Receive monthly Table of Contents alerts from Orthopaedic Proceedings
Comprehensive article alerts can be set up and managed through your account settings
View my account settingsThe aim of the New Zealand Elbow Arthroplasty Register is to evaluate the provision of elbow arthroplasty across the entire country by both recording accurate technical information and measuring the clinical outcomes of all elbow replacements performed in New Zealand. An initial form is completed at the time of surgery which includes details of the patient, surgical indications, the surgical procedure, the implant and the operating surgeon. Six months following surgery, all registered patients are asked to complete a questionnaire to measure the pain and function of the replaced elbow and to comment on any post operative complications. Data from 99 consecutive primary and 16 revision elbow arthroplasties was prospectively collected from January 2000 till December 2003. Rheumatoid arthritis was the commonest indication (63 cases) and the outcome was significantly better than for trauma and osteoarthritis. The Coonrad-Morrey was the most commonly used prosthesis (86 cases) followed by the Kudo (eight cases) and the Acclaim (five cases). 21 surgeons performed elbow arthroplasty during the study period but only five performed on average more than one case per year. Their results at six months were statistically superior to those provided by other surgeons. The number of complications reported by patients and the revision rate within the study period was low. An infection was seen in only two patients. The New Zealand Elbow Arthroplasty Register has become a robust method of assessment of the provision of elbow arthroplasty within the country. Our findings support the idea that elbow arthroplasty should not be performed by general orthopaedic surgeons on an occasional basis.
We compare the management and outcome of two management stratergies for the perfused but pulseless hand following stabilisation of grade III supracondylar fractures in children.
For this study we looked at 15 patients treated in two centres (all treated by the senior author) between 1995 and 2004. The patients were designated to group I if the pulseless hand had been observed or group II if they underwent immediate exploration. Data collected included time to surgery, neurological deficit, time to return of pulse and subsequent symptoms of forearm claudication. All patients were seen at week 1,3 and followed for at least 6 months post surgery. Radiographs were reviewed to determine the adequacy of reduction of the fracture.
The mean age of patient was 3.8 years. Median time to surgery was 6 hours. 6 children had evidence of anterior interosseus nerve palsy. 12 cases were reduced anatomically, 3 had minimal fracture gap. Of the 8 patients in group I (observation) 2 had secondary exploration and one developed claudication symptoms. All had palpable radial pulse at 3 months.6 of the 7 patients in group II (exploration) were seen to have brachial artery tethering, 2 with median nerve entrapment. 5 of them had subsequent return of radial pulse within 24 hours.
Satisfactory radiological reductionof the fracture does-not exclude vessel or nerve entrapment. We would advocate early exploration of the artery if the pulse does not return within 24 hours.
Goodfellow & Bullough (1968) first described the pattern of articular cartilage wear in the elbow. More recent post mortem studies have shown that advanced degenerative changes can develop in the radio-capitellar (lateral) compartment of elbow joints of elderly subjects in which the humeroulnar (medial) compartment remains remarkably well preserved. We have reviewed the findings in a consecutive series of 117 elbow arthroscopies performed on patients with elbow pain resistant to conservative treatments (age range 21–80 years: mean age 51 years). We documented established degenerative changes involving articular cartilage in 68 patients (59%). In this group we found that in 60 patients (88%) the degenerative changes were confined to the lateral compartment and contrasted with normal appearances of the articular cartilage of the medial compartment.
The post mortem studies carried out on mainly elderly subjects demonstrated that the degree of degenerative change in the elbow is age dependant and involves predominantly the lateral compartment of the joint. Our study would support these observations, but indicates that symptomatic degenerative change occurs at a much earlier age than had previously been thought.
We consider that lateral compartment degenerative change is a distinct clinical entity. It begins in relatively young patients in whom the x ray appearance may be normal or near normal and is often diagnosed as lateral epicondylitis. Our observations taken together with the reported post mortem studies indicate that primary osteoarthritis of the elbow begins in the lateral compartment of the joint and may remain confined to the lateral compartment throughout life. We believe that new treat ment strategies need to be developed specifically for patients with primary osteoarthritis as opposed to degenerative joint disease due to other causes.
We present a single-surgeon series of surgical release of post-traumatic flexion contracture of the elbow performed via a limited lateral approach. We undertook a retrospective review of patients having surgery for established post-traumatic flexion deformity of the elbow. All patients underwent anterior capsulectomy via a limited lateral approach. Patients with an intrinsic contracture also had the intra-articular lesion addressed at the time of surgery. Short-term follow-up was available from clinical review until discharge. Medium-to-longterm follow-up was conducted by telephone interview supplemented by clinical review in selected cases.
Between 1998 and 2004, 23 patients were treated surgically for established flexion contracture of the elbow. There were 15 males and 8 females with a median age of 35yrs (range 16–52yrs). In sixteen patients the contracture was not associated with damage to the joint surface (extrinsic) and in seven it was (intrinsic). The mean pre-operative deformity was 55 degrees (95%CI 49 “ 61) which was corrected at the time of surgery to 18 degrees (95%CI 12 “ 23). The mean residual deformity was 25 degrees (95%CI 20 “ 31). The difference between the pre-operative and discharge deformities was significant (Wilcoxson test p< 0.001). In the extrinsic group the mean deformity at discharge was 21 degrees (95%CI 17 “ 25) compared to 34 degrees (95%CI 19 “ 49) in the intrinsic group “ this difference was significant (Mann-Whitney U test p< 0.01). In those patients with an extrinsic contracture all elbows had a return of functional extension. One patient suffered a post-operative complication with transient dysaesthesia in the distribution of the ulnar nerve which resolved after six weeks. Surgical release of post-traumatic flexion contracture of the elbow via a limited lateral approach is a safe, reliable technique with the best results achieved in patients with an isolated extrinsic contracture.
The aim of this study was to establish the consensus of opinion amongst trauma surgeons for the management of displaced supracondylar fractures of the humerus in children.
We carried out a postal questionnaire involving 130 orthopaedic surgeons with an interest in paediatric trauma. They were identified as being members of the British Society for Children’s Orthopaedic Surgery.
We received a response rate of 65%. One third of respondents believe that in uncomplicated fractures, reduction should occur within 6 hours of injury and one half felt that ‘pulseless’ fractures should be treated in the same time frame. 60% said they would explore a pulseless arm after midnight, but only 20% would reduce and stabilise uncomplicated fractures. 82% of surgeons stabilise displaced grade III fractures with K wires, of these, the majority would use a‘crossed’ configuration. If after stabilisation the arm remained pulseless, only 16% said they would explore the brachial artery immediately, 23.5% would seek a vascular opinion and 60.5% of surgeons would observe for 24 hours. If the arm remained pulseless but pink after 24 hours, the majority of surgeons would continue to observe and rely on collateral circulation for distal perfusion.
The majority of surgeons would stabilise displaced supracondylar fractures as soon as possible but not after midnight unless the arm was pulseless. If the hand remained pink but pulseless, most felt that continued observation beyond 24 hours was acceptable.
The normal shoulder requires the basic mechanical characteristics of range of motion, stability and strength. However, each of these characteristics can be compromised by arthritis or rotator cuff tear and are often associated with strong pain. Shoulder arthoplasty is one of the most common solutions for pain relief and to restore shoulder functionality. There are many available designs of prosthesis trying to address different shoulder pathologies. Despite this, there are relatively few studies investigating the biomechanics of a total joint replacement and suggest advantages, disadvantages and possible solutions.
The Newcastle shoulder model has been used to investigate the biomechanical properties of a total shoulder replacement having a reverse anatomy design. This model allows the simulation of implantation of the prosthesis and the prediction of muscle and joint forces. To address the requirement of accurate insertion of the prosthesis, the standard surgical procedure has been simulated. The current model was modified to represent the bones, muscles and implant alignment after surgery.
Load sharing results for standardised tasks (Abduction, Forward Flexion) showed great differences between anatomical and prosthetic models. In the latter the shear forces on the glenoid site were reversed, the compression stresses were reduced and the joint contact vectors were always within the humeral cup providing joint stability. This is an important effect of the reverse design, which reverses the envelope of the joint forces increasing also the muscle moment arms crossing the GH joint. The most affected group is the m.deltoid that becomes able to compensate for the dysfunctional rotator cuff muscles. The biomechanical model suggests that a reverse anatomy design can restore GH joint stability for patients with severe RC damage. Increased muscle moment arms also compensate for the lost contribution of the RC muscles to elevation.
We present the early results of 36 primary total elbow arthroplasties using the Acclaim prosthesis. The Acclaim prosthesis was used in 46 primary total elbow arthroplasties between July 2000 and August 2002. All operations were performed or directly supervised by the two senior authors (IAT and JKS). There were 32 females and 14 males. The mean age at surgery was 64 years (range, 34–93). The underlying pathology was rheumatoid arthritis in 39, osteoarthritis in five and post-traumatic arthritis in two. The early results of 36 cases are presented at a minimum follow-up of two years. Patients were assessed using the American Shoulder and Elbow Surgeons patient self assessment form and the range of movement of the elbow measured. The Wrightington method was used for radiographic analysis of lucencies. There was good relief of pain and range of movement improved. The mean preoperative pain score was 8.1 and decreased to 2.1 at latest follow up. The mean disability score increased from 34.2 to 66.1. The mean overall satisfaction rating following surgery was 9.3 on a visual analogue scale from zero to ten. The mean range of flexion increased from 83oto105o. The mean flexion gain was just over 10o and the mean extension gain was just over 12o. There were 11 cases of intraoperative fracture of the humeral condyle. One of these fractures failed to unite and required revision to a linked prosthesis because of persistent instability. There was one case of deep infection. There were three cases of ulnar neuropathy, one of which resolved. There was no evidence of loosening. The Acclaim total elbow arthroplasty gives good symptomatic relief and improvement in function according to the American Shoulder and Elbow Surgeons patient self assessment form. These early results are encouraging but the frequency of intra-operative fractures is of some concern.
