Introduction:

Historically the incidence of Achilles re-ruptures has been described as around 5% after surgical repair and up to 21% after conservative management. In 2008 we commenced a dedicated Achilles tendon rupture clinic for both conservative and surgically managed patients using new standardised operating procedures (SOP). We have evaluated the impact of this new service, particularly with regard to re-rupture rate.

Introduction:

Patient reported outcome measures are becoming more popular in their use. Retrospective scoring is not yet a validated method of data collection but one that could greatly decrease the complexity of research projects. We aim to compare preoperative and retrospective scores in order to assess their correlation and accuracy.

Objective

The objective of this study was to evaluate the rotation and translation of each joint in the hindfoot and compare the load response in healthy feet with that in stage II posterior tibial tendon dysfunction (PTTD) flatfoot by analysing the reconstructive three-dimensional (3D) computed tomography (CT) image data during simulated weight-bearing.

Objectives

The goals of this study were: 1) to determine if high-fat diet (HFD) feeding in female mice would negatively impact biomechanical and histologic consequences on the Achilles tendon and quadriceps muscle; and 2) to investigate whether exercise and branched-chain amino acid (BCAA) supplementation would affect these parameters or attenuate any negative consequences resulting from HFD consumption.

Introduction

Longstanding complex muliplanar foot deformities represent a significant challenge. The traditional surgical techniques involve excessive dissection and excision of large bony wedges or modifications of the triple fusion to correct the deformity. The majority of the reports in the literature present collective data on different deformity patterns and also mix paediatric and adult patients, even with multiple correction techniques. The aim of this study was to evaluate the clinical, radiological and functional outcomes of the gradual correction of a single common deformity pattern of equino-cavo-varus using a single correction technique of the V-osteotomy and the Ilizarov frame.

Background

The Weil osteotomy is successful in the management of metatarsalgia and toe deformity. The aim is to achieve controlled shortening whilst avoiding plantarflexion. Recognised complications of the Weil osteotomy include a ‘floating toe’ in up to 20% or more of cases.

Introduction

Osteoarthritis commonly affects the first metatarsophalangeal joint. Stress across this joint has been postulated to increase the incidence of osteoarthritis. Certain foot structures have been associated with a higher incidence of osteoarthritis of the big toe. Utilizing finite elemental analysis, bone stress across the first metatarsophalangeal joint was calculated during mid stance phase of gait and compared in different foot structures.

Background

Evaluation of outcomes and satisfaction following hallux valgus (HV) surgery is usually retrospective and rarely uses patient-reported outcome measures (PROMs).

Introduction

Fifth metatarsal fracture is a common injury. Current practice supports conservative management, with surgery in the event of non-union. Early fracture clinic review is not perceived to improve patient experience or increased detection of non-union. A new protocol standardises treatment to symptom level and discharges patients from ED with advice but without any routine follow-up arranged. A leaflet advises on management, prognosis and helpline details and there is an open-access policy for those whose symptoms persist to investigate potential non-union.

Introduction

Ankle replacement is now common in the UK.

In a tertiary referral NHS practice, between 1997–2011 we implanted two types of cementless mobile bearing total ankle replacements (TAR).

Introduction

Periprosthetic cyst formation following ankle replacement, requiring revision surgery, has previously been reported. The exact pathogenesis of cyst formation is unclear but considered to be due to a combination of biological and mechanical factors. Our objective was to review the incidence of periprosthetic cyst formation following Mobility ankle replacement and their outcome.

Aim

We aimed to study the effect of BMI on clinical and patient-reported outcomes in patients with TAR with a minimum follow-up of three years.

Introduction

Mesenchymal stem cells (MSCs) are a potential source of cells for the repair of articular cartilage and osteochondral defects (OCD) in the ankle. Synovial tissue has been shown to be a rich source of MSCs with the ability to undergo chondrogenic differentiation. Although these cells represent a heterogenous population, clonal populations have not been previously studied.

Objectives

The Manchester–Oxford Foot Questionnaire (MOXFQ) is a validated 16-item, patient-reported outcome measure for evaluating outcomes of foot or ankle surgery. The original development of the instrument identified three domains. This present study examined whether the three domains could legitimately be summed to provide a single summary index score.

Aim

Young patients with ankle arthritis that remains symptomatic in spite of conservative treatment and following arthroscopic debridement are usually offered either ankle fusion or ankle replacement. Both these options are far from ideal in this age group. The aim of this study was to evaluate functional outcomes following ankle distraction to determine whether it is a reliable alternative for the treatment of ankle arthritis in young adults.

Introduction

Post-traumatic arthritis is the commonest cause of arthritis of the ankle. Development of arthritis is dependent on the restoration of pre-injury anatomy. To assess the effect of grade of lead surgeon on the accuracy of surgical reduction, we performed a retrospective radiographic analysis of all ankle fractures undergoing open reduction and internal fixation, in a single institution.

Introduction

Postoperative pain following the 3 component ankle arthroplasty (AA) (Mobility™) is a recognised problem without any apparent cause. This study aimed to determine pattern of postoperative pain following Total Ankle Arthroplasty (TAA) and its management options.

Background

Despite the suggestion by Virchow in 1856 that thrombosis was the result of venous stasis, endothelial dysfunction and hypercoagulability there are some fundamental questions which remain to be answered. The published studies fail to provide specific details such as cast type and anatomical location of the thrombosis, but instead focus on the incidence of VTE and which chemical thromboprophylaxis is most effective. Previous studies of VTE in trauma patients have involved small numbers of patients and have not look at the risk medium to long term risk. Most importantly they have not looked at the site of the VTE. This makes interpretation of the link between cast and VTE even more complex.

Introduction

Minimally invasive Achilles tendon repair has recently gained popularity amongst foot and ankle surgeons. This study aims to quantify the risk of sural nerve injury when using the Achillon device (Integra), as well as delineate its anatomical relationship to the Achilles tendon.

Introduction

The Mobility™ prosthesis [Depuy] is the most extensively used TAR in the UK, though there are few published results. We present our complete experience of the Mobility prosthesis in a diverse population.

Introduction

Up to 70% of patients with symptomatic Morton's neuroma proceed to surgery having failed non-operative management. The success of surgical excision is up to 85% but carries with it significant morbidity. Radiofrequency ablation (RFA) is a less invasive alternative.

Introduction

The aim of this study is to better understand the anatomy of the forefoot to minimise surgical complications following minimally invasive forefoot surgery.

First metatarsophalangeal joint (MTPJ) arthrodesis plays a significant role in the management of symptomatic hallux rigidus. Several open and very few percutaneous techniques have been described in the literature. The authors present a new minimally invasive technique along with patient reported outcome, radiological parameters and a discussion on this novel technique.

