Introduction: A learning curve is a recognised phenomenon in surgery. It implies that the frequency of peri-operative adverse events will decrease with the increase in experience of the surgeon. Evidence shows increased instruction and experience in a specific surgical task leads to improved performance. There is conflicting evidence as to whether there is a learning curve for total ankle replacement, and a paucity of evidence for foot and ankle surgery as a whole. Current evidence is centered on perioperative complications, rather than functional outcome.

Aim: To determine whether a learning curve effect is present during the first year of independent practice by measuring patient outcome.

Materials and Methods: 150 patients underwent elective foot or ankle surgery during the first 12 months of a newly appointed consultant’s practice. Preoperative and six month postoperative functional scores were recorded, together with perioperative complications. Two patients died of unrelated causes in the first 12 months. 121 patients (81.8%) were followed up for a minimum of six months by telephone. Functional outcome was assessed with a modified American Orthopaedic Foot and Ankle Society midfoot Score (85 points). Outcome was compared between the first and second six-month periods using the student’s t-test.

Results: Eighty procedures were undertaken during the first six months compared to 70 in the second. Total ankle replacements were only undertaken in the latter period. Otherwise there was no statistical difference in the caseload. One wound infection occurred during each period and other perioperative complications were equivalent. Functional improvement was greater in the group from the second 6 months (+23.86 v’s +18.69). This difference did not reach statistical significance (p = 0.061).

Discussion and Conclusion: There is a trend, approaching significance, towards a learning curve during a foot and ankle consultant surgeon’s first year of practice. Collating data from other new consultants may demonstrate a learning curve with statistical significance.

Introduction: Osteoporosis is a skeletal disorder characterised by decreased bone mineral density (BMD) and a subsequent increased risk of fragility fractures. This disease is commonly associated with postmenopausal females with an increasing incidence into later life, over 50% of females over 80 have osteoporosis. At the opposite spectrum of life, decreased BMD is traditionally associated with the female athletic triad, with hormonal imbalance leading to skeletal insufficiency. Considered a “silent disease” until a fracture occurs, as orthopaedic surgeons we must be able to identify those at risk of osteoporosis and refer promptly for dual energy x-ray absorptiometry (DEXA) scanning to prevent future fragility fractures in this specific patient cohort.

Methods: We carried out an epidemiological analysis of all female patients under the age of 30 referred for DEXA scanning in a university teaching hospital over a 3 year period. We analysed mode of referral, risk factors, T-score and subsequent fractures with an aim to highlight an underestimated level of osteopenia/osteoporosis in the younger patient.

Results: We identified 102 patients eligible for our study, with a mean age of 25.34 (Range- 17–29). As per the World Health Organisation (WHO) osteopenia was defined as osteopenia as a T-Score between −1 and −2.5, with osteoporosis below −2.5. The mean T score of these patients was −1.037 (range −3.2 to 2.4). Medical teams initiated the majority of referrals (77%), followed by General Practitioners (17%), Gynaecologists (4%), Paediatricians (1%) and Surgeons(1%). Risk factors included excess steroid use for medical conditions (41%), decreased body mass index (BMI) (27%), ceoliac disease (12%) and radiological evidence of osteopenia (7%). 34% of these patients had suffered a fall with 12% of patients suffering from a fragility fracture.

Conclusion: We identified a definite cohort of young female patients who had a mean T-score within the levels for osteopenia. Over one third had suffered a fall and 12% had suffered a fragility fracture despite a young age. With ever increasing patient numbers in both fracture and orthopaedic clinics and increased pressure on resources, it is imperative that we still take thorough histories to identify those young female patients that are at risk of osteoporosis. With appropriate follow up and investigations, they can be started on necessary treatment and prevent subsequent fragility fractures, the incidence of which appears to be underestimated.

Scarf osteotomy is a commonly performed method of hallux valgus correction. Release of deforming lateral soft tissue structures is an integral part of this correction. The aim of this study was to determine if there was any difference in the correction achieved by dorsal and transarticular releases as part of a scarf osteotomy.

This radiological study was performed at a single institution. One surgeon utilised the dorsal first web approach for the distal soft tissue release and one the transarticular approach. There were 23 patients in each group. The same post-operative regime was used on both sets of patients. Data was collected on hallux valgus angle (HVA), intermetatarsal angle (IMA) and AFS sesamoid scoring.

