A delay in operative intervention for ankle fracture in the presence of blistering at the operative site is generally considered to reduce problems with soft tissue complications including infection. No evidence exists to show an increased rate of complications. Previous work has characterised two types of blisters clear- and blood-filled. It has been suggested that the presence of a blood-filled blister confers a higher risk of wound healing complications compared with a clear-filled blister.

We present a series of patients who underwent surgery for ankle fracture, in the presence of blisters at the operative site, without any change to standard management of the fracture. We also present a review of the literature.

We prospectively followed six patients who underwent early internal fixation (no delay in surgical intervention) of ankle fracture in the presence of blisters at the operative site. In many cases the surgical incisions were made through the blistered skin. No patients had any additional treatment for their blisters. All patients were treated with the same postoperative protocol.

All six patients with both blister types went on to fracture union with no soft tissue complications and no cases of infection.

This initial observational study supports the treatment of ankle fractures with early internal fixation in the presence of soft tissue blisters at the operative site. It is possible that the stabilisation of underlying skeleton results in better healing of the skin and other soft tissues which is a concept often employed in the management of open fractures. We plan to carry out further prospective work on a larger number of patients as part of a randomized trial to confirm this finding.

The Bologna–Oxford (BOX) total ankle replacement (TAR) was developed with the aim of achieving satisfactory pain-free movement of the ankle. To date, only one single multicentre study has reported its clinical results. The aim of this study was to conduct an independent review of its mid-term results.

We retrospectively reviewed a total of 60 prospectively followed patients in whom 62 BOX TARs had been implanted between 2004 and 2008. We used the American Orthopedic Foot and Ankle Society (AOFAS) score to assess the clinical results. Standardised radiographs taken at the time of final follow-up were analysed by two observers. The overall survival was 91.9% at a mean follow-up of 42.5 months (24 to 71). The mean AOFAS score had improved from 35.1 points (sd 16.6; 4 to 73) pre-operatively to 78.0 (sd 10.7; 57 to 100) at final follow-up (p < 0.01). Tibial radiolucencies < 2 mm in width were seen around 16 TARs. Talar radiolucencies < 2 mm were seen around four TARs. A total of 47 patients (78.3%) were very satisfied or satisfied with the outcome. Five patients required revision for functional limitation or continuing pain.

Introduction

The aetiology of hallux valgus is almost certainly multifactoral. The biomechanics of the first ray is a common factor to most. There is very little literature examining the anatomy of the proximal metatarsal articular surface and its relationship to hallux valgus deformity.

A Morton's neuroma is a compressive neuropathy most commonly affecting the common digital nerve of the third inter-space. Symptoms are variable but usually the diagnosis can be made quite easily and the diagnosis is essentially a “clinical” one. When symptoms relate to the second inter-space the clinician needs to be alert to mechanical causes of metatarsalgia leading to secondary irritation of the nerve. Imaging with MRI scanning and/or ultrasound can be helpful but equally can be misleading, as there may be false positives and false negatives. In the case of ultrasound the accuracy of imaging depends on the experience and expertise of the radiologist.

Morton's neuroma surgery is usually associated with high levels of success but some reports suggest as many as 30% of patients under-going such surgery are dissatisfied with the outcome. The reasons for failed surgery can be broadly divided into three groups: a) wrong diagnosis b) wrong surgery and c) right diagnosis and right operation but unfavourable outcome. Wrong diagnosis is most commonly encountered in second space pathology when there is an underlying mechanical reason for the symptoms such as second MTP joint synovitis. This is usually secondary to joint overload associated with first ray insufficiency eg hallux valgus. This is the so-called Moron's neuroma. Wrong surgery occurs when the wrong space is operated upon, when mechanical causes are overlooked or when a plantar incision is made over the weight-bearing part of the forefoot, leading to painful scar formation. Wrong surgery can also involve failure to recognise anomalous anatomy within the space or insufficient nerve resection. Unfavourable outcomes include infection, stump neuroma formation or the onset of CRPS. Occasionally despite an appropriate assessment and operation a patient will derive no relief of symptoms and the cause of the pain remains totally unexplained.

Careful history and examination and careful pre-operative planning can reduce the incidence of failed Morton's neuroma surgery. The role of imaging is probably greater in such cases compared with those presenting with a primary Morton's neuroma but the diagnosis remains essentially clinical. Stump neuroma resection should be considered in patients presenting with repeat symptoms especially if there is initial surgical success followed by recurrent symptoms. If two explorations result in no success then a third exploration is unlikely to resolve the problem. Some patients are left with intractable symptoms and should be referred to a pain specialist, as further surgery often has nothing more to offer.

I consider the term ‘minimally invasive surgery’ (MIS) to represent a wide range of techniques directed at achieving a surgical objective with less collateral tissue damage. The surgeon choosing to employ such techniques may aspire to achieve improved or more consistent outcome for their patients but is this so? What are the complications? In certain areas of surgery the concept of MIS is well established (e.g. knee and ankle arthroscopy). In forefoot surgery the concept has been met with interest but also skepticism. Much of this skepticism pivots around concerns that the loss of direct vision (maintained in arthroscopic techniques) may increase the risk of complications. In other words, there is a concern that due to the loss of direct visualization (replaced by intra-operative xray imaging), any benefit that might arise from the less invasive technique of the operation will be negated by either poorer quality of surgical correction or higher risk of injury to adjacent structures. All surgery is associated with a degree of risk and in considering the complications specifically associated with MIS of the forefoot we must try to separate out those complications related to the specific MIS technique involved and those that are not. In other words, we need to identify whether the complication has occurred as a result of incorrect surgical planning (e.g. wrong choice of osteotomy/flaws in surgical objective), poor execution of the surgical technique, or as a result of the MIS instrumentation/equipment. I will discuss the above in relation to my experience of complications encountered whilst employing minimally invasive surgical techniques in the treatment of forefoot pathology over the last 2 years.

