Introduction: Arthrodesis of 1st MTPJ is performed using various fixation techniques including lag screws, dorsal plate and screws, K-wiring. We evaluated the strength of fixation using two staples placed at right angles.

Methods: Ten pairs of cadaveric feet were dissected to harvest the hallux MTPJ. Planar cut of articular surfaces using a micro-saggital saw. The bony ends were then approximated with an intervening blade and fixed using 2 staples placed at right angles. The specimen was supported on either ends and subjected to 3 point loading using a materials testing machine (Instron). The load at which the joint opened up sufficiently to let the blade fall was recorded. The load at which the construct failed was then recorded

Results: The joint opened up at an average of 41 Newtons. The load to failure was 130 Newtons. The corresponding average values in kilograms were 4.19 kilograms for the opening of the joint and 12.61 kilograms for the failure of the construct. On full weight bearing using the heel weight bearing shoes that we normally use post-operatively, the forces going through the forefoot were 0 newtons/kilograms, calculated using a TEK SCAN (measures the foot pressure on walking)

Conclusion: It is safe to walk patients using a heel weight bearing shoe (Benefoot post op wedge shoe) following 1st MTPJ fusion using staples (uniclip-NewDeal). This is a major advantage compared to other methods of fixation that require plaster cast immobilisation thus reducing inconvenience, plaster expenses and possible complications like DVT.

Introduction: Arthrodesis of 1st metatarsophalangeal joint is a reliable procedure for the treatment of symptomatic arthritis. Various techniques are in use to facilitate arthrodesis. We evaluated our results using a new and simple construct of two staples applied perpendicular to one another.

Material and Methods: Prospective observational study. A total of 29 patients (26 females, 3 males), Mean age 59yrs. 34 Hallux MTP joint fusions, 5 of them bilateral. Pre-operative diagnosis was Osteoarthritis in 27 and Rheumatoid arthritis in 2.

Technique: Medial incision, planar cuts using saw. Staples placed dorsoventrally and mediolaterally.

Patients: were mobilised in heel weight bearing post op shoe for 4–6 weeks. All patients had regular clinical and radiological assessment. Mean followup was 24 months.

Results: Pre-op mean AOFAS score was 31 (Modified AOFAS score, total value 90 Portion of MTP joint motion was not included). Post-op mean AOFAS (modified) score was 81. 26 patients were very satisfied with the outcome of surgery, 2 were satisfied with reservation and one patient was not satisfied. 28 out of 29 patients would recommend this procedure to others. Ability to wear shoes improved in 26, same in 2 and worse in one patient. There were two mal-unions, one superficial wound infection treated with antibiotics and 6 patients had prominent staples requiring removal. There was no radiological non-union

Conclusion: Our technique of 1st MTP joint arthrodesis using 2 staples applied perpendicular to each other provides a reliable and stable construct that does not require use of plaster post-operatively. This has resulted in painfree post-op period without any need for plaster thus saving time and avoiding complications of plaster i.e stiffness and DVT. We strongly recommend the use of this type of fixation.

Day case surgery is commonplace in the field of orthopaedic surgery, being suitable for a wide range of both trauma & elective procedures. It became apparent within our unit that an unacceptably high number of cases were being cancelled for a variety of reasons. We set out to identify these reasons and thereby develop a simple screening process to reduce the number of cancellations.

Initial audit over a 1 year period showed 25% of the 907 day case patients were being cancelled. We subdivided the reasons for these cancellations at both pre-operative assessment and on the day of surgery into avoidable [e.g. no carer / telephone, uncontrolled BP, high BMI and ischaemic heart disease] and unavoidable [e.g. surgery no longer required, patient unwell, list cancelled for emergencies, patient DNA].

The majority of our cancellations fell into the “avoidable” category, predominantly at pre-operative assessment. Accordingly, we devised a simple screening questionnaire to be used by clinicians in out-patients at the time of listing for surgery, based on the RCS guidelines (1985). If any of the questions were answered “Yes”, the patient was not suitable for day case surgery. The patient information letter was also changed, informing patients that non-attendance would result in their removal from the waiting list.

Re-audit of 727 patients over the next 12 months showed a fall in cancellations to only 11%, with the majority of these being for unavoidable reasons.

