Introduction

The aim of this study was to compare the results and length of stay of patients of early (within 12 hours) versus conventional (after 48 hours) ankle fixation our hospital.

Ankle fractures are common injuries affecting all age groups and constitute a large proportion of the orthopaedic trauma caseload. Frequently a large number of bed days are utilized waiting for swelling to subside and a theatre slot to become available. We audited current practice and then implemented a home therapy program (HTP). If HTP criteria were met then patients with reduced, unstable ankle fractures were taught how to use crutches and allowed home from the emergency department in order to ice and elevate at home. They were then admitted from clinic for surgery the same day and then discharged when safe and comfortable.

The purpose of this study was to prospectively compare the local management of surgically stabilised ankle fractures before and after instigating a home therapy program.

43 consecutive patients met our inclusion criteria and underwent surgical fixation of unstable ankle fractures over a three month period (February to April 2008.) The average length of hospital stay was 8 days (1–18), 4.5 days pre-operatively and 3.5 days post operatively.

Forty-eight patients underwent surgical fixation of unstable ankle fractures over a four month period (November 2008 to February 2009.) Twenty-one met the home therapy criteria. The average length of hospital stay was reduced to three days, 1.6 days pre-operatively and 1.3 days post operatively. Additionally a patient survey revealed high levels of satisfaction with the HTP.

The home therapy program has effectively reduced hospital stay both pre and post-operatively. Patients mobilising at home pre-operatively mobilise earlier post-operatively and are discharged home earlier. Over the three-month period of HTP, 131 bed days were saved which equates to a saving of £30,000.

Purpose: The aim of this study was to compare the results and length of stay of patients of early ankle fracture fixation with conventional fixation in a busy District General Hospital in UK.

Method: A retrospective study was conducted using data from case records, electronic patient record, clinical coding information, clinic letters and Picture Archiving and Communications System (PACS). Two hundred patients who underwent ankle fracture fixation from July 2004 to June 2005 were included. We looked into age, place of living, Weber classification, mechanism of injury, comorbidities especially diabetes and peripheral vascular disease, addictions mainly smoking, whether patient was anticoagulated, delay for theatre with reasons, length of stay in hospital and complications if any. Other things to looked at were, overlying skin condition, the amount of swelling at the time of presentation to A& E, associated ankle dislocation or talar shift needing reduction, injury types-open or closed or with associated neuro-vascular injury. In-operative management – what method was used ie malleolar screws, diastasis screw, fibular plating, calcaneotalotibial nail or external fixater etc.

Results: In the 12-month retrospective review, there were 200 ankle fractures that required surgical intervention. Only twenty-two of these had surgery within 12 hours (mean length of stay, 3.3 days), and sixty-seven of these had surgery within 48 hours (mean length of stay, 4.9 days), and 111 had surgery after 48 hours (mean length of stay, 9.4 days). Finally we calculated the cost (784 bed days – £235 thousands) incurred to the trust in terms of extra bed occupancy and treating the complications as a result of wait.

Conclusion: This study shows that early operative intervention for ankle fractures reduces the length of hospital stay. Intensive physiotherapy and co-ordinated discharge planning are also essential ingredients for early discharge. We want to emphasise on the ‘Window of Opportunity’ ie initial 12 hours to fix ankle fractures to decrease overall morbidity and cost.

Spinal pathologies requiring spinal/neurospinal unit’s input/opinion from tertiary centres for their management are initially admitted to DGHs. The referral is made by mailing radiographs with clinical details to the on-call registrar who gets back with a management plan. This arrangement is fraught with delays at various levels having an impact on patient care, financial and medico-legal implications. We discuss these issues between index DGH (Poole General Hospital) and its tertiary referral centres.

To review the existing management of spinal injury admissions at our hospital, analyse critical/adverse incidents and to identify areas for improving patient care.

A comprehensive retrospective review of all spinal admissions/referrals made to tertiary centres over 6 months was undertaken. Twenty eight of the 64 admissions warranted referrals. A structured proforma was used to document the time of admission, time of booking and performing scans, time of referral & response from tertiary centre and time of transfer from hospital notes and delays at each level were critically analysed.

Seven of the 28 referrals had either neurodeficit or spinal instability. Common issues were delay in obtaining CT/MRI scans (av 2.5 days), delay due to reporting/failing to act on results (av 1.8 days), delays due to missing/lost in transit’ scans (av 1.5 day), delay in obtaining opinion (av 4 days) and non-availability of bed for transfer (av 5.5 days). There was 1 mortality and 5 other complications while awaiting transfer. The financial costs incurred were approximately £73,000 & loss of 246 patient-days.

