Painful neuromas may follow traumatic nerve injury. We carried out a double-blind controlled trial in which patients with a painful neuroma of the lower limb (n = 20) were randomly assigned to treatment by resection of the neuroma and translocation of the proximal nerve stump into either muscle tissue or an adjacent subcutaneous vein. Translocation into a vein led to reduced intensity of pain as assessed by visual analogue scale (5.8 (sd 2.7) vs 3.8 (sd 2.4); p < 0.01), and improved sensory, affective and evaluative dimensions of pain as assessed by the McGill pain score (33 (sd 18) vs 14 (sd 12); p < 0.01). This was associated with an increased level of activity (p < 0.01) and improved function (p < 0.01). Transposition of the nerve stump into an adjacent vein should be preferred to relocation into muscle

Background. Morton's neuroma is the enlargement of an interdigital nerve most commonly located between the third and fourth metatarsals. It is susceptible to entrapment and therefore is a common cause of disabling foot pain. Greek foot is a normal variant where the first metatarsal is shorter than the second metatarsal. To our knowledge there is currently no reported association between Greek foot and Morton's neuroma in the literature. Material and methods. Retrospective study of 184 patients. Two separate cohorts were recruited. Cohort (A): 100 randomly selected patients with no foot pain. Cohort (B): 84 patients with foot pain and Mortons's neuroma. The foot shape was determined by using a self-assessment tool and plain radiographs. Statistical analyses were performed using the Chi square test on the association between Greek foot and Morton's neuroma. A value of P = < 0.05 was considered statistically significant. Results. Our study shows a statistically significant association between Greek foot and Morton's neuroma with a prevalence of Greek foot in Cohort (A) of 20% (95% C.I.:12%–28%) and in Cohort (B) of 63% (95% C.I.:53%–73%). (P = 2.6 × 10. −9. ). Discussion. This study has shown a possible association between the presence of a Greek foot and the presence of Morton's neuroma. We can conclude that people with foot pain are more likely to have Greek foot than Egyptian foot and that the prevalence of Greek foot is higher in patients with Morton's neuroma than in the asymptomatic population. Although our study design has limitations and does not allow full statistical analysis, we do believe that the shown association between Greek foot and Morton's neuroma can help clinicians and other health care providers in establishing the diagnosis of Morton's neuroma in patients with a painful foot

Background. Morton's neuroma (MN) is a common cause of metatarsalgia. Whilst there are a many treatment modalities available, studies looking at the long term effectiveness of most forms of treatment are scarce. The injection of MN with alcohol has gained popularity over the past ten years with widespread media coverage. Many surgeons have anecdotally questioned the long-term effectiveness. Sixty patients underwent alcohol injection for the treatment of MN by Radiologists at our institution. These results were originally published showing 92% (92/100) success rates and only 3% (3/100) requiring surgical excision at a mean follow up of 10.5 mths. The authors concluded that alcohol injection was comparable to results for surgical excision. Methods. We were able to review forty five of this original cohort with an average follow up of 61 (range, 33 to 73) months. The modified Johnson score and visual analogue scales were used to assess the patients and compare these results to five year results available in the literature for surgical management. Results. Our results indicated that by five years 36% (16/45) had undergone surgical treatment and a further 45% (13/29) had return of symptoms. Only 29% (13/45) remained symptom free. Results at five years showed statistically significant differences (P< 0.05) compared to surgical management, with 67.8% complete resolution of symptoms with surgery and 33% in the alcohol injection group. Conclusion. Injection with alcohol sclerosant for MN has been marketed as a definitive management option comparable to surgical excision. Our investigation illustrated that although short term results are encouraging; alcohol injection does not offer permanent resolution of symptoms for most patients, can be associated with considerable morbidity and that results are not comparable to surgery. Our investigation provides the only long term data for alcohol injection treatment of MN

Introduction. Lower limb amputation is associated with significant morbidity and mortality. Reflecting the predominance of vascular or diabetic disease as a cause for lower limb amputation, much of the available literature excludes lower limb amputation secondary to trauma in the reporting of complication rates. This paucity in the literature represents a research gap in describing the incidence of complications in lower limb amputation due to trauma, which we aim to address. Materials and Methods. Retrospective analysis of a prospectively collected database of all traumatic lower limb amputations secondary to trauma from a regional multidisciplinary amputee service at Queen Mary's Hospital. Electronic patient records and paper notes were consulted for evidence of re-operation, infection (superficial or deep), phantom limb pain and neuroma. 222 patients were screened and 108 included in the data analysis. Results. Records identified 108 lower limb amputations secondary to trauma in 99 patients with a mean age of 34 years (at time of amputation). Average follow-up was 225 months. 33.6% of patients underwent re-operation, 25.2% had at least one episode of infection. Of those who underwent re-operation, 47.2% had evidence of infection. 42% and 3.7% of patients described phantom limb pain and neuroma respectively. Conclusions. Lower limb amputations secondary to trauma exhibit higher rates of re-operation and infection compared to vascular or diabetic amputees. This first study to provide high quality data describing the incidence of complications such as re-operation, infection, phantom limb pain and neuroma in lower limb amputations secondary to trauma

