Introduction:

The os-calcis is the most common tarsal bone to fracture. It can lead to a debilitating arthritis and has considerable socio-economic implications.

In the literature there is great debate as to whether operative or non-operative management has a better outcome. Previous smaller case series report improved results from surgery whereas the one randomised trial showed no overall benefit from surgery. However sub-group analysis identified patients that had a better outcome with operative management. Results from the UK heel fracture trial are awaited. We present a 5 year series from a single centre, single surgeon that includes 143 fractures. There are currently no comparable published data.

Background

Femoroacetabular impingement (FAI) may be a predisposing factor in progression of osteoarthritis. The use of hip arthroscopy is in its infancy with very few studies currently reported. Early reports show favourable results for treatment of young patients with FAI. This prospective study over a larger age spectrum represents a significant addition to this expanding field of minimally invasive surgery.

The most important determinant of treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement.

We developed clinical criteria for potential instability and applied them to a prospective series of patients. Criteria included: a medial clear space of < 4mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; a high-energy fracture mechanism. Patients with a medial clear space of < 4mm and none of these criteria were considered to have stable fractures, while those with a medial clear space of > 4mm were considered to have a displaced fracture.

We studied 152 consecutive skeletally mature patients with undisplaced, potentially unstable malleolar fractures treated by the senior author between 1st January 1998 and 31st December 2007. Patients were treated in a below-knee walking cast (136 patients) or a functional ankle brace (16 patients) for six weeks. Weight bearing was encouraged throughout. Weight bearing radiographs were obtained at one week and six weeks. Displacement was defined as talar displacement with a medial clear space > 4mm. Demographic, clinical and radiological data were collected prospectively.

There were 88 male and 64 female patients, with a median age of 43 years. Criteria for possible instability were: medial tenderness, 115 patients; proximal fibular fracture, 29 patients; bimalleolar fracture, 17 patients; other criteria, 15 patients. Three fractures displaced (risk of displacement 2.0%, 95% CI 0.4–5.7%). All displaced within the first week and were treated by open reduction and internal fixation. One bimalleolar fracture developed a symptomatic medial malleolar non-union which was treated by percutaneous screw fixation (risk of non-union 5.9%, 95% CI 0.1%–28.7%). All the other fractures achieved clinical union by 8 weeks.

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.

Purposes of the study: Anterior cruciate ligament (ACL) deficiency is associated with degenerative osteoarthritis especially when it is present with meniscal injury; We assessed the impact of certain aetiological factors in chondral degeneration in the ACL deficient knee.

Methodology and Results: Fifty-eight patients who underwent consecutive primary arthroscopic anterior cruciate ligament reconstruction using the four strand hamstring graft between 10/06/2004 and 29/06/2006 were retrospectively analysed.

Patient’s charts and radiology findings were reviewed with special attention to operative notes and preoperative knee MR imaging. Patients with knee symptoms prior to presenting injury were excluded.

The mechanism of injury, the time elapsed from the original injury to anterior cruciate ligament reconstruction, associated meniscal injury, and quality of cartilage in the knee- at the time of MR imaging and ACL reconstruction were noted. Degenerative cartilage changes were graded upon reconstruction using the Outerbridge classification.

The average time from Injury to MR imaging and MR to ACL reconstruction was 4.85 and 12.65 months respectively.

We found a direct relationship between the time elapsed after the ACL injury and the severity of the chondral lesion (p< 0.05). Furthermore, a significant worsening in chondral degeneration of the involved knee was seen when the MR imaging and ACL reconstruction were more than 12 months apart (p< 0.01).

Conclusion: We conclude that chondral lesions and degeneration are more likely to be caused by an extended period of knee instability following ACL injury as opposed to age related degeneration or direct trauma to the weight bearing area of the knee.

Early reconstruction may protect the knee from chondral wear and subsequent degenerative arthritis.

The contribution of incorrectly fitting footwear to the development of foot pain and deformity has been citied as an etiologic factor but is something that has not been fully evaluated. We examined the relationship between footwear characteristics and the prevalence of common forefoot problems in patients attending foot clinic.

Methods: Prospective study measuring shoe size (width & Length) and foot measurements in 50 patients attending foot clinic with foot problems. Comparison made with 50 random people with no foot complaints. Deformities, medical histories and pain scores were documented.

Results: Clinic patients: Mean age 49 range(19–68). 12 male 38 female. 21 out of 50 wearing shoes half a shoe size too small, 7 patients wearing shoes half a shoe size larger. 32 patients wearing shoes narrower than feet mean 6mm (range 2–9mm.) Deformities: 27 hallux valgus, 3 bunionette, 6 hammertoes, 5 callosities. Mean pain VAS 5 range (3–10). 11 patients were diabetic, 6 had peripheral vascular disease.

Random patients: Mean age 41 range(19–65). 19 male 31 female. 7 out of 50 wearing shoes half a size smaller, 13 wearing shoes half a size larger, 15 wearing shoes narrower than feet mean 4 mm (range 2–7mm). Deformities: 6 hallux valgus, 3 hammer toes, 8 callosities. Mean pain VAS 1 (1–3). 8 people were diabetic.

Conclusion: A large proportion of patients attending foot clinic wore ill-fitting shoes. Women wore shoes that were shorter and narrower compared to their feet than men. Wearing shoes smaller and narrower than the feet was associated with hammer toes, hallux valgus deformity and foot pain. Incorrectly fitting footwear may be a significant contributing factor associated with forefoot pathology and foot pain. These findings highlight the need for footwear assessment in the management of foot problems.