A total of fifteen cases of first MPTJ arthrodesis were included in this prospective continuous series from September 2011 to June 2012. Mean age was 56 years and the indication for surgery was hallux rigidus in 13 of 15 cases. All patients underwent the same minimally invasive procedure by the same primary surgeon (AHS), 13 of 15 as day cases. Clinical outcome and patient satisfaction were assessed by the Manchester-Oxford Foot Questionnaire (MOXFQ) preoperatively and at most recent follow up. Radiographic and clinical evaluation of fusion was also assessed. No patients were lost to follow up and all scores were collected by an independent surgical practitioner to avoid bias. Mean follow up was six months (range 1 to 9 months).

The MOXFQ score for cases where fusion was achieved (n=14) improved from a mean 40/64 preoperatively to a mean 15/64 at last follow up (p=0.001). Patient satisfaction was overall very good.

This minimally invasive technique for first MTPJ arthrodesis is simple and can achieve results similar or better than open techniques in experienced hands. Further cases are needed to expand this series and evaluate for further complications.

When performing scarf osteotomies some surgeons use intraoperative radiography and others do not. Our experience is that when using intraoperative radiography we often change the osteotomy position to improve the correction of the hallux valgus angle and sesamoid position.

We report the results of a single surgeon series of 62 consecutive patients who underwent a scarf osteotomy for hallux valgus. The first 31 patients underwent surgery without the use of intraoperative radiographs and the subsequent 31 patients underwent surgery with the use of intraoperative radiographs, this reflects a change in the surgeons practice. Hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle and sesamoid position using the Hardy Clapham grading system were recorded. All patients had measurements recorded from weight baring radiographs taken pre operatively as well as at 6 and 12 weeks post operatively. Intraoperative measurements were also recorded for all patients in the intraoperative radiography group.

The mean hallux valgus angle preoperatively was 28.5° in the control group and 30.5° in the intraoperative radiography group. The mean hallux valgus angle in the control group at 6 weeks was 12.4° and at 12 weeks was 12.6°. The mean hallux valgus angle in the intraoperative radiography group at 6 weeks was 10.5° and at 12 weeks was 9.8°.

The median sesamoid position pre operatively was 4 for both groups. At 6 and 12 weeks the sesamoid position improved by a median of 1 position in the control group and 2 positions in the intraoperative radiography group (p<0.05).

We recommend that surgeons who do not routinely use intraoperative radiography undertake a trial of this. We have found that the use of intraoperative radiography improves the correction of hallux valgus angle and sesamoid position. These have been shown to increase patient satisfaction and reduce recurrence.

Introduction

Hallux valgus surgical correction has a variable but significant risk of recurrence. Symptoms result from an iatrogenic first brachymetatarsia following the index surgical procedure. First metatarsal shortening has been shown to correlate with the onset of transfer metatarsalgia. We describe the use of the scarf osteotomy to both correct the recurrent deformity and lengthen the shortened first metatarsal.

Introduction

With increasing numbers of primary total ankle replacements being performed, the number of revision ankle surgeries is expected to rise also. We present the results of the revision procedures for failed Scandinavian total ankle replacements.

Introduction

Bone Marrow Oedema Syndrome (BMOS) is an unusual and poorly understood condition. It commonly affects the hips and knees and is reported to have a tendency to recur. The foot and ankle are less frequently involved but nevertheless patients can be severely impaired. Only case reports of BMOS of the foot and ankle have been published.

The aim of this study is to evaluate the sites of occurrence, risk factors, efficacy of immobilisation, response to intravenous biphosphonates and local or remote recurrence over the following years.

Introduction

Total ankle replacement (TAR) surgery remains a reasonable alternative to arthrodesis in a select group of patients with end stage ankle joint arthritis. We describe the early results of a prospective study of the first 50 Zenith total ankle replacements performed by a single surgeon (SKG).

Aim

A prospective cohort of patients undergoing total ankle arthroplasrty for arthritis following pilon fractures was included in the present study. This group of patients generally have poor soft tissue envelope and have had previous surgical interventions prior to the ankle arthroplasty, making the arthroplasty more difficult as well as prone to complications.

Introduction

Surgeons, commissioners and patients are increasingly seeking more in depth details on outcomes of total ankle replacement (TAR). We set out to perform a detailed and up to date meta-analysis of the outcomes of TAR, with a focus on PROMS.

Introduction

Venous thromboembolism (VTE) represents a major cause of morbidity, mortality and financial burden to the NHS. Acquired risk factors are well documented, including immobilisation, lower limb plaster cast and surgery. NICE guidance on VTE prophylaxis within orthopaedics currently excludes operative ankle fracture fixation (ankle ORIF).

Introduction

Excision of prominent metatarsal heads for severe rheumatoid forefoot deformity is well established in clinical practice but results may deteriorate with time. The Stainsby forefoot arthroplasty however, recognises the pathological anatomy of the deformity and is designed to preserve the metatarsal heads by repositioning the plantar plates and forefoot fat pad underneath them.

Introduction

Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, a review of literature suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomittant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes.

Introduction

We present a consecutive series of 19 patients with 22 intra-articular calcaneal fractures treated by percutaneous arthroscopic fixation (percutaneous arthroscopic calcaneal osteosynthesis “PACO”). Traditional open reduction and fixation regularly has significant wound complications. PACO has the advantage of direct visualization of the joint surface reduction with the benefit of minimal soft tissue trauma and wound complications.

Introduction

There are a number of options available for surgical management of hallux rigidus. Ceramic implants of the first metatarsophalangeal joint (MTPJ) have been available for years; however there are no published long-term results existing.

Background

Lisfranc/midfoot injuries are complex injuries with a reported incidence of 1 in 55000 in literature and frequently overlooked. But, recently they are becoming more commonly diagnosed with advent of CT scan and examination under anaesthesias (EUA) for suspicion fractures. Here we present a case series results of a single surgeons experience over the last 6 years.

Minimally invasive chevron and akin osteotomy are being used in a few centres in the UK. The purpose of our study was to analyse our early results and present our early experience of minimally invasive chevron and akin osteotomy (MICA) for the correction of mild to moderate hallux valgus.

This study assessed the radiological and clinical measurements, American Orthopaedic Foot and Ankle Society (AOFAS) scores, pain scores and patient satisfaction associated with performance of the MICA, for the treatment of hallux valgus.

Between September 2010 and April 2012, 96 consecutive patients (122 feet) who underwent MICA were assessed. The overall satisfaction rate was over 90%. The mean total AOFAS score was 89.7 points. VAS for pain reduced from a mean of 7.4 to less than 1 point. On weight bearing anterior-posterior foot radiographs there was a significant improvement in the mean IMA and HVA.

Complications included 2 episodes of superficial infection (1.6%), 1 fracture (0.8%), 4 incidence of nerve injury (3.3%) (Numbness) and 9 patients requiring removal of screw (7.4%). However, these screw removals occurred early on in the study and diminished after a slight modification in surgical technique.

Based on our findings we concluded that MICA is an effective procedure with good patient satisfaction in the treatment of mild to moderate hallux valgus.

Introduction

Operative fixation of ankle fractures is often deferred due to swelling to avoid the risk of wound problems. The routine practice is to admit the patient and operate once the swelling has subsided. We introduced a new pathway to manage these ankle fractures at home preoperatively to improve service efficiency. We studied the impact of home therapy on length of inpatient stay and associated problems.

Introduction

Patients who present with atypical foot pain in a non specific sensory distribution may benefit from having nerve conduction studies (NCS). The aim of this study was to confirm whether NCS is a useful tool.

Introduction

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints.

Introduction

Whilst most cases of plantar fasciitis can be resolved with existing conservative established treatment options, a few intractable cases can be difficult to resolve. New biologic treatments have been proposed for a variety of soft tissue tendon problems. We evaluated the results of PRP in the treatment of recalcitrant chronic cases of plantar fasciitis.

Introduction

Hallux Rigidus affects 2–10% of population, usually treated with cheilectomy or arthrodesis, however, for the subclass of patients who refuse to undergo fusion, Arthroplasty is an alternative solution, it maintain some degree of motion and provide pain relief. Toefit; is one of the prostheses being used. It is a total joint replacement with polyethylene insert.

The aim of this study is to find clinical and radiological outcomes of Toefit arthroplasty.

Achilles tendinopathy is chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. It involves a triad of pain, swelling and impaired function. Primary treatment is rest, analgesia, corticosteroid injections and physiotherapy (eccentric training and heel pads to correct gait). Some patients remain symptomatic and further treatment options need considering.

NICE produced a document from the Interventional Procedures Advisory Committee in 2009 which reviewed the literature and evidence for extracorporeal shockwave treatment (ESWT). Low energy shock wave treatment (SWT) is thought to stimulate soft tissue healing, inhibit pain receptors and promote angiogenesis. NICE guidance was that ESWT could be used in refractory Achilles tendinopathy if used for clinical governance, audit or research.

Patients with refractory Achilles tendinopathy were enrolled between October 2010 and 2011. They received three sessions of ESWT over three week. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale (six points, high is worsening) were reassessed at 6 and 16 weeks post treatment.

51 patients completed follow up. The mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. There was a significant improvement (p<0.05) in VAS scores observed from baseline and 16 weeks post treatment. This was also the case in the VISA-A scores. The mean Likert score was 3 (somewhat improved) at 16 weeks but there was no statistical significance.

This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy. Patients over 60 possibly have a worse outcome along with patient who had symptoms for over 25 months. Follow up scores at one year are due to be collected and the data will be submitted to NICE.

Introduction

Stress fractures in the foot are common; the common practice is to look for any factor in the history or for any foot deformity that could cause the fracture. Once found, it is common to treat the fractures without further investigations. The aim of this study is to assess if we are missing any underlying metabolic disorder associated with such injury.

Background

The conflict in Afghanistan has been epitomised by the emergence of the Improvised Explosive Device (IEDs). Improvements in protection and medical treatments have resulted in increasing numbers of casualties surviving with complex lower extremity injuries. To date, there has been no analysis of foot and ankle blast injuries as a result of IEDs. Therefore the aims of this study are to report the pattern of injury and determine which factors were associated with a poor clinical outcome.

Introduction

The muscles of the leg collectively comprise the calf pump, however the action of each muscle group on calf pump function is not known. Patients with foot or ankle injury or surgery are often advised to perform foot and ankle movements to help prevent deep venous thrombosis. Our aim was to determine which foot and ankle movements were most effective in stimulating the calf pump. Method: Nine healthy participants were enrolled in this research and ethics approved prospective study. Participants with a previous history of peripheral vascular disease, varicose veins, deep venous thrombosis or previous foot and ankle surgery were excluded. Each participant followed a standardized protocol of foot and ankle movements, starting with foot in neutral position and the baseline and movement peak systolic velocity within the popliteal vein was measured during each movement. The movements tested were toe dorsiflexion, toe plantar flexion, ankle dorsiflexion, ankle plantar flexion.

Introduction

The Z or “scarf” osteotomy was first described by Meyer in 1926 and then by Burutaran in 1976. It was later popularised by Weil in the USA and Barouk in Europe in the 1990's and is now an accepted technique that forms part of a surgeons' armamentarium. The theory of Diffusion of Innovations was described by Rogers in 1962 to explain how novel ideas are accepted into practice across different industries, including medicine. It has never previously been used to study the adoption of ideas in foot and ankle surgery.

Introduction

Chronic mid body Achilles tendinopathy is a common problem. There is no consensus on treatment. The aim of this review was to assess the effectiveness of physiotherapy interventions (non surgical and non pharmacological) for this condition.

Background and objective

Metatarsals stress fractures are common in athletes and dancers. Occasionally, such fractures could occur without trauma in peripheral neuropathic patients. There is no published series describing outcome of stress fractures in these patients. This study analyse these fractures, treatment and outcome.

Introduction

Scar sensitivity is a recognised complication of foot surgery. However there is very little published about it. This study looks at the incidence and natural history of scar sensitivity following hallux valgus surgery.

Aim

Single-photon emission computed tomography is a new imaging modality combining high detail CT with highly sensitive triple phase nuclear bone scanning to help clinicians in diagnosis and management of various conditions. Little has been published about its particular usefulness in foot and ankle pathology. We conducted a prospective study to evaluate the role of SPECT for the same.

Numerous procedures have been reported for the hallux valgus correction of the great toe. Scarf osteotomy is a versatile osteotomy to correct varying degrees of mild to moderate hallux valgus deformity. It can also be used for lengthening of the 1st ray as a revision procedure to treat metatarsalgia in patients who had previous shortening osteotomy.

We wish to report a patient who had lengthening SCARF osteotomy for the metatarsalgia following previous hallux valgus correction and developed arthritis of the 1st MTPJ in a short term which required fusion. A 49 year old female patient was seen with pain and tenderness over the heads of the 2nd and3rd metatarsal of the right foot. She had hallux valgus correction 10years ago with a shortening osteotomy of the 1st metatarsal. She developed metatarsalgia which failed to conservative management.

She had a lengthening SCARF osteotomy for the metatarsalgia in 2004. She had good symptomatic relief for two years and then started having pain over the 1st MTPJ. On examination she had limited movements of the 1st MTPJ and tenderness over the dorsolateral aspects of the 1st MTPJ suggestive of arthritis. Radiographs of the foot showed healed osteotomy with no evidence of AVN of the 1st MT head but features suggestive of osteoarthritis. She had fusion of the 1st MTPJ performed in 2008 for the arthritis following which symptoms resolved.

