Aim

To determine the influence of tendo achilles (TA) rupture gap distance and location on clinical outcome managed with accelerated functional rehabilitation.

Introduction

We performed a longitudinal outcome study involving the operative management of ankle fractures at two university teaching hospitals. This was a retrospective review of the quality of reduction and a prospective study into the functional outcome.

Introduction

Venous thromboembolism (VTE) is an uncommon complication of foot and ankle surgery but has the potential for significant morbidity and mortality. The incidence, risk factors and prevention of VTE in foot and ankle surgery is not clear.

Introduction

Major ankle and hindfoot surgery has traditionally been performed as an inpatient. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to contemplate performing major ankle and hindfoot operations as a day-case. This could have a significant impact on length of stay for these major cases, saving resources and in keeping with government policy.

In this study, we prospectively audited the outcome of the first cohort of patients undergoing major ankle and hindfoot surgery as a day-case against a series of standards.

We present the results of 90 consecutive children with displaced fractures of the forearm treated by elastic stable intramedullary nailing with a mean follow-up of 6.6 months (2.0 to 17.6). Eight (9%) had open fractures and 77 (86%) had sustained a fracture of both bones. The operations were performed by orthopaedic trainees in 78 patients (86%). All fractures healed at a mean of 2.9 months (1.1 to 8.7). There was one case of delayed union of an ulnar fracture. An excellent or good functional outcome was achieved in 76 patients (84%). There was no statistical difference detected when the grade of operating surgeon, age of the patient and the diaphyseal level of the fracture were correlated with the outcome. A limited open reduction was required in 40 fractures (44%).

Complications included seven cases of problematic wounds, two transient palsies of the superficial radial nerve and one case each of malunion and a post-operative compartment syndrome. At final follow-up, all children were pain-free and without limitation of sport and play activities.

Our findings indicate that the functional outcome following paediatric fractures of the forearm treated by elastic stable intramedullary nailing is good, without the need for anatomical restoration of the radial bow.

We performed a systematic review of the optimal management of septic arthritis in children as recommended in the current English literature using MEDLINE, EMBASE, CINAHL, the Cochrane Library and reference lists of retrieved articles without date restrictions up to 31 January 2009. From 2236 citations, 227 relevant full-text articles were screened in detail; 154 papers fulfilled the inclusion criteria, from which conclusions were drawn on the management of infected joints in children.

Our review showed that no single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively joint infection. The roles of aspiration, arthrotomy and arthroscopy in treatment are not clear cut, and the ideal duration of antibiotic therapy is not yet fully defined. These issues are discussed. Further large-scale, multi-centre studies are needed to delineate the optimal management of paediatric septic arthritis.

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.

We describe a case of lumbosacral plexopathy caused by an isolated aneurysm of the common iliac artery. The patient presented with worsening low back pain, progressive numbness and weakness of the right leg in the L2-L4 distribution. This had previously been diagnosed as sciatica. A CT scan showed an aneurysm of the right common iliac artery which measured 8 cm in diameter. Despite being listed for emergency endovascular stenting, the aneurysm ruptured and the patient died.

It is important to distinguish a lumbosacral plexopathy from sciatica and to bear in mind its treatable causes which include aneurysms of the common and internal iliac arteries.

Study Design: Prospective study with a 2-year follow-up.

Background: Intradiscal electrothermal therapy (IDET) was developed as an intermediate stage between conservative measures (analgesia, physiotherapy and injections) and radical surgery (fusion and disc replacement) for the treatment of internal disc disruption (IDD). Recent reports have questioned the efficacy and safety of this treatment.

Objective: To assess the long-term outcome of patients with discogenic low back pain (≥ 6 months duration) treated with IDET who had previously failed to improve with nonoperative treatment

Methods: Forty patients with IDD determined by pre-operative provocative discography and MRI were treated with IDET. VAS pain scores, SF-36 scores, analgesic usage and sitting tolerance (mins) were collected pre-treatment and at 12 and 24 months. Subsequent treatments were recorded. The differences in the outcome scores were tested by Wilcoxon signed rank tests.

Results: Average age was 46 years (range 25–62 years) with 44% males and 56% females. No significant improvement was seen in pain intensity as measured by VAS and bodily pain SF-36 scores pre treatment and at 12 and 24 months post IDET. There were no significant differences in the remaining SF-36 subscales. Only 11% used less pain medication. Sitting tolerance improved between pre and 1-year post IDET, the difference was not significant. Eight (20%) patients underwent further surgery; 5 disc replacement and 3 fusions at 1-year post treatment.

