Aims

Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm². However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus.

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A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

Background. Ankle fractures are extremely common but unfortunately, over 20% fail to obtain good to excellent recovery. For those requiring surgical fixation, usual-care post-surgery has included six-weeks cast immobilisation and non-weightbearing. Disuse atrophy and joint stiffness are detrimental sequelae of this management. While rehabilitation, starting at two-weeks post-surgery is viewed as safe, the literature contains methodological flaws and a lack of focus on early exercise, perpetuating the controversy over the effectiveness of early exercise interventions. Objectives. Our objectives were to determine if following operative fixation for Weber B fracture, the physiotherapy intervention, early motion and directed exercise (EMADE), applied in the clinical setting, were superior to Usual-care at 12-weeks (primary outcome) and 24-weeks. Design and Methods. We undertook a pragmatic-RCT, recruiting 157 surgically fixed Weber B ankle fracture patients, to establish if EMADE was superior to the Usual-care of 6-weeks immobilisation. The EMADE physiotherapy intervention (between week-2 and 4 post-surgery) utilised a removable cast and combined non-weightbearing progressive home exercises with manual therapy, advice and education. The primary outcome measure was the OMAS at 12-weeks. Results. 130 participants returned their 12-weeks post-surgery data, exceeding the 60/group threshold set by the a-priory power calculation. Group OMAS means were; 62.0 and 48.8 (SD 21, 22.5) EMADE, Usual-care respectively, yielding a clinically meaningful mean difference of 13.2 on the OMAS and a statistical difference (95% CI p< 0.001, 5.66 to 20.73). Both clinically meaningful and statistically significant findings were maintained at week-24. There were no intervention related or unexpected adverse events, including instability. Conclusions. This clinic set pragmatic-RCT yielded both clinical and statistical outcomes at week-12 in favour of the EMADE physiotherapy intervention over the Usual-care of 6-weeks immobilisation, in surgically fixed Weber B ankle fracture patients. These positive findings were maintained at week-24 and justify EMADE physiotherapy as a viable treatment option

Aims. A multicentre, randomized, clinician-led, pragmatic, parallel-group orthopaedic trial of two surgical procedures was set up to obtain high-quality evidence of effectiveness. However, the trial faced recruitment challenges and struggled to maintain recruitment rates over 30%, although this is not unusual for surgical trials. We conducted a qualitative study with the aim of gathering information about recruitment practices to identify barriers to patient consent and participation to an orthopaedic trial. Methods. We collected 11 audio recordings of recruitment appointments and interviews of research team members (principal investigators and research nurses) from five hospitals involved in recruitment to an orthopaedic trial. We analyzed the qualitative data sets thematically with the aim of identifying aspects of informed consent and information provision that was either unclear, disrupted, or hindered trial recruitment. Results. Recruiters faced four common obstacles when recruiting to a surgical orthopaedic trial: patient preferences for an intervention; a complex recruitment pathway; various logistical issues; and conflicting views on equipoise. Clinicians expressed concerns that the trial may not show significant differences in the treatments, validating their equipoise. However, they experienced role conflicts due to their own preference and perceived patient preference for an intervention arm. Conclusion. This study provided initial information about barriers to recruitment to an orthopaedic randomized controlled trial. We shared these findings in an all-site investigators’ meeting and encouraged researchers to find solutions to identified barriers; this led to the successful completion of recruitment. Complex trials may benefit for using of a mixed-methods approach to mitigate against recruitment failure, and to improve patient participation and informed consent. Cite this article: Bone Jt Open 2021;2(8):631–637

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This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme.

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The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

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.

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To compare the cost-utility of removable brace compared with cast in the management of adult patients with ankle fracture.

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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.

