This study sought to determine the medium-term patient-reported and radiographic outcomes in patients undergoing surgery for hallux valgus. A total of 118 patients (162 feet) underwent surgery for hallux valgus between January 2008 and June 2009. The Manchester-Oxford Foot Questionnaire (MOXFQ), a validated tool for the assessment of outcome after surgery for hallux valgus, was used and patient satisfaction was sought. The medical records and radiographs were reviewed retrospectively. At a mean of 5.2 years (4.7 to 6.0) post-operatively, the median combined MOXFQ score was 7.8 (IQR:0 to 32.8). The median domain scores for pain, walking/standing, and social interaction were 10 (IQR: 0 to 45), 0 (IQR: 0 to 32.1) and 6.3 (IQR: 0 to 25) respectively. A total of 119 procedures (73.9%, in 90 patients) were reported as satisfactory but only 53 feet (32.7%, in 43 patients) were completely asymptomatic. The mean (SD) correction of hallux valgus, intermetatarsal, and distal metatarsal articular angles was 18.5° (8.8°), 5.7° (3.3°), and 16.6° (8.8°), respectively. Multivariable regression analysis identified that an American Association of Anesthesiologists grade of > 1 (Incident Rate Ratio (IRR) = 1.67, p-value = 0.011) and recurrent deformity (IRR = 1.77, p-value = 0.003) were associated with significantly worse MOXFQ scores. No correlation was found between the severity of deformity, the type, or degree of surgical correction and the outcome. When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, the long-term results are worse than expected when compared with the short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years. Cite this article: Bone Joint J 2015;97-B:208–14

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. Fusion represents an effective treatment option in patients affected by end-stage arthritis. To minimise the risk of non-union following fusion, biological preparations such as bone marrow aspirate concentrate (BMAC) are commonly used intra-operatively. Mechanotransduction represents an emerging field of research whereby physical stimuli can be used to modulate the behaviour and differentiation of cells. Blast waves (a subtype of shock waves) are one such physical stimulus. The aim of this study was to investigate whether the osteogenic potential of BMAC can be enhanced using a blast wave, and thus improve its efficacy in fusion surgery. Methods. Human BMAC samples were obtained from three healthy patients and exposed to a single blast wave (peak overpressure= 50psi), before being placed in a suspension of mesenchymal stem cells, to represent the biological environment of the fusion site. Three test groups were used: MSC (the experimental control); MSC + BMAC; MSC + BMAC + blast wave. Calcium mineralisation assays were performed on the MSCs on Day 7 and 14 to assess for osteoblastic transformation. Results. Calcium mineralisation on Day 7 was significantly increased in the MSC + BMAC group compared to the MSC group (mean percentage change 42.12 vs 0.0, p=0.012). The MSC + BMAC + blast wave group also demonstrated significantly increased levels compared to the MSC + BMAC group (84.56 vs. 42.14, p = 0.039). The difference in calcium mineralisation between the MSC and MSC + BMAC + blast wave groups was strongly significant (0.00 vs. 84.56, p = 0.003). Conclusion. Exposure of BMAC to a single blast wave enhances its osteogenic potential. This represents a potential novel way to improve healing following fusion surgery and reduce the rates of non-union

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. 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

Background. There are many different procedures described for the correction of hallux valgus deformity. Minimally invasive surgery has become increasingly popular, with clinical and radiological outcomes comparable to traditional open osteotomy approaches. There is increasing interest in hallux valgus deformity correction using third-generation minimally invasive chevron akin osteotomy (MICA) technique. Objective. To assess the radiographic correction and 2 year clinical outcomes of third-generation MICA using validated outcome measures. Methods. This is a prospective single-surgeon case series of 420 consecutive feet undergoing MICA surgery between July 2014 and November 2018. Primary clinical outcome measures included the Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D, and the Visual Analogue Pain Scale. Secondary outcome measures included radiographic parameters, and complication rates. Results. Pre-operative and 2 year post-operative patient reported outcomes were collected for 334 feet (79.5%). At minimum 2 year follow-up, the MOXFQ scores (mean ± standard deviation (SD)) had improved for each domain: pain; pre-operative 43.9±21.0 reduced to 9.1±15.6 post-operatively (p<0.001), walking and standing; pre-operative 38.2±23.6 reduced to 6.5±14.5 post-operatively (p<0.001) and social interaction; pre-operative 47.6±22.1, reduced to 6.5±13.5 post-operatively (p<0.001). At 2 year follow-up, the VAS Pain score (mean ± SD) improved from a pre-operative of 31.3±22.4 to 8.3±16.2 post-operatively (p<0.001). 1–2 intermetatarsal angle (mean ± SD) reduced from 15.4°±3.5° to 5.8°±3.1° (p<0.001) and hallux valgus angle reduced from 33.1°±10.2° to 9.0°±5.0° post-operatively (p<0.001). Conclusion. Third-generation MICA showed significant improvement in clinical outcomes at 2 year follow-up and can be successfully used for correction of a wide range of hallux valgus deformities

