Hallux valgus continues to frustrate foot and ankle surgeons the world over. The condition is mostly clear in its aetiology but unclear in its pathogenesis. The key, as in all surgery, is decision making, patient selection and to have many surgical options available. The key things to consider are: joint congruency, the presence of arthritis, the presence of metatarsus adductus, the intermetatarsal angle, the hallux valgus angle and the presence of interphalangeal deformity. I consider true hypermobility of the first ray and Achilles tendon tightness to be less important factors. Patient expectations are particularly important as most patients with hallux valgus are women who want to wear high-heeled shoes!. The most successful operations consist of a combination of soft tissue and bony procedures. The most common error in bunion surgery, in my opinion, is the use of a procedure with inadequate power to correct the deformity. When the joint is markedly arthritic and deformed an arthrodesis is the procedure of choice. I will discuss the above points in the lecture

About 20% of orthopaedic surgery is foot and ankle. This area of orthopaedics has undergone huge changes in last few decades. Not that long ago we were still performing Keller's procedure for bunions and using a Charnley clamp for ankle fusions. It is becoming increasingly more difficult for the general orthopaedic surgeon to stay abreast of current surgical treatment. Some of the newer foot and ankle surgical surgical techniques will be discussed. Ankle arthroplasty is undergoing a period of revival. This is a difficult procedure with results not as reliable as hip and knee arthroplasty and I would not recommend it to the occasional foot and ankle surgeon. Ankle arthroscopy is now a commonly performed procedure and with the right equipment is a procedure that is useful to the generalist. Foot and ankle fusion are now performed with rigid internal fixation. The actual procedures are not difficult but it does require a reasonable amount of experience to obtain the correct position of the fusion. Bunion surgery is commonly done and can result in disappointment for all. The newer surgical options for the correction of hallux valgus will be discussed

Recent Department of Health guidelines have recommended that bunion surgery should be performed as a day case in a bid to reduce hospital costs, yet concurrently improving patient outcomes. Following an audit in 2012/3, we implemented a number of measures in a bid to improve the rates of day case first ray surgery. In this paper, we look to see if these measures were effective in reducing the length of stay in first ray surgery. We performed a prospective case note review of all patients undergoing first ray surgery between 01/01/2012 and 01/02/2013, and found the rates of same day discharge in this group to be lower than expected at just 24.19%. We recognised that the most commonly cited reasons for delayed discharge were that patients not being assessed by physiotherapy, and were unable to have their take home medication (TTO's) dispensed as pharmacy had closed. To address this, we implemented a pre-operative therapy led foot school, and organised ward analgesia packs which may be dispensed by ward staff, thus bypassing the need for pharmacy altogether. Together, we coined the term “care package” for these measures. We then performed a post implementation audit between 01/01/2014 to 01/01/2015 to ascertain if these measures had been effective. We identified 62 first ray procedures in the preliminary audit, with an average age of 50.5 years (range 17–78 years) and a M:F ratio of 1:5. The most commonly performed procedures were Scarf osteotomy, 1st MTPJ fusion, and distal Chevron osteotomy. We compared this to 63 first ray procedures post implementation of the care package. The average age was 55.3 years (range 15–78 years) and the M:F ratio was 1:2.5, and there was a similar distribution in terms of specific procedures. We found the length of stay had reduced from 1.00 to 0.65 days (p= 0.0363), and the rate of same day discharge had increased from 24.6% to 44.6% (p= 0.0310). We also noted that St Helens Hospital (SHH), the dedicated day case surgery unit, had a significantly increased rate of same day discharge than Whiston Hospital (WH- the main hospital) at 87.5% and 28.89% respectively (p= 0.0002). Preoperative physiotherapy assessment is an important tool in reducing length of stay for first ray surgery. The use ward analgesia packs has a synergistic effecting in increasing day case first ray surgery. We therefore commend its use to other centers. Additionally, we have shown dedicated day case surgery units are more effective at achieving same day discharge than general hospitals

Purpose of study:. Congenital hallux varus is a rare condition presenting with medial deviation of the big toe. It consists of 2 variants: classical congenital hallux varus caused by an abnormal metatarsal-phalangeal articulation, and a more recently described variant due to a “bracket physis” of the first metatarsal. Our aim was to perform an audit of the spectrum of presentation of congenital hallux varus with its management and complications in our unit over a five year period. Description of methods:. A retrospective review of congenital hallux varus treated by a single surgeon was performed. Clinical notes, photographs and x-rays were reviewed. Two surgical methods of treatment were used as directed by clinical and radiological findings. Summary of results:. Four patients with congenital hallux varus were identified. Three had bilateral involvement, i.e. seven feet were treated. The ages of the patients ranged from 1 to 9 years, with 2 boys and 2 girls receiving treatment. In two patients (4 feet) the deformity was associated with pre-axial polydactyly. One patient had associated hand deformities. Only one of our four patients had a “bracket physis” and was treated with a metatarsal osteotomy. The other three patients (6 feet) were treated by soft tissue realignment using the Farmer procedure. One patient who had bilateral Farmer procedures subsequently developed a bunion over the 1st metatarso-phalangeal joint of one foot due to uncovering of the metatarsal head. No complications or recurrences were recorded in the other three patients on follow up visits. Conclusion:. Careful clinical and X-ray analysis is important to determine the type of congenital hallux varus and which method of surgical treatment is appropriate. Long term follow up is required to identify subsequent deformities