The Ponseti method has been proven to be the gold standard of treatment for clubfoot. The question however remains about the treatment of atypical and complex feet with this method. The Ponseti technique has been used to treat all clubfeet at the our institution for the past 10 years. We interviewed 70 patients (114 affected feet) ages 5–9 regarding the current state of their clubfoot using the 10 item Disease Specific Instrument (DSI) developed by Roye et al. Of these, 16 patients had a complex foot defined by a transverse medial crease. The DSI scores from all patients were transformed onto a 100 point scale and compared based on overall score as well as functional outcome and satisfaction. There was no significant difference in the overall scores with a mean of 76.43 (sd= 21.1) in patients who did not have a complex deformity compared to a mean of 79.17 (sd= 19.4) in those who did have a complex foot (p=0.644). On the functional subscale the mean scores were 74.07 (sd=27.1) and 89.58 (sd=25.9) for patients who had non-complex and complex feet, respectively (p=0.474). Regarding satisfaction, the non-complex group had a mean score of 79.51 (sd=19.7) compared to the mean of 78.75 (sd=16.7) in the complex group (p=0.888). Primary treatment with the Ponseti method achieves very successful correction of the clubfoot deformity with good outcome scores. Furthermore, even in patients with a complex deformity, the Ponseti method still achieves equally successful outcomes

Hallux valgus (HV) deformities have been well defined in the adult population. HV appears to be more prevalent in elderly and female populations and it is postulated that women's shoe wear contributes to its progression. This study was a pilot to quantify the prevalence of foot deformities and foot pain in an adolescent population. Our cohort consisted of 202 school children aged 11–17 recruited from two schools in Edinburgh. Foot health data was recorded via the Manchester Scale (MHVS) and the Oxford Ankle and Foot Questionnaire (OAFQ). Photographic assessment of all participants allowed MHVS to be calculated by two orthopaedic surgeons. The photographic assessment was then repeated by the same surgeon 12 months later to allow inter and intra observer reliability to be calculated. Results showed that the prevalence of HV in our cohort was 32.7% and there was a female preponderance 56% to 44%. Other foot measurements revealed 48.5% had HV-interphalangeus, 25.7% had a low medial longitudinal arch and 22.3% had a valgus hindfoot angle. Significantly more females (18%) than males (5%) wore shoes narrower than their feet (p=0.003). OAFQ scores revealed that foot pain was more common in those with HV deformities although not statistically significant (75% to 68%, p=0.243). The prevalence of foot pain was negatively correlated with age (r=−0.175, p=0.14). This study suggests that there is a significant prevalence of HV and foot pain amongst female adolescents. This will need to be confirmed by a population study based on power calculation informed by this pilot

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is the most reliable surgical option, for hallux rigidus from end-stage osteoarthritis. The aim of the study was to compare the functional outcomes of memory nickel-titanium staples versus a compression plate with a cross screw construct for first MTPJ arthrodesis using the Manchester–Oxford Foot Questionnaire (MOXFQ). Patients who underwent MTPJ arthrodesis using either memory nickel-titanium staples or a compression plate with a cross screw construct were identified from the surgical lists of two orthopaedic consultants. Pre and post-operative MOXFQ questionnaire, a validated patient-reported outcome measure, was administered, and responses were analysed to derive the MOXFQ summary index. The study included 38 patients (staple group N=12 and plate and cross screw group N=26). 23 patients were female and 15 were male. Mean age was 64.8 years (SD 9.02; 40 to 82). Initial analysis showed no significant difference in preoperative MOXFQ scores between the groups (p = 0.04). Postoperatively, the staple group exhibited a mean improvement of 36.17, surpassing the plate group's mean improvement of 23. Paired t-test analysis revealed a statistically significant difference (t-score= 2.5, p = 0.008), favouring the use of staples. The findings indicate that the use of staples in MTPJ arthrodesis resulted in a significantly greater improvement in MOXFQ scores compared to plates. Further research is needed to explore the underlying factors contributing to this difference and to evaluate long-term effects on patient outcomes

