Spezializing in subfields of Orthopaedics is common in anglo-american countries for more than 20 years. IThe aim of this paper is to demonstrate the necessity of fellowship programms in extremity orientated subfileds of orthopaedics. Analyzing the results of ankle arthrodesis performed by general orthopaedic surgeons campared to ankle arthrodesis performed by spezialized foot and ankle surgeons the difference in results will be demonstrated. Patients and methods. In 40 patients an ankle arthrodesis was performed between 1998 and 2012. Group A was formed by 20 consecutive patients treated by spezial trained Foot and Ankle surgeons and group B was formed by 20 patients treted by general orthopaedic surgeons. The average age in group A at the time of surgery was 59,9y (34 to79y) compared to 63,4y (41 to 80y) in group B. The average follow up was 34 months respectively 32 months after surgery. The study included a spezial questionnaire with the AOFAS score and rating of patients dissatisfaction. The successful healing of the arthrodesis was determied by using standardized radiographs, Furthermore a pedobarography, and a videoanalyzis of the walking was incuded. Results. All procedures in group A were performed using an anterior approach. Neither pseudarthroses, equinus or other malositions were detected in this group. In group B wurdenin 16 patients an anterior and in 4 patients a lateral approach was used. Complications included 3 pseudarthroses, 4 equinus malpositions, 4 varus malpositions, 4 valgus malpositions and 8 penetrations of the subtalar joint. The AOFAS score on average was 78 (46–92) points in group A and 75 (34 – 94) in group B. Conclusion. The analyzis of the data revealed that the results in Group A were comparable to the results published in the literature. Results in group B were inferior to those in group A and to the results published in the literature of Foot and Ankle surgery. Foot and Ankle surgery became more demanding over the last decades. As already shown in anglo-american countries spezializing in certain fields of orthopaedics is a necessity. More complex hindfoot surgery should be performed in special centers with an adequate case load

Background: There is increasing concern regarding radiation exposure to surgeons’ using fluoroscopic guidance during orthopaedic procedures. However, there is currently a paucity of information regarding the level of radiation exposure to the foot and ankle surgeon during fluoroscopically assisted foot and ankle surgery. Methods: We conducted a 12 month prospective study to measure radiation dose absorbed by the hands of a dedicated right handed foot and ankle surgeon. A thermo-luminescent dosimeter ring (TLD) was worn on little finger of each hand. Measurement of the cumulative radiation dose was recorded on a monthly basis. Results: A total of 80 foot and ankle cases involving fluoroscopy were performed. The total screening time was 3028seconds (s) (mean screening time 37.4s). Screening time correlated positively with the number of procedures performed (r=0.92, p< 0.001), and with radiation dose in both the left TLD (r=0.85, p=0.0005) and right TLD (r=0.59, p=0.0419). There was no significant difference in radiation dose between either hand (p=0.62). The total radiation dose to the right TLD over the 12 months was 2.4 milli-sieverts. Conclusion: Radiation dose incurred during orthopaedic foot and ankle procedures is proportional to the screening time. Our results show radiation exposure to be well below the annual dose limit set by the International Commission on Radiological Protection. This work demonstrates a simple and convenient method for evaluating a single surgeon’s radiation exposure

Aims. Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England. Methods. A questionnaire was sent to all 136 NHS trusts audited in the 2018 National Diabetic Foot Audit (NDFA). The questionnaire asked about the structure of diabetic foot care services. Results. Overall, 123 trusts responded, of which 117 admitted patients with diabetic foot disease and 113 had an orthopaedic foot and ankle surgeon. A total of 90 trusts (77%) stated that the admission involved medicine, with 53 (45%) of these admissions being exclusively under medicine, and 37 (32%) as joint admissions. Of the joint admissions, 16 (14%) were combined with vascular and 12(10%) with orthopaedic surgery. Admission is solely under vascular surgery in 12 trusts (10%) and orthopaedic surgery in 7 (6%). Diabetic foot abscesses were drained by orthopaedic surgeons in 61 trusts (52%) and vascular surgeons in 47 (40%). Conclusion. Orthopaedic surgeons make a significant contribution to both acute and elective diabetic foot care currently in the UK. This contribution is likely to increase with the movement of vascular surgery to a hub and spoke model, and measures should be put in place to increase the team based approach to the diabetic foot, for example with the introduction of a best practice tariff. Cite this article: Bone Jt Open 2022;3(8):618–622

