While the demand for orthopaedic surgical expertise in the developing world is in critically short supply, short-term remedy from visiting doctors cannot solve this long-term healthcare problem. Capacity building by senior and training orthopaedic surgeons from established Western training programmes can offer a significant contribution to the orthopaedic patient in the developing world and the gains for those visiting are extremely valuable. We report on several visits by a UK orthopaedic team to a hospital in Kabul, Afghanistan and discuss the operative and non-operative case mix and the benefits in terms of local capacity building and the unique experience of those visiting.
Lumbar spine foraminal stenosis has previously been defined by the foraminal and posterior disc height. We performed a study to determine whether residual clinically significant foraminal stenosis correlates with foraminal dimensions and peri-neural fat signal loss in a group of patients with leg pain undergoing surgery for lateral recess stenosis. We retrospectively studied the pre-operative para-sagittal MRI slices of 57 patients undergoing lumbar decompression and measured pre- and post-operative VAS as a primary outcome measure to evaluate surgical success. We performed a linear regression analysis comparing change in VAS score, 1 year VAS and percentage change in VAS with foraminal height and width and found no significant correlation (R2 <0.2 for all correlations). We identified a sub-group of 16 patients with absent perineural foraminal fat signal with a significantly increased probability of post-operative VAS>2 compared to patients with present fat signal (p=0.0001) who all had foraminal height <10mm. In conclusion, we were unable to define dimensional foraminal parameters for clinically significant foraminal stenosis on para-sagittal MRI. Obliteration of perineural fat was associated with worse outcome and post-operative leg pain. The aetiology of foraminal stenosis is multi-factorial and more detailed imaging of the foramen is required. We recommend that coronal and fine para-sagittal MRI slices are analysed to evaluate patients with central and lateral recess stenosis for co-existing foraminal stenosis.
Subtalar dislocation is a significant injury characterised by late complications, including subtalar arthritis. We describe a rare case of irreducible posterior subtalar dislocation due to incarceration of a fracture of the anterior process of the calcaneum in the subtalar joint, and discuss appropriate management.
