From 1975 to 1990 we performed subtalar or triple arthrodesis on 54 patients; 48 of them were reviewed after a mean follow-up of 10 years (6 to 15). There were 17 subtalar fusions in 14 patients and 37 triple arthrodeses in 28 patients. We assessed tibiotalar ankle function using the criteria of Mazur which gives a points score of a maximum of 100. Radiological evidence of degenerative change was graded on a scale of 0 to 4. The mean Mazur score was 85 for the subtalar fusions and 78 for the triple arthrodeses. The radiological score showed no degenerative changes in 36 feet (24 triple and 12 subtalar arthrodeses) and an increase of one grade in 14 feet (10 triple and 4 subtalar), of two grades in three feet (all triple arthrodeses) and of three grades in one foot after a subtalar arthrodesis. We found no statistically significant difference in the radiological score in unilateral fusions between feet with subtalar and triple arthrodeses and the contralateral foot. In all four feet which showed an increase in degenerative changes of two or more grades, there was an abnormality of the tibiotalar joint before the fusion operation. Of the 14 feet which showed an increase of one grade, there was a similar increase on the contralateral side in nine. Our findings show that subtalar or triple arthrodesis has little adverse influence on the function of the tibiotalar joint, even after many years

1. Between 1936 and 1945, 525 patients with sciatic pain were treated at the Princess Elizabeth Orthopaedic Hospital, Exeter. Of these, 225 had neurological signs and they were selected for review; 147 were traced. 2. Of these, 123 were treated by means of plaster jackets and twenty-four were treated by other methods. The late results of treatment in the two groups were about the same, roughly one-third being "cured," one-third "relieved," and one-third "not relieved.". 3. Nevertheless examination of the immediate results suggests that protection by means of a plaster jacket had at least a palliative effect, relieving acute symptoms and allowing early rehabilitation. Moreover it should be emphasised that in limiting the investigation to cases of sciatica with evidence of nerve root pressure only the more severe cases have been included. 4. Permanent relief after immobilisation in plaster was greatest when the duration of symptoms was short, and when the patient was treated during his first attack. It was least in patients who showed all three signs of nerve root pressure—diminished ankle jerks, hypo-aesthesia, and muscle hypotonicity. 5. Absence of tendon reflexes due to nerve root pressure, and areas of hypo-aesthesia, tend to remain permanently; but diminution of reflexes and loss of muscle power may recover

Aims

The aim of this study was to examine the association between postoperative glycaemic variability and adverse outcomes following orthopaedic surgery.

This retrospective study analyses the results of subtalar bone block distraction arthrodesis used in the treatment of late complications of calcaneal fractures, acute severely comminuted fractures, nonunion (and malunion) of attempted subtalar arthrodeses, avascular necrosis of the talus, and club-foot deformity. Of 39 patients (41 feet) who had this procedure, 35 (37 feet) returned for follow-up after a mean of 70 months (26 to 140). There were 24 men (25 feet) and 11 women (12 feet) with a mean age of 41 years (16 to 63). Each completed a standardised questionnaire, based on the hindfoot-scoring system of the American Orthopaedic Foot and Ankle Society and were reviewed both clinically and radiologically. Of the 37 operations, 32 (87%) achieved union. The mean hindfoot score (maximum of 94 points) increased from 21.1 points (8 to 46) preoperatively to 68.9 (14 to 82) at the final follow-up. The mean talocalcaneal and calcaneal pitch angles were 20.5° and 4.9° before operation, 25.9° and 8.3° immediately after, and 24.6° and 7.7° at the final follow-up, respectively. The mean talar declination angle improved from 6.5° (−10 to 22) before operation to 24.8° (14 to 32) at the final follow-up. The mean talocalcaneal height increased from 68.7 mm before operation to 74.5 mm immediately after and 73.5 mm at the final follow-up. Of the 37 arthrodeses available for review, 32 were successful; 29 patients (30 arthrodeses) were satisfied with the procedure. Minimal loss of hindfoot alignment occurred when comparing radiographs taken immediately after operation and at final follow-up

Aims

The classical longitudinal incision used for the direct anterior approach (DAA) to the hip does not follow the tension lines of the skin and can lead to impaired wound healing and poor cosmesis. The purpose of this retrospective study was to determine the satisfaction with the scar, and functional and radiographic outcomes comparing the classic longitudinal incision with a modified skin crease ‘bikini’ when the DAA is used for total hip arthroplasty (THA).

