Aims

Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent.

Introduction

Various rehabilitation shoes are prescribed to protect the forefoot following surgery. Patients often complain of discomfort in other areas as a result of the postoperative shoe, including the knee, hip and lower back. This has never been quantified. This study aims to establish the effect on other joints using gait analysis. Methods: 11 healthy volunteers were investigated using various common types of postoperative shoe. They were studied with gait analysis equipment and the joint motion assessed with commercial software. The effect of commercial devices designed to minimise gait changes by lifting the contralateral foot were also evaluated.

Introduction

Many journals require outcome data at 2 years post-operative for the assessment of operative procedures in spinal surgery. This study seeks to clarify the timescale of improvement after surgery to see if a shorter period of assessment will indicate the final outcome.

Purpose: To determine whether the tendon harvester can influence harvested tendon characteristics and soft tissue disruption

Summary: We compared two harvesters with regards to the length of tendon obtained and soft tissue disruption during hamstring tendon harvesting. Thirty six semitendinosus and gracilis tendons were harvested using either a closed stripper or a blade harvester in 18 paired knees from 9 human fresh cadavers. Use of the blade harvester gave longer lengths of usable tendon (p=0.002), whilst minimising the stripping of muscle (p=0.013).

Conclusion: Our results suggest that the type of harvester per se can influence the length of tendon harvested as well as soft tissue disruption. Requesting such data from the industry prior to deciding which harvester to use seems desirable.

Purpose: To evaluate the intra and inter-observer variation of the Schatzker and AO/OTA classifications in assessing tibial plateau fractures, using plain radiographs.

Summary: Fifty tibial plateau fractures were classified independently by 6 observers as per the Schatzker and AO/OTA classifications, using antero-posterior and lateral plain radiographs. Assessment was done on two occasions 8 weeks apart.

We found that both the Schatzker and AO/OTA classifications have a high intra-observer (kappa=0.57 and 0.53 respectively), and inter-observer (kappa=0.41 and 0.43 respectively) variation. Classification of tibial plateau fractures into unicondylar vs. bicondylar and pure splits vs. articular depression +/− split conferred improved inter and intra-observer variation.

Conclusions: The high inter-observer variation found for the Schatzker and AO/OTA classifications must be taken into consideration when these are used as a guidance of treatment and when used in evaluating patients’ outcome. Simply classifying tibial plateau fractures into unicondylar vs. bicondylar and pure splits vs. articular depression +/− split may be more reliable.

Fine-wire fixators are a powerful tool in the management of acute fractures, non-unions, mal-unions and limb lengthening. The tension in the wires is very important in achieving stiffness of the whole fixator construct and current guidelines suggests tensioning wires to 900-1275N. There is evidence that during long term use the tension in the wires can reduce significantly. The effects of a reduction in tension on the fixator stiffness has been well characterised however the effect on the stresses imparted on the bone at the interface with the wire remain unknown. The main aim of this study was to identify any relationship between wire tension and wire-bone interface pressure.

An experimental system utilizing artificial cancellous bone mounted on a tensioned 2mm wire and then loaded by a material testing machine was employed. Pressure sensitive film allowed determination of interface stresses. The experiment was repeated at wire tensions of 600, 900 and 1200N. All other variables were kept the same during testing.

The highest pressures were found closest to the wire. At 1200N the peak pressures were 6-8 MPa, at 900N of tension the pressures rose to 8-10 MPa and at 600N pressures up to 14 MPa were observed. Deeper in the bone the pressures observed at 600N tension were double that seen at 1200N.

This is the first characterisation of the relationship between interface pressure and wire tension in fine-wire fixators. At 1200N the highest pressures are less than the compressive yield strength of cancellous bone whereas at both 600 and 900N pressures are greater than the yield which may lead to loosening. We therefore conclude that a tension of 1200N be employed when applying fine-wire fixators and during long term treatments the tensions should be regularly monitored to prevent loss of tension.

