Urinary catheterisation may be associated with a risk of infection in hip and knee arthroplasty, however post-operative urinary retention can be distressing for the patient. This study investigates the factors that might predict the need for post-operative catheterisation.

A prospective blinded study of 128 consecutive patients undergoing lower limb arthroplasty was carried out. Data obtained included sex, age, joint (hip or knee), prostate score (IPSS), previous urinary retention, co-morbidities and residual bladder volume after attempted complete voiding measured using an ultrasound bladder scanner. Anaesthetic type and requirement for urinary catheterisation postoperatively were recorded. Predictive risk factors were identified using binary logistic regression, and expressed as odds ratios (OR) and 95% confidence intervals (CI).

The mean age was 69.5 years. There were 56 males and 72 females. 38 patients (30%) required post-operative catheterisation. Logistic regression identified the following predictive risk factors: bladder scan volume per ml increase (OR 1.006; CI 1.000–1.012); male sex (OR 5.51; CI 2.01–15.16); previous catheter (OR 4.26; CI 1.53–11.82); spinal/epidural/combined spinal epidural anaesthesia (OR 6.78; CI 1.75–26.32); moderate IPSS score (OR 5.15; CI 1.73–15.37); severe IPSS score (OR 3.53; CI 0.605–20.54). Our model specificity is 91%, positive predictor value 71% and negative predictor value 82%.

Introduction

Urinary catheterisation can cause bacteraemia and therefore may be associated with a risk of infection in hip and knee arthroplasty. However postoperative urinary retention can be distressing for the patient. This study investigates the factors that might predict the need for postoperative catheterisation in order to help develop a protocol to decide who should be electively catheterised.

Introduction

Scar sensitivity is a recognised complication of foot surgery. However there is very little published about it. This study looks at the incidence and natural history of scar sensitivity following hallux valgus surgery.

Introduction

The mainstay of treatment in non-insertional Achilles tendinopathy is non-operative, however between 1/4 and 1/3 of patients fail this. The main symptom is pain which appears to be related to new nerve endings that grow into the tendon with the neovessels from the paratenon. Treatments which strip the paratenon from the tendon are showing promise including formal paratenon stripping via Achilles tendinoscopy. The pain and swelling in Achilles tendinopathy is usually on the medial side leading to the postulation that the plantaris tendon may have a role to play.

Thromboembolic disease is associated with a high degree of morbidity and mortality. There is increasing pressure for elective orthopaedic patients, including those undergoing foot and ankle surgery, to be prescribed chemical thromboprophylaxis post-operatively in order to reduce the risk of a thromboembolic event. The risks of chemical thromboprophylaxis in terms of increased bleeding, wound problems and HIT are well documented. The aim of this study was to determine the incidence of clinically significant thromboembolic events in patients undergoing elective foot and ankle surgery with and without the use of aspirin.

We audited a consecutive series of 1625 patients undergoing elective foot and ankle surgery between 2003 and 2010. Between 2003 and 2006 inclusive, aspirin was used post operatively as chemical thromboprohylaxsis. Between 2007 and 2010, no chemical thromboprohylaxsis was used. The follow-up period for all patients was at least three months post-operatively. Most patients were reviewed at 3 months by the senior surgeon. Those who were reviewed less than 3 months (patients undergoing minor procedures) were contacted via telephone to confirm whether a thromboembolic event had been diagnosed.

There was no loss to follow up. Of the 1625 patients, 555 patients received aspirin and 1070 patients received no chemical thromboprohylaxsis. 5 of 1625 (0.31%) patients developed a clinically significant thromboembolic event. 3 patients developed a DVT at an average time of 5 weeks post operatively. 2 patients developed non-fatal PE at an average time of 7 weeks post operatively. 3 of the 5 thromboembolic events occurred in the aspirin group (all DVT's) whereas 2 of the 5 (all PE) developed in the non aspirin group.

The incidence of clinically significant thromboembolic events is low in elective orthopaedic foot and ankle surgery. We suggest that the benefit of chemical thromboprophylaxis does not outweigh its potential risks in foot and ankle surgery.

Background: Foot injuries represent a small but important proportion of injuries to professional rugby union players. There are no detailed epidemiological studies regarding these injuries.

