Background. Surgical intervention for hallux valgus and hallux rigidus is an option for patients presenting with severe pain and deformity. Literature suggest that patients with high Pain Catastrophisation Scores (PCS) have poorer outcomes in spinal and to a lesser extent in arthroplasty surgery. There is however very little evidence pertaining to foot and ankle surgery. Aim. We aimed to study whether catastrophisation as measured by PCS influenced the outcomes following surgery for Hallux valgus and rigidus. Methodology. Ethical approval for this prospective portfolio study was obtained from NRES Committee South Central and Oxford. Approval was granted from the local R&D department prior to data collection. All patients listed for surgery for hallux pathology to the four senior authors were invited to participate. Recruitment into the study started in September 2017 and is ongoing. Pain catastrophising score (PCS), Manchester Oxford Foot Questionnaire (Mox-FQ), Visual analog scale (VAS) for pain and EQ-5D-3L questionnaires were completed Pre-op (baseline), and at 3, 6 and 12- months post-surgery. Results. 93 patients with minimum follow-up of 6 months were analysed using SPSS software. A P-value of less than 0.05 was considered significant. The mean age of the patients was 58.5 years and 83% were women. 70% of the patients had surgery for hallux valgus and rest for rigidus. Both PROMS and PCS improved significantly following surgical intervention. Patients with higher pre-operative PCS had a worse 6-month PROM score and more pain. Conclusion. This study confirms that pre-operative catastrophisation as demonstrated by a high PCS score has an adverse effect on outcomes following hallux surgery. Risk stratifying patients based on their Pre-op PCS scores may be a useful strategy to identify those at risk of poorer outcomes. We recommend that behavioural change interventions should be considered to try to improve outcomes in patients with pre-op PCS

Introduction. Early clinical examination combined with MRI following a high ankle sprain allows accurate diagnosis of syndesmosis instability. However, patients often present late, and for chronic injuries clinical assessment is less reliable. Furthermore, in many centres MRI may be not be readily available. The aims of the current study were to define MRI characteristics associated with syndesmosis instability, and to determine whether MRI patterns differed according to time from injury. Methods. Retrospectively, patients with an unstable ligamentous syndesmosis injury requiring fixation were identified from the logbooks of two fellowship trained foot and ankle surgeons over a five-year period. After exclusion criteria (fibula fracture or absence of an MRI report by a consultant radiologist), 164 patients (mean age 30.7) were available. Associations between MRI characteristics and time to MRI were examined using Pearson's chi-square tests or Fisher's exact tests (significance set at p< 0.05). Results. Overall, 100% of scans detected a syndesmosis injury if performed acutely (within 6 weeks of injury), falling to 83% if performed after 12 weeks (p=0.001). In the acute group, 93.5% of patients had evidence of at least one of either PITFL injury (78.7%), posterior malleolus bone oedema (60.2%), or a posterior malleolus fracture (15.7%). In 20% of patients with a posterior malleolus bone bruise or fracture, the PITFL was reported as normal. The incidence of posterior malleolus bone bruising and fracture did not significantly differ according to time. Conclusion. For unstable ligamentous syndesmosis injuries, MRI becomes less sensitive over time. Importantly, posterior malleolus bone oedema or fracture may be the only evidence of a posterior injury. Failure to recognise instability may lead to inappropriate management of the patient, long term pain and arthritis. We therefore advocate early MRI as it becomes more difficult to ‘grade’ the injury if delayed

This study investigated athletes presenting with grade II syndesmosis injuries and identified the clinical and radiological factors important in differentiating a stable from dynamically unstable injury and those findings associated with a longer recovery and return to sport.

Sixty-four athletes were prospectively assessed with an average follow-up of 37 months (range 24–66 months). Athletes with an isolated distal syndesmosis (+/− medial deltoid ligament) injury were included. Those athletes with a concomitant ankle fracture were excluded. Those considered stable (grade IIa) were treated conservatively with a boot and progressive rehabilitation. Those with clinical signs of instability underwent arthroscopy and if instability was confirmed (grade IIb) the syndesmosis was stabilized surgically. The clinical assessment of injury to individual ligaments of the ankle and syndesmosis were recorded along with MRI findings, complications and time to return to play.