Minimally Invasive foot surgery remains controversial

Potential benefits include a reduced incidence of wound complications, faster return to employment and normal footwear. There are no studies published regarding the results of minimally invasive dorsal cheilectomy.

Body Image is defined as our internalised sense of what we look like. For most of us, there is a relatively good match between what we think we look like and how we appear to other people. Body image can also be studied in terms of what you look like in the eyes of an observer and the pressures that occur to look a certain way. Body Dysmorphic Disorder (BDD) is the most extreme type of body image problem and consists of a preoccupation with one or more features that is not noticeable to others or the person's concern is markedly excessive. The preoccupation is associated with many time consuming rituals such as mirror gazing or constant comparing. It is associated with a poor quality of life, social isolation, depression and a high risk of committing suicide. Any part of the body may be involved but the foot is an uncommon focus for people with BDD. Such individuals often have needless dermatological treatment and cosmetic surgery. Body image problems and especially BDD is easily trivialised and stigmatised. People with BDD can benefit from cognitive behaviour therapy and certain types of medication.

Data is scant on the critical question of whether patients with endstage ankle arthritis are better served by a fusion or a replacement.

The STAR trial, a prospective case control study, comparing safety and efficacy of STAR ankle replacement at 24 months for 158 replacements and 66 fusions:

This FDA trial showed the STAR ankle replacement had better function, equivalent pain relief and a higher rate of complications and secondary procedures as ankles treated with fusion. A separate prospective cohort comparison of 200 ankle replacements vs. 94 ankle fusions performed by the collaborative consortium of Canadian Orthopaedic Foot and Ankle Surgeons (COFAS) suggests similar patient oriented outcomes at 24 months. Patients' self-assessment questionnaires do not show significant differences between the two groups.

The main medium/long-term concerns with ankle replacement remain component subsidence (especially talar subsidence) and polyethylene wear. Forces across the ankle are considerable, and the orientation of those forces to the underlying trabecular structure are a concern. Whether 2 or 3 part ankles will provide better bearing wear results remains unknown. With older designs, at 10 years the Swedish registry found approximately 60% survivorship. This registry has also shown better survivorship in patients with rheumatoid disease and with increased surgeon experience. More recent results related to the Hintegra and AES components show better midterm (5 year) revision rates in selected surgeons hands, than seen with older designs.

A large meta-analysis of ankle fusion and replacement published data by Haddad et al reported a mean nonunion rate of 10%. The main long-term concerns with ankle fusion are limitations of motion, and the development of premature arthritis in adjacent foot joints. In a study of an average of 9 year outcome of the Agility ankle replacement suggested that the incidence secondary arthritis is halved by replacement as compared to fusion.

The diagnosis of Osteochondral Chondral Lesion of the talar dome is ever more regularly made. Though algorithms of management have emerged by recognising the position, size and the most reliable treatment options, the problem of the failed or relapsed case has only been considered in limited publications.

When considering the failed case a variety of possibilities have to be considered.

The characteristics of the patient have to be considered. The nature of the original presentation and the history of the present as opposed to the past compliant are worth noting. Patients who have no history of trauma do seem to have a different natural history and response to treatment. The young and the old may well respond differently.

Factors preventing recovery from surgery such as ongoing instability of the ankle or hindfoot deformity creating on going abnormal pressures on the joint surface should be looked for.

The possibility that the surgery undertreated or missed the full nature of the lesion has to be considered. The possibility of an untreated further pathology should be reviewed.

The severity of the original lesion and it's likely response to treatment should be considered. Larger cystic lesions would be more likely to have a poorer outcome. Ultimately if there are persistent symptoms and evidence of ongoing unresolved pathology on the joint surface alternative techniques to resurface the joint should be considered.

Background & aim

There have been many operations described for the treatment of hallux valgus deformities and b ette done separately with variable success rates. Our aim is to radiologically assess the outcome following simultaneous osteotomies to the 1st and 5th metatarsals in symptomatic patients with splay foot. To our knowledge, this procedure has not been described in the literature yet.

Introduction

Comminuted mid-foot fractures are uncommon. Maintenance of the length and alignment of the medial column, with restoration of articular surface congruity, is associated with improved outcomes. Conventional surgery has utilised open or closed reduction with K-wire fixation, percutaneous techniques, ORIF, external fixation or a combination of these methods.

In 2003 temporary bridge plating of the medial column was described to reconstruct and stabilise the medial column. The added advantage of locking plates is the use of angle-stable fixation. We present our experience with temporary locking plates in complex mid-foot fractures.

We report a single surgeon series of 33 arthroscopic subtalar fusions performed through a 2-portal sinus tarsi approach on 32 patients between March 2004 and February 2009. Background pathologies included primary arthrosis, post-traumatic arthritis, planovalgus foot, rheumatoid disease, sinus tarsi syndrome and CTEV.

97% [32/33] of fusions as assessed by both clinical and radiological means were achieved within 16 weeks [76% [25/33] within 12 weeks] with only a single outlier which had fused by 22 weeks. There were no deep infections, thrombotic events or neuromas. Five patients suffered complications of which four were successfully treated with a satisfactory outcome. One patient developed persistent pain and was eventually referred to another centre for further management.

In our experience arthroscopic subtalar fusion surgery has been demonstrated to give excellent outcomes with minimal complications. Furthermore, it is a technique allowing surgery even in patients with significant hindfoot deformity. It is a suitable operation even for patients with a compromised soft tissue envelope which would normally preclude an open procedure.

The patient-reported Manchester-Oxford Foot Questionnaire (MOXFQ), with 3 dimensions (Walking/standing(W/S), Pain, Social interaction(SI)) has previously been validated in patients undergoing hallux valgus surgery. A preliminary cross-sectional evaluation of its measurement properties relating to surgery on different regions of the foot and ankle is presented here.

