Approaching the ruptured anterior cruciate ligament

Anterior cruciate ligament (ACL) disruptions are common injuries that currently hold a fearsome reputation among athletes of all abilities and disciplines. Indeed, if the diagnosis is missed at first presentation, it is difficult to attribute ongoing instability and recurrent injury to an ACL tear. Classically, patients then often improve shortly before repeatedly reinjuring their knee. At some point, the knee may lock, necessitating an arthroscopic meniscectomy. Tragically, this then hastens the progression of joint arthrosis and the decline of the joint function. While the burden of responsibility does not lie solely with the junior doctor or the general practitioner, it is often at the first consultation that the natural history of this devastating injury is decided. The ability to recognise, institute early management and reassure patients with ACL tears about the future is an invaluable asset to the non-specialist junior doctor. Once diagnosed, the responsibility of advising and further counselling of patients with ACL injuries is best left to the orthopaedic knee specialist. Family practitioners and emergency room doctors should not feel pressured to offer advice on specialist areas such as return to sports without reconstruction or indeed the need for reconstruction. Indeed, decisions to return to sports with ACL-deficient knees have all too often led to disastrous reinjury events to the articular cartilage and/or the menisci.     

Cholesterol granuloma of the kidney mimicking a tumour.

Introduction Cholesterol granulomas are lesions consisting of cholesterolcrystals and foreign body giant cells [1]. Lipid disturbancesare thought to play a role in their aetiology. They are rarehistological     

Magnesium-based bioabsorbable screw fixation for hallux valgus surgery – A suitable alternative to metallic implants

BackgroundThe primary aim of this pilot study was to prospectively evaluate outcomes of the MgYREZr bioabsorbable screw in the setting of hallux valgus corrective surgery. The secondary aim was to compare the outcomes against a control group treated with conventional titanium screws.MethodsA consecutive series of patients with hallux valgus deformity (n = 24) underwent forefoot reconstruction surgery with a scarf osteotomy to the first metatarsal using MgYREZr screws. Functional scores, radiological outcomes, and complication profile were recorded over 12 months. Results were compared against a control group of patients (n = 69) using titanium alloy screws.ResultsAt 1-year post-operative, both functional and radiological outcomes showed significant improvements. Compared to the control group, there was no significant difference in functional outcomes, yet radiological improvements were significantly better in the control group.ConclusionsThe MgYREZr bioabsorbable screw is a suitable alternative to titanium alloy screws for hallux valgus corrective surgery.     

Tibiotalocalcaneal Arthrodesis With the Hindfoot Arthrodesis Nail: A Prospective Consecutive Series From a Single Institution

Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure. We report a series of 20 patients who underwent TTCA using an intramedullary nail. Of the 20 patients, 7 (35%) had diabetes mellitus. The patient experiences and outcomes were analyzed. Their mean age was 61.1 (range 39 to 78) years. The minimum follow-up period was 13 (mean 28, range 13 to 49) months. Surgical indications included diabetic Charcot arthropathy in 7 (35%), hindfoot osteoarthritis in 10 (50%), and severe equinovarus deformity in 3 (15%). A calcaneal spiral blade was used in 2 patients (10%). Significant improvements (p < .05) were observed in 5 of 8 Short-Form 36-item Health Survey components, the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale (p < .001), and visual analog scale for pain (p < .001). The mean length of the hospital stay was 6.7 (range 1 to 27) days. Of the 20 patients, 76.9% had improvement in their activity postoperatively. Also, 81.8% were able to resume their preoperative work after a mean of 7.89 (range 3 to 24) months. Overall, 19 patients (95%) reported favorable outcomes. Superficial wound infection (n = 4; 20%) and deep wound infection (n = 3; 15%) were the most common complications (35%), with 1 case (5%) culminating in a below-the-knee amputation. Radiographic union was achieved in 16 of the tibiotalar joints (80%), 16 subtalar joints (80%), and 4 tibiocalcaneal fusions (20%). In a subgroup analysis of 7 patients with diabetes mellitus (35%), the incidence of wound complications and fusion was comparable to that of the primary cohort. TTCA performed with an intramedullary nail appears to offer a reliable and safe alternative for patients with severe ankle and hindfoot pathologic entities, including those with diabetes mellitus.     

