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Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_9 | Pages 20 - 20
16 May 2024
Bernasconi A Cooper L Lyle S Patel S Cullen N Singh D Welck M
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Introduction

Pes cavovarus is a foot deformity that can be idiopathic (I-PC) or acquired secondary to other pathology. Charcot-Marie-Tooth disease (CMT) is the most common adult cause for acquired pes cavovarus deformity (CMT-PC). The foot morphology of these distinct patient groups has not been previously investigated. The aim of this study was to assess if morphological differences exist between CMT-PC, I-PC and normal feet (controls) using weightbearing computed tomography (WBCT).

Methods

A retrospective analysis of WBCT scans performed between May 2013 and June 2017 was undertaken. WBCT scans from 17 CMT-PC, 17 I-PC and 17 healthy normally-aligned control feet (age-, side-, sex- and body mass index-matched) identified from a prospectively collected database, were analysed. Eight 2-dimensional (2D) and three 3-dimensional (3D) measurements were undertaken for each foot and mean values in the three groups were compared using one-way ANOVA with the Bonferroni correction.


The Bone & Joint Journal
Vol. 103-B, Issue 6 | Pages 1127 - 1132
1 Jun 2021
Gray J Welck M Cullen NP Singh D

Aims

To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle.

Methods

We carried out a retrospective search of our records from 2000 to 2019 of patients seen in our adult tertiary referral foot and ankle unit with a diagnosis of functional dystonia.


The Bone & Joint Journal
Vol. 101-B, Issue 3 | Pages 348 - 352
1 Mar 2019
Patel S Malhotra K Cullen NP Singh D Goldberg AJ Welck MJ

Aims

Cone beam CT allows cross-sectional imaging of the tibiofibular syndesmosis while the patient bears weight. This may facilitate more accurate and reliable investigation of injuries to, and reconstruction of, the syndesmosis but normal ranges of measurements are required first. The purpose of this study was to establish: 1) the normal reference measurements of the syndesmosis; 2) if side-to-side variations exist in syndesmotic anatomy; 3) if age affects syndesmotic anatomy; and 4) if the syndesmotic anatomy differs between male and female patients in weight-bearing cone beam CT views.

Patients and Methods

A retrospective analysis was undertaken of 50 male and 50 female patients (200 feet) aged 18 years or more, who underwent bilateral, simultaneous imaging of their lower legs while standing in an upright, weight-bearing position in a pedCAT machine between June 2013 and July 2017. At the time of imaging, the mean age of male patients was 47.1 years (18 to 72) and the mean age of female patients was 57.8 years (18 to 83). We employed a previously described technique to obtain six lengths and one angle, as well as calculating three further measurements, to provide information on the relationship between the fibula and tibia with respect to translation and rotation.


The Bone & Joint Journal
Vol. 100-B, Issue 7 | Pages 945 - 952
1 Jul 2018
Malhotra K Chan O Cullen S Welck M Goldberg AJ Cullen N Singh D

Aims

Gastrocnemius tightness predisposes to musculoskeletal pathology and may require surgical treatment. However, it is not clear what proportion of patients with foot and ankle pathology have clinically significant gastrocnemius tightness. The aim of this study was to compare the prevalence and degree of gastrocnemius tightness in a control group of patients with a group of patients with foot and ankle pathology.

Patients and Methods

This prospective, case-matched, observational study compared gastrocnemius tightness, as assessed by the lunge test, in a control group and a group with foot and ankle pathology. Gastrocnemius tightness was calculated as the difference in dorsiflexion of the ankle with the knee extended and flexed.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_21 | Pages 19 - 19
1 Dec 2017
Goldberg A Glazebrook M Daniels T de Vries G Pedersen M Younger A Singh D Blundell C Sakellariou A Baumhauer J
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Introduction

Studies have compared outcomes of first metatarsophalangeal joint (MTPJ1) implant hemiarthroplasty and arthrodesis, but there is a paucity of data on the influence of patient factors on outcomes. We evaluated data from a prospective, RCT of MTPJ1 implant hemiarthroplasty (Cartiva) and arthrodesis to determine the association between patient factors and clinical outcomes.

Methods

Patients ≥18 years with Coughlin hallux rigidus grade 2, 3, or 4 were treated with implant MTPJ1 hemiarthroplasty or arthrodesis. Pain VAS, Foot and Ankle Ability Measure (FAAM) Sports and ADL, and SF-36 PF scores were obtained preoperatively, and at 2, 6, 12, 24, 52 and 104 weeks postoperatively. Final outcomes, MTPJ1 active peak dorsiflexion, secondary procedures, radiographs and safety parameters were evaluated for 129 implant hemiarthroplasties and 47 arthrodeses. Composite primary endpoint criteria for clinical success included pain reduction ≥30%, maintenance/improvement in function, and no radiographic complications or secondary surgical intervention at 24 months. Predictor variables included: grade; gender; age; BMI; symptom duration; prior MTPJ1 surgery; preoperative hallux valgus angle, ROM, and pain. Two-sided Fisher's Exact test was used (p< 0.05).


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_14 | Pages 26 - 26
1 Dec 2015
Baumhauer J Singh D Glazebrook M Blundell C Wansbrough G de Vries G Le I Nielson D Petersen E Sakellariou A Solan M Younger A Daniels T
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Patients with advanced stage hallux rigidus from 12 centers in Canada and the UK were randomized (2:1) to treatment with a small (8/10 mm) hydrogel implant (Cartiva) or 1st MTP arthrodesis. VAS pain scale, validated outcome measures (FAAM sport scale), great toe active dorsiflexion motion, secondary procedures, radiographic assessment and safety parameters were evaluated.

236 patients were initially enrolled, 17 patients withdrew prior to randomization, 17 patients withdrew after randomization and 22 were non-randomized training patients, leaving 152 implant and 50 arthrodesis patients. Standard demographics and baseline outcomes were similar for both groups.

Mean VAS pain scores decreased from 6.8 and 6.9 respectively for the implant and arthrodesis groups from baseline to 1.4 and 0.7 at 24 months. Similarly, the FAAM sports score improved significantly from baseline levels of 37 and 36 to 24 months level of 77 and 82 respectively for the implant and arthrodesis groups. First MTP active dorsiflexion motion improved an average of 4° at 3 months after implant placement and was maintained at 24 months.

Secondary surgeries occurred in 17 (11.2%) implant patients and 6 (12.0%) arthrodesis patients. Fourteen (9.2%) implants were removed and converted to arthrodesis and 6 (12.0%) arthrodesis patients had painful hardware requiring removal. There was no case of implant fragmentation, wear, or bone loss. Analysis of a single composite endpoint utilizing the three primary study outcomes (pain, function, and safety) showed statistical equivalence between the2groups.

Conclusion

In patients requiring surgery for advanced stage hallux rigidus, treatment with a small synthetic cartilage implant resulted in comparable clinically important pain relief and functional outcomes compared to 1st MTP arthrodesis while preserving and often improving great toe motion. Secondary surgical intervention was similar in the implant and arthrodesis groups. Revision from a small implant plug to arthrodesis can be performed if needed.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_14 | Pages 22 - 22
1 Dec 2015
Chambers S Goldberg A Cullen N Singh D
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This study used the lunge test to measure the difference between ankle dorsiflexion with the knee flexed and extended in persons with and without foot and ankle pathology. This may help us devise a weight bearing test for GT.

Rationale

There is little credible research comparing GT in people with and without foot and ankle pathology. There is no normative data for ankle dorsiflexion range measured using a Lunge test and prevalence of GT in the normal population.