All athletes returned to the same level of professional sport – 28 with IIa injuries returned at a mean of 45 days whereas the 36 with grade IIb injuries returned to play at a mean of 64 days (p< 0.001). Clinical assessment of injury to the ligaments of the syndesmosis correlated well with MRI findings. Those with a positive squeeze test were 9.5 times as likely and those with a deltoid injury 11 times more likely to have an unstable syndesmosis confirmed arthroscopically. The combination of injury to the AITFL and deltoid ligament was associated with a delay in return to sport. Concomitant injury to the ATFL indicated a different mechanism of injury with the syndesmosis less likely to be unstable and was associated with an earlier return to sport.

Clinical and MRI findings may differentiate stable from dynamically unstable grade II injuries and identify which athletes may benefit from early arthroscopic assessment and stabilization. It also suggests the timeframe for expected return to play.

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.

Background. Open subtalar arthrodesis has been associated with a moderate rate of non-union, as high 16.3%, and high rates of infection and nerve injury. Performing this operation arthroscopically serves to limit the disruption to the soft tissue envelope, improve union rates and reduce infection. Our study describes our outcomes and experience of this operation. Method. Retrospective review of all patients who underwent an arthroscopic subtalar arthrodesis between 2023 and 2008. We excluded patients undergoing concurrent adjacent joint arthrodesis. The primary aim was to report on rates of union. Secondary outcomes included reporting on conversion to open procedure, duration of surgery, infection, and iatrogenic injury to surrounding structures. Results. 135 patients were included in the final analysis. 129 patients (95.5%) achieved union. The median time to fusion was 98 days. All cases were performed through sinus tarsi portals. 38 cases were performed with an additional posterolateral portal. Most cases (107/77%) were performed with 2 screws. 3 cases (2.2%) were converted to open procedures. The median tourniquet time was 86 minutes but available in only 88 (65%) cases. There were 4 (2.9%) superficial infections and no deep infections. 1 patient sustained an injury to FHL and there were no reported nerve injuries. Conclusions. At present this is the largest series of arthroscopic subtalar arthrodeses. We demonstrate that this operation can achieve high rates of union with low rates of infection with an equally low likelihood of needing to convert to an open procedure with modest operative times. In our experience the addition of a posterolateral portal does not appear to increase the incidence of nerve injury and aids in the visualisation of all 3 facets

Purpose. To explore the relationship in terms of time scale between pre-operative expectations and postoperative outcomes and satisfaction after Hallux valgus surgery. Methods. A patient derived questionnaire was developed and 30 patients aged 19 to 67 were included undergoing primary hallux valgus correction with a first metatarsal osteotomy and distal soft tissue release. Patients were asked pre-operatively to quantify their expected time scale for improvement in pain, ability to walk unaided, ability to drive, routine foot wear and foot feeling normal at 6 weeks, 3 and 6 months following surgery, and to indicate their confidence in achieving this result. Patients recorded postoperative outcomes achieved at number of weeks. Ordinal logistic regression multivariate modelling was used to examine predictors of postoperative satisfaction. Results. 90% of the patients were able to walk unaided and drive before or around the expected time scale at an average of five weeks' time. Persistent pain subsided at an average of two weeks post operatively which led to high satisfaction Although differences between patients' expectation and achievement were minimal at 6 weeks post-operatively, there was some discrepancy at 3 months, with patient expectations far exceeding achievement. The least satisfactory outcome was normal feeling of foot at six months follow up. There were significant correlations between failure to achieve expectations and the importance patients attached to recovery. Conclusions. This study underlines the importance of taking preoperative expectations into account to obtain an informed choice on the basis of the patient's preferences. Patients' pre-operative expectations of surgical outcome exceed their functional achievement but satisfaction remains high if pain control and ability to walk unaided is achieved early after hallux valgus corrective surgery

Introduction. This is a multi-centre, prospective, observational study of 503 INFINITY fixed bearing total ankle arthroplasties. We report the minimum two-year results of this prosthesis which was introduced to the UK Market in 2014 and is now the most used ankle arthroplasty in the National Joint Registry of England and Wales. Methods. Patients were recruited from 11 centres in the United Kingdom between June 2016 and November 2019. Demographic, radiographic, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Foot Ankle Questionnaire and Euroquol 5D-5L) were collected preoperatively, at 6 months, 1 year and 2 years and 5 years. The average age was 67.8 (range 23.9 to 88.5) and average BMI 29.3 (18.9 to 48.0). The COFAS grading system was used to stratify deformity. There were 261 (51.9%) COFAS Type 1, 122 (24.2%) COFAS Type 2, 31 (6.2%) COFAS 3 and 89 (17.7%) COFAS type 4. 38 patients (7.6%) presented with inflammatory arthritis. 99 (19.7%) implantations utilised patient specific instrumentation. Complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts and/or subsidence. Results. The mean follow up was 34.2 months (range 24–64). 15 patients have died, 8 withdrawn and 3 lost to follow up. 8 implants (1.6%) have been revised. According to the Glazebrook classification there were low grade complications in 6.6%, medium grade in 1.4% and high grade in 1.6%. There have been an additional 13 non revision re-operations (2.6%) at the latest follow up. There was a significant (p < 0.01) improvement across all functional outcome scores at a minimum of 2yr follow up. Discussion and conclusion. This large cohort has shown a low early revision rate and high functional outcomes with a low-profile fixed bearing prosthesis

Background. Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below knee amputation; particularly in cases of severe soft tissue destruction. Aim. Assess the outcomes of combined ortho-plastics treatment of complex calcaneal osteomyelitis. Method. A retrospective review was performed of all patients who underwent combined single stage ortho-plastics treatment of calcaneal osteomyelitis (2008–2022). Primary outcome measures were osteomyelitis recurrence and BKA. Secondary outcome measures included flap failure, operative time, complications, length of stay. Results. 33 patients (16 female, 17 male, mean age = 54.4 years) underwent combined ortho-plastics surgical treatment for BACH “complex” calcaneal osteomyelitis with a median follow-up of 31 months (s.d. 24.3). 20 received a local flap, 13 received a free flap. Fracture-related infection (39%) and diabetic ulceration (33%) were the commonest causes. 54% of patients had already undergone at least one operation elsewhere. There were seven cases of recurrent osteomyelitis (21%); all in the local flap group. One patient required a BKA (3%). Recurrence was associated with increased mortality risk (OR 18.8 (95% CI 1.5–227.8), p=0.004) and reduced likelihood of walking independently (OR 0.14 (95% CI 0.02–0.86), p=0.042). Local flap reconstruction (OR 15 (95% CI 0.8–289.6), p=0.027) and peripheral vascular disease (OR 39.7 (95% CI 1.7–905.6), p=0.006) were associated with increased recurrence risk. Free flap reconstruction took significantly longer intra-operatively than local flaps (443 vs 174 minutes, p<0.001), but without significant differences in length of stay or frequency of out-patient appointments. Conclusions. Single stage ortho-plastic management was associated with 79% eradication of infection and 3% amputation in this complex and co-morbid patient group. Risk factors for failure were peripheral vascular disease and local flap reconstruction. Whilst good outcomes can be achieved, this treatment requires high levels of in-patient and out-patient care

Aims. To systematically review qualitative studies of patients with distal tibia or ankle fracture, and explore their experience of injury and recovery. Methods. We undertook a systematic review of qualitative studies. Five databases were searched from inception to 1 February 2022. All titles and abstracts were screened, and a subset were independently assessed. Methodological quality was appraised using the Critical Appraisal Skills Programme (CASP) checklist. The GRADE-CERQual checklist was used to assign confidence ratings. Thematic synthesis was used to analyze data with the identification of codes which were drawn together to form subthemes and then themes. Results. From 2,682 records, 15 studies were reviewed in full and four included in the review. A total of 72 patients were included across the four studies (47 female; mean age 50 years (17 to 80)). Methodological quality was high for all studies, and the GRADE-CERQual checklist provided confidence that the findings were an adequate representation of patient experience of distal tibia or ankle fracture. A central concept of ‘being the same but different’ conveyed the substantial disruption to patients’ self-identity caused by their injury. Patient experience of ‘being the same but different’ was expressed through three interrelated themes, with seven subthemes: i) being proactive where persistence, doing things differently and keeping busy prevailed; ii) living with change including symptoms, and living differently due to challenges at work and leisure; and iii) striving for normality, adapting while lacking in confidence, and feeling fearful and concerned about the future. Conclusion. Ankle injuries were disruptive, draining, and impacted on patients’ wellbeing. Substantial short- and longer-term challenges were experienced during recovery. Rehabilitation and psychosocial treatment strategies may help to ameliorate these challenges. Patients may benefit from clinicians being cognisant of patient experience when assessing, treating, and discussing expectations and outcomes with patients. Cite this article: Bone Jt Open 2023;4(3):188–197

Aims. A local injection may be used as an early option in the treatment of Morton’s neuroma, and can be performed using various medications. The aim of this study was to compare the effects of injections of hyaluronic acid compared with corticosteroid in the treatment of this condition. Methods. A total of 91 patients were assessed for this trial, of whom 45 were subsequently included and randomized into two groups. One patient was lost to follow-up, leaving 22 patients (24 feet) in each group. The patients in the hyaluronic acid group were treated with three ultrasound-guided injections (one per week) of hyaluronic acid (Osteonil Plus). Those in the corticosteroid group were treated with three ultrasound-guided injections (also one per week) of triamcinolone (Triancil). The patients were evaluated before treatment and at one, three, six, and 12 months after treatment. The primary outcome measure was the visual analogue scale for pain (VAS). Secondary outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) score, and complications. Results. Both groups showed significant improvement in VAS and AOFAS scores (p < 0.05) after 12 months. The corticosteroid group had a significantly greater reduction in VAS and increase in AOFAS scores compared with the hyaluronic acid group, at one, three, and six months, but with no significant difference at 12 months. There were no complications in the hyaluronic acid group. There were minor local complications in six patients (six feet) (25.0%) in the corticosteroid group, all with discolouration of the skin at the site of the injection. These minor complications might have been due to the three weekly injections of a relatively high dose of corticosteroid. No patient subsequently underwent excision of the neuroma. Conclusion. An ultrasound-guided corticosteroid injection showed statistically significantly better functional and pain outcomes than an ultrasound-guided injection of hyaluronic acid for the treatment of a Morton’s neuroma at many timepoints. Thus, a corticosteroid injection should be regarded as a primary option in the treatment of these patients, and the only indication for an injection of hyaluronic acid might be in patients in whom corticosteroid is contraindicated. Cite this article: Bone Joint J 2024;106-B(10):1093–1099

Background. The literature on the outcome of revision total ankle arthroplasty (TAA) remains limited. We aim to report the clinical and radiological outcomes of revision TAA at a high-volume centre in the UK. Methods. Retrospective review of 28 patients that underwent 29 revision TAA procedures using INBONE II prosthesis. Demographic, radiological, and patient reported outcome measures data were analysed. Results. The mean (range) duration from primary TAA to revision was 87.5 (16–223) months. The main indication for the revision was aseptic loosening of the primary TAA (82.8%). Additional procedures were required in 75.9% of patients. At mean (range) follow-up of 40 (24- 60) months, the infection, re-operation, and implant survival rates were 6.9%, 6.9% and 96.5% respectively. A significant postoperative improvement in the component alignment radiographic measures was observed. Osteolysis, subsidence, loosening and heterotopic ossification rates were comparable to other reports and did not influence the clinical outcome. A significant improvement was observed in the MOXFQ (all domains) and the EQ-5D (three domains) at 24 months postoperatively. Conclusions. Revision TAA using INBONE II was associated with good short-term survival and improvement in the postoperative scores at 2 years. Maintenance of the postoperatively improved alignment was documented at follow up. The relatively high survival rate in this series supports the notion that revision TAA is a satisfactory option for failed primary TAA

Objective. The purpose of this study was to determine the outcomes of revision ankle replacements, using the Invision implant and impaction allograft for massive talar dome defects following primary ankle replacement failure. Outcomes were assessed in terms of bone graft incorporation; improvement in patient reported outcome measures (PROMs); and survivorship of the revision ankle arthroplasty. Methods. A retrospective review of prospectively collected data identified eleven patients who had massive bone cysts and underwent revision of a failed primary total ankle replacement to the Invision revision system, combined with impaction grafting using morselized femoral head allograft. These revisions occurred at a single high volume ankle arthroplasty centre. Computed tomography (CT) scans were used to assess bone graft incorporation and the Manchester-Oxford Foot Questionnaire (MOXFQ) and EQ-5D scores were used pre and post operatively to assess PROMs. Results. The mean follow up was 18 months (12–48months). In all eleven patients, improvement was reported in the post-operative MOXFQ and EQ-5D scores. CT scans showed bone graft incorporation in all cases. None of the patients have required further surgery and are continue to do well clinically at latest follow up. Conclusions. In the short term, this study confirms revision ankle replacements with the Invision prosthesis and impaction with morselized femoral head allograft is a suitable revision option for primary ankle replacement failure with massive talar bone loss. Long term follow up continues of these complex patients