Varus ankle osteoarthritis (OA) is typically associated with peritalar instability, which may result in altered subtalar joint position. This study aimed to determine the extent to which total ankle replacement (TAR) in varus ankle OA can restore the subtalar position alignment using 3-dimensional semi-automated measurements on WBCT. Fourteen patients (15 ankles, mean age 61) who underwent TAR for varus ankle OA were retrospectively analyzed using semi- automated measurements of the hindfoot based on pre-and postoperative weightbearing WBCT (WBCT) imaging. Eight 3-dimensional angular measurements were obtained to quantify the ankle and subtalar joint alignment. Twenty healthy individuals were served as a control groups and were used for reliability assessments. All ankle and hindfoot angles improved between preoperative and a minimum of 1 year (mean 2.1 years) postoperative and were statistically significant in 6 out of 8 angles (P<0.05). Values The post-op angles were in a similar range to as those of healthy controls were achieved in all measurements and did not demonstrated statistical difference (P>0.05). Our findings indicate that talus repositioning after TAR within the ankle mortise improves restores the subtalar position joint alignment within normal values. These data inform foot and ankle surgeons on the amount of correction at the level of the subtalar joint that can be expected after TAR. This may contribute to improved biomechanics of the hindfoot complex. However, future studies are required to implement these findings in surgical algorithms for TAR in prescence of hindfoot deformity

Introduction. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to perform major foot/ankle operations as day-case. This could have significant impact on length of stay, saving resources and is in keeping with government policy. However, there are theoretical concerns about complications and low patient satisfaction due to pain. Methods. The survey was developed following review of the literature and was approved for distribution by the BOFAS (British Orthopaedic Foot & Ankle Society) scientific committee. An online survey (19 questions) was sent to UK foot and ankle surgeons via the BOFAS membership list. Major foot/ ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge, with day surgery as the intended pathway. Results. A total of 132 surgeons responded, 80% from Acute NHS Trusts. The majority (78%) thought that more procedures could be performed as day-case at their centre. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. Despite post-operative pain and patient satisfaction being theoretical concerns for day-case surgery in this population; these outcomes were only measured by 34% and 10% of respondents respectively. The top perceived barriers to performing more major foot and ankle procedures as day-case were: Lack of physiotherapy input pre/post-operatively (23%), Lack of out of hours support (21%). Conclusions. There is consensus among surgeons to do more major foot/ ankle procedures as day-case. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. There is a need to scope the provision of physiotherapy pre/post-operatively and out of hours support at sites where this is a perceived barrier

Introduction. Early clinical examination combined with MRI following a high ankle sprain allows accurate diagnosis of syndesmosis instability. However, patients often present late, and for chronic injuries clinical assessment is less reliable. Furthermore, in many centres MRI may be not be readily available. The aims of the current study were to define MRI characteristics associated with syndesmosis instability, and to determine whether MRI patterns differed according to time from injury. Methods. Retrospectively, patients with an unstable ligamentous syndesmosis injury requiring fixation were identified from the logbooks of two fellowship trained foot and ankle surgeons over a five-year period. After exclusion criteria (fibula fracture or absence of an MRI report by a consultant radiologist), 164 patients (mean age 30.7) were available. Associations between MRI characteristics and time to MRI were examined using Pearson's chi-square tests or Fisher's exact tests (significance set at p< 0.05). Results. Overall, 100% of scans detected a syndesmosis injury if performed acutely (within 6 weeks of injury), falling to 83% if performed after 12 weeks (p=0.001). In the acute group, 93.5% of patients had evidence of at least one of either PITFL injury (78.7%), posterior malleolus bone oedema (60.2%), or a posterior malleolus fracture (15.7%). In 20% of patients with a posterior malleolus bone bruise or fracture, the PITFL was reported as normal. The incidence of posterior malleolus bone bruising and fracture did not significantly differ according to time. Conclusion. For unstable ligamentous syndesmosis injuries, MRI becomes less sensitive over time. Importantly, posterior malleolus bone oedema or fracture may be the only evidence of a posterior injury. Failure to recognise instability may lead to inappropriate management of the patient, long term pain and arthritis. We therefore advocate early MRI as it becomes more difficult to ‘grade’ the injury if delayed