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

Background. Optimal management of displaced intra-articular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiological outcomes of minimally invasive surgery (MIS) versus non-operative treatment in displaced intra-articular calcaneal fracture up to 2-years. Methods. All displaced intra-articular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma centre were considered for inclusion. The decision to treat was made by a multidisciplinary meeting. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction & internal fixation. Non-operative protocol involved symptomatic management with no attempt at closed reduction. All fractures were classified, and the MOXFQ/EQ-5D-5L scores were used to assess foot and ankle and general health-related quality of life outcomes respectively. Results. 101 patients were recruited at a level 1 major trauma centre, between August 2014 and January 2019. Our propensity score matched 44 patients in the surgical cohort to 44 patients in the non-surgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (p<0.05) however the patients in the surgical cohort had a significantly higher EQ-5D-5L Index score (p<0.05). There was also a higher return to work (91% vs 72%, p<0.05) and physical activity rate (46 vs. 35%, p<0.05) in the surgical cohort despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. 14% of patients in the non-operative cohort subsequently underwent arthrodesis compared to none of the patients in the surgical cohort. Conclusion. In this study, we found operative treatments were associated with low rates of surgical complication at 2-years and long term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared to nonoperative treatment

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

The responsiveness of the Manchester–Oxford Foot Questionnaire (MOXFQ) was compared with foot/ankle-specific and generic outcome measures used to assess all surgery of the foot and ankle. We recruited 671 consecutive adult patients awaiting foot or ankle surgery, of whom 427 (63.6%) were female, with a mean age of 52.8 years (18 to 89). They independently completed the MOXFQ, Short-Form 36 (SF-36) and EuroQol (EQ-5D) questionnaires pre-operatively and at a mean of nine months (3.8 to 14.4) post-operatively. Foot/ankle surgeons assessed American Orthopaedic Foot and Ankle Society (AOFAS) scores corresponding to four foot/ankle regions. A transition item measured perceived changes in foot/ankle problems post-surgery. Of 628 eligible patients proceeding to surgery, 491 (78%) completed questionnaires and 262 (42%) received clinical assessments both pre- and post-operatively. The regions receiving surgery were: multiple/whole foot in eight (1.3%), ankle/hindfoot in 292 (46.5%), mid-foot in 21 (3.3%), hallux in 196 (31.2%), and lesser toes in 111 (17.7%). Foot/ankle-specific MOXFQ, AOFAS and EQ-5D domains produced larger effect sizes (> 0.8) than any SF-36 domains, suggesting superior responsiveness. In analyses that anchored change in scores and effect sizes to patients’ responses to a transition item about their foot/ankle problems, the MOXFQ performed well. The SF-36 and EQ-5D performed poorly. Similar analyses, conducted within foot-region based sub-groups of patients, found that the responsiveness of the MOXFQ was good compared with the AOFAS. This evidence supports the MOXFQ’s suitability for assessing all foot and ankle surgery

We analysed the clinical and radiological outcomes of a new surgical technique for the treatment of heterozygote post-axial metatarsal-type foot synpolydactyly with HOX-D13 genetic mutations with a mean follow-up of 30.9 months (24 to 42). A total of 57 feet in 36 patients (mean age 6.8 years (2 to 16)) were treated with this new technique, which transfers the distal part of the duplicated fourth metatarsal to the proximal part of the fifth metatarsal. Clinical and radiological assessments were undertaken pre- and post-operatively and any complications were recorded. Final outcomes were evaluated according to the methods described by Phelps and Grogan. Forefoot width was reduced and the lengths of the all reconstructed toes were maintained after surgery. Union was achieved for all the metatarsal osteotomies without any angular deformities. Outcomes at the final assessment were excellent in 51 feet (89%) and good in six (11%). This newly described surgical technique provides for painless, comfortable shoe-wearing after a single, easy-to-perform operation with good clinical, radiological and functional outcomes. Cite this article: Bone Joint J 2013;95-B:929–34

