Introduction

We hereby present results of controlled randomized trial of use of popliteal block for pain relief in ankle and hind foot surgery.

Materials and methods

We have studied 63 patients over period of 9 months. Patients who needed ankle or hind foot procedure were selected for trial. Patients were explained about the trial and popliteal block along with leaflets at preoperative clinics. Patients were randomized on the day of surgery. A sealed envelop stating whether patient will go to block group (A) or no block group (B) was opened in the anaesthetic room before the patient was anaesthetized. Patients were evaluated for subjective pain scores at 30 min, 6 hrs, 12 hrs and 24 hrs after surgery. Amount of anaelgesic required and time to first dose was documented. Popliteal blocks were given by one foot and ankle consultant and one trained fellow. The block was administered in lateral position at 0.8 mA stimulus to detect the nerve. The data was compared statistically between group A and B.

Introduction: We present the results of a controlled randomized trial of the use of a popliteal block for pain relief in ankle and hindfoot surgery.

Materials and methods: We studied 47 patients over period of nine months in 2007 to 2008. Patients undergoing an ankle or hindfoot procedure were included in the trial. The trial was explained to the patients. Written information leaflets were also used in the preoperative clinics. Patients were randomized on the day of surgery. A sealed envelope randomizing the patient to block (A), or no block (B) was opened in the anaesthetic room before the patient was anaesthetised. Patients were subjective pain scores were recorded at 30 min, 6, 12 and 24 hours after surgery. The amount of analgesia required and time to first dose was documented. One foot and ankle consultant and one trained fellow gave the popliteal blocks. The block was administered in the lateral position at 0.8 mAmp stimulus to detect the nerve. Group A and B data was compared statistically.

Results: The average pain scores in group A were reported to be 1.2 at 30min, 1.23 at 6, 2.1 at 12 and 3 at 24 hours. In group B it was 1.2 at 30min, 7.2, 8.1 and 4 at 6, 12 and 24 hours. There was a statistical significant difference in the pain scores at 6 and 12 hours. There was no statistical significant difference in the pain scores at 30 min and 24 hours.

Conclusion: Popliteal block gives effective pain relief in ankle and hindfoot surgery. We believe that it may reduce anaesthetic and analgesic drug requirement as well.

We present our results in 89 consecutive patients (138 feet), minimum FU of 24/12.

Methods: Typical indications were IM angles > 13 degrees, incongruent MTP1 joints.

Contraindications included abnormal DMMA, significant 1st MTP arthritis, hypermobility of 1st MTC joint, revision surgery.

All patients underwent a 3-in-1 procedure with soft tissue release in 1stwebspace, medial bunionectomy with capsulorraphy and basal crescentic osteotomy.

A 25 mm blade on oscillating driver was used. Fixation was staples(70%),screws(20%),K- wires(10%).

Post op, PWB, progressing to FWB at 3/52.

AOFAS forefoot scores at pre-op, 6/12, 12/12 and 24/12.

Weight bearing radiographs obtained at pre-op, 3/12, 12/12.

Results:

M:F=19:70

Age 31–79 (Mean 64)

89 patients, 138 feet

AOFAS scores improved from average 42/100 preop to 76/100 at 6/12.

Radiographic correction excellent in78% of patients.

74 % of patients extremely satisfied,15 %satisfied,11 %unsatisfied with outcome.

Complications:

Nonunion=2

Infection=2 superficial,1 deep

Recurrence of deformity at 6/12 = 2

12/12 = 2

Transfer metatarsalgia M2 due to overriding of distal M1=3

Conclusions: Basal Dome Osteotomy with soft tissue correction is powerful and reproducible for the correction of moderate and severe Hallux Valgus. There is an initial learning curve. Much less soft tissue dissection required compared to the SCARF procedure. Results are very satisfactory.

Subtalar joint stiffness is an under recognized complication of ankle fractures. We set out to objectively measure its prevalence and impact on Activities of Daily Living (ADL).

Method:

60 ankle fractures included in study. All patients had contralateral normal ankle.

M:F=21:39

Average age: 36 (19 – 84)

Weber: A B C

21 27 12

27 patients underwent ORIF (12C + 15B)

39 patients had plaster casts for between 2 and 6 weeks. (27B + 12C)

Postop regimes included early mobilization and POP application (AO recommendation)

Weber A (21) treated symptomatically.

Examinations for study at 3/12 and 6/12 post injury.

Subtalar and ankle movements were assessed by the same examiner (as per Hoppenfeld)

Subjective questions about subtalar stiffness and their impact on ADL were asked.

Results:

At 3/12, 56 patients (17A + 27B + 12C) had subjective and clinical impairment of subtalar movement.

32 patients (2A + 20B + 10C) had moderate to severe impairment (> 30%)

At 6/12, 42 patients (9A + 23B + 10C) had subjective symptoms and clinical impairment of subtalar function. Of these, 26 (0A + 18B + 8C) had > 30% impairment vs. controls.

Conclusions: Symptomatic subtalar joint stiffness with limitation of ADL is a significant sequel of ankle fractures and results in long term morbidity. This has implications in assessing functional outcome of these common injuries.

We present our results with a modified Mann-Thompson procedure in 47 patients (86 feet). Minimum follow up was 24 months.

All patients had moderate to advanced forefoot deformities.

Methods:

M:F=12:35

43/47 bilateral

Simultaneous procedures in bilateral cases.

Popliteal block analgesia used routinely.

Technique:

Medial incision centered on MTP1 joint. Minimal bony and soft tissue resection. Fixation carried out with staples (78 feet),K-wires (8 feet)

Transverse incision centered on the lesser MTP joints made. Combination of soft tissue release, lesser MT head resection in cascade fashion from dorsal distal to proximal plantar performed. Lesser toe deformities treated by a combination of closed osteoclasis, soft tissue release and bony resection. Transarticular K-wire fixation then performed for all lesser toes.

Bulky postop dressing and post op shoes used.

Immediate FWB permitted.

Transarticular K-wires removed at 4/52.

Results:

AOFAS Forefoot Scores assessed at preop,6/12,12/ 12,and24/12.

Subjective patient assessment of procedure requested.

Average AOFAS scores improved from 37to72(67 – 84)

40 patients extremely pleased with the results. 5 patients pleased with reservations and 2 patients disappointed with the outcome.

Complications:

3 superficial wound infections

2 metal work related problems

2 early loss of lesser toe correction

3 late deformities of lesser metatarsals requiring surgery

Conclusion: This procedure offers excellent, reproducible biomechanical correction with high rates of patient satisfaction.

Introduction Exposure of the lesser metatarsophalangeal (MTP) joints is needed for many procedures e.g. forefoot arthroplasty and multiple Weil-type osteotomies. Traditionally collateral incisions and plantar incisions have been described. However exposure using these is often difficult and inadequate in the presence of rheumatoid arthritis (RA) and associated deformities. Transverse incisions offer excellent exposure, extensibilty, versatility and improved range of movements with decreased neurovascular compromise. Aesthetic wound healing is common. We describe our results following the use of a curved transverse incision for the Mann-Thompson type of arthroplasty and multiple Weil osteotomies. A single incision was used to expose all lesser MTP joints.

Method A total of 34 consecutive patients with either procedure were included, comprising 52 feet including 18 bilateral forefoot arthroplasty and 10 multiple Weil osteotomies. All patients were followed up for 12 months. A questionnaire was completed for each patient at conclusion of surgery, and then at 6 and 12 months. Ease of exposure, visualisation of target areas, wound healing, neurovascular complications and average range of movement were assessed. Four surgeons were involved in the study: one consultant, one NT middle grade, and two specialist registrars.

Results Three minor wound healing complications were noted, with no need for repeat surgery. No neurovascular complications were noted, cosmesis was good-to-excellent in all, a global range of movement of 30 degrees was achieved in 95%. Ease of exposure and visualisation of the target area was good-to-excellent in all patients. All surgeons reported satisfaction with the approach and rated it superior to the collateral and plantar incisions.

Conclusion We believe that this represents excellent results in this difficult group of patients. The curved transverse incision is a workhorse incision for the lesser MTP joints.

Although it is generally accepted that surgical treatment is the treatment of choice in chronic TA ruptures, therapeutic options are difficult. Traditional options include grafts (natural, allografts and synthetic grafts) and end to end repair. Natural grafts described include fascia lata and plantaris tendon. Synthetic materials such as Dacrongrafts, Marlex mesh and carbon fibers have been used. There are significant complications from graft and end to end repair. These include wound necrosis, delayed union, infection, foreign body reaction and devastating tissue loss. Also functional results are suboptimal after delayed reconstruction.

Tendon transfer is another method that has been described for the treatment of these injuries. The tendons used were the flexor hallucis lomgus, flexor digitorum longus and the peronei . The FHL tendon transfer is considered advantageous to other tendon transfers because it is stronger, its axis of force is close to that of the TA and harvesting the tendon is easy and unlikely to cause any complications.

We report excellent results following four operations in three patients treated with flexor hallucis longus tendon transfer for chronic Achilles tendon ruptures. All patients were on long term steroid treatment and an end to end repair would have been associated with a high complication rate.

We believe that FHL transfer to replace the TA is a low morbidity alternative which gives good to excellent results in individuals with low to moderate demand.