Total Knee Arthroplasty (TKA) in obese patients has been under rigorous scrutiny due concerns of less satisfying results and increased risk of perioperative complications. We conducted a prospective study to observe functional scores between obese and non obese patients at two years after mini-robot computer assisted TKA. Average stay, time for wound to be dry and perioperative complications were also compared.

A prospective study was conducted between February 2007 and February 2008 involving 50 patients. Two different groups of 25 each were made on the basis of body mass index (BMI). Oxford and Knee society scores were obtained at two years to observe difference in functional scores between these groups.

Rate of post operative complications or hospital stay was comparable between the two groups. Oxford and Knee society scores improved significantly in both the groups postoperatively. Obese patients had better Oxford and Knee society scores, which were not statistically significant.

There is no difference in early functional outcome and complications between obese and non obese patients after navigated TKA. Navigated TKA in obese patients help precise component placement with appropriate soft tissue balancing leading to improved results.

Computer navigated Total Knee Arthroplasty is routinely performed with gratifying results. New navigation software is now designed to help surgeons balance soft tissues in Total Knee Arthroplasty (TKA). The aim of our study was to compare functional scores at two years between two different techniques of knee balancing.

A prospective randomized control study was conducted between February 2007 and February 2008 involving 52 patients. Two different techniques of knee balancing were used namely, measured resection and gap balancing technique. Each group had 26 patients. Oxford and Knee society scores were done at two years to understand if one technique was better than other.

Oxford and Knee Society Scores improved significantly in both the groups but gap balancing technique achieved slightly better functional scores which were not significant on statistical analysis.

Computer assisted measured resection and gap balancing techniques in TKA reliably improves functional scores postoperatively. Either of the techniques if performed correctly with appropriate patient selection will have satisfactory outcomes.

Hallux valgus is a common condition and surgical correction has remained a challenge. Scarf osteotomy with Akin procedure is well accepted method. Akin procedure gives spurious correction of the distal alignment of big toe. This study was performed to see alternative way to get best correction without additional phalangeal procedure. Senior author used innovative Y-V medial capsulorraphy with standard Scarf osteotomy. This technique allows reduction of MP joint along with correction of pronation deformity and reduction of sesamoids.

We report the use of a modified Y-V medial capsular repair in association with Scarf osteotomy for Hallux valgux in 45 patients (55 feet) aged 18 to 76 years (mean 43 years) between October 2004 and December 2005. Clinical follow up was both subjective and objective. Patients were asked about rating of their satisfaction and objective assessment was done in form of AOFAS score. Using this technique none of the patients required an additional proximal phalangeal osteotomy with metatarsal osteotomy. At six months follow up American Orthopaedic Foot and Ankle Society score improved from 46 to 87. Intermetatarsal (IM) angle and the hallux valgus (HV) angle improved from 16° to 9° and from 31° to 16° respectively (p< 0.05). At final follow up 8 patients were very satisfied, 12 were satisfied while 5 were not satisfied.

Of the 55 procedures 51 did not develop any complications. Two had superficial infections, treated successfully with oral antibiotics only. Two patients had recurrence, one was treated with Akin and second patient declined surgery as she was not bothered with it.

We recommend the use of this modified ‘Y-V’ medial capsular repair to reduce the need for an additional procedure to augment the correction achieved during Scarf osteotomy for hallux valgus. This reduces hallux valgus angle and maintains it.

The authors report the use of a modified ‘Y-V’ medial capsular repair in association with Scarf osteotomy for Hallux valgus in 55 patients (62 feet) aged 18 to 61 years (mean 43 years) between July 2004 and July 2005. All patients were followed up for minimum 6 months by questionnaire, physical examination (American Orthopaedic Foot and Ankle Society score) and comparison of preoperative and post operative x rays.

Using this technique none of the patients required an additional proximal phalangeal osteotomy (Akin Oste-otomy). At six months follow up American Orthopaedic Foot and Ankle Society score improved from 46 to 87. Intermetatarsal (IM) angle and the hallux valgus (HV) angle improved from 16 degree to 9 degree and from 31 degree to 16 degrees respectively (p less than 0.05).

Of the sixty two procedures 59 did not develop any complications. Two had superficial infections which required oral antibiotics only. One partial loss of correction of hallux valgus occurred for which the patient refused a second operation. Seven cases had some residual pronation deformity of the big toe identified by the patients who felt the deformity was ‘about 50%’ compared to before the operation.

Akins osteotomy achieves an apparent correction of hallux valgus without addressing subluxation of meta-tarso-phalangeal joint. Our technique reduces the meta-tarso-phalangeal joint and corrects the hallux valgus angle anatomically.