This case highlights that arthritis of the 1st MTPJ can occur in the absence of an AVN of the metatarsal head and patients need to be warned of this potential complaining when having the lengthening SCARF osteotomy for metatarsalgia following a previous shortening osteotomy of the 1st ray.

The relationship between hindfoot and forefoot kinematics is an important factor in the planning of ankle arthrodesis and ankle arthroplasty surgery. As more severe ankle deformities are corrected, improved techniques are required to assess and plan hindfoot to forefoot balancing.

Gait analysis has previously been reported in patients with ankle arthritis without deformity. This group of patients have reduced intersegment motion in all measured angles. We have looked at a small group of patients with hindfoot deformity and ankle arthritis awaiting fusion or replacement.

Using the Oxford Foot Model we have assessed lower limb kinematics with a focus on hindfoot to forefoot relationships. The results of our pilot study are in variance to previous studies in that we have shown that in the presence of hindfoot/ankle deformity, the forefoot range of motion increases. We feel that these data may impact on surgical planning.

This study looked at the effect on referral for surgical opinion of introducing ESP Physiotherapy (1 physiotherapist) and Podiatry (2 podiatrists) clinics on the number of foot and ankle patients who were seem for a surgical opinion and subsequently surgery.

Prior to the introduction of the ESP clinics the number of patients was approximately 1 in every 8 was listed for surgery. At the time of the study the ESP clinics accounted for half of the new patients seen in orthopaedic foot & ankle clinics. The other half was seen by the surgical team (3 surgeons).

Introduction

In 1927, Lambrinudi described a variant triple fusion for the treatment of paralytic “drop foot”. This involved closing wedge osteotomies and fusion to correct the deformities predominantly caused by Polio. The eradication of Polio has seen a shift in its use to the correction of other complex hind foot deformities. The technique has relevance in modern Orthopaedics for other neurological and degenerate conditions. There have been few published series of this technique since 1927.

We describe a series of 14 complex corrective triple arthrodeses to illustrate the power of Lambrinudi's concepts. We believe Lambrinudi's original description has relevance in terms of modern day complex hindfoot deformity correction.

Introduction

The exact action of the Peroneus Longus muscle on the foot is not fully understood. It is involved in a number of pathological processes like tendonitis, tenosynovitis, chronic rupture and neurological conditions. It is described as having a consistent insertion to the base of the first metatarsal, but there have also been reports of significant variations and additional slips. Our aim was to further clarify the anatomy of the main insertion of the Peroneus Longus tendon and to describe the site and frequency of other variable insertion slips.

It is recognised that as the severity of hallux valgus (HV) worsens, so do the clinical and radiological signs of arthritis in the first metatarsophalangeal joint.

However, few studies specifically document the degenerate changes. The purpose of this study is to determine if intraoperative mapping of articular erosive lesions of the first MTP joint can be correlated to clinical and/or radiographic parameters used during the preoperative assessment of the HV deformity.

This is a case series report on the outcomes of patients that have received ORIF of their calcaneal fractures at Craigavon Hospital, Northern Ireland, for the first 2 years since it opened. It is a one surgeon series.

Introduction

Hallux valgus is a common orthopaedic complaint with multiple surgical options. There are many methods available for assessing whether sufficient translation of the first metatarsal can be achieved with a metatarsal translational osteotomy alone. None of the current methods take into account the breadth of the metatarsal. With current PACS technology a radiograph can be zoomed to any size and we postulate that by using the surgeon's thumb (or any suitable digit), as a sizing tool, a safe clinical decision can be made concerning whether a translational metatarsal osteotomy alone will provide sufficient correction.

Introduction

Calcaneal osteotomy is often performed together with other procedures to correct hindfoot deformity. There are various methods of fixation ranging from staples, headed or headless screws or more recently stepped locking plates. It is not clear if one method is superior to the other. In this series we compare the outcome of various methods of fixation with particular attention to the need for subsequent hardware removal.

The management of unstable ankle fractures is challenging due the difficulty in differentiating between stable and unstable fracture patterns. The aim of our study was to examine our practice and to determine if the operative management of unstable ankle fractures resulted in significantly improved radiographic parameters.

Between June 2008 and December 2008, we identified all skeletally mature patients who were diagnosed with an ankle fracture after having radiographs in the radiology department at our institution. We analysed the case notes and radiographs of these patients retrospectively. The fractures were classified according to the Weber and Lauge-Hansen classification. Radiographs were evaluated for shortening of the fibula, widening of the joint space, or malrotation of the fibula. Three measurements were used to ascertain whether the correct fibular length has been restored – the circle sign, the talocrural angle, and the tibiofibular (or Shenton) line.

Of 1064 patients who had radiographs, 123 patients sustained a fracture of the ankle. There were 61 females and 62 males, with a median age of 47 years. There were 20 Weber A, 80 Weber B and 12 Weber C ankle fractures. Eleven fractures could not be classified according to the Weber classification. According to the Lauge-Hansen classification there were 44 Supination-External rotation (SER) stage II fractures, 35 Supination-External rotation (SER) stage IV fractures, and 7 Pronation-External rotation (PER) stage III fractures. In the unstable SER stage IV fractures, 30 of the 35 patients had operative treatment and there was no statistically significant difference in the average Talocrural angles in the operative (78.9°) and nonoperative groups (83.4°). None of the patients with an SER stage IV fracture managed nonoperatively had an adequate circle sign compared to 14 of the 30 patients in the operative group who had an adequate circle sign. In the PER stage III fractures 4 of the 7 patients had operative treatment. The average Talocrural angle in the operative group was 79.1° versus 75.3° in the nonoperative group, with all patients in the operative group having an adequate circle sign compared to none in the nonoperative group. The patient numbers in the PER stage III group however were too small to show a statistically significant difference. In 4 patients with unstable fracture patterns, the use of a third tubular plate to bridge a fibula fracture without an inter-fragmentary lag screw led to inadequate restoration of fibular length in all cases.

It is important to recognise unstable ankle fracture patterns and, in patients treated operatively, to restore fibular length and rotation. Operative management of unstable SER stage IV and PER stage III ankle fractures can restore normal radiographic parameters. We highlight certain technical pitfalls in restoring fibular length such as the inappropriate use of the semi-tubular plate as a bridging plate.

The purpose of this study was to evaluate the early functional outcome of this new modification of the Brostrom-Gould lateral ligament reconstruction using suture anchors and triple breasting of ATFL.

AOFAS hindfoot scoring system was the primary outcome measure used. Between January 2008 and May 2011, data was collected prospectively, pre and postoperatively. Surgery for all patients included ankle arthroscopy plus whatever other minor procedure was indicated and was performed by the senior author. Postoperatively at 3 months and 12 months and in May 2011 patients were asked to attend a research clinic and their scores were obtained.

