Purpose

To establish whether incidental durotomy complicating lumbar spine surgery adversely affects long-term outcome.

Background & aim

There have been many operations described for the treatment of hallux valgus deformities and b ette done separately with variable success rates. Our aim is to radiologically assess the outcome following simultaneous osteotomies to the 1st and 5th metatarsals in symptomatic patients with splay foot. To our knowledge, this procedure has not been described in the literature yet.

To establish whether incidental durotomy complicating lumbar spine surgery adversely affects long-term outcome.

Data was collected prospectively. The study population comprised 200 patients. 19 patients who sustained dural tears (Group A) were compared to a control group of 181 patients with no tear (Group B). Outcomes were measured with the SF-36, Oswestry Disability Index (ODI) and visual analogue scores for back (VB) and leg (VL) pain. Scores for the 2 groups were compared pre-operatively, at 2 and 6 months post-op for all patients and at long-term follow-up (range 2-9 years) for patients in group A.

In addition for patients in group A the patients satisfaction with the procedure, ongoing symptoms, employment status and analgesic intake were documented

Pre-operative scores were similar between the 2 groups apart from significantly higher vb scores (63 –A vs 46-B). Results at 2 and 6 months showed no significant differences between the 2 groups. Outcome scores for group A at long-term follow-up do not show any significant decline.

Our study demonstrates that incidental dural tears complicating lumbar spine surgery do not adversely affect outcome in the long-term

Twenty-five Regnauld’s procedures were performed in 20 patients with painful hallux valgus. This procedure involves the removal of proximal one-third of the proximal phalanx which is fashioned into a ‘hat-shaped graft’ and replaced as an osteochondral autogenous graft. The average age at operation was 56 years (range 39–76). After a mean follow-up of 3 years, 4 months (range 2.5–5.7 years), all the patients were assessed clinically and radiologically. The mean hallux valgus angle preoperatively was 29.3° (range 20–50°). At follow-up, a mean correction of 16.9° was obtained. In our study, 92% of patients were satisfied with the operation, but 8 patients (40%) showed progression of osteoarthritis of the first metatarsophalangeal joint. At 10 year follow up all these patient are satisfied with procedure and doing well. In view of the high incidence of degenerative changes in the first metatarsophalangeal joint, this procedure should be reserved for those patients over the age of 65 years or those with early osteoarthritic changes in the first metatarsophalangeal joint.

Aim of study (background): Probability of survival (Ps) is calculated presently by using the TRISS methodology for trauma patients. This utilises physiological scoring parameters, injury scoring system and the patient age. The physiological parameters need to be recorded for determining the RTS, but this data is often missed. The aim of our study was to assess how the essential variables correlate with the Ps and if any other variables contribute significantly to the Ps. Depending on the correlation of any new variables, is it time to change the formula for calculating Ps?

Material and methods: A retrospective study was carried out involving 678 trauma patients. The ISS and RTS scores were calculated from the trauma charts. The relationship between ISS, RTS, age and GCS with Ps was assessed using the correlation and regression analysis and then the affect of gender on Ps was assessed using a T test.

Results: ISS of trauma victims had a mean of 10.22. The results showed a strong negative correlation between ISS and Ps with an r value of −0.633 (p< 0.005). GCS correlated strongly with Ps, with an r value of 0.733 (p< 0.005). In the regression analysis; ISS and GCS showed a strong correlation with Ps. RTS made the weakest contribution to Ps, followed by age. GCS made the strongest unique contribution. There also no significant difference in the mean scores of Ps for males and females (p< 0.005).

Conclusion: The results indicated significantly strong correlations between ISS and GCS with Ps. There was a poor correlation between RTS and Ps. This is helpful for the patients in whom RTS scores cannot be calculated, as GCS can be used in place of RTS. There may be a need for a new system to calculate Ps using GCS and gender.

Aim: Our aim was to measure plantar foot pressures in normal individuals and to compare them with variations in patients with metatarsalgia.

Methodology: We measured the plantar foot pressures in different parts of the foot in normal subjects of various ages and then compared this with foot pressures of patients with metatarsalgia. For measurement and statistical analysis, the plantar contact of the foot was divided into six anatomical divisions. The foot pressures were measured under the hallux, head of first metatarsal, over heads of second, third and fourth metatarsals, the fifth metatarsal, midfoot and hindfoot. This was measured using the FSCAN insole pedobarograph system (Tekscan, Inc, Boston, MA).

The foot pressures were measured in Kilopascals(Kpa). Independent T-tests was used to compare mean pressure distributions in the six anatomical divisions. We found the mean pressures through the 5th metatarsal head – 217(t=−2.32,p< 0.05) and midfoot 94(t=−3.17, p< 0.05), were significantly higher when compared to pressures in normal subjects (table 1).

