Does local infiltration analgesia in total joint arthroplasty offer any protection from prosthetic joint infections? An invitro experimental study.

Many local anaesthetic agents are now reported to have anti-microbial properties in various studies, and this ability to inhibit microbial growth is not uniform. As local anaesthetics are commonly infiltrated into the surgical field for perioperative pain management, it is very important to know if this practice offers any protection against surgical site infections. METHODS: In this study, three of the most common prosthetic joint infection-causing organisms, namely, Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli, were chosen and tested against the commonly used local anaesthetics. The suspension of each organism was inoculated onto three different Mueller-Hinton agar plates and a drop of an undiluted solution of each local anaesthetic agent is inoculated onto one of the three culture plates; vancomycin and gentamicin discs were used as controls. RESULTS: The local anaesthetic agents tested could not inhibit the growth of any of the microorganisms. As there was no inhibition of bacterial growth in the experiment with the above three agents, further experiment with a diluted mixture was not performed. CONCLUSIONS: It can be concluded that local infiltration of anaesthetic agents is less likely to provide any perioperative protection against prosthetic joint infections but may interfere with some diagnostic tests for microbiology.

Long-term results of dorsal neuroma/nerve transposition in the surgical management of Morton's neuroma and correlation with intraoperative anatomical variations.

BACKGROUND: Morton's neuroma (MN) is a common cause of forefoot pain. After failure of conservative management, surgical procedures include neurectomy or neuroma preserving procedures; resection of deep transverse intermetatarsal ligament only (DTIML), dorsal neurolysis, dorsal nerve transposition (DNT). OBJECTIVES: This retrospective study evaluates the long-term results of open DNT, and it also reports anatomical variants in the plantar interdigital nerve. MATERIAL AND METHODS: The study included 39 patients (30 females and 9 males) who were treated for MN between 2002 and 2016. RESULTS: The mean pre-operative Giannini score of 13 (0-30) improved to 61 (20-80) (p < .0001), with only 6 patients scoring less than 50 (poor). Using Coughlin's criterion for overall satisfaction, 9 patients (23%) reported excellent, 18 patients (46%) good, 6 patients (15%) fair and 6 patients (15%) reported poor results. In the long term, 25 patients (64%) had no pain, 8 patients (20%) had mild pain, and 6 patients (16%) had severe pain. Ten patients (26%) reported normal sensitivity in their toes, 26 patients (66%) had numbness, and 3 patients (8%) reported dysesthesia in their toes. Twenty-two patients (56%) could wear fashionable shoes, 11 patients (28%) comfortable shoes, and 6 patients (16%) modified shoes. Regarding walking distance, 30 patients (77%) had no limitation, and 9 patients (23%) reported some limitation. Nineteen per cent regretted having surgery. Around 40% (17 out of 43 web spaces) showed anatomical variations in either the nerve or in the web space and we could not identify any specific risk factors in relation to the outcome. CONCLUSION: Dividing the DTIML or dorsal neurolysis should be considered as the primary surgical treatment and, if this fails, neurectomy would be an option. DNT can be considered if one is concerned about stump neuroma, but this may be technically demanding and in some patients it may not be possible. LEVEL OF EVIDENCE: Level IV - Case Control Retrospective study.

Comparative Analysis of Dorsal Nerve Relocation versus Dorsal Neurectomy in the Surgical Management of Morton's Neuroma.

This clinical study compares the use of dorsal nerve relocation (DNR; also known as dorsal nerve transfer) and dorsal neurectomy (DN) in the surgical management of Morton's neuroma within the surgical directorate of an NHS Hospital Trust (Princess Royal University Hospital) in the South East of England between 2002 and 2009. Approaches to the surgical management of Morton's neuroma are dependent on the views of individual surgeons, rather than empirical evidence and varied considerably, so this study was essentially all about checking whether best practice is being followed and making improvements. Data were collected using an in-depth review of patients' case notes and patient questionnaires. In total, there were 47 cases (51 web spaces), 25 (28 web spaces) in the DNR group, and 22 (23 web spaces) in the DN group. The key indication for surgery in all cases reviewed was failure of the condition to improve using conservative methods. The mean follow-up duration was 36 months (12-89) in the DNR group and 41 months (12 69) in the DN group. Coughlin's criterion was used to analyze individual records. The results suggest that DNR is more effective (92%) than DN in the surgical management of Morton's neuroma (82%). Key advantages of DNR include earlier return to wearing routine footwear, earlier return to normal routine/work, and better resolution of sensory symptoms in the toes. Although DNR is a slightly longer procedure than DN, minor difficulties were encountered relating to nerve mobilization because of overlying prominent veins or multiple nerve branches rather than a single nerve. DNR avoids the risk of a stump neuroma formation. Our results, although supporting the literature, are not statistically significant. There are no direct comparative studies between DNR and DN in the literature, and therefore potential for more studies in the form of prospective randomized trials to establish a robust evidential basis for the surgical management of Morton's neuroma are needed.

