Background

The association between idiopathic scoliosis and intrinsic abnormalities of the spinal cord are well known. MRI is the most sensitive imaging modality available to diagnose an intraspinal anomaly. The use of a routine ‘screening MRI’ prior to scoliosis correction is controversial.

Aim

The purpose of the study was to assess the outcomes of the surgical management of humeral shaft non-unions.

Surgeon’s ability to anticipate the implant size requirements for total knee replacements is important to the success of the procedure. Previously, this has been inconsistently accomplished using plain radiographs. The purpose of this study is to assess the accuracy of digital templating software in predicting the size requirements of the femoral and tibial implants in total knee replacements.

Thirty consecutive PFC (DePuy) total knee replacements were templated preoperatively using digital templating software (TraumaCad, Orthocrat Ltd). The knees were templated by two surgeons working independently using standardised digital AP and lateral radiographs. All films were magnification-calibrated using markers of known size. Postoperatively, the predicted implant size was compared to the actual components selected at the time of surgery.

The size of the femoral prosthesis was accurately selected on the AP view in 53.5% and on the lateral in 66% of cases. The size of the tibial implant was correctly selected on the AP view in 65.5% and on the lateral in 70.5% of cases. The tibial prosthesis was always templated within one size. The femoral prosthesis was predicted within two sizes (93% on AP + 98% on lateral +/− 1 size). There was no correlation with failure of the software to recognise the metal marker and inadequate lateral x-rays.

The lateral x-ray was found to be more reliable than the AP on predicting both the femoral and tibial implants. The tibia was more accurately templated than the femur on average. There was good inter-observer and intra-observer reliability for both prostheses (0.75 – 0.85). Discrepancies in templating may have been due to inaccuracies in placement of the metal marker at the time of x-raying or due to fixed flexion deformities, which may have affected the magnification of the x-ray. Overall, templating using digital software was marginally superior to the standard acetate method.

Scarf osteotomy is a z-osteotomy of the 1st metatarsal and is proposed to correct anatomical and functional deformities of hallux valgus. This procedure allows early ambulation and early return of function. This study was conducted to evaluate clinical and paedobarographic results following this procedure in a district general hospital.

From August 2000, we prospectively collected the data on 43 feet (32 consecutive patients) followed up for 12 months. We collected the data pre-operatively, 3,6 and 12 months post-operatively using AOFAS score, weight-bearing radiographs and paedobarographs. From the paedobarographs (Musgrave), the forefoot function was evaluated using peak pressure, force time integral and pressure time integrals.

Mean total AOFAS score increased from 45.13 pre-operatively to 94.5 post-operatively (p< 0.001). Postoperatively, the hallux valgus angle decreased from 29.83° to 11.79° and 1–2 intermetatarsal angle decreased from 12.48° to 6.37° (p< 0.001). Post-operatively, peak pressure has increased under the 1st metatarsal head and decreased under the 2nd metatarsal head. Force time integral and pressure time integrals also showed similar changes. We have not noticed significant alteration of forefoot pressures under the lateral part of forefoot.

Using scarf osteotomy, we achieved good correction of the hallux valgus deformity and significant improvement of AOFAS scores. We also noted alteration of the forefoot function with increased pressure under the 1st metatarsal and reduced pressure under the 2nd metatarsal head.

Conclusion: We believe that scarf osteotomy is a versatile and reliable procedure in the management of hallux valgus.

Recently, there has been a reluctance to perform hip arthrodesis. The number of patients requiring the conversion from hip arthrodesis to arthroplasty has also decreased. We present the functional results following conversion of hip arthrodesis to total hip arthroplasty at a specialist hip centre.

76 patients who underwent conversion of hip arthrodesis to total hip arthroplasty between 1963 and 2000 at the Centre for Hip Surgery, Wrightington Hospital, were included in this retrospective study. 9 patients died of unrelated causes and 7 patients were lost to follow up. The functional scoring was performed using the Merle d’Aubigné and Postel score.

The mean age at the time of surgical hip arthrodesis was 16.7 years and at the time of conversion was 48.7 years. Back pain is the most common indication for the conversion. All the patients were pleased with the clinical outcome following conversion to Arthroplasty. 6 patients had postoperative complications. The mean Merle d’Aubigné and Postel score increased from 8.97 to 13.46 at the latest follow-up. The mean wear rate was 0.06 mm/year. Survival of hip arthroplasty was 92.78 % at 18 years.

