Background

The internet has revolutionized the way we live our lives. Over 60% of people nationally now have access to the internet. Healthcare is not immune to this phenomenon. We aimed to assess level of access to the internet within our practice population and gauge the level of internet use by these patients and ascertain what characteristics define these individuals.

Method

A questionnaire was given to delegates at the British Orthopaedic Foot & Ankle Society (BOFAS) annual scientific meeting 3rd–5th November 2010. A total of 75 questionnaires were included within the analysis. The questionnaire asked delegates for their most commonly performed procedure for a variety of common foot and ankle conditions.

Residual club foot (CTEV) is a challenging deformity which may require transfer of the tibialis anterior tendon to a more lateral position. The senior author has developed a modified SPLATT for residual forefoot supination in CTEV.

We describe the SPLATT procedure and evaluate clinical and radiological outcomes of 11 patients(14 feet) (mean follow up 6.6 years; range 5.5–8.9) (mean age 6.9 years; range 2.9–10.0). Two patients had cerebral palsy, 1 spina bifida and 1 juvenile rheumatoid arthritis, the remaining 7 patients were ideopathic.

Outcome measures based on patient centred assessment of function and foot appearance, by using the patient applied assessments of Chesney, Utukuri and Laaveg & Ponsetti (there is increasing recognition that doctor-centred or radiograph-based scoring systems do not tally well with patient satisfaction).

Objective assessment of outcome was provided by measurement of certain radiological parameters on the immediate pre-operative and the follow up weight-bearing radiographs (1st ray angle, talar-1st metatarsal angle, talar-2nd metatarsal angle, talo-calcaneal angle). The calcaneal line passing through the medial 1/3 of the cuboid or medial to the fourth metatarsal was also noted. The Blecks grade was recorded (pre-op 100% moderate-severe; post-op 88% mild-moderate). Parents assessed outcome based upon ‘best level of activity’, functional limitation and willingness to recommend treatment to others.

Mean Chesney score at the time of follow up was 12.3 (8 to 15); mean Utukuri score was 15.8 (10 to 24); Laaveg and Ponsetti score was 81.5 (67 to 95). The best activity level achievable was ‘unlimited’ in 4 patients, ‘football’ in 4 patients, ‘running’ in 1 and limited by an associated condition in 2 patients (1 juvenile rheumatoid arthritis; 1 cerebral palsy related spastic paraparesis). All patients/parents indicated that they would undergo the same procedure again. One patient had delayed wound healing treated successfully with dressings.

The 1st ray angle pre-operatively was 61.2°(range 50–70°), post-operatively it was 62.1°(range 50–81°). The talar-1st metatarsal angle was 28.8°(range 15–44°) pre-operatively and 19.1°(range 4–34°) post-operatively. The pre and post–operative talar-2nd metatarsal angles were 22.5°(range 0–35°) and 12.3(range 0–29°) respectively, the talo-calcaneal angle was 17.5°(range 10–35°) and 13.7(range 5–20°) respectively. The pre and postoperative lateral talo-calcaneal angles were 34.5°(range 25–40°) and 30.6(range 13–45°).

The recognition that patient orientated subjective assessment is gaining in acceptance, and confirm patient satisfaction with function, cosmesis and pain levels with the SPLATT procedure. More traditional radiological outcome measures also confirm that the modified SPLATT is a safe, effective and acceptable procedure.

Metatarsus adductus (MA) is associated with a medially facing distal facet of the medial cuneiform (with a normal first metatarsal) and varus/adducted deformities of the metaphysis of the lesser metatarsals. A number of patients with severe symptomatic metatarsus adductus do not improve with time. A number of surgical techniques have been described but the series are small and use radiological rather functional outcomes. It is clear however that the failure and complication rate with these procedures is high. A combined medial cuneiform and lesser metatarsal basal closing wedge osteotomy has potential advantages over more commonly used procedures (including the combined cuneiform-calcaneal) osteotomy, by correcting at the level of deformity.

We reviewed a consecutive series of 15 cases (11 severe idiopathic metatarsus adductus, 4 with history of clubfoot) (all Bleck’s grade severe) treated with combined cuneiform-metatarsal osteotomies. Patients were followed up for a mean of 30 months using child-, parent and clinician-based outcome measures as well as radiological assessment. Outcomes are also compared to currently used and historical procedures.

Bleck’s grade improved to 65% normal 35% mild post op; Radiographic improvements (all p< 0.001); 1stray angle 30°→62°, 1stMT-Talar angle 43°→9°, 2ndMT-Talar angle 41°→8°, 2ndMT-Calcaneal angle 48°→14°, 5thMT-Calcaneal angle improved from 13°→3°. Mean postop scores; Chesney - 14 (12–15); Utukari – 13 (10–18); Laaweg – 93 (81–100); Vitale – 13 (10–14). None of the radiographic scores correlated with the clinical scores. All children gained improved levels of activity.