Conclusion: We have demonstrated increased pressures transmitted through the outer aspect of the sole of the foot, in patients suffering from metatarsalgia. This can be used further to plan any foot- orthosis or surgery to distribute pressures more evenly across the sole of the foot.

Aim: 1. To assess the role of the CT scan in management of intra-articular fractures of the calcaneum. 2. Does the scan makes any difference to the management decision, obtained from assessing the plain radiograph?.

Methodology: This study involved 24 patients with intra-articular fracture of the calcaneum who had both a plain radiograph and a CT scan as a part of their assessment. Three consultants who were blinded to the actual management and names of the subjects were independently asked to grade the radiographs and CT scans, as operative or non-operative, on different occasions. The data was matched to the actual management and was subjected to statistical analysis.

Results: The data was non-parametric and related. The SIGN test was used to analyse the agreement between the three observers and if the decisions made in each of the groups were significantly different from the actual management. There was no statistically significant difference, between the management decision from the radiographs or CT and the actual management.

The change in management that the CT scan brought about was also assessed for each of the observers using the McNemars test. The CT scan did not make any significant difference to the decision made based on the plain radiographs, on whether to operate or not.

A Cochran Q test used to assess the variability of the decisions, showed that there was more inter-observer variability in decision making, using the CT based assessment (Q=9.50, p=0.009) as compared to plain radiographs (Q=3.84, p=0.14).

Conclusion: We conclude that, the CT scan should only be requested when a decision is made to operate on the fracture, based on plain radiographs. This may help with pre-operative planning of fracture fixation. It does not have to be obtained as a routine to assess all intra-articular fractures of the calcaneum.

CT- scan as an management tool is being used extensively in managing calcaneal fractures. We set out to see if a CT-scan makes any difference to the management plan as obtained by looking at the plain radiograph. We also looked at the correlation with the actual management.

Methodology: This was a retrospective study involving 24 patients with fracture of the calcaneum. These patients had both a plain radiograph and a CT- scan to help decide on management. The actual management that each of these patients had was documented. Three consultants who were blinded to the actual management and names of the subjects were independently asked to grade the radiographs, as operative or non-operative. They were then similarly, asked to decide on operation or no-operation based on blinded CT- scans. The data obtained from the three observers were compared to the actual management and were subjected to statistical analysis.

Results: As the data was categorical and matched, the Mcnemars test was used to test the association between the management plan obtained from the radiographs and the management plan obtained from the CT scans, for each consultant. They were also compared with the actual management. The statistical analysis showed that there was no statistically significant association between the management decision obtained from the radiographs and the CT san, for all three observers. Radiograph and CT scan based management decisions also did not correlate with the actual management.

Conclusion: The CT scan should only be done when a definite decision is made to operate on a patient, based on plain radiographs. Calcaneal fractures which are decided not to operate, based on X rays, should not have a CT scan as a routine as it provides no valuable additional information.

Background and Aim: It was observed by the senior author over 15 years that if the foot became dependant in the 1st 48 hours after foot surgery, the patient suffered marked swelling and pain. This effect seemed less after about 48 hours. The practice was adopted of keeping the foot elevated for at least 48 hours. Aware of the work of John Tooke and Gerry Rayman with postural effects on laser Doppler skin flow, we set out to see if there was a demonstrable scientific basis for this practice.

Materials and Method: Laser Doppler flow meter was used to assess blood flow in 14 patients, (16 feet), undergoing foot and ankle surgery. Flow was recorded in the big toe, at heart level and on dependency, preoperatively, and then sequentially at 24, 48, 72 and 96 hours post operatively. Postural vasoconstriction was calculated using the formula; Postural Vas.(%)=Blood flow at heart level – Blood flow on depend./ X 100 Blood flow at heart level The time taken for blood flow in the toe to get back to the pre-operative values was assessed. Room temperature, patient temperature and patient position were all kept constant.

Results: Postural vasoconstriction was recorded for all 14 patients at 48 hours, for 7 patients at 72 hours, and for 2 patients at 96 hours post operatively. All patients had an ankle block, except 2 patients who had a popliteal block. The mean postural vasoconstriction preoperatively was 51.31%; mean at 24 hours post op. was 23.05% mean at 48 hours post op. was 36.62% and mean at 72 hours post op. was 44.24%. The mean operative time was 87.25 minutes. There was a significant difference between the pre-op levels and the 24, 48 and 72 hours post-op levels (p< 0.05). At 96 hours post-op, the difference wasn’t significant. Greater operative time was associated with less postural vasoconstriction at the 72 hours postoperatively.