Conclusion: Our series demonstrates good outcome and patient satisfaction and high survival of the arthroplasty following the conversion from arthrodesis. Hip arthrodesis could be considered as a holding procedure in selected group of young patients with a later successful conversion to arthroplasty.

To report the experience with the new device, the Long Proximal Femoral Nail (Long PFN) in patients with impending pathological femoral fractures to identify the advantages and complications associated with its usage. This is the first in the series on the use of Long PFN for patients with femoral metastases.

Between April 2000 and September 2001, twenty-five consecutive patients with femoral pathological lesions were prophylactically stabilised using Long PFN. The nailings were performed using a percutaneous closed technique. Lateral femoral Line (LFL) technique was used for location of the entry point and easy insertion for the nail. Only the proximal one-fifth of the femur was reamed to accommodate the 17 mm diameter of the proximal part of the nail.

We had technical problems in three patients. The overall mobility of the patients improved in twenty patients and the mobility remained the same as pre-operative level in five patients. Good to excellent pain relief achieved in eighteen patients. The pain relief was fair in five patients and poor in two patients. We had no mechanical failure of the implant in our series.

Long PFN, a modified reconstruction nail, can be inserted percutaneously and has an easy operation technique. Our early experience with Long PFN in the management of impending femoral fractures has been favourable.

Non-union of femoral and tibial shaft fractures is a serious complication, prolonging patient morbidity and ultimately influencing functional recovery. The aim of the study was to assess the effectiveness of different surgical options in the treatment of non-union of femoral shaft fractures after initial intramedullary nailing.

Between January 1995 and November 2003, 320 patients with femoral or tibial shaft fractures were treated with closed intramedullary nailing. The mechanism of injury, fracture pattern, concomitant injuries, subsequent surgical treatment and complications were prospectively recorded and retrospective analysis was performed.

16 of the 157 patients (10%) with femoral fractures and 31 of the 161 patients (19%) with tibial fractures developed non-union after initial primary intramedullary nailing. This group of patients had 2–3 further operations before union was established. 26 patients had initial dynamisation and 11 had exchange nailing alone. The remaining patients had autologous bone grafting and/or internal fixation with a plate. Subsequently a further 3 patients required dynamisation, 2 required exchange nailing and another 3 bone grafting. Finally 2 patients required a fourth procedure to reach solid union.

Our experience showed that exchange nailing and dynamisation are the most effective method of treatment of non-union of femoral and tibial shaft fractures after intramedullary nailing.

Between April 1999 and December 2001 forty-one patients (forty-five femora) with metastatic lesions in the proximal femur involving intertrochanteric and subtrochanteric regions were stabilised with Proximal Femoral Nail (PFN). Thirty-eight patients (forty-two femora) were followed up for a mean period of 20 months (range 3 weeks to 35 months). There was an overall increase in mobility in 60% of the patients and the rest remained the same. Mean Preoperative Visual analog scale rating for thigh pain was 8.1 versus 3.4 for postoperative score (p< 0.01). There were no complications with respect to PFN. There were three post operative complications – chest infection, superficial wound dehiscence and pulmonary embolism. All these complications resolved without any further deterioration. Since these lesions do not usually heal well a cephalomedullary device is ideal to withstand long-term cyclic loading. Minimal operative trauma, mechanical stability, early mobilisation, pain relief and short hospital stay are the advantages of PFN in stabilising impending fractures of the proximal femur.

Aim: To report our experience with a newly devised Long Proximal Femoral Nail [Long PFN] for treating complex subtrochanteric femoral fractures. The nail has the advantage of providing rotational as well as axial stability in the proximal femur with its hip pin in addition to the strong hip screw and easy operation technique. Methods: Twenty-four consecutive patients with twenty-four displaced subtrochanteric femoral fractures were treated with long PFN. The fractures were classified according to the Seinsheimer’s criteria. In 9 patients, the proximal femur had posteromedial wall comminution with displacement. The average age of the patients was 68.7 years. Closed reduction of the fracture was attempted in all cases and when it failed to achieve satisfactory reduction, a limited open reduction and cerclage cabling of the fracture was performed prior to the nailing with a particular emphasis on the postero-medial wall reconstruction. Result: The average follow up period was 49.7 weeks. All fractures in our series achieved bony union with an average time to union of 24.5 weeks. No patients had implant failure and no deep infection noted in the patients who had limited open reduction. Two patients had chest infection and one had non-fatal pulmonary embolism. Conclusion: Long PFN is a reliable implant in the treatment of complex subtro-chanteric fractures. Posteromedial wall reconstruction of the proximal femur is mandatory when treating sub-trochanteric fractures with Long PFN to avoid mechanical failure and non-union.