Our findings indicate that this technique can be used effectively in children > 4 years and is a safe alternative to historical procedures, with excellent radiographic/ clinical outcomes, and a low complication rate.

Horse riding is a popular competitive sport and leisure pursuit worldwide. Previous research has highlighted the unpredictable and independent nature of horses and high injury risk inherent in travelling at speeds of up to 65kph, 3-metres above the ground on an animal weighing between 450–500kg. In Ireland, jockeys register with the Turf Club as either professional or amateur with the remaining riders participating as unregistered.

The aim of this study is to determine the national incidence of acute spinal cord injury (ASCI) and vertebral body injury (VBI) in horse riding in the Republic of Ireland, and to compare and contrast injury characteristics in registered and unregistered riders over an 11-year period (1995–2005).

Chart review and structured telephone interview was performed in all cases to determine mechanism of injury, discipline, protective equipment, immediate management and whether the rider considered the injury could be prevented. American Spinal Injuries Association (ASIA) impairment score was used to classify outcome. Data for injuries sustained in competitive racing, for both registered and unregistered riders, was correlated with Irish Turf Club race records to ensure accuracy.

Results: Sixteen cases of ASCI and 46 of VBI were identified over the study period (Table 1). Over the study period, there was a mean annual incidence of 1.5 (1 to 4) ASCI and 4 VBI (0 to 7). Cervical injuries were significantly more likely to result in ASCI (n=14 (52%), p=0.004) than either thoracic or lumbar injuries. Riders who had an ASCI spent more days in hospital (p=0.007); were less likely to have had a previous riding injury (p= 0.046); and following injury, less likely to return to horse riding at any level (p= 0.033). Seven ASCI (44%) and ten VBI (22%) patients were managed operatively. Three ASCI (19%) and 4 VBI (9%) occurred in registered riders. A fall in flight jumping was the commonest injury pattern (32%) overall, with 60% of ASCI and 26% of VBI by this mechanism occurring in registered riders. Overall, only 19% of riders report wearing a back protector at the time of injury. Of these, 30% sustained cervical injury, 17% thoracic injury and 0% lumbar injury. For ASCI riders, final ASIA impairment classification was A= 4, B= 2, D= 4 and E= 5.

Conclusion: Equestrian sports, both for registered and unregistered riders pose substantial risk. Despite greater compliance with wearing of protective equipment, registered riders are at increased risk of sustaining ASCI than unregistered risers. Morbidity is significant following ASCI, with ten riders permanently disabled as a direct result of participation.

Introduction: Many surgeons recommend surgical resection of symptomatic tarsal coalition. The success of this procedure in reducing symptoms has been well described in the literature, but long term results remain scarce. In 1967 Mitchell et al described a series of 41 resections of calcaneonavicular coalition with an average 6 year follow up. In 1990 Gonzalez et al described two groups who underwent a total of 75 resections of calcaneonavicular coalition by multiple surgeons. We describe the largest combined series of calcaneonavicular and talocalcaneal coalition resection with a minimum follow up of 3 years and a maximum of 12 years (average 9.5 years).

Methods: We retrospectively studied the clinical results of a consecutive series of 79 primary resections for tarsal coalition in 63 patients carried out by the senior author over a 12 year period. A standard resection procedure was performed in each case. Duration of symptoms, side of maximal symptoms, activity level, family history, peroneal spasm, and patient weight preoperatively was recorded retrospectively using medical records. Visual analogue pain scores, analgesia requirement, activity level, time to return to maximum activity, occupation, patient and parent satisfaction level, peroneal spasm, range of motion, AOFAS ankle-hindfoot score, and patient body mass index was recorded at follow up.

Results: At follow up the majority of patients had mild or no pain and did not require regular analgesia, had some limitation of recreational activities but not of daily activities, and had some stiffness. The majority of patients and parents were satisfied with the outcome.

Discussion: Resection of tarsal coalition is recommended when symptomatic but also is recommended bilaterally when present regardless of symptomatology of the lesser affected foot.

Introduction: A retrospective evaluation of early results of arthroereisis.

Material and Methods: Eight feet in five patients with pathological flexible planovalgus deformity that had failed non-operative management were treated with subtalar arthroereisis using the Kalix prosthesis. Diagnosis include oblique talus (2), vertical talus (1), diplegia secondary to head injury (1) and type I neurofibromatosis (1). The average age of patients was 6.4 years (range 4–12), and average follow-up was 9.9 months(range 4–20). Outcome was assessed using clinical assessment of the foot axis and functional improvement and radiographic measurements of change in the talocalcaneal angle and talonavicular sag.

