Introduction

Trends in hallux valgus surgery continue to evolve. Basal metatarsal osteotomy theoretically provides the greatest correction, but is under-represented in the literature. This paper reports our early experience with a plate-fixed, opening- wedge basal osteotomy, combined with a new form of distal soft tissue correction (in preference to Akin phalangeal osteotomy).

Lag screw fixation with plate osteosynthesis is the usual recommendation for oblique non-comminuted lateral malleolus fractures. Lag screw fixation may sometimes pose varying difficulties depending on the orientation of the fracture and in osteoporotic bones where the process may cause disintegration of the bone.

The purpose of this study was to evaluate whether additional lag screw fixation with plate osteosynthesis offered any advantage over plate only fixation in non-comminuted oblique fractures of the lateral malleolus. A simple method of fixation was employed where the fracture was reduced and held temporarily with a K wire. After fixation with plate the K wire was removed. A total of 20 patients who had non-comminuted unstable oblique fractures of their lateral malleolus that had been surgically fixed plate only fixation were retrospectively evaluated. The patients were aged between 17 and 70 yrs. Evaluation of the success of fixation, complications, resultant mobility and patient satisfaction was based on information gathered from X-ray findings and clinic notes. These results were compared to an agematched group of 20 consecutive patients treated with lag screw fixation and plate osteosynthesis. There was no significant difference in the rate of or functional outcomes in either groups. Lag screw fixation offers no additional advantage when combined with plate synthesis of non-comminuted oblique lateral malleolus fractures.

Background: Local blocks, as the sole means of anaesthesia, in forefoot surgery have previously been described. This technique is not widely practised in the UK but we have routinely used such blocks for many years. Our aim was to assess how well patients tolerated this technique.

Methods: 64 consecutive day cases of fore-foot surgery were recruited prospectively for local anaesthetic block. A range of operations were performed including basal osteotomy of 1st metatarsal and MTPJ arthrodesis. No patients declined to be included. Peripheral nerve blockade was performed by the orthopaedic surgeon or his registrar. Efficacy of block was assessed intra-operatively with a visual analogue score (VAS) of 0 to 10 (10 being worst pain imaginable and 0 being no pain). Overall satisfaction with the anaesthetic procedure was assessed on a 5 point scale (from 1 = very unsatisfied to 5 = very satisfied) at 2 weeks.

Results: Average time to perform the block was 6 minutes (range 3 to 12 mins). Mean VAS for knife to skin was 0.38 (95% confidence ± 0.31) and for ankle tourniquet was 1.44 (95% confidence ± 0.51). At follow up mean satisfaction at 2 weeks was 4.2 out of 5 (95% confidence ± 0.30) with only 9 patients lost to follow up (86% of patients followed up). No complications were reported.

Conclusion: Our experience is that these blocks are quick and easy to perform in the hands of orthopaedic surgeons. They are well tolerated and effective. They result in a considerable cost saving in terms of theatre efficiency and anaesthetist and ODP resources. These savings are still being evaluated.

Purpose: To evaluate retrospectively the functional and radiographic outcome of patients who had a thumb trapeziometacarpal (TM) joint arthrodesis using a T-plate, chevron bone cuts and autologous punch graft harvested from ipsilateral distal radius.

Material and Methods: Between 2001 and 2006, 32 trapeziometacarpal (TM) joint fusions were performed in 24 patients using the above technique. The study group comprised of 16 females and 8 males with average age 52 years (range 42–62 years). Average follow-up was 14.8 months (range 14–60 months). Indications for surgery were: failure of conservative treatment; severe pain; and diminished thumb function hampering everyday life. All patients had radiological evidence of advanced TM joint arthritis (Eaton and Littler grade II to III).

In all cases, chevron bone cuts have been used. The fixation has progressed from K-wires, through single and double lag screws, tension-band wire, to an AO mini T-plate which is the present technique. With the K-wire, or simple screw methods, the failure rates were up to 50%, leading to many revision operations. Bone graft is used; in first 15 cases this was ‘Allomatrix’ but we now use local bone from the distal radius, taken with an AO tap guide used as a trephine.

Functional outcomes were assessed using Quick DASH score, and Gartland and Werley score. There was also a radiographic review. The grip and pinch strength were compared with the contralateral side. We also looked at the progression of disease at scaphotrapezial joint after the fusion of TM joint.

Results: Patient-rated outcome scores indicated very good pain relief with preservation of grip and pinch strength. There were 2 cases (7%) of non-union which required revision surgery and were probably due to poor screw placement in the trapezium. In 8 patients (25%), pain related to prominent metalwork required plate removal. In no case was there x-ray or symptomatic progression of the disease at scaphotrapezial joint. Clinically, 75% rated good, 15% fair, and 10% poor results.

