Introduction

Rivaroxiban is a direct inhibitor of factor Xa, a licensed oral thromboprophylactic agent that is increasingly being adopted for lower limb arthroplasty. Rivaroxiban has been NICE-approved for use in primary hip and knee arthroplasty following the RECORD 4 trials; proving it more effective in preventing venous thrombo-embolic (VTE) events compared to enoxaparin. Enhanced Recovery Programmes (ERP) are designed to enable patients to recover quickly and return home safely within a few days.

Introduction: Osteoid Osteomas are not uncommon, benign bone tumours which have well-defined clinical, radiological and pathological characteristics. These tumours can potentially affect any bone in the body, but show a predilection for long tubular bones. The clinical presentation can easily be confusing, if the site in question is rare and the presentation atypical. Lesions occurring in the foot often pose particular problems in diagnosis, often leading to delays in treatment. Although there have been accounts of the post traumatic presentations of osteoid osteomas, no direct link has been established between trauma and its incidence.

Case Report: A 38 year old gentleman was referred by his GP with an eighteen month history of right midfoot pain after a football injury which forced his right foot into hyperextension and abduction. Initial radiographs after the injury were normal. The pain did not respond to non-steroidal anti-inflammatory drugs (NSAIDs) and there were no nocturnal exacerbations. Examination at presentation showed an antalgic gait with medial mid-foot tenderness centred over the first tarso-metatarsal joint (TMTJ). Repeat radiographs showed mild degenerative changes in the first TMTJ. A bone scan showed a hot spot over the right cuneiform bones. Subsequent computed tomography (CT) showed an osteoid osteoma, with a characteristic central calcific nucleus within the nidus, of the medial border of the lateral cuneiform bone. The osteoma was treated with en-bloc excision and the diagnosis was confirmed by histology.

Conclusion: Despite the advances in its treatment, osteoid osteoma of the foot can pose a difficult diagnostic puzzle. This condition should always be kept in mind when faced with persistent, post-traumatic foot pain, even in the absence of roentgenographic findings. In such cases a high index of suspicion and a low threshold for appropriate imaging can lead to the timely diagnosis and treatment of this tumour.

Osteogenesis imperfecta (OI) is characterised by decreased bone density and increased bone fragility.

We studied the effect of bisphosphonates on clinical features and bone mass, enrolling to the study 22 children with OI treated with these drugs. Sixteen of them received continuous oral alendronate and six received cyclical IV pamidronate. Evaluation included mobility score, fracture rate, chemistry of skeletal remodelling, iliac crest biopsy and DEXA assessment of bone mass.

After 18 months of bisphosphonate therapy, 10 patients were fully assessed. There was a definite clinical improvement, with significantly improved mobility (p =0.04), a reduction in the annualised fracture rate from 1.27 to 0.44, and significant improvement in bone mass density (p =0.01).

There have been very few reports in the literature of gout and pseudogout of the spine. We describe six patients who presented with acute sciatica attributable to spinal stenosis with cyst formation in the facet joints. Cytopathological studies confirmed the diagnosis of crystal arthropathy in each case.

Specific formation of a synovial cyst was identified pre-operatively by MRI in five patients. In the sixth, the diagnosis was made incidentally during decompressive surgery. Surgical decompression alone was undertaken in four patients. In one with an associated degenerative spondylolisthesis, an additional intertransverse fusion was performed. Another patient had previously undergone a spinal fusion adjacent to the involved spinal segment, and spinal stabilisation was undertaken as well as a decompression.

In addition to standard histological examination material was sent for examination under polarised light which revealed deposition of urate or calcium pyrophosphate dihydrate crystals in all cases.

It is not possible to diagnose gout and pseudogout of the spine by standard examination of a fixed specimen. However, examining dry specimens under polarised light suggests that crystal arthropathy is a significant aetiological factor in the development of symptomatic spinal stenosis associated with cyst formation in a facet joint.

The purpose of this study was to determine factors contributing to the high incidence of fractures in patients with spastic quadriplegic cerebral palsy in residential care, and to assess the effect of vitamin D therapy.

Over a period of four years, 20 patients in a cohort of 88 had sustained 56 long bone fractures. We compared them to an age-matched group from the same cohort with no history of fractures. The mobility of patients, who spent their time indoors, was severely restricted in both groups.

There was radiological and biochemical evidence of rickets and osteomalacia in both groups, but the disease was more severe in the fracture group. There was a significant relationship between the number of fractures and the use of anticonvulsant therapy.

Administration of vitamin D (5 000 IU per day) to both the fracture and control group over three months resulted in a marked increase in mean serum calcium (p =0.01), and a dramatic decrease (p < 0.003) in mean alkaline phosphatase to a level just above normal. All non-ambulatory residents with cerebral palsy now receive a maintenance dose of 50 000 IU of calciferol a month. No further fractures have occurred since vitamin D administration.

We recommend vitamin D supplementation for all non-ambulatory children with cerebral palsy in residential care who do not get regular exposure to sunlight.