Introduction. Charcot neuroarthropathy (CN) of foot and ankle presents significant challenges to the orthopaedic foot and ankle surgeon. Current treatment focuses on conservative management during the acute CN phase with offloading followed by deformity correction during the chronic phase. However, the deformity can progress in some feet despite optimal offloading resulting ulceration, infection, and limb loss. Our aim was to assess outcomes of primary surgical management with early reconstruction. Methods. Between December 2011 and December 2019, 25 patients underwent operative intervention at our specialist diabetic foot unit for CN with progressive deformity and or instability despite advanced offloading. All had peripheral neuropathy, and the majority due to diabetes. Twenty-six feet were operated on in total - 14 during Eichenholtz stage 1 and 12 during stage 2. Fourteen of these were performed as single stage procedures, whereas 12 as two-stage reconstructions. These included isolated hindfoot reconstructions in seven, midfoot in four and combined in 14 feet. Mean age at the time of operation was 54. Preoperative ulceration was evident in 14 patients. Results. Mean follow up was 45 months (Range 12–98). There was 100% limb salvage. One-year ambulation outcomes demonstrate FWB in bespoke footwear for 17 patients and in an ankle foot orthosis (AFO), Charcot restraint orthopaedic walker (CROW) or bivalve cast for seven. All preoperative ulceration had healed. Union was achieved in 18/21 hindfoot reconstructions and 7/18 midfoot reconstructions. There were nine episodes of return to theatre, of which five were within the first 12 months. There was one episode of new ulceration. Conclusion. Surgical management of acute CN (Eichenholtz one and two) of the foot provides functional limb salvage. In particular, hindfoot reconstruction shows good rates of bony union. It should be considered in ‘foot at risk’ presentations of acute CN foot

Introduction: In April 2007, NICE published guidance on reducing the risk of venous thromboembolism. Immobilization of a limb in plaster was identified as a risk factor for thromboembolism. NICE recommend that all orthopaedic patients with risk factors are offered low molecular weight heparin (LMWH) whilst an inpatient. There was no cost effective evidence to continue treatment as an outpatient in foot and ankle patients. Foot and ankle surgery often requires prolonged periods of immobilization postoperatively. This study aims to provide a snapshot of current practice amongst foot and ankle surgeons in the UK, highlighting any differences between current practice and NICE guidelines. Materials and Methods: A random sample of the 267 members of the British Foot and Ankle Surgery Society listed in the 2007 BOA Handbook was obtained. In order to have a 90% confidence level, the sample size was calculated to be 71. The specialist teams identified were contacted by telephone and questioned on their use of thromboprophylaxis for elective patients in plaster. The results were collated and compared to NICE guidelines. Results: 94% of foot and ankle surgeons prescribe LMWH to post operative elective inpatients in plaster. 65% of specialists continue thromboprophylaxis for out-patients. The duration and agent of thromboprophylaxis varied markedly. The commonest agents were LMWH and aspirin. The length of treatment ranged from ten days to the duration of plaster immobilization. Discussion: The results highlight a trend amongst foot and ankle surgeons to exceed current NICE guidelines for thromboprophylaxis, continuing treatment for an extended outpatient period. Although there was shown to be no cost effective evidence to continue treatment, the practice continues. Conclusion: The vast majority of UK foot and ankle surgeons fulfill the NICE recommendations on thromboprophylaxis. There is a clear need for a policy statement from BOFAS on the extended use of thromboprophylaxis for outpatients immobilized in plaster

