Cost-Utility Analysis of Total Ankle Replacement Compared with Ankle Arthrodesis for Patients Aged 50-85 Years with End-Stage Ankle Osteoarthritis: The TARVA Study

BACKGROUND

Patients with end-stage ankle osteoarthritis suffer from reduced mobility and quality of life and the main surgical treatments are total ankle replacement (TAR) and ankle fusion (AF).

OBJECTIVES

Our aim was to calculate the mean incremental cost per quality-adjusted life-year (QALY) of TAR compared with AF in patients with end-stage ankle osteoarthritis, over 52 weeks and over the patients' lifetime.

METHOD

We conducted a cost-utility analysis of 282 participants from 17 UK centres recruited to a randomised controlled trial (TARVA). QALYs were calculated using index values from EQ-5D-5L. Resource use information was collected from case report forms and self-completed questionnaires. Primary analysis was within-trial analysis from the National Health Service (NHS) and Personal Social Services (PSS) perspective, while secondary analyses were within-trial analysis from wider perspective and long-term economic modelling. Adjustments were made for baseline resource use and index values.

RESULTS

Total cost at 52 weeks was higher in the TAR group compared with the AF group, from the NHS and PSS perspective (mean adjusted difference £2539, 95% confidence interval [CI] £1142, £3897). The difference became very small from the wider perspective (£155, 95% CI -  £1947, £2331). There was no significant difference between TAR and AF in terms of QALYs (mean adjusted difference 0.02, 95% CI -  0.015, 0.05) at 52 weeks post-operation. The incremental cost-effectiveness ratio (ICER) was £131,999 per QALY gained 52 weeks post-operation. Long-term economic modelling resulted in an ICER of £4200 per QALY gained, and there is a 69% probability of TAR being cost effective at a cost-effectiveness threshold of £20,000 per QALY gained.

CONCLUSION

TAR does not appear to be cost effective over AF 52 weeks post-operation. A decision model suggests that TAR can be cost effective over the patients' lifetime but there is a need for longer-term prospectively collected data. Clinical trial registration ISRCTN60672307 and ClinicalTrials.gov NCT02128555.

Safety of the neurovascular bundles when performing minimally invasive calcaneal osteotomy: A cadaveric study

BACKGROUND

Calcaneal osteotomies correct hindfoot deformities and are often performed using a minimally invasive technique. The aim was to compare the safety of three calcaneal osteotomy techniques (oblique, chevron with apex anterior and chevron with apex posterior).

METHODS

Each osteotomy technique was performed on five cadavers (n = 15). These were then dissected to identify any injury to the neurovascular bundles. The distance between the burr and these structures was measured.

RESULTS

Using the apex posterior technique, the burr was closer to the medial and lateral neurovascular structures, and in one case the sural nerve was injured. There were no neurovascular injuries using the other techniques.

CONCLUSIONS

Minimally invasive surgery using a burr is generally a safe, reliable method for performing calcaneal osteotomies. The chevron with apex posterior osteotomy should be performed with caution given the closer relationship between the burr and neurovascular bundles. The other two techniques provide safer alternatives.

LEVEL OF EVIDENCE: 4

Two to Five-Year Outcomes of Total Ankle Arthroplasty with the Infinity Fixed-Bearing Implant: A Concise Follow-up of a Previous Report

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Metal debris release is commonly seen from explanted total ankle replacements

This study aimed to characterise the damage mechanisms present on the metal components used in various contemporary total ankle replacements. Twenty-seven explanted total ankle replacements comprising 8 different designs (3 fixed bearing and 5 mobile bearing) were analysed using various explant analysis techniques. Pitting and scratching were the most commonly observed wear features. Microscopic analysis revealed metallic pitting on 52% of tibial components and 95% of talar components. Pitting was identified on more cobalt-chromium than titanium alloy tibial components (63% versus 0%). Non-contact profilometry confirmed the presence of pitting, with significant (p < 0.05) differences in the measured average surface roughness values of pitted and unpitted areas for tibial and talar components. There was macroscopically visible sliding plane scratching, indicating the presence of hard third body particles, on 78% of talar components. Changes to the non-articulating surfaces coatings in terms of coating loss and/or changes in reflectivity was identified visually on 80% of metal components. Scanning electron microscopy with energy dispersive X-ray spectroscopy identified metallic embedded debris in 19% of polyethylene inserts. This explant study demonstrates the release of metal debris from both the metallic tibial and talar component articulating surfaces and non-articulating surface coatings of various contemporary total ankle replacements. Metal particulate debris release from total ankle replacements may be more common than previously recognised. Metal debris should be considered in further study into the aetiology of failed total ankle arthroplasty.