Results: Arthroereisis was never performed in isolation, additional procedure included achilles tendon lengthening (2), gastrocnemius recession (6), talonavivular and spring ligament plication (5) and split tibialis anterior tendon transfer (1). All patients had improvement of foot function and restoration of foot axis to a position parallel to the axis of progression. Restoration and maintenance of the talocalcaneal angle was excellent in all cases with preoperative average of 42 degrees (range 20–70), improved to a postoperative average of 23 (range, 0 – 40). Talonavicular sag improved from preoperative average of 16.5 degrees (range 0–32), to post operative average of 26 degrees (range 18–35). Complications include persistent first ray extension which required a Lapidus procedure (1), Ongoing minor discomfort (1). No patients or parents were dissatisfied.

Discussion: The preliminary report supports the use of this technique in selected cases. Sizing of the implant and intraoperative assessment of correction of deformity and balanced surgery are critical to success. It is a simple and rapid procedure with advantages over alternatives such as Osteotomy and fusion. Long term results need further evaluation.

This study reviewed the subjective, clinical, and radiological outcome of 24 patients (31 feet) treated by basal metatarsal osteotomy with a modified McBride procedure for severe (intermetatarsal angle > 150) hallux valgus, carried out at our institution with an average follow-up time of 29 months.

At the time of follow-up, 40% of the patients were very satisfied, 45% were satisfied, and 15% were not satisfied. The mean Hallux – Metatarsophalangeal – Interphalangeal scale score raised significantly from 39 points (17 – 64) pre-operatively, to 82 (39 – 96) points at follow-up (p < 0.001). The Lesser - Metatarsophalangeal – Interphalangeal scale score raised significantly from 46 points (26 – 69) pre-operatively, to 84 (33 – 97) points at follow-up (p < 0.001). The radiological angles, including M1-M2, M1-P1, M1-M5, and DMAA improved significantly (p < 0.001). 12 of these cases had a M1-M2 angle post correction > 15°. Among the 9 complications recorded, 7 were minor and 2 required an additional procedure.

The basal metatarsal osteotomy coupled with a modified McBride procedure resulted in an overall high satisfaction rate, as well as significant clinical and radiological improvements in our series. Nevertheless, the range of motion of the first MTP joint remained low: 30 – 75° in 67% and < 30° in 6%. Furthermore, the failure to correct the M1-M2 angle to < 15° in 12 cases was probably due to the severe nature of the M1-M2 angle in these patients pre-operatively (21–33°).

Basal metatarsal osteotomy with a modified McBride procedure remains a safe procedure with excellent results, both subjectively and objectively, in patients with severe hallux valgus

Aim: The literature suggests that the incidence of osteomyelitis in the paediatric population has changed. We undertook to examine changes in incidence, causative organisms and treatment regimes over a 13 year period.

Methods: Patients admitted with a diagnosis of osteomyelitis between January 1991 and January 2004 were identified from hospital records and data collected from their medical and laboratory records.

Results: A total of 362 patients were admitted over the study period with a mean age of 5.9 years. A significant decrease in the number of patients presenting over the study period with osteomyelitis was noted, from a peak of 77 cases in 1991 to 12 cases in 2003 (p< 0.05). There was no significant difference in patient age or length of hospital stay over the study period. The majority of cases involved the lower appendicular skeleton with Staphylcoccus Aureus being the commonest organism cultured (accounting for 60% of positive cultures). All cases were initially treated empirically with intravenous Flucloxicillin and oral Fusidic acid. Surgical debridement/decompression was required in 11% of cases.

Conclusion: Osteomyelitis now appears to be a rare condition in children with a marked decrease in the incidence being noted over the study period. This correlates with the introduction of the Haemophilus Influenzae B vaccination in Ireland and may partly explain the decrease in incidence. The majority of cases settled on a course of non-operative management.

Introduction: This retrospective study examined the clinical characteristics, radiological findings, management, and functional outcome in 34 rehabilitated patients who presented with traumatic central cord syndrome.

Methods: Between 1994 and 2004 a total of 34 patients with central cord syndrome were admitted to the National Spinal Injuries Unit. There were 29 men and 5 women. The mean age was 56.1 years (15 to 88). The mean follow up time was 4.9 years. Patients were divided into three groups by age, < 50 years (10 patients), 50–70 years (16 patients), and > 70 years (8 patients). The American Spinal Injury Association (ASIA) system recorded the motor and sensory scores, of upper and lower limbs, on admission, discharge and during rehabilitation. Patients underwent radiological investigation that included plain film, CT, and MRI of the cervical spine.

Results: The mechanism of injury was a fall in 58.8%, road traffic accident in 35.2% and other in 6%. Alcohol was a contributing factor in 32.4% of cases. Seven patients had a spinal fracture. The cervical spine was involved in 5 cases with the remaining 2 cases involving the thoracic spine. Seventy percent of patients received intravenous steroids. Over half (53%) of the patients had some degree of cervical spondylosis while cord changes were seen in almost all of the patients (79.4%). In the majority of cases (70.4%) the affected level was C3/4. Disc herniation was present in one third of cases (33.2%). The mean upper limb ASIA score on admission was 7.6, on discharge was 12.4 and at follow up was 20.2. A similar pattern was also observed in the lower limb with scores of 12.1, 13.7, and 20.5 respectively. Sensory loss also improved with time. 88.2% of those admitted required urinary catheterization, with 23.5% being discharged to the National Rehabilitation Hospital with a catheter in situ. Surgical decompression was performed in 7 cases. The remainder of patients wore a Miami-J cervical collar.

Conclusion: As was shown in the original paper by Schneider et al (1954), hyperextension of a degenerative cervical spine was the predominant mechanism of injury. The return of lower limb function precedes that of upper limb, with autonomic function recovering in the majority of cases.

Discussion: In this study patients in the younger age groups had better recovery of function and had fewer complications. The original paper by Schneider et al. stated that conservative treatment was most appropriate, however, in this review surgery was performed in specific cases such as those with cord compression secondary to disc herniation. Alcohol was a significant contributing factor.

Introduction: Recent data from the UK suggests that the incidence of osteomyelitis in the paediatric population is declining. However, the incidence in the Scandic countries has risen in the late eighties and nineties. We undertook to examine the epidemiology of osteomyelitis presenting to a paediatric teaching hospital in an Irish urban setting.

Patients and Methods: We undertook a retrospective review to identify patients admitted over a twenty-five year period with a diagnosis of osteomyelitis. Patients were identified from hospital records, theatre log-books and a departmental database. Demographic data was collected, as were details of the infected bony structure, treatment required and organism cultured.

Results: A total of 291 patients were admitted over a twenty-four year period, from 1977 to 2000.

A marked reduction in osteomyelitis was noted over the twenty-four year incidence of the study. In addition, a shift in the causative organism was noted from an incidence of H Influenzae in the 70’s of up to 30%, to less than 5% in the 90’s. The treatment regime changed markedly over the course of the study period, with a significantly reduced duration of hospital stay reflecting the move away from protracted periods of hospitalisation.

Conclusion: A marked fall in osteomyelitis has occurred in the paediatric population. This may be due to improved living conditions and the introduction of H Influenzae vaccinations. The duration of hospital stay has declined markedly and the introduction of newer imaging modalities has aided diagnosis, allowing early aggressive intervention. However, as osteomyelitis is becoming increasingly rare, a higher index of suspicion is required, particularly from non-specialists who are more likely to be the first to encounter these patients.

Introduction and Aims: Despite being a relatively common condition in childhood, there is little information in the world literature documenting the foot deformities seen in the Hereditary Motor and Sensory Neuropathies (HMSN). The aim of this paper was to thoroughly investigate the foot deformities seen in children with HMSN.

Method: We reviewed 104 feet from 52 children with HMSN seen for the first time in clinics at the Central Remedial Clinic, Dublin and The Children’s Hospital at Westmead, Sydney between January 1996 and June 2003. All patients were reviewed by a consultant neurologist and orthopaedic surgeon. The data we collected included: HMSN type, sex, age at first presentation, type of foot deformity, bilaterality of deformity, symmetricality of deformity, whether surgery had been required, age at surgery and the details of the surgery performed. We divided surgery types into soft tissue procedures alone and combined soft tissue and bony procedures.

Results: Sixty-nine feet had a cavovarus deformity, 23 feet had a planovalgus deformity and 12 feet had no significant deformity. All cases with deformity had bilateral involvement, and of those with deformity, only 45% had symmetrical involvement. In HMSN I, III, IV, V and X linked HMSN, cavovarus was the most common deformity. However, in HMSN II, 55% of feet had a planovalgus deformity, 36% had a cavovarus deformity and 9% no deformity. Forty-three feet required surgery of some type. Thirty-four feet with a cavovarus deformity had surgery, 17 required soft tissue surgery and 17 combined bony and soft tissue surgery. Nine feet with a planovalgus deformity had surgery, seven required soft tissue surgery alone, and two had combined surgery.

