The focus on evidence-based medicine has led to calls for increased levels of evidence in surgical journals. The purpose of the present study was to review the levels of evidence in articles published in the foot and ankle literature and to assess changes in the level of evidence over a decade. All articles from the years 2000 and 2010 in Foot and Ankle International, Foot and Ankle Surgery, and all foot and ankle articles from JBJS A and JBJS B were analysed. Animal, cadaveric, basic science, editorials, surveys, letters to Editor and correspondence were excluded. Articles were ranked by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine.Background
Methods
Calcaneal osteotomy is often performed together with other procedures to correct hindfoot deformity. There are various methods of fixation ranging from staples, headed or headless screws or more recently stepped locking plates. It is not clear if one method is superior to the other. In this series we compare the outcome of various methods of fixation with particular attention to the need for subsequent hardware removal. A retrospective review of the records of a consecutive series of patients who had a calcaneal osteotomy performed in our unit within the last 5 years was undertaken. All patients had had their osteotomy through an extended lateral approach to their calcaneous. The subsequent fixation was performed using one of three methods; a lateral plate placed through the same incision; a ‘headless’; or a ‘headed’ screw through a separate stab incision inserted through the infero-posterior heel. Records were kept of subsequent symptoms from the hardware and need for metalwork removal as well as any complications. When screws were inserted the entry point in relation to the weight-bearing surface of the calcaneous was also recorded.Introduction
Patients and Methods
The recent emphasis on using “evidence based medicine” for decision-making in patient care has prompted many publishers to mention the level of evidence of articles in their journals. The “quality” of a journal may thus be reflected by the proportion of articles with high levels of evidence and assist it achieve citations and therefore an Impact Factor. The purpose of this study was to survey published Foot and Ankle literature to evaluate changes in the level of evidence over ten years. Articles from Foot and Ankle International, JBJS Br, JBJS Am, Foot and Foot and Ankle Surgery were used. We looked at the years 2000 and 2010 and ranked the articles by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine. 498 articles were ranked. Studies of animals, studies of Background
Methods
Previous studies have demonstrated the need of accurate reduction of ankle syndesmosis. Measurement of syndesmosis is difficult on plain radiographs. Recently, a difference of 2mm in anterior and posterior measurements at incisura of the inferior tibio-fibular joint on CT has been described as a measure of malreduction (depicted as ‘G’ for ease of description). Our practice changed towards routine post operative bilateral CT following syndesmosis fixation to assess the reduction and identify potential problems at an early stage. The aim of this primarily radiological study was to determine if the use of bilateral cross sectional imaging brings additional benefit above the more conventional practice of unilateral imaging. Between 2007 and 2009, nineteen patients with ankle fractures involving the syndesmosis were included in the study group who had bilateral CT post operatively. The values of ‘G’ and the mean diastasis (MD) were calculated, representing the average measurement between the fibula and the anterior and posterior incisura.Introduction
Method
Bone marrow oedema syndrome (BMES) of the foot and ankle is an uncommon and often misdiagnosed condition. It is usually thought to be a benign self limiting condition, without any We retrospectively reviewed 8 patients with the diagnosis of BMES. There were 6 males and 2 females with an average age of 51 years (38–63 years). All patients had acute onset of severe pain in the foot without any history of trauma. None of the patients had history of excessive alcohol or steroid intake. 5 patients (63%) had bilateral involvement of migratory nature. All patients had characteristic features on MR scans, with involvement of 3 or more bones in the foot.Introduction
Materials and Methods
Single stage total We performed single stage total Fusion was achieved in 7 feet (64%) at an average time of 17 weeks. In 4 patients, non-union persisted but they were pain free at latest review and would not consider further surgery. Average duration of follow-up was 20 months (range 6–24 months). All patients had stiff hindfeet with a jog of movement at the Total
To evaluate efficacy of blood conservation strategies on transfusion requirements in adult scoliosis surgery and establish a protocol for cross matching. Retrospective review of 50 consecutive adult scoliosis patients treated using anterior only(14,28%), posterior only(19,38%) or combined(17,34%) approaches. All patients were anaesthetised by the same anaesthetist implementing a standard protocol using cell salvage, controlled hypotension and antifibrinolytics. Mean age was 24.6 years. BMI was 21.9. On an average 9.5(6-15) levels were fused, with an average duration of surgery of 284.6(130-550) minutes. Antifibrinolytics were used in 31(62%) of the patients which included Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Patients on antifibrinolytics had a significantly (p<0.05) lower blood loss (530ml) as compared to other patients (672ml). Mean volume of the cell saved blood re-transfused was 693.8 ml and mean postoperative HB level dropped to 10.7 g/dl(7.7-15) from a mean preoperative of 13.3 g/dl(10-17). 7(42%) with combined approaches and 3(15.8%) with posterior only approach required blood transfusion, 4/50(8%) of which required intra while 6/50(12%) required intra and postoperative transfusion. None of the patients having anterior surgery alone required blood transfusion.Purpose
Methods and Results
Our study aims to evaluate the efficacy of Wallis implant in management of discogenic back pain. We have prospectively studied thirty patients between 2006 and 2007. Average age of patients was 40.8 years. Average follow-up period 20.6 months (9-28). Main inclusion criteria includes failure of conservative management of low back pain due to degenerative disc disease, preservation of 50% of the disc height and positive discographic features. In majority of the patients the implant was put in at the level of L4-L5. Pre-op and post op SF36 and Oswestry Disability Index (ODI) scores were assessed during clinic follow-up and by telephonic interview. Mean SF36 score improved from thirty-seven (8.3 – 54.3) to 51.4. Mean ODI improved from forty-three (20-60) to 26.5(2-60) (p = 0.026). Complications including superficial infection occurred in one patient, deep infection in one patient, erosion of spinous process in one and displacement of the implant in one case. Three (10%) patients had revision surgery due to various reasons. Wallis interspinous dynamic stabilization system could be used as a soft stabilisation device avoiding fusion and short-term results are promising. In selected group of discogenic low back pain patients it is a useful interim procedure. Long-term follow-up of our series is ongoing.