Recent advances in arthroplasty for the hip and the knee have motivated modern foot and ankle research to perfect the implant and technique for the optimal total ankle replacement. Unlike in the hip where different approaches can be done with similar implants, the approach of a total ankle is intimately associated to the prosthetic design. The anterior and lateral approaches have pros and cons regarding their respective soft tissue complications, osteotomy necessity, orientation of the bone cut and gutter visualization. While both have been studied independently, very few reports have compared both in the same setting. This study retrospectively looked at the difference in reoperations rate after each ankle arthroplasty within two years estimating that both had similar rate of return to the operating room. A retrospective study was conducted from a single center between 2014 and 2017 including a total of 115 total ankles performed by one of four fellowship-trained foot and ankle surgeon. Re-operations were reported in the charts as an operative report. The index approach used was determined by the surgeon's practice preference. Patients were included when they had a primary TAR in the timeframe noted and had a complete dataset up to at least the two-year data. This cohort comprised 67 anterior and 48 lateral with balanced demographic for age (95%CI 63–67 yo) and gender (47% F). The lateral group had more complex cases with higher COFAS type arthritis. Comparing the two groups, a total of 40 reoperations (7 anterior, 33 lateral) occurred in 27 patients (5A, 22L). One patient had up to four related reoperations. The only revision was in the anterior group. The only soft tissue reconstruction was an STSG in the lateral group. Nine reoperations were irrigation debridement related to an infective process (3 A, 6L). The majority (19/33) of reoperations in the lateral group were gutter debridement (8) or lateral hardware removal (11). Operative time was not statistically different. The odds ratio of having a reoperation with a laterally based TAR was 6.19 compared to the anterior group. This retrospective study outlines the intermediate results at two years of lateral and anterior total ankle replacements. This is a first study of this kind in the literature. This study did show that there were more reoperations after a laterally-based TAR than an anterior TAR, recognizing the significant case complexity imbalance between groups. This speaks to the relative increase resource utilization of laterally based TAR patients. Both implant designs carry different reoperation rates favoring the anterior group however larger prospective datasets will be needed with patient-reported outcome

Background: There is increased concern regarding radiation exposure to surgeons using fluoroscopic guidance throughout various procedures. However, relatively little information exists on the level of radiation exposure to the foot and ankle surgeon during fluoroscopically assisted foot and ankle surgery. Methods: We are conducting an ongoing proespective study to measure radiation exposure to the hands of a single orthopaedic foot and ankle surgeon (RD). Over a 12-month period, thermoluminescent dosimeter rings are worn on the little finger of each hand of the operating surgeon. The rings are changed at six week intervals. Measurement of the overall radiation exposure is being recorded over this time period. Results: This is an ongoing prospective study started in December 2004. We are measuring: total number foot and ankle cases using fluoroscopy, the total screening time for foot and ankle procedures, the mean screening time per procedure and the total radiation exposure to the thermoluminescent dosimetry rings. Conclusion: Preliminary results show that radiation exposure is well below the current annual dose limit. In our study, radiation exposure during orthopaedic foot and ankle procedures is expected to comply with current recommendations of the European Committee on Radiation Protection and is well below dose limits set by the International Commission on Radiological Protection

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

Numerous studies have demonstrated that concomitant lower back pain (LBP) results in worse functional outcomes in patients undergoing surgical treatment for the management of end stage hip and knee arthritis. However, no equivalent studies have analysed the impact of back pain on the outcomes of patients with end stage ankle arthritis. Furthermore, given that two widely accepted surgical options exist in the treatment of ankle arthritis, namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA), it is possible that one surgical technique may be superior in patients with LBP. The aim of this study was to determine the incidence of LBP in people with ankle arthritis, analyse its effect on functional outcomes, and explore whether there was a treatment advantage from either TAA or AA. Prospectively collected data from the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was analysed in this study. All patients with ankle arthritis who underwent surgery performed by three fellowship-trained foot and ankle surgeons at a single institution between January 2003 and July 2012 were studied. Patient demographics were collected pre-operatively, including the absence or presence of back pain, and post-operative follow up was performed at 2 and 5 years, evaluating patient-reported functional outcome measures including the Ankle Arthritis Score (AAS) and the 36-item short form survey (SF-36). Using a linear regression model, a multivariate analysis was performed to examine the relationship between back pain, TAAs and AAs. In total, 451 patients were studied. 164 patients (36.4%) presented with concomitant LBP. At presentation, the LBP group had worse AAS scores (54.8 vs 57.8 p. At 2 years postoperatively, the AAS score was the same in both groups (28.9 vs 26.8 p = 0.3), but patients with LBP had worse SF-36 PCS (42.1 vs 36.6 p 0.05) in any of the functional outcome scores at 2 or 5 years post-operatively. The results of this study suggest there is no advantage of TAA over AA in the treatment of ankle arthritis in patients with concomitant lower back pain. Although pre-operative back pain resulted in worse SF-36 outcomes at 2 and 5 years post- operatively, this was not the case for AAS scores

