Introduction

Hallux Rigidus affects 2–10% of population, usually treated with cheilectomy or arthrodesis, however, for the subclass of patients who refuse to undergo fusion, Arthroplasty is an alternative solution, it maintain some degree of motion and provide pain relief. Toefit; is one of the prostheses being used. It is a total joint replacement with polyethylene insert.

The aim of this study is to find clinical and radiological outcomes of Toefit arthroplasty.

Background and objective

Metatarsals stress fractures are common in athletes and dancers. Occasionally, such fractures could occur without trauma in peripheral neuropathic patients. There is no published series describing outcome of stress fractures in these patients. This study analyse these fractures, treatment and outcome.

Introduction

There is no published series described change in bone mineral density (BMD) after ankle replacement. We present the results of a prospective study examining the effect of total ankle replacement (TAR) upon local bone mineral density (BMD).

Total ankle replacement (TAR) is increasingly offered as an alternative to ankle fusion for the management of severe ankle arthritis. As with all other types of joint arthroplasty, there are risks involved and complications that occur; these increase with case complexity. We present the complications and management from a single-centre series.

Since 2006, we have performed 150 Mobility TARs with up to 4 years' follow-up. We have excluded 16 that are part of a separate RCT and 10 with less than 3 months' follow-up. 124 TARs were included in our study (117 patients). Three ankles (2.4%) had superficial wound infections treated successfully with antibiotics. One ankle (0.8%) required an arthroscopic washout and debridement but the implant was retained. 11 ankles (8.9%) had a periprosthetic fracture: One was intraoperative; 10 were postoperative (2 fixed). Four patients (3.2%) developed CRPS. One ankle required fusion surgery (following subsidence of the talar component) with another one pending revision (ligament instability causing implant displacement). No patient had a symptomatic deep vein thrombosis or thromboembolic event.

Our figures are comparable with other series. Our complication rate has not changed significantly over time. Our results, at present, suggest that most complications (98%) with the Mobility TAR can be satisfactorily managed without having a detrimental effect on the implant.

There have been proven and promising results with total ankle replacement. However, there is a significant complication rate that must be made clear to the patient via informed consent; the rate still remains higher than for hip and knee arthroplasty.

Background

Postoperative pain following (Mobility TM) ankle arthroplasty (AA) is recognised problem. This study aimed to determine pattern of postoperative pain following Ankle arthroplasty (AA).

Introduction

The standard practice of uncomplicated total ankle replacement (TAR) involves postoperative immobilisation. Periprosthetic fracture is a well-recognised complication following ankle arthroplasty. It occurs predominantly as a stress reaction on the medial tibial metaphysis during the postoperative rehabilitation period. Occasionally it occurs during surgery. We present fractures from a single-centre series of Mobility TARs.

While hidden blood loss has been shown to occur in hip fractures the timing and cause have not yet been demonstrated. This study investigated the degree of pre-operative blood loss within the first 24hrs after intertrochanteric hip fracture.

188 patients with extracapsular hip fractures had their full blood count taken on admission and after 24 hours. The haemoglobin (Hb) and haematocrit (Hct) were noted at each time. Fractures were grouped as undisplaced or displaced. Those who were operated on prior to the 24hr blood sample were excluded. All patients with intracapsular or sub-trochanteric fractures were excluded, as were any who received a blood transfusion prior to their 24hr blood sample being taken. The tests for differences between blood samples and the existence of displacement were performed using paired and independent Student’s t-test. The level of significance was set at P< 0.05. All data was analysed using SPSS statistical software version 11.

The overall fall in the Hb within 24hr was significant (1.6 g/dl, P< 0.001), as was the fall in the haematocrit (0.05, P< 0.05). Displaced fractures had a significantly lower Hb at 24hrs than undisplaced (10.6g/dl vs 11.8 g/dl, P=0.001). The fall in Hb was significantly greater in displaced fractures compared to undisplaced (1.7g/dl vs 1.2g/dl, P< 0.05). Changes in the Hct mirrored those of the Hb.

