Aims. The conversion of previous hip fracture surgery to total hip arthroplasty (CTHA) can be surgically challenging with unpredictable outcomes; reported complication rates vary significantly. This study aimed to establish the medium-term survival and outcomes of CTHA performed following a previous hip fracture surgery. Methods. All CTHAs performed at our tertiary orthopaedic institution between January 2008 and January 2020 following previous ipsilateral hip fracture surgery were included. Patients were followed up clinically using Oxford Hip Scores (OHS), and radiologically until death or revision surgery. Postoperative complications, radiological implant failure, and indications for revision surgery were reviewed. Results. A total of 166 patients (167 hips) were included in the study, with a mean age of 71 years (42 to 99). Of these, 113 patients (67.7%) were female. CTHA followed cannulated screw fixation in 75 cases, hemiarthroplasty in 18, dynamic hip screw fixation in 47, and cephalomedullary nail in 27 cases. Patients were followed up for a mean of four years (0.1 to 9.3). During the follow-up period, 32 patients (19.2%) died. Overall, 14 patients (8.4%) suffered a complication of surgery, with intraoperative fractures (4.2%) and dislocations (3.6%) predominating. The survival probability was 96% at 9.53 years in the cemented group and 88% at 9.42 years in the uncemented group (p = 0.317). The median OHS improved from 13 (IQR 7.75 to 21.25) preoperatively to 39 (IQR 31 to 45) postoperatively in the uncemented group, and from 14 (IQR 10.5 to 22) to 38 (IQR 27 to 45) in the cemented group. Conclusion. This study highlights that CTHA from hip fracture surgery is associated with higher complication rates than conventional THA, but good medium-term results can be achieved. Their classification within the NJR requires review, acknowledging the increased potential for complications. Cite this article: Bone Jt Open 2025;6(2):195–205

Aims. Revision hip arthroplasty for femoral stem loosening remains challenging due to significant bone loss and deformities requiring specialized revision stems. The aim of this study was to evaluate the clinical and radiological outcomes, and survival, of a consecutive series of femoral revisions performed using a primary cementless stem with tapered geometry and rectangular cross-section at medium-term follow-up. Methods. We retrospectively evaluated 113 patients (115 hips) with intraoperative Paprosky type I (n = 86) or II (n = 29) defects, who underwent femoral revision with Alloclassic Zweymüller SL stem for one-stage aseptic revision or two-stage septic revision from January 2011 to December 2020. The mean follow-up was 77.9 months (SD 33.8). Nine patients were lost to follow-up (deceased or not available), leaving 104 patients (106 hips) for the clinical and radiological analysis. Clinical assessment was performed with Harris Hip Score (HHS) and visual analogue scale (VAS) before surgery and at final follow-up. Results. There were 60 males and 53 females with a mean age at time of surgery of 71.2 years (SD 12.6). The mean HHS and VAS significantly improved at final follow-up, from 33.7 (SD 13.0) and 5.8 (SD 1.8) preoperatively to 66.4 (SD 16.8) and 2.1 (SD 1.8) postoperatively, respectively (p = 0.001 and p = 0.001). Overall, 28 patients (25%) showed non-progressive radiolucent lines at the level of proximal femur without radiological or clinical signs of loosening. One patient had a recurrence of periprosthetic joint infection after a two-stage procedure requiring re-revision surgery. One patient underwent exchange of modular components for recurrent dislocation, and another case of dislocation was treated conservatively. The survival with aseptic loosening as endpoint was 100%, while stem revision for any reason was 99.1% at up to 152 months’ follow-up. Conclusion. Alloclassic Zweymüller SL primary stem showed favourable medium-term results and survival for revision total hip arthroplasty in Paprosky type I and II defects. Cite this article: Bone Jt Open 2025;6(2):186–194

