Aims

Surgeon and patient reluctance to participate are potential significant barriers to conducting placebo-controlled trials of orthopaedic surgery. Understanding the preferences of orthopaedic surgeons and patients regarding the design of randomized placebo-controlled trials (RCT-Ps) of knee procedures can help to identify what RCT-P features will lead to the greatest participation. This information could inform future trial designs and feasibility assessments.

The December 2024 Foot & Ankle Roundup³⁶⁰ looks at: Tibiotalar sector and lateral ankle instability; Isolated subtalar fusion and correction of progressive collapsing foot deformity; Diabetic control and postoperative complications following ankle fracture fixation; Are insoles of any benefit for plantar fasciitis?; Postoperative foot shape and patient-reported outcome following surgery for progressing collapsing foot deformity; Calcaneo-stop procedure for symptomatic flexible flatfoot in children.

Aims

The Cartiva synthetic cartilage implant (SCI) entered mainstream use in the management of first metatarsophalangeal joint (MTPJ) arthritis following the positive results of large trials in 2016. Limited information is available on the longer-term outcomes of this implant within the literature, particularly when independent from the originator. This single-centre cohort study investigates the efficacy of the Cartiva SCI at up to five years.

Aims

This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures.

Introduction. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to perform major foot/ankle operations as day-case. This could have significant impact on length of stay, saving resources and is in keeping with government policy. However, there are theoretical concerns about complications and low patient satisfaction due to pain. Methods. The survey was developed following review of the literature and was approved for distribution by the BOFAS (British Orthopaedic Foot & Ankle Society) scientific committee. An online survey (19 questions) was sent to UK foot and ankle surgeons via the BOFAS membership list. Major foot/ ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge, with day surgery as the intended pathway. Results. A total of 132 surgeons responded, 80% from Acute NHS Trusts. The majority (78%) thought that more procedures could be performed as day-case at their centre. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. Despite post-operative pain and patient satisfaction being theoretical concerns for day-case surgery in this population; these outcomes were only measured by 34% and 10% of respondents respectively. The top perceived barriers to performing more major foot and ankle procedures as day-case were: Lack of physiotherapy input pre/post-operatively (23%), Lack of out of hours support (21%). Conclusions. There is consensus among surgeons to do more major foot/ ankle procedures as day-case. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. There is a need to scope the provision of physiotherapy pre/post-operatively and out of hours support at sites where this is a perceived barrier

The June 2024 Foot & Ankle Roundup³⁶⁰ looks at: First MTPJ fusion in young versus old patients; Minimally invasive calcaneum Zadek osteotomy and the effect of sequential burr passes; Comparison between Achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional Achilles tendinopathy; Revision ankle arthroplasty – is it worthwhile?; Tibiotalocalcaneal arthrodesis or below-knee amputation – salvage or sacrifice?; Fusion or replacement for hallux rigidus?.

Introduction. Charcot neuroarthropathy (CN) of foot and ankle presents significant challenges to the orthopaedic foot and ankle surgeon. Current treatment focuses on conservative management during the acute CN phase with offloading followed by deformity correction during the chronic phase. However, the deformity can progress in some feet despite optimal offloading resulting ulceration, infection, and limb loss. Our aim was to assess outcomes of primary surgical management with early reconstruction. Methods. Between December 2011 and December 2019, 25 patients underwent operative intervention at our specialist diabetic foot unit for CN with progressive deformity and or instability despite advanced offloading. All had peripheral neuropathy, and the majority due to diabetes. Twenty-six feet were operated on in total - 14 during Eichenholtz stage 1 and 12 during stage 2. Fourteen of these were performed as single stage procedures, whereas 12 as two-stage reconstructions. These included isolated hindfoot reconstructions in seven, midfoot in four and combined in 14 feet. Mean age at the time of operation was 54. Preoperative ulceration was evident in 14 patients. Results. Mean follow up was 45 months (Range 12–98). There was 100% limb salvage. One-year ambulation outcomes demonstrate FWB in bespoke footwear for 17 patients and in an ankle foot orthosis (AFO), Charcot restraint orthopaedic walker (CROW) or bivalve cast for seven. All preoperative ulceration had healed. Union was achieved in 18/21 hindfoot reconstructions and 7/18 midfoot reconstructions. There were nine episodes of return to theatre, of which five were within the first 12 months. There was one episode of new ulceration. Conclusion. Surgical management of acute CN (Eichenholtz one and two) of the foot provides functional limb salvage. In particular, hindfoot reconstruction shows good rates of bony union. It should be considered in ‘foot at risk’ presentations of acute CN foot