Within 4 weeks prior to foot or ankle surgery, 671of 764 consecutive eligible patients (87.8% response rate) were assessed with the: (i) MOXFQ questionnaire, (ii) SF-36 general health survey (iii) American Orthopaedic Foot & Ankle Society (AOFAS) scales. Sample characteristics: mean age 53 years 427 (63.6%) female. Patients were booked for (main) surgery on Hallux (210, 31.3%), Lesser Toes (119, 17.7%), Mid foot (22, 3.3%), Ankle/Hind foot (311, 46.3%) and whole foot/multiple regions (9, 1.3%)

MOXFQ item response rates were high (<2% missing on any one item) with responses generally well distributed across response categories. Item-total correlations within each dimension were generally above recommended levels. Internal consistency, as assessed by Cronbach's alpha, were 0.93, 0.84 and 0.71 for the W/S, Pain and SI dimensions, respectively. Within Hallux, Lesser toes and Ankle/hind foot surgical subgroups (low numbers precluded mid foot and whole/multiple region analyses), alphas for these subscales were similar. Convergent validity of MOXFQ was demonstrated by correlations between the 3 dimensions (W/S, Pain, SI) with similar dimensions of the SF-36 and relevant AOFAS scales. A priori hypotheses were generally supported.

The MOXFQ demonstrates good baseline measurement properties in patients undergoing a range of foot and ankle surgery, suggesting its suitability as an outcome measure for clinical trials of foot and ankle surgery in general. The SI dimension, concerned with cosmesis and social participation has somewhat weaker properties but remains useful. Evidence for the MOXFQ's responsiveness across the range of foot and ankle surgery is yet to be assessed.

Introduction

The mainstay of treatment in non-insertional Achilles tendinopathy is non-operative, however between 1/4 and 1/3 of patients fail this. The main symptom is pain which appears to be related to new nerve endings that grow into the tendon with the neovessels from the paratenon. Treatments which strip the paratenon from the tendon are showing promise including formal paratenon stripping via Achilles tendinoscopy. The pain and swelling in Achilles tendinopathy is usually on the medial side leading to the postulation that the plantaris tendon may have a role to play.

Background

Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency.

Conventionally, medial malleolus fractures are treated surgically with anatomical reduction and internal fixation using screws. There seems to be no consensus, backed by scientific study on the optimal screw characteristics in the literature.

We retrospectively examined case notes and radiographs of 48 consecutive patients taken from our trauma database (21 male, 27 female) with an average age of 50 years (range 16-85) who had undergone medial malleolus fracture fixation with screws at the Royal Free Hospital, London between January 2009 and June 2010.

The most commonly used screw was the AO 4.0 mm diameter cancellous partially-threaded screw in 40, 45 and 50 mm lengths (40 mm n = 28, 45 mm n = 26, 50 mm n = 23) with the threads passing beyond the physeal scar in all cases. Incomplete reduction defined as > 1mm fracture displacement was observed on post-operative x-rays in 12 out of 48 cases (25%), all of which relied on partially-threaded screw fixation. In 5 cases where AO 4.0 mm diameter fully-threaded screws engaging the physeal scar had been used, no loss of reduction was observed.

This unusual, occasional use of fully-threaded screws prompted us to investigate further using a porcine model and adapted pedo-barographic transducer. We compared pressures generated within the fracture site using AO 4.0 mm partially-threaded cannulated screws, 4.0 mm partially-threaded cancellous screws and 4.0 mm fully-threaded cancellous screws.

Fully-threaded cancellous 4.0 mm diameter screws generated almost 3 times the compression of a partially-threaded cancellous screw with superior stability at the fracture. Partially-threaded screws quickly lost purchase, compression and stability particularly when they were cannulated. We also observed that screw thread purchase seemed enhanced in the physeal region.

We conclude that fully-threaded cancellous 4.0 mm AO screws are superior to longer partially-threaded screws and that use of cannulated 4.0 mm partially-threaded screws should be avoided in fixation of medial malleolus fractures.

The incidence of venous thromboembolism (VTE) is unknown in elective foot and ankle surgery. In March 2010 we surveyed the current practice in VTE prophylaxis in elective foot and ankle surgery amongst members of the British Orthopaedic Foot and Ankle Society (BOFAS).

The response rate was 53%. The total the number of elective foot and ankle operations performed by the surveyed group was 33,500 per annum. The perceived incidence of DVT, PE and fatal PE was 0.6%, 0.1% and 0.02%. In our study the number of patients needed to treat to prevent a single fatal PE is 10,000 although this figure is open to significant bias.

The National Institute for Health and Clinical Excellence (NICE) recently published guidelines on reducing the risk of venous thromboembolism in surgical patients. These guidelines cover all surgical inpatients and uses data extrapolated from other groups of patients. We question the applicability of these guidelines to patients undergoing elective foot and ankle surgery. We consider that this data justifies the prospective study of the incidence of VTE in patients undergoing elective foot and ankle surgery, without the use of chemical thromboprophylaxis.

Metatarsal fractures are extremely common injuries accounting for 10% of all fractures seen in our accident and emergency departments (3). The vast majority can be treated conservatively. There is no standardised treatment, but it is commahplace to immobilise the foot and ankle joint in a below-knee back-slab, full cast or functional brace for a period of up to 6 weeks, weight-bearing the patient as pain allows. This practice is time-consuming and expensive, not to mention debilitating, and carries a morbidity risk to the patient.

We describe a simple, effective and cheap treatment method for metatarsal fracture management using the functional forefoot-offloading shoe (FOS). This is clinically proven to offload pressure on the metatarsals and is commonly used in both elective forefoot surgery and in diabetic patients.

Between January and September 2009, we identified 57 patients attending our fracture clinic with new metatarsal fractures. 28 met our inclusion criteria.

All patients reported a significant improvement in their pain

At Injury – mean 8.21 out of 10 (range 4-10)

After FOS fitting - mean 2.92 out of 10 (range 0-6)

The forefoot-offloading shoe is an excellent alternative to plaster casting or functional boot immobilisation, offering high patient satisfaction, an excellent outcome and a considerable cost-saving to the hospital trust.

