Aims

Postoperative rehabilitation regimens following ankle arthrodesis vary considerably. A systematic review was conducted to determine the evidence for weightbearing recommendations following ankle arthrodesis, and to compare outcomes between different regimens.

Aims

Fractures of the distal femur can be challenging to manage and are on the increase in the elderly osteoporotic population. Management with casting or bracing can unacceptably limit a patient’s ability to bear weight, but historically, operative fixation has been associated with a high rate of re-operation. In this study, we describe the outcomes of fixation using modern implants within a strategy of early return to function.

Methods

A retrospective review of 80 patients with unilateral slipped capital femoral epiphysis from 1998–2012 was undertaken to determine the outcome of the unaffected hip. All patients were treated with either prophylactic single Richards screw fixation or observation of the uninvolved hip and were followed up for at least 12 months. The unaffected hip of 44 patients (mean age 12.6 years, range 9–17) had simultaneous prophylactic fixation and 36 patients (mean age 13.4 years, range 9–17.4) were managed with observation.

Distal femoral fracture fixation has historically been associated with high rates of reoperation because of mal-union, non-union and implant failure. We hypothesised that recent advances in distal femoral locking plate design and material along with an improved understanding of biomechanical principles would improve outcome. In a 5-year retrospective study utilising electronic patient records and serial radiographs (including recall by letter where there was no radiological evidence of union) we identified a series of 129 distal femoral fractures treated with modern locking plates in 123 patients. The majority were female (80%), elderly (mean 73 years) and infirm (72/123 ASA 3 or more). A consultant performed the operation in 67% of cases. 49% were followed to radiological union, while 25% died within the follow up period. Reoperation rate for implant failure was 4%, with all failures occurring early (within 5 months). Our follow up correlates with the infirm elderly population concerned. Our cohort shares many similarities with hip fracture patients and we propose that this group should receive equal surgical priority and optimum management also be rewarded by enhanced tariffs. Modern locking plates used in combination with the correct biomechanical principles are performing well in our centre.

The “Golden Patient” is suitability worked up to be the first theatre case of the day; the aim being to improve theatre efficiency. A previous audit of theatre activity demonstrated that the average knife to skin time being achieved across 3 daily trauma lists was 10.12. Over 2-months we introduced a Golden Patient Pathway and completed the audit cycle. The pathway involved a checklist to ensure the completion of essential clinical tasks for each designated golden patient. Activities from 74 trauma theatre cases were reviewed. 47 golden patients remained first whilst 27 were deferred for reasons including non-suitability for golden patient status and emergent cases given clinical priority. The average theatre call time was 24 minutes earlier and the average knife-to-skin time was 15 minutes earlier than non-golden patients during the re-audit. However, when compared to the initial audit the knife-to-skin time had only improved by 3 minutes. Reasons effecting theatre efficiency are multifactorial and other organisational changes had occurred between the audits. This study demonstrates that while the Golden Patient Pathway can improve theatre start times it is not the whole solution. Communication, anaesthetic job plans, portering arrangements, equipment storage and theatre staffing also need to be reviewed.

Background:

Achilles pathology is a serious and frequently occurring problem, especially in elite athletes. Recent research has suggested a role for the plantaris tendon in non-insertional achilles tendinopathy. We report on the outcomes after excision of the plantaris tendon in elite athletes.

Background: Local blocks, as the sole means of anaesthesia, in forefoot surgery have previously been described. This technique is not widely practised in the UK but we have routinely used such blocks for many years. Our aim was to assess how well patients tolerated this technique.

Methods: 64 consecutive day cases of fore-foot surgery were recruited prospectively for local anaesthetic block. A range of operations were performed including basal osteotomy of 1st metatarsal and MTPJ arthrodesis. No patients declined to be included. Peripheral nerve blockade was performed by the orthopaedic surgeon or his registrar. Efficacy of block was assessed intra-operatively with a visual analogue score (VAS) of 0 to 10 (10 being worst pain imaginable and 0 being no pain). Overall satisfaction with the anaesthetic procedure was assessed on a 5 point scale (from 1 = very unsatisfied to 5 = very satisfied) at 2 weeks.

Results: Average time to perform the block was 6 minutes (range 3 to 12 mins). Mean VAS for knife to skin was 0.38 (95% confidence ± 0.31) and for ankle tourniquet was 1.44 (95% confidence ± 0.51). At follow up mean satisfaction at 2 weeks was 4.2 out of 5 (95% confidence ± 0.30) with only 9 patients lost to follow up (86% of patients followed up). No complications were reported.

