Introduction:. In 2009 the Smart Toe implant was introduced as an option for lesser toe fusion in our department. The Smart Toe is an intramedullary device made from Nitinol, an alloy that can change shape with a change of temperature, expanding within the intramedullary canals of the proximal and middle phalanx to achieve fixation. The advantages of the Smart Toe are that patients are spared 6 weeks with K-wires protruding from their toes and there is no need for wire removal. We conducted a retrospective review of radiographic and clinical outcomes to assess the performance of this implant. Methods:. We present a consecutive series of 192 toe fusions using the Smart Toe implant in 86 patients, between January 2009 and November 2013. All radiographs and case notes were reviewed to assess for radiological fusion, satisfactory clinical outcome and complications. Results:. One patient was lost to all follow up. Radiographic follow up was available for 186 of 192 implants (95%). 137 toes (74%) were fused by 6 weeks, and 152 (81%) at final follow up. Clinical notes were available for 182 implants (94%) in 85 patients. At 6 weeks 50 patients reported satisfactory outcomes in 105 toe fusions (58%). At final follow up 70 patients reported satisfactory outcomes in 150 toe fusions (82%). 7 patients experienced complications in 19 toes (10%). 2 implants were broken and 2 implants had cut out. There were 3 phalanx fractures. In all 4 toes were revised, and there was 1 amputation. Clinically, out of the 34 non-united toes only 5 were symptomatic. Conclusion:. Overall 82% of toe fusions using the Smart Toe implant yielded entirely satisfactory clinical outcomes. Radiographic fusion occurred in 81% but most non-unions were asymptomatic. There were a small number of significant complications, and 4 patients out of 85 required revision surgery

Introduction. Lesser toe proximal interphalangeal joint arthrodesis is a common forefoot procedure for correction of claw toe deformities. The most common method of fixation is with k-wires. Although this is a very cost-effective method of fixation, well-known disadvantages include pin site infection, non union, wire migration and the inconvenience to the patients of percutaneous wires for up to six weeks. For these reasons, intramedullary devices for joint fixation without crossing the distal IP joint have been developed. Many different designs are currently available. The Smart Toe prosthesis which has appeared as a type I and II, is one such implant. In two recent studies using type I, the use of this implant is advocated. We wish to present our experience with the use of the Smart Toe II. Methods. In this retrospective study we present a radiological review of 46 consecutive cases in 25 patients who underwent lesser toe interphalangeal arthrodeses using the Smart Toe II implant between July 2010 and November 2014 by the senior author. There were 7 (28%) male and 18 (72%) female patients. Post operative radiographs, taken at a mean follow up of 6 months, were reviewed for non-union, migration and implant failure. Results. There were 9 (20%) implant fractures, 10 (22%) radiological non- unions and 5 (11%) implant migrations. 4 toes (9%) were sufficiently symptomatic to require revision. Conclusion. In contrast to two previous studies, our series showed a high rate of implant fracture and non-union, sometimes leading to the need for revision surgery. We recommend caution in use of the Smart Toe II and welcome further reports of results. If our experience is replicated, we suggest the device's use is withheld pending appropriate studies to identify and address the reasons for implant failure, especially if more of the radiological failures come to require revision

The Swansea Morriston Achilles Rupture Treatment (SMART) programme was introduced in 2008. This paper summarises the outcome of this programme. Patients with a rupture of the Achilles tendon treated in our unit follow a comprehensive management protocol that includes a dedicated Achilles clinic, ultrasound examination, the use of functional orthoses, early weight-bearing, an accelerated exercise regime and guidelines for return to work and sport. The choice of conservative or surgical treatment was based on ultrasound findings. . The rate of re-rupture, the outcome using the Achilles Tendon Total Rupture Score (ATRS) and the Achilles Tendon Repair Score, (AS), and the complications were recorded. An elementary cost analysis was also performed. . Between 2008 and 2014 a total of 273 patients presented with an acute rupture 211 of whom were managed conservatively and 62 had surgical repair. There were three re-ruptures (1.1%). There were 215 men and 58 women with a mean age of 46.5 years (20 to 86). Functional outcome was satisfactory. Mean ATRS and AS at four months was 53.0 (. sd . 14), 64.9 (. sd. 15) (n = 135), six months 67.8 (. sd. 16), 73.8 (. sd. 15) (n = 103) and nine months (72.4; . sd. 14) 72.3 (. sd. 13) (n = 43). The programme realised estimated cost savings exceeding £91 000 per annum. The SMART programme resulted in a low rate of re-rupture, a satisfactory outcome, a reduced rate of surgical intervention and a reduction in healthcare costs. Cite this article: Bone Joint J 2015; 97-B:510–15

Van Nes rotationplasty may be used for patients with congenital proximal focal femoral deficiency (PFFD). The lower limb is rotated to use the ankle and foot as a functional knee joint within a prosthesis. A small series of cases was investigated to determine the long-term outcome. At a mean of 21.5 years (11 to 45) after their rotationplasty, a total of 12 prosthetic patients completed the Short-Form (SF)-36, Faces Pain Scale-Revised, Harris hip score, Oswestry back pain score and Prosthetic Evaluation Questionnaires, as did 12 age- and gender-matched normal control participants. A physical examination and gait analysis, computerised dynamic posturography (CDP), and timed ‘Up & Go’ testing was also completed. Wilcoxon Signed rank test was used to compare each PFFD patient with a matched control participant with false discovery rate of 5%.

There were no differences between the groups in overall health and well-being on the SF-36. Significant differences were seen in gait parameters in the PFFD group. Using CDP, the PFFD group had reduced symmetry in stance, and reduced end point and maximum excursions.

Patients who had undergone Van Nes rotationplasty had a high level of function and quality of life at long-term follow-up, but presented with significant differences in gait and posture compared with the control group.

Cite this article: Bone Joint J 2013;95-B:192–8.