A significant number of patients return with persistent symptoms following surgical release of the posterior interosseous nerve for radial tunnel syndrome. The aim of this study was to attempt to explain this fact in anatomical terms by defining the anatomy of the posterior interosseous nerve and its branches in relation to the supinator muscle and arcade of Frohse. Using standard dissection tools 20 preserved cadaveric upper limbs were dissected. The radial nerve and all its branches within the radial tunnel were exposed and a digital calliper was used to measure distances. The bifurcation of the radial nerve to posterior interosseous nerve and superficial sensory branch occurred at a median distance of 4.35mm proximal to the elbow joint-line. The bifurcation was proximal to the joint-line in 11 cases, at the level of the joint-line in one case and distal in eight cases. There was a range of 0–5 branches to the supinator originating proximal to the entry point of the posterior interosseous nerve under the arcade of Frohse at a median distance of 10.27mm (medial branches) or 11.11mm (lateral branches) distal to the elbow join-line. These branches either passed under the arcade of Frohse or entered through the proximal edge of the superficial belly of the supinator. In 10 limbs there was a variable number of branches to the supinator originating under its superficial belly and in five limbs multiple perforating posterior interosseous nerve branches within the muscle were identified. This variation in anatomy we believe may explain the persistence of symptoms following surgical release of the posterior interosseous nerve for radial tunnel syndrome and suggests that careful exploration of all the nerve branches during surgical decompression should be routinely performed.
The purpose of this study was to assess the efficacy of physiotherapy approaches to treatment of rotator cuff tendinopathies (RCT). Ninety shoulders were randomised in the study. A power calculation performed demonstrated using a factorial study design, 85 shoulders would be needed for 80% power at 95% confidence. All participants gave informed consent and ethical approval was granted by the Cambridge LREC. The primary outcome measure was the Shoulder Pain and Disability Index. Participants were blinded to their allocation and were randomised to one of four groups: Therapeutic Exercise(T), Manual Therapy(M), combined T/M (X), or Placebo(P). Participants were seen for two baseline assessments with a 4-week interval and then randomised. Final assessments were performed one week after the last session. The analysis involved a comparison between groups in change from baseline SPADI using ANCOVA adjusting for baseline scores. This involved testing for any interaction between M and T, and subsequently testing for main effects of M and T. Adjusted baseline and final SPADI scores (SD) by group were: X 41.6(15.4), 21.1(20.8); T 47.6(19.3), 26.3(14.7); M 44.1(17.9), 33.1(23.3); and P 39.5(24.7), 36.6(30.6). The main effects (with Significance, Standard Error and Confidence Interval) by group were: Baseline=0.686 (SE=0.104;CI=0.479,0.892); T=−13.347 (p=0.002;SE=4.091;CI=−21.479,−5.215); X=5.479 (p=0.510;SE=8.284; CI=−10.991,21.950); M=−4.126 (p=0.314;SE=4.077;CI=−12.230,3.978). A statistically significant reduction in SPADI was observed for the T group alone. There was no significant interaction effect with the addition of manual therapy and the M group did not improve significantly. It appears that best practice for treatment of RCT should centre around therapeutic exercise.
Ultrasound imaging has become an essential adjunct to clinical examination when assessing a patient with suspected rotator cuff pathology. With the new high-resolution portable machines it has become feasible for the shoulder surgeon to perform the scans himself in the clinic and save a great deal of time. This study was conducted to examine the accuracy of the ultrasound scans performed by a single surgeon over a period of four years. The ultrasound findings were uniformly documented and collected prospectively. Out of a total of 364 scanned patients we selected 143 who ultimately received an operation and we compared the surgical findings with the ultrasound reports. The intra-operative findings included 77 full thickness supraspinatus tears, 24 partial thickness tears and 42 normal cuffs. Three full thickness tears were missed on ultrasound and reported as normal / partially torn. Four normal/ partially torn cuffs were thought to have a full thickness tear. This presents 96.3% sensitivity and 94.3% specificity for full thickness tears. Three partial thickness tears were reported normal on ultrasound and eight normal cuffs were thought to have partial thickness tears. This presents 89% sensitivity and 93.7% specificity for partial thickness tears. The size estimation of full thickness tears was more accurate for large/massive tears (96%) than moderate (82%) and small/pinhole tears (75%). The tear sizes were more often underestimated which may partly reflect disease progression during the unavoidable time lag between scan and surgery. We conclude that shoulder ultrasound performed by a sufficiently trained orthopaedic surgeon is a safe and reliable practice to identify rotator cuff tears.
Progressive arthritis can occur in association with massive tears of the rotator cuff. Altered joint kinematics are commonly proposed as the principle causative factor but this does not explain the absence of arthropathy in some patients. We have investigated the role of the
The management of bony lesions associated with glenohumeral instability has been open to debate. Invariably a significant period of time elapses between injury and surgery during which the bony fragment may atrophy and reduce both in size and in quality. Histomorphometric bone analyses were prospectively performed on the glenoid bone fragments harvested during the modified Latarjet operation. The main purpose of the study was to assess the viability of the bone. Biopsies were obtained from 21 patients that had given informed consent. Median age was 21 years (range 16–50). All were male patients. The most important sports identified were rugby (64%) and water sports (surfing, water polo, water skiing, surfing (21%)). Mean glenoid bone loss on CT scan was 17% (range 10–50%). Thirty-three percent had bone loss greater than 20%. Gross morphology of glenolabral fragments identified a single large fragment (11/21); dominant large fragment plus smaller fragments (7/21); multiple fragments (4/21). Single large fragments comprised 52% of the study. Mean volume and mass of bony fragments were 2.18 ml (range 1–3 ml) and 1.64 gms (range 0.43–2.8 g), respectively. Histology of the specimens revealed no bone in three of the 21 specimens. Bony necrosis was present in 8/18 (44%) of the specimens. From a histopathological point of view, reattachment of these devitalized bone fragments by screws or anchors may result in predictable operative failure and recurrent instability. We can therefore not support the practice of “repair” of bony Bankart lesions based on the above findings.
The aim of this study was to assess the accuracy of Magnetic Resonance Arthrography (MRA) in symptomatic shoulder joint instability. Data were collected prospectively from MR Arthrograms performed in 40 consecutive patients with recurrent symptomatic instability. MR Arthrograms included views in the stress ABER position of the shoulder. Subsequently all patients underwent an arthroscopic shoulder stabilisation and the arthroscopic and MR Arthrographic findings were correlated. In case of discrepancy the films and operative findings were reviewed.
There were thirty three male and seven female patients with a mean age of 28 years (range 18–40). MR Arthrography showed 37 anterior-inferior tears (22 displaced Bankart tears, 8 nondisplaced Bankart tears, 5 chronic ALPSA lesions and 2 AGL lesions) and 3 posterior lesions. There were 3 discrepancies of which 2 were cases of missed Bankart lesion on MRArthrogram and one case of reverse Perthes lesion present on MRArthrogram but not seen on arthroscopy. Despite a review of the films, the missed Bankart’s lesions were not visualised. In the present study, MR arthrography had a 95% sensitivity in detecting ligamentolabral pathology and a positive predictive value of 0.975 in diagnosing a lesion in recurrent shoulder instability.
The results show that MR Arthrogram is a highly useful tool for investigating recurrent shoulder instability with very high sensitivity and positive predictive value. Of the 40 patients who underwent arthroscopy there were only 2 cases where MR Arthrography did not demonstrate an arthroscopically detected abnormality.
We report our experience of revision shoulder arthroplasty at Wrightington Hospital. Thirty-Nine patients had undergone revision surgery and followed up for a minimum of two years. Patients were scored using the Constant score and the ASES score pre-operatively and post operatively. All patients had X-ray evaluation for loosening and migration. Of the thirty-nine patients, 16 were failed humeral head replacement (HHR) and 16 were failed total shoulder replacement (TSR). All but two of the HHR were revised for glenoid erosion to a TSR, there was an equal proportion of patients with rheumatoid arthritis and osteoarthritis. Of the 16 patients undergoing revision surgery for failed TSR 6 were rheumatoid, 4 had osteoarthritis and 5 had posttraumatic arthritis. The main reasons for revision include glenoid loosening (7) instability (4) and peri-prosthetic fracture (2). The average constant scores post operatively for HHR and TSR were 35.5 (sd+/− 21.1) and 29.1 (sd+/− 12.1) respectively. The average ASES scores for HHR and TSR were 60.5(sd +/ 27.8) and 50.1(sd +/− 22.0) respectively. There was no statistical difference between the two groups in respect to the constant scores (p value 0.18) or ASES scores (p value 0.16). Overall, the pain relief was good post operatively following both HHR and TSR. The mean visual analogue score for pain following HHR was 3.2 and following TSR 3.5. Range of movement, function and strength was poor following both HHR and TSR.