Background. A pedobarograph is a device that records pressures exerted by the foot on contact with the ground. Clinically most publications using pedobarography investigated diabetic foot pressures for prevention of ulcers, and assessing gait and sway. Only limited work was done on the effects of foot surgery on foot pressures. Any comparison between papers is hampered by the absence of available defined normal ranges of foot pressures. Aims of Study. The objective of the research project is to describe the foot pressures for 250 volunteers and to identify any trends and relationships of age, sex, body mass index (BMI), shoe & foot size and ethnic origin to foot pressures. The study is to provide a baseline upon which further comparative clinical research can be built. Materials and Methods. a sample size of 250 volunteers was determined after statistical advice. Ethics approval was sought. Recruitment was done after consent from Leicester Royal Infirmary and Leicester University. Volunteers with lower limb injury, diabetes, peripheral vascular disease or spinal cord injuries were excluded. Participants walked barefooted onto a (Takscan) matrix pressure mat. They walked at a speed they considered normal for themselves, as recommended by Taylor et al. We used the two step initiation protocol, invented by Myers-Rice et al to control the stride length, volunteers stood two steps away from the mat and hit the mat in their second step. Five steps per foot were collected for each patient and the average per foot area was calculated. The five steps method provided a coefficient of reliability of 0.94. Each foot was divided into 13 areas using the Tekscan software package. Data analysis was done using SPSS. Study participants’ characteristics (age, sex, foot size, height, weight and BMI) were summarised as a whole and by ethnic group, in tabular and graphical form. Histograms of foot pressure parameters (mean peak pressure at the medial and lateral heel, the mid foot, the head of each metatarsal and at each toe) were generated. The confidence interval was set to 95% and the level of significance to 0.05. Regression analysis testing was carried out to determine any significant relations between the variables. Coefficient of determination was reported for models including age, sex and ethnic origin, with and without adjustment for other body size measures. Results. Study population demographics, as well as BMI, height, weight and the average foot size were described. The average peak foot pressure for each foot area for each ethnic group was described and compared. Regression analysis of the variables has shown statistically significant associations between >70 years age group and low midfoot pressure, high BMI/weight and high midfoot pressure, big foot size and high midfoot pressure. The white western European group had the highest overall foot pressures

Introduction. Venous thromboembolism (VTE) is an uncommon complication of foot and ankle surgery but has the potential for significant morbidity and mortality. The incidence, risk factors and prevention of VTE in foot and ankle surgery is not clear. Materials and methods. We conducted a systematic review of the literature using MEDLINE, EMBASE, CINAHL, the Cochrane library and reference lists of retrieved articles without language or date restriction upto 31st July 2010. The Coleman methodology score was used to evaluate the quality of studies. From 985 citations, 38 full text articles fulfilled the inclusion criteria. Conclusions were drawn on the incidence, risk factors and prevention of VTE in foot and ankle surgery. Results. The incidence of symptomatic VTE in foot and ankle surgery in general is low; higher incidence has been reported in tendoachilles surgery. There is some evidence that history of prior VTE, immobilisation, non-weight bearing, obesity, hormone replacement therapy and oral contraceptives predispose to VTE in foot and ankle surgery. The evidence on the efficacy of different thromboprophylaxis agents and the optimum duration of treatment is unclear. Conclusion. The current evidence on VTE prophylaxis in foot and ankle surgery is insufficient to draw any firm conclusions. Long term effects of VTE in foot and ankle surgery need to be investigated further. Further large scale, multicentre studies are needed to delineate the role of VTE prophylaxis in foot and ankle surgery

Introduction. It has been postulated that a mild clubfoot does better than a severe clubfoot no matter what treatment course is taken. There have been previous efforts to classify clubfoot. For units worldwide that use the Ponseti Method of clubfoot management, the Pirani scoring system is widely used. This scoring system has previously been shown to predict the number of plasters required to gain correction. Our study aimed to investigate whether the Pirani score gave an indication of longer-term outcome using tibialis anterior tendon transfer as an endpoint. Methods. A prospectively collated database was used to identify all patients treated in the Ponseti clinic at the Royal Manchester Children's Hospital between 2002 and 2005 with idiopathic clubfoot who had not received any treatment prior to their referral. Rate of tibialis tendon transfer as well as the patient's presenting Pirani score were noted. Feet were grouped for analytical purposes into a mild clubfoot (Pirani score <4) and a severe clubfoot (Pirani score 4) category depending on initial examination. Clinic records were reviewed retrospectively to identify patients who were poorly compliant at wearing boots and bars and were categorised into having “good” or “bad” compliance with orthosis use. Results. 132 feet in 94 children were included in the study. 30 (23%) tibialis tendon transfers were performed at a mean of 4.2 years (range 2.3–5.5 years). Children with severe clubfoot had a significantly higher rate of tendon transfer compared with those with mild clubfoot (28% vs. 6%; p=0.0001). 81% of patients were classified as being “good” boot wearers. Tibialis tendon transfer rates in those who were poorly compliant with boot usage were significantly higher compared with those with good compliance (52% vs. 16%; p=0.0003). There was a significantly higher tendon transfer rate in those with severe disease and poor compliance compared with good compliance (69% vs. 20%; p=0.0002). There was no association between boot compliance and tendon transfer rates in those with mild disease. Conclusion. This study shows that late recurrences, requiring tibialis anterior tendon transfer, are associated with severity of disease at presentation and compliance with use of orthoses. Tendon transfer rates are higher for those with severe disease. We have confirmed previous reports that compliance with orthotic use is associated with recurrence. However, the novel findings regarding recurrence rates in mild clubfeet may have implications regarding usage of orthoses in the management of mild idiopathic clubfeet after initial manipulation using the Ponseti method

