Recurrent dislocation of peroneal tendons is uncommon and there are few reports of the long-term results after repair. The Singapore operation, first described in 1985, is an anatomical repair based on the Bankart-like lesion seen in the superior peroneal retinaculum. We reviewed 21 patients after a mean follow-up of 9.3 years, and found no recurrence. Eighteen had good functional results and had returned to their previous levels of vocational and sports activities. The three fair results were due to painful scars or neuromas

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

Introduction. Positive reports from implant designer centres on the use of fibular nails in the complex ankle fractures has resulted in a marked increase in their use nationally. Our aim in this study was to report on the outcomes of the use of all fibular nails in two major trauma centres. Methods. All patients who underwent ankle fracture fixation using a fibular nail in two major trauma centres, were included for analysis. MTC 1 included patients from April 2013 to May 2015, and MTC 2 included patients February 2015 to March 2018. A minimum follow up of 1 year was achieved for all patients. Radiographic reduction was confirmed by Pettrones criteria at time of operation and at 6 weeks and 1 year post-operatively. Kellgren Lawrence radiographic criteria was used to classify osteoarthritis. All complications and further surgery were recorded. Results. Forty-four patients underwent fibular nail fixation in the two centres. The average age was 59 (range 21–91). Using Pettrones criteria, 86% were malreduced at time of operation. A further 34% deteriorated by at least 1 grade by 6 weeks and an additional 16% (n=7) deteriorated by at least 1 grade by 1 year. 57% had developed radiographic evidence of osteoarthritis by 1 year. Only 4.5% (2ankles) maintained complete reduction by 1 year. Other significant complications were reported in 43% of patients. Conclusion. Both major trauma centres report the same experience in the use of fibular nails for ankle fracture fixation. As previously reported in smaller number studies, initial reduction is challenging. Worryingly, the majority of well-reduced lose position with time. We suggest that the fibula nail is used with caution and as part of an appropriately approved audit

Background. Neglected clubfoot in this series is defined as untreated equino-cavo-adducto-varus in older children, or adults. Relapsed clubfoot is the residual deformity that remains after single or multiple surgical interventions. Severe neglected clubfoot rarely exists today in developed countries, except in some emigrants from low- and middle-income countries. Acute surgical management with corrective mid-foot osteotomy and elongation of the Achilles tendon has excellent functional outcome. Objective. To assess the functional outcome of acute correction of neglected Talipes-quino-varus deformity in adults. Methods. This is cross sectional, hospital–based study that took place in Khartoum, Sudan. Forty patients were included in this study. Midfoot osteotomy and elongation of the Achilles tendon were performed to all patients. Data was collected using a questionnaire and the functional outcome has been assessed using the American Orthopaedic Foot and Ankle Society Score (AOFAS). This score was measured before surgery and one years after surgery. Results. The mean age was 19.9±4.7 years. Males were 25 (62.5%) and females were 15 (37.5%). The mean preoperative AOFAS score was 37.7±7.1 (poor). This score improved to 80.7±13.7 (good to excellent), two years after surgery. However, this indicates significant change in the functional outcome after the operation (P value < 0.05). Excellent post-operative functional outcome was found among patients aged 18 – 23 years 18 (50%) P. value: 0.021. The majority of patients 36(90%) were fully satisfied with the operation, 2(5%) partially satisfied and 2(5%) were unsatisfied. Conclusion. Acute correction of neglected and relapsed TEV with elongation of the Achilles tendon and single midfoot osteotomy has excellent functional outcome as assessed by AOFAS Score. The satisfaction with this procedure is impressive. The younger age population showed better outcomes with this procedure

Introduction. Primary ankle arthroplasty (TAR) is increasingly used to treat end-stage ankle arthritis. Reported revision rates of TAR vary from 8.5% to 11.1% at 9 years. Revision surgery remains technically challenging with options ranging from simple joint debridement to tibio-talar-calcaneal fusion. The efficacy of these procedures remains unclear and there is no consensus on optimal revision options. Methods. A retrospective cohort study was performed of all patients undergoing surgery for a failed primary TAR at the Nuffield Orthopaedic Centre (2004–2021). TAR failure was determined by clinical assessment, serial radiographs and CT scans. Primary outcome measures included type and time of index surgery post TAR. Secondary outcomes included frequency of re-operations, post-operative complications, patient reported outcomes and union rate (for revision arthrodesis procedures). Results. 70 failed TARs in 69 patients (35M:34F, mean 65.7 years, s.d.=11.6) underwent re-operation a mean of 6.24 years (range 1–30) post primary. In total, 107 operations were performed including revision fusion (n=50), revision arthroplasty (n=14), bearing exchange (n=9) and joint clearance (n=9). The overall revision fusion union rate was 73.5% over a mean of 12.5 months (s.d.=7.6). 16/23 (69.6%) Tibio-Talo-Calcaneal and 9/12 (75%) ankle fusions (previous subtalar/triple fusion) using a hindfoot nail united over a mean 11.4 months (s.d.=6.0) and 15 months (s.d.=9.48) respectively. Only 64% of ankle fusions using screws alone united (mean=10.6 months, s.d.=8.14). The average post-operative MOXFQ score was 28.3 (s.d.=19.3). 73% said the operation improved their function and would recommend it to a friend/family member. Conclusion. Despite low post-operative MOXFQ scores, over 70% of patients were satisfied with re-operation for a failed TAR. Over 26% of all TAR revision fusions fail to unite with the highest non-union rates observed post ankle arthrodesis with screws alone (36.4%)