Soft tissue tumours on the sole of the foot are rare and difficult to diagnose, we report a series of five patients who presented with a late diagnosis of a soft tissue tumour on the soles of their feet.

We reviewed the notes of five patients who presented with lesions on the soles of their feet. There were 3 males and two females with an age range from 35yrs to 78 yrs. Our results showed that there was at least a one year delay in their diagnosis from their initial symptoms. They all sought medical treatment late, and were all originally diagnosed with benign lesions at their first presentation. All but one, were found to have malignant lesions on biopsy which required surgical excision. As a consequence of the delay in their presentation and diagnosis, there was also a delay in their treatment.

Our conclusions are that tumours on the soles of the feet are difficult to diagnose and almost invariably present late.

Introduction and aims: Numerous questionnaires are available to assess outcome of hip arthroplasty, but as yet there is no consensus as to which are the most appropriate to use following acetabular osteotomy. We have prospectively evaluated a quality of life measure validated for patients from the United Kingdom and self-administered disease and hip specific questionnaires in patients undergoing Bernese periacetabular osteotomy and compared these to outcome as measured by the Harris hip and Merle d’Aubigne and Postel hip scores.

Method: Since 1997, 24 Bernese periacetabular osteotomies have been performed at our institution. Only patients with a primary diagnosis of development dysplasia of the acetabulum, no evidence of degenerative disease and a minimum of 24 months of follow-up were included in this study. Any non life-threatening co-morbid conditions were documented and recorded. Harris hip (HHS), Merle d’Aubigne and Postel (MDP), Nottingham Health Profile (NHP) and Oxford Hip scores (OHS) were calculated pre-operatively and post-operatively at 6 weeks, 12 weeks, 6 months, one year and then yearly.

Results: Patients have been followed up for an average of 3.2 years (range: 1–5.5 years). The male: female ratio was 1: 8.5. The average age at time of operation was 32.3 years (range 18 – 48). No patient required further surgery or conversion to total hip arthroplasty. Mean postoperative HHS was 89.9. MDP 16.4 and OHS 16.3. All dimensions of the NHP demonstrated improvement of greater than 50 %. The MDP and OHS were most sensitive to time of assessment in the post-operative period. There was no significant difference in the order of magnitude of improvement between any of the scores.

Conclusion: This study has demonstrated that the Bernese periacetabular osteotomy, in a carefully selected group of patients, has a reproducibly good outcome as measured by a variety of scoring methods dependent upon both clinician and patient derived assessment.

We present the early results of the Bernese osteotomy via an ilioinguinal approach performed at an U.K. district general hospital with no links to the Bernese group.

Between 1997 and 2002, 19 such osteotomies have been performed at our institution. Average follow-up is 3.2 years (range: 1–5.5 years). The male: female ratio was 1: 8.5. Average age at time of operation was 32.3 years (range 18 – 48). 14 were classified as having Severin grade 2 dysplasia and 5 as having Severin grade 3 dysplasia. The average preoperative Merle d’Aubigne and Postel score was 12.7 points (range 6 – 15). 21.1% of patients were rated as good, as 57.8% fair and 21.1% poor.

At most recent follow-up of preserved hip joints total mean score had increased to 16.3 (range 13 – 18). 26.3% of hips were graded as excellent, 58.9% as good and 14.8% as fair. The average postoperative values for the lateral centre-edge angle and acetabular index were 42.3° and 10.0° respectively which represents an average of 31.4° and 24.7° of improved lateral and loading zone coverage after osteotomy. The preoperative severity of osteoarthritis according to the criteria of Tonnis was grade 1 in 15.8% and grade 2 in 26.3%. Only one joint deteriorated sufficiently for it to be converted to a total hip arthroplasty. There was an overall complication rate of 59.9% comprised of 47.4% trivial, 10.4% moderate and 0.05% major complications. Our early results demonstrate the steep learning curve of this technically demanding operation and are encouraging.