The foot and ankle outcome score (FAOS) has been evaluated for many conditions of the foot and ankle. We evaluated its construct validity in 136 patients with osteoarthritis of the ankle, its content validity in 37 patients and its responsiveness in 39. Data were collected prospectively from the registry of patients at our institution. All FAOS subscales were rated relevant by patients. The Pain, Activities of Daily Living, and Quality of Life subscales showed good correlation with the Physical Component score of the Short-Form-12v2. All subscales except Symptoms were responsive to change after surgery. We concluded that the FAOS is a weak instrument for evaluating osteoarthritis of the ankle. However, some of the FAOS subscales have relative strengths that allow for its limited use while we continue to seek other satisfactory outcome instruments. Cite this article: Bone Joint J 2015; 97-B:662–7

Introduction. Bone marrow oedema syndrome (BMES) of the foot and ankle is an uncommon and often misdiagnosed condition. It is usually thought to be a benign self limiting condition, without any sequelae. However, it can cause disabling pain for a prolonged period of time. Materials and Methods. We retrospectively reviewed 8 patients with the diagnosis of BMES. There were 6 males and 2 females with an average age of 51 years (38–63 years). All patients had acute onset of severe pain in the foot without any history of trauma. None of the patients had history of excessive alcohol or steroid intake. 5 patients (63%) had bilateral involvement of migratory nature. All patients had characteristic features on MR scans, with involvement of 3 or more bones in the foot. Results. All patients had their limbs immobilised in a below knee cast and asked to mobilise non weight bearing for 6–8 weeks. Thereafter, they were allowed to mobilise with a pneumatic walker, increasing weight bearing as pain allowed. The walker was discarded at an average of 26 weeks. All 8 patients had complete relief of pain after an average of 14 months (4–22 months). All were able to return to their work environment but 2 complained of occasional aching and swelling of their feet, at the end of their shift at work. 2 patients were treated with bisphosphonates and 2 had targeted local anaesthetic injections with good pain relief. None were treated with Iloprost. Conclusions. BMES affecting the foot and ankle is an uncommon condition. Symptoms tend to be prolonged and may result in chronic swelling and aching around the ankle. Symptoms do tend to improve with time with or without intervention

Aims

The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS).

Aims

To systematically review qualitative studies of patients with distal tibia or ankle fracture, and explore their experience of injury and recovery.

Introduction. Scar sensitivity is a recognised complication of foot surgery. However there is very little published about it. This study looks at the incidence and natural history of scar sensitivity following hallux valgus surgery. Materials and Methods. Patients who had open hallux valgus surgery from December 2008 to December 2009, with a minimum follow up of 12 months, were contacted. Data regarding scar symptoms, their duration, severity at their worst and interventions undertaken were collected. Patients also completed a Roles and Maudsley patient satisfaction score. Results. 125 patients were contacted with response rate of 84%. 30% of patients had experienced scar symptoms following surgery. Of these, 20% had undertaken some form of nonsurgical intervention. The mean duration of symptoms was 16 weeks, and 95% of patients experienced resolution of symptoms. 99% of patients would opt to have the surgery again. Roles and Maudsley score ranged from 1 to 2. Discussion. Nearly one third of patients experienced scar symptoms, however nearly all resolved completely with or without simple treatments. Symptoms were not severe and did not affect satisfaction, function or the decision to have the surgery again. Educating patients preoperatively about scar sensitivity can relieve anxiety and improve the patient experience and they can be advised on simple and effective strategies should this common side effect occur. The results of this study provide the surgeon with valuable information in the consent and education of patients. Also, the fact that nearly all symptom settled within 16 weeks brings into question one of the purported advantages of minimally invasive surgery. Conclusion. Scar symptoms following hallux valgus surgery are common, but mild and almost all resolve in time

Persistent pain is a common cause of disability in patients after fractures of the calcaneum. Amongst the possible causes for post traumatic pain is the development of degenerative osteoarthritis of the posterior facet of the subtalar joint. However there are many other causes of post-traumatic hindfoot pain which require consideration prior to treatment. Knowledge of the patho-anatomy of calcaneal fractures is required to reach an accurate diagnosis. Significant symptoms and disability may be treated by arthrodesis of the subtalar joint. Post-traumatic arthritis in the non-operatively treated calcaneal fracture is however usually associated with deformity of the hindfoot, disordered hindfoot biomechanics, lateral wall fibular impingement and fibular tendon dysfunction. Fractures treated by primary open reduction and fixation should be well aligned but despite anatomic reduction may also develop posterior facet arthritis. Symptoms may also be caused by prominence or impingement of the implant, particularly of locked perimeter plates on the lateral wall. Patients therefore require careful assessment prior to surgery and any operative measures have to address these key features in order to produce a satisfactory clinical result. This lecture will address the potential problems of this type of surgery and key features in the clinical assessment and imaging of these patients. Subtalar arthrodesis in the presence of deformity is technically complex and requires careful planning in order to correct the deformity and to produce a well aligned hindfoot to allow corrected biomechanics without impingement and the fitment of suitable footwear. The surgical techniques and different types of surgery required to adequately manage the posterior facet and deformity will be covered and will include arthroscopically assisted in-situ fusion, the safe approaches for open surgery and techniques to reconstruct the lateral wall, fibular tendon function and osteotomies required to restore calcaneal height and alignment

