Hind and mid foot arthritis is often noted in patients who have previously had an ankle arthrodesis. It has been suggested that this arthritis may be precipitated or exacerbated as a direct result of the ankle fusion. The aim of this study was to investigate the degree and pattern of pre-existing ipsilateral foot arthritis in patients who have subsequently undergone ankle arthrodesis. A retrospective review of the most recent pre-operative radiographs of 70 patients who underwent 71 arthrodeses between 1993-2003 was performed. Patients with rheumatoid disease were excluded. The immediate pre-operative AP and lateral ankle radiographs were assessed and the presence and severity of osteoarthritis for the sub-talar, talo-navicular, naviculo-cuneiform and calcaneo-cuboid joints was recorded using the Kellgren and Lawrence grading score. This was performed simultaneously by two reviewers and a consensus obtained. A total score out of 16 was given for each radiograph. 68 (96%) of the radiographs reviewed showed evidence of pre-existing hind or mid foot arthritis prior to ankle fusion. The sub-talar joint was the most commonly and severely affected. The median total arthritis score for each radiograph was 5. There was no association between age or causative pathology and the degree of arthritis. This study has demonstrated that hind and mid foot arthritis is very common in patients with co-existent ankle arthritis prior to ankle fusion. This has previously been assumed to have developed as a result of the surgery but is, in fact, present at the time of the operation and this needs to be taken into consideration when evaluating the results of ankle arthrodesis
Use of epidural analgesia post-operatively in spinal surgery is becoming increasingly common. We have conducted a prospective study examining the side-effects associated with epidurals and the need for additional analgesia in 36 adult patients undergoing either lumbar spine decompression, lumbar spine fusion, or a combination of decompression and fusion. A mixture of bupivacaine and fentanyl was used for up to 72 hours post-operatively via an epidural catheter placed under direct vision at the time of surgery. All patients had urinary catheters inserted peri-operatively. 15 patients experienced one or more side-effects; 6 patients had a subjectively unpleasant sensory block, 3 patients developed a motor block, 4 patients had pruritus, 3 developed hypotension, and 2 had episodes of nausea or vomiting. All these features resolved upon reduction of the epidural rate or cessation of the epidural. All patients required additional oral analgesia at some point during their observation. There were no serious complications, such as infection, permanent neurological deficit, or cord compression. We conclude epidural analgesia following lumbar spine surgery is a safe practice, although the high rate of side-effects necessitates close observation by fully trained staff. It appears additional oral analgesia is required to obtain satisfactory levels of analgesia.
The average time to clinical union was 14 weeks (6–23 weeks) and the average time to radiological union was 16 weeks (6–37 weeks). There were 6 (16%) non-unions in this series 2 of which were fibrous non-unions. Both patients with fibrous non-unions experienced minimal or no symptoms and did not require further intervention. Of the 4 other non-unions, 3 were revised using an open technique, the fourth patient again being minimally symptomatic and not wanting further surgery. 1 patient suffered a traumatic displacement of the arthrodesis, requiring an open revision which went on to successful union at 3 months. There were no other complications in this series and, of note, there were no cases of metalwork removal for prominence or pain.
