Introduction:

The dorsal closing wedge calcaneal osteotomy has been described for the treatment of insertional pathology of the tendo-achilles. The aim of this study was to evaluate the efficacy of the technique using outcome measures.

Purpose: The aim of this study was to analyze the outcome of AO cannulated screws for undisplaced fracture neck of femur and find out the correlation in outcome with respect to co-morbidities in a general trauma unit in UK.

Method: A retrospective study was conducted using data from electronic patient record, clinical coding information, clinic letters and GP’s. 315 patients who underwent AO screws for fracture neck of femur during 2000 to 2004 were included. We looked into age, place of living, classification, mechanisn of injury, comorbidities, mobility before fracture, allergy, addictions, whether patient was anticoagulated, delay for theatre with reasons, length of stay in hospital, complications and treatment for complications. We assessed reasons for other admissions later on, need and type of another operation, consequently developed comorbidities, patient getting fracture of other side and its treatment, time and cause of death if happened?

Results: There were 81 males and 234 females in the study. Mean age of patients was 72 years (range 50–96 years). Non-union occurred in 19 patients (6%) and avascular necrosis occurred in 49 patients (15.5%). Reoperation with an arthroplasty was required in 69 patients (21.9 %). The incidence of avascular necrosis with internal fixation at 1 year was 31 (9.8%). Fifty-one (16%) patients died in 2 year period. The age, walking ability of the patient, and associated co-morbidities were of statistical significance in predicting fracture healing complications. We correlated our complications with comorbidities and found them more in patients with end-stage renal failure, steroid intake, osteoporosis and diabetes mellitus etc.

Conclusion: The rate of fracture healing complications and reoperations in patients with undisplaced fractures was high in our series with two year follow up. It was even higher in patients with age greater than 80 years and some specific comorbidities. We should also consider co-morbidities and age before deciding for internal fixation rather than only the fracture configuration (Treat patient not the X-rays). Outcome is multifactorial and depends on many predictive factors. Each patient should be evaluated carefully and we should treat the physiological age and not the chronological age.

Purpose: The aim of the study was to analyze the outcome of AO cannulated screws for fractures neck of femur in patients with Diabetes mellitus.

Method: Sixty-two patients aged 50 years or more (17 males & 45 females) who underwent AO screws for fracture neck of femur over seven years (1999–2005) and followed-up for a minimum of two years formed the study population. A retrospective review of data from electronic patient record (EPR), clinical coding, clinic & GP letters was made. Age, residential placement, Garden’s classification of fracture, mode of injury, associated other co morbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected.

Results: The mean age of patients was 67 years (range 52–96 yrs). Eleven patients died in two years time. Forty-one patients were less than 75 years of age and 21 patients were more than 75 years of age. All the patients more than 75 years of age had undisplaced intracapsular fractures. Thirteen patients were type I and 49 patients were type II diabetic. Non-union and avascular necrosis occurred in nine (17%) & 13 (26%) patients respectively. Revision surgery in the form of total hip replacement or hemiarthroplasty were performed in 21 (41%) cases. The incidence of avascular necrosis following osteosynthesis at one year was 14%. Age, control of diabetes, postoperative complications, pre-fracture mobilization status etc. Complications like wound infection were more principally in patients who had poorly-controlled diabetes.

Conclusion: Patients with diabetes mellitus have metabolic bone disease due to vasculitis. This increases the risk of complications associated with fracture fixation such as non-union, cut-through and avascular necrosis (AVN). The complications and revision surgery rate was high in patients with displaced fractures and with poorly controlled diabetes. Comorbidities like diabetes and patient’s age were also strong predictors of healing in addition to fracture configuration. Looking at very high complication and re-operation rate, our recommendation in patients with diabetes is primary hemiarthroplasty irrespective of femoral head displacement, if there age is more than 75 years.

Aim: To assess medium term results of MOJE arthroplasty for degenerative Hallux Rigidus.

Materials and Methods: Patients over 18 years of age with symptomatic degenerative hallux rigidus, with at least three years follow up were included in the study. Patients who had previous surgery for hallux rigidus were excluded. A press fit Moje ceramic on ceramic prosthesis was implanted using the standard technique. Patients were non-weight bearing for the initial two weeks followed by physiotherapy according to the Moje protocol. All patients were assessed radiologically and clinically using the AOFAS (American Orthopaedic Foot and Ankle Society) and Foot Function Index (FFI – R, short form) as the primary outcome measure and a Visual Analogue Pain score (VAS) as the secondary outcome measure. Radiological assessment was carried out independently by two authors. Prosthesis loosening was defined as more than 5mm subsidence (sum of proximal and distal components), implant tilting and presence of osteolytic lesions. Revision of arthroplasty was taken as an end point to define failure.

Results: 27 Moje replacements of the first metatarso-phalangeal joint in 25 patients operated by one surgeon were included in the study. There were 22 female and 3 male patients with a mean age of 61 (range: 48–83). Mean preoperative range of movement (sum of dorsi and plantar flexion) was 310 (range: 10–65). Mean preoperative FFI – R score was 100 (range: 53–183); mean preoperative AOFAS score was 45 (range: 28–64); mean preoperative VAS was 8 (range: 3–10). The average follow up was 49 months (range: 36–60). There were no wound complications. Postoperatively, 5 joints (19%) required closed manipulation and 3 joints (11%) required open arthrolysis to improve the range of movement. Three joints (11%) drifted into valgus, two of them requiring a corrective Akin osteotomy of the proximal phalanx. One patient (4%) required open reduction for dislocation and one patient required excision of the medial sesamoid for persistent pain. In all, 12 replacements (44%) were symptomatic enough to require a further procedure. None of the joints required revision. The mean postoperative range of movement was 350 (range: 15–60, p=0.85, Relative Risk=1.069, 95% Confidence Interval: 0.72–1.59). There was improvement in postoperative FFI–R score (mean: 41, Range: 27–66, p=0.007, RR=0.53, 95% CI: 0.34–0.83), AOFAS score (mean: 83, range: 68–100, p=0.07, RR: 1.5, 95% CI: 0.98–2.38) and VAS (mean: 1, range: 0–5, p=0.04, RR: 0.80, 95% CI: 0.0.66–0.97). Radiologically, there were signs of loosening of prosthesis in 4 joints (15%) without an adverse outcome in pain and functional scores.

Discussion: There is a high incidence of stiffness requiring further surgical procedure to improve the range of movement following this replacement. Although pain and function scores improve with Moje arthroplasty, patients should be counselled that their range of movement may not improve and annual long-term clinical and radiological surveillance would be necessary to assess the integrity of this prosthesis. Further studies including larger number of patients with longer follow up are required to assess the long-term results of this procedure.