Displaced distal radius fractures in children have been treated in above elbow plaster casts since the last century. Cast index has been calculated previously, which is a measure of the sagittal cast width divided by the coronal cast width measurement at the fracture site. This indicates how well the cast was moulded to the contours of the forearm. We retrospectively analysed the cast index in post manipulation radiographs to evaluate its relevance in redisplacement or reangulation of distal forearm fractures. Consecutive radiographic analysis.Introduction
Study Design
In order to manage painful subluxation/dislocation secondary to cerebral palsy, 12 hips in 11 patients received combined femoral and Chiari pelvic osteotomies with additional soft tissues releases at an average age of 14.1 (9.1-17.8) years. Pain relief, improvement in the arc of movement, sitting posture and ease of perineal care was recorded in all, and these features have been maintained at an average follow-up of 13.1 (8-17.5) years. The improvement of general mobility was marginal, but those who were community walkers benefited the most. Pre-operative radiological measurements have been modified post-operatively to use lateral margin of the neo-acetabulum produced by the pelvic osteotomy. The radiological migration index improved from a mean of 80.6% to 13.7% [p<0.0001]. The mean changes in CE angle and Sharp's angle were 72° (range 56°- 87°) [p<0.0001] and 12.3° (range 9°- 15.6°) [p< 0.0001] respectively. Radiological evidence of progressive arthritic change was seen in only one hip, in which only a partial reduction had been achieved, and there was early joint space narrowing in another. Heterotopic ossification was observed in one patient with athetoid quadriplegia who remained pain free. In seven hips the lateral Kawamura approach, elevating the greater trochanter, provided exposure for both osteotomies and allowed the construction of a dome-shaped iliac osteotomy, while protecting the sciatic nerve. This combined procedure provides a stable hip with sustained pain relief for the adolescent and young adult presenting with pain.
Most high-energy trauma to lower legs, ankles and feet result in severe crush injuries. We performed a retrospective case series study Eight patients (7M: 1F) with mean age of 28 years (range -18 -35 years) were included. Four had Grade 3 open fractures of the distal tibia and 5 had open foot fractures. Two had neurovascular injuries. Four patients had associated injuries with mean ISS of 9 (range 8-16) and a mean MESS score of 3.5 (3-7). All had undergone some form of internal and external fixation within approximately 24 hours (8 hrs to 4 days). The mean follow-up period was two years (range 1-4 years). At final follow-up patients' health was measured using SF-36 questionnaire. Six patients had their fractures healed at a mean of 4.8 months (4-9 m). Two patients had fully functional foot with occasional complaints of painful ankle. Two patients had CRPS1 undergoing treatment. Two patients are unable to walk due to chronic pain and deformity. Comparison of the SF-36 scores with the age-matched UK normal controls without foot and ankle injuries showed significantly worse scores in physical function (PF: p<0.01) and role physical (RP: p< 0.01) categories. Our surgical instinct dominates decision-making, favouring salvage rather than amputation in these young groups of patient. They gradually suffer a cocktail of crippling disease characterised by psycho-socio-economic and physical disability. Should we be depleting our resources in salvaging these complex limb injuries?
