Ankle lateral ligament complex injury is common. Traditional ‘Brostrum’ repair, performed either open or arthroscopically, still has a protracted post-operative period. The ‘Internal Brace’ provides a scaffold for the ligament repair and acts as a ‘check-rein’ preventing further injury.

16 patients with ankle instability and injury to the Anterior-Talo-Fibular-Ligament (ATFL) confirmed on MRI were identified. All had completed a period of conservative treatment. All had symptoms of pain in the region of the ATFL and described a feeling of instability. Surgery was performed under general anaesthetic and regional popliteal block. Anterior ankle arthroscopy demonstrated a positive ‘drive through’ in all cases. The ATFL was absent and in the majority replaced by incompetent scar. Scar tissue was removed from the anterior aspect of the ankle allowing visualisation of the fibula and lateral talar neck. Using the Internal Brace system (Arthrex), a 3.5mm swivel-lock with fibre-tape was placed into the fibula. With the ankle in plantar flexion, to allow appropriate tensioning, the distal end of the fibre-tape was secured to the talar neck, at a 45 degree angle, with a 4.75mm biotenodesis screw. The patient was placed into a moon-boot for 7–10 days and mobilised fully weight-bearing. Pre-op score, using EDQ-5, MOXFQ, AOFAS and visual analogue scores, with post-op PROMS were performed.

All patients reported improvement in their symptoms at 6 week visit. The majority were back to normal activities at 12 weeks. The few that were not, had missed physiotherapy appointments for various reasons. There were no infections and no implant failures.

Arthroscopy allows direct visualisation for accurate placement of the Internal Brace. Post-operatively recovery is expedited due to the stability provided by the ‘Brace’, permitting a more aggressive rehabilitation programme. The greatest potential is arguably for the elite athlete, where an accelerated return to full activity has significant occupational implications.

We undertook a retrospective audit to assess quality of service provided by Nurse-Led Review Clinic at Glasgow Royal Infirmary for patients sustaining ankle fracture requiring surgical stabilisation. Nursing staff had received training from the senior author regarding clinical examination and radiograph interpretation.

We retrospectively reviewed the clinical documentation and radiographs of 104 patients who attended from January 2009 to December 2009. Any clinical issues were identified and radiographs were scrutinised by two of the authors to assess accuracy of interpretation. Nurse-led management was then assessed as to its appropriateness. Finally two retrospective questionnaires were used to assess both the nurses and patients satisfaction with the clinic.

Nurse-led clinic protocol: First appointment 10 days: Wound review, application of lightweight plaster. Second appointment 6 weeks: Removal of plaster, check radiographs. Final appointment 12 weeks: Clinical assessment, radiographs, discharge. Clinical assessment: ensure wound satisfactory, range of movement and weight-bearing are improving. Radiographic criteria: 6 weeks: Assess for talar shift, lucency or metal-work concerns. 12 weeks: Assess evidence of fracture union, infection, loosening or backing out. If any concerns with the patients' progress nursing staff would discuss with the consultant.

First appointment: 7 wound problems. 5 managed by nurses and resolved. 2 discussed with surgeon, 1 settled, 1 required oral antibiotics. 3 radiographs discussed with surgeon. 2 conservative management. 1 re-operation. Second appointment: 7 wounds managed by nurses. 1 failure of fixation, discussed for re-operation. 2 concerns regarding metal in joint – treated conservatively. Final appointment: 7 referred to physiotherapy as slow to fully weight-bear. 5 discussed for removal of syndesmosis screw. 1 screw in joint, admitted for re-operation.

Clinical care provided at Nurse-Led clinic is appropriate and effective. Both nursing staff and patients were satisfied with the care provided. Nurse-led clinic reduces demands on fracture clinic appointments and is a safe, cost effective initiative.

Complex Regional Pain Syndrome (CRPS) is regarded as an uncommon clinical complication to orthopaedic surgery. Few have looked into its prevalence in foot and ankle surgery.

This is a retrospective cohort study of all patients undergoing foot and ankle surgery, operated on by the foot and ankle team in our department in 2009. The objectives of this study was to determine the prevalence CRPS in these patients post-operatively and to examine the associated factors.

17 patients from 390 (4.4%) were identified as meeting the IASP (International Association for the Study of Pain) criteria for the diagnosis of CRPS. Of these, the majority were female (n = 14, 82.4%) and the average age was 47.2 (SD 9.7). All were elective patients. The majority involved operating on the forefoot (n = 9, 52.9%), followed by the hindfoot and ankle (3 cases each, 17.6%). Most of these patients had new onset CRPS (n = 12, 70.6%), with no previous history of the condition. 3 patients (17.6%) had documented nerve damage and therefore suffered from CRPS Type 2. Blood results were available for 14 (82.4%) patients at a minimum of 3 months post-operatively, and none had elevated inflammatory markers. 5 of the patients (29.4%) were smokers and 8 (47.1%) had a pre-existing diagnosis of anxiety or depression.

At present, based on our findings, we recommend that middle-aged women, with a history of anxiety or depression, undergoing elective foot surgery be specifically counselled on the risk of developing CRPS at consenting. We recommend similar studies to be undertaken in other West of Scotland orthopaedic units.

The arterial supply of the talus has been extensively studied in the past but there is a paucity of information on the arterial supply to the navicular and a very limited understanding of the intra-osseous supply to the surface of either of these bones. This is despite the likely importance of this supply in relation to conditions such as osteochondral lesions of the dome of the talus, and avascular necrosis and stress fracture of the navicular.

Using cadaveric limbs, dissection of the source vessels was performed followed by arterial injection of latex. The talus and navicular were then removed en bloc, preserving the integrity of the injected arterial vasculature. The specimens were then processed using a new, accelerated diaphanisation technique. This rendered the tissue transparent, allowing the injected vessels to be visualised and then mapped onto a 3D virtual reconstruction of the bone. The vasculature to the subchondral surfaces of the talus and navicular, and the source vessel entry points that provide arterial supply into the navicular were identified.

This study gives quantifiable evidence of the areas of consistently poor blood supply which may help explain the clinical pattern of talar and navicular pathology. It also provides as yet unpublished information on the arterial supply of the human navicular bone.