The Ponseti method is the gold standard treatment for congenital talipes equinovarus (CTEV), with the British Consensus Statement providing a benchmark for standard of care. Meeting these standards and providing expert care while maintaining geographical accessibility can pose a service delivery challenge. A novel ‘Hub and Spoke’ Shared Care model was initiated to deliver Ponseti treatment for CTEV, while addressing standard of care and resource allocation. The aim of this study was to assess feasibility and outcomes of the corrective phase of Ponseti service delivery using this model. Patients with idiopathic CTEV were seen in their local hospitals (‘Spokes’) for initial diagnosis and casting, followed by referral to the tertiary hospital (‘Hub’) for tenotomy. Non-idiopathic CTEV was managed solely by the Hub. Primary and secondary outcomes were achieving primary correction, and complication rates resulting in early transfer to the Hub, respectively. Consecutive data were prospectively collected and compared between patients allocated to Hub or Spokes. Mann-Whitney U test, Wilcoxon signed-rank test, or chi-squared tests were used for analysis (alpha-priori = 0.05, two-tailed significance).Aims
Methods
Certain cases of patello-femoral maltracking can lead to articular surface wear. Though most can be treated non-operatively, where there is increasing wear surgical intervention may be necessary. Patellar tracking is difficult to assess and though several different types of maltracking or loading have been described, each case warrants precise assessment of the wear patterns. Without this knowledge a logical approach to realignment surgery is impossible. 60 consecutive cases (age range 18–50 years) presenting with anterior knee pain were arthroscoped over a 4 year period. These patients all had been selected with either patellar instability or surface wear indicated either clinically, a positive radiograph, bone scan or MRI. All patients were arthroscoped through standard anterolateral and antero-medial portals and also a superolateral and occasionally a supero-medial approach. The areas of articular damage were mapped on diagrams and recorded photographically. Patella views were taken in flexion and extension, and on passively stretching the patella medially and laterally. We found 6 distinct patterns of wear which appear to indicate 6 different maltracking abnormalities. The largest group, 46 patients, consisted of lateral trackers, with 21 patients demonstrating medial facet and lateral femoral condylar wear. Assessment of the articular surface of the patello-femoral groove from inferior portals is highly misleading and superior portals are needed for proper assessment. Medial facet wear can occur in lateral instability or medial compression. Lateral maltracking at engagement or distally are the commonest patterns.
It is recognised that those patients who present sciatica and significant preceding back pain will be disappointed, following discectomy, with the relief of the sciatica alone, as considerable degenerate disc will remain. Though a bilateral fenestration exposure as much disc possible was removed right down to the back of the anterior longitudinal ligament. Intervertebral fusion was not used. Of 25 patients, with a mean follow up of 20 months, 59% reported a significant improvement in pain (p<
0. 05) and function (p<
0. 05) following surgery. Post-operative radiography did not reveal malalignment or instability.
Cauda equina syndrome (CES) due to central disc prolapse produces acute neurological deficit. We investigated long-term urological disability after surgery for CES and the impact of emergency versus next day surgery. 20 CES patients (M=F), were assessed using a validated quality of life questionnaire; comparison was made with a matched group undergoing simple lumbar disc surgery. Median length of history before presentation was seven days. Nine were operated on within 4. 5 hours, the remainder all within 24 hours after neurosurgical admission. While the patients’ perception was of good general health (no different from controls), urological symptoms adversely affected their lives (P=0. 02). Only two patients had no urological symptoms. Emergency surgery (within 4. 5 hours of presentation) was not associated with reduced disability.