Recent innovations in total ankle replacement (TAR) have led to improvements in implant survivorship, accuracy of component positioning and sizing, and patient outcomes. CT-generated pre-operative plans and cutting guides show promising results in terms of placement enhancement and reproducibility in clinical studies. The purpose of this study was to determine the accuracy of 1) implant sizes used and 2) alignment corrections obtained intraoperatively using the cutting guides provided, compared to what was predicted in the CT generated pre-operative plans. This is a retrospective study looking at 36 patients who underwent total ankle arthroplasty using a CT generated pre-operative planning system between July 2015 and December 2017. Personalized pre-operative planning data was obtained from the implant company. Two evaluators took measurements of the angle corrected using pre- and post-operative weight bearing ankle AP X-rays. All patients had a minimum three-month follow-up with weightbearing postoperative radiographs. The actual correction calculated from the radiographic assessment was compared with the predicted angles obtained from pre-operative plans. The predicted and predicted alternative component sizes and actual sizes used were also compared. If either a predicted or predicted alternative size was implanted, we considered it to be accurate. Average age for all patients was 64 years (range 40–83), with a body mass index of 28.2 ± 5.6. All surgeries were performed by two foot and ankle surgeons. The average total surgical time was 110 ± 23 minutes. Pre-operative alignment ranged from 36.7 degrees valgus to 20 degrees varus. Average predicted coronal alignment correction was 0.8 degrees varus ± 9.3 degrees (range, 18.2 degrees valgus to 29 degrees varus) and average correction obtained was 2.1 degrees valgus ± 11.1 degrees. Average post-op alignment was consistently within 5 degrees of neutral. There were no significant differences between the predicted alignments and the postoperative weightbearing alignments. The predicted tibia implant size was accurate in all cases. The predicted sizes were less accurate for talar implants and predicted the actual talar implant size used in 66% of cases. In all cases of predicted talar size mismatch, surgical plans predicted 1 implant size larger than used. Preliminary analyses of our data is comparable to previous studies looking at similar outcomes. However, our study had higher pre-operative deformities. Despite that, post-op alignments were consistently within 5 degress of neutral with no significant difference between the predicted and actual corrections. Tibial implant sizes are highly accurate while talar implant sizes had a trend of being one size smaller than predicted. Moreover, this effect seems to be more pronounced in the earlier cases likely reflective of increasing surgeon comfort with the implant with each subsequent case. These results confirm that pre-operative cutting guides are indeed helpful in intra-operative implant selection and positioning, however, there is still some room for innovation

Ankle arthrodesis is the gold standard for treatment of end stage ankle arthritis. We analysed the data of 124 Ankle Arthrodesis (Open Ankle Arthrodesis (OAA) −27; Arthroscopic Ankle Arthrodesis (AAA)- 97) performed between January 2005 and December 2015 by fellowship trained foot and ankle surgeons in a single institution. Based on preoperative deformity (AAA- 28 degree valgus to 26 degrees varus; OAA- 41 degree valgus to 28 degree varus), they were subdivided into 2 groups based upon deformity more than 15 degrees. Union rates, time to union, length of hospital stay and patient related factors like smoking, alcoholism, diabetes, BMI were assessed. Mean age of patients was 60 years (Range 20 to 82 years)(Male:Female-87:32). Overall fusion rate was 93% in AAA and 89% in OAA (p=0.4). On sub group analysis of influence of preoperative deformity, there was no difference in union rates of AAA versus OAA. 7 patients in AAA and 3 in OAA required further procedures. Average time to union was 13.7 in AAA and 12.5 weeks in OAA (p=0.3). Average hospital stay was 2.6 days in AAA and 3.8 days in OAA (p=0.003). Smoking, alcoholism, Diabetes, BMI did not have any correlation with union rates. Although both AAA and OAA showed good union rates, hospital stay was significantly shorter in AAA. A larger deformity did not adversely affect union rates in AAA. Time to union was higher in AAA though it was statistically insignificant. Lifestyle risk factors did not have cumulative effect on union. We conclude that AAA is a reproducible method of treating end stage tibiotalar arthritis irrespective of preoperative deformity and patient related factors