We audited all patients who underwent Foot and Ankle surgery at the University Hospital of Wales over one financial year (April 2007 – March 2008). Patients were identified from the hospital OPCS-4 coding system and all scheduled and unscheduled visits to hospital investigated. Both trauma and elective patients were included. Patients were followed up for a mean period of 9 months (Range 1–14 months) following surgery. The records for 1052 patients were evaluated. Of these, 77% were elective cases and 23% were trauma related. Overall about 10 % of our foot and ankle patients (100/1052) either attended the A&
E Department or had an unplanned clinic visit at some stage of their follow up. Three quarters of these patients were admitted to hospital (median stay 1 day, range 1–51 days). Twenty five patients (24 A&
E; 1 medical) simply re-attended, but were not admitted. The majority of these (58%) had plaster-related problems (8\24) or superficial wound infections (6/24). The remaining patients presented with pain around the operated area, and were discharged after investigation. One patient presented to the physicians 44 days after excision of a Morton’s neuroma with a DVT. Seventy five patients (7%) were re-admitted to hospital. Two were admitted under the physicians: one with a pulmonary embolus (30 days post ORIF ankle) and one following a cardiac arrest (20 days post ORIF ankle). Out of the remainder 34 patients had planned removal of metalwork, 9 patients had metalwork removed because of infection and 21 patients had soft-tissue infection requiring antibiotics or debridement. Overall, 9 patients underwent revision surgery (0.85%). The overall infection and thromboembolic rate was 3.42 %(6 A&
E + 30 T&
O/1052) and 0.28% (1A&
E + 2 medical/1052) respectively.
We aimed to evaluate the effects of implementing blood conservation strategies on transfusion requirements in adult patients undergoing scoliosis correction surgery. We retrospectively studied 50 consecutive adult patients who underwent scoliosis correction surgery (anterior, posterior or combined) between 2003 and 2007. All patients had a standard transfusion protocol. Age, BMI, pre and post operative haemoglobin, levels fused, duration of surgery, hospital stay, anti-fibrinolytics used and blood transfused was noted. 50 patients with mean age 24.6 years and mean BMI 21.9 kg/m2 were studied. 14 patients had anterior surgery, 19 patients had posterior surgery and 17 had combined anterior and posterior procedures. Mean number of levels fused was 9.5 (6–15) and mean duration of surgery was 284.6 minutes (135–550 minutes). Antifibrinolytics were used in 31 patients (62%), Aprotinin in 21(42%) and Tranexamic acid in 10 (20%). Mean blood loss in patients who received anti fibrinolytics was 530mls while mean blood loss in the other patients was 672mls. (p<
0.05). Blood transfusion was not required in any of the patients undergoing anterior correction only while 7 patients (41%) undergoing anterior and posterior correction and 3 patients (15.8%) undergoing posterior correction only required blood transfusion. Mean volume of cell saved blood re-transfused was 693.8 mls and mean hospital stay was 9.2 days. Mean pre-op haemoglobin was 13.2 g/dl (10.4–17.4) and mean post-op haemoglobin was 10.7 g/dl (7.7–15). 4 patients (8%) required intra and post-operative blood transfusion while 6 patients (12%) required blood transfusion postoperatively. In conclusion, the use of anti-fibrinolytics like Aprotinin and Tranexamic acid reduces blood loss in scoliosis surgery. In the current scenario, with Aprotinin no longer available for use, our study would recommend the use of Tranexamic acid alongwith other blood conservation measures. In our unit we do not have blood cross matched for anterior surgery alone.
Sacroiliac joint (SIJ) is a diarthrodial joint and can often be a source of chronic low back pain complex. We present a percutaneous technique for SIJ fusion and the functional and radiological outcome following arthrodesis with HMA (Hollow modular anchorage; Aesculap Ltd, Tuttlingen) screws. Fifteen consecutive patients operated for SIJ fusion between Sep 2004 and Aug 2007 were included in the study. The diagnosis was confirmed with MRI and diagnostic injections. Pre-operative and post-operative functional evaluation was performed using SF-36 questionnaire and Majeed’s scoring system. Postoperative radiological evaluation was performed using plain radiographs. The HMA screws packed with bone substitute were implanted percutaneous under fluoroscopic guidance. The study group included 11 females and 4 males with a mean age of 48.7 years. Mean follow-up was 14 months. Mean SF-36 scores improved from 37 to 80 for physical function and from 53 to 86 for general health. The differences were statistically significant (Wilcoxon signed rank test; p <
0.05). Majeed’s score improved from mean 37 preoperative to mean 79 postoperative. The difference was statistically significant (student t test, p<
0.05). 13 had good to excellent results. The remaining 2 patients had improvement in SF-36 from mean 29 to 48. Persisting pain was potentially due to coexisting lumbar pathology. Intra-operative blood was minimal and there were no post-operative or radiological complications. Percutaneous HMA screws are a satisfactory way to achieve sacroiliac stabilisation.
In our unit we do not have blood cross matched for anterior surgery alone.
