Outcome of trans-metatarsal amputations in patients with diabetes mellitus.

BACKGROUND: This retrospective case series reports the reoperation rate, survival rate and mobility status in patients with diabetes mellitus who had undergone a trans-metatarsal amputation (TMA) managed within a diabetic foot care service. METHODS: Forty-one consecutive patients (37 men, 4 women) underwent a TMA with primary wound closure between January 2008 and December 2017. Eighty-eight per cent (36/41) of the patients were followed-up for a mean of 2.3 years. The outcomes were retrospectively reviewed. RESULTS: Four (11%) of the 36 patients required reoperation, including three (8%) major amputations. All of the patients requiring a reoperation had peripheral vascular disease. Eleven patients died giving a four-year survival rate of 69% (25/36). Of the surviving patients who had not required revision to a major amputation 96% (21/22) were fully mobile in bespoke orthoses. A third used a walking cane. CONCLUSION: This study shows that a TMA with primary wound closure in patients with diabetes mellitus, is effective for limb salvage with low reoperation and major amputation rates. A well healed TMA stump provides independent mobility in the majority of patients. The failures occurred in patients with peripheral vascular disease who, even after percutaneous trans-luminal angioplasty, had a 19% major amputation rate. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Experience and outcome data of the British non-arthroplasty hip registry.

INTRODUCTION: The non-arthroplasty hip registry (NAHR) is a United Kingdom national register that monitors the efficacy of hip preservation surgery. We aim to highlight early experiences of incorporating the NAHR into our practice at a tertiary centre. METHODS: Between December 2013 and February 2015, 381 patients were identified on the NAHR database that had undergone non-arthroplasty hip surgery. Patient-related outcome measures EuroQuol 5D-5L (EQ-5D) and the International Hip Outcome Tool 12 (iHOT-12) were recorded at baseline and 6 months. RESULTS: The 289 arthroscopic surgeries showed a statistical significant difference (p<0.05) in iHOT-12 for both males (45.21-65.07) and females (34.57 to 55.53), and in EQ-5D for both males (0.59-0.75) and females (0.56-0.65). The 92 open procedures showed a statistical significant difference (p<0.05) in both iHOT-12 (31.71-62.42) and EQ-5D (0.54-0.68). CONCLUSIONS: Overall our results from the NAHR indicate hip preservation surgery is effective at relieving pain and improving quality of life in the short term.

Management of Paget's Disease of the Calcaneum.

The calcaneum is not the most common site for Paget's disease of bone, with only a few reports of monostotic involvement. We present 2 cases of Paget's disease of bone affecting the calcaneus, present an overview of the published data, and describe our management of these interesting cases.

The role of external fixators in paediatric trauma.

We report a retrospective review of all paediatric trauma patients managed with an external fixator admitted to our institution over a 7-year period. We identified 30 fractures in 28 children. The fractures included 20 tibiae, 5 femurs, 2 humerii, 2 radii and 1 phalanx. The indications were 23 open fractures, 4 comminuted fractures and 3 closed fractures in poly-traumatised patients. It was the definitive treatment in 13 fractures. The mean length of total time with an external fixator was 9.6 weeks (range 1-38 weeks.) Difficulties encountered were eight problems, one obstacle and two true complications. There were no cases of re-fracture following removal of the external fixator. This review confirms that there is a role for the use of external fixation in selected paediatric fractures with a low complication rate.

Patients' preferred mode of travel to the orthopaedic theatre.

AIM: To determine the preferred mode of travel to the operating theatre for elective orthopaedic patients. METHODS: Data was collected prospectively over a 2-wk period at an elective Orthopaedic Treatment Centre. Patients were asked to complete a patient satisfaction questionnaire following their surgery on their experience and subsequent preferred mode of transport to theatre. The data was then recorded in a tabulated format and analysed with percentages. Fisher's exact test was used to determine if there was any statistical association between patients' preference to walk and various groups; in-patient or day case procedures, and whether patients were < 60 years or > 60 years of age. RESULTS: Seventy patients (40 females and 30 males) fully completed the questionnaire. In total there were 33 d-cases and 37 in-patients. The spectrum of orthopaedic sub-specialties included was knee (41%), hip (17%), foot and ankle (24%), spine (13%) and upper limb (4%). Patient satisfaction for overall experience of travelling to theatre was either excellent (77%) or good (23%). Following their experience of travelling to theatre, 87% (95%CI: 79%-95%) of the total cohort would have preferred to walk to the operating theatre. There was a statistically significant association (P = 0.003) between patients' preference to walk and whether they were day-case or in-patients. Similarly, there was a statistically significance association (P = 0.028) between patients' preference to walk and whether they were < 60 years or > 60 years of age. CONCLUSION: This study confirms the majority of Orthopaedic elective patients would prefer to walk to theatre, when given the choice and if practically possible.