Anterior drawer laxity and patient satisfaction, activity resumption and complications were some of the other information recorded. A mean follow up of 25 months on 18 ankles is presented which is amongst the longest in the literature for this procedure. Comparing pre and postoperative AOFAS scores revealed a statistically significant mean improvement of 39 points p < 0.05 with mean preoperative score being 53 and at 25 months being 89. All ankles felt clinically stable on repeated anterior drawer testing. 8 patients had resumed normal pre-injury level of activities (including sports), 8 had some reduction in normal level of activity and 2 did not carry out physical prior to operation. One patient complained of scar tenderness otherwise no complications were noted. 13 patients were extremely satisfied with results of surgery, 4 were very satisfied and 1 was moderately satisfied.

The mid-term results of our modification show it to be safe, reproducible and highly successful in producing clinically and functionally stable ankles with high patient satisfaction. This includes a statistically significant improvement in AOFAS scores. This exceeds the results in the published literature.

Open cheilectomy is an established surgical treatment for hallux rigidus. Cheilectomy is now being performed using minimally invasive (MIS) techniques. In this prospective study we report the outcome of minimally invasive cheilectomy comparing the results with a matched group who had cheilectomy using standard open procedure

Introduction

The Ponseti regime was introduced in Swansea in 2003 for the treatment of congenital talipes equinovarus (CTEV). The aim of this retrospective cohort study was to compare children treated with this regime with a historical group treated traditionally before then.

Patient reported outcomes and satisfaction as a measure of service quality is becoming an increasingly important tool in local service assessment as well as a quality indicator within commissioning frameworks. We analyse the introduction of SCP led MDT facilitated patient group meetings addressing the education and preparation of patients listed for ankle and hindfoot surgery at WSH HYPOTHESIS- To identify the outcome benefits to patients from this type of quality initiative. This has been previously demonstrated in other specialities in the trust such as hip and knee replacement resulting in mandatory attendance as part of the care pathway.

Feedback was gathered via a patient questionnaire from 60 patients invited to meetings over an 18 month period. Two groups of patients who have undergone hindfoot/ankle surgery at WSH were compared. Group 1 attended a 1 hour MDT meeting preoperatively designed to educate the patient on all aspects of their surgery from pre assessment through to post operative management. Group 2 did not attend any such meeting whether invited or not.

Method

A questionnaire was given to delegates at the British Orthopaedic Foot & Ankle Society (BOFAS) annual scientific meeting 3rd–5th November 2010. A total of 75 questionnaires were included within the analysis. The questionnaire asked delegates for their most commonly performed procedure for a variety of common foot and ankle conditions.

Introduction

Morton's Neuroma is routinely treated by excision of the interdigital nerve. Traditional surgery works by denervation, but the results are variable, and recurrence is common. Multiple Morton's Neuromas present a difficult clinical challenge. MR and ultrasound often demonstrate a normal nerve or an interdigital bursa. Some experts advise division of the intermetatarsal ligament rather than excision. This case series evaluates an alternative method of treatment.

Failed Hallux Valgus Surgery Aim

We aim to explore the reasons behind long term failure of hallux valgus surgery.

Introduction

The incidence of deep venous thrombosis (DVT) in patients with lower limb cast immobilization occurs in up to 20% of patients. This may result from altered calf pump function causing venous stasis. Our aim was to determine the effects of below knee cast on calf pump function.

Introduction

The aim of this study was to assess whether routine X-Rays at six weeks altered the subsequent management of patients who underwent a Scarf osteotomy.

MIS (minimally invasive surgery) aims to improve cosmesis and facilitate early recovery by using a small skin incision with minimal soft tissue disruption. When using MIS in the forefoot, there is concern about neurovascular and tendon damage and cutaneous burns. The aim of this anatomical study was to identify the structures at risk with the proposed MIS techniques and to determine the frequency of iatrogenic injury.

Determination of ankle stability is straightforward when the injury involves both the medial and lateral malleolus. However it can be challenging when the medial injury involves the deltoid ligament. Radiographic diagnosis of ankle instability highly depends on the measurement of medial clear space. As the shape of talus has been postulated akin to a trapezoid, the medial clear space may be influenced by the portion of talus occupying the mortise. Hence the medial clear space may be influenced by the position of the ankle. We sought to evaluate the impact of ankle plantarflexion and division of the deltoid ligament on the medial clear space.

For the study 10 fresh-frozen cadaveric lower limbs were used. Mortise radiographs were taken at neutral, 15 and 30 degrees of plantarflexion and neutral external rotation. These measurements were repeated after dividing the deltoid ligament. To ensure consistent ankle position, the ankle was placed in a specially constructed rig, which recreated the above positions. The medial clear space and talar tilt were measured. Differences in the means between the groups were determined with the paired ‘t’ test and ANOVA within the groups. Statistical significance was set a p-value of 0.05.

Increasing the plantarflexion from neutral to 30 degrees in both groups resulted in increase in the medial clear space and talar tilt. The mean increase in medial clear space became statistically significant at 30 degrees when compared to neutral. Between the groups there was a significant difference in medial clear space at 30 degrees plantarflexion. Dividing the deltoid ligament also had a significant effect on talar tilt.

Plantarflexion has an influence on the medial clear space in ankle mortise views therefore pre and post ankle fixation radiographs must be interpreted with caution.

There is no optimal treatment for osteochondral defects of the talus after failed primary surgical treatment. To treat these patients, a 15-mm diameter metal implant was developed for the medial talar dome. The present study was undertaken to evaluate the clinical effectiveness of the metal implantation technique for osteochondral lesions of the medial talar dome.

This is a prospective case series. The inclusion criteria were the combination of a large OCD (ϕ >12 mm) of the medial talar dome, persistent complaints >1 year after treatment, and clinically relevant pain levels. The exclusion criteria were: age <18 years, OCD size >20 mm, ankle osteoarthritis grade 2 or 3, concomitant ankle pathology, and diabetes. The primary outcome measure was the Numeric Rating Scale pain (NRS) rest, walking, running, and stair climbing. Secondary outcome measures were: Foot Ankle Outcome Score (FAOS), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, and clinical and radiographic complications. The Wilcoxon signed ranks test was used to calculate p-values.

Between October 2007 and March 2009 10 patients were included. The median follow-up was 2 years (range, 2–3 years). On preoperative CT scanning, the median lesion size was 15 (range, 12–20) × 11 (range, 8–14) mm. The NRS rest improved from a median of 3 (0–7) preoperatively to 0.5 (0–2) at final follow-up (p = 0.017), NRS walking from 6.5 (4–8) to 1 (0–4) (p = 0.005), NRS running from 9 (6–10) to 3 (0–10) (p = 0.024), and NRS stair climbing from 6 (4–8) to 1 (0–7) (p = 0.012). The FAOS improved significantly on four of five subscales. The AOFAS improved from a median of 70 (47–75) before surgery to 89 (69–100) at final follow-up (p = 0.008). There were three temporary complications: hyposensibility about the scar in two and a superficial wound infection in one. There were no radiographic complications.

Locked plates confer angular stability across fusion sites, and as such are more rigid than either screws or intramedullary nails. This gives the advantage of reducing motion to enhance union rates and potentially allowing early weight bearing. The Philos plate (Synthes) is a contoured locking plate designed to fix humeral fractures but which also fits the shape of the hindfoot and provides strong low profile fixation. Its successful use for tibiotalocalcaneal (TTC) arthrodesis has been reported.

Our aim was to prospectively evaluate the use of the Philos plate in hindfoot arthrodesis Twenty-one hindfoot arthrodeses were performed using the Philos plate between Oct 2008 and Jan 2010. Patients were followed up for a minimum of 1 year and had preoperative and 6 monthly AOFAS hindfoot scores and serial radiographs until union. Overall there were 15 ankle fusions, 5 tibiotalocalcaneal fusions and 1 subtalar fusion. At 6 months there were 13 unions and 9 non-unions (4 ankle, 5 TTC) giving a non-union rate of 38% overall and 25% for ankle fusions in isolation. Mean AOFAS scores at 6 months were 74/100 for the union group and 47 for non-unions (chi squared p < 0.001). No patient in the non-union group went on to fuse within a year without further surgery. Both groups had similar case mixes including osteoarthritis, AVN of the talus and failed arthroplasty. They also had similar co-morbidities, rates of smokers and bone grafting.

Our conclusion is that the high non-union rates are probably due to the lack of compression conferred across the join by the Philos plate as there is no compression hole and we did not supplement the fixation with a lag screw. We recommend using locked plates for hindfoot arthrodesis only with additional compression.

Introduction

There is less literature reporting outcomes following total ankle replacement (TAR) in patients presenting with a coronal plane deformity preoperatively. This study compares clinical and patient reported outcomes at 1 year between TAR patients with and without coronal plane deformity.

Background

The recent emphasis on using “evidence based medicine” for decision-making in patient care has prompted many publishers to mention the level of evidence of articles in their journals. The “quality” of a journal may thus be reflected by the proportion of articles with high levels of evidence and assist it achieve citations and therefore an Impact Factor.

The purpose of this study was to survey published Foot and Ankle literature to evaluate changes in the level of evidence over ten years.

Total ankle replacement (TAR) is increasingly offered as an alternative to ankle fusion for the management of severe ankle arthritis. As with all other types of joint arthroplasty, there are risks involved and complications that occur; these increase with case complexity. We present the complications and management from a single-centre series.

Since 2006, we have performed 150 Mobility TARs with up to 4 years' follow-up. We have excluded 16 that are part of a separate RCT and 10 with less than 3 months' follow-up. 124 TARs were included in our study (117 patients). Three ankles (2.4%) had superficial wound infections treated successfully with antibiotics. One ankle (0.8%) required an arthroscopic washout and debridement but the implant was retained. 11 ankles (8.9%) had a periprosthetic fracture: One was intraoperative; 10 were postoperative (2 fixed). Four patients (3.2%) developed CRPS. One ankle required fusion surgery (following subsidence of the talar component) with another one pending revision (ligament instability causing implant displacement). No patient had a symptomatic deep vein thrombosis or thromboembolic event.

Our figures are comparable with other series. Our complication rate has not changed significantly over time. Our results, at present, suggest that most complications (98%) with the Mobility TAR can be satisfactorily managed without having a detrimental effect on the implant.

There have been proven and promising results with total ankle replacement. However, there is a significant complication rate that must be made clear to the patient via informed consent; the rate still remains higher than for hip and knee arthroplasty.

Numerous techniques are used for the fusion of failed TAR. We wish to report our results of the revision of failed TAR to fusion.

Between July 2005 and February 2011 the senior author had performed 20 arthrodeses in 19 patients (13 male and 6 female) who had failed total ankle arthroplasty (TAR). Their mean age was 63.5 years. All of them had the AES total ankle replacement. (Biomet UK). The mean period from the original TAR to fusion was 51 months (6 to72). The indication for revision of TAR to fusion was septic loosening in 4 patients and osteolysis and or aseptic loosening in 16 cases. Three types of fusion techniques were used.

The mean follow-up was 15 months. All 3 tibiotalar arthrodeses with screws alone fused successfully. Of the 13 patients where the fusion was augmented with an Ilizarov frame, 4 were done for septic loosening. There were 2 non unions of which one was stable without pain and the other required a further revision fusion with a frame and subsequently fused. Of the 9 patients who had a fusion with a frame for osteolysis and or aseptic loosening, there was one non union which was revised to a tibiotalocalacaneal fusion with a hind foot nail. The nail fractured at the level of the posterior oblique screw hole. The patient subsequently developed a relatively pain free non-union of the tibiotalar joint and not required further surgical intervention. The remaining 8 ankles fused at a mean of 5 months. The average time of frame removal was 17 weeks. There was four pin-site infection all of which settled with oral antibiotics. 5 patients had tibiotalocalacaneal fusion with a hind foot nail. The indication for the hind foot nail was significant osteolysis and loss of talar bone stock. The average shortening as a result of the fusion for the failed TAR was 1.5cms.

Our results were comparable to the previous reports of arthrodesis for failed total ankle replacement. We recommend the use of tibiotalocalcaneal fusion with a hind foot nail in the presence of severe osteolysis or accompanying subtalar arthritis. In the presence of good bone stock an ankle fusion supplemented with a circular frame gives a good predictable outcome.

Introduction

Single photon emission computed tomography (SPECT) can be used to create a three dimensional image of a radiopharmaceutical bone scan. This combined with high resolution CT scan (SPECT-CT) with bone windows allows the linking of the information obtained in both investigations. The multiplanar anatomical information provided by CT is therefore linked with the functional, biological information of bone scintigraphy. The painful total ankle replacement has a number of potential causes of discomfort including impingement and loose components. Correct identification of the source of pain will assist surgeons in treating the source of the pain while avoiding unnecessary surgery. We present our experience of the use of SPECT-CT to investigate patients with ongoing pain following Total Ankle Replacement (TAR).

Introduction

Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (CO) is a well-recognised surgical treatment for stage II posterior tibial tendon dysfunction (PTTD). Whilst excellent results are quoted for short and medium term follow-up, the long-term outcome of this procedure is unknown.