This study identified a significant blood loss that occurs within the first 24hrs after an intertrochanteric hip fracture, prior to theatre. The cause is unlikely to be secondary to dehydration as the Hct fell with the Hb. Thus the most likely cause is the trauma itself. The admission Hb is possibly an inaccurate measure of the true value and patients may be more shocked than first thought. A more liberal resuscitation policy may be warranted.

Introduction: A single hip screw is the recommended method of fixation for slipped upper femoral epiphysis (SUFE). Current practice favours the placement of the screw in the centre of the femoral head on both anteroposterior and lateral planes to avoid the risks of chondrolysis and avascular necrosis (AVN).

Aims: To investigate the correlation between different positions of the screw in the femoral head and the prevalence of AVN, chondrolysis, late slippage, and the time to epiphyseal closure.

Methods: The clinical notes and radiographs of 38 consecutive patients (61 hips), who underwent single screw fixation for SUFE, were evaluated retrospectively with a mean follow up of 36 months. Two way ANOVA and post hoc test was performed to analyse the correlation between the different variables and the outcome, at 5% significance level.

Results: There were 16 acute slips, 18 chronic slips and 10 acute on chronic slips. 17 slips were treated prophylactically. Mild slip was encountered in 39 hips, moderate in 4 and severe in 1 hip. Central-Central position was only achieved in 51% of cases. The most significant results of the study were as follows. I: No significant difference between the time to epiphyseal closure and the position of the screw. II. No late slippage or chondrolysis was observed in our series.

Conclusion: Our results showed that the position of the screw, other than in the centre of the femoral head, has the ability to provide physeal stability and has no correlation with the timing to closure of the epiphysis and the risk of avascular necrosis or chondrolysis. We therefore recommend that other positions be considered if the “optimal central-central position” is not initially achieved specifically for the treatment of mild SUFE as the potential hazards from several attempts to achieve the optimum position outweigh the benefits.

Purpose of study: A single dynamic hip screw is the recommended method of fixation for slipped upper femoral epiphysis (SUFE). Current practice favours placement of the screw in the centre of the femoral head on both anteroposterior and lateral planes. This study investigated screw placement in the femoral head for SUFE and the prevalence of AVN, chondrolysis, late slippage, and time to physeal closure.

Method: Clinical notes and radiographs of 38 consecutive patients (61 hips), who underwent single screw fixation for SUFE, were evaluated retrospectively with a minimum follow up of 24 months (24–56). Two way ANOVA and post hoc tests were performed to analyse the correlation between the different variables and the outcome, at a 5% significance level.

Results: There were 16 acute slips, 18 chronic slips and 10 acute on chronic slips. 17 slips were treated prophylactically. Mild slip was noted in 39 hips, moderate in 4 and severe in 1 hip. A central-central position was only achieved in 50% of cases. No significant difference between the time to physeal closure and the screw position was found. No late slippage, AVN or chondrolysis occurred in this series.

Conclusions: Our results demonstrate that positions of the screw, other than in the centre of the femoral head, provide adequate stability. There is no correlation between screw position and the time to physeal closure, the risk of avascular necrosis or chondrolysis. We recommend that positions other than the “optimal central-central position” be accepted if not initially achieved, especially for mild SUFE. The potential hazards from several attempts to achieve the optimum position outweigh the benefits.

Background: To evaluate bone mineral density in patients with scoliosis of different causes and compare it to the expected values for the age, gender and body mass.

Methods: A Prospective, observational case series. From October 2003 to December 2004, Bone Mineral Density (BMD) of patients with different types of Scoliosis was recorded. Patients listed for corrective spinal surgery in our institute were included in the study (Total of 68 patients). BMD on lumbar spine and whole body was measured by DXA scan and recorded in form of Z-scores. Z-scores = number of Standard Deviations (SD) above or below age matched norms; it is age and gender specific standard deviation scores. Data collected using the same DXA scan equipment and software.