1. In a club foot the small inverted and elevated heel is considered to be the most important deforming influence in preventing complete correction and in promoting relapse. 2. Correction of the varus and an increase in the vertical height of the heel are achieved by opening up the medial aspect of the calcaneum and inserting a wedge of bone. This abolishes the inverting action of the calcaneal tendon and brings the heel down on to the ground directly under the line of the tibia so that it touches first in walking. The weight is then shifted on to the forefoot, as in the normal gait, thus producing gradual correction of supination and adduction. 3. The operation may have to be repeated, but with the varus fully corrected and a plantigrade heel there is no chance of relapse, and progressive improvement, not only in gait and shoe wear but also in the development of the foot and leg, can be expected. 4. Skin closure is a difficulty, and though the resulting scar is sometimes conspicuous, it is masked to some extent by being on the postero-medial aspect of the ankle. 5. The ideal age for the operation is about three to four years, but there is virtually no upper age limit. 6. In older patients presenting severe residual deformity it may be necessary to correct the heel and then the equinus of the forefoot by a tarso-metatarsal wedge, thus avoiding damage to the mid-tarsal and subtalar joints. 7. By adopting these principles, soft-tissue release operations, so often disappointing and sometimes damaging, can be avoided and in no patient should there ever be the need to resort to the mutilating "triple wedge" resection. 8. The most important feature of the operation is correction of the varus; it is better to over-correct than to under-correct (Figs. 20 and 21). It is a simple matter to deal with the valgus later if necessary

Aims

The purposes of this study were to clarify first, the incidence of peroneal tendon dislocation in patients with a fracture of the talus and second the factors associated with peroneal tendon dislocation.

The results and complications of 104 vascularised fibular grafts in 102 patients are presented. Bony union was ultimately achieved in 97 patients, with primary union in 84 (84%). The mean time to union was 15.5 weeks (8 to 40). In 13 patients, primary union was achieved at one end of the fibula and secondary union at the other end. In these patients, the mean time to union was 31.1 weeks (24 to 40). Five patients failed to achieve union, with a resultant pseudarthrosis (3 patients) or amputation (2 patients). There were various complications. Immediate thrombosis occurred in 14 cases. In two of 23 patients with osteomyelitis, infection recurred at two and six months after surgery, respectively. Both patients had active osteomyelitis less than one month before the operation. Bony infection occurred in a patient with a synovial sarcoma of the forearm one year after surgery. In 15 patients, 19 fractures of the fibular graft occurred after bony union, all except one within one year after union. In patients in whom an external fixator had been used, fracture occurred soon after its removal. Union was difficult to achieve in cases of congenital pseudarthrosis of the tibia. Appropriate alignment of the fibular graft is an important factor in preventing stress fracture. The vascularised fibula should be protected during the first year after union. Postoperative complications at the donor site included transient palsy of the superficial peroneal nerve in three patients, contracture of flexor hallucis longus in two and valgus deformity of the ankle in three. Vascularised fibular grafts are useful in the reconstruction of massive bony defects. We believe that meticulous preoperative planning, including choosing which vessels to select in the recipient and the type of fixation devices to use, and care in the introduction of the vascularised fibula, can improve the results and prevent complications

1. An experimental study of the effects of nerve and muscle lesions upon the growth of bone has been made. In each case animals were subjected to unilateral lesions in the hind limb, the other limb serving as a control. The growth of the tibia was measured by calculating the difference between the length of the bone on a radiograph at the beginning of the experiment and the length of the dried bone after necropsy. The weights of the dried bones were compared. 2. In the young rabbit simple exposure of the common peroneal nerve, or division of the sural nerve, produced no change in the growth rate of the tibia. Division of both peroneal nerves, producing paralysis of the muscles below the knee, led to lengthening of the affected tibia, and this lengthening persisted until maturity several months later. A similar lengthening was seen after division of the tendons around the ankle. In spite of this lengthening the tibia on the side of the operation was almost always lighter than its fellow. 3. In the puppy division of the anterior nerve roots supplying the hind limb produced a significant lengthening of the tibia of the affected limb three months after operation. No significant changes in limb length occurred after lumbar sympathectomy in the puppy. 4. The significance of these experimental nerve lesions has been considered together with recent observations upon the growth of bone in the presence of lower motor neurone lesions in the child. From this analysis it is suggested that the initial effect of paralysis is to produce lengthening of the affected bone. This lengthening is probably due to the hyperaemia of disuse. In the presence of persistent paralysis the growth of the limb is ultimately depressed. This depression is rarely seen in the experimental animal because the growing period is relatively short. The possible causes of this secondary depression of bone growth have been considered