Background. We compared platelet rich plasma (PRP) injection to cortisone (40mg triamcinolone) injection in the treatment of chronic plantar fasciitis resistant to traditional nonoperative management. The aims were to compare early and long term efficacy of PRP to that of Steroid (3, 6 and 12 months after injection). Methods. 60 heels with intractable plantar fasciitis with failed conservative treatment were randomized to either PRP or Steroid injection. All patients were assessed with Roles-Maudsley (RM) Score, Visual Analogue Score (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Data was collected prospectively on the cohort, pre-treatment, at 3, 6 and 12 months post injection. The mean scores of the two groups were compared using Student t test. Results. Pre-injection, the two groups were well matched with no statistically significant difference in the values. At 3 months, all three outcome scores in both groups had significantly improved from their pretreatment level with no significant difference between the groups (PRP: RM 3.7 to 2.0, VAS 8.3 to 3.5, AOFAS 58 to 84; Steroid: RM 3.6 to 1.9, VAS 8.3 to 2.8, AOFAS 57 to 86). At 6 months, improvement was maintained in both groups with no significant difference between groups (PRP: RM 2.1, VAS 3.7, AOFAS 89; Steroid: RM 2.2, VAS 3.3, and AOFAS 84). At 12 months, all outcome measures were significantly better for the PRP group as response in the steroid group had deteriorated (PRP: RM 1.9, VAS 3.3 and AOFAS 89; Steroid: RM 2.6, VAS 5.1 and AOFAS 77: p = 0.008, 0.02 and 0.002 respectively). Conclusions. PRP is better for the treatment of chronic plantar fasciitis as compared to steroid. It shows no statistical difference in effectiveness early on, but unlike steroid, its effectiveness does not wear off with time, making it more durable

Aims

This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years.

Nice guidelines recommend VTE prophylaxis to patients in below knee casts following foot and ankle surgery following risk assessment. The guidelines are controversial and BOFAS recommendations reiterate the risk factors but highlight poor evidence to support these guidelines. Implementation has been variable dependent on interpretation. 58 patients who underwent hindfoot procedures and were immobilised in a cast were identified. These patients were under the care of two consultants, one of whom anticoagulates with daily enoxaparin and one who does not, providing a de facto case-control design. The patients were followed up to identify those who subsequently suffered a DVT or PE, and the clinical circumstances. 2 cases of VTE events were noted in 58 patients undergoing foot and ankle surgery. Both were elective cases managed postoperatively in cast and treated with prophylaxic enoxaparin. Both of these presented to hospital with signs of VTE greater than 6 weeks following surgery after cast removal and discontinuation of enoxaparin. No patients were considered high risk according to NICE guidelines. None of the patients who received no thromboprophylaxis had a clinical DVT. Within our study group we found that VTE thromboprophylaxis does not influence clinically evident VTE rates. Patients who developed VTE were not considered high risk by definition of NICE guidelines but only at increased risk due to their immobility. The VTE events were initiated while the patients were receiving thromboprophylaxis. The effectiveness of the guidelines in predicting patients who would benefit from chemoprophylaxis is questionable from this study. NICE guidelines on VTE thromboprophylaxis have been received with some concerns. Although this investigation studied only a relatively small number of patients, it raises issues about the clinical effectiveness of the guidelines in foot and ankle patients

Background. The aim of this prospective study was to assess the effectiveness of a single ultrasound-guided steroids injection in the treatment of Morton's neuromas and whether the response to injection correlates with the size of neuroma. Methods. Forty three patients with clinical features of Morton's neuroma underwent ultrasound scan assessment. Once the lesion was confirmed in the relevant web space, a single corticosteroids injection was given using 40 mg Methylprednisolone along with 1% Lidocaine. All scans and injections were performed by a single musculoskeletal radiologist. Patients were divided into two groups based on the size of the lesion measured on the scan. Group 1 included patients with neuromas of 5mm or less and Group 2 patients had neuromas larger than 5mm. The Visual Analogue Scale (Scale:0 to 10), the American Orthopaedic Foot and Ankle Society score (AOFAS) and the Johnson satisfaction scale were used to assess patients prior to injection and then at 6 weeks, 6 months and 12 months following the injection. Results. Thirty nine patients had confirmed neuromas. Group 1 (lesion ≤5mm) included 17 patients (mean age, 30 years) (7 males, 10 females) and Group 2 (lesion >5mm) had 22 patients (mean age, 33 years) (8 males, 14 females). VAS scores, AOFAS scores and Johnson scale improved significantly in both groups at 6 weeks (p < 0.0001). At 6 months post-injection, this improvement remained significant only in group 1 with regards to all scores (p < 0.001). At 12 months, there was no difference between both groups and outcome scores nearly approached pre-injection scores. The need for surgical treatment for persistent symptoms was similar in both groups (p = 0.6). Conclusion. A single ultrasound-guided corticosteroids injection offers generally a short-term pain relief for symptomatic Morton's neuromas. The effectiveness of the injection is likely to be more significant and long-lasting for lesions smaller than 5mm

