march 2015 - highgate private hospital · podiatric surgery • parotidectomy ... our nursing team...
TRANSCRIPT
GP Educational Programme_Interested to hear the latest about the world of ENT, Orthopaedics, General Surgery and more? Reserve your place at one of our GP Seminars today
Hear From Our Experts_Interesting and informative case studies from our Consultants
Orthopaedic Treatments_
Get back to being you faster, at Highgate Private Hospital
Meet our New Primary Care Manager _Tina Jaswal
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MARCH2015
Contents Hospital Director Welcome...
p.2 Hospital Director Welcome
p.3 Services at a Glance
p.5 GP Educational Programme 2015
p.7 Introducing Highgate Private Hospital
p.9 Choose and Book Directory of Services
p.11 Meet our New Primary Care Manager
p.11 Clinical News – What’s New?
p.12 Forth Operating Theatre
p. 13 The Physiotherapy Department Thrives
at Highgate Private Hospital
p.15 New Services: Cardiac Diagnostics
p.16 Orthopaedic Treatments
p.16 Coming Soon: Medical Admissions Unit
p.17 Imaging and Diagnostics
p.18 New Specialist Consultants
p.21 Hear From Our Experts:
p.21 Modern Management of Sciatica
p.23 Tuberculosis of the Calcaneum Masquerading
as Haglund’s Deformity
p.27 Developments in Knee Replacement
p.28 Custom Total Hip Replacements
p.29 How to find us
p.30 How to refer to us
Dear Doctor,Welcome to our March edition of In Touch,
Highgate Private Hospital’s magazine for GPs and
Referrers. We continue to receive comments that
this is a useful and educational publication and
we are always open to your ideas, feedback
and contribution.
On behalf of the team I would like to thank you
for continuing to choose Highgate Private Hospital
as a partner in your practice.
These are exciting times at the hospital following our
£15m redevelopment project and the number of service
developments that have followed. If there is anything
we can do to help and support you and your teams
please get in touch. You are also always welcome
to visit us and it would be our pleasure to show you
around our facilities.
Mark LyonsHospital Director
T: 020 8347 3888
Imaging andDiagnostics _
• MRI, • CT • X-Ray • Ultrasound
New Services:CardiacDiagnostics _
Including resting ECGs, Echocardiograms, 24-hour, 48-hour, 7 day ECG holter monitoring and more
KneeReplacement_
The world of Orthopaedic Surgery is a fast-moving one, find out more inside
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p.1 InTouch — MARCH 2015 InTouch — MARCH 2015 p.2
• Orthopaedics
• Podiatric Surgery
• Pain Management
• General Surgery
• Urology
• Ear, Nose and Throat
Choose & Book NHS Services include
• CT (high-definition, low-dose)
• MRI
• 3D & 4D Ultrasound
• X-Ray
• Fluoroscopy
• Endoscopy
• Cardiac Diagnostics (ECGs, 24 hour and
48 hour ECG monitoring, event monitors,
24 hour BP monitoring and transthoracic
echocardiograms
Read more on page 15
SEARCH: *Aspen *Highgate
Imaging & Diagnostics
• Audiology &
Hearing Aid Services
• Bariatrics
• Breast Surgery
• Cardiology
• Colorectal Surgery
• Cosmetic Surgery
• Dermatology
• Diagnostic Imaging:
MRI, CT, Ultrasound
& X-Ray
• Ear, Nose & Throat
• Endoscopy
• Gastroenterology
• General Medicine
• General Surgery
• Gynaecology
• Health Screening
• Neurology
• Neuro Surgery
• Nutrition
• Oral & Maxillofacial
Surgery
• Orthopaedics
• Paediatrics
• Pain Management
• Physiotherapy
• Podiatry
• Private GP Services
• Psychology
• Respiratory
Medicine
• Rheumatology
• Sports Injury
• Travel Clinic
• Urology
• Vascular Surgery
• Weight
Management
Services at a Glance...
or call us on 020 8341 4182Visit highgatehospital.co.uk
For any further information or to find
out more about the services we offer:_
Insured and Self Funding Patients
NEW SERVICE: Cardiac Diagnostics page 14
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Highgate Private Hospital is pleased to offer you an
annual programme of educational seminars. Places
are taken up quickly, so please contact us to reserve
your place now. We can also provide more flexible
Consultant Seminar options including Breakfast,
Lunchtimes and Evenings at your practice.
To confirm a place at one of our seminars or to arrange
for us to bring a specialist to you, please call our
Primary Care Manager:
GP Masterclass
Saturday 28th March 2015 8.30am –12.30pm
Dr Pamela MangatManaging Rheumatology Conditions
Consultant Rheumatologist
Dr Dan Rossouw Common Shoulder Conditions in General Practice
Consultant Orthopaedic Upper Limb Surgeon
Mr Syed Tahir HussainModern Trends in Vascular Surgery
Consultant Vascular Surgeon
Mr Ron MillerDifficult Urological Problems in General Practice
Consultant Urological and Minimally Invasive Surgeon
GP Evening Seminar
Thursday 19th March 2015
6.30pm – 8.30pm
Mr Hasan MukhtarColonoscopy; The Facts
Consultant General Surgeon
Mr Simon Kennon
Update in Atrial Fibrillation and Aortic Stenosis
Consultant Cardiologist
GP EducationalProgramme...