Conclusion: Cavovarus is the most common foot deformity seen in patients with HMSN. However, a planovalgus deformity is not uncommon, and in HMSN II, planovalgus is seen more frequently than cavovarus. Surgical intervention was required in just under half of the feet with deformity. Surgery, and in particularly combined soft tissue and bony surgery, is required more often to treat feet with a cavovarus deformity than with a planovalgus deformity.

Aim When first metatarsophalangeal (MTP) joint fusion is performed in the presence of a high first intermeta-tarsal angle (IMA), an important question to arise is whether the first metatarsal varus will correct with MTP fusion alone or whether an additional basal osteotomy is necessary. We compared the pre-operative IMAs to the post-operative angles to answer this question.

Method Twenty patients had a first MTP fusion for severe hallux valgus deformity performed by the senior author over a 2-year period. All were female. Mean age was 54.2 years (range 42–78). Seven patients had rheumatoid arthritis. Their IMAs were retrospectively measured on weight bearing X-rays taken pre-operatively and 6 weeks post-operatively. They were recalled for an additional measurement at a mean of 13.72 months (range 6–30).

Results Pre-operatively the mean hallux valgus angle was 46.55 degrees and the mean IMA was 16.65 degrees (range 12–26). The mean 6 week post-operative IMA was 10.35 degrees (range 6–15) with a mean improvement of 6.3 degrees (range 0–12). The mean IMA at final follow-up was 8.67 degrees (range 5–12). The mean final improvement was 8.22 degrees (range 4–14). In eight patients with a pre-operative IMA of 15 degrees or less the mean improvement was 6.13 degrees. In 10 patients with an pre-operative IMA of 16 degrees or more, the mean improvement was 9.9 degrees.

Significance First MTP joint fusion in hallux valgus deformity permanently reduces the IMA. As the pre-operative IMA increases from moderate to severe, there is a significant increase in post-operative correction. An additional basal osteotomy is not indicated.

Plantar faciitis is a repetitive microtrauma overload injury of the attachment of the plantar fascia at the inferior aspect of the valvaneus. Several aetiological factors have been implicated in the development of plantar faciitis, however the role of hamstring tightness has not previously been assessed.

Materials and Methods: 15 volunteers (mean age 25 years) were prospectively analysed for the difference in forefoot loading using a don-Joy brace applied to each knee simultaneously. The brace was locked at varying degrees of knee flexion (0°, 20°, 40°). Body weight was measured for each volunteer. 15 patients (mean age 41 years) with a diagnosis of plantar faciitis were similarly analysed on the pedobarograph, however they also had their hamstring tightness assessed by means of measuring the popliteal angle. The mean popliteal angle measured was 28.5°. 15 age and sex matched controls (mean age 42 years) then had their hamstring tightness assessed. The mean popliteal angle was 12.5°.

Increasing the angle of flexion from 0–20° at the knee joint led to statistically significant increase in pressure in the forefoot phase by an average of 0.08K/cm2s (p, 0.05,t-test). An increase from 20 – 40° led to increased forefoot phase pressure of 0.15 kg/cm2s (p0.05, t-test). The percentage time spent in contact phase reduced from 30 to 26.5 to 16 with increasing flexion (P< 0.05). However there was an inverse increase in the time spent in the forefoot phase 51–58–69 with increasing degrees of flexion (P< 0.05). Thus the authors feel that an increase in hamstring tightness may induce prolonged fore foot loading.

Spinal injuries are among the most devastating injuries related to recreational sport. There are few studies specifically on spinal injuries in horseback riding. The purpose of our study was to determine the factors contributing to horse-riding accidents and to assess the usefulness of wearing protectors while horse riding.

All patients with spinal injuries admitted to our unit over a six-year period (1993–1998) were reviewed. Of 957 patients admitted to the National Spinal Injuries Unit from 1993–1998, 25 patients incurred spinal injury while horse riding. Age, sex, occupation and injury details were collected for all patients. All 25 patients were also contacted retrospectively to collect further details in relation to the specifics of the horse-riding event.

There were 16 male and 9 female patients with a mean age of 35 years (range 17–61). There were nine cervical fractures/dislocations, eleven thoracic fractures, and eight lumbar fractures. Four patient sustained injuries at more than one level. In relation to spinal cord injury, two patients had complete neurological deficit, a further ten had incomplete lesions. Thirteen patients had no neurological deficit. Surgical intervention was required in eleven patients.