We recommend the use of this modified ‘Y-V’ medial capsular repair to correct the hallux valgus angle and reduce the need for an additional procedure to augment the correction achieved during Scarf osteotomy for hallux valgus.

Objective: This is a prospective, randomised, double blind trial to assess the effectiveness of intrathecal fentanyl in the relief of post-operative pain in patients undergoing lumbar spine surgery.

Method: 60 patients were recruited. All received our standard analgesic regime with morphine PCA via a syringe driver. They were electronically randomised to two groups – one received 15 micrograms of fentanyl intathecally; the other had nothing. The fentanyl was administered by the operating surgeon under direct vision at the end of the procedure.

All patients were monitored in recovery for two hours. Visual Analogue Scale (VAS) pain scores were assessed at 2, 4, 24 and 48 hours post-op. The time to first bolus delivery of PCA was recorded as was the total amount of morphine PCA used. Both patient and assessor were blinded.

Results: The patients randomised to receive fentanyl showed a significant decrease in their mean VAS pain scores for the first 24 hours. Their time to first bolus of PCA was significantly increased. They also used 40% less morphine PCA (p< 0.05 in all cases). None of the patients suffered respiratory compromise requiring treatment and they all left recovery after 2 hours to be nursed on the general ward.

Conclusion: Intrathecal fentanyl is effective at reducing post-operative pain and PCA morphine use after lumbar spinal surgery. We support its use over morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on a general ward.

We wish to report the use of a modified ‘Y-V’ medial capsular repair in association with Chevron osteotomy fixed rigidly with Barouk screw for Hallux valgus in 45 patients (52 feet) aged 16 to 70 years (mean 47 years) between July 2004 and September 2005. All patients were retrospectively reviewed by questionnaire, physical examination (American Orthopaedic Foot and Ankle Society score) and comparison of preoperative and post operative x rays.

Using this technique none of the patients required additional immobilization apart from wool and crepe bandage following surgery. All osteotomies healed without any problem. There was no deep infection reported in this series. There were two superficial infection treated with oral antibiotics. There is no recurrence of deformity so far. At an average of six months follow up American Orthopaedic Foot and Ankle Society score improved significantly. Intermetatarsal (IM) angle and the hallux valgus (HV) angles were also improved considerably.

Stabilization of Chevron osteotomy with k wires, plaster of Paris is well known but these techniques have problems of infection and stiffness. Osteotomies carried out without any stabilization has high recurrence rate. Fixation of osteotomy with Barouk screw is a very simple procedure, which not only gives stability and compression to osteotomy but also reduces need for any plaster immobilization thus speed up rehabilitation. This also gives extra confidence to surgeon to allow patient for early weight bearing and mobilization.

We also recommend the use of modified ‘Y-V’ medial capsular repair to correct the hallux valgus angle and reduce the meta tarso-phalangeal joint leading to reduction in possibility of recurrence.

Purpose: Periprosthetic fractures around hip prostheses are difficult problems because these fractures range from the very simple (requiring no surgical intervention) to the complex (requiring major surgery). This paper evaluates the primary stability and restoration of femoral bone stock following treatment of Vancouver type B-2 periprosthetic fracture of the femur using an extensively hydroxy-apatite coated revision stem implant.

Methods: We have prospectively reviewed 9 cases with B-2 periprosthetic fracture operated at our centre between 1996 to 2001. Of the nine patients, 4 were male and 5 female. The mean age was 76.7 years (50-92). All patients were treated by femoral revision using an extensively hydroxy-apatite coated titanium revision femoral stem (Restoration HA, Stryker, Rutherford, NJ). Fixation was augmented with a combination of cerclage cables and onlay cortical strut allografts.

Results: There has been no loss to follow-up. 1 patient died, but at most recent follow-up the fracture had united with radiological evidence of bone on-growth to the stem. Mean follow up in the rest of the cohort was 3.3 years. There was radiological evidence of fracture union in all patients. Mean subsidence of the stem was 0.22mm. At most recent follow-up the mean Harris Hip Score had improved to 77.2 (63-93). Favourable bone remodelling was observed in all patients with no evidence of stress shielding so far. At most recent follow-up there have been no cases of mechanical failure, deep infection or dislocations. No patient is awaiting further revision.

Conclusion and Significance: Te Restoration HA stem has produced excellent clinical results in our study. We have observed no intra operative fracture and low postoperative complication rate. We are extremely encouraged by the observed femoral remodelling. There has been no case of mechanical failure as yet and there is no reason to expect, once union and on-growth have occurred, that loosening will be a problem. In treating this challenging and increasingly common complication of total hip replacement, femoral revision using an extensively HA coated revision femoral component offers a reliable method of femoral fixation leading to successful fracture healing and early return to function.