Aims. The number of revision total ankle arthroplasties (TAAs) which are undertaken is increasing. Few studies have reported the survival after this procedure. The primary aim of this study was to analyze the survival of revision ankle arthroplasties using large datasets. Secondary aims were to summarize the demographics of the patients, the indications for revision TAA, further operations, and predictors of survival. Methods. The study combined data from the National Joint Registry and NHS Digital to report the survival of revision TAA. We have previously reported the failure rates and risk factors for failure after TAA, and the outcome of fusion after a failed TAA, using the same methodology. Survival was assessed using life tables and Kaplan Meier graphs. Cox proportional hazards regression models were fitted to compare failure rates. Results. A total of 228 patients underwent revision TAA. The mean follow-up was 2.6 years (SD 2.0). The mean time between the initial procedure and revision was 2.3 years (SD 1.8). The most commonly used implant was the Inbone which was used in 81 patients. A total of 29 (12.7%) failed; nine (3.9%) patients underwent a further revision, 19 (8.3%) underwent a fusion, and one (0.4%) had an amputation. The rate of survival was 95.4% (95% confidence interval (CI) 91.6 to 97.5) at one year, 87.7% (95% CI 81.9 to 91.7; n = 124) at three years and 77.5% (95% CI 66.9 to 85.0; n = 57) at five years. Revision-specific implants had a better survival than when primary implants were used at revision. A total of 50 patients (21.9%) had further surgery; 19 (8.3%) underwent reoperation in the first 12 months. Cox regression models were prepared. In crude analysis the only significant risk factors for failure were the use of cement (hazard ratio (HR) 3.02 (95% CI 1.13 to 8.09)) and the time since the primary procedure (HR 0.67 (95% CI 0.47 to 0.97)). No risk factors for failure were identified in multivariable Cox regression modelling. Conclusion. Revision TAAs have good medium term survival and low rates of further surgery. New modular revision implants appear to have improved the survival compared with the use of traditional primary implants at revision. Cite this article: Bone Joint J 2023;105-B(11):1184–1188

Introduction. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to perform major foot/ankle operations as day-case. This could have significant impact on length of stay, saving resources and is in keeping with government policy. However, there are theoretical concerns about complications and low patient satisfaction due to pain. Methods. The survey was developed following review of the literature and was approved for distribution by the BOFAS (British Orthopaedic Foot & Ankle Society) scientific committee. An online survey (19 questions) was sent to UK foot and ankle surgeons via the BOFAS membership list. Major foot/ ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge, with day surgery as the intended pathway. Results. A total of 132 surgeons responded, 80% from Acute NHS Trusts. The majority (78%) thought that more procedures could be performed as day-case at their centre. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. Despite post-operative pain and patient satisfaction being theoretical concerns for day-case surgery in this population; these outcomes were only measured by 34% and 10% of respondents respectively. The top perceived barriers to performing more major foot and ankle procedures as day-case were: Lack of physiotherapy input pre/post-operatively (23%), Lack of out of hours support (21%). Conclusions. There is consensus among surgeons to do more major foot/ ankle procedures as day-case. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. There is a need to scope the provision of physiotherapy pre/post-operatively and out of hours support at sites where this is a perceived barrier

