Introduction

Enhanced recovery programmes (ERP) have recently been adopted in the UK, enabling patients to recover quickly and return home sooner. Choice of anaesthetic is an important factor effecting post-operative outcome; studies show regional anaesthesia is more cost-effective, decreasing the incidence of venous thromboembolic events and reducing intra-operative blood loss, the need for transfusion and the length of hospital stay.

The relationship between hindfoot and forefoot kinematics is an important factor in the planning of ankle arthrodesis and ankle arthroplasty surgery. As more severe ankle deformities are corrected, improved techniques are required to assess and plan hindfoot to forefoot balancing.

Gait analysis has previously been reported in patients with ankle arthritis without deformity. This group of patients have reduced intersegment motion in all measured angles. We have looked at a small group of patients with hindfoot deformity and ankle arthritis awaiting fusion or replacement.

Using the Oxford Foot Model we have assessed lower limb kinematics with a focus on hindfoot to forefoot relationships. The results of our pilot study are in variance to previous studies in that we have shown that in the presence of hindfoot/ankle deformity, the forefoot range of motion increases. We feel that these data may impact on surgical planning.

Retrospective analysis of radiology reports of conventional MRI in 100 patients with definite spinal stenosis to determine the incidence of reported “foraminal stenosis”.

Prospective study of MRI including T2 coronal and T2 STIR coronal sequences in 57 patients with suspected stenosis. Three surgeons and one radiologist independently compared the diagnoses on conventional and coronal scans.

Patients with suspected spinal stenosis undergoing MRI.

Incidence of “foraminal stenosis” on radiologists' reports.

Diagnoses obtained by different scanning methods.

Retrospective analysis: “foraminal stenosis” called by radiologists in 46% using conventional axial and sagittal sequences.

Prospective study - 57 patients: conventional sequences diagnosed lateral recess stenosis well but also suggested foraminal stenosis in 33%. However, coronal sequences clearly showed no foraminal nerve compression.

In degenerative spondylolisthesis conventional scans suggested foraminal stenosis in 8 of 11 cases. Coronals showed no foraminal stenosis.

Excellent correlation was found in normal spines and in disc herniation. In far lateral disc herniation and isthmic spondylolisthesis, true foraminal stenosis was confirmed by conventional and coronal imaging.

Additional coronal MRI sequences prove that foraminal stenosis is over-diagnosed and is rare in spinal stenosis, but true foraminal nerve compression occurs in isthmic spondylolisthesis and far lateral disc herniation.

Objectives: To determine the effect of an Orthogeriatric team (OGT) upon patient management pre-operatively after its incorporation into a regional trauma centre of a district general hospital in the UK.

Design: Prospective audit covering all patients admitted with a fractured hip for surgery one year before and one year after the establishment of an OGT.

Method: A total of 288 fractured hips were operated on during February 2004 to February 2005. From February 2005 the OGT was created, consisting of a Staff Grade and 2 Senior House Officers (junior residents), assisted part-time by a consultant. Patients were medically managed and optimised for theatre; 301 patients underwent surgery in the 1st year from Feb 2005 to 2006.

The data was collected prospectively from admission, and entered onto a database.

Results: Before the set up of the OGT only one-quarter (25%) of patients were operated on within 24hours compared to almost one-half of patients (44%) under the care of the OGT. Of the patients waiting more than 24hours, delay while waiting for special tests was similar but there was a significant difference in the percentages of patients delayed due to lack of theatre time and poor medical condition. Only 5% of patients under the care of the OGT were delayed due to medical co-morbidity compared with 44% when solely under orthopaedic care.

Conclusion: Focused high-quality medical input provided by a specialist Orthogeriatric team resulted in significantly reduced delays to theatre for patients admitted with a fractured hip. This is in the context of our hip fracture population becoming increasingly frail with increasing medical problems and continuing pressures on operating time. In the environment of financial constraint, this study confirms that reduction in time to theatre, effective, appropriate investigation and lower complication rates are likely offset the cost of the team. This may provide a model for other units.

The results of three years of treatment of children’s forearm fractures with flexible titanium nails was compared with the results from three original papers (Lascombes 1998, Richter 1998, Cullen 1998).

37 cases were identified using our trauma database and the main theatre database. 25 sets of case notes and x-rays were reviewed (age 4-16). The indication for fixation was fracture instability, either primarily or after initial conservative management. 6 cases were compound fractures. The fractures were reduced under general anaesthetic and then fixed using the ‘AO titanium elastic nail instrument and implant set’ (Synthes). 9 out of the 19 closed fractures needed to be opened for satisfactory reduction. Average theatre time was 104 minutes (25–165).

Average hospital stay was two days (1–4). 22 of the patients were immobilised in plaster of Paris for an average of 5 weeks. Nails were removed on average 4 months after insertion (1–10 months). 16% had minor complications which included transient nerve impairment, superficial infection and refracture. All patients were considered to be fully recovered when discharged.

Use of flexible nails in our district general hospital is comparable to previously published series in terms of case mix and complication rates.