Introduction. The dichotomy between surgical repair and conservative management of acute Achilles tendon ruptures has been eliminated through appropriate functional management. The orthoses used within functional management however, remains variable. Functional treatment works on the premise that the ankle/hindfoot is positioned in sufficient equinus to allow for early weight-bearing on a ‘shortened’ Achilles tendon. Our aim in this study was to test if 2 common walking orthoses achieved a satisfactory equinus position of the hindfoot. Methods. 10 sequentially treated patients with 11 Achilles tendon injuries were assigned either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus corrected vacuum brace system (EEB). Weight bearing lateral radiographs were obtained in plaster and the orthosis, which were subsequently analysed using a Carestream PACS system. The Mann-Whitney test was used to compare means. Results. Initial radiographs of all patients in cast immobilization showed a mean tibio-talar angle (TTA) of 55.67° (SD1.21) and a mean 1. st. metatarsal-tibia angle (1MTA) of 73.83° (SD9.45). There were 6 Achilles tendons treated in the FAWW. Their measurements showed a mean TTA of 27.67°(SD7.71) and 1MTA 37.00 (5.22). 5 tendons were treated using an EEB; there was a statistically significant (p< .05) increase in both the TTA 47.6° (SD5.90) and 1MTA 53.67 (SD5.77) compared to the FAWW group. Discussion. Plantar-flexion at the ankle was significantly greater in the EEB comparative to the FAWW, and very similar to the initial equinus cast. The use of wedges produced an equinus appearance through the midfoot, without producing equinus in the hindfoot as the heel pad rests on the top wedge. We express caution in the use of wedges for Achilles treatment as they do not shorten the Achilles tendon and may result in a lengthened tendon and reduced plantar-flexion power in the long-term

Vacuum orthoses are being applied in the care of patients with foot and lower leg conditions, as ankle fractures or sprains. The lower leg is protected and immobilized, which increases mobility. Due to the design, the orthoses lead to a difference in leg length, i.e. the side with the orthosis becomes longer, which changes the gait kinematics. To prevent or mitigate the unfavourable effects of altered gait kinematics, leg length-evening devices (shoe lifts) are offered that are worn under the shoe on the healthy side. Our aim was to evaluate the effect of such a device on the normality of gait kinematics. Gait analysis was conducted with 63 adult, healthy volunteers having signed an informed consent form that were asked to walk on a treadmill at a speed of 4.5km/h in three different conditions:. barefoot - as reference for establishing the normality score baseline. with a vacuum orthosis (VACOPed, OPED GmbH, Germany) and a sport shoe. with a vacuum orthosis and a shoe lift (EVENup, OPED GmbH, Germany). Data was sampled using the gait analysis system MCU 200 (LaiTronic GmbH, Austria). The positions of the joint markers were exported from the software and evaluated for the joint angles during the gait cycle using custom software (implemented in DIAdem 2017, National Instruments). A normality score using a modification of the Gait Profile Score (GPS) was calculated in every 1%-interval of the gait cycle and evaluated with a Wilcoxon signed rank test. The GPS value was reduced by 0.33° (0.66°) (median and IQR) while wearing the shoe lift. The effect was statistically significant, and very large (W = 1535.00, p < .001; r (rank biserial) = 0.52, 95% CI [0.29, 0.70]). The significant reduction of the GPS value indicates a more normal gait kinematics while using the leg length-evening device on the contralateral shoe. This rather simple and inexpensive device thus might improve patient comfort and balance while using the vacuum orthoses

Objectives. The evidence base to inform the management of Achilles tendon rupture is sparse. The objectives of this research were to establish what current practice is in the United Kingdom and explore clinicians’ views on proposed further research in this area. This study was registered with the ISRCTN (ISRCTN68273773) as part of a larger programme of research. Methods. We report an online survey of current practice in the United Kingdom, approved by the British Orthopaedic Foot and Ankle Society and completed by 181 of its members. A total of ten of these respondents were invited for a subsequent one-to-one interview to explore clinician views on proposed further research in this area. Results. The survey showed wide variations in practice, with patients being managed in plaster cast alone (13%), plaster cast followed by orthoses management (68%), and orthoses alone (19%). Within these categories, further variation existed regarding the individual rehabilitation facets, such as the length of time worn, the foot position within them and weight-bearing status. The subsequent interviews reflected this clinical uncertainty and the pressing need for definitive research. Conclusions. The gap in evidence in this area has resulted in practice in the United Kingdom becoming varied and based on individual opinion. Future high-quality randomised trials on this subject are supported by the clinical community. Cite this article: Bone Joint Res 2015;4:65–9