Cancellations are a source of inconvenience, distress and frustration to both clinician and patient, are a waste of hospital time and resources, and lead to an increase in waiting lists. Our study demonstrates the value of closing the loop in audit, leading to a dramatic reduction in cancellations. Audit is a useful tool to improve patient care, and is not merely a “number-crunching” exercise.

Total knee arthroplasty is sometimes associated with excessive bleeding necessitating blood transfusion. Transfusion is associated with risk of disease transmission and immunological burden to the recipient. Material and methods: 100 patients undergoing primary total knee replacement were randomly allocated into 2 groups: a) immediate release of drain following release of tourniquet and b) delaying release of the clamp by one hour. Drains were removed at 48 hours post-op. Results:Average amount of postoperative bleeding in the immediate release group was 1050 ml (95% CI interval for mean 728 to 1172) compared to delayed release group of 732 ml (95% CI interval for mean 620 to 845). Applying Mann- Whitney U test p< 0.001 which was highly signiþcant. Corrected drop in Hb% at 48 hours showed an average difference of 0.17 gm% less drop in the delayed release group. 78 units were transfused in the immediate group compared to 66 units in the delayed group. There was no difference in parameters like length of stay (average 13 days in both groups), bruising around the knee, oozing or blister formation between the two groups. Three patients had DVT and 1 PE in the immediate release group, 2 cases of DVT in the delayed release group. One patient required MUA in the immediate release group compared to 3 in the delayed group. Conclusion:Our result conclusively shows that delaying release of drain by an hour can signiþcantly reduce blood loss. It is a simple method without any associated complications and can reduce transfusion requirements in patients undergoing knee replacement surgery.

We present the results of the first two years of experience with the Weil osteotomy at The Royal Oldham Hospital and endeavour to define its role in the management of intractable plantar keratosis (IPK) and complication rate.

All patients undergoing Weil osteotomy in 2000 & 2001 were included in this prospective study. A total of 21 consecutive patients, having 61 lesser metatarsal osteotomies were reviewed (95% female). The mean age was 62 years (range 12 to 86). The mean follow-up period was 17 months (range seven to 28 months). Fourteen patients (66%) had no previous foot surgery. In 11 patients (53%) only Weil osteotomy was performed; in the other 10 patients (47%) the procedure was combined with surgery to the first ray for the correction of hallux valgus deformity.

There were no major complications. Superficial wound infections in four (19%) patients were treated successfully with antibiotics. No screws needed to be removed and no non-union / avascular necrosis were seen. Only one patient was left with residual pain and stiffness on ambulation but the rest (95%) were able to walk comfortably in either normal shoe wear or trainers.

We found that the patients consistently reported pain relief although some stiffness of the toes may remain. The majority of patients were satisfied with the outcome in terms of symptoms and function when evaluated by using the American Orthopaedic Foot and Ankle Society scoring system. Excellent results (90–100 points) were achieved in 10 patients (47%), good (80–89 points) in six patients (28%), fair (70–79 points) in four (20%) and poor (less than 70 points) in only one patient (5%). We conclude that although there is a considerable learning curve that must be overcome the Weil osteotomy can be a reliable procedure that effectively reduce the load under the lesser metatarsal heads.

Some radiological features of the lumbar spine of 84 patients with spastic diplegia were compared with 50 control subjects. The average age of the patients was 20.1 years (3 to 39). Spondylolysis of the fifth lumbar vertebra was found in 21%, four times more frequently than in normal subjects. No patient under nine years of age had spondylolysis and the frequency increased with age. The average angle of lumbar lordosis in spastic patients in the standing position was greater than in normal subjects, and increased with age. The patients had a decreased sacrofemoral angle which caused an increase in Ferguson's angle and explained the increased angle of lumbar lordosis.

We performed Kawamura's dome osteotomy of the pelvis, with simultaneous distal transfer of the greater trochanter on 101 hips in 91 patients with osteoarthritis secondary to hip dysplasia. The mean age at operation was 30 years (15 to 55), and follow-up was for a mean of 8.3 years (5 to 14). Clinical evaluation using the Merle d'Aubigne score showed 92% excellent or good results. Radiologically, 91 hips had good acetabular remodelling and showed no signs of progression of osteoarthritis. In ten hips the osteoarthritic process progressed despite the osteotomy and six of these eventually underwent total hip replacement. Factors which were significantly associated with a poor outcome included an advanced stage of osteoarthritis, valgus deformity of the proximal femur, old age at the time of operation and postoperative persistence of abductor insufficiency.