Subtalar nonunion has a detrimental effect on patients' function, and pose a significant challenge for surgeons particularly in the setting of higher risk factors. We retrospectively analyzed a consecutive series of 49 subtalar nonunions between October 2001 and July 2013. Patient records and radiographs were reviewed for specific patient demographics and comorbidities, subsequent treatments, revision fusion rate, use of bone graft, complications, and clinical outcome.Background
Methods
Cheilectomy and arthrodesis are accepted procedures for symptomatic hallux rigidus. Although good functional outcomes have been reported, there is little data available on post-operative sporting ability for these patients. We investigated sporting ability and functional outcomes of two cohorts of patients, the first underwent dorsal cheilectomy and the second arthrodesis.Background
Aims
The mid foot joints are usually the first to be affected in Charcot neuroarthropathy (CN). Reconstruction is technically demanding and fraught with complications. We present our experience of mid foot fusion in CN from a tertiary diabetic foot centre. We undertook mid foot corrective fusion in 27 feet (25 patients). Twelve of these had concurrent hind foot fusion. Eleven patients had type 1 diabetes, 12 had type 2 and 2 were non-diabetics. 23 patients were ASA grade 3 and 2 were ASA 2. 21 feet had ulcers preoperatively and mean HbA1c was 8.2. 13 patients had diabetic retinopathy and 6 had nephropathy.Introduction
Patients and methods
Patients with neglected rupture of the Achilles tendon typically present with weakness and reduced function rather than pain. Shortening of the musculotendinous unit and atrophy of the muscle belly in chronic rupture potentially leads to poorer recovery following tendon transfer. Few papers have looked at the outcomes of FHL reconstruction specifically in neglected TA rupture. Of those that have none report functional outcomes following a transtendinous repair. Twenty patients with irreparable unilateral tendoachilles ruptures treated with transtendinous FHL reconstruction between 2003 and 2011 were reviewed. Achilles Tendon Rupture Score (ATRS), AOFAS hindfoot score, Tegner score and SF12 were recorded. Standard isokinetic assessment of ankle plantarflexion was performed with a Cybex dynamometer. Great toe flexion strength was tested clinically.Introduction
Methods
The dichotomy between surgical repair and conservative management of acute Achilles tendon ruptures has been eliminated through appropriate functional management. The orthoses used within functional management however, remains variable. Functional treatment works on the premise that the ankle/hindfoot is positioned in sufficient equinus to allow for early weight-bearing on a ‘shortened’ Achilles tendon. Our aim in this study was to test if 2 common walking orthoses achieved a satisfactory equinus position of the hindfoot. 10 sequentially treated patients with 11 Achilles tendon injuries were assigned either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus corrected vacuum brace system (EEB). Weight bearing lateral radiographs were obtained in plaster and the orthosis, which were subsequently analysed using a Carestream PACS system. The Mann-Whitney test was used to compare means.Introduction
Methods
To determine the influence of tendo achilles (TA) rupture gap distance and location on clinical outcome managed with accelerated functional rehabilitation. Twenty six patients with acute complete TA ruptures underwent ultrasound (US) within a week of injury. Measurements included the distance of the rupture from the enthesis and the gap distance between the tendon edges in three positions – foot plantigrade, maximum equinus and maximum equinus with 90o knee flexion. All patients were managed non-operatively in functional weightbearing orthoses. Nineteen patients were followed up at a mean of 6.1 years (range 5.8–6.5). Outcomes included ultrasound confirmation of healing, Achilles Tendon Rupture Score (ATRS) and Modified Lepilahti score (MLS).Aim
Methods
Injections are used to treat a wide variety of pathologies. Our aim was to evaluate the efficacy and safety of foot and ankle injections in our clinic. We performed a retrospective review of notes and a telephone questionnaire audit into the clinical outcome of all patients who underwent an injection of the foot or ankle in a year. All procedures were performed in an out-patient setting by a consultant musculoskeletal radiologist using either ultrasound or X-ray guidance, with a minimum of two year follow-up. According to the pathology treated, the type of injection included depomedrone, hyaluronic acid and high volume saline injections.Introduction
Materials and methods
Müller Weiss disease (MWD) is characterized by lateral navicular necrosis which is associated with a varus alignment of the subtalar joint, varying degrees of arthritis of the talonavicular-cuneiform joints and a paradoxical flatfoot deformity in advanced cases. Although arthrodesis of the hindfoot is commonly used, we present the results of a previously unreported method of treatment using a calcaneus osteotomy incorporating a wedge and lateral translation. Fourteen patients with MWD who were treated with a calcaneus osteotomy were retrospectively reviewed. There were seven females and seven males with an average age of 56 years (range 33–79), and included one grade 5, five grade 4, four grade 3 and four grade 2 patients. Patients had been symptomatic for an average of eleven years (range 1–14), and all underwent initial conservative treatment with an orthotic support that posted the heel into valgus. The primary indication for surgery was a limited but positive response to the use of the orthotic support, and a desire to avoid an arthrodesis of the hindfoot. Patients were followed for an average of three years following the procedure (range 1 – 7 years). Patients rated their pain on a visual analogue pain scale as an average of 8 (range 6–9) prior to surgery and an average of 2 postoperatively (range 0–4). The AOFAS scores improved from a mean of 29 (range 25 – 35) preoperatively to a mean of 79 (range 75–88) postoperatively. Hindfoot range of motion remained and the extent of arthritis of the navicular complex was unchanged. No patient has since required an arthrodesis. Since the majority of MWD patients respond to an orthotic support which changes the load of the hindfoot and forefoot, we believed that patients would respond positively to a calcaneal osteotomy as an alternative treatment.Results