Training on induction day, implementation of spinal care pathway and diligent documentation/communication coupled with succinct referral were strictly enforced following this study. The website www.neurorefer.co.uk was set up by Wessex neurological centre to streamline referrals and enhance efficiency. This website has now grown into a national secure referral portal incorporating other referral centres.

Our aim was to determine the prevalence of shoulder symptoms in patients with type I compared to type 2 diabetes mellitus and evaluate the clinical presentation of patients diagnosed with adhesive capsulitis. This was a retrospective case-note review of 164 diabetic patients treated for shoulder symptoms from 1996 to 2007. Diabeta 3 for relevant Diabetic data. We used ANOVA, Tukey HSD, Chi-Square and Fisher’s Exact tests.

The incidence of treated shoulder patients in diabetic population: 1.04%. 86 males; 78 females. Average age 58 years (22 – 83). DM Type I 34% (46/136); Type II 66% (90/136). Mean duration of DM at presentation: 10 years (1–33). Mean HbA1c at presentation 8.3%. Retinopathy 16% (19/90); Neuropathy 12% (12/88).

The diagnoses were: Impingement 101 (62%); Adhesive Capsulitis 35 (21%); Cuff tear 17 (10%); Arthritis 11 (7%).

Mean recorded pre-treatment ROM: Impingement (flexion 117°, abduction 103°, ER 36°); Adhesive Capsulitis (flexion 90°, abduction 75°, ER 12°); Cuff tear (flexion 109°, abduction 95°, ER 45°); Arthritis (flexion 67°, abduction 93°, ER 18°).

Adhesive Capsulitis was significantly related to: HbA1c (9.9%); p< 0.001, Type I DM; p< 0.003, Duration of DM (average 17.5 yrs); p< 0.03.

An interesting statistically significant (p< 0.003) correlation was found between Type 2 DM and Impingement Syndrome.

Treatments included: Injection (53), MUA (49), Arthroscopy (99), Open Surgery (56). 82% patients satisfactorily discharged (mild/no pain and improved ROM: flexion > 150°, abduction > 150° and ER > 50°) after an average 3.4 months. Three referred to pain clinic, sixteen patients didn’t attend their follow-up appointment and seven died. Eleven relapsed (eight adhesive capsulitis).

Persistent symptoms were more common in Diabetic patients with adhesive capsulitis, which was found to be significantly related to Type I DM, its duration and control (HbA1c levels). Type II Diabetics are more likely to be affected with impingement syndrome. Close liaison with the Diabetology Department is essential for effective treatment of Diabetic Shoulder pathology.

Purpose: To review the existing coding for knee surgery and ascertain its appropriateness & accuracy for surgical procedures, associated co-morbidities and complications.

Methods: A retrospective review of 100 consecutive knee surgeries (50 arthroplasties and 50 arthroscopies) performed between July-August 2007 was undertaken. The coding data excel sheet and comprehensive hospital records were analysed.

Results: The accuracy of primary procedural codes was 100% & 88% respectively for arthroplasty & arthroscopy. However this respectively fell down to 56 & 60% when the accuracy for entire description of surgical procedure was taken into consideration. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility esp. for arthroscopies. In arthroplasties, patients had similar codes irrespective of whether they had patellar resurfacing or not. Co-morbidities were coded appropriately in 24% of arthroplasty & 36% of arthroscopy patients. The common co-morbidities missed were drug allergies, hypercholesterolemia, heart conditions (IHD, MI, AF, valvular pathologies) and h/o malignancy & deep vein thrombosis. Post-op adverse events were coded in only 2/5 arthroplasties (40%) and 0/3 arthroscopies (0%) respectively.

Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for reimbursement but also for data quality and audit. Coding database also serves as a powerful research tool. The financial implications with respect to generation of appropriate reimbursement i.e. healthcare resource group (HRG) codes (which are dictated by official population and census survey procedural [OPCS4.4] & international classification of diseases [ICD–10] co-morbidity codes) are discussed. The limitations of the existing coding system are highlighted and discussed. Literature emphasizes on the qualification of coders, legible & comprehensive documentation of surgeries & co-morbidities by treating physicians and regular interaction between coders and clinicians. Reimbursement for arthroscopy is less in the NHS unlike in BUPA where it is on par with open surgeries.

Introduction: Spinal pathologies requiring spinal/neurospinal unit’s input/opinion from tertiary centers for their management are initially admitted to DGHs. The referral is usually done by mailing patient’s x-rays/scans with clinical details to the on-call registrar who gets back with a management plan. This arrangement is fraught with delays at various levels having an impact on patient care, mortality & morbidity, financial and medicolegal implications. We discuss these issues between index DGH (Poole Gen Hosp, Dorset) and its tertiary referral centers (Southampton/Reading/Bristol/Oxford/Stanmore).