Conclusion: The present form of trapeziometacarpal arthrodesis is reproducible and offers an excellent alternative to trapeziectomy especially in younger patients.

Type of study/level of evidence: Therapeutic IV.

Purpose: To evaluate retrospectively the functional and radiographic outcome of patients who had a thumb trapeziometacarpal (TM) joint arthrodesis using a T-plate, chevron bone cuts and autologous punch graft harvested from ipsilateral distal radius.

Material and Methods: Between 2001 and 2006, 32 trapeziometacarpal (TM) joint fusions were performed in 24 patients using the above technique. The study group comprised of 16 females and 8 males with average age 52 years (range 42–62 years). Average follow-up was 14.8 months (range 14–60 months). Indications for surgery were: failure of conservative treatment; severe pain; and diminished thumb function hampering everyday life. All patients had radiological evidence of advanced TM joint arthritis (Eaton and Littler grade II to III).

In all cases, chevron bone cuts have been used. The fixation has progressed from K-wires, through single and double lag screws, tension-band wire, to an AO mini T-plate which is the present technique. With the K-wire, or simple screw methods, the failure rates were up to 50%, leading to many revision operations. Bone graft is used; in first 15 cases this was ‘Allomatrix’ but we now use local bone from the distal radius, taken with an AO tap guide used as a trephine.

Functional outcomes were assessed using Quick DASH score, and Gartland and Werley score. There was also a radiographic review. The grip and pinch strength were compared with the contralateral side. We also looked at the progression of disease at scaphotrapezial joint after the fusion of TM joint.

Results: Patient-rated outcome scores indicated very good pain relief with preservation of grip and pinch strength. There were 2 cases (7%) of non-union which required revision surgery and were probably due to poor screw placement in the trapezium. In 8 patients (25%), pain related to prominent metalwork required plate removal. In no case was there x-ray or symptomatic progression of the disease at scaphotrapezial joint. Clinically, 75% rated good, 15% fair, and 10% poor results.

Conclusion: The present form of trapeziometacarpal arthrodesis is reproducible and offers an excellent alternative to trapeziectomy especially in younger patients.

Type of study/level of evidence: Therapeutic IV.

Introduction and Aim: In 1995, sterile maggots (blow fly larvae) became available commercially for the first time since the mid-1930s. We have used them in managing ‘problem wounds’ in an orthopaedic unit. We have re-assessed the value of maggot debridement therapy (MDT) in present-day orthopaedics.

Method and Results: To date 95 patients have been treated. (Average age 62; range 16–91). Eighty-five percent of cases involved the lower limb. The remainder were upper limb, apart from one spinal lesion and one sacral sore. Twenty percent of patients had diabetes; six amputation stumps were treated. In 60% of cases a single application was used, the larvae being left in-situ for three to five days. Some wounds required up to three applications. The dressing technique is easily learnt and is ideal for outpatient clinics. The most appropriate wounds are those with a wide opening, extensive slough, and natural drainage. The greatest benefit follows infection with gram-positive cocci, and anaerobes. In eight cases, MRSA infection was cured or controlled.

Larvae provide optimal wound healing conditions, by literally eating pus and bacteria, and also by stimulating granulation tissue to form. However, they cannot produce wound healing if a major sequestrum or implant is present. In general, patient acceptance was good, but five patients requested early removal of maggots. Since 2001, the maggots have been available in sachet form (the so-called ‘Bio-bag’) and this packaged application has made the treatment more readily acceptable, and easier.

Overall we judged that MDT had produced healing or improvement in 80% of infected wounds. Unusual wounds, such as animal bites, a sea -urchin lesion, and infected gout produced some of the most striking cures.

Conclusion: Maggot therapy uniquely minimises both the need for surgical debridement and antibiotics. We therefore recommend its continued use.

We studied prospectively 81 consecutive patients undergoing hip surgery using the Hardinge (1982) approach. The abductor muscles of the hip in these patients were assessed electrophysiologically and clinically by the modified Trendelenburg test. Power was measured using a force plate. We performed assessment at two weeks, and at three and nine months after operation.

At two weeks we found that 19 patients (23%) showed evidence of damage to the superior gluteal nerve. By three months, five of these had recovered. The nine patients with complete denervation at three months showed no signs of recovery when reassessed at nine months. Persistent damage to the nerve was associated with a positive Trendelenburg test.