Achilles tenotomy as an office procedure and current practising trends among New Zealand orthopaedic surgeons.

BACKGROUND: Percutaneous Achilles tenotomy (PAT) is performed during the final phase of casting with Ponseti method. Several settings have been proposed as venues for this procedure, however it is increasingly being performed in theatre under a general anaesthetic (GA). General anaesthesia, however, is expensive and not without risks. The purpose of the present study was to compare results of outpatient releases to theatre releases, and assess current practising trends among orthopaedic surgeons. METHODS: Retrospective comparison of patients with idiopathic clubfoot managed by Ponseti method who had Achilles tenotomy performed in outpatient clinic and in theatre. Surveys were sent to all POSNZ members to determine current practising trends in New Zealand. Parental satisfaction surveys were performed. Comparative cost analysis was performed using hospital billing information. RESULTS: The current study includes 64 idiopathic congenital clubfeet (19 bilateral cases). PAT was performed on 26 clubfeet under local anaesthetic in an outpatient setting, and 33 clubfeet under GA in a theatre setting. There was no significant difference for post-operative complications, or recurrence (p=0.67). Those in theatre group were exposed to a greater number of general anaesthetics before the age of four. Among practising New Zealand paediatric orthopaedic surgeons, 77.78% perform this in theatre under general anaesthesia, while only 22.22% perform PAT in outpatient clinic. The main barriers included concerns regarding pain control, concerns regarding incomplete release, concerns regarding distress to family and concerns regarding sterility. Parental satisfaction surveys found pain management to be excellent. Financial data was analysed and indicative costs were $6,061 NZD per procedure in theatre, compared to $378 NZD per procedure in clinic. CONCLUSION: PAT performed in a clinic setting is both safe and efficacious with results comparative to that performed in theatre. There was no difference in post-operative complications or recurrence. Parental satisfaction to this procedure is excellent. There are significant financial advantages. Based on this data, our institution now performs all releases in an outpatient setting.

The acromiohumeral centre edge angle: A new radiographic measurement and its association with rotator cuff pathology.

BACKGROUND: Various radiographic measurements that describe humeral head coverage by the acromion and the effect on rotator cuff pathology have been reported. This study aimed to describe and validate a new radiographic measurement, the acromiohumeral centre edge angle (ACEA). METHODS: We compared the ACEA on computed tomography (CT) and plain X-ray to determine whether X-ray is accurate for measuring this angle. We then compared the results from this control population with 107 patients with acute rotator cuff tears. We compared functional outcomes in rotator cuff tear patients to determine whether the ACEA has any effect on outcome after surgery. An intra- and inter-observer variability analysis was performed and we compared the ACEA to the acromial index (AI) on rotation X-rays. RESULTS: The ACEA was comparable on CT and plain X-ray and was most accurate when true anteroposterior glenohumeral X-rays were used (15.94° vs. 15.87° on CT, p = 0.476). The ACEA showed high intra- and inter-observer reproducibility and was unchanged on internal and external rotation X-rays (20.48 vs. 20.47, p = 0.842), whereas the AI was significantly different (0.74 vs. 0.70, p < 0.001). The ACEA was significantly higher in our rotator cuff tear patients than the control population (23.9° vs. 16.6°, p < 0.001), although a higher ACEA was not associated with poorer outcomes. CONCLUSION: The ACEA is a valid measurement for describing humeral head coverage by the acromion and can be accurately measured on plain radiographs with good reproducibility. It is unaffected by shoulder rotation and was significantly higher in patients with acute rotator cuff tears.

How effective is our current Orthopaedic Prioritisation Tool for scoring patients for arthroplasty surgery?

AIM: To compare those patients who are being accepted onto the waiting list for total hip and knee arthroplasty surgery with those patients who are being declined surgery, using a validated functional questionnaire. METHOD: The clinic records from all patients seen for consideration of total hip or knee arthroplasty at Hawkes Bay Hospital during the preceding four months were reviewed. We sent the Oxford Hip and Knee Score questionnaire to all patients who had been put forward for consideration of surgery. RESULTS: Of the 150 patients we surveyed, 81 had been accepted onto the waiting list and received a date for surgery within the next four months and 69 had been declined surgery. Of the 81 patients who had been accepted onto the waiting list for surgery, 61 returned the Oxford questionnaire with an average score of 10.9. Of the 69 patients who had been declined surgery, 59 returned the Oxford questionnaire with an average score of 10.8. Thus the mean Oxford score was not statistically different between those patients being accepted onto the waiting list for surgery and those being declined surgery (p=0.925). CONCLUSION: No difference was found between those patients being accepted onto the waiting list for total hip or knee arthroplasty and those being declined surgery in Hawkes Bay after using the Oxford Hip and Knee Score as a measure of functional impairment. The average Oxford score indicates that patients being seen in Hawkes Bay Hospital for consideration of total hip or knee arthroplasty are severely functionally impaired as a result of their condition.