Objectives: To review the existing management of spinal injury admissions at Poole DGH, analyse critical/ adverse incidents and efforts aimed at minimising them, to identify areas for improving patient care & safety and to draft a regional management protocol/care pathway for spinal admissions.

Methods: A comprehensive retrospective review of all spinal admissions/referrals made to tertiary centers over 6 months (Jan–June 05) was undertaken. 28 of the 64 admissions warranted referrals. A structured proforma was used to document the time of admission, time of formulating clinical diagnosis, time of booking scans, time of performing scans, time of referral to tertiary centre, time of response from tertiary centre and time of transfer were retrieved from case notes and reasons for delay (if any) at each level were critically analysed.

Results: 7 of the 28 referrals had either neurodeficit or spinal instability. Common reasons for delay were delay in obtaining CT/MRI scans (av 2.5 days), delay due to reporting/failing to act on scan results (av 1 day), delays due to missing/‘lost in transit’ scans (av 1.5 day), delay in obtaining opinion from tertiary centre (av 4 days) and non-availability of bed for transfer (av 5.5 days). There was 1 mortality and 5 other complications while awaiting transfer. The financial costs incurred were appx £73,000 & loss of 246 patient-days.

Discussion: Training of junior doctors at induction, implementation of spinal care pathway and diligent documentation/communication coupled with succinct referral to the tertiary centre were strictly enforced following this study. The website www.neurorefer.co.uk was set up by Wessex neurological centre, Southampton to streamline referrals, circumvent lost in transit scans and enhance efficiency which has now grown into a national secure referral portal incorporating other referral centers.

The inhibition of neural input by infiltration of local anaesthetic around the operation site prior to the trauma of an operation may reduce subsequent pain post-operatively. Prevention of the normal phenomenon of central and peripheral sensitisation in the nervous system stops the post operative hypersensitivity state that manifests as a decrease in the pain threshold at the site of injury. The underlying clinical principle is for therapeutic intervention to be made in advance of the pain rather than as a reaction to it ¹. We performed a prospective double blind randomised clinical trial to measure the effect of pre operative infiltration of local anaesthetic around arthroscopy wounds compared to post-operative infiltration on post operative pain relief.

Thirty six patients undergoing day case unilateral knee arthroscopy between October 2000 and March 2001 were studied. All patients gave written informed consent. They were randomised into 2 groups using block randomisation to ensure equal group sizes. The sealed envelope technique was used. The pre-operative group had 10ml 0.25% bupivicaine infiltrated around the arthroscopy portal site following induction of general anaesthesia (G.A.), the post-operative group received 10ml 0.25% bupivicaine after the procedure but before reversal of the G.A. The injection technique and G.A. used were standardised. Pain was assessed using a 10cm Visual Analogue Score (VAS) at pre-operative, 1, 2 and 24h post-operative. At each assessment the patients were blinded to the previous scores that they had submitted. Oral analgesic use in the post-operative 24 hours was also recorded.

There were 18 patients in each group. Demographic details did not differ between the 2 groups. One patient in the post-operative group was excluded, as intravenous sedation was required in recovery due to an extreme anxiety state. The mean Visual Acuity Pain Scores (VAS) were lower in the post-operative group (1.3) compared to the pre-operative group (1.58) at pre-operative assessment. However this difference was not statistically significant (p =0.5607). At 1h post op the mean VAS in the post op group was 1.58 and in the pre op group 2.59 (p =0.18). The mean VAS at 2h post op in the pre op group was 1.76 compared to 1.82 in the post op group (p =0.9932).

At 24h the pre op group had a lower mean VAS (2.25) than the post op group (2.4). This difference was however not statistically significant (p =0.7418).

Analysis of the postoperative analgesia requirement in both groups failed to reveal a statistically significant difference (p =0.3965). In day case knee arthroscopy under general anaesthesia there is no beneficial role in the use of pre-emptive local anaesthetic infiltration around the arthroscopy portal sites as compared to post-operative infiltration.

Introduction: We performed a prospective double blind randomised clinical trial to measure the effect of pre-operative infiltration of local anaesthetic around arthroscopy wounds compared to post-operative infiltration on post operative pain relief. The underlying clinical principle is for therapeutic intervention to be made in advance of the pain rather than as a reaction to it.

