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Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 33 - 33
1 Jan 2011
Jowett A Birks C Blackney M
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Medial malleolar stress fractures are uncommon even in the sporting population. They tend to occur almost exclusively in athletes involved in sports involving running and jumping. We believe that stress fractures of the medial malleolus may be the end stage of chronic anteromedial ankle impingement in elite running and jumping athletes. Anterior impingement spurs are thought to be caused by repetitive microtrauma at the limit of dorsiflexion causing subperiosteal haemorrhage and subsequent ossification. More specifically the lower surface of the anterior tibia and the anterior part of the medial malleolus undergo similar trauma during severe supination injuries. Repetitive trauma to the cartilage from the kicking action in soccer is also thought to play a part, the cartilage responding by the formation of scar tissue and subsequent calcification.

We present five cases of elite athletes (three AFLplayers, one sprinter and one A Grade cricketer) who presented to our establishment with vertical stress fractures of the medial malleolus over a three year period (2004–7). In each case preoperative imaging revealed an anteromedial bony spur on the tibia. All patients had the fractures internally fixed and at the same sitting had arthroscopic debridement of the impingement spur.

Average time to union was 10.2 weeks (6–16). At most recent review (average 18 months (8–37)) all fractures had united and all patients had resumed sporting activity. No patient had suffered a further fracture of the medial malleolus.

We believe this region of impingement causes premature abutment of the talus on the tibia in the supination-adduction motion that in severe trauma leads to the vertical fracture through the medial malleolus according to the Lauge-Hansen classification. We therefore feel it should be addressed at the time of fracture fixation to reduce the re-fracture rate.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 9 - 9
1 Jan 2011
Jowett A Birks C Blackney M
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Chronic exertional compartment syndrome of the foot is well recognised. There has been debate over the exact number and location of compartments. While the medial compartment has been consistently reported, the exact anatomy of the fasciotomy has been poorly documented in orthopaedic literature.

Over a four year period (2003–7) five patients (seven feet) with history and examination findings compatible with chronic exertional compartment syndrome affecting the medial compartment of the foot were treated in our unit. There were three female patients and two males, average age 23 (17–34).

Assessment was made using the Stryker compartment pressure monitor inserted into the compartment following exertion. The measurements were compatible with chronic exertional compartment syndrome according to the Pedowitz criteria. The patients then underwent complete surgical release of the medial compartment of the foot. This involved two small oblique incisions, over the proximal and distal ends of the muscle belly of abductor hallucis, the fascia on the superficial and deep surfaces was then released, thus releasing the distal end of the tarsal tunnel. Decompression was bilateral in one, sequential in one and unilateral in three. Three patients also had surgical treatment of chronic compartment syndrome elsewhere in their lower limbs. One patient underwent a simultaneous calcaneal osteotomy for a planovalgus foot.

Preoperative post exertional compartment pressure measurements were 67.8 (32–114) at 1 minute and 50.2 (28–97) at 5 minutes. At an average of 21 (9–57) months follow up all but one patient had significant relief of their symptoms.

We recommend that the surgical treatment of chronic exertional compartment syndrome affecting the medial compartment of the foot should involve full release of the fascia both superficial and deep to abductor hallucis. It is safe to perform this bilaterally and in association with other lower limb decompressions as required.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_I | Pages 22 - 22
1 Mar 2005
Birks C Jones DG Hodgson B
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We report intermediate term results of a technique of acetabular augmentation using block femoral head autograft and the uncemented expansion cup for adult hip dysplasia.

A retrospective review of one surgeon (BFH) series of consecutive total hip replacements for hip dysplasia using femoral head acetabular augmentation was carried out. The technique involves sectioning the femoral head longitudinally reversing and fixing it to the deficient acetabulum with 6.5mm AO screws. This is then reamed to accept the uncemented expansion cup. Patients were identified from audit databases. Patients completed clinical questionnaires, examination and radiographic evaluation.

Fifteen hips were identified in twelve patients (three bilateral). The average at age at surgery was 54 (44–58) years. There were eight females (eleven hips). Three patients (three hips) were unable to be contacted. Average follow up was 8.4 (4.8–11.4) years. Preoperative centre edge angle was 14 (−10–30) degrees. One patient developed a deep infection requiring early staged revision. One patient was not satisfied with her results at follow up. Mean Harris Hip Score was 83 (63–100), mean WOMAC Score was 76 (50–95). Range of motion was well maintained in all patients. Four patients had other co-morbidities affecting their results. Radiological review shows all grafts to have united with no screw breakage and no cup loosening.

At eight year follow up there is high satisfaction, good clinical and radiological results. These results demonstrate good intermediate term results using this technique in total hip replacement with acetabular dysplasia.


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_III | Pages 272 - 272
1 Nov 2002
Birks C Barnes M Crawford H
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Aim: To determine the length of stay after adolescent idiopathic scoliosis (AIS) surgery in Starship and Mercy Hospitals to ascertain whether there is a difference in the length of stay of patients having AIS surgery in a private hospital compared with a public hospital. To determine the variables having significant influence on the length of stay.

Methods: Patients between the ages of 10 and 20 who had surgery for AIS during the period 1/1/96 to 31/12/2000 were identified from theatre logbooks. Patients who had anterior and posterior surgery were excluded. A retrospective analysis of case notes was carried out. Fisher’s Exact Test was used to analyse categorical data while Student T Test was used for continuous variables.

Results: Thirty-three patients fulfilled the entry criteria. Sixteen male patients were operated on in Starship Hospital. Seventeen patients had operations at Mercy Hospital but only one of these was male. The groups were not significantly different in terms of age, sex, weight, ASA, number of levels, or curve pattern. The Mercy Hospital patients had a significantly lower Cobb angle (by 12 degrees). The Starship Hospital patients tended to retain their PCA pumps longer and tended to use more PCA morphine, however, this result was not significant. The Mercy Hospital patients had their intravenous access removed and were mobilised significantly earlier (1.7 and 1.9 days earlier respectively). The Mercy Hospital patients had a significantly shorter length of stay (6.4 and 8.4 days respectively, p= 0.0002).

Conclusions: Patients at the Mercy Hospital had a significantly shorter post-operative length of stay after AIS surgery. This was not completely explained by the lower Cobb angle seen in the Mercy Hospital patients. The Mercy Hospital patients had their drips removed and were mobilised significantly earlier. This may be the key to early discharge.