Introduction. Hallux valgus surgical correction has a variable but significant risk of recurrence. Symptoms result from an iatrogenic first brachymetatarsia following the index surgical procedure. First metatarsal shortening has been shown to correlate with the onset of transfer metatarsalgia. We describe the use of the scarf osteotomy to both correct the recurrent deformity and lengthen the shortened first metatarsal. Methods. 36 lengthening scarf osteotomies were undertaken in 31 patients. Clinical (AOFAS and SF12 scores) and radiographic measures (IMA, HVA) were taken pre- and post-operatively. The maximum theoretical lengthening was 10mm, to prevent first MTP joint stiffness post-operatively. The actual lengthening was determined and measured intra-operatively. Results. There were 28 female and three male patients, with mean age at presentation 53.4 years. The mean follow-up was 3.9 years. Four cases were lost to follow-up. The mean first metatarsal lengthening achieved was 4.9mm (range 1–8mm). All of the osteotomies united without complication. The mean IMA reduction was 4.0° (p<0.001) and HVA 13.0° (p<0.001). The mean AOFAS score increase was 33.8 (p<0.001). There was no correlation between change in IMA and AOFAS score (r=−0.13) or between improvement in HVA and AOFAS score (r=−0.02). There was a positive trend but no correlation (r=0.28) between amount of metatarsal lengthening and change in AOFAS score. The inter- and intra-observer correlation was excellent. The SF12 physical sub-domains improved more than the mental sub-domains. Conclusion. We describe the largest series of lengthening scarf osteotomies for recurrent hallux valgus and symptomatic iatrogenic first brachymetatarsia. The significant improvement in both clinical and radiographical measures suggests the procedure is successful, with a low complication rate. Lengthening did not reduce the MTPJ range of movement. We hypothesise that restoring both the length and alignment enables greater weight-bearing under the first metatarsal head, reducing biomechanical transfer metatarsalgia

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

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

Hindfoot arthrodesis with retrograde intramedullary nailing has been described as a surgical strategy to reconstruct deformities of the ankle and hindfoot in patients with Charcot arthropathy. This study presents case series of Charcot arthropathy patients treated with two different retrograde intramedullary straight compression nails in order to reconstruct the hindfoot and assess the results over a mid-term follow-up.

Aims

The aim of this prospective study was to evaluate the intermediate-term outcomes after revision anatomical ankle ligament reconstruction augmented with suture tape for a failed modified Broström procedure.

We have evaluated the clinical effectiveness of a metal resurfacing inlay implant for osteochondral defects of the medial talar dome after failed previous surgical treatment. We prospectively studied 20 consecutive patients with a mean age of 38 years (20 to 60), for a mean of three years (2 to 5) post-surgery. There was statistically significant reduction of pain in each of four situations (i.e., rest, walking, stair climbing and running; p ≤ 0.01). The median American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 62 (interquartile range (IQR) 46 to 72) pre-operatively to 87 (IQR 75 to 95) at final follow-up (p < 0.001). The Foot and Ankle Outcome Score improved on all subscales (p ≤ 0.03). The mean Short-Form 36 physical component scale improved from 36 (23 to 50) pre-operatively to 45 (29 to 55) at final follow-up (p = 0.001); the mental component scale did not change significantly. On radiographs, progressive degenerative changes of the opposing tibial plafond were observed in two patients. One patient required additional surgery for the osteochondral defect. This study shows that a metal implant is a promising treatment for osteochondral defects of the medial talar dome after failed previous surgery.

Cite this article: Bone Joint J 2013;95-B:1650–5.

We describe five adolescent patients aged between 13 and 16 years with bipartite ossification of the posteromedial aspect of the talus. All presented without a history of trauma.

All the ankles had a similar radiological appearance. Clinically, some restriction of movement was noted in three ankles and two subtalar joints, In addition, pain was noted over the posteromedial aspect of the ankle in three patients. In each patient the bipartite fragment was excised through a posteromedial approach to the ankle. Complete resolution was achieved at six months in three patients, with the remaining two describing exercise-induced symptoms. In one of these this precluded participation in sport.

Despite numerous anatomical variations within the tarsus, a case series of a bipartite talus has not previously been reported. This anatomical variation should be recognised to avoid misinterpretation as post-traumatic or other pathological processes. In the presence of recalcitrant symptoms excision is an option, but this is not universally successful in abolishing symptoms.

Hallux rigidus was first described in 1887. Many aetiological factors have been postulated, but none has been supported by scientific evidence. We have examined the static and dynamic imbalances in the first metatarsophalangeal joint which we postulated could be the cause of this condition. We performed a finite-element analysis study on a male subject and calculated a mathematical model of the joint when subjected to both normal and abnormal physiological loads.

The results gave statistically significant evidence for an increase in tension of the plantar fascia as the cause of abnormal stress on the articular cartilage rather than mismatch of the articular surfaces or subclinical muscle contractures. Our study indicated a clinical potential cause of hallux rigidus and challenged the many aetiological theories. It could influence the choice of surgical procedure for the treatment of early grades of hallux rigidus.