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

Introduction. Surgical reconstruction of Charcot joint deformity is increasingly being offered to patients. In our centre a hybrid type fixation technique is utilised: internal and external fixation. This combined fixation has better wound management and earlier mobilisation in this deconditioned patient group. The aim of this study was to assess clinical, radiological and patient reported outcomes for all patients who underwent this hybrid technique. Methods. This is a prospective observational case series of all patients who underwent surgical reconstruction of Charcot foot deformity in a single centre between June 2017 and June 2023. Patient demographics, smoking status, diabetic control and BMI were recorded. Outcomes were determined from case notes and included clinical outcomes (complications, return to theatre, amputation and mortality) radiological outcomes and patient reported outcomes. The follow up period was 1–7 years post operatively. Results. 42 reconstructions were included. At the time of surgery the mean age was 59.1 years (29 – 91 years), average HbA1c was 65.2 (33–103); this did not correlate with return to theatre rate. 4 procedures were internal fixation alone (9.5%), 3 external fixation alone (7.1%) and 35 were combined fixation (83.3%). At most recent follow up 7 patients were deceased (16.7%), 2 patients had ipsilateral amputations, 2 had contralateral amputations. 11 patients had issues with recurrent ulcerations. Excluding refreshing of frames and operations on the contralateral side, 17 patients (40%) returned to theatre. We aim to present a detailed analysis of the rate of post-operative complications, return to theatre, radiographic outcomes and patient reported outcomes. Conclusion. This is the largest UK based case series of hybrid type Charcot joint reconstructions and shows that hybrid fixation is a viable option for patients undergoing Charcot joint reconstruction. To best confirm findings and determine which patients have the best post-operative prognosis a larger multi-centre study is required

Introduction. Total ankle replacement as a valid treatment for end stage ankle arthritis, is gaining popularity and every year there is an increasing number of procedures. With revision rates as high as 21% at 5 years and 43% at 10 years there is a need for understanding and reporting the outcome of revision ankle replacement. Our aim was to study the patient reported outcomes following revision TAR with a minimum of 2 year follow up. Methods. All patients that underwent a revision total ankle replacement between 2012 and 2016 were included in the study. All patients received a post-operative questionnaire comprising of MOX-FQ score, EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) and patients satisfaction questionnaire with a minimum of 2 years follow up. Results. 33 patients had a revision total ankle replacement between 2012 and 2016. 2 patients were deceased therefore 31 patients were included in the study. 4 patients declined participation for completing questionnaires. We received 15/27 (55.5%) completed questionnaires. The mean MOX-FQ average domain score for pain was (50.6 ± 26.9), walking/standing (62.4 ± 36.5) and social function was (43.7± 31.0). The mean FAOS scores were (52.5 ± 30.6; pain), (54.5 ± 29.2; symptoms), (62.1 ± 30.5; ADL) and (35.5 ± 28.2; for quality of life). The mean overall health score today for EQ-5D was 73.9/100. 50% of patients were satisfied with the pain relief and return to sports and recreation obtained following the operation, 57% were satisfied with the improved in daily activities. 78.5% were overall satisfied with the results from surgery. Conclusion. Revision total ankle replacement gives overall satisfactory results demonstrated from patients reported outcomes at a minimum of 2 years following surgery

Introduction. Charcot neuroarthropathy (CN) of foot and ankle presents significant challenges to the orthopaedic foot and ankle surgeon. Current treatment focuses on conservative management during the acute CN phase with offloading followed by deformity correction during the chronic phase. However, the deformity can progress in some feet despite optimal offloading resulting ulceration, infection, and limb loss. Our aim was to assess outcomes of primary surgical management with early reconstruction. Methods. Between December 2011 and December 2019, 25 patients underwent operative intervention at our specialist diabetic foot unit for CN with progressive deformity and or instability despite advanced offloading. All had peripheral neuropathy, and the majority due to diabetes. Twenty-six feet were operated on in total - 14 during Eichenholtz stage 1 and 12 during stage 2. Fourteen of these were performed as single stage procedures, whereas 12 as two-stage reconstructions. These included isolated hindfoot reconstructions in seven, midfoot in four and combined in 14 feet. Mean age at the time of operation was 54. Preoperative ulceration was evident in 14 patients. Results. Mean follow up was 45 months (Range 12–98). There was 100% limb salvage. One-year ambulation outcomes demonstrate FWB in bespoke footwear for 17 patients and in an ankle foot orthosis (AFO), Charcot restraint orthopaedic walker (CROW) or bivalve cast for seven. All preoperative ulceration had healed. Union was achieved in 18/21 hindfoot reconstructions and 7/18 midfoot reconstructions. There were nine episodes of return to theatre, of which five were within the first 12 months. There was one episode of new ulceration. Conclusion. Surgical management of acute CN (Eichenholtz one and two) of the foot provides functional limb salvage. In particular, hindfoot reconstruction shows good rates of bony union. It should be considered in ‘foot at risk’ presentations of acute CN foot

