MARCH 2015 - Highgate Private Hospital · PODIATRIC SURGERY • Parotidectomy ... our nursing team p.11 InTouch — MARCH 2015 p.12. ... patients from diagnosis through to treatment

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

E: [email protected]

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

p.3 p.4

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

[email protected]

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

Introducing Highgate Private Hospital...

p.7

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:


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


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.


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

F: [email protected]

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



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

[email protected]

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.


Dr Basil Almahdi MB ChB, FRCA, FFPMRCA

– Consultant in Pain Medicine

Outpatient clinics:Monday evenings (Ad Hoc),

Tuesday afternoons (Ad Hoc),

Friday mornings


[email protected]

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


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


[email protected]

Main NHS hospital:East & North Hertfordshire

NHS Trust

Outpatient clinics:Thursday mornings (alternative

weeks), Wednesday afternoons


[email protected]

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


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.


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


[email protected]

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


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.


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


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)


Radiograph at presentation to the orthopaedic department

Figure 1

Figure 2


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”.


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

replacements seem to function so well that patients genuinely can forget

they are there. Whilst it may seem sensible to tinker with the design of

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modification (especially it’s lifespan) will not be known for many years.

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to cut the femur and the tibia at just the right angles so that the knee

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to maximise function.

So, how does this differ from standard knee replacement surgery?

Well, we start the operation about 6-8 weeks before the patient actually

comes into hospital! A CT scan of the patient’s knee is sent to the

U.S.A. and from this, technicians generate a ‘virtual knee model’ on

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recreated on the inner surface of two jigs that are manufactured. These

jigs will fit perfectly onto the patients bones during the operation, and

the jigs have slots through which my air-powered saw blade will fit.

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advise what size of implant to use in the operation. The operation itself

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excellent rehabilitation after the surgery is just as vital - all my effort

during the operation will come to nothing unless my patient works hard

with the physiotherapists to maximise the eventual clinical outcome.

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

the conservative methods of treatment have been unsuccessful. The

success of total hip replacements has led to the increased use in younger

patients. Older and active patients have been able to return to many

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A custom hip replacement is

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Symbios Total Hip Implants

Symbios is an Orthopaedic company that

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patients are assessed after clinical examination

and by X-rays to determine whether or not a

custom hip replacement is required. Precision

preoperative planning using the Symbios protocol

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size that is adapted to the patient’s anatomy. The data

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The implant is coated with hydroxyapatite, which promotes integration with

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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

Symbios patients function compared with

those having standard implants. This is the hip

replacement I would have myself...Mr Henry Atkinson

MBChB, BSc (Hons), MRCS, FRCS Ed (Tr & Orth)



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MARCH 2015 - Highgate Private Hospital · PODIATRIC SURGERY • Parotidectomy ... our nursing team p.11 InTouch — MARCH 2015 p.12. ... patients from diagnosis through to treatment