Background:. Various angles have been used to grade the severity of hallux valgus deformity. They are useful in surgical planning but do not correlate with symptom severity or improvement. We feel that there is a fundamental mismatch between the width of the forefoot and the width of the hindfoot and that this is more clinically relevant, we describe two techniques for measuring this. We aim to measure the degree of foot narrowing after surgery and moreover how this correlates to the severity of pre- and post operative outcomes. Methods:. 200 consecutive bunion operations were assessed with weight bearing radiographs. The HVA and IMA were measured according to standard practice. We also assessed forefoot width using two methods we have described. The first is the ‘Forefoot Width’ measured as a perpendicular to the midfoot (a technique we have previously validated). The ‘Foot Ratio’ is calculated as a function of the calcaneal width. Clinical outcomes were assessed using the MOXFQ and AOFAS. Results:. Bunion surgery narrows the osseous width of the forefoot. This narrowing can be by as much as 23 mm in cases with severe deformity. We found that the Forefoot: Hindfoot ratio correlated with symptom severity and that normalisation of the ratio to below 2.5 was associated with better outcomes. This is important as small absolute corrections were associated with good outcomes. Conclusion:. Our measure of Forefoot Width is reproducible and allows for variations such as forefoot adductus. We feel that the Forefoot: Hindfoot ratio is more important as this determines the ability to fit into off-the-shelf footwear rather than requiring bespoke or modified footwear. This is the first study to look at the ability to narrow the forefoot and has important implications in determining patient selection and post-operative outcomes

Objectives. The Manchester–Oxford Foot Questionnaire (MOXFQ) is a validated 16-item, patient-reported outcome measure for evaluating outcomes of foot or ankle surgery. The original development of the instrument identified three domains. This present study examined whether the three domains could legitimately be summed to provide a single summary index score. . Methods. The MOXFQ and Short-Form (SF)-36 were administered to 671 patients before surgery of the foot or ankle. Data from the three domains of the MOXFQ (pain, walking/standing and social interaction) were subjected to higher order factor analysis. Reliability and validity of the summary index score was assessed. Results. The mean age of the participants was 52.8 years (. sd. 15.68; 18 to 89). Higher order principle components factor analysis produced one factor, accounting for 74.7% of the variance. The newly derived single index score was found to be internally reliable (α = 0.93) and valid, achieving at least moderate correlations (r ≥ 0.5, p < 0.001) with related (pain/function) domains of the SF-36. Conclusions. Analyses indicated that data from the MOXFQ can be presented in summary form. The MOXFQ summary index score (MOXFQ-Index) provides an overall indication of the outcomes of foot and ankle surgery. Furthermore, the single index reduces the number of statistical comparisons, and hence the role of chance, when exploring MOXFQ data

Aims. The purpose of this study was to analyse the biomechanics of walking, through the ground reaction forces (GRF) measured, after first metatarsal osteotomy or metatarsophalangeal joint (MTP) arthrodesis. Patients and Methods. A total of 19 patients underwent a Scarf osteotomy (50.3 years, standard deviation (. sd. ) 12.3) and 18 underwent an arthrodesis (56.2 years,. sd. 6.5). Clinical and radiographical data as well as the American Orthopaedic Foot and Ankle Society (AOFAS) scores were determined. GRF were measured using an instrumented treadmill. A two-way model of analysis of variance (ANOVA) was used to determine the effects of surgery on biomechanical parameters of walking, particularly propulsion. Results. Epidemiological, radiographical and clinical data were comparable in the two groups and better restoration of propulsive function was found after osteotomy as shown by ANOVA (two way: surgery × foot) with a surgery effect on vertical forces (p < 0.01) and a foot effect on anteroposterior impulse (p = 0.01). Conclusion. Patients who underwent Scarf osteotomy had a gait pattern similar to that of their non-operated foot, whereas those who underwent arthrodesis of the first (metatarsophalangeal) MTP joint did not totally recover the propulsive forces of the forefoot. Take home message: The main findings of this study were that after surgical correction for hallux valgus, patients who underwent scarf osteotomy had a gait pattern similar to that of their non-operated foot in terms of forefoot propulsive forces (Fz3, Iy2), whereas those who underwent arthrodesis of the first MTP joint had not. Cite this article: Bone Joint J 2016;98-B:641–6

