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Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 7 - 7
1 Jan 2013
Zaidi R Abbassian A Cro S Guha A Hasan K Cullen N Singh D Goldberg A
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Background

The focus on evidence-based medicine has led to calls for increased levels of evidence in surgical journals. The purpose of the present study was to review the levels of evidence in articles published in the foot and ankle literature and to assess changes in the level of evidence over a decade.

Methods

All articles from the years 2000 and 2010 in Foot and Ankle International, Foot and Ankle Surgery, and all foot and ankle articles from JBJS A and JBJS B were analysed. Animal, cadaveric, basic science, editorials, surveys, letters to Editor and correspondence were excluded. Articles were ranked by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 60 - 60
1 Sep 2012
Abbassian A Zaidi R Guha A Cullen N Singh D
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Introduction

Calcaneal osteotomy is often performed together with other procedures to correct hindfoot deformity. There are various methods of fixation ranging from staples, headed or headless screws or more recently stepped locking plates. It is not clear if one method is superior to the other. In this series we compare the outcome of various methods of fixation with particular attention to the need for subsequent hardware removal.

Patients and Methods

A retrospective review of the records of a consecutive series of patients who had a calcaneal osteotomy performed in our unit within the last 5 years was undertaken. All patients had had their osteotomy through an extended lateral approach to their calcaneous. The subsequent fixation was performed using one of three methods; a lateral plate placed through the same incision; a ‘headless’; or a ‘headed’ screw through a separate stab incision inserted through the infero-posterior heel. Records were kept of subsequent symptoms from the hardware and need for metalwork removal as well as any complications. When screws were inserted the entry point in relation to the weight-bearing surface of the calcaneous was also recorded.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 63 - 63
1 Sep 2012
Zaidi R Abbassian A Guha A Singh D Goldberg A
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Background

The recent emphasis on using “evidence based medicine” for decision-making in patient care has prompted many publishers to mention the level of evidence of articles in their journals. The “quality” of a journal may thus be reflected by the proportion of articles with high levels of evidence and assist it achieve citations and therefore an Impact Factor.

The purpose of this study was to survey published Foot and Ankle literature to evaluate changes in the level of evidence over ten years.

Methods

Articles from Foot and Ankle International, JBJS Br, JBJS Am, Foot and Foot and Ankle Surgery were used. We looked at the years 2000 and 2010 and ranked the articles by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine. 498 articles were ranked. Studies of animals, studies of cadavera, basic-science articles were excluded.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 64 - 64
1 Sep 2012
Mukhopadhyay S Metcalfe A Guha A Mohanty K Hemmadi S Lyons K O'Doherty D
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Introduction

Previous studies have demonstrated the need of accurate reduction of ankle syndesmosis. Measurement of syndesmosis is difficult on plain radiographs. Recently, a difference of 2mm in anterior and posterior measurements at incisura of the inferior tibio-fibular joint on CT has been described as a measure of malreduction (depicted as ‘G’ for ease of description). Our practice changed towards routine post operative bilateral CT following syndesmosis fixation to assess the reduction and identify potential problems at an early stage. The aim of this primarily radiological study was to determine if the use of bilateral cross sectional imaging brings additional benefit above the more conventional practice of unilateral imaging.

Method

Between 2007 and 2009, nineteen patients with ankle fractures involving the syndesmosis were included in the study group who had bilateral CT post operatively. The values of ‘G’ and the mean diastasis (MD) were calculated, representing the average measurement between the fibula and the anterior and posterior incisura.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 61 - 61
1 Sep 2012
Guha A Abbassian A Zaidi S Goldberg A Singh D
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Introduction

Bone marrow oedema syndrome (BMES) of the foot and ankle is an uncommon and often misdiagnosed condition. It is usually thought to be a benign self limiting condition, without any sequelae. However, it can cause disabling pain for a prolonged period of time.

