Introduction. Day Case Surgery (defined as same day discharge) is a priority within the National Health Service and has been shown to provide beneficial outcomes for patients and hospitals. We report our experience developing a Day Case Programme for Total Ankle Replacement (TAR). Methods. Prior to the introduction of a Day Case Programme, average length of stay following TAR in our unit was 3.5 days. Stakeholders were consulted about ways in which same day discharge could be facilitated. Patients' post-operative pain charts were reviewed prior to the introduction of this programme. Inclusion criteria included non-complex surgery (anticipated tourniquet < 2hrs), friend or relative support and pre-operative walking-aid assessment. An enhanced recovery protocol included long-acting popliteal block and dexamethasone. Patients were discharged with opiate analgesia and written pain instructions. Patients were asked to complete a pain and satisfaction questionnaire. Patient Reported Outcome Measures (PROMs) were recorded. Results. From September 2017 to April 2019 21 of 70 patients underwent TAR as a Day Case. Mean age was 67 years (43-85 years). Complications included two delayed wound healings and one representation on day three with urinary retention. No patients reported post-operative nausea or vomiting, 60% did not use Oramorph at home. Average Visual Analogue Score for pain was 23/100 on day one and 21/100 day three post-operatively. There was no significant difference in pre-operative or overall change in MOXFQ, VAS or EQ5D PROMS. Conclusions. Early results suggest that Day Case Total Ankle Replacements are safe. Appropriate patient selection is necessary. Day Case Surgery relies on support and communication between multiple teams to organise and run effectively

Background. Procedural sedation (PS) requires two suitably qualified clinicians and a dedicated monitored bed space. We present the results of intra-articular haematoma blocks (IAHB), using local anaesthetic, for the manipulation of closed ankle fracture dislocations and compared resource use with PS. Methods. Patients received intra-articular ankle haematoma blocks for displaced ankle fractures requiring manipulation between October 2020 to April 2021. The technique used 10ml of 1% lignocaine injected anteromedially into the tibiotalar joint. Pain scores (VAS), time from first x-ray to reduction, and acceptability of reduction were recorded. A comparison was made by retrospective analysis of patients who had undergone PS for manipulation of an ankle fracture over the six month period March – August 2020. Results. During the periods assessed, 25 patients received an IAHB and 28 received PS for ankle fractures requiring manipulation (mean age 57.8yr vs 55.1yr). Time from first x-ray to manipulation was 65.9 min (IAHB) vs 82.9 min (PS) (p = 0.087). In the IAHB group mean pain scores pre, during and post manipulation were 6.1, 4.7 and 2.0 respectively (‘pre’ to ‘during’ p < 0.05; ‘pre’ to ‘post’ p < 0.01). In the IAHB group, 23 (92%) had a satisfactory reduction without need of PS or general anaesthetic. In the PS group 23 (82%) had a satisfactory reduction. There was no significant difference in the number of unsatisfactory first attempt reductions between the groups. There were no cases of deep infection post operatively in either group. Conclusion. Intra-articular haematoma block of the ankle appears to be an efficacious, safe and inexpensive means of providing analgesia for manipulation of displaced ankle fractures. Advantages of this method include avoiding the risks of procedural sedation, removing the requirement of designated clinical space and need for qualified clinicians to give sedation, and the ability to re-manipulate under the same block

Purpose. Ankle and hindfoot surgery is associated with severe post-operative pain, leading to a reliance on opiate analgesia and its side effects, longer hospital stays, and patient dissatisfaction. Popliteal sciatic nerve blockade has the potential to resolve these issues. We present our experience with using a continuous local anaesthetic nerve block delivered by an elastomeric pump in patients undergoing major foot and ankle surgery. Methods. All patients undergoing major ankle or hindfoot surgery during a one-year period under a single surgeon were eligible for a continuous popliteal block. An ultrasound-guided popliteal nerve catheter was inserted immediately before surgery and a bolus of bupivacaine infiltrated. Using a 250ml elastomeric pump, a continuous infusion was started immediately post operatively and terminated 48 hours later. Prospective data including post-operative analgesia, nausea and vomiting (PONV), length of stay (LOS), pain scores, and patient satisfaction were recorded daily for 48 hours post operatively. Results. Eighty-one patients (53 male, 28 female) with a mean age 60 years (24–84 years) were included. 66 patients received spinal anaesthesia with 15 having general anaesthetics. There were no complications associated with the nerve catheters. At day 1 post op, 49 (60%) patients reported having no or mild pain. 68 (84%) patients had no PONV. 27 (33%) patients did not require any opiate analgesia during their post op period. Average LOS for all patients was 54 hours, with 41 (51%) discharged within 48 hours. 74 (91%) reported good or excellent pain management in the post operative period. Conclusions. Continuous popliteal sciatic nerve blockade is a safe and effective method for controlling post-operative pain, reducing opiate-induced side effects, and optimising length of stay. Patient-reported outcomes support its use in major ankle and hindfoot surgery. Furthermore, reduced costs from early discharge in combination with a daycase tariff uplift can bring significant financial savings