Perceived barriers and facilitators of day-case surgery for major foot and ankle procedures? A cross-sectional survey of United Kingdom surgeons

BACKGROUND

Advances in minimally invasive surgery and improved post-operative pain management make it possible to consider performing even major foot/ankle operations as day-case. This could have significant benefits for patients and the health service. However there are theoretical concerns about post-operative complications and patient satisfaction due to pain.

AIM

To scope the current practice of foot and ankle surgeons on day-case surgery for major foot and ankle procedures in the United Kingdom (UK).

METHODS

An online survey (19 questions) was sent to UK foot and ankle surgeons via the British Orthopaedic Foot & Ankle Society membership list in August 2021. Major foot and ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge, with day surgery as the intended treatment pathway.

RESULTS

132 people responded to the survey invitation with 80% working in Acute NHS Trusts. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. 78% felt that there was scope to perform more procedures as day-case at their centre. Post-operative pain (34%) and patient satisfaction (10%) was not highly measured within their centres. Lack of adequate physiotherapy input pre/post-operatively (23%) and lack of out of hours support (21%) were the top perceived barriers to performing more major foot and ankle procedures as day-case.

CONCLUSION

There is consensus among UK surgeons to do more major foot/ankle procedures as day-case. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. There is a need for nationally agreed protocols to optimise the delivery of and measurement of outcomes in this type of surgery. At a local level, the provision of physiotherapy and out of hours support should be explored at sites where this is a perceived barrier.

Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial

BACKGROUND

End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF).

OBJECTIVE

To determine which treatment is superior in terms of clinical scores and adverse events.

DESIGN

A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307).

SETTING

17 National Health Service trusts across the United Kingdom.

PATIENTS

Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure.

INTERVENTION

Patients were randomly assigned to TAR or AF surgical treatment.

MEASUREMENTS

The primary outcome was change in Manchester-Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible.

RESULTS

Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was -5.6 (95% CI, -12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (-11.1 [CI, -19.3 to -2.9]).

LIMITATION

Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques.

CONCLUSION

Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%.

PRIMARY FUNDING SOURCE

National Institute for Health and Care Research Heath Technology Assessment Programme.

A Multicenter Retrospective Cohort Study of First Metatarsophalangeal Joint Arthrodesis

In this multicenter study, we evaluated commonly used methods of fixation and 2 methods of joint preparation for first metatarsophalangeal joint fusion, in terms of radiological union and revision rates. Included were 409 consecutive fusions in 385 patients. The overall union rate was 91.4% (34/409). About 29.4% (10/34) of our nonunions were symptomatic. Preoperative hallux valgus showed a statistically significant relation to nonunion (odds ratio [OR] = 9.33, p = .017). Other potential contributing factors like gender (OR 1.9, p = .44), diabetes (OR = 0, p = .99), steroid use (OR = 2.07, p = .44), inflammatory arthritis (OR = 0, p = .99), and smoking (OR = 2.69, p = .34) did not attain statistical significance. Further, the methods of fixation like solid screws (OR = 0, p = .99), plate (OR = 3.6, p = .187), or cannulated screws (OR = 0.09, p = .06) showed no correlation with incidence of nonunion. We compared 2 techniques of joint preparation and found no significant difference in union rates (chi-square = 1.0426, p = .30). Our crude comparison of costs showed the average saving to the trust per year could be 33,442.50£ by choosing screws over plates. To conclude, only hallux valgus had a statistically significant relation to nonunion. All other variables had no significant impact on the union. Solid screw seems to be economically the most viable option and a valid alternative.

