Positive reports from implant designer centres on the use of fibular nails in the complex ankle fractures has resulted in a marked increase in their use nationally. Our aim in this study was to report on the outcomes of the use of all fibular nails in two major trauma centres. All patients who underwent ankle fracture fixation using a fibular nail in two major trauma centres, were included for analysis. MTC 1 included patients from April 2013 to May 2015, and MTC 2 included patients February 2015 to March 2018. A minimum follow up of 1 year was achieved for all patients. Radiographic reduction was confirmed by Pettrones criteria at time of operation and at 6 weeks and 1 year post-operatively. Kellgren Lawrence radiographic criteria was used to classify osteoarthritis. All complications and further surgery were recorded.Introduction
Methods
Anatomic reduction of talar body fractures is critical in restoring congruency to the talocrural joint. Previous studies have indicated a maximum of 25% talar body exposure without malleolar osteotomy. The aim of this study was to investigate the percentage talar body exposure when using the lateral transligamentous approach. The lateral transligamentous approach to the talus was undertaken in 10 fresh frozen cadaveric specimens by surgeons inexperienced in the approach, following demonstration of the technique. An incision was made on the anterolateral aspect of the ankle augmented by the removal of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) from their fibular insertions. A bone lever was then placed behind the lateral aspect of the talus and levered forward with the foot in equinus and inversion. The talus was disarticulated and high resolution images were taken of the talar dome surface. The images were overlain with a reproducible nine-grid division. Accessibility to each zone within the grid with a perpendicular surgical blade was documented. ImageJ software was used to calculate the surface area exposed with each approach.Introduction
Methods
The treatment of posterior malleolar fractures is developing. Mason and Molloy (Foot Ankle Int. 2017 Nov;38(11):1229-1235) identified only 49% of posterior malleolar rotational pilon type fractures had syndesmotic instabilities. This was against general thinking that fixation of such a fragment would stabilize the syndesmosis. We examined 10 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University in a solution of formaldehyde. The lower limbs were carefully dissected to identify the ligamentous structures on the posterior aspect of the ankle. To compare the size to the rotational pilon posterior malleolar fracture (Mason and Molloy 2A and B) we gathered information from our posterior malleolar fracture database. 3D CT imaging was analysed using our department PACS system.Introduction
Methods
There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. In our previous multicenter study (Powell, BOFAS 2016) we showed that the Olerud-Molander Ankle Score (OMAS) was 79 for unimalleolar fractures and 65 for bi malleolar fractures, however it dropped significantly to 54 in trimalleolar fractures. In creating a treatment guiding classification, we report our results in a system change in management of posterior malleolar fractures in our unit. All fractures were classified according to Mason and Molloy classification (BOFAS 2015, FAI 2017) based on CT scans obtained pre-operatively. This dictated the treatment algorithm. Type 1 fractures underwent syndesmotic fixation. Type 2A fractures underwent ORIF through a posterolateral incision, and type 2B and 3 fractures underwent ORIF through a posteromedial incision. The patient remained NWB for 6 weeks postoperative. Data was collected from December 2014 to July 2017.Background
Method
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. 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.Introduction
Methods
We performed a longitudinal outcome study involving the operative management of ankle fractures at two university teaching hospitals. This was a retrospective review of the quality of reduction and a prospective study into the functional outcome. All patients undergoing open reduction internal fixation of the ankle between November 2006 and November 2007 at one centre, and January to December 2009 at the other were included. Adequacy of reduction was assessed on the initial post-operative radiographs using Pettrone's criterion. The post-operative functional outcome was recorded using the Lower Extremity Functional Scale (LEFS), completed by postal or telephone follow-up at 64 months post injury (60–74 months).Introduction
Methods