HHR fail in a predictable way and can be revised with conversion to a TSR. TSR fail in a variety of ways and there revision surgery is demanding and complex. Both types of revision offer good pain relief but poor function.
The site of the non-union is approached through the pre-existing scar and any remaining metalwork is removed. The ends of the non-union are mobilised and bone is resected from both ends until there is fresh bleeding. The two bone ends are fashioned such that one will fit as a spike inside the medullary cavity of the other. The bone ends are held in position with two temporary K wires until the frame has been applied.
A standard four ring Ilizarov frame is applied with Rancho pins in the proximal humerus and a half ring in the distal humerus. The temporary K wires are removed and the frame is compressed to increase the contact between the bone ends. The routine hospital stay is one week and the patients are given intravenous antibiotics throughout their admission.
They are reviewed in the outpatient clinic at monthly intervals and the frame is used to compress the bone ends by two to three millimetres on each visit. When there are radiographic signs of union the frame is removed under a general anaesthetic.
The purpose of this study was to test the null hypothesis that patients with partial thickness rotator cuff tears do not suffer more pain or stiffness than those with full thickness tears. A power study determined that 68 partial thickness tears were required in the study in order to prove a clinically important difference (± = 0.05 and 2 = 0.2). Consecutive patients undergoing arthroscopy and bursoscopy for rotator cuff related problems were assessed using a pain analogue scale and their shoulder movements were measured. Information was gained both pre- and intra-operatively about possibly relevant confounders including age, site size and thickness of tears, and endocrine disorders. Exclusion criteria included glenohumeral arthropathy, frozen shoulder, instability and major traumatic injuries, as well as the inability to understand the pain score. 439 shoulders (428 patients) were included in the study; 216 shoulders had no cuff tear, 95 had partial thickness tears (75 joint side, 1 intrasubstance, 19 bursal side), and 128 shoulders had full thickness tears. There was no significant difference (p< 0.05) in the pain scores or range of movement between full and partial thickness tears. Age was the only independent variable to have an effect on pain score.
The null hypothesis has been upheld. This study contradicts the findings of previous research and challenges commonly held assertions on this topic. Neither pain nor stiffness can be used clinically as discriminators between partial and full thickness rotator cuff tears.
Thirty-five patients (85%) reported none or minimal pain. 81% were negative for provocative AC signs. Internal rotation increased by average of 5 vertebrae levels. The Constant, the WORC and Oxford Scores were improved by 23 points, 674 points and 16 points respectively (p< 0.05). 71% reported good or excellent function by the 3rd post-operative month.
The aim of this study was to observe cellular and vascular changes in different stages of full thickness rotator cuff tear.
Biopsies of the Supraspinatus tendon in 40 patients with chronic rotator cuff tears undergoing surgery were analysed using histological and contempary immunocytochemical techniques. Sections were stained with primary antibodies against PCNA (Proliferating cell nuclear antigen), CD34 (QBEnd 10), CD45 (Leucocyte Common Antigen), CD68, D2-40 (Lymphatic Endothelial Marker) and Mast Cell Tryptase. A histological analysis was performed with Mayer’s Haemotoxylin and Eosin, Congo Red and Toluidine Blue.
The reparative response and inflammatory component (figure 1) of the tissue was seen to diminish as the rotator cuff tear size increased. This was evidenced by increasing degeneration and oedema, reducing fibroblast proliferation, reduced thickening of the synovial membrane and reducing vascularity. Macrophage, other leucocyte and mast cell numbers also reduced as tear size increased. Large and massive tears revealed a higher degree of chondroid metaplasia and amyloid deposition when compared to smaller sized tears. There was no association with the patient’s age or duration of symptoms.
Small sized rotator cuff tears retain the greatest potential to heal and have a significant inflammatory component. Tissue from large and massive tears is of such a degenerate nature that it may never heal and this is probably a significant cause of re-rupture after surgical repair in this group. Selection of patients for reconstructive surgery should take into account the composition and healing potential of tendon tissue and its relationship to tear size in chronic tears of the rotator cuff.
This is a prospectively randomised blind study to determine which treatment- Manipulation under anaesthesia (MUA) or Hydrodilatation is more effective for proven shoulder adhesive capsulitis. Forty patients with adhesive capsulitis were randomised to receive either of the two treatments. All patients were assessed by an independent investigator, with Visual Analogue Scores (VAS) and Constant scores, at three intervals “ pre-treatment, 2 months and 6 months following treatment. Twenty patients (mean age 55.2 years (44–70); duration of symptoms 33.7 weeks (8–76)) received hydrodilatation and eighteen (mean age 54.5 years (39–69); duration of symptoms 43.5 weeks (12–102)) underwent MUA (two patients dropped out). VAS scores in the hydrodilatation group were pre treatment 6.1 (n=20), 2.4 (n=18;p=0.001) at 2 months and 1.7 (n=17; p=0.0006) at 6 months. VAS scores in the MUA group were pre treatment 5.7 (n=18), 4.7 (n=16) at 2 months, and 2.7 (n=15;p=0.0006) at 6 months. The VAS pain scores in the hydrodilatation group were significantly better than the MUA group over the six month follow-up (p< 0.0001)Constant scores in the hydrodilatation group were 30.8 pre treatment, 57.4 (p=0.0004) at 2 months and 65.9 (p=0.0005) at 6 months. In the MUA group, Constant scores were 38 pre treatment, 60.2 (p=0.001) at 2 months and 59.5 (p=0.0006) at 6 months. Constant scores in the hydrodilataion group were again significantly better than the MUA group over the six month follow-up (p= 0.02). At final follow up, 93% of patients were satisfied or very satisfied after hydrodilatation compared to 71% of those receiving an MUA.
We have for the first time prospectively measured the outcome of two treatments “ MUA and hydrodilatation in patients with adhesive capsulitis. Our results suggest that although both treatments are effective in the majority of patients, hydrodilatation is significantly more effective than a manipulation under anaesthesia.
To study the outcome of complex proximal humeral fracture sequelae (Type 3 & 4) treated with the Delta III Total Shoulder Replacement (TSR) Prosthesis. This is a prospective outcome study involving 10 patients mean age (71.5 yrs). All patients failed conservative treatment of proximal humeral fractures. Mean time from injury to surgery was 10.5 (+/− 11.5) months. All patients underwent a Delta III TSR via McKenzie approach by a single surgeon. Patients were assessed clinically with Constant scores, asked whether they were satisfied, and radiologically with plain film radiographs. Since last review one patient has died. Mean time at follow up was 20.8 months post-operation (12 “32 months). Three patients had undergone early revision for dislocation. Since last review two patients have developed deep infection, one treated with washout and suction drain, one with removal of prosthesis. One patient has a clinical diagnosis of complex regional pain syndrome. Three patients are very happy with the outcome of surgery, one is happy, one unhappy and four very unhappy. The mean pre-operative Constant scores was 8.9 (2–15), at first review 44.4 (15–96) and now 35.8 (4–76). The mean pain score on a visual analogue scale (0–10) was 3.6 (0–10). Radiographs showed no progressive notching of the glenoid in any patient. Mean flexion was 93 degrees (10,170), mean abduction 61 degrees (10,100) and mean external rotation was “1 degrees (−20,20).
This is a new technique for treating proximal humeral fracture sequelae. Some individual results are excellent. There has been a high complication rate and a significant rate of poor results. At this time we cannot recommend the reverse geometry prosthesis for the treatment of proximal humeral fracture sequelae.
This study was performed to evaluate the efficacy of interscalene block combined with general anaesthetic for common surgical procedures of shoulder and the potential of this procedure for providing day case shoulder surgery.
114 consecutive patients undergoing shoulder surgery were audited using a questionnaire immediately after operation and at 6, 12 and 48 hours after operation. Pain scores were recorded based on visual analogue scale, type of operation, duration of operation, postoperative stay and complications. At 48 hours overall pain control was assessed and patients were asked about having their operation done as a day case.
104 patientswho responded to the questionnaire were included in the study. There were 52 males and 52 females with overall mean age of 49 years (range 18–85). 75 patients underwent arthroscopic decompression, 15 patients underwent arthroscopy assisted mini open cuff repair, 9 underwent open glenohumeral stabilisation and the rest five underwent open Mumford procedure. Mean operation time was 47 minutes (range 25–90). 97 (93%) patients had no pain immediately postoperatively, 76 (73%) patients were pain free at 6 hours and 39 (38%) were pain free at 12 hours. Mean pain scores art 6 hours was 3 and at 12 hours were 4. 101 patients said their pain was well controlled throughout the first 48 hours by simple oral analgesics. 84 (83%) patients expressed an opinion that they could have been managed as day case provided they were adequately counselled about the procedure. 6(5.7 %)patients showed signs of Horner’s syndrome that resolved by 12 hours. No other complications related to inter scalene block occurred.
This study has shown that interscalene block is a safe procedure providing sustained adequate pain relief after shoulder surgery. It could allow a high percentage of patients undergoing shoulder surgery to be discharged home on the day of surgery.
