Simple foot holder saves your theatre practitioner's back: a technical tip.

We provide a simple technique for foot positioning during preoperative skin preparation. Prone headrest made of gel polymer is used to support the patient's leg to keep the foot up. This will protect your operating theatre practitioner's back avoiding any mechanical back strain. It will also save money by preventing sickness and reducing workplace litigation from back injuries.

Painful sesamoid of the great toe.

The painful sesamoid can be a chronic and disabling problem and isolating the cause can be far from straightforward. There are a number of forefoot pathologies that can present similarly to sesmoid pathologies and likewise identifying the particular cause of sesamoid pain can be challenging. Modern imaging techniques can be helpful. This article reviews the anatomy, development and morphological variability present in the sesamoids of the great toe. We review evidence on approach to history, diagnosis and investigation of sesamoid pain. Differential diagnoses and management strategies, including conservative and operative are outlined. Our recommendations are that early consideration of magnetic resonance imaging and discussion with a specialist musculoskeletal radiologist may help to identify a cause of pain accurately and quickly. Conservative measures should be first line in most cases. Where fracture and avascular necrosis can be ruled out, injection under fluoroscopic guidance may help to avoid operative intervention.

Sugioka transtrochanteric valgus osteotomy for hinge abduction in children.

UNLABELLED: We report our experience of Sugioka transtrochanteric valgus osteotomy (TVO) for hinge abduction in children. The advantages are early union with simple fixation and preservation of proximal femoral geometry. Lateral displacement of the greater trochanter improves abductor limp. A total of 24 patients of mean age 10.2 years underwent TVO. The neck shaft angle increased by mean 11.75 degrees. Migration index increased by mean 3.88%. Average limb length discrepancy at final follow-up was 10.8 mm. The mean modified Iowa hip score was 75.1. Our results indicate that Sugioka TVO is a successful procedure for hinge abduction of the hip. LEVEL OF EVIDENCE: Level IV (case series).

Residual clubfoot in children.

The deformities encountered in any patient who has residual clubfoot comprise various degrees of equinus, varus, adduction, supination, cavus, and toe deformity. Joint flexibility or stiffness, tarsal dysmorphism, articular incongruence, and progressive degrees of degeneration may be present. Add to this the scars of previous attempts at correction and various etiologic factors, and surgeons can find that treatment solutions are far from straightforward. A philosophy of careful history, examination, investigation, and surgery à la carte will provide a safe foundation for treating patients who have these often complex and difficult problems. A surgical strategy progressing from proximal to distal, performing soft tissue surgery before fixed deformity occurs, extra-articular osteotomies to correct bony deformity, and augmentation with rebalancing of soft tissue-deforming forces will help improve pain and function for many patients. Joint fusions should be reserved as a last salvage option to avoid future degeneration of adjacent joints.

Orthopaedic training worldwide: how they compare? A pilot study.

INTRODUCTION: Advances in Orthopaedics and changing concepts should result in regular review and if necessary restructuring of training programmes periodically to accommodate these changes. However, most countries have orthopaedic training programmes which have remained unchanged over decades. There is very little information available in the literature concerning orthopaedic training programmes worldwide. AIM: The aim of this study was to collect information concerning various training programmes worldwide for comparison. The top ten countries by population and all G8 countries were selected. A survey in the form of a questionnaire was disseminated to a selection of trainees and trainers from these countries and responses tabulated for analysis. Significant variation was evident in training structure, time spent on training and training environment. CONCLUSION: There is a need for constant monitoring of training programmes worldwide to accommodate the ever-changing world of Orthopaedics which could potentially be of mutual benefit to trainees, trainers and the population at large of the countries involved.

Medial impingement after ankle replacement.

