This study analyses the outcomes of litigation claims in trauma and orthopaedic surgery between 2... more This study analyses the outcomes of litigation claims in trauma and orthopaedic surgery between 2008/2009 and 2018/2019. Utilizing a formal request to the NHS Resolution under the Freedom of Information Act, the data related to claims against orthopaedic surgery were obtained. A total of 8548 claims were analysed and regrouped to perform a meaningful analysis for the type of claims and the type of injuries. The total pay-out cost for the settled claims was over £1.2 billion. The most common types of claims were related to mismanagement (39.0%), diagnostic issues (17.6%), perioperative issues (15.9%) and alleged incompetence (10.2%). The most common primary causes for claims were patients' dissatisfaction (52.2%), damage to the limbs (19.0%) and neurological injuries (9.2%). The highest amounts of damages paid out were related to patients' dissatisfaction (37.7%), burns and bruising (31.0%), neurological injuries (24.5%) and damage to the limbs (22.3%). The number of claims and the pay-out cost were found to be steadily increasing; however, there was a slightly declining trend observed during the last two years. The cost of litigation continues to have a significant financial impact on the NHS. The recent declining trend is encouraging; however, surgeons need to take consistent diligent steps to avoid preventable causes that lead to litigation claims. The proposed change in the coding system of claims in the NHS Resolution will not only help to formulate a clear classification system but will also improve the learning from previous experience.
Objective: We aim to review the risks and outcomes of fractures in patients with pre-existing men... more Objective: We aim to review the risks and outcomes of fractures in patients with pre-existing mental health disorders. Methods: Articles published in the English language from Jan 2000 to March 2020 were searched through PubMed, Ovid, Embase, ScienceDirect and ISI Web of Knowledge. Medical Subject Headings (MeSH) terms were used along with text words. Applying the inclusion and exclusion criteria, of the 390 searched articles, 13 were included for final analysis in line with recommendations from PRISMA guidelines. Main Results: Total participants from all these studies were 1,11,61,087 with a combined mean age of 51.4 years. Two-thirds of the participants were females. The combined mean of fractures and falls was 61.8% among all participants in included studies. The combined mean incidence of mental health disorders was 74.3% among all participants with fractures. Use of psychotropic medications was found to be associated with impairment of cognition, psychomotor function and bone mineral density leading to a substantial increase in fracture risk. Conclusion: Patients with fractures and underlying mental health disorders were reported to have a prolonged hospital stay, poor functional outcomes and increased risk of chronic pain syndrome. Strategies should be in place for early identification of psychiatric disorders following a fracture to mobilize psychosocial support and facilitate discharge.
A R T I C L E I N F O Keywords: Tendonitis injection hyaluronic acid pain swelling outcomes adver... more A R T I C L E I N F O Keywords: Tendonitis injection hyaluronic acid pain swelling outcomes adverse effects A B S T R A C T Aim: The aim of this study was to evaluate the efficacy and safety of a single, peri-tendinous injection of hyal-uronic acid for mid-portion, non-insertional Achilles tendinopathy. Materials And Methods: A prospective, open labelled, single center, pilot study was conducted. All patients enrolled received a single peri-tendinous injection of Ostenil Tendon™ (40 mg/2 ml 2% HA with 0.5% mannitol). Outcome measures were Visual Analogue Scale (VAS) pain score and Manchester-Oxford Foot Questionnaire (MOxFQ) scores at 2 weeks and at final follow at 12 weeks. Any major and minor adverse effects were recorded. To assess change in VAS and MOxFQ scores, t test and Wilcoxon signed rank test were employed. Results: Seventeen patients were enrolled in this study with a mean follow-up of 12 weeks. Mean pre-injection VAS score was 9.38 cm (9-9.8), which significantly reduced post-injection to a mean score of 4.09 cm (2-8) at week-2 stage, and further improved to 3.01 cm (2-3.9) at the final follow-up (p < 0.0001). MOxFQ score showed a significant improvement from pre-injection value of 67.77 (63.03-72.55) to 31.18 (13-60) at week-2 stage, and further improved to 24.20 (15.73-32.67) at the final follow-up (p < 0.0001). The mean improvement from pre-injection to the final follow up was 43.57 (34.25-52.90). No adverse effects for injections were recorded. Conclusion: This small series suggests an encouraging response of a single injection of HA as an effective and safe option for non-insertional Achilles tendinopathy.
Pulled elbow is more common between the ages of 1 and 4 years. A few cases have been reported in ... more Pulled elbow is more common between the ages of 1 and 4 years. A few cases have been reported in the literature under the age of 1 year. The usual mechanism of injury is forced pronation of an extended arm. We present a case of pulled elbow in an 8 months old infant with an atypical mechanism. The child rolled over to her side and stopped moving her left elbow. After excluding fracture with plain radiographs, pulled elbow was suspected on clinical assessment. Supination-flexion reduction method was used under analgesia. The child was observed until started mobilising the arm fully. A high index of suspicion for pulled elbow should be kept in infants despite the absence of the usual presentation. Careful clinical assessment and prompt reduction method result in regaining the normal function.
Silastic implants for the first metatarsophalangeal joint (MTPJ) have been in use for over 50 y... more Silastic implants for the first metatarsophalangeal joint (MTPJ) have been in use for over 50 years. Initial reports were associated with high failure rates leading to development of new designs that are currently in use. The aim of this article is to review the historical evolution and the outcomes of silastic implants for the treatment of end-stage OA of the first MTPJ. Databases were searched for studies reporting the outcomes of silastic implants for the first MTPJ. Various relevant search terminologies were used. Studies reporting the outcomes of metallic implants or arthrodesis were excluded. The literature search revealed 522 studies, of which 28 were included. Eight studies used single-stemmed implants and 20 used double-stemmed implants for their patients. Twenty-eight studies had a total of 2354 feet with silastic replacements in 1884 patients (1968 to 2003) with an average age of 53 years and the average follow-up was 85.3 months. There were a total of 5.3% (124 feet) failed prostheses. Improvement in pain was reported in 76.6% (1804 feet) with an average patient satisfaction rate of 84%. Radiological changes around the implants were found to be significantly higher with single-stemmed implants (30.3%) compared to the double-stemmed implants (14.7%) (p < 0.05). Significantly more single-stemmed implants failed (11%) than the double-stemmed implants (3.6%) (p < 0.05). Despite the initial reports of failed implants and complications , first-and second-generation silastic implants were associated with high patient satisfaction and pain improvement. Current literature lacks long-term outcomes of implants currently in use.
Aims:
We report the long-term clinical and radiological outcomes of a consecutive series of 200 t... more Aims: We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants. Patients and Methods: Between November 1993 and February 2000, 200 consecutive STAR prostheses were implanted in 184 patients by a single surgeon. Demographic and clinical data were collected prospectively and the last available status was recorded for further survival analysis. All surviving patients underwent regular clinical and radiological review. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scoring system. The principal endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan–Meier survival curves were generated with 95% confidence intervals and the rate of failure calculated for each year. Results: A total of 84 patients (87 ankles) were alive by the end of this study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis (RA), n = 40; OA, n = 47), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery. A total of 32 implants failed (16%), requiring revision surgery. The mean time to revision was 80 months (2 to 257). The implant survival at 15.8 years, using revision as an endpoint, was 76.16% (95% confidence interval (CI) 64.41 to 87.91). We found a steady but low decrease in survival over the study period. The mean AOFAS score improved from 28 (10 to 52) preoperatively to 61 (20 to 90) at long-term follow-up. Conclusion: STAR prostheses in the United Kingdom have now been largely superseded by newer design TAAs, potentially with improved characteristics and surgical techniques. The long-term survivorship for the STAR prosthesis can provide a benchmark for these later designs of ankle arthroplasty.
Approximately 50% of ankle fractures require internal fixation. A tourniquet is often used to cre... more Approximately 50% of ankle fractures require internal fixation. A tourniquet is often used to create a bloodless operative field, but its effect on hospital length of stay (LOS) is unclear. This article reports a parallel-group observer-blinded randomized trial of the effect of tourniquet use on LOS. One hundred eighty-eight adult patients requiring internal fixation of ankle fracture were randomized to surgery with or without a tourniquet. LOS was analyzed on intention-to-treat principles using Poisson regression. As a secondary outcome, duration of operation was analyzed by analysis of covariance. Mean LOS was 1.79 days in the tourniquet group and 1.65 days in the no-tourniquet group. The covariate-adjusted rate ratio for LOS (reference group: no tourniquet) was 1.084 (95% confidence interval 0.871, 1.348; p = .470). Sensitivity analyses (unadjusted intention-to-treat analysis and as-treated analysis) gave similar nonsignificant results. The covariate-adjusted mean difference in duration of operation was 3.03 minutes (95% confidence interval −4.96, 11.02; p = .455), favoring the tourniquet group; sensitivity analyses again gave similar results. Adverse events did not differ significantly between groups. In conclusion, the use of a tourniquet during internal fixation does not significantly influence hospital LOS, of which preinjury medical condition of the patient appears to be the most important determinant.
Aims Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complicatio... more Aims Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent. Patients and Methods A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants. Results There were wound-healing problems in nine ankles (3.2%), superficial infection in 20 ankles (7.2%), and deep infection in six ankles (2.2%). Intraoperative fractures occurred in medial malleoli in 27 ankles (9.7%) and in lateral malleoli in four ankles (1.4%). Aseptic loosening and osteolysis were seen 16 ankles (5.8%). Fracture of the polyethylene component occurred in one ankle (0.4%) and edge-loading in seven ankles (2.5%). We observed medial gutter pain in 31 ankles (11.1%). The incidence of thromboembolism occurred in two ankles (0.7%). The results were found to be comparable to the previously reported complications of total ankle arthroplasty in the literature. Conclusion Total ankle arthroplasty continues to evolve and improve the ankle function. Despite high overall complication rates with TAA surgery, most complications appear to be minor and do not affect final clinical outcome. Our results and literature review will help in the consent process and provide detailed complication rates for an informed consent.
Fractures of the lateral and the posterior processes of the talus are uncommon and frequently mis... more Fractures of the lateral and the posterior processes of the talus are uncommon and frequently missed because of a low level of suspicion and difficulty in interpretation on plain radiographs. Missed fractures can lead to persistent pain and reduced function. Lateral process fractures are usually a consequence of forced dorsiflexion and inversion of fixed pronated foot. These are also commonly known as snowboarder’s fractures. The posterior process of the talus is composed of medial and lateral tubercles, separated by the groove for the flexor hallucis longus tendon. The usual mechanism of injury is forced hyperplantarflexion and inversion causing direct compression of the posterior talus, or an avulsion fracture caused by the posterior talofibular ligament. CT scans are helpful in cases of high clinical suspicion. There is a lack of consensus regarding optimal management of these fractures; however, management depends on the size, location and displacement of the fragment, the degree of cartilage damage and instability of the subtalar joint. Non-operative treatment includes immobilization and protected weight-bearing for six weeks. Surgical treatment includes open reduction and internal fixation or excision of the fragments, depending on the size. Fractures of the lateral and the posterior processes of the talus are uncommon but important injuries that may result in significant disability in cases of missed diagnosis or delayed or inadequate treatment. Early diagnosis and timely management of these fractures help to avoid long-term complications, including malunion, nonunion or severe subtalar joint osteoarthritis.
Introduction: The objective of our study was to assess the outcome of primary total hip arthropla... more Introduction: The objective of our study was to assess the outcome of primary total hip arthroplasty performed using direct anterior approach and to compare them with posterior approach.
Tendon ossification has a multifactorial aetiology. We present a case of a massive ossification w... more Tendon ossification has a multifactorial aetiology. We present a case of a massive ossification within the substance of patellar tendon. A 79-years-old male who had a previous history of patellar tendon rupture and its surgical repair. He gradually developed a large bony mass within the patellar tendon and progressive symptoms of arthritis in the knee joint. The patient underwent a total knee replacement along with simultaneous excision of the entire bony lump and primary repair of the patellar tendon. The knee was mobilised gradually after surgery and achieved satisfactory range of motion, function and alleviation of symptoms without any complication.
Introduction: Meniscus injury is associated with ACL (anterior cruciate ligament) injury. It woul... more Introduction: Meniscus injury is associated with ACL (anterior cruciate ligament) injury. It would be ideal to repair all meniscus tears but failure rate is high.
It is a common observation that pain and stiffness in patients known to have arthritis get worse ... more It is a common observation that pain and stiffness in patients known to have arthritis get worse in cold and damp weather conditions. The objective of this article is to review the available literature on this subject and to put forward an explanation for this common clinical finding. Literature search revealed twelve relevant articles including laboratory experiments and prospective questionnaire-based human studies. Various investigators have tried to study the effect of cold weather on arthritic symptoms and have suggested different theories. The effect of temperature changes localized to the joints has shown to increase stiffness at lower temperatures and decrease stiffness at higher temperatures. The effect of these changes has been found more pronounced in elderly population with arthritis and patients with advanced disease. The evidence to support this common observation is weak; however some studies have reported a trend towards worsening of pain and stiffness with falling temperature and barometric pressure in arthritic patients.
As the prevalence of syphilis rises, an increase in tertiary syphilis with spinal involvement is ... more As the prevalence of syphilis rises, an increase in tertiary syphilis with spinal involvement is predicted. We report what we believe to be the first case of compressive cervical spine syphilitic gummata, with central cord compression signs. We also review the relevant literature to date. The diagnosis of syphilis in the spine relies on the physician to be aware of it as part of the differential diagnosis. Treponemal laboratory tests are an important aid in establishing a diagnosis.
Annals of The Royal College of Surgeons of England, 2012
INTRODUCTION Management of metastatic spinal disease has changed significantly over the last few ... more INTRODUCTION Management of metastatic spinal disease has changed significantly over the last few years. Different prognostic scores are used in clinical practice for predicting survival. The aim of this study was to assess the accuracy of prognostic scores and the role of delayed presentation in predicting the outcome in patients with metastatic spine disease. METHODS Retrospectively, four years of data were collected (2007)(2008)(2009)(2010). Medical records review included type of tumour, duration of symptoms, expected survival and functional status. The Karnofsky performance score was used for functional assessment. Modified Tokuhashi and Tomita scores were used for survival prediction. RESULTS A total of 55 patients who underwent surgical stabilisation were reviewed. The mean age was 63 years (range: 32-87 years). The main primary sources of tumours included myeloma, breast cancer, lymphoma, lung cancer, renal cell cancer and prostate cancer. Of the cases studied, 29 patients had posterior instrumented stabilisation alone, 10 patients had an anterior procedure alone and 16 patients (with an expected survival of more than one year) had both anterior and posterior procedures performed. Twenty-three patients presented with spinal cord compression. The mean follow-up duration was 9 months (range: 1-39 months). Patients who were treated within one week of referral survived longer than anticipated. Patients were divided into three groups based on their expected survival. Actual survival was better in all three groups after surgery. Discrepancies in scores were prominent in patients with myeloma, breast and prostate cancers. Functional outcome was better in patients under 65 years of age. CONCLUSIONS The prognostic scoring systems are not uniformly effective in all types of primary tumours. However, they are useful in decision making for surgical intervention, taking other factors into account, in particular the age of the patient, the type and stage of the primary tumour and general health.
There is no established evidence to support the use of drains after total knee arthroplasty (TKA)... more There is no established evidence to support the use of drains after total knee arthroplasty (TKA). The aim of our study was to compare the requirement for blood transfusion after primary total knee arthroplasty with and without the use of closed suction drains and cost analysis of performing routine blood group and save.
This study analyses the outcomes of litigation claims in trauma and orthopaedic surgery between 2... more This study analyses the outcomes of litigation claims in trauma and orthopaedic surgery between 2008/2009 and 2018/2019. Utilizing a formal request to the NHS Resolution under the Freedom of Information Act, the data related to claims against orthopaedic surgery were obtained. A total of 8548 claims were analysed and regrouped to perform a meaningful analysis for the type of claims and the type of injuries. The total pay-out cost for the settled claims was over £1.2 billion. The most common types of claims were related to mismanagement (39.0%), diagnostic issues (17.6%), perioperative issues (15.9%) and alleged incompetence (10.2%). The most common primary causes for claims were patients' dissatisfaction (52.2%), damage to the limbs (19.0%) and neurological injuries (9.2%). The highest amounts of damages paid out were related to patients' dissatisfaction (37.7%), burns and bruising (31.0%), neurological injuries (24.5%) and damage to the limbs (22.3%). The number of claims and the pay-out cost were found to be steadily increasing; however, there was a slightly declining trend observed during the last two years. The cost of litigation continues to have a significant financial impact on the NHS. The recent declining trend is encouraging; however, surgeons need to take consistent diligent steps to avoid preventable causes that lead to litigation claims. The proposed change in the coding system of claims in the NHS Resolution will not only help to formulate a clear classification system but will also improve the learning from previous experience.
Objective: We aim to review the risks and outcomes of fractures in patients with pre-existing men... more Objective: We aim to review the risks and outcomes of fractures in patients with pre-existing mental health disorders. Methods: Articles published in the English language from Jan 2000 to March 2020 were searched through PubMed, Ovid, Embase, ScienceDirect and ISI Web of Knowledge. Medical Subject Headings (MeSH) terms were used along with text words. Applying the inclusion and exclusion criteria, of the 390 searched articles, 13 were included for final analysis in line with recommendations from PRISMA guidelines. Main Results: Total participants from all these studies were 1,11,61,087 with a combined mean age of 51.4 years. Two-thirds of the participants were females. The combined mean of fractures and falls was 61.8% among all participants in included studies. The combined mean incidence of mental health disorders was 74.3% among all participants with fractures. Use of psychotropic medications was found to be associated with impairment of cognition, psychomotor function and bone mineral density leading to a substantial increase in fracture risk. Conclusion: Patients with fractures and underlying mental health disorders were reported to have a prolonged hospital stay, poor functional outcomes and increased risk of chronic pain syndrome. Strategies should be in place for early identification of psychiatric disorders following a fracture to mobilize psychosocial support and facilitate discharge.
A R T I C L E I N F O Keywords: Tendonitis injection hyaluronic acid pain swelling outcomes adver... more A R T I C L E I N F O Keywords: Tendonitis injection hyaluronic acid pain swelling outcomes adverse effects A B S T R A C T Aim: The aim of this study was to evaluate the efficacy and safety of a single, peri-tendinous injection of hyal-uronic acid for mid-portion, non-insertional Achilles tendinopathy. Materials And Methods: A prospective, open labelled, single center, pilot study was conducted. All patients enrolled received a single peri-tendinous injection of Ostenil Tendon™ (40 mg/2 ml 2% HA with 0.5% mannitol). Outcome measures were Visual Analogue Scale (VAS) pain score and Manchester-Oxford Foot Questionnaire (MOxFQ) scores at 2 weeks and at final follow at 12 weeks. Any major and minor adverse effects were recorded. To assess change in VAS and MOxFQ scores, t test and Wilcoxon signed rank test were employed. Results: Seventeen patients were enrolled in this study with a mean follow-up of 12 weeks. Mean pre-injection VAS score was 9.38 cm (9-9.8), which significantly reduced post-injection to a mean score of 4.09 cm (2-8) at week-2 stage, and further improved to 3.01 cm (2-3.9) at the final follow-up (p < 0.0001). MOxFQ score showed a significant improvement from pre-injection value of 67.77 (63.03-72.55) to 31.18 (13-60) at week-2 stage, and further improved to 24.20 (15.73-32.67) at the final follow-up (p < 0.0001). The mean improvement from pre-injection to the final follow up was 43.57 (34.25-52.90). No adverse effects for injections were recorded. Conclusion: This small series suggests an encouraging response of a single injection of HA as an effective and safe option for non-insertional Achilles tendinopathy.
Pulled elbow is more common between the ages of 1 and 4 years. A few cases have been reported in ... more Pulled elbow is more common between the ages of 1 and 4 years. A few cases have been reported in the literature under the age of 1 year. The usual mechanism of injury is forced pronation of an extended arm. We present a case of pulled elbow in an 8 months old infant with an atypical mechanism. The child rolled over to her side and stopped moving her left elbow. After excluding fracture with plain radiographs, pulled elbow was suspected on clinical assessment. Supination-flexion reduction method was used under analgesia. The child was observed until started mobilising the arm fully. A high index of suspicion for pulled elbow should be kept in infants despite the absence of the usual presentation. Careful clinical assessment and prompt reduction method result in regaining the normal function.
Silastic implants for the first metatarsophalangeal joint (MTPJ) have been in use for over 50 y... more Silastic implants for the first metatarsophalangeal joint (MTPJ) have been in use for over 50 years. Initial reports were associated with high failure rates leading to development of new designs that are currently in use. The aim of this article is to review the historical evolution and the outcomes of silastic implants for the treatment of end-stage OA of the first MTPJ. Databases were searched for studies reporting the outcomes of silastic implants for the first MTPJ. Various relevant search terminologies were used. Studies reporting the outcomes of metallic implants or arthrodesis were excluded. The literature search revealed 522 studies, of which 28 were included. Eight studies used single-stemmed implants and 20 used double-stemmed implants for their patients. Twenty-eight studies had a total of 2354 feet with silastic replacements in 1884 patients (1968 to 2003) with an average age of 53 years and the average follow-up was 85.3 months. There were a total of 5.3% (124 feet) failed prostheses. Improvement in pain was reported in 76.6% (1804 feet) with an average patient satisfaction rate of 84%. Radiological changes around the implants were found to be significantly higher with single-stemmed implants (30.3%) compared to the double-stemmed implants (14.7%) (p < 0.05). Significantly more single-stemmed implants failed (11%) than the double-stemmed implants (3.6%) (p < 0.05). Despite the initial reports of failed implants and complications , first-and second-generation silastic implants were associated with high patient satisfaction and pain improvement. Current literature lacks long-term outcomes of implants currently in use.
Aims:
We report the long-term clinical and radiological outcomes of a consecutive series of 200 t... more Aims: We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants. Patients and Methods: Between November 1993 and February 2000, 200 consecutive STAR prostheses were implanted in 184 patients by a single surgeon. Demographic and clinical data were collected prospectively and the last available status was recorded for further survival analysis. All surviving patients underwent regular clinical and radiological review. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scoring system. The principal endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan–Meier survival curves were generated with 95% confidence intervals and the rate of failure calculated for each year. Results: A total of 84 patients (87 ankles) were alive by the end of this study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis (RA), n = 40; OA, n = 47), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery. A total of 32 implants failed (16%), requiring revision surgery. The mean time to revision was 80 months (2 to 257). The implant survival at 15.8 years, using revision as an endpoint, was 76.16% (95% confidence interval (CI) 64.41 to 87.91). We found a steady but low decrease in survival over the study period. The mean AOFAS score improved from 28 (10 to 52) preoperatively to 61 (20 to 90) at long-term follow-up. Conclusion: STAR prostheses in the United Kingdom have now been largely superseded by newer design TAAs, potentially with improved characteristics and surgical techniques. The long-term survivorship for the STAR prosthesis can provide a benchmark for these later designs of ankle arthroplasty.
Approximately 50% of ankle fractures require internal fixation. A tourniquet is often used to cre... more Approximately 50% of ankle fractures require internal fixation. A tourniquet is often used to create a bloodless operative field, but its effect on hospital length of stay (LOS) is unclear. This article reports a parallel-group observer-blinded randomized trial of the effect of tourniquet use on LOS. One hundred eighty-eight adult patients requiring internal fixation of ankle fracture were randomized to surgery with or without a tourniquet. LOS was analyzed on intention-to-treat principles using Poisson regression. As a secondary outcome, duration of operation was analyzed by analysis of covariance. Mean LOS was 1.79 days in the tourniquet group and 1.65 days in the no-tourniquet group. The covariate-adjusted rate ratio for LOS (reference group: no tourniquet) was 1.084 (95% confidence interval 0.871, 1.348; p = .470). Sensitivity analyses (unadjusted intention-to-treat analysis and as-treated analysis) gave similar nonsignificant results. The covariate-adjusted mean difference in duration of operation was 3.03 minutes (95% confidence interval −4.96, 11.02; p = .455), favoring the tourniquet group; sensitivity analyses again gave similar results. Adverse events did not differ significantly between groups. In conclusion, the use of a tourniquet during internal fixation does not significantly influence hospital LOS, of which preinjury medical condition of the patient appears to be the most important determinant.
Aims Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complicatio... more Aims Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent. Patients and Methods A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants. Results There were wound-healing problems in nine ankles (3.2%), superficial infection in 20 ankles (7.2%), and deep infection in six ankles (2.2%). Intraoperative fractures occurred in medial malleoli in 27 ankles (9.7%) and in lateral malleoli in four ankles (1.4%). Aseptic loosening and osteolysis were seen 16 ankles (5.8%). Fracture of the polyethylene component occurred in one ankle (0.4%) and edge-loading in seven ankles (2.5%). We observed medial gutter pain in 31 ankles (11.1%). The incidence of thromboembolism occurred in two ankles (0.7%). The results were found to be comparable to the previously reported complications of total ankle arthroplasty in the literature. Conclusion Total ankle arthroplasty continues to evolve and improve the ankle function. Despite high overall complication rates with TAA surgery, most complications appear to be minor and do not affect final clinical outcome. Our results and literature review will help in the consent process and provide detailed complication rates for an informed consent.
Fractures of the lateral and the posterior processes of the talus are uncommon and frequently mis... more Fractures of the lateral and the posterior processes of the talus are uncommon and frequently missed because of a low level of suspicion and difficulty in interpretation on plain radiographs. Missed fractures can lead to persistent pain and reduced function. Lateral process fractures are usually a consequence of forced dorsiflexion and inversion of fixed pronated foot. These are also commonly known as snowboarder’s fractures. The posterior process of the talus is composed of medial and lateral tubercles, separated by the groove for the flexor hallucis longus tendon. The usual mechanism of injury is forced hyperplantarflexion and inversion causing direct compression of the posterior talus, or an avulsion fracture caused by the posterior talofibular ligament. CT scans are helpful in cases of high clinical suspicion. There is a lack of consensus regarding optimal management of these fractures; however, management depends on the size, location and displacement of the fragment, the degree of cartilage damage and instability of the subtalar joint. Non-operative treatment includes immobilization and protected weight-bearing for six weeks. Surgical treatment includes open reduction and internal fixation or excision of the fragments, depending on the size. Fractures of the lateral and the posterior processes of the talus are uncommon but important injuries that may result in significant disability in cases of missed diagnosis or delayed or inadequate treatment. Early diagnosis and timely management of these fractures help to avoid long-term complications, including malunion, nonunion or severe subtalar joint osteoarthritis.
Introduction: The objective of our study was to assess the outcome of primary total hip arthropla... more Introduction: The objective of our study was to assess the outcome of primary total hip arthroplasty performed using direct anterior approach and to compare them with posterior approach.
Tendon ossification has a multifactorial aetiology. We present a case of a massive ossification w... more Tendon ossification has a multifactorial aetiology. We present a case of a massive ossification within the substance of patellar tendon. A 79-years-old male who had a previous history of patellar tendon rupture and its surgical repair. He gradually developed a large bony mass within the patellar tendon and progressive symptoms of arthritis in the knee joint. The patient underwent a total knee replacement along with simultaneous excision of the entire bony lump and primary repair of the patellar tendon. The knee was mobilised gradually after surgery and achieved satisfactory range of motion, function and alleviation of symptoms without any complication.
Introduction: Meniscus injury is associated with ACL (anterior cruciate ligament) injury. It woul... more Introduction: Meniscus injury is associated with ACL (anterior cruciate ligament) injury. It would be ideal to repair all meniscus tears but failure rate is high.
It is a common observation that pain and stiffness in patients known to have arthritis get worse ... more It is a common observation that pain and stiffness in patients known to have arthritis get worse in cold and damp weather conditions. The objective of this article is to review the available literature on this subject and to put forward an explanation for this common clinical finding. Literature search revealed twelve relevant articles including laboratory experiments and prospective questionnaire-based human studies. Various investigators have tried to study the effect of cold weather on arthritic symptoms and have suggested different theories. The effect of temperature changes localized to the joints has shown to increase stiffness at lower temperatures and decrease stiffness at higher temperatures. The effect of these changes has been found more pronounced in elderly population with arthritis and patients with advanced disease. The evidence to support this common observation is weak; however some studies have reported a trend towards worsening of pain and stiffness with falling temperature and barometric pressure in arthritic patients.
As the prevalence of syphilis rises, an increase in tertiary syphilis with spinal involvement is ... more As the prevalence of syphilis rises, an increase in tertiary syphilis with spinal involvement is predicted. We report what we believe to be the first case of compressive cervical spine syphilitic gummata, with central cord compression signs. We also review the relevant literature to date. The diagnosis of syphilis in the spine relies on the physician to be aware of it as part of the differential diagnosis. Treponemal laboratory tests are an important aid in establishing a diagnosis.
Annals of The Royal College of Surgeons of England, 2012
INTRODUCTION Management of metastatic spinal disease has changed significantly over the last few ... more INTRODUCTION Management of metastatic spinal disease has changed significantly over the last few years. Different prognostic scores are used in clinical practice for predicting survival. The aim of this study was to assess the accuracy of prognostic scores and the role of delayed presentation in predicting the outcome in patients with metastatic spine disease. METHODS Retrospectively, four years of data were collected (2007)(2008)(2009)(2010). Medical records review included type of tumour, duration of symptoms, expected survival and functional status. The Karnofsky performance score was used for functional assessment. Modified Tokuhashi and Tomita scores were used for survival prediction. RESULTS A total of 55 patients who underwent surgical stabilisation were reviewed. The mean age was 63 years (range: 32-87 years). The main primary sources of tumours included myeloma, breast cancer, lymphoma, lung cancer, renal cell cancer and prostate cancer. Of the cases studied, 29 patients had posterior instrumented stabilisation alone, 10 patients had an anterior procedure alone and 16 patients (with an expected survival of more than one year) had both anterior and posterior procedures performed. Twenty-three patients presented with spinal cord compression. The mean follow-up duration was 9 months (range: 1-39 months). Patients who were treated within one week of referral survived longer than anticipated. Patients were divided into three groups based on their expected survival. Actual survival was better in all three groups after surgery. Discrepancies in scores were prominent in patients with myeloma, breast and prostate cancers. Functional outcome was better in patients under 65 years of age. CONCLUSIONS The prognostic scoring systems are not uniformly effective in all types of primary tumours. However, they are useful in decision making for surgical intervention, taking other factors into account, in particular the age of the patient, the type and stage of the primary tumour and general health.
There is no established evidence to support the use of drains after total knee arthroplasty (TKA)... more There is no established evidence to support the use of drains after total knee arthroplasty (TKA). The aim of our study was to compare the requirement for blood transfusion after primary total knee arthroplasty with and without the use of closed suction drains and cost analysis of performing routine blood group and save.
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Papers by Haroon Majeed
Methods: Articles published in the English language from Jan 2000 to March 2020 were searched through PubMed, Ovid, Embase, ScienceDirect and ISI Web of Knowledge. Medical Subject Headings (MeSH) terms were used along with text words. Applying the inclusion and exclusion criteria, of the 390 searched articles, 13 were included for final analysis in line with recommendations from PRISMA guidelines.
Main Results: Total participants from all these studies were 1,11,61,087 with a combined mean age of 51.4 years. Two-thirds of the participants were females. The combined mean of fractures and falls was 61.8% among all participants in included studies. The combined mean incidence of mental health disorders was 74.3% among all participants with fractures. Use of psychotropic medications was found to be associated with impairment of cognition, psychomotor function and bone mineral density leading to a substantial increase in fracture risk.
Conclusion: Patients with fractures and underlying mental health disorders were reported to have a prolonged hospital stay, poor functional outcomes and increased risk of chronic pain syndrome. Strategies should be in place for early identification of psychiatric disorders following a fracture to mobilize psychosocial support and facilitate discharge.
We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.
Patients and Methods:
Between November 1993 and February 2000, 200 consecutive STAR prostheses were implanted in 184 patients by a single surgeon. Demographic and clinical data were collected prospectively and the last available status was recorded for further survival analysis. All surviving patients underwent regular clinical and radiological review. Pain and
function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scoring system. The principal endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan–Meier survival curves were generated with 95% confidence intervals and the rate of failure calculated for each year.
Results:
A total of 84 patients (87 ankles) were alive by the end of this study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis (RA), n = 40; OA, n = 47), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery. A total of 32 implants failed (16%), requiring revision surgery. The mean time to revision was 80 months (2 to 257). The implant survival at 15.8 years, using revision as an endpoint, was 76.16% (95% confidence interval (CI) 64.41 to 87.91). We found a steady but low decrease in survival over the study period. The mean AOFAS score improved from 28 (10 to 52)
preoperatively to 61 (20 to 90) at long-term follow-up.
Conclusion:
STAR prostheses in the United Kingdom have now been largely superseded by newer design TAAs, potentially with improved characteristics and surgical techniques. The long-term survivorship for the STAR prosthesis can provide a benchmark for these later designs
of ankle arthroplasty.
requiring internal fixation of ankle fracture were randomized to surgery with or without a tourniquet. LOS was analyzed on intention-to-treat principles using Poisson regression. As a secondary outcome, duration of operation was analyzed by analysis of covariance. Mean LOS was 1.79 days in the tourniquet group and 1.65 days in the no-tourniquet group. The covariate-adjusted rate ratio for LOS (reference group: no tourniquet) was 1.084 (95% confidence interval 0.871, 1.348; p = .470). Sensitivity analyses (unadjusted intention-to-treat analysis and as-treated analysis) gave similar nonsignificant results. The covariate-adjusted mean difference in duration of operation was 3.03 minutes (95% confidence interval −4.96, 11.02; p = .455), favoring the tourniquet
group; sensitivity analyses again gave similar results. Adverse events did not differ significantly between groups. In conclusion, the use of a tourniquet during internal fixation does not significantly influence hospital LOS, of which preinjury medical condition of the patient appears to be the most important determinant.
Lateral process fractures are usually a consequence of forced dorsiflexion and inversion of fixed pronated foot. These are also commonly known as snowboarder’s fractures.
The posterior process of the talus is composed of medial and lateral tubercles, separated by the groove for the flexor hallucis longus tendon.