Regional anaesthetic for foot surgery has been discussed as a method of post operative analgesia. Ankle block as the sole anaesthetic for foot surgery has not been extensively reviewed in the literature. Aim. To describe our experience of forefoot surgery under ankle block. Methods. 71 consecutive forefoot procedures (65 patients) were carried out under ankle block. A mixture of 10ml 2% Lidocaine with 10ml 0.5 % Bupivacine was administered to the superficial peroneal, deep peroneal, sural and saphenous nerves. Ankle tourniquet was employed in all procedures. Patients were contacted post operatively and completed a standardised questionnaire including an incremented pain assessment ranging from 0-10 (0 no pain, 10 severe pain). Results. 61 female and 4 male patients were contacted (age range 33-67y). Procedures included 48 first metatarsal osteotomies, 15 cheilectomies, 2 first MTP joint replacements, and 6 fusions. 17 patients (26 %) reported some discomfort during the block procedure (average pain score 1.2). No patients reported any pain during their operation(s). 14 patients (22%) required supplementation of the block. Average pain score at 6, 12, 24 and 48 hours following surgery were 0.66, 2.9, 2.4 and 1.3 respectively. All patients were discharged home and walking on the same day. None complained of nausea or required parentral analgesia. There were no readmissions. Each patient confirmed they would have surgery under regional block rather than general anaesthesia and would recommend this technique to family and friends. Discussion. There are many advantages in being able to perform these small procedures under regional anaesthesia. Our initial observational study suggests forefoot surgery under ankle block alone may be safe and effective. Anaesthesia obtained permits the majority of forefoot procedures and provides lasting post-operative analgesia. Combined with intra-operative sedation, use of ankle tourniquet and same day discharge it has very high patient acceptance and satisfaction

Achilles tendinopathy is chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. It involves a triad of pain, swelling and impaired function. Primary treatment is rest, analgesia, corticosteroid injections and physiotherapy (eccentric training and heel pads to correct gait). Some patients remain symptomatic and further treatment options need considering. NICE produced a document from the Interventional Procedures Advisory Committee in 2009 which reviewed the literature and evidence for extracorporeal shockwave treatment (ESWT). Low energy shock wave treatment (SWT) is thought to stimulate soft tissue healing, inhibit pain receptors and promote angiogenesis. NICE guidance was that ESWT could be used in refractory Achilles tendinopathy if used for clinical governance, audit or research. Patients with refractory Achilles tendinopathy were enrolled between October 2010 and 2011. They received three sessions of ESWT over three week. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale (six points, high is worsening) were reassessed at 6 and 16 weeks post treatment. 51 patients completed follow up. The mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. There was a significant improvement (p<0.05) in VAS scores observed from baseline and 16 weeks post treatment. This was also the case in the VISA-A scores. The mean Likert score was 3 (somewhat improved) at 16 weeks but there was no statistical significance. This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy. Patients over 60 possibly have a worse outcome along with patient who had symptoms for over 25 months. Follow up scores at one year are due to be collected and the data will be submitted to NICE

Introduction. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (CO) is a well-recognised surgical treatment for stage II posterior tibial tendon dysfunction (PTTD). Whilst excellent results are quoted for short and medium term follow-up, the long-term outcome of this procedure is unknown. Materials and Methods. We reviewed the clinical outcome of patients with a symptomatic flexible flatfoot deformity undergoing this procedure at a mean follow up of 15.3 +/−0.7 years (range 14.4–16.5). We identified 48 patients who underwent surgery by the senior author between 1994 and 1996. We were able to contact 30 patients of whom 20 were available for clinical review. 10 patients participated via telephone interview, and also completed postal questionnaires. Results. All scores improved significantly from preoperative to latest follow-up. The mean AOFAS score improved from 48.4 presurgery to 90.0+/−13.6 (range 54–100) postsurgery. The pain component improved from a mean of 12.3 to 35.0+/−8.1 (range 20–40). Function score improved from 35.8 to 45.5+/−6.1 (range 30–50). Visual analogue score improved from 7.3 to 1.3+/−2.2 (range 0–6). Seven patients had only fair objective alignment, however six of those were totally satisfied and one satisfied with minor reservations, and all said they would have the surgery again. The mean SF36 physical component score was 39.8+/−8.4 and this showed significant correlation with the AOFAS score (r = 0.61, p = 0.009). Five patients developed further pain unresponsive to analgesia and orthotics and underwent further surgery in the form of calcaneocubuoid fusion, talonavicular fusion or triple fusion at a mean of 5.5+/−4.7 years (range 0.7–11.8) following initial surgery. 25(83%) patients were pain free and functioning well at an average of 15.3 years following surgery. Conclusion. We believe that FDL transfer and CO provides long-term pain relief and satisfactory function in the treatment of Stage II PTTD

Introduction. Major ankle and hindfoot surgery has traditionally been performed as an inpatient. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to contemplate performing major ankle and hindfoot operations as a day-case. This could have a significant impact on length of stay for these major cases, saving resources and in keeping with government policy. In this study, we prospectively audited the outcome of the first cohort of patients undergoing major ankle and hindfoot surgery as a day-case against a series of standards. Methods. Twenty four consecutive patients who underwent ankle or hindfoot surgery between August 2009 and April 2010 were considered for day surgery. Seven patients were deemed not suitable due to co-existing medical conditions or insufficient help at home. This left 17 patients who had ankle or hindfoot surgery as a day case. All patients received an ultrasound-guided regional nerve block and spinal or general anaesthesia. The data was collected on patient demographics, diagnosis, and type of surgical procedure. Patients received the standard follow-up regimen for a particular procedure. Patient satisfaction was assessed using a standard questionnaire which included self-monitoring of post-operative pain at 6, 24 and 48 hrs. In addition, any adverse outcomes were recorded. Results. The average age was 48 (range 23-67) years. There were 7 males and 10 females. The surgical procedures included arthroscopic ankle fusion (5), subtalar fusion (5), talonavicular fusion (1) midfoot fusion with calcaneal osteotomy (1), tibialis posterior reconstruction (3) tendo-achilles reconstruction (1) and arthroscopy and lateral ligament reconstruction (1). 93% patients reported that they were given enough information and advice about their operation as a day case. No patients reported severe pain at 6 hrs. One patient had severe pain at 24 hrs post-op. Four patients (23%) had significant pain at 48 hrs and required strong analgesia. Thirteen (77%) patients stated that they would recommend having this surgery as a day-case if they were having it again whereas four (23%) would prefer staying in overnight. The average length of stay for the patients deemed unsuitable for day surgery was 3.8 (range 1-6) days. Conclusions. Our initial results of performing major ankle and hindfoot procedures as day surgery are encouraging but pain control at 48 hrs still remains an unsolved issue and further optimisation is needed

Aims

Arthroplasty for end-stage hallux rigidus (HR) is controversial. Arthrodesis remains the gold standard for surgical treatment, although is not without its complications, with rates of up to 10% for nonunion, 14% for reoperation and 10% for metatarsalgia. The aim of this study was to analyze the outcome of a double-stemmed silastic implant (Wright-Medical, Memphis, Tennessee, USA) for patients with end-stage HR.

Aims

The aim of this study was to describe the technique of distraction osteogenesis followed by arthrodesis using internal fixation to manage complex conditions of the ankle, and to present the results of this technique.

While many forefoot procedures may be performed as a day case, there are no specific guidelines as to which procedures are suitable. This study assessed the early post-operative pain after forefoot surgery performed a day case, compared with conventional inpatient management.

A total of 317 consecutive operations performed by a single surgeon were included in the study. Those eligible according to the criteria of the French Society of Anaesthesia (SFAR) were managed as day cases (127; 40%), while the remainder were managed as inpatients.