Purpose

Tarsal Tunnel Syndrome (TTS) was first reported by Keck and Lam separately in 1962. It has been regarded as the lower limb equivalent to Carpal Tunnel Syndrome (CTS). The gold standard of diagnosis proposed over the years is nerve conduction study (NCS). In reality, TTS is much harder to diagnose and treat compared to CTS. Signs and symptoms can be mimicked by other foot and ankle conditions. Our unit had not seen a single positive nerve conduction result of TTS in clinically suspicious cases. We have therefore audited our 10 year experience.

Introduction

Syndesmosis injuries are significant injuries and require anatomical reduction. However, stabilisation of these injuries with syndesmosis screws carries specific complications and many surgeons advocate a second operation to remove the screw. Primary Tightrope suture fixation has been shown to be an effective treatment for syndesmotic injuries and avoids the need for a second operation.

Introduction

Following recommendations in the NHS Plan, all Trusts in the UK now send copies of correspondence to patients as standard practice. It is not clear whether patients wish to receive such correspondence, nor whether this practices an additional workload on the NHS as patients seek clarification on the medical terminology used in their letters.

Introduction

Ankle replacement is a major surgery with significant soft tissue dissection and bleeding. The skin quality is often poor in these patients due to age, edema, venous congestion, arteriopathy or previous procedures and soft tissue injury. The chances of wound infection increase with delayed wound healing. Absorbent non-adherent dressing (ABD) and VAC dressing applied in theatre after ankle replacement were assessed in a cohort of 147 patients with wound complications, pain, satisfaction and length of stay as outcome measures.

Background

Morton's Neuroma is a proximal neuralgia that affects the web spaces of the toes and is currently of unknown aetiology. Currently surgical excision is considered the gold standard treatment based on RCT and cohort studies. However patient derived outcomes have not previously been assessed. We addressed these aspects with our study.

Introduction

This project reports differences in outcome measures after total ankle arthroplasty (TAA) for patients with Osteoarthritis (OA), Rheumatoid Arthritis (RA) and Post-traumatic Osteoarthritis (PTOA).

Introduction

There are approximately 1.2 million patients using orthotics in the UK costing the NHS in excess of £100 million per annum. Despite this, there is little data available to determine efficacy and patient compliance. There have been a few reports on patient satisfaction, which indicate that between 13-50% of patients are dissatisfied with their orthotics. Our aim was to evaluate patient reported satisfaction with orthotics prescribed and to investigate the reasons behind patient dissatisfaction.

Introduction

Peri prosthetic fracture is a recognised complication following Total ankle arthroplasty (TAA). There is limited literature on post operative management following TAA and controversies exist based on surgeon preferences. This project reports the incidence of peri- prosthetic fractures in patients managed with 2 different post-operative protocols.

Injuries to the lateral ligamentous complex of the ankle are common. The most commonly injured ligament is the anterior talofibular ligament (ATFL) followed by the calcaneofibular ligament (CFL). The posterior talofibular ligament (PTFL) is less commonly injured. There are few studies reporting the incidence of PTFL injury and less data available which describes the significance of this injury. We aim to establish an incidence of PTFL injury and allude to the possible significance of such an injury.

Congenital hallux varus had been a well-described condition for many years before acquired hallux varus as a condition arising from bunion correction was not described until 1935. In that year, McBride discussed this potential problem when describing this as a potential problem from his described technique, identifying possible mechanisms to prevent the disorder from occurring. Authors such as Joplin and Kelikian echoed the concept in the early 1960's, spawning a series of corrective procedures. Miller brought this to common practice in 1975, describing the tendon imbalance seen across the precarious 1^st MTP joint.

The first metatarsophalangeal joint moves in the sagittal plane, dorsiflexion and plantarflexion only. Four intrinsic muscles stabilize the digit, with the abductor and adductor hallucis taking the lion share of this function. The abductor tendon actually functions primarily as a plantarflexor of the first metatarsophalangeal joint 83% of the time (Thompson) due to its primary plantar location. This fact, in combination with the pronation generally seen in severe bunion deformities, contributes to acquired hallux varus following bunion correction. Besides the obvious cause of over-correction of the metatarsal osteotomy creating hallux varus, imbalance of the tendon complex post-operatively can create an equally catastrophic circumstance. Hawkins demonstrated that severing the adductor tendon complex (the conjoined tendon) will not product hallux varus when the hallux is not rotated. However, in more severe hallux valgus, pronation of the hallux may be proportional to the deformity of the hallux itself. This rotational deformity places the insertions of the abductor (and medial insertion of the flexor brevis) more plantarward and lateral, increasing the valgus deformity. If the entire conjoined tendon is sectioned and the internal rotation deformity corrected the insertion of the contracted abductor moves medially, pulling the toe into varus. If the center of the base of the proximal phalanx is brought beyond the mid-point of the first metatarsal head, the extensor hallucis longus will bowstring, pulling the great toe into varus while creating a hallux flexus deformity. Finally, if the lesser toes are in varus and not corrected, this deforming force will create hallux varus following bunion correction with a lateral release. The message is clear: not all patients require a lateral release, and, if done, should be done with caution.

Once present, correction can be difficult. Tendon transfers utilizing the extensor hallucis longus (Johnson) or extensor hallucis brevis (Myerson) only have beneficial effects in non-arthritic, mobile first metatarsophalangeal joints. In addition, if metatarsal deformity is not corrected, the deformity will recur. Thus, in many circumstances, arthrodesis of the first metatarsophalangeal joint becomes the treatment of choice, and is commensurate with a disappointed patient who underwent a primary bunion correction and was left with a fused great toe.

This lecture will explore the above mechanism and salvage situations, in hopes of eliminating this unwelcomed outcome from your practice.

Most of the controversy surrounding management of the adult acquired flatfoot deformity revolves around the correction of Stage 2 deformity. Stage 1 deformity, uncommonly corrected surgically, involves tenosynovitis with preservation of tendon length and absence of structural deformity. Attempts at tenosynovectomy in light of structural deformity leads to operative failure, found in 10% of Teasdall and Johnson's 1992 patient population. Thus, with tenosynovectomy rarely becoming an operative situation, Stage 2 deformity becomes the mainstay of operative treatment of the adult flatfoot. Stage 2 deformity patients present with swelling medially, the inability to do a single heel raise, with a passively correctable subtalar joint. The tendon is functionally torn. In recent years, authors have subdivided Stage 2 deformity even further into A and B subcategories, where A involves less than 50% uncovering of the talonavicular joint, and B patients more than 50%. Recently, Anderson has added a C subtype, which may be applied to either A and B patients, in patients who have forefoot varus. Thus, Stage 2 patients suffer from pain that begins medially and progresses to the subfibular region over time. Most important, recognition of the continued sub classification in Stage 2 disease echoes the fact that this disorder is on a continuum, challenging the surgeon to recognize subtleties that, if unrecognized, lead to a poor patient outcome. The mainstay of treatment in Stage 2 disease is the medial slide calcaneal osteotomy, which realigns the hindfoot axis reducing valgus, improves the medial arch, protects the FDL tendon transfer, and allows the Achilles tendon to become a strong inverter. Over shift of the calcaneus can compromise the outcome, as will a lack of recognition of the congenital subtleties such that a valgus hindfoot can have a varus orientation to the calcaneus, both leading to lateral overload. A pure medial slide of a calcaneus that has a varus orientation does not correct deformity, rather, it creates it. Thus, an axial calcaneal view must be studied carefully, for a varus orientation may be corrected via a closing wedge osteotomy commensurate with the medial shift of the tuberosity. As noted above, the flexor digitorum longus tendon transfer is the staple procedure to replace the damaged posterior tibial tendon. This transfer balances the eversion power of the peroneal tendons, works in phase with the former posterior tibial tendon in the stance phase of gait, and replaces a painful diseased posterior tibial tendon. However, over tensioning the transfer results in a tenodesis rather than a functional tendon transfer, the relative weakness of the FDL tendon (30% as strong as the PTT) creates difficulty with heel raise, and inappropriate transfer to distal tarsal bones may compromise the result by limiting torque from the transferred tendon. Preservation of the posterior tibial tendon in combination with the transferred FDL tendon remains a consideration without answer, though Rosenfeld (2005) suggests a substantial improvement in strength through PTT preservation. Failure of the above protocol for treating Stage 2 disease most often revolves around the insufficient corrective power of the tandem procedures in longstanding ruptures. According to Guyton (2001), only 50% of patients report a perception in deformity improvement following FDL/calcaneal osteotomy procedures, and only 4% report a significant improvement in pre-existing deformity. Sangeorzan (2001) found such patients could not achieve a painless plantigrade foot due to acquired ligament laxity (primarily the Spring Ligament). Sangeorzan applied Evans' pediatric procedure to adults without confirming the pathomechanics of correction. Some speculate the windlass effect on the plantar fascia creates correction (refuted by Horton, 1998, finding the plantar fascia is loosened by a lateral column lengthening), others believe tightening the peroneus longus through lateral column lengthening increases first ray plantarflexion, restoring the medial arch. Controversy also remains in answering Cooper's (1997) claim that lengthening through the calcaneus creates static increase in pressure about the calcaneocuboid joint (1.4mPa total) that may lead to an arthritic joint long term. Painful lateral overload following lateral column lengthening remains difficult problem to both prevent and correct. This last point leads to some focusing their efforts on restoration of the medial column. This group focuses on the “C” type deformity noted by Anderson, those with forefoot varus. It is known that the medial column is supported by the navicular, the cuneiforms, and the first, second, and third metatarsals. While a Cotton (opening wedge medial cuneiform) osteotomy, a first tarsometatarsal joint arthrodesis, or a metatarsal osteotomy has value, the surgeon must note that this only corrects the first ray. Complete correction of the medial column is best achieved through naviculocuneiform joint arthrodesis. Standing radiographs commonly reveal collapse at that level; however, surgeons are reticent to perform such fusions in light of the higher nonunion rate.

Heel pain is very prevalent. Pain, especially after a period of rest, is the main symptom. Reduced ability to walk long distances and inability to participate in exercise and sport are other complaints. Plantar heel pain is most commonly caused by plantar fasciitis. Whilst only the recalcitrant cases reach secondary care, this can still be a significant workload. In the Royal Surrey County Hospital, Guildford, we see approximately 200 cases of recalcitrant heel pain each year. The vast majority of cases never come to hospital and are managed in primary care (1500/yr in podiatry alone). Effective primary treatments should reduce the number of long-term sufferers.

Recalcitrant cases of plantar fasciitis often have atypical symptoms. Radiological imaging is extremely useful in clarifying the diagnosis. Ultrasound is our preferred modality. There is a spectrum of pathology that affects the plantar fascia, and this is less well classified than for the achilles tendon, where the distinction between insertional tendinopathy and tendinopathy of the main body of the tendon is helpful in guiding treatment.

The evidence for many forms of treatment for plantar fasciitis is weak. Currently, the use of formal calf stretching programs is widely considered to be the best first-line treatment. There are additional benefits with stretches to the fascia itself. The mechanism by which these stretches help is not well established. Calf contracture is, however, associated with a variety of clinical problems in the foot and ankle. This is especially true for isolated gastrocnemius contracture. There is also laboratory evidence that increased plantar fascia strain is seen with increased calf muscle tension. Surgery to release a gastrocnemius contracture improves biomechanics and has been used in refractory cases of heel pain with good effect.

Radial extracorporeal shock wave lithotripsy is the latest version of this non-invasive treatment. Results in our centre are encouraging. For selected cases of atypical plantar fasciopathy injection treatments are effective.

Persistent pain is a common cause of disability in patients after fractures of the calcaneum. Amongst the possible causes for post traumatic pain is the development of degenerative osteoarthritis of the posterior facet of the subtalar joint. However there are many other causes of post-traumatic hindfoot pain which require consideration prior to treatment. Knowledge of the patho-anatomy of calcaneal fractures is required to reach an accurate diagnosis. Significant symptoms and disability may be treated by arthrodesis of the subtalar joint.