Call her direct on:07718 698 908
or email her at: [email protected]
Bringing our Specialists to you...
There are many more events to come throughout the
year so if you would like to be kept updated with our
events programme and to receive your invitations
electronically, please forward your email address to
Tina JaswalPrimary Care Manager
–
Seminar 1 Seminar 1
Seminar 2 Seminar 2
Seminar 3
Seminar 4
For any further information
call Tina on 07718 698 908
p.5 InTouch — MARCH 2015 p.6
Choose & Book Directory of Services...
Conditions Treated: • Arthritis • Foot Pain • Capsulitis
• Bunion/Hallux Valgus• Tendon Injury• Osteotomy
Procedures Performed:• Bunion Repair • Excision of Neuroma Morton’s
Conditions Treated:• Acute Back Pain• Chronic Pain• Musculoskeletal Pain• Sciatica
• Neuropathic Pain• Spinal Pain• Fibromyalgia
Procedures Performed: • Spinal Injections• Sacroiliac Joint Injections • Epidural Injections• Facet Joint Injections
• Denervation• Trigger Point Injections
Conditions Treated: • Shoulder– Shoulder Pain– Rotator Cuff Tear– Osteoarthritis– Tendonitis
• Spine– Back Pain
• Hand & Wrist – Trigger Finger– Dupuytren’s Contracture – Ganglion– Carpal Tunnel Syndrome
• Hip– Hip Pain– Osteoarthritis– Bursitis
• Knee– Osteoarthritis– Knee Trauma
• Foot & Ankle – Ankle Pain– Arthralgia of the Ankle
or Foot– Osteoarthritis – Bunions/Hallux Valgus
Procedures Performed: • Arthroscopy (Shoulder, Knee,
Ankle)• Bunionectomy/Hallux Valgus• Excision of Morton’s Neuroma• Hip/Knee Hemiarthroplasty • Primary Total Hip/Knee
Replacement• Anterior Cruciate Ligament
Repair • Trigger Finger Release• Carpal Tunnel Decompression • Excision of Ganglion • Subacromial Decompression• Rotator Cuff Repair
• Tendon Repair • Lumbar Discectomy• Lumbar Decompression • Excision Coccyx • Facet Joint Injection• Epidural Injection
Conditions Treated:• Inguinal Hernia• Umbilical Hernia • Lumps & Bumps• Lipoma
• Skin Lesions • Benign Cysts• Cholecystitis• Haemorrhoids
Procedures Performed: • Repair of Inguinal Hernia
& Umbilical Hernia• Excision & Biopsy of Lumps
& Bumps
• Laparoscopic Cholecystectomy• Anal Fissure/Fistula Surgery• Haemorrhoidectomy
Conditions Treated: • Stress Incontinence• Fibroids• Menorrhagia
• Ovarian Cysts• Bartholin’s Cysts/Abscesses
Procedures Performed: • Anterior/Posterior Repair• Ovarian Cystectomy• Hysteroscopy
• Vaginal Hysterectomy
Conditions Treated: • Ear Problems • Swallowing Problems• Thyroid Problems• Nasal Blockages • Sinusitis• Allergic Rhinitis • Salivary Gland Problems• Ear Drum Perforations
• Conductive Hearing Loss (age 59 or Below)
• Tonsillitis
Procedures Performed: • Tonsillectomy• Adenoidectomy • Functional Endoscopic Sinus
Surgery (FESS)• Nasal Polypectomy • Septo Rhinoplasty • Partial Thyroidectomy• ParotidectomyPODIATRIC SURGERY
PAIN MANAGEMENT
ORTHOPAEDICS
GENERAL SURGERY
UROLOGY
ENT
For Choose and Book referrals:
T: 020 8347 3864/3856
F: 0208 347 3873
By using the NHS Choose and Book scheme, your patients don’t have to travel far for first-class treatment. A combination of a broad
range of medical treatments, Specialist Consultants, experienced nursing staff and luxury surroundings has given us our reputation
for excellence in North London for the last 30 years. Together we can offer patients the treatment they need when it suits them.
NHS services currently available:
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SEARCH: *Aspen *Highgate
Meet our New Primary Care Manager... Fourth Operating Theatre... Tina joins us with over 20 years’ experience in the Healthcare industry,
having completed a BSc Hons in Nutrition with Biology and Dietetics in 1994.
This includes four years of experience in the Private Healthcare Sector as a
Primary Care Manager, working closely with GPs and Consultants to make
Private Healthcare Services more accessible. Tina is very much looking
forward to help create a working partnership with Primary Care Teams
and Highgate Private Hospital.
Clinical News…What’s New?
