Whereas arthroscopic arthrodesis of the ankle is commonplace and of the subtalar joint is established, reports of arthroscopic talo-navicular fusion are a rarity. To review a case series to establish if arthroscopic talo-navicular arthrodesis is a feasible surgical option.Background
Aim
Disability and slow return to sport and work after tendon rupture are major challenges. Platelet Rich Plasma (PRP) is an autologous supraphysiological concentration of platelets from whole blood that has demonstrated positive cellular and physiological effects on healing in laboratory conditions but evidence from adequately powered robust clinical trials is lacking. We aimed to determine the clinical efficacy of PRP for treatment of acute Achilles tendon rupture. In a placebo-controlled, participant- and assessor-blinded, trial at 19 NHS hospitals we randomly assigned 230 adults starting acute Achilles rupture non-surgical management to PRP injection or dry-needle insertion (placebo) to the rupture gap under local anaesthetic. Patients with confounding or contraindicated concurrent medical conditions were excluded. The primary outcome was muscle-tendon function, assessed by the limb symmetry index (LSI, uninjured limb/injured limb × 100, higher scores better) of the work (Joules) performed during the heel-rise endurance test at 24 weeks. Secondary outcomes were: Achilles Tendon Rupture Score (ATRS, 0–100, higher scores better), quality of life (SF-12), pain, and goal attainment. Trial registration: ISRCTN54992179Background
Methods
This study aimed to examine how physical activity and health-related quality of life (HRQoL) evolved over the first year after total knee replacement (TKR) for patients with and without post-operative chronic knee pain. 83 adults participating in the PEP-TALK, a RCT testing the effectiveness of a behaviour change physiotherapy intervention versus usual rehabilitation post-primary TKR, were analysed. UCLA Activity Score and EQ-5D-5L values for participants with and without chronic knee pain (14 points or lower in the Oxford Knee Score Pain Subscale at six months post-TKR) were compared at six and 12 months post-TKR. We evaluated recovery trajectory those with or without chronic pain at these time points.Abstract
INTRODUCTION
METHODS
Traditional open approaches for subtalar arthrodesis have reported nonunion rates of 5–16% and significant incidence of infection and nerve injury. The rationale for arthroscopic arthrodesis is to limit dissection of the soft tissues in order to preserve blood supply for successful fusion, whilst minimising the risk of soft tissue complications. The aim of this study was to determine the outcomes of sinus tarsi portal subtalar arthrodesis. Case records of all patients undergoing isolated arthroscopic subtalar arthrodesis by two senior surgeons between 2004 and 2014 were examined. All patients were followed up until successful union or revision surgery. The primary outcome measure was successful clinical and radiographic union. Secondary outcome measures included occurrence of infection and nerve injury. Seventy-seven procedures were performed in 74 patients, with successful fusion in 75 (97.4%). One (1.3%) superficial wound infection and one (1.3%) transient sural nerve paraesthesia occurred. Fixation with a single screw provided sufficient stability for successful arthrodesis. To our knowledge this is the largest reported series of isolated arthroscopic subtalar arthrodeses to date, and the first series reporting results of the two portal sinus tarsi approach. This approach allows access for decortication of all three articular facets, and obviates the need for a posterolateral portal, features which may explain the high union rate and low incidence of sural nerve injury in our series.
Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe a purely arthroscopic technique for excising talocalcaneal coalitions. We present a retrospective two-surgeon case series of the first eight patients (nine feet). Subtalar arthroscopy is performed from two standard sinus tarsi portals with the patient in a saggy lateral position. Coalitions are resected with a barrel burr after soft tissue clearance with arthroscopic shavers. Early postoperative mobilisation and non-steroidal anti-inflammatory drugs prevent recurrence of coalition. Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 to 5.5 years.Introduction:
Methods:
In a consecutive series of 71 arthroscopic subtalar arthrodeses performed between 2004 and 2011, 14 also involved arthroscopic decortication of the talonavicular joint (double arthrodesis) and 4 the subtalar, talonavicular and calcaneocuboid joints (triple arthrodeses). We examined complications, union rates in all 18 patients and clinical outcomes in 16 for whom this was the sole procedure.Introduction:
Methods:
Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe an entirely arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet). Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 year to 5.5 years. Subtalar movements were improved in all feet. Deformity was not always fully corrected but pain and SAFAS scores improved in all patients bar one. They all had a rapid return to good function apart from this same patient who required subsequent fusions. The posterior tibial nerve was damaged in one patient. Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from any operative technique. Patient selection and preoperative planning are crucial. This series from two independent surgeons supports the feasibility and effectiveness of this technique.