Talar body fractures are high energy intraarticular injuries that are best management by anatomical reduction and secure fixation to improve outcomes. The talus is relatively inaccessible surgically and requires extensive soft tissue dissection and/or osteotomies to gain adequate open visualisation. There are a small number of case reports on arthroscopic assisted fixation in the literature. This case series reports on the technique and early outcomes of six patients all of whom presented with significant intraarticular displacement and who were managed entirely arthroscopically. The fractures were of the main body of the talus involving the ankle and subtalar joints and all had preoperative CT scans. All six patients underwent posterior ankle and subtalar arthroscopy with cannulated screws used to stabilise the fractures after reduction. Visualisation of the fracture reduction was excellent. After 10 days in a backslab, the patients were protected in a boot and encouraged to actively move their ankles. Weight bearing was permitted once union appeared complete. There were no early complications of infection, avascular necrosis or VTE. There was one patient that had a non-clinically significant migration of a screw. Two patients were lost to follow up early due to being visitors. The mean length of follow up was 12 months in the remainder. The remaining four patients all returned to their preoperative level of activity. All had demonstrable subtalar stiffness. There was no early post-traumatic arthritis. This series represents the largest so far published. The main flaw in this report is the lack of long term follow up. While this report cannot state superiority over open techniques it is a safe, effective and acceptable technique that has significant conceptual benefits

Background. The use of a knotless TightRope for the stabilisation of a syndesmotic injury is a well-recognised mode of fixation. It has been described that the device can be inserted using a “closed” technique. This presents a risk of saphenous nerve entrapment and post-operative pain. Aim. We aimed to establish the actual risk of injury to the Saphenous Nerve using a “closed” technique for the insertion of a TightRope. Method. 20 TightRopes were inserted into Fresh Frozen Cadavers. This was done using the senior authors preferred technique of divergent tightropes with the distal implant directed slightly anterior to the fibula-tibia axis and the proximal implant slightly posterior in order to simulate the greatest risk to the nerve. This was done under image Intensifier guidance to simulate an intraoperative environment. The medial side of the distal tibia was then dissected to directly record and measure the relationship of the TightRope to the Saphenous Nerve. Measurements were taken using digital calipers from the centre of the button on the medial side of the TightRope to the centre of the nerve at the point of closest proximity. Results. 12 TightRopes were found to exit posterior to the nerve, 7 anterior and 1 penetrated through the centre of the nerve. The mean distance from the centre of the button to the nerve was 6.99mm (range 0.72–14.52mm, standard deviation 4.33mm). In 9 of the 20 TightRopes, the nerve was found to be less than 5mm away. Conclusion. Our findings demonstrated that the risks of damaging or indeed entrapping the Saphenous nerve were high, and therefore we would advocate an open incision on the medial side with judicious exploration to ensure there is no damage to the medial neurological structures

Introduction. Anatomic reduction of talar body fractures is critical in restoring congruency to the talocrural joint. Previous studies have indicated a maximum of 25% talar body exposure without malleolar osteotomy. The aim of this study was to investigate the percentage talar body exposure when using the lateral transligamentous approach. Methods. The lateral transligamentous approach to the talus was undertaken in 10 fresh frozen cadaveric specimens by surgeons inexperienced in the approach, following demonstration of the technique. An incision was made on the anterolateral aspect of the ankle augmented by the removal of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) from their fibular insertions. A bone lever was then placed behind the lateral aspect of the talus and levered forward with the foot in equinus and inversion. The talus was disarticulated and high resolution images were taken of the talar dome surface. The images were overlain with a reproducible nine-grid division. Accessibility to each zone within the grid with a perpendicular surgical blade was documented. ImageJ software was used to calculate the surface area exposed with each approach. Results. The mean percentage area of talar dome available through the transligamentous approach was 77.3 % (95% confidence interval 73.3, 81.3). In all specimens the complete lateral talar process was accessible, along with the lateral and dorsomedial aspect of the talar neck. This approach gives complete access to Zones 1,2, 3,5 & 6 with partial access to Zones 4,8 & 9. Conclusion. The lateral transligamentous approach to the talus provides significantly greater access to the talar dome as compared to standard approaches. The residual surface area that is inaccessible with this approach is predominantly within Zone 4 and Zone 7, the posteromedial corner

