Background. Forefoot surgery is often performed under regional anaesthesia (ankle block) in awake patients, using tourniquet or esmarch bandage to obtain bloodless field. The purpose of this study was to examine the value and need for local tourniquet pain control using local subcutaneous analgesic mixture in patients undergoing forefoot surgery under regional anaesthesia. We prospectively randomized 56 patients who underwent forefoot surgery under ankle block to receive subcutaneous local anaesthetic mixture under the tourniquet. We checked for local tourniquet pain score (VAS 0–100) and skin condition during and after the procedure. Results. Tourniquet was quite tolerable in both groups, with an average VAS score of 7–21. No difference was observed between groups throughout most of the procedure. No correlation between VAS scores and procedure length or patient's age or gender. Conclusion. Ankle tourniquet is well tolerated by patients without need for local anaesthetics

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. Major ankle and hindfoot surgery has traditionally been performed as an inpatient. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to contemplate performing major ankle and hindfoot operations as a day-case. This could have a significant impact on length of stay for these major cases, saving resources and in keeping with government policy. In this study, we prospectively audited the outcome of the first cohort of patients undergoing major ankle and hindfoot surgery as a day-case against a series of standards. Methods. Twenty four consecutive patients who underwent ankle or hindfoot surgery between August 2009 and April 2010 were considered for day surgery. Seven patients were deemed not suitable due to co-existing medical conditions or insufficient help at home. This left 17 patients who had ankle or hindfoot surgery as a day case. All patients received an ultrasound-guided regional nerve block and spinal or general anaesthesia. The data was collected on patient demographics, diagnosis, and type of surgical procedure. Patients received the standard follow-up regimen for a particular procedure. Patient satisfaction was assessed using a standard questionnaire which included self-monitoring of post-operative pain at 6, 24 and 48 hrs. In addition, any adverse outcomes were recorded. Results. The average age was 48 (range 23-67) years. There were 7 males and 10 females. The surgical procedures included arthroscopic ankle fusion (5), subtalar fusion (5), talonavicular fusion (1) midfoot fusion with calcaneal osteotomy (1), tibialis posterior reconstruction (3) tendo-achilles reconstruction (1) and arthroscopy and lateral ligament reconstruction (1). 93% patients reported that they were given enough information and advice about their operation as a day case. No patients reported severe pain at 6 hrs. One patient had severe pain at 24 hrs post-op. Four patients (23%) had significant pain at 48 hrs and required strong analgesia. Thirteen (77%) patients stated that they would recommend having this surgery as a day-case if they were having it again whereas four (23%) would prefer staying in overnight. The average length of stay for the patients deemed unsuitable for day surgery was 3.8 (range 1-6) days. Conclusions. Our initial results of performing major ankle and hindfoot procedures as day surgery are encouraging but pain control at 48 hrs still remains an unsolved issue and further optimisation is needed

We describe the surgical technique and results of arthroscopic subtalar release in 17 patients (17 feet) with painful subtalar stiffness following an intra-articular calcaneal fracture of Sanders’ type II or III. The mean duration from injury to arthroscopic release was 11.3 months (6.4 to 36) and the mean follow-up after release was 16.8 months (12 to 25). The patient was positioned laterally and three arthroscopic portals were placed anterolaterally, centrally and posterolaterally. The sinus tarsi and lateral gutter were debrided of fibrous tissue and the posterior talocalcaneal facet was released. In all, six patients were very satisfied, eight were satisfied and three were dissatisfied with their results. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from a mean of 49.4 points (35 to 66) pre-operatively to a mean of 79.6 points (51 to 95). All patients reported improvement in movement of the subtalar joint. No complications occurred following operation, but two patients subsequently required subtalar arthrodesis for continuing pain.

In the majority of patients a functional improvement in hindfoot function was obtained following arthroscopic release of the subtalar joint for stiffness and pain secondary to Sanders type II and III fractures of the calcaneum.

This study assessed if transfer of the extensor hallucis longus is a valid alternative treatment to split transfer of the tibialis anterior tendon in adult hemiplegic patients without overactivity of the tibialis anterior.

One group of 15 patients had overactivity of tibialis anterior in the swing phase, and underwent the split transfer. A further group of 14 patients had no overactivity of tibialis anterior, and underwent transfer of extensor hallucis longus. All patients had lengthening of the tendo Achillis and tenotomies of the toe flexors. All were evaluated clinically and by three-dimensional gait analysis pre- and at one year after surgery. At this time both groups showed significant reduction of disability in walking. Gait speed, stride length and paretic propulsion had improved significantly in both groups. Dorsiflexion in the swing phase, the step length of the healthy limb and the step width improved in both groups, but only reached statistical significance in the patients with transfer of the extensor hallucis longus. There were no differences between the groups at one year after operation.

When combined with lengthening of the tendo Achillis, transfer of the extensor hallucis longus can be a valid alternative to split transfer of the tibialis anterior tendon to correct equinovarus foot deformity in patients without overactivity of tibialis anterior.