We report a single surgeon series of 33 arthroscopic subtalar fusions performed through a 2-portal sinus tarsi approach on 32 patients between March 2004 and February 2009. Background pathologies included primary arthrosis, post-traumatic arthritis, planovalgus foot, rheumatoid disease, sinus tarsi syndrome and CTEV. 97% [32/33] of fusions as assessed by both clinical and radiological means were achieved within 16 weeks [76% [25/33] within 12 weeks] with only a single outlier which had fused by 22 weeks. There were no deep infections, thrombotic events or neuromas. Five patients suffered complications of which four were successfully treated with a satisfactory outcome. One patient developed persistent pain and was eventually referred to another centre for further management. In our experience arthroscopic subtalar fusion surgery has been demonstrated to give excellent outcomes with minimal complications. Furthermore, it is a technique allowing surgery even in patients with significant hindfoot deformity. It is a suitable operation even for patients with a compromised soft tissue envelope which would normally preclude an open procedure.
We present the clinical and radiological outcome of a prospective series of 22 Buechel-Pappas Total Ankle Replacements (TAR) implanted in 19 patients with a mean follow-up of 9 years (range 6 to 13). The only published long term results of this prosthesis in the literature are from the originators' unit. Patients have been prospectively reviewed yearly since 1991. None was lost to follow-up. The primary diagnosis was rheumatoid arthritis in 11 and osteoarthritis in 8 patients. 12 patients were female. Mean patient age was 64 (range 39 to 81). At the time of review 4 patients (6 ankles) had died between 12 and 69 months post-operatively of unrelated causes with their prostheses in situ. One patient had a below knee amputation for chronic venous ulceration 11 years after a TAR which until that point had continued to function well. One patient with severe rheumatoid arthritis had the implant removed at 8 weeks for deep infection. Another patient with rheumatoid arthritis had the TAR revised to a tibio-talar-calcaneal fusion 59 months post-operatively for talar avascular necrosis. One patient has pain from impingement and another patient with rheumatoid arthritis has intermittent pain at 8 years following her TAR. Every other implant continues to function well. The New Jersey LCS ankle assessment scores increased from a mean of 35 pre-operatively to 82 post-operatively. The increases were largely due to pain relief and improved function with the pre-operative range of motion being preserved. These scores have been maintained in the long term. No surviving implant is radiologically loose. Our results suggest that the Buechel-Pappas TAR offers good clinical and radiological long-term results to patients with often disabling ankle arthritis
DDH incidence falls from 5–20 per 1000 at birth to 1–2 per 1000 by 3 weeks. Some patients present late and frequently require surgical intervention. If the hip cannot be contained without tension, these children undergo open reduction +/− a femoral shortening, varus and derotation osteotomy. Salter’s osteotomy, may be performed either at index surgery or later in the presence of persisting acetabular dysplasia. Our aim was to see if we could predict which cases of persistent DDH would require both femoral and pelvic surgery to contain the affected hip, using a single plain AP radiograph of the pelvis in the outpatient setting. We performed a retrospective study of all children older than 18 months with persistent DDH of one or both hips, over the last 5 years, who had undergone femoral and/or pelvic surgery to contain the hip. Plain AP pelvic radiographs were standardised according to the method described by Tonnis. From these radiographs the acetabular indices and child’s age in months, were recorded. Syndromic and children with non-standard x-rays were excluded. Thirty nine hips (34 female, 5 male), age range of 18–102 months, formed our study group. 53% of hips having femoral surgery later required pelvic surgery for persisting acetabular dysplasia. Examining the data in these cases, the difference between the acetabular index of the normal and affected hip was always greater than 20 degrees and the child’s age in months. Using this method we conclude that it is possible to predict which cases of persistent DDH will require pelvic surgery to fully contain the affected hip and that this can be done with one AP pelvic radiograph in the outpatient clinic. The benefit is avoidance of unnecessary pelvic osteotomies, and being able to determine the cases which should have a pelvic osteotomy at index procedure.
Open Tibiotalocalcaneal fusion has been shown to be an effective treatment for arthritis and complex foot deformities, but with a high complication rate. We are reporting the results of the first 14 feet undergoing arthroscopic tibiotalocalcaneal arthrodesis.
