Scarf osteotomy is widely used as a surgical treatment for hallux valgus. It is a versatile osteotomy, allowing shortening, depression or medial displacement of the capital fragment but it remains uncertain how stresses within the bone subsequently vary. The aim of this study was to design a computerised model to explore the effect on bone stress of changing the position of bony cuts for a scarf osteotomy.

A computerised image was constructed using finite element analysis. This utilises a mathematical technique to form element equations which represent the effect of applied force to the object appropriate to each finite element. Maximum bone stresses were then measured using different osteotomy variables. The osteotomy variables studied were the length of the longditudinal cut, apex of the distal cut to articular cartilage, resection level of the longditudinal cut and combinations of these variables. A saw bone model was used to test the findings of the study.

The results of this study show that lowering the longditudinal resection level and shortening via the distal cut beyond 6 mm will decrease bone stress. Additionally, raising the longditudinal resection level and shortening via the proximal cut caused an increase in bone stress. A saw bone model confirmed the findings of the study.

In conclusion, our experience is that finite element analysis is a very useful model in studying the bony stresses for a scarf osteotomy and assists in optimising the direction and angle of bony cuts used.

In the belief that many of the barriers that patients face when deciding upon an ankle or hindfoot fusion procedure stem from inadequate information about the procedure and its outcomes, the novel concept of a “Fusion forum” has been developed: a nurse-led informal group meeting to facilitate patients’ understanding and perception of fusion procedures. The aims were to provide more in-depth information than it is possible to deliver during the limited time of an initial doctor-patient consultation, to get the patient to meet and question a guest (an expatient who has previously had a fusion procedure) and to allow patients time to reflect upon their choices.

The value of the fusion forum has been evaluated by a questionnaire which was completed by the first 48 patients who attended the forum. 96% (46/48) of respondents felt that the quality of information that they were given was excellent or good. No respondent thought that the information was unsatisfactory. Patients were asked how valuable they had found meeting the guest. Four patients did not respond to this question. All of the respondents thought that meeting another patient who had already undergone the procedure was excellent or good

The mechanics of setting up a foot and ankle fusion forum is discussed, along with the lessons learnt from the first cohort of patients. This process has been found to greatly increase patient understanding of arthrodesis. It has been found during the consent process in pre-admission clinic that patients demonstrate a more in-depth understanding of the operative procedure, a more comprehensive knowledge of what the whole process involves, as well as the relative risks and benefits and the expected time of recovery.

Purpose: Evaluation of a hands free crutch. This interesting device is intended for patients who have undergone foot and ankle surgery and should be non-weight bearing. It involves a knee tray attached to a vertical beam with a rubber foot. The crutch is strapped to the lower limb and weight is transferred though the proximal tibia.

Methods: Five Volunteers were assessed using the crutch, the K9 walker and 2 standard crutches in a simulated environment.

A comparison was made between this device and the K9 walker which has been shown to be a liberating walking aid indoors. Tasks from activities of daily living, productivity and transfers were included. Assessment was undertaken by the Occupational Therapy Team.

The hands free crutch was also compared with non weight bearing using two crutches to gauge performance outdoors. Assessment of ease of use and safety was undertaken by the Physiotherapy Team.

Results: Domestic chores including cleaning, cooking and shopping were possible using this device. Sitting activities were noted to be more difficult, because of the necessity to remove the crutch on each occasion.

Although speed was significantly greater (p< 0.0001.) using two crutches, the hands free crutch permitted safe outdoor mobilisation on even or uneven ground, up and down slopes with a gradient of 1 in 10 and up and down stairs. Good single leg stance stability was predictive of ease of use and safety for the hands free crutch.

Discussion: The hands free crutch is suited to motivated and physically able patients. Other lower limb pathology contraindicates the use of this device, but in patients with upper limb pathology it would permit non-weight bearing mobilisation. Good balance is paramount and perhaps a falls risk assessment should be performed prior to use.

Introduction: Adolescent peroneal spastic flatfoot (PSF) is often regarded as synonymous with tarsal coalition. Inflammatory arthropathies, infections and tumours may, however, all present in this way, and in a few patients with PSF no definitive pathology may be identified.

We aim of to evaluate the causes of adolescent PSF and to develop an an algorithm for its investigation and the management of those patients in whom no underlying pathology is identified.

Methods: All adolescent patients presenting to the senior author with PSF over a two year period were evaluated first for tarsal coalition by means of clinical examination, plain x-rays and CT scanning. If this proved inconclusive an MRI scan was performed and bloods sent for inflammatory and infective markers. If these too identified no treatable cause the patients were treated with a manipulation under anaesthetic, injection of steroid and local anaesthetic into the subtalar joint and immobilization in a below knee cast for 4 weeks. They then received physiotherapy and a talar neutral orthosis. Follow-up was at 4 weeks post-injection and continued until symptoms resolved.

Results: Five patients were found to have PSF with no identifiable cause. All were male, aged 12–17 at presentation. Four completed the treatment. Mean final follow-up was at 10 months post-procedure. All patients reported relief of pain following the procedure and returned to normal activity. At final follow-up, three were still participating in regular sport. One patient suffered a recurrence of his pain.