The aim of this randomised, controlled trial is to compare subacromial steroid injections, physiotherapy and both interventions with a control treatment in early painful arc of the shoulder.
Over a six-month period patients with “painful arc”, of less than six months duration, were recruited via their GPs. Eligible patients were consented to enter the trial and were then randomised, by sealed envelopes, to one of four arms of the study: control (normal analgesia and/or non-steroidal anti-inflammatory medication), a specified and repeatable Exercise and Manual Therapy Package (EMTP), a course of up to three subacromial steroid injections or both the EMTP and the steroid injections. The interventions and clinic follow-ups were over an 18-week period. A final postal questionnaire was sent out at one year. The progress of the patients was monitored using the Oxford Shoulder Score (OSS) and the SF36 general health questionnaire.
Seventy-nine GPs referred 186 patients, of whom 112 were randomised (Control=27, EMTP=29, Injections=28, Both=28). 64 patients were female and 48 male. The mean age was 54.5 years (range 23–88 years). Ninety patients completed the trial (Control=20, EMTP=22, Injections=26, Both=22). Sixty-two returned the follow-up questionnaire. By paired sample t-tests, no significant differences were found between the OSS scores or SF-36 (physical health total) at the beginning and end of the intervention period, or at one year. Two patients in the injection group went on to surgery, along with one each in the control and EMTP groups.
We have found no significant differences in outcome between steroid injections, a physiotherapy package, both treatments, or symptomatic treatment in our group of patients presenting with symptoms of painful arc of the shoulder.
The purpose of this study is to report the 1 to 5 year results of arthroscopic Rotator Cuff repairs.
Between November 2001 to May 2003, 115 consecutive patients were operated (73 males and 42 females) with arthroscopic repair. 13 patients were lost to follow up, leaving 102 patients available for follow up. Patients were evaluated using the Constant score, satisfaction levels and ultrasound scan to evaluate cuff integrity. Failures were defined as dissatisfied patients and those who had had a re-operation. Re-tear rate was recorded.
The mean follow up time was 23.8 months (range 12–61). Mean age was 57.3 years (range 23–78). 47% had a history of trauma. There were 107 patients (95.5%) with full thickness tears and 5 (4.5%) had partial thickness tears. Of the full thickness tears, 8 (7.6%) were massive in size, 36 (34%) large, 44 (41.5%) medium and 18(17%) small. Isolated Supraspinatus (SSP) tear was recorded in 83.5% and subscapularis tear in 7 %. A combination of SSP tear with infraspinatus and teres minor was found in 9.6%.
86% had Acromioplasty (ASD) with or without an AC joint excision arthroplasty. Two patients had Bankart repairs in addition at the time of cuff repair.
The mean pre op Constant score was 40.9 points (95% CI 37.3 to 44.5), which had improved to 84.8 (CI 82.2 to 86.9) at last follow-up. 78% returned to same work and 82% returned to pre injury leisure activity. There were 20 re-tears (19.6%). eight of the 102 patients were not satisfied. Five of these patients had revision operation.
Arthroscopic cuff repair shows high satisfaction rate (92%) and good functional results with 20% re-tear rate, while offering all the advantages of arthroscopic surgery.
Thin section CT scanning has shown a higher rate of pseudarthrosis with ALIF than previously reported with standard radiological modalities. Cadaveric studies have demonstrated that posterior stabilisation would increase stiffness of the motion segment and is likely to enhance the rate of fusion with ALIF. The results of thin section CT scanning of ALIF, with and without posterior stabilisation, has not been reported previously.
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.
The questionnaire comprised statements paired with a 7-point scale, ranging from 0 (do not agree) to 6 (completely agree), therefore respondents marking 0–2 would be disagreeing, and those marking 4–6 would be agreeing with that statement.
97/109 (90%) respondents agreed the patient could continue to live normally, 38 (35%) would say the scan is essentially normal and 51 (47%) would not. 21/109 (19%) would say the scan is significantly abnormal and were likely to give restrictive movement advice (13/21 v 26/88: p=0.01). Clinicians who advise against painful movements were likely to seek a surgical opinion (19/32 v 13/77: p< 0.0001)
percentage of patients with ‘acute’ (<
12 weeks) and ‘chronic’ (≥12 weeks) LBP [H: acute LBP = 4.7%, chronic LBP = 95.3%; P: acute LBP= 84.7%, chronic LBP= 15.3%; χ2 = 120.34, df=1, p<
0.001]; mean number of treatments [H=5 treatments (SD=3.8); P=2.5 treatments (SD=2); t = −6.0, df = 123, p<
0.0001]; median duration of treatment [H=6 weeks (IRQ=4-12); P=1 week (IRQ=0.14-2) p<
0.0001].
Lumbar facet joint pain cannot be reliably diagnosed clinically, the International Spinal Injection Society recommends two diagnostic local anaesthetic blocks before radiofrequency (RF) denervation [
Scoring systems may improve diagnostic accuracy. The two most popular scores disagree on the interpretation of pain induced by extension/rotation:
‘Cochin Criteria’ [
Helbig &
Lee [
Patients were selected clinically and did not undergo diagnostic blocks.
Cochin criteria, Helbig & Lee scores, work status, and outcome were taken from the case notes.
Likelihood ratios were calculated for the scores, their individual components, and work status.
Pain on extension/rotation weakly indicates a poor response to facet joint denervation.
X-rays do not help with the diagnosis.
Social factors may be more important than clinical signs.
MEDLINE (1951→) EMBASE (1974→) CINAHL (1982→) PsycINFO (1806→) AMED (1985→) PEDro.
In addition, national guidelines and key texts were hand-searched. Each red flag identified in the literature was classified using The Guidelines Development Group’s format (where 100% coverage = ‘unanimity’; 75–99% = ‘consensus’; 51–74% = ‘majority view’; and 0–50% = ‘no consensus’), and the findings summarized.
CONCLUSION: In our model the prevailing osmolality was a powerful regulator of GAG accumulation by cultured nucleus cells. In vivo prevailing osmolality is governed by GAG concentration. These results thus indicate GAG synthesis rates are regulated by GAG concentration, with implications both for the aetiology of degeneration and for tissue engineering.
reported practice (based on a vignette of a patient with non-specific LBP) beliefs and attitudes about LBP(using the HC-PAIRS, Rainville et al 1995)
Thirty patients with were treated with Dynesys system. All had discography and positional MRI preoperatively and nine months post-operatively.
The patients were divided in to two groups. The first in which only Dynesys was used and the second in which Dynesys was used with fusion.
The ROM of the end plate angle at the instrumented segments in group-A reduced from 5.24o to 2.18o{difference 3.06o(p< 0.005)} and in group-B reduced from 6.69o to 2.46o,{difference 4.23o(p=0.008)}. The ROM of the end plate angle at adjacent level in group-A changed from 8.26o to 7.0o {reduction 1.26o(p=0.388)},while in group-B increased from 6.91o to 8.64o, {difference 1.73o(p=0.149)}
The mean anterior disc height in-group A reduced by 1.43mm (p< 0.005) from 9.75mm to 8.32mm, and the posterior one was increased from 6.27mm to 6.77mm {difference of 0.5mm,(p=0.008)}. In group-B the anterior disc height reduced by 1.11mm (pre-op=10.44mm,post-op= 9.33mm,p=0.049) and the posterior one by 0.16mm (pre-op 6.98mm to post-op 6.82mm,p=0.714).
Stature change has been used to indicate the stress associated with specific tasks. Interpretation of stature change is often related to the diurnal change found in healthy participants. However, it has not been determined whether individuals with chronic Low Back Pain (LBP) experience a similar diurnal pattern. The aim of this study is to investigate diurnal stature change in individuals with and without CLBP.
Eight participants with LBP and eight matched asymptomatic controls took part in the investigation. Twenty-four stature measurements were made across a 24 hour period using a standing stadiometer. Differences between the two groups were analysed using two-way ANOVAs (time x group). Correlations between stature change and levels of low-back discomfort were examined using Spearman’s rho.
A clear diurnal variation was found for both groups, with the trough to peak variation in stature of 17.9 mm (LBP) and 17.6 mm (control) groups did not differ significantly (P > 0.05). Both groups experienced their greatest stature change in the 1st hour after rising 31.3% (LBP) and 44.6% (Control) of the total stature change. Towards the end of the day stature in the chronic LBP group reached a plateau while the control group continued to shrink. Between 2pm and 6pm both groups demonstrated a previously unreported recovery of stature. Reasons underlying this finding could be hormonal, behavioural or due to hydration status and require further investigation. A significant correlation was found between low-back discomfort and stature change in the LBP group, whereby when stature was lost greater discomfort was experienced and when stature recovery discomfort decreased.
The effect of pain on lifestyle is paramount to the patient, physical symptoms for the clinician. Acknowledging this disparity may reduce frustration experienced in consultations as both have different communication and management needs. Indicating treatment success by focusing on lifestyle improvement in patients rather than reductions in physical symptoms may be more appropriate.
We conducted a community survey of the prevalence, health impact and location of chronic pain. We explored the relationship and patterns of chronic pain that commonly occur, with a view to understanding why some treatment approaches may be more appropriate than others for particular patterns of pain.