Materials and Methods

We retrospectively reviewed 8 patients with the diagnosis of BMES. There were 6 males and 2 females with an average age of 51 years (38–63 years). All patients had acute onset of severe pain in the foot without any history of trauma. None of the patients had history of excessive alcohol or steroid intake. 5 patients (63%) had bilateral involvement of migratory nature. All patients had characteristic features on MR scans, with involvement of 3 or more bones in the foot.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 37 - 37
1 Sep 2012
Guha A Zaidi S Abbassian A Cullen N Singh D
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Single stage total talectomy with tibio-calcaneal arthrodesis in adult patients has been rarely reported in the literature. In patients with severe rigid, unbraceable equinovarus deformities, talectomy can offer excellent correction.

We performed single stage total talectomy with tibiocalcaneal arthrodesis on 11 feet in 10 patients (6F; 5M) of average age 67 years (range 54–77 years). 6 patients had neuropathic deformity, 2 had failed fusion procedures and 2 had severe Rheumatoid hindfoot disease. The fusion was undertaken using a hindfoot nail and screws in 5 patients, plate and screws in 4 patients, a hindfoot nail in 1 and cancellous screws in 1 patient. All patients followed the standard post operative protocol and were reviewed at 2, 6 and 12 weeks and thereafter every 4 weekly till union. All patients were mobilised strictly non weight bearing for the first 6 weeks and thereafter, touch weight bearing was allowed with the leg in a protective cast. Full weight bearing was allowed once the fusion had consolidated.

Fusion was achieved in 7 feet (64%) at an average time of 17 weeks. In 4 patients, non-union persisted but they were pain free at latest review and would not consider further surgery. Average duration of follow-up was 20 months (range 6–24 months). All patients had stiff hindfeet with a jog of movement at the tibio navicular articulation. All patients had a stable, plantigrade, braceable foot and were community ambulators. All patients were satisfied with the outcome.

Total talectomy with tibiocalcaneal arthrodesis is a useful procedure to correct severe rigid equinovarus deformities in adults. The tibionavicular articulation forms a pseudarthrosis and retains a jog of movement. Retention of the head of the talus with talotibial arthrodesis is unnecessary. We recommend this procedure as a salvage option in this difficult problem.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXI | Pages 24 - 24
1 Jul 2012
Guha A Khurana A Bhagat S Pugh S Jones A Howes J Davies P Ahuja S
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Purpose

To evaluate efficacy of blood conservation strategies on transfusion requirements in adult scoliosis surgery and establish a protocol for cross matching.

Methods and Results

Retrospective review of 50 consecutive adult scoliosis patients treated using anterior only(14,28%), posterior only(19,38%) or combined(17,34%) approaches. All patients were anaesthetised by the same anaesthetist implementing a standard protocol using cell salvage, controlled hypotension and antifibrinolytics.

Mean age was 24.6 years. BMI was 21.9. On an average 9.5(6-15) levels were fused, with an average duration of surgery of 284.6(130-550) minutes. Antifibrinolytics were used in 31(62%) of the patients which included Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Patients on antifibrinolytics had a significantly (p<0.05) lower blood loss (530ml) as compared to other patients (672ml). Mean volume of the cell saved blood re-transfused was 693.8 ml and mean postoperative HB level dropped to 10.7 g/dl(7.7-15) from a mean preoperative of 13.3 g/dl(10-17).

7(42%) with combined approaches and 3(15.8%) with posterior only approach required blood transfusion, 4/50(8%) of which required intra while 6/50(12%) required intra and postoperative transfusion. None of the patients having anterior surgery alone required blood transfusion.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_X | Pages 95 - 95
1 Apr 2012
Guha A Mukhopadhyay S Ahuja S
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Our study aims to evaluate the efficacy of Wallis implant in management of discogenic back pain.

We have prospectively studied thirty patients between 2006 and 2007. Average age of patients was 40.8 years. Average follow-up period 20.6 months (9-28). Main inclusion criteria includes failure of conservative management of low back pain due to degenerative disc disease, preservation of 50% of the disc height and positive discographic features. In majority of the patients the implant was put in at the level of L4-L5.