Aim. This retrospective case series reports the reoperation, major amputation, survival rates and mobility status in diabetic patients who underwent a trans-metatarsal amputation (TMA) managed within a multi-disciplinary diabetic foot care service. Methods and patients. Forty-one consecutive patients (37 men, 4 women) underwent a TMA between January 2008 to December 2017. They were retrospectively reviewed. The mean age at the time of surgery was 63 years (range 39 – 92). Results. Eighty-eight per cent (36/41) of the patients were followed-up. Four (11%) of the 36 patients required reoperation, including three major amputations (8%). All the patients requiring a reoperation were vasculopaths. The four-year patient survival rate following a TMA was 69% (25/36). Ninety-six per cent (21/22) of the surviving patients not requiring revision to a major amputation were fully mobile in bespoke orthoses, of whom a third required a stick. Conclusion. This study shows that transmetatarsal amputation in patients with diabetes, managed in a multi-disciplinary diabetic foot care service, is effective for limb salvage

A complete design-manufacturing process for delivering customized foot orthoses by means of digital technologies is presented. Moreover, this feasibility study aims to combine a semi-automatic modelling approach with the use of low-cost devices for 3D scanning and 3D printing. In clinical practice, traditional methods for manufacturing customized foot orthoses are completely manual, mainly based on plaster casting plus hand fabrication, and are widely used among practitioners. Therefore, results depend on skills and expertise of individual orthoptists and podiatrists that need considerable training and practice in order to obtain optimal functional devices. On the other side, novel approaches for design and manufacturing customized foot orthoses by means of digital technologies (generally based on 3D scanning, 3D modelling and 3D printing) are recently reported as a valid alternative method to overcome these limitations. This study has been carried out in an interdisciplinary approach between the staff of Design and Methods in Industrial Engineering and the staff of Podology with the aim to assess the feasibility of a novel user-friendly and cost-effective solution for delivering customized functional foot orthoses. More specifically, a Generative Design (GD) workflow has been developed to enable practitioners without enough CAD skills to easily 3D modelling and interactively customize foot orthoses. Additionally, low-cost devices for 3D scanning and 3D printing that have been acquired by the Podology Lab, were also tested and compared with the high-cost ones of the Department of Industrial Engineering. The complete process is divided into three main steps. The first one regards the digitization of the patient's foot by means of 3D laser scanner devices. Then a user-friendly 3D modelling approach, developed for this purpose as GD workflow, allows interactively generating the customized foot orthosis, also adjusting several features and exporting the watertight mesh in STL format. Finally, the last step involves Additive Manufacturing systems to obtain the expected physical item ready to use. First, for what concerns the digitizing step, the acquired data resulting from 3D scanning by means of the low-cost system (Sense 3D scanner) appears accurate enough for the present practical purposes. Then, with respect to the 3D modelling step, the proposed GD workflow in Grasshopper is intuitive and allows easily and interactively customizing the final foot orthosis. Finally, regarding the Additive Manufacturing step, the low cost 3D printer (Wasp Delta 40 70) is capable to provide adequate results for the shell of the foot orthosis. Moreover, this system appears really versatile in reason of the capability to print in a wide range of different filaments. Therefore, since the market of 3D printing filaments is rapidly growing, building sessions with different materials (both flexible and rigid such, for example, PLA, AB and PETG) were completed. This study validated, in terms of feasibility, that the use of a GD modelling approach, in combination with low-cost devices for 3D scanning and 3D printing, is a real alternative to conventional processes for providing customized foot orthosis. Moreover, the interdisciplinary approach allowed the transfer of skills and knowledge to the practitioners involved and, also, the low-cost devices Sense 3D scanner and Wasp Delta 40 70 that have been acquired by the Podology Lab, were demonstrated suitable for this kind of applications

Cervical orthoses are currently used in the pre-hospital stabilization of trauma patients and also as part of the definitive non-operative treatment of injuries of the cervical spine. The construct stability of orthoses is compromised by virtue of the fact that the cervical spine exhibits the greatest range of movement amongst the spinal segments and also because of the complex composite nature of neck movements. To date, data has been difficult to attain comparing the various orthoses, in the various planes of movement of the cervical spine. Various methods including the use of inclinometers, goniometers, radiography, computerized tomography and cineroentgenography have been used in an attempt to measure these movements but none have provided satisfactory triplanar data. This paper uses the Zebris ultrasonic 3-D motion analysis system to measure flexion, extension, range of lateral bending and range of axial rotation in five similar male and five similar female subjects with no history of neck injuries. The subjects were tested in a soft and hard collar, Philadelphia, Miami J and Minerva. Results show that the Minerva is significantly the most stable construct for restriction of movement in all planes in both groups (p< 0.002 vs. all groups, Student’s t-test), but more impressively in the female group. In the male group, the standard hard collar performs second best in flexion, lateral bending and axial rotation. In the female group, the second most stable orthosis is the Philadelphia in flexion/extension and the hard collar in lateral bending and axial rotation (p< 0.05 vs. next most stable in all cases, Student’s t-test). The soft collar in both groups offered only minimal resistance to movement in any plane, e. g. 45.07° vs. 46.45° extension vs. normal in males and 40.15° vs. 41.8° extension vs. normal in females. Looking at these results together allows the ranking of the measured orthoses in order of the three-dimensional stability they offer. Furthermore, they validate the Zebris as a reliable and safe method of measurement of the complex movements of the cervical spine with low intersubject variability. In conclusion, this paper, for the first time presents reproducible data incorporating the composite triplanar movements of the cervical spine thus allowing comparative analysis of the three-dimensional construct stability of the studied orthoses

Summary. Bi-plane Image matching method is very useful technique to evaluate the loaded 3D motion of each cervical level. Introduction. Cervical orthoses are commonly used to regulate the motion of cervical spines for conservative treatment of injuries and for post-operative immobilization. Previous studies have reported the efficacy of orthoses for 2D flex-extension or 3D motions of the entire cervical spine. However, the ability of cervical orthoses to reduce motion might be different at each intervertebral level and for different types of motion (flexion-extension, rotation, lateral bending). The effectiveness of immobilizing orthoses at each cervical intervertebral level for 3D motions has not been reported. The purpose of this study is to evaluate the effectiveness of the Philadelphia collar to each level of cervical spines with 3D motion analysis under loading condition. Patients & Methods. Patient Sample: Four asymptomatic volunteer subjects were recruited and provided informed consent. Approval of the experimental design by the institutional review board was obtained. These 4 individuals were without any history of cervical diseases or procedures. The presence of any symptoms, spinal disorders and anatomical abnormalities in fluoroscopic images or CT was a criterion of exclusion from this study. Outcome Measures: To evaluate the efficacy of the Philadelphia collar, ANOVA was used to compare the range of motion with and without collar at the C3/4, C4/5, C5/6 and C6/7 intervertebral levels for each motion. The level of statistical significance was set at p<0.05. When a statistical difference was detected, post hoc Tukey tests were performed. Methods. Three-dimensional models of the C3-C7 vertebrae were developed from CT scans of each subject using commercial software. Two fluoroscopy systems were positioned to acquire orthogonal images of the cervical spine. The subject was seated within the view of the dual fluoroscopic imaging system. Pairs of images were taken in each of 7 positions: neutral posture, maximum flexion and extension, maximum left and right lateral bending, and maximum left and right rotation. The images and 3D vertebral models were imported into biplane 2D-3D registration software, where the vertebral models were projected onto the pair of digitised images and the 3D bone pose was adjusted to match its radiographic projection in each image. Relative motions between each vertebral body were calculated from body-fixed coordinate systems using a flexion-lateral bending-axial rotation Cardan angle sequence. Results. Flexion range was significantly reduced with the collar at each cervical level. Extension range was significantly reduced at the C3/4 level. Rotation and lateral bending were reduced for C3/4, C4/5, C5/6 levels with the collar. Discussion/Conclusion. The Philadelphia Collar significantly reduces cervical motion at C3/4, C4/5 and C5/6 levels in almost all motions (except for extension). At the C6/7 level, this type of collar has limited effectiveness reducing cervical motion. We used 3D radiographic measurements to quantify the effectiveness of the Philadelphia collar for reducing cervical motion. Bi-plane 2D-3D registration method is useful technique to evaluate 3D motion of cervical spines