The groups were comparable in terms of gender, body mass index and smoking status, although the mean age of the inpatients was higher (p < 0.001) and they had higher mean American Society of Anaesthesiologists scores (p = 0.002). The most severe daily pain was on the first post-operative day, but the levels of pain were similar in the two groups; (4.2/10, sd 2.5 for day cases, 4.4/10, sd 2.4 for inpatients; p = 0.53). Overall, 28 (9%) of patients who had their surgery as a day case and 34 (11%) of inpatients reported extreme pain (≥ 8/10). There were more day case patients rather than inpatients that declared their pain disappeared seven days after the surgery (p = 0.02). One day-case patient with excessive bleeding was admitted post-operatively.

Apart from the most complicated cases, forefoot surgery can safely be performed as a day case without an increased risk of pain, or complications compared with management as an inpatient.

Cite this article: Bone Joint J 2015;97-B:1645–50.

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy is a well-recognised form of treatment for stage II posterior tibial tendon dysfunction. Although excellent short- and medium-term results have been reported, the long-term outcome is unknown. We reviewed the clinical outcome of 31 patients with a symptomatic flexible flat-foot deformity who underwent this procedure between 1994 and 1996. There were 21 women and ten men with a mean age of 54.3 years (42 to 70). The mean follow-up was 15.2 years (11.4 to 16.5). All scores improved significantly (p < 0.001). The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up. The mean pain component improved from 12.3 to 35.2 (20 to 40). The mean function score improved from 35.2 to 45.6 (30 to 50). The mean visual analogue score for pain improved from 7.3 to 1.3 (0 to 6). The mean Short Form-36 physical component score was 40.6 (sd 8.9), and this showed a significant correlation with the mean AOFAS score (r = 0.68, p = 0.005). A total of 27 patients (87%) were pain free and functioning well at the final follow-up. We believe that flexor digitorum longus transfer and calcaneal osteotomy provides long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

Cite this article: Bone Joint J 2015;97-B:346–52.

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration.

In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:1299–1311.

In this randomised controlled trial, we evaluated the role of elastic compression using ankle injury stockings (AIS) in the management of fractures of the ankle. A total of 90 patients with a mean age of 47 years (16 to 79) were treated within 72 hours of presentation with a fracture of the ankle, 31 of whom were treated operatively and 59 conservatively, were randomised to be treated either with compression by AIS plus an Aircast boot or Tubigrip plus an Aircast boot. Male to female ratio was 36:54. The primary outcome measure was the functional Olerud–Molander ankle score (OMAS). The secondary outcome measures were; the American Orthopaedic Foot and Ankle Society score (AOFAS); the Short Form (SF)-12v2 Quality of Life score; and the frequency of deep vein thrombosis (DVT).

Compression using AIS reduced swelling of the ankle at all time points and improved the mean OMAS score at six months to 98 (95% confidence interval (CI) 96 to 99) compared with a mean of 67 (95% CI 62 to 73) for the Tubigrip group (p < 0.001). The mean AOFAS and SF-12v2 scores at six months were also significantly improved by compression. Of 86 patients with duplex imaging at four weeks, five (12%) of 43 in the AIS group and ten (23%) of 43 in the Tubigrip group developed a DVT (p = 0.26).

Compression improved functional outcome and quality of life following fracture of the ankle. DVTs were frequent, but a larger study would be needed to confirm that compression with AISs reduces the incidence of DVT.

Cite this article: Bone Joint J 2014; 96-B:1062–9.

We investigated the clinical and radiological outcome after unilateral fracture of the lateral process of the talus in 23 snowboarders with a mean follow-up of 3.5 years (12 to 76 months). In this consecutive cohort study both operative and non-operative cases were considered.

The mean American Orthopaedic Foot and Ankle Society hindfoot score was 94 (82 to 100). The non-operative group of seven with a minimally-displaced fracture scored higher (98 points) than the operative group of 16 with displaced or unstable fractures (93 points). In 88% of operative cases, significant concomitant hindfoot injuries were found at operation. All but eight (35%) patients (six operative and two non-operative) regained their pre-injury level of sporting activity. Subtalar osteoarthritis was present in nine (45%) of the 20 patients available for radiological review, including one late-diagnosed non-operative case and eight operative cases with associated injuries or fracture comminution.

The outcome after fracture of the lateral process of the talus in snowboarders is favourable provided an early diagnosis is made and adequate treatment, which is related to the degree of displacement and associated injuries, is undertaken.