Conclusion: The patients with IDD did not show any improvement at 1-year or 2-year post IDET. A significant proportion of patients required further surgery. We believe that the efficacy of IDET is doubtful.

Study design: Prospective cohort study.

Objective: To investigate association between recovery from low back pain (LBP) and body mass index (BMI) in patients with LBP undergoing physiotherapy.

Introduction: The relationship between obesity and LBP has long been debated. There are no published studies examining the influence of BMI on recovery from LBP.

Methods: One hundred and forty patients with chronic LBP and no neurological deficit underwent a back-specific physiotherapy programme. BMI and recovery parameters such as pain intensity (visual analogue scale scores), and self-experienced impairment and disability scores were measured. The range of motion of the lumber spine was also recorded. These variables were compared pre and post treatment. Statistical analysis was performed using paired t tests, Spearman’s rank correlation coefficients and ANCOVA.

Results: Mean age was 38 years (range 18–67) with 62% males and 38% females. The treatment resulted in significant improvements in all the recovery parameters (P < 0.005, paired t test). No significant association was detected between the BMI of subjects and % changes in pain intensity, self-experienced impairment and disability, and range of motion of the lumbar spine. A comparative analysis of the after treatment recovery parameter scores in normal (BMI ≤24.9), overweight (BMI 25–29.9) and obese (BMI ≥ 30) revealed no significant differences in the mean pain intensity and mean self-experienced impairment and disability scores.

Conclusion: Although a BMI within normal range is desirable for prevention of many health conditions including LBP, it does not influence the overall recovery from low back pain in patients undergoing physiotherapy treatment.

Study Design: Prospective longitudinal study with a 2-year follow-up.

Background: Intradiscal electrothermal therapy (IDET) was introduced to bridge the gap between conservative measures (analgesia, physiotherapy and standard injection therapy) and radical surgery (disc replacement and fusion) for the treatment of internal disc disruption (IDD). Recent reports have questioned the efficacy and safety of this so called less invasive treatment technology.

Objective: To assess the long-term outcome of patients with chronic discogenic low back pain (< 6 months duration) treated with IDET who had previously failed to improve with comprehensive nonoperative treatment.

Methods: Forty patients with IDD determined by provocative discography and pre-operative MRI were treated with IDET. VAS pain scores, SF-36 scores, analgesic usage and sitting tolerance times (mins) were collected pre-treatment and at 12 and 24 months. Subsequent treatments were recorded. Statistical analysis was performed using Wilcoxon signed rank tests to test for differences in the outcome parameter scores.

Results: Average age was 46 years (range 25–62 years) with 44% males and 56% females. The study group demonstrated no significant improvement in pain intensity as measured by VAS and bodily pain SF-36 scores pre treatment and at 12 and 24 months post IDET. There were no significant differences in the remaining SF-36 subscale scores at 0, 12 and 24 months after treatment. Analgesia requirement remained the same in 77% of the patients; 12% required stronger analgesia and only 11% used less pain medication. Although sitting tolerance improved between pre and 1-year post IDET, the difference was not significant. Eight (20%) patients underwent further surgery in the form of a disc replacement or fusion at 1-year post treatment.

Conclusion: The patients with chronic discogenic low back pain in this study did not show any improvement at 1-year or 2-year post IDET treatment. A significant proportion of patients underwent further surgery for persisting low back pain. We believe that the efficacy of IDET in the treatment of chronic discogenic low back pain is doubtful.

Although supracondylar fracture is a very common elbow injury in childhood, there is no consensus on the timing of surgery, approach for open reduction and positioning of fixation wires. We report our ten-year experience between 1993 and 2003 in 291 children.

Most fractures (285; 98%) were extension injuries, mainly Gartland types II (73; 25%) and III (163; 56%). Six (2%) were open fractures and a neurovascular deficit was seen in 12 (4%) patients. Of the 236 children (81%) who required an operation, 181 (77%) were taken to theatre on the day of admission. Most (177; 75%) of the operations were performed by specialist registrars. Fixation was by crossed Kirschner wires in 158 of 186 (85%) patients and open reduction was necessary in 52 (22%).

A post-operative neurological deficit was seen in nine patients (4%) and three (1%) required exploration of the ulnar nerve. Only 22 (4%) patients had a long-term deformity, nine (3%) from malreduction and three (1%) because of growth arrest, but corrective surgery for functional limitation was required in only three (1%) patients.