Introduction. Cervical orthoses are commonly used to regulate the motion of cervical spines for conservative treatment of injuries and for post-operative immobilization. Previous studies have reported the efficacy of orthoses for 2D flex-extension or 3D motions of the entire cervical spine. However, the ability of cervical orthoses to reduce motion might be different at each intervertebral level and for different types of motion (flexion-extension, rotation, lateral bending). The effectiveness of immobilizing orthoses at each cervical intervertebral level for 3D motions has not been reported. The purpose of this study is to evaluate the effectiveness of the Philadelphia collar to each level of cervical spines with 3D motion analysis under loading condition. Patients & Methods. Patient Sample Four asymptomatic volunteer subjects were recruited and provided informed consent. Approval of the experimental design by the institutional review board was obtained. These 4 individuals were without any history of cervical diseases or procedures. The presence of any symptoms, spinal disorders and anatomical abnormalities in fluoroscopic images or CT was a criterion of exclusion from this study. Outcome Measures To evaluate the efficacy of the Philadelphia collar, ANOVA was used to compare the range of motion with and without collar at the C3/4, C4/5, C5/6 and C6/7 intervertebral levels for each motion. The level of statistical significance was set at p < 0.05. When a statistical difference was detected, post hoc Tukey tests were performed. Methods. Three-dimensional models of the C3–C7 vertebrae were developed from CT scans of each subject using commercial software (see Figure 1). Two fluoroscopy systems were positioned to acquire orthogonal images of the cervical spine. The subject was seated within the view of the dual fluoroscopic imaging system (see Figure 2). Pairs of images were taken in each of 7 positions: neutral posture, maximum flexion and extension, maximum left and right lateral bending, and maximum left and right rotation. The images and 3D vertebral models were imported into biplane 2D-3D registration software, where the vertebral models were projected onto the pair of digitized images and the 3D bone pose was adjusted to match its radiographic projection in each image (see Figure 3). Relative motions between each vertebral body were calculated from body-fixed coordinate systems using a flexion-lateral bending-axial rotation Cardan angle sequence. Results. Flexion range was significantly reduced with the collar at each cervical level. Extension range was significantly reduced at the C3/4 level. Rotation and lateral bending were reduced for C3/4, C4/5, C5/6 levels with the collar. Discussion/Conclusion. The Philadelphia Collar significantly reduces cervical motion at C3/4, C4/5 and C5/6 levels in almost all motions (except for extension). At the C6/7 level, this type of collar has limited effectiveness reducing cervical motion. We used 3D radiographic measurements to quantify the effectiveness of the Philadelphia collar for reducing cervical motion. Bi-plane 2D-3D registration method is useful technique to evaluate 3D motion of cervical spines

Background: Non-operative treatment for plantar fasciitis varies widely and includes the use of night ankle-foot orthoses (AFO’s). Some studies have shown that this is more effective in the initial management of plantar fasciitis than anti-inflammatory therapy. During sleep the foot and ankle tend to assume a plantarflexed position, which results in tightness of the calf muscle group, accounting for the stiffness and pain experienced by patients as they take their first weight bearing steps in the morning. However, when the foot and ankle are kept in a dorsiflexed stretched position at night, stress relaxation occurs and the plantar fascia relaxes. Aim: Compliance with night AFO’s that dorsiflex the foot/ankle has always been a problem. This study compares the effectiveness of a posterior AFO, which dorsiflexes the foot, with an anterior AFO, which maintains the foot in plantigrade, asking whether it is absolutely necessary to dorsiflex the foot and ankle during the night to avoid early morning pain and stiffness, or whether it is it sufficient just to maintain the foot in plantigrade. Methods: 18 participants were recruited on a voluntary basis and at random from among those patients referred to the Orthotics department with plantar fasciitis to be provided with a night orthosis. The inclusion criterion was that the diagnosis was purely plantar fasciitis with no secondary diagnosis, symptoms or complications. Each participant was given a questionnaire to fill in; this evaluated how satisfied the participants were with the orthosis with regards to comfort, ease of use and appearance, and whether the pain in the foot was reduced and at what stage was it reduced. The two types of AFO’s used in this study were:. A posterior AFO that holds the foot in dorsiflexion. The amount of dorsiflexion could be adjusted. An anterior AFO that keeps the ankle and foot in plantigrade, with no adjustment to the amount of dorsiflexion. Results: 67% of the participants confirmed that morning pain and stiffness was less after wearing the AFO; this included 78% of those that wore the anterior AFO and 56% of those that used the posterior orthosis. 56% of all participants reported that the orthoses were uncomfortable and disrupted sleep. The most uncomfortable was the posterior AFO (89%), as opposed to the anterior one (22%). Both types of orthoses were reported to be relatively easy to don and doff (89% anterior AFO and 78% posterior AFO). On a scale of 1 to 10, the participants were asked to grade the pain before starting the orthosis treatment regime, after 6 weeks of wearing the AFO and again 6 weeks later. On average, the anterior AFO reduced the pain from 7 to 2.1, while the posterior orthosis only reduced the pain from 8.1 to 6.7. Conclusion: In general, plantar fasciitis night AFO’s are poorly tolerated orthoses, however, their use can be justified in that the pain levels are reduced. The anterior AFO seems to be more effective in achieving this, without dorsiflexing the foot/ankle beyond plantigrade. Thus, one could argue that there is no need to dorsiflex to achieve the goal. However, further investigation is necessary with a larger patient cohort