Conclusion: Our experience is that these blocks are quick and easy to perform in the hands of orthopaedic surgeons. They are well tolerated and effective. They result in a considerable cost saving in terms of theatre efficiency and anaesthetist and ODP resources. These savings are still being evaluated.

We conducted a prospective randomised controlled trial to compare the standard Ponseti plaster method with an accelerated method for the treatment of idiopathic congenital talipes equinovarus. The standard weekly plaster-change method was accelerated to three times per week. We hypothesised that both methods would be equally effective in achieving correction. A total of 40 consecutive patients (61 feet) were entered into the trial. The initial median Pirani score was 5.5 (95% confidence interval 4.5 to 6.0) in the accelerated group and 5.0 (95% confidence interval 4.0 to 5.0) in the standard control group. The scores decreased by an average 4.5 in the accelerated group and 4.0 in the control group. There was no significant difference in the final Pirani score between the two groups (chi-squared test, p = 0.308). The median number of treatment days in plaster was 16 in the accelerated group and 42 in the control group (p < 0.001). Of the 19 patients in the accelerated group, three required plaster treatment for more than 21 days and were then assigned to the standard control method. Of the 40 patients, 36 were followed for a minimum of six months.

These results suggest that comparable outcomes can be achieved with an accelerated Ponseti method. The ability to complete all necessary manipulations within a three-week period facilitates treatment where patients have to travel long distances.

Background: Guidelines for the management of Low Back Pain (LBP) consistently recommend that initial assessment should focus on the detection of serious spinal pathologies. In 1994 the UK Clinical Standards Advisory Group introduced the concept of “red flags”. One flag is the presentation of back pain in people under the age of 20. LBP in children is common, with an annual and lifetime prevalence of around 30%. Because many cases of benign and malignant spinal tumours and spinal infection have been documented in this age group, young people with LBP who are referred to secondary care are investigated by MRI.

Purpose: The purpose of this study is to review the incidence of tumour and infection in subjects under age 20, who present to secondary care with LBP, but do not have concerning objective findings such as neurology, fever, acute deformity or scoliosis.

Method/Results: A retrospective analysis of the MRI database, at a specialist orthopaedic hospital, from 1994 until 2005 identified 403 limited MRI’s taken in LBP patients under the age of 20. Analysis revealed 2 radiological reports of spinal tumour, 1 ependymoma and 1 osteoid osteoma and no cases of spinal infection. Histology confirmed pathology in the ependymoma but excluded serious pathology in the osteoid oste-oma. Other MRI findings, included minor degenerative change (17%), pars defect (9%) and disc prolapse (4%). Therefore, over an 11 year period only 0.25% of young people with LBP who underwent limited MRI were found to have serious pathology.

Conclusion: In conclusion, LBP is relatively common in people under the age of 20 and can be severe enough to warrant secondary care referral. However, in the absence of other objective findings, serious pathologies such as cancer and infection remain rare. These results support the use of limited MRI for screening. However, further research into the clinical value of “under 20” as an independent red flag is recommended.

Primary care trusts (PCTs) are encouraged to create musculoskeletal services to improve access and reduce pressure on orthopaedic clinics. Previous reports have suggested problems can arise.

A PCT with a population of 100,000 launched a musculoskeletal service in July 2004. The foot and ankle component was in partnership with the local secondary care foot team. Treatment and referral guidelines were agreed. The PCT staff reviewed GP referrals to orthopaedic clinics. They could forward letters to the acute trust orthopaedic department or initially treat the patients in primary care.

We audited referrals from October-December 2004, allowing 3 months to establish the service and 6 months follow-up.

617 orthopaedic referrals were received, including 123 (19.9%) adult foot and ankle problems. 82 patients were treated initially in primary care: 54 by the podiatrist, 20 by the physiotherapist and 8 by the specialist GP. Commonest problems were metatarsalgia (12), hallux valgus (10), Achilles tendonopathy (9), plantar heel pain (9), generalised foot pain (8) and arthritis (6). The commonest intervention was attendance at a physiotherapy programme (26) followed by advice (22), usually about shoewear, insoles (14) and injections (8). Ten patients were referred to secondary care after initial treatment in the community, all in accordance with guidelines; four were listed for surgery. Four patients failed to attend and information was missing on six.

31 referrals were sent directly to secondary care, 29 of which were according to guidelines. 9 were offered surgery, 9 had other specialist care, 6 required services which could not be accessed directly by the PCT team and 3 failed to attend.

Primary and secondary care can work together successfully to deliver services for patients with foot and ankle problems, though waiting time remains a challenge.