Conclusion: Adolescent peroneal spastic flatfoot is often, but not always due to tarsal coalition.

If this and other treatable causes have been excluded, treatment with the regime described may give good symptomatic relief in the short to medium term.

Introduction: Many mini compression screws are now available for fixation in procedures such as metatarsal osteotomies or arthrodeses of the foot.

The aim of the current study is to compare the compression forces achieved by mini compression screws on cortical and cancellous bone models.

Material and Methods: The screws that were tested are listed in the table below. The compression forces were tested by inserting a pressures load measurement cell between longitudinally-split sheep tibia as a cortical bone model and longitudinally split retrieved femoral heads as a cancellous bone model.

Results: The Headed AO 3.5 mm cortical screw gave the best compression force and the Bold was the weakest, both in cortical and cancellous bone. The relative compression forces of the other tested screws were different between cortical and cancellous bone. Compression with the headless screws was lost as soon as the screw penetrated through the cortex in the cortrical bone model.

Conclusions: The indications for using headless self-tapping screws should be reserved for fixation of cancellous bone or of metatarsal or Akin osteotomies where compression is not required for union. When compression is important, such as in MPJ, tarso-metatarsal or talonavicular arthrodeses, Headed AO 3.5 mm or 2.7 mm cortical or 4 mm cancellous screws, which give better compression, should be used.

Morton’s Metatarsalgia is a painful condition and can often be debilitating. The value of surgical exicion has been doubted due to low success rate of surgical intervention.

Objective: The purpose of this study is to examine the variation in the management steps of Morton’s Metatarsalgia.

Methods: Several Surgeons from different European countries answered a questionnaire in regard to their routine management of a typical Morton’s Neuroma patient.

Results: 25 surgeons (100%) stated they would routinely elicit intermetatarsal tenderness in comparison to 14(56%) and 10 (40%) surgeons who would routinely elicit Intermetatrsal tenderness and Mulder’s click respectively. The majority of them (84%) will routinely request plain foot radiograph, while 7 surgeons(28%) uses ultrasound routinely. Coservative management is initiated by 16 surgeons(64%). Local injection was first line of treatment among 13 surgeons (56%). Surgical treatment is favoured by 10 surgeons(40%), while only one surgeon (4 %) would use ultrasound guided injection routinely. The popular surgical approach is dorsal incision (75%). If surgical option was chosen then neurectomy is attempted by 17 (68%) surgeons.

Conclusion: Considerable variation exists among continental surgeons in their initial management of a typical Morton’s Neuroma patient. This is probably due to lack of understanding of the true aetiology of the Morton’s “Neuroma”.

Objective of the Study: To assess the clinical effectiveness of ultrasound guided injection in the management of Morton’s Metatarsalgia.

Patients and Methods: Patients, that were clinically diagnosed to with interdigital Morton’s neuroma were treated with ultrasound guided injection of local anaesthetic and steroid. Fifty three patients were available for follow-up, and all had detailed telephone questionnaires completed. These questionnaires included a pre and post injection symptom score, as well as a Johnson Satisfaction score.

Results: 69% of patients had ultrasound diagnosis of Morton’s neuroma and 31% had an ultrasound diagnosis of intermetatarsal bursa. Mean follow up was11.4 months (Range: 3-23 months).67% of the patients were satisfied with the results of treatment. At follow up 63% of patients had no limitation in activity levels, and had no need to modify their shoe wear. Of all patients included in the study, only 3 patients have gone on to require surgery for ongoing symptoms.

Conclusion: Some studies have suggested that neither injection nor imaging have a role in the treatment of Morton’s neuroma. This study, however, demonstrate that ultrasound guided placement of local anaesthetic and steroid in either an intermetatarsal bursa or Mor-ton’s neuroma gives a good short and medium term symptom relief and in the majority of cases avoids the need for surgery.

Introduction: Many mini compression screws are now available for fixation in procedures such as metatarsal osteotomies or arthrodeses of the foot.

The aim of the current study is to compare the compression forces achieved by the relatively new commercial mini compression screws on cortical and cancellous bone models.

Material and Methods: The screws that were tested are listed in the table below. All screws apart from the AO screws are headless and cannulated; and all screws apart from the AO cortical screw are self-tapping. The compression forces were tested by inserting a pressures load measurement cell between longitudinally-split sheep tibia as a cortical bone model and longitudinally split retrieved femoral heads as a cancellous bone model. The screws were inserted across the 2 halves with gradual compression after allowing the reading of the cell to settle.

Results: The Headed AO 3.5 mm cortical screw gave the best compression force, both in cortical and cancellous bone and the Bold was the weakest both in cortical and cancellous bone. The relative compression forces of the other tested screws were different between cortical and cancellous bone. Compression with the headless screws was lost as soon as the screw penetrated through the cortex in the cortrical bone model.

Conclusions: The indications for using headless self-tapping screws should be reserved for fixation of cancellous bone or of metatarsal or Akin osteotomies where compression is not required for union. When compression is important, such as in MPJ, tarso-metatarsal or talo-navicular arthrodeses, Headed AO 3.5 mm or 2.7 mm cortical or 4 mm cancellous screws, which give better compression, should be used.