The Chevron osteotomy was described in 1976. There have, however, been only short- to mid-term follow-up reviews, often with small numbers of patients. We looked at 112 feet (73 patients) with a minimum follow-up of ten years following Chevron osteotomy with a distal soft-tissue procedure. Clinical evaluation was calculated using the hallux score of the American Orthopedic Foot and Ankle Society (AOFAS). For 47 feet (30 patients), the results were compared with those from an interim follow-up of 5.6 years. The AOFAS-score improved from a pre-operative mean of 46.5 points to a mean of 88.8 points after a mean of 12.7 years. The first metatarsophalangeal (MTP) angle showed a mean pre-operative value of 27.6° and was improved to 14.0°. The first intermetatarsal (IM) angle improved from a pre-operative mean value of 13.8° to 8.7°. The mean pre-operative grade of sesamoid subluxation was 1.7 on a scale from 0 to 3 and improved to 1.2. Measured on a scale from 0 to 3, arthritis of the first MTP joint progressed from a mean of 0.8 to 1.7. Comparing the results in patients younger and older than 50 years, the Chevron osteotomy performed equally in both age groups. Analysing the subgroup of 47 feet with a post-operative follow-up of both 5.6 and 12.7 years, the AOFAS pain and the overall score showed a further improvement between both follow-up evaluations. The MTP angle, first IM angle and sesamoid position remained unchanged. The progression of arthritis of the first MTP joint between 5.6 and 12.7 years post-operatively was statistically significant. Only one patient required a revision procedure due to painful recurrence of the deformity. Excellent clinical results following Chevron osteotomy not only proved to be consistent, but showed further improvement over a longer follow-up period. The mean radiographic angles were constant without recurrence of the deformity. So far, the statistically significant progression of first MTP joint arthritis has not affected the clinical result, but this needs further observation

Aims

A high rate of suicide has been reported in patients who sustain fractures, but the association remains uncertain in the context of other factors. The aim of this study was to examine the association between fractures and the risk of suicide in this contextual setting.

Aims

The aim of this study was to evaluate the effects of using a portable, accelerometer-based surgical navigation system (KneeAlign2) in total knee arthroplasty (TKA) on the alignment of the femoral component, and blood loss.

The mucopolysaccharidoses (MPS) are a group of inherited lysosomal storage disorders with clinical manifestations relevant to the orthopaedic surgeon. Our aim was to review the recent advances in their management and the implications for surgical practice.

The current literature about MPSs is summarised, emphasising orthopaedic complications and their management.

Recent advances in the diagnosis and management of MPSs include the recognition of slowly progressive, late presenting subtypes, developments in life-prolonging systemic treatment and potentially new indications for surgical treatment. The outcomes of surgery in these patients are not yet validated and some procedures have a high rate of complications which differ from those in patients who do not have a MPS.

The diagnosis of a MPS should be considered in adolescents or young adults with a previously unrecognised dysplasia of the hip. Surgeons treating patients with a MPS should report their experience and studies should include the assessment of function and quality of life to guide treatment.

Cite this article: Bone Joint J 2017;99-B:1132–9

Increasing innovation in rapid prototyping (RP) and additive manufacturing (AM), also known as 3D printing, is bringing about major changes in translational surgical research.

This review describes the current position in the use of additive manufacturing in orthopaedic surgery.

Cite this article: Bone Joint J 2018;100-B:455-60.

Aims

The aim of this study was to explore the patients’ experience of recovery from open fracture of the lower limb in acute care.

1. A hope expressed in 1940, that further cases of spontaneous fracture of the lowest third of the apparently normal fibula would be described, has been fulfilled. The literature is here reviewed. Five further personal cases are added. 2. The clinical and radiographic features, diagnosis, treatment and results are considered in the light of the information so far available. Special note is made of misleading freedom of ankle and tarsal movements and the occasional absence of tenderness. 3. It is established that fractures of the lowest third occur particularly in two groups of subjects: 1) young male runners and skaters; 2) active and hard-pressed women of middle age and over. 4. In male runners and skaters the fracture usually occurs through slender, mainly cortical bone, two inches or more above the tip of the lateral malleolus; in middle-aged women the fracture is usually distal to the interosseous ligament through thicker, mainly cancellous bone, one and a half inches from the tip of the lateral malleolus. 5. The most convenient name for both groups of fractures in the lowest third is low fatigue fracture of the fibula. 6. A review of the literature of fatigue fracture of the uppermost third of the fibula shows that it is very often precipitated by jumping. The most convenient name for it is high fatigue fracture of the fibula. 7. Like all clinical classifications this distinction between low and high fractures has exceptions (a low fracture of one fibula in a runner was followed later by a high fracture of the other; most military fractures were high, but a few may have occurred at other levels). 8. Fatigue fracture of the fibula, high or low, may be bilateral. 9. A fracture similarly situated to the high fatigue fracture of the fibula has been frequent in parachute schools. It is a speculative possibility that military and parachutist fractures of the upper third of the fibula indicate the link between true fatigue fractures (as exemplified by march fractures with minimal trauma often repeated) and purely traumatic fractures (with adequate trauma applied once only)

Objectives

The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery.