Untreated clubfoot results in serious disability, but mild to moderate residual deformities can still cause functional limitations and pain. Measuring the impact of clubfoot deformities on children's wellbeing is challenging. There is little literature discussing the variability in outcomes and implications of clubfoot based on where geographically the child resides. Although the use of patient reported outcome measures (PROMs) is steadily growing in pediatric orthopaedics, few studies on clubfoot have incorporated them. The most widely used PROM for pediatric foot and ankle pathology is the Oxford Foot and Ankle Questionnaire for Children (OXFAQ-C) that include a physical, school and play, emotional and shoe wear domains. The aim of this study is to evaluate the validity and regional differences in scores of the OXFAQ-C questionnaire to identify functional disability in children with clubfoot in India and Canada. This is a retrospective cohort study of children in Indian and Canadian clubfoot registries aged 5-16 years who completed >1 parent or child OXFAQ-C. The OXFAQ-C was administered once in 01/2020 to all patients in the Indian registry, and prospectively between 06/2019 and 03/2021 at initial visit, 3, 6, 12 months post-intervention, then annually for the Canadian patients. Demographic, clubfoot, and treatment data were compared to OXFAQ-C domain scores. Descriptive statistics and regression analysis were performed. Parent-child concordance was evaluated with Pearson's Coefficient of Correlation (PCC). The cohort had 361 patients (253 from India, 108 from Canada). Non-idiopathic clubfoot occurred in 15% of children in India and 5% in Canada, and bilateral in 53% in India and 50% in Canada. Tenotomy rate was 75% in India and 62% in Canada. Median age at presentation was 3 months in India and 1 month in Canada. Mean Pirani score at presentation and number of Ponseti casts were 4.9 and 6.1 in India and 5.3 and 5.7 in Canada, respectively. Parents reported lower scores in all domains the older the child was at presentation (p Canadians scored significantly lower for all domains (p < 0 .001), with the difference being larger for child-reported scores. The greatest difference was for physical domain. Canadian parents on average scored their child 6.21 points lower than Indian parents, and Canadian children scored a mean of 7.57 lower than Indian children. OXFAQ-C scores differed significantly between Indian and Canadian children despite similar demographic and clubfoot characteristics. Younger age at presentation and tenotomy may improve OXFAQ-C scores in childhood. Parent-child concordance was strong in this population. The OXFAQ-C is an adequate tool to assess functional outcomes of children with clubfeet. Cultural validation of patient reported outcome tools is critical

Aims. To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population. Methods. In all, 73 children with idiopathic club foot were included: 31 children treated with the Ponseti method (mean age 8.3 years; 24 male; 20 bilaterally affected, 13 left and 18 right sides analyzed), and 42 treated with primary surgical correction (mean age 11.6 years; 28 male; 23 bilaterally affected, 18 left and 24 right sides analyzed). Foot function data was collected during walking gait and included Oxford Foot Model kinematics (Foot Profile Score and the range of movement and average position of each part of the foot) and plantar pressure (peak pressure in five areas of the foot). Oxford Ankle Foot Questionnaire, Disease Specific Index for club foot, Paediatric Quality of Life Inventory 4.0 were also collected. The gait data were compared between the two club foot groups and compared to control data. The gait data were also correlated with the data extracted from the questionnaires. Results. Our findings suggest that symptomatic children with club foot deformity present with similar degrees of gait deviations and perceived disability regardless of whether they had previously been treated with the Ponseti Method or surgery. The presence of sagittal and coronal plane hindfoot deformity and coronal plane forefoot deformity were associated with higher levels of perceived disability, regardless of their initial treatment. Conclusion. This is the first paper to compare outcomes between Ponseti and surgery in a symptomatic older club foot population seeking further treatment. It is also the first paper to correlate foot function during gait and perceived disability to establish a link between deformity and subjective outcomes. Cite this article: Bone Joint Open 2020;1-7:384–391

The Ponseti method is the gold standard treatment for clubfoot. It begins in early infancy with weekly serial casting for up to 3 months. Globally, a commonly reported barrier to accessing clubfoot treatment is increased distance patients must travel for intervention. This study aims to evaluate the impact of the distance traveled by families to the hospital on the treatment course and outcomes for idiopathic clubfoot. No prior studies in Canada have examined this potential barrier. This is a retrospective cohort study of patients managed at a single urban tertiary care center for idiopathic clubfoot deformity. All patients were enrolled in the Pediatric Clubfoot Research Registry between 2003 and April 2021. Inclusion criteria consisted of patients presenting at after percutaneous Achilles tenotomy. Postal codes were used to determine distance from patients’ home address to the hospital. Patients were divided into three groups based on distance traveled to hospital: those living within the city, within the Greater Metro Area (GMA) and outside of the GMA (non-GMA). The primary outcome evaluated was occurrence of deformity relapse and secondary outcomes included need for surgery, treatment interruptions/missed appointments, and complications with bracing or casting. A total of 320 patients met inclusion criteria. Of these, 32.8% lived in the city, 41% in the GMA and 26% outside of the GMA. The average travel distance to the treatment centre in each group was 13.3km, 49.5km and 264km, respectively. Over 22% of patients travelled over 100km, with the furthest patient travelling 831km. The average age of presentation was 0.91 months for patients living in the city, 1.15 months for those within the GMA and 1.33 months for patients outside of the GMA. The mean number of total casts applied was similar with 7.1, 7.8 and 7.3 casts in the city, GMA and non-GMA groups, respectively. At least one two or more-week gap was identified between serial casting appointments in 49% of patients outside the GMA, compared to 27% (GMA) and 24% (city). Relapse occurred in at least one foot in 40% of non-GMA patients, versus 27% (GMA) and 24% (city), with a mean age at first relapse of 50.3 months in non-GMA patients, 42.4 months in GMA and 35.7 months in city-dwelling patients. 12% of the non-GMA group, 6.8% of the GMA group and 5.7% of the city group underwent surgery, with a mean age at time of initial surgery of 79 months, 67 months and 76 months, respectively. Complications, such as pressure sores, casts slips and soiled casts, occurred in 35% (non-GMA), 32% (GMA) and 24% (city) of patients. These findings suggest that greater travel distance for clubfoot management is associated with more missed appointments, increased risk of relapse and treatment complications. Distance to a treatment center is a modifiable barrier. Improving access to clubfoot care by establishing clinics in more remote communities may improve clinical outcomes and significantly decrease the burdens of travel on patients and families

Introduction. In cases of unilateral clubfoot, the leg and foot is visually smaller than the opposite, uninvolved side. Parents want to know how much smaller the leg and foot will be. The purpose of this study was to answer this question and compare the results of children treated with a posterior medial release (PMR) with those treated with the Ponseti method (PM). Methods. This is a prospective, longitudinal study of calf circumference and foot length. We measured the calf circumference with a tape measure at the visually maximum girth of the uninvolved side and at the symmetrical position of the involved side. We measured each foot length from the tip of the hallux to the end of the heel. We recorded the measurements at each follow-up visit in a database and analysed the data using linear regression analysis. Results. We followed 93 children (65 PMR, 28 PM) for a mean of 68 months (SD 55, range 6-252) The ratio men/women was 53/40. Mean percent calf size difference was 9.83% (95%CL 8.74-10.92%). Mean percent foot size difference was 8.70% (95%CL 7.54-9.87%). From the numbers available, no differences between the two procedures are evident. Conclusion. Children with a unilateral clubfoot have c10% smaller calf circumference and foot length as compared to the uninvolved side. We found no differences between children treated with PMR or PM, implying the smaller size is intrinsic to the condition and not due to type of treatment

Aim. Failed consolidation (nonunion) after foot and ankle arthrodesis is a major complication, which can lead to additional revision arthrodesis with increased risk of morbidity. Multiple factors can contribute to developing a nonunion, including a low-grade infection. The aim of this study was to investigate the rate of unsuspected low-grade infection in revision arthrodesis for nonunions after foot and ankle arthrodesis. We also analyzed the outcome of unsuspected low-grade infections. Method. We conducted a retrospective study in The Sint Maartenskliniek, The Netherlands. All patients who underwent revision arthrodesis for assumed aseptic nonunion after foot and ankle arthrodesis between January 2020 and July 2021 were included. Patients were excluded if <5 tissue samples were obtained during revision arthrodesis or if they were treated for infection after the index arthrodesis. For the included patients, at least 5 tissue samples for culture were taken during the revision arthrodesis. The causative microorganisms, antibiotic susceptibility and treatment were assessed. An unsuspected infection was defined as ≥2 positive cultures with phenotypical identical microorganisms. Success was defined as union on imaging during clinical follow-up, without signs of persistent infection after finishing the antibiotic treatment. Results. In total 91 revision arthrodesis due to nonunion were performed. The mean duration between index and revision arthrodesis was 571 days. In 14 patients, an unexpected infection was diagnosed. The most frequent causative bacteria identified were Cutibacterium acnes (n=10) and Staphylococcus spps. (n=5). One infection was caused by a Gram-negative bacilli (Acinetobacter spps.). Two infections were polymicrobial. Of the 14 infections, 12 were treated with antibiotics for 12 weeks, 1 for 6 weeks and 1 was not treated. After one-year follow-up, the success rate was 86% and in one patient re-surgery was performed for a non-infectious reason. Conclusions. In 18% of the revisions for nonunion after foot and ankle arthrodesis, an unexpected low- grade infection was the cause of the nonunion. Nonunion occurring after foot and ankle arthrodesis is a severe complication, leading to additional revision arthrodesis. Low-grade infection should be considered as possible explanation of the nonunion, despite the lack of local inflammatory signs. As 18% of the nonunions were unexpectedly caused by low-grade infection, we strongly recommend obtaining at least 5 tissue samples for culture during revision arthrodesis. The outcome of unexpected infection as cause of nonunion is good, when treated with targeted antibiotics for 12 weeks

Introduction. A common acute orthopaedic presentation is an ulcerated or infected foot secondary to diabetic neuropathy. Surgical debridement or amputation are often required to manage this complication of diabetes. International literature indicates that amputation may lead to further complications and an increased mortality rate. The aim of this study is to investigate the mortality rate associated with different surgical interventions. This will inform surgical management of patients presenting with acute foot complications from diabetes. Methods. This is a retrospective review of patients with diabetic foot infections aged >16 years attending Middlemore Hospital over a 10-year period (2012–2021). Clinical records were examined to determine whether patients were managed with no surgery, surgery but not amputation, or amputation. We recorded relevant baseline characteristics and comorbidities. Regression models were used to determine factors associated with mortality. Results. Over the study period, 1260 patients were included in analysis. Patients were divided into three groups, a control group who received no surgical intervention (n=554), those receiving surgery but not amputation (n=269), and those who underwent amputation (n=437). After adjustment for potential confounders, mortality rates were significantly higher in those who underwent amputation compared with those who received surgical intervention without amputation. Survival probability at 1 year and 5 years was highest in the surgical intervention but not amputation group. Conclusion. It is clinically important that there is a lower mortality rate in patients who undergo surgical intervention without amputation. Treatment that aims to salvage the limb rather than amputate should be considered in management of patients with diabetic foot complications to optimise their care

Progressive collapsing foot deformity (PCFD) is a common condition with an estimated prevalence of 3.3% in women greater than 40 years. Progressive in nature, symptomatic flatfoot deformity can be a debilitating condition due to pain and limited physical function; it has been shown to have one of the poorest preoperative patient reported outcome scores in foot and ankle pathologies, second to ankle arthritis. Operative reconstruction of PCFD can be performed in a single-stage manner or through multiple stages. The purpose of this study is to compare costs for non-staged (NS) flatfoot reconstructions, which typically require longer hospital stays, with costs for staged (S) reconstructions, where patients usually do not require hospital admission. To our knowledge, the comparison between single-staged and multi-staged flatfoot reconstructions has not been previously done. This study will run in conjunction with one that compares rates of complications and reoperation, as well as patient reported outcomes on function and pain associated with S and NS flatfoot reconstruction. Overall, the goal is to optimize surgical management of PCFD, by addressing healthcare costs and patient outcomes. At our academic centre with foot and ankle specialists, we selected one surgeon who primarily performs NS flatfoot reconstruction and another who primarily performs S procedures. Retrospective chart reviews of patients who have undergone either S or NS flatfoot reconstruction were performed from November 2011 to August 2021. Length of operating time, number of primary surgeries, length of hospital admission, and number of reoperations were recorded. Cost analysis was performed using local health authority patient rates for non residents as a proxy for health system costs. Rates of operating room per hour and hospital ward stay per diem in Canadian dollars were used. The analysis is currently ongoing. 72 feet from 66 patients were analyzed in the S group while 78 feet from 70 patients were analyzed in the NS group. The average age in the S and NS group are 49.64 +/− 1.76 and 57.23 +/− 1.68 years, respectively. The percentage of female patients in the S and NS group are 63.89% and 57.69%, respectively. All NS patients stayed in hospital post-operatively and the average length of stay for NS patients is 3.65 +/− 0.37 days. Only 10 patients from S group required hospital admission. The average total operating room cost including all stages for S patients was $12,303.12 +/− $582.20. When including in-patient ward costs for patients who required admission from S group, the average cost for operating room and in-patient ward admission was $14,196.00 +/− $1,070.01 after flatfoot reconstruction. The average in-patient ward admission cost for NS patients was $14,518.83 +/− $1,476.94 after flatfoot reconstruction. The cost analysis for total operating room costs for NS patients are currently ongoing. Statistical analysis comparing S to NS flatfoot reconstruction costs are pending. Preliminary cost analysis suggests that multi-staged flatfoot reconstruction costs less than single-staged flatfoot reconstruction. Once full assessment is complete with statistical analysis, correlation with patient reported outcomes and complication rate can guide future PCFD surgical management

Abstract. Background. Distinction between foot and ankle wound healing complications as opposed to infection is crucial for appropriate allocation of antibiotic therapy. Our aim was to evaluate the diagnostic accuracy of white cell count (WCC) and C-reactive protein (CRP) as diagnostic tools for this distinction in the non-diabetic cohort. Methods. Data were reviewed from a prospectively maintained Infectious Diseases Unit database of 216 patients admitted at Leicester University Hospitals – United Kingdom between July 2014 and February 2020 (68 months). All diabetic patients were excluded. For the infected non-diabetic included patients, we retrospectively retrieved the inflammatory markers (WCCs and CRP) at the time of presentation. Values of CRP 0–10 mg/L and WCC 4.0–11.0 ×109 /L were considered normal. Results. 25 patients met our inclusion criteria. Infections were confirmed microbiologically with positive intra-operative culture results. 7 (28%) patients with foot osteomyelitis (OM), 11 (44%) with ankle OM, 5 (20%) with ankle septic arthritis, and 2 (8%) patients with post-surgical wound infection were identified. Previous bony surgery was identified in 13 (52%) patients. 21 (84%) patients did have raised inflammatory markers while 4 (16%) patients failed to mount an inflammatory response even with subsequent debridement and removal of metalwork. CRP sensitivity was 84%, while WCC sensitivity was only 28%. Conclusion. CRP had good sensitivity, whereas WCC is a poor inflammatory marker in the detection of such cases. In presence of a clinically high level of suspicion of foot or ankle infection, a normal CRP should not rule out the diagnosis of OM

Aim. Treatment recommendations for periprosthetic joint infections (PJI) include surgical debridement, antibiotic therapy or staged revision. In surgical related foot and ankle infections (SR-FAI), implant removal will lead to instability. Debridement is difficult because the implant is outside the joint. Recommendations regarding PJI treatment can therefore not be extrapolated to the treatment of SR-FAI. Method. We searched PubMed for the etiology and treatment of SR-FAI, taken into account the time of occurrence, causative microorganisms and surgical treatment options. We integrated this knowledge into a treatment algorithm for SR-FAI. Results. Within the first 6 weeks after surgery, it is difficult to distinguish acute osteomyelitis from surgical site infection in which infection is limited to the soft tissue. The predominantly causative microorganism is Staphylococcus aureus. No debridement can be performed, because of the diffuse soft tissue inflammation and the absence of a joint space. If early SR- FAI is suspected without signs of systemic symptoms, fistula or abscess, empirical antibiotic treatment covering Staphylococcus aureus is recommended. If there is suspicion of ongoing SR-FAI after 2 weeks of empirical treatment, samples for culture after an antibiotic free window should be obtained to identify the causative microorganisms. If SR-FAI is confirmed, but there is no consolidation yet, targeted antibiotic treatment is given for 12 weeks without initial implant removal. In all other cases, debridement and samples for culture should be obtained after an antibiotic free window. Staged revision surgery will be performed if there is still a nonunion. Conclusions. Treatment algorithm regarding PJI cannot be extrapolated to the treatment of SR-FAI. Until now, no treatment guideline for SR-FAI is available. We have introduced a treatment algorithm for the treatment of SR-FAI. The guideline will be validated during the next 2 years

Progressive collapsing foot deformity (PCFD) is a complex foot deformity with varying degrees of hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. In its management, muscle and tendon balancing are important to address the deformity. Peroneus brevis is the primary evertor of the foot, and the strongest antagonist to the tibialis posterior. Moreover, peroneus longus is an important stabilizer of the medial column. To our knowledge, the role of peroneus brevis to peroneus longus tendon transfer in cases of PCFD has not been reported. This study evaluates patient reported outcomes including pain scores and any associated surgical complications for patients with PCFD undergoing isolated peroneus brevis to longus tendon transfer and gastrocnemius recession. Patients with symptomatic PCFD who had failed non-operative treatment, and underwent isolated soft tissue correction with peroneus brevis to longus tendon transfer and gastrocnemius recession were included. Procedures were performed by a single surgeon at a large University affiliated teaching hospital between January 1 2016 to March 31 2021. Patients younger than 18 years old, or undergoing surgical correction for PCFD which included osseous correction were excluded. Patient demographics, medical comorbidities, procedures performed, and pre and post-operative patient related outcomes were collected via medical chart review and using the appropriate questionnaires. Outcomes assessed included Visual Analogue Scale (VAS) for foot and ankle pain as well as sinus tarsi pain (0-10), patient reported outcomes on EQ-5D, and documented complications. Statistical analysis was utilized to report change in VAS and EQ-5D outcomes using a paired t-test. Statistical significance was noted with p<0.05. We analysed 43 feet in 39 adults who fulfilled the inclusion criteria. Mean age was 55.4 ± 14.5 years old. The patient reported outcome mean results and statistical analysis are shown in Table one below. Mean pre and post-operative foot and ankle VAS pain was 6.73, and 3.13 respectively with a mean difference of 3.6 (p<0.001, 95% CI 2.6, 4.6). Mean pre and post-operative sinus tarsi VAS pain was 6.03 and 3.88, respectively with a mean difference of 2.1 (p<0.001, 95% CI 0.9, 3.4). Mean pre and post-operative EQ-5D Pain scores were 2.19 and 1.83 respectively with a mean difference of 0.4 (p=0.008, 95% CI 0.1, 0.6). Mean follow up time was 18.8 ± 18.4 months. Peroneus brevis to longus tendon transfer and gastrocnemius recession in the management of symptomatic progressive collapsing foot deformity significantly improved sinus tarsi and overall foot and ankle pain. Most EQ-5D scores improved, but did not reach statistically significant values with the exception of the pain score. This may have been limited by our cohort size. To our knowledge, this is the first report in the literature describing clinical results in the form of patient reported outcomes following treatment with this combination of isolated soft tissue procedures for the treatment of PCFD. For any figures or tables, please contact the authors directly

Introduction. Charcot Arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. The traditional surgical method of extensive surgical exposure, excision of bone, acute correction and internal fixation is not always appropriate in presence of active ulceration, deep infection and poor bone quality. Minimally invasive osteotomies and gradual correction of deformities with a circular frame are proving helpful in minimizing complications. We present our experience with the use of Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. Materials and Methods. Our indication for the treatment with TSF is recurrent or intractable ulceration with or without active bone infection or a history of infection in a deformed foot and/or ankle. There are 2 female and 8 male patients in this cohort. We used a long bone module for ankle and hindfoot deformities (3 patients) and a forefoot 6×6 butt frame (7 patients) for midfoot deformities. An osteotomy through midfoot was performed in all chronic stable midfoot deformity cases and a calcaneal osteotomy and gradual correction through ankle in when hindfoot and ankle deformities co-existed. Results. Our outcome measures are a complete healing of ulcer and infection without recurrence, clinically plantigrade foot and ability to wear regular shoes or diabetic footwear. We achieved this outcome in 9 out of 10 patients. Successful patients remain ulcer free at minimum 7 and maximum 14 years follow up. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. Conclusions. Our results confirm that Taylor Spatial Frame treatment is a good alternative to traditional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities

Anesthetic peripheral nerve blocks (PNB) have been shown to be more advantageous than general anesthesia in a variety of surgical operations. In comparison to conventional methods of general anesthesia, the choice of regional localized infiltration has been shown to shorten hospital stays, decrease hospital readmissions, allow early mobilization, and reduce narcotic use. Perioperative complications of PNBs have been reported at varying rates in literature. Thus, the purpose of this study was to provide a review on the clinical evidence of PNB complications associated with foot and ankle surgeries. A systematic review of the literature was completed using PubMed search terms: “lower extremity”, “foot and ankle”, “nerve block”, and “complications”. All studies reporting minor and major complications were considered along with their acute management, treatments, and postoperative follow up timelines. The range of complications was reported for Sensory Abnormalities, Motor Deficits, Skin and systemic complications (local anesthetic systemic toxicity & intravascular injections). A designation of the scientific quality (Level I-IV) of all papers was assigned then a summary evidence grade was determined. The search strategy extracted 378 studies of which 38 studies were included after criteria review. Block complications were reported in 20 studies while 18 studies had no complications to report. The quality of evidence reviewed ranged from Level I to Level IV studies with follow up ranging from twenty four hours to one-three year timelines. The range of complications for all studies reporting sensory abnormalities was 0.53 to 45.00%, motor deficits 0.05 to 16.22% and skin and systemic complications 0.05 to 6.67%. Sensory abnormalities that persisted at last follow up occurred in six studies with incidence ranging from 0.23 to 1.57%. Two studies reported motor complications of a foot drop with an incidence of 0.05% and 0.12%. When considering only the highest quality studies (Level 1) that had complications to report, the complications rate was 10.00% to 45.00% for sensory abnormalities, 7.81 to 16.22% for motor deficits, 6.67% for skin complications and 2.50% for systemic complications. High quality studies (Level I providing Summary Grade A Evidence) reporting all complications with a range of incidence from 0 to 45%. While most of these complications were not serious and permanent, some were significant including sensory abnormalities, foot drop and CRPS. Based on this systematic review of the current literature, the authors emphasize a significant rate of complications with PNB and recommend that patients are appropriately informed prior to consenting to these procedures

In 2010, we published results of Ponseti versus primary posteromedial release (PMR) for congenital talipes equinovarus (CTEV) in 51 prospective patients. This study reports outcomes at a median of 15 years from original treatment. We followed 51 patients at a median of 15 years (range 13–17 years) following treatment of CTEV with either Ponseti method (25 patients; 38 feet) or PMR (26 patients; 42 feet). Thirty-eight patientsd were contacted and 33 participated in clinical review (65%), comprising patient reported outcomes, clinical examination, 3-D gait analysis and plantar pressures. Sixteen of 38 Ponseti treated feet (42%) and 20 of 42 PMR treated feet (48%) had undergone further surgery. The PMR treated feet were more likely to have osteotomies and intra- articular surgeries (16 vs 5 feet, p<0.05). Of the 33 patients reviewed with multimodal assessment, the Ponseti group demonstrated better scores on the Dimeglio (5.8 vs 7.0, p<0.05), the Disease Specific Instrument (80 vs 65.6, p<0.05), the Functional Disability Inventory (1.1 vs 5.0, p<0.05) and the AAOS Foot & Ankle Questionnaire (52.2 vs. 46.6, p < 0.05), as well as improved total sagittal ankle range of motion in gait, ankle plantarflexion range at toe off and calf power generation. The primary PMR group displayed higher lateral midfoot and forefoot pressures. Whilst numbers of repeat surgical interventions following Ponseti treatment and primary PMR were similar, the PMR treated feet had greater numbers of osteotomies and intra-articular surgeries. Outcomes were improved at a median of 15 years for functional data for the Ponseti method versus PMR, with advantages seen in the Ponseti group over several domains. This study provides the most comprehensive evaluation of outcomes close to skeletal maturity in prospective cohorts, reinforcing the Ponseti Method as the initial treatment of choice for idiopathic clubfeet

Introduction. Patients undergoing total knee arthroplasty (TKA) with end-stage osteoarthritis of knee have secondary foot and ankle pathology. Some compensatory changes occur at ankle and subtalar joint secondary to malalignment and deformity at the knee joint. Purpose was to evaluate the changes in hindfoot malalignment and foot deformities in patients with advanced osteoarthritis of knee requiring TKA and effect of correction of knee deformities post TKA on foot/Ankle alignment. Methods. 61 consecutive patients with Kellgren-Lawrence grade IV osteoarthritis knee undergoing TKA were enrolled in a prospective blinded study. Demographic data, deformities at knee and ankle, hindfoot malalignment and functional outcome scores such as VAS, KSS, WOMAC scores, Foot and Ankle Disability Index (FADI) and Foot posture index (FPI) were recorded preoperatively and postoperatively at 6, 12 weeks and final follow up (range: 6–21 months; mean: 14.2months). Results. Statistically significant improvement was observed in KSS score, WOMAC score, FADI and FPI after TKA. There was improvement in ankle valgus after correction of knee varus deformity. Hind foot changes mainly occured at subtalar joint. Hallux valgus (10 patients), and Pesplanus (5 patients) were associated with advanced osteoarthritis of knee. Gait profile score and Gait deviation index improved significantly after TKA. There was increased stance phase and decreased stride length in knee osteoarthritis patients which improved after TKA. Conclusion. Hind foot malalignment with foot deformities (hind foot valgus) occur secondary to knee malalignment and deformities (varus deformity) in advanced osteoarthritis of knee which subsequently improve following TKA

Introduction. Although weight-bearing CT of the foot definitely reflects the morphology and deformity of joint, it is hard to obtain the standing CT due to difficulty of availability. Although 3D imaging reconstruction using radiographs has been reported in other joints, there is no study about foot joint. The purpose of this study is to develop a semi-automatic method based on a deformable surface fitting for achieving the weight-bearing 3D model reconstruction from standing radiographs for foot. Methods. Our method is based on a Laplacian surface deformation framework using a template model of foot. As pre- processing step, we obtained template surface meshes having the average shapes of foot bones (talus, calcaneus) from standing CT images (Planmed Verity) in 10 normal volunteers. In the reconstruction step, the surface meshes are deformed following guided user inputs with geometric constraints to recover the target shapes of 30 patients while preserving average bone shape and smoothness. Finally, we compared reconstructed 3D model to original standing CT images. Analysis was performed using Dice coefficients, average shape distance, maximal shape distance. Results. The obtained reconstruction model is close to the actual standing foot geometry (Dice coefficients 0.89, average shape distance 0.88 mm, maximum shape distance 6.33 mm). We present the accuracy and robustness of our method via comparison between the reconstructed 3D models and the original bone surfaces. Conclusions. Weight-bearing 3D foot model reconstruction from standing radiographs is concise and the effective method for analysis of foot joint alignment and deformity

The Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) is a validated patient reported outcome tool for paediatric foot and ankle conditions. It includes three domains with a maximum score of 100: physical, school and play, and emotional. The purpose of this cross-sectional study is to examine the differences between self-reported child and parent responses of different age groups, genders, and child-parent combinations. During a ten-month period, paediatric patients aged eight to 16 years and their parents completed the OxAFQ-C during routine clinic visits, providing a total 116 child-parent questionnaire dyads. Demographics and diagnostic information was obtained through medical record review. Parent and child responses in each domain were compared for concordance and for effect of demographic variables on the results. Means and standard deviations for parent and child questionnaires for each domain were reported and compared using a two-sample Wilcoxon rank-sum test. A multivariate regression model was used to assess the correlation between demographic characteristics with domain scores. Absolute agreement between patient and parent questionnaires was assessed using intra-class correlation coefficients (ICC) with a two-way random effects model. Seventy patients (60.3%) were female and 46 (39.7%) were male, the majority of parent respondents were mothers (85.3%), followed by fathers (11.2%). Mean patient age was 12.4 (± 2.2) years. Higher scores were reported by the child in every domain, though only the emotional domain score showed statistical significance (p = 0.024) between the parent scores. Male children scored significantly higher than females in school and play domain, (mean 82.38 vs 71.13, p = 0.037) and in the emotional domain (means 90.89 vs79.10, p = 0.002). Parents of males scored significantly higher than parents of females only in the emotional domain (means 86.95 vs 72.67, p = 0.001). Children younger than 13 years old scored significantly higher than older children in the emotional domain (p = 0.004). Child and parent responses for the OxAFQ-C are statistically concordant in the physical and school and play domains. Though children consistently scored themselves higher than their parents did in all domains, only differences in responses for the emotional domain were significant. The level of agreement between parent and child increases with in patients over 13 years of age. Both females and parents of females report lower scores than males and their male parents. Though the use of OxAFQ-C is supported and confirms parent perception of their child's foot and ankle condition is accurate, further research is needed to better understand gender and age differences on response concordance

Aim. Since surgical site infections (SSIs) remain among the most common complications of orthopedic (trauma) surgery, there has been unwavering attention for potential predictors of a SSI. Specifically in surgical fields with a high complication rate, such as foot/ankle surgery, risk factor identification is of great importance. Recently, some studies have suggested environmental factors such as season to be of influence on the number of SSI. Specifically patients operated on in the summer are reported to have a higher incidence of SSIs, compared to other seasons. The aim of this study is to identify if “seasonality” is a significant predictor for SSI in a cohort of (trauma) surgical foot and ankle procedures. Method. This retrospective cohort study included all patients undergoing trauma related surgery (fracture fixation, arthrodesis, implant removal and tendon repair) of the lower leg, ankle and foot. Procedures were performed at a single Level 1 Trauma Center in the Netherlands between September 2015 until February 2019. Potential risk factors/ confounders for SSI were identified using univariate analysis (Chi-Square/Mann-Whitney U). Procedures were divided in two groups: 1) performed in summer (June, July or August), 2) not performed in summer (September-May). The number of SSIs was compared between the 2 groups, correcting for confounders, using multivariate regression. Results. A total of 605 procedures were included, largely fracture fixation (371, 61.2%). Patients were on average 46 y/o and the majority was male (369, 60.9%). The total number of SSIs was 34 (5.6%). Age, American Society of Anesthesiologists (ASA) classification (1–2 or 3–4) and open fractures were identified as possible predicting factors of SSI. No difference in SSIs was found between summer and other seasons, neither in univariate analysis (4 (3.2%) vs 30 (6.3%), p=0.271), nor when corrected for confounders. Moreover, in multivariate analysis only an ASA of >2 and an open fracture remained as independent predictors of SSI. Conclusions. No seasonality could be identified in the rate of SSI after trauma surgery of the lower leg, ankle and foot in this cohort. A possible explanation for this lack of effect could be the temperate oceanic climate of the Netherlands. Larger temperature and precipitation differences may also influence the incidence of SSIs. However, previous studies suggesting seasonality in SSIs might also be purely based on coincidence, especially when uncorrected for confounders

Background. The gold standard of care of clubfoot is the Ponseti method of serial manipulation and casting, followed by percutaneous tendo-achilles tenotomy. In our setting, registrars work in district hospitals where they run Ponseti clubfoot clinics with little or no specialist supervision. They use the Pirani score to serially assess improvement of the deformity during casting and to determine whether the foot is ready for tenotomy. Purpose of Study. To test the inter-observer reliability of the Pirani score, and whether it can be used by non-specialist doctors running Ponseti clubfoot clinics. Methods. Ethics permission was obtained from our institution. This is a prospective study where patients under the age of one year with idiopathic clubfoot were recruited from clubfoot clinics at our institution, over a period of four months. Following a training session using the original description of the score, each foot was independently assessed using the Pirani score by two paediatric orthopaedic surgeons, two orthopaedic registrars and two medical officers. The inter-observer reliability was assessed using the Fixed-marginal Kappa statistic and Percentage agreement. The first 15 feet were used as a learning curve, and hence excluded from final analysis. Results. 73 feet in 37 patients with idiopathic clubfoot (25 boys, 12 girls) under the age of 1 year were included in the study. The Kappa statistic and percentage agreement for the six variables of the Pirani score were determined. Whilst the overall agreement was determined by the Kappa statistic to be slight to fair, the two consultants were found to have a higher inter-observer reliability than the registrars and medical officers. Conclusion. Our results conflict with previously published studies in that the inter-observer reliability of the Pirani score was poor. In addition, we feel that this score cannot be reliably used by non-specialist doctors running Ponseti clubfoot clinics. NO DISCLOSURES

Patients' perspective and experience is heavily modulated by their understanding of their pre-operative disability along with their overall coping strategy and life philosophy. Given that evidence-based practice is relying on patient-reported outcomes more and more, the orthopaedic community must be diligent in differentiating patients that may have the same objective outcome but vary widely on a patient-reported subjective basis. In clinical practice, patient selection is often a sensitive, experience-based decision process that screens for catastrophization, recognizing that certain patients will not benefit from a simple surgery. It is well appreciated that patient's catastrophization can affect their subjective outcome but there is little reported literature on this abstract concept. The study set out to determine if post-operative outcomes correlated with pre-operative catastrophization scales. This current study set out to look at a cohort of complex consecutive foot and ankle cases and describe the relationship between Patient Catastrophizing Score (PCS) and multiple functional outcomes that are used commonly in foot and ankle specifically (SF-12 & FAOS). The PCS has three subcategory rumination, helplessness and magnification. A single institution undertook recruitment in consecutive patients within three surgeon's practice. In the end, 46 patients were found to be eligible in the study with an average age of 54.72 ± 14.41 years-old, a majority female 30 / 46 (65.22%), a minority employed at the pre-operative visit 19/46 (41%) and with an average BMI of 26.2 ± 5.56. We found that the mental component of the SF12 had a statistically significant negative effect with the rumination score (r=−1.03) (p = 0.01) and the helplessness score (r=−1.05) (0.001). There was no statistically significant effect for the physical component of the SF-12. Looking at the FAOS Pain component, it correlated was significantly with the PCS rumination (Multivariate : r= −7.6 (p=0.002) Univariate: r=−2 (0.03)) and helplessness (Multivariate : r=−6.73 (p=0.01) Univariate: r=−1.5 (p=0.03)). Otherwise the FAOS ADL component showed correlation as well with the PCS rumination (Multivariate: r=−4.67 (p=0.02) Univariate : r=−1.85 (p=0.01)), helplessness (Multivariate r=−5.89 (p = 0.01) Univariate r=−1.81 (p = 0.001)) and total score (Multivariate : r=3.74 (p=0.02) Univariate r=−0.75 (p=0.01)). The FAOS Quality of life component was statistically significant for the rumination score (Univariate r=−11.59) (p < 0.05) and the helplessness score (Univariate r=−9.65) (p = 0.002) also the PCS total (Univariate r=8.54) (p = 0.0003). As layed out in our hypothesis, this study did show an association between an increase patient catastrophizing score pre-operatively and a worse outcome in the following scores: Mental component of SF12, FAOS Pain, FAOS ADL and FAOS Quality of life components. This is an association and no causality can be proven within the limits of this current pilot study, but remains alarming. In elective surgeries, catastrophization should be screened for using the PCS form and potentially modulated pre-operatively with the help of allied health therapist while a patient is on the waitlist

Spezializing in subfields of Orthopaedics is common in anglo-american countries for more than 20 years. IThe aim of this paper is to demonstrate the necessity of fellowship programms in extremity orientated subfileds of orthopaedics. Analyzing the results of ankle arthrodesis performed by general orthopaedic surgeons campared to ankle arthrodesis performed by spezialized foot and ankle surgeons the difference in results will be demonstrated. Patients and methods. In 40 patients an ankle arthrodesis was performed between 1998 and 2012. Group A was formed by 20 consecutive patients treated by spezial trained Foot and Ankle surgeons and group B was formed by 20 patients treted by general orthopaedic surgeons. The average age in group A at the time of surgery was 59,9y (34 to79y) compared to 63,4y (41 to 80y) in group B. The average follow up was 34 months respectively 32 months after surgery. The study included a spezial questionnaire with the AOFAS score and rating of patients dissatisfaction. The successful healing of the arthrodesis was determied by using standardized radiographs, Furthermore a pedobarography, and a videoanalyzis of the walking was incuded. Results. All procedures in group A were performed using an anterior approach. Neither pseudarthroses, equinus or other malositions were detected in this group. In group B wurdenin 16 patients an anterior and in 4 patients a lateral approach was used. Complications included 3 pseudarthroses, 4 equinus malpositions, 4 varus malpositions, 4 valgus malpositions and 8 penetrations of the subtalar joint. The AOFAS score on average was 78 (46–92) points in group A and 75 (34 – 94) in group B. Conclusion. The analyzis of the data revealed that the results in Group A were comparable to the results published in the literature. Results in group B were inferior to those in group A and to the results published in the literature of Foot and Ankle surgery. Foot and Ankle surgery became more demanding over the last decades. As already shown in anglo-american countries spezializing in certain fields of orthopaedics is a necessity. More complex hindfoot surgery should be performed in special centers with an adequate case load