Return to physical activity after gastrocnemius recession

AIM To prospectively investigate the time taken and patients' ability to resume preoperative level of physical activity after gastrocnemius recession. METHODS Endoscopic gastrocnemius recession(EGR) was performed on 48 feet in 46 consecutive sportspersons, with a minimum follow-up of 24 mo. The Halasi Ankle Activity Score was used to quantify the level of physical activity. Time taken to return to work and physical activity was recorded. Functional outcomes were evaluated using the short form 36(SF-36), American Orthopedic Foot and Ankle Society(AOFAS) Hindfoot score and modified Olerud and Molander(O and M) scores respectively. Patient's satisfaction and pain experienced were assessed using a modified Likert scale and visual analogue scales. P-value 0.05 was considered statistically significant.RESULTS Ninety-one percent(n = 42) of all patients returned to their preoperative level of physical activity after EGR. The mean time for return to physical activity was 7.5(2-24) mo. Ninety-eight percent(n = 45) of all patients were able to return to their preoperative employment status, with a mean time of 3.6(1-12) mo. Ninety-six percent(n = 23) of all patients with an activity score 2 were able to resume their preoperative level of physical activity in mean time of 8.8 mo, as compared to 86%(n = 19) of patients whose activity score was ≤ 2, with mean time of 6.1 mo. Significant improvements were noted in SF-36, AOFAS hindfoot and modified O and M scores. Ninety percent of all patients rated good or very good outcomes on the Likert scale.CONCLUSION The majority of patients were able to return to their pre-operative level of sporting activity after EGR.     

Radiation exposure and the urologist: what are the risks?

Purpose

Endourology is established in urology practice with routine use of fluoroscopic guidance. Medical personnel are rarely exposed to direct radiation exposure but secondary exposure occurs via radiation scatter. There are few reports on scatter radiation exposure and the subsequent risk to medical personnel involved in urological fluoroscopic procedures. We review the risks of scatter radiation exposure to medical personnel with reference to the routine use of fluoroscopic imaging in urological practice.

Materials and Methods

We measured staff radiation exposure during a series of ureteral endourological procedures using LiF:Mg,Ti thermoluminescent dosimeters placed at the extremities of the operating surgeon, the assistant and the scrub nurse. Doses for percutaneous nephrolithotomy (PCNL) procedures were calculated by extrapolating from the ureteral procedure thermoluminescent dosimeter data. Theoretical scattered radiation dose rates were also calculated.

Results

The average ureteral procedure fluoroscopy time was 78 seconds with an exposure rate of 71 kV, 2.4 mA. The surgeon received the highest radiation exposure with the lower leg (11.6 ± 2.7 μGy) and foot (6.4 ± 1.8 μGy) receiving more radiation than the eyes (1.9 ± 0.5 μGy) and hands (2.7 ± 0.7 μGy). For a predicted annual caseload of 50 ureteral cases, the dose received does not exceed 0.12% of the Ionising Radiations Regulations 1999 annual dose limit for adult workers. Radiation exposure during PCNLs is higher but does not exceed 2% of the annual dose limits even if 50 PCNLs are performed annually.

Conclusions

Fluoroscopic screening results in radiation exposure of medical personnel. The estimate of maximum scatter radiation exposure to the surgeon for 50 PCNL procedures a year did not exceed 10 mGy. This amount is less than 2% of permissible annual limits of equivalent dose to the extremities. Medical personnel should be aware of scatter radiation risks and minimize radiation exposure when involved in fluoroscopic screening procedures.     

Examination of the varus ankle, foot, and tibia

A detailed clinical examination is an essential component in the assessment of the cavus foot. A complex interaction of pathologic conditions can only be assessed completely with physical examination. Imaging such as computed tomography or magnetic resonance imaging (MRI) may confound the physician, such as in anterior talofibular ligament tears on MRI while the ankle is stable or arthritic joints that are asymptomatic but abnormal on imaging. At the end of the day, the physical examination supersedes all other investigations. After investigations have been performed, the patient needs to be reviewed and the results interpreted in light of the clinical findings. At this point the examiner will be able to determine what is significant and decide on an appropriate treatment plan.