Introduction: One of the complications of first metatatarsal osteotomies is metatarsalgia secondary to shortening of the first metatarsal. Conservative treatment with insoles is not acceptable to all patients and the traditional treatment of this condition is by shortening osteotomies of the lesser metatarsals (eg Weil, Helal)- the latter osteotomies themselves have complications of causing pain or stiffness in the lesser toes.

Purpose: The aim of this work is to report our results of step cut metatarsal lengthening of iatrogenic first brachymetatarsia.

Patients and Methods: 16 female patients had metatarsal lengthening of iatrogenic first brachymetatarsia. A typical Scarf type osteotomy was used in the first 4 cases and a simple step cut of equal thicknesses along the axis of the first metatarsal was performed in the next 12 procedures.

Results: When 10mm lengthening was done, the metatarsalgia was relieved in all of the 6 patients, in contrary to only 50% relief of symptoms in the patients when less then 8mm lengthening was achieved.

Conclusions: One stage step cut lengthening osteotomy of the iatrogenic short first metatarsal, when over 8mm length is achieved, is safe with good results and is a preferable alternative to shortening osteotomies of the lesser metarsals in the treatment of metarsalgia due to inappropriate shortening of the first metatarsal.

Objective To survey current antithrombotic prophylaxis regimes of foot and ankle surgeons in the UK, and their self-reported rates of deep vein thrombosis (DVT) and pulmonary embolism (PE).

Method A postal questionnaire was sent to 180 members of the British Orthopaedic Foot and Ankle Society requesting regime and types of antithrombotic prophylaxis (if any) used for elective forefoot, elective midfoot, open elective ankle, elective ankle arthroscopy and ankle trauma surgery, and numbers of cases of DVT and PE.

Results Ninety surgeons responded (50%). Surgeons had been practising as consultants with a special interest in foot and ankle surgery for an average of 8.9 years, and performed an average of 24 foot and ankle cases per month. Ten per cent never used antithrombotic prophylaxis in foot and ankle surgery, 64/90 used it routinely for certain cases, and 17/90 used it routinely in all patients. The most common types of prophylaxis were low molecular weight heparin, aspirin and TED stockings. In an approximate overall total of 223,500 foot and ankle cases, the self reported DVT rate was 0.1%. There were 45 reported PEs (0.02%). There was no significant difference in the rate of DVT between those who never, sometimes or always used prophylaxis. Only 5.5% surgeons employed a specific screening protocol to identify high risk patients.

Discussion There is widely varying clinical antithrombotic practice among foot and ankle surgeons in the UK, with no significant difference in reported DVT rates. This has implications for clinical practice and medicolegal issues.

Although the use of split tibialis anterior tendon transfer (combined with the Rose calcaneal osteotomy and reinforcement of the spring ligament) is a recognised procedure in the treatment of stage II tibialis posterior dysfunction, there is a paucity of data regarding its results. Forty-three patients who underwent reconstruction between 1997 and 2003 were evaluated pre- and postoperatively using the AHS scoring system. The average age was 57, and the mean follow-up time was 51 months (range 10–83).

The average AHS score pre-op. was 58 and post-op. was 85. Sixty-six per cent of patients achieved single heel raise. Eighty-four per cent expressed a subjective satisfaction rate, whilst 16% had no improvement. Seventy-eight per cent were able to use normal shoes and 58% did not require the use of any orthotics. The minor complication rate was 16% with no major complications. All osteotomies united uneventfully. Two patients have developed subtalar osteoarthritis, and six calcaneal screws had to be removed for prominence and tenderness.

Our results compare very favourably with other less anatomical reconstructions, but without the donor site morbidity and very low complication rates. A subjective satisfaction rate of 84% has been achieved.

Background

Various clinical outcome studies have consistently reported high dissatisfaction rate (25–33%) among the patients after hallux valgus surgery. We believe that a patient’s pre-operative expectations may play a major role in post-operative satisfaction.

Patients & Methods

Questionnaires were sent to 104 patients anonymously who were given a list of reasons and asked which they hoped to improve by having the surgery. They were also asked to list, in the order of priority, goals that they hoped to achieve from surgery.

Results

Overall, improvement in the ability to walk was the most important reason. Most patients also wished to reduce pain over bunion and to regain the ability to wear daily shoes. However, the expectations of patients vary significantly according to age. Patients under 40 placed more importance on their ability to wear dress shoes and improvement in functional activities. Patients between the age of 40 and 60 were more interested to improve physical appearance. Pain on other toes, and the abilities to squat and climb stairs are the main concerns for patients above 60. For the male patients, to be able to continue work is the second most important reason after improvement in walking ability. This is in contrast to the female group where the ability to wear shoes of their choice is more important. Occupation did not make any significant difference.

Conclusions

This study shows that patients have different expectations that can influence the choice of operation. We believe that understanding patients preoperative expectation is crucial in achieving better patient satisfaction, and it should be an important consideration in planning appropriate operation for the patients.