Purpose: The aim of this study was to describe the epidemiology of foot injuries sustained by a cohort of professional rugby union players and identify areas that may be targeted for injury prevention in the future.

Study design: Descriptive epidemiological study.

Methods: Medical personnel prospectively recorded injuries in professional, premiership rugby union players in England over 4 seasons. Injuries to the foot were identified and the time away from training and playing was reported.

Results: A total of 147-foot injuries were sustained resulting in 3,542 days of absence in total. Acute events accounted for 73% of all foot injuries, with chronic, mostly overuse conditions, accounting for 25% (undiagnosed 2%). Chronic conditions led to proportionately more time away from training and playing (p< 0.001). Specifically, stress fractures in the foot accounted for 8% of the total foot injuries but 22% of the absence. Navicular stress fractures had the longest recovery time with the mean return to training and match play of 188 days.

Conclusions: In collision sports, such as rugby, injury is inevitable, but clinicians should always be seeking ways to minimise their occurrence and impact. This study revealed significant morbidity associated with chronic and overuse foot injuries in these professional athletes. With greater attention paid to risk factors, some of these injuries, and importantly, recurrent injuries may be avoided.

Introduction: Adequately managing post-operative pain following ankle and hindfoot surgery can be difficult. Conventional analgesics have significant side effects including nausea and gastric irritation. The results of a pilot study of continuous infusion v’s single bolus popliteal block encouraged us to perform the full PRCT.

Method: The trial was approved by the local Research and Ethics Committee and registered with the European Clinical Trials Database. Approval was obtained from the Medicines and Healthcare products Regulatory Authority (MHRA) for the use of normal saline infusion as a placebo. The recommendations of Good Clinical Practice in the conduct of clinical trials on medicinal products for human use were respected.

Inclusion criteria were all patients who were undergoing significant hind foot or ankle procedures. Exclusion criteria included coexisting peripheral neuropathy and any inability to fill in the questionnaire.

The pilot study provided a standard deviation of pain scores which allowed us to calculate the sample size required; 25 patients in each group would have 90% power to detect a difference in means VAS scores of 3 which we considered to be clinically significant. A total number of 56 (to allow for 10% loss to follow-up) were recruited. The patients and the assessors were blinded to the treatment allocated. Sealed envelopes contained random allocations and were opened by the anaesthetist. A bolus of 20ml 0.25% bupivacaine was injected and then the catheter was inserted and connected to a pump. Patients were randomly assigned to receive either an infusion of normal saline or bupivacaine over the next 72 hours.

The patients were asked to complete a visual analogue pain chart, three times daily, for 72 hours postoperatively. Data was also recorded regarding supplementary opiate analgesic requirements and any problems or complications.

Statistical analysis was performed using MedCalc for Windows, version 9.6.4 (MedCalc software, Mariakerke, Belgium). A Mann-Whitney U test was used for the non-parametric data sets.

Results: Both groups had very low median VAS pain scores on the day of operation and there was no difference between the two; study 1.167, control 1.000 (p=0.893). On the 3 post operative days studied there were significantly lower pain scores in the study group; day 1: 1.67 v’s 3.67 (p=0.003), day 2: 1.33 v’s 2.83 (p=< 0.001), day 3: 1.11 v’s 2.56 (p=< 0.001).

There was no difference in median milligrams of morphine usage on the day of operation; study = 10, placebo = 10 (p = 0.942). The morphine usage was lower in the study group on all post operative days and this was significant on days 2& 3; day 1: 10 v’s 15 (p=0.054), day 2: 10 v’s 20 (p=< 0.001), day 3: 7.5 v’s 10 (p=0.02). Median total morphine requirements over the 3 post operative days were 30mg for the study group compared to 52.5mg for the control group and this was significant (p=0.012).

The study group on average spent less nights as an inpatient with a median value of 1 compared to 2 for the control but this was not significant (p=0.430).

There were no major complications with the administration of the blocks or with the catheters.

Conclusion: The bolus of bupivacaine given to all patients prior to surgery meant that low pain scores were seen in both groups in the immediate post operative period with no significant difference between them. The continuous infusion of bupivacaine via a pain pump provided significantly better analgesia than normal saline with significantly less requirement for supplementary oral analgesic agents over the 72 hours after major ankle or hind foot surgery. This is a safe and effective method of managing post operative pain in these patients.

Introduction: When conservative treatment of posterior ankle impingement syndrome (PAIS) fails, operative intervention is indicated. Traditionally this involved an open approach. More recently posterior ankle arthroscopy has been employed. We report the first series of results from an exclusively elite athlete population.

Method: We looked retrospectively at a prospectively compiled database of a consecutive series of elite professional soccer players on whom we have performed posterior ankle arthroscopy for both bony and soft tissue PAIS over the past 5 years. We reviewed our clinical and operative notes and those of the Football Association medical team. Statistical analysis was performed using MedCalc for Windows, version 9.6.4 (MedCalc software, Mariakerke, Belgium).

Results: One player was lost to follow up leaving 27 out of 28 players in the study.

The mean time to return to training post operatively was 34 days (24–54) and to playing was 41 days (29–72). Significant correlations were found between the length of symptoms and the number of pre operative injections (Spearman’s rank correlation coefficient = 0.806. p< 0.001) and the length of symptoms pre-operatively and return to training (Correlation coefficient = 0.383. p=0.048) and return to play (Correlation coefficient = 0.385. p=0.048). Return to training was significantly faster after soft tissue debridement with FHL release than after bony surgery (p=0.046 Kruskal-Wallis test). There was one surgical complication in the form of a persistent portal leakage. This was successfully treated by resting the ankle in a boot for 2 weeks. One patient had recurrent symptoms 3 months after surgery; this was successfully treated with an ultrasound guided injection. There were no infections and no neurovascular injuries.

Conclusion: Posterior ankle arthroscopy is safe and effective in the treatment of posterior ankle impingement syndrome in the elite soccer player with return to training expected at an average of 5 weeks.

Introduction: The pathogenesis of chronic tendinopathy is unclear. The role of the increased apoptosis of tenocytes has been suggested by high intratendinous levels of glutamate being demonstrated in patients with tendinosis. Nitric oxide is a known mediator of apoptosis and nitric oxide synthase (NOS) isoforms have been shown to be upregulated in rotator cuff tendons as a result of chronic overuse. We found, the same upregulation of NOS in the Achilles tendon in non-insertional Achilles tendinopathy in a previous study.

The purpose of this study was to investigate whether apoptotic cells were present in these tissues with raised eNOS and iNOS levels.

Methods: Samples were obtained from the Achilles Tendons of patients with in non-insertional Achilles tendinopathy who had failed conservative treatment for at least six months and were undergoing a surgical procedure. Consent was obtained preoperatively from all patients and ethical approval was granted by the research ethics committee.

Several biopsies were taken of the visibly abnormal tendon tissue. Control samples were taken from macroscopically normal tendon correlating with areas of normal tissue on MRI.

Standard immunohistochemical techniques were used to identify the expression of endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS).

Apoptotic cells were identified using terminal deoxynucleotidyl transferase-mediated dUTP neck end labelling (TUNEL reaction) with TdT-FragEL and the demonstration of Caspase-3 activation.

A power calculation was performed which showed that 14 patients in each group would be required to show a 50% difference between the two groups using a level of significance of 5%.

Results: Significant differences were found between the diseased tendon and the controls for all of the parameters measured. The mean Caspase-3 cell count for diseased tendon was 51.9 compared to 28.3 for the controls (p=0.000001). The mean TUNEL cell count for diseased tendon was 24.1 compared to 14.8 (p=0.00014). iNOS densitometry revealed a mean of 26.1 for the diseased tissue verses 15.0 for the controls (p=0.000009) and the values for eNOS were 48.3 and 23.7 respectively (p=0.015).

Conclusions: Apoptosis clearly plays a role in the development of non-insertional Achilles tendinopathy and appears to be related to the presence of raised eNOS and iNOS levels.

It is possible that, by blocking the apoptotic pathway, the tendinopathic process could be halted. This may lead to the development of treatments strategies for early Achilles tendinopathy.