Post-traumatic arthritis in the non-operatively treated calcaneal fracture is however usually associated with deformity of the hindfoot, disordered hindfoot biomechanics, lateral wall fibular impingement and fibular tendon dysfunction.

Fractures treated by primary open reduction and fixation should be well aligned but despite anatomic reduction may also develop posterior facet arthritis. Symptoms may also be caused by prominence or impingement of the implant, particularly of locked perimeter plates on the lateral wall.

Patients therefore require careful assessment prior to surgery and any operative measures have to address these key features in order to produce a satisfactory clinical result.

This lecture will address the potential problems of this type of surgery and key features in the clinical assessment and imaging of these patients.

Subtalar arthrodesis in the presence of deformity is technically complex and requires careful planning in order to correct the deformity and to produce a well aligned hindfoot to allow corrected biomechanics without impingement and the fitment of suitable footwear.

The surgical techniques and different types of surgery required to adequately manage the posterior facet and deformity will be covered and will include arthroscopically assisted in-situ fusion, the safe approaches for open surgery and techniques to reconstruct the lateral wall, fibular tendon function and osteotomies required to restore calcaneal height and alignment.

The aetiology of hallux valgus is well published and largely debated. Hypermobility at the TMTJ was initially described by Morton, but it was not till Lapidus that its association with hallux valgus was hypothesized. However, little has been published on the anatomy of the tarsometatarsal joint. Our aim was to determine whether there was an anatomical basis for the coronal hypermobility in hallux valgus.

Aims

Malignant tumours of the foot and ankle are rare, but easily missed. NICE guidelines for bone and soft tissue tumours may be less appropriate for the foot and ankle than elsewhere. The purpose of this study was to identify the clinical features and treatment of malignant tumours arising in the foot and ankle to see if guidelines should be modified.

Medial Displacement Osteotomy (MDO) of the os calcis is used to correct the hind foot valgus in a flat foot deformity. Screw fixation is commonly used although contemporary locking plate systems are now available. This study tested the hypothesis that a 10mm MDO would support a higher load to failure with a locked step plate than with a single cannulated screw.

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.

TMTJ fusion is performed for arthritis or painful deformity. K-wire and trans-articular screws are usually used to stabilize the joints. We present our experience with LP for TMTJ fusion in first 100 joints.

Thromboembolic disease is associated with a high degree of morbidity and mortality. There is increasing pressure for elective orthopaedic patients, including those undergoing foot and ankle surgery, to be prescribed chemical thromboprophylaxis post-operatively in order to reduce the risk of a thromboembolic event. The risks of chemical thromboprophylaxis in terms of increased bleeding, wound problems and HIT are well documented. The aim of this study was to determine the incidence of clinically significant thromboembolic events in patients undergoing elective foot and ankle surgery with and without the use of aspirin.

We audited a consecutive series of 1625 patients undergoing elective foot and ankle surgery between 2003 and 2010. Between 2003 and 2006 inclusive, aspirin was used post operatively as chemical thromboprohylaxsis. Between 2007 and 2010, no chemical thromboprohylaxsis was used. The follow-up period for all patients was at least three months post-operatively. Most patients were reviewed at 3 months by the senior surgeon. Those who were reviewed less than 3 months (patients undergoing minor procedures) were contacted via telephone to confirm whether a thromboembolic event had been diagnosed.

There was no loss to follow up. Of the 1625 patients, 555 patients received aspirin and 1070 patients received no chemical thromboprohylaxsis. 5 of 1625 (0.31%) patients developed a clinically significant thromboembolic event. 3 patients developed a DVT at an average time of 5 weeks post operatively. 2 patients developed non-fatal PE at an average time of 7 weeks post operatively. 3 of the 5 thromboembolic events occurred in the aspirin group (all DVT's) whereas 2 of the 5 (all PE) developed in the non aspirin group.

The incidence of clinically significant thromboembolic events is low in elective orthopaedic foot and ankle surgery. We suggest that the benefit of chemical thromboprophylaxis does not outweigh its potential risks in foot and ankle surgery.

The arterial supply of the talus has been studied extensively in the past. These have been used to improve the understanding of the risk of avascular necrosis in traumatic injuries of the talus. There is, however, poor understanding of the intra-osseous arterial supply of the talus, important in scenarios such as osteochondral lesions of the dome. Previous studies have identified primary sources of arterial supply into the bone, but have not defined distribution of these sources to the subchondral regions.

This study aims to map the arterial supply to the surface of the talus. Cadaveric limbs (n=10) were dissected to identify source vessels for each talus. The talus and navicular were removed, together with the source vessels, en bloc. The source vessels were injected with latex and processed using a new, accelerated diaphanisation technique. This quickly rendered tissue transparent, allowing the injected vessels to be visualised. Each talus was then reconstructed using a digital microscribe, allowing a three dimensional virtual model of the bone to be assessed. The terminal points of each vessel were then mapped onto this model, allowing the distribution of each source vessel to be determined.

This study will provide quantifiable evidence of areas consistently restricted to single-vessel supply, and those consistently supplied by multiple vessels. These data may help to explain the distribution and mechanisms behind the development of the subchondral cysts of the talus.

In recent years the Weil osteotomy has become the dominant technique employed by most surgeons for distal metatarsal osteotomy. This is generally a reliable technique but problems with stiffness can frequently occur in the operated metatarso-phalangeal joints. We present our experience with a minimally invasive distal metatarsal extra-articular osteotomy technique. This technique utilises a high-speed burr via a tiny skin portal to perform a distal metatarsal extra-articular osteotomy under image intensifier guidance without the need for fixation.

A consecutive series of 55 osteomies in 21 patients were included in the study. All osteotomies were performed for metatarsalgia/restoration of metatarsal cascade. The mean age was 49 (38-78), and 20/21 were female. The senior author performed all surgery. All patients were allowed to weight bear immediately in a postoperative shoe and then an ordinary shoe from 4-6 week post-operatively. Mean follow-up was 8 months (4-13) and patients were assessed clinically and scored using the AOFAS scoring system and a subjective outcome score.

The mean AOFAS score improved significantly postoperatively. All patients were very satisfied/satisfied with the outcome. Two patients had minor superficial portal infections, which resolved with oral antibiotics. One patient reported irritating numbness and stiffness in toes (1st case performed). Most patients reported swelling persisting to 3-4 months. There was one symptomatic delayed at 4 months treated successfully with short air boot immobilisation. There were no mal unions.

This series suggests that MIS distal metatarsal osteotomy results compare well with outcomes reported with modern open techniques such as the Weil. We now favour an MIS distal metatarsal osteotomy technique for most indications due to the minimal stiffness observed postoperatively as well as much reduced surgical time without the need for tourniquet.

Injury to the syndesmosis occurs in approximately 10% of all patients with ankle fractures. Anatomic restoration of the syndesmosis is the only significant predictor of functional outcome. Several techniques of syndesmosis fixation are currently used such as cortical screws, bioabsorbable screws and more recently introduced suture-button fixation. No single technique has been shown to be superior to the others.

The objective of this research project is to investigate whether treatment with a tightrope (suture-button fixation) gives superior results than the use of a cortical screw in the treatment of acute syndesmotic ankle injuries with regards to function, pain, satisfaction and return to normal activities.

Research Ethics Committee approval was obtained. 40 patients with syndesmotic ankle injuries associated with diastasis were prospectively recruited, 20 in each group. Patients were randomized to one of the 2 groups. At 12 weeks, American Orthopaedic Foot and Ankle Society (AOFAS) scores and a computerized tomography (CT) scan of both the ankles was obtained. At 1 year, AOFAS scores and satisfaction was assessed.

32 patients have been recruited so far, 20 in the tightrope group and 12 in the cortical screw group. Mean AOFAS scores at 3 months post-op were 90.67 in the Tightrope group and 84 in the screw group. The difference was not significant (p= 0.096). CT scans revealed that the quality of syndesmosis reduction was equally good with both the techniques. Metalwork prominence was common with both the devices.

Background

The Plantaris Longus Tendon (PLT) may be implicated in Achilles (AT) tendinopathy. Different mechanical characteristics may be the cause. This study is designed to measure these.

Aim

To determine the effects of knee and ankle position on tendo Achilles (TA) gap distance in patients with acute rupture using ultrasound.

Evidence-based orthopaedic surgery emphasizes the need to properly design and perform high-quality randomized controlled trials to minimize bias and to truly ensure the effectiveness of orthopaedic interventions. The currently available best evidence suggests to load and move the Achilles tendon after an open or percutaneous repair for an acute rupture.

Following repair of the torn AT, patients are immobilized with their ankle in gravity equines. They are encouraged to bear weight on the operated limb as soon as possible to full weightbearing, and discharged home on the day of the procedure. All patients are given an appointment for review 2 weeks postoperatively, when they receive a single cast change, with the ankle accommodated in a removable anterior splint in a plantigrade position, secured to the lower leg and foot with Velcro straps. Removal of the foot straps under supervision of a physiotherapist allowes the ankle to be plantar flexed fully but not dorsiflexed. These exercises are performed against manual resistance. At 6 weeks postoperatively, the anterior splint is removed, and the patient referred to physiotherapy for active mobilization.

At 12 weeks postoperatively, patients are assessed as to whether they are able to undertake more vigorous physiotherapy, and encouraged to gradually return to their normal activities. Progressive activities are incorporated as strength allowed, with the aim to return to unrestricted activities 6 months following surgery.

Introduction/Aim

Thromboembolism is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. It was therefore, our aim to identify a difference in symptomatic thromboembolism by treating acute Achilles tendon rupture patients with conventional non- weight bearing plaster versus functional weight bearing mobilisation.

Painful peroneal spastic flatfeet without coalition or other known etiologies in adolescence, remains a difficult condition to treat. We present eight such cases with radiological and surgical evidence of bony abnormalities in the lateral subtalar region just anterior to the posterior facet.

All patients had presented as tertiary referrals with recalcitrant pain and had undergone a trial of orthotics and physiotherapy. Diagnostic workup included a clinical and radiographic evaluation. Clinical examination consisted of gait examination, foot alignment, range of motion, torsional profile of the lower limbs and marking of symptomatic foci. All patients had standing weightbearing anteroposterior and lateral projections of the foot and ankle, CT and/or MRI scans of the foot. Coalitions and other known intra-articular pathologies like subtalar arthritis were ruled out. All patients had bilateral flatfeet but unilateral peroneal spasm.

All patients had an accessory anterolateral talar facet (ATF) which was arising as an anterior and distal extension of the lateral process of the talus. This caused lateral impingement between the facet and the calcaneum, confirmed by bone edema around the sinus tarsi and marked at the apex of the angle of Gissane on MRI scans. All patients had stiff subtalar joints with very limited movement under anaesthesia, indicating peroneal muscle contracture. Patients were treated with a combination of facet excision, fractional peroneal and gastrosoleus lengthening and calcaneal lengthening to correct the flatfoot and prevent lateral impingement.

Background

Talar neck fractures occur infrequently and are associated with high complication rates. Anatomical restoration of articular congruity is important. Adequate exposure and stable internal fixation of these fractures are challenging.

Fusion remains the standard of care and is associated with a high satisfaction rate. But.… fusion generally requires 6 weeks of restricted weight bearing or immobilization. Potential problems include 1) nonunion, 2) malunion, 3) sesamoid pain (from DJD), 4) late onset IP1 DJD.

