Introduction

Despite the multiple patho-aetiological basis of Hallux valgus (HV), corrective osteotomy is a common and globally performed orthopaedic procedure. Over-correction of the inter-metatarsal angle (IMA), however, is not without consequence. Through increased joint pressures, over-correction may predispose to joint degeneration. Hypothesizing that over-correction leads to an increase in intra-articular joint pressures, we constructed a mechanical simulation of the 1^st metatarsal-phalangeal joint.

The aim of this study is to assess the accuracy of patients' shoe size as a predictor of femoral component size of Oxford unicompartmental knee replacement (UKR).

A retrospective study was conducted to identify the correlation between patients' shoe size (British system) and the femoral component size. After excluding patients who died (n=2) and patients in whom the implanted femoral component size was inaccurate (n=13), the remaining cases (93 UKR in 88 patients) formed the study sample. Postoperative radiographs were reviewed to determine femoral component fit. We found positive correlation between shoe size and femoral component size. In females; a shoe size from 2.5 to 6 predicted a small femoral component and shoe size from 6.5 to 8.0 predicted a medium femoral component. In males, a shoe size from 6 to 9.5 predicted a medium femoral component and a shoe size from 10 to 13 predicted a large femoral component. This relation predicted the femoral component size accurately in 80% of cases. In the rest of cases, the prediction was only one size smaller or larger than the ideal size. A subgroup analysis, after excluding patients who changed their shoe size during adulthood after foot surgery or pathology (n=20), showed an accuracy rate of 81%.

Shoe size is a simple method that predicts femoral component size more accurately than other methods currently used such as templating, tibial component size and height based on gender.

Aim of study: ‘Dark discs’ (intervertebral discs with normal shape and height but low signal intensity on T2-weighted MRI) are believed by some authors to represent an early stage in the degenerative process although other authors have suggested that they are simply an appearance of the normal aging process. This study addresses the above question by investigating the correlation between disc morphology on MRI of the lumbar spine (‘dark disc’ or obviously degenerative signs such as annular tear, loss of disc height and shape and end plate changes) and the distribution of lower back pain.

Background: It is generally accepted that spinal levels appearing degenerate on MRI may act as ‘pain generators’ either directly or indirectly (by affecting adjacent structures or levels). Furthermore, histopathologic and discographic studies have shown transmition of specific patterns of somatic pain from degenerate spinal levels.

Methods: 231 consecutive patients (mean age: 45 years, SD:15.9) presenting with mechanical lower back pain of more than six months duration completed topographic graphs of the distribution of their back pain (categorised for this study as upper-, mid-, low-lumbar and sacroiliac area pain) and underwent an MRI of the lumbar spine. Chi-square test was used to investigate the association between presence of abnormalities at any spinal level and pain at any of the considered body areas. Two sets of analyses were performed: one including ‘dark discs’ in the ‘pain generators’ group and the other excluding the ‘dark discs’ from this group.

Results: When the ‘dark discs’ were not considered as ‘pain generators’ the only association to reach statistical significance was that between L5/S1 abnormalities and mid-lumbar pain (P=0.02). However, inclusion of the ‘dark discs’ in the ‘pain generators’ group increased the strength of the association between L5/S1 abnormalities and mid-lumbar pain (P< 0.01) and also resulted in the associations between L3/4 and L4/5 level abnormalities and sacroiliac area pain reaching statistical significance (P=0.02 and P< 0.01 respectively).

Conclusion: The significant statistical effect of considering ‘dark discs’ as ‘pain generators’ on the association between specific spinal level abnormalities and presence of back pain in well-defined areas suggests that the MRI appearance of a ‘dark disc’ should be considered an early stage in the degenerative process and not simply an effect of normal aging.

A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients.

Advances in the design of the components for total ankle replacement have led to a resurgence of interest in this procedure.