Introduction: The pathogenesis of chronic tendinopathy is unclear. A role for increased apoptosis of tenocytes has been suggested. Nitric oxide is thought to be a mediator of apoptosis and nitric oxide synthase (NOS) isoforms have been shown to be up regulated in rotator cuff tendons as a result of chronic overuse. We found, the same up regulation of NOS in the Achilles tendon in non-insertional Achilles tendinopathy in a previous study.

The purpose of this study was to investigate whether apoptotic cells were present in these tissues with raised endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) levels.

Methods: Consent was obtained preoperatively from all patients and the research and ethics committee granted ethical approval. Samples were obtained from the Achilles Tendons of patients with non-insertional Achilles tendinopathy who had failed conservative treatment for at least six months and were undergoing a surgical procedure. Several biopsies were taken of the visibly abnormal tendon tissue. Control samples were taken from macroscopically normal tendon correlating with areas of normal tissue on MRI. Standard immunohistochemical techniques were used to identify the expression of eNOS and iNOS. Apoptotic cells were identified using terminal deoxynucleotidyl transferase-mediated dUTP neck end labelling (TUNEL reaction) with TdT-FragEL and the demonstration of Caspase-3 activation.

Results: Significant differences were found between the diseased tendon and the controls for all of the parameters measured. The mean Caspase-3 cell count for diseased tendon was 51.9 compared to 28.3 for the controls (p=0.000001). The mean TUNEL cell count for diseased tendon was 24.1 compared to 14.8 (p=0.00014). iNOS densitometry revealed a mean of 26.1 for the diseased tissue verses 15.0 for the controls (p=0.000009) and the values for eNOS were 48.3 and 23.7 respectively (p=0.015).

Conclusions: Apoptosis clearly plays a role in the development of non-insertional Achilles tendinopathy and appears to be related to the presence of raised eNOS and iNOS levels. It is possible that, by blocking the apoptotic pathway, the tendinopathic process could be halted. This may lead to the development of treatments strategies for early Achilles tendinopathy.

Introduction: Sciatic nerve blocks have been used to reduce post-operative analgesia and allow early discharge for patients undergoing foot and ankle surgery. This study aims to identify utilisation of this procedure and to ascertain if there is a consensus amongst surgeons as to best practise with regards to who performs the block and how it is performed.

Method: We surveyed current committee members of the American and members of the British orthopaedic foot and ankle surgery societies (AOFAS and BOFAS).

Results: More than half of those who responded perform over 90% foot and ankle surgery. 77% performed sciatic nerve blockade through the popliteal approach (26% used the subgluteal approach). The most common position was supine with 80% being performed by the anaesthetist. 45% never used ultrasonography to detect the position of the nerve and variable levels of nerve stimulation were used. 30% used an infusion catheter with 20% allowing discharge to home with the catheter. 42% of surgeons where happy to have the block performed under full anaesthesia. The commonest complication cited was prolonged anaesthesia, the majority of which resolved. Performing the block awake or sedated did not seem to alter the number of complications seen.

Discussion: This study represents a current practice review of sciatic nerve blocks performed in foot and ankle surgery and shows a variety of techniques used. Although this is now a widely used block, no consensus has been reached as to the use of ultrasound, level of nerve stimulation or whether the patient needs to be awake for the procedure. The use of infusion catheters (especially after discharge) has not been widely utilised, especially amongst UK surgeons.

Introduction: Computer assisted knee arthroplasty (CAKA) has been shown in a number of studies to result in improved post-operative alignment of prostheses. However prosthetic alignment is only one part of total knee arthroplasty surgery and outcome is likely to depend on other factors such as soft tissue balancing.

Our study compared the functional outcome following knee arthroplasty using CAKA or conventional instrumentation, and investigated whether the theoretical advantage of improved prosthesis alignment with CAKA resulted in improved functional outcome.

Materials and Methods: Data on 299 patients have been recorded to date. 139 patients have a minimum one year follow up. No patients were lost to follow up. All patients were operated on by a single surgeon at a dedicated arthroplasty centre and were allocated to one of two groups: Computer assisted navigation using a robot assisted technique (PiGalilieo, Plus Orthopaedics, Rotkreuz, Switzerland), or using conventional instrumentation. In both groups the prosthesis used was the TC-Plus Self-aligning bearing (Plus Orthopaedics).