Should the Tibiotalar Angle Be Measured Using an AP or Mortise Radiograph? Does It Matter?

Understanding the tibiotalar angle (TTA) is key to planning for deformity correction. The TTA is an important radiographic tool to determine alignment or malalignment of the ankle and hindfoot. Two methods of measuring the TTA have been described: the midline TTA (MTTA) and the lateral TTA (LTTA). The aim of this study was to compare the 2 angles as measured on mortise and anteroposterior (AP) radiographs in a series of normal and pathological cases. A radiographic review was performed of sequential ankle AP and mortise radiographs taken between January 2016 and September 2017 across 4 specialist orthopedic centers. Patients were categorized into a normal group, where patients had normal radiological appearances, and an arthritis group, where patients had radiographic arthritis. The MTTA and the LTTA were measured. The overall mean ± standard deviation MTTA was 88.7° ± 5.1°, and mean LTTA was 87.5° ± 5.2° (p < .01). There was no statistically significant difference between the MTTA and LTTA in the normal group or on AP radiographs alone (p = .09). There was a statistically significant difference between the MTTA and LTTA in the arthritis group (p < .01) and when measured on mortise radiographs (p = .02). The MTTA had no difference when measured on the AP and mortise radiographs. There was a statistically significant difference in the LTTA between AP and mortise radiographs (p = .04). We have shown the MTTA to be a reliable and reproducible tool in all patients, on AP and mortise radiographs. The type of radiograph does not alter the measurement of deformity. In contrast, we have shown the LTTA to be unreliable and statistically different when measured on AP and mortise radiographs.

A Feasibility Study Comparing Platelet-Rich Plasma Injection With Saline for the Treatment of Plantar Fasciitis Using a Prospective, Randomized Trial Design

Platelet-rich plasma (PRP) has been advocated for treatment of plantar fasciitis but there are few good-quality clinical trials to support its use. We conducted a feasibility study of PRP versus saline for treatment of plantar fasciitis. Patients with 6 months or more of magnetic resonance imaging-proven plantar fasciitis, who had failed conservative treatment were invited to participate in the study. Patients were block randomized to either PRP or an equivalent volume of saline. The techniques used for injection and rehabilitation were standardized for both groups. The patient and assessor were blinded. Visual analogue scale (VAS) for pain and painDETECT score were recorded preoperatively and at 6 months follow-up. From 35 patients approached, 28 (19 female, mean age 50 years) were recruited, with 14 randomized to each arm. At 6 months, 8 patients (28.6%) were lost to follow-up. There was a significant change in VAS score from baseline to follow-up in both intervention (mean change 37.2, P = .008) and control (mean change 42.2, P = .003) groups. There was no correlation between preoperative painDETECT score and change in VAS. Recruitment and loss to follow-up rates were relatively high. Both treatments resulted in a similar, significant, improvement in symptoms. Levels of Evidence: Level II.

How Knowledge Relates to Confidence in Orthopedics and Emergency Medicine Regarding Return to Sport and Rehabilitation in Foot and Ankle Trauma

OBJECTIVE

The aim of this study was to survey the knowledge of registrars in emergency medicine and orthopedics on 5 common injuries to the foot and ankle and compare this knowledge, and self-reported confidence in giving it, with that of consultants and physiotherapists of various levels of experience.

DESIGN

An online survey was used to gather the information using scenario-based open and closed questions.

PARTICIPANTS

A total of 102 health care professionals, who regularly deal with sports injuries, were recruited. These included consultant orthopedic surgeons with a subspecialty interest in foot and ankle surgery, orthopedic surgeons in other specialties, extended scope physiotherapy practitioners (ESPs) in foot and ankle and general musculoskeletal practice, emergency medicine consultants, emergency medicine registrars, orthopedic registrars, senior physiotherapists, and junior physiotherapists.

SETTING

The participants were drawn from various health care institutions in the North East of England.