Surgery to the midfoot (usually fusion) may be performed for trauma, arthritis, deformity or combinations. There are reports of good results, meaning primary fusion rates of 90+percent, 12 % serious complication rates and need for hardware removal 1n 25% of cases from specialist centres (Nemec et al AOFAS 2010). But even these good results mean 10% of patients needing lengthy revision surgery, and a third needing some additional intervention. Surgery to the midfoot, like all surgery has both consequences (which everyone experiences) and complications (which some peolple get). The consequences of midfoot surgery are time in hospital, long periods in cast (often non-weight bearing) and long rehabilitation periods leading to a “second best” result where pain is relieved, but mechanics and full function are not restored, and longterm stiffness and swelling are comon. Usually the patient still needs to restrict activities and wear orthotics or adaptive footwear. The commonest complication is probably a failure to inform patients of the consequences of surgery – inevitably leading to disappointment with result and outcome. Common complications include:. Wound, nerve and vascular problems. Delayed union, malunion and non-union. General complications such as DVT and embolism. All these complications are more common in patients who smoke, are diabetic or have a BMI over 30. By showing examples of problems seen in the last 15 years of tertiary referral (and the authors own cases), a system to minimise complications, and to address them when they occur, will be presented, based on:. Good preparation and timely accurate information. Planning surgery (approach, execution and post operative management). Rehailitation and after surgery care. These can usually only be brought together by a surgeon performing this surgery on a regular basis, and with the support of an equally experienced multi-disciplinary team

Aims. Various radiological parameters are used to evaluate a flatfoot deformity and their measurements may differ. The aims of this study were to answer the following questions: 1) Which of the 11 parameters have the best inter- and intraobserver reliability in a standardized radiological setting? 2) Are pre- and postoperative assessments equally reliable? 3) What are the identifiable sources of variation?. Patients and Methods. Measurements of the 11 parameters were recorded on anteroposterior and lateral weight-bearing radiographs of 38 feet before and after surgery for flatfoot, by three observers with different experience in foot surgery (A, ten years; B, three years; C, third-year orthopaedic resident). The inter- and intraobserver reliability was calculated. Results. Preoperative interobserver reliability was high for four, moderate for five, and low for two parameters. Postoperative interobserver reliability was high for four, moderate for five, and low for two parameters. Intraobserver reliability was excellent for all parameters preoperatively as recorded by observer A (PB) and B (MP), and for eight parameters as recorded by observer C (SR). Intraobserver reliability was excellent for ten parameters postoperatively as recorded by observer A and B, and for eight parameters as recorded by observer C. Conclusion. The following parameters can be recommended. For preoperative and postoperative evaluation of flatfoot: anteroposterior, talonavicular coverage angle; lateral, talometatarsal I angle, calcaneal pitch angle, and cuneiform-medial height (high interobserver reliability); and anteroposterior, talometatarsal II angle; lateral, talocalcaneal angle,tibiocalcaneal angle (moderate interobserver reliability). For more experienced observers, we also recommend the anteroposterior talometatarsal I angle (moderate reliability). The inter- and intraobserver reliability for most parameters were similar pre- and postoperatively. The experience of the observer and the definition and ability to measure the parameters themselves were sources of variation. Cite this article: Bone Joint J 2018;100-B:596–602

The rate of surgical site infection after elective foot and ankle surgery is higher than that after other elective orthopaedic procedures.

Since December 2005, we have prospectively collected data on the rate of post-operative infection for 1737 patients who have undergone elective foot and ankle surgery. In March 2008, additional infection control policies, focused on surgical and environmental risk factors, were introduced in our department.

We saw a 50% reduction in the rate of surgical site infection after the introduction of these measures. We are, however, aware that the observed decrease may not be entirely attributable to these measures alone given the number of factors that predispose to post-operative wound infection.

Cite this article: Bone Joint J 2015;97-B:516–19.