Aims. Valgus subsidence of uncemented tibial components following medial unicompartmental knee arthroplasty (UKA) poses a challenge in the early postoperative phase, necessitating a comprehensive understanding of its prevalence, risk factors, and impact on patient outcomes. Methods. This prospective multicentre study analyzed 97 knees from 90 patients undergoing UKA across four participating hospitals. A standardized surgical technique was employed uniformly by all participating surgeons. Postoperative evaluations were conducted preoperatively, and one day, four weeks, three months, and one year postoperative, encompassing weightbearing radiographs, bone mineral density assessments, and clinical outcome reports using the Forgotten Joint Score and Oxford Knee Score. Statistical analyses, including non-parametric correlation analysis using the Kendall correlation coefficient and Mann-Whitney U test, were performed to explore associations between subsidence and various patient-related or radiological parameters. Results. A total of eight patients showed more than 2° valgus subsidence (8.2%), higher than previously reported rates. There were significant correlations between subsidence and higher preoperative varus alignment of the tibia, larger adaptation of the preoperative varus to a postoperative neutral or valgus alignment, mediolateral undersizing of the tibial component, excessive lateral load of tibial component by more lateral position of femoral component relative to tibial component, a lower T-score, and female sex. Our study found no significant difference in pain scores between subsidence and non-subsidence groups at various postoperative milestones. Conclusion. These findings corroborate earlier suggested risk factors based on biomechanical models. Further research might provide the opportunity to identify high-risk groups preoperatively and adapt treatment strategies for these patients. Cite this article: Bone Jt Open 2025;6(2):178–185

Background. Fourth-generation percutaneous or minimally invasive hallux valgus surgery utilizes a transverse osteotomy to achieve deformity correction. There are only a small number of series reporting the clinical and radiological outcomes of transverse osteotomies, many of which have methodological limitations such as small sample size, limited radiographic follow up or use of non-validated outcome measures. The aim of this study was to provide a methodological robust investigation into percutaneous transverse osteotomies for hallux valgus deformity. Method. A prospective series of consecutive patients undergoing fourth generation metatarsal extra-capsular transverse osteotomy (META) performed by a single surgeon (PL) between November 2017 and January 2023. The primary outcomes were radiographic deformity correction and clinical foot function assessed using the Manchester-Oxford Foot questionnaire (MOXFQ). Radiographic deformity (Hallux valgus angle (HVA) and intermetatarsal angle (IMA), sesamoid position) was assessed according to AOFAS guidelines. Secondary outcomes included Visual Analogue Scale for Pain and radiographic deformity recurrence (defined as HVA >20° at final radiographic follow up). Results. 729 feet from 483 patients (456 Female, 27 Male, mean age 57.9±11.9 years) underwent META. Radiographic data (minimum 12 months post-surgery) was available for 99 .7% of feet with mean follow up of 2.6±1.3 years (range 1.0–5.7). There was a statistically significant improvement (p<0.05) in both HVA; 29.5±8.5° to 7.3±6.7°, and IMA, 12.9±3.4° to 4.6±2.5°. All MOXFQ domains showed significant improvement (p<0.05); Index 36.6±19.1 to 11.8±13.8, Pain 40.1±22.1 to 15.6±16.4, Walking/Standing 32.2±23.2 to 10.2±15.8 and Social Interaction 40.0±20.6 to 9.7±14.0. The recurrence rate was 4.5% (n=33). The complication rate was 6.1% which included a screw removal rate of 2.9%. Conclusion. This is the largest consecutive series of any percutaneous osteotomy technique to correct hallux valgus deformity. This study demonstrates that the technique leads to significant improvement in clinical and radiographic outcomes with a low rate of recurrence

Background. Freibergs infraction is osteonecrosis of lesser metatarsal heads, most commonly affecting adolescent females. They usually present with pain and swelling of the forefoot. Surgical options include open debridement, cheilectomy, micro fracture osteotomy and excision arthroplasty. The aim of the study is to present the results of our surgical method based on the principle of neo-angiogenesis, neo-osteogenesis and neo-chondrogenesis with bone grafting and AMIC membrane application for Freiberg's disease of lesser metatarsals. Methods. A prospective analysis of twelve patients who had Freiberg's infraction of the lesser toe metatarsals treated with open debridement, microfracture, bone grafting and application of AMIC membrane was carried out. The patients were followed up to seven years and the outcome measures were scored using Smillie's classification, radiological findings and the Manchester-Oxford Foot Questionnaire (MOxFQ). Results. There were 9 (75%) female and 3(25%) male patients. The mean age was 42.7 years (range- 19 to 60). The mean follow-up time was 6.6 years. The most common site was second metatarsal, ten (83%) followed by third metatarsal, two (17%). According to Smillie's classification three lesions were labelled as Stage 3 and ten as Stage 4. There were no postoperative infections. None of the patients needed any further surgical intervention. The mean base line MOxFQ was 43.75 (SD- 43.75±12.40) which improved to 7.19(SD-7.18±4.63) the mean baseline EQ-5D improved from 7.85 (SD-7.85±5.08) to1.39(SD-1.39±0.75) at the final follow up. 80 % of the patients had complete remodelling of the head of metatarsal at the final follow up radiology. Conclusions. Open debridement of the Freiberg\'s disease combined with microfracture of the defect, bone grafting and application of AMIC membrane gives good long term functional outcomes