RESULTS

Consultant foot and ankle surgeons and extended scope practitioners in foot and ankle both scored significantly on knowledge of rehabilitation program design than either set of registrars. For 2 of the case scenarios, there was a significant difference in scores between either orthopedic consultants or ESPs and registrars (p < 0.05). For total score, there was a trend for extended scope practitioners to score higher than both sets of registrars, but this did not reach significance. Correlation coefficients for knowledge and self-reported confidence ranged between 0.009 and 0.33, demonstrating only weak positive linear correlation between scenario score and reported confidence in advice given.

CONCLUSIONS

The most significant area of gaps in knowledge among the 2 groups of registrars was in the specifics of rehabilitation programs. There was markedly higher confidence with greater seniority. Registrars in emergency medicine and orthopedics are likely to benefit from case-based teaching in sports injury rehabilitation.

Clinical and Radiographic Outcomes of the Infinity Total Ankle Arthroplasty System

Category:

Ankle Arthritis

Introduction/Purpose:

We report our early results of the Infinity Total Ankle Arthroplasty (TAA) system, a third generation, constrained implant, recently introduced to the UK market.

Methods:

All ankles were uncemented and standard instrumentation was used. Patients were reviewed at 3, 6 and 12 months for radiological and clinical assessment including Ankle Osteoarthritis Score (AOS), Visual Analogue Scale (VAS) and subjective component of AOFAS Ankle/Hindfoot score.

Results:

Mean age was 66 (range 42-88), 14 females and 21 males. The mean follow-up 12 months (range, 4-18 months), and no patients were lost to follow-up. The diagnosis was post-traumatic in 15 cases, primary osteoarthritis in 15 and inflammatory arthritis in 5 cases. Preoperative coronal alignment deformity was < 10 degrees in 54%, 10-20 degrees in 43% and >20 degrees in 3%. Mean AOS score improved from from 64 to 24, AOFAS score improved from 19/70 to 49/70 and VAS from 7.0 to 2.0. Tibial component subsidence was noted in 1 case (3%), and asymptomatic periprosthetic lucent lines in 6 cases (17%). No ankles were revised. Complications included intraoperative medial malleolar fracture (8.5%), delayed wound healing (14%), tibial osteotomy non-union (3%), and regional pain syndrome (3%). The mean radiographic coronal plane alignment of the tibial component was 1.9 degrees varus (range, 5.3 varus to 1.7 valgus) and its mean sagittal plane alignment 2.8 (range -1.7 to 8.5) degrees dorsiflexion.

Conclusion:

Our early experience has demonstrated good patient outcomes, low complication rate and reproducible alignment with the Infinity implant.

The Preoperative ‘6 Pack’ for Patients With Ankle Arthritis

Category:

Ankle Arthritis

Introduction/Purpose:

There is paucity of literature relating to information needs of patients in Orthopaedic Surgery, despite the fact that Orthopaedic Surgeons in the UK welcome the use of patient decision aids for joint replacement surgery. This multi- centre study aimed to study the information needs of patients for surgical treatment of ankle arthritis from 6 different hospitals across the North East region of England.

Methods:

Ethical permissions were obtained for this multi-centre qualitative research study. The study recruited 18 patients from 6 hospitals across the North East of England. They were invited to take part in patient focus group meetings. 3 focus groups were conducted with 4-8 patients/ group. These groups were facilitated by independent researchers using a semi-structured discussion approach. Patients were asked for their views on information needs for surgical treatment of ankle arthritis. The focus group meetings were digitally recorded and transcribed verbatim. Data was analysed using the nVIVO software with framework analysis.

Results:

The analysis highlighted 4 main themes: A) Factors influencing surgical decision making B) Information needs of patients C) Information provision and D) Patient expectations. Theme B is discussed in detail for this abstract. Primary information needs requested by over 70% of patients were: 1. Desire to meet with patients who had undergone similar surgical procedure 2. Information on post-operative rehabilitation 3. Information on return to work and driving 4. Experience of consultant team 5. Written information regarding procedures (advantages, disadvantages, survivorship and outcomes) and 6. Personalized decision support based on individual patient’s lifestyle and preferences. These components form the Preoperative/information ‘6 pack’.

