Introduction

Angular deformities of the distal femur can be corrected by opening, closing and neutral wedge techniques. Opening wedge (OW) and closing wedge (CW) are popular and well described in the literature. CW and OW techniques lead to leg length difference whereas the advantage of neutral wedge (NW) technique has several unique advantages. NW technique maintains limb length, wedge taken from the closing side is utilised on the opening side and since the angular correction is only half of the measured wedge on either side, translation of distal fragment is minimum. Leg lengths are not altered with this technique hence a useful technique in large deformities. We found no reports of clinical outcomes using NW technique. We present a technique of performing external fixator assisted NW correction of large valgus and varus deformities of distal femur and dual plating and discuss the results.

Introduction

Fracture related infections (FRI) following intramedullary nailing for tibial shaft fractures remain challenging to treat with associated high patient morbidity and healthcare costs. Recently, antibiotic-coated nails have been introduced as a strategy to reduce implant related infection rates in high-risk patients. We present the largest single-centre case series on ETN PROtect® outcomes reporting on fracture union, infection rates and treatment complications.

Introduction

Sagittal pelvic tilt (SPT) can change with spinal pathologies and fusion. Change in the SPT can result in impingement and hip instability. Our aim was to determine the magnitude of the SPT change for hip instability to test the hypothesis that the magnitude of SPT change for hip instability is less than 10° and it is not similar for different hip motions.

Purpose

We share our experience in management of failed in-situ pinning in severe unstable Slipped Capital Femoral Epiphysis (SCFE) by surgical dislocation approach.

Background

The approach to Intramedullary (IM) fixation of long bone fractures remains a controversial issue. Early reports demonstrated less favourable results of retrograde nailing as compared with antegrade options due to higher non-union rates. The aim of this audit was to evaluate the outcomes of practice within the Trauma and Orthopaedic department with relation to IM nail fixation of diaphyseal femur fractures.

Introduction

We aim to assess the functional outcome, patient perceived satisfaction and implant survival at a mean follow up of 13[10–16] years following revision knee replacement.

Introduction

We aim to assess the functional outcome, patient satisfaction and implant survival at a mean follow up of 13[10–16] years following revision for infected total knee replacement.

Background

Post-operative pain following forefoot surgery can be difficult to control with oral analgesia so regional analgesic methods have become more prominent in foot and ankle surgery. It was the aim of this study to evaluate the efficacy of a combination of popliteal and ankle blocks and decide if they provide significantly better post-operative analgesia than ankle block alone in forefoot surgery.

Aims of study: The aim of this study was to analyze the results of oxford unicompartmental knee replacement in a distrct general hospital in UK.

Methods of study: A prospective study of 50 patients undergoing minimally invasive oxford unicompartmental knee replacement for osteoarthritis was conducted between 2001 and 2005. All patients were operated by the senior author of the study. Oxford Phase III medial unicompartmental (meniscal bearing) instrumentation and implants used in all cases.

Pre-op oxford knee score was recorded in all the patients. Post-op scores were recorded annually and at final follow up. X-rays were analyzed for implant positioning and loosening. Data were analyzed using SPSS version 12.

Results: Mean age of patients in our group was 65 years (range 44–78 years). There were 32 females and 18 males in the study. There were no intra-operative complications in any of the patients. Average duration of follow up was 16 months (range 6 months–4 years). Significant improvement in Oxford Knee score was noted after the surgery (43.7 vs. 20.8) (p< 0.05). Average duration of hospital stay was 4 days (range 3–6 days).

Conclusion: Oxford unicompartmental knee replacement gives excellent results, given careful patient selection, meticulous surgical technique and post-operative rehabilitation.

Introduction: It is commonly believed that there is deterioration of one grade of mobility with fracture neck of femur in elderly population. Several studies have been published in literature regarding outcome after operative management of fractures of proximal femur, but none of these focus on deterioration of mobility or its grades after the surgery.

Methods: A prospective pilot study of 50 consecutive patients with fracture neck of femur, who presented to the department were included in the study. Mobility and mortality was assessed at 6weeks and I year post operatively. We used a grading system of mobility with grades from I – VI, where grade I means fully independently mobile and grade VI stands for a bed ridden patient.

Results: Results showed that deterioration of mobility grade was much worse then conventionally thought. Out of 20 patients who were independently mobile without any aid preoperatively, only 5 patients were capable of walking with a stick. The overall mortality at 1 year post-op. was 40%. Patient’s age, residential status, MMS, ASA grade, preoperative mobility and mobility at 6weeks showed good prediction of post operative mortality in these patients.

Conclusion: Contrary to common belief much severe mobility deterioration was seen in patients following fracture neck of femur in elderly patients. Thus, deterioration of mobility becomes a very important factor to be considered in planning the management of these patients.