The causes of pain after TKA can be local (intra or extra-articular) or referred from a remote source. Local intra-articular causes include prosthetic loosening, infection, aseptic synovitis (wear debris, hemarthrosis, instability, allergy), impingement (bone soft tissue or prosthetic), an un-resurfaced patella and stress fracture of bone or the prosthesis. Some surgeons think that isolated component mal-rotation can be a source of pain, but component mal-rotation is rarely present in the absence of other technical abnormalities. Local extra-articular causes include pes anserine bursitis, saphenous neuroma/dysasthesias, post-tourniquet dysasthesias, complex regional pain syndrome and vascular claudication. Referred pain is most often from an arthritic hip or radicular pain from a spinal source. Patients with fibromyalgia can have persistent pain following their knee arthroplasty and should be warned of this possibility. Evaluation of the patient includes a history, physical exam, joint aspiration and plain radiographs. In selected patients, an anesthetic joint injection, bone scan, CT scan or MRI with metal subtraction may be helpful in the diagnosis. The joint aspiration should include a CBC and differential as well as an aerobic and anaerobic culture. Fungal and TB cultures are sometimes indicated. Re-operation for pain of unknown etiology following TKA is unlikely to yield an excellent result and both surgeons and patients should be aware of this probability

The approach to total hip arthroplasty (THA) should allow adequate visualization and access so as to implant in optimal position whilst minimizing muscle injury, maintaining or restoring normal soft tissue anatomy and biomechanics and encouraging a rapid recovery with minimal complications. The direct anterior approach (DAA) for THA was first performed in Paris, by Robert Judet in 1947. This procedure has since been performed consistently by a small group of surgeons and has recently gained great popularity. Access to the hip can be safely performed with one or two assistants. The advantages of the anterior approach for hip arthroplasty are several. First, the hip is an anterior joint, closer to the skin anterior than posterior. Second, the approach follows the anatomic interval between the zones of innervation of the superior and inferior gluteal nerves lateral and the femoral nerve medial. Third, the approach exposes the hip without detachment of muscle from the bone. Care must be taken to avoid cutting the lateral femoral cutaneous nerve which runs over the fascia of the sartorius. The mini-incision variation of this exposure was developed by Joel Matta in 1996. He rethought his approach to hip arthroplasty and by abandoning the posterior approach and adopting the anterior approach his goals were: lower risk of dislocation, enhanced recovery, and increased accuracy of hip prosthesis placement and leg length equality. This approach preserves posterior structures that are important for preventing dislocation while preserving important muscle attachments to the greater trochanter. The lack of disturbance of the gluteus minimus and gluteus medius insertions facilitates gait recovery and rehabilitation while the posterior rotators and capsule provides active and passive stability and accounts for immediate stability of the hip and a low risk of dislocation. Using the anterior approach, patients are allowed to mobilise their hip freely. The gluteus maximus and tensor fascia latae muscles insert on the iliotibial band which joins them and form a ´hip deltoid´. Lack of disturbance of these abductors and pelvic stabilisers is another benefit of the anterior approach and accelerates gait recovery. The lateral femoral cutaneous nerve is at risk when the fascia is incised between the tensor fascia latae and the sartorius muscle. Damaging it may lead to a diminished sensation on the lateral aspect of the thigh and formation of a neuroma. A disadvantage of the approach is the fact that a special operating table with traction is required. Potential complications include intra-operative femoral and ankle fractures. These can be avoided through careful manipulation of the limb. If a femoral fracture occurs, the incision can be extended distally along the anterolateral aspect of the thigh, and splitting the interval between the rectus femoris and the vastus lateralis. In obese or muscular patients, where visibility is in doubt, an increase of the incision length will give the surgeon the required view. The choice of approach used to perform a primary THA remains controversial. The primary goal of a hip replacement is pain relief, functional recovery and implant longevity performed with a safe and reproducible approach without complications. The anterior approach is promising in terms of hospital stay and functional recovery. Although recent studies suggest that component placement in minimally invasive surgery is safe and reliable, no long-term results have been published. Further follow-up and development is necessary to compare the results with the posterior approach. The proposed benefits of with the DAA are not supported by the current available literature. The issues regarding the difficult learning curve, rate of complications, operative time, requirement for trauma tables and image intensifier should be taken into account by surgeons starting with the DAA in THA