Giant cell tumour of tendon sheath is usually benign in nature but their tendency to recur is well known, this cause problems for surgeons and there is always a puzzle in determining the appropriate therapy. This study was done to highlight characteristics, differential diagnosis and current options of treatment for giant cell tumour of tendon sheath.

We report two cases treated at our hospital. Both are females, one of 24 years while other was 65 years at the time of diagnosis. First patient had incidental associated benign teratoma of ovary as well. One tumour was of thumb in non dominant hand while in older patient it was at distal interphalangeal joint of ring finger in dominant hand. Both presented with history of slowly growing painful swelling, they were treated with local excision but in both patients there was an aggressive local recurrence. Revision surgery was performed with wider local excision. There was no recurrence this time.

Giant cell tumour of tendon sheath is mostly benign condition but need to be differentiated from serious conditions like clear cell sarcoma. Therapy of choice is local excision. Wider excision after surgery should be reconsidered where microscopic examination reveals a lesion with characteristics suggestive of potential aggressive behaviour. A literature review and discussion of salient diagnostic and treatment issues is included.

Treatment of unicameral bone cysts ranges from injections of corticosteroids, bone marrow with allogenic demineralised bone matrix to open bone grafting procedure. These procedures have their own disadvantages in form of infection, fracture, long-term morbidity, repeat procedure and high recurrence rate.

We describe here a new, technically simple and safe technique with minimal morbidity and short hospital stay. We treated 2 young children with active bone cyst (that did not heal with pathological fractures in past 18 months) by this technique and in both the cases bone cyst healed without any complications.

In patient with active bone cyst at the proximal end of humerus, under image intensifier control distal humerus perforated with 3.5 mm drill and a pre bent 2.5 mm, flexible, intramedullary nail passed into the medullary canal and then to proximal end of bone cyst. Nail now rotated sequentially at 5 mm intervals to destroy the architecture of the cyst completely until no resistance is felt. Wound closed with skin sutures and steristrips. Post operatively both children were comfortable and discharged home next day. In both cases cyst healed uneventfully.

Though we have small experience but technique looks very promising.

Malignant change in existing benign enchondroma of phalanx of hand to chondrosarcoma of hand is extremely rare. Books suggest that chondrosarcoma does not arise in small bones of hands and feet although in literature few cases have been reported but not described comprehensively.

We report a rare case of chondrosarcoma in distal phalanx of ring finger in a 75- year old healthy female who had cystic lesion for past 25 years with recurrent fractures. Patient came to us with severe pain and tender, hard swelling of distal phalanx of left ring finger. X ray showed pronounced expansion of the terminal phalanx surrounded partially by a shell of bone, with focal spotty calcification with in the lesion. Because of sudden increase in size and pain of swelling, an amputation was performed at distal inter phalangeal joint. Histopathology showed grade II myxoid chondrosarcoma with pre-existing enchondroma. Wound healed nicely. Extensive investigation in form of CT chest and bone scan did not show any metastasis. Five year follow up did not show any local recurrence or distant metastasis.

Clinical suspicion should be aroused in an older individual with a previously relatively quiescent lesion that becomes larger and painful. Usually course of the tumour is slow and metastasis to lungs is late. Treatment of choice is disarticulation a joint proximal to lesion. Prognosis is good if metastasis has not occurred. Once diagnosis is made, patient should be investigated to look for any possible metastasis and must be regularly followed up. A literature review and discussion of salient diagnostic and treatment issues is included.

The image intensifier is an essential part of orthopaedic trauma surgery. The Image Intensifier can move in a number of planes and has to be positioned accurately. Frustration arises in the surgeon, the radiographer and the rest of the theatre staff when the image intensifier is moved in the wrong direction and there are also increased radiation hazards to all involved if unnecessary x-rays are taken due to incorrect positioning. Communication between the surgeon and the radiographer lies at the heart of safe practice. A questionnaire was designed and circulated to all the radiographers using the image intensifier and to orthopaedic surgeons including consultants, SpRs in London southwest deanery and SHOs of St George’s Hospital, London. They were then asked to write descriptors on a diagram illustrating the major movements of the image intensifier (Vertically up/down, to the patients left/right and head/feet). The questionnaires were completed by 32 radiographers and 48 surgeons (8 consultants, 33 registrars and 7 SHOs). There was very little consensus either within or between the groups as to what command should be used for which direction. A set of directions was agreed upon and put on image intensifier machine. When used these produced a significant reduction in misunderstood commands Confusion abounds when directing the Image Intensifier. When a set of directions can be agreed upon stress reduces and satisfaction improves although it is difficult to measure the reduction in radiation exposure.