Failed Hallux Valgus Surgery Aim. We aim to explore the reasons behind long term failure of hallux valgus surgery. Patients & Methods. A series of patients with problems following failed hallux valgus surgery presenting to a tertiary referral unit is presented. There were 47 patients with 55 problematic feet, 45 were female. The mean age was 59 years (Range 25–79). The failed bunions were compared to a prospectively collected series of 80 patients with successful 1st metatarsal osteotomies, 40 ludloff and 40 scarf osteotomies. Before the index surgery, all the patients in the failed group, the predominant symptom was pain. Only 53% admitted deformity was an issue. A wide spectrum of procedures were performed, 13 Wilson's, 11 Keller's, 8 Chevron, 3 Bunionectomy, 2 Scarf, 1 Basal and 1 Mitchell's. In 16 patients the original procedure was unknown. The mean time to developing problems was 9.4 years (Range 0–45) with mean time to presentation 13.6 years. (Range 0–47) Radiographs revealed 2/3 of patients had relative shortening of the first metatarsal. Over 80% of x-rays demonstrated evidence of degenerative change. The mean AOFAS score deteriorated with increased shortening. The failed bunions had statistically significantly different AOFAS pain scores (15.1 vs 31.9 p < 0.05), function scores (25.02 vs 31.9 p < 0.05). Additionally, the hallux valgus angle was significantly higher (24 vs 11.7 p < 0.05) although there was no change in DMMA between the two groups (13 vs 7.6 p > 0.05). There was a significantly higher incidence of first ray shortening (12% vs 0% p < 0.05). Discussion. This represents an unusual series, with nothing similar in the literature. Problems following hallux valgus surgery do not present for over 10 years. Functional Scores deteriorate with increasing shortening. MTPJ degeneration is common and from our data we are unable to explain why

A Morton's neuroma is a compressive neuropathy most commonly affecting the common digital nerve of the third inter-space. Symptoms are variable but usually the diagnosis can be made quite easily and the diagnosis is essentially a “clinical” one. When symptoms relate to the second inter-space the clinician needs to be alert to mechanical causes of metatarsalgia leading to secondary irritation of the nerve. Imaging with MRI scanning and/or ultrasound can be helpful but equally can be misleading, as there may be false positives and false negatives. In the case of ultrasound the accuracy of imaging depends on the experience and expertise of the radiologist. Morton's neuroma surgery is usually associated with high levels of success but some reports suggest as many as 30% of patients under-going such surgery are dissatisfied with the outcome. The reasons for failed surgery can be broadly divided into three groups: a) wrong diagnosis b) wrong surgery and c) right diagnosis and right operation but unfavourable outcome. Wrong diagnosis is most commonly encountered in second space pathology when there is an underlying mechanical reason for the symptoms such as second MTP joint synovitis. This is usually secondary to joint overload associated with first ray insufficiency eg hallux valgus. This is the so-called Moron's neuroma. Wrong surgery occurs when the wrong space is operated upon, when mechanical causes are overlooked or when a plantar incision is made over the weight-bearing part of the forefoot, leading to painful scar formation. Wrong surgery can also involve failure to recognise anomalous anatomy within the space or insufficient nerve resection. Unfavourable outcomes include infection, stump neuroma formation or the onset of CRPS. Occasionally despite an appropriate assessment and operation a patient will derive no relief of symptoms and the cause of the pain remains totally unexplained. Careful history and examination and careful pre-operative planning can reduce the incidence of failed Morton's neuroma surgery. The role of imaging is probably greater in such cases compared with those presenting with a primary Morton's neuroma but the diagnosis remains essentially clinical. Stump neuroma resection should be considered in patients presenting with repeat symptoms especially if there is initial surgical success followed by recurrent symptoms. If two explorations result in no success then a third exploration is unlikely to resolve the problem. Some patients are left with intractable symptoms and should be referred to a pain specialist, as further surgery often has nothing more to offer

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. Patients and Methods. We retrospectively reviewed all patients who underwent internal fixation of a fracture of the ankle between 2008 and 2013. The primary outcome was the rate of deep infection and the secondary outcome was any surgical site infection (SSI). Associations with the risk factors and possible confounding variables were analysed univariably and multivariably with backwards elimination. Results. A total of 1043 patients were included; 64 (6.1%) had a deep infection and 146 (14.0%) had SSI. Obesity was strongly associated with both outcomes (odds ratio (OR) 2.21, p = 0.017 and OR 1.68, p = 0.032) in all analyses. Alcohol overuse was similarly associated, though significant only in unadjusted analyses. Surprisingly, smoking did not yield statistically significant associations with infections. Conclusion. These findings suggest that obesity and possibly alcohol overuse are independent risk factors for the development of infection following surgery for a fracture of the ankle. This large study brings new evidence concerning these common risk factors; although prospective studies are needed to confirm causality. Cite this article: Bone Joint J 2017;99-B:225–30