The usual mechanism of injury is forced hyperplantarflexion and inversion causing direct compression of the posterior talus, or an avulsion fracture caused by the posterior talofibular ligament. CT scans are helpful in cases of high clinical suspicion.
There is a lack of consensus regarding optimal management of these fractures; however, management depends on the size, location and displacement of the fragment, the degree of cartilage damage and instability of the subtalar joint. Non-operative treatment includes immobilization and protected weight-bearing for six weeks. Surgical treatment includes open reduction and internal fixation or excision of the fragments, depending on the size.
Fractures of the lateral and the posterior processes of the talus are uncommon but important injuries that may result in significant disability in cases of missed diagnosis or delayed or inadequate treatment. Early diagnosis and timely management of these fractures help to avoid long-term complications, including malunion, nonunion or severe subtalar joint osteoarthritis.
Methods: Articles published in the English language from Jan 2000 to March 2020 were searched through PubMed, Ovid, Embase, ScienceDirect and ISI Web of Knowledge. Medical Subject Headings (MeSH) terms were used along with text words. Applying the inclusion and exclusion criteria, of the 390 searched articles, 13 were included for final analysis in line with recommendations from PRISMA guidelines.
Main Results: Total participants from all these studies were 1,11,61,087 with a combined mean age of 51.4 years. Two-thirds of the participants were females. The combined mean of fractures and falls was 61.8% among all participants in included studies. The combined mean incidence of mental health disorders was 74.3% among all participants with fractures. Use of psychotropic medications was found to be associated with impairment of cognition, psychomotor function and bone mineral density leading to a substantial increase in fracture risk.
Conclusion: Patients with fractures and underlying mental health disorders were reported to have a prolonged hospital stay, poor functional outcomes and increased risk of chronic pain syndrome. Strategies should be in place for early identification of psychiatric disorders following a fracture to mobilize psychosocial support and facilitate discharge.
We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.
Patients and Methods:
Between November 1993 and February 2000, 200 consecutive STAR prostheses were implanted in 184 patients by a single surgeon. Demographic and clinical data were collected prospectively and the last available status was recorded for further survival analysis. All surviving patients underwent regular clinical and radiological review. Pain and
function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scoring system. The principal endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan–Meier survival curves were generated with 95% confidence intervals and the rate of failure calculated for each year.
Results:
A total of 84 patients (87 ankles) were alive by the end of this study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis (RA), n = 40; OA, n = 47), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery. A total of 32 implants failed (16%), requiring revision surgery. The mean time to revision was 80 months (2 to 257). The implant survival at 15.8 years, using revision as an endpoint, was 76.16% (95% confidence interval (CI) 64.41 to 87.91). We found a steady but low decrease in survival over the study period. The mean AOFAS score improved from 28 (10 to 52)
preoperatively to 61 (20 to 90) at long-term follow-up.
Conclusion:
STAR prostheses in the United Kingdom have now been largely superseded by newer design TAAs, potentially with improved characteristics and surgical techniques. The long-term survivorship for the STAR prosthesis can provide a benchmark for these later designs
of ankle arthroplasty.
requiring internal fixation of ankle fracture were randomized to surgery with or without a tourniquet. LOS was analyzed on intention-to-treat principles using Poisson regression. As a secondary outcome, duration of operation was analyzed by analysis of covariance. Mean LOS was 1.79 days in the tourniquet group and 1.65 days in the no-tourniquet group. The covariate-adjusted rate ratio for LOS (reference group: no tourniquet) was 1.084 (95% confidence interval 0.871, 1.348; p = .470). Sensitivity analyses (unadjusted intention-to-treat analysis and as-treated analysis) gave similar nonsignificant results. The covariate-adjusted mean difference in duration of operation was 3.03 minutes (95% confidence interval −4.96, 11.02; p = .455), favoring the tourniquet
group; sensitivity analyses again gave similar results. Adverse events did not differ significantly between groups. In conclusion, the use of a tourniquet during internal fixation does not significantly influence hospital LOS, of which preinjury medical condition of the patient appears to be the most important determinant.
Lateral process fractures are usually a consequence of forced dorsiflexion and inversion of fixed pronated foot. These are also commonly known as snowboarder’s fractures.
The posterior process of the talus is composed of medial and lateral tubercles, separated by the groove for the flexor hallucis longus tendon.
The usual mechanism of injury is forced hyperplantarflexion and inversion causing direct compression of the posterior talus, or an avulsion fracture caused by the posterior talofibular ligament. CT scans are helpful in cases of high clinical suspicion.
There is a lack of consensus regarding optimal management of these fractures; however, management depends on the size, location and displacement of the fragment, the degree of cartilage damage and instability of the subtalar joint. Non-operative treatment includes immobilization and protected weight-bearing for six weeks. Surgical treatment includes open reduction and internal fixation or excision of the fragments, depending on the size.
Fractures of the lateral and the posterior processes of the talus are uncommon but important injuries that may result in significant disability in cases of missed diagnosis or delayed or inadequate treatment. Early diagnosis and timely management of these fractures help to avoid long-term complications, including malunion, nonunion or severe subtalar joint osteoarthritis.