A Comparison of Two Designs of Postoperative Shoe on Function, Satisfaction, and Back Pain After Hallux Valgus Surgery.

Background. The reverse camber shoe is commonly used after hallux valgus corrective surgery to offload the forefoot but is associated with back pain and poor compliance. Recent designs of postoperative shoes may obviate the need for a reverse camber. The purpose of this study was to compare the effects of a reverse camber shoe and a noncambered shoe with transitional rigidity after hallux valgus correction. Methods. A cohort of 80 feet was prospectively studied undergoing surgery at a single NHS trust. The first 40 feet received the reverse cambered Jura Medical Off-loader Heel shoe and the subsequent 40 feet received the noncambered DonJoy Podalux shoe. No demographic differences existed between the groups and data were collected at 2 weeks, 6 weeks, and 6 months. The Manchester-Oxford Foot Questionnaire (MOXFQ), a 5-question survey and dichotomous question about back pain was used to assess clinical outcome and radiographs were reviewed by 2 orthopaedic surgeons to monitor for loss of correction. Results. Both groups experienced comparable improvements in MOXFQ and shoe satisfaction from 2 weeks compared with 6 weeks. Six patients experienced back pain in the reverse cambered shoe group and none in the noncambered shoe group. Five patients stopped using the reverse cambered shoe during the first 6 weeks after surgery and none stopped using their prescribed noncambered shoe. No loss of corrections were observed in either group. Conclusion. Both shoe designs gave equal foot specific functional and radiological outcomes, but the noncambered shoe with transitional rigidity was associated with less back pain and better compliance. Levels of Evidence: Level II: Prospective comparative study.

Cadaveric experiments to evaluate pressure wave generated by radial shockwave treatment of plantar fasciitis.

BACKGROUND: Shockwave treatment is increasingly used for plantar fasciitis and Achilles tendinopathy. To be effective it is believed that high pressure must be achieved in the tissues. We report on the first human cadaveric experiments to characterize pressure from radial shockwave therapy (rSWT) for plantar fasciitis. METHODS: The pressure from rSWT was measured in two cadaveric feet using a needle hydrophone. Maximal pressure and energy flux were calculated from the measurements. RESULTS: The pressure persisted longer than supposed, for up to 400µs. The peak negative pressure was up to two Mega Pascal. The predicted energy in the tissue strongly depended on the time interval used in calculations. CONCLUSIONS: The measured pressure may be sufficiently high to cause cavitation in the tissue, which is one of the proposed healing mechanisms associated with rSWT. The results suggest that the energy is imparted to the tissues for much longer than previously thought.

A Retrospective Study Comparing Crossed and Lateral Wire Configurations in Paediatric Supracondylar Fractures.

BACKGROUND: Supracondylar fractures are common in children and are associated with significant morbidity. The purpose of our study was to assess and compare the clinical and radiological outcome of management of supracondylar fractures by both wire configurations, along with identifying factors that predispose to complications. MATERIALS & METHODS: We retrospectively reviewed all paediatric cases admitted with a supracondylar fracture over a five year period. We reviewed case notes, theatre records and radiographs to determine the age of the patient, classification of fracture, treatment method, delay to theatre, duration of surgery, wire configuration, Baumann´s angle, radiocapitellar alignment, anterior humeral alignment and complications. RESULTS: During the five year period we admitted 132 patients and complete notes were available for 123 patients for analyses. For all the patients managed with wire stabilisation 23% developed complications, including 13% with significant complications including nerve injuries and fracture displacements. All five nerve injuries had crossed wires, whereas all for fracture displacements had lateral wires. Baumann´s angle was 76.7 degrees in the group with no complication and 72.2 degrees in the significant complication group (p=0.02). Radiocapitellar line and anterior humeral line were not satisfactory in 5% and 15% of the group with no complications, and 17% and 33% of the group with significant complications. CONCLUSION: We found more complications in lateral pinning configurations, although all nerve injuries were in patients with crossed wire configurations. The factors we believe are associated with a higher likelihood of complications are inadequate post-operative radiological appearance.

Total knee arthroplasty with an oxidised zirconium femoral component: a 5-year follow-up study.

PURPOSE: To report the early results of the Oxinium Genesis II prosthesis with an oxidised zirconium femoral component in 55 patients. METHODS: 71 knees in 21 men and 34 women aged 32 to 75 (mean, 55) years were evaluated; 16 of the patients had bilateral staged total knee replacements with a mean interval of 9 (range, 6-16) months between surgeries. The indications for surgery included osteoarthritis (n=57), rheumatoid arthritis (n=13) and revision from a unicompartmental knee replacement for osteoarthritis (n=1). Postoperatively, patients were evaluated using the Knee Society score (KSS), the modified Oxford Knee Score, and the SF-12 health survey, as were component position, leg and knee alignment, and prosthesis-bone interface or fixation on radiographs. RESULTS: The mean follow-up was 62 (range, 51-88) months. The mean KSS, Oxford Knee Score, and SF-12 physical component score improved significantly. Radiolucent lines (<2 mm) were noted in the tibial cement-bone interface in 17 knees (most commonly in zones 4 and 1) and in the femoral cement-bone interface in one knee. The alignment of the knees and positioning of the components were acceptable. There were no revisions for septic or aseptic loosening. CONCLUSION: Early results of the Oxinium Genesis II prosthesis are comparable to the standard total knee prostheses.