Conclusion:

When developing information materials and decision tools for patients, providing them with the Ankle Arthritis ‘6 pack’ will enable them to make a more informed choice of the surgical options offered by the consultant.

Does the Learning Curve of Minimally Invasive Chevron and Akin Osteotomies Affect Outcome of Hallux Valgus Correction?

Category:

Bunion

Introduction/Purpose:

Minimally invasive chevron and akin osteotomy (MICA) has become increasingly popular in the correction of hallux valgus deformity. This study compared the radiological outcomes of the first cases performed by 2 surgeons using this technique with open scarf and akin osteotomy

Methods:

A retrospective review of hallux valgus corrections performed in Northumbria Healthcare NHS Trust between March and September 2014. Consecutive patients who underwent MICA correction by 2 surgeons trained on a cadaveric course were compared with a group of patients with mild to moderate deformity that underwent open scarf correction. Pre and post radiographic assessment was performed measuring the hallux valgus angle (HVA), the intermetatarsal angle (IMA) and medial sesamoid position (MTS) using Hardy and Clapham classification. Radiographic measurements where statistically compared for difference and complications were recorded.

Results:

14 MICA procedures were identified and compared with 14 scarf procedures. Average age of the MICA group was 46 vs. 55 for the scarf group. Pre operative radiographic measurements showed no statistical difference between MICA vs. scarf: Mean HVA 26.9 vs. 28.2 degrees (p 0.698), mean IMA 14.7 vs. 15.3 degrees (p 0.512) and mean MTS grade 5 vs. 5.5 (p 0.251). Change in these parameters between MICA vs. scarf also did not show any statistical difference: Mean HVA change 17.2 vs. 19.2 degrees (p 0.396), mean IMA change 8.5 vs. 8.1 degrees (p 0.680) and mean MTS grade change 2.6 vs.3.2 (p 0.149). In the MICA group, 1 procedure was converted to open and post operatively 1 screw was removed due to length. In the scarf group 1 patient developed a superficial infection that resolved with antibiotics and 1 prominent screw for akin osteotomy required removal.

Conclusion:

Early experience of MICA resulted in similar outcomes and complications compared with open scarf and akin osteotomy.

How Knowledge Relates to Confidence in Orthopaedics and Emergency Medicine Regarding Rehabilitation in Foot and Ankle Trauma

Category:

Sports

Introduction/Purpose:

The aim of this study was to survey the knowledge of registrars in emergency medicine and orthopaedics on five common injuries to the foot and ankle and compare this knowledge, and self-reported confidence in giving it, with that of consultants and physiotherapists of various levels of experience.

Methods:

An online survey was used to gather the information using scenario based open and closed questions. A total of 102 healthcare professionals, who regularly deal with sports injuries, were recruited. This included consultant orthopaedic surgeons with a subspecialty interest in foot and ankle surgery,. orthopaedic surgeons in other specialties, extended scope physiotherapy practitioners (ESPs) in foot and ankle and general musculoskeletal practice, emergency medicine consultants, emergency medicine registrars, orthopaedic registrars, senior physiotherapists and junior physiotherapists. The participants were drawn from the various healthcare institutions in the North East of England.

Results:

Consultant foot and ankle surgeons and extended scope practitioners in foot and ankle both scored significantly on knowledge of rehabilitation programme design than either set of registrars. For two of the case scenarios there was a significant difference in scores between either orthopaedic consultants or ESPs and registrars (p < 0.05). For total score there was a trend for extended scope practitioners to score higher than both sets of registrars but this did not reach significance. Correlation coefficients for knowledge and self-reported confidence ranged between 0.009 and 0.33, demonstrating only weak positive linear correlation between scenario score and reported confidence in advice given.

