Introduction. Mode of non-operative management of thoracolumbar spine fracture continues to remain controversial with the most common modality hinging on bracing. TLSO is the device with a relative extension locked position, and many authors suggest they may have a role in the healing process, diminishing the load transferred via the anterior column, limiting segmental motion, and helping in pain control. However, several studies have shown prolonged use of brace may lead to skin breakdown, diminished pulmonary capacity, weakness of paraspinal musculature with no difference in pain and functional outcomes between patients treated with or without brace. Aims. To identify number of spinal braces used for spinal injury and cost implications (in a DGH), to identify the impact on length of stay, to ascertain patient compliance and quality of patient information provided for brace usage, reflect whether we need to change our practice on TLSO brace use. Methods. Data collected over 18-month period (from Jan.2020 to July 2021). Patients were identified from the TLSO brace issue list of the orthotic department, imaging (X-rays, CT, MRI scans) reviewed to confirm fracture and records reviewed to confirm neurology and non-operative management. Patient feedback was obtained via post or telephone consultation. Inclusion criteria- patients with single or multi -level thoracolumbar osteoporotic or traumatic fractures with no neurological involvement treated in a TLSO brace. Exclusion criteria- neurological involvement, cervical spine injuries, decision to treat surgically, concomitant bony injuries. Results. 72 braces were issued in the time frame with 42 patients remaining in the study based on the inclusion/exclusion criteria. Patient feedback reflected that 62% patients did not receive adequate advice for brace usage, 73% came off the brace earlier than advised, and 60% would prefer to be treated without a brace if given a choice. The average increase in length of stay was 3 days awaiting brace fitting and delivery. The average total cost burden on the NHS was £127,500 (lower estimate) due to brace usage. Conclusion. If there is equivalence between treatment with/without a brace, there is a need to rethink the practice of prescribing brace for all non-operatively treated fractures and a case-by-case approach may prove more beneficial

Purpose of study. To study the effect of different shoes and orthotics have on patellar tendon tensile forces. Patellar tendinopathy is an overuse injury that affects tennis players and in high impact sports like basketball, volleyball and running has an incidence of 20%. The tensile forces in the patellar tendon can be reliably measured with an intratendinously placed fibre optic tube and wireless transmission device allows for dynamic testing. The biggest strain differentials have been confirmed in jumps from 30cm height. Tennis is played on 3 major different court surfaces and there is a variety of commercially designed tennis shoes on the market. Materials and methods. 6 male tennis players, ages 18–49 were enrolled for this study. A fibre optic cannula was placed in the middle of the proximal pole of patella tendon from lateral to medial direction in the dominant knee. The patellar tendon tensile forces deform the fibre optic cannula in turn modulating the light signal passing through the optic cannula. The drag in the fibre optic sensor signal was used to measure the tensile forces in the patellar tendon. MLTS 700 goniometer were utilized to measure and record the amount of flexion with each jump to standardize results for different shoes and orthotics. Results. The results of patellar tendon tensile forces measurements for different players, different shoes and orthotics showed no trend or statistical difference for any particular shoe or orthotic. Conclusions. Fibre optic measurements of the effect of different shoes on patellar tendon tensile forces did not show a distinct advantage for any shoe above another. 1 DISCLOSURE