Methodology

97 ankles with foot and ankle (FA) pathology and 89 ankles of healthy volunteers (HV) without FA pathology were recruited from the royal national orthopaedic hospital (RNOH). Degrees of ankle dorsiflexion range were measured using an inclinometer and a version of the lunge test with the knee flexed and extended. These findings were then compared between groups.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_17 | Pages 31 - 31
1 Nov 2014
Swann A Goldberg A Cullen N Singh D
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Introduction:

Wound healing and poor bone healing are complications seen in patients who smoke and some surgeons prefer not to operate on smokers. However, self reporting of smoking by patients may be biased. This study compares self-reporting of smoking habits and cotinine levels in the urine of our patients.

Method:

77 patients admitted for an osteotomy or arthrodesis procedure between September 2013 and May 2014 agreed to participate in this study. A questionnaire was completed and a urine sample was obtained and tested for cotinine, a metabolite of nicotine, by 2 techniques: a dipstick, the COT One Step Cotinine Test, yielding a positive result when the cotinine in the urine exceeds 200 ng/mL and the Concateno laboratory assay test, providing a mean value to give a qualitative reading whereby the cut off for non-smokers is 500ng/ml.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_2 | Pages 2 - 2
1 Jan 2014
Shamsuddin M McCarthy I Singh D Goldberg A
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Aims:

With the advent of standing CT and MRI scans, there is increasing interest in establishing the role and usefulness of these investigations. When ordering a standing investigation, we assume that 100% of body weight is loaded through the limb, but most machines have handlebars for support and some have seats to allow patients the opportunity to sit. The aim of this study was to evaluate the amount of load going through the lower limbs in various positions supported and unsupported, to explore the range and variation in measurements obtained.

Methods:

Following ethics and local IRB approval, 40 healthy volunteers were asked to stand on an electronic weighing scales and be measured for height. They were then asked to stand on an identical electronic weighing scale on the PedCAT standing CT.

Their weight was measured single and double leg stance, with the hands supported and unsupported on the side bars. The subjects were then asked to sit with a single and then both legs on the scale.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_2 | Pages 3 - 3
1 Jan 2014
Singh D Goldberg A Turner A
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Introduction:

Cone Based CT (CBCT) scanning uses a point source and a planar detector with parallel data acquisition and volumetric coverage of the area of interest. The pedCAT (Curvebeam USA) scanner is marketed as a low radiation dose, compact, faster and inexpensive CT scanner that can be used to obtain both non- weightbearing and true 3 dimensional weightbearing views.

Method:

A review of the first 100 CBCT scanning in our unit has been performed to assess ease of scanning, imaging time, radiation dose and value of imaging as opposed to conventional imaging.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_21 | Pages 40 - 40
1 Apr 2013
Ferrero A Cullen N Singh D
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Introduction

Bone Marrow Oedema Syndrome (BMOS) is an unusual and poorly understood condition. It commonly affects the hips and knees and is reported to have a tendency to recur. The foot and ankle are less frequently involved but nevertheless patients can be severely impaired. Only case reports of BMOS of the foot and ankle have been published.

The aim of this study is to evaluate the sites of occurrence, risk factors, efficacy of immobilisation, response to intravenous biphosphonates and local or remote recurrence over the following years.

Methods

A retrospective review of 25 adult patients who have been diagnosed with BMOS have been followed-up for an average of 5.8 years (range: 2–11). Six patients have not been traced.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 6 - 6
1 Sep 2012
Monda M Cullen N Singh D Goldberg A
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Introduction

The Z or “scarf” osteotomy was first described by Meyer in 1926 and then by Burutaran in 1976. It was later popularised by Weil in the USA and Barouk in Europe in the 1990's and is now an accepted technique that forms part of a surgeons' armamentarium. The theory of Diffusion of Innovations was described by Rogers in 1962 to explain how novel ideas are accepted into practice across different industries, including medicine. It has never previously been used to study the adoption of ideas in foot and ankle surgery.

