We undertook a retrospective cohort study to determine if body mass index (BMI) is an independent factor in determining patient outcome following total hip replacement (THR). Outcomes were determined using the Oxford Hip Score, a questionnaire designed to evaluate self-reported function and pain levels in people with hip pain. We looked at all THRs carried out on patients with a BMI of ≥30 over a 38 month period (220 operations) and compared these with 220 randomly selected THRs carried out on patients with a BMI of <30 within the same 38 month period. For each case we recorded patient BMI, P score and Oxford scores. We calculated the difference between pre-operative and one-year post-operative Oxford hip scores. We used Kendall's rank correlation to assess any potential correlation between BMI and functional change, and the Mann-Whitney U test to establish if functional change between the groups was statistically significant. Our study indicates that BMI is not an independent factor in determining relative subjective functional change following THR. Although it showed that patients with a BMI of ≥30 have worse function both before and after THR, there was no statistically significant difference between the two groups in terms of functional change. We therefore suggest that patients with a higher BMI be considered candidates for THR as they can expect the same degree of functional improvement. Given the trend for increasing numbers of obese patients in the population these findings could have a significant impact on the future of THR operations.

Introduction

Morton's Neuroma is routinely treated by excision of the interdigital nerve. Traditional surgery works by denervation, but the results are variable, and recurrence is common. Multiple Morton's Neuromas present a difficult clinical challenge. MR and ultrasound often demonstrate a normal nerve or an interdigital bursa. Some experts advise division of the intermetatarsal ligament rather than excision. This case series evaluates an alternative method of treatment.

Introduction

More than 60% of patients presenting with a hip fracture have significant medical co-morbidities and a one year mortality rate between 14% and 47%. The rating scale for the American Society of Anaesthetists (ASA) is a reliable predictor of both surgical risk and mortality with ASA 4 patients having 100% mortality at one year.1,2

Introduction

Various rehabilitation shoes are prescribed to protect the forefoot following surgery. Patients often complain of discomfort in other areas as a result of the postoperative shoe, including the knee, hip and lower back. This has never been quantified. This study aims to establish the effect on other joints using gait analysis. Methods: 11 healthy volunteers were investigated using various common types of postoperative shoe. They were studied with gait analysis equipment and the joint motion assessed with commercial software. The effect of commercial devices designed to minimise gait changes by lifting the contralateral foot were also evaluated.

Nice guidelines recommend VTE prophylaxis to patients in below knee casts following foot and ankle surgery following risk assessment. The guidelines are controversial and BOFAS recommendations reiterate the risk factors but highlight poor evidence to support these guidelines. Implementation has been variable dependent on interpretation.

58 patients who underwent hindfoot procedures and were immobilised in a cast were identified. These patients were under the care of two consultants, one of whom anticoagulates with daily enoxaparin and one who does not, providing a de facto case-control design. The patients were followed up to identify those who subsequently suffered a DVT or PE, and the clinical circumstances.

2 cases of VTE events were noted in 58 patients undergoing foot and ankle surgery. Both were elective cases managed postoperatively in cast and treated with prophylaxic enoxaparin. Both of these presented to hospital with signs of VTE greater than 6 weeks following surgery after cast removal and discontinuation of enoxaparin. No patients were considered high risk according to NICE guidelines. None of the patients who received no thromboprophylaxis had a clinical DVT.

Within our study group we found that VTE thromboprophylaxis does not influence clinically evident VTE rates. Patients who developed VTE were not considered high risk by definition of NICE guidelines but only at increased risk due to their immobility. The VTE events were initiated while the patients were receiving thromboprophylaxis. The effectiveness of the guidelines in predicting patients who would benefit from chemoprophylaxis is questionable from this study.

NICE guidelines on VTE thromboprophylaxis have been received with some concerns. Although this investigation studied only a relatively small number of patients, it raises issues about the clinical effectiveness of the guidelines in foot and ankle patients.

The treatment of very distal tibial fractures and pilon fractures is difficult. There is a wide variation in the severity of injury and the options for surgical management. Plates and external fixation each have their advantages. This retrospective study looks at complications and technical tips for anterolateral plating.

35 consecutive distal tibial platings were evaluated. The AO classification for each fracture was determined and any patient factors affecting outcome. Outcome variables included time to radiological union, infection rate, wound breakdown rate, and joint movement after treatment.

There were 32 anterolateral platings and 3 medial platings. The union rate was 95%. There were two deep infections which required surgical treatment. There were two wound breakdowns, one of which required plastic surgical intervention. Two patients had prominent metalwork, requiring removal. Other complications included deep peroneal nerve palsy, stiffness, and vascular compromise. The complication rates were lower for surgeons operating more frequently on these fractures. Two patients subsequently required bone transport and one required an amputation.

The complication rate found was similar to that reported in the literature. The few complications were however very significant for the patient and also for the surgeon as they required bone transport. Complications other than infection occurred in the few cases performed by surgeons low on their learning curve. We present technical tips for surgery. The presence of callus only after mobilisation indicates that union is slow.

Anterolateral plating is a viable option for distal tibial fractures, especially 43B fractures. There is a learning curve associated with their use. Complication rates are low overall, but significant consequences can accompany complications. As an alternative to external fixation, distal locking plates are not a pain free option for the surgeon, as well as for the patient.