Background

Post-operative pain following forefoot surgery can be difficult to control with oral analgesia so regional analgesic methods have become more prominent in foot and ankle surgery. It was the aim of this study to evaluate the efficacy of a combination of popliteal and ankle blocks and decide if they provide significantly better post-operative analgesia than ankle block alone in forefoot surgery.

Background: Postoperative pain following forefoot surgery can be difficult to control with oral analgesia so regional analgesic methods have become more prominent.

Aim: It is the aim of this study to evaluate the efficacy of a combination of popliteal and ankle blocks and decide if they give significantly better postoperative analgesia than ankle block alone in forefoot surgery.

Methods: This is a prospective, randomised, controlled and single blind study. The total number of patients is 80 with 40 patients in the ankle block only group (control) and 40 patients in the ankle and popliteal block group. All patients underwent forefoot surgery. Postoperative pain was evaluated in the form of a visual analogue scale and verbal response form. Evaluations took place four times for each patient: in the recovery room, 6 hours postoperatively, 24 hours postoperatively and on discharge. The pain assessor, who helped the patient complete the pain evaluation forms, was blinded to the number of blocks used. The amount of opiate analgesia required whilst an inpatient was also recorded. On discharge the patient was asked to rate their satisfaction with the pain experienced during their hospital stay. Results were analysed using Mann-Whitney tests.

Results: Results show that pain is significantly less in recovery (p=0.044) and after 24 hours (p=0.0012) for those patients with combined blocks. Satisfaction with pain relief is also higher for these patients. No complications were found as a consequence of having two peripheral nerve blocks.

Conclusions: A popliteal block in conjunction with an ankle block does reduce postoperative pain significantly more than ankle block alone after forefoot surgery.

Radiological examination is a useful tool in assessing osteoarthritis (OA) in the knee. We have compared the extent of osteoarthritis in the knee graded on radiographs and by intraoperative observation to determine if there is significant difference with relevance to preop-erative planning.

Radiographs for fifty-eight patients were graded for OA under blind conditions using the Ahlback classification system and direct measurement of the medial and lateral joint spaces. Intraoperative assessment of the corresponding joint surfaces was performed under blind conditions by a separate surgeon and graded using the Outerbridge classification system.

OA was found to be more common in the medial compartment than the lateral, both on radiographs and intraoperatively. Spearman correlation coefficient for the medial compartment comparing joint space narrowing and intraoperative assessment was −0.545. For the lateral compartment the Spearman correlation coefficient was lower at –0.406. Positive predictive values for OA in the medial and lateral compartments on radiography were 90% and 66.67% respectively. Negative predictive values for OA in the medial and lateral compartments on radiography were 44.74% and 34.69% respectively.

Conclusion: We have demonstrated that although radiographs have reasonable to good accuracy at showing OA in both compartments the absence of OA on radiographs does not correlate well with the absence of OA in the knee. This is of importance when planning operations, particularly unicompartmental knee replacement, as intraoperative findings of bilateral disease will change the operation required.

Problem-based learning medical courses are now in the majority in the UK. This type of teaching, based on research by Barrow in the 1960s, seeks to integrate basic sciences and clinical teaching, leading to the acquisition of an integrated knowledge base that is readily recalled and applied to the analysis and solution of problems. We noticed an apparent difference in the core anatomical knowledge in a group of 4th year medical students during their orthopaedic placement, some of whom had been taught a traditional course and some a PBL course. We set out to quantify this difference.

60 simple anatomy questions were asked, with 30 minutes allowed, and no negative marking. 33 students were PBL taught, and 27 by a traditional course, with a roughly equal male: female ratio. The average score in the PBL group was 39.2% (range 11–52%), whereas the traditional group averaged 73.7% (range 63–79%).

A second study was undertaken on two groups of 80 second year medical students, at 2 different UK universities with comparable teaching standards and entry requirements, both being well-established courses. Again, a simple 50-question anatomy paper was used, without negative marking. The traditional course students scored a mean of 37.5 (25–46), and the PBL group scored a mean of 32.3 (18–45). The results were statistically significant (p< 0.0001).

Our results suggest that the difference between the two groups with regard to core anatomical knowledge increases with progression through training. This has significant implications due to PBL courses being in the majority. During the usually short orthopaedic attachment, it will become increasingly difficult for clinicians to teach effectively due to the lack of this knowledge.