The cervical spine exhibits the greatest range of motion amongst the spinal segments due to its tri-planar components of movement. As a result, measurement of movements has proved difficult. A variety of methods have been used in an attempt to measure these movements but none have provided satisfactory triplanar data. This paper uses the Zebris ultrasonic 3-D motion analysis system to measure flexion, extension, range of lateral bending and range of axial rotation in five similar male and five similar female subjects with no history of neck injuries. The subjects were tested unrestrained and in soft and hard collars, as well as in Philadelphia, Miami J and Minerva orthoses. Results show that the Minerva is the most stable construct for restriction of movement in all planes in both groups (p< 0.001 vs. all groups (p=0.01 vs. Philadelphia in female extension), ANOVA). In the male group, the standard hard collar provides the second best resistance to flexion, lateral bending and axial rotation. The female group showed no one orthosis in second place overall. Looking at these results allows ranking of the measured orthoses in order of their three-dimensional stability. Furthermore, they validate the Zebris as a reliable and safe method of measurement of the complex movements of the cervical spine with low intersubject variability. In conclusion, this paper, for the first time presents reproducible data incorporating the composite triplanar movements of the cervical spine thus allowing comparative analysis of the three-dimensional construct stability of the studied orthoses. In addition, these results validate the use of the Zebris system for measurement of cervical spine motion

Appropriate clinical studies that address the efficacy and effectiveness of orthotic treatment in general are difficult to identify, particularly in postoperative treatment of congenital clubfeet. Clinical experience, however, seems to necessitate casting and splinting for a certain time after surgical correction to prevent relapses. Although treatment recommendations range from three months to two years after surgery, duration and intensity of orthotic therapy may depend on the severity of the clubfoot deformity, underlying disorders and the surgeon’s experience. Knee-ankle-foot orthoses with a knee flexion of 90 are most commonly prescribed after the removal of postoperative casts. They allow appropriate abduction of the foot, and daily stretching exercises that can be performed by the parents in combination with physical therapy. Most splints are made of polyethylene or polypropylene, and current designs include static or rigid ankle and forefeet. Some authors also recommend significantly smaller orthoses that are used in metatarsus varus treatment: Denis-Browne bars and orthoses with locking or elastic swivel joints that allow the hindfoot and forefoot components to be adjusted in relation to each other. However, since they do not have a moulded heal, they tend to slip off and cannot prevent recurrence of the equinus. Their application is also restricted to pre-walking infants unless considered for use at night. Outflare shoes (anti-varus shoes) also keep the forefoot in the “corrected position”. To obtain a necessary 3-point correction, however, certain construction principles are mandatory. The hindfoot must be kept in high heel cup and the first metatarsal is pushed laterally against the counter-pressure that is exerted on the cuboid by the most distal and lateral part of the heel cup. After introduction of continuous passive motion (CPM) into the treatment of congenital clubfeet, some groups have published encouraging results. Although the advocates of this treatment state that the duration of plaster cast immobilisation can be shortened after surgery, further evaluation of outcome and cost-effectiveness of this approach is necessary

Hinged elbow orthoses (HEO) are often used to allow protected motion of the unstable elbow. However, biomechanical studies have not shown HEO to improve the stability of a lateral collateral ligament (LCL) deficient elbow. This lack of effectiveness may be due to the straight hinge of current HEO designs which do not account for the native carrying angle of the elbow. The aim of this study was to determine the effectiveness of a custom-designed HEO with adjustable valgus angulation on stabilizing the LCL deficient elbow. Eight cadaveric upper extremities were mounted in an elbow motion simulator in the varus position. An LCL injured (LCLI) model was created by sectioning of the common extensor origin, and the LCL. The adjustable HEO was secured to the arm and its effect with 0°, 10°, and 20° (BR00, BR10, BR20) of valgus angulation was investigated. Varus-valgus angles and ulnohumeral rotations were recorded using an electromagnetic tracking system during simulated active elbow flexion with the forearm pronated and supinated. We examined 5 elbow states, intact, LCLI, BR00, BR10, BR20. There were significant differences in varus and ER angulation between different elbow states with the forearm both pronated and supinated (P=0 for all). The LCLI state with or without the brace resulted in significant increases in varus angulation and ER of the ulnohumeral articulation compared to the intact state (P 0.05). The difference between each of the brace angles and the LCLI state ranged from 1.1° to 2.4° for varus angulation and 0.5° to 1.6° for ER. Although there was a trend toward decreasing varus and external rotation angulation of the ulnohumeral articulation with the application of this adjustable HEO, none of the brace angles examined in this biomechanical investigation was able to fully restore the stability of the LCL deficient elbow. This lack of stabilizing effect may be due to the weight of the brace exerting unintentional varus and torsional forces on the unstable elbow. Previous investigations have shown that the varus arm position is highly unstable in the LCL deficient elbow. Our results demonstrate that application of an HEO with an adjustable carrying angle does not sufficiently stabilize the LCL deficient elbow in this highly unstable position and varus arm position should continue to be avoided in the rehabilitation programs of an LCL deficient elbow