Pre-op and post op SF36 and Oswestry Disability Index (ODI) scores were assessed during clinic follow-up and by telephonic interview. Mean SF36 score improved from thirty-seven (8.3 – 54.3) to 51.4. Mean ODI improved from forty-three (20-60) to 26.5(2-60) (p = 0.026). Complications including superficial infection occurred in one patient, deep infection in one patient, erosion of spinous process in one and displacement of the implant in one case. Three (10%) patients had revision surgery due to various reasons.

Wallis interspinous dynamic stabilization system could be used as a soft stabilisation device avoiding fusion and short-term results are promising. In selected group of discogenic low back pain patients it is a useful interim procedure. Long-term follow-up of our series is ongoing.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_IV | Pages 105 - 105
1 Mar 2012
Guha A Das S Debnath U Shah R Lewis K
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Introduction

Displaced distal radius fractures in children have been treated in above elbow plaster casts since the last century. Cast index has been calculated previously, which is a measure of the sagittal cast width divided by the coronal cast width measurement at the fracture site. This indicates how well the cast was moulded to the contours of the forearm. We retrospectively analysed the cast index in post manipulation radiographs to evaluate its relevance in redisplacement or reangulation of distal forearm fractures.

Study Design

Consecutive radiographic analysis.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_III | Pages 74 - 74
1 Feb 2012
Debnath U Guha A Karlakki S Evans G
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In order to manage painful subluxation/dislocation secondary to cerebral palsy, 12 hips in 11 patients received combined femoral and Chiari pelvic osteotomies with additional soft tissues releases at an average age of 14.1 (9.1-17.8) years. Pain relief, improvement in the arc of movement, sitting posture and ease of perineal care was recorded in all, and these features have been maintained at an average follow-up of 13.1 (8-17.5) years.

The improvement of general mobility was marginal, but those who were community walkers benefited the most. Pre-operative radiological measurements have been modified post-operatively to use lateral margin of the neo-acetabulum produced by the pelvic osteotomy. The radiological migration index improved from a mean of 80.6% to 13.7% [p<0.0001]. The mean changes in CE angle and Sharp's angle were 72° (range 56°- 87°) [p<0.0001] and 12.3° (range 9°- 15.6°) [p< 0.0001] respectively. Radiological evidence of progressive arthritic change was seen in only one hip, in which only a partial reduction had been achieved, and there was early joint space narrowing in another. Heterotopic ossification was observed in one patient with athetoid quadriplegia who remained pain free. In seven hips the lateral Kawamura approach, elevating the greater trochanter, provided exposure for both osteotomies and allowed the construction of a dome-shaped iliac osteotomy, while protecting the sciatic nerve.

This combined procedure provides a stable hip with sustained pain relief for the adolescent and young adult presenting with pain.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_II | Pages 91 - 91
1 Feb 2012
Debnath U Parfitt D Guha A Hariharan K
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Most high-energy trauma to lower legs, ankles and feet result in severe crush injuries. We performed a retrospective case series study

Eight patients (7M: 1F) with mean age of 28 years (range -18 -35 years) were included. Four had Grade 3 open fractures of the distal tibia and 5 had open foot fractures. Two had neurovascular injuries. Four patients had associated injuries with mean ISS of 9 (range 8-16) and a mean MESS score of 3.5 (3-7). All had undergone some form of internal and external fixation within approximately 24 hours (8 hrs to 4 days). The mean follow-up period was two years (range 1-4 years). At final follow-up patients' health was measured using SF-36 questionnaire.

Six patients had their fractures healed at a mean of 4.8 months (4-9 m). Two patients had fully functional foot with occasional complaints of painful ankle. Two patients had CRPS1 undergoing treatment. Two patients are unable to walk due to chronic pain and deformity. Comparison of the SF-36 scores with the age-matched UK normal controls without foot and ankle injuries showed significantly worse scores in physical function (PF: p<0.01) and role physical (RP: p< 0.01) categories.

Our surgical instinct dominates decision-making, favouring salvage rather than amputation in these young groups of patient. They gradually suffer a cocktail of crippling disease characterised by psycho-socio-economic and physical disability. Should we be depleting our resources in salvaging these complex limb injuries?


