Background

Reduced bone mineral density is recognised as a risk factor for hip fractures and fragility fractures in general. Vitamin D is important in maintaining healthy bone mineral levels and can therefore affect risk of hip fracture. We investigated the correlation between vitamin D levels and bone mineral density, as well as fracture type, in neck of femur fractures and also assessed the relationship of vitamin D and social deprivation.

Background

Patient reported outcomes/experience measures have been a fundamental part of the NHS since 2009. Osteotomy procedures for hallux valgus produce varied outcomes due to their subjective nature. We used PROMS2.0, a semi-automated web-based system, which allows collection and analysis of outcome data, to assess what the patient reported outcome/experience measures for scarf+/− akin osteotomy for hallux valgus are at UHSM.

Background

PROMS and PREMS are a fundamental and essential part of the NHS. Chilectomy and fusion procedures for hallux rigidus produce varied outcomes due to their subjective nature. PROMS2.0, a semi-automated web-based system, which allows collection and analysis of outcome data, to compare what PROMS/PREMS for chilectomy/fusion for hallux rigidus are at UHSM including variance across osteoarthritis grades.

Background

Patient reported outcomes measures are a fundamental part of the NHS. Since 2009, they have been used to measure quality from the patient's perspective. PROMS2.0 is a semi-automated web based system, which allows collection and analysis of outcome data. This study looks at the factors, which can influence PROMS. These include looking at general trends which affect reported outcomes such as surgeon, age and gender. We also look to assess the reasons for non-uptake in the study.

We describe a case series using calcium sulphate bio composite with antibiotics (Cerament/Stimulan) in treating infected metalwork in the lower limb.

Eight patients aged 22–74 (7 males, 1 female) presented with clinical evidence of infected limb metal work from previous orthopaedic surgery. Metal work removal with application of either cerement in 5 cases (10–20ml including 175mg–350mg gentamycin) or stimulan in 3 cases (10–20ml including either 1g vancomycin or clindamycin 1.2g or 100mg tigecycline) into the site was performed. Supplemental systemic antibiotic therapy (oral/intravenous) was instituted based on intraoperative tissue culture and sensitivity.

Four patients had infected ankle metalwork, 2 patients infected distal tibial metalwork and 2 had infected external fixators. Metal work was removed in all cases. The mean pre operative CRP was 15.8mg/l (range 1–56mg/l). The mean postoperative CRP at 1 month was 20.5mg/l (range 2–98mg/l). The mean pre op WCC was 7.9×10⁹(range 4.7–10.5 ×10⁹). Mean post op WCC at 1 month was 7.1×10⁹(range 5.0–9.2×10⁹). The organisms cultured included enterobacter, staphylococcus aureus, staphylococcus epidermidis, staphylococcus cohnii, stenotrophomonas, acinetobacter, group B streptococcus, enterococcus and escherichia coli. No additional procedures were required in any case. All surgical wounds went on to heal uneventfully. Infection control and union was achieved both clinically and radiologically in all cases.

Our results support the use of a calcium sulphate bio composite with antibiotic as an adjuvant for effective local infection control in cases with implant related bone sepsis. The technique is well tolerated with no systemic or local side effects. We believe that implant removal, debridement and local antibiotic delivery can minimise the need for prolonged systemic antibiotic therapy in such cases.

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. Its effect on sesamoid function and the pathomechanics of this joint have not been described.

Fresh frozen cadaveric specimens without evidence of forefoot deformity were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in various positions of dorsiflexion and plantarflexion using a MicroScribe, enabling quantitative analyses in a virtual 3D environment.

In 75% of specimens, there was some degree of chondral loss within the metatarsosesamoid articulation. The metatarsal surface was more commonly affected. These changes most frequently involved the tibial metatarsosesamoid joint.

The tibial sesamoid had an average excursion of 14.2 mm in the sagittal plane when the 1st MTP joint was moved from 10 degrees of plantarflexion to 60 degrees of dorsiflexion; the average excursion of the fibular sesamoid was 8.7 mm. The sesamoids also move in a medial to lateral fashion when the joint was dorsiflexed. The excursion of the tibial sesamoid was 2.8 mm when the joint was maximally dorsiflexed while that of the fibular sesamoid was 3.2 mm.

There appears to be differential tracking of the hallucal sesamoids. The tibial sesamoid has comparatively increased longitudinal excursion whilst the fibular sesamoid has comparatively greater lateral excursion.