There were 29 patients with Adolescent Idiopathic Scoliosis and 7 patients with congenital or infantile scoliosis. Z-scores from patients with neuromuscular scoliosis also included, 10 patients with cerebral palsy and 11 with muscular dystrophies (mainly Duchenne MD). There were also 3 patients with Neurofbromatosis and 8 patients with other conditions (miscellaneous). Outcome measures were bone mineral density in patients with different types of scoliosis in form of Z-scores.

Results: Bone mineral density was significantly lower than normal for the age, gender and body mass in all patients with neuromuscular scoliosis; whole body z-score in group with cerebral palsy was −1.00 and −1.30 in muscular dystrophies group. Lumbar spine BMD was even lower in lumbar spine, mean z-score, – 4.51 in cerebral palsy and −2.36 in muscular dystrophies (mainly Duchenne MD). In idiopathic Scoliosis group mean BMD was markedly lower than normal for the age, gender and body mass, mean z-score = – 1.87, however whole body BMD was within the normal range, mean z-score = +0.124. Similar results were found in congenital and infantile scoliosis group, mean lumber z-score= – 1.36 and whole body z-score, – 0.30. In patients with neurofibromatosis, there were low BMD on spine, mean z-score was −1.19 while whole body z-score was + 0.19. In group of patients with other miscellaneous causes of scoliosis or syndromic scoliosis lumbar mean z-score= −2.22 and whole body mean z-score was −1.67.

Conclusion: This study showed that BMD on spine was lower than normal for the age, gender and body mass in all patients with scoliosis and the condition was even worse in neuromuscular and sydromic scoliosis. There was no correlation between spine BMD and whole body BMD. Spine BMD was lower than normal in almost all patients even when whole body BMD was within normal range. Thus we believe that DXA scan is a useful adjunct in the preoperative assessment of scoliotic patients prior to spinal surgery.

We have investigated the contaminating bacteria in primary hip arthroplasty and their sensitivity to the prophylactic antibiotics currently in use. Impressions (627) of the gloved hands of the surgical team in 50 total hip arthroplasties were obtained on blood agar. The gloves were changed after draping, at intervals of 20 minutes thereafter, and before using cement. Changes were also undertaken whenever a visible puncture was detected. The culture plates were incubated at 37°C for 48 hours. Isolates were identified and tested for sensitivity to flucloxacillin, which is a recognised indicator of sensitivity to cefuroxime. They were also tested against other agents depending upon their appearance on Gram staining.

We found contamination in 57 (9%) impressions and 106 bacterial isolates. Coagulase-negative staphylococci were seen most frequently (68.9%), but we also isolated Micrococcus (12.3%), diphtheroids (9.4%), Staphylococcus aureus (6.6%) and Escherichia coli (0.9%). Of the coagulase-negative staphylococci, only 52.1% were sensitive to flucloxacillin and therefore to cefuroxime. We believe that it is now appropriate to review the relevance of prophylaxis with cefuroxime and to consider the use of other agents.

We conducted a randomised, controlled trial to determine whether changing gloves at specified intervals can reduce the incidence of glove perforation and contamination in total hip arthroplasty. A total of 50 patients were included in the study. In the study group (25 patients), gloves were changed at 20-minute intervals or prior to cementation. In the control group (25 patients), gloves were changed prior to cementation. In addition, gloves were changed in both groups whenever there was a visible puncture. Only outer gloves were investigated.

Contamination was tested by impression of gloved fingers on blood agar and culture plates were subsequently incubated at 37°C for 48 hours. The number of colonies and types of organisms were recorded. Glove perforation was assessed using the water test. The incidence of perforation and contamination was significantly lower in the study group compared with the control group. Changing gloves at regular intervals is an effective way to decrease the incidence of glove perforation and bacterial contamination during total hip arthroplasty.

We describe a patient who sustained a widely displaced, high-energy, mid-shaft clavicular fracture in association with brachial plexus damage. The distal fragment was subsequently found to have penetrated the thoracic cavity. We describe the treatment of this rare injury with a successful outcome.