Introduction. Fifth metatarsal fractures have been regularly classified by zones, with the description of a Jones fracture commonly being misrepresented. The aim of this study was to map the fracture patterns across the entire metatarsal shaft, and correlate with their outcomes. Methods. A historic cohort study was completed of all fifth metatarsal fractures presenting to our unit between February 2016 – July 2021. Fracture patterns were individually mapped and designated as zone 1-shaft, including designation of fractures which bridge each zone (zone 1–2 etc). Fracture patterns were cumulatively combined using GNU Image Manipulation Program to show the combined fracture map patterns per outcome. The clinical notes were examined to assess patient outcome. Results. 1331 fractures were included in this study and presented graphically as fracture maps by outcome. The number of fractures which did not propagate across more than 1 zone was 78.59% (1046/1331). The fracture type which had the highest rate of discharge at VFC without reattendance was Zone 1 fractures (360/519, 69.36%), with the lowest being fractures where the fracture spanned zone 1-shaft (p<0.001). The total number of fractures that underwent surgery was 1.35% (18/1331). The fracture pattern which had the highest rate of surgical intervention was a fracture that spanned zone 2–3 (5/43, 11.63%) followed by a fracture that spanned zone 1–3 (1/11, 9.9%). The number of appointments given to patients ranged from discharged from VFC to 7 face to face appointments. The patients with the lowest discharge rate prior to 4 appointments was zone 2–3. Conclusions. In our series, almost a quarter of fractures spanned across the previously described fracture zones. This would explain the low inter-observer rating in previous studies. The classic Jones fracture would span zones 2/3, which in our series had the highest rate requiring surgery and lowest rate of discharge before 4 appointments

Background. The ability to return to physical activity is an important indicator of surgical success for end-stage ankle arthritis. There is paucity of literature comparing outcomes between surgical procedures. This study aimed to compare outcomes for physical activity and return to function between total ankle replacement (TAR) and ankle arthrodesis (AA) at 1-year follow-up. Methods. This was a single-centre prospective follow-up study. Patients who underwent TAR (n=33) or AA (n=25) between 2022–2023 completed questionnaires on FAOS scores (Pain, Symptoms, ADL and QOL domains), International Physical Activity Questionnaire (IPAQ), satisfaction scores and return to work/driving. IPAQ physical activities were compared across domains of work, transportation, domestic and leisure activities. Results. AA patients were younger (59.1 vs. 65.8). The AA group had better average FAOS scores for pain, symptoms, ADL, and QOL compared to TAR (51.2 vs. 29.2; 40.6 vs. 67.8, 46.8 vs. 66.4, 31.3 vs. 48.3) (p=0.526), but the TAR group reported higher overall satisfaction (77% vs. 66.6%). Earliest return to work was reported at 2 weeks (TAR) vs. 3 weeks (AA) group and driving at 3 weeks (TAR) vs. 4 weeks (AA). More TAR patients returned to vigorous (25%) and moderate (17.6%) physical activity versus AA (0% and 0%). For transport, 4 AA patients vs. 12 TAR patients returned to this activity. AA patients travelled 30 minutes to 2 hours per week, while TAR patients travelled 30 minutes to 5 hours. For household activities, 15.7% of TAR patients reported vigorous activity versus 0% in AA. AA patients spent less time on average leisure walking (1.25 hrs vs. 2 hrs), and more time sitting per day (9.2 hrs vs. 5.9 hrs). Conclusion. The TAR group demonstrated earlier return to work, driving, and higher levels of physical activity compared to AA patients at 1-year follow-up, despite the AA group having better FAOS scores

Background

Acute Achilles tendon ruptures can be a devastating injury with a prolonged recovery period (1). Following the UKSTAR trial, Achilles tendon ruptures are predominately treated with a functional rehabilitation bracing program (2). The aim of treatment is to avoid lengthening of the tendon, and hence the resultant loss of function. The Achilles tendon resting angle (ARTA) provides a simple assessment of tendon length that can be performed in the clinical setting (3). This study assesses the Achilles tendon resting angle over a 52-week period and the correlation with functional outcome.

