Correction of moderate to severe hallux valgus with combined proximal opening wedge and distal chevron osteotomies: a reliable technique.

AIMS: The mainstay of surgical correction of hallux valgus is first metatarsal osteotomy, either proximally or distally. We present a technique of combining a distal chevron osteotomy with a proximal opening wedge osteotomy, for the correction of moderate to severe hallux valgus. PATIENTS AND METHODS: We reviewed 45 patients (49 feet) who had undergone double osteotomy. Outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) and the Short Form (SF) -36 Health Survey scores. Radiological measurements were undertaken to assess the correction. The mean age of the patients was 60.8 years (44.2 to 75.3). The mean follow-up was 35.4 months (24 to 51). RESULTS: The mean AOFAS score improved from 54.7 to 92.3 (p < 0.001) and the mean SF-36 score from 59 to 86 (p < 0.001). The mean hallux valgus and intermetatarsal angles were improved from 41.6(o) to 12.8(o) (p < 0.001) and from 22.1(o) to 7.1(o), respectively (p < 0.001). The mean distal metatarsal articular angle improved from 23(o) to 9.7(o). The mean sesamoid position, as described by Hardy and Clapham, improved from 6.8 to 3.5. The mean length of the first metatarsal was unchanged. The overall rate of complications was 4.1% (two patients). CONCLUSION: These results suggest that a double osteotomy of the first metatarsal is a reliable, safe technique which, when compared with other metatarsal osteotomies, provides strong angular correction and excellent outcomes with a low rate of complications. Cite this article: Bone Joint J 2016;98-B:1202-7.

Laparoscopic entry techniques and complications.

OBJECTIVE: To identify laparoscopic entry techniques employed by gynecologists in the United Kingdom to determine if the consensus technique is adhered to, and to observe whether entry technique affects complication rate. METHOD: An anonymous postal questionnaire was sent to gynecologists with an interest in laparoscopic surgery in the United Kingdom. RESULTS: At total of 568 questionnaires were sent and 345 (60.7%) were returned. Of gynecologists who returned the questionnaire 194 (57%) reported occurrence of a major bowel or vascular complication. In terms of the key elements of the consensus document there was no significant difference in entry technique used between those that reported major injury (vascular, bowel, or both), and those that did not. CONCLUSIONS: This survey demonstrates the variation in entry techniques used by gynecologists in the United Kingdom. Without a good evidence-base to the contrary no entry technique can be stated as safer than another.

Laparoscopy or laparotomy for distal tubal surgery? A meta-analysis.

Of couples with subfertility, 25% have complete or partial blockage of the fallopian tube. Since the advent of in vitro fertilization (IVF), the role of tubal surgery has diminished. However, this type of surgery continues to be undertaken on selected patients with mild tubal disease, and in those with severe tubal disease, in centres where IVF is not available. This systematic review was undertaken to compare pregnancy outcomes after laparoscopic surgery with that of open microsurgical technique. Studies comparing laparoscopic techniques with conventional microsurgery requiring laparotomy for treatment of distal tubal disease were included. The relevant trials were identified from Cochrane Menstrual Disorders and Subfertility Groups of Specialised Register of Controlled Trials (searched up to July 2005). The following strategies were adapted using the OVID platform, MEDLINE (1966 to July 2005), Cochrane Central Register of Control Trials, CENTRAL, and EMBASE (1980 to July 2005). Outcomes analysed were: 'take home baby' rate, intrauterine pregnancy rate and ectopic pregnancy rate per pregnancy. Subgroup analysis was carried out to compare intrauterine pregnancy rate in the laparoscopy and conventional microsurgery groups according to the extent of tubal damage. Six relevant studies were identified. Overall, no significant difference was observed in the intrauterine pregnancy rate between the two groups, combined OR 1.32 (95% confidence interval [CI], 0.58 - 3.02). For patients with mild tubal disease, there was no significant difference in the intrauterine pregnancy rate between treatment and control group, OR 1.06 (95% CI, 0.42 - 2.70). For patients with severe tubal disease, there was a significantly increased intrauterine pregnancy rate in the laparotomy group, OR 0.34 (95% CI, 0.14 - 0.86). Appropriate patient selection is the main factor affecting outcome in terms of fertility. These data do not indicate a significant difference in pregnancy rates between open and laparoscopic techniques for lesser degrees of tubal damage. Other factors, such as costs and hospital stay, will come into the decision making, and are likely to favour laparoscopic techniques. If a decision is made to open the badly damaged tubes of a patient, then an open microsurgical technique should be employed.

Pain relief in hysterosalpingography.

BACKGROUND: Hysterosalpingography (HSG) is a method of testing for tubal patency. Various pharmacological strategies are available that may reduce the pain during the procedure. OBJECTIVES: To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing hysterosalpingography (HSG) for investigation of subfertility. SEARCH STRATEGY: This review has drawn on the search strategy developed for the Menstrual Disorders and Subfertility Group. In addition MEDLINE and EMBASE were searched up to July 2006. SELECTION CRITERIA: All randomised controlled trials investigating the pharmacological interventions for pain relief during HSG were investigated. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the first two authors. Differences of opinion were registered and resolved by the third author. Results for each study were expressed as mean pain score and standard error of the mean with 95% confidence intervals. MAIN RESULTS: The included eight trials reported on 570 women undergoing HSG.Overall, there was no evidence of benefit of using any analgesia compared with placebo for pain relief during the procedure (standard mean difference (SMD) of -0.05 (95%CI -0.25 to 0.14) or up to 29 minutes after HSG SMD 0.17, (95%CI -1.00 to 1.34)). Four RCTs involving 219 women found evidence of benefit with any analgesia in comparison to placebo for pain relief more than 30 minutes after HSG, with the SMD of -0.82(95%CI-1.18 to -0.45). One RCT involving 91 women compared the effectiveness of opioid analgesics versus non-opioid analgesics and reported no evidence of difference in pain relief at any stage of the procedure. One RCT involving 20 women compared the use of topical analgesia with a paracervical block, with analysis demonstrating more benefit to be gained from using topical analgesia during HSG, with the SMD of -2.03 (95%Cl-3.16 to -0.91). AUTHORS' CONCLUSIONS: There is little evidence of benefit in terms of pain relief of any of the interventions considered in this study during or immediately after HSG. However, there is limited evidence of pain reduction 30 minutes after the procedure. Further RCTs should consider the role of non steroidal antiinflammatories (NSAIDs) and intrauterine anaesthetic during HSG.

The quality of smear taking training for hospital medical trainees.

INTRODUCTION: Training for cervical smear takers in primary care is well established. We aimed to assess the adequacy of training in cervical smear taking among hospital medical trainees. METHOD: An anonymous questionnaire survey was conducted among hospital medical trainees within the North West region of England. The questionnaire assessed the trainees' level of confidence in their knowledge and skills in the theoretical and practical aspects of cervical smear taking, and the training they had received. The standards used were as stated in the National Health Service Cervical Screening Programme Resource Pack for Training Smear Takers (July 1998). These included practical smear taking, pre- and post-test counselling, the background to cervical screening, the National Health Service Cervical Screening Programme, the role of the Health Authority and the laboratory, provision for women with special needs, acceptability, accountability and quality assurance. RESULTS: Seventy-eight per cent of trainees returned the questionnaires. Although all the trainees were confident about taking smears, a significant percentage was concerned about the theoretical and specific issues associated with smear taking such as the care of women with special needs. Only 60.7% had received formal training in practical smear taking. Furthermore, only 48.3% had been formally trained in the clinical management of smears. CONCLUSION: There appears to be an urgent need for formal training in the theory and practice of smear taking and for the standardization of the course content. The introduction of training in liquid-based cytology provides us with a golden opportunity to address this deficit.

The effect of simple laparoscopic surgery on the serum level of the tumour marker CA 125.

In the event of unexpectedly finding an ovarian cyst at the time of laparoscopy, serum CA 125 assay is helpful in deciding the subsequent management of the cyst. It is unclear, however, when the CA 125 should be checked. There has been some debate as to the effect of laparoscopy on the level of CA 125 and whilst it is widely accepted that laparotomy will increase the level of CA 125 the effects of laparoscopy have not been investigated until now. Pre and post operative CA 125 levels were measured in 20 patients undergoing simple laparoscopic surgery. Analysis of the results indicate that simple laparoscopic procedures have an insignificant effect on serum CA 125 levels checked in the immediate post operative period.