Arthroscopy of the ankle and subtalar joints are established techniques in foot and ankle surgery. Arthroscopic ankle arthrodesis is well described and is useful in patients with a poor soft tissue envelope. Subtalar fusion is traditionally an open procedure with potentially significant complications but there is little published on arthroscopic subtalar arthrodesis. 22 patients, made up of 9 males and13 females were operated on from March 2004 to present day with 12 to 36 months follow up. Indications for surgery included primary osteoarthritis and degeneration secondary to previous calcaneal fracture, tibialis posterior insufficiency, neurological conditions and previous ankle fusion. 8 Patients had a concurrent arthroscopic ankle fusion and 4 patients also had a talonavicular fusion. All patients had surgery by the senior author and followed the same postoperative course. Patients were protected in plaster for 12 weeks with gradual increase to fully weightbearing at 6 weeks and x-rays taken at 6 and 12 weeks. Successful outcome was taken as clinical and radiological evidence of fusion. 21 patients (95.5%) achieved fusion by 12 weeks. There has been 1 nonunion but there have been no wound breakdowns, deep infections or other serious complications. Previous authors have reported variable complication rates and significant rates of delayed and non-unions following open subtalar fusion. These early results suggest that arthroscopic subtalar fusion is a safe and reliable method with a high success rate and a low complication rate. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.
Patients’ who had consulted both mainstream and CAM practitioners reported the poorest health outcomes (EQ 5D = 0.55), followed by those who consulted just mainstream practitioners (EQ 5D = 0.61), and those who had consulted no one (EQ 5D = 0.72). The best health outcomes were reported amongst those who had just consulted CAM practitioners (EQ 5D =0.78). In multivariate analyses, the most powerful predictors of consulting both mainstream and CAM practitioners were working and having high levels of pain related disability.
We conducted a community survey of the prevalence, health impact and location of chronic pain. We explored the relationship and patterns of chronic pain that commonly occur, with a view to understanding why some treatment approaches may be more appropriate than others for particular patterns of pain. In 2002, 2504 randomly sampled patients from 16 General Practices in the South East of England responded to a postal questionnaire about chronic pain. Those with chronic pain completed a pain drawing. We calculated descriptive statistics, relative risk and correlations to identify the associations and risks of having linked pain. The highest prevalences were low back (23%), shoulder (20%) and knee (18%) pain. The number of pain sites experienced was age related in men but less so in women. Lower body pain was more age related than upper body and non musculoskeletal pain. Multi site pain was more common than single site pain. Of those with low back, knee and shoulder pain, 14%, 4.5 % and 1.9% had only low back, knee and shoulder pain respectively. Correlations and minimum spanning trees showed that chronic upper and lower body pain are distinct and axial pain link the two. Chronic pain is more likely to be multi site, especially at middle age. Research, physical treatments and approaches to managing chronic pain are often site specific, therefore specialising treatment to one area eg low back pain often negates the bigger issue. This may help explain the self perpetuating problem of persistent chronic pain.
A prospective audit was conducted at an associate teaching hospital in the south west to assess the outcome of operative treatment of ankle fractures of all patients over the age of 50 years in the last 2 years. The aim of the study was to assess whether change in timing of surgery for ankle factures in accordance with the CEPOD guidelines has affected the outcome in terms of early complications. This is a follow up paper to the one published from this institution in 1994 (data 1988 to 1989). Since then the CEPOD rules have led to changes in theatre protocols, so very few ankles are fixed out of hours. Over this period there has been the emergence of MRSA which was not a problem in the 1990s. We retrospectively reviewed the notes and x-rays for 107 consecutive patients older than 50 years who had their ankles fixed over a period of 2 years spanning 2003 to 2004. Our series had 12.1% incidence of clinical infections, 15.9% delayed wound healing as compared to 1.8% and 5.2% in previous publication from this institution. In our study 17.7% of ankles were fixed within 24 hours as opposed to 84.2 % in the previous paper. All of the infected wounds (100%) occurred in patients who had their operations 48hrs or more post injury. We also came across 2 cases of MRSA infection in our series. We are concerned that changes in CEPOD rules as well as new hospital practice has resulted in delays in time to fixation. This seems to be the only variable to result in increased infection rates and delays in wound healing leading to increase in hospital stay and reoperations.
Patients who consulted complementary practitioners were more likely to be female, to be psychologically distressed, to work, to have left school aged over 16 and to have severe pain (p<
0.05 in all cases). Working was independently associated with consulting a complementary practitioner (Exp (B) = 2.0, p=0.00)
Explored patient’s or practitioners; beliefs and expectations, or both. Studied patients with chronic musculoskeletal pain, which does not have a known systemic, inflammatory or malignant origin treated in primary or community care. The full review group resolved disagreements. Full text articles meeting the inclusion criteria will be obtained and coded further into non-randomised studies, randomised studies and qualitative studies. Data abstraction forms will be developed for each type of study. Data abstraction will be undertaken by two members of the group working independently.
To determine the most powerful predictors of consultation for CLBP from pain severity, troublesomeness, health related quality of life and psychological distress
Chi square tests will be undertaken to explore the relationship between troublesomeness of CLBP and consultations for pain in general and with whether consulted mainstream or complementary practitioners. Multiple logistic regression will be undertaken to explore the most powerful predictors of consultation for CLBP.