Following our £15m investment,
Highgate Private Hospital is proud of
its state of the art skirtless laminar
flow operating theatre, complementing
the existing set of operating suites
We now have a: We also have: Upgraded to a: Extended the:
Nurse led Pre-assessment clinic
7 day Senior Management Team cover (in addition to
24hr Resident Medical
Officer cover)
2 bed High Dependency Unit
Size and expertise of our nursing team
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My wife and I have been going for Physio sessions with Lucie Bond at Highgate Private Hospital every fortnight for the past two months or so. Ms Bond is very knowledgeable about our predicaments and has given expert advice, with a light and positive approach. We have both benefitted enormously and enjoy the routines she has devised for us. Many thanks to all concerned. Patrick and Raynes Minns
Natasha Price — Managing Director, Central Health Physiotherapy
We are delighted to have been looking after local patients and some Highgate Private Hospital staff too who have taken advantage of a great service in their place of work.
Recently we‘ve also started a domiciliary Physiotherapy service. So for those patients who are not able to travel to the Hospital, we will treat them in the comfort of their own home.
Opening hours:Monday to Thursday 8am – 7pm
Fridays 8am – 6.30pm
For Physiotherapy referrals: T: 020 8341 4182
F: 020 8347 3896
Now a year since opening, the Physiotherapy department, run in partnership with
Central Health Physiotherapy at Highgate Private Hospital continues to grow.
The Physiotherapy Department Thrives at Highgate Private Hospital
The outpatient team provides physiotherapy for sports injuries,
upper and lower limb problems, back, shoulder, neck pain
and posture-related problems.
Our Physiotherapists also have a wealth of knowledge in all other
areas of Physiotherapy including Women’s Health, Neurology,
Vestibular problems and Paediatrics. The team have a specialist
interest in Hypermobility Syndrome and are lucky to work
with the eminent Professor Graham who is one of the leading
UK Rheumatologists within this area.
Ergonomics is also provided, including workstation assessment,
both in pro-active and reactive form.
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Whether your patients need knee or hip surgery,
removal of a bunion or have a joint or muscle
problem that just doesn’t seem to go away, we
can help.
Highgate Private Hospital can care for your
patients from diagnosis through to treatment
and rehabilitation.
• Reassurance and advice from expert Surgeons,
Physicians, Physiotherapists,
Podiatrists and Orthotists
• Hip, knee, shoulder, back, elbow, wrist, foot and
ankle pain assessed and treated
• Experts in back and neck problems
• Specialists in Sports Injury available
• Rapid access to diagnostic tests
• Private Medical Insurance? Highgate Private Hospital
is approved by all major insurers
• Paying for your treatment? Highly competitive,
all inclusive and transparent prices
If your patients are suffering from an injury or recurring
problem, we can help. To book an appointment:
T: 020 8341 4182
E: 020 8347 3896
W: www.highgatehospital.co.uk/orthopaedic-treatment
Medical Admissions Unit at Highgate Private Hospital
To further enhance our services at Highgate Private Hospital we will soon be
able to provide GPs with a quick and accessible service for Medical Admissions.
Orthopaedic Treatments
Coming Soon...
Cardiac Diagnostics
New Services Whats new at Highgate...
In addition to Cardiac CT, our Cardiac Diagnostic tests include resting ECGs, Echocardiograms,
24 hour, 48-hour and 7 day ECG holter monitoring, event monitors and 24 hr BP ambulatory monitors.
We offer a rapid test completion and reporting turnaround
times recognising the need for quick results. Patients
suffering with palpitations, uncontrolled hypertension
or suspected murmurs can be referred directly
to our Cardiac Diagnostic services.
Services Offered:
• Resting ECGs
• Echocardiograms
• 24-hour, 48-hour and 7 day
ECG monitoring
• Event Monitors
• 24-hour BP Ambulatory Monitors
To book appointments for Cardiac Diagnostic Services:
T: 020 8341 4182
F: 020 8347 3896
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Meet our new -
Specialist Consultants...
We are extremely excited to welcome on board a number
of new Consultants that have recently joined us...
At Highgate Private Hospital we provide rapid access to Imaging and Diagnostic services. Having an
understanding of how important rapid diagnosis is, we work closely with our Consultant Radiologists
to ensure radiology reports are with you within 24-48 hours for:
MRI, CT, US, X-Ray and Flouroscopy
Offered Across:
Imaging and Diagnostics Services
• Health Screening
• Gastroenterology
• General Medicine
• Gynaecology & early
Pregnancy
• Neurology/ENT
• MSK/Sports
• Respiratory Medicine
• Urology
• Cardiology/Vascular
• Cardiac CT Services
To book an MRI, CT, US, X-Ray, Flouroscopy
scan and for Interventional Radiology:
T: 020 8347 3866
F: 020 8347 3857
Dr Kwok Tang MD, FRCP
– Consultant Gastroenterologist & Hepatologist
Outpatient clinics:Monday evenings
Referrals & Appointments:020 8341 4182
Main NHS hospital:Barnet and Chase Farm Hospitals
NHS Trust & Royal Free London
NHS Foundation Trust
Clinical interests:General gastroenterology,
advanced endoscopy, liver
disease, pancreato-biliary
disorders, IBS/IBD, bowel
cancer screening.
