Background

Corrective fusion of a deformed / unstable Charcot neuroarthropathy (CN)of the midfoot and hindfoot is performed with the aim to prevent ulcers and maintain patient mobility.

Aims

Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.

Diabetes is a poor prognostic indicator after an ankle fracture. Many surgeons avoid operating due to concerns regarding complications.

We performed a retrospective analysis of complication rates for acute ankle fractures in diabetics with a control non-diabetic patient treated by all surgeons in our unit and assessed factors for success including long-segment fixation.

Patient records were cross-referenced with departmental databases and a review of all ankle fractures managed in our department was conducted from 2012. All patients subjected to a retrospective-review of their follow-up for at least 6-months. Radiographs were assessed of the ankle before and at completion of treatment being reviewed independently (RA & FR).

We identified the HB1Ac (diabetic-control) and systematic co-morbidities. Fractures were classified into unimalleolar, bi malleolar and trimalleolar and surgery grouped into standard or long-segment-rigid fixation.

Statistical analysis was conducted using absolute/relative risk (RR); numbers needed to treat (NNT) were calculated. We compared a control-group, a diabetic group managed conservatively, and undergoing surgery; comparing the concept of rigid fixation and prolonged imobilisation in isolation or combined.

Further sub-analysis conducted assessing diabetic neuropathy, retinopathy and nephropathy. Ethics approval was granted as per our institutional policy by our governance lead.

We identified 154 diabetic ankle fractures, seventy-six had conservative-treatment; 78 had operative fixation of which 23 had rigid-long-segment-fixation.

The diabetic-groups had a higher risk-relative-risk of complication − 3.2 (P< 0.03) being linked to systematic complications of diabetes e.g. neuropathy 5.8 (P< 0.003); HBA1c 4.6 P< 0.004); and neuropathy or retinopathy 6.2 (P< 0.0003).

Relative-risk reduction of complications occurred following surgery with prolonged immobilization (0.86) and rigid-fixation (0.65). The Number-Needed-to-Treat required to see a benefit from rigid fixation was 7.

Diabetics have a higher risk for complications, however the risk is not as great as previously reported. We provide evidence of rigid-long-segment-fixation with prolonged-immobilization improving-outcomes.

Diabetes is a poor prognostic indicator after an acute ankle fracture. Many surgeons avoid essential surgery due to their concerns regarding complications.

We performed a retrospective analysis of complication rates for acute ankle fractures in diabetics with a control non-diabetic patient treated by all surgeons in our unit and assessed factors for success including long-segment fixation methodologies.

Patient records were cross-referenced with departmental databases and a retrospective review of all ankle fractures managed in our department was conducted from 2014. All patients subjected to a retrospective review of their notes and assessment of their follow up for at least 6 months. Radiographs were assessed of the ankle before and at completion of treatment were reviewed independently (RA and FR).

We identified all patients with a diabetic ankle fracture their HB1Ac (for diabetic control) and systematic co-morbidities. Fractures were classified into unimalleolar, bi malleolar and trimalleolar and surgery grouped into standard or long-segment-rigid fixation. Statistical analysis was conducted using absolute/relative risk (RR); numbers needed to treat (NNT) were calculated. We compared a control-group, a diabetic group managed conservatively, and undergoing surgery; comparing the concept of rigid fixation. Further sub-analysis conducted to assess differences between diabetic neuropathy, retinopathy and nephropathy. Ethics approval was granted as per our institutional policy by our governance lead.

We identified 64 patients with a diabetic ankle fractures, their fracture pattern and a control group. Thirty-one had conservative treatment; 33 had operative fixation of which 13 had rigid fixation. Compared to the control (n=32) both diabetic groups had a higher risk of possible complication. The relative risk was between 3.1–3.4 (P<0.002) and linked to systematic complications of diabetes e.g. neuropathy 5.9 (P<0.003); HBA1c 4.6 P<0.004); and neuropathy and retinopathy 6.2 P<0.0003). We observed RR is reduced for a complication occurring following surgery with prolonged immobilization (0.86) and rigid fixation (0.65) and NNT required to see a benefit from rigid fixation was 7. The overall RR for a complication was similar between conservative and surgical management (4.6 vs.5.1).

We agree diabetics have a higher risk for complications than non-diabetics, however the risk is not as great as previously reported. There is little difference in surgical or conservative treatment but strong evidence indicating rigid long-segment-fixation with prolonged-immobilization could improve the risk benefit ratio when compared to non- operative management alone but further evaluation is required.

Introduction

Corrective fusion for the unstable deformed hind foot in Charcot Neuroarthropathy (CN) is quite challenging and is best done in tertiary centres under the supervision of multidisciplinary teams.

Informed consent is integral to good-practice. It protects the patient and offers proof of discussion and interaction between the surgeon and the patient. We compare efficacy of last clinic consent, specialised consent clinic with or without provision of patient specific literature.

Group A patients underwent written consent at their last outpatient clinic and conformation of consent on the morning of surgery. Group B underwent consent in designated pre-admission clinic in the week prior to surgery. Group (C) attended the same preadmission clinic and were provided with a surgeon dictated written explanation of their surgery and particular risks. This included a explanation of the procedure, complications, risks and rewards in layman's terms, aimed at patients with a reading age of 14 years, with advice concerning alternative procedures and the consequences of taking no action. The risks are graded: common, less common and rare.

All patients undertook a pre-surgery questionnaire on the morning of surgery by an independent observer prior to any contact with the surgical team. Questions focused on their planed procedure, post-operative instructions and possible complications in order to assess the recall of the consent process. A VAS-scale was added to assess overall satisfaction. Statistical analysis was undertaken by a T-test.

In total 162-patients were assessed, the response rate was 68.5% (n=111). In-group A (n=16) 18.8% patients remembered 3 relevant complications, 56.2% recalled their post-operative considerations their overall satisfaction was 4/10. In-group B (n=57) 45.5% remembered three complications, 63.7% recalled their postoperative considerations and had a patient satisfaction of 5/10. In-group C (n=38) 48.3% remembered three complications, and 70.7% recalled postoperative considerations, the overall satisfaction improved to 6/10.

We observed that the consent process is improved by the use of routine pre-operative consent clinics; however the addition of patient specific literature is observed to further improve recall and satisfaction.

Introduction

Ankle replacement is now common in the UK.

In a tertiary referral NHS practice, between 1997–2011 we implanted two types of cementless mobile bearing total ankle replacements (TAR).

To date, there are no clear guidelines from the National Institute of Clinical Excellence or the British Orthopaedic Association regarding the use of Autologous Blood Transfusion (ABT) drains after elective primary Total Knee Replacement (TKR). There is little evidence to comparing specifically the use of ABT drains versus no drain. The majority of local practice is based on current evidence and personal surgical experience.

We aim to assess whether the use of ABT drains effects the haemoglobin level at day 1 post-operation and thus alter the requirement for allogenic blood transfusion. In addition we aim to establish whether ABT drains reduce post-operative infection risk and length of hospital stay.

Forty-two patients undergoing elective primary TKR in West London between September 2011 and December 2011 were evaluated pre- and post-operatively. Patient records were scrutinised. The patient population was divided into those who received no drain post-operatively and those with an ABT drain where fluid was suctioned out of the knee in a closed system, filtered in a separate compartment and re-transfused into the patient.

Twenty-six patients had ABT drains and 4 (15.4%) required an allogenic blood transfusion post-operatively. Sixteen patients received no drain and 5 (31.3%) required allogenic blood. There was no statistical difference between these two groups (p=0.22). There was no statistical difference (p=0.75) in the average day 1 haemoglobin drop between the ABT drain and no drain groups with haemoglobin drops of 2.80 and 2.91 respectively. There was no statistical difference in the length of hospital stay between the 2 groups (p=0.35). There was no statistical difference (p=0.26) in infection rates between the 2 groups (2 in ABT drains Vs. 0 in no drains). Of the 2 patients who experienced complications one had cellulitis and the other had an infected haematoma, which was subsequently washed out.

The results identify little benefit in using ABT drains to reduce the requirement for allogenic blood transfusion in the post-operative period following TKR. However, due to small patient numbers transfusion rates of 31.3% in the ABT drain group Vs. 15.4% in the no drain group cannot be ignored. Therefore further studies including larger patient numbers with power calculations are required before a true observation can be identified.

Much has been written about ESP (Extended Scope Practitioners) lead clinical services, the vast majority of which have been developed in secondary care. Little evidence is available on the efficacy of ESP. clinics either for both the patient and weather they stream line back pain treatment. We present an interim audit of an assessment pathway for community management and MDT practice for lower back pain.

56 patients were reviewed with a revised ESP assessment tool and then presented to an MDT meeting. Each, assessment was 45 minutes long and outcome measures used included ODI and STaRT scores. Patients were telephoned at 12 weeks following their appointment and then at 18 weeks, to ascertain the progress they were making and to see if the 18-week target had been met.

56 patients were reviewed from September 2009. The average ODI, was 63%, and 56% at 12 weeks; most patients had a STaRT score of 6, and 3 on the psychological component it the beginning of the study. The EQ-5D scores were observed to show an improvement. MRI rates were 3.8% and the DNA rate was 7%. A total of 11 MRI requests; the results of 7 of these were available for analysis. The scans that were requested all showed a disc lesion that was amenable to surgical decompression or stabilization. Overall patients were very satisfied.

Our formatted methodology allowed clinical governance at source to measure the efficacy of patient treatment. Early results suggest an efficient in delivering an acceptable standard of care as long as they are properly supported.

Little data exists on predicting the actual outcome of patients with fracture neck of femur when aged over 90. This group represents a complex of medical problems and where a delay in surgery can impact on patient recovery. In this study we evaluated the POSSUM scores at time of admission and time of surgery. We aim to define the actual mortality and morbidity of this group, if the possum had any predictive value, and any correlation with outcome.

132 patients over 90 with a fracture where followed from 2005–7, and a control cohort were followed up in 2005–6. A collection form was prepared to collect standard data on physiological status, with a standard scoring system on admission (Ortho possum), at the time of operation, comparing their progress and clinical outcome post-op. It also recorded co-morbidities and other outcomes. Statistical analysis was conducted using SPSS.

132 patient notes were reviewed and 130 patients in the control group. 5 had no surgery and the average age was 93 (90–103) vs. 76 in the control group. The majority of over 90’s were admitted from home by ambulance (n=99); and the cause of the fracture was recorded as a fall (n=68). 74 patients at admission were using a stick or a frame (24 were independent). Only 2 patients were on warfain.

At the point of admission the physiological POSSUM score on average was 23.48 (18–44) and at surgery it was 23.52 (16–38). This meant that the predicted mortality increased from 0.103 to 0.104. The average time to surgery was 1.5 days (0–12 days). However delays in surgery increased the POSSUM score and higher Possum scores were correlated with increased number of complications (p> 0.002), increased time to mobilisation (p> 0.003), and reduced mobility as compared to admission at day 15 and longer hospital admissions (p> 0.005).

In hospital mortality was 0.068 with a higher total POSSUM score prior to surgery of 36.29 for these patients compared to those patients who died after discharge. 35 patients died in total at 2 years post discharge (36%). Of these patients those within the 30 day mortality post discharge was 0.087 with a higher Total POSSUM score of 28.55 compared with the 120 day mortality post discharge of 0.194 with Total POSSUM score of 27.55; predicted mortality for the whole group was 0.28 using the Possum score (actual 0.27). Of the 35 patients that died 22 had higher Possum scores at surgery than admission.

