Abstract

Traditional open approaches for subtalar arthrodesis have reported nonunion rates of 5–16% and significant incidence of infection and nerve injury. The rationale for arthroscopic arthrodesis is to limit dissection of the soft tissues in order to preserve blood supply for successful fusion, whilst minimising the risk of soft tissue complications. The aim of this study was to determine the outcomes of sinus tarsi portal subtalar arthrodesis.

Case records of all patients undergoing isolated arthroscopic subtalar arthrodesis by two senior surgeons between 2004 and 2014 were examined. All patients were followed up until successful union or revision surgery. The primary outcome measure was successful clinical and radiographic union. Secondary outcome measures included occurrence of infection and nerve injury.

Seventy-seven procedures were performed in 74 patients, with successful fusion in 75 (97.4%). One (1.3%) superficial wound infection and one (1.3%) transient sural nerve paraesthesia occurred. Fixation with a single screw provided sufficient stability for successful arthrodesis.

To our knowledge this is the largest reported series of isolated arthroscopic subtalar arthrodeses to date, and the first series reporting results of the two portal sinus tarsi approach. This approach allows access for decortication of all three articular facets, and obviates the need for a posterolateral portal, features which may explain the high union rate and low incidence of sural nerve injury in our series.

This study reviewed all patients who received an EXOGEN Express bone stimulating device (BSD) to treat delayed union / non-union following operative treatment for a long bone fracture & evaluate if our results are comparable with the NICE guideline expectations.

A retrospective review of records between December 2004 & January 2013 revealed 113 patients treated with a BSD. A total of 59 patients were eligible for analysis, (operative treatment for a long bone fracture with adjuvant EXOGEN BSD for non-union or delayed union). Twenty-one were open fractures.

The BSD was applied at a mean of 264 days post-operatively. Thirty-five patients went on to have a 2nd operation before union was achieved. Forty-two patients went on to union following application of the BSD. Mean time to union was 293 days. Seventeen patients failed to unite by the end of the study. There were no adverse reactions to the EXOGEN BSD in this cohort.

This study has shown that the use of an EXOGEN BSD is a safe, non-invasive method to successfully treat long bone non-unions following initial operative surgery, with potential cost savings (a potential saving of £48,888 to the hospital according to NICE estimations) compared to the standard re-operative management.

Introduction:

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe a purely arthroscopic technique for excising talocalcaneal coalitions. We present a retrospective two-surgeon case series of the first eight patients (nine feet).

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe an entirely arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet).

Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 year to 5.5 years.

Subtalar movements were improved in all feet. Deformity was not always fully corrected but pain and SAFAS scores improved in all patients bar one. They all had a rapid return to good function apart from this same patient who required subsequent fusions. The posterior tibial nerve was damaged in one patient.

Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from any operative technique. Patient selection and preoperative planning are crucial. This series from two independent surgeons supports the feasibility and effectiveness of this technique.

We report a single surgeon series of 33 arthroscopic subtalar fusions performed through a 2-portal sinus tarsi approach on 32 patients between March 2004 and February 2009. Background pathologies included primary arthrosis, post-traumatic arthritis, planovalgus foot, rheumatoid disease, sinus tarsi syndrome and CTEV.

97% [32/33] of fusions as assessed by both clinical and radiological means were achieved within 16 weeks [76% [25/33] within 12 weeks] with only a single outlier which had fused by 22 weeks. There were no deep infections, thrombotic events or neuromas. Five patients suffered complications of which four were successfully treated with a satisfactory outcome. One patient developed persistent pain and was eventually referred to another centre for further management.

In our experience arthroscopic subtalar fusion surgery has been demonstrated to give excellent outcomes with minimal complications. Furthermore, it is a technique allowing surgery even in patients with significant hindfoot deformity. It is a suitable operation even for patients with a compromised soft tissue envelope which would normally preclude an open procedure.

Introduction: Severe haemophilia affects 1 in 10,000 men. The ankle along with the hip and knee are commonly affected. Ankle fusion is the preferred surgery for end stage arthritis in the younger patient although debate exists as to the preferred technique. We conducted a retrospective review of the arthroscopic ankle fusions on haemophiliacs from Oxford and compared data with that of a specialist unit in London using an open technique.

Materials and Methods: We reviewed 22 ankles (22 patients) from Oxford and 10 ankles (8 patients) from London. 90% had Type A haemophilia with similar regular monthly Factor VIII usage: 17941 U/month (Oxford) compared with 17992 (London). 73% of patients in the Oxford Group and 100% of the London group had Hepatitis C and/or HIV.

Results: Union was achieved in all patients. The mean time to union in the open group was 9.1 weeks (Mode- 8 weeks, Range 7–14) compared to 12.2 weeks (Mode- 12 weeks, Range 8–24) in the arthroscopic group. Screw removal was required in 4 patients (3 arthroscopic v’s 1 open). 1 patient in the arthroscopic group suffered a pseudoaneurysm of the dorsalis pedis artery. The arthroscopic group spent less time in hospital- 5.7 days compared to 9.5. Factor VIII usage was less in the arthroscopic group- 32,882 Units compared to 40013.

Discussion: Patients of this nature should be managed in centres used to dealing with their complex needs. Arthroscopic ankle fusion in haemophiliacs is safe for these patients. Although arthroscopic fusion may take slightly longer to unite, there are benefits in terms of reduced patient stay and factor VIII requirement and therefore costs.