Daycase surgery has advantages for patients, clinicians and trusts. The Best Practice Tariff uplift is £200/case for Minor Foot Procedures performed as daycases. Before discharge, Foot & Ankle daycase procedures in Cheltenham General Hospital require physiotherapy assessment and frequently an orthotic aid. This audit analysed length of stay of daycase patients on a Foot and Ankle list. The standard was 100% of daycase patients to be discharged the same day. Length of stay for a consecutive series of patients was calculated for all daycase procedures from October to December 2010. An intervention was made comprising a weekly multidisciplinary bulletin from the Orthopaedic Consultant. This highlighted post-operative weight-bearing instructions and orthotic requirements for forthcoming daycase patients to physiotherapists, nursing staff and junior doctors. The data was compared with a second consecutive series of patients from October to December 2011. The first series included 38 listed daycases of which 61% (23 patients) were daycase discharges. The second series comprised 41 listed daycases who received pre-operative physiotherapy assessment and provision of required orthotic aids; 85% (35 patients) of this group were discharged the same day. Data analysis using Fisher's exact test reveals this intervention had a statistically significant impact on the number of patients discharged the same day (p < 0.0207). The financial implications are increased Best Practice Tariff with an £1800 uplift and reduction in the estimated cost of unnecessary overnight stays of £4640 over the 3 months. Improved multidisciplinary communication can significantly improve the patient experience, bed occupancy and cost of care

The aim of this study was to compare immediate weight-bearing mobilisation with traditional plaster casting in the rehabilitation of non-operatively treated Achilles tendon ruptures. Forty-eight patients with Achilles tendon rupture were randomised into two groups. The treatment group was fitted with an off-the-shelf carbon-fibre orthotic and the patients were mobilised with immediate full weight-bearing. The control group was immobilised in traditional serial equinus plaster casts. The heel raise within the orthotic and the equinus position of the cast was reduced over a period of eight weeks and then the orthotic or cast was removed. Each patient followed the same rehabilitation protocol. The primary outcome measure was return to the patient's normal activity level as defined by the patient. There was no statistical difference between the groups in terms of return to normal work [p=0.37] and sporting activity [p=0.63]. Nor was there any difference in terms of return to normal walking and stair climbing. There was weak evidence for improved early function in the treatment group. There was 1 re-rupture of the tendon in each group and a further failure of healing in the control group. One patient in the control group died from a fatal pulmonary embolism secondary to a DVT in the ipsilateral leg. Immediate weight-bearing mobilisation provides practical and functional advantages to patients treated non-operatively after Achilles tendon rupture. However, this study provides only weak evidence of faster rehabilitation

Traditional risk factors for post-operative neuropathy include learning curve of surgical approach, DDH, and significant leg lengthening (>1 inch). Despite these risk factors, the most common scenario of a neuropathy is in a routine THA, by an experienced surgeon, for osteoarthritis, with no leg lengthening. Post-operative hematoma can lead to nerve compression, albeit rarely. The usual clinical presentation is of an acute event, with a previously intact nerve, sometime within the first days of surgery. Once diagnosed, immediate surgical decompression should be performed. Sciatic neuropathy is the most common, regardless of surgical approach, but the posterior approach poses the highest risk. Routine gluteus maximus tendon release may help to reduce the risk. When seen in the PACU, our approach is to immediately perform CT imaging to evaluate nerve integrity or to check on acetabular screw position. If no underlying cause is identified, the patient will be managed conservatively with foot orthotics and monitored for recovery. Femoral nerve palsy (FNP) can result in significant initial disability. Fortunately most patients recover function (although it can take over 18 months). In the early post-operative period it is often diagnosed after a patient complains of the leg giving away while attempting to walk. A knee brace will assist the patient with mobilization while the nerve recovers. The highest incidence of FNP is described for the direct lateral approach. Superior gluteal nerve (SGN) palsy is related to the direct lateral approach and may be avoided if the gluteus medius split is made within the safe zone (<5 centimeters from the tip of the greater trochanter). While early post-operative limp is common after the direct lateral approach, the true reported incidence of SGN palsy is low. Few studies showed that the persistent positive Trendelenburg test and limp is not exclusively related to the SGN damage and therefore the clinical effect of the SGN damage remains controversial. Lateral femoral cutaneous nerve can be affected during the direct anterior hip approach. One study suggests the presence of peri-incisional numbness in over 80% of patients. This is akin to numbness seen lateral to the incision after TKA. The incidence of meralgia paresthetica is extremely low (<1%)