Osteochondral lesions of the talus (OLTs) are common pathologies, associated to chronic pain and disability. Currently, there is no agreed gold standard for surgical treatment of OLTs, due to lack of superiority trials. Aim: Compare the post operative outcomes of osteochondral autologous transplantation (OATS) and matrix associated stem cell transplantation (MAST), as primary and revision procedures Methods: Prospective study of OATS and MAST from 2013 to 2023, in a single surgeons practice Primary study outcome: rate of revision. Secondary outcomes: PROMS (VAS and FAOS), complications and return to sports. Data collected via chart, radiological review, and telephonic survey. Inclusion criteria: aged 16 years and above; OLTs greater than 10mm2, Primary and Revision. Exclusion criteria: Unable to/Refused consent (N=1), Rheumatological joint disease (N=1). Degenerative joint. Lost to follow up. Statistical analysis with Chi-squared test, Fischers exact test, Wilcoxon sum test, and linear regression. Results: N=90. Equal distribution of OATS being used for primary and for revision (50% (16) /50% (16)), MAST had a slight prevalence of revision over primary (55% revision (32) / 45% primary (26) p 0.6). There was a significant association between prior surgery and the need for a revision procedure in the MAST cohort. (β = 1.491, SE = 0.562, p = 0.008). Return to sport was seen in 90% of the OAST and 67% of MAST (p 0.11). There was statistically significant improvement in PROMs for both techniques (VAS and FAOS), but no significant change between the outcomes in primary versus revision surgeries. Conclusion: OATS is an appropriate technique for managing OLTs, both as a primary and salvage procedure, with significant improvement of PROMS (VAS and FAOS), and elevated rate of return to sports (90%). MAST as a primary intervention showed similar outcomes to those of OATS, but poorer outcomes as a salvage procedure, with higher rates of revision thereafter (p .01)

Background. Medial wall blowout (MWB) ankle fractures have not previously been described in the literature. Our aim in this study was to analyse the morphology of medial wall blowout fractures and their radiological outcomes. Methods. The MWB fracture fragments were characterised into four groups. A type 1A fracture was described as an anteromedial column fragmentation. Type 1B fractures consisted of posteromedial column fragmentation. Type 2 fracture consisted of both column wall fragmentation and type 3, any medial wall fragmentation with medial joint impaction. Results. Over 2000 patients were identified across ten years with medial malleolar fractures across two centres; of these, 196 had MWB fractures with CT imaging. There were 95 1A fractures (48.5%), 31 1B fractures (15.8%), 40 Type 2 fractures (20.4%) and 30 type 3 fractures (15.3%). Type 1B fractures were significantly more likely to undergo plate fixation than other types (p = .001). MWB fractures occurred most in PER fracture types (50.8%). Type 2 fractures were different because they occurred more with SER-type mechanisms. PM fractures were a common association (82.4%), most commonly M+M type 1. MWB type 1B occurred more with M+M 2B fractures. The overall malreduction rate was 11.8%, although 1B fracture types had significantly higher malreductions (22.6%, p=.041). The overall nonunion rate was 20.6%, the highest nonunion reported in the type 2 fractures (33.3%), although not significant. Tibialis posterior tendon entrapment was common (47.3%), although it was significantly more likely in type 2 fractures (74.4%, p = 0.001). Conclusion. The MWB fractures are an uninvestigated subtype of ankle fractures. The 1B type has a higher rate of malreduction, which could be due to its higher association with PM fractures. Tib post needs specific attention with these fracture types, especially Type 2 fractures