Introduction: Ankle sprain is one of the common presentations in Accident and Emergency. Accurate diagnosis is critical and sometime difficult without special investigation such as Magnetic Resonance Imaging (MRI) or arthroscopy.

Aim: The purpose of this project was to evaluate magnetic resonance imaging (MRI) accuracy for diagnosing and defining ankle pathology.

Method: Retrospective review of 36 patients who underwent both MRI and Arthroscopy. All cases were seen by single orthopaedic surgeon with special interest in foot and ankle surgery. MRI scan were reviewed by consultant radiologist at our institute. Arthroscopy was used as a standard for comparing MRI results. Sensitivity and Specificity was calculated by qualified statistician.

Results: For osteochondral lesion the Sensitivity of 85.7 %, Specificity of 93.3% and Accuracy of 89.7% was noticed. Anterior and posterior tibiofibular ligament (ATFL and PTFL) pathology had a Sensitivity of 100 %, Specificity of 100% and Accuracy of 100%, while anterior inferior tibiofibular ligament pathology had a Sensitivity of 66.6 %, Specificity of 95% and Accuracy of 86.6%.

Conclusion: Although MRI is a useful tool in exclusion of pathological condition its sensitivity and accuracy in diagnosing ligament injury is not encouraging.

Plantar fibromatosis is a relatively rare disease compared to its counterpart in the hand. Though it is considered to be a part of Dupuytrens diathesis it has been less exhaustively studied to enable evidence based management strategies.

We followed up all patients presenting with plantar fibromatosis to our institute between 1980 and 2006, identifying 41 patients. 6 patients were lost to followup. Thirty-five patients with 60 involved feet were included in the study. There were 22 males and 13 females, all white Caucasians. The median age at presentation was 45 (19–63 years), and the median follow up was 10 years (2–25 years)

Twenty-one of our patients had palmar Dupuytren’s disease, six had knuckle pads, four had Peyronie’s disease, four had other superficial fibomatoses and two keloids. Six were diabetic, four had epilepsy of whom two took valproate and one phenobarbitone. Eight patients had a family history of fibromatoses.

The most common presentation was a painful lump (20); 13 patients had a painless lump (13) and two had only pain. All patients reported a proliferative phase of enlarging nodule size, often with pain, which lasted 1–4 years (median 2 years). Thereafter most patients reported improvement in symptoms (size of lump and pain) as well as function. As we came to recognise this, we treated most patients with symptomatic measures and observation only. At review, 17 patients considered their symptoms were improving, 14 were stable and only four had noticed deterioration. Seven patients, mostly early in the series, were treated by wide excision; six had recurrence at review although only one was symptomatic.

Plantar fibromatosis is a benign condition which stabilises and may improve after an initial proliferative phase lasting about two years Most patients require no intervention.

A prospective study of 72 patients with Morton’s neuroma was carried out outlining presenting symptoms, significance of clinical examination and the beneficial effect of various treatment modalities. They were followed up for at least 6 weeks. There were 51 females (70%) and 21 males (30%) with average age of 52 years.

Bilateral symptoms were present in 15% cases with remaining 85% cases having unilateral symptoms. Commonest symptom observed was pain in the web space, commonest being 3^rd space (70%) and others being 2^nd space (18%), 4^th space (4%) and combination of two spaces (8%). In 90% of these cases, pain was aggravated by walking and wearing closed shoes; and relieved by taking rest.

Paraesthesia in adjacent toes was present in 46% cases. Clinically palpable Mulder’s click was seen in 54% cases.

Shoe modification was tried in 33% patients, with little benefit. All 72 patients underwent corticosteroid and local anaesthetic injection in the outpatient clinic. Fair to good pain relief was obtained in 76% cases with average duration of pain relief of 2.8 weeks (range (0–8 weeks)). No pain relief was achieved in 24% cases.

Twenty-eight patients (38%) who either had inadequate pain relief at 6 weeks following injection; or had recurrence of pain eventually underwent surgical excision/decompression using plantar approach. None of them had any complication related to surgery. All patients had excellent pain relief at a minimum of 6 months follow up after the surgery. 90 % of the patients who underwent surgery had VAS pain score of 0 at 6 months follow up.

Thus, single injection treatment is a very useful treatment modality achieving satisfactory results in 76% of patients. Surgical excision/decompression should be reserved for patients with no pain relief/recurrence after the injection.

PURPOSE OF STUDY: We report our experience with multiple flexible intramedullary nailing (Ender nailing) of fractures of shaft of the femur in paediatric age group.