– GASTROENTEROLOGY
Training & background:
Dr Tang graduated from the University of Edinburgh Medical School, with subsequent broad postgraduate Gastroenterology/Hepatology higher specialist
training in London at Guys & St Thomas’s Hospitals, University College Hospital, and completing training at the Institute of Liver Studies, King’s College
Hospital. He is dual-accredited in both Gastroenterology and General Internal Medicine. Dr Tang was awarded a Wellcome Institute Research Fellowship and
conducted full-time research at the Institute of Hepatotogy, University College London (2000 - 2003), completing his MD thesis in Hepatitis/Liver disease,
presenting and publishing widely in this field. He is the lead in Hepatology at Barnet and Chase Farm Hospitals and runs a broad Liver and Pancreatobiliary
Service with a dedicated Hepatitis Treatment Clinic.
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Dr Basil Almahdi MB ChB, FRCA, FFPMRCA
– Consultant in Pain Medicine
Outpatient clinics:Monday evenings (Ad Hoc),
Tuesday afternoons (Ad Hoc),
Friday mornings
Referrals & Appointments:020 8341 4182
Main NHS hospital:Whittington Health NHS Trust
Clinical interests:Spinal degenerative disease,
chronic pain syndromes,
sciatica, bone metastases,
osteoid osteoma, nerve root
pain and neuropathic pain.
– PAIN MANAGEMENT
Training & background:
Dr Basil Almahdi qualified as a medical doctor in 1997. He completed his specialist training in London, and gained a higher degree in Pain Management at
University College Hospital as a Fellow in pain medicine at the National Hospital for Neurology and Neurosurgery, Queen Square. Dr Almahdi is bilingual, also
speaking Arabic fluently. He takes pride in his holistic approach to patient care, allowing patients to make considered decisions and agree a treatment plan.
His emphasis on educating patients empowers them to manage their pain in the best possible way.
Professor Diana Gorog MB, BS, FRCP, MD, PhD, CCST
– Consultant Cardiologist
Dr Tim Lockie MBChB, Bsc. (First Class Hons.),
PhD, MRCP
– Consultant Cardiologist
Outpatient clinics:By appt only
Referrals & Appointments:020 8341 4182
Main NHS hospital:East & North Hertfordshire
NHS Trust
Outpatient clinics:Thursday mornings (alternative
weeks), Wednesday afternoons
Referrals & Appointments:020 8341 4182
Main NHS hospital:Royal Free London NHS
Foundation Trust
Clinical interests:Coronary artery disease,
angina and palpitations.
Clinical interests:Ischaemic heart disease, chest
pain, angina, myocardial
infarction, heart failure and
revascularisation, general
cardiology, arrhythmia
management, palpitations,
shortness of breath, syncope,
hypertension, secondary
prevention and valve disease.
– CARDIOLOGY
– CARDIOLOGY
Training & background:
Professor Diana Gorog is a Consultant Cardiologist and Clinical Director for Cardiology at East & North Hertfordshire NHS Trust, and Honorary Senior Clinical
Lecturer at Imperial College, London. Having qualified at St Bartholomew’s Hospital Medical School, London, she undertook her postgraduate cardiology
training at the Hammersmith, Royal Brompton, Royal Free, St Thomas’ and St Mary’s Hospitals. She went on to obtain both a postgraduate MD and
subsequent PhD in cardiology from the University of London, and was appointed as a consultant cardiologist in 2005. She sees patients with all types of
heart disease, including angina, palpitations hypertension, heart failure and valvular heart disease. She undertakes coronary angiography and angioplasty,
including complex coronary intervention and pacemaker implantation. She is actively engaged in research, with a special interest in thrombosis and coronary
angioplasty and has published 70 peer reviewed papers and is a regular presenter of academic work at international cardiologymeetings.
Training & background:
Dr. Lockie specialises in complex PCI, primary angioplasty for acute heart attacks, intravascular imaging and coronary physiology and has an ongoing interest
in cardiovascular research being the principle site investigator for several large, multinational studies. He is the clinical lead for the cardiac catheterisation labs
at the Royal Free Hospital and in developing local guidelines. Dr Lockie also has responsibility in education and maintaining the institutional databases for
heart attacks and PCI. He sits on the national advisory board for the British Cardiac Society, representing the North Central London region.
Dr. Lockie believes in a multidisciplinary and holistic approach to the treatment of patients with cardiac problems involving the latest and most sophisticated
investigations and techniques, but also careful clinical assessment, always placing the patient’s needs and concerns at the centre of any management plan.
Dr Christos Dimitriou MBBS, MRCPsych
– Consultant Psychiatrist
Outpatient clinics:By appt only
Referrals & Appointments:020 8341 4182
Main NHS hospital:East London NHS Foundation Trust
Clinical interests:Adult ADHD, Anxiety, Bipolar
Disorder, Depression and
treatment resistant Depression,
alcohol and drug addiction,
OCD, Trauma and PTSD,
psychiatric complications of
chronic pain.
– PSYCHIATRY
Training & background:
Dr Dimitriou was born in Greece and came to London in 1993 after obtaining his medical degree. In 1994 he obtained the Diploma in Clinical Neurology at
the National Institute of Neurology and Neurosurgery, going on to train in Psychiatry. After being awarded membership of the Royal College of Psychiatrists
in 2003, Dr Dimitriou completed his specialist training and immediately went on to lead a clinical team as a Consultant from 2006. Throughout his career,
Dr Dimitriou has worked in posts all over London, from specialist Brain Injury Rehabilitation work to the treatment of substance misuse for the Priory Group.
In 2009, Dr Dimitriou’s commitment to delivering the best quality of care led to his appointment as an Associate Clinical Director in Adult Mental Health
Services, covering the City & Hackney area of east London between 2009-2012. He continues to lead a vibrant NHS team in addition to his private practice.
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Sciatica due to a lumbar disc herniation can be a pretty miserable condition to manage, both for the patient and for the General Practitioner managing it.
In the past patients accepted explanations and
education but now with easy internet access,
almost everybody wants a scan and instant relief
of pain. There are massive resource issues involved
and quite often this is not even feasible in the
NHS setting.
In this short article, I have attempted some ‘myth
busting’ and to answer the questions that patients
expect their GP’s to know the answers to.
1. Does pain improve without treatment
after a lumbar disc herniation?
Yes it does. In general 75% of patients improve
within 6 weeks, 90% in 3 months and 93% in
6 months. In reality, this means someone who
has not got better in 3-6 months is unlikely to
get better without intervention. The difficulty
is in expecting patients nowadays to soldier on
for that length of time.
Anti-inflammatory medication, activity
modification and strong analgesia can
improve pain but a lot of patients get side
effects of analgesia.
2. Does every patient require an MRI scan?
If cost and access was not an issue, it would be
ideal to get an MRI for every patient with sciatica.
Given the natural history though, it is unlikely
to help everyone as a substantial number would
need nothing. Convincing someone who sits
before you that it is worth waiting for a while
before an MRI is requested is a difficult problem.
In general, patients with red flag symptoms and
signs should have a scan.
3. What is the best way of relieving pain?
Sciatica can be soul destroying and if analgesia
(escalating) does not work, a well targeted nerve
root block or epidural can provide very good
relief of symptoms. It is hard to expect patients
who are losing their livelihood to let the natural
history make their pain better. Injections done
by experienced Surgeons or Pain Specialists can
give dramatic relief. Injections are steroids that
reduce the inflammation around the nerve root.
This can result in a marked improvement in pain
and allow the disc herniation to shrink and relieve
pressure on the nerve (natural history). In patients
who don’t get relief of pain even after injections,
surgery may be required.
4. Role of surgery
Surgery (microdiscectomy) is sometimes required
to treat a prolapsed disc. The only absolute
indication is the Cauda Equina Syndrome.
This is a surgical emergency and patients who are
thought to have this condition need to be sent to
the A and E of a hospital. Referral must not
be delayed. All other indications are relative.
Persistent severe pain despite trial non operative
treatment and recurrent attacks of pain (relapses)
are the main reasons why patients end up having
surgery. It is largely a quality of life procedure
and the results are usually very gratifying with
about 90% of patients losing their leg pain quite
dramatically. Recurrence of a disc herniation is not
infrequent (7% over 5 years) as the whole disc
is not removed. Sometimes scarring around the
nerve can result in a degree of pain that spoils the
outcome of an initially successful operation.
Post operatively sitting is discouraged for 3 weeks
but working and appropriate exercises aid in the
rehabilitation after surgery.
The results of surgery are as good as a hip
replacement and unfortunately patients have
so many opinions from friends and family saying
that a spinal operation can cause them to be in
a wheelchair, that they often have nihilistic views
about surgery.
5. Role of alternative methods of treatment
Treatment by Physiotherapists, Osteopaths
and Chiropractors can usefully settle pain
down. Over vigorous manipulation stands
the risk of dislodging more disc material and
causing more pain.
This must be avoided. A lot of treatment methods
depend on the fact that natural history does
make the condition better. Pilates and core
strengthening exercises help by strengthening
the back and preventing worsening.
Hear from our Experts...
Modern Management of SciaticaBy Mr Rajiv Bajekal (MCh (Orth), FRCS (Orth)
Consultant Orthopaedic Surgeon
Red Flag Features:
• Age below 20 and above 60
• History of previous neoplasia
• Night pain, severe enough to wake somebody
up and not allow them to sleep or difficulty in
sleeping systemic symptoms
• Progressive neurological symptoms and in
particular bilateral leg pain, perianal numbness,
lack of bladder sensation, incontinence, etc.