Conclusion: Results showed that it takes longer than 72 hours for microcirculation to get back to normal rather than 48 hours, but the return towards normality was evident by that time. The results emphasised the importance of post-operative foot elevation for at least 48 hours due of this phenomenon. With increasing operative time, it took longer for the microcirculation to get back to normal. The longer the surgery the longer the period of elevation required. We believe that this practice minimises post operative complications; such as oedema, wound breakdown, pain on dependency. No patients suffered DVT’s or PE’s. However, patients did start with active and passive foot and lower limb physiotherapy soon after surgery.

Introduction Plantar foot pressure measurements using pressure distribution instruments is a standard tool for diagnostic and therapeutic interventions. Foot pressure studies have measured pressure distributions in patients with various conditions such as rheumatoid arthritis, diabetes and obesity . Pressure studies in metatarsalgia and Hallux rigidus, to our knowledge, has not been reported previously. Our aim was to measure plantar foot pressures in normal individuals and to compare them with variations in patients with metatarsalgia and Hallux rigidus. This data may enable us to identify areas of abnormal pressure distributions and thus plan foot-orthosis or surgical intervention.

Materials and Methods This was a case control study. We measured the plantar foot pressures in different parts of the foot in normal subjects of various ages and then compared this with foot pressures of patients with metatarsalgia and hallux rigidus. For measurement and statistical analysis, the plantar contact of the foot was divided into six anatomical divisions. The foot pressures were measured under the hallux, head of first metatarsal, over heads of second, third and fourth metatarsals, the fifth metatarsal, midfoot and hindfoot. This was measured using the FSCAN insole pedobarograph system (Tekscan, Inc, Boston, MA).

Results The foot pressures were measured in Kilopascals(Kpa). Independent T-tests was used to compare mean pressure distributions in the six anatomical divisions. Comparing normal with metatarsalgia, the mean pressures through the 5th metatarsal head 217(t=−2.32,p< 0.05) and midfoot 94(t=−3.17, p< 0.05), were significantly higher when compared to pressures in normal subjects. In patients with hallux rigidus, the mean pressures through the hallux 314 (t=−3.62, p< 0.01) and mid-foot 140 (t=-5.11, p< 0.01), were significantly higher, as compared to pressures in normal subjects.

Discussion Metatarsalgia is a condition that presents with pain under the region of the 2nd to 4th metatarsal heads. Hence, the normal response of the body would be to avoid putting increased pressure through this region, thus causing increased pressures to be transmitted through other parts of the foot. The foot pressures through the hallux and midfoot were higher in patients with hallux rigidus (compared to normal). This results in pressure imbalances and thus may contribute to pain, deformity and abnormal gait. Our study, confirms this, the mean plantar foot pressures were higher under the 5th metatarsal head and the midsole as compared to normal subjects. This could be explained by the tendency to walk on the outer aspect of the sole to avoid the painful area. Thus, any foot orthosis or surgery should aim to redistribute these forces.

Conclusion We have demonstrated increased pressures transmitted through the outer aspect of the sole of the foot, in patients suffering from metatarsalgia. The pressures through the Hallux and midfoot were higher in oatients with hallux rigidus. This information can be used further to plan any foot-orthosis or surgery to distribute pressures more evenly across the sole of the foot.

Objective: Our aim was the record variation in foot pressures through parts of the foot, in normal subjects and compare with foot pressure distribution in patients with conditions of the foot such as symptomatic hallux rigidus and metatarsalgia.

Methodology: This was an observational study. We assessed the foot pressure distributions in 30 normal subjects, using the foot pressure pedobarograph system. The foot pressures were measured through the Hallux, 1st Metatarsal head, 2,3,4th metatarsal heads, 5 metatarsal head, midfoot and hindfoot. Foot pressure in patients with hallux rigidus and metatarsalgia were compared with the pressures in normal subjects, using statistical analysis.

Results: The foot pressures were measured in Kilopascals(Kpa). Independent T test was used to compare pressures. In patients with hallux rigidus, the mean pressures through the hallux 314 (t= −3.62, p< 0.01) and midfoot 140 (t=−5.11, p< 0.01), were significantly higher, as compared to pressures in normal subjects. In patients with metatarsalgia, the mean pressures through the 5th metatarsal head 217 (t=−2.32, p< 0.05) and midfoot 94 (t=−3.17, p< 0.01), was significantly higher when compared to pressures in normal subjects.