Introduction

Medial calcaneal displacement osteotomy with an FDL tendon transfer is a common method of correcting pes planus deformity secondary to grade II tibialis posterior dysfunction. There is currently no evidence that calcaneal displacement alters the centre of pressure in the foot from a medial to a more central position as the normal shape is reconstituted.

Treatment of the rheumatoid forefoot involves resection arthroplasty of the MTP joints of the lesser toes. This can either involve resection of the metatarsal heads or, as described by Stainsby: resection of the proximal phalanx. The Stainsby procedure is a well accepted technique, however despite this there is very little information on the outcome of this procedure.

Introduction

Foot and ankle is a well-established and growing sub specialty in orthopaedics. It accounts for 20 to 25 per cent of an average department's workload. There are two well established foot and ankle specialist journals but for many surgeons the Journal of Bone and Surgery (JBJS) remains the preeminent journal in orthopaedics and a highly sought after target journal for publication of research. It is our belief that foot and ankle surgery is underrepresented in the JBJS. We undertook a study to test this hypothesis.

Akins original description of his osteotomy did not describe the use of any metal work. Today the osteotomy is most commonly held and fixed with either a staple or screw. We describe the results obtained with a simple suture technique. Methods Data was collected prospectively on 125 patients undergoing an Akin osteotomy. Hallux valgus (HV) and intermetatarsal (IM) angles pre and postoperatively were recorded. Patients were reviewed at 6 week follow up. Cost analysis was also performed comparing different fixation types.

111 of the patients were female and 14 male. The average age at time of surgery was 49 years. 104 cases were in conjunction with hallux valgus correction while 21 cases were for hallux interphalangeus. The mean preoperative HV angle was 33.3 degrees (range 22 to 53), and the IM angle 13.3 degrees (range 9 to 25). At the 6 week follow up all patients had shown signs of radiological union. The postoperative HV angle was 12.4 degrees (range 7 to 17) and the IM angle 6.4 degrees (range 5 to 11). All patients maintained their correction. There were no complications, infections or fixation problems. All patients were satisfied with their surgery and would have it repeated again. The suture technique was the most cost effective method.

We describe a quick, easy, implant free method of fixing the Akin osteotomy. There is no need for metalwork removal and in today's world of austerity and the current climate of widespread budget constraints we describe a cost effective method which is clinically just as effective as methods requiring a staple or screw.

The saphenous nerve is classically described as innervating skin of the medial foot to the first MTP joint and thus is at risk in surgery to the medial ankle and foot. However, it has previously been demonstrated that the dorsomedial branch of the superficial peroneal nerve consistently supplies the dorsomedial forefoot, and therefore previous descriptions of the saphenous nerve maybe erroneous.

We undertook a cadaveric study to assess the presence and variability of this nerve.

21 cadaveric feet were dissected from a level 5 cm above the medial malleolus, and distally to the termination of the saphenous nerve. In 16 specimens (76%), a saphenous nerve was present, of which 14 were anterior to the saphenous vein. Two of 16 nerves terminated above the medial malleolus. Therefore, only 14 of 21 specimens (66%) had a saphenous nerve present at the level of the medial malleolus. In seven of these 14 specimens (50%), the nerve terminally branched before the level of the tip of the malleolus. The mean distance reached in the foot was 46mm. Only two nerves reached the forefoot, at 97mm and 110 mm from the ankle joint respectively. At the ankle, the mean distance of the nerve from the tibialis anterior tendon was 9mm, and the saphenous vein 1.2mm.

Peroneal tendon subluxation although rare, is a commonly misdiagnosed cause of lateral ankle pain and instability. The orientation and depth of the lateral retromalleolar groove is a major contributor to peroneal stability, but is little understood. We attempt to quantify the groove using three directional mapping techniques.

Eight age and sex matched embalmed cadaveric feet were dissected to expose the peroneal tendons and the retromalleolar groove. A hand held digitiser was used to map the version and inclination of the groove in a 3D virtual environment. The length and depth of the groove and its orientation were calculated using the cartilage boundary and the centroid of the curved surface.

Four male and four female specimens (mean age 80 Yrs) were studied. The groove was noted to be concave in 62%, flat in 25 % and concave in 12.5 %. Flatter groove were more commonly noted in (2/4) females. There was a significant difference in length and width of the groove between male and female feet. The mean length of the groove in male specimens was 6.2cm (5.4–6.7cm), and in female specimens 5.5cm (4.4–5.9cm). The mean width in males was 5.3mm (5.0–6.1mm) and in females 4.5mm (3.7–5.3mm). There was no significant difference noted in the depth of the groove between male and female feet. The mean depth in males was 2.3mm (0.8–3.1) and in female 2.2mm (0–2.4mm).

Knowledge of peroneal groove geometry in treatment of peroneal tendon instability is important. There appears to be a consistent difference in the anatomy of the groove between the sexes. Although men have longer and wider grooves than woman, the depth is the same in both sexes.

Background

The aim of this prospective study was to assess the effectiveness of a single ultrasound-guided steroids injection in the treatment of Morton's neuromas and whether the response to injection correlates with the size of neuroma.

Background

Forefoot surgery is often performed under regional anaesthesia (ankle block) in awake patients, using tourniquet or esmarch bandage to obtain bloodless field. The purpose of this study was to examine the value and need for local tourniquet pain control using local subcutaneous analgesic mixture in patients undergoing forefoot surgery under regional anaesthesia.

We prospectively randomized 56 patients who underwent forefoot surgery under ankle block to receive subcutaneous local anaesthetic mixture under the tourniquet. We checked for local tourniquet pain score (VAS 0–100) and skin condition during and after the procedure.

Introduction

There is no published series described change in bone mineral density (BMD) after ankle replacement. We present the results of a prospective study examining the effect of total ankle replacement (TAR) upon local bone mineral density (BMD).

Introduction

Various rehabilitation shoes are prescribed to protect the forefoot following surgery. Patients often complain of discomfort in other areas as a result of the postoperative shoe, including the knee, hip and lower back. This has never been quantified. This study aims to establish the effect on other joints using gait analysis. Methods: 11 healthy volunteers were investigated using various common types of postoperative shoe. They were studied with gait analysis equipment and the joint motion assessed with commercial software. The effect of commercial devices designed to minimise gait changes by lifting the contralateral foot were also evaluated.

Introduction

Bone marrow oedema syndrome (BMES) of the foot and ankle is an uncommon and often misdiagnosed condition. It is usually thought to be a benign self limiting condition, without any sequelae. However, it can cause disabling pain for a prolonged period of time.

Introduction

The delayed presentation of Achilles tendon rupture is common, and is a difficult problem to manage. A number of surgical techniques have been described to treat this problem. We describe the use of Flexor Hallucis Longus (FHL) transfer to augment the surgical reconstruction of the delayed presentation of achilles tendon rupture.