The 4th England and Wales NJR showed that 83% of total knee replacements were cemented (47,626 knees). This study aimed to compare modern techniques of cementation of the proximal tibia in an experimental model against tourniquet-less knee replacement surgery with cancellous bone suction and a cement gun.

A metal box was constructed to approximate the proximal tibia and open cell sawbone simulated the tibia with simulated blood flow and bone suction. Each sample was prepared in an identical fashion except for the cementing technique. The techniques compared were of

Tourniquet,

Samples were subsequently sectioned, polished and the cemented area measured using a planimeter.

ANOVA testing demonstrated that the techniques were significantly different (p< 0.0001). Bonferroni Comparison demonstrated that the Exeter technique gave significantly better cement penetration for central and lateral measurements (p< 0.0001 and p< 0.0001) compared to all other methods.

The authors believe that our technique of cementation of the proximal tibia offers an easy and reproducible way of getting good quality cementing of the tibial component in total knee replacement and this is borne out by our experimental model.

Arthroscopy of the ankle and subtalar joints are established techniques in foot and ankle surgery. Arthroscopic ankle arthrodesis is well described and is useful in patients with a poor soft tissue envelope. Subtalar fusion is traditionally an open procedure with potentially significant complications but there is little published on arthroscopic subtalar arthrodesis.

22 patients, made up of 9 males and13 females were operated on from March 2004 to present day with 12 to 36 months follow up. Indications for surgery included primary osteoarthritis and degeneration secondary to previous calcaneal fracture, tibialis posterior insufficiency, neurological conditions and previous ankle fusion. 8 Patients had a concurrent arthroscopic ankle fusion and 4 patients also had a talonavicular fusion.

All patients had surgery by the senior author and followed the same postoperative course. Patients were protected in plaster for 12 weeks with gradual increase to fully weightbearing at 6 weeks and x-rays taken at 6 and 12 weeks. Successful outcome was taken as clinical and radiological evidence of fusion.

21 patients (95.5%) achieved fusion by 12 weeks. There has been 1 nonunion but there have been no wound breakdowns, deep infections or other serious complications.

Previous authors have reported variable complication rates and significant rates of delayed and non-unions following open subtalar fusion. These early results suggest that arthroscopic subtalar fusion is a safe and reliable method with a high success rate and a low complication rate.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

To determine whether sacral chordoma is monoclonal or polyclonal in origin, a new assay to study the polymorphic human androgen receptor locus (HUMARA) was applied. The ratio of maternal inactive X-chromosone to the paternal inactive X (Lyon hypothesis) was determined via a methylation-specific polymerase chain reaction (PCR) technique. Seven of seven informative samples showed a polyclonal proliferation pattern. This study suggests that chordomas are more comparable to mesenchymal neoplasms than to monoclonal hematopoeitic neoplasms.

The purpose of this study was to determine whether sacral chordoma is monoclonal or polyclonal in origin via a new molecular genetic assay of the x-chromosome.

A polyclonal proliferation pattern was identified in all informative samples studied.

Characterization of the genetic tumorigenesis of this unpredictable neoplasm may lend insight into its biological behavior and offer novel therapeutic intervention.

Utilizing a new assay to study the polymorphic human androgen receptor locus (HUMARA), the ratio of maternal inactive X-chromosome to the paternal inactive X (Lyon hypothesis) is determined via a methylation-specific polymerase chain reaction (PCR) technique to detect X-chromosome polymorphisms. Eight female chordoma patients had their DNA harvested and their x-chromosome inactivation pattern and polymorphisms determined and compared to control. A polyclonal proliferation pattern was identified in seven of seven informative samples. The eighth sample showed a single x chromosome allele in normal and tumor tissue and was thus viewed as uninformative.

We report results using the hydroxyapatite coated, distally locking Cannulok revision hip prosthesis. The component was used to treat periprosthetic and pathological fractures, often in the presence of aseptic loosening or infection in a group of elderly patients. 16 patients with a mean age of 78 years underwent surgery by a single surgeon over a period of 3 years. They were followed up clinically and radiologically for an average of 24 months.

The mean modified Merle D’Aubigne and Oxford Hip Scores were 14 and 23.6 respectively. These results are comparable to the published results for the previous version of the Cannulok hip, and other revision hip revision series.

We believe the implant provides a relatively simple and effective reconstructive option that can be used as an alternative to more extensive surgical options in elderly patients with periprosthetic fractures.

Many techniques exist for reduction of anterior dislocation of the shoulder. The two commonest methods are the Hippocratic and Kocher. Iatrogenic complications have been linked to both techniques; though reports of brachial plexus traction-injury from the Hippocratic method are rare compared to the more common complication of surgical neck of humerus fracture secondary to the Kocher technique.

Method Questionnaires were sent to 125 Orthopaedic and 125 A& E departments in the UK, asking staff to independently comment on their preferential reduction technique in anterior dislocation of the shoulder.

Results Overall 62% performed the Kocher method and 29% performed a Hippocratic reduction. However, 64% of Orthopaedic consultants performed a Hippocratic reduction (34% performing Kocher) compared to only 14% of A& E consultants, (70% of whom performed a Kocher reduction).

Conclusion The significant risk of humeral neck fracture in performing a Kocher reduction, especially in an inadequately anaesthetised patient in the A& E setting, and the overwhelming preference of Orthopaedic consultants to perform a Hippocratic reduction, indicate that the Kocher method should not be employed.