The pre-operative deformity as measured by hallux valgus angle and intermetatarsal angle where similar for both groups (p= 0.25, 0.79 respectively) with a significant difference in severity of AFS scoring in the dorsal group (p < 0.001). Patients who underwent a dorsal approach release had a mean improvement in IMA of 5.46 degrees compared to 3.86 in the transarticular group. The HVA improved by 17.92 degrees in the dorsal group compared to 8.08 in the transarticular group. Both these results were statistically significant (p= < 0.01,< 0.002 respectively). There was a statistically significant difference in number of patients returning to within normal limits of the HVA (p= < 0.05); 18 patients returned to a normal hallux valgus angle after undergoing the dorsal approach compared to 9 patients in the transarticular group.

Our study shows that when performing a distal soft tissue release in conjunction with a scarf osteotomy for correction of hallux valgus, a dorsal first web approach is significantly better at correcting the HVA as compared to a transarticular approach. We would, therefore, recommend the use of a dorsal approach when performing this surgery.

Introduction: Compromised by pre-existing medical co-morbidities, weakened by the second hit of surgery, elderly patients with hip fractures are amongst the most challenging cases to manage appropriately in the acute hospital setting.

Aim: To document the frequency and outcome of post operative medical complications in elderly patients following surgery for hip and proximal femoral fractures.

Methods: Retrospective analysis of acute admissions to a University teaching hospital with hip and pertrochanteric fractures over an 18 month period. Medical records and radiographs were reviewed for details relating to location of fracture, in-patient morbidity, mortality and length of stay. In-patient fracture referrals and patients under 65 years of age were excluded.

Results: From a total of 438 fracture fixation procedures or prosthetic replacements, 368 patients were eligible for analysis. The mean age of patients was 83.6 years. The mean length of stay was 14.2 days.

142 patients experienced significant postoperative morbidity consisting of 24 myocardial infarctions, 46 respiratory tract infections, 33 urinary tract infections, 3 cerebral vascular accidents and 36 exacerbations of congestive cardiac failure. There was no correlation between morbidity and location or type of fracture. The mean age (86.1 yrs) and length of stay (26 days) was greater in the morbidity group (p< 0.05). The overall post operative in-patient mortality rate was 9%, rising to 50% in those who suffered a myocardial infarction and 33% in those with exacerbations of congestive cardiac failure.

Conclusion: This study reinforces the poor prognosis conferred by a hip fracture on the elderly patient both in terms of morbidity and mortality. As the population ages and life expectancy increases, health services will come under ever more pressure to cater for the expansion in numbers of hip fracture patients. Greater resources and dedicated professional medical staff are required in order that the best possible care and outcome may be achieved for these patients

Aim: An epidemiological analysis of spontaneous community acquired septic arthritis cases in an elderly population at a university teaching hospital

Method: We studied confirmed cases of spontaneous septic arthritis in the over 65 population. Patients with prosthetic joint infections were excluded from the study. We analysed data relating to initial presenting complaint and clinical examination, haematological and microbio-logical tests along with ultimate patient outcome.

Results: There were 7 confirmed cases of spontaneous septic arthritis in over 65 population in the last 6 months (2 hips, 5 knees). The mean age was 72.14 (range 65–82) with a mean length of stay of 49 days. Those with septic arthritis of the knee presented with swelling, pain and immobility. Hip cases presented with pain and immobility. All patients were systemically well at time of presentation, with no other foci of infection detected after septic screening. All patients had aspirate and arthroscopic/arthrotomy confirmed infection. Staphylococcus Aureus was isolated from 6 joint aspirations and Pseaudomonas Auruginosa from one patient. Complications of treatment included acute renal failure, cardio/respiratory failure, disseminated infection and death (1 case).

Conclusion: Septic arthritis must be considered as a differential diagnosis in all patients with joint pain, swelling and immobility. This diagnosis is not confined to the paediatric population. A backround of degenerative disease and the occult presentation in the elderly may delay diagnosis. Sepsis must be considered in the elderly with joint pathology, with treatment initiated in a prompt and aggressive manner to prevent the sequelae that ensues.

Introduction: Gait analysis studies of patients following ankle arthrodesis have demonstrated a functional gait, largely due to tarsal hypermobility compensating for lost tibio-talar motion. We present a prospective radiographic study comparing the pre and post-operative range of motion of the foot following ankle arthrodesis. In this study, we introduce a radiographic technique using reliable anatomic landmarks to measure sagittal range of motion of the foot after ankle arthrodesis.