Background. Corrective fusion of a deformed / unstable Charcot neuroarthropathy (CN)of the midfoot and hindfoot is performed with the aim to prevent ulcers and maintain patient mobility. Methods. Between October 2007 and July 2018, 103 CN mid and hind foot corrections in 95 patients were performed. There were 34 hind-foot, 38 mid-foot and 31 combined hind and mid-foot surgeries. 83 feet had single stage corrections, whereas 20 required a staged operation. Results. Ninety-five patients were prospectively followed up. The mean patient age in our study was 57 years (21 – 85). Twenty-seven patients had type1 diabetes, 64 patients had type 2 and 4 patients had a neuropathy secondary to other conditions. Forty patients (42%) were offered a below knee amputation prior to attending our foot clinic. At a mean follow up of 56 months (12 – 140) we achieved 100% limb salvage with a 75% full bone fusion rate. There were 17 mortalities within our cohort at a mean period of 3 years. Ninety-seven percent (n=92) patients were mobilizing post-operatively in orthotic footwear. Fifty-two feet had pre-operative ulcers. Post-operatively 17 feet (16 patients) had persistent ulceration. Eight patients had ulcer resolution following further surgery and alteration of footwear, one patient has been listed for a below knee amputation for unstable non-union, whilst the remaining 7 patients have stable ulcers which are managed with dressings. Of the 26 feet (25 patients) with non-unions, 6 patients had revision fixation procedures whilst 8 patients required minor surgical procedures. The remaining 11 patients are stable non-unions who are asymptomatic and weight bearing. Other complications included a deep infection rate of 8% (n=7). Conclusion. We demonstrated a 100% limb salvage rate and an 83% success rate in ulcer resolution. We recommend this be done with the support of the multi-disciplinary team

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 identify a core outcome set of postoperative radiographic measurements to assess technical skill in ankle fracture open reduction internal fixation (ORIF), and to validate these against Van der Vleuten’s criteria for effective assessment. Methods. An e-Delphi exercise was undertaken at a major trauma centre (n = 39) to identify relevant parameters. Feasibility was tested by two authors. Reliability and validity was tested using postoperative radiographs of ankle fracture operations performed by trainees enrolled in an educational trial (IRCTN 20431944). To determine construct validity, trainees were divided into novice (performed < ten cases at baseline) and intermediate groups (performed ≥ ten cases at baseline). To assess concurrent validity, the procedure-based assessment (PBA) was considered the gold standard. The inter-rater and intrarater reliability was tested using a randomly selected subset of 25 cases. Results. Overall, 235 ankle ORIFs were performed by 24 postgraduate year three to five trainees during ten months at nine NHS hospitals in England, UK. Overall, 42 PBAs were completed. The e-Delphi panel identified five ‘final product analysis’ parameters and defined acceptability thresholds: medial clear space (MCS); medial malleolar displacement (MMD); lateral malleolar displacement (LMD); tibiofibular clear space (TFCS) (all in mm); and talocrural angle (TCA) in degrees. Face validity, content validity, and feasibility were excellent. PBA global rating scale scores in this population showed excellent construct validity as continuous (p < 0.001) and categorical (p = 0.001) variables. Concurrent validity of all metrics was poor against PBA score. Intrarater reliability was substantial for all parameters (intraclass correlation coefficient (ICC) > 0.8), and inter-rater reliability was substantial for LMD, MMD, TCA, and moderate (ICC 0.61 to 0.80) for MCS and TFCS. Assessment was time efficient compared to PBA. Conclusion. Assessment of technical skill in ankle fracture surgery using the first postoperative radiograph satisfies the tested Van der Vleuten’s utility criteria for effective assessment. 'Final product analysis' assessment may be useful to assess skill transfer in the simulation-based research setting. Cite this article: Bone Jt Open 2022;3(6):502–509

Aims

When a total ankle arthroplasty (TAA) fails, it can be converted to a fusion or a revision arthroplasty. Despite the increasing numbers of TAAs being undertaken, there is little information in the literature about the management of patients undergoing fusion following a failed TAA. The primary aim of this study was to analyze the survival of fusions following a failed TAA using a large dataset from the National Joint Registry (NJR).

Aims

Despite the increasing numbers of ankle arthroplasties, there are limited studies on their survival and comparisons between different implants. The primary aim of this study was to determine the failure rates of primary ankle arthroplasties commonly used in the UK.

Aims

Osteochondral lesions of the talus (OLT) are a common cause of disability and chronic ankle pain. Many operative treatment strategies have been introduced; however, they have their own disadvantages. Recently lesion repair using autologous cartilage chip has emerged therefore we investigated the efficacy of particulated autologous cartilage transplantation (PACT) in OLT.

Aims

The Cartiva synthetic cartilage implant (SCI) entered mainstream use in the management of first metatarsophalangeal joint (MTPJ) arthritis following the positive results of large trials in 2016. Limited information is available on the longer-term outcomes of this implant within the literature, particularly when independent from the originator. This single-centre cohort study investigates the efficacy of the Cartiva SCI at up to five years.

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.

Aims

Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE.