This study looks at whether orthopaedic clinical officers, a cadre of clinicians who are not doctors, can effectively manipulate idiopathic clubfeet using the Ponseti technique. One hundred consecutive cases of uncomplicated idiopathic clubfeet in newborn babies were manipulated by orthopaedic clinical officers. Fifty-seven of these were fully corrected to a plantigrade position by Ponseti manipulation alone, and a further 41 were corrected by manipulation followed by a simple percutaneous tenotomy. Orthopaedic clinical officers therefore corrected 98 out of 100 feet; the remaining 2 feet were referred for surgical correction. This shows that the Ponseti method is suitable for use by nonmedical personnel in the developing world to achieve a plantigrade foot.

Ann R Coll Surg Engl 2007; 89: 722-724 722Malawi is a small, but densely populated, country in subSaharan Africa. The population is approximately 12 million. 1 The average income is less than one UK pound a day and it is currently ranked as one of the poorest and least developed countries in the world -55% of the population is below the international poverty line of one US dollar per day. 2It has a network of 21 district hospitals, one in each rural health district, and four central hospitals in the four major urban areas. Together, these government hospitals cover approximately 60% of the country's health needs. In addition, there are several mission and independent hospitals which together cover the other 40%. There has been recent interest in district hospital surgery in Africa with the publication of the new World Health Organization book Surgery at the District Hospital 3 encouraging surgery to be done at a district level where it is needed rather than being transferred to tertiary centres. There has also been investment in district surgery in Malawi recently with the completion of two European Union funded district hospitals in the south of the country. Both of these have several operating theatres. There are only 15 trained surgeons of any specialty in Malawi and there are no surgeons stationed at any of the district hospitals. Most district hospitals have one doctor, the district health officer, who is recruited straight from internship and is busy with running the hospital and health district as well as overseeing the clinical work. The district health officer is helped by a number of clinical officers who are paramedic clinicians with 4 years' practically orientated training. Surgeons from central hospitals also periodically visit the districts to run clinics and sometimes to operate. We decided to investigate exactly what surgery was being done in the country as a whole. We have already reported a limited survey of district activity. 4 This study examines surgical activity over a 1-year period in both district and central hospitals. Patients and MethodsTwo of the authors visited every district and central hospital in Malawi over the course of 2004 as part of routine clinical support visits. They met with the district health officer or clinical officers i nvolved with surgery and reviewed the operating theatre log book. All operations done in the operating theatres in 2003 were recorded. In many hospitals, procedures such as drainage of abscesses were done in the out-patient departments and were not recorded. Eye operations were often done by visiting teams who kept separate records. These were not recorded. Operations were classified into the categories outlined in the

Total knee replacement and high tibial osteotomy are common orthopaedic operations with low complication rates. Such surgery is in close proximity to the popliteal artery (PA), the behaviour of which during flexion of the knee is poorly understood. We used Duplex ultrasonography to determine the distance of the PA from the posterior tibial surface at 0 degrees and 90 degrees of flexion in 100 knees. When the knee was flexed the PA was closer to the posterior tibial surface at 1 to 1.5 cm below the joint line in 24% and at 1.5 to 2 cm below the joint line in 15%. There was a high branching anterior tibal artery in 6% of knees. We provide an anatomical account to help to explain our findings by using cadaver dissections, arteriography and static MRI studies.

Overall the establishment of a nationwide club foot treatment programme was of benefit to a large number of children with club feet and their families. In a poor country with many demands on health funding many challenges remain. The supply of plaster of Paris and splints was inadequate, clinic staff felt isolated, and patient compliance was limited by many factors which need further research.

We describe the survival of 134 consecutive JRI Furlong hydroxyapatite-coated uncemented total hip replacements. The mean follow-up was for 14.2 years (13 to 15). Patients were assessed clinically, using the Merle d'Aubigné and Postel score. Radiographs were evaluated using Gruen zones for the stem and DeLee and Charnley zones for the cup. Signs of subsidence, radiolucent lines, endosteal bone formation (spot welds) and pedestal formation were used to assess fixation and stability of the stem according to Engh's criteria. Cup angle, migration and radiolucency were used to assess loosening of the cup. The criteria for failure were revision, or impending revision because of pain or loosening. Survival analysis was performed using a life table and the Kaplan-Meier curve. The mean total Merle d'Aubigné and Postel score was 7.4 pre-operatively and 15.9 at follow-up. During the study period 22 patients died and six were lost to follow-up. None of the cups was revised. One stem was revised for a periprosthetic fracture following a fall but none was revised for loosening, giving a 99% survival at 13 years. Our findings suggest that the long-term results of these hydroxyapatite-coated prostheses are more than satisfactory.