Only six riders, all of who were either jockeys or horse trainers, wore back protectors. Of the 19 patients without a back protector there were 5 cervical, 10 thoracic and 6 lumbar injuries. Two patients sustained injuries at more than one level. However, of the six riders wearing a protective jacket there was a completely different fracture pattern level with 4 cervical injuries, only one thoracic injury and on e lumber injury.

The variation in injury level between the group wearing protective back supports and those without is noteworthy. While the numbers are too small to draw a significant conclusion it would appear that there is a trend for riders wearing a back protector to suffer less thoracic and lumbar injuries relative to cervical injuries.

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is the gold standard treatment of a wide range of pathologies involving the 1st MTPJ. Numerous methods of internal fixation and bone end preparation have been reported to perform this procedure, however there is no universal technique. Therefore in an effort to bring together the best features of the different surgical techniques, a low profile contoured titanium plate (Hallu-S plate), with a compression screw, with a ball and socket bone end preparation were designed. A prospective study was carried out to determine the efficacy of using the Hallu-S plate for 1st MTPJ arthrodesis.

1st MTPJ arthrodesis, using the Hallu-S plate, was carried out in 11 consecutive patients. The procedure was performed in isolation and with other forefoot procedures. Cast immobilization was not used in patients with an isolated 1st MTPJ arthrodesis and the patients were allowed to mobilize (heel walking – full weight bearing) between 2 and 6 weeks postoperatively. The changes in the level of pain and activities of daily living using the AOFAS Hallux score, pre-operatively and at the last assessment, and the time to bone union were assessed.

The mean follow-up time was 10 months (STD 6 months) and there was statistically significant increase in the AOFAS Hallux score. All radiographs at 6 weeks showed bone union and an appropriate degree of dorsiflexion in relation to 1st metatarsal (20–25). The combination of the Hallu-S plate and a ball and socket preparation has both operative and biomechanical advantages over previously described techniques. This combination ensures the biomechanics of the 1st ray are maintained and a better functional result is achieved.

The surgical treatment of chronic Achilles tendon ruptures is essential to restore the normal gait pattern. There are a variety of surgical techniques described, including primary repair, augmentation with tendon transfers, augmentation with aponeurosis flaps and bridging techniques. In recent times augmentation with tendon transfers or aponeurosis flaps are the most commonly performed procedures. Our study examined the biomechanical effect of using the flexor hallicus longus in an augmented chronic Achilles tendon repair on gait pattern and forefoot loading distribution using pedobaragraphical analysis.

We, pedobarographically examined the gait patterns of 10 patients who had undergone augmented chronic Achilles tendon repair using the flexor hallicus longus tendon. The mean age at the time of injury was 59 years of age (range 46–70). The mean follow-up time was 38 months. All patients reported good to excellent results. The mean AOFAS ankle score was 96.25 (range 90–100). There was no statistically significant difference between the loading distributions of the operated foot relative to the contralateral side.

While there is no comparative study examining the outcomes of the varying surgical techniques for chronic Achilles tendon repair, the use of the flexor hallicus longus tendon in augmented chronic Achilles tendon repair has been proven as an effective repair to restore normal function while not compromising the biomechanics of the 1st ray or the loading distribution of the forefoot.

Apert’s syndrome (or acrocephalosyndactyly type 1) is a rare condition characterized by anomalies of the skull (craniosynostosis) in conjunction with complex syndactyly of the hands and feet. There are many studies involving the description and management of hand deformities in Apert’s syndrome. The study of foot anomalies however in children with Apert’s syndrome has been limited to individual case reports and small series. Plain radiographic studies have shown that during childhood, progressive fusion of the bones of the feet occurs. The management of these children’s feet has never been addressed in the literature.

Seven patients with Apert’s syndrome were included in our study. The study group consisted of 2 girls and 5 boys, age range 4–16 years. We performed plain radiography, 3-D computed tomography and paedobarographic studies on all seven children based on our observation that some children with Apert’s had prominent metatarsal heads with symptomatic callosities under the first and second metatarsal heads. Five of the seven children studied demonstrated a specific pattern both on paedobarographic studies and 3D computed tomography of an excessively plantar flexed, fused first and second rays.

A corrective extension osteotomy of the fused first and second rays were then carried out in one patient with an excellent post-operative result. We propose that by early recognition and correction of the pattern of an excessively plantar flexed first and second ray would improve both function and footwear.

There are numerous ankle and hindfoot scores in existence, which have been devised and used to assess surgical interventions. All have in common that there has been little or no work done to demonstrate their validity, reliability or sensitivity to change. Which score one chooses to use for the assessment of outcome will at present depend largely on personal preference.

We have undertaken a study to assess four of the most commonly used scores, those of Mazur (1978), Takakura (1990), AOFAS (1994) and Kofoed (1995) as well as a little used but well designed score, The Foot Function Index (1991).

A cohort of twenty patients who had undergone a unilateral total ankle replacement (STAR) for rheumatoid or osteoarthritis were assessed by a single observer. The time following operation ranged from six to 48 months. All completed the above scores as well as a SF36 questionnaire. Using the SF36 as a “Gold standard” the scores were compared, both in terms of their overall results and also more specifically in terms of subsections such as pain and function.

Our results, though not to be interpreted as validation, do give some rational basis for the choice of score to use in assessing total ankle replacements.

Background The non-motorised microscooter has become the urban transport of choice for children in Ireland. Recently, Josefson highlighted the rising trend of scooter-related injury in the US and predicted possible significant impacts in human and socioeconomic terms.

Materials and Methods. A prospective study was undertaken of all referrals with scooter injuries to accident and emergency departments and fracture clinics in the first three months of the year. These cases were then reviewed at 6 months post injury

Results: There were 151 microscooter injuries seen in the first 3 months of the year, Forming over 4% of all trauma seen over this period. Eighty nine of the patients (59%) were female, and the mean age at presentation was 8.5 years (range 3–15 years). The peak referral rates for January, February and March measured 48%, 29% and 23% respectively. A survey of attending paediatric outpatients over this period revealed that 75% of households possessed at least 1 scooter, and in those households with children aged between 4 and 14 years, the rate of micoscooter possession increased to 83%. Eighty four children suffered fractures and dislocations, 59 suffered soft tissue injuries, 8 had isolated head injuries. Upper limb fractures and dislocations were the most common injury (75 of 84 bone and joint injuries). Fracture of distal third of radius and ulna, was the most common single injury. upper limb fractures wer seen frequently. A high proportion of these had apex dorsal angulation with or without displacement (Smith deformity). Lower limb fractures were relatively rare. The pattern of soft tissue injuries and lacerations mostly affected the head and neck 25 (17%), the lower limb was involved in 19 (13%) and upper limb in 15 (10%) of patients. No major head injuries occurred. Only 5 patients had any adult supervision at the time of their injury. No children wore any formal protective clothing or apparatus. In the 84 patients who had suffered bony injury, at 6 months, 110 patients (73%) had

The long term outcome of open debridement for the treatment of anterior impingement in the ankle in 27 patients was assessed. Using pre-operative radiographs, patients were grouped according to both the McDermott and the van Dijk scoring systems for anterior impingement. The accuracy of these classifications in predicting outcome was assessed. Clinical outcome was evaluated using the Ogilvie-Harris scoring system, a visual analogue of patient satisfaction, time to return to full activities, and the ability to return to sports at the pre-morbid level. Follow-up radiographs were used to assess the recurrence of osteophytes. The incidence of talar osteochondral lesions at surgery was assessed.

At a mean follow-up of 7.3 years, 23 of 25 (92%) patients without joint space narrowing had a good or excellent result. Improvement in the Oglivie-Harris score was seen in all patients. In athletes, 19 of 24 (79%) were able to return to sports at the pre-morbid level. Two patients with pre-operative joint space narrowing had poor results.

Recurrence of osteophytes was the norm and most patients did not feel their range of dorsiflexion ever returned to normal, but symptomatic relief enabled most patients to return to high level sport.

Our results for non-arthritic joints suggest that this is a safe and successful procedure.

Biomechanical foot orthoses (or foot wedges) are commonly used in clinical practice. The aim of this study was to investigate the effect of foot wedges on plantar pressure during normal gait.

Thirty normal adult subjects (11 men, 19 women; mean age = 25.2 years, range = 18–36 years) walked along a floor-mounted wooden walkway incorporating the Musgrave™ pressure plate under six testing conditions : (1) barefoot; (2) tubigrip stocking; (3) tubigrip stocking and medial forefoot wedge; (4) tubigrip stocking and lateral forefoot wedge; (5) tubigrip stocking and medial heel wedge; and (6) tubigrip stocking and lateral heel wedge. Pelite™ foot wedges were placed underfoot inside the tubigrip stocking.

Recorded footprints were divided into four quadrants (anteromedial (AMQ), anterolateral (ALQ), posteromedial (PMQ), and posterolateral (PLQ)). Statistical analysis of quadrant plantar pressures, anterior-posterior plantar pressure ratios, medial-lateral plantar pressure ratios and mean centre of pressure to mid-axis distances was performed using the paired t-test.

Forefoot wedges caused earlier forefoot loading (p< 0.05). They increased anterior-posterior plantar pressure distribution (p< 0.001): medial wedges increased AMQ plantar pressure (p< 0.001) and decreased PLQ plantar pressure (p< 0.01); lateral wedges increased ALQ plantar pressure (p< 0.001) and decreased PLQ plantar pressure (p< 0.01).

