Introduction. Bone Marrow Oedema Syndrome (BMOS) is an unusual and poorly understood condition. It commonly affects the hips and knees and is reported to have a tendency to recur. The foot and ankle are less frequently involved but nevertheless patients can be severely impaired. Only case reports of BMOS of the foot and ankle have been published. The aim of this study is to evaluate the sites of occurrence, risk factors, efficacy of immobilisation, response to intravenous biphosphonates and local or remote recurrence over the following years. Methods. A retrospective review of 25 adult patients who have been diagnosed with BMOS have been followed-up for an average of 5.8 years (range: 2–11). Six patients have not been traced. Results. There were 6 males and 13 females with an average age at presentation of 45.8 and 58.8 years respectively. No statistically significant risk factors could be identified. The talus was the commonest affected bone (68% of the cases) followed by the intermediate cuneiform and the adjacent second metatarsal (21%) and the cuboid with the adjacent third and fourth metatarsals (15%). All 19 patients were treated initially with a pneumatic walker: 5 patients had a resolution of their symptom at an average time of 7 weeks. Of the 14 patients who had not improved by approximately 8 weeks, nine received intravenous zolendronate along with the same pneumatic walker and 5 continued with the pneumatic walker alone. The 9 patients who received a single dose of zolendronate experienced significant improvement within an average of 3.6 weeks. Eight patients out of the 19 continue to have pain. Conclusion. BMOS is often a diagnosis of exclusion. The talus is the most affected bone in the foot and ankle. The majority of patients in this study have improved with a brace and or intravenous zolendronate

Aims

In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method.

Introduction. Diabetes is increasing on a global scale. By 2030, 10% of the global population, ½ billon people, are predicted to have diabetes. Potentially there will be a corresponding increase in number of patients referred for surgery. Traditional surgical management of these patients is challenging. Presented is a case series utilizing Minimally Invasive Surgical Techniques of percutaneous metatarsal neck osteotomies, metatarsal head debridement, mid-foot closing-wedge osteotomies and hind-foot arthrodesis, for the surgical management of diabetic foot pathology. The potential socio-economic benefits analysis with regards to reduction in out-patient and theatre time, patient length of stay and time to healing are also postulated. Methods. Minimally Invasive Surgical Techniques of metatarsal neck osteotomy, metatarsal head debridement, closing wedge osteotomy, mid-fusion and hind-foot arthrodesis nailing are described. Procedures are preformed as day cases with fluoroscopic guidance. Low speed, high torque burrs and wedges, create the osteotomies, which can be held with percutaneous fixation. Comparative cost analysis of conservative treatment, including clinic visits, out-patient debridement, dressings, intravenous and oral antibiotics, versus Minimally Invasive Surgical Techniques is presented. Results. Six patients had metatarsal osteotomies for mechanical ulceration. Five reported good outcome. One patient required revision to forefoot arthroplasty due to mal-union. Five patients had debridement of metatarsal heads, which healed on average at six to eight weeks. Eight patients had mid-foot arthrodesis. Two infected cases required removal of metalwork. Three patients had hind-foot arthrodesis for arthritis following ankle fracture with degeneration and deformity. Patients had good short and early medium term outcomes, with no reports of below-knee amputation. This technique is reproducible once the initial learning curve is mastered. Comparative cost analysis, suggests significant financial savings by reducing inpatient admissions, clinic visits and theatre time. Conclusion. Minimally Invasive Surgical Techniques may provide an alternative surgical management for diabetic patient with foot and ankle pathology

Introduction:. We report our 10-year experience of post-operative complications of calcaneal fractures treated by internal fixation and attempt to correlate these with previously cited patient risk factors. Methods:. All calcaneal fractures treated by internal fixation in our Major Trauma Centre between September 2002 and September 2012 were identified. Patient indices (age, gender, smoking status and pre-existing co-morbidities), time to surgery and method of surgery (open reduction and internal fixation (ORIF) versus closed reduction and percutaneous fixation) were recorded. Primary outcome was the incidence of wound infection requiring intravenous antibiotics and/or re-operation. Statistical analysis through Mann-Whitney-Wilcoxon testing and relative risk ratio calculations with 95% Confidence Intervals (CI) was performed. Results:. 98 calcaneal fractures in 92 patients were identified. 79 (80.6%) fractures occurred in males, 19 (19.4%) in females. 54 (55.1%) were smokers and 44 (44.9%) non-smokers. 18 (18.4%) were treated by closed reduction and percutaenous fixation and 80 (81.6%) by ORIF. 3 (3.1%) patients (all male) developed post-operative wound infection (RR 0.96, 95% CI 0.92–1.00), of which 1 was a smoker (RR 1.03 95% CI 0.95–1.11). All infections occurred in patients treated percutaneously (RR 6.33, 95% CI 3.99–10.08). There was no significant difference in mean time to surgery (p=0.069) and mean age (p=0.31) for those patients experiencing wound complications and those who did not. Conclusions:. This study reports an overall wound infection rate in keeping with current literature. There was no statistically significant increased risk of wound infection in smokers or male patients. All infections occurred in patients who had percutaneous treatment. These findings support the continued treatment of displaced calcaneal fractures by open reduction and internal fixation through a conventional extended lateral approach. There is no justification in denying surgery to males or smokers although these two factors have been cited as poor prognostic indicators in earlier studies