Introduction. Following publication of the Ankle Injury Management (AIM) trial in 2016 which compared the management of ankle fractures with open reduction and internal fixation (ORIF) versus closed contact casting (CCC), we looked at how the results of this study have been adopted into practice in a trauma unit in the United Kingdom. Methods. Institutional approval granted to identify eligible patients from a trauma database. 143 patients over 60 years with an unstable ankle fracture between 2017 and 2019 (1 year following publication of the AIM trial) were included. Open fractures, and patients with insulin-dependent diabetes or peripheral vessel disease were excluded (as per AIM criteria). Radiographs were reviewed for malunion and non-union. Clinical notes were reviewed for adverse events. Minimum follow up was 24 months. Results. Of the 143 patients, 42 patients (29.4%) received a moulded cast with a return to theatre rate of 21.4%, malunion rate of 30.1%, and infection or wound problem rate of 4.8%. When the exact phrase “close contact cast” was specified in 21 patients (14.7%), there was a 19.0% return to theatre rate, 28.6% malunion rate, and a 4.8% infection or wound problem rate. 101 patients (70.6%) had ORIF with a return to theatre rate of 10.9%, malunion rate of 5.0%, and infection or wound problem rate of 13.9%. Discussion. Our results show a high rate of complication with cast management of unstable ankle fractures in this older population. This was improved where CCC was specified, but remains higher even than those published in the AIM trial. Whilst there is certainly a role for CCC in carefully selected patients, we would advise caution in the widespread adoption of a close contact casting technique

Background. Total ankle replacements (TARs) are becoming increasingly more common in the treatment of end stage ankle arthritis. As a consequence, more patients are presenting with the complex situation of the failing TAR. The aim of this study was to present our case series of isolated ankle fusions post failed TAR using a spinal cage construct and anterior plating technique. Methods. A retrospective review of prospectively collected data was performed for 6 patients that had isolated ankle fusions performed for failed TAR. These were performed by a single surgeon (IW) between March 2012 and October 2014. The procedure was performed using a Spinal Cage construct and grafting in the joint defect and anterior plating. Our primary outcome measure was clinical and radiographic union at 1 year. Union was defined as clinical union and no evidence of radiographic hardware loosening or persistent joint lucent line at 1 year. Results. The mean follow-up was 37.3 months (SD 13.2). Union was achieved in 5 of the 6 patients (83%). One patient had a non-union that required revision fusion incorporating the talonavicular joint that successfully went on to unite across both joints. Another patient had radiographic features of non-union but was clinically united and asymptomatic and one required revision surgery for a bulky symptomatic lateral malleolus with fused ankle joint. Conclusion. The failing TAR presents a complex clinical situation. After removal of the implant there is often a large defect which if compressed leads to a leg length discrepancy and if filled with augment can increase the risk of non-union. Multiple methods have been described for revision, with many advocating fusion of both the ankle joint and subtalar joint. We present our case series using a spinal cage and anterior plating that allows preservation of the subtalar joint and a high rate of union