Typical nerve root block
Nerve
root block
EpiduralFacet block
Transforaminal
epidural
DiscogramSympathetic
ganglion block
Orthopaedics Special
p.21 InTouch — MARCH 2015 InTouch — MARCH 2015 p.22
The eponymous Haglund’s Deformity,
first described in 1928 by Patrick Haglund,1
a Swedish Orthopaedic Surgeon, is a chronic
enlargement of the posterior-superior
prominence of the calcaneum.2
It is a normal anatomical variant often referred
to as the “pump bump” as the prominence can
become irritated especially by footwear with rigid
backs such as pumps leading to insertional
Achilles tendinitis. Achilles tendinitis described
by Clain & Baxter3 as an overuse phenomenon,4
occurs when the bursa between the calcaneum
and the Achilles tendon (formed by the union
of the tendon of the soleus and gastrocnemius
muscles) becomes inflamed causing heel pain,
degeneration of the Achilles tendon insertion
and tenderness on palpation.
Achilles tendinitis is common with a reported
incidence in the USA somewhere in the region of
6.5-18% in runners, though the actual incidence
is unknown.5 Presence of a Haglund’s deformity
is not pathognomonic of insertional Achilles
Tendinitis as illustrated by a retrospective study
by Kang et al4 who found Haglund’s deformity
was equally present in asymptomatic patients.
Tuberculosis (TB) is caused by bacteria
(Mycobacterium tuberculosis) and despite being
both curable and preventable is second only to
Human Immunodeficiency Virus (HIV)/AIDS as
the single greatest infectious agent leading to
death.6,7 Though it most commonly affects the
lungs, it can also be found extrapulmonary. The
World Health Organisation declared TB a global
emergency in 1993.
The United Kingdom (UK) has an estimated
13/100,000 cases per population with most cases
occurring in major cities, particularly London
equating to around 9,000 cases and approximately
40% of them reportedly diagnosed in London.
These figures appear quite low when compared
to the African, Western Pacific and South East
Asian Populations but have resulted in Britain
being the only nation in Western Europe with
rising levels.
Case Report
A 66 year old Asian gentleman was presented
to the Foot & Ankle Clinic with a 5 month
history of right ankle pain of gradual onset.
He had had no prior events. He was able to
bear weight but experienced pain behind the
ankle on mobilisation.
He reports that he had a calcium injection in the
recent past in India that had given him 3 weeks of
relief. At first presentation to our UK orthopaedic
department, he had swelling around his Achilles
tendon insertion with a palpable lump which was
tender on palpation. Radiography demonstrated
Haglund’s deformity and also possible calcification
at the attachment of the Achilles Tendon.
The patient was offered but declined surgery,
and an injection of corticosteroid given at his
request. He had symptomatically improved at this
clinic review 1 month later, and was therefore
discharged. He presented to orthopaedic
outpatients with recurring ankle pain and again
declined surgery, instead requesting a repeat
corticosteroid injection. He was counselled for
risks and unsuitability of continuing with steroid
injections as the mainstay of treatment but as he
was persistent in his request, it was reluctantly
given. By his 3 month follow up, he had
deteriorated rather than improved and this
time opted to add his name to the waiting
list for surgery.
Over the subsequent 2 weeks, his general
health declined, prompting admission under
the physicians with acute anorexia, abdominal
distension secondary to ascites and groin
lymphadenopathy. He was given a differential
diagnosis of lymphoma and proceeded to
lymph node biopsy and an ascitic tap.
The histology results of the lymph node biopsy
revealed granulomatous lymphadenitis consistent
with TB but no culture had been obtained.
The physicians therefore commenced him on
quadruple agent anti-TB treatment with the
aim of converting to dual agent anti-TB treatment
at the 8 weeks mark and complete the course
by 6 months.
Unfortunately, he developed hepatotoxicity
after 1 month and was therefore readmitted
to hospital under the physicians to re-introduce
anti-TB treatment due to hepatotoxicity. At this
time, his groin lymph node biopsy site was noted
to be constantly oozing.
They also noted he had swelling and fluctuation
around the Achilles tendon and heel and
investigated this with plain radiographs and
an MRI. (Figure 2).
A subsequent image guided needle biopsy showed thick pus. The aspirate was sent to the laboratory where it stained positive
for auramine indicating TB calcaneum with subsequent culture for AFB (Acid Fast Bacilli) confirming the diagnosis of TB
calcaneum. He was recommenced on an anti-TB medication.
Considering the complexity of the situation, and presence of a cold abscess at the heel (of unknown duration), we advised
against surgical intervention at that time, but instead advised immobilisation in an Aircast™ boot and continuation of medical
treatment. He continued to improve.
Two months after completion of the 6-month course of treatment, a follow-up MRI demonstrated calcaneal involvement with
abscess tracking from the calcaneum pointing superficial to the Achilles tendon and little sign of improvement.
More From Our Experts...
Tuberculosis of the Calcaneum Masquerading as Haglund’s Deformity: A Rare Case and Brief Literature ReviewBy Mr Pinak Ray (MS, MCh Orth,FRCS Orth)
Consultant Orthopaedic Surgeon
Radiograph at presentation to the orthopaedic department
Figure 1
Figure 2
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References:
1. Haglund P Beitrag zur Klinik der Achillesshne. Arch Orthop Chir 1928;49:49.
2. Sella EJ, Caminear DS, McLarney EA Haglund’s Syndrome. The Journal of Foot and Ankle Surgery 1998;37:110–4.
3. Clain MR, Baxter DE Achilles Tendinitis. Foot Ankle 1992;13:482–7.4. Kang S, Thordarson DB, Charlton TP Insertional Achilles
Tendinitis and Haglund’s Deformity. Foot & Ankle International 2012;33:487–91.
