Introduction:

TTC fusion for the salvage of failed TARs with significant bone loss using a hindfoot nail and femoral head allograft has been reported in a number of small series. We present our experience of this procedure.

Introduction Exposure of the lesser metatarsophalangeal (MTP) joints is needed for many procedures e.g. forefoot arthroplasty and multiple Weil-type osteotomies. Traditionally collateral incisions and plantar incisions have been described. However exposure using these is often difficult and inadequate in the presence of rheumatoid arthritis (RA) and associated deformities. Transverse incisions offer excellent exposure, extensibilty, versatility and improved range of movements with decreased neurovascular compromise. Aesthetic wound healing is common. We describe our results following the use of a curved transverse incision for the Mann-Thompson type of arthroplasty and multiple Weil osteotomies. A single incision was used to expose all lesser MTP joints.

Method A total of 34 consecutive patients with either procedure were included, comprising 52 feet including 18 bilateral forefoot arthroplasty and 10 multiple Weil osteotomies. All patients were followed up for 12 months. A questionnaire was completed for each patient at conclusion of surgery, and then at 6 and 12 months. Ease of exposure, visualisation of target areas, wound healing, neurovascular complications and average range of movement were assessed. Four surgeons were involved in the study: one consultant, one NT middle grade, and two specialist registrars.

Results Three minor wound healing complications were noted, with no need for repeat surgery. No neurovascular complications were noted, cosmesis was good-to-excellent in all, a global range of movement of 30 degrees was achieved in 95%. Ease of exposure and visualisation of the target area was good-to-excellent in all patients. All surgeons reported satisfaction with the approach and rated it superior to the collateral and plantar incisions.

Conclusion We believe that this represents excellent results in this difficult group of patients. The curved transverse incision is a workhorse incision for the lesser MTP joints.

There is a legal and ethical obligation to gain informed consent before treatment commences. A number of bodies have issued guidelines for obtaining consent and these include the Department of Health, the GMC, The Royal College Surgeons of England, and the B.O.A. For a patient to give their informed consent to surgery they must receive sufficient information about their illness, proposed treatment and its prognosis. There are no specific guidelines regarding joint replacement. With this in mind a retrospective case note study was undertaken involving 100 patients who had undergone a hip replacement. Noting the documented discussion at all stages of patient contact.Fifty percent of patients had been seen and listed in the Outpatients by a Consultant, 25% were discussed with the Consultant responsible and the remainder were listed without Consultant input. In only 33 % of cases were any specific risks recorded. This had fallen to 4% on their visit to pre operative assessment clinic. All the consent forms were completed at the time of admission for surgery. Forty percent of these on the day of surgery. The majority were completed by SHOs (58%), while only 4% were completed by consultants. None of the forms noted the lead surgeon. All the consent forms noted some frequently occurring risks. However there was a large variance in the details recorded. The study highlights that the majority of complications are only documented on the consent form, with little note of the dialogue leading up to it. It is also apparent that there is no agreement as to what represents a significant or frequent complication.

This review raises a number of important issues. There needs to be a national standardisation of the process of consent. We propose the introduction of a specific consent form for hip replacements that provide improved documentation of the standardised risks involved. This should also include guidelines regarding prosthesis choice, surgical approach and the extent of trainee involvement. In addition we would also suggest there is a need to improve sequential documented discussion up to the point of surgery and introduce specific training for juniors carrying out consent.

All patients over 65 yrs with an ISS greater than 15 attending Edinburgh Royal Infirmary between 1997 and 2000 were prospectively entered into the study. Patients were followed until death or discharge home. The patients were divided into, group 1 [patients who survived], and group 2 [those who died.]

A total of 72 patients were included in the study, 42 males and 31 females. 42 patients survived, and 31 died.

Group 1 consisted of 29 males and 15 females with an average age of 75.23yrs. Group 2 consisted of 13 males and 18 females with an average age of 78.05yrs. All incidents involved blunt trauma. The three main mechanisms of injury were RTA, Fall less than 2 meters, and Fall greater than 2 meters.

Five patients required intubation in group 1 and 12 patients in group 2.The average GCS was lower in group 1 compared to the group 2. All Injuries with AIS of greater than 3 were analysed. The total number of injuries was greater in the group 2. Group 1 required 214 days in HDU/ITU and a total of 943 in-patient days. Group 2 in comparison needed 62 HDU/ITU days and 169 in-patient days. The major cause of death was head and spinal injury 11 (35%), and Multiple injuries 9 (29%).

A total number of 1952 days were spent in rehabilitation prior to discharge, with an average of 46.48 days. Post trauma the level of independence was significantly reduced.

The injuries are exclusively blunt and in the majority of cases secondary to motor vehicle accidents. Predictors of mortality appear to include, intubation, head and neck injuries, GCS, and chest injuries. Current outcome scores correlate inaccurately. These patients require long hospital stays with a large amount of intensive care input. After discharge rehabilitation is universally required. These patients place a large demand on the NHS and social services; the total cost of their care was approximately £2,500,000.