In 2002, 2504 randomly sampled patients from 16 General Practices in the South East of England responded to a postal questionnaire about chronic pain. Those with chronic pain completed a pain drawing. We calculated descriptive statistics, relative risk and correlations to identify the associations and risks of having linked pain.
The highest prevalences were low back (23%), shoulder (20%) and knee (18%) pain. The number of pain sites experienced was age related in men but less so in women. Lower body pain was more age related than upper body and non musculoskeletal pain. Multi site pain was more common than single site pain. Of those with low back, knee and shoulder pain, 14%, 4.5 % and 1.9% had only low back, knee and shoulder pain respectively. Correlations and minimum spanning trees showed that chronic upper and lower body pain are distinct and axial pain link the two.
Chronic pain is more likely to be multi site, especially at middle age. Research, physical treatments and approaches to managing chronic pain are often site specific, therefore specialising treatment to one area eg low back pain often negates the bigger issue. This may help explain the self perpetuating problem of persistent chronic pain.
Focus group methodology was used to explore the experiences, beliefs and treatment expectations of chronic low back pain (LBP) patients in order to identify what components of treatment they considered to be of most value: specific emphasis was placed on the importance of advice and exercise to these patients.
Removing the non-core answers from the LBOS gave an R squared value of 0.130
Removing the weighting of the LBOS gave an R squared value of 0.132
Removing the non-core questions and weighting system of the LBOS gave an R squared value of 0.133
This study aimed to assess whether patients with different pain sources could be differentiated using the Oswestry Disability Index (ODI) (a validated patient questionnaire scoring ten different aspects of pain and function in patients with LBP; higher scores correlating with greater disability).
Patients with disc pain had significantly greater overall disability and scored higher for sitting, sleeping and social activity than those with facet or sacroiliac pain as judged by the 95% confidence limits of the median (p< 0.05). Patients with facet pain scored higher for walking and standing compared to those with sacroiliac pain.
For disc pain scores were higher for sitting and standing than for walking, and for facet pain scores were higher for standing than for sitting or walking.
The aim is to study whether cannabis has any role as a pain relief agent in chronic degenerated disc disease without spinal stenosis.
This suggests that the transverse process or its associated structures have an important stabilizing function on the spine.
Demographics, operation type and epidural rate were all correlated with the need for catheterization. In all cases the residual volumes were recorded.
The average residual volume at catheterization was 936mls, with a maximum of 2200mls. All patients were managed with intermittent catheterisation, most, (63%) requiring only a single episode before spontaneously voiding.
We were therefore unable to predict which patients would require catheterisation. Questioning and bladder palpation was found to be unreliable when assessing overdistention.
Our study demonstrated that patients undergoing spinal surgery using epidural analgesia should be closely monitored in order to prevent overdistention of the bladder and has led to a proactive regimen for spinal patients with epidural analgesia in our unit.
Degeneration of the intervertebral disc results in patent cracks [1] and a decrease in osmotic pressure associated with loss of fixed charges. The relationship between mechanical load and damage in the disc is very poor [2]. This finding is at odds with physical intuition. The subject of this study is relationship between the development of patent cracks and the decrease in osmotic pressure in the degenerating disc in the light of the physics of swelling [3–7]. We restrict the experimental part of this study to hydrogel, thus avoiding complications associated with biological variability. The finite element modelling [6,7] used in this study catches salient features of stress profiles measured by Mc Nally and al.
Thin hydrogel samples with a crack of 5 mm are used. The crack opens as a result of decreasing osmotic pressure in the experiments and in the simulation. The initial uniform stress distribution turns into a distribution with a decreased average stress level and a high stress around the crack tip. A decrease in osmotic pressure opens an existing crack in swelling materials independently from external mechanical load. Hence, disc degeneration causes the overall stress to decrease, while local stress around a crack tip increases. This mechanism may explain why damage in the disc is so poorly correlated with mechanical load [3] and why the degenerated disc is characterized by patent cracks [1]. The process of crack opening in the degenerating disc is comparable to the crack development in an aging oaken beam, while loosing its turgor.
Isolated arthrodesis of the subtalar joint has the advantage that it preserves some motion at the midfoot. In cadaveric studies, movement at the Talonavicular joint is reduced by up to 74% and at the Calcaneocuboid joint by up to 44%. This allows some midfoot flexibility, which would not occur with a triple arthrodesis.
There are several methods of performing a subtalar arthrodesis, broadly divided into extra or intra articular techniques, using structural or cancellous bone graft and a variety of fixation methods.
Earlier studies on primary arthrodesis have shown rate of non union from 0 – 6%. More recently, larger studies have reported higher rates of non union from 14 – 17%.
We present the results of 95 subtalar fusions performed with a standard technique, using one screw from the calcaneum to the talar dome, with 100% follow up.
Between 1993 and 2003 the senior author performed 105 subtalar arthrodeses. We performed a retrospective chart review. All patients with a primary subtalar fusion were included. All cases had been refractory to conservative therapy.
The senior author reviewed all patients until fusion had occurred or a diagnosis of nonunion was established. Fusion was diagnosed when the patient were pain free while fully weight bearing, with a clinically rigid subtalar joint and radiographs showing trabeculae crossing the arthrodesis. A CT scan was performed in all cases where nonunion was suspected, and the patient complained of persistent pain.
A total of ninety five subtalar arthrodeses were performed in ninety two patients. All were reviewed with clinical and radiological examination, until union had occurred or nonunion diagnosed. The average time to union was 5.0 months, range 3 – 12 months. The outcomes, graded using the method of Angus and Cowell, were 21 Fair, 7 Poor and 67 Good results
We aim to assess the outcome of ankle arthrodesis performed for painful osteoarthritis in the presence of a coronal plane deformity of 20 degrees or more. To our knowledge this is the first reported series of such a cohort of patients. We have a consecutive and complete series of 24 patients with 26 ankle arthrodeses which were all performed for painful osteoarthritis in the presence of large coronal plane deformity. These patients have a minimum of twelve months clinical follow up. The results showed a low non union rate of 8% (2 ankles). These have subsequently been refused satisfactorily, and were excluded from further analysis. The results of the remaining 24 ankles which united primarily show that they were very pleased with the outcome of their surgery. AOFAS scores were used to measure pain and function both pre operatively and post operatively. These scores showed large improvements for both pain and function, and had a high statistical significance (p< 0.0005). All patients improved in their walking distance and many patients reduced their need for walking aids. Stair climbing ability was also improved in some patients. It is recognised that an ankle arthrodesis usually relieves pain but does not result in a normal gait and full function. We feel that the high level of patient satisfaction in this series was due to the combination of deformity correction, restoring a functional foot position, and achieving a painless ankle. Arthroplasty of the ankle is a good procedure for relief of pain and restoration of function. However In the presence of a large coronal plane deformity ankle arthroplasty is known to fare badly with early failure. Therefore for patients with painful osteoarthritis and a coronal plane deformity of 20 degrees or more, we recommend ankle arthrodesis as the procedure of choice.
The standard protocol described by Ponseti was used for treatment.
Mean period of follow up was 12 months (6– 30 months).
Evaluation was by the Pirani club foot score.
Average number of casts required were 6.
Tenotomy was required in 80% of feet.
At the latest follow up approximately 15% of feet recurred following treatment and were managed surgically. Poor compliance was noted to be the main cause of failure in these patients. We have recently modified our splint and hope this will address some of the reasons for poor compliance. There was also a smaller subgroup of patients (approximately 5%) which failed to respond to the treatment regime and could not be brought to the point were tenotomy would be appropriate.
A visual analogue scale (VAS) was employed as a direct indicator of pain and indirectly, supplemental analgesic requirement. Measurements were made pre-operatively and postoperatively.
Age, weight and tourniquet times were compared with Mann Whitney U test and Chi-square. Pain scores and analgesic requirements were compared using ANOVA at a 5% significance level.
Arthrodesis of the ankle joint gives satisfactory short and medium-term results; however, in the longer term, it frequently leads to sub-talar and mid-tarsal osteoarthritis which is difficult to treat. Use of mobile bearings have significantly improved the results of ankle replacement. This a mid term follow up (1 to 5 years)of Buechel-Pappas ankle replacements performed by the senior author.34 total ankle replacements performed by one surgeon from October 1999 to May 2004 were reviewed retrospectively. Pre and post operative VAS scores, AOFAS scores were evaluated to find patient satisfaction and outcome. Tourniquet time as recorded in operation notes showed the learning curve for the procedure. Males : Females- 1:1.4. Mean age was 65 years (range : 33 to 83). Indication for surgery was primary osteoarthritis in 13, post traumatic arthritis in 14 and rheumatoid arthritis in 8. Average VAS score was 8.2 pre operative and improved to 2.0 at follow-up. AOFAS score improved from 39.1 to 72. Operating time averaged 113 minutes in 1999 and 85 in 2004. Significant complications were medial impingement (8) out of which 3 patients needed further surgery, intra-operative malleolar fractures (medial 4, lateral 1 and posterior 1, all healed successfully) and injury to cutaneous nerves (4) 3 patients had superficial infection which settled with antibiotics, but there were no cases of deep infection. 58 % were very happy, 32.5 % were happy, 9.5 % were not happy with the result. 2 patients had ankle fusion on the opposite side earlier, both were happier with the replaced side. Ankle replacements appear to offer a good alternative to fusion in selected patients. There is a significant risk of minor complications. Medial impingement may need further debridement at a later stage.