5. Schweitzer ME, Karasick D MR Imaging of Disorders of the Achilles Tendon. American Journal of Roentgenology 2000;175:613–25.
6. Swain B, Mishra K, Pattnaik D, P P Dutta Tuberculosos of Calcaneum: a case report. Ind J Tub 2001;48:209–10.
7. World Health Organization Tuberculosis Fact Sheet No104. In: 2012.
8. Jerosch J, Schunck J, Sokkar SH Endoscopic calcaneoplasty (ECP) as a surgical treatment of Haglund’s syndrome. Knee Surg Sports Tramatol Arthros 2007;15:927–34.
9. Johnson JW, Zalavras C, Thordarson DB Surgical management of insertional calcific Achilles tendinosis with a central tendon splitting approach. Foot Ankle Int 2006;27:245–50.
10. Shrier I, Matheson GO, Kohl HW 3rd Achilles Tendonitis: are corticosteroid injections useful or harmful? Clin J Sports Med 1996;6:245–50.
11. Paavola M, Kannus P, Järvinen TA, Józsa L, Järvinen M Treatment of Tendon Disorders. Is there a role for corticosteroid injection? Foot Ankle Clin 2002;7:501–13.
12. Trikha V, Gupta V, Shishir R, Kumar R Tuberculosis of Calcaneus: Assessing Treatment Response by Tc-99m MDP Scintigraphy. Clinical
Nuclear Medicine 2004;29:506.13. Mittal R, Gupta G, Rastogi S Tuberculosis of The Foot. J Bone Joint
Surg Br 1999;81-B:997–1000.14. Tuli SM Tuberculosis of the skeletal system (bones, joints, spine
andbursal sheaths)., 2nd ed. New Delhi: Jaypee Brothers Medical Publishers, 1991.
15. Bhat SK, Sastry AS, Sharada M, Nagaraj ER Tuberculosos of Calcaneum: a rare case report. International Journal of Collaborative Research in Internal Medicine & Public Health 2012;4:1601–5.
16. Dhillon MS, Sharma S, Gill SS, Nagi ON Tuberculosis of bones and joints of the foot: an analysis of 22 cases. Foot Ankle 1993;14:505–13.
17. Dhillon MS, Nagi ON Tuberculosis of the foot and ankle. Clini Orthop Relat Res 2002;398:107–13.
18. Choi WJ, Han SH, Joo JH, LeeJW Diagnostic dilemma of tuberculosis in the foot and ankle. Foot Ankle Int 2008;29:711–5.
19. Chen S, Wang T, Lee C Tuberculous Ankle Versus Pyogenic Septic Ankle Arthritis; a retrospective comparison. Jpn J Infect Dis 2011;64:139–42.
20. Cooper DG, Fazal MA, Williams RL Isolated tuberculous osteomyelitis of the bones of the hindfoot: a case report and review of the literature. Foot and Ankle Surgery 2001;7:181–5.
21. The World Health Organisation WHO Global Tuberculosis Report 2012. In: 2012.
22. Tuli SM General Principles of Osteoarticular Tuberculosis. Clin Orthop 2002;398:11–9.
Our patient has completed a total course of 18 months of anti-tuberculous chemotherapy (6 months then 12 months).
It is our belief his heel pain was secondary to early developing Tuberculosis, and that the Haglund’s Deformity is incidental.
We therefore have no plans to surgically resect the prominence and should heel pain recur, we plan to repeat an
MRI to ensure no re-emergence of the mycobacterium.
At orthopaedic review in May, the abscess had
self-drained and formed an ulcer, confirmed by
ultrasound and in the meantime, the physicians
recommenced his anti-TB treatment for a
predicted duration of 12 months.
Six months later, he had occasional pain
approximately at tendo-Achilles region, but
no ankle pain. He could walk without much
discomfort. There was no tenderness over the
calcaneum or tendo-Achilles and he had good
range of movements at the ankle. Clinically the
ulcer was improving but still not healed. There
was no distal neurovascular deficit. Radiographs
demonstrated some resolution of calcaneal lesion
in comparison to earlier films.
After 8 months of anti-TB treatment, the wound
over Achilles tendon had almost completely
healed and an ultrasound revealed the tendon
to be “absolutely normal.” New bone formation
was noted over calcaneum. The latest MRI
revealed complete resolution and healing with
no residual abscess.
Discussion
The patient was offered surgery to resect the Haglund’s Deformity, but on
two occasions requested and received steroid injection before considering
operative treatment. This is the first case to our knowledge, of Tuberculosis
Abscess of the Achilles Tendon Insertion heralding the disease. It is not
known whether the patient had dormant TB that was activated by the
corticosteroid injection, though the locus of infection developed six months
after the injection of [KENOLOG™]. We believe that his symptoms of heel
pain and tenderness on initial presentation to the department were in fact
the first manifestation of his extrapulmonary tuberculosis.