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

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.

Aims

The aim of this study was to evaluate the functional outcome in patients undergoing implant removal (IR) after fracture fixation below the level of the knee.

Aims

To our knowledge, there is currently no information available about the rate of venous thromboembolism (VTE) or recommendations regarding chemoprophylaxis for patients whose lower limb is immobilized in a plaster cast. We report a retrospective case series assessing the rate of symptomatic VTE in patients treated with a lower limb cast. Given the complex, heterogeneous nature of this group of patients, with many risk factors for VTE, we hypothesized that the rate of VTE would be higher than in the general population.

Aims

This study reports the outcomes of a technique of soft-tissue coverage and Chopart amputation for severe crush injuries of the forefoot.

Aims

The aim of this study was to present a series of patients with aseptic failure of a total ankle arthroplasty (TAA) who were treated with fusion of the hindfoot using a nail.

Aims

The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations.

Objectives

Inflammation of the retrocalcaneal bursa (RB) is a common clinical problem, particularly in professional athletes. RB inflammation is often treated with corticosteroid injections however a number of reports suggest an increased risk of Achilles tendon (AT) rupture. The aim of this cadaveric study was to describe the anatomical connections of the RB and to investigate whether it is possible for fluid to move from the RB into AT tissue.

Aims

Lifestyle risk factors are thought to increase the risk of infection after acute orthopaedic surgery but the evidence is scarce. We aimed to investigate whether smoking, obesity and alcohol overuse are risk factors for the development of infections after surgery for a fracture of the ankle.

Objectives

The aim of this study was to compare the biomechanical stability and clinical outcome of external fixator combined with limited internal fixation (EFLIF) and open reduction and internal fixation (ORIF) in treating Sanders type 2 calcaneal fractures.

Aims

The mainstay of surgical correction of hallux valgus is first metatarsal osteotomy, either proximally or distally. We present a technique of combining a distal chevron osteotomy with a proximal opening wedge osteotomy, for the correction of moderate to severe hallux valgus.

Most of the literature on surgical site infections following the surgical treatment of fractures of the ankle is based on small series of patients, focusing on diabetics or the elderly. None have described post-operative functional scores in those patients who develop an infection. We performed an age- and gender-matched case–control study to identify patient- and surgery-related risk factors for surgical site infection following open reduction and internal fixation of a fracture of the ankle. Logistic regression analysis was used to identify significant risk factors for infection and to calculate odds ratios (OR). Function was assessed using the Olerud and Molander Ankle Score. The incidence of infection was 4% (29/717) and 1.1% (8/717) were deep infections. The median ankle score was significantly lower in the infection group compared with the control group (60 vs 90, Mann–Whitney test p < 0.0001). Multivariate regression analysis showed that diabetes (OR = 15, p = 0.031), nursing home residence (OR = 12, p = 0.018) and Weber C fractures (OR = 4, p = 0.048) were significant risk factors for infection.

A low incidence of infection following open reduction and internal fixation of fractures of the ankle was observed. Both superficial and deep infections result in lower functional scores.

Cite this article: Bone Joint J 2014;96-B:636–40.

Charcot neuro-osteoarthropathy (CN) of the midfoot presents a major reconstructive challenge for the foot and ankle surgeon. The Synthes 6 mm Midfoot Fusion Bolt is both designed and recommended for patients who have a deformity of the medial column of the foot due to CN. We present the results from the first nine patients (ten feet) on which we attempted to perform fusion of the medial column using this bolt. Six feet had concurrent hindfoot fusion using a retrograde nail. Satisfactory correction of deformity of the medial column was achieved in all patients. The mean correction of calcaneal pitch was from 6° (-15° to +18°) pre-operatively to 16° (7° to 23°) post-operatively; the mean Meary angle from 26° (3° to 46°) to 1° (1° to 2°); and the mean talometatarsal angle on dorsoplantar radiographs from 27° (1° to 48°) to 1° (1° to 3°).

However, in all but two feet, at least one joint failed to fuse. The bolt migrated in six feet, all of which showed progressive radiographic osteolysis, which was considered to indicate loosening. Four of these feet have undergone a revision procedure, with good radiological evidence of fusion. The medial column bolt provided satisfactory correction of the deformity but failed to provide adequate fixation for fusion in CN deformities in the foot.

In its present form, we cannot recommend the routine use of this bolt.

Cite this article: Bone Joint J 2015; 97-B:809–13

The treatment of peri-prosthetic joint infection (PJI) of the ankle is not standardised. It is not clear whether an algorithm developed for hip and knee PJI can be used in the management of PJI of the ankle. We evaluated the outcome, at two or more years post-operatively, in 34 patients with PJI of the ankle, identified from a cohort of 511 patients who had undergone total ankle replacement. Their median age was 62.1 years (53.3 to 68.2), and 20 patients were women. Infection was exogenous in 28 (82.4%) and haematogenous in six (17.6%); 19 (55.9%) were acute infections and 15 (44.1%) chronic. Staphylococci were the cause of 24 infections (70.6%). Surgery with retention of one or both components was undertaken in 21 patients (61.8%), both components were replaced in ten (29.4%), and arthrodesis was undertaken in three (8.8%). An infection-free outcome with satisfactory function of the ankle was obtained in 23 patients (67.6%). The best rate of cure followed the exchange of both components (9/10, 90%). In the 21 patients in whom one or both components were retained, four had a relapse of the same infecting organism and three had an infection with another organism. Hence the rate of cure was 66.7% (14 of 21). In these 21 patients, we compared the treatment given to an algorithm developed for the treatment of PJI of the knee and hip. In 17 (80.9%) patients, treatment was not according to the algorithm. Most (11 of 17) had only one criterion against retention of one or both components. In all, ten of 11 patients with severe soft-tissue compromise as a single criterion had a relapse-free survival. We propose that the treatment concept for PJI of the ankle requires adaptation of the grading of quality of the soft tissues.

Cite this article: Bone Joint J 2014;96-B:772–7.

We hypothesised that a minimally invasive peroneus brevis tendon transfer would be effective for the management of a chronic rupture of the Achilles tendon. In 17 patients (three women, 14 men) who underwent minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum, at a mean follow-up of 4.6 years (2 to 7) the modified Achilles tendon total rupture score (ATRS) was recorded and the maximum circumference of the calf of the operated and contralateral limbs was measured. The strength of isometric plantar flexion of the gastrocsoleus complex and of eversion of the ankle were measured bilaterally. Functional outcomes were classified according to the four-point Boyden scale.

At the latest review, the mean maximum circumference of the calf of the operated limb was not significantly different from the pre-operative mean value, (41.4 cm, 32 to 50 vs 40.6 cm, 33 to 46; p = 0.45), and not significantly less than that of the contralateral limb (43.1 cm, 35 to 52; p = 0.16). The mean peak torque (244.6 N, 125 to 367) and the strength of eversion of the operated ankle (149.1 N, 65 to 240) were significantly lower (p < 0.01) than those of the contralateral limb (mean peak torque 289, 145 to 419; strength of eversion: 175.2, 71 to 280). The mean ATRS significantly improved from 58 pre-operatively (35 to 68) to 91 (75 to 97; 95% confidence interval 85.3 to 93.2) at the time of final review. Of 13 patients who practised sport at the time of injury, ten still undertook recreational activities.

This procedure may be safely performed, is minimally invasive, and allows most patients to return to pre-injury sport and daily activities.

Cite this article: Bone Joint J 2015;97-B:353–7.

Limited forefoot amputation in diabetic patients with osteomyelitis is frequently required. We retrospectively reviewed diabetic patients with osteomyelitis, an unhealed ulcer and blood pressure in the toe of > 45 mmHg who underwent limited amputation of the foot with primary wound closure. Between 2006 and 2012, 74 consecutive patients with a mean age of 67 years (29 to 93), and a median follow-up of 31 months, were included. All the wounds healed primarily at a median of 37 days (13 to 210; mean 48). At a median of 6 months (1.5 to 18; mean 353 days), 23 patients (31%) suffered a further ulceration. Of these, 12 patients (16% of the total) required a further amputation.

We conclude that primary wound closure following limited amputation of the foot in patients with diabetes is a safe and effective technique when associated with appropriate antibiotic treatment.

Cite this article: Bone Joint J 2013;95-B:1083–7.