Functional outcome was measured using the Oxford Knee Score (OKS).

A power analysis was performed with alpha of 0.05 and power of 80%. In order to detect a difference of 4 points in the OKS, 126 patients were required. This number was exceeded in our study at one year.

Results: The mean OKS at one year follow up was 24.9 (range 12 – 54, s.d. 9.8) for the CAKA group and 25.3 (range 12–49, s.d. 9.7) for the control group. There was no significant difference in functional outcome at one year between the two groups (p = 0.41).

At two years follow up the mean OKS was 25.39 (range 13 – 53, s.d. 10.3) for the CAKA group and 24.14 (range 12–43, s.d. 9.1) for the control group (p = 0.33). The results for the two year follow up group should be treated with caution as further patient numbers are awaited to obtain adequate power.

Conclusions: Although several studies show that use of CAKA results in improved prosthesis alignment, our study indicates that CAKA does not result in improved functional outcome as assessed by the patient at short term follow up. Improved prosthesis alignment is thought to result in improved long term outcome, however long term studies are necessary to show whether the known advantages of CAKA in improved prosthesis alignment results in improved patient satisfaction and increased implant survival. These further studies are important in order to justify the increased costs associated with CAKA.

Introduction: Computer assisted knee arthroplasty (CAKA) has been shown in a number of studies to result in better post-operative alignment of prostheses. However good prosthetic alignment is only one part of total knee arthroplasty surgery and outcome is likely to depend on other factors such as soft tissue balancing. Our study aimed to compare the functional outcome following knee arthroplasty using CAKA or conventional instrumentation, and to determine whether the theoretical advantage of improved prosthesis alignment with CAKA resulted in improved functional outcome.

Materials and Methods: Data on 299 patients have been recorded to date. 139 patients have a minimum one year follow up. No patients were lost to follow up All patients were operated on by a single surgeon at a dedicated arthroplasty centre and were allocated to one of two groups: Computer assisted navigation using a robot assisted technique (PiGalilieo, Plus Orthopaedics, Rotkreuz, Switzerland), or using conventional instrumentation. In both groups the prosthesis used was the TC-Plus Self-aligning bearing (Plus Orthopaedics). Functional outcome was measured using the Oxford Knee Score (OKS). There was no statistical difference in pre-operative OKS and demographic data between the two groups

A power analysis was performed with alpha of 0.05 and power of 80%. In order to detect a difference of 4 points in the OKS, 126 patients were required. This number was exceeded in our study at one year.

Results: The mean OKS at one year follow up was 24.9 (range 12–54, standard deviation (s.d) 9.8) for the CAKA group and 25.3 (range 12– 49, s.d. 9.7) for the control group. There was no significant difference in functional outcome at one year between the two groups (p = 0.41). At two years follow up the mean OKS was 25.39 (range 13–53, s.d. 10.3) for the CAKA group and 24.14 (range 12– 43, s.d. 9.1) for the control group (p = 0.33). The results for the two year follow up group should be treated with caution as further patient numbers are awaited to obtain adequate power.

Conclusion: Although several studies show that use of CAKA results in improved prosthesis alignment, our study indicates that CAKA does not result in improved functional outcome as assessed by the patient at short term follow up. Improved prosthesis alignment is thought to result in improved long term outcome, however long-term studies are necessary to show whether the known advantages of CAKA in improved prosthesis alignment results in improved patient satisfaction and increased implant survival in order to justify the increased costs associated with CAKA.

To study the outcome of complex proximal humeral fracture sequelae (Type 3 & 4) treated with the Delta III Total Shoulder Replacement (TSR) Prosthesis. This is a prospective outcome study involving 10 patients mean age (71.5 yrs). All patients failed conservative treatment of proximal humeral fractures. Mean time from injury to surgery was 10.5 (+/− 11.5) months. All patients underwent a Delta III TSR via McKenzie approach by a single surgeon. Patients were assessed clinically with Constant scores, asked whether they were satisfied, and radiologically with plain film radiographs. Since last review one patient has died. Mean time at follow up was 20.8 months post-operation (12 “32 months). Three patients had undergone early revision for dislocation. Since last review two patients have developed deep infection, one treated with washout and suction drain, one with removal of prosthesis. One patient has a clinical diagnosis of complex regional pain syndrome. Three patients are very happy with the outcome of surgery, one is happy, one unhappy and four very unhappy. The mean pre-operative Constant scores was 8.9 (2–15), at first review 44.4 (15–96) and now 35.8 (4–76). The mean pain score on a visual analogue scale (0–10) was 3.6 (0–10). Radiographs showed no progressive notching of the glenoid in any patient. Mean flexion was 93 degrees (10,170), mean abduction 61 degrees (10,100) and mean external rotation was “1 degrees (−20,20).

This is a new technique for treating proximal humeral fracture sequelae. Some individual results are excellent. There has been a high complication rate and a significant rate of poor results. At this time we cannot recommend the reverse geometry prosthesis for the treatment of proximal humeral fracture sequelae.

The purpose of the study was to objectively compare the effects of the scaphoid and Colles’ type casts on hand function. Currently there is no such published study.

Both casts are commonly used to immobilise suspected and radiologically proven undisplaced scaphoid fractures. There is no difference in non-union rates. The scaphoid incorporates the thumb in palmar abduction, whereas the Colles’ type cast leaves the thumb free. Although necessary for bone healing, immobilisation disrupts function and may require intensive corrective physiotherapy. Unnecessary immobilisation of uninvolved joints should be avoided when use does not compromise fracture stability.

We compared the effect of the two casts on hand function in 20 healthy right hand dominant volunteers using the Jebsen-Taylor Hand Function Test, which uses seven subtests designed to test tasks representative of everyday functional activities. Data were obtained through a mixed between and within subject design.

Using the Jebsen-Taylor Hand Function Test, median overall scoring in the Colles’ type cast was 2.5 times that obtained in the scaphoid. In timing individual subtests, the analyses show significant differences (p< 0001) between the presence and absence of a cast. When comparing the two cast types, mean times for all subtests are less in the Colles’ than in the scaphoid, with the difference reaching statistical significance in five out of seven subtests.

Having either type of cast significantly impairs handling and finger dexterity, and so affects activities of daily living. A scaphoid, however, is much more limiting than a Colles’ type cast. This makes it clearly more inconvenient for the patient with socioeconomic implications and occasionally issues of compliance during a long period of immobilisation.

Aim: To show that the Delta III Total Shoulder Replacement (TSR) Prosthesis is an alternate treatment for complex proximal humeral fracture sequelae (Type 3 & 4)

Methods: This is a prospective outcome study involving 10 patients (mean age (71.5 yrs). All patients failed conservative treatment with a mean time to surgery of 10.5 (+/− 11.5) months and a mean follow up of 8.2 months (6–24mnths). All patients underwent a Delta III TSR via McKenzie approach by a single surgeon.

Patients were assessed with constant and age adjusted Constant scores, radiographs and subjective questionnaire and whether they were satisfied at 6 weeks, 3, 6, 12, 24 months.

Results: At 6 months, age adjusted Constant scores changed form a mean 8.9 (5.3) pre-op to 50.1 (20.9). Six patients were satisfied, 2 unsure and 2 unsatisfied; elevation improved the most, with external rotation the least affected. Age adjusted power increase by 40.4 %, with a subjective function (10 points) improving by 32.6 %. X-rays at 6 months showed two glenoid notches in contact with the inferior screws. Three patients underwent revision surgery (total 5 revisions) for acute post – operative dislocations – all had inserts changed. Intra-operative tension assessment (by means of anterior dislocation of the humerus) was found to be a useful test of stability. Revision surgery found to be a significant predictor of poorer function at 6 months. (p< 0.025). No stem failures noted. Significantly better constant scores achieved with shorter period of time from fracture to delta replacement (p< 0.045). A single wound infection was treated successfully with oral antibiotics.

Conclusion: The results of the Delta III TSR in this difficult group of patients, appear satisfactory in terms of patient satisfaction, subjective and objective functional assessment and 6 months prosthesis survival (100%), and appear to offer a better functional outcome than hemiarthroplasty.