Background

Open subtalar arthrodesis has been associated with a moderate rate of non-union, as high 16.3%, and high rates of infection and nerve injury. Performing this operation arthroscopically serves to limit the disruption to the soft tissue envelope, improve union rates and reduce infection. Our study describes our outcomes and experience of this operation.

Introduction

This is a multi-centre, prospective, observational study of 503 INFINITY fixed bearing total ankle arthroplasties. We report the minimum two-year results of this prosthesis which was introduced to the UK Market in 2014 and is now the most used ankle arthroplasty in the National Joint Registry of England and Wales.

Tendoscopy in the treatment of peroneal tendon disorders is becoming an increasingly safe, reliable, and reproducible technique. Peroneal tendoscopy can be used as both an isolated procedure and as an adjacent procedure with other surgical techniques. The aim of our study was to review all peroneal tendoscopy that was undertaken at the AOC, by the senior authors (IGW, SH), and to determine the safety and efficacy of this surgical technique.

Introduction

Flexor Hallucis Longus (FHL) tendon transfer is a well-recognised salvage operation for irreparable tendon Achilles (TA) ruptures and intractable Achilles tenonopathy. Several case series describes the technique and results of arthroscopic FHL tendon transfers. We present a comparative case series of open and arthroscopic FHL tendon transfers from Southmead Hospital, Bristol, UK.

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.

The Zenith^TM total ankle replacement (Corin, Cirencester) is a mobile-bearing implant based on the Buechal Pappas design. Key features are the simple fully-jigged instrumentation aiming to improve accuracy and reproducibility of implant positioning, cementless calcium phosphate coated surfaces for improved early osseointegration, and titanium nitride-coated bearing surfaces to resist wear. We present early to mid-term survival data for 155 total ankle replacements implanted by three surgeons in our institute.

Case records of all patients undergoing Zenith^TM Total Ankle Replacement by three senior surgeons, including a member of the design team, between 2007 and 2014 were examined. Patients were examined clinically and radiographically annually after the early postoperative period. The primary outcome measure was implant survival. Secondary outcome measures included complication rates, parameters of radiographic alignment, and radiographic evidence of cysts and loosening.

One hundred and fifty-five cases were performed for a mixture of primary pathologies, predominantly primary or posttraumatic arthrosis. Mean follow-up was 50 months. Implant survival was 99.0% at 3 years (n=103), 94.0% at 5 years (n=50), and 93.8% at 7 years (n=16). One patient was revised to arthrodesis for aseptic loosening, one arthrodesis was performed for periprosthetic infection with loosening, and one below-knee amputation was performed for chronic pain. Three cases underwent further surgery to address cysts, and 7 malleolar fractures were reported. Medial gutter pain was experienced by 9% of patients.

Overall, our data show excellent early and mid-term survivorship for the Zenith^TM Total Ankle Replacement. Simple fully-jigged instrumentation allows accurate and reproducible implant alignment.

Aim:

Ankle sprains are one of the most common sports injuries. Around 10–20 % of the acute ankle sprains may lead to the sequelae of chronic ankle instability. Around 15–35% of the patients have residual pain following successful lateral ligament reconstruction. One of the reasons suggested for the persistent symptoms following lateral ligament reconstruction has been the presence of intra-articular pathology.

Background

Traditional measurements of hindfoot alignment are based on the tibio-calcaneal angle and do not take the forefoot into account. We have developed an algorithm based on standard radiographs to calculate calcaneal offset using Ground Reaction Force (GRF).

Simultaneous arthrodesis of the ankle and subtalar joints is an established treatment option for combined ankle and subtalar arthritis or complex hindfoot deformities. The use of a curved intra medullary nail has potential advantages in terms of stability, hindfoot alignment and avoidance of the lateral neurovascular bundle.

We devised a comparative description of the results of hindfoot fusion using a curved locking nail before and after the introduction of anatomically specific modifications to the device through a retrospective review of notes and radiographs of patients undergoing simultaneous ankle and subtalar fusion by retrograde intramedullary nailing using an ACE¯ (Humeral Nail. Patients undergoing the same procedure using the Tibiotalocalcaneal [TTC] Nail System [DePuy] were recruited and studied prospectively. The outcome was assessed by a combination of notes review, clinical examination and telephone questionnaire.

Between 1996 and 2004, 71 arthrodeses in 67 patients have been performed. The average follow up is 27 months [3-73] and mean age 58 years. Fifty-two arthrodeses utilised the ACE humeral nail and nineteen used the newer TTC nail. Both nailing systems are locked proximally and distally and provide a short radius laterally directed distal curve. Mean time to union is 4.3 months [3-10]. Average AOFAS hindfoot score post-operatively is 65, with a mean improvement of 40 points from the pre-operative score in the TTC nail group. Post-operative complications included deep infection, amputation and a non-union rate of 10% overall. In the humeral nail group, four symptomatic stress reactions [8%] and three fractures of the tibia [6%] occurred at the tip of the nail. No stress-riser effect has to date been seen in the TTC nail group. Prominent metalwork removal has also been significantly reduced in the TTC nail group.

Our results show hindfoot fusion using a curved intramedullary nail to be an effective technique in complex cases of hindfoot arthritis and deformity. Anatomically specific alterations to the nail have resulted in a significant reduction in certain complications. Alternate proximal locking options in the TTC nail have reduced prominent metalwork and, more significantly, the incidence of stress reactions and fractures appears to have been eliminated.

Introduction: Non-union following hindfoot arthrodesis remains a significant risk in foot and ankle surgery. In the reported series of revision hindfoot arthrodeses non-union rates range from 9 to 25% with approximately half these patients going on to a transtibial amputation. Bone morphogenic proteins (BMP) are a group of naturally occurring proteins with strong osteoinductive properties, which have shown promise in the treatment of fracture non-unions and primary hindfoot arthrodesis surgery. This article reports our experiences with rhBMP-7 as an adjunct to revision arthrodesis surgery in this high-risk subset of patients.

Methods: Eight patients with at least one previous non-union and two or more risk factors for non-union and one patient on steroids with a failed total ankle replacement were prospectively recruited to the study. A revision arthrodesis procedure with internal fixation was performed according to the senior author’s revision protocol with the addition of 3.5mg rhBMP-7 combined with 40mls of bone marrow aspirate. Bone graft was used only if there was structural bone loss. Outcome was assessed clinically and radiologically.

Results: Follow-up ranges from 3 to 22 months (average 13 months). Clinically 8 of the 9 patients had a pain free, stable arthrodesis. Seven patients were satisfied with their functional improvement and pain relief. Radiologically two patients have united, six patients have partial unions with ongoing progression towards union and one patient has a painless non-union. There was one wound infection and one malunion. No complications related to rhBMP-7 were experienced.

Conclusion: Revision arthrodesis with adjuvant rhBMP-7 has led to limb salvage in this group of high-risk patients. However, rhBMP-7 is not a panacea for achieving union and does not replace meticulous surgical planning and technique. Achieving bony union in this subset of patients remains a high risk and protracted process. No concerns about the short-term safety of rhBMP-7 were raised.

Introduction: Fresh autogenous cancellous bone graft is the material of choice in reconstruction and fusion procedures in foot and ankle surgery. There are many potential donor sites for graft harvest, all with recognised minor and major complications. The proximal tibia is one such potential site, and is particularly suited to foot and ankle surgery being within the operative field and under tourniquet control.

Purpose: To assess pain, morbidity and ability to weight bear in a large group of patients undergoing foot and ankle surgery utilising cancellous bone graft from the proximal tibia.

Method: A retrospective audit was undertaken of 148 procedures performed over a period of five years. Minimum follow-up was 3 months. Data were obtained from operation notes and patient interview.

Results: Most patients had no pain (78%) or very mild pain (20%) at the site of graft harvest immediately following surgery. At review, 96% had no pain; 4% had very mild pain with certain activities such as kneeling. There were no major complications. 4 patients (2.7%) had persisting areas of parasthaesia at review, but none were troubled by it. One patient had a superficial wound problem that resolved. The ability to bear weight was dictated by the primary procedure. Usually this was from 2–3 weeks. There were no complications related to early weight bearing in this series.

Conclusion: The proximal tibia is a suitable and safe site for bone graft harvest for foot and ankle surgery. There is no need for additional restriction in weight bearing following this procedure.

Introduction: Osteochondral lesions of the Talar Dome(OCD) remain a difficult therapeutic problem. One solution has been to consider using autologous chondrocyte implants. Though initial results of this technique are interesting the donor sites have always been in a normal knee. The presence of knee symptoms subsequently in some patients might be regarded as inevitable. This paper reports on the viabilty of donor material taken from the ankle.

Materials: Twenty four patients have been recruited to a pilot study of the viability of obtaining donated chondral material for Matrix Autologous Condrocyte Implantation. There were 14 men and 10 women. Their mean age was 37.3 years (range 17–63). All were complaining of presistent symptoms of pain and some insecurity following previous conventional surgery for treatment of a symptomatic OCD. All had MRI evidence of ongoing changes in keeping with persistent problems related to an OCD.

Methods: All patients had an initial arthroscopy of the affected ankle to reassess the state of the joint surface. Donor articular cartilage was obtained from one of three sites. The anterior part of the joint surface on the talar neck, from the medial articular facet of the talus or rarely from an area of articular cartilage on the edge of the lesion. The mean weight of the donor harvest was 133 micrograms(range51–450).

Results: All donated graft material produced viable implantable graft material between 5 and 7 weeks from harvest. Cell counts ranged from 12.3 million to 20 million with cell viabilities of 98% or above. These figures are directly comparable with the results obtained from the knee despite the original donor weights being less.

Conclusion: If this technique is contemplated the use of the affected ankle as a donor site is a viable alternative to the knee.

Aim: A medium term review of total ankle replacements with a view to reviewing follow up protocols, reassessing the usefulness of the SF12 Health Survey questionnaire, and to determine factors that may indicate early failure.

Method: Sixty-five ankle replacements in 58 patients with an average age at operation of 65 (44–80) (32 males: 23 females, 3 died) were reviewed after a mean of 41 months (8–97 months). They were assessed via postal questionnaire and a research clinic with regard to their pain, difficulty and SF 12 scores, their outcome perception and range of movement. Additionally, we looked retrospectively at their notes and latest X-rays.

Results: Indications for operation were OA (79.5%), RA (18.2%) and psoriatic arthropathy (2.3%). Patients’ perceptions of their outcomes were 41(78.8%) good, 5(9.6%) moderate and 6(11.5%) poor. The average “mean pain score” was 3.6 and average “mean difficulty score “ was 4.0. There was no significant change between the pre and post-operative mean SF 12 scores. Save for 2 anomalies, poor outcomes and SF12 scores were only seen in post-traumatic OA(100%) and RA patients. Prostheses used were Beuchel-Pappas, OSG and DePuy Mobility. There are no revisions to date. The average range of movement was 26°. X-rays generally showed good prosthesis alignment, minimal insert wear, occasional non-enlarging, small (1–2mm) cysts around the tibial component.

Conclusions: The SF 12 scores seem to be unresponsive. The pain and difficulty scores more reflect the patients’ perception of outcome. With the low incidence of revision, risk factors for early failure are difficult to establish but patients with radiological cysts, talar collapse or more severe deformities of the foot/ankle might be the ones who need regular review.

Aim: To report the clinical and radiological results of patients undergoing hindfoot fusion using an intramedullary nail. Methods: Retrospective review of notes of patients undergoing combined ankle and subtalar arthrodesis using retrograde intramedullary nailing. The procedure is performed mainly for the treatment of complex hindfoot deformities or following failed total ankle arthroplasty. Outcome was assessed by notes review, clinical examination and telephone questionnaire. Results: Between 1995 and 2001 56 arthrodeses in 52 patients have been performed. The average follow up is 3 years. Approach to the joints was via an anterolateral incision unless previous surgery dictated otherwise. All cases utilised an ACE¨ humeral nail which was locked proximally and distally. Most procedures utilised bone graft from the þbula, proximal tibia, iliac crest or allograft femoral head. Mean tourniquet time was 114 mins. Post-operative management generally consisted of 3 months plaster immobilisation. Post-operative complications included deep infection, amputation, stress fracture, non-union & prominent metalwork. At review 90% of patients were satisþed and approximately 90% felt the pain level & function of their foot had improved. Average postoperative AOFAS hindfoot score was 65. Conclusion: Hindfoot fusion by intramedullary nailing is an effective technique in complex cases of deformity and in many cases is the only alternative to amputation. Patient satisfaction appears to be high but the procedure is demanding and the complication rate can be signiþcant.

Aim

To report the clinical and radiological results of patients undergoing hindfoot fusion using an intramedullary nail.

Methods

Retrospective review of notes and radiographs of the patients of 2 surgeons who perform combined ankle and subtalar arthrodesis using retrograde intramedullary nailing with an ACE® humeral nail. The procedure is performed mainly for the treatment of combined ankle and subtalar arthritis or complex hindfoot deformities. Outcome was assessed by a combination of notes review, clinical examination and telephone questionnaire.

Results

Between 1995 and 2001 54 arthrodeses in 51 patients have been performed. The average follow up is 3 years. Approach to the joints was via a vertical anterolateral incision unless previous surgery dictated otherwise. All cases utilised an ACE® humeral nail which was locked proximally and distally. Most procedures utilised bone graft from the fibula, proximal tibia, iliac crest or allograft femoral head. Mean tourniquet time was 122 mins. Intra operative complications included one fractured tibia and one fractured medial malleolus. Postoperative management generally consisted of 3 months plaster immobilisation. Only 3 cases were immobilised significantly longer than this. Postoperative complications included deep infection, amputation, stress fracture, non-union & prominent metalwork. At review almost 78% of patients were satisfied with the results of surgery and approximately 80% felt the pain level & function of their foot had improved. Average postoperative AOFAS hindfoot score was 73.

Conclusion

Hindfoot fusion by intramedullary nailing is an effective technique in complex cases of deformity and in many cases is the only alternative to amputation. Patient satisfaction appears to be high but the procedure is demanding and the complication rate can be significant.

We review the early results of 13 patients who underwent hip arthroplasty as the initial treatment following acetabular fracture. The indications for performing THA over open reduction and internal fixation included fractures of poor prognosis, dome comminution, femoral head damage and comorbidity. Fractures were fixed in a limited fashion and an uncemented Harris-Galante cup was inserted with bone grafting. All femoral components were cemented Exeters.

There were two deaths. The first in the immediate post-operative period due to massive pulmonary embolism and the second in the early rehabilitation period due to pre-existing respiratory problems.

The remaining 11 patients were assessed at an average of 37 months (13–68). The mean Charnley hip score was 15 (8–18) and the mean Harris hip score 82 (33–100). One acetabular cup had loosened accounting for the lowest scores and awaits revision. All fractures united by 6 months and all other components appeared stable at radiological review. Technical difficulties of this procedure will be discussed.