In summary we found that there was no significant difference in the mortality and morbidity in the over 90’s fracture neck of femur group than the control. The Possum scoring system over predicted overall mortality and morbidity. Our results indicate a dedicated team to deal with these patients may well be of benefit to improve surgical Possum scores and outcome.

Introduction: There is little evidence for the long term efficacy of selective nerve root injections (SNRI) in the control of lumbar radiculopathy. We report the 5 year results of a prospective study of SNRI in the lumbar spine.

Methods: All patients considered to be operative candidates by two treating surgeons (JMP and DJS) with unilateral/bilateral radicular leg pain were included. Patients had a mean history of radicular symptoms of 12.8 months (4 months–3 years). All had an SNRI under image intensifier control with local anaesthetic and steroid. Each patient was evaluated pre-operatively, 2 months, 6 months, 1 year, 2 year and 5 years with VAS and ODI scores.

Results: Sixty-two consecutive patients were reviewed. The mean age of patients was 54.5 years (36–80 years). 92 injections were performed. Symptoms were caused by degenerative disease (n=32), disc herniation (n=25), and previous surgery (n=3).

The ‘disc’ group was significantly younger than ‘degenerative’ group (49.4 yrs vs. 58.4 yrs; p=0.004). There were significant improvements in low back pain (LBP), leg pain (LP), and ODI at 2 months in all patients. At 5 years the disc group did better with both leg and back pain; whilst there was only a significant reduction in leg pain in the degenerative group. Over 90% (n=56) of patients had no operative intervention; a subgroup of 8 had further injections. Within the degenerative group, ODI and VAS deteriorate early on indicating that a second injection option in this group may be worthwhile.

Conclusion: At five-years, most patients avoid operative treatment because of improved symptom control with SNRI. Regression analysis showed “duration of symptoms” and “age” is predictive of good outcome at one year post SNRI, but gender and, diagnosis are not.

Background: Nerve Root pain is a problem caused by mechanical compression from disc herniation or foraminal stenosis, which stimulates an inflammatory response. We present a review of the evidence for corticosteroid infiltration in nerve root infiltration (NRI).

Methods: Medline, Embase, trial registries, conference proceedings and article reference lists were searched to identify randomised controlled trials of the use of NRI in the treatment of radicular pain. For the purpose of this meta-analysis, the control group “no steroid” was chosen to encompass various subtypes. The primary outcomes were Oswestry Disability Scores (ODI) and Visual Analogue Scores (VAS) for pain. Outcomes were compared at 3 and 6 months from injection. For the purpose of the meta-analysis, repeat injection and progression to surgery are grouped as a composite endpoint.

Results: We identified 96 papers; but only 5 RCT’s which included 402 patients receiving NRI; 202 were randomised to receiving steroids. No trials reported significant intergroup differences in baseline VAS or ODI.

At 3 months there was no significant difference in VAS or ODI between the groups. Only two trials reported ODI data at 6 months but a significant effect in favour of the control arm was noted (P = 0.040). Four of the five trials reported the need for further injection or surgery due to failure but no significant difference between the groups was found (P = 0.038).

Conclusion: Our analysis suggests that the addition of steroids to local anaesthetic agents or placebo solutions confers no additional benefit, but the theoretical risk of infection. Further information is needed on hospital stay, economic and long term responses, and is required to counter confounding with small trials and study numbers, and any methodological heterogeneity.

We present an evaluation of basic surgical orthopaedic operative training in the last 15 years, using multiple trauma and elective training procedures in orthopaedics. Identifying the influence of competency training and EWTD on Basic Surgical Training. Whilst trying to identify the area’s the MMC should concentrate on to provide a competent trainng programme.

We assessed clinical exposure using 45 Basic Surgical Trainee Logbooks, from posts in 1990 (n=6), 1995 (n=7), 2000 (n=10), and 2004–5 (n=22); and looked at numbers of carpel tunnel decompression, and emergency hip, wrist, and ankle surgeries conducted. As well as the number of external fixators trainees were exposed to. In the 2004–5 group we prospectively assessed competency and knowledge of fracture neck of femur surgery.