Medical management of a tuberculous cold is an acceptable strategy
in the first instance, with formal I&D being reserved for complicated,
non-responsive or specific sites of abscess. On this occasion, the lesion
healed without surgical intervention. The calcaneum is notoriously difficult
to heal and frequently succumbs to delayed healing or secondary infections.
Tuberculosis cases globally are decreasing, but in the UK, the rates are once
again increasing and the rise of Human Immunodeficiency Virus (HIV) and
the development of multi-drug resistant strains of Mycobacterium
tuberculosis are postulated as causative factors.20
Globally in 2011, there were an estimated 8.7 million new cases
(of which 13% represent co-infections with HIV) and 1.4 million
deaths from tuberculosis with approximately 1 million deaths
among HIV-negative individuals.
Cooper et al20 also identify the rise of increasingly atypical presentations.
Mittel et al13 suggests that TB should be suspected in all cases of long-
standing foot pain while Dhillon et al16 warn that it should be suspected
in high risk groups, such as Asian immigrants.
Conclusion
Extrapulmonary TB is more common in HIV positive patients, but our patient
was not HIV positive and had not been diagnosed with tuberculosis in the
past. We believe that his symptoms of heel pain and tenderness on initial
presentation to the department were in fact the first manifestation of his
extrapulmonary tuberculosis. Calcaneal TB is rare and cases in the literature
are scarce with reports seldom originating from the UK. Furthermore, this case
serves as an aide-mémoire to clinicians of all specialties, that the initial clues to
the diagnosis of tuberculosis infection may be extrapulmonary manifestations.
Given the rising rates of tuberculosis and the multifactorial propensity for the
increased incidence in cities, this case highlights an important differential in
the diagnosis of a multitude of seemingly common presentations, including
Haglund’s deformity and associated insertional Achilles tendonitis. As observed
by other authors, “a high index of suspicion has to be maintained in high risk
groups like Asian immigrants”16 and the clinician should be mindful that unlike
our patient, concomitant extraskeletal lesions may not always be present.
Multidrug antituberculous chemotherapy (for 12 to 18 months) is the mainstay
of treatment.22 As illustrated by our case, the calcaneal lesion fully resolved
without surgical intervention after an appropriate duration of medical
treatment. In all cases, medical treatment should be the first line of treatment,
and should continue for a prolonged period.
Literature Review
There have been no other cases of TB Abscess
of the calcaneum/Achilles tendon insertion
masquerading as Haglund’s Deformity reported
in the literature.
Routine surgical resection of the deformity is an
acceptable treatment favoured by many surgeons
including the senior author.4,8,9 Treatment of
Achilles Tendinitis with local injection of steroid
is an acceptable modality, though there is a
lack of high level evidence to support it.10,11
Extrapulmonary tuberculosis is reported
to account for 1-3% of all tuberculosi.12–15
Tuberculosis of the foot and ankle is rare16–18
and in the absence of HIV, its frequency
decreases further.
Calcaneal TB is rare and cases in the literature are
scarce with reports seldom originating from the
UK. In a retrospective series by Chen et al19 ankle
TB accounted for 0.24% of all cases of TB during
a 20-year study period.
Dhillon,16,17 a prolific commentator on skeletal
tuberculosis, observed that tuberculosis of
the foot and ankle, leads to diagnostic and
therapeutic delays, due to the site being an
uncommon focus, coupled with a lack of
awareness, and the ability of TB to mimic other
disorders both clinically and on radiographs.
He also recommends medical treatment of such
infections, advising surgical treatment to be
reserved for those cases of “intractable disease
or as a salvage procedure for patients with
deformed hindfoot joints”.
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New and RelapseNotification Ratea
1990–2011Year
New and
Relapse
United Kingdon of Great Britain and Northern Ireland
1990 5 908
1995 6 176
2000 6 220
2005 8 173
2009 7 008
2010 7 219
10 13 2011 7 850
The world of orthopaedic surgery is a fast-moving one, and nowhere more
so than in knee surgery. While total knee replacement is well established,
outcome studies show great variability. Only about 10-15% of knee
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Developments in Knee ReplacementBy Mr Simon Mellor BSc (Hons), MB ChB, M.Phil, FRCS (Orth)
Consultant Trauma & Orthopaedic Surgeon
Hip arthritis is no longer a condition that is seen in the older patient.
Total hip replacements are being performed in younger patients after
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Custom Total Hip ReplacementsBy Mr Harold Nwaboku MBBS, FRCSeng, FRCSed FRCS (Trauma & Orthopaedics)
Consultant Trauma & Orthopaedic Surgeon
By accurately matching the hip anatomy of
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I have been truly amazed at how well my
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MBChB, BSc (Hons), MRCS, FRCS Ed (Tr & Orth)
Consultant Orthopaedic Surgeon
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