Participants were identified from respondents reporting chronic pain in a postal questionnaire survey administered through a local general practice. Participants were allocated to groups according to the severity of their pain, as measured by the Chronic Pain Grade. Those with grades II and I were allocated to group one and those with grades III and IV to group two.
We wish to report a technique for the reconstruction of the late presenting Tendo Achilles rupture. A proximal intra muscular Z lengthening through a separate incision facilitates distal translation of the proximal tendon stump, allowing direct repair distally with minimum tension. Post operatively, a below knee cast is applied for six weeks, with progressive dorsiflexion at two weekly intervals. A dorsiflexion restriction splint accompanies early physiotherapy for a further six weeks, with unprotected weight bearing commencing at three months. There were eleven patients in the study group with an average follow up of 24 months. All tendons united. There were no re-ruptures. Two distal wound breakdowns occurred and one of these healed by secondary intention. Good single stance power returned in patients with smaller separations but greater calf wasting and weakness was observed in those patients with large separations. We conclude that this technique can be employed for the reconstruction of late presenting Achilles tendon ruptures, but great care is required with soft tissue dissection distally.
The operative and non-operative treatment options for acute tendo achilles rupture are well documented in the literature. The management of late presenting tendon rupture is usually operative, and can be complicated by acute shortening of the muscle-tendon unit and leave repairs under tension, which may lead to re-rupture. We report the use of the sliding graft technique for reconstruction of late presenting rupture. A proximal intra muscular Z lengthening through a separate incision facilitates distal translation of the proximal tendon stump, allowing direct repair distally with minimum tension. Post operatively a below knee cast is applied for six weeks with progressive dorsiflexion at two weekly intervals. A dorsiflexion restriction splint accompanies early physiotherapy for a further six weeks with unprotected weight bearing commencing at three months. There were eleven patients in the study group with an average follow up of 13 months. All tendons united. There were no re-ruptures. Two distal wound breakdowns occurred and one of these healed by secondary intention. Good single stance power returned in patients with smaller separations but greater calf wasting and weakness was observed in those patients with large separations. We conclude that this technique can be employed for the reconstruction of late presenting tendo achilles ruptures but great care is required with soft tissue dissection distally. Consideration could be given to deep flexor transfers in the widely separated case.
The aim of our study was to demonstrate the safety of the use of a maximal allowable blood loss formula to reduce the transfusion requirements of elective primary arthroplasty patients. In the UK, many arthroplasties are performed each year. Many patients will receive blood transfusion post operatively. Often these patients don’t predonate blood, and most units don’t use re-infusion drains. Blood is both costly, and potentially hazardous product to use; we felt it may be beneficial to patients to reduce the unnecessary use of allogenic blood. We began with a prospective six-month audit, of transfusion requirements of our elective primary arthroplasty patients, establishing our blood use. Our results showed that 66% (58% knees, 73% hips) had at least one unit of blood post operatively, averaging 1.3 units per patient (1.1 knees, 1.5 hips). Following this, we instituted a new protocol for postoperative blood transfusion. The protocol involved calculation of a maximum allowable blood loss (MABL) the patient could safely lose prior to the need for blood transfusion. This value is based on the patients weight and preoperative haematocrit. Blood loses up to this value would be made up with colloid replacement. When this MABL value is reached the patient has a bedside measurement of their haematocrit. If it has fallen below 0.3 for males and 0.27 for female patients then they are transfused blood, one unit at a time until it is at or above these reference values. As a ‘safety net’ all patients have a formal full blood count on days 1,2, and 3, and are transfused if their Hb is less than 8.5 g/dl. This protocol was in place for one year (Feb. 2001-Feb. 2002). Our results show, on average a reduction of blood use from 1.3 units to 0.56 units per patient. The percentage transfused was reduced from 66% to 24% (11% knees, 34% hips). Overall we had a significant reduction of 59% in units of blood transfused to patients following the new protocol. And feel that this method demonstrates a safe system to reduce transfusion requirements.
We describe the histology of a specimen taken from an amputated leg seven months after a 15 cm bone gap in the tibia had been closed by bone transport. Lengthening appeared to have occurred by repeated minor trauma to the bone, with the fractured trabeculae in sufficiently close contact for the repair process to proceed. Osteogenesis did not occur through a cartilage phase, but the fracture gaps were bridged by collagen fibres, around which new bone formed. Microfractures had repaired by primary healing with woven bone and with no microcallus. Small regions of bone were necrotic. Resorption of the necrotic bone and remodelling of the immature bundle and woven bone were still at an early stage, suggesting that complete remodelling in man may take years rather than months.