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 312 - 312
1 Jul 2011
Guha A Mukhopadhyay S Reddy M Thomas R
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Background: The bunionette is a lateral prominence of the fifth metatarsal head. It is usually caused by a wide intermetatarsal angle (IMA) between the 4th and 5th metatarsals with associated varus of the metatarsophalangeal (MTP) joint. Increased pressure placed on the head of the 5th metatarsal results in pain and plantar callus formation. Failure of conservative treatment warrants bony corrective surgery. Various distal, shaft and basal osteotomies have been described in the literature.

Methods: We have used a ‘reverse’ scarf osteotomy in 12 cases (10F: 2M) with a mean follow-up of 12 months (range 5–22 months). All patients filled up a Foot Function Index (FFI) questionnaire pre-operatively and a repeat questionnaire at the latest follow-up. All angles were measured on a weight bearing AP radiograph of the foot. Post-operatively we mobilised the patients immediately using a heel bearing shoe. All osteotomies healed sufficiently at 6 weeks to allow unprotected weight bearing. Full weight bearing was allowed after clinical and radiological union was achieved.

Results: Pre-op mean IMA was 13.1 degrees (range: 10.4–18 degrees) and mean 5th MTP angle was 19.9 degrees (range 12.7–25.5 degrees). Pre-op mean FFI was 34.2 (range 14–71.3). Post operatively, mean IMA was 7.27 degrees (range: 2.0–11.5 degrees); mean 5th MTP angle was 6.36 degrees (range: 2.8–9.0 degrees) and post-operative mean FFI was 5 (range 0–16.7). All except one patient were pleased with the cosmetic correction obtained. One patient did not like the scar but her foot was asymptomatic and her FFI improved from 27 to 0. All patients would undergo the same procedure on the other foot if required and would recommend the same to a friend.

Conclusion: ‘Reverse’ Scarf osteotomy in the correction of bunionette deformity offers promising results in the short term. Further longterm follow-up would help to establish the benefits of this procedure.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_II | Pages 147 - 147
1 May 2011
Rath N Guha A Khurana A Hemmadi S Thomas R Odoherty D
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We audited all patients who underwent Foot and Ankle surgery at the University Hospital of Wales over one financial year (April 2007 – March 2008).

Patients were identified from the hospital OPCS-4 coding system and all scheduled and unscheduled visits to hospital investigated. Both trauma and elective patients were included. Patients were followed up for a mean period of 9 months (Range 1–14 months) following surgery.

The records for 1052 patients were evaluated. Of these, 77% were elective cases and 23% were trauma related. Overall about 10 % of our foot and ankle patients (100/1052) either attended the A& E Department or had an unplanned clinic visit at some stage of their follow up. Three quarters of these patients were admitted to hospital (median stay 1 day, range 1–51 days).

Twenty five patients (24 A& E; 1 medical) simply re-attended, but were not admitted. The majority of these (58%) had plaster-related problems (8\24) or superficial wound infections (6/24). The remaining patients presented with pain around the operated area, and were discharged after investigation. One patient presented to the physicians 44 days after excision of a Morton’s neuroma with a DVT.

Seventy five patients (7%) were re-admitted to hospital. Two were admitted under the physicians: one with a pulmonary embolus (30 days post ORIF ankle) and one following a cardiac arrest (20 days post ORIF ankle). Out of the remainder 34 patients had planned removal of metalwork, 9 patients had metalwork removed because of infection and 21 patients had soft-tissue infection requiring antibiotics or debridement. Overall, 9 patients underwent revision surgery (0.85%).

The overall infection and thromboembolic rate was 3.42 %(6 A& E + 30 T& O/1052) and 0.28% (1A& E + 2 medical/1052) respectively.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 27 - 28
1 Jan 2011
Guha A Khurana A Saxena N Pugh S Jones A Howes J Rhys-Davies P Ahuja S
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We aimed to evaluate the effects of implementing blood conservation strategies on transfusion requirements in adult patients undergoing scoliosis correction surgery. We retrospectively studied 50 consecutive adult patients who underwent scoliosis correction surgery (anterior, posterior or combined) between 2003 and 2007. All patients had a standard transfusion protocol. Age, BMI, pre and post operative haemoglobin, levels fused, duration of surgery, hospital stay, anti-fibrinolytics used and blood transfused was noted.

50 patients with mean age 24.6 years and mean BMI 21.9 kg/m2 were studied. 14 patients had anterior surgery, 19 patients had posterior surgery and 17 had combined anterior and posterior procedures. Mean number of levels fused was 9.5 (6–15) and mean duration of surgery was 284.6 minutes (135–550 minutes). Antifibrinolytics were used in 31 patients (62%), Aprotinin in 21(42%) and Tranexamic acid in 10 (20%). Mean blood loss in patients who received anti fibrinolytics was 530mls while mean blood loss in the other patients was 672mls. (p< 0.05). Blood transfusion was not required in any of the patients undergoing anterior correction only while 7 patients (41%) undergoing anterior and posterior correction and 3 patients (15.8%) undergoing posterior correction only required blood transfusion. Mean volume of cell saved blood re-transfused was 693.8 mls and mean hospital stay was 9.2 days. Mean pre-op haemoglobin was 13.2 g/dl (10.4–17.4) and mean post-op haemoglobin was 10.7 g/dl (7.7–15). 4 patients (8%) required intra and post-operative blood transfusion while 6 patients (12%) required blood transfusion postoperatively.

In conclusion, the use of anti-fibrinolytics like Aprotinin and Tranexamic acid reduces blood loss in scoliosis surgery. In the current scenario, with Aprotinin no longer available for use, our study would recommend the use of Tranexamic acid alongwith other blood conservation measures. In our unit we do not have blood cross matched for anterior surgery alone.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 28 - 28
1 Jan 2011
Khurana A Guha A Mohanty K Ahuja S
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Sacroiliac joint (SIJ) is a diarthrodial joint and can often be a source of chronic low back pain complex. We present a percutaneous technique for SIJ fusion and the functional and radiological outcome following arthrodesis with HMA (Hollow modular anchorage; Aesculap Ltd, Tuttlingen) screws.

Fifteen consecutive patients operated for SIJ fusion between Sep 2004 and Aug 2007 were included in the study. The diagnosis was confirmed with MRI and diagnostic injections. Pre-operative and post-operative functional evaluation was performed using SF-36 questionnaire and Majeed’s scoring system. Postoperative radiological evaluation was performed using plain radiographs. The HMA screws packed with bone substitute were implanted percutaneous under fluoroscopic guidance.

The study group included 11 females and 4 males with a mean age of 48.7 years. Mean follow-up was 14 months. Mean SF-36 scores improved from 37 to 80 for physical function and from 53 to 86 for general health. The differences were statistically significant (Wilcoxon signed rank test; p < 0.05). Majeed’s score improved from mean 37 preoperative to mean 79 postoperative. The difference was statistically significant (student t test, p< 0.05). 13 had good to excellent results. The remaining 2 patients had improvement in SF-36 from mean 29 to 48. Persisting pain was potentially due to coexisting lumbar pathology. Intra-operative blood was minimal and there were no post-operative or radiological complications.

Percutaneous HMA screws are a satisfactory way to achieve sacroiliac stabilisation.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 482 - 482
1 Sep 2009
Guha A Khurana A Saxena N Pugh S Jones A Howes J Davies P Ahuja S
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Introduction: Scoliosis surgery involves major blood loss, at times exceeding estimated blood volume.

Aim: To evaluate the effects of implementing blood conservation strategies (including cell salvage, controlled hypotension and anti-fibrinolytic drugs) on transfusion requirements in adult patients undergoing scoliosis correction surgery. To establish a protocol for cross matching of blood.

Study Design: We retrospectively studied 50 consecutive adult patients who underwent scoliosis correction surgery (anterior, posterior or combined) between 2003 and 2007. All patients were anaesthetised by the same anaesthetist who implemented a standard transfusion protocol. Age, BMI, pre and post operative haemoglobin, levels fused, duration of surgery, hospital stay, antifibrinolytics used and blood transfused was noted.