Introduction. There are approximately 1.2 million patients using orthotics in the UK costing the NHS in excess of £100 million per annum. Despite this, there is little data available to determine efficacy and patient compliance. There have been a few reports on patient satisfaction, which indicate that between 13-50% of patients are dissatisfied with their orthotics. Our aim was to evaluate patient reported satisfaction with orthotics prescribed and to investigate the reasons behind patient dissatisfaction. Methods. Seventy consecutive patients receiving foot orthoses at the Royal National Orthopaedic Hospital were retrospectively asked to complete a questionnaire and to bring their shoes and orthotics to research clinic. The inside width of the shoes and corresponding width of the orthotic were measured. A semi-structured interview was carried out on 10 patients, including those that were satisfied or unsatisfied, using qualitative research methods to identify issues that are important to patients. Results. Forty out of 70 patients (57%) completed the questionnaire either by telephone or in the clinic. There was a statistically significant difference between the width of the orthotics and the inside diameter of the shoes that the orthotic was meant to fit in. Dissatisfaction with the new custom made insoles was reported in 28% of patients. Half of these patients reported that the insoles did not fit with their feet into their shoes, and 30% indicated a preference for cosmetic issues over function. The majority of patients had tried numerous homemade or off the shelf versions prior to attending the orthotic department. Conclusion. There is a high level of patient dissatisfaction with orthotics. This dissatisfaction was due to a disconnection between prescribed foot orthoses and shoes purchased by patients. There is an urgent need to join up these two industries to prevent financial waste and improve the cost-effectiveness of orthotic services

Aims: The aim of this study is to determine the forefoot pressure distribution in normal subjects and in patients with metatarsalgia and to present an application of the electronic pedobarography in the design of orthoses. Methods: A control group of 358 normal subjects and a pathological group of 100 patients with metatarsalgia were studied with a wireless portable system for plantar pressure dynamic measurement. Each patient of the pathological group had their metatarsal head loads reequil-ibrated according to the loads obtained in the control group, by means of a set of orthopaedic sights located below the metatarsal heads which supported the lowest load, increasing its pressure support and lightening thus the overloaded metatarsal heads. The aim was to obtain a balance between the þve metatarsal heads similar to the control group. This balance was assessed with the electronic portable system. Results: The pathological group had a signiþcantly higher pressure under the third metatarsal head. The third metatarsal head pressure was significantly decreased, and the þrst, fourth and þfth metatarsal head pressures were signiþcantly increased by means of orthopaedics sights. Conclusions: The forefoot pressure distribution in patients with metatarsalgia differs from normal subjects. Redistribution of metatarsal head loads assessed by means of a electronic system can contribute to the design of orthoses to treat metatarsalgia

Introduction: Adult acquired flatfoot is a common cause of foot pain. The majority of series describe surgery although important non-surgical series exist. This series of 166 patients gives an overview of the clinical spectrum of the condition and outcomes. Materials and Methods: Data was collected prospectively on 166 consecutive patients with adult acquired flatfoot between 1995 and 2005. 104 patients were reviewed at a median of eight years (range 3–13). A standardised clinical examination, AOFAS hindfoot and visual analogue satisfaction scores were performed. Results: There were 40 men (median age 56 years) and 126 women (median age 60 years). 68% had other musculoskeletal problems. Patients were Truro staged at presentation; Stage 1: 26 patients. Stage 2A: 84 patients. Stage 2B: 25 patients. Stage 2C: 23 patients. Stage 3: 6 patients. Stage 4: 2 patients. Stage 1 patients were younger (p< 0.001). 133 patients had soft-tissue symptoms, but 33 had degenerative problems. Degenerative patients had a higher median age (p=0.0138) and stiffer deformities (p< 0.0001). Most patients (131, 78.9%) were managed conservatively. Surgery was commoner in the arthritic group (p=0.001). Fifty-two conservatively treated feet were clinically reassessed. In 31 (59%) patients the Truro stage had not changed, 11 (21%) had improved and 10 (20%) had deteriorated. Twenty percent of patients treated with orthoses stopped using them after 18 to 24 months. In non-surgically treated patients, the median AOFAS score was 73/100 and satisfaction score 71/100. In surgically treated patients the median AOFAS score was 74/100 and satisfaction score 83/100. Discussion: There is a young group of patients with adult acquired flatfoot, with soft tissue symptoms but no progressive deformity. There is a large group with a flexible deformity who can mostly be treated with orthoses, and an older group with stiffer, arthritic deformities who are more likely to need surgery. Conclusion: Final outcomes and satisfaction were similar in surgically and non-surgically treated patients