Aim: To report the experience with the new device, the Long Proximal Femoral Nail (Long PFN) in patients with impending pathological femoral fractures to identify the advantages and complications associated with its usage. This is the þrst in the series on the use of Long PFN for patients with femoral metastases. Methods: Between April 2000 and September 2001, twenty-þve consecutive patients with femoral pathological lesions were prophylactically stabilised using Long PFN. The nailings were performed using a percutaneous closed technique. Lateral femoral Line (LFL) technique was used for location of the entry point and easy insertion for the nail. Only the proximal one þfth of the femur was reamed to accommodate the 17 mm diameter of the proximal part of the nail. Results: We had technical problems in three patients. The overall mobility of the patients improved in twenty patients and the mobility remained the same as preoperative level in þve patients. Good to excellent pain relief achieved in eighteen patients. The pain relief was fair in þve patients and poor in two patients. We had no mechanical failure of the implant in our series. Conclusion: Long PFN, a modiþed reconstruction nail, which can be inserted percutaneously and has an easy operation technique. Our early experience with Long PFN in the management of impending femoral fractures has been favourable.

Introduction: Arthodesis provides a durable, painless and stable hip. Conversion to arthroplasty was has been recommended to relieve the excessive stresses in the neighbouring joints. We present the long term results following conversion of hip athrodesis to total hip artho-plasty at specialist hip centre. Method and material: 67 patients underwent the conversion between 1963 and 2000 at the centre for hip surgery, wrightington hospital were included in the study. 45 patients are available for the evaluation. Merle d’ Aubigne and Postel as modified by Charnley was used for clinical scoring. The most recent radiograph in patients with surviving arthoplasty was analysed. Results: The mean age at the time of arthodesis was 16.8 years. The conversion to hip arthroplasty was performed after a mean period of 32.3 years (range 12 to 54 years). The mean folowup was 16.37years (range 2–28). The mean Merle d’ Aubigne and Postel score increased from 7.95 to 13.45 postoperatively. All the patients were delighted with the conversion. 7 patients had revision and 1 had pseudoarthrosis. Conclusion: Hip arthrodesis is a useful holding procedure for young persons with painful hip. This could be successfully converted to Hip arthroplasty after an interval of relatively high physical activity during young adult life.

Introduction: Scarf osteotomy is a zosteotomy of 1st metatarsal and is proposed to correct anatomical and functional deformities of hallux valgus. This procedure allows early ambulation without cast and early return of function. However, this is a technically demanding procedure. This study was conducted to evaluate clinical and paedobarographic results following this procedure in a district general hospital. Method and materials: We prospectively collected the data from 71 feet in 54 patients. We collected the AOFAS scores preoperatively, 3 and 6 months. Hallux vagus, 1–2 intermetatarsal angles and sesamiod subluxation were measured from weight bearing radiographs taken preoperatively, 6 weeks and 6 months. We evaluated the forefoot function using peak pressure, force time integral and pressure time integral parts of paedobarographs (Musgrave) preoperatively, 3 and 6 months. Results: Total AOFAS score increased from 43.11 preoperatively to 84.96 at 3 months postoperatively (p< 0.0001, 95% CI of 44.5 to 35.5). The hallux valgus angle decreased from 30.1 to 9.92 at 6 weeks post operatively (p< 0.0001, 95% CI of 22.21 to 18.27). The mean peak pressure under the 1st metatarsal head was reduced from 3.09 (95% CI 2.49 Ð3.70) to 2.25 (95% CI1.80–2.71) at 6 months. The mean peak pressure under the 2nd metatarsal head was reduced from 6.29(95% CI 5.44–7.13) to 5.01 (95% CI 3.98–6.05) at 6 months. Force time and Pressure time integrals also showed similar changes. Conclusions: Scarf osteotomy produced improvement in the postoperative scores, radiological angles and forefoot pressures. In conclusion, scarf osteotomy is a versatile and reliable procedure in the management of hallux valgus.