From a peak in operative surgery in 1990 numbers have fallen. Today, BST’s participate in 165 emergency hip cases (mean 4.6 procedures per trainee), today, 4.8% (n=8) as primary surgeon. In 1990, and 2000 trainees were primary surgeon in 43.4% (n = 12/32) and 25.2% (n=33/131) respectively.

Trainees are comfortable with closure of skin, subcutaneous and muscular layers but not access; 91% (n=20) required assistance in positioning, and reduction, and recognition of correct alignment. Only 9.1% (n=2) felt competent without senior supervision (mean Orthopaedic BST experience 15.3 months) in hip surgery; whilst none knew of an intra-operative technique to reduce young adult capsular hip fractures. With regards to wrist and ankle fixation the decline has been dramatic decline by 11.1 and 5.9 procedures per trainee. Whilst, the numbers of forearm manipulations peaked in 1990–1995; it has since dropped to less than 5 per trainee in 2005 from 15–16. In 2005, it was also seen that a in a 6 month period a trainee in a typical district general hospital would be lucky to see an external fixator applied (average 0.6 per trainee in 6 month period).

The decline of elective surgery is shown in carpel tunnel decompressions attended. In 1990 9.8 (6–14) were conducted as a primary operator, in 2005, it was 0.5 (0–3). The greatest decline in procedures of 46.3% occurred between 2000, to 2005. A comparison of total operating showed 88.9 (n=79–125) procedures in 6 months were lost between 1990 and 2005; with a 58.6% loss in trauma.

This study suggests deficiency in operative competence today due to reduced opportunities. Thus emphasis should be placed on rota’s being matched to operative exposure, as trainee case numbers have declined sharply particularly in the last 5 years. The MMC should therefore ensure that trainees in the ST1 to 3 years reach their competencies with adequate time in the operating theatre.

We present the use of the Orthopaedic POSSUM Score and Surgical Risk Score (SRS) to identify optimal time for fracture neck of femur surgery. The objective of this study was to identify the physiological status of patients at admission and compare the results of operative physiological condition and differences in predictive and actual operative outcomes.

1238 consecutive hip fractures from Jan 2005 to July 2006 at 3 hospitals were assessed. Collection of demographic, admission and operative POSSUM, and SRS scores, fracture pathology, physiological status, and postoperative outcome were conducted.

In total, 1031 (83.3%) patients had surgery. The median age was 72.6 (range 55–95, mean 68). Majority had significant systemic multiple co-morbidity (78%), an average ASA score of 3.3. POSSUM predicted 18.7% (n= 194) of death at 30 days, where as the surgical risk score predicted 13.8% (n=142 deaths), the actual mortality was 11.7% (n=120).

The difference between admission and operative physiological POSSUM score increased with operative delay (see table 1). Physiological scores greater than 30 had a 67.8% risk of 30-day mortality. 361 patients had an increase in physiological score from admission to operation, resulting in higher analgesic requirements and reduced mobility scores (P< 0.005). These patients had a 12.6% increase in mortality when compared with patients operated earlier with a similar initial score (P< 0.005). Furthermore delayed surgery (> 48 hours) lead to reduced in return mobility, function, increased wound infections and other medical complications.

Possum and SRS over predict operative mortality, but are useful in prioritising their time of surgery. Declining operative physiological POSSUM scores indicate room for improvement in preoperative care, and for specific protocols if surgery has to be delayed to prevent further physiological deterioration, and induce optimal functional outcomes.

We undertook a prospective randomised controlled trial to investigate the efficacy of autologous retransfusion drains in reducing the need for allogenic blood requirement after unilateral total knee replacement. We also monitored the incidence of post-operative complications. There were 86 patients in the control group, receiving standard care with a vacuum drain, and 92 who received an autologous drain and were retransfused postoperatively. Following serial haemoglobin measurements at 24, 48 and 72 hours, we found no difference in the need for allogenic blood between the two groups (control group 15.1%, retransfusion group 13% (p = 0.439)). The incidence of post-operative complications, such as wound infection, deep-vein thrombosis and chest infection, was also comparable between the groups. There were no adverse reactions associated with the retransfusion of autologous blood.