Flexor digitorum longus tendon harvest length utilising a limited operative exposure: A cadaveric study.

BACKGROUND: Flexor digitorum longus (FDL) is a commonly used donor tendon for transfer to substitute for a dysfunctional tibialis posterior in the management of adult acquired flatfoot deformity. The tendon transfer is attached to the navicular bone via a drill hole. Interference-fit screws are an alternative means of securing a transferred tendon allowing for a shorter length of graft and less extensive dissection. The aim of this cadaveric study was to investigate the length of FDL tendon harvest required for transfer and to determine if this length of tendon can be obtained without formal dissection to the Knot of Henry. METHODS AND RESULTS: The FDL tendon was exposed in 8 cadaveric specimens via a medial hindfoot incision. The tendon was divided proximal to the Knot of Henry. The lengths of the skin incisions and the length of the FDL tendon harvest were measured. No specialist tendon harvesting instruments were used. The average length of the skin incision was 9.0cm (95% confidence intervals 8.0-10.0cm). The average length of the harvested FDL tendon was 6.7cm (95% confidence intervals 6.4-7.0cm). CONCLUSION: This study demonstrates that the FDL tendon can be safely and adequately harvested via a limited exposure. The average length of FDL tendon harvest via this approach compares favourably with other descriptions of approaches. This shorter graft length is more than adequate, allowing at least 2cm for fixation by interference screw to a tunnel in the navicular bone.

Volar plating for distal radius fractures--do not trust the image intensifier when judging distal subchondral screw length.

BACKGROUND: The use of the volar plate to treat distal radius fractures is increasing but despite the theoretical advantages of a volar approach there have been reports of extensor tendon ruptures due to prominent screw tips protruding past the dorsal cortex. The valley in the intermediate column between Lister tubercle and the sigmoid notch of the distal radius makes it difficult to rely on fluoroscopy to judge screw length. Our aim was to quantify the dimensions of this valley and to demonstrate the danger of relying on intraoperative image intensification fluoroscopy to determine lengths of distal screws. METHODS AND RESULTS: We measured the depth of this valley in the intermediate column of the distal radius in 33 patients with computed tomographic (9 patients) or magnetic resonance image (24 patients) scans of the wrist. There was a consistent valley in all images examined [average 1.8 mm (95% confidence interval, 1.6-2.0 mm)]. Thirty-nine percent of wrists had a valley depth of at least 2 mm. CONCLUSIONS: Standard lateral views or rotation of the forearm to obtain oblique views does not identify prominent screw tips; and whatever the rotation of the forearm, screw tips protruding beyond dorsal cortex may look as if it is within the bone when in fact it is out. When drilling we suggest noting the depth at which the drill bit just penetrates dorsal cortex and routinely downsize the distal screw length by 2 mm. We caution against relying on flourosocopy when judging the length of the distal subchondral screws.

Intra-neural Ewing's sarcoma of the upper limb mimicking a peripheral nerve tumour. A report of 2 cases.

Ewing's sarcoma is a malignant round cell tumour of bone commonly affecting children and young adults. Intra-neural Ewings is very rare form of extraosseous Ewing's sarcoma (EES), posing diagnostic and therapeutic challenges. We report two cases of intra-neural EES presenting with elbow pain and swelling, mimicking an upper limb peripheral nerve sheath tumour. Following a CT guided biopsy to confirm diagnosis, the patients were treated with a combination of surgical resection, chemotherapy and radiotherapy. These cases highlight the potential diagnostic challenges as their presentation can be misleading due to the non-specificity of symptoms. These are highly aggressive tumours with the propensity to metastasize. We review importance of collective radiological and immunohistochemical analysis followed by early, aggressive multimodal treatment within a multidisciplinary setting. This provides the best prognosis in the context of upper limb peripheral nerve tumours.

Proximal femoral replacements for metastatic bone disease: financial implications for sarcoma units.

Metastatic pathological fractures of the proximal femur are increasingly treated by endoprosthetic proximal femoral replacement. We report the results and the costs incurred performing these procedures at our supra-regional sarcoma unit. Sixty-two patients underwent 63 proximal femoral replacements for metastatic bone disease over a seven-year period. Breast cancer was the most common primary pathology. One patient underwent a revision procedure for infection. Twenty-two patients suffered dislocations, most commonly those undergoing a conventional arthroplasty articulation. The estimated cost of a proximal femoral replacement is 18,002 pounds at our centre. Less than half of this is reimbursed under Payment by Results. Endoprosthetic replacement of the proximal femur is an effective treatment of metastases, but is poorly reimbursed under current funding arrangements.