Traditionally, arthritis is a disease which generally affects the elderly population. However, the incidence in young patients is well described and is increasing with the ever-growing obese population. Currently, the non-surgical treatment of osteoarthritis consists of corticosteroid injections, hyaluronic acid injections, weight loss, physical therapy, bracing, orthotics, narcotics, and non-steroidal anti-inflammatory drugs (NSAIDS). Oral medications (NSAIDS, tramadol, and opioids) can provide effective pain relief. Improvement with NSAIDs has been reported to be 20% relative to baseline, with better improvements seen with selective cox-2 inhibitors, which also have reduced gastrointestinal and renal toxicity. Additionally, the recent AAOS guidelines strongly recommend using NSAIDs or tramadol for pain relief. Although narcotics are effective analgesics, their use in young arthritic patients can potentially predispose individuals to future opioid dependency, and thus should be used sparingly. The primary purpose of physical therapy is to improve range of motion, strengthen muscles, and improve proprioception. Currently, the AAOS strongly recommends that patients undergo self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education. Similarly, they moderately recommended that patients with a BMI ≥ 25 undergo weight loss for symptomatic arthritis. Bracing options consist of the following: off-loader braces and transcutaneous nerve stimulation braces. These work to either off-load pressure in the knee or to scramble small nerve pain sensation, respectively. Corticosteroid injections are used to minimise pain and reduce inflammation in the joint associated with arthritis. However, their long-term repetitive use in young patients is not recommended, and current AAOS guidelines are inconclusive on their effectiveness. Additionally, the AAOS guidelines strongly recommend against the use of acupuncture, glucosamine/chondroitin, and hyaluronic acid injections

Aim. We report the results of Cobb I procedure and Rose calcaneal osteotomy for stage II posterior tibial dysfunction in a consecutive series of thirty patients. Methods. These patients were reviewed prospectively after average of 30 months (range: 12-92 months). An experienced independent, biomechanics specialist carried out the ultrasound examination to assess dynamic function of the posterior tibial tendon at final follow-up. Results. Twenty-eight patients were available for final follow-up. Two patients died of unrelated causes. Mean age was 60 years (range: 40-81 years). Average AOFAS score improved from 53.6 pre-operatively to 89.8 at final follow-up. Twenty-five (89%) patients were able to perform single heel raise. Six (22%) were using some form of orthotics at final follow-up. All calcaneal osteotomies united. On ultrasound examination, the posterior tibial tendon was intact in all patients and it was found to be mobile in twenty-six (93%) patients. There was one superficial wound infection and two prominent screws were removed. Three patients had subtalar joint arthritis. The surgical intervention improved the quality of life in all but two patients and only two patients were not satisfied with the surgery. Conclusion. These results suggest that a combination of Cobb I procedure and Rose Calcaneal osteotomy is a safe, effective, reliable and attractive option for the treatment of stage II posterior tibial tendon dysfunction, which provides dynamic function of posterior tibial tendon without sacrificing the primary function of long flexor tendons in foot and ankle

Peroneal spastic flatfeet without coalition or other known etiologies in adolescence remain a challenge to manage. We present eight such cases with radiological and surgical evidence of bony abnormalities in the subtalar region just anterior to the posterior facet. All patients had presented as tertiary referrals with recalcitrant pain and had undergone a trial of orthotics and physiotherapy. Diagnostic workup included a clinical and radiographic evaluation. Clinical examination consisted of gait examination, foot alignment, range of motion, torsional profile of the lower limbs and marking of symptomatic foci. All patients had standing weightbearing AP and lateral projections of the foot and ankle. CT and/or MRI scans of the foot were performed in axial coronal and saggital planes. Coalitions and other intraarticular known pathologies were ruled out. All patients had bilateral flatfeet but unilateral peroneal spasm. All patients had an accessory talar facet in front of the posterior subtalar facet. This caused lateral impingement between the facet and the calcaneum, confirmed by bone edema around the sinus tarsi. All patients had stiff subtalar joints with very limited movement under anaesthesia, indicating peroneal muscle contracture. Patients were treated with a combination of facet excision, peroneal lengthening and calcaneal lengthening to correct the flatfoot and prevent lateral impingement. We propose a mechanism of subtalar impingement between the anterior extra-articular part of the talar lateral process and the Gissane angle and believe that resection of the accessory facet without addressing the the primary driving force for impingement, which is the structural malalignment in flatfeet, would only give partial relief of symptoms. This impingement appears to occur with growth spurts in adolescents, in patients with known flatfeet