INTRODUCTION. Proper ligament engagement is an important topic of discussion for total knee arthroplasty; however, its importance to total ankle arthroplasty (TAA) is uncertain. Ligaments are often lengthened or repaired in order to achieve balance in TAA without an understanding of changes in clinical outcomes. Unconstrained designs increase ankle laxity,. 1. but little is known about ligament changes with constrained designs or throughout functional activity. To better understand the importance of ligament engagement, we first investigated the changes in distance between ligament insertions throughout stance with different TAA designs. We hypothesize that the distance between ligaments spanning the ankle joint would increase in specimens following TAA throughout stance. METHODS. A validated method of measuring individual bone kinematics was performed on pilot specimens pre- and post-TAA using a six-degree-of-freedom robotic simulator with extrinsic muscle actuators and motion capture cameras (Figure 1). 2. Reflective markers attached to surgical pins and radiopaque beads were rigidly fixed to the tibia, fibula, talus, calcaneus, and navicular for each specimen. TAAs were performed by a fellowship-trained foot and ankle surgeon on two specimens with separate designs implanted (Cadence & Salto Talaris; Integra LifeSciences; Plainsboro, NJ). Each specimen was CT-scanned after robotic simulations of stance pre- and post-TAA. Specimens were then dissected before a 3D-coordinate measuring device was used to digitize the ligament insertions and beads. Ligament insertions were registered onto the bone geometries within CT images using the digitized beads. Individual bone kinematics measured from motion capture were then used to record the point-to-point distance between centers of the ligament insertions throughout stance. RESULTS. Results from the pilot specimens are presented for the calcaneofibular ligament (CFL) only. The distance between the CFL insertions was larger throughout stance following Cadence implantation (Figure 2A) and was decreased throughout most of stance following Salto Talaris implantation (Figure 2B). The percent change in CFL distance with respect to static standing was also increased with the Cadence implant (Figure 2C) and similar to intact following Salto Talaris implantation (Figure 2D). Ankle motion was similar to intact with the Cadence (Figure 3A) and was decreased with the Salto Talaris (Figure 3B). DISCUSSION. This study suggests that ligament length during stance changes following TAA. The Cadence implant similarly replicated ankle kinematics but CFL length was increased throughout stance which supports our hypothesis. In contrast, the Salto Talaris implant reduced ankle motion and decreased the CFL length. Although the slack length and pre-strain of the CFL were unknown, the distance between insertions from the pilot specimens provides preliminary insight into how ligament mechanics change post-TAA during functional activity. CLINICAL RELEVANCE. Preliminary results of ligament length changes throughout stance may indicate that ligament mechanics change post-TAA and could affect patient outcomes. Changes may be even more pronounced when a soft tissue release or reconstruction is performed to correct malalignment. For any figures or tables, please contact the authors directly