The equinovarus hind foot deformity is one of the most common deformities in children with spastic paralysis and is usually secondary to cerebral palsy. Split posterior tibialis tendon transfer is performed to balance the flexible spastic varus foot and is preferable to posterior tibialis lengthening, as the muscle does not loose its power and therefore the possibility of a valgus or calcaneovalgus deformity is diminished. The cohort of the study consisted of 50 children with cerebral palsy who underwent split posterior tibial lengthening to manage spastic equinovarus hind foot deformity. Our inclusion criteria were: ambulatory patients with cerebral palsy, age less than 6 years at the time of the operation, varus deformity of the hind foot during gait, flexible varus hind foot deformity, and the follow-up at least 4 years. We retrospectively evaluated 33 ambulant patients with flexible spastic varus hind foot deformity. Twenty-eight patients presented unilateral and 5 bilateral involvement. The mean age at the time of the operation was 10,8 years (6–17) and the mean follow-up was 10 years (4–14). Eighteen feet presented also equinus hind foot deformity, requiring concomitant Achilles cord lengthening. Clinical evaluation was based on the inspection of the patients while standing and walking, the range of motion of the foot and ankle, callus formation and the foot appearance using the clinical criteria of Kling et al. Anteroposterior and lateral weight-bearing radiographs of the talo-first metatarsal angle were measured. The position of the hind foot was evaluated according to the criteria of Chang et al for the surgical outcome. 20 feet were graded excellent, 14 were graded good and 4 were graded poor. Feet with recurrent equinovarus deformity or overcorrection into valgus or calcaneovalgus deformity were considered as poor results. There were 23 feet presenting concomitant cavus foot component that underwent supplementary operations performed at the same time with the index operation. None of the feet presented mild or severe valgus postoperatively, while 4 feet presented severe varus deformity and underwent calcaneocuboid fusion sixteen and eighteen months after the index operation. On the anteroposterior and lateral weight-bearing radiographs the feet with severe varus had a negative talo-first metatarsal angle (mean −26,8 ± 18,4), those with mild varus had a mean of −14,5 ± 12,2. In feet with the hind foot in neutral position the mean value was 5.0 ± 7.4. The results of the feet in patients with hemiplegic pattern were better and significantly different than the diplegic and quadriplegic ones (p = 0.005). The results in our cases were in general satisfactory as 34 out of 38 feet were graded excellent and good. The feet with poor results presented a residual varus deformity due to intraoperative technical errors

Objective. In many institutions, serial casting and splinting requires many weeks of treatment and frequently results in surgery. This study evaluated the results of neonatal clubfoot correction with the Furlong method. This method was created by Furlong M.B. and Lawn G.W. in New York and was published in Archives of Pediatrics in 1960. Materials and Methods. This study reviews 95 neonates with 128 severe clubfeet (initial Pirani score 4,0 or more). Patients with arthrogrypotic clubfeet and other syndromes were not included. Age at presentation ranged from 4 hours to 18 days. All patients had no previous treatment. The cast application with extra space above the foot was performed as follows: a special elastic pad was placed on the dorsal aspect of the foot and fixed with a cotton bandage. Then plaster cast was applied with knee flexion 110–120 degrees. After the cast was set, the elastic pad was removed, leaving a reserve space on the dorsal aspect of the foot. The cast was changed every 3–7 days. Typical corrective maneures were performed. Foot displacement into dorsiflexion occured spontaneously as an active motion and also with manipulations. Abduction braces or knee-flexed splints were applied after the complete foot correction. Pirani score and foot dorsiflexion angle were documented during each step of correction. Results. A detailed rating system (with radiologic criteria) was used for result evaluatiion. Correction was successful in all but 5 patients. 90 % required less than 6 casts. There were 12 recurrences and they were related with compliance with the abduction brace, but not with age or number of casts required for correction. Only 13 patients required surgery (6 posterior releases, 6 posteromedial releases and 1 complete subtalar release). Mean follow-up was 12 years. 23% of feet were evaluated as excellent, 71 %- as good and 6%- as poor results. Conclusion. The Furlong method is succesful in obtaining initial correction in the idiopathic clubfoot patient. This method corrects the neonatal congenital clubfoot in 85% without any surgery