Despite advancements, revision rates following total ankle replacement (TAR) are high in comparison to other total joint replacements. This explant analysis study aimed to investigate whether there was appreciable metal particulate debris release from various contemporary TARs by describing patterns of material loss. Twenty-eight explanted TARs (9 designs: 3 fixed and 6 mobile bearing), revised for any reason, were studied. The articulating surfaces of the metal tibial and talar components as well as the polyethylene insert were assessed for damage features using light microscopy. Based on the results of the microscopic analysis, scanning electron microscopy with energy dispersive X-ray spectroscopy was performed to determine the composition of embedded debris identified, as well as non-contacting 3D profilometry. Pitting, indicative of material loss, was identified on the articulating surfaces of 54% of tibial components and 96% of talar components. Bearing constraint was not found to be a factor, with similar proportions of fixed and mobile bearing metal components showing pitting. More cobalt-chromium than titanium alloy tibial components exhibited pitting (63% versus 20%). Significantly higher average surface roughness (Sa) values were measured for pitted areas in comparison to unpitted areas of these metal components (p<0.05). Additionally, metallic embedded debris (cobalt-chromium likely due to pitting of the tibial and talar components or titanium likely from loss of their porous coatings) was identified in 18% of polyethylene inserts. The presence of hard 3. rd. body particles was also indicated by macroscopically visible sliding plane scratching, identified on 79% of talar components. This explant analysis study demonstrates that metal debris is released from the articulating surfaces and the coatings of various contemporary TARs, both fixed and mobile bearing. These findings suggest that metal debris release in TARs may be an under-recognised issue that should be considered in the study of painful or failed TAR moving forwards

Tendoscopy in the treatment of peroneal tendon disorders is becoming an increasingly safe, reliable, and reproducible technique. Peroneal tendoscopy can be used as both an isolated procedure and as an adjacent procedure with other surgical techniques. The aim of our study was to review all peroneal tendoscopy that was undertaken at the AOC, by the senior authors (IGW, SH), and to determine the safety and efficacy of this surgical technique. Methods. From 2000 to 2017 a manual and electronic database search was undertaken of all procedures by the senior authors. Peroneal tendoscopy cases were identified and then prospectively analysed. Results. 51 patients (23 male, 28 female) were identified from 2004–2017 using a manual and electronic database search. The mean age at time of surgery was 41.5 years (range 16–83) with a mean follow-up time post operatively of 11.8 months (range 9–64 months). The main indications for surgery were lateral and/or postero-lateral ankle pain and lateral ankle swelling. The majority of cases showed unstable peroneal tendon tears that were debrided safely using tendoscopy. Of the 51 patients, 23 required an adjacent foot and ankle operation at the same time, 5 open and 17 arthroscopic (12 ankle, 5 subtalar). Open procedures included 2 first ray osteotomies, 2 open debridements of accessory tissue, one PL to PB transfer. One patient also had an endoscopic FHL transfer. Complication rates to date have been low: 2 superficial wound infections (4%) and one repeat tendoscopy for ongoing pain. A small proportion of patients with ongoing pain were treated with USS guided steroid injections with good results. Conclusion. Our series of peroneal tendoscopy has a low complication rate with high patient satisfaction at discharge. Results of tendoscopic treatment are similar to open techniques, however its advantages make tendoscopic procedures an excellent method to treat peroneal tendon disorders

Background. Traditionally, the extended lateral approach (ELA) was the favoured approch for calcaneal fractures, but has been reported to have high incidence of wound complications. There has been a move amongst surgeons in the United Kingdom towards the sinus tarsi approach (STA) due to its minimally invasive nature, attempting to reduce such complications. Aims. To evaluate outcomes of ELA and STA for all consecutive calcaneal fracture fixation in our institution over a 10yr period. Method. Retrospective cohort study of all calcaneal fractures surgically treated with either approach between January 2008 and January 2018. Anatomic restoration was assessed radiologically by the change in Gissane's and Bohler's angles and calcaneal width. Post-operative complications including metalwork removal were recorded. Results. 35 calcaneal fractures were managed surgically via either approach during this period (21 STA and 14 ELA). There was a statistically significant improvement in the radiological makers when the post-operative films were compared to pre-operative ones. When the post-operative films from the 2 groups were compared against each other, there was no significant difference (p< 0.05) in any of the radiological markers. In the ELA group, 2 patients (14.3%) developed deep infections requiring metalwork removal and 1 had delayed wound healing (7.1%). No deep infections occurred with the STA; 1 patient (4.8%) had a superficial infection, treated with antibiotics. Of patients who had metalwork in situ for more than 1 year, 37.5% of the STA group required removal due to pain compared to only 16.7% with ELA. Conclusions. We have moved from ELA to STA. Our results have shown no difference in restoration of calcaneal anatomy but with a decrease in post-operative wound complications including infection. However, we have shown an increase in metalware removal in the STA group and it is important to ascertain the cause and significance of this