To examine the mid-term survival, clinical and patient reported outcomes of the silastic 1st metatarsophalangeal joint replacement for the treatment of end stage hallux rigidus. We reviewed 83 consecutive silastic arthroplasties performed in 79 patients for end stage hallux rigidus. There were 3 men and 76 women; mean age 63 years (range 45–78 years). No patient was lost to follow up. Average follow-up was 5.3 years (1.1–11.3 years). The EQ 5D–5L Health index, Manchester-Oxford Foot Questionnaire (MOXFQ), visual analogue scale (VAS) of pain and overall satisfaction rate (Likert scale) were collected for patient reported outcomes.Aim
Methods
Patients presenting with an acute tendoachilles (TA) rupture are managed in a dedicated clinic led by a Foot & Ankle Consultant and specialist physiotherapist. The diagnosis is made clinically and no ultrasound scan is performed. All management, rehabilitation and follow-up is undertaken within this clinic by the specialist physiotherapist, with Consultant support as required. Patients are offered a choice of conservative or surgical management (percutaneous TA repair). Both groups undergo a standardised functional rehabilitation regimen. All patients treated through our dedicated clinic between May 2010 and April 2016 were identified. Patient outcomes were reported using the validated Achilles Tendon Repair Score (ATRS). ATRS scores were collected at 3, 6 and 12 months post-injury. Re-rupture and complication rates were also documented.Background
Methods
Treatment for Freiberg's disease is largely conservative. For severe disease and refractory cases, there are various surgical options. Most studies are from the Far-Eastern population and have short follow-up. The purpose of this study was to report the 5 year clinical outcomes of a dorsal closing wedge osteotomy in the treatment of advanced Freiberg´s disease in a Caucasian population. Twelve patients (12 feet), with a mean age of 30.7 years (range 17–55), were treated with a synovectomy and a dorsal closing wedge osteotomy of the affected distal metatarsal. There were 10 females and 2 males. All patients were born in the United Kingdom. Clinical outcomes were independently evaluated pre and postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and a subjective satisfaction score. Nine (75%) feet involved the 2nd metatarsal and 3 feet (25%) involved the 3rd metatarsal. According to the Smillie classification, 6 feet were Grade IV and 6 feet were grade V. Radiological union was evaluated postoperatively. No patients were lost to follow up and the mean follow-up time was 5.2 years (4–7). AOFAS scores improved from 48.1 +/− 7.4 to 88.9 +/− 10.1 postoperatively (p< 0.001) giving a mean improvement of 40.8. 92% of patients were satisfied with their operation at latest follow-up, reporting excellent or good results. All patients had postoperative radiological union. One patient had a superficial postoperative infection that was successfully treated with oral antibiotics. A dorsal closing wedge osteotomy is an effective treatment of advanced Freiberg´s disease in a Caucasian population, with good outcomes and few complications.
Active patients may benefit from surgical repair of the achilles tendon with the aim of preserving functional length and optimising push-off power. A mini-open device assisted technique has the potential to reduce wound complications, but risks nerve injury. We present the largest published series of midsubstance achilles tendon repairs using the Achillon® device. A prospective cohort study was run at the Princess Royal Devon & Exeter Hospital between 2008 and 2015. We included all patients who presented with a midsubstance Achilles tendon rupture within 2 weeks of injury, and device assisted mini-open repair was offered to a young active adult population. All patients in the conservative and surgical treatment pathway had the same functional rehabilitation protocol with a plaster for 2 weeks, and a VACOped boot in reducing equinus for a further 8 weeks.Introduction
Methods
We performed a longitudinal outcome study involving the operative management of ankle fractures at two university teaching hospitals. This was a retrospective review of the quality of reduction and a prospective study into the functional outcome. All patients undergoing open reduction internal fixation of the ankle between November 2006 and November 2007 at one centre, and January to December 2009 at the other were included. Adequacy of reduction was assessed on the initial post-operative radiographs using Pettrone's criterion. The post-operative functional outcome was recorded using the Lower Extremity Functional Scale (LEFS), completed by postal or telephone follow-up at 64 months post injury (60–74 months).Introduction
Methods
Fixation of posterior malleolar fragments associated with ankle fractures aims to stabilise the syndesmosis and prevent posterior subluxation. Haraguchi described 3 types of posterior malleolar fractures, with type 2 being a medial extension injury, these fractures often involve medial and posterior fragments. We describe the techniques and outcomes for a double window posteromedial approach allowing optimal reduction and stabilisation. A retrospective review was performed at 2 units, Bristol Royal Infirmary and QE Hospitals Birmingham, between August 2014 and April 2016. Inclusion criteria were all patients having this posteromedial approach for closed ankle fracture fixation. Patients were assessed for complications and postoperative ankle function with the Olerud and Molander scoring system.Introduction
