Introduction. There are approximately 1.2 million patients using orthotics in the UK costing the NHS in excess of £100 million per annum. Despite this, there is little data available to determine efficacy and patient compliance. There have been a few reports on patient satisfaction, which indicate that between 13-50% of patients are dissatisfied with their orthotics. Our aim was to evaluate patient reported satisfaction with orthotics prescribed and to investigate the reasons behind patient dissatisfaction. Methods. Seventy consecutive patients receiving foot orthoses at the Royal National Orthopaedic Hospital were retrospectively asked to complete a questionnaire and to bring their shoes and orthotics to research clinic. The inside width of the shoes and corresponding width of the orthotic were measured. A semi-structured interview was carried out on 10 patients, including those that were satisfied or unsatisfied, using qualitative research methods to identify issues that are important to patients. Results. Forty out of 70 patients (57%) completed the questionnaire either by telephone or in the clinic. There was a statistically significant difference between the width of the orthotics and the inside diameter of the shoes that the orthotic was meant to fit in. Dissatisfaction with the new custom made insoles was reported in 28% of patients. Half of these patients reported that the insoles did not fit with their feet into their shoes, and 30% indicated a preference for cosmetic issues over function. The majority of patients had tried numerous homemade or off the shelf versions prior to attending the orthotic department. Conclusion. There is a high level of patient dissatisfaction with orthotics. This dissatisfaction was due to a disconnection between prescribed foot orthoses and shoes purchased by patients. There is an urgent need to join up these two industries to prevent financial waste and improve the cost-effectiveness of orthotic services

Arthrodesis of both the ankle and the hindfoot has been discussed in the literature since the early part of the last century. Techniques have been modified substantially since these early discussions, though complications remain a frustrating element in patient management. Early procedures relied on molded plaster casts to hold fixation in corrected positions. Successful outcomes were hampered by loss of reduction in these casts and subsequent malunions. In addition, motion within these casts lead to a high rate of nonunion between the opposed bony surfaces. The era of internal fixation allowed compression across arthrodesis sites, enhancing union but creating a host of technical errors leading to unsatisfying results. Malunion is also seen in post-traumatic situations. In particular, non-operative management of calcaneus fracture (or other hindfoot fractures) leads to not only arthritis of the involved joint surfaces, but malunion complicating successful fusion. Fusion in-situ leads to a high level of patient dissatisfaction, leading surgeons to challenging deformity correction while trying to achieve successful arthrodesis in compromised joints. This lecture will focus on two types of malunion, one iatrogenic, one acquired. Revision triple arthrodesis (iatrogenic) can range from simple to challenging. A variety of studies document patient dissatisfaction following correction via this technique, ranging from Graves and Mann (1993) where the highest dissatisfaction rate was in highest in valgus malunion, to Sangeorzan and Hansen (1993), who found a 9% failure rate, most with varus malunion. The precarious balance required to create a plantigrade foot via triple arthrodesis with pre-existing deformity leaves even the most skilled surgeon challenged. As such, this component of the lecture will focus on recognition and correction of malunion based on a structured algorithmic approach we first presented in 1997. This algorithm is based on recognition of the apex of the deformity, and creating osteotomies to achieve balance. We reviewed 28 patients who returned for follow-up examination who received treatment through this algorithm and found a statistically significant improvement in pre- and postoperative AOFAS ankle/hindfoot score, from an average of 31 points preoperatively to 59 postoperatively (p<0.01). All patients united, and all stated they would undergo the revision procedure again. Comparisons of pre- and postoperative shoe wear modification demonstrated a statistically significant improvement (p=0.01). Preoperatively, 20 patients required restrictive devices such as ankle foot orthoses and orthopaedic shoes. Postoperatively, only 1 patient required such a restrictive device. In fact, 17 patients required no modifications to their shoe wear at all. The second component to this lecture will assess acquired hindfoot deformity, from malunion created by calcaneus fractures. A 2005 JBJS study by Brauer, et.al. found operative management resulted in a lower rate of subtalar arthrodesis with a shorter time off work compared to non-operative management. Removing the expense of time off work still netted a $2800 savings for operative management over non-operative management. Sanders echoed these thoughts in a JBJS 2006 paper, suggesting patients with displaced intra-articular calcaneal fractures may benefit from acute operative treatment given the difficulty encountered in restoring the calcaneal height and the talo-calcaneal relationship in symptomatic calcaneal fracture malunion. Thus, with these challenges in mind, the goal of this component of the lecture is to introduce methods to achieve balance and union with calcaneus fracture malunion. Vertically oriented multiplanar calcaneal osteotomy may assist the surgeon in avoiding the higher non-union rate associated with bone-block arthrodesis procedures. In this vein, the challenges associated with bone block subtalar arthrodesis will be explored

Aims

Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined.

Aims

This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years.

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

Between March 1995 and January 2000 we reviewed retrospectively 84 patients with hammer-toe deformity (99 feet; 179 toes) who had undergone metatarsophalangeal soft-tissue release and proximal interphalangeal arthroplasty. The median follow-up was 28 months. Patients were assessed by the American Orthopaedic Foot and Ankle Society Scores (AOFAS) and reviewed by independent assessors. The median AOFAS score was 83, with 87% of patients having a score of more than 60 points; 83% were satisfied and 17% were dissatisfied with the procedure. Pain at the metatarsophalangeal joint was the commonest cause of dissatisfaction, with 14% having moderate or severe pain. Only 2.5% had instability and 9% had formation of callus. There was no statistical difference for the age and gender of the patients, the number of toes operated on, associated surgery for hallux valgus or length of follow-up. Our study was based on an anatomical model and shows good results with no recurrence of deformity

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.

We present a review of litigation claims relating to foot and ankle surgery in the NHS in England during the 17-year period between 1995 and 2012.

A freedom of information request was made to obtain data from the NHS litigation authority (NHSLA) relating to orthopaedic claims, and the foot and ankle claims were reviewed.

During this period of time, a total of 10 273 orthopaedic claims were made, of which 1294 (12.6%) were related to the foot and ankle. 1036 were closed, which comprised of 1104 specific complaints. Analysis was performed using the complaints as the denominator. The cost of settling these claims was more than £36 million.

There were 372 complaints (33.7%) involving the ankle, of which 273 (73.4%) were related to trauma. Conditions affecting the first ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective practice. Overall, claims due to diagnostic errors accounted for 210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery and 149 (13.5%) from alleged mismanagement.

Our findings show that the incorrect, delayed or missed diagnosis of conditions affecting the foot and ankle is a key area for improvement, especially in trauma practice.

Cite this article: Bone Joint J 2014;96-B:1510–14.

Aims

This is the first prospective study to report the pre- and post-operative patient reported outcomes and satisfaction scores following excision of interdigital Morton’s neuroma.

This study sought to determine the medium-term patient-reported and radiographic outcomes in patients undergoing surgery for hallux valgus. A total of 118 patients (162 feet) underwent surgery for hallux valgus between January 2008 and June 2009. The Manchester-Oxford Foot Questionnaire (MOXFQ), a validated tool for the assessment of outcome after surgery for hallux valgus, was used and patient satisfaction was sought. The medical records and radiographs were reviewed retrospectively. At a mean of 5.2 years (4.7 to 6.0) post-operatively, the median combined MOXFQ score was 7.8 (IQR:0 to 32.8). The median domain scores for pain, walking/standing, and social interaction were 10 (IQR: 0 to 45), 0 (IQR: 0 to 32.1) and 6.3 (IQR: 0 to 25) respectively. A total of 119 procedures (73.9%, in 90 patients) were reported as satisfactory but only 53 feet (32.7%, in 43 patients) were completely asymptomatic. The mean (SD) correction of hallux valgus, intermetatarsal, and distal metatarsal articular angles was 18.5° (8.8°), 5.7° (3.3°), and 16.6° (8.8°), respectively. Multivariable regression analysis identified that an American Association of Anesthesiologists grade of > 1 (Incident Rate Ratio (IRR) = 1.67, p-value = 0.011) and recurrent deformity (IRR = 1.77, p-value = 0.003) were associated with significantly worse MOXFQ scores. No correlation was found between the severity of deformity, the type, or degree of surgical correction and the outcome. When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, the long-term results are worse than expected when compared with the short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years.

Cite this article: Bone Joint J 2015;97-B:208–14.

As it remains unproven that hypermobility of the first tarsometatarsal joint (TMTJ-1) is a significant factor in hallux valgus deformity, the necessity for including arthrodesis of TMTJ-1 as part of a surgical correction of a hallux valgus is questionable. In order to evaluate the role of this arthrodesis on the long-term outcome of hallux valgus surgery, a prospective, blinded, randomised study with long-term follow-up was performed, comparing the Lapidus procedure (which includes such an arthrodesis) with a simple Hohmann distal closing wedge metatarsal osteotomy. The study cohort comprised 101 feet in 87 patients: 50 feet were treated with a Hohmann procedure and 51 with a Lapidus procedure. Hypermobility of TMTJ-1 was assessed pre-operatively by clinical examination. After a mean of 9.25 years (7.25 to 11.42), 91 feet in 77 patients were available for follow-up. There was no difference in clinical or radiological outcome between the two procedures. Also, there was no difference in outcome between the two procedures in the subgroup clinically assessed as hypermobile. This study does not support the theory that a hallux valgus deformity in a patient with a clinically assessed hypermobile TMTJ-1 joint requires fusion of the first tarso-metatarsal joint.

Cite this article: Bone Joint J 2013;95-B:1222–6.

The rate of surgical site infection after elective foot and ankle surgery is higher than that after other elective orthopaedic procedures.

Since December 2005, we have prospectively collected data on the rate of post-operative infection for 1737 patients who have undergone elective foot and ankle surgery. In March 2008, additional infection control policies, focused on surgical and environmental risk factors, were introduced in our department.

We saw a 50% reduction in the rate of surgical site infection after the introduction of these measures. We are, however, aware that the observed decrease may not be entirely attributable to these measures alone given the number of factors that predispose to post-operative wound infection.

Cite this article: Bone Joint J 2015;97-B:516–19.

We reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release.

The mean hallux valgus angle improved from −11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from −0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean American Orthopaedic Foot and Ankle Society score improved from 77 to 95 points.

In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications.

We consider that distal chevron metatarsal osteotomy with a medial wedge osteotomy and medial capsular release is a useful procedure for the correction of hallux varus after surgery for hallux valgus.

The responsiveness of the Manchester–Oxford Foot Questionnaire (MOXFQ) was compared with foot/ankle-specific and generic outcome measures used to assess all surgery of the foot and ankle. We recruited 671 consecutive adult patients awaiting foot or ankle surgery, of whom 427 (63.6%) were female, with a mean age of 52.8 years (18 to 89). They independently completed the MOXFQ, Short-Form 36 (SF-36) and EuroQol (EQ-5D) questionnaires pre-operatively and at a mean of nine months (3.8 to 14.4) post-operatively. Foot/ankle surgeons assessed American Orthopaedic Foot and Ankle Society (AOFAS) scores corresponding to four foot/ankle regions. A transition item measured perceived changes in foot/ankle problems post-surgery. Of 628 eligible patients proceeding to surgery, 491 (78%) completed questionnaires and 262 (42%) received clinical assessments both pre- and post-operatively. The regions receiving surgery were: multiple/whole foot in eight (1.3%), ankle/hindfoot in 292 (46.5%), mid-foot in 21 (3.3%), hallux in 196 (31.2%), and lesser toes in 111 (17.7%). Foot/ankle-specific MOXFQ, AOFAS and EQ-5D domains produced larger effect sizes (> 0.8) than any SF-36 domains, suggesting superior responsiveness. In analyses that anchored change in scores and effect sizes to patients’ responses to a transition item about their foot/ankle problems, the MOXFQ performed well. The SF-36 and EQ-5D performed poorly. Similar analyses, conducted within foot-region based sub-groups of patients, found that the responsiveness of the MOXFQ was good compared with the AOFAS.

This evidence supports the MOXFQ’s suitability for assessing all foot and ankle surgery.

We carried out a retrospective study to assess the clinical results of lengthening the fourth metatarsal in brachymetatarsia in 153 feet of 106 patients (100 female, six males) using three different surgical techniques. In one group lengthening was performed by one-stage intercalary bone grafting secured by an intramedullary Kirschner-wire (45 feet, 35 patients). In the second group lengthening was obtained gradually using a mini-external fixator after performing an osteotomy with a saw (59 feet, 39 patients) and in the third group lengthening was achieved in a gradual manner using a mini-external fixator after undertaking an osteotomy using osteotome through pre-drilled holes (49 feet, 32 patients). The mean age of the patients was 26.3 years (13 to 48). Pre-operatively, the fourth ray of the bone-graft group was longer than that of other two groups (p < 0.000). The clinical outcome was compared in the three groups. The mean follow-up was 22 months (7 to 55).

At final follow-up, the mean lengthening in the bone-graft group was 13.9 mm (3.5 to 23.0, 27.1%) which was less than that obtained in the saw group with a mean of 17.8 mm (7.0 to 33.0, 29.9%) and in the pre-drilled osteotome group with a mean of 16.8 mm (6.5 to 28.0, 29.4%, p = 0.001). However, the mean time required for retention of the fixation in the bone-graft group was the shortest of the three groups. Patients were dissatisfied with the result for five feet (11.1%) in the bone-graft group, eight (13.6%) in the saw group and none in the pre-drilled osteotomy group (p < 0.000). The saw group included eight feet with failure of bone formation after surgery. Additional operations were performed in 20 feet because of stiffness (n = 7, all groups), failure of bone formation (n = 4, saw group), skin maceration (n = 4, bone-graft group), malunion (n = 4, bone-graft and saw groups) and breakage of the external fixator (n = 1, saw group).

We conclude that the gradual lengthening by distraction osteogenesis after osteotomy using an osteotome produces the most reliable results for the treatment of fourth brachymetatarsia.