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The purpose of this study is to examine the adductus impact on the second metatarsal by the nonosteotomy nonarthrodesis syndesmosis procedure for the hallux valgus deformity correction, and how it would affect the mechanical function of the forefoot in walking. For correcting the metatarsus primus varus deformity of hallux valgus feet, the syndesmosis procedure binds first metatarsal to the second metatarsal with intermetatarsal cerclage sutures.

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In the context of tendon degenerative disorders, the need for innovative conservative treatments that can improve the intrinsic healing potential of tendon tissue is progressively increasing. In this study, the role of pulsed electromagnetic fields (PEMFs) in improving the tendon healing process was evaluated in a rat model of collagenase-induced Achilles tendinopathy.

Introduction:. Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe a purely arthroscopic technique for excising talocalcaneal coalitions. We present a retrospective two-surgeon case series of the first eight patients (nine feet). Methods:. Subtalar arthroscopy is performed from two standard sinus tarsi portals with the patient in a saggy lateral position. Coalitions are resected with a barrel burr after soft tissue clearance with arthroscopic shavers. Early postoperative mobilisation and non-steroidal anti-inflammatory drugs prevent recurrence of coalition. Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 to 5.5 years. Results:. Pain and SAFAS scores improved in 7 patients. Subtalar movements were improved in all feet and were sustained to final follow-up. All patients achieved early good function and returned to sports and demanding jobs. One patient's pain recurred requiring subsequent fusions. One posterior tibial nerve was damaged. Both of these patients had coalitions extending across more than one quarter of the posterior facet. Conclusion:. Minimal destruction of bone and soft tissues with an arthroscopic technique allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from both open and arthroscopic excision of tarsal coalitions. Patient selection and preoperative planning are crucial to avoid relapse and complication. If significant degenerative changes are present at surgery or resections are too extensive onto the posterior facet early recurrence of pain may occur. This series from two independent surgeons supports the feasibility and effectiveness of this technique

Evidence-based orthopaedic surgery emphasizes the need to properly design and perform high-quality randomized controlled trials to minimize bias and to truly ensure the effectiveness of orthopaedic interventions. The currently available best evidence suggests to load and move the Achilles tendon after an open or percutaneous repair for an acute rupture. Following repair of the torn AT, patients are immobilized with their ankle in gravity equines. They are encouraged to bear weight on the operated limb as soon as possible to full weightbearing, and discharged home on the day of the procedure. All patients are given an appointment for review 2 weeks postoperatively, when they receive a single cast change, with the ankle accommodated in a removable anterior splint in a plantigrade position, secured to the lower leg and foot with Velcro straps. Removal of the foot straps under supervision of a physiotherapist allowes the ankle to be plantar flexed fully but not dorsiflexed. These exercises are performed against manual resistance. At 6 weeks postoperatively, the anterior splint is removed, and the patient referred to physiotherapy for active mobilization. At 12 weeks postoperatively, patients are assessed as to whether they are able to undertake more vigorous physiotherapy, and encouraged to gradually return to their normal activities. Progressive activities are incorporated as strength allowed, with the aim to return to unrestricted activities 6 months following surgery

