Introduction

There are nearly 500,000 people with undiagnosed diabetes mellitus in the UK. The incidental finding vascular calcification on plain radiographs in patients with undiagnosed diabetes has the potential to alter patient management in those presenting with pathology. We hypothesised that the presence of vascular calcification on plain radiographs of the foot may predict the diagnosis of diabetes. The primary aim of this case control study was to determine the positive predictive value of vascular calcification to diagnose diabetes. Secondary aims were to determine the odds of having diabetes dependent on other known risk factors for calcification.

Introduction

The current treatment for Freiberg's osteochondrosis centres around either: simple debridement or debridement osteotomy. The main principle of the osteotomy is to rotate normal articular cartilage into the affected area. We recommend the use of CT scanning to delineate the amount of available, unaffected cartilage available to rotate into the affected space.

Introduction

Ankle fractures in the elderly are an increasing problem with our aging population. Options for treatment include non-operative and operative with a range of techniques available. Failure of treatment can lead to significant complications, morbidity and poor function. We compared the outcomes of two operative techniques, intramedullary hindfoot nailing (IMN) and fibular-pro-tibia fixation (FPT). This is the largest analysis of these techniques and there are no comparative studies published.

Aim

Left sided hip fractures are more common but no obvious cause has been identified. Left handedness has previously been associated with an increased risk of fracture for a number of sites but to the best of our knowledge no association between handedness and hip fracture has previously been reported.

Aims

Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot.

Introduction

Standard teaching of dislocated ankles was always reduce then x-ray. However the 2016 BOAST guidelines stated “Reduction and splinting should be performed urgently for clinically deformed ankles. Radiographs should be obtained before reduction unless this will cause an unacceptable delay”. We aimed to audit our practice against the BOAST guidelines and look at time from attendance to reduction.

Background

Avulsion fractures of the base of the fifth metatarsal are some of the commonest foot injuries. The robust scientific evidence on the optimal non-operative treatment of these fractures is scant. We designed and conducted a prospective randomised non-inferiority controlled trial of symptomatic treatment versus cast immobilisation with the null hypothesis that cast immobilisation gave substantial benefit over the symptomatic treatment in terms of patient reported outcome measures(PROMs). The alternative hypothesis was that symptomatic treatment was not inferior.

Aims

The purpose of this study was to compare symptomatic treatment of a fracture of the base of the fifth metatarsal with immobilisation in a cast.

Our null hypothesis was that immobilisation gave better patient reported outcome measures (PROMs). The alternative hypothesis was that symptomatic treatment was not inferior.

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy is a well-recognised form of treatment for stage II posterior tibial tendon dysfunction. Although excellent short- and medium-term results have been reported, the long-term outcome is unknown. We reviewed the clinical outcome of 31 patients with a symptomatic flexible flat-foot deformity who underwent this procedure between 1994 and 1996. There were 21 women and ten men with a mean age of 54.3 years (42 to 70). The mean follow-up was 15.2 years (11.4 to 16.5). All scores improved significantly (p < 0.001). The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up. The mean pain component improved from 12.3 to 35.2 (20 to 40). The mean function score improved from 35.2 to 45.6 (30 to 50). The mean visual analogue score for pain improved from 7.3 to 1.3 (0 to 6). The mean Short Form-36 physical component score was 40.6 (sd 8.9), and this showed a significant correlation with the mean AOFAS score (r = 0.68, p = 0.005). A total of 27 patients (87%) were pain free and functioning well at the final follow-up. We believe that flexor digitorum longus transfer and calcaneal osteotomy provides long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

Cite this article: Bone Joint J 2015;97-B:346–52.

Introduction:

The surgical treatment of intractable metatarsalgia has been traditionally been an intra-articular Weil's type of metatarsal osteotomy. In such cases, we adopted the option of performing a minimally invasive distal metaphyseal metatarsal ostetomy (DMMO) to decompress the affected ray. The meta-tarsophalangeal joint was not jeopardised. We present our outcomes of Minimally Invasive Surgery for metatarsalgia performed at our teaching hospital.

Introduction

Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (CO) is a well-recognised surgical treatment for stage II posterior tibial tendon dysfunction (PTTD). Whilst excellent results are quoted for short and medium term follow-up, the long-term outcome of this procedure is unknown.

Introduction: Deep infection is a devastating complication following hip arthroplasty. In the early 1970’s Staphylococcus Aureus (SA) was believed to be the causative organism in most cases and Coagulase Negative Staphylococccus (CNS) was widely regarded as a contaminant. It subsequently became recognised that the majority of infections are caused by CNS rather than SA, probably due to the use of peri-operative antimicrobial agents and laminar air flow in theatre.

Aims: The aim of this study was to look at the causative organisms in patients with an infected total hip replacement to see if the pattern of infection has changed with time.

Methods: Between February 1999 and November 2004, 95 patients underwent 1^st stage revision surgery at the Northern General Hospital for definite infection following total hip replacement. At least 5 tissue samples were taken at the time of surgery prior to antibiotic administration. Infection was confirmed when at least 3 of the samples were positive on microbiological culture. We retrospectively reviewed the records of these patients and identified the causative organisms.

