Introduction:

Instability and synovitis of the lesser metatarsalphalangeal (MTP) joints is a significant cause of forefoot pain. Plantar plate imaging traditionally has been through MRI and fluoroscopic arthrography. We have described ultrasound arthrography as a less resource-intensive technique without radiation exposure. We report the correlation between ultrasound arthographic and surgical findings.

Ankle fractures account for 10% of all fractures. Most deformed looking ankles are manipulated in the emergency departments (ED) on clinical judgement in order to improve the outcome and avoid skin complications. It is accepted that significantly displaced ankle injuries with neurovascular (NV) compromise or critical skin should be reduced prior to imaging.

However, is it really possible to understand the injury to an ankle without an x-ray or other imaging? The other possible injuries around the ankle, presenting with swelling and deformity of the ankle region, may include a ligamentous, talar, subtalar, Chopart joint or calcaneal injury. Does the risk of waiting for the imaging outweigh the benefit of manipulation of an undiagnosed injury?

This prospective study involved the analysis of all patients with ankle injuries referred to orthopaedics between November 2009 and February 2010. Results: Over the audited period 100 referrals were identified (43 male, 57 female). The average age was 50.4 years (range 5–89). Only 2% of fractures were open. Manipulation in the ED was performed for 44% of patients. Of these, 39% (17 cases) were manipulated and supported in plaster slab without an initial x-ray; 3 due to vascular deficit, 2 due to critical skin and 12 with no documented reason!

Re-manipulation in the ED as well as definitive open reduction and internal fixation (ORIF) were significantly lower in those patients who had an x-ray prior to manipulation (p < 0.05). ORIF was performed in 68% of all patients. Importantly, 80% of ankles manipulated in ED went on to have ORIF which was significantly higher than the 47% in the non-manipulation cohort (p < 0.05).

We conclude that taking ankle injury radiographs prior to any attempt at manipulation, in the absence of NV deficit or critical skin, will constitute best practice.

INTRODUCTION

Warfarin remains the treatment of choice for the majority of patients with venous thromboembolism, atrial fibrillation and valvular heart disease or valve replacement unless contraindicated. Poor management of patients on warfarin often leads to delay in surgery, life threatening bleeding during or after operation and unnecessary delay in discharge from hospitals in United Kingdom.

Background

Post-operative pain following forefoot surgery can be difficult to control with oral analgesia so regional analgesic methods have become more prominent in foot and ankle surgery. It was the aim of this study to evaluate the efficacy of a combination of popliteal and ankle blocks and decide if they provide significantly better post-operative analgesia than ankle block alone in forefoot surgery.

Introduction: An osteotomy in the proximal first metatarsal corrects the metatarsal head position with much less movement of the fragment than an equivalent distal osteotomy. Most described techniques are technically demanding and reported complications including non-union, mal-union and transfer pain. We present our results of an opening wedge osteotomy with a medial wedge plate. We also present the pitfalls and tips to avoid complications.

Materials and Methods: Thirty-four procedures in 30 patients were performed using the Arthrex wedge plate. Demographic and clinical data, AOFAS scores and radiological measurements of standardised radiographs were collected for all the patients.

Results: All patients were females. The average age was 52 years. Twenty-seven were primary procedures and 7 patients had had previous, failed 1st ray surgery. No bone graft was used. Thirty-two feet showed clinical and radiological signs of union. Four complications occurred and one was treated with metatarsophalangeal joint fusion. One had an infection. Two patients had broken screws. The average hallux valgus angle and inter-metatarsal angle corrections were 200 and 90 respectively. Average increase in AOFAS scores: preoperative 47 to postoperative 81.

Discussion: The spacer in the plate acts as a pillar and obviates the need for a bony strut. Keeping an intact lateral cortex and preventing any shaft displacement was important in avoiding transfer pain. 4.5mm or smaller plates appear to have fewer problems and better scores, al though this was statistically unproven. Screw breakage in the absence of infection had no bearing on overall outcome. Some patients with poor fixation may benefit from non-weight bearing for the first 6 weeks.

Conclusion: The wedge plate osteotomy is a powerful tool to correct moderate to severe hallux valgus. It does not need additional bone graft and has a favorable clinical and radiological outcome. The prelude to optimum result was meticulous technique avoiding the discussed pit falls.

Background: Postoperative pain following forefoot surgery can be difficult to control with oral analgesia so regional analgesic methods have become more prominent.

Aim: It is the aim of this study to evaluate the efficacy of a combination of popliteal and ankle blocks and decide if they give significantly better postoperative analgesia than ankle block alone in forefoot surgery.

Methods: This is a prospective, randomised, controlled and single blind study. The total number of patients is 80 with 40 patients in the ankle block only group (control) and 40 patients in the ankle and popliteal block group. All patients underwent forefoot surgery. Postoperative pain was evaluated in the form of a visual analogue scale and verbal response form. Evaluations took place four times for each patient: in the recovery room, 6 hours postoperatively, 24 hours postoperatively and on discharge. The pain assessor, who helped the patient complete the pain evaluation forms, was blinded to the number of blocks used. The amount of opiate analgesia required whilst an inpatient was also recorded. On discharge the patient was asked to rate their satisfaction with the pain experienced during their hospital stay. Results were analysed using Mann-Whitney tests.