Methods

This paper uses publication volume as a surrogate marker for adoption, as described previously by the authors. Briefly, a systematic review of the literature was carried out. MESH headings included ‘Hallux Valgus’, and ‘osteotomy’ or ‘SCARF’ or ‘Z osteotomy’ or ‘bunionectomy’. 2818 publications were identified and the abstracts were reviewed excluding 2699 publications for non-relevance. The data was analysed by year of publication, country of origin, as well as for level of evidence.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 60 - 60
1 Sep 2012
Abbassian A Zaidi R Guha A Cullen N Singh D
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Introduction

Calcaneal osteotomy is often performed together with other procedures to correct hindfoot deformity. There are various methods of fixation ranging from staples, headed or headless screws or more recently stepped locking plates. It is not clear if one method is superior to the other. In this series we compare the outcome of various methods of fixation with particular attention to the need for subsequent hardware removal.

Patients and Methods

A retrospective review of the records of a consecutive series of patients who had a calcaneal osteotomy performed in our unit within the last 5 years was undertaken. All patients had had their osteotomy through an extended lateral approach to their calcaneous. The subsequent fixation was performed using one of three methods; a lateral plate placed through the same incision; a ‘headless’; or a ‘headed’ screw through a separate stab incision inserted through the infero-posterior heel. Records were kept of subsequent symptoms from the hardware and need for metalwork removal as well as any complications. When screws were inserted the entry point in relation to the weight-bearing surface of the calcaneous was also recorded.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 63 - 63
1 Sep 2012
Zaidi R Abbassian A Guha A Singh D Goldberg A
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Background

The recent emphasis on using “evidence based medicine” for decision-making in patient care has prompted many publishers to mention the level of evidence of articles in their journals. The “quality” of a journal may thus be reflected by the proportion of articles with high levels of evidence and assist it achieve citations and therefore an Impact Factor.

The purpose of this study was to survey published Foot and Ankle literature to evaluate changes in the level of evidence over ten years.

Methods

Articles from Foot and Ankle International, JBJS Br, JBJS Am, Foot and Foot and Ankle Surgery were used. We looked at the years 2000 and 2010 and ranked the articles by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine. 498 articles were ranked. Studies of animals, studies of cadavera, basic-science articles were excluded.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 61 - 61
1 Sep 2012
Guha A Abbassian A Zaidi S Goldberg A Singh D
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Introduction

Bone marrow oedema syndrome (BMES) of the foot and ankle is an uncommon and often misdiagnosed condition. It is usually thought to be a benign self limiting condition, without any sequelae. However, it can cause disabling pain for a prolonged period of time.

Materials and Methods

We retrospectively reviewed 8 patients with the diagnosis of BMES. There were 6 males and 2 females with an average age of 51 years (38–63 years). All patients had acute onset of severe pain in the foot without any history of trauma. None of the patients had history of excessive alcohol or steroid intake. 5 patients (63%) had bilateral involvement of migratory nature. All patients had characteristic features on MR scans, with involvement of 3 or more bones in the foot.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 37 - 37
1 Sep 2012
Guha A Zaidi S Abbassian A Cullen N Singh D
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Single stage total talectomy with tibio-calcaneal arthrodesis in adult patients has been rarely reported in the literature. In patients with severe rigid, unbraceable equinovarus deformities, talectomy can offer excellent correction.

We performed single stage total talectomy with tibiocalcaneal arthrodesis on 11 feet in 10 patients (6F; 5M) of average age 67 years (range 54–77 years). 6 patients had neuropathic deformity, 2 had failed fusion procedures and 2 had severe Rheumatoid hindfoot disease. The fusion was undertaken using a hindfoot nail and screws in 5 patients, plate and screws in 4 patients, a hindfoot nail in 1 and cancellous screws in 1 patient. All patients followed the standard post operative protocol and were reviewed at 2, 6 and 12 weeks and thereafter every 4 weekly till union. All patients were mobilised strictly non weight bearing for the first 6 weeks and thereafter, touch weight bearing was allowed with the leg in a protective cast. Full weight bearing was allowed once the fusion had consolidated.