Results: 50 patients with mean age 24.6 years and mean BMI 21.9 kg/m2 were studied. 14 patients had anterior surgery, 19 patients had posterior surgery and 17 had combined anterior and posterior procedures. Mean number of levels fused was 9.5 (6–15) and mean duration of surgery was 284.6 minutes (135–550 minutes). Anti-fibrinolytics were used in 31 patients (62%), Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Mean blood loss in patients who received anti fibrinolytics was 530mls while mean blood loss in the other patients was 672mls. (p< 0.05). Blood transfusion was not required in any of the patients undergoing anterior correction only while 7 patients (41%) undergoing anterior and posterior correction and 3 patients (15.8%) undergoing posterior correction only required blood transfusion. Mean volume of cell saved blood re-transfused was 693.8 mls and mean hospital stay was 9.2 days. Mean pre-op haemoglobin was 13.2 g/dl (10.4–17.4) and mean post-op haemoglobin was 10.7 g/dl (7.7–15). 4 patients (8%) required intra and post-operative blood transfusion while 6 patients (12%) required blood transfusion postoperatively.

Conclusion: Use of anti-fibrinolytics like Aprotinin and Tranexamic acid reduces blood loss in scoliosis surgery. In the current scenario, with Aprotinin no longer available for use, our study would recommend the use of Tranexamic acid alongwith other blood conservation measures.

In our unit we do not have blood cross matched for anterior surgery alone.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 495 - 495
1 Sep 2009
Khurana A Guha A Howes J Jones A Davies P Mohanty K Ahuja A
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Introduction: Sacroiliac joint (SIJ) is a diarthrodial joint and can often be a source of chronic low back pain complex. We present a percutaneous technique for SIJ fusion and the functional and radiological outcome following the arthrodesis.

Aims and Objectives: To evaluate the functional and radiological outcome following percutaneous technique for SIJ fusion with HMA (Hollow modular anchor-age) screws.

Materials and Methods: 15 consecutive patients operated for SIJ fusion between Sep 2004 and Aug 2007 were included in the study. The diagnosis was confirmed with MRI and diagnostic injections. Pre-operative and post-operative functional evaluation was performed using SF-36 questionnaire and Majeed’s scoring system. Postoperative radiological evaluation was performed using plain radiographs. The Hollow modular anchorage (HMA) screws (Aesculap Ltd, Tuttlingen) packed with bone substitute were implanted percutaneous under fluoroscopic guidance

Results: The study group included 11 females and 4 males with a mean age of 48.7 years. Mean follow-up was 14 months. Mean SF-36 scores improved from 37 to 80 for physical function and from 53 to 86 for general health. The differences were statistically significant (Wilcoxon signed rank test; p < 0.05). Majeed’s score improved from mean 37 preoperative to mean 79 postoperative. The difference was statistically significant (student t test, p< 0.05). 13 had good to excellent results. The remaining 2 patients had improvement in SF-36 from mean 29 to 48. Persisting pain was potentially due to coexisting lumbar pathology. Intra-operative blood was minimal and there were no post operative or radiological complications in any patient.

Conclusion: Percutaneous HMA screws are a satisfactory way to achieve sacro-iliac stabilisation.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_I | Pages 138 - 138
1 Mar 2008
Debnath U Parfitt D Guha A Hariharan K
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Purpose: To evaluate the outcome of salvage surgery with external fixation in these rare and severe lower limb injuries

Methods: Eight patients (7M: 1F) with mean age of 28 years (range −18 −35 years) were included. Four had Grade 3 open fractures of the distal tibia and 5 had open foot fractures. Two had neurovascular injuries. Four patients had associated injuries with mean ISS of 9 (range 8–16) and a mean MESS score of 3.5 (3–7). All had undergone some form of internal and external fixation within approximately 24 hours (8 hrs to 4 days). The mean follow up period was two years (range 1 – 4 years). At final follow-up patient’s health was measured using SF-36 questionnaire.