Between January 1999 and December 2004, 16 patients with a failed total ankle replacement were referred to our unit. In the presence of infection, a two-stage salvage procedure was planned. The first involved the removal of the components and the insertion of a cement spacer. Definitive treatment options included hindfoot fusion with a circular frame or amputation. When there was no infection, a one-stage salvage procedure was planned. Options included hindfoot fusion with an intramedullary nail or revision total ankle replacement. When there was suspicion of infection, a percutaneous biopsy was performed. The patients were followed up for a minimum of 12 months.

Of the 16 patients, 14 had aseptic loosening, five of whom underwent a revision total ankle replacement and nine a hindfoot fusion. Of the two with infection, one underwent fusion and the other a below-knee amputation. There were no cases of wound breakdown, nonunion or malunion.

Management of the failed total ankle replacement should be performed by experienced surgeons and ideally in units where multidisciplinary support is available. Currently, a hindfoot fusion appears to be preferable to a revision total ankle replacement.

Aims: The aim of the present study was to investigate the correlation between the topography of the reported symptoms of ‘mechanical’ lower back pain and the findings from the MRI of the lumbar spine.

Methods: Topography (‘pain charts’) of the lower back pain (upper, middle, lower lumbar and sacro-iliac areas) and the MRI findings (disc morphology, Modic-type end plate changes, presence and degree of spondylolisthesis) of 230 consecutive patients with ‘mechanical’ lower back pain without neurological symptoms were studied. Chi-square test was used for the statistical analysis.

Results: Analysis showed that the presence of L5/S1 level pathology is associated (p=0.018) with pain in the middle lumbar area. No other statistically significant association between pathology of another level and pain in other lumbar areas was observed.

Conclusions: Contrary to the general belief, pathology of the lowest lumbar spinal level as diagnosed from MRI may be associated with pain in the middle lumbar area while other pathological levels are not necessarily associated with specific areas of pain in the lower back.

The resurgency of ankle replacement in the last 10 years has prompted a need for effective management of failing prostheses. We present the early to mid-term results for revision surgery of 17 arthroplasties in 17 patients from our tertiary referral centre.

Between 1999 and 2004, two Consultant Foot and Ankle Surgeons revised failing ankle arthroplasties in 17 patients (age range 51–74 years). All patients were assessed with tissue cultures and histology that were harvested at the time of surgery and managed in conjunction with a specialist Bone Infection Unit.

Intraoperative frozen section was used to aid management, but usually pre-operative decisions had been made which included

one or two stage reimplantation

Many of the patients had had previous “revision surgery” such as change of meniscal components, arthroscopic debridements and excision of impingeing osteophytes.

Indications for implantation had been osteoarthritis in 59%, rheumatoid arthritis in 18% and post-trauma in 23%. Heel shift procedures to correct malalignment had been performed in 12%.

The implants comprised 15 Scandinavian Total Ankle Replacements (STAR), one Agility and one Buechel-Pappas. Three patients had fractured malleoli secondary to bone loss.

Cultures and histology confirmed the presence of infection in 24% (defined as positive histology and more than 2/6 positive cultures) with aseptic loosening in the remainder.

One infected patient underwent amputation at his request. Six non-infected patients had successful revision of two or three components, one infected patient had Ilizarov fusion and lengthening. The remainder underwent successful hindfoot fusion over a locked intramedullary nail, even in the presence of infection, with suppression to union.

Study Design: A six-year retrospective analysis of all instrumented spinal fusions performed in the Nuffield Orthopaedic Centre and the John Radcliffe Hospital.

Objective: To assess the incidence of infection following instrumented spinal fusion, the nature of the infecting organisms and their subsequent management.

Subjects: All patients who had undergone removal of spinal metalwork were analysed for evidence of infection. The indications for removal of metalwork included proven deep infection, refractory postoperative pain or planned removal after thoraco-lumbar fracture.

Outcome Measures: Successful treatment of infection was documented when the patient was asymptomatic and inflammatory markers remained within normal limits following cessation of antibiotic therapy. Failure was documented when the patient had recurrent sepsis, refractory pain following removal of metalwork or died.