Conclusion: The foot pressures through the hallux and midfoot were higher in patients with hallux rigidus (compared to normal). Thus any foot orthosis or surgery should aim to relieve the pressure through these regions. Whereas, foot pressures through 5th metatarsal head and midfoot were higher in patients with metatarsalgia (compared to normal). This reflects the adaptation the foot develops to avoid the painful region and thus any orthosis or surgery should try to spread the foot pressures evenly across the foot.

Aim: Assessing Polyethylene wear is very important in following up patients after Total hip replacement (THR) and Livermore method (using callipers) is routinely used by clinicians in calculating this wear. Our aim was to assess if ‘Imagika’, a new computer software programme can accurately assess polyethylene wear(PE-wear). We also compared the computer software with the Livermore method in calculating wear.

Method: We used 15 different THR X rays of patients who had an ABG total hip replacement done. X rays that were included for the calculations were taken at different time intervals following the operation. Wear was calculated on each X ray by 3 clinicians using both the methods, on 3 separate occasions. We compared the Livermore method and the computer software for consistency of measurements and also calculated the inter and intra observer variability for both.

Results: There was a statistically significant difference (at the 5% level) between the measurements taken by the Imagika software and the Livermore method. F(1,88) = 5.38, p< 0.05. There was a statistically significant difference in the inter-observer measurements using the Livermore method. F(2,42) = 4.18, p< 0.05, but there was no significant inter-observer variation using the Imagika computer software. There was no statistically significant difference (at the 5%level) in the intra-observer variability of both groups.

Conclusion: The Imagika computer software proved to be better than the Livermore method in calculating wear with regards to inter-observer bias. There was also a significant difference between measurements taken using both methods. We conclude that the computer software may be a more accurate tool in the assessment of PE-wear in the future.

Aim of study (background): Probability of survival (Ps) is calculated presently by using the TRISS methodology. This utilises physiological scoring parameters, injury scoring system and age. The physiological parameters need to be recorded for determining the RTS, but are frequently missed. The aim of my study was to assess if any other variables contribute significantly to the Probability of survival, and if they do is it time to change the variables used to calculate the Probability of survival?

Material and methods: A retrospective study was carried out from January’01 to August’03. The relationship between Injury Severity Score (ISS), Revised Trauma Score (RTS), age and Glasgow Coma Score (GCS) with Probability of survival was assessed using the correlation and regression analysis and then the affect of gender on probability of survival was assessed.

Results: ISS had a mean of 21.69 (range, 2–50). The results showed a strong negative correlation between ISS and Ps with an r value of −0.692 (p< 0.005). GCS correlated strongly with Ps, with an r value of 0.457 (p< 0.005). In the regression analysis; ISS, RTS, age and GCS showed a strong correlation with Ps. RTS made the strongest unique contribution to Ps, followed by age, ISS and then GCS. There also was a significant difference in the mean scores of Ps for males and females (p< 0.005).

Conclusion: The results indicated significantly strong correlations between GCS and Ps. This is helpful for the patients in whom RTS scores cannot be calculated, as GCS can be used in place of RTS. Results also showed that gender affects Ps and hence could be used in calculations. There may be a need for a new system to calculate Ps using GCS and gender.

Aim The senior author observed over 15 years that if the foot became dependant during the first 48 hours following foot surgery, the patient suffered marked swelling and pain. This effect seemed less after about 48 hours. Aware of the work of Tooke and Rayman (1986) with postural effects on laser Doppler skin flow, we set out to see if there was a demonstrable scientific basis for this practice.

Method Laser Doppler flow meter was used to assess blood flow in 14 patients (16 feet), peri-operatively. Flow was recorded in the big toe, at heart level and on dependency, pre-operatively, and at 24, 48, 72 and 96 hours post-operatively. Postural vasoconstriction (PV) was calculated using the formula:

\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \[PV\ (\%)\ =\ Blood\ flow\ at\ heart\ level\ {-}\ Blood\ flow\ on\ dependency\ {\times}\ 100\] \end{document}

Blood flow at heart level

Results PV was recorded for all 14 patients at 48 hours, for seven at 72 hours, and for two at 96 hours post-operatively. The mean PV pre-operatively was 51.31%; at 24 hours post-op. was 23.05%; at 48 hours post-op. was 36.62%; and at 72 hours post-op. was 44.24%. There was a significant difference between the pre-op. levels and the 24, 48 and 72 hours post-op. levels (p< 0.05).

Significance of work It takes longer than 72 hours for microcirculation to get back to normal rather than 48 hours, but the return towards normality was evident by that time. This emphasised the importance of postoperative foot elevation for at least 48 hours due of this phenomenon. We believe that this practice minimises post-operative complications, such as oedema, wound breakdown and pain on dependency.