Results: Six patients had their fractures healed at a mean of 4.8 months (4–9 m). Two patients had fully functional foot with occasional complaints of painful ankle. Two patients had CRPS1 undergoing treatment. Two patients are unable to walk due to chronic pain and deformity. Comparison of the SF -36 scores with the age-matched UK normal controls without foot and ankle injuries showed significantly worse scores in physical function (PF: p< 0.01) and role physical (RP: p< 0.01) categories

Conclusions: Our surgical instinct dominates the decision-making favoring salvage with external fixation primarily rather than amputation in these young groups of patient. Should we be depleting our resources in salvaging these complex limb injuries?


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_I | Pages 143 - 143
1 Mar 2008
Debnath U Guha A Karlakki S Evans G
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Purpose: This is a retrospective study, analysing the long term outcome following Chiari osteotomy and varus derotation osteotomy, which was performed as a part of one stage surgical reconstruction for painful subluxed or dislocated hips in cerebral palsy patients

Methods: Between 1986 and 1993, 12 hips in 11 patients underwent the above procedure. Adequate hip reduction was achieved in 11 hips and an acceptable reduction in the other. Immediate pain relief and subsequent improvement in range of movement of the hip, sitting posture and ease of perineal care was recorded in all. Average age at the surgery was 14.1 (9.1–17.8) years. At the recent follow-up, patients were seen along with the parents or carers and reassessed for pain, sitting comfort, mobility and ease of perineal care. Radiographs were obtained and assessed for acetabular cover, degree of femoral head lateralisation, changes in the hip joint including secondary arthritic changes

Results: At an average follow-up of 13.4 years (range 8.1–17.2 years), all patients remain pain free and continue to maintain improved sitting posture and personal hygiene. Improvement to mobility was marginal, but those who were community walkers to begin with benefited the most. No significant progressive arthritic changes or lateral migration were seen in any of the patients except one, in whom only a partial reduction was achieved. Minor joint changes were seen in 2 other patients.

Conclusions: Overall, Chiari osteotomy produces lasting benefits and the possible avascular necrosis and secondary arthritic changes in the hip joint appear to be minimal when compared with the long term benefits


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_III | Pages 398 - 398
1 Oct 2006
Shoaib A Guha A Balendran R Kuiper J
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Introduction: Tension band wiring is a common technique for olecranon fracture fixation. The most commonly used material for the tension band is stainless steel wire. There are however problems associated with stainless steel wire. Ethibond (Ethicon Ltd, Edinburgh) has previously been cited as a suitable alternative material but not FiberWire. The biomechanical properties of FiberWire (Arthrex Ltd, Sheffield) as a tension band material have not been evaluated. This study aimed to investigate the properties of FiberWire and compare them with stainless steel wire and Ethibond.

Methods: Saw-bone olecranons were osteotomised identically to create an olecranon fracture. Identical tension band constructs were produced using stainless steel wire, Ethibond and FiberWire. The construct was tested by cyclical loading with an ESH dynamic testing machine (Brierley Hill, West Mids). A preload of 5N was applied before cyclical loading at levels up to 200N. The fracture gap was measured with a displacement transducer (Tokyo Sokki Kenkyujo Co, Japan).

Results: At loading up to 100N, the stainless steel wire allowed an average fracture gap of 200 micrometers. 5 gauge Ethibond allowed a larger fracture gap of 350 micrometers (p< 0.05). 2 gauge Fiberwire did not allow a significantly different fracture gap to Ethibond.

Discussion: The fracture gap with suture material was greater than with stainless steel wire, but still less then 0.5mm with loading of 100N. Free body diagram calculations determine that in a 70 kg man, this would correspond to the forces expected in extending the elbow against gravity. This means that these alternative materials are mechanically suitable for use in clinical practice for tension bands. This can avoid some of the complications of stainless steel wire.

Conclusion: 5 gauge Ethibond and 2 gauge FiberWire are biomechanically suitable as alternatives to stainless steel wire in tension band wire fixation of olecranon fractures.