Introduction. Early clinical examination combined with MRI following a high ankle sprain allows accurate diagnosis of syndesmosis instability. However, patients often present late, and for chronic injuries clinical assessment is less reliable. Furthermore, in many centres MRI may be not be readily available. The aims of the current study were to define MRI characteristics associated with syndesmosis instability, and to determine whether MRI patterns differed according to time from injury. Methods. Retrospectively, patients with an unstable ligamentous syndesmosis injury requiring fixation were identified from the logbooks of two fellowship trained foot and ankle surgeons over a five-year period. After exclusion criteria (fibula fracture or absence of an MRI report by a consultant radiologist), 164 patients (mean age 30.7) were available. Associations between MRI characteristics and time to MRI were examined using Pearson's chi-square tests or Fisher's exact tests (significance set at p< 0.05). Results. Overall, 100% of scans detected a syndesmosis injury if performed acutely (within 6 weeks of injury), falling to 83% if performed after 12 weeks (p=0.001). In the acute group, 93.5% of patients had evidence of at least one of either PITFL injury (78.7%), posterior malleolus bone oedema (60.2%), or a posterior malleolus fracture (15.7%). In 20% of patients with a posterior malleolus bone bruise or fracture, the PITFL was reported as normal. The incidence of posterior malleolus bone bruising and fracture did not significantly differ according to time. Conclusion. For unstable ligamentous syndesmosis injuries, MRI becomes less sensitive over time. Importantly, posterior malleolus bone oedema or fracture may be the only evidence of a posterior injury. Failure to recognise instability may lead to inappropriate management of the patient, long term pain and arthritis. We therefore advocate early MRI as it becomes more difficult to ‘grade’ the injury if delayed

Aims

The Manchester-Oxford Foot Questionnaire (MOxFQ) is an anatomically specific patient-reported outcome measure (PROM) currently used to assess a wide variety of foot and ankle pathology. It consists of 16 items across three subscales measuring distinct but related traits: walking/standing ability, pain, and social interaction. It is the most used foot and ankle PROM in the UK. Initial MOxFQ validation involved analysis of 100 individuals undergoing hallux valgus surgery. This project aimed to establish whether an individual’s response to the MOxFQ varies with anatomical region of disease (measurement invariance), and to explore structural validity of the factor structure (subscale items) of the MOxFQ.

The February 2024 Foot & Ankle Roundup³⁶⁰ looks at: Survival of revision ankle arthroplasty; Tibiotalocalcaneal nail for the management of open ankle fractures in the elderly patient; Accuracy of a patient-specific total ankle arthroplasty instrumentation; Fusion after failed primary ankle arthroplasty: can it work?; Treatment options for osteochondral lesions of the talus; Managing hair tourniquet syndrome of toe: a rare emergency; Ultrasound-guided collagenase therapy for recurrent plantar fibromatosis: a promising line of therapy?.