Aim. Young patients with ankle arthritis that remains symptomatic in spite of conservative treatment and following arthroscopic debridement are usually offered either ankle fusion or ankle replacement. Both these options are far from ideal in this age group. The aim of this study was to evaluate functional outcomes following ankle distraction to determine whether it is a reliable alternative for the treatment of ankle arthritis in young adults. Material and methods. Data was collected prospectively for 15 patients (9 males and 6 females, mean age 31.9 years) with “stage 2” ankle arthritis who failed conservative treatment and continued to be symptomatic following arthroscopic ankle debridement. Distraction of 8 mm was done using a dynamic constrained ankle circular frame and all patients were allowed full weight bearing all through the distraction process. The subjective functional evaluation was based on the American Orthopaedic Foot and Ankle Score (AOFAS), the Foot Disability Index (FADI) and the Visual Analogue Score (VAS). In 10 patients the Manchester Oxford Foot questionnaire (MOXFQ) and the Short Form (SF) 12 patient satisfaction questionnaire were also filled preoperatively and at final follow up. Results. At a minimum follow-up of 24 months (mean 34.4) none of the patients required fusion or replacement. There was a significant improvement in all the functional outcome scores. There was also a significant improvement in the ankle joint space on weight bearing x-rays. Conclusion. Based on these results the use of ankle distraction can be considered a useful option for the treatment of symptomatic “stage 2” ankle arthritis in young adults. Longer-term follow-up and comparison with alternative techniques will be required to evaluate the true effectiveness of this treatment option

Introduction. Chronic mid body Achilles tendinopathy is a common problem. There is no consensus on treatment. The aim of this review was to assess the effectiveness of physiotherapy interventions (non surgical and non pharmacological) for this condition. Methods. A systematic review of the literature was conducted. A search of published and grey literature databases was undertaken (1999- December 2010). Two reviewers independently assessed the studies for eligibility using a strict inclusion and exclusion criteria. All eligible articles were assessed critically using the Pedro score. Data on cohort characteristics, diagnostic criteria, treatment intervention, outcome measures and results was extracted. A narrative research synthesis method was adopted. Results. 209 studies were identified. Nine publications met the review inclusion criteria. Methodological quality was adequate for all nine studies; however, blinding was a limitation for most. Interventions investigated were; Exercises (n = 2), Low level laser therapy (n = 1), Low energy shockwave treatment (SWT) (n = 3), Air cast brace (n = 2) and Insoles (n = 1). Some evidence exists for eccentric exercises in combination with SWT or Laser. However, contrary to other reviews, eccentric exercises were not found to be superior to other physiotherapy treatments. Conclusions. There is insufficient evidence to determine which method of physiotherapy is most appropriate for a chronic Achilles tendinopathy. Further well designed randomised controlled trials assessing physiotherapy interventions with specific diagnostic criteria and appropriate outcome tools are required to determine the efficacy of physiotherapy for the condition

Introduction. The Z or “scarf” osteotomy was first described by Meyer in 1926 and then by Burutaran in 1976. It was later popularised by Weil in the USA and Barouk in Europe in the 1990's and is now an accepted technique that forms part of a surgeons' armamentarium. The theory of Diffusion of Innovations was described by Rogers in 1962 to explain how novel ideas are accepted into practice across different industries, including medicine. It has never previously been used to study the adoption of ideas in foot and ankle surgery. Methods. This paper uses publication volume as a surrogate marker for adoption, as described previously by the authors. Briefly, a systematic review of the literature was carried out. MESH headings included ‘Hallux Valgus’, and ‘osteotomy’ or ‘SCARF’ or ‘Z osteotomy’ or ‘bunionectomy’. 2818 publications were identified and the abstracts were reviewed excluding 2699 publications for non-relevance. The data was analysed by year of publication, country of origin, as well as for level of evidence. Results. There were 120 publications relating to SCARF osteotomy, which when plotted on a graph produced an s shaped curve. 58% of publications came from Europe and 38% from the USA. There was only a single level 1 paper published in 2008. Discussion. This study confirms that publication volume is a surrogate marker for adoption and that SCARF osteotomy became adopted by the late 2000's as indicated by the plateau on an s-shaped curve. Post market surveillance has led to a further rise in recent publications indicating that certain issues still need resolving before the laggards adopt this technique. Despite SCARF having been around for more than 80 years, very little high level evidence has been published of its effectiveness. Recommendations are made as to how future innovations should be introduced in foot and ankle surgery