Traditional treatment of idiopathic flatfoot in the adult population include calcaneal neck lengthening or fusions. These surgical methods result in abnormal function with significant complication rates. Our prospective study aimed to quantify the functional and radiological outcome of a new technique for spring ligament reconstruction using a hamstring graft, calcaneal osteotomy and medial head of gastrocnemius recession if appropriate. 22 feet were identified from the senior authors flatfoot reconstructions over a 3 year period (Jan 2013 to Dec 2015). 9 feet underwent a spring ligament reconstruction. The control group were 13 feet treated with standard tibialis posterior reconstruction surgery. Follow up ranged from 8 to 49 months. Functional assessment comprised VAS heath and pain scales, EQ-5D and MOXFQ scores. Radiographic analysis was performed for standardised parameters.Introduction
Methods
We aimed to retrospectively identify risk factors for delayed / non-union for first metatarsophalangeal joint fusion. Case notes and radiograph analysis was performed for operations between April 2014 and April 2016 with at least 3 months post-operative follow up. Union was defined as bridging bone across the fusion site on AP and lateral radiographic views with no movement or pain at the MTPJ on examination. If union was not certain, CT scans were performed. All patients operations were performed/supervised by one of three consultant foot surgeons. Surgery was performed through a dorsal approach using the Anchorage compression plate. Blinded pre-operative AP radiographs were analysed for the presence of a severe hallux valgus angle equal or above 40 degrees. Measurement intra-observer reliability was acceptable (95%CI:1.6–2.3 degrees). Smoking and medical conditions associated with non-union underwent univariate analysis for significance.Introduction
Methods
There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. Current ankle classification systems do not account for differences in fracture patterns or injury mechanisms, and as such, the clinical outcomes of these fractures are difficult to interpret. The aim of this study was to analyse our posterior malleolar fractures to better understand the anatomy of the fracture. In a series of 42 consecutive posterior malleolar, who all underwent CT imaging, we have described anatomically different fracture patterns dictated by the direction of the force and dependent on talus loading. We found 3 separate categories. Type 1 – a rotational injury in an unloaded talus resulted in an extraarticular posterior avulsion of the posterior ligaments. This occurred in 10 patients and was most commonly associated with either a high fibular spiral fracture or a low fibular fracture with Wagstaffe fragment avulsion. The syndesmosis was usually disrupted in these patients. Type 2 – a rotational injury in a loaded talus resulting in a posterolateral articular fracture, of the posterior incisura. This occurred in 16 patients and was most commonly associated with a posterior syndesmosis injury, low fibular spiral fracture and an anterior collicular fracture of the medial malleolus. Type 3 – axially loaded talus in plantarflexion causing a posterior pilon. This occurred in 16 patients and was most commonly associated with a long oblique fracture of the fibular and a Y shape fracture of the medial malleolus. The syndesmosis was usually intact in these patients. In conclusion, the anatomy of the posterior malleolar should not be underestimated and requires careful consideration during treatment and categorisation in outcome studies to prevent misinterpretation.
The insertion footprint of the different muscles tendon fascicles of the Achilles Tendon on the calcanium tuberosity has not been described before. Twelve fresh frozen leg specimens were dissected to identify the different Achilles Tendon fascicles insertion footprint on the calcaneum in relation to their corresponding muscles. Further ten embalmed cadaveric leg specimens were examined to confirm an observation on the retrocalcaneal bursa.Introduction:
Method:
The purpose of this study was to review the outcomes and complications of all circular external fixators (frames) used for the management of acute lower limb trauma in our institution over a twenty year period. We retrospectively reviewed a prospectively compiled database of all frames applied in our institution and identified all frames which were applied for acute lower limb trauma. We identified 68 fractures in 63 patients. There were 11 femoral fractures and 57 tibial fractures. All fractures were classified using the AO Classification system, and most fractures were Type C fractures. We used an Ilizarov frame in 53 patients and a Taylor Spatial Frame in 15 patients. The mean time in frame was 365 days for a femoral fracture and 230 days for a tibial fracture. There were five tibial non-unions giving an overall union rate of 93%. Factors associated with non-union included high energy trauma and cigarette smoking. The vast majority of lower limb fractures can be treated using ‘conventional’ methods. Complex fractures which are not amenable to open reduction and internal fixation or cast immobilisation can be treated in a frame with excellent results. The paucity of published reports regarding the use of frames for complex trauma reflects the under-utilisation of the technique.
It has been shown that inadequate reduction of the sesamoids can lead to recurrent hallux valgus. It can be difficult however to assess the sesamoid position. We propose a simple method of grading sesamoid position; the sesamoid width ratio. We aim to assess for a difference in ratio between those with and without hallux valgus and subsequent correlation with increased deformity. The new grading system can then be tested for inter-observer reliability. 277 (103 normal, 87 preoperative, 87 postoperative) AP weight bearing foot radiographs were analysed for hallux valgus angle (HVA), intermetatarsal angle (IMA), and both medial and lateral sesamoid width (mm). The sesamoid width ratio (SWR; lateral/medial width) was then calculated. Using statistical methods based upon HVA and IMA grading, three groups of increasing hallux valgus severity, in accordance with SWR, were defined; normal ≥1.30, moderate 1.29–0.95 and severe ≤0.94. Sixty images (10 normal, 25 preoperative, 25 postoperative) were then sent on disc to three separate reviewers to assess for inter-observer error.Introduction:
Methods:
Inadequate reduction and fixation of ankle fractures leads to poor clinical outcomes although there are no well-established criteria to evaluate the quality of surgical fracture fixation of the ankle. The aim of our study was to validate Pettrone's criteria that can be used in the radiological assessment of the quality of ankle fracture fixation that predict the functional outcome. A retrospective study was completed following the operative management of ankle fractures at a University teaching hospital between 1st January 2009 and 31st December 2009 were included in the study. Exclusion criteria were paediatric fractures, polytrauma, and fractures involving the tibial plafond. The fracture pattern was classified using the AO classification system. Three independent Foot and Ankle Consultants assessed the quality of surgical ankle fracture fixation using Pettrone's criteria. Approximately one year following the surgery, functional outcome was obtained using Lower Extremity Function Score (LEFS) and a modified American Orthopaedic Foot and Ankle Society score (AOFAS). The Mann-Whitney test was used for the LEFS and AOFAS functional scores. Logistic regression was performed upon age and gender with regards to functional outcome. Given that the Kappa coefficient is a pair wise statistic, the average pair wise agreement for each category of the Pettrone criteria was also determined.Introduction:
Methods:
Patient reported outcome measures are becoming more popular in their use. Retrospective scoring is not yet a validated method of data collection but one that could greatly decrease the complexity of research projects. We aim to compare preoperative and retrospective scores in order to assess their correlation and accuracy. 36 patients underwent elective foot and ankle surgery. All patients were scored preoperatively using the SF-12 and FFI. Patients then recorded both PROMs retrospectively at the three month follow up (av. 139 days). Results were then analyzed for statistical significance.Introduction:
Methods:
When performing scarf osteotomies some surgeons use intraoperative radiography and others do not. Our experience is that when using intraoperative radiography we often change the osteotomy position to improve the correction of the hallux valgus angle and sesamoid position. We report the results of a single surgeon series of 62 consecutive patients who underwent a scarf osteotomy for hallux valgus. The first 31 patients underwent surgery without the use of intraoperative radiographs and the subsequent 31 patients underwent surgery with the use of intraoperative radiographs, this reflects a change in the surgeons practice. Hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle and sesamoid position using the Hardy Clapham grading system were recorded. All patients had measurements recorded from weight baring radiographs taken pre operatively as well as at 6 and 12 weeks post operatively. Intraoperative measurements were also recorded for all patients in the intraoperative radiography group. The mean hallux valgus angle preoperatively was 28.5° in the control group and 30.5° in the intraoperative radiography group. The mean hallux valgus angle in the control group at 6 weeks was 12.4° and at 12 weeks was 12.6°. The mean hallux valgus angle in the intraoperative radiography group at 6 weeks was 10.5° and at 12 weeks was 9.8°. The median sesamoid position pre operatively was 4 for both groups. At 6 and 12 weeks the sesamoid position improved by a median of 1 position in the control group and 2 positions in the intraoperative radiography group (p<0.05). We recommend that surgeons who do not routinely use intraoperative radiography undertake a trial of this. We have found that the use of intraoperative radiography improves the correction of hallux valgus angle and sesamoid position. These have been shown to increase patient satisfaction and reduce recurrence.
Benefits of day case foot and ankle surgery includes reduced hospital stay, associated cost savings for the hospital, high patient satisfaction and quicker recovery with no increase in complication rates. In 2007, we set up the preoperative foot and ankle group. Patients were seen three weeks before surgery by a specialist nurse, physiotherapist and a preoperative evaluation is done. The therapist explains the patient's weightbearing status and advices on how to carry this out. Our aim was to reduce inpatient hospital stay and increase our day case procedures. We evaluated length of stay and physiotherapy intervention for all our patients during the first three months of 2007 to 2011. Mean length of stay was calculated and Mann-Whitney U test was performed using median.Background
Methods
The incidence of osteochondral lesions following ankle fractures varies in the literature between 17-70%. They are commonly associated with chronic pain and swelling in patients diagnosed with such pathology. There is less evidence about the relationship between OCL and the development of post-traumatic osteoarthritis, the most common type of ankle arthritis. Through the use of MRI 8 weeks following ankle fractures, we investigated the incidence of OCL in patients treated both surgically and conservatively for ankle fractures of all AO subtypes.Introduction
Methods
1737 elective foot and ankle cases were prospectively audited from Dec 2005 to end June 2010. All cases were brought back to a specialist nurse dressing clinic between 10 and 17 days post op. Data was collected at the dressing clinic with a standardised proforma on the type of surgery, the state of the wound and any additional management required. Those patients with a pre-existing infection were excluded. Of the 1737 cases 201 (11.6%) had a minor wound problems such as excessive post op bleeding into the dressings, suture problems, early removal of K wires, delayed wound healing and minor infection. 42 patients required antibiotics (2.4%) 8 patients had a deep wound infection (0.5%) requiring intravenous antibiotics and or further surgery. There were 1185 forefoot procedures 36 of which developed an infection (3%), overall infections of the mid/hindfoot was 6 (1%). Practice has changed as a result of the audit (reviewed annually). We have changed our closure techniques (reducing suture problems). For the past 2 years all of our elective foot and ankle patients now go to an ultra clean ward (Joint Replacement Unit) and we have shown a reduction in infection rates by over 50% since. Our infection rate before the JRU was 3.3% with 0.7% deep infection rate (818 procedures) and after the introduction of the JRU our infection rate has ped to 1.6% superficial and 0.3% deep infection p<.001. This large series prospective study sets a benchmark for infection rates in elective foot and ankle surgery. It also highlights the benefit of a dedicated orthopaedic elective unit with rigorous infection control policy and the need to regularly review our results.
NHS governance demands that services provided are clinically effective and safe. In the current financial climate and threats over public sector spending cuts, services offered by health care providers should also be cost-effective and profitable. Surgical specialties are often perceived as expensive with high implant costs. The aim of this audit was to cost the profit margin for foot/ankle surgery and test the accuracy of coding data collected. Theatre data between January-April 2010 was retrospectively reviewed. Equipment inventories, operation notes and radiographs were reviewed for implants used. Clinical coding data was analysed and coded separately by the surgeon for comparison. Theatre expenses were calculated and accuracy estimated. Tariff generated and patient expenses were calculated and a final profit margin revealed. Wilcoxon matched-pair testing compared hospital recorded and surgeon calculated data. 95 cases were included (51 forefoot, 5 midfoot, 6 arthroscopy, 12 hindfoot, 21 other), 65 female and 30 male patients. Theatre inventories were correct in 11% of cases. Mean inventory costs recorded were £90 and following surgeon analysis, £319. Total actual inventory cost was £30,306.23 but £8548.58 was recorded (p<0.0001). OPCS codes were deemed correct in 43% and incorrect in 57% of cases. Operation profit margin, including theatre, ward and salary costs was recorded as £158,229 but corrected profit margin with d inventories and OPCS codes was £121,584 (p=0.001).Materials and Methods
Results
Over 80% of patients with advanced breast cancer will develop bone metastases for which there is no cure. Although thought to involve a complex cascade of cell-cell interactions, the factors controlling the development of bone metastases are still poorly understood. Osteoblasts may have an important role in mediating homing and proliferation of breast cancer cells to the bony environment. This study aimed to examine the potential role osteoblasts have in the migration of circulating tumour cells to bone and the factors involved in this attraction. Culture of osteoblasts and MDA-MB-231 breast cancer cells was performed. Breast cancer cell migration in response to osteoblasts was measured using Transwell Migration Inserts. Potential mediators of cell migration were detected using ChemiArray & ELISA assays. A luminometer based Vialight assay was used to measure breast cancer cell proliferation in response to factors secreted by osteoblasts. There was a 3-4 fold increase of MDA-MB-231 migration in response to osteoblasts. ChemiArray analysis of osteoblast-conditioned medium revealed a range of secreted chemokines including IL-6 & 8, TIMP 1 & 2 and MCP-1. Initially, MCP-1 was quantified at 282 pg/ml, but rose to over 9000 pg/ml when osteoprogenitor cells were differentiated into mature osteoblasts. Inclusion of a monoclonal antibody to MCP-1 in osteoblast-conditioned medium resulted in a significant decrease in breast cancer cell migration to osteoblasts. There was no significant change in proliferation of MDA-MB 231 cells when exposed to osteoblast-conditioned medium. Osteoblasts are capable of inducing breast cancer cell migration mediated at least in part by chemokine secretion. MCP-1 produced by the osteoblasts was shown to play a central role in mediating homing of the breast cancer cells. Increased understanding of the pathways involved in the development of bone metastases may provide new targets for therapeutic intervention.
