoing foot & ankle surgery, when the aim is healing by primary intention. However, the addition of adhesive strips over the subcuticular suture has become an accepted method of closure despite being based on anecdotal, rather than experimental evidence.

Methods: We performed a prospective study to compare the postoperative wound complications of combination closure (3/0 Monocryl & steri strips) with subcuticular closure alone (3/0 Monocryl). Patients undergoing foot & ankle surgery were allocated to either group on an alternate basis. The wounds of sixty consecutive patients were assessed clinically for wound complications at one-week post op.

Results: Patients who had a combined closure were more likely to develop a wound discharge (23% vs 7%), friable skin (53% vs 3%) and were more likely to have non-opposed wound edges (60% vs 23%). They were also twice as likely to return to clinic for a further wound check (20% vs 10%).

Discussion: Adhesive strips were originally developed as wound dressings and offer no improvement in the tensile strength of the subcuticular closure. Instead their addition exposes the surgical wound to the possibility of epidermal injury from the adhesive in the tape and increases the likelihood of developing wound complications. We recommend meticulous closure of surgical wounds of the foot and ankle with continuous, absorbable, subcuticular suture without adhesive strips, for an optimal outcome.

Introduction: A posterior entry point, a neutral tip position and stem alignment are recommended for an even cement mantle and an optimal outcome in total hip arthroplasty (THA). Our aim was to highlight any differences between the two approaches in obtaining a neutral stem tip position, particularly in the saggital plane.

Methods: We examined the post op, digitised radiographs of 100 (50 each group) polished, tapered Exeter THA, inserted via the antero-lateral or posterior approaches. The stem tip position was defined as the distance, in millimetres, between the centre of the femoral canal and the centre of the stem tip, in both the coronal and saggital planes.

Results: There was a significant difference between the two approaches in the saggital stem tip position only (p= 0.01), but not in coronal tip position (p=0.1). When not in neutral, stems inserted by the antero-lateral approach showed a marked deviation towards the posterior cortex. This was not the case with the posterior approach.

Discussion: Our results illustrate that a neutral stem tip position in THA, and subsequently an even cement mantle, is significantly more difficult to obtain with an antero-lateral approach than a posterior approach. A posterior approach to the hip avoids the cuff of glutei that can lever the proximal stem anteriorally causing an anterior entry point and a posterior stem tip position. It also illustrates how the anatomy of the proximal femur in the saggital plane makes a neutral stem alignment difficult to achieve with either approach.

The Roger Anderson external fixator was used in the treatment of unstable fractures of the distal radius in 52 patients, and the results evaluated after a follow-up averaging 58 months. The indications for its use were failure to maintain adequate closed reduction using plaster, and instability of the fracture as determined by the initial radiographs. Our radiological criteria for instability included dorsal angulation of more than 20 degrees, fractures involving the joint, radial shortening of more than 10 mm, and severe dorsal comminution. Using the Lucas modification of the Sarmiento demerit point-rating system, we found that 46 patients (89%) had good or excellent results and six (11%) were classified as fair. There were no poor results. Seven patients (14%) developed complications. None of these affected the long-term results except in one elderly woman where the pins loosened and had to be removed.