Results: 80 spinal infections following instrumented fusions were found between 1997 and 2003. 34 of the infecting organisms were propionibacteria, 19 were coagulase negative staphylococcus, 10 were staphylococcus aureus, 8 were methicillin resistant staphylococcus aureus, 3 were coliforms, 2 were proteus, 2 were diphtheroids, 1 was alpha haemolytic streptococcus and 1 was anaerobic streptococcus. 29 of these infections were polymicrobial. Of 55 patients who had metalwork removed secondary to pain, 20 patients had proven infection postoperatively (36.3%). Preoperative inflammatory markers failed to accurately predict the presence of infection for trauma patients. Our management of infection is removal of metalwork with six intraoperative samples sent for culture and histology specimens, followed by administration of at least six weeks of intravenous or oral antibiotic, depending on the organism and its antibiotic sensitivity. Prolonged treatment is used where inflammatory markers remain raised.

Conclusions: Infection of spinal implants presents different management problems to those which follow infected total joint replacement. The lack of specific clinical, laboratory and radiological findings in patients who are subsequently diagnosed as having infections associated with spinal instrumentation presents a challenging clinical problem. We found the most predictive sign of infection following instrumented fusion of scoliotic spines was postoperative pain. CRP and ESR were unreliable as predictors of infection.

We reviewed the outcome of 116 primary cemented Omnifit 7000 series total knee arthroplasties implanted into 108 patients over a period of two years with a mean follow up of 68 months (range, 48–90). During the review period, 12 patients died and 8 patients were lost to follow up (24 knees). The mean Knee Society score postoperatively at review was 86 (range, 65 to 95). The mean functional score at review was 76 (range, 60 to 100). The mean range of motion at review was 100 degrees (range, 85 to 115). Radioluscent lines greater than or equal to 1mm in width were present in 9 (10%) of the femoral views, 12 (14%) of the tibial AP views, 4 (4%) of the tibial lateral views and there was no evidence of progression of the radioluscent lines.

There were three revisions; one because of an early deep joint infection, on due to instability in the AP plane and one due to aseptic loosening. The clinical and radiographic results with a minimum five year follow up show very satisfactory results. The Omnifit 7000 series provides results, which compare well with other cemented arthroplasties in the medium term.

Introduction: The use of lower limb tourniquets is routine in lower limb surgery. Several methods have been used often based on surgical preference. Aim: To establish the pain quality in patients undergoing forefoot surgery with the tourniquet placed at the ankle and the calf. Method: A prospective randomised trial was undertaken. Assessment of peri-operative and postoperative pain in 30 patients undergoing forefoot surgery under local anaesthetic was undertaken. All calf and ankle tourniquets were inßated just before surgery. Patients were concealed randomised to either midcalf or ankle tourniquet. Cuffs were inßated to 100 mm Hg above the systolic pressure. Pain and pulse were measured pre-operatively and at 5 minutes, 10 minutes and at 10-minute intervals. We also assessed the quality of the þeld. Results: Both the tourniquet positions gave very good þelds however the use of the ankle tourniquet was far less painful at 5,10,20 and 30 minutes after the operation started p< 0.0001. Conclusion: We conclude that the ankle tourniquet gives an excellent bloodless þeld whilst providing a far less discomfort.

Our aim was to determine if a tourniquet placed on the ankle has any advantage in forefoot surgery over the position on the midcalf. We randomised 30 patients who were undergoing forefoot surgery under under local anaesthesia into two groups. One had a tourniquet on the ankle and the other on the mid calf. All calf and ankle tourniquets were inflated to 100 mm Hg above the systolic pressure, just before the surgical procedure.

The blood pressure, pulse and level of pain were recorded at intervals of five minutes during the operation. The surgeon evaluated the quality of the anaesthesia, the bloodless field, and the site of the tourniquet.

The patients tolerated the tourniquet on the ankle much more. Both the tourniquet positions gave good operative fields, however the use of the ankle tourniquet was less painful at 5,10,20 and 30 minutes after the operation had started (p< 0.01). Physiological parameters were better in the ankle group.

We conclude that the ankle tourniquet gives a good bloodless field and provides improved pain tolerance for forefoot surgery carried out under local anaesthesia.