Arthordesis of small joints of the foot is a commonly performed procedure in orthopaedics. A variety of fixation devices have been used for this purpose. Nickel-Titanium Memory compression staples for arthrodesis have been used in our institute since June 2003. We report the results of the procedure over a period of 7years involving 252 feet in 232 consecutive patients who underwent arthrodesis or an osteotomy fixation using compression staples. The patients were evaluated to determine the period of immobilization in cast and the time to radiographic joint fusion. The emphasis of this study was to validate the safety of the implant for fusion of small joints of the foot, as well as to determine whether there is a demonstrable trend in time to fusion and period of immobilization required. The average time to fusion was 7.2 weeks, the average period of immobilisation was 6.5 weeks. Successful union was achieved in 98% cases. We report the follow up results, finer technical aspects of the procedure and pitfalls to avoid whilst performing the fusions

Introduction. Medial column insufficiency in patients with painful acquired flatfoot can be difficult to appreciate. The reverse Coleman block test is used in this study to predict medial column instability. Methods. Patients who underwent a procedure for medial column insufficiency with use of the reverse Coleman block test pre-operatively were investigated. Weight bearing radiographs were used to determine the joints in the medial column contributing to the deformity and also to estimate the angle which the first ray must be depressed to re-establish hindfoot neutrality. The reverse Coleman block test corrects a mobile valgus heel to a neutral position by placing a block, of appropriate height, under the first metatarsal head. With the heel in neutral and the relative forefoot supination compensated the foot returns to a neutral anatomic position. Gender, age, complications and radiological outcomes were investigated. Results. Over the last three years 25 medial column procedures were performed for painful insufficiency on 17 females and five males by the senior author. Three patients underwent staged bilateral procedures. The average age was 62 years old. Three feet had been on operated on the medial column previously. The pre-operative weight bearing lateral radiographs showed instability in the medial column greater than 5° in 12 cases. With the reverse Coleman block test instability was seen in 25 cases and the deformity increased from an average of 7° (range 0° to 25°) to 14° (range 5° to 30°). Post-operative weight bearing radiographs, with fusion of the unstable joint, the average medial column alignment was 1° (range −10° to 10°). Three patients developed superficial infections requiring oral antibiotics for treatment. One patient had a non-union requiring revision surgery. Discussion. The reverse Coleman block test revealed instability in 13 out of 27 cases not seen with simple weight bearing lateral radiographs. The test also on average doubled the size of any deformity seen. This aided pre-operative planning to predict the scale of deformity correction required. Conclusion. The reverse Coleman block test is a useful test to determine medial column insufficiency and assist with pre-operative planning

Aims. The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients. Methods. In this multicentre study, 120 patients aged ≥ 60 years with an acute unstable AO/OTA type 44-B fracture of the ankle were randomized to fixation with either a nail or a plate and followed for 24 months after surgery. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Secondary outcome measures were the Manchester-Oxford Foot Questionnaire, the Olerud and Molander Ankle score, the EuroQol five-dimension questionnaire, a visual analogue score for pain, complications, the quality of reduction of the fracture, nonunion, and the development of osteoarthritis. Results. At 24 months, the median AOFAS score was equivalent in the two groups (nail 90 (interquartile range (IQR) 82 to 100), plate 95 (IQR 87 to 100), p = 0.478). There were statistically more complications and secondary operations after nail than plate fixation (p = 0.024 and p = 0.028, respectively). There were no other significant differences in the outcomes between the two groups. Conclusion. The functional outcome after nail and plate fixation was equivalent; however, the complication rate and number of secondary operations was significantly higher after nail fixation. These results suggest that plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly. Cite this article: Bone Joint J 2023;105-B(1):72–81

Aims. Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. Methods. A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). Results. In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. Conclusion. A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing. Cite this article: Bone Jt Open 2024;5(3):236–242

