Aims. The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. Methods. This UK-based multicentre retrospective national audit studied foot and ankle patients who underwent surgery between 13 January and 31 July 2020, examining time periods pre-UK national lockdown, during lockdown (23 March to 11 May 2020), and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included. A total of 43 centres in England, Scotland, Wales, and Northern Ireland participated. Variables recorded included demographic data, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. Results. A total of 6,644 patients were included. Of the operated patients, 0.52% (n = 35) contracted COVID-19. The overall all-cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n = 9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n = 3 deaths). Matching for age, American Society of Anesthesiologists (ASA) grade, and comorbidities, the odds ratio of mortality with COVID-19 infection was 11.71 (95% confidence interval 1.55 to 88.74; p = 0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and among patients with and without COVID-19 infection. After lockdown the COVID-19 infection rate was 0.15% and no patient died of COVID-19. Conclusion. COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and postoperative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions. Cite this article: Bone Joint Open 2021;2(4):216–226

Introduction. VTE is a possible complication of foot and ankle surgery, however there is an absence of agreement on contributing risk factors in the development of VTE. The primary outcome of this study was to analyse the 90-day incidence of symptomatic VTE following foot and ankle surgery and to determine which factors may increase the risk of VTE. Methods. This was a national, multi-centre prospective audit spanning a collection duration of 9 months (2022/2023). Primary outcomes included incidence of symptomatic VTE and VTE related mortality up to 90 days following foot and ankle surgery and Achilles tendon rupture, and analysis of risk factors. Results. In total 11,363 patients were available for analysis. 5,090 patients (44.79%) were elective procedures, 4,791 patients (42.16%) were trauma procedures (excluding Achilles ruptures), 398 patients (3.50%) were acute diabetic procedures, 277 patients (2.44%) were Achilles ruptures undergoing surgery and 807 patients (7.10%) were Achilles ruptures treated non-operatively. There were 99 cases of VTE within 90 days of admission across the whole group (Total incidence = 0.87%), with 3 cases of VTE related mortality (0.03%). On univariate analysis, increased age and ASA grade showedhigher odds of 90-day VTE, as did previous cancer, stroke, history of VTE, and type of foot and ankle procedure / injury (p<0.05). However, on multivariate analysis, the only independent predictors for 90-day VTE were found to be the type of foot and ankle procedure (Achilles tendon rupture = Odd's Ratio 11.62, operative to 14.41, non-operative) and ASA grade (grade III/IV = Odd's Ratio 3.64). Conclusion. The incidence of 90-day post procedure VTE in foot and ankle surgery in this national audit was low. Significant, independent risk factors associated with the development of 90-day symptomatic VTE were Achilles tendon rupture management and high ASA grade

Objectives. The primary aim was to determine the differences in COVID-19 infection rate and 30 day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second national lockdowns. Design. Multicentre retrospective national audit. Setting. This was a combined retrospective (Phase 1) and prospective (Phase 2) national audit of foot and ankle procedures in the UK in 2020. Participants. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway. Results. 10,846 patients were included, 6,644 from phase 1 and 4,202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6,470) and 0.21% on a green pathway (9/4,280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p = .109), lockdown (p = .923) or post-lockdown (p = .577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p < .001) and lockdown periods (p < .001). There was no significant difference in COVID-19 related mortality between pathways. Conclusions. There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways; however the success of the pathways only became significant in phase 2 of the study. The study shows a developing success in using green pathways in reducing the risk to patients undergoing foot and ankle surgery

Objectives. The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. Design. Multicentre retrospective national audit. Setting. UK-based study on foot and ankle patients who underwent surgery between the 13. th. January to 31. st. July 2020 – examining time periods pre- UK national lockdown, during lockdown (23. rd. March to 11. th. May 2020) and post-lockdown. Participants. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Main Outcome Measures. Variables recorded included demographics, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. Results. 6644 patients were included. In total 0.52% of operated patients contracted COVID-19 (n=35). The overall all cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n=9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n=3 deaths). Matching for age, ASA and comorbidities, the OR of mortality with COVID-19 infection was 11.71 (95% CI 1.55 to 88.74, p=0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and amongst patients with and without COVID-19 infection. After lockdown COVID-19 infection rate was 0.15% and no patient died of COVID-19 infection. Conclusions. COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and post-operative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions

Introduction. Ottawa ankle rules originally described in 1992 have been shown to improve the pick-up rates of ankle fractures and avoid the need for unnecessary X-rays, thus minimising cost and radiation to the patient. We decided to carry out an audit at our hospital to look at the pick-up rates of ankle fractures and ways to minimise x-rays for the patient both in A&E and in the orthopaedic department. Methods. Ankle x-rays of 1088 trauma patients over a 7 month period from Dec 2009 to June 2010 (inclusive) were reviewed. Patients with ankle fractures were classified according to Weber type, and whether they were treated surgically or non-operatively. Non-operatively treated ankle fractures then formed the main sub-group of our study, looking at the number of follow-up X-rays and the amount of subsequent displacement. The amount of displacement was classified into non-displaced (0 mm), minimally displaced (<2mm) and displaced (>2 mm). Results. 171 patients (out of 1088) were found to have fractured their ankle giving a pick up rate of 16%. (cf a pickup rate of 26% described in literature with implementation of Ottawa rules). The pick up rate fluctuated each month from 31% in December to a meagre 6% fractures in June and this could be due to summertime sports injuries causing less fractures and more sprains. We noted a third more x-rays were ordered in Spring than Winter. There were no changes in junior staff in either the A&E or the orthopaedic department to account for the monthly variations. Conservatively managed fractures were followed up in the fracture clinic (n = 95, 56%) 16% (n = 11) of the conservatively managed patients were classified as Weber A fractures 84% (n=58) as Weber B fractures. No Weber C fractures were conservatively managed. Of the eleven Weber A fractures only one was minimally displaced. Conservatively managed Weber A fractures received an average of 1.36 x-rays on follow up in the Orthopaedic department. Of the Weber B fractures 42 were non-displaced whilst 16 were minimally displaced, and these received an average of 3.23 x-rays on follow up. None of these progressed to displacement > 2mm. Conclusion. Based on our audit, we have introduced a policy to limit the number of follow-up of X-rays for minimally displaced and undisplaced Weber A & B fractures to one. We have also re-emphasized the importance of Ottawa rule implementation in our A&E department

Purpose. Tarsal Tunnel Syndrome (TTS) was first reported by Keck and Lam separately in 1962. It has been regarded as the lower limb equivalent to Carpal Tunnel Syndrome (CTS). The gold standard of diagnosis proposed over the years is nerve conduction study (NCS). In reality, TTS is much harder to diagnose and treat compared to CTS. Signs and symptoms can be mimicked by other foot and ankle conditions. Our unit had not seen a single positive nerve conduction result of TTS in clinically suspicious cases. We have therefore audited our 10 year experience. Methods and Results. This is a retrospective audit. Patient list retrieved from neurophysiology. 42 patients were identified. All were referred with a clinical suspicion of TTS. There was no single positive nerve conduction result showing tarsal tunnel compression. Of these, 27 case notes were retrieved (64%). The demographics are: A) age (23 to 78), B) 12 males, 15 females, and C) 12 involving left side, 4 right side and 11 bilateral. These studies were conducted according to national guidelines. There were 8 abnormal studies: 4 showing spinal radiculopathy, 3 showing higher peripheral neuropathy and 1 showing tibial nerve irritation following previous decompression. 4 cases were operated on. These are: 2 for removal of lumps, 1 for partial plantar fascia release, and 1 for redo-decompression. As for the rest: 16 had no change in the symptoms and were discharged, 6 were referred to other disciplines, 2 resolved spontaneously, 2 lost to follow up and 1 resolved after a total knee replacement. Conclusion. Our result does not reflect the findings reported in the literature in the past. Our neurophysiologist also agreed it is very rare to see one positive test. We feel that our understanding of TTS is not complete. The routine NCS done at resting position may not be able to replicate the clinical situations which bring on the symptoms in the first place. Changing lifestyle and improved footwear designs may also have contributed to a change in disease presentation. Further studies are required to clarify the situation

NHS governance demands that services provided are clinically effective and safe. In the current financial climate and threats over public sector spending cuts, services offered by health care providers should also be cost-effective and profitable. Surgical specialties are often perceived as expensive with high implant costs. The aim of this audit was to cost the profit margin for foot/ankle surgery and test the accuracy of coding data collected. Materials and Methods. Theatre data between January-April 2010 was retrospectively reviewed. Equipment inventories, operation notes and radiographs were reviewed for implants used. Clinical coding data was analysed and coded separately by the surgeon for comparison. Theatre expenses were calculated and accuracy estimated. Tariff generated and patient expenses were calculated and a final profit margin revealed. Wilcoxon matched-pair testing compared hospital recorded and surgeon calculated data. Results. 95 cases were included (51 forefoot, 5 midfoot, 6 arthroscopy, 12 hindfoot, 21 other), 65 female and 30 male patients. Theatre inventories were correct in 11% of cases. Mean inventory costs recorded were £90 and following surgeon analysis, £319. Total actual inventory cost was £30,306.23 but £8548.58 was recorded (p<0.0001). OPCS codes were deemed correct in 43% and incorrect in 57% of cases. Operation profit margin, including theatre, ward and salary costs was recorded as £158,229 but corrected profit margin with d inventories and OPCS codes was £121,584 (p=0.001). Discussion. Informed decisions on service provision depend upon the reliability of information provided. Operative data collection by personnel needs to be improved to provide precise information to enable more accurate income and expenditure figures. Conclusion. Elective foot and ankle surgery is a profitable surgical sub-specialty

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

Thromboembolic disease is associated with a high degree of morbidity and mortality. There is increasing pressure for elective orthopaedic patients, including those undergoing foot and ankle surgery, to be prescribed chemical thromboprophylaxis post-operatively in order to reduce the risk of a thromboembolic event. The risks of chemical thromboprophylaxis in terms of increased bleeding, wound problems and HIT are well documented. The aim of this study was to determine the incidence of clinically significant thromboembolic events in patients undergoing elective foot and ankle surgery with and without the use of aspirin. We audited a consecutive series of 1625 patients undergoing elective foot and ankle surgery between 2003 and 2010. Between 2003 and 2006 inclusive, aspirin was used post operatively as chemical thromboprohylaxsis. Between 2007 and 2010, no chemical thromboprohylaxsis was used. The follow-up period for all patients was at least three months post-operatively. Most patients were reviewed at 3 months by the senior surgeon. Those who were reviewed less than 3 months (patients undergoing minor procedures) were contacted via telephone to confirm whether a thromboembolic event had been diagnosed. There was no loss to follow up. Of the 1625 patients, 555 patients received aspirin and 1070 patients received no chemical thromboprohylaxsis. 5 of 1625 (0.31%) patients developed a clinically significant thromboembolic event. 3 patients developed a DVT at an average time of 5 weeks post operatively. 2 patients developed non-fatal PE at an average time of 7 weeks post operatively. 3 of the 5 thromboembolic events occurred in the aspirin group (all DVT's) whereas 2 of the 5 (all PE) developed in the non aspirin group. The incidence of clinically significant thromboembolic events is low in elective orthopaedic foot and ankle surgery. We suggest that the benefit of chemical thromboprophylaxis does not outweigh its potential risks in foot and ankle surgery

Aims. Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England. Methods. A questionnaire was sent to all 136 NHS trusts audited in the 2018 National Diabetic Foot Audit (NDFA). The questionnaire asked about the structure of diabetic foot care services. Results. Overall, 123 trusts responded, of which 117 admitted patients with diabetic foot disease and 113 had an orthopaedic foot and ankle surgeon. A total of 90 trusts (77%) stated that the admission involved medicine, with 53 (45%) of these admissions being exclusively under medicine, and 37 (32%) as joint admissions. Of the joint admissions, 16 (14%) were combined with vascular and 12(10%) with orthopaedic surgery. Admission is solely under vascular surgery in 12 trusts (10%) and orthopaedic surgery in 7 (6%). Diabetic foot abscesses were drained by orthopaedic surgeons in 61 trusts (52%) and vascular surgeons in 47 (40%). Conclusion. Orthopaedic surgeons make a significant contribution to both acute and elective diabetic foot care currently in the UK. This contribution is likely to increase with the movement of vascular surgery to a hub and spoke model, and measures should be put in place to increase the team based approach to the diabetic foot, for example with the introduction of a best practice tariff. Cite this article: Bone Jt Open 2022;3(8):618–622

Introduction. Positive reports from implant designer centres on the use of fibular nails in the complex ankle fractures has resulted in a marked increase in their use nationally. Our aim in this study was to report on the outcomes of the use of all fibular nails in two major trauma centres. Methods. All patients who underwent ankle fracture fixation using a fibular nail in two major trauma centres, were included for analysis. MTC 1 included patients from April 2013 to May 2015, and MTC 2 included patients February 2015 to March 2018. A minimum follow up of 1 year was achieved for all patients. Radiographic reduction was confirmed by Pettrones criteria at time of operation and at 6 weeks and 1 year post-operatively. Kellgren Lawrence radiographic criteria was used to classify osteoarthritis. All complications and further surgery were recorded. Results. Forty-four patients underwent fibular nail fixation in the two centres. The average age was 59 (range 21–91). Using Pettrones criteria, 86% were malreduced at time of operation. A further 34% deteriorated by at least 1 grade by 6 weeks and an additional 16% (n=7) deteriorated by at least 1 grade by 1 year. 57% had developed radiographic evidence of osteoarthritis by 1 year. Only 4.5% (2ankles) maintained complete reduction by 1 year. Other significant complications were reported in 43% of patients. Conclusion. Both major trauma centres report the same experience in the use of fibular nails for ankle fracture fixation. As previously reported in smaller number studies, initial reduction is challenging. Worryingly, the majority of well-reduced lose position with time. We suggest that the fibula nail is used with caution and as part of an appropriately approved audit

Lateral approach open calcaneal osteotomy is the described gold standard procedure in the management of hindfoot deformity. With development of minimally invasive surgery, a MIS approach has been described, citing fewer wound complications and lower risk of sural nerve injury. This audit compares MIS to the traditional procedure. A retrospective review of all patients undergoing calcaneal osteotomy in Northumbria Trust in the past 5 years was performed. A total of 105 osteotomies were performed in 97 patients; 28 (13M:15F) in MIS group and 77 (40M:37F) had an open approach. The average age was 52.1 (range 16–83) for MIS and 51.5 (range 18–83) in the open group. All patients were followed up for development of wound complication, nerve injury and fusion rate. Wound complications were similar (10.7% in MIS group vs 10.3% in Open group) with no significant difference (p=0.48). Patients were treated for infection in 3(3.8%) cases in the open group and 2(7.1%) in the MIS group. This difference was not significant (p=0.43). 4 (14.3%) patients in the MIS group had evidence of sural nerve dysfunction post-operatively (managed expectantly), compared to 12(15.5%) patients in the open group (p=0.44). Of these, 2 went on to undergo neuroma exploration. There was no difference in nerve dysfunction in varus or valgus correction. Mean translation in the open group was measured as 7.3mm(SD=1.91;3 to 13mm) and 7.5mm(SD=1.25;5 to 10mm) in the MIS group. Translation was similar in varus or valgus correction. Non-union occurred in 2 patients in the MIS group and none in the open group (p= 0.06). MIS calcaneal osteotomy is a safe technique, that works as effectively as osteotomy performed through an open approach. There were lower rates of nerve injury, wound complication and infection, but this was not significantly different comparing groups. There was a higher risk of non-union in MIS technique

Introduction. The management of open or unstable ankle and distal tibial fractures pose many challenges. In certain situations, hindfoot nailing (HFN) is indicated, however this depends on surgeon preference and regional variations exist. This study sought to establish the current management and outcomes of complex ankle fractures in the UK. Methods. A National collaborative study in affiliation with BOTA was conducted and data retrospectively collected between January 1. st. – June 30. th. 2019. Adult patients with open and closed complex ankle fractures (AO43/44) were included. Complex fractures included the following patient characteristics: diabetes ± neuropathy, rheumatoid arthritis, alcoholism, polytrauma and cognitive impairment. We obtained data on fixation choice and patient outcomes. Institutional approval was obtained by all centres, and statistical analysis was performed including propensity matching. Results. Fifty-six centres provided data for 1360 patients. The average age of the cohort was 53.9 years ±19 (SD) with a male/female ratio of 1:1.3. 920 patients were ASA 1/2, 440 were ASA 3/4; 316 had diabetes, and 275 were open fractures. Most fractures were AO44 (71.2%) and more commonly associated with diabetes (P<0.001), alcoholism (P<0.007), open (P<0.013), and advanced age (55.7 vs. 46.3). 1227 patients underwent primary-fixation (111 HFN), with the remainder treated with external-fixation (84 definitive). Of the 111 HFN, 35% underwent primary fusion. Wound complication and thromboembolic rates were greater in the HFN group compared to ORIF groups (P<0.003), being more evident in the HFN group with primary fusion even after propensity matching. However, 1081 patients were non-weightbearing post-op contrary to the BOAST guidance. Conclusion. This is the first National collaborative audit of complex ankle fractures. Hindfoot nails were used in 9% of patients and we observed more complications in this group when compared to other cohorts. Despite BOAST guidance, only 21% of patients undergoing operative management were instructed to fully weightbear post-operatively

Background. Diabetes is bad, common and diabetic foot ulcers (DFU) once established lead to high rates of amputation. In Nottingham our standard management for infected diabetic foot ulcers is surgical debridement, microbiological sampling, packing with gentamicin beads and targeted antibiotic therapy. Recently we have switched to packing with Stimulan, which is a purified synthetic calcium sulphate compound that can be mixed with patient appropriate antibiotics, is biodegradable and delivers better elution characteristics compared to gentamicin beads. Aim. To assess the efficacy of Stimulan compared to Gentamicin beads in the surgical management of infected diabetic foot ulcers. Methods. In 2012/13 the department audited its results of DFU surgical management with gentamicin beads. In 2014/5 the audit was repeated but Stimulan was used instead due to the perceived advantages Patients with infected DFU that could comply with treatment were included. Patients who had other sources of sepsis, non-compliant or moribund were excluded. Treatment pathways were identical apart for the use of Stimulan in 2014/5. The primary outcome measure was ulcer healing. The secondary outcome measure was length of stay and recurrence. Results. Each group had 23 patients. The gentamicin group had a DFU for 12.3 months(3weeks-5 years) before presentation for surgery compared to the Stimulan group 6.1 months(2weeks-5years). Both groups had failed non-surgical management. The majority of the ulcers were located on the forefoot. In the stimulan group 70% (16/23) of ulcers had healed with an average of 4 months(2–7 months) compared to 57% (13/23) in the Gentamicin group within 6months(1–12). The length of stay was shorter in the Stimulan group 7 days (1–70) compared to 28days(1–70) in the Gentamicin group. Conclusion. In our review Stimulan was superior to Gentamicin beads in the management of infected diabetic foot ulcers. We believe it has a role to play in limb salvage

Introduction. Standard teaching of dislocated ankles was always reduce then x-ray. However the 2016 BOAST guidelines stated “Reduction and splinting should be performed urgently for clinically deformed ankles. Radiographs should be obtained before reduction unless this will cause an unacceptable delay”. We aimed to audit our practice against the BOAST guidelines and look at time from attendance to reduction. Methods. We retrospectively reviewed all case notes of patients admitted via A&E at the Northern General Hospital with a fractured ankle between August 2016 and January 2017. Time of arrival, time to x-ray and time to reduction were recorded in a database for analysis. Results. 65 patients with acute ankle fractured dislocations were identified from 140 acute fractured ankle referrals to the orthopaedic on-call team. 55 of these had a pre-reduction x-ray. Time from arrival to a radiograph of a reduced ankle in cast was 3hrs 59 minutes for those who had a pre-reduction radiograph compared with 1hr 3 minutes for those who didn't have a pre-reduction radiograph. 12.5% of those with no pre-reduction radiograph required re-manipulation compared with 31% of those who did have a pre-reduction radiograph. Conclusion. Having a pre-reduction x-ray significantly increases the time until there is radiological evidence of a reduced ankle. There was an associated higher risk of requiring a further manipulation in those who had a pre-reduction radiograph. A larger review is currently being undertaken to better understand the possible reasons for this

The effect of BMI on patient-reported outcomes following total ankle replacement (TAR) is uncertain and the change in BMI experienced by these patients in the 5 years following surgery has not been studied. We report a series of 106 patients with complete 5-year data on BMI and patient-reported outcome scores. Patients undergoing TAR between 2006 and 2009, took part in the hospital joint registry, which provides routine clinical audit of patient progress following total joint arthroplasty; therefore, ethics committee approval was not required for this study. Data on BMI, Foot and Ankle Score (FAOS) and SF-36 score were collected preoperatively and annually postoperatively. Patients who were obese (BMI >30) had lower FAOS scores pre-operatively and at 5 years, however this did not reach significance. Both obese (p = 0.0004) and non-obese (p < 0.0001) patients demonstrated a significant improvement in FAOS score from baseline to 5 years. This improvement was more marked for the non-obese patients. No significant differences were seen for SF36 scores between obese and non-obese patients either at baseline or 5 years. There was a trend for improved score in both groups. Mean pre-operative BMI was 28.49. Mean post-operative BMI was 28.33. The mean difference between pre- and post-operative BMI was −0.15, which was not statistically significant (p=0.55). There were no significant differences in revisions in the obese (2) and non-obese (1 and one awaited) groups at 5 years. This data supports use of TAR in the obese population, as significant increases in mean FAOS score were seen in this group at 5 years. Obesity did not have a significant influence on patients' overall health perceptions, measured by the SF36 and a trend for improvement was seen in both obese and non-obese patients. TAR cannot be relied upon to result in significant post-operative weight-loss without further interventions

1737 elective foot and ankle cases were prospectively audited from Dec 2005 to end June 2010. All cases were brought back to a specialist nurse dressing clinic between 10 and 17 days post op. Data was collected at the dressing clinic with a standardised proforma on the type of surgery, the state of the wound and any additional management required. Those patients with a pre-existing infection were excluded. Of the 1737 cases 201 (11.6%) had a minor wound problems such as excessive post op bleeding into the dressings, suture problems, early removal of K wires, delayed wound healing and minor infection. 42 patients required antibiotics (2.4%) 8 patients had a deep wound infection (0.5%) requiring intravenous antibiotics and or further surgery. There were 1185 forefoot procedures 36 of which developed an infection (3%), overall infections of the mid/hindfoot was 6 (1%). Practice has changed as a result of the audit (reviewed annually). We have changed our closure techniques (reducing suture problems). For the past 2 years all of our elective foot and ankle patients now go to an ultra clean ward (Joint Replacement Unit) and we have shown a reduction in infection rates by over 50% since. Our infection rate before the JRU was 3.3% with 0.7% deep infection rate (818 procedures) and after the introduction of the JRU our infection rate has ped to 1.6% superficial and 0.3% deep infection p<.001. This large series prospective study sets a benchmark for infection rates in elective foot and ankle surgery. It also highlights the benefit of a dedicated orthopaedic elective unit with rigorous infection control policy and the need to regularly review our results

Introduction. Syndesmosis injuries are significant injuries and require anatomical reduction. However, stabilisation of these injuries with syndesmosis screws carries specific complications and many surgeons advocate a second operation to remove the screw. Primary Tightrope suture fixation has been shown to be an effective treatment for syndesmotic injuries and avoids the need for a second operation. Materials and Methods. A retrospective audit identified patients who were treated for syndesmosis injuries over a two year period. Theatre and clinic costs were obtained to compare the cost of syndesmosis fixation using diastasis screws with the estimated cost of primary syndesmosis fixation using a Tightrope suture. Results. 79 patients received diastasis screw fixation of syndesmosis injuries between January 2007 and January 2009. The mean number of follow up clinic appointments was 3.7 following initial surgery, and 2.2 following diastasis screw removal. Allowing for device, theatre time and clinic appointment costs, and an estimated average of 4 follow up appointments following Tightrope syndesmosis fixation, primary fixation with this device could a saving of 34 theatre slots, 68 outpatient clinic appointments, and £12,138 per year at our hospital. Discussion. Biomechanical studies have demonstrated a reduction in normal tibiotalar external rotation with the presence of a diastasis screw, and there are several published reports of complications when these screws are retained. The Tightrope suture provides reduction of the syndesmosis whilst allowing normal physiological movement at the distal tibiofibular joint and negates the need for a second operation to remove the implant. In addition there may be improvements in foot and ankle scores and a faster return to work when these devices are used compared with traditional screw fixation. Conclusion. In addition to the patient benefits, our audit suggests that there may be significant financial benefits associated with primary syndesmosis fixation with Tightrope sutures

We report an audit of 208 patients with a mean age of 39 years (16 to 65) attending the Orthopaedic Assessment Unit at the Wellington Hospital between January 2006 and December 2007 with an injury of the tendo Achillis requiring immobilisation in a cast. Information on assessment of venous thromboembolism (VTE) risk, prophylactic measures and VTE events for all patients was obtained from the medical records. A VTE risk factor was documented in the records of three (1%) patients. One of the 208 patients received aspirin prophylaxis; none received low molecular weight heparin. In all, 13 patients (6.3%, 95% confidence interval 3.4 to 10.5) developed symptomatic VTE during immobilisation in a cast, including six with a distal deep-vein thrombosis (DVT), four with a proximal DVT, and three with a confirmed pulmonary embolus. This incidence of symptomatic VTE is similar to that reported following elective hip replacement. We propose that consideration is given to VTE prophylaxis during prolonged immobilisation of the lower limbs in a cast, to ensure that the same level of protection is provided as for patients undergoing elective hip replacement

Introduction. 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. Materials and methods. 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. Results. Overall 410/446 (92%) patients reported a significant improvement in symptoms and 227 (62%) reported complete resolution of their pain, with 127 (28%) remaining asymptomatic at two year follow-up. The mode time of recurrence of pain was three months. 59 (13%) underwent a further injection and 102 (23%) underwent operative intervention within the follow-up period. There were no reported infections. Complications occurred in two percent of patients, including steroid flare, pain and plantar plate ruptures. Conclusion. Injections are a safe and effective option for treating a variety of foot and ankle conditions and reduce the need for surgery. They are particularly effective for the treatment of ankle soft tissue impingement. They appear ineffective in providing significant improvement in pain for longer than three months in conditions such as plantar fasciitis and hallux rigidus