Heel wedges delayed forefoot loading (p< 0.02). They decreased anterior-posterior plantar pressure distribution (p< 0.05): medial wedges decreased ALQ plantar pressure (p< 0.01); lateral wedges decreased ALQ plantar pressure (p< 0.01) and increased PLQ plantar pressure (p< 0.001).

Foot wedges did not significantly affect medial-lateral plantar pressure distribution.

We conclude that foot wedges do affect plantar pressure in those with normal feet and normal gait. Foot wedges affected anteroposterior plantar pressure distribution but did not affect mediolateral plantar pressure distribution.

Abstract: The early stages of ankle arthroplasty were complicated by unsatisfactory surgical results and poor patient satisfaction. This paper reveals far greater patient satisfaction and excellent surgical results achieved from the STAR uncemented ankle replacement.

Materials and Methods: We reviewed the first 29 STAR ankle replacements carried out by the senior author. Patients were reviewed clinically and radiographically according to the AAOS hind-foot score. Failure was deemed to be revision of the implant. Reason for surgery was rheumatoid arthritis in twelve patients and primary or secondary osteoarthritis in seventeen patients.

Results: One patient required revision surgery. This was an osteopoenic rheumatoid patient and the revision was for component subsidence. Three patients from the initial stages required minor soft tissue and bony resection at a second procedure with retention of the prosthesis. Patient satisfaction was high. Clinically, the average ROM was 5deg dorsiflexion and 12 deg plantarflexion. Patient satisfaction was extremely high. While the AAOS score does not give a grading, we also applied the Kofoed scale and 28 of our patients achieved a good or excellent result.

Conclusion: We conclude that the STAR uncemented ankle replacement achieves very good clinical results and excellent patient satisfaction.

The intermetatarsal angle is widely used to determine whether a basal or distal metatarsal osteotomy should be used to correct a hallux valgus deformity. We have noticed that the point of intersection of the long axes of the first and second metatarsals on standard pre-operative weight-bearing AP radiographs consistently predicts the type of osteotomy required.

A basal osteotomy is generally recommended if the inter-metatarsal angle is ≥14°, whereas a distal osteotomy is usually sufficient if the angle is less than 14°.

Sixty standardised pre-operative AP weight bearing in-patients undergoing hallux valgus correction were included in our study. The intermetatarsal angle was measured in a standard fashion. The point of intersection in the foot was recorded in terms of the distance from the talonavicular joint.

Using a Pearson’s Correlation coefficient, our study revealed that an intermetatarsal angle of 14° or more consistently intersected either within the talar head or distal to thetalonavicular joint. We propose that this as an accurate and simple method of pre-operatively determining the choice of metatarsal osteotomy.

Flat foot due to rupture of the tibialis posterior tendon has not previously been described in children. We present three young patients who developed unilateral pes planus after old undiagnosed lacerations of the tendon. Transfer of the flexor hallucis longus to the distal stump of the tibialis posterior tendon achieved good results in all three cases.

We performed basal chevron metatarsal osteotomy on 32 feet (31 patients) for painful hallux valgus associated with an increased intermetatarsal 1/2 angle (> 12 degrees). Pedobarographic and radiological examinations were done preoperatively and at a minimum of six months postoperatively. The average hallux valgus angle was improved from 40.9 degrees to 19.2 degrees and the intermetatarsal 1/2 angle from 16.5 degrees to 6.8 degrees. The mean angle of declination of the first metatarsal was decreased by 1.4 degrees. The pedobarographs showed a significant reduction in areas sustaining pressure > 5 kg/cm2, an increased total foot contact area and a higher percentage forefoot contact area on heel raise. There was a high level of patient satisfaction with relief of symptoms and improved appearance of the foot.

We reviewed and radiographed 30 skeletally-mature patients after isolated closed femoral shaft fractures in childhood which had been treated conservatively. When the fracture had occurred between the ages of 7 and 13 years, the limb overgrew about 1 cm regardless of sex, upper limb dominance, age, fracture site or configuration. Excessive fracture overlap at the time of injury, but not at union, increased limb overgrowth. Angulation of the fracture remodelled in children injured under 10 years of age, but in older patients this sometimes added to limb shortening. Rotational deformities were minor and gave no symptoms. Treatment of the 7- to 13-year-old patient should aim at 1 cm overlap at union, with correction of angular deformity being more important in children over 10 years of age. This management of fractures will give a maximum leg length discrepancy of 1 cm at skeletal maturity.