Introduction. Chronic ankle instability is a common condition that can be effectively treated with arthroscopic lateral ankle ligament reconstruction to restore ankle stability and function. The aim of this study was to assess the functional outcomes of arthroscopic lateral ligament reconstruction using the MOXFQ, VAS, and EQ5D patient-reported outcome measures (PROMs). Methods. This prospective series included 38 patients who underwent arthroscopic lateral ligament reconstruction for chronic ankle instability between December 2019 and April 2022. All patients completed the MOXFQ, VAS, and EQ5D PROMs preoperatively, as well as at6, and 12 months postoperatively. The MOXFQ is a disease-specific PROM that assesses foot and ankle function, while the VAS measures pain and the EQ5D evaluates health-related quality of life. Results. At the 12-month follow-up, the mean MOXFQ Index score had improved significantly from 53.3 ± 23.1 preoperatively to 16.0 ±21.1 (p < 0.001). Similarly, the mean VAS score had improved from 36.2 ± 22.4 preoperatively to 14.7 ± 15.0 (p < 0.001), and the meanEQ5D score had improved from 0.55 ± 0.26 preoperatively to 0.87 ± 0.12 (p < 0.001). No major complications were observed. Conclusion. Arthroscopic lateral ligament reconstruction is an effective treatment for chronic ankle instability, with significant improvements in clinical and health-related quality of life outcomes

Midfoot arthrodesis is the conventional surgical intervention for midfoot arthritis. Arthrodesis aims to stabilise, realign and fuse the affected joints, providing patients with improved pain and function. Current research neglects the measurement of patient reported outcomes. This study aimed to investigate objective, and patient reported outcomes of midfoot arthrodesis. The secondary aim was to identify variables predicting the development of non-union. An automated search of online patient records identified 108 eligible patients (117 feet). The rates of union, re-operations, and complications were calculated using radiographs and medical records. Logistic regression was used to model variables influencing the odds of non-union. All living patients were posted a Manchester Oxford Foot Questionnaire (MOx-FQ), a patient reported outcome assessment. Pre-operative MOx-FQ results were available in a minority of cases. Students t-test was used to compare pre- and post-operative MOx-FQ scores. The rate of union achieved was 74%. The rate of re-operations was 35%. The rate of complications was 14%. Bone grafts and staple fixation independently impacted the odds of non-union. Bone grafts decreased the odds of non-union, whilst staple fixation increased the odds. This finding agrees with the opinion of other researchers. We recommend the use of bone grafts, and the avoidance of fixation with staples. Previous attempts have been made to assess patient outcomes. However, this study is the first to use the MOx-FQ, a validated questionnaire. Therefore, this study establishes a baseline for improvements in patient reported outcomes

The aim of this study was to evaluate the long-term outcomes of patients who had sustained an unstable ankle fracture with a posterior malleolus fracture (PMF) and without (N-PMF). Adult patients presenting to a single academic trauma centre in Edinburgh, UK, between 2009 and 2012 with an unstable ankle fracture requiring surgery were identified. The primary outcome measure was the Olerud Molander Ankle Score (OMAS). Secondary measures included Euroqol-5D-3L Index (Eq5D3L), Euroqol-5D-VAS and Manchester Oxford Foot Questionnaire (MOXFQ). There were 304 patients in the study cohort. The mean age was 49.6 years (16.3–78.3) and 33% (n=100) male and 67% (n=204) female. Of these, 67% (n=204) had a PMF and 33% did not (n=100). No patient received a computed tomography (CT) scan pre-operatively. Only 10% of PMFs (22/204) were managed with internal fixation. At a mean of 13.8 years (11.3 – 15.3) the median OMAS score was 85 (Interquartile Range 60 – 100). There was no difference in OMAS between the N-PMF and PMF groups (85 [56.25 – 100] vs 85 [61.25 – 100]; p = 0.580). There was also no difference for MOXFQ (N-PMF 7 [0 – 36.75] vs PMF 8 [0–38.75]; p = 0.643), the EQ5D Index (N-PMF 0.8 [0.7 – 1] vs PMF 0.8 [0.7 – 1]; p = 0.720) and EQ5D VAS (N-PMF 80 [70 – 90] vs PMF 80 [60 – 90]; p = 0.224). The presence of a PMF does not affect the long-term patient reported outcomes in patients with a surgically managed unstable ankle fracture

