Introduction: Every ten seconds, somewhere in the world, someone dies of tobacco-related causes. The adverse effects of smoking on the cardiovascular, respiratory, and immune systems have been well documented. Results of foot surgery are also gravely affected by cigarette smoking, with poorer clinical outcomes, lower rates of osteotomy union, bony fusion and higher rates of postoperative infection. However, data on surgeon’s awareness and their practices to overcome the adverse effects of smoking in elective foot surgery is limited.

Aim: The purpose of this study was to report the results of a survey of experienced foot and ankle surgeons regarding their awareness about detrimental effects of smoking and the measures they take in their practice to prevent them.

Methods: A survey of members of British Foot and Ankle Society was done to document surgeon’s awareness and attitudes towards detrimental effects of smoking in patients undergoing elective foot surgery and the measures they take to prevent these problems. Survey was returned by 104 of the 225 surgeons (47%).

Results: One hundred and two (99%) of the surgeons were aware of the damaging effects of smoking in foot and ankle surgery. Eightynine (84%) of these recorded the smoking habits of their patients in their dictated notes. However, only 9% respondent admitted recording the smoking habits of their patients in consent form and warn them about forthcoming risk of complications at the time of consenting. Only twentyfour (23%) had varying protocol’s to prevent smoking related operative complications.

Conclusions: Most of the surgeons appreciate the harmful effects of smoking. However they are unaware of the extent to which it causes problems. Majority of the members would like the society to propose a unified policy or evidence based guidelines to deal with smoking related problems in foot surgery.

Introduction: Laser Doppler Flowmetry (LDF) is an established technique for the measurement of perfusion in tissues, which has been applied in animal and human studies. Despite many studies the implications of perfusion and blood flow abnormalities in the rotator cuff (RC) in vivo are not clearly understood. This study aims to assess the blood flow in the normal and diseased RC using Laser Doppler Flowmetry (LDF) technique.

Methods: With Ethics approval and informed consent patients undergoing arthroscopy for impingement or cuff tear (diseased cuff) or for shoulder instability (normal cuff) were recruited. Following diagnostic arthroscopy and bursoscopy measurements of the blood flux in the RC using the LDF were made at 6 points. Five of these were in the cuff over a 4 cm² area from the insertion at the greater tuberosity (A,E – @ Tuberosity level, C-Muscelotendinous junction, B,D – between the two) and one (F) in the deep surface. Diseased RC were subgrouped into mild (B1), moderate (B2) and severe (B3- cuff tear) impingement grades (Copeland-Levy Classification). The arthroscopy, grading, and probe placement were made by the two senior authors. LDF flux (unit of measurement of the perfusion – LDFf) was recorded over 30 seconds at each measurement point. The mean of these readings was calculated.

Results: 56 patients were recruited. 35 Males (62.5%) and 21 Females (37.5%).

336 measurements were recorded.

The observed mean LDFf was 32.8 (27.4–38.1; 95% CI) , 25.4 (22.4–28.5) and 43.1 (37.8–48.4; 95% CI) For Normal, Impingement and Tear cases, respectively (p< 0.0001, One-way ANOVA).

The LDFf was lowest in the Impingement without tear grade (B2) with a statistically significant increase at the edges of a cuff tear.

Conclusion: Preliminary recordings of LDF show changes are in keeping with current knowledge of the pathology. LDFf decreases with advancing impingement, being least affected in the musculotendinous junction. There is a substantial increase in LDFf at the edges of RC tears. This might reflect an attempted reparative response.

The Constant-Murley score has gained wide acceptance for evaluation of shoulder function. The strength component of the Constant score accounts for 25 out of 100 points. It has been criticized for lack of consistency in defined measurement method.

The aim of this study was to evaluate the effect of various variables on the strength component measurement of the Constant score.

Material & Methods We conducted a series of experiments using a digital force gauge (EZ force). We evaluated the effect of strength measurements with 1) patient in sitting & standing positions 2) strength gauge fixed to an immobile platform or hanging free fixed to the floor by the examiners foot 3) patient’s arm in 45 degrees and 90 degrees of abduction 4) plane of elevation in frontal or scapular plane and 5) patient making a fist or keeping the palm open during the test. These experiments were done in groups of 20 patients. We have compared as well this device and the Isobex Myometer.

Results No statistical differences were found between individual measurements with regard to patient’s position (standing-sitting), device setting (Fixed –Hanging), position of the arm in varying degrees of abduction or the plane of elevation. Strength assessment obtained when patient made a fist compared to open palm was found to be higher (p=0.006). The measurements showed good intra-observer reliability.

The readings of the EZ force and the Isobex myometer were comparable.

Conclusions It seems that the shoulder strength measurements as part of the Constant functional score may be performed with the patient sitting or standing, with the arm at varying degrees of abduction and in different planes of elevation without causing any significant deviation in the measurement.

No influence was found as well to the device being either fixed to an immobile platform or fixed to the floor by the examiner’s foot. These make these measurements easy to perform and reproducible using the newly designed digital force gauge (EZ force).