Ankle replacements appear to offer a good alternative to fusion for most arthritic conditions. Use of mobile bearings has significantly improved results of ankle replacement. Ankle replacements still have a significant minor-complication rate which does not seem to affect the long-term outcome. Medial impingement as a complication has been reported with popular designs. We reviewed the senior author's first five years of Buechel-Pappas ankle replacements looking at AOFAS scores, VAS scores, patient satisfaction, learning curve of the surgeon and complications. Eight patients out of a total of 34 reported symptoms of medial impingement at follow-up. Four patients underwent revision surgery for this. Ankle replacements have a significant proportion of minor complications, one of which is medial impingement. Whether this is due to implant design, residual arthritis in medial recess or soft-tissue pathology is uncertain but revision surgery may be required.

Secondary prevention of osteoporosis after Colles fracture: Current practice.

OBJECTIVES: Colles fracture in the elderly is accepted as evidence of osteoporosis. NICE (National Institute of Clinical Excellence) recommends osteoporosis treatment in all fragility fractures over 75 without a DXA (Dual Energy X-ray Absorptiometry) scan and after DXA scan in younger patients. All clinicians involved in the patient's care are said to be responsible for this. METHODS: We reviewed current practice in United Kingdom to find out the role played by orthopaedic surgeons in organising this treatment. We sent a questionnaire to 150 BOTA (British Orthopaedic Trainees Association) members by e-mail. RESULTS: The response rate excluding bounced mails was 63%. Only 5% of respondents prescribed osteoporosis treatment and 32% requested general practitioner to do this. Twenty-four percent referred the patients for either DXA or to an osteoporosis service. Although 86% were aware of NICE guidelines regarding osteoporosis, only 35% thought it could amount to negligence on the surgeon's part for not dealing with this. Fourteen percent worked in hospitals having an osteoporosis service which co-ordinated further management of these patients. Eleven percent expressed concerns over the source of funding for the management of osteoporosis and said that this was the reason for not offering treatment themselves. CONCLUSION: This survey highlights the importance of concrete local protocols in management of osteoporosis especially secondary prevention after an osteoporotic fracture. At present, it appears to be safe practice to indicate this in correspondence to patient's general practitioner and inform the patient as well.

Bicortical K-wires for distal radius fracture fixation: how many?

The aim of this study was to find out whether number and position of K-wires influence the stability of distal radius fractures treated by percutaneous wire fixation. Patients who underwent K-wire fixation for unstable fractures of the distal radius over a period of three years were included in this retrospective study. Radiographs taken immediately after the procedure and radiographs taken after removal of K-wires were analysed to study three radiological parameters: palmar or dorsal tilt, radial inclination and ulnar variance. Loss of these angles was analysed statistically against the number of wires (2 or 3) and position of wires (from radial styloid or a combination of styloid and dorsal wires). Ninety-five fractures were analysed with a mean age of 52.8 years and male to female ratio of 1:2. Average loss of radial inclination was 5.2 degrees, loss of palmar tilt was 8.3 degrees and loss of ulnar variance was 3.4 mm. Using 3 wires or using a dorsal wire in addition to the styloid wires both improved the final radial length by 1.2 mm and 2 mm respectively, but the effects were statistically not significant. We found that the number or position of wires did not influence radiological outcome. Based on our findings we recommend the use of two K-wires: one from the radial styloid and one from the dorsal side for these fractures.

Bone allografting: an Indian experience.

Freeze-drying is considered to be the best technique for allograft preparation and storage. This method is, however, unsuitable for use in developing countries due to high costs. Ethylene oxide sterilization is still controversial because of its effect on osteoinductive capacity. This study involved setting up a bone bank for the first time. Cancellous bone collected from 40 patients was cleaned thoroughly, chemically processed, and sterilized with ethylene oxide gas and stored doubly packed. The grafts were implanted in 11 patients with 14 nonunions. Patients were followed up clinically and radiologically. Thirteen sites were united at the end of 12 months, taking an average of 44.8 weeks to unite. Allograft was also used in 8 benign bone lesions, which showed incorporation of the graft by 29 weeks. This study shows cancellous allograft is suitable for packing cavities in the treatment of benign bone lesions and in treatment of nonunion. There was one deep infection. The low infection rate confirms the efficacy of ethylene oxide as a reliable option for sterilization of bone allograft, and it is also cost effective.