The Trauma Triage clinic (TTC) is a Virtual Fracture clinic which permits the direct discharge of simple, isolated fractures from the Emergency Department (ED), with consultant review of the clinical notes and radiographs. This study details the outcomes of patients with such injuries over a four-year period. All TTC records between January 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and soft tissue mallet finger injuries were included. Application of the direct discharge protocol, and any deviations were noted. All records were then re-assessed at a minimum of three years after TTC triage (mean 4.5 years) to ascertain which injuries re-attended the trauma clinic, reasons for re-attendance, source of referral and any subsequent surgical procedures. 6709 patients with fractures of the radial head (1882), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and soft tissue mallet finger injures (370) were identified. 963 (14%) patients were offered in-person review after TTC, of which 45 (0.6%) underwent a surgical intervention. 299 (4%) re-attended after TTC direct discharge at a mean time after injury of 11.9 weeks and 12 (0.2%) underwent surgical intervention. Serious interventions, defined as those in which a surgical procedure may have been avoided if the patient had not undergone direct discharge, occurred in 1 patient (0.01%). Re-intervention after direct discharge of simple injuries of the elbow, hand and foot is low. Unnecessary deviations from protocol offer avenues to optimise consumption of service resources

Open reduction and internal fixation (ORIF) with trans-articular screws or dorsal plating is the standard surgical technique for displaced Lisfranc injuries. This aim of this study is to compare the clinical outcomes of percutaneous reduction and internal fixation (PRIF) of low energy Lisfranc injuries with a matched, control group of patients treated with ORIF. Over a seven-year period (2012–2019), 16 consecutive patients with a low energy Myerson B2-type injury were treated with PRIF. Patient demographics were recorded within a prospectively maintained database at the institution. This study sample was matched for age, sex and mechanism of injury to a control group of 16 patients with similar Myerson B2-type injuries treated with ORIF. Clinical outcome was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Manchester Oxford Foot Questionnaire (MOXFQ). At a mean follow up of 43.0 months (95% CI 35.6 – 50.4), both the AOFAS and MOXFQ scores were significantly higher in the PRIF group compared to the control ORIF group (AOFAS 89.1vs 76.4, p=0.03; MOXFQ 10.0 vs 27.6, p=0.03). There were no immediate postoperative complications in either group. At final follow up, there was no radiological evidence of midfoot osteoarthritis in any patient in the PRIF group. Three patients in the ORIF group developed midfoot osteoarthritis, one of whom required midfoot fusion. PRIF is a technically simple, less invasive method of operative stabilisation of low energy Lisfranc injures which also appears to be associated with better mid-term clinical outcomes compared to ORIF

Aims. No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. Methods. Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler’s angle and calcaneal width, and posterior facet reduction. Results. Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001). Conclusion. The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286–293

Aims. The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size. Methods. This observational prospective cohort study included 70 patients with operatively treated rotational type PMAFs, respectively: 23 Haraguchi Type I (large posterolateral-oblique), 22 Type II (two-part posterolateral and posteromedial), and 25 (avulsion-) Type III. There was no standardized protocol on how to address the PMAFs and CT-imaging was used to classify fracture morphology and quality of postoperative syndesmotic reduction. Quantitative 3D-CT (Q3DCT) was used to assess the quality of fracture reduction, respectively: the proportion of articular involvement; residual intra-articular: gap, step-off, and 3D-displacement; and residual gap and step-off at the fibular notch. These predictors were correlated with the Foot and Ankle Outcome Score (FAOS) at two-years follow-up. Results. Bivariate analyses revealed that fracture morphology (p = 0.039) as well as fragment size (p = 0.007) were significantly associated with the FAOS. However, in multivariate analyses, fracture morphology (p = 0.001) (but not fragment size (p = 0.432)) and the residual intra-articular gap(s) (p = 0.009) were significantly associated. Haraguchi Type-II PMAFs had poorer FAOS scores compared with Types I and III. Multivariate analyses identified the following independent predictors: step-off in Type I; none of the Q3DCT-measurements in Type II, and quality of syndesmotic reduction in small-avulsion Type III PMAFs. Conclusion. PMAFs are three separate entities based on fracture morphology, with different predictors of outcome for each PMAF type. The current debate on whether or not to fix PMAFs needs to be refined to determine which morphological subtype benefits from fixation. In PMAFs, fracture morphology should guide treatment instead of fragment size. Cite this article: Bone Joint J 2020;102-B(9):1229–1241

Aims

This study aimed to investigate the clinical characteristics and outcomes associated with culture-negative limb osteomyelitis patients.