Introduction. Global data on BKA mortality is dominated by US Veterans population studies, while smaller single-centre UK cohorts observe a wide range of 1 year mortality (13.8%-61.1%). There is no consensus on mortality rates, perioperative complications and at-risk groups post diabetic BKA in England. Methods. England Hospital Episodes Statistics (HES) data was combined with ONS mortality data (2000–2022) and cleaned using STATA 18. The primary outcome was the rate of all cause mortality. Secondary outcomes were causes of death, re-amputation rates, temporal variation in mortality, and 90 day peri-operative complications. Mortality and amputation free survival was calculated with Kaplan-Meier curve analysis using R, STATA 18. Multivariate logistic regression stratified patient variables associated with mortality and/or re-amputation rate. Results. 28,045 BKA were performed for diabetes in the 20-year period; decreasing from 8.1/100,000 (2002) to 6.5/100,000 (2022). The rates were significantly higher in white males aged 60–79 years old (14/100,000 in 2023). The mortality rates following BKA for diabetic foot disease were 7.1% at 30 days, 12.7% at 90 days, 24.6% at 1 year, and 61.2% at 5 years. Only 17% of patients survived to 10 years post BKA. The 90-day reoperation rate for any cause was 20.7%. The ipsilateral re-amputation rate at any time was 10.4% (n=2909), and the contralateral amputation rate was 8.2% (n=2304). Additional 90-day complications included PE (0.75%, n=211), MI (3.6%, n=1019) and Stroke (1.1%, n=316). Multi-regression analysis demonstrated significantly higher BKA associated mortality rates at all time points in male, British-Asians with higher deprivation status. Conclusions. This landmark 20-year England diabetic population study has revealed high rates of death, further amputation and peri-operative morbidity post BKA. Asian Males in their 60s have the highest mortality rates and represent an at-risk group. Overall, there has been little improvement in post BKA mortality over the last 20 years

The aim was to demonstrate that Supramalleolar osteotomy is a valuable treatment method in eccentric ankle arthritis in young and middle aged since it is an under-utilised procedure. We retrospectively analysed the outcome of it performed over 12 year period. We also compared the results of recently introduced computer-assisted PSI Integrated custom-made implants with standard implants. Data was analysed from 48 patients over a period of 12 years of which 40 were by standard implant and 8 by computer assisted custom implant. 31 varus, 18 valgus deformity. The mean age was 57 (26–79 y/o), male:female ratio was 27:19. Mean follow-up was 15.25 months for standard implants; For the computer-assisted procedures the follow up range is 24 to 2 months. TAS, TTS and TT angels were measured pre and post-operatively. Fixation using a plate with/without bone graft or custom-made implant was performed by a single surgeon. MOXFQ and AOFAS questionnaires were completed pre and post-operatively. All followed similar rehabilitation programme. Average radiological healing time was 24.3 weeks. MOXFQ score improved from 55.17 to 25.11 and AOFAS from 20.16 to 56.21. Complications were 2 non-unions, 1 delayed union, 1 stress fracture. 8 patients require fusion/replacement between 3–5 years. The PSI Integrated computer-assisted technique gave improved accuracy than standard freehand method with better scores and a smoother approach for the surgeon. Early results with this technique are encouraging as we were able achieve 3 dimentional correction compared to the 2 dimentional correction achieved by the freehand method. Our results are comparable to similar studies. Being a joint preserving technique, Supra Malleolar Osteotomy should be considered either as an interim or definitive procedure especially with the development of computer assisted technologies which makes the technique easier to reproduce

Background. Hallux Valgus (HV) is a common forefoot deformity that can cause pain and difficulty with walking. There are a range of surgical techniques to treat HV deformity, but there is a risk of recurrence. This paper reviews the clinical assessment and management of recurrent HV as well as a detailed description of how percutaneous surgical techniques can be used to treat recurrent HV. This paper identifies technical challenges of percutaneous HV surgery for recurrent HV deformity as well as strategies to address and mitigate these. Method. This was a multicenter retrospective review of adult patients who had recurrent hallux valgus deformity (defined as hallux valgus angle&gt;15° and having previously undergone primary surgical intervention for HV deformity correction) who were treated with a percutaneous metatarsal extra-capsular transverse osteotomy (META) technique, with at least one year of follow-up data. Demographic information, hallux valgus angle, intermetatarsal angle, Manchester-Oxford Foot Questionnaire (MOXFQ), visual analog scale (VAS), and EQ-5D-5L scores were collected. Results. We retrospectively evaluated 34 feet from 32 patients with a mean age of 63.1±9.2 (range 41–82) who underwent revision hallux valgus surgery using a percutaneous technique. The mean follow up was 3.6±2.3 (range 0.5–8.7 years. The breakdown of index HV surgeries was: 17 Chevron, 9 Scarf/Akin, 6 medial bunionectomy, 1 Lapidus, 1 proximal rotation osteotomy. There was a statistically significant improvement in both clinical foot function and radiographic deformity after surgery. The mean HV angle decreased from 32.9±8.6° to 13.4±7.3°, and the intermetatarsal angle decreased from 12.7±3.8° degrees to 3.8±3.1°(p<0.05). The mean MOXFQ Index score significantly improved from 49.4±23.1 to 14.6±19.4 (p<0.05). Conclusion. This paper suggests that percutaneous surgical techniques using a transverse osteotomy and screw fixation can successfully treat a wide range of recurrent HV deformity severities with significant improvement in clinical and radiographic outcomes