A multilobed osteochondroma of the hamate: case report.

Osteochondromas arising from the carpal bones are unusual, and when they occur they usually arise from the scaphoid. We report a case of a single, multilobed osteochondroma arising from the hamate that was successfully excised, with no evidence of recurrence at 4-year follow-up.

Painful disc lesion: can modern biplanar magnetic resonance imaging replace discography?

STUDY DESIGN: A new magnetic resonance imaging (MRI) classification of disc degeneration was correlated with discography. It was also studied for intraobserver and interobserver variability in interpreting disc abnormality and for the capability in predicting symptomatic disc. OBJECTIVE: To correlate the results of discography with a new MRI classification for disc degeneration and the presence of the vertebral endplate changes and the high intensity zone (HIZ). SUMMARY OF BACKGROUND DATA: MRI and discography have been compared in numerous studies as methods for detecting disc degeneration. The results were conflicting and the role of MRI in assessing discogenic pain remains ambiguous. METHODS: One hundred thirty-one discs in 55 patients were studied with pain provocation discography and MRI. A new MRI classification was correlated to discography and assessed together with the presence of end plate changes and HIZ, by the sensitivity and specificity in predicting a painful disc. RESULTS: MRI classification had a good intra and interobserver agreement and a significant correlation with discographic findings. The sensitivity and specificity of MRI in predicting painful disc was 94% and 77%. The sensitivities and specificity of HIZs was 27% and 87% and for end plate changes was 32% and 98%, respectively. CONCLUSIONS: Although MRI is an excellent investigation for assessing disc morphology it should be interpreted along with discography findings before planning fusion surgery. The proposed MRI classification is a useful aid in predicting painful degenerative disc. The utility of HIZs and end plate changes is limited due to low sensitivity.

Tailor's bunion: a review.

The tailor's bunion is a painful bony prominence on the lateral aspect of the fifth metatarsal head that occurs in many individuals, but seldom causes symptoms. This article reviews the current literature regarding the presentation, etiology, and management of the tailor's bunion. The first line of management should be conservative, with advice on shoe wear. Orthotics may be useful if a symptomatic tailor's bunion results from excessive subtalar joint pronation. Operative management, indicated when symptoms are not controlled nonoperatively, aims to decrease foot width and the prominence of the tailor's bunion. Procedures can be grouped into resections and distal, diaphyseal, and proximal osteotomies. A distal osteotomy is recommended if medial translation of the head for one-third of the width of the metatarsal shaft produces a normal fourth-fifth intermetatarsal angle. A proximal osteotomy can be performed in the face of larger deformities. The management of recurrent tailor's bunion is still controversial. If the recurrence is due to under-correction, or if the initial procedure was not the best suited to that particular patient, then revision surgery may be helpful, after the cause of the failure has been established. Although unpopular, resection should be considered as the final salvage procedure.

Scott wiring for direct repair of lumbar spondylolysis.

STUDY DESIGN: This is a retrospective study of consecutive patients who underwent Scott wiring for symptomatic lumbar spondylolysis using the MacNab criteria. OBJECTIVE: The aim of the study was to assess the clinical outcome of the procedure after a mean follow-up period of more than 10 years. SUMMARY OF THE BACKGROUND DATA: Previous studies have shown this technique to be effective in the management of patients up to the age of 25 years who have symptomatic lumbar spondylolysis with or without a Grade 1 slip. No study has been published with regard to the long-term outcome of Scott wiring. METHODS: Between 1986 and 1993, Scott wiring was performed for 15 patients younger than 25 years of age who had symptomatic lumbar spondylolysis. MacNab criteria were used to assess their pre- and postoperative status. A postal questionnaire was used to assess their clinical outcome. Their notes also were studied to find subsequent episodes of low back pain. RESULTS: The postoperative questionnaires were returned by 14 patients. The mean follow-up period was 10.9 years. Of the 14 patients, 12 had a "good" or "excellent" result according to MacNab criteria. The two patients classified as "poor" required further procedures for continued low back pain. CONCLUSIONS: The Scott wiring technique is recommended for the treatment of symptomatic lumbar spondylolysis in patients younger than 25 years because it gave "good" or "excellent" results in approximately 86% of the patients with a mean follow-up period of 10.9 years.