Conclusion:

The most significant area of gaps in knowledge amongst the two groups of registrars was in the specifics of rehabilitation programmes. There was markedly higher confidence with greater seniority, which correlated poorly with differences in specific knowledge. Registrars in emergency medicine and orthopaedics are likely to benefit from case based teaching in sports injury rehabilitation.

Arthroscopic versus open ankle arthrodesis: a multicenter comparative case series

BACKGROUND

Ankle arthrodesis results in measurable improvements in terms of pain and function in patients with end-stage ankle arthritis. Arthroscopic ankle arthrodesis has gained increasing popularity, with reports of shorter hospital stays, shorter time to solid fusion, and equivalent union rates when compared with open arthrodesis. However, there remains a lack of high-quality prospective data.

METHODS

We evaluated the results of open and arthroscopic ankle arthrodesis in a comparative case series of patients who were managed at two institutions and followed for two years. The primary outcome was the Ankle Osteoarthritis Scale score, and secondary outcomes included the Short Form-36 physical and mental component scores, the length of hospital stay, and radiographic alignment. There were thirty patients in each group.

RESULTS

Both groups showed significant improvement in the Ankle Osteoarthritis Scale score and the Short Form-36 physical component score at one and two years. There was significantly greater improvement in the Ankle Osteoarthritis Scale score at one year and two years and shorter hospital stay in the arthroscopic arthrodesis group. Complications, surgical time, and radiographic alignment were similar between the two groups.

CONCLUSIONS

Open and arthroscopic ankle arthrodesis were associated with significant improvement in terms of pain and function as measured with the Ankle Osteoarthritis Scale score. Arthroscopic arthrodesis resulted in a shorter hospital stay and showed better outcomes at one and two years.

Venous thromboembolic events following foot and ankle surgery in the English National Health Service

Diagnostic and operative codes are routinely collected for every patient admitted to hospital in the English NHS. Data on post-operative complications following foot and ankle surgery have not previously been available in large numbers. Data on symptomatic venous thromboembolism events and mortality within 90 days were extracted for patients undergoing fixation of an ankle fracture, first metatarsal osteotomy, hindfoot fusions and total ankle replacement over a period of 42 months. For ankle fracture surgery (45 949 patients), the rates of deep-vein thrombosis (DVT), pulmonary embolism and mortality were 0.12%, 0.17% and 0.37%, respectively. For first metatarsal osteotomy (33 626 patients), DVT, pulmonary embolism and mortality rates were 0.01%, 0.02% and 0.04%, and for hindfoot fusions (7033 patients) the rates were 0.03%, 0.11% and 0.11%, respectively. The rate of pulmonary embolism in 1633 total ankle replacement patients was 0.06%, and there were no recorded DVTs and no deaths. Statistical analysis could only identify risk factors for venous thromboembolic events of increasing age and multiple comorbidities following fracture surgery.

Venous thromboembolism following foot and ankle surgery is extremely rare, but this subset of fracture patients is at a higher risk. However, there is no evidence that thromboprophylaxis reduces this risk, and these national data suggest that prophylaxis is not required in most of these patients.

Intra-articular injection versus portal infiltration of 0.5% bupivacaine following arthroscopy of the knee

The administration of intra-articular local anaesthetic is common following arthroscopy of the knee. However, recent evidence has suggested that bupivacaine may be harmful to articular cartilage. This study aimed to establish whether infiltration of bupivacaine around the portals is as effective as intra-articular injection.

We randomised 137 patients to receive either 20 ml 0.5% bupivacaine introduced into the joint (group 1) or 20 ml 0.5% bupivacaine infiltrated only around the portals (group 2) following arthroscopy. A visual analogue scale was administered one hour post-operatively to assess pain relief. Both patients and observers were blinded to the treatment group. A power calculation was performed.

The mean visual analogue score was 3.24 (sd 2.20) in group I and 3.04 (sd 2.31) in group 2. This difference was not statistically significant (p = 0.62).

Infiltration of bupivacaine around the portals had an equivalent effect on pain scores at one hour, and we would therefore recommend this technique to avoid the possible chondrotoxic effect of intra-articular bupivacaine.