Introduction. Acute Achilles Tendon Ruptures (ATR) cause lasting muscular deficits and impair function and quality of life. This study aimed to understand recovery post rupture by examining tendon structure using ultrasound tissue characterisation (UTC), isometric plantarflexor strength, physical activity and patient reported outcomes (PROM). Methods. Cross-sectional study design consisting of 90 participants. Data were collected from 15 participants at six different rehabilitation timepoints (0, 8, 10 weeks, 4, 6, 12 months). Participants were recruited from a National Health Service clinic using non-surgical management. Findings. Participants mean (SD) age 48 years (16), 91% male, body mass index 29kg/m2, 54% white British with a median of 1 comorbidity. Primary mechanism of injury was sport (71.1%). Deep vein thrombosis rate was 9.3%. Based on UTC, ruptured tendon cross-sectional area (CSA) was 287.55 mm2 at 10 weeks, 203.62mm2 at 12 months. Disorganised fibrillar structure was 32% lower at 12 months than 10 weeks. Disorganised fibre percentage was consistent at each assessment point (10 weeks:32%, 12 months:30%). Isometric plantarflexor strength on the ruptured limb at 12 months was 61.3kg (20.8) or 0.7x body weight (BW) whilst the non-ruptured limb was 93.3kg (29.5) or 1.1x BW. Daily steps increased from 3720 (1889.8) at week 0 to 9048.4 (2750.1) at 12 months. PROMs at 12 months; ATRS 75.1 (16.5), EQ-5D index .91, EQ-5D VAS 75 (23), SF-36 Physical Functioning 84.3 (9.2), Tampa Scale for Kinesiophobia 34.7 (4.8). Conclusion. There is substantial remodelling of the tendon during the initial 12 months post ATR, with tendon CSA differing 29% across assessment points. Proportion of disorganised collagen remains consistent from 10 weeks to 12 months post ATR, whilst CSA reduces. Individuals presenting with ATR managed non-surgically have a 34% or 0.4xBW isometric strength deficit at 12 months and still present with fear of movement and reduced function based on PROMs

Aims. We compared the clinical outcomes of a fixed bearing (Infinity) and a mobile bearing (Zenith) ankle replacement in a demographically similar group of patients, from a single, non designer centre. Methods. Between December 2010 and May 2016, 118 consecutive mobile bearing prostheses (Zenith) and between September 2017 and November 2019, 118 consecutive fixed bearing (Infinity) prostheses were implanted in a total cohort of 230 patients. Demographic, clinical, and patient reported outcome measures (PROMs) data were collected. The end point of the study was failure of the implant requiring revision of one or more of the components. Kaplan Meier survival tables were generated. Results. Demographics were similar for both groups (age, pre-operative arthritic diagnosis and co-morbidities). 32 patients (36 ankles) died during follow-up, but none required revision. Of the surviving 198 patients (200 ankles; 93 Zenith, 107 Infinity), mean follow-up was 9.1 years (6.0 – 13.1 years) for Zenith and 5.0 years for Infinity (3.6 – 6.8 years). A total of 11 implants (9.3%) failed for Zenith and 1 implant (0.8%) failed for Infinity, requiring revision. Average time to failure for Zenith was 3.4 years (0.4 – 10.5 years) and the time to failure for Infinity was 4.1 years. Implant survival at five years, using revision as an endpoint, was 91.3% for Zenith and 98.7% for Infinity. There was a mean improvement in Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ) from 85.0 to 32.8 for Zenith and 79.3 to 26.4 for Infinity, and visual analogue scale (VAS) scores from 7.0 to 3.2 for Zenith and 6.9 to 2.7 for Infinity. The commonest reason for revision was aseptic loosening for both implants. Conclusion. Our results show a significantly better survivorship for the fixed bearing over the mobile bearing prosthesis. Whilst the fixed bearing prosthesis had better PROMS scores, this was not significant