Arthritis in the ankle causes considerable malalignment in the anteroposterior plane. The DTL is not affected by the destruction of the tibiotalar joint and is independent of slight variations in the positioning of the foot and radiological magnification.
Radiographs of 200 cases of TAR were reviewed. The anterior and posterior outlines of the talus could not be seen in all cases (e.g. preoperative talonavicular fusion). As a result 49 cases of inflammatory arthritis (49 of 119) and 6 of osteoarthritis (6 of 81) could not be assessed.
There was a lesser tendency for subluxation in the inflammatory group of patients although the body of the talus itself was more deformed. The average preoperative value was ‘36.1’ and the post operative value was ‘38.9’.
This study does not refute the distal metatarsal articular angle as an entity, but does confirm the inaccuracy of extrapolating the DMAA from plain AP radiographs.
Patients who failed conservative treatment and underwent surgery had histological examination of achilles tendon and histochemical analysis for isomers of NOS (eNOS and iNOS) as a marker of NO production.
Histological examination did not show any difference in collagen synthesis or remodelling between the 2 groups and there was no evidence of stimulated wound fibroblasts in the GTN group. There was no difference between the groups in the expression of eNOS or iNOS.
A comparison was made between this device and the K9 walker which has been shown to be a liberating walking aid indoors. Tasks from activities of daily living, productivity and transfers were included. Assessment was undertaken by the Occupational Therapy Team.
The hands free crutch was also compared with non weight bearing using two crutches to gauge performance outdoors. Assessment of ease of use and safety was undertaken by the Physiotherapy Team.
Although speed was significantly greater (p< 0.0001.) using two crutches, the hands free crutch permitted safe outdoor mobilisation on even or uneven ground, up and down slopes with a gradient of 1 in 10 and up and down stairs. Good single leg stance stability was predictive of ease of use and safety for the hands free crutch.
Morton’s syndrome is an entrapment of a digital nerve between the metatarsal heads in the foot causing pain between the metatarsal heads. 41 subjects with signs and symptoms of Morton’s syndrome were prospectively examined with an ultrasound scan and the size of the bifurcation of the interdigital nerve was recorded if it was visible. Each subject completed a Visual Analogue Scale and short form McGill Pain Questionaire before an injection of local anaesthetic and corticosteroid was administered. The subjects were reviewed after 6 weeks and the pain scores repeated.
26 subjects had positive ultrasounds with a mean width of 5.1 mm, range 2.7–9.8 mm and 15 subjects had negative ultrasounds. Differences in mean ranks of VAS scores between the two groups were borderline statistically significant for scores before injection (p=0.064). Difference in mean rank of VAS score was significant after injection (p=0.013).
Differences in mean ranks of MPQ scores were borderline statistically significant for changes in scores (p=0.062). Difference in mean rank of MPQ score was significant after injection (p=0.007). None of the correlations between nerve width and any of VAS or MPQ outcome measures were statistically significant.
This study demonstrates that the larger the neuroma on the ultrasound, the more painful it is for the patient. This study suggests that patients who have a small or absent neuroma demonstrated on the ultrasound scan are more likely to have their pain reduced to an acceptable level with an injection of local anaesthetic and corticosteroid than those patients with a large neuroma. Ultrasound examination is a useful tool in the management of patients with Morton’s syndrome.
We performed two independent randomised controlled trials to assess the potential benefits of immediate weight-bearing mobilisation for Achilles tendon ruptures. The first trial on surgically treated patients provides strong evidence of improved functional outcome for patients mobilised fully weight-bearing after operative repair of their Achilles tendon rupture. The two cases of re-rupture in the treatment group suggest that careful patient selection may be required as patients need to follow a structured rehabilitation regime.
The second trial performed upon non-operatively treated patients provides only weak evidence of a functional benefit from immediate weight-bearing mobilisation. However, the practical advantages of immediate weight-bearing did not predispose the patients to a higher complication rate. In particular there was no evidence of tendon lengthening or a higher re-rupture rate. We would therefore advocate the use of immediate weight-bearing mobilisation for the rehabilitation of all patients with rupture of the Achilles tendon.
Claw toes are treated by a variety of soft tissue and bony proceduresbased on the severity of the deformity. We evaluated the results of Stainsby procedure for claw toes. This is a retrospective analysis of the results of Stainsby procedure for claw toes of the foot done by a single surgeon over a 10 year period. All patients who had claw toes,secondary to Rheumatoid and Non rheumatoid causes and treated by this procedure were included in the study. All the patients operated between Jan 1995 -Dec 2004 and who had minimum follow-up of 6 months after surgery were included in the study. Follow up evaluation was by clinical examination, review of case notes and telephone conversation.
42 patients underwent this procedure of which 38 were available for evaluation. Average follow-up was 43.5 months (6–110months). 26 rheumatoid and 21 non-rheumatoid feet were evaluated based on the AOFAS score. The mean AOFAS score was 76.5. The scores for the Rheumatoid and Non-Rheumatoid groups were 81.5 and 72.6 respectively.81% were satisfied with the result of the operation and 83% would recommend this surgery for friends and relatives. Six patients had superficial infection, 2 had broken k-wires, 2 had DVT, and 2 had recurrence of deformity.
We conclude that Stainsby procedure for claw toes is a procedure which has good results in the long term and can be taken up as a procedure of choice for severe claw toes.
One of the factors that influence the outcome after Achilles tendon rupture is gait abnormality. We prospectively assessed 14 patients with Achilles tendon rupture and 15 normal control subjects using an in-shoe plantar pressure measurement system. There was a significant reduction in peak mean forefoot pressure in the early period of rehabilitation (p < 0.001). There was a concomitant rise in heel pressure on the injured side (p=0.05). However, there was no difference in cadence, as determined by the duration of the terminal stance and pre-swing phases as a proportion of the total stance component of the gait cycle. The forefoot pressure deficit in the Achilles tendon rupture group was smaller when assessed six months after the injury but was still significant (p=0.029). Pedobarographic assessment of patients after Achilles tendon rupture confirms that there are marked abnormalities within the gait cycle. Rehabilitation programmes which address these abnormalities may improve outcome.
The Clinical assessment was based on modified American Orthopaedic Foot and Ankle Society’s hallux-metatarsophalangeal scale. The subjective assessment was done by a questionnaire and radiological assessment was done by using digital radiographs.
Lumps of the foot present relatively infrequently to the orthopaedic service. There have been very few published studies looking at presenting characteristics or the differential diagnosis of such lesions. We report our experience of foot lumps treated surgically looking at the patient demographics, presenting characteristics, diagnoses encountered and the diagnostic accuracy of the surgeon. All patients who underwent excision or biopsy of a foot lump over a period of 4 years were studied; 101 patients were identified. Average age was 47.3 years (range 14–79); there was a significant female preponderance with 73 females and 28 males (p< 0.0001). Pain was the single most common presenting complaint followed by footwear problems. Only three patients attended because of cosmetic reasons and neurological symptoms were very rare with only one patient complaining of paraesthesia. Certain lesions were more commonly encountered in specific zones of the foot. 32 different histological types were identified, ganglion cysts were the most commonly encountered lesions and there was only one malignant lesion encountered in this study. Only 58 out of the l01 lumps were correctly diagnosed prior to surgery.
We have shown that there are a wide variety of potential diagnoses, which have to be considered when examining a patient with a foot lump. There is a low diagnostic accuracy for foot lumps and therefore surgical excision and histological diagnosis should be sought if there is any uncertainty.
The patients’ overall satisfaction with the result of their foot surgery was determined using a Likert scale and the results can be seen in Table 1.
Patients in the podiatric surgical group were significantly more satisfied with the result of their foot surgery than those in the orthopaedic group (p< 0.008; Mann Whitney U test).
Similar statistically significant differences were also seen between the two groups relating to patient satisfaction with their pre and post-operative consultations and information concerning their proposed surgery and its outcome.
CT- scan as an management tool is being used extensively in managing calcaneal fractures. We set out to see if a CT-scan makes any difference to the management plan as obtained by looking at the plain radiograph. We also looked at the correlation with the actual management.
The foot pressures were measured in Kilopascals(Kpa). Independent T-tests was used to compare mean pressure distributions in the six anatomical divisions. We found the mean pressures through the 5th metatarsal head – 217(t=−2.32,p< 0.05) and midfoot 94(t=−3.17, p< 0.05), were significantly higher when compared to pressures in normal subjects (table 1).
The aim of the current study is to compare the compression forces achieved by mini compression screws on cortical and cancellous bone models.
Proximal fifth metatarsal fractures distal to the tuberosity, also known as Jones’ fractures, are troublesome fractures to manage with a high incidence of delayed union and nonunion.
We conducted a retrospective study of 32 patients with fractures of the fifth metatarsal distal to the tuberosity over a three year period. The aim was to assess healing with non-weight bearing and variations of weight bearing mobilization including minimal, partial and full weight bearing. This is one of the largest reported series of such fractures. These fractures were classified as acute fractures (14 fractures), fractures with features of delayed union (15 fractures) and fractures with features of nonunion (three fractures) at presentation according to the radiological classification used by Torg in 1984. These patients were treated in a plaster cast and mobilised either non-weight bearing or with variations of weight bearing. These patients were followed up for a mean of 16 months.