Varus ankle osteoarthritis (OA) is typically associated with peritalar instability, which may result in altered subtalar joint position. This study aimed to determine the extent to which total ankle replacement (TAR) in varus ankle OA can restore the subtalar position alignment using 3-dimensional semi-automated measurements on WBCT. Fourteen patients (15 ankles, mean age 61) who underwent TAR for varus ankle OA were retrospectively analyzed using semi- automated measurements of the hindfoot based on pre-and postoperative weightbearing WBCT (WBCT) imaging. Eight 3-dimensional angular measurements were obtained to quantify the ankle and subtalar joint alignment. Twenty healthy individuals were served as a control groups and were used for reliability assessments. All ankle and hindfoot angles improved between preoperative and a minimum of 1 year (mean 2.1 years) postoperative and were statistically significant in 6 out of 8 angles (P<0.05). Values The post-op angles were in a similar range to as those of healthy controls were achieved in all measurements and did not demonstrated statistical difference (P>0.05). Our findings indicate that talus repositioning after TAR within the ankle mortise improves restores the subtalar position joint alignment within normal values. These data inform foot and ankle surgeons on the amount of correction at the level of the subtalar joint that can be expected after TAR. This may contribute to improved biomechanics of the hindfoot complex. However, future studies are required to implement these findings in surgical algorithms for TAR in prescence of hindfoot deformity

Aims

Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined.

The December 2023 Foot & Ankle Roundup³⁶⁰ looks at: Subchondral bone cysts remodel after correction of varus deformity in ankle arthritis; 3D-printed modular endoprosthesis reconstruction following total calcanectomy; Percutaneous partial bone excision in the management of diabetic toe osteomyelitis; Hemiepiphysiodesis is a viable surgical option for Juvenile hallux valgus; Ankle arthroplasty vs arthrodesis: which comes out on top?; Patient-related risk factors for poorer outcome following total ankle arthroplasty; The Outcomes in Ankle Replacement Study.

The October 2023 Foot & Ankle Roundup³⁶⁰ looks at: Risk factors for failure of total ankle arthroplasties; Effects of synovial fluid fracture haematoma to tissue-engineered cartilage; Coronal plane deformity in CMT-cavovarus feet using automated 3D measurements; Immediate weightbearing after ankle fracture fixation – is it safe?; Unlocking the mystery of Mueller-Weiss disease; Diabetic foot management: predictors of failure.

Aims

The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

The August 2023 Foot & Ankle Roundup³⁶⁰ looks at: Achilles tendon rupture: surgery or conservative treatment for the high-demand patient?; First ray amputation in diabetic patients; Survival of ankle arthroplasty in the UK; First metatarsophalangeal joint fusion and flat foot correction; Intra-articular corticosteroid injections with or without hyaluronic acid in the management of subtalar osteoarthritis; Factors associated with nonunion of post-traumatic subtalar arthrodesis; The Mayo Prosthetic Joint Infection Risk Score for total ankle arthroplasty.

Aims. Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England. Methods. A questionnaire was sent to all 136 NHS trusts audited in the 2018 National Diabetic Foot Audit (NDFA). The questionnaire asked about the structure of diabetic foot care services. Results. Overall, 123 trusts responded, of which 117 admitted patients with diabetic foot disease and 113 had an orthopaedic foot and ankle surgeon. A total of 90 trusts (77%) stated that the admission involved medicine, with 53 (45%) of these admissions being exclusively under medicine, and 37 (32%) as joint admissions. Of the joint admissions, 16 (14%) were combined with vascular and 12(10%) with orthopaedic surgery. Admission is solely under vascular surgery in 12 trusts (10%) and orthopaedic surgery in 7 (6%). Diabetic foot abscesses were drained by orthopaedic surgeons in 61 trusts (52%) and vascular surgeons in 47 (40%). Conclusion. Orthopaedic surgeons make a significant contribution to both acute and elective diabetic foot care currently in the UK. This contribution is likely to increase with the movement of vascular surgery to a hub and spoke model, and measures should be put in place to increase the team based approach to the diabetic foot, for example with the introduction of a best practice tariff. Cite this article: Bone Jt Open 2022;3(8):618–622