Methods
There have been multiple techniques described to determine hindfoot alignment radiographically. The 2-dimensional nature of radiographs fails to take into account the contribution of the remainder of the foot to overall alignment. A new radiographic technique has been published in which the hindfoot alignment is calculated using the Ground Reaction Force Calcanea Offset. This technique accounts for the individual forefoot contribution to alignment, but is still limited by it´s 2-dimensional nature. The purpose of this study was to compare the hindfoot moment arm (HMA) described by Saltzman and the hindfoot alignment angle (HAA) described by Williamson, with a technique determining the ground reaction force calcaneal offset (GRF-CT) using 3-dimensional weight bearing CT Scans. The HMA, HAA, and GRF-CT 3-D weight bearing CT scans were measured by three different investigators. Each of these measurements were calculated twice on separate occasions by each investigator to determine the intra- and inter-observer reliability.Background
Methods
Platelet rich plasma has been advocated for the treatment of plantar fasciitis but there are few good quality clinical trials to support its use. We report a pilot double blind randomised controlled trial of platelet rich plasma versus normal saline. Patients with more than 6 months of MRI proven plantar fasciitis who had failed conservative management were invited to participate in this study. Patients were block randomised to either platelet rich plasma injection (intervention) or equivalent volume of normal saline (control). The techniques used for the injection and rehabilitation were standardised for both groups. The patient and independent assessor were blinded. Visual analogue scale for pain (VAS) and painDETECT were recorded pre-op and at 6 months. Twenty-eight patients (19 females, mean age 50 years) were recruited, with 14 randomised to each arm. At 6 month follow-up, 8 patients (28.6%) were lost to follow-up. There was a significant change in VAS score from baseline to follow-up in both intervention (mean change 37.2, p = 0.008) and control (mean change 42.2, p = 0.003) groups. However there was no difference between the arms in terms of the change in VAS score from baseline to follow-up (p = 0.183). There was no correlation between pre-op PainDETECT score and change in VAS.Methods
Results
We describe a case series using adjuvant calcium sulphate bio composites with antibiotics in treating infected metalwork in the foot and ankle. 11 patients aged 22–81 (9 males, 2 females) were treated with clinical evidence of infected limb metal work from previous orthopaedic surgery. Metal work removal with intra osseous application of either cerement in 8 cases (10–20ml including 175mg–350mg gentamycin) or stimulan in 3 cases (5–12ml including 1g vancomycin) into the site was performed. Supplemental systemic antibiotic therapy (oral/intravenous) was instituted based on intraoperative tissue culture and sensitivity.Aim
Method
This prospective cohort study aimed to determine if the size of the tendon gap following acute tendo Achillis rupture influences the functional outcome following non-operative treatment. All patients presenting with acute unilateral tendo Achillis rupture were considered for the study. Dynamic ultrasound examination was performed to confirm the diagnosis and measure the gap between ruptured tendon ends. Outcome was assessed using dynamometric testing of plantarflexion and the Achilles tendon rupture score (ATRS) six months after the completion of a rehabilitation programme.Aims
Patients and methods
Traditional treatment of idiopathic flatfoot in the adult population include calcaneal neck lengthening or fusions. These surgical methods result in abnormal function with significant complication rates. Our prospective study aimed to quantify the functional and radiological outcome of a new technique for spring ligament reconstruction using a hamstring graft, calcaneal osteotomy and medial head of gastrocnemius recession if appropriate. 22 feet were identified from the senior authors flatfoot reconstructions over a 3 year period (Jan 2013 to Dec 2015). 9 feet underwent a spring ligament reconstruction. The control group were 13 feet treated with standard tibialis posterior reconstruction surgery. Follow up ranged from 8 to 49 months. Functional assessment comprised VAS heath and pain scales, EQ-5D and MOXFQ scores. Radiographic analysis was performed for standardised parameters.Introduction
Methods
We aimed to retrospectively identify risk factors for delayed / non-union for first metatarsophalangeal joint fusion. Case notes and radiograph analysis was performed for operations between April 2014 and April 2016 with at least 3 months post-operative follow up. Union was defined as bridging bone across the fusion site on AP and lateral radiographic views with no movement or pain at the MTPJ on examination. If union was not certain, CT scans were performed. All patients operations were performed/supervised by one of three consultant foot surgeons. Surgery was performed through a dorsal approach using the Anchorage compression plate. Blinded pre-operative AP radiographs were analysed for the presence of a severe hallux valgus angle equal or above 40 degrees. Measurement intra-observer reliability was acceptable (95%CI:1.6–2.3 degrees). Smoking and medical conditions associated with non-union underwent univariate analysis for significance.Introduction
Methods