Methods: 36 patients undergoing daycase unilateral knee arthroscopy between October 2000 and March 2001 were studied. The pre-operative group had 10ml 0.25% bupivicaine infiltrated around the arthroscopy portal site following induction of general anaesthesia (G.A.), the postoperative group received 10ml 0.25% bupivicaine after the procedure but before reversal of the G.A. Pain was assessed using a 10cm Visual Analogue Score (VAS) at pre-operative, 1, 2 and 24 hours post operative. At each assessment the patients were blinded to the previous scores that they had submitted. Oral analgesic use in the post-operative 24 hours was also recorded.

Results: There were 18 patients in each group. The mean Visual Analogue Pain Scores (VAS) were lower in the post-op group (1.3) compared to the pre-op group (1.58) at pre-operative assessment. However this difference was not statistically significant (p=0.5607).

At 1 hour post-op the mean VAS in the post-op group was 1.58 and in the pre-op group 2.59. This difference was not statistically significant (p=0.18).

The mean VAS at 2 hours post-op in the pre-op, group was 1.76 compared to 1.82 in the post-op group. This difference was not statistically significant (p=0.9932).

At 24 hours the pre-op group had a lower mean VAS (2.25) than the post-op group (2.4). This difference was however not statistically significant (p=0.7418).

Analysis of the post-operative analgesia requirement in both groups failed no reveal a statistically significant difference (p=0.3965).

Conclusion: In daycase knee arthroscopy under general anaesthesia there is no beneficial role in the use of pre-emptive local anaesthetic infiltration around the arthroscopy portal sites as compared to post-operative infiltration.

There has been speculation as to whether the outcome of revision total knee arthroplasty (TKA) is as successful as primary TKA. The purpose of this study was to assess patient outcomes following revision TKA and compare them to patient outcomes following primary TKA.

This study collected data prospectively from patients operated upon by one surgeon using one prosthesis in each group. Patients completed SF12 and WOMAC questionnaires pre-operatively and at six and twelve months post-operatively. In the primary TKA group there were 84 patients. In the revision TKA group there were 60 patients. Statistical analysis was performed using paired and unpaired t-tests.

Results showed that the improvements in SF12 physical scores and WOMAC pain, stiffness and function scores in both primary TKA and revision TKA patients were statistically significant (p < 0.0001). There was no significant difference in the magnitude of the improvement in SF12 physical (p = 0.7145) and WOMAC pain (p = 0.0902), stiffness (p = 0.1557) and function (p = 0.3152) scores between the primary and revision patients following surgery.

The mental scores of patients in both groups showed no significant difference following surgery (Primary p = 0.823, Revision p = 0.7095).

The findings show that primary and revision TKA lead to a comparable improvement in patient perceived outcomes of physical health parameters.

However, there is no significant improvement in patient perception of mental health.

Aim: The aim of this study was to evaluate the results of the Co-ordinate revision knee prosthesis (Depuy Ltd, Johnson and Johnson, Warsaw, In) between 1995–2001.

Methods: One hundred and thirty-three knees (126 patients) undergoing revision total knee replacement between 1995–2001 were followed up prospectively. Surgery was performed by one surgeon (senior author). The patients were scored pre-operatively and postoperatively with SF-12 and WOMAC score. Surgery was performed for aseptic loosening (92%) and infection (8%). The changes in SF-12 physical score and the WOMAC score between pre and post operation were significant (SF-12 p < 0.0018, WOMAC pain p< 0.0001, WOMAC stiffness p< 0.0001, WOMAC Function p< 0.0001)). The prosthesis produced reliable relief of pain and improved range of movement with minimal complications.

Conclusion: This modular knee revision system produced satisfactory results in dealing with bone loss and instability in the medium term.

Shoulder surgery is associated with moderate to severe post-operative pain. A pain free post-operative period is desirable and appreciated by both patients and therapists and is essential for early rehabilitation. Analgesia can be provided either locally or systemically or by combining the two.

A prospective, randomised double blind study was designed to assess the effectiveness of an existing postoperative local analgesic method: using Marcaine through subacromial catheter.

Thirty-nine patients were included in the trial. All patients had simple arthroscopic subacromial decompression and no additional pathology to the shoulder. At the end of the operation a standard epidural catheter was inserted into the subacromial space under visual control. Sixteen patients had 0.25% Bupivacaine and 23 patients had normal Saline given in 10 ml boluses six hourly, until required. All patients had access to conventional pain relief (paracetamol, non-steroids, minor opioids, morphine). VAS scores were taken before and one hour after the study bolus was given. In addition the patients were assessed for quality of sleep, opinion about the analgesia provided by the catheter and VAS of pain prior to and post physiotherapy sessions. The physiotherapist also recorded the active forward flexion of the operated shoulder. The number of doses required and all additional analgesic medication were recorded.

The use of subacromial local anaesthetic provides significantly better pain relief (P=0.029). However, patients with subacromial local anaesthetic