Our findings correspond with those observed by Torg and we describe a correlation between the radiological appearance of the fracture at presentation and the clinical course. Prevailing guidelines for the management of these fractures are ambiguous. A standardized classification is important because there is great variability in the types of fractures and appropriate treatment. It is important that radiological features are correlated with clinical features and appropriate treatment instituted. The treatment of choice for acute fractures is immobilization of the limb in a below-knee non-weight bearing plaster for 6 to 8 weeks. Fractures with delayed union may eventually heal if treated non-operatively, although this may take up to 20 weeks. An active athlete will benefit from early surgery. Fractures with symptomatic nonunion require surgery.
Morton’s Metatarsalgia is a painful condition and can often be debilitating. The value of surgical exicion has been doubted due to low success rate of surgical intervention.
Shape memory phenomenon whereby the metal changes its characteristics depending on the ambient temperature it is exposed to is well described in the metallurgical literature. In cold conditions (0–5° C) the alloy becomes plastically deformable and its shape can be changed at will, but would rapidly regain its original shape and strength at higher temperatures. This study assesses the effectiveness of shape memory staples as a method of internal fixation in foot and ankle surgery.
All patients who underwent foot and ankle surgery in which Memory® staples were used for fixation were included in the study. The patients were evaluated with regard to period of immobilisation in cast, period of restricted weight bearing and time to radiological joint fusion or union of osteotomy.
Memory® staples had been used in a total of 40 procedures; 13 procedures (6 MTPJ fusions, 7 Akin osteotomies) were done in the forefoot while the rest were carried out in the mid or hind foot. Bone grafting was used only in one hind foot arthrodesis. A strong arthrodesis or union was achieved in all the patients. The average time to fusion was 7.2 weeks (range 6–12) with an average period of immobilisation of 4.3 weeks (range 0–12). The average time to full weight bearing was 5.2 weeks (range 0–6). Breakage of the staple was noticed in one patient but the joint went on to unite satisfactorily. Staple back out or displacement was not noticed in any of the cases.
The early experience with the use Memory® staples in foot and ankle surgery is encouraging; we did not encounter any technical problems and there is a suggestion that these implants may reduce the time to fusion/ healing thereby reducing the recovery time following foot and ankle surgery.
Claw toes are treated by a variety of soft tissue and bony proceduresbased on the severity of the deformity. We evaluated the results of Stainsby procedure for claw toes. This is a retrospective analysis of the results of Stainsby procedure for claw toes of the foot done by a single surgeon over a 10 year period. All patients who had claw toes, secondary to Rheumatoid and Non rheumatoid causes and treated by this procedure were included in the study. All the patients operated between Jan 1995 -Dec 2004 and who had minimum follow-up of 6 months after surgery were included in the study. Follow up evaluation was by clinical examination, review of case notes and telephone conversation.
42 patients underwent this procedure of which 38 were available for evaluation. Average follow-up was 43.5 months (6–110months). 26 rheumatoid and 21 non-rheumatoid feet were evaluated based on the AOFAS score. The mean AOFAS score was 76.5. The scores for the Rheumatoid and Non-Rheumatoid groups were 81.5 and 72.6 respectively.81% were satisfied with the result of the operation and 83% would recommend this surgery for friends and relatives. Six patients had superficial infection, 2 had broken k-wires, 2 had DVT, and 2 had recurrence of deformity.
We conclude that Stainsby procedure for claw toes is a procedure which has good results in the long term and can be taken up as a procedure of choice for severe claw toes.
Thirty patients underwent tibio-talo-calcaneal fusion using an interlocking arthrodesis intramedullary nail device with locking screws. Although the nail is described as being stiffer in flexion, rotation and cantilever bending it was noted that the placement of the locking screw holes were not sufficiently in-tune with the variations found in nature. The placement of the holes and locking screws with relation to the heights of the talus and calcaneum were measured on post operative xrays and conclusions drawn from the variations found. It was felt that the intramedullary nail is a good device when used for tibio-talo-calcaneal fusion but that the design could be improved in order to improve patient outcome.
Ankle replacements appear to offer a good alternative to fusion in most arthritic conditions. Use of mobile bearings have significantly improved results of ankle replacement. These have a significant minor complication rate including nerve injury, fractures. One of the significant complications noted in our series was medial impingement. 34 Buechel-Pappas total ankle replacements performed by the senior author from October 1999 to May 2004 were reviewed retrospectively. Mean follow up of 2.8 years. 8 patients reported medial impingment symptoms at follow up. 3 patients underwent repeat surgery for this problem. One patient underwent arthroscopic debridement of scar tissue and impinging bone by another surgeon which gave good symptomatic relief. Two other patients had tibialis posterior tendonitis and underwent surgical decompression of the tendon. Both were found to be having degenerative tendons with partial tears. We discuss the findings, literature review and other complications of ankle replacements as well. Whether medial impingement is due to implant design or inherent pathology of ankle has to be studied further. Other implant designs like Agility may treat arthritis in medial and lateral gutters but can still cause soft tissue impingement. Whether these are due to implant design, residual arthritis in medial recess or soft tissue pathology is uncertain. This may be caused by the cylindrical shape of talar component (the physiologic talus has a cone shape with smaller radius on medial side). This has not been proven yet, but has been addressed in newer designs like Salto and Hintegra prostheses.
Background: Since 2003 we have offered correction of bilateral hallux valgus to suitable patients as a daycase but there is nothing in the literature to support this as safe practice. Two published series support unilateral hallux valgus surgery as a daycase. We prospectively evaluated 30 bilateral daycase patients assessing complications and overall satisfaction rating.
If this and other treatable causes have been excluded, treatment with the regime described may give good symptomatic relief in the short to medium term.
Subtalar joint stiffness is an under recognized complication of ankle fractures. We set out to objectively measure its prevalence and impact on Activities of Daily Living (ADL).
60 ankle fractures included in study. All patients had contralateral normal ankle. M:F=21:39 Average age: 36 (19 – 84) Weber: A B C 21 27 12 27 patients underwent ORIF (12C + 15B) 39 patients had plaster casts for between 2 and 6 weeks. (27B + 12C) Postop regimes included early mobilization and POP application (AO recommendation) Weber A (21) treated symptomatically. Examinations for study at 3/12 and 6/12 post injury. Subtalar and ankle movements were assessed by the same examiner (as per Hoppenfeld) Subjective questions about subtalar stiffness and their impact on ADL were asked.
At 3/12, 56 patients (17A + 27B + 12C) had subjective and clinical impairment of subtalar movement. 32 patients (2A + 20B + 10C) had moderate to severe impairment (>
30%) At 6/12, 42 patients (9A + 23B + 10C) had subjective symptoms and clinical impairment of subtalar function. Of these, 26 (0A + 18B + 8C) had >
30% impairment vs. controls.
The recognition, investigation and management of osteoid osteoma has been well documented. Treatment can either be medical or surgical, studies have shown both options to have almost equal long term outcomes. However only surgical treatment involving complete excision of the lesion allows for confirmatory tissue diagnosis of osteoid osteoma especially important in cases where symptoms and signs are atypical. Several methods of surgical treatment with varying degrees of success have been described in literature. Here we describe a surgical techniques for the treatment of osteoid osteoma which enables removal of the lesion in a precise manner using a precision bone graft trephine with minimal excision of bone. This technique will be very useful in the excision of lesions in areas in which excessive excision of bone can lead to an unstable bony structure which can predispose to fracture. To our knowledge this surgical technique in the management of osteoid osteoma has not been described in the literature.
We present our results with a modified Mann-Thompson procedure in 47 patients (86 feet). Minimum follow up was 24 months.
All patients had moderate to advanced forefoot deformities.
M:F=12:35 43/47 bilateral Simultaneous procedures in bilateral cases. Popliteal block analgesia used routinely.
Medial incision centered on MTP1 joint. Minimal bony and soft tissue resection. Fixation carried out with staples (78 feet),K-wires (8 feet) Transverse incision centered on the lesser MTP joints made. Combination of soft tissue release, lesser MT head resection in cascade fashion from dorsal distal to proximal plantar performed. Lesser toe deformities treated by a combination of closed osteoclasis, soft tissue release and bony resection. Transarticular K-wire fixation then performed for all lesser toes. Bulky postop dressing and post op shoes used. Immediate FWB permitted. Transarticular K-wires removed at 4/52.
AOFAS Forefoot Scores assessed at preop,6/12,12/ 12,and24/12. Subjective patient assessment of procedure requested. Average AOFAS scores improved from 37to72(67 – 84) 40 patients extremely pleased with the results. 5 patients pleased with reservations and 2 patients disappointed with the outcome.
3 superficial wound infections 2 metal work related problems 2 early loss of lesser toe correction 3 late deformities of lesser metatarsals requiring surgery
Primary care trusts (PCTs) are encouraged to create musculoskeletal services to improve access and reduce pressure on orthopaedic clinics. Previous reports have suggested problems can arise.