Introduction. Definitive treatment for ankle arthritis is either Total Ankle Replacement (TAR) or Ankle Fusion (AF). AF may pre-dispose to hindfoot fusion resulting in a debilitatingly rigid ankle-hindfoot complex. In comparison, TAR may protect against adjacent joint disease but is associated with high revision rates. We do not know the life-time risks of further surgery, adjacent joint disease progression and rare but serious complications of TAR versus AF. Methods. An England population cohort study was performed using the ONS mortality linked Hospital Episode Statistics database (1998–2023). The primary outcome was Kaplan-Meier curve analysis of revision surgery free survival of TAR versus AF. Secondary outcome measures were the rates of any re-operation to the ankle/hindfoot, including hindfoot fusion rate, 90-day complications, and peri-operative mortality. Results. 10,335 TAR and 30,704 AF were analysed. The revision rate of TAR was significantly higher than AF at all time points, including 5 years (6.7% vs 2.1%), 10 years (11.1% vs 2.9%) and 20 years (13.1% vs 3.1%). There was no significant difference in 20-year risk of hindfoot fusion following AF (5.94%, 95% CI 5.15 to 6.8%) versus TAR (4.80%, 95% CI 3.4% to 6.6%). TAR was associated with higher risks of intra-operative fracture (0.42% vs 0.10%, RR = 4.35) and re-operation for wound infection (0.26% vs 0.15%, RR 1.74) but fewer pulmonary emboli (0.23% vs 0.58%, RR = 0.40).28.9% of TAR resulted in a further operation; 60% of which were for exploration/debridement, infection, aspiration and/or revision. Conclusions. Both TAR and AF are safe definitive treatments of ankle arthritis with low peri-operative risk. The risk of subsequent hindfoot fusion after AF is very low and not significantly higher than after TAR. England TAR revision rates are lower than reported globally with many smaller operations performed before the more complex revision surgery

Background. Distinguishing stable from unstable ankle fractures is key to successful ankle fracture management. Gravitational stress views (GSV) may be a convenient and less painful alternative to manual stress testing. The aim of this study was to assess whether this test accurately predicts ankle instability. Methods. Patients presenting to a single trauma centre between 2011 and 2013 with an isolated fibula fracture and a an anatomically-aligned mortise on initial plain film radiographs were reviewed. After initial x-ray, patients underwent a gravity stress view. Measurements from plain film radiographs were recorded and analysed. Electronic case notes and National Imaging Archives were reviewed retrospectively at a minimum of 10 years post-injury. Patients were contacted to complete patient reported outcome measures (PROMS). Results. One-hundred and forty-two (142) patients met the inclusion criteria and were included in the study. Mean initial film medial clear space (MCS) measurement was 3.46mm (1.0 to 6.0) compared to GSV MCS that was 4.9mm (2.0 to 8.8) (p<0.001). No patient underwent surgery and all patients had successful conservative management with anatomical union seen at their 6 week radiograph. No patient returned with a complication related to their ankle fracture during the follow-up period. With a MCS acquired from GSV of >5mm, 65 patients would have undergone unnecessary surgical intervention. At MCS of >6mm, 26 patients would have undergone surgery unnecessarily and at a MCS of >7mm 10 patients would have had unnecessary surgery. To date, 50 patients have provided PROMs. Mean Olerud and Molander Score (OMAS) at 10 years was 86.63 (SD 23.27, 95% CI 79.47 – 93.79), Manchester Oxford Foot Questionnaire (MOXFQ) was 79.41 (SD 32.94, 95% CI 69.39 – 89.42) and Euroqol-5D-3L was 0.86 (SD0.22, 95% CI 0.79 – 0.93). Conclusion. Stress views may over-diagnose instability in patients with an isolated fibula fracture in an otherwise normal initial radiograph

Introduction. The treatment of critical-sized bone defects in foot and ankle surgery remains challenging. Traditional methods, such as bone transport, bulk allograft, vascularized bone graft, and Masquelet procedures carry risks including multiple surgeries, donor site morbidity, infection, and non-union. Recently, custom 3D-printed implants have emerged, offering improved anatomical compatibility, eliminating the need for tissue harvesting, and often requiring only a single operation. This study aims to present the largest UK series of custom 3D-printed implants in foot and ankle surgery. Methods. A retrospective multicentre collaborative study was conducted in 10 NHS Trusts. Demographic, surgical and radiographic variables were recorded including: age; sex; side; type of operation; complications; and postop imaging at 6 weeks, 3 months, 6 months and 12 months. Baseline characteristics were described for demographic variables. Categorical variables were expressed as frequencies and percentages. Results. Data was collected on a total of 34 patients. The mean age of patients was 54 years (range 29 to 83). 68% of patients were men. Avascular necrosis was the most common indication for surgery (35%) followed by trauma (21%), total ankle replacement failure (21%), infection (12%), Charcot arthropathy (6%) and AVN and infection (3%). The most common operation performed was a fusion augmented with a truss (44%) and 91% of patients had a combination of regional and general anaesthetic. All patients had an ASA grade of less than 4. Of the patients that had follow-up imaging, the implants were reported intact by 94% at 6 weeks, 78% at 3 months, 68% at 6 months and 67% at 12 months. Discussion. This is the largest case series of custom-made foot and ankle implants in the UK to date. The clinical and radiographic outcomes at one year Follow-up are satisfactory. Further work is required to assess long term implant survivorship