Aims: Hallux valgus operations cannot always be carried out immediately due to long waiting lists. Effect of waiting for hallux valgus surgery has not been under investigation in a randomized controlled study. Methods: 209 consecutive patients (mean age 48 years, 93% female) with a painful hallux valgus were randomized in three groups: immediate operation or one year waiting time with or without foot orthoses. The follow-up period was 2 years. Main outcome measure was pain intensity during walking (VAS 0 to 100). Results: During the þrst year 64/71, 0/69 and 4/69 patients were operated in surgery, orthosis and no-orthosis groups, respectively, and during the two-year follow-up 66, 43 and 48, respectively. At one-year follow-up the pain was least intensive in surgery group. At two year follow-up the pain intensity was similar in all groups. The satisfaction with treatment was the best in the surgery group and orthosis group as was the fact also with the cosmetic disturbances. The total costs of care were similar in all groups. Conclusion: Immediate operation is superior to delayed operation or foot orthoses, as the beneþt from surgery is obtained already during the þrst follow-up year. If this, however, because of limited operative capacity is not possible, one year waiting, with or without orthois, does not jeopardize the results

Introduction: Tibialis posterior tendon dysfunction is a common cause of foot pain and dysfunction in the middle aged patients. Initially, it presents as medial ankle pain and swelling, with or without a flexible flat foot, later progressing on to a fixed deformity. Operative management for the early stages of tendon dysfunction poses a significant workload on hospitals and physical burden on patients. We have evaluated non-operative management of early tibialis posterior tendon dysfunction (. 1. ). Methods: This is a prospective study on patients with stage I and II tibialis posterior tendon dysfunction treated with a structured physiotherapy protocol. Twelve consecutive patients referred to a foot and ankle consultant with early tibialis posterior dysfunction from July 2008 were included in the study. The physiotherapy regime includes repetitive resisted active dorsiflexion, inversion, eversion, heel rise, and tip toe walking. The intensity of physiotherapy is progressively increased over the period of four months in four phases. Criteria for successful rehabilitation are ability to perform greater than ten single stance heel rises and tip toe walking for more than 100 yards. Patients who cannot achieve the expected progression were re-referred for surgical intervention. All the patients were referred for support with orthoses, however, only a few received the orthoses during the treatment period. The outcome was assessed using the validated outcome score Foot Function Index (FFI) before and after physiotherapy regimen. Results: The study group consisted of 10 females and two males with 10 unilateral and two bilateral cases. The mean age was 59 years (48 to 79). The average number of physiotherapy visits was five. Prior to treatment the mean number of single stance tip toes performed by the patients was four. Out of 12 patients, ten successfully completed the rehabilitation. The mean FFI before rehabilitation was 55, which improved to 19 at the end of four months rehabilitation. On analysis using a paired t test 95% CI for mean difference: (25.07, 46.93) P < 0.0001. The improvement was consistent with all the three components of FFI (pain, activity and function) (p< 0.0001). Conclusion: This study suggests early tibialis posterior tendon dysfunction can be treated effectively with structured physiotherapy

Introduction: Current evidence for treatment of Achilles tendon rupture suggests that open surgical repair reduces the re-rupture rate compared to conservative treatment, but with a higher risk of infection. Modern non-surgical treatment and surgical aftercare involves early weight-bearing in functional orthoses. It is therefore appropriate to measure the re-rupture rates and outcomes in patients treated in this manner. Materials and methods: Between 2002 and 2008 our unit prospectively collected data on 80 patients treated with a below-knee functional orthoses for complete Achilles tendon rupture. Patients made their own choice of treatment following evidence-based counselling. The patients were treated either surgically or conservatively and entered the appropriate arm of the standard orthotic and early weight-bearing treatment protocol. Patients were contacted by telephone or post for follow-up and completed a VISA-A and Achilles Total Rupture Score (ATRS) questionnaire. Results: There were 61 Males, 19 Females with an age range of 24–80 (median 42). The median time in the functional brace was eight weeks. 51 patients were treated conservatively and 29 patients surgically. The conservative group were a decade older (median age 47y, range 27–80) than the surgical group (median age 37y, range 24–55y). In the non-operative treatment group the re-rupture rate was 3.9% (2/51, 95% confidence interval 0.5–13.5%). In the surgical group it was 3.4% (1/29, 95% confidence interval 0–17.8%), in this group the wound infection rate was 6.8% (2/29, 95% confidence interval 0.9–22.8%) with no nerve injuries reported. The median ATRS was 82 in the conservative group and 95 in the surgical group. The median VISA-A scores were 57 and 92 respectively. Discussion: Our case series shows comparable low re-rupture rates in both groups. Functional scores, using the newly validated ATRS score, were lower in the non-surgical, older group. Conclusion: Functional care after surgical and non-surgical treatment of Achilles rupture produces similar re-rupture rates

Introduction. It has been postulated that a mild clubfoot does better than a severe clubfoot no matter what treatment course is taken. There have been previous efforts to classify clubfoot. For units worldwide that use the Ponseti Method of clubfoot management, the Pirani scoring system is widely used. This scoring system has previously been shown to predict the number of plasters required to gain correction. Our study aimed to investigate whether the Pirani score gave an indication of longer-term outcome using tibialis anterior tendon transfer as an endpoint. Methods. A prospectively collated database was used to identify all patients treated in the Ponseti clinic at the Royal Manchester Children's Hospital between 2002 and 2005 with idiopathic clubfoot who had not received any treatment prior to their referral. Rate of tibialis tendon transfer as well as the patient's presenting Pirani score were noted. Feet were grouped for analytical purposes into a mild clubfoot (Pirani score <4) and a severe clubfoot (Pirani score 4) category depending on initial examination. Clinic records were reviewed retrospectively to identify patients who were poorly compliant at wearing boots and bars and were categorised into having “good” or “bad” compliance with orthosis use. Results. 132 feet in 94 children were included in the study. 30 (23%) tibialis tendon transfers were performed at a mean of 4.2 years (range 2.3–5.5 years). Children with severe clubfoot had a significantly higher rate of tendon transfer compared with those with mild clubfoot (28% vs. 6%; p=0.0001). 81% of patients were classified as being “good” boot wearers. Tibialis tendon transfer rates in those who were poorly compliant with boot usage were significantly higher compared with those with good compliance (52% vs. 16%; p=0.0003). There was a significantly higher tendon transfer rate in those with severe disease and poor compliance compared with good compliance (69% vs. 20%; p=0.0002). There was no association between boot compliance and tendon transfer rates in those with mild disease. Conclusion. This study shows that late recurrences, requiring tibialis anterior tendon transfer, are associated with severity of disease at presentation and compliance with use of orthoses. Tendon transfer rates are higher for those with severe disease. We have confirmed previous reports that compliance with orthotic use is associated with recurrence. However, the novel findings regarding recurrence rates in mild clubfeet may have implications regarding usage of orthoses in the management of mild idiopathic clubfeet after initial manipulation using the Ponseti method

Introduction: In children with MMC characteristic kinematic gait patterns and center of mass motion have been identified for different lumbo-sacral levels, which may vary in specific muscle paresis definitions and ambulatory outcome. The goal was to investigate compensatory movements employed in MMC in groups with successive paresis in the following major muscle groups: plantarflexors, dorsiflexors, hip abductors and hip extensors. Patients and Methods: 28 children with MMC (m=10.3 y), walking independently participated in a gait study. A classification based on paresis on the primary muscle groups was established using standard Manual Muscle Test (MMT). Five groups of MMC were established based on successive paresis (0-2 MMT) of the plantarflexors,dor-siflexors, hip abductors, and hip extensors. Subjects were tested in their habitual orthoses, if any. All children underwent full-body three-dimensional gait analysis (VICON, Oxford). Five kinematic cycles from each side were analyzed and group averages were calculated. Results: The most striking compensatory movements were observed in the frontal and transverse planes in the trunk, pelvis, and hips. Trunk sway increased sequentially from Groups 1 to 5, with the largest interval occurring at the onset of hip abductor paresis (Group 4). Trunk and pelvic rotation were observed to completely alter at the onset of hip abductor paresis (Group 4), where an internal position occurs during stance and external during swing. ‘Pelvic hike,’ or the lifting of the pelvis during swing, was observed in as early as Group 2 with plantarflexor paresis, becoming more pronounced in the latter groups. Large hip abduction was observed during stance at the onset of hip abductor paresis (Group 4). The onset of dorsiflexor paresis result in few kinematic changes since all subjects in Groups 2 and 3 wore orthoses. Sagittal plane differences were observed at the onset of hip extensor paresis (Group 5), where the trunk and pelvis were more posteriorly tipped and hips less flexed. Discussion The classification method aids in understanding the specific compensatory mechanisms employed when the muscle functions are successively lost. Plantarflexor paresis is evident in all three planes in even the trunk. Abductor weakness results in large frontal and transverse plane changes. Hip extensor weakness is mostly evident in the sagittal plane. By understand-ingthe characteristic movements employed, an improved basis for evaluation and treatment can be established