Tarsal Tunnel Syndrome Secondary to an Unreported Ossicle of the Talus: A Case Report.

Tarsal tunnel syndrome (TTS) is a compression neuropathy of the posterior tibial nerve in the tarsal tunnel. In about 80% of patients, a specific cause can be identified for TTS. We present a case of TTS secondary to an ossicle in close relation to the talus that, to our knowledge, has not previously been reported. A 26-year-old male presented with left ankle and foot pain that increased with activity and playing football. He had a tingling sensation and paresthesia in the sole and medial border of the foot along the distribution of the medial and lateral plantar nerves. Clinically, he had hard swelling at the floor of the tarsal tunnel, and Tinel's sign was positive. Computed tomography showed an accessory ossicle articulating with the posteromedial aspect of the talus, separating the flexor digitorum longus and flexor hallucis longus tendons, with tenosynovitis of the tibialis posterior, flexor digitorum longus and flexor hallucis longus tendons. Surgical release of the tarsal tunnel and excision of the ossicle were performed. Postoperatively, the patient showed dramatic improvement and had no complications or recurrence of symptoms after 8 months of follow-up. More interestingly, to the best of our knowledge, this ossicle has not been previously reported to cause TTS.

Informed consent documentation for total hip and knee replacement using generic forms with blank spaces.

PURPOSE: To analyse informed consent documentation of 100 patients undergoing elective primary total hip replacement (THR) or total knee replacement (TKR) using generic forms with blank spaces. METHODS: Informed consent documentation of 57 men and 43 women (mean age, 54 years) undergoing elective primary THR (n=50) or TKR (n=50) using generic forms with blank spaces were analysed. The consent forms were explained to the patients mostly on the morning of surgery by a consultant surgeon (n=21), specialist registrar (n=23), or senior house officer (n=56). Data on patient demographics, planned procedure, benefits and risks of surgery, and the grade of the surgeon were collected. RESULTS: In the consent forms for THR, the most frequently documented complications included infection (98%), bleeding (96%), deep vein thrombosis (94%), nerve damage (94%), blood vessel damage (94%), and pain (90%). Common complications (2-5% of occurrence) that were less frequently documented included prosthesis wear or loosening (76%), dislocation (68%), and leg length discrepancy (62%). In the consent forms for TKR, the most frequently documented complications included infection (96%), bleeding (92%), deep vein thrombosis (90%), nerve damage (90%), and blood vessel damage (90%). Common risks (2-5% of occurrence) that were less frequently documented included pain (84%), prosthesis wear or loosening (54%), and knee stiffness (40%). CONCLUSION: Documentation of all clinically significant complications was insufficient when generic informed consent forms with blank spaces were used. The use of standardised procedure-specific consent forms is recommended.

Audit of operation notes in an orthopaedic unit.

PURPOSE: To audit operation notes of 50 patients according to the guidelines of the Royal College of Surgeons. METHODS: Proforma operation notes of 50 consecutive patients treated in an orthopaedic department were audited by a single reviewer, according to the guidelines of the Royal College of Surgeons in terms of date and time of surgery, name of surgeon, procedure, operative diagnosis, incision details, signature, closure details, tourniquet time, postoperative instructions, complications, prosthesis used, and serial numbers. RESULTS: There were 45 trauma cases and 5 elective cases. The operating surgeons were consultants (32%), senior registrars (36%), and registrars (32%). 28% and 72% of the operation notes were written by operating surgeons and assistants, respectively. Of the 14 operating surgeons who wrote their own notes, one was a consultant, 6 were senior registrars, and 7 were registrars representing 6%, 33%, and 44% of the respective grades of surgeons. All the notes were handwritten; 20% had illegible parts (all in the description of the operative technique). Documentation was good for date and time of surgery (100%), name of surgeon (100%), procedure (100%), duration of surgery (94%), operative diagnosis (92%), incision details (84%), and signature (84%). Documentation was poor for tourniquet time (32%; pneumatic tourniquet was used in 25 patients, only 8 of whom were documented), closure details (16%), and postoperative instructions (24%). CONCLUSION: Documentation of operative details in our department was generally good, except for closure details, tourniquet time, and postoperative instructions.

A new technique of single portal endoscopic carpal tunnel release.

Since the first description of endoscopic carpal tunnel release (ECTR) in 1987 by Okutsu many endoscopic techniques have been developed, but the majority of the literature on ECTR has dealt with the Chow and Agee techniques. ECTR is indicated for carpal tunnel syndrome that is not responding to conservative treatment for 6 months. This new technique of ECTR is a single-portal technique using instruments originally designed for endoscopic cubital tunnel release, with no disposable instruments used. It also has the advantage of performing the release with the median nerve protected under direct vision. Ten cases were operated with this technique after performing the procedure on 8 hands of 4 fresh frozen cadavers. There were no neurovascular or tendon injuries with this technique and patients were satisfied with the results.