Based on this study, the cost-effectiveness and continued use of autologous drains in total knee replacement should be questioned.

Introduction: We present the use of Orthopaedic POSSUM Score and Surgical Risk Score (SRS) in femoral neck fracture surgery. The objective of this study was to identify the physiological status at admission and at operation and identify differences in predictive and actual patient operative outcomes.

Material and Methods: All 338 consecutive, hip fractures from December to July 2005 at three hospitals were assessed prospectively. Collection of demographic, admission, and operative POSSUM, and SRS scores, fracture pathology, physiological status, and outcomes were analyzed.

Results: In total, 306 (90.5%) patients had surgery. The median age was 73 years (range 55–95). The majority had co-morbidities (77.5%; n=237), as suggested by average ASA scores of 3.2. POSSUM predicted mortality was 13.6% (n=25) at 30 days, whereas the SRS predicted 11.4% (n=21), but mortality was 7.1% (n=13) if operated before 48 hours. Differences between admission and operative physiological Possum score increased with operative delay. Physiological scores over 30 had a 67.8% risk of 30-day mortality. Eighty-six patients had an increase in physiological score from admission to operation, resulting in higher analgesic requirements and reduced mobility scores (P< 0.005).

Discussion: Possum and SRS had a tendency to predict prior than actual operative mortality. Nevertheless, comparison of admission and operative physiological POSSUM scores indicate room for improvement in pre-operative care if surgery is delayed.

Introduction: An accepted treatment of lateral compartment osteoarthritis with valgus deformity is to correct the malalignment, and unload the affected compartment. Previous techniques have used large fixation plates to secure complete osteotomy sites. We present a prospective study using a novel incomplete opening wedge osteotomy, in treating lateral compartment osteoarthritis in active patients younger than 65.

Methods: We assessed all patients (n=26) who underwent opening wedge femoral osteotomy with Puddu plate fixation over a 5 – year period by one surgeon (PRA). All patients had long leg X rays and arthroscopic evaluation; revealing either grade 3 and 4 osteoarthritis within the lateral compartment; 11 secondary to lateral menisectomy, 4 to complex trauma to the lateral tibial plateau, the others were diagnosed with primary osteoarthritis. Pre operative and post-operative Knee Society and Oxford Knee scores and long leg X rays were used to monitor subjective and functional improvement.

Results: Patients had a mean age of 48, (mode 56); ASA of 1 (range 1–2); and BMI of 24 (range 20–26). Mean follow up time was 46.8 months (6–62 months). Results in table 1 show early benefits in post-operative pain and improved function scores, which were maintained to 42 months. All patients had radiological union by 3 months (2–8months). Plates were removed as a minor procedure in some patients at 8 months (6–18 months), and did not lead to loss of correction or conversion to total knee replacement within the study.

Subjective and functional progress was observed by using the Oxford Knee Score and the Knee Society Score, early results showed an improvement from in the Oxford Knee score from 54.4 (+/−5.7) to 27.2 (+/−4.7)*, and the improvement was maintained at 12**, 30**, and 62** months (*P< 0.002; **P< 0.005). The same pattern was repeated with the knee society score where a pre opetrative score of 53.9 (+/−4.8) improved to 87.6 (+/−6.2) at 6 months and was 82.4(+/−8.7) at 62 months.

No infections were recorded, or differences in pre and post-operative flexion were observed at 36 months (P< 0.005) in all patients. However, 3 patients required further manipulation to overcome post-operative stiffness. Plates were removed only for local discomfort, and follow up showed there was no loss of corrective angulation.

Conclusion: These results suggest using the puddu plate is an alternative to unicompartmental or total knee arthroplasty in young active patients with lateral compartment osteoarthritis, without significant morbidity.