A PCT with a population of 100,000 launched a musculoskeletal service in July 2004. The foot and ankle component was in partnership with the local secondary care foot team. Treatment and referral guidelines were agreed. The PCT staff reviewed GP referrals to orthopaedic clinics. They could forward letters to the acute trust orthopaedic department or initially treat the patients in primary care.
We audited referrals from October-December 2004, allowing 3 months to establish the service and 6 months follow-up.
617 orthopaedic referrals were received, including 123 (19.9%) adult foot and ankle problems. 82 patients were treated initially in primary care: 54 by the podiatrist, 20 by the physiotherapist and 8 by the specialist GP. Commonest problems were metatarsalgia (12), hallux valgus (10), Achilles tendonopathy (9), plantar heel pain (9), generalised foot pain (8) and arthritis (6). The commonest intervention was attendance at a physiotherapy programme (26) followed by advice (22), usually about shoewear, insoles (14) and injections (8). Ten patients were referred to secondary care after initial treatment in the community, all in accordance with guidelines; four were listed for surgery. Four patients failed to attend and information was missing on six.
31 referrals were sent directly to secondary care, 29 of which were according to guidelines. 9 were offered surgery, 9 had other specialist care, 6 required services which could not be accessed directly by the PCT team and 3 failed to attend.
Primary and secondary care can work together successfully to deliver services for patients with foot and ankle problems, though waiting time remains a challenge.
Arthrodesis of 1st MTP joint is a reliable procedure for hallux rigidus. We have studied the effects of first MTP joint arthrodesis on activities of daily living and leisure activities
We evaluated pre op scoring for pain, walking distance, walking up hill – stairs, foot wear, return to leisure activity and work, chronicity of symptoms, associated symptoms, radiological appearance pre op, post op and at radiological fusion and complication rate.
All patients were followed up.
The patients were contacted with questionnaire to evaluate the function after the fusion.
The patients were asked whether they would participate in the foot pressure study; which was done with the help of podiatrist at same trust.
We have tried to correlate the functional outcome and its relation to foot pressure.
We present our results in 89 consecutive patients (138 feet), minimum FU of 24/12.
Contraindications included abnormal DMMA, significant 1st MTP arthritis, hypermobility of 1st MTC joint, revision surgery.
All patients underwent a 3-in-1 procedure with soft tissue release in 1stwebspace, medial bunionectomy with capsulorraphy and basal crescentic osteotomy.
A 25 mm blade on oscillating driver was used. Fixation was staples(70%),screws(20%),K- wires(10%).
Post op, PWB, progressing to FWB at 3/52.
AOFAS forefoot scores at pre-op, 6/12, 12/12 and 24/12.
Weight bearing radiographs obtained at pre-op, 3/12, 12/12.
M:F=19:70 Age 31–79 (Mean 64) 89 patients, 138 feet AOFAS scores improved from average 42/100 preop to 76/100 at 6/12. Radiographic correction excellent in78% of patients. 74 % of patients extremely satisfied,15 %satisfied,11 %unsatisfied with outcome.
Nonunion=2 Infection=2 superficial,1 deep Recurrence of deformity at 6/12 = 2 12/12 = 2 Transfer metatarsalgia M2 due to overriding of distal M1=3
We present our four-year experience with a new minimally invasive method for ambulatory treatment of lumbar discal herniation: micro video endoscopic dissectomy.
Video endoscopic surgery associates microsurgical procedures similar to those used in conventional surgery with a very precise technique. This method was used for 50 patients presenting lumbar disc herniation diagnosed with magnetic resonance imaging using the MacNab criteria, placing priority on the neurological risk of sensorimotor deficit.
Clinical outcome was also evaluated with the MacNab criteria. These patients were able to walk early, resumed work rapidly, and had little lumbar pain and few complications.
Exact knowledge of the site of the lesion, and a better understanding of the traumatic mechanisms have led to a major improvement in the surgical approach used for the treatment of thoracolumbar fractures.
The first reports of a combined anterior and posterior approach recommended a two-week recovery period between the two stages.
It was observed however that the rate of complications was higher and that at the time of the second stage patients had a poor nutritional status which increased the rate of mortality. It was also remarked however that a sequential approach performed on the same day could be achieved.
Recently, the simultaneous anterior and posterior approach was reported by Farcy and others. Their preliminary results indicate that in terms of duration of anesthesia, blood loss, and complications, the simultaneous method is better than the sequential method.
The purpose of our work was to report an analysis of the mechanical and biological benefits of the simultaneous approach for the treatment of thoracolumbar spinal fractures.
Material and method: Among a series of 485 hips with LPCd, 148 (30.5%) with massive involvement were identified. Ninety-six (64.9%)severe forms were analyzed at the end of growth. Magnetic resonance imaging, scintigraphy and arteriography were used to better assess the femoral head and identify hips at risk. These hips were treated surgically: Salter osteotomy (SA), triple pelvis osteotomy (TO), or varus osteotomy (VA). Three groups of infants were identified according to age at diagnosis of LPCd: less than 6 years, 6–9 years, more than 9 years. Outcome was considered good (Stulberg 1 and 2, Mose good), fair (Stulberg 3, Mose fair), or poor (Stulberg 4 and 5, Mose poor).
Material and results: The heel was amputated in four children (lawn mower or bicycle spoke accidents). Cover was obtained with a sural (three first-intention) neurovascular island flap with a distal pedicle. The long-term assessment evaluated function as well as residual growth of the calcaneum. Four lawn mower accidents produced lesions involving the toes and the mediotarsal area which did not require emergency flap cover. Dorsal retractions occurred in all four cases and progressed secondarily, later requiring a good quality skin flap and dorsal release. In five children lesions of the toes, forefoot, or the entire foot occurred in five children whose foot was crushed under car (or truck) wheels or was injured during fall from a wall. In these children, the urgent or secondary skin problems predominated in the dorsal area and required a variety of flaps.
Material and method: We have treated 62 cases of Ewing tumor of the iliac bone since 1976, 36 males and 25 females, mean age 16.5 years (range 4 – 47). Thirteen patients presented primary metastases. Mean tumor size, measured by digital imaging, was 729 cm3. Adapted chemotherapy was given in all cases. Local treatment included exclusive radiotherapy in 20 patients, radiochemotherapy in 15 and exclusive en bloc extratumoral resection in 27.
Case reports: Case n° 1 was a 16-year-old girl who presented a Ewing sarcoma involving the left iliopubic ramus. No other foci could be identified on the plain x-rays, scintigraphy and bone computed tomography. Preopeartive magnetic resonance imaging revealed a metastatic focus in the neck of the homolateral femur. The two foci were resected after preoperative chemotherapy: resection of the left hemi-pelvis and resection of the upper potion of the femur with replacement with a pelvic prosthesis and and massive prosthesis for the proximal femur. Eight years later, the patient has remained in complete primary remission, consulting for orthopedic gait problems related to prosthetic loosening. Case n° 2 was a 13-year-old boy who presented an Ewing sarcoma of the upper tibial metaphysic. Preoperative magnetic resonance imaging revealed three other metastatic localizations in the homolateral femur. Bifocal resection of the tibia and the femur was performed with implantation of an active growth prosthesis. Chemotherapy was continued. Seven years later, the patient remains in primary complete remission. Lengthening the prosthesis has enabled equivalent growth for the two limbs. The patient has a normal life style excepting contact sports which are prohibited. Case n° 3 was a 17-year-old boy who presented a voluminous Ewing sarcoma of the right pelvis. Search for extension revealed a unique metastasis in the fourth lumbar vertebra. The patient was given preoperative chemotherapy before resection of the pelvic tumor then two months later resection of the vertebral metastasis. The patient died 4.5 years later from a traffic accident. He had remained in complete remission.
Discussion and conclusion: These three cases of complete long-term primary remission of patients with primary bone metastases show that like other bone sarcomas, eradication of all recognized bone metastases is essential for the prognosis of Ewing sarcoma.
all three cuts are performed via a single intra-pelvic approach; For severe extreme dysplasia (Hip Study Group classification), a two-thirds triple osteotomy is performed (original technique). Currently the best indication appears to be a young patient (less than 30 years) with moderate to severe dysplasia, without intra-articular suffering and without any sign of early stage joint degradation.
The femoroacetabular conflict is a recognized cause of hip pain in young patients. It is associated with rim tears. Two types of conflict have been described: impingement due to retroversion of the acetabulum and «cam effect» associated with insufficient head/neck offset. A recent subject of debate has been isolated treatment of the rim tear without treating the often unrecognized bone anomaly. The purpose of this study was to assess short-term outcome after surgical remodeling of the head/neck junction for the treatment of femoroacetabular conflicts.
Osteoid osteoma is a benign bone tumor usually observed in children and adults, generally in the femur or tibia. Pain relief with aspirin is a classical clinical characteristic. Computed tomography is the exploration of choice providing reliable diagnosis. Cure can be achieved with surgical resection. We present an exceptional case of osteoid osteoma located in the patella.
correct offset of the femur, measured as the distance between the center of the head and the anatomic axis of the shaft; offset of the center of rotation, measured as the distance between the center of the head and the pubic symphesis. Addition of these two offsets gives the overall offset. The purpose of this work was to analyze postoperative offset after standard total hip arthroplasty as a function of the preoperative head-shaft angle.