Complete joint replacement has been performed with a number of different designs since the early 1970's. The metal and poly designed implants are associated with a high failure rate, presumably from high shear loads, eccentric axial loads, poor fixation and bone stock problems. Resurfacing of both sides of the joint with a one piece silicone based crosslinked rubber {“silastic”} in rheumatoid patients appears to function better with use of metal grommets to reduce generation of particle debris and foreign body reaction. These silastic implants are still used by surgeons in select low-demand rheumatoid patients. Salvage after failure of any of these total joint replacements can be challenging because of loss of bone stock.

3 other methods are used to resurface the joint in severe OA: 1) resurfacing the proximal phalangeal side only, 2) resurfacing the metatarsal head only and 3) resurfacing the joint with and interposition arthroplasty. 1) advantage of the proximal phalangeal side resurfacing is simplicity of geometry; the disadvantage is disruption of the FHB attachment and the relative scarcity of severe cartilage damage at that side of the joint. 2) Advantage of the metatarsal head side for resurfacing is that is the typical location of the arthritic change; the disadvantage is potential interference with the sesamoid complex and bulkiness of fixation could lead to a more difficult salvage. 3) The advantage of interposition arthroplasty is the maintenance of bone stock; disadvantages include inconsistent local tissue and somewhat less predictable outcomes.

In this talk I will focus primarily on the technique and results of a proximal phalangeal resurfacing approach for OA of the MTP1 joint.

Ankle sprains in the athlete are one of the most common injuries, and syndesmosis type sprains seem to becoming diagnosed at an increasing rate. There still exists a paucity of information on optimal conservative and operative management.

Deltoid ligament insufficiency has been shown to decrease tibiotalar contact area and increase peak pressures within the lateral ankle mortise. Sectioning of the deltoid ligament has been shown to decrease tibiotalar contact area by 43%. This detrimental effect may create an arthritic ankle joint if left unresolved. Reconstructive efforts thus far have been less than satisfactory. Pankovich and Shivaram described the deltoid ligament as having superficial and deep components based on insertion sites. The superficial layer originates from the anterior colliculus of the medial malleolus and inserts on the navicular, calcaneus and talus. The deep layer originates from the intercollicular groove and posterior colliculus and inserts on the talus. Boss and Hintermann noted that the most consistent and strongest bands of the deltoid were the tibiocalcaneal and posterior deep tibiotalar ligaments. Chronic deltoid ligament insufficiency may be seen in several disorders including trauma and sports injuries, posterior tibial tendon disorders, prior triple arthrodesis with valgus malunion, or total ankle arthroplasty with improper component positioning or pre-existing ligament laxity. The reconstruction of the deltoid ligament in these settings may be critical to the prevention of tibiotalar arthrosis or failure of ankle prostheses from edge loading and polyethylene wear.

The reconstructive technique we describe, under low torque, was able to restore eversion and external rotation stability to the talus, which was statistically similar to the native deltoid ligament. In addition, though we maximally tension this graft to give the most secure repair possible, we did not note any increased stiffness in the ankle joint through our measurement techniques. This unusual, positive secondary effect is different from that noted in studies of lateral ligament reconstruction, where ligament tensioning by all methods attempts to reproduce the native tension and not exceed it. All medial ankle ligament repairs of substance involve some type of tendon-weave (whether autograft or allograft) to achieve reconstruction. Our technique develops its strength not only from the anatomic orientation of the reconstructed ligament, but the strength of the components chosen to fix the tendon graft to the bone. The use of Endobuttons allows the entire graft to sit within the tunnels, without the potential violation of the graft ends achieved through techniques utilizing interference screw fixation. Tensioning the graft proximally through the tibia against a rigid distal construct allows greater tension to be placed on the graft at the deltoid ligament site itself than techniques which employ distal tensioning while holding the ankle into inversion. Finally, the use of a looped graft proximally secured with a post that may be moved even further proximally at the surgeon's discretion creates superior tension to achieve medial column rigidity in grossly unstable situations. Thus, given the critical importance of the deltoid ligament and the relative paucity of repair/reconstruction options available, we believe this novel approach will assist the clinician in anatomically reconstructing this challenging condition.

Deltoid ligament reconstruction technique using semitendinosis allograft, with superimposed line drawing demonstrating orientation of looped graft.

Clubfoot deformity is the most common congenital musculoskeletal disorder (1). Approximately one in one thousand people are born with at least one clubfoot; between 150,000 and 200,000 babies are born with a clubfoot each year (2). Eighty percent of these cases occur in developing countries, and the majority is left untreated. When infants are treated with a non-invasive casting technique pioneered by Ignacio Ponseti M.D., they generally can be “cured” with relative ease. In the United States, 97% of patients given this treatment can walk successfully and are able to live normal lives (3). The Ponseti Method requires several plaster casts but either no or minimal surgery, can be taught fairly easily not only to doctors but also to healthcare workers, nurses, and other people who have some knowledge and training in healthcare. Also, it requires plaster casting, making it an inexpensive treatment.

Dr. Ignacio Ponseti first performed his non-invasive treatment in 1949, but didn't publish his results until 1963. Two more papers, published in 1979 and 1995 described the long-term outcomes of treatment. In 1996 Oxford Press published a book detailing his approach. Although the treatment has always had high success rates, a lack of publicity prevented it from becoming more widely used until the late 1990s.

Its basic mechanism consists of a series of plaster casts and manipulations that gradually reshape the foot around a fixed talus to obtain correction. Generally, between five and seven casts are required. The casts extend from the toes to the upper thigh and hold the knees at a right angle. One of the most important aspects of this method is timing: infants can be given treatment starting at seven days old and ideally should begin treatment before reaching eight months of age.

Brazil, Uganda, Malawi and Chile now have official national programs, which are sponsored by each country's Ministries of Health, in which clinics in each country treat clubfoot disorder using the Ponseti Method. China set up a national program in 2005, but with a population of 1.3 billion people, it will take several years to complete the training. The prevalence of the Ponseti Method varies in the sixty other countries with healthcare workers trained in the treatment.

This talk will review the principles of treatment and focus on results of recurrence after initial treatment with the Ponseti Method.