Giant synovial cyst is commonly seen in association with rheumatoid arthritis. The Baker’s cyst around the knee is the commonest example but it has also been described at the elbow and hip. The possibility of a synovial cyst around the hip is unfamiliar to most clinicians including those who regularly deal with inguinal swellings and those specialising in musculoskeletal conditions. This is often overlooked as a cause of symptoms in inguinal area and lower limb.

We present a report on two patients in whom abnormal pulsatile masses in the groin caused diagnostic difficulty. Patients were initially admitted under vascular surgeons with a clinical diagnosis of aneurysm. Ultrasound examination was useful in excluding aneurysm. Detailed clinical examination revealed painful restricted hip movements and an X–ray showed evidence of arthritis in hip joint. CT Scan confirmed it to be a synovial cyst. Computed Arthrotomogram or Arthrography showed communication of the cyst with hip joint.

Synovial cysts and iliopsoas bursa enlargement may be more common than previously reported. They may present as a pulsatile mass due to close proximity to femoral vessels and should be considered as a differential diagnosis in patients with unusual inguinal swelling.

We present a case of L2/3 interspinous bursitis treated with extraspinal injections. No previous investigations have used fluoroscopically guided spinal injections to confirm the clinical relevance of the MRI features of this type of bursae. Autopsy studies have revealed an increased incidence of interspinous lumbar bursal cavities with advancing age. Afflicted patients present with localised, midline lower lumbar pain exacerbated by extension. In young athletes these symptoms can mimic spondylolysis. MRI is useful in detecting soft-tissue injury of the posterior elements.

Fluoroscopically guided diagnostic and therapeutic extraspinal injections can be used for confirmation and treatment of pain from such bursae.

Aims: Most centres cross-match blood preoperatively for primary joint arthroplasty operations. But is it really necessary? Background of study: We did a audit involving 110 primary hip and 105 knee arthroplasty operations 5 years ago. Results showed that only 35% of our patients used cross-matched blood. Around 7% were transfused on the day of surgery and none urgently. After this we changed our practice to cross-match only those patients with preoperatively haemoglobin less than 10 or ones with antibodies in blood. We re-audited our practice this year in a study. Methods: We looked prospectively at 100 primary total hip and 100 primary total knee arthroplasty operations in a audit. None of these patients were cross-matched. Exclusion criteria were bilateral operations, Pre-operative haemoglobin of less than 10, antibodies in blood. Risk factors included taking drugs like NSAIDS, steroids or aspirin or those suffering from diseases causing vascular fragility like Rheumatoid arthritis or those with any blood coagulation disorders. Results: Blood loss was increased by various risk factors however our study did not prove its (signiþcant) effect on blood transfusion requirement. None of our patients required urgent transfusion. 5% of our patients required transfusion within 24 hours of surgery and in all 20% required post-operative transfusion. Blood transfusion requirements are increased by increased intra-operative blood loss but it does not correlate with post-operative drainage. Conclusions: We advocate a routine practice of only group and save of blood in a standard unilateral joint arthroplasty surgery. This method is advocated by British Transfusion Society, validated in literature and is cost effective.

Aims: Operative treatment of trochanteric fractures in patients with below knee amputation on the same limb is a rare and challenging problem. This is difficult not only because of the absence of foot but also due to coexisting medical problems. The aim of this study was to analyse the problems involved in the treatment of this rare problem. Methods: We reviewed 13 such patients being treated at East kent Hospital Trust over 7 years between Nov 1993 and Dec 2000 constituting less than. 026% of total fracture neck of femur patients. All patients were treated by DHS fixation. Six of these had Reverse boot traction applied during surgery and seven of these had upper tibial pin traction. Results: We observed that boot traction is easy and quick method with less complications. Also these patients rehabilitated better than pin traction group. They started using their prosthesis in 3 days as compared to 7 days in pin traction group. Patients in whom Reverse boot technique was used were discharged home earlier (in 14 days as compared to 21 days) than patients who had pin traction applied during surgery. Results: Although this study included a very small number of patients but it is a largest of its type. Based on our results we recommend that reverse boot traction should be used in all such patients.

Aims: Operative treatment of trochanteric fractures in patients with below knee amputation on the same limb is a rare and challenging problem. This is difficult not only because of the absence of foot but also due to coexisting medical problems. The aim of this study was to analyse the problems involved in the treatment of this rare problem.

Methods: We reviewed 13 such patients being treated at East kent Hospital Trust over 7 years between Nov 1994 and Dec 2001 constituting less than .026% of total fracture neck of femur patients. All patients were treated by DHS fixation. Six of these had Reverse boot traction applied during surgery and seven of these had upper tibial pin traction.

Results: We observed that boot traction is easy and quick method with less complications. Also these patients rehabilitated better than pin traction group. They started using their prosthesis in 3 days as compared to 7 days in pin traction group. Patients in whom Reverse boot technique was used were discharged home earlier (in 14 days as compared to 21 days) than patients who had pin traction applied during surgery.

Results: Although this study included a very small number of patients but it is a largest of its type. Based on our results we recommend that reverse boot traction should be used in all such patients.