Introduction

Hallux Valgus was thought to alter the forefoot function with defuctioning of the first ray with a resulting overloading of the second ray. The scarf osteotomy is a z-osteotomy of the first metatarsal and is proposed to correct anatomical and functional deformities of hallux valgus. This study was conducted to evaluate forefoot pressures using the Musgrave foot print system following this procedure in a district general hospital.

Method

We prospectively collected the data from 43 feet in 31 consecutive patients. We evaluated the forefoot function using peak pressure, force time integral and pressure time integral parts of pedobarographs (Musgrave) pre-operatively, three and six months postoperatively.

Results

The mean peak pressure under the first metatarsal head was reduced from 3.09 (95% CI 2.49 −3.70) to 2.25 (95% CI1.80–2.71) at six months. The mean peak pressure under the second metatarsal head was reduced from 6.29 (95% CI 5.44–7.13) to 5.01 (95% CI 3.98–6.05) at six months. Force time integral under the first metatarsal head was reduced from 1.34 (95% CI 1.06–1.62) to 0.97 (95% CI 0.74–1.19)) at six months. Force time integral under the second metatarsal head also reduced from 2.66 (95% CI 2.27–3.06) to 2.41(95% CI 1.98–2.85). Pressure time integrals also showed similar changes.

Conclusion

Scarf osteotomy produced decrease in the forefoot pressures under the medial part of forefoot. We have not noticed significant alteration of forefoot pressures under the lateral part of forefoot.

Introduction: It is commonly believed that markedly increased femoral anteversion is a primary abnormality and a consistent feature of hip dysplasia. It is also considered to be one of the main factors leading to redislocation. Apart from limited cadaveric studies, the true normal range of anteversion in infants is largely unknown. We measured femoral anteversion in infants using ultrasound. We are presenting our results measuring the femoral anteversion in both normal and DDH hips.

Methods and materials: Anteversion measurements are taken at the time of routine ultrasound screening for Developmental Dysplacia of Hip. This method was previously validated. We measured femoral anteversion in 76 infants with normal hips. We measured femoral ante-version in 27 hips with DDH. The mean femoral ante-version in normal babies is compared to the value in the babies with hip dysplasia using unpaired t-test.

Results: The mean value of femoral anteversion in normal babies in our series was 46.75° with 95% reference interval of 36.34° to 57.17°. The mean femoral anteversion in dysplastic hips was 50.39° with a 95% reference interval of 34.88° to 65.89°. The difference between normal and dysplastic hips was statistically significant (p value −0.0095 and 95% CI of 6.36° to 0.90°). This showed a small increase of femoral anteversion in the dysplastic hips.

Conclusion: We established reference ranges of femoral anteversion in normal and dysplastic hips. Our series showed only a small increase of femoral anteversion in the dysplastic hips. We showed that the markedly increased femoral anteversion was not a primary abnormality in hip dysplasia.

Introduction

The scarf osteotomy is a z-osteotomy of the first metatarsal. This is a technically demanding procedure which allows early ambulation without cast and early return of function. This study was conducted to evaluate clinical results following this procedure in a district general hospital.

Method

We prospectively collected the data from 67 feet in 53 consecutive patients followed up for six months. Four patients were lost to follow up. We collected the AOFAS score preoperatively, and at three and six months. Hallux valgus angle, first-second intermetatarsal angle and sesamoid subluxation were measured from weight bearing radiographs taken preoperatively and at six weeks and six months.

Results

Total AOFAS score increased from 43.1 preoperatively to 85.0 at three months postoperatively (p< 0.0001, 95% CI of 44.5 to 35.5). The AOFAS scores at three and six months also showed significant difference (p< 0.0001, 95% CI of 4 to 10). All the components of AOFAS showed similar improvement postoperatively. The hallux valgus angle decreased from 30.1 to 9.9 degrees at six weeks post operatively (p< 0.0001, 95% CI of 22.21 to 18.27). The first-second intermetatarsal angle decreased from 12.6 to 6.4 at 6 weeks post operatively (p< 0.0001, 95% CI of 5.1 to 7.14). Sesamoid subluxation was reduced in the majority of cases. We had two fractures of the metatarsal head, three wound infections and six cases of transient neuropraxia of the cutaneous nerves.

Conclusion

With Scarf osteotomy, we achieved good correction of the hallux valgus deformity and significant improvement of AOFAS score. It is a versatile and reliable procedure in the management of hallux valgus.