Results: The 95 patients were infected with 130 different organisms. Of these 32% were SA including MRSA (7.2%), 27% CNS, 13.6% Enterococcus, 4.8% pseudomonas and 3.2% Streptococcci. 29% of patients had polymicrobial infection.

Discussion: Data published in the literature as well as historical data from our unit suggest that CNS is by far the most common organism causing prosthetic hip joint infection. Our results however, show a recent decrease in the proportion of CNS and an increase in SA and polymicrobial infection.

Introduction: Planovalgus is a clinical deformity on weightbearing. Extra-articular calcaneal lengthening osteotomy, is a recognised surgical treatment for symptomatic flat feet. The aim of this study was to assess the difference in pedal pressures and radiographic parameters in the assessment of patients undergoing lateral column lengthening for planovalgus deformity.

Methods: Operative records of one surgeon were reviewed over a 5 year period to identify those who had undergone a lateral column lengthening procedure. 10 patients, 14 feet were identified. Patients were recalled for post-operative pedobarography and pre- and post-operative X-rays were identified. Peak plantar pressures were measured at 8 sites and a line plotted to show maximum deviation of pressure progression from the anatomical axis of the foot. 5 angles on X-rays were measured by 2 observers on 2 occasions.

Results: Difference in pressure under the 3^rd metatarsal head (p=0.0004), hallux (p=0.02) and medial midfoot (0.001) suggested a highly significant change. Results for the first (p=0.41) and second (p=0.91) metatarsal heads showed no change. The centre of pressure maximum deviation, plotted using a line drawn between the second toe and the rear of the heel was found to be highly significant postoperatively (p=0.00051) indicating that load bearing shifted from medial to lateral. Changes in X-ray angles of the lateral talo-1^st metatarsal angle(p=0.006), calcaneal pitch(p=0.002), AP talocalcaneal angle(0.0001) and talonavicular coverage(p=0.003) were all highly significant.

Discussion: Lateral lengthening in adolescent feet changes the pedal pressures in an advantageous way.

Total hip arthroplasty surgery may be associated with substantial loss of blood often necessitating blood transfusion.

The risks associated with blood transfusions are widely known. Haemostatic drugs have been tried in the past to try and reduce this, and there has been renewed interest in these recently, in particular Aprotinin (Bayer).

Aprotinin is a serine protease inhibitor, which has been shown to reduce blood loss in cardiac surgery by up to eighty percent.

The aim of our study was to investigate whether or not high dose Aprotinin can reduce blood loss and transfusion rates in patients’ undergoing total hip arthroplasty.

This was a randomised double blind controlled clinical trial, where 50 patients were randomised to receive either Aprotinin (2 x 106 KIU followed by an infusion of 5 x 105 KIU/hr), or an equivalent volume of normal saline.

Blood loss and transfusion rates were measured as well as the incidence of deep vein thrombosis.

There was a significant reduction in total blood loss seen in the Aprotinin group, median 817±350, when compared to the control group, median 1191±386. This translates to a 31% reduction in blood loss.

DVT and transfusion rates were not significantly different between the two groups.

There was no complications or deaths seen in the Aprotinin group.

The use of high dose Aprotinin results in a reduction in blood loss in total hip arthroplasty. It has been proved to reduce blood loss in cardiac surgery, and although papers have shown it can reduce blood loss in orthopaedic surgery, its’ use should not as yet be routine.

Further work is required to investigate the possibility of a future role for Aprotinin in orthopaedic surgery, as well as its’ mode of action. Until then more established methods of blood conservation should be used.

The aim of the study was to analyze the results of the Bayley-Walker Fixed Fulcrum Total Shoulder Replacement done at our institution.

We present a retrospective study of 13 Bayley-Walker Total Shoulder Replacement (BWTSR) with a short follow-up of three to 38 months. Indications for the surgery included severe pain, and all the patients had a dysfunctional rotator cuff not considered to be amenable to surgical repair. Five patients had had previous failed rotator cuff repairs. One patient had a shoulder dislocation following a rotator cuff repair. Not all patients had glenohumeral arthritis. Five males and eight females were treated with BWTSR with a mean age of 66.5 years. Eight patients had left sided BWTSR and five patients had right shoulders replaced. A McKenzie approach was most commonly employed. Post-operatively in most cases early assisted active mobilisation was encouraged.

The Oxford shoulder assessment questionnaire was used in the postoperative subjective assessment. Constant functional assessment score improved on average from 24.3 preoperative to 64.5 postoperative. Complications include significant glenoid fracture during surgery in three patients. One patient had significant infection which responded to treatment, the joint survived and the patient has a good result. One patient had dislocation of the UHDPE liner due to faulty technique.

We conclude that BWTSR is a reliable procedure in a painful rotator cuff deficient shoulder. In suitable patients better results can be achieved than with non-constrained prostheses. The worst results of BWTSR are comparable to the poor results of unconstrained replacement.

Two patients presented with pain in the arm and a radiographic lesion of the upper humerus which warranted surgical exploration and excision biopsy. In both cases the pathology was inflammatory and involved the insertion of pectoralis major. Tendinitis of the pectoralis major with an associated lesion of the humerus has not previously been described.