This greater excursion of the tibial sesamoid could explain the higher incidence of sesamoiditis in this bone. The differential excursion of the 2 metatarsosesamoid articulations is also a factor that should be considered in the design and mechanics of an effective hallux MTP joint arthroplasty.

Our unit has pursued a policy of using donor nerves from the same limb for grafting. Nerves which have already been affected by the primary injury are selected where possible, thus avoiding any new sensory deficit.

The exact action of the Peroneus Longus muscle on the foot is not fully understood. It is involved in a number of pathological processes like tendonitis, tenosynovitis, chronic rupture and neurological conditions. It is described as having a consistent insertion to the base of the first metatarsal, but there have also been reports of significant variations and additional slips.

Our aim was to further clarify the anatomy of the main insertion of the Peroneus Longus tendon and to describe the site and frequency of other variable insertion slips.

The course of the distal peroneus longus tendon and its variable insertion was dissected in 20 embalmed, cadaveric specimens. The surface area of the main insertion footprint was measured using an Immersion Digital Microscibe and 3D mapping software. The site and frequency of the other variable insertion slips is presented.

There was a consistent, main insertion to the infero-lateral aspect of the first metatarsal in all specimens. The surface area of this insertion was found to be proportional to the length of the foot. The insertion in males was found to be significantly larger than females. The most frequent additional slip was to the medial cuneiform. Other less frequent insertion slips were present to the lesser metatarsals.

The main footprint of the Peroneus Longus tendon is on the first metatarsal. There appears to an additional slip to the medial cuneiform frequently. Although we are unsure about the significance of these additional slips, we hope it will lead to a better understanding of the mechanism of action of this muscle and its role both in the normal and pathological foot.

Regional anaesthetic for foot surgery has been discussed as a method of post operative analgesia. Ankle block as the sole anaesthetic for foot surgery has not been extensively reviewed in the literature. We aimed to describe our experience of forefoot surgery under ankle block.

Sixty-six consecutive forefoot procedures (59 patients) were carried out under ankle block. Patients were contacted post operatively and completed a standardised questionnaire including an incremental pain assessment ranging from 0-10 (0 no pain, 10 severe pain).

Forty nine female and 10 male patients (age range 20-85y) were included. Procedures included 33 first metatarsal osteotomies, 15 cheilectomies, 3 first MTP joint replacements, 5 fusions, 4 excision of neuroma and 6 other procedures. 22 patients (33% of cases) reported discomfort during the block procedure (average pain score 1.5). 6 patients reported pain during their operation(s), average score 0.26. Average pain scores at 6, 12, 24 and 48 hours following surgery were 2.0, 3.2, 2.7 and 2.1 respectively. All patients were discharged home and walking on the same day. There were no readmissions. Each patient confirmed they would have surgery under regional block rather than general anaesthesia and would recommend this technique to family and friends.

There are many advantages in being able to perform these relatively small procedures under regional anaesthesia. The anaesthesia obtained permits the majority of forefoot procedures and provides lasting post-operative analgesia. Combined with intra-operative sedation, use of ankle tourniquet and same day discharge; it has very high patient acceptance and satisfaction.

Advantages of arthroscopic surgery in orthopaedic practice are well documented. The use and scope of ankle arthroscopy has evolved in the last decade. Its role in both the evaluation and treatment of chronic ankle pain has become more important with identification of newer pathologies. We aimed to identify the indications and complications of ankle arthroscopy in chronic ankle pain and to correlate the arthroscopic findings with pre-operative MRI/CT.

A retrospective analysis of all procedures done in our unit from 2005-2009. Patient records, X- rays and scans were reviewed. 77 patients were included in the study (46 male/31 female). The commonest age group was the 4^th decade. There was a male preponderance in the younger age group (<50y), and a female preponderance in the older age groups (>50y). The commonest indication was impingement syndrome (44%/mean age 38y), followed by osteochondral lesions of the talus (23%/mean age 36y) and Osteoarthritis (22%/mean age56y). Other pathology included synovitis, Rheumatoid Arthritis, instability, AVN and combined pathologies. Pre-op MRI scans correlated with arthroscopic findings in 59%. The pathology most missed by MRI was impingement. 1 patient developed wound infection and another iatrogenic tendon rupture. 78% reported improvement in their symptoms following the procedure.

Ankle arthroscopy is a safe and effective procedure. It is particularly useful in the diagnosis and treatment of impingement syndromes and osteochondral lesions. Although there are serious recognised complications, their incidence is low. Patients with chronic symptoms and normal MRI/CT may have treatable pathology on arthroscopy.