Results: Results show that pain is significantly less in recovery (p=0.044) and after 24 hours (p=0.0012) for those patients with combined blocks. Satisfaction with pain relief is also higher for these patients. No complications were found as a consequence of having two peripheral nerve blocks.

Conclusions: A popliteal block in conjunction with an ankle block does reduce postoperative pain significantly more than ankle block alone after forefoot surgery.

A prospective study of 72 patients with Morton’s neuroma was carried out outlining presenting symptoms, significance of clinical examination and the beneficial effect of various treatment modalities. They were followed up for at least 6 weeks. There were 51 females (70%) and 21 males (30%) with average age of 52 years.

Bilateral symptoms were present in 15% cases with remaining 85% cases having unilateral symptoms. Commonest symptom observed was pain in the web space, commonest being 3^rd space (70%) and others being 2^nd space (18%), 4^th space (4%) and combination of two spaces (8%). In 90% of these cases, pain was aggravated by walking and wearing closed shoes; and relieved by taking rest.

Paraesthesia in adjacent toes was present in 46% cases. Clinically palpable Mulder’s click was seen in 54% cases.

Shoe modification was tried in 33% patients, with little benefit. All 72 patients underwent corticosteroid and local anaesthetic injection in the outpatient clinic. Fair to good pain relief was obtained in 76% cases with average duration of pain relief of 2.8 weeks (range (0–8 weeks)). No pain relief was achieved in 24% cases.

Twenty-eight patients (38%) who either had inadequate pain relief at 6 weeks following injection; or had recurrence of pain eventually underwent surgical excision/decompression using plantar approach. None of them had any complication related to surgery. All patients had excellent pain relief at a minimum of 6 months follow up after the surgery. 90 % of the patients who underwent surgery had VAS pain score of 0 at 6 months follow up.

Thus, single injection treatment is a very useful treatment modality achieving satisfactory results in 76% of patients. Surgical excision/decompression should be reserved for patients with no pain relief/recurrence after the injection.

Background: Postoperative pain following forefoot surgery can be difficult to control with oral analgesia so regional analgesic methods have become more prominent in foot and ankle surgery. The effects of ankle and popliteal blocks performed separately have been well described in the literature but we have not found any study that looks at the combined effects of the two procedures. It is the aim of this study to evaluate the efficacy of a combination of these blocks and decide if they provide significantly better postoperative analgesia than ankle block alone in forefoot surgery.

Methods: This is an ongoing prospective, randomised, controlled and single blind study. Proposed end-point should be reached in 3 months. The total number of patients to be included will be 60, with 30 in ankle block only group (control) and 30 in ankle and popliteal blocks group. All patients are to undergo forefoot surgery. Postoperative pain is evaluated in the form of a visual analogue scale and verbal response form. Evaluations take place four times for each patient: in the recovery room, 6 hours postoperatively, 24 hours postoperatively and on discharge. The pain assessor, who helps the patient complete the pain evaluation forms, is blinded to the number of blocks used. The amount of opiate analgesia required whilst as an inpatient will also be recorded. On discharge the patient is asked to rate their satisfaction with the pain experienced during their hospital stay. Results will be analysed using paired Students t test.

Results: Early results are showing that combined ankle and popliteal blocks provide better analgesic effect than ankle block alone. This is shown both in the patient response forms and also in reduced amounts of opiate analgesia required. Further discussion of the results and conclusions will be drawn once the study has been completed.

Numerous techniques have been described for ankle arthrodesis. Arthroscopic arthrodesis with internal fixation has evolved to reduce the complications associated with open arthrodesis. We present our technique of arthroscopic ankle fusion using two medial cannulated screws with specially designed dished washers

The tibiotalar joint is debrided arthroscopically and internal fixation is achieved with two medial cannulated screws with designed dished washers. Seven ankle arthrodeses were performed on six patients; one underwent bilateral arthrodesis.

All the patients suffered from OA (four post traumatic) and were aged between 53–61 (mean 55.4). There were four males and two females. The follow up ranged from 8–18 months (mean 10).

All the patients achieved ankle fusion. Time for fusion ranged from 6 to 18 weeks, five fused within 12 weeks. Pre operative pain scores improved from 6–10 out of 10 (mean 7.2) to 1–3 out of 10 (mean 1.4) post-operative. Post-operative AAFOS ankle hind foot score ranged from 74–89 out of 100 (mean 81.8). One patient required further operations for adjustment of fixation and one suffered a stress fracture at the level of the proximal screw.

This method of arthroscopic ankle fusion provides an effective alternative to open arthrodesis for selected patients with OA achieving good initial results.

Introduction

The existence of various techniques of ankle arthrodesis shows that there are pros and cons in each method. We describe our experience of ankle arthrodesis using a paediatric angle blade plate.

Materials and methods

10 ankle arthrodeses were performed in nine patients. All patients were reviewed independently in special clinics. The objective assessment was performed by detailed clinical examination and the subjective assessment was made including overall patient satisfaction. The American Orthopedic Foot and Ankle Society ankle/hind foot scoring system was used. The technique of ankle arthrodesis was similar in all patients using an anteromedial or anterolateral incision, preparation of articular surface and paediatric angle blade plate fixation with or without bone grafting. Time to union was assessed by clinical and radiological examinations.

Results

Radiological union was achieved in nine patients in a mean time of 16 weeks. Fibrous union occurred in one patient. Eight patients were very satisfied with their treatment. The patient with fibrous union had a marginal improvement of symptoms with pain score improved from nine to seven. The mean AOFAS score was 84.

Conclusion

Ankle arthrodesis with a paediatric angle blade plate is a useful method of managing intractable cases of ankle arthritis. The technique is simple and effective with excellent success rate.

Introduction

This study has evaluated the results of plantar fascia release through a plantar incision.

Materials and Methods

A 4cm curved incision on the plantar surface of the heel, was used to release the plantar fascia in children. The incision allowed complete visualisation of the entire origin of the plantar fascia. The procedure was performed as part of treatment for pes cavus or resistant clubfoot.

There were 27 feet in 17 patients. The ages ranged from three to sixteen years. The minimum follow up was six months after surgery. The wound was assessed for pain, numbness, and problem scarring as well as heel pad symptoms. A modified functional score was used. (American Orthopaedic Foot and Ankle Society Ankle/ Hindfoot Scale)

Results

All wounds healed within two weeks. The scar was clearly visible in seven patients, and visible only on close inspection in 10 patients. None had heel tenderness, hypersensitivity or numbness and there were no signs of pad atrophy. Fifteen patients had no pain, while two had minimal pain score of two on the visual analogue scale. The functional score was more than 90. All the patients were satisfied with the cosmetic appearance of the scar.

Conclusion

The plantar incision is safe, effective and provides excellent visualisation of the plantar fascia for complete release with minimal morbidity.

The aim of this study was to review the effectiveness of percutaneous release of the common extensor origin for tennis elbow. The operative technique is similar to that previously reported by Hohmann in 1949.

There were 29 patients (31 elbows) that underwent the procedure between 1991 and 1998. There were 14 males and 15 females; 19 were right handed, and 17 had the dominant arm involved. The mean age was 51.8 years (range 34–65); the mean duration of symptoms was 21.7 months (range 8–60 months). All patients had a minimum of 12 months of conservative treatment including NSAIDs, splinting, physical therapy and local anaesthetic and steroid injections (2–6 injections). All operations were performed as day case procedures, with the majority (25) done under local anaesthetic. 24 patients were independently reviewed using Hospital for Special Surgery Elbow Assessment and a questionnaire. Grip strength measurements were performed using JAMAR Dynanometer and the level of patient satisfaction was recorded.

5 patients could not attend the special review clinics. They were contacted over the phone and necessary data recorded. The mean follow up was 45.2 months (range 8–88 months). 24 patients scored above 70 points and were very satisfied, 6 patients were considered failures as their symptoms warranted formal open release operation; only two reported an improvement following the open releases, with the remainder still symptomatic at the last follow up. An overall success rate of 81% was recorded. Complications were rare - one patient who had bruising of forearm after the procedure.

In conclusion this procedure can be recommened as an efficacious first line of surgical treatment, with advantages of being safe, quick to perform and with minimal morbidity.

The use of antenatal abdominal ultrasound (AAU) in the diagnosis of clubfoot is established. The accuracy of the investigation is unclear, leaving difficulties for the clinician involved in counselling parents.

This study was conducted to investigate the accuracy of AAU in the diagnosis of clubfoot. We assessed the AAU findings of mothers of 20 children with varying degrees of clubfoot deformity between 1993 to 1998. There were 12 males and 8 females; 30 feet were affected - 6 were left, 8 right sided and 8 were bilateral. There were two sets of twins, each with bilateral deformity. The mean foetal age at diagnosis was 23.4 weeks ( range 18–35 weeks).

Three patients had oligohydramnios and two had polyhydramnios. One patient had an amniocentesis that was normal. Karyotyping was not performed. There were no false positive or false negative results.

Our results show 100% concurrence between the scan results and the clinical findings at birth. Three clubfeet were reported as being positional; their clinical diagnoses revealed a mild deformity that needed no treatment other than reassurance and advice. Twenty one feet were treated with physical therapy, manipulation and serial castings. Six feet required surgery.

AAU in the second trimester of pregnancy is a reliable method of diagnosing clubfoot, and the parents can be counselled with confidence regarding management. As AAU is currently offered to almost all pregnant women, it can be expected that more cases of clubfeet will be diagnosed in the antenatal period. An orthopaedic surgeon must be prepared to counsel parents even before a clinical examination is possible.