Introduction. Arthroscopic ankle fusion is an effective treatment for end stage ankle arthritis. It reliably improves pain but at the expense of ankle motion. Development of adjacent degenerative joint disease in the foot is thought to be a consequence of ankle fusion due to altered biomechanics. However, it has been reported to be present on pre-operative radiographs in many patients. There is very little evidence reporting the long-term outcomes of patients undergoing arthroscopic ankle fusion and particularly those requiring secondary procedures for adjacent joint disease. Material and methods. We reviewed the operative records of 149 patients who had undergone arthroscopic ankle fusion under the care of two consultant foot and ankle surgeons between 2002 and 2006. We contacted patients by telephone to determine whether they had required further investigation or surgery on the same foot after their index procedure. Secondary outcome measures included a Manchester Oxford Foot Questionnaire (MOQFQ) score and a patient satisfaction score. Results. 149 patients underwent 151 arthroscopic ankle fusions. Nine had died or developed dementia and 30 patients had incomplete hospital records leaving 111 available for follow-up with a response rate of 55% (65 ankles). The average time to follow-up was 12.0 years (9.5–16.6 years). 14 patients (22%) had undergone a secondary procedure including injections on the foot or ankle of the same side as the index procedure. Four of these procedures were arthrodeses and three of these were of the subtalar joint. Mean MOQFQ score was 18.0 (0–55). Overall 83% (54) patients were very satisfied or satisfied with their ankle fusion. Conclusions. Arthroscopic ankle arthrodesis results in high patient satisfaction rates at long-term follow-up. The number of patients requiring a secondary procedure due to ongoing pain and adjacent degenerative joint disease in their foot following ankle arthrodesis is low

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. Materials and Methods. We evaluated the effect of weightbearing on the results of measurements and decision making by expert evaluators. Twenty one expert foot & ankle surgeons were given weightbearing and nonweightbearing anteroposterior plain foot films of patients with hallux valgus. They were asked to measure three standard angles and then to select the most appropriate procedure out of a short list. Results. Using paired Student T-test, no difference in the angles measured or the procedures chosen was detected between weightbearing and nonweightbearing films. Conclusion. Although it is generally accepted that decisions regarding the treatment of hallux valgus should be based on plain weightbearing films, in this study we established the nonweightbearing films can be reliably used to choose the surgical procedure

Hallux valgus continues to frustrate foot and ankle surgeons the world over. The condition is mostly clear in its aetiology but unclear in its pathogenesis. The key, as in all surgery, is decision making, patient selection and to have many surgical options available. The key things to consider are: joint congruency, the presence of arthritis, the presence of metatarsus adductus, the intermetatarsal angle, the hallux valgus angle and the presence of interphalangeal deformity. I consider true hypermobility of the first ray and Achilles tendon tightness to be less important factors. Patient expectations are particularly important as most patients with hallux valgus are women who want to wear high-heeled shoes!. The most successful operations consist of a combination of soft tissue and bony procedures. The most common error in bunion surgery, in my opinion, is the use of a procedure with inadequate power to correct the deformity. When the joint is markedly arthritic and deformed an arthrodesis is the procedure of choice. I will discuss the above points in the lecture

About 20% of orthopaedic surgery is foot and ankle. This area of orthopaedics has undergone huge changes in last few decades. Not that long ago we were still performing Keller's procedure for bunions and using a Charnley clamp for ankle fusions. It is becoming increasingly more difficult for the general orthopaedic surgeon to stay abreast of current surgical treatment. Some of the newer foot and ankle surgical surgical techniques will be discussed. Ankle arthroplasty is undergoing a period of revival. This is a difficult procedure with results not as reliable as hip and knee arthroplasty and I would not recommend it to the occasional foot and ankle surgeon. Ankle arthroscopy is now a commonly performed procedure and with the right equipment is a procedure that is useful to the generalist. Foot and ankle fusion are now performed with rigid internal fixation. The actual procedures are not difficult but it does require a reasonable amount of experience to obtain the correct position of the fusion. Bunion surgery is commonly done and can result in disappointment for all. The newer surgical options for the correction of hallux valgus will be discussed

The unresolved ankle sprain is one of the most common referrals to a specialist orthopaedic foot & ankle surgeon. These injuries occur in sports people as well as workers, and frequently cause prolonged sporting inactivity or time off work. The unresolved ankle sprain can be defined as that injury which does not resolve with appropriate conservative treatment within six weeks. The pathology causing an ankle sprain to be unresolved can involve soft tissue or bony structures. Thorough clinical and radiological assessment is necessary to secure the diagnosis, institute effective surgical treatment and counsel the patient accurately with regards to prognosis for the injury. This paper discusses the differential diagnosis & surgery in order to resolve prolonged disability after the common ankle sprain