Fusion was achieved in 7 feet (64%) at an average time of 17 weeks. In 4 patients, non-union persisted but they were pain free at latest review and would not consider further surgery. Average duration of follow-up was 20 months (range 6–24 months). All patients had stiff hindfeet with a jog of movement at the tibio navicular articulation. All patients had a stable, plantigrade, braceable foot and were community ambulators. All patients were satisfied with the outcome.

Total talectomy with tibiocalcaneal arthrodesis is a useful procedure to correct severe rigid equinovarus deformities in adults. The tibionavicular articulation forms a pseudarthrosis and retains a jog of movement. Retention of the head of the talus with talotibial arthrodesis is unnecessary. We recommend this procedure as a salvage option in this difficult problem.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXII | Pages 71 - 71
1 May 2012
Molvik H Smitham P Cullen N Singh D Goldberg A
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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.

Methods

We surveyed 90 consecutive patients in three Consultant Foot & Ankle surgeons' new outpatient clinics at our institution. Sixty patients received a copy of the letter sent to their GP (standard practice) and 30 patients received a letter in plain English addressed to the patient and a copy was sent to the GP (new practice). Patients were sent a cover letter explaining the study a copy of their clinic note and also a questionnaire that asked details about their preferred methods of communication. In addition qualitative interviews with 4 GP Partners were carried out to harbour their opinions.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXII | Pages 78 - 78
1 May 2012
Smitham P Molvik H Smith K Attard J Cullen N Singh D Goldberg A
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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.

Methods

Seventy consecutive patients receiving foot orthoses at the Royal National Orthopaedic Hospital were retrospectively asked to complete a questionnaire and to bring their shoes and orthotics to research clinic. The inside width of the shoes and corresponding width of the orthotic were measured. A semi-structured interview was carried out on 10 patients, including those that were satisfied or unsatisfied, using qualitative research methods to identify issues that are important to patients.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXII | Pages 1 - 1
1 May 2012
Singh D
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One of the complications of hallux valgus surgery is shortening of the first metatarsal and this becomes particularly symptomatic in patients with a pre existing short metatarsal (Morton's foot or Greek foot). Initial treatment consists of appropriate insoles which incorporate not only relief of pain due to pressure metatarsalgia under the lesser metatarsal heads but also a Morton type extension under the big toe. Insoles with metatarsal relief are, however, not always well tolerated and surgery becomes necessary. The options are to shorten the lesser metatarsal heads or lengthen the previously shortened first metatarsal. Arthrodesis of the great toe metatarso-phalangeal joint can provide functional length to the first metatarsal.

We have achieved good results in lengthening of the first metatarsal and believe that it is a safe option which avoids trauma to the lesser metatarso-phalangeal joints. The technique is presented and depends on whether there is a residual hallux valgus or whether the toe is well aligned. The operation should address the plane of the deformity and reverse the cause of the lengthening.

Emphasis should however be placed in not getting the complication in the first instance and the incidence of the problematic short first metatarsal has significantly reduced since the decrease in popularity of the Wilson osteotomy.


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 12 | Pages 1583 - 1586
1 Dec 2009
Singh D Dudkiewicz I

Metatarsalgia is a recognised complication following iatrogenic shortening of the first metatarsal in the management of hallux valgus. The traditional surgical treatment is by shortening osteotomies of the lesser metatarsals.

We describe the results of lengthening of iatrogenic first brachymetatarsia in 16 females. A Scarf-type osteotomy was used in the first four cases and a step-cut of equal thicknesses along the axis of the first metatarsal was performed in the others.

The mean follow-up was 21 months (19 to 26). Relief of metatarsalgia was obtained in the six patients in whom 10 mm of lengthening had been achieved, compared to only 50% relief in those where less than 8 mm of lengthening had been gained.

One-stage step-cut lengthening osteotomy of the first metatarsal may be preferable to shortening osteotomies of the lesser metatarsals in the treatment of metatarsalgia following surgical shortening of the first metatarsal.