METHODS: We did a prospective review of 20 children (mean age- 8.8 years; range- 6.5 to 15 years) treated with Ender nailing. Fall from height was the predominant mechanism of injury (18 children). The mean follow-up period was 16.3 months (range- 4 to 28 months).

RESULTS: 18 fractures united by 6-8 weeks and 2 fractures united by 8-10 weeks. Minor limb length discrepancies were seen in this series (range, -5mm to +10mm). 2 children had shortening of 5mm while 4 children with upper third fractures had 10mm lengthening. All patients were able to squat on floor and sit cross-legged. All but one patient had full hip and knee range of motion. Varus angulation of 15 degree was seen in 2 patients who were non-compliant and had started early weight bearing. Backing out of 1 nail was seen in 1 patient and the nail was extracted. TEN outcome scoring system was used to critically analyse the results. 16 children had excellent outcome, 2 children had satisfactory outcome and 2 children (with varus malunion) had poor outcome.

CONCLUSION: Ender nailing is a safe and effective method for treatment of femoral shaft fractures in children between the age of 6 and 15 years. Patient compliance is crucial for a satisfactory outcome since early full weight bearing can predispose to varus malunion.

To assess the reliability of the pre-operative measurement methods used in the management of the hallux valgus deformity, five observers assessed 50 pre-operative standing foot radiographs on two occasions in order to assess the reliability of radiological hallux valgus assessment using the inter-metatarsal angle (IMA), hallux valgus angle (HVA) and joint congruency. Five published methods of angle measurements described by Hawkins, Venning and Hardy, Mitchell, Miller and Nestor were used.

Kappa statistics were used to assess the reliability of the diagnosis of congruency. Regarding IMA and HVA, mean values between the methods were assessed by one-way ANOVA. The differences between the methods and observers were assessed by two-way ANOVA.

Results: Diagnosis of congruency showed good agreement (k=0.608) over two occasions, although this did vary by observer.

The mean IMA and HVA measurements varied significantly between methods on both occasions (p< 0.0001). Mitchell’s method had the lowest and Miller’s the highest mean values.

Analysis of variance showed both method and observer variations were significant for IMA. But HVA measurements differed significantly only by observers.

Conclusion: The reliability of IMA and HVA measurements is poor whichever measuring method is used and these methods are not interchangeable. Study papers should state the measurement method used. For the pre- and post-operative assessment the same method should be used.

Aims: To assess the reliability and repeatability of the þve described methods of measuring hallux valgus (HVA) and intermetatarsal angles (IMA). The diagnosis of congruency of þrst MTP joint was also assessed. Methods: Five Orthopaedic staff analysed 50 pre-operative standing foot radiographs on two occasions. ANOVA was used to examine the difference between the þve methods and between the þve observers, for both IMA and HVA. Kappa test was used to measure agreement in diagnosing congruency between two occasions. Results: The mean IMA and HVA varied signiþcantly between some of the methods (p< 0.00001). The ANOVA model showed that both method and observer variations (p=0.0264 and p< 0.001 respectively) were signiþcant for IMA and there was no signiþcant difference between measurement methods (p=0.7882) for HVA. The intraobserver reliability of congruency was good (k=0.608) but the interobserver reliability was only fair (k=0.261). A second IMA measurement will lie between 4.2û less and 4.6û more than the þrst IMA measurement 95% of the time. A second HVA measurement will lie between 6û less and 5.6û more than the þrst HVA measurement 95% of the time. Conclusions: This study shows that the different methods give signiþcantly different results. The methods are, therefore, not interchangeable. There was no advantage to any of the method in terms of reliability. All methods had considerable inter- and intra- observer variability that makes these measurements unreliable.

The five different methods of measuring hallux valgus (HVA) and intermetatarsal angles (IMA) and the diagnosis of congruency of first MTP joint were studied on 50 pre-operative standing foot radiographs, to test if these methods were reliable and the results reproducible enough to be used in a treatment algorithm for hallux valgus.

Analysis of variance (ANOVA) was used to examine the difference between the five methods and between the five observers. Kappa test was used to measure agreement in diagnosing congruency between two occasions.

The mean IMA and HVA varied significantly (p< 0.00001). The ANOVA model showed that method and observer variations were both significant for IMA; there was no significant difference between measurement methods for HVA. Congruency had good (k=0.608) intraobserver and fair (k=0.261) interobserver reliability. A second IMA measurement will lie between 4.2° less and 4.6° more than the first IMA measurement 95% of the time. A second HVA measurement will lie between 6° less and 5.6° more than the first HVA measurement 95% of the time.

Overall, there was no advantage to any of the measurement methods, although some observers were better than others. All methods had considerable inter- and intra-observer variability that makes these measurements unreliable.