The best method of stabilisation of the ankle syndesmosis remains a topic of debate; a relatively recent development is the ankle tightrope – a tensionable fibrewire suture device. Despite over 30,000 successful surgeries reported, evidence supporting its use when compared with screw fixation remains extremely limited. We retrospectively compared two consecutive groups of patients whose syndesmotic injuries were stabilised either with a tightrope or screws. The aim of our study was to compare complications arising after insertion of these devices.

All patients undergoing tightrope stabilisation of the syndesmosis between January 2006 and February 2009 were included as the treatment group. The control group was made up of a similar number of consecutive patients who underwent screw stabilisation between November 2010 and January 2011. Data was obtained through theatre records, case notes and from the local PACS X-ray system. Eighteen eligible cases were identified in the tightrope group compared with sixteen eligible cases treated with screws. Both groups had similar baseline demographics with respect to distribution of age and gender.

Twenty two percent (n = 4) of tightropes were removed secondary to wound breakdown or knot prominence. Other complications included persistent syndesmotic widening (n = 2, 11%), knot prominence without removal (n = 1, 5.5%) and synostosis (n = 1, 5.5%). In comparison, only 1 patient (6.3%) experienced a complication (pain and decreased RoM) in the control group. A total of 14 screws were removed. Thirteen screws were removed uneventfully. One patient was discharged to another hospital for a planned removal of screw, but was lost to follow-up. The remaining two patients elected not to have their screws removed.

Single stage total talectomy with tibio-calcaneal arthrodesis in adult patients has been rarely reported in the literature. In patients with severe rigid, unbraceable equinovarus deformities, talectomy can offer excellent correction.

We performed single stage total talectomy with tibiocalcaneal arthrodesis on 11 feet in 10 patients (6F; 5M) of average age 67 years (range 54–77 years). 6 patients had neuropathic deformity, 2 had failed fusion procedures and 2 had severe Rheumatoid hindfoot disease. The fusion was undertaken using a hindfoot nail and screws in 5 patients, plate and screws in 4 patients, a hindfoot nail in 1 and cancellous screws in 1 patient. All patients followed the standard post operative protocol and were reviewed at 2, 6 and 12 weeks and thereafter every 4 weekly till union. All patients were mobilised strictly non weight bearing for the first 6 weeks and thereafter, touch weight bearing was allowed with the leg in a protective cast. Full weight bearing was allowed once the fusion had consolidated.

Fusion was achieved in 7 feet (64%) at an average time of 17 weeks. In 4 patients, non-union persisted but they were pain free at latest review and would not consider further surgery. Average duration of follow-up was 20 months (range 6–24 months). All patients had stiff hindfeet with a jog of movement at the tibio navicular articulation. All patients had a stable, plantigrade, braceable foot and were community ambulators. All patients were satisfied with the outcome.

Total talectomy with tibiocalcaneal arthrodesis is a useful procedure to correct severe rigid equinovarus deformities in adults. The tibionavicular articulation forms a pseudarthrosis and retains a jog of movement. Retention of the head of the talus with talotibial arthrodesis is unnecessary. We recommend this procedure as a salvage option in this difficult problem.

This project highlights the red flags in postoperative rehabilitation of total ankle replacement (TAR) patients managed with two different postoperative rehab regimes.

20 TAR patients were recruited for a pilot RCT between 2008 and 2011; they were randomized to 2 groups (immobilisation in a below knee plaster cast for 6 weeks vs. early mobilisation following TAR); all patients underwent a graded outpatient Physiotherapy program until 12 weeks postoperatively. Assessments included questionnaires, complications, American Orthopaedic Foot and Ankle Score (AOFAS) done preoperatively, 3 and 6 months after surgery

Background

Hallux valgus is a complex deformity of the first ray and forefoot, which can be surgically treated by different procedures and osteotomies. Preoperative planning includes antero-posterior and lateral plain films. The effect of weightbearing on the results of the standardized measurements is still the subject of debate.

Background

Ankle arthrodesis results in significantly improved pain and function for patients with end-stage ankle arthritis. Arthroscopic ankle arthrodesis has gained increasing popularity with reports of shorter hospital stays, time to union and equivalent union rates to open arthrodesis. However, there remains a lack of good quality prospective data.

Background

Short term results of silastic implant of first MTPJ are successful. However reservations exist regarding long term results. The aim of this study is to evaluate long term outcome of silastic implant prosthesis in treatment of hallus rigidus.

We reviewed 108 feet in 83 patients who were operated on between 1988 and 2003. Mean age at operation = 55(SD 8.1). Mean follow up = 8.31 years (SD 3.3). Patients were assessed using the American Orthopaedic Foot and Ankle Scoring system (AOFAS). Passive and active arc of motion were measured. To assess patients' satisfaction they are asked if they would repeat the procedure and also using a visual analogue scale (VAS) to express their overall satisfaction with the outcome. All the patients had anteroposterior and oblique views. Radiographs were assessed for loosening and osteolysis.

Introduction

Greater length of stay (LOS) after elective surgery results in increased use of health care resources and higher costs. Within the realm of foot and ankle surgery, improved perioperative care has enabled a vast majority of procedures to be performed as a day surgery. The objective of this study was to determine the perioperative factors that predict a prolonged LOS after elective ankle replacement or fusion.

Nice guidelines recommend VTE prophylaxis to patients in below knee casts following foot and ankle surgery following risk assessment. The guidelines are controversial and BOFAS recommendations reiterate the risk factors but highlight poor evidence to support these guidelines. Implementation has been variable dependent on interpretation.

58 patients who underwent hindfoot procedures and were immobilised in a cast were identified. These patients were under the care of two consultants, one of whom anticoagulates with daily enoxaparin and one who does not, providing a de facto case-control design. The patients were followed up to identify those who subsequently suffered a DVT or PE, and the clinical circumstances.

2 cases of VTE events were noted in 58 patients undergoing foot and ankle surgery. Both were elective cases managed postoperatively in cast and treated with prophylaxic enoxaparin. Both of these presented to hospital with signs of VTE greater than 6 weeks following surgery after cast removal and discontinuation of enoxaparin. No patients were considered high risk according to NICE guidelines. None of the patients who received no thromboprophylaxis had a clinical DVT.

Within our study group we found that VTE thromboprophylaxis does not influence clinically evident VTE rates. Patients who developed VTE were not considered high risk by definition of NICE guidelines but only at increased risk due to their immobility. The VTE events were initiated while the patients were receiving thromboprophylaxis. The effectiveness of the guidelines in predicting patients who would benefit from chemoprophylaxis is questionable from this study.

NICE guidelines on VTE thromboprophylaxis have been received with some concerns. Although this investigation studied only a relatively small number of patients, it raises issues about the clinical effectiveness of the guidelines in foot and ankle patients.