Aims. First metatarsal Pronation is increasingly recognised as an important component of Hallux valgus (HV) and can contribute towards intraoperative malreduction, postoperative recurrence and patient reported outcome measures (1,2,3). There are numerous radiological ways to measure metatarsal rotation on plain radiographs and weight bearing CT (WBCT), however there are no clinical tests to evaluate metatarsal pronation pre- or intra-operatively. This study therefore aimed to examine the relationship between clinical pronation of the toe and metatarsal pronation. Methods. Single-centre, retrospective analysis over 5 years. Measurements were performed on WBCT images with digital reconstructions to add soft tissues. First metatarsal rotation was measured using the Metatarsal Pronation Angle as previously described (4). Toe rotation was measured by the Phalangeal Condylar Angle (PCA), the angle between the condyles of the proximal phalanx and the floor, and the Nail Plate Angle (NPA), the angle of the base of the nail plate to the floor in the coronal Plane. These were obtained from 50 feet in Hallux valgus patients, and 50 control patients with CTs done for osteochondral lesions without hallux valgus or hindfoot malalignment. Results. The HV group comprised 41 women and 9 men, mean age 52.4. Control group, 23 women and 23 male, mean age 40.25. Inter and Intra Observer reliability both excellent (ICC &gt;0.95) for all measurements. When comparing HV vs control, MPA was 11.7 vs 6.0 (p&lt;0.001), PCA 31.8 vs 4.7 (p&lt;0.001), NPA 18.3 vs 6.0 (p&lt;0.0001). NPA correlated with PCA. NPA and PCA correlate with Hallux valgus Angle (p&lt;0.001), but not with MPA (p 0.567). Conclusion. These results suggest that clinical toe pronation increases as HV angle increases but not with metatarsal pronation, which therefore cannot be used as a clinical marker. Toe pronation is similar at the base and at the nail, suggesting rotation happens at the MTPJ

Introduction. Minimally invasive (percutaneous) distal first metatarsal osteotomy with internal fixation is an established technique for hallux valgus deformity correction. Published data is limited to 2–3 years follow-up. This study aimed to assess patients undergoing MICA (Minimally Invasive Chevron and Akin) with minimum 5-year follow up, to evaluate the longer-term results of this procedure using validated patient reported outcome measures (PROMs). Methods. Five-year PROM data was prospectively collected from 117 patients who underwent 169 primary MICA osteotomies between July 2014 and April 2018, performed by a single surgeon. Primary clinical outcome measures included visual analogue scale for pain (VAS-pain), Manchester-Oxford Foot Questionnaire (MOXFQ) and EuroQol-5 Dimensions Index (EQ-5D). Data were collected preoperatively, at 2 years and after a minimum of 5 years. Statistical significance was set at p< 0.05. Results. 169 MICA were performed on 117 patients (112 females, 5 males). Mean follow-up was 6.7 years (standard deviation (SD) 0.96 years). All patients completed minimum 5-year follow-up scores. The MOXFQ scores (mean ± SD) for all 169 feet improved for all domains: from 44.5 ± 22.1 preoperatively to 10.3 ± 17.0 post-operatively for Pain (p<0.001), from 39.2 ± 24.5 to 9.3 ± 17.9 for Walking and Standing (p<0.001) and from 48.2 ± 22.8 to 8.7 ± 17.6 for Social Interaction (p<0.001). VAS-pain improved from 30.8 ± 22.7 to 12.9 ± 21. (p<0.001). EQ-5D Index improved from 0.74 ± 0.14 to 0.90 ± 0.12 (p<0.001). Conclusion. This is the largest study at this time point presenting PROM data following minimally invasive distal first metatarsal osteotomy. It is also the longest in follow up for this technique. This study demonstrates significant improvement in PROMs at the mid-term and MICA can be considered as an effective and long-lasting option for the management of hallux valgus deformity