Late presentation of a partial median nerve palsy following a Gartland III supracondylar humeral fracture.

A 28-year-old male patient was referred to the Peripheral Nerve Injury Unit at the Royal National Orthopaedic Hospital for evaluation and treatment of a neuropathic type pain he had developed in his right arm. Some twenty years previously, he had sustained a Gartland type III supracondylar humeral fracture with what was thought clinically to be an anterior interosseous nerve palsy. The fracture was reduced and the nerve palsy subsequently recovered with non operative measures. At his subsequent delayed presentation, surgical exploration revealed that the median nerve epineurium was embedded within the bone at the level of the previous fracture. A good clinical result was obtained following neurolysis. The case report highlights a late presentation of median nerve palsy following interposition of the neural structure within the reduced distal humeral fracture site; it shows that delayed surgery can be effective.

The short-term effects of high volume image guided injections in resistant non-insertional Achilles tendinopathy.

We investigated neovascularisation, tendon thickness and clinical function in chronic resistant Achilles tendinopathy following high volume image guided injections (HVIGI). The subjects involved 11 athletes (mean age 43.5 years+/-11.6, range 22-59) with resistant tendinopathy of the main body of the Achilles tendon for a mean of 51.4 months (+/-55.56, range 4-144) who failed to improve with an eccentric loading program (mean 11.8 months+/-2.6, range 8-16). The morphological features, neovascularisation and maximal tendon thickness were assessed with power Doppler ultrasound. Clinical function was measured with the Victorian Institute of Sports Assessment-Achilles tendon (VISA-A) questionnaire. All the tendinopathic Achilles tendons were injected with 10 mL of 0.5% bupivacaine hydrochloride, 25 mg of hydrocortisone acetate, and 40 mL of 0.9% NaCl saline solution under real time ultrasound guidance. All outcome measures were recorded at baseline and after a short-term follow-up (mean 2.9 weeks, range 2-4). The results showed a statistically significant difference between baseline and 3-week follow-up in all the outcome measures after HVIGI. The grade of neovascularisation reduced (3-1.1, p=0.003), the maximal tendon diameter decreased (8.7-7.6 mm, p<0.001), and the VISA-A scores improved (46.3-84.1, p<0.001). In conclusion, HVIGI for resistant tendinopathy of the main body of the Achilles tendon is effective to improve symptoms, reduce neovascularisation, and decrease maximal tendon thickness at short-term follow-up.

Rotatory atlanto-axial dislocation in an infant with osteogenesis imperfecta.

This is a case report of a 15-month-old patient with osteogenesis imperfecta (OI) who sustained atlanto-axial dislocation. Our objective is to report a unique case of traumatic atlanto-axial subluxation in a child with osteogenesis imperfecta associated with bilateral femoral fractures. The management is discussed. Atlanto-axial dislocation occurring with associated osteogenesis imperfecta is very rare. There have been no previous reported cases. A 15-month-old girl with osteogenesis imperfecta sustained a traumatic atlanto-axial dislocation. The child was followed-up through presentation, diagnosis, management and post-discharge. The initial diagnosis was confirmed with a CT scan. The patient was treated conservatively with a halo-traction for 4 weeks followed by a halo jacket for a further 4 weeks. Both appliances were fitted under general anaesthetic. An anatomical reduction was achieved. There was no neurological deficit at any stage. The child has had a successful outcome. She is asymptomatic with a full range of movement at the atlanto-axial joints at 9 months. In conclusion, this paper records our management of this rare problem.