Crossover second toe deformity is a multiplanar deformity derived from multiple etiologies with the common endpoint of metatarsophalangeal joint instability. The stability of the joint is compromised through laxity of the volar plate, secondary rupture of the lateral collateral ligament, and ultimately dorsal subluxation or dislocation of the metatarsophalangeal joint. The digital malalignment often includes a hammertoe deformity, but should not be confused with a routine clawtoe. Elimination of alternative diagnoses relies on precise palpation to negate Morton's neuroma, 2nd metatarsalgia, Freiberg's infraction, and 2nd metatarsal stress fracture. Radiographs assist in the diagnosis in not only eliminating the above mentioned differential diagnoses, but also in evaluating confounding anatomic variables such as hallux valgus, metatarsus primus varus, and metatarsal length. These variables may necessitate additional osteotomies in conjunction with ligament reconstruction to minimise recurrence. Operative intervention has revealed long term failure of secondary ligament reconstruction, mandating tendon transfers such as the flexor-to-extensor and the extensor digitorum brevis to support the repair. We will explore these techniques and subsequent modifications to achieve patient satisfaction

Background. Subtalar fusion is traditionally an open procedure with potentially significant complications but there is little published on arthroscopic subtalar arthrodesis. Methods. We present the first UK series of 33 arthroscopic subtalar fusions in 32 patients, with a variety of pathologies. Results. There were 14 males and 18 females operated on between March 2004 and February 2009. Patients with previous hindfoot fusions were excluded as were patients who underwent combined arthroscopic hindfoot fusions. All patients had surgery by the senior author and followed an identical post-operative management plan. No patients were lost to follow-up. Successful outcome was taken as clinical and radiological evidence of fusion. We report a 100% union rate with 75.8% [25/33] union by 12 weeks, 97% [32/33] by 16 weeks with a single outlier achieving fusion at 22 weeks. There were no wound breakdowns, deep infections, neuromas or thrombotic events. Two patients required removal of metalwork. One patient developed mild CRPS and a further patient became symptomatic from concomitant calaneo-cuboid and talo-navicular joint arthrosis. Discussion. Previous authors have reported variable complication rates and significant rates of delayed and non-unions following open subtalar fusion. This technique respects the soft tissue envelope and therefore is less traumatic to the hindfoot. Our early results suggest that isolated arthroscopic subtalar fusion is a safe and reliable technique, even in patients with deformity, with an excellent union rate and minimal complications

Introduction and aims. We present a series of patients who have had secondary reconstruction of war injuries to the upper and lower limbs, sustained during the Iraq and Afghanistan conflicts. Material and Methods. All patients were seen at the combined Peripheral Nerve Injuries Clinic at the Defence Medical Centre for Rehabilitation, Headley Court. All surgery was performed at Odstock Hospital. Procedures include scar excision and neurolysis (all patients), release of scar contractures, tenolysis, tendon transfers, revision nerve grafts, excision of neuroma, and soft tissue reconstruction using pedicled or free flaps. Results. 24 patients have been treated at the time of submission. We have used 13 free flaps (1 free groin flap, 9 anterolateral thigh, 3 parascapular, with 4 as through-flow flaps) and 1 pedicled groin flap, with no flap losses. There were 6 amputation stump revisions (1 above elbow, 5 below knee). The majority (n=23) have had nerve recovery distal to the level of injury following revision surgery. Conclusions. Nerve repairs recover following neurolysis (and revision nerve graft if necessary) with provision of good soft tissue cover. Release of scar contractures with flap cover allows healing of chronic wounds and permits mobilisation of joints. Thin fascio-cutaneous flaps provide good contour and can be elevated more easily than skin grafted muscle flaps for secondary surgery. Free or regional flaps are preferable to local flaps in high energy-transfer military wounds. Immediate complex reconstruction is not always appropriate in multiply-injured patients

Aims

There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.

Aims

To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on ‘green’ (non-COVID-19) sites during the COVID-19 pandemic.

The use of ultrasound-guided wire localisation of lesions is not well described in the orthopaedic literature. We describe a case of an impalpable schwannoma of the femoral nerve and another of sacroiliitis with an associated pelvic abscess. In both, surgical localisation was difficult. Peri-operative ultrasound-guided wire localisation was used to guide surgery and minimise tissue damage, thereby optimising the results and recovery of the patient.

We reviewed 234 benign solitary schwannomas treated between 1984 and 2004. The mean age of the patients was 45.2 years (11 to 82). There were 170 tumours (73%) in the upper limb, of which 94 (40%) arose from the brachial plexus or other nerves within the posterior triangle of the neck. Six (2.6%) were located within muscle or bone. Four patients (1.7%) presented with tetraparesis due to an intraspinal extension.

There were 198 primary referrals (19 of whom had a needle biopsy in the referring unit) and in these patients the tumour was excised. After having surgery or an open biopsy at another hospital, a further 36 patients were seen because of increased neurological deficit, pain or incomplete excision. In these, a nerve repair was performed in 18 and treatment for pain or paralysis was offered to another 14.

A tender mass was found in 194 (98%) of the primary referrals. A Tinel-like sign was recorded in 155 (81%). Persistent spontaneous pain occurred in 60 (31%) of the 194 with tender mass, impairment of cutaneous sensibility in 39 (20%), and muscle weakness in 24 (12%).

After apparently adequate excision, two tumours recurred. No case of malignant transformation was seen.