Materials and Methods: Between 2002 and 2007, we performed 154 arthrodesis procedures of the ankle. Patients were suitable for inclusion in this study if an isolated arthrodesis of the ankle was performed for post traumatic arthritis with a minimum of 1 year follow-up without any additional hindfoot operations. Preoperative and post-operative passive plantar flexion and dorsiflexion radiographs were obtained in a standardized fashion. Anatomic landmarks were then used to measure and compare tibio-talar, mid-tarsal, and subtalar movement.

Results: There were 48 patients who met the inclusion criteria for this study. Preoperatively, the mean measured motion was as follows: total sagittal motion 35o, tibio-talar motion18o, mid-tarsal (transverse tarsal + naviculo cuneiform + tarsometatarsal joints) motion 12o (34% of pre-op sagittal arc), subtalar motion 5.5o (15% of pre-op sagittal arc), and mid-tarsal + subtalar motion 17.5o (49% of pre-operative sagittal motion). These changed post operatively to a mean motion as follows: total sagittal motion 18.5o, (52% of preoperative sagittal motion), mid-tarsal motion 10o (28% of pre-op sagittal arc), subtalar motion 10.5o (27% of pre-op sagittal arc), and mid-tarsal + subtalar motion 20.5o (54% of pre-operative sagittal motion).

Discussion: This study presents an accurate and reproducible means of measuring the sagittal plane range of motion of the hindfoot and ankle, and documents the presence of increased motion in the subtalar and talonavicular joints after ankle arthrodesis.

Ankle arthrodesis is a common operation with published fusion rates ranging from 62–100%. The literature documents the difficulties of obtaining arthrodesis in certain patients for example with neuroarthropathy, but the risk of non union related to deformity, bone quality, bone defects and systemic disease has not previously been reported.

Between 2002 and 2006 we performed an ankle arthrodesis in 154 patients, and analyzed these patients retrospectively to delineate categories of risk factors for achieving arthrodesis. From this analysis we devised a preoperative radiographic scoring system to grade complexity of pre-operative ankle arthrodesis. The scoring system is based upon 5 categories; size and plane of deformity, presence and size of bone defects, presence and area of avascular necrosis, site of previous fracture in post-traumatic arthritis and predisposing condition causing the arthritis. Each category has potential scores of 1–5, apart from the latter which is scored up to 6, with higher scores being more severe. The grade of complexity is derived from a cumulative score from all 5 categories.

Statistical analysis revealed good intra and inter- observer correlation. Multivariate regression analysis demonstrated that this scoring system correlates with the techniques used for arthrodesis as well as outcome. This study demonstrated that if the method of arthrodesis is altered according to the relative risk of non –union then there is no significant difference in outcome between patients of high and low risk for non-union

We present a new scoring system for severity of pre-operative condition in ankle arthrodesis patients and introduce an algorithm for surgical correction based upon this pre-operative scoring system. The surgical techniques for the arthrodesis are presented, ranging from simple screw fixation to more complex bone grafting techniques, bone stimulation and alternative methods of fixation.

Introduction; Distal tibial physeal fractures are the commonest cause of growth arrest and deformity secondary to failure to achieve and maintain an accurate reduction. Our study compared assessment of displacement and screw placement using X-ray alone compared to CT scans. Methods; 62 consecutive fractures over a 4 year period were used. Displacement was measured on 18 Salter Harris III and IV fractures by 7 surgeons separately using X-rays alone. These measurements were compared to those made from the CT scans. Screw placement was drawn onto tracings of outlines of of single cuts of CT scans by 4 surgeons seperately for all 62 fractures using X-rays alone. This was repeated one week later using the CT scans. Ideal screw placement was considered to perpendicularly bisect the fracture line. Differences between the ideal and observer measurements were analysed using the paired t-test. Results; The surgeons were incorrect in determining whether there was more or less than 2mm of displacement in 33.3 Ð 50% of cases (mean = 38.9%) . There was a statistically signiþcant difference (p < 0.0001) in accuracy of screw insertion point and direction between using X-rays and Ct scans for all surgeons and fracture types. Conclusions; We recommend that CT scans are essential for accurate pre-operative assessment of distal tibial physeal fractures.