Introduction: Adult acquired flat foot deformity is recognised as a spectrum of pathology related to tibialis posterior dysfunction (TPD) and plantar ligament insufficiency. Cobb has described a method of reconstruction in pure Johnson and Strom type II TPD using a split Tibialis Anterior musculo-tendinous graft.

Methods: We describe a prospective study of 32 patients treated by the Cobb technique and a medial displacement translational os calcis osteotomy for Johnson and Strom type II TPD. There were 28 females and four males (age range 44–66, average 54) each with unilateral disease. The average follow up was 5.1 years, range 3 to 7.2 years. Each patient had failed conservative management and the staging was confirmed clinically and radiologically (ultrasound scanning and MRI). The surgery was performed as described by Cobb but with a bone tunnel in the navicular rather than the medial cuneiform. Postoperative immobilisation in plaster was for eight weeks followed by orthotics and physiotherapy.

Results: All the os calcis osteotomies healed uneventfully. 29 of the 32 patients were able to perform a single heel rise test (none prior to surgery) at twelve months follow-up. These patients had grade 5 power of the tibialis posterior tendon. The others had grade 4 power and were also happy with the result. The mean American orthopaedic foot and ankle society (AOFAS) hindfoot score was 82. There was one superficial wound infection successfully treated by antibiotics and a temporary dysaesthesia in the medial plantar nerve in another.

Discussion: This prospective study confirms that the Cobb technique is an excellent method of treating pure Johnson and Strom type II TPD after failed conservative management. The procedure is performed with a medial displacement os calcis osteotomy but in selected cases may be combined with spring ligament repair and lateral column lengthening. An updated classification will be presented designed to facilitate the decision making process in this difficult condition.

Introduction: We reviewed the complications and recovery of patients treated for Achilles tendon rupture by percutaneous repair, open repair, and non-operative management in a tertiary referral centre between 2001 and 2003.

Materials and Methods: We identified patients who underwent Achilles tendon rupture repair by percutaneous or open methods from the logbooks of Consultants and the operating theatre register. We used plaster room records were also used to identify patients who received non-operative treatment. We collated demographic and management details, and compared them with published rates relating to average age range, demographic, and management details.

Results: In the 20 patients who underwent open repair, one (4.8%) patient sustained a re-rupture, four (19%) sustained minor complications, and one (4.8%) had a major complication. In the 31 patients who underwent percutaneous repair, one (3.2%) patient sustained a major complication, six (19.4%) patients experienced minor wound complications, and there were no re-ruptures. In the 12 patients who underwent conservative management, re-ruptures occurred in one patient (8.3%), minor complications occurred in five patients (41.7%), and there were no major complications. The median recovery time in the open, percutaneous and conservative groups was 25 weeks, 26 weeks and 18.5 weeks respectively.

Discussion and Conclusion: In our setting, percutaneous repair is the most successful management method, with no re-ruptures and very few complications. Although conservative management produced the highest rate of complications, each patient will have different needs due to their age, occupation or level of sporting activity. Ultimately, the decision of the management regime used probably lies with the patient.

Open reduction and internal fixation for displaced intra-articular fractures of the calcaneum has become an established method of treatment. A recent randomised, controlled trial has questioned the benefits of surgery, in particular, pain relief. We reviewed the cases undertaken in our department, complications, which have arisen, and their treatment. We have devised a management plan in conjunction with the department of plastic surgery to minimise the effect of these complications. There were 124 procedures carried out over a 12 years period, 116 unilateral and 4 bilateral in 120 patients (106 males and 14 females, age range [18 to 66]). Two further patients were included who had had surgery in another hospital and had been referred to our plastic surgery unit with significant wound complications. The patients were retrospectively assessed with a case note review and an updated clinical evaluation. The assessment focussed particularly on wound complications including breakdown classified as either major or minor, and association with infection, haematoma and drainage. Neurological symptoms were also noted. There were five major wound complications, three from our unit and two from another hospital. Infection was present in three cases. Four healed uneventfully but one of the infected group subsequently had a below knee amputation for refractory infection. Minor wound breakdown was more common. There was no association with haematoma or drainage but wound breakdown occurred more frequently in patients who smoked. Neurological complications were infrequent and temporary. In conclusion this study confirmed that there is a significant morbidity associated with the surgical management of these fractures, although, the vast majority of patients’ wounds healed uneventfully. With a sensible management plan, which involves working in conjunction with plastic surgeons, even major soft tissue complications may be addressed.

Background Open reduction and internal fixation for displaced intra-articular fractures of the calcaneum has become an established method of treatment. A recent randomised, controlled trial has questioned the benefits of surgery, in particular, pain relief.

Method We reviewed the cases undertaken in our department, complications which have arisen, and their treatment. We have devised a management plan in conjunction with the department of plastic surgery to minimise the effect of these complications. There were 124 procedures carried out over a 12-year period, 116 unilateral and 4 bilateral in 120 patients (106 males and 14 females, age range 18–66). Two further patients were included who had had surgery in another hospital and had been referred to our plastic surgery unit with significant wound complications.

The patients were retrospectively assessed with a case note review and an updated clinical evaluation. The assessment focussed particularly on wound complications including breakdown classified as either major or minor, and association with infection, haematoma and drainage. Neurological symptoms were also noted.

Results There were five major wound complications, three from our unit and two from another hospital. Infection was present in three cases. Four healed uneventfully but one of the infected group subsequently had a below knee amputation for refractory infection. Minor wound breakdown was more common. There was no association with haematoma or drainage but wound breakdown occurred more frequently in patients who smoked. Neurological complications were infrequent and temporary.

Conclusion This study confirmed that there is a significant morbidity associated with the surgical management of these fractures, although the vast majority of patients’ wounds healed uneventfully. With a sensible management plan, which involves working in conjunction with plastic surgeons, even major soft tissue complications may be addressed.

Introduction We report a modified technique using peroneus brevis for reconstruction of the anterior talofibular and calcaneo-fibular ligaments in the ankle for chronic instability.

Method The surgery was carried out using a double drill-hole in the distal fibula with either a complete or partial tendon graft. An examination under anaesthetic with ankle arthroscopy has been utilised to confirm the clinical diagnosis and assess the articular surfaces. In appropriate cases a translational os calcis osteotomy is added to correct varus hindfoot deformity.

Forty-five procedures were carried out over a 10-year period. The patients were retrospectively assessed with a case note review, and an updated clinical evaluation. The assessment focussed on pain, stability and impact on daily living.

Results Our results compare favourably with existing techniques for lateral ligament reconstruction, with most patients being satisfied with the improvement in pain relief and stability. These will be discussed in detail. Complications included superficial wound infections and sensory neurological symptoms. There were two failures following surgery both of which were associated with a high body mass index and joint laxity.

Conclusion This procedure provides anatomical reconstruction, is technically undemanding and gives adequate pain relief, stability and return to sporting activity. With careful patient selection, including treatment of intra-articular pathology and hindfoot deformity, it is a useful alternative to the methods currently available.

Purpose

To evaluate patient satisfaction and expectations of surgery following forefoot arthroplasty.

Methods

Between October 1993 and June 1999, forefoot arthroplasty (Kate/Kessel/Kay procedure) was performed or directly supervised by the senior author (D. McBride) in a cohort of 55 patients. All had inflammatory arthritis and had failed non-operative management. The clinical result was assessed using a self-administered patient satisfaction questionnaire. The questionnaire asked patients to rate their level of satisfaction in terms of pain relief, wound healing, stiffness and appearance. The patients expectations from the surgery in terms of their level of disability and the achievement of the operation in addition to their pain experience following their operation was assessed.

Results

Median time to follow-up was 41 months (range seven to seventy-seven). Forty-three of the 55 patients returned the completed questionnaire. The median age at operation of the respondents was 59 years (range 42 to 69) compared with 49 years (range 44 to 63) for the non-respondents. Of the 43 respondents, 30 were female and 13 male.

In terms of their expectations of the surgery, 20 (47%) stated that the operation had achieved what they had expected while 10 (23%) considered the operation to have achieved more than they had expected. The level of disability following their operation was as expected in 21 (49%), more than expected in 11 (26%) and less than expected in four (9%). 23 (55%) noted no change to their walking capacity while it had increased in 11 (26%) and decreased in eight (19%). There were two wound haematomas, five superficial wound infections and three cases of delayed wound healing which extended the post-operative hospital stay. Seventy-nine percent of patients however reported complete satisfaction with their wound healing. In those patients that had reported having had pain (n=31) at some time following their operation, two (7%) had experienced it for less than seven days, four (13%) for between one and four weeks, one (3%) for between one and three months and 23 (77%) for more than three months.

Conclusions

Overall patients were generally satisfied with their operation in terms of pain relief, wound healing and appearance. Additionally, in the majority of patients, the achievements of the procedure and the associated disability were as expected. Previous authors have outlined the various surgical factors, which are said to lead to a good outcome. Whilst it is important to bear these factors in mind we have found that some of our patients appeared to have a good result when these criteria were not met. While other patients meeting these criteria were not necessarily satisfied. This suggests areas for further research.