Intra-articular opening medial tibial wedge osteotomy (plafond-plasty) for the treatment of intra-articular varus ankle arthritis and instability.

BACKGROUND: Although supramalleolar osteotomy with an opening medial wedge or a closing lateral wedge have been described for varus ankle deformity, these may be associated with failure due to persistence of the medial intra-articular defect, resulting in recurrent varus deformity. We report the results of a retrospective study assessing the outcome of an intra-articular opening wedge osteotomy of the distal medial tibia (plafond-plasty) for intra-articular varus ankle deformity associated with osteoarthritis and ankle instability. METHOD: The results of 19 plafond-plasties in 19 patients for correction of intra-articular varus osteoarthritis of the ankle associated with ankle instability were reviewed. Fourteen men and five women of a mean age of 47 (range, 32 to 63) years were treated. Followup ranged from 14 to 98 (mean, 59) months. RESULTS: Lateral ligament reconstruction was done at the time of the surgery in 18 out of 19 patients. The radiographic parameters including the TAS and TAL showed no statistical significant improvement when compared pre and post operatively. The varus ankle tilt deformity improved from 18 degrees preoperatively to 10 degrees postoperatively (p < 0.05). The pre- and postoperative AOFAS score improved significantly from 46 to 78, respectively (p < 0.05). Two patients underwent ankle arthrodesis at 7 and 36 months, and two patients underwent ankle replacement at 30 and 48 months following the index procedure. Of the remaining 15 patients, 14 reported stable or very stable ankles, and 15 of the 19 were either satisfied or very satisfied with the outcome of treatment. CONCLUSIONS: These results demonstrate that plafond-plasty osteotomy associated with lateral ligament reconstruction may be a suitable for patients presenting with intra-articular varus ankle osteoarthritis associated with ankle instability, providing pain relief and better function and stability in most patients.

Biological foreign body implantation in victims of the London July 7th suicide bombings.

On the morning of July 7, 2005, a co-ordinated attack by suicide bombers on the London public transport system resulted in four explosions at densely packed civilian targets. Of the victims of these attacks, 194 were treated at the Royal London Hospital, where among the most severely injured an unusual pattern of injury was seen. Bone fragments from other victims (or possible the bomber) were found embedded as biological foreign bodies within the soft tissues of several patients. We present case reports of five of these patients, and discuss problems arising from the management of their injuries. Allogenic bony foreign bodies, rarely reported in the medical literature, present unusual problems in their management, in particular the risk of transmitting blood borne diseases, which should be anticipated and addressed in a hospital's major incident planning.

Impact of London's terrorist attacks on a major trauma center in London.

During the morning rush hour on Thursday, 07 July 2005, a series of four bombs exploded, affecting London's public transport system. These terrorist attacks killed 52 people and injured > 700. A major incident was declared, and the Royal London Hospital (RLH) was a primary receiving hospital. A total of 194 patients presented to the RLH. Twenty-seven patients required admission. A total of 11 amputations were performed on eight patients. One patient died intra-operatively. Another patient died on Day 6 due to complications related to a head injury. Coordination is vital to the implementation of the hospital's Major Incident Plan in such an emergency. Subsequent internal reviews of the response of the RLH on 07 July 2005 highlighted problems with communication and documentation, as well as the need for extra staffing. These areas should be improved for the management of future major incidents.

Synovial sarcoma mimicking haemophilic pseudotumour.

This is a case of a 36-year-old gentleman with haemophilia A who was presented with an acute atraumatic soft tissue swelling in the right thigh. Open biopsy was performed with the resultant diagnosis of a synovial cell sarcoma. Although the clinical findings were nonspecific they could easily have been found in a bleeding haemophilic pseudotumour. The findings reported on MRI scan initially were highly consistent with those present in patients with mild haemophilia. An important part of orthopaedic management in haemophilia is concerned with intraarticular and intramuscular bleeding. Haematomas are common and sarcomas are rare. However the absence of trauma should alert the clinician to the possibility that the abnormality may represent haemorrhage into a tumour and not just haematoma, even in a haemophilic patient.