The purpose of this study is to assess the improvement in pain and function of the ankle when arthrodiastasis is used for end stage juvenile idiopathic arthritis [JIA] in the paediatric population.

All patients treated with ankle arthrodiastasis, 2009–2013 were studied. Clinical, radiological and survivorship data were examined. The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) and Parents (OxAFQ-P), along with the American Orthopaedic Foot and Ankle Society (AOFAS) Clinical rating system for Ankle-Hindfoot were recorded pre-operatively and at 6 months.

Eight patients (9 ankles) with severe tibiotalar JIA, refractory to medical management were treated. Average age at surgery was 14.5 years (range 8–19). Average length of arthrodiastasis was 3.5 months. Length of follow-up averaged 13 months (range 5–28 months).

All scores showed an improvement at 6 months. OxAFQ-C scores (out of 60) improved on average from 23 to 43. OxAFQ-P scores also improved from19 to 39. The largest improvement was found for the physical subsection. AOFAS Ankle-Hindfoot score (out of 100) averaged 34 pre-op and 74 at 6 months. Pain scored out of 10 decreased from an average of 7.4 to 4.3 at 6 months. All patients and parents were satisfied with the surgery and would have the procedure performed again.

Radiological studies demonstrated cartilage regeneration, joint restoration and deformity correction with arthrodiastasis. Survivorship was good (75%) at 36 months, but 2 patients (3 ankles) had subsequent surgery in the adult sector for progression of disease despite initial improvement following arthrodiastasis.

This case series demonstrates the efficacy of ankle arthrodiastasis as a surgical option in severe end-stage ankle inflammatory arthritis in paediatric patients in the short to midterm. It improved functional scores and pain scores which should delay the need for more radical joint fusion or replacement procedures in this challenging surgical condition.

AIM

To evaluate patient outcomes in surgically managed ankle fractures with respect to fracture pattern, timing of surgery and length of stay.

Background: Arthroscopic menisectomy is one of the most commonly performed procedures in the NHS, yet there is no recent review of contemporary knee arthroscopy for meniscal tears or comparisons of tear morphology and clinical findings. We aim to address this problem with a large, prospective longitudinal study.

Aims: The aims of this study were to examine the anatomical location and morphology of meniscal tears encountered at arthroscopy and to correlate this to the clinical findings.

Method: Data on 775 consecutive patients undergoing knee arthroscopy by a single surgeon between 1994 and 2004 was prospectively collected. Clinical data included age, sex, history of trauma, joint line tenderness and presence of an effusion. Meniscal tears were arthroscopically classified by site (medial/lateral, anterior/middle/posterior) and type (flap, horizontal cleavage, bucket-handle, radial, degenerative and other).

Results: Data was complete for 724 patients (517 male and 207 female [m:f 2.5:1]). The mean age was 48 years (range 10 to 87 years). Mean duration of symptoms was 8 months.

54% of meniscal tears were medial, 12% lateral and 10% bilateral. Patients with a lateral tear were significantly younger (45 Vs 51 yrs, p< 0.001).

The most common type of medial tear was a flap tear (34%), followed by horizontal cleavage tears [HCT] (18%). The posterior 1/3 is the most common position. Laterally the tear morphology shows HCT comprising 25% and degenerative tears 17%, with the most common position a middle 1/3 tear. Lateral tears are more common in females (p< 0.05)

Patients with bucket handle tears were significantly younger (41 Vs 53yrs, p< 0.001) and more likely to have a history of trauma (p< 0.001). Medial joint line tenderness was the most sensitive test (79%) and had the highest positive predictive value (81%). McMurry’s test is the most specific for both medial and lateral tears (90%) but is not sensitive. Medial meniscal tears are more accurately diagnosed clinically than lateral (79% Vs 50%).

Conclusion: Meniscal tears are a common pathology, particularly on the medial side. Morphology and position of tears vary as to which side the tear is. Clinical details can help determine the type of tear found with clinical examination being more accurate for medial meniscal tears.

Aims: To assess whether patients undergoing one or two level open decompression of their lumbar spinal stenosis could have an interspinous device inserted with equal or less risk of complications and whether patient satisfaction is improved.

Background: The reported incidence of lumbar spinal stenosis [LSS] varies [1.7% to 8%], as do the results of open surgical decompression. Implanting interspinous devices [ID] to relieve symptoms of LSS is a newer concept which has good short term results.

Patients: Data was collected from 48 consecutive patients undergoing one or two level decompressions for symptoms of lumbar spinal stenosis from February 2008 to March 2009.

Methods: Retrospective case note analysis of clinic letters, operation notes and inpatient stays was carried out. Two types of interspinous device (BacJac and X-stop) were used and the results have been collated.

Results: 29 open decompressions [22 one level, 7 two level] were performed compared to 19 interspinous device insertions [7 one level, 9 two level]. Surgery was performed for patients with leg pain although 27 patients had concomitant back pain.

The average age of the patients for open decompression (63yrs +/− 11) compared to interspinous device (63yrs +/− 9) was equal. Male to female ratio for Open Vs ID [1.4:1 Vs 1.1:1] did not differ significantly (p = 0.39). The ASA grades were higher for the interspinous device group with an average of 2.5 compared to 2.1 in the open group.

The length of anaesthetic was on average shorter for the interspinous devices, which included a higher proportion of 2 level decompressions. The average length of stay on average was identical at 1.3 days, complications were similar [5% Vs 7%] with patient satisfaction higher [81% Vs 68%], although statistically insignificant [p=0.79]

Conclusion: There are certain criteria advised by the American Academy of Orthopaedic Surgeons to aid in selection of suitable patients for interspinous device insertion. 10 of the 29 patients for open decompression fitted these criteria.

Interspinous device insertion is a less invasive procedure and can be carried out on patients with a higher anaesthetic risk, even being performed under sedation. It should be considered for patients with symptoms of LSS instead of open decompression as there is no effect on length of stay or complication rate and there is a trend toward a decrease in anaesthetic time with improved patient satisfaction in the short term.

Purpose: After surgeons at a regional centre for orthopaedics began to use a simplified version of multimodal analgesia protocol in total knee arthroplasty (TKA), using intra-operative periarticular infiltration of bupivacaine and epinephrine, it was decided to review which methods of anaesthesia and analgesia were being used in the unit and how effective these were in terms of postoperative analgesic requirements and patient mobility.

Methods: A retrospective casenote review was conducted of 67 consecutive patients undergoing primary TKA. Data were collected in the areas of demographics, anaesthetic analgesia, mobility and length of stay.

Results: Of 67 patients, 31 received periarticular local anaesthetic, 23 underwent femoral nerve block and 13 had neither. Patients who had the periarticular injection required significantly less morphine. In addition, length of stay was shorter and mobility was achieved sooner in these patients.

Discussion: Our technique of periarticular injection is the simplest to be described to date, using injection of bupivacaine and epinephrine alone. Unlike most previous studies, we have shown a significant improvement in postoperative mobility and a reduction in length of hospital stay, as well as confirming previous findings of a reduction in the use of opioids. This study also confirms the efficacy of bupivacaine in periarticular injections, as most previous trials have used ropivacaine, and shows that the technique is practical for use in an NHS orthopaedic unit.

Conclusion: This study has described the use of a simple technique of analgesia by periarticular injection, which has reduced the amount of opiate analgesia required postoperatively, as well as showing benefits in mobility and length of hospital stay.