Bizarre parosteal osteochondromatous proliferation (BPOP) is a benign lesion of bone originally described by Nora et al in 1983. To date there are no UK-based case series in the literature. Here we present the Scottish Bone Tumour Registry (SBTR) experience of this rare lesion.

A retrospective analysis of SBTR records was performed. Histological specimens were re-examined by a consultant musculoskeletal oncology pathologist. Radiographs were re-reported by a consultant musculoskeletal radiologist. From 1983-2009, 13 cases were identified; 6 male, 7 female. Age ranged from 13-65. All patients presented with localised swelling. Pain was present in 5 and trauma in 2. 9 lesions affected the hand, 3 the foot, and 1 the tibial tuberosity. 12 lesions were excised and 1 curetted. There were 7 recurrences of which 6 were excised. 1 patients' recurrence was not treated. 1 lesion recurred a second time. This was excised. There were no metastases. Radiographs typically showed densely mineralised lesions contiguous with an uninvolved cortex. Cortical breakthrough was present in 1 case and scalloping in another. Histology characteristically showed hypercellular cartilage with pleomorphism and calcification/ossification without atypia; bone undergoing maturation; and a spindle-cell stroma.

SBTR records indicate that BPOP is a rare lesion with no sex predilection that affects patients over a wide age range. Minor antecedent trauma was present in only 2 cases. In agreement with Nora et al. we feel that trauma is unlikely to represent an aetiological factor. Recurrence was over 50% in this series. Although this is similar to that found in other reports, it may indicate that more extensive resection is required for this aggressive lesion. Finally, although radiological/histological findings are often bizarre there have been no reported metastases and so it is important that BPOP is not mistaken for, or treated as, a malignant process such as chondrosarcoma.

Regional anaesthetic for foot surgery has been discussed as a method of post operative analgesia. Ankle block as the sole anaesthetic for foot surgery has not been extensively reviewed in the literature.

We aimed to describe our experience of forefoot surgery under ankle block alone. 21 consecutive forefoot procedures (18 patients) were carried out under ankle block. The blocks were performed by the senior authors. A mixture of 10ml 2% Lidocaine with 10ml 0.5 % Bupivacaine was administered to the superficial peroneal, deep peroneal, sural and saphenous nerves. Ankle tourniquet was employed in all procedures. The patients were contacted post operatively and completed a standardised questionnaire including an incremented pain assessment ranging from 0-10 (0 no pain, 10 severe pain). 17 female and 1 male patients were contacted (age range 33-67y). Procedures included 13 first metatarsal osteotomies, 3 cheilectomies, 2 first MTP joint replacements, and 5 fusions. 14 patients requested a short acting sedative (midazolam). 5 patients (27 %) reported some discomfort during the block procedure (average pain score 1.2). No patients reported any pain during their operation(s). 4 patients (22%) required supplementation of the block. Average pain score at 6, 12, 24 and 48 hours following surgery were 0.66, 2.9, 2.4 and 1.3 respectively. All patients were discharged home and walking on the same day. None complained of nausea or required parenteral analgesia; there were no readmissions. Each patient confirmed they would have surgery under local block rather than general anaesthesia and would recommend this technique to family and friends.

Forefoot surgery under ankle block alone is safe and effective. Anaesthesia obtained permits the majority of forefoot procedures and provides lasting post-operative analgesia. Combined with intraoperative sedation, use of ankle tourniquet and same day discharge, it has very high patient acceptance and satisfaction.

The extended lateral approach offers a safe surgical approach in the fixation of calcaneal fractures. Lateral plating of the calcaneum could put structures on the medial side at risk. The aim was to identify structures at risk on the medial side of the calcaneum from wires, drills or screws passed from lateral to medial.

Ten embalmed cadaveric feet were dissected. A standard extended lateral approach was performed. The DePuy perimeter plate was first applied and 2mm K-wires were drilled through each of the holes. The medial side was now examined to determine the structures at risk through each hole. The process was repeated with the Stryker plate. The calcaneum was divided into 6 zones, by two vertical lines, from the margins of the posterior facet and a transverse line along the axis of the bone through the highest point of the peroneal tubercle.

The DePuy and the Stryker plates have 12 screw positions, 5 of which are common. With both systems, screw positions in zone 1 risk injury to the medial plantar nerve and zone 3 the lateral plantar nerve. A screw through zone 2 compromises the medial plantar in both. Screws through zone 4 risk the lateral plantar nerve with the DePuy plate. Screws through zone 5 of the DePuy plate risk the medial calcaneal nerve. Zone 5 of the Stryker plate and Zone 6 of both are safe.

There is significant risk to medial structures from laterally placed wires, drills or screws. Subtalar screws have the highest risk and have to be carefully measured and placed. The Stryker plating system is relatively safer than the DePuy perimeter plate with three safe zones out of six.

The role of digital radiography has evolved in recent years. In many hospitals, radiographs have been completely digitised and moved to Picture Archiving and Communications System (PACS). Pre-operative templating for arthroplasty has been a major problem as a result.

We investigate the accuracy of Orthoview™ software in templating for hip and knee arthroplasty. A retrospective review of 20 Stryker-Exter hip and 20 Biomet-Vanguard knee arthroplasties was conducted. Anonymised preoperative radiographs were reviewed by experienced orthopaedic surgeons. Templated component sizes were compared with actual implanted component sizes. All radiographs were digitised on Kodak Carestream PACS. Five surgeons were asked to separately review the radiographs to avoid intra-observer error.

In templating for hip arthroplasty, Orthoview™ was 80% accurate in predicting the femoral stem size within one size of the actual component used. It predicted the offset with 100% accuracy. In 90% of patients, the actual head implant was within one size of the templated head. The system was able to predict the acetabular component size in only 30%. In knee arthroplasty, Orthoview™ was 80% accurate within one size of the actual component used for the femur and 90% for the tibia.

Orthoview™ enables the flexibility of digitised films to be used for pre-operative templating. It is reasonably accurate in prediction of femoral sizing in both hip and knee arthroplasty and tibial size in knee arthroplasty. It is considerably less useful for acetabular sizing. Surgeons should keep this variability in mind until more accurate systems are available.

A consensus regarding management of calcaneal fractures eludes orthopaedic surgeons. While operative treatment has gained more acceptance, surgical morbidity remains high. We undertook a retrospective review of early complications and radiological outcomes following internal fixation of calcaneal fractures in our unit over 15 months.

A consecutive series of 33 patients who underwent fixation of the Calcaneus was selected. Patient records, X-rays and scans were reviewed.

37 fractures in 33 patients underwent fixation. 81 % were male. Mean age at surgery was 37yrs (19 -59yrs). 35 % were operated within 1 wk of injury and 13% after 2 wks of injury. 43% were Sanders' type III, 18% type II and 13% tuberosity avulsion fractures. 63% had a reversed/zero Bohler's angle. Mean post-op Bohler's angle was 32 degrees. Overall complication rate was 32%, with a combined deep infection rate of 8%. All patients with infection were male, and 70% were smokers. 86% were above 40yrs of age (mean 47yrs). The deep infection rate for intra-articular fractures was 3% and for tuberosity avulsion fractures 40%. Majority of patients with wound complications had been operated within 7 days of injury.

Males over 40yrs and smokers seem to be at most risk of wound complications. Time to surgery/delay in surgery up to 2 wks did not seem to have any adverse consequences. Complications increase with fracture complexity and avulsion fractures have highest risk of wound breakdown. Near anatomical restoration of the articular surface is possible in most.

Talar neck fractures are associated with high complication rates with significant associated morbidity. Adequate exposure and stable internal fixation remains challenging. We investigated the anterior extensile approach for exposure of these fractures and their fixation by screws introduced through the talo-navicular articulation. We also compared the quality and quantity of exposure of the talar neck obtained by this approach, with the classically described medial/lateral approaches.

An anterior approach to the talus between the tibialis anterior and the extensor hallucis tendons protecting both the superficial and deep peroneal nerves was performed on 5 fresh frozen cadaveric ankles . The surface area of talar neck accessible was measured using an Immersion Digital Microscribe and analysed with Rhinoceros 3D graphics package. Standard antero-medial and antero –lateral approaches were also carried out on the same ankles, and similar measurements taken. Seven talar neck fractures underwent operative fixation using the anterior approach with parallel cannulated screws inserted through the talo-navicular joint.

3D mapping demonstrated that the talar surface area visible by the anterior approach (mean 1200sqmm) is consistently superior to that visible by either the medial or lateral approaches in isolation or in combination. Medial malleolar osteotomy does not offer any additional visualisation of the talar neck. 3D reconstruction of the area visualised by the three approaches confirms that the anterior approach provides superior access to the entirety of the talar neck. 5 male and 2 female patients were reviewed. All had anatomical articular restoration, and no wound problems. None developed non union or AVN.

The anterior extensile approach offers superior visualisation of the talar neck in comparison to other approaches for anatomical articular restoration. We argue that this approach is safe, adequate and causes less vascular disruption.