Minimally invasive hallux valgus correction: Is it better than open surgery?

BACKGROUND: The aim was to compare the minimally invasive (MIS) chevron osteotomy to the well-established open chevron osteotomy for the correction of hallux valgus deformity. METHODS: Two retrospective cohorts of patients treated with MIS or open chevron osteotomy for hallux valgus correction, matched for age and gender with a minimum follow up of six months were reviewed. Functional outcomes were evaluated using pre and post-operative Manchester Oxford Foot and Ankle Questionnaire (MOXFQ), Visual Analog Score (VAS) for pain and the Unified Elective Orthopaedic Score (UnEOS). Two independent, blinded examiners evaluated the radiographic correction of hallux valgus (HV) and intermetatarsal (IM) angle. RESULTS: A Total of 54 cases (27 per study group) with a mean follow-up of 25.9 months were included in the study. Pre-operatively, VAS (p = 0.76) and MOXFQ (p = 0.46) scores and HV angle (p = 0.1) were comparable in both groups. However, IM angle was significantly larger in the MIS group (p = 0.005). Post-operatively there was significant improvement in VAS and MOXFQ scores as well as significant correction of the HV and IM angles (p < 0.0001) for both groups. Comparing the two procedures, there was no significant difference between groups for VAS (p = 0.34), MOXFQ scores (p = 0.56) and HV angles (p = 0.069) but the MIS technique was significantly better in improving the IM angle (p = 0.016). The post-operative UnEOS score and the Satisfaction UnEOS domain reached excellent levels for the entire cohort with no statistical difference between the two groups (p = 0.2 and 0.28 respectively). CONCLUSION: Results show MIS chevron osteotomy provides better radiographic correction of the IM angle but functional outcomes for all parameters were comparable to the open technique. It can therefore be considered at least equivalent to standard open surgery when compared using validated Patient Reported Outcome Measures (PROMs).

Radicular arm pain.

Cervical radiculopathy is a neurological condition caused by dysfunction or compression of a cervical nerve root. Patients often report unilateral neck pain with radiation to the ipsilateral arm, often with sensory changes in a dermatomal distribution. Weakness and reflex changes are also commonly found and can be very troubling for patients. Careful history and examination is important to identify any more concerning features such as progressive symptoms and features of myelopathy, which could prompt surgical management. Although the majority of patients will see an improvement in their symptoms over time with conservative management, surgery is indicated in patients with debilitating pain, progressive neurology, significant weakness, instability or myelopathy. Advancements in surgical techniques offer a range of potential operations that should be considered carefully for each patient. This article outlines the clinical approach to presentation, pathophysiology, diagnosis and management.

Supracondylar fractures of the humerus in children: is departmental documentation hitting national standards?

BACKGROUND/AIMS: The British Orthopaedic Association's Standards for Trauma for the management of supracondylar humerus fractures in children specify that: 'A documented assessment of the limb, performed on presentation, must include the status of radial pulse, digital capillary refill time and the individual function of the radial, median (including anterior interosseous) and ulnar nerves.' METHODS: The documentation of cases of supracondylar humerus fractures over 1 year was retrospectively analysed. An electronic pro forma for supracondylar humerus fractures was introduced, with prompts for the pieces of documentation required to meet national standards. The use of this pro forma was audited after 6 months and 12 months use. RESULTS: Documentation ranged from 10% for anterior interosseous nerve to 53% for radial pulse. In the second reaudit, documentation ranged from 86% for anterior interosseous nerve to 95% for median nerve function. There were 17 patients for whom all documentation was present, and for these patients the pro forma had been used. Use of an electronic clerking pro forma improves adherence. CONCLUSIONS: Full documentation of neurovascular status in paediatric supracondylar fractures is vital to allow for effective preoperative and postoperative further assessment. With the move into paperless documentation, online pro formas can help clinicians with effective assessment and documentation.

Coracoid Osteotomy, Greater Tuberosity Take Down and Latarjet Procedure for Missed Bilateral Locked Anterior Shoulder Fracture-Dislocations in a Young Man.

Introduction: It is rare to see chronic bilateral anterior fracture-dislocations as a result of seizure, and we present a case of this type and review of the literature. Despite the signs and symptoms of shoulder dislocation being well documented, and X-ray imaging being good at identifying such pathology, there are a few cases in the literature of missed or chronic shoulder dislocation (a shoulder that has been dislocated for more than 3 weeks) but these are extremely rare. Our case represents the first example of chronic bilateral locked anterior fracture-dislocations requiring open reduction and coracoid osteotomy with GT takedown to gain adequate exposure and allow soft tissue release to facilitate joint reduction. No other case has used anchors to achieve GT fixation, and our patient is the youngest published case with such pathology. Case Report: A 16-year-old boy presented to the emergency department with reduced range of movements in both shoulders. Six weeks prior he had suffered an epileptic seizure. X-rays confirmed bilateral anterior shoulder dislocations with displaced greater tuberosity (GT) fractures. Staged open reduction was performed in the right and then left shoulder. Coracoid osteotomy with takedown of the malunited GT fracture was needed to assist with gradual soft tissue contracture release and a successful relocation. Latarjet procedure was then performed and the GTs were fixed using rotator cuff anchors. At 6 months post-operation, on the right side, he achieved forward flexion to 150o and abduction to 120o. On the left side, forward flexion was 110o and abduction was 90o. X rays showed satisfactory maintenance of the reduction without signs of avascular necrosis of the humeral head. Conclusions: Surgical management of this injury in this way is effective and achieves good results in the first 6 months of follow up. A high index of suspicion should be employed for this injury in post-ictal patients with shoulder pain. Early mobilization and effective physiotherapy is essential post-operatively to achieve good short-term range of motion.

Metastatic spinal cord compression.

Metastatic spinal cord compression is compression of the spinal cord or cauda equina as a result of metastatic deposits in the spinal column. It affects approximately 4000 cases per year in England and Wales. Prompt identification and treatment of metastatic spinal cord compression is necessary to prevent irreversible neurological injury, treat pain and maintain patients' mobility, function and independence. Survival of patients with common malignancies has improved significantly with the ongoing development of radiotherapy and chemotherapy, as well as improved surgical treatment of resectable primary tumours. This article outlines the clinical approach to presentation, pathophysiology, diagnosis and management.

Navigation knee replacement.

Total knee replacement (TKR) achieves an immediate and exceptional restoration in the quality of life that is comparable only to a few other procedures. It has been suggested that the most common cause of revision TKR is error in surgical technique, from malpositioning of the components which results in a poorer post-operative outcome. Based on the theoretical assumption that the use of computer-assisted systems (CAS) in TKRs may improve implant alignment and thus implant longevity, the use of this technology is becoming increasingly popular. This article (a) reviews whether computer-assisted TKR (CASTKR) results in improved prosthesis alignment compared with the conventional technique, (b) assesses the functional and clinical outcomes of CASTKR and (c) evaluates the cost-effectiveness of using this technology.

Distal humerus lateral condyle fracture and Monteggia lesion in a 3-year old child: a case report.

We describe a case of a Monteggia fracture dislocation and an ipsilateral lateral humeral condyle fracture in a 3-year-old child. This is a rare combination of injuries with no previously reported cases in the literature. This case emphasises that when a fracture is detected around an elbow there should be a high index of suspicion for other injuries in the region.