Knee mechanics - Knee forces during ADL and sports activities in TKA patients. Background. Tibiofemoral forces are important in the design and clinical outcomes of TKA. Knee forces and kinematics have been estimated using computer models or traditionally have been measured under laboratory conditions. Although this approach is useful for quantitative measurements and experimental studies, the extrapolation of results to clinical conditions may not always be valid. We therefore developed a tibial tray combining force transducers and a telemetry system to directly measure tibiofemoral compressive forces in vivo. Methods. Tibial forces were measured for activities of daily living, athletic and recreational activities, and with orthotics and braces, for 4 years postoperatively. Additional measurements included video motion analysis, EMG, fluoroscopic kinematic analysis, and ground reaction force measurement. A third-generation system was developed for continuous monitoring of knee forces and kinematics and for classifying and identifying unsupervised activities outside the laboratory using a wearable data acquisition hardware. Results. Peak forces measured for the following activities were: walking (2.6±0.2xBW); jogging (4.2±0.2)xBW; stationary bicycling (1.3±0.15)xBW; golfing (4.4±0.1)xBW; tennis (4.3±0.4)xBW; skiing (4.3±0.1)xBW; hiking(3.2±0.3)xBW; StairMaster exercise (3.3±0.3)xBW; Elliptical machine exercise (2.3±0.2)xBW; leg press machine (2.8±0.1)xBW; knee extension machine (1.5±0.03)xBW, rowing machine (0.9±0.1)xBW. Conclusions. In vivo measured knee forces can be used to enhance existing in vitro models and wear simulators and to improve prosthetic designs and biomaterials as well as guide physicians in their recommendations to patients of “safe” activities following TKA

Background. Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems including combined arthritis of the ankle and subtalar joints, complex hindfoot deformities and failed total ankle arthroplasty. The aim of this study was to report the elective results of combined subtalar and ankle arthrodesis using one design of dynamic retrograde intramedullary compression nail-the T2 Ankle Arthrodesis Nail(Stryker). Methods. Retrospective review identified 53 consecutive patients who had 55 tibiotalocalcaneal arthrodesis procedures by two surgeons(ITS and NJT) using T2 Ankle nail fixation. 3 patients died of unrelated causes before follow up was complete which left 50 patients(52 nails); the largest consecutive series in the use of this device. Mean follow up was 23.5(3–72) months with the average age of patients being 61(range 22–89) years. An 84% response was achieved to a function and patient satisfaction questionnaire. Main indications for treatment were combined ankle and subtalar arthritis(63%-33/52) or complex hindfoot deformities(23%-12/52). Outcome was assessed by a combination of Clinical notes review, clinical examination, and telephone questionnaire. Results. 46 patients(83.6%) achieved union at a mean time of 3.7 months.8 patients required an allograft(femoral head) bone block procedure. 4 patients(10%) subjectively thought that the procedure was of no benefit or had a poor result whilst 35(83%) had a good or excellent result. The mean visual analog scale(VAS) score for preoperative functional pain was 7.1 compared to the mean post operative(VAS) score of 1.9(p< 0.001). Complications consisted of 2 amputations, 2 deep infections and 5 removals of broken or painful screws. The use of preoperative functional aids and orthotics dropped from 32% to 18% and 22% to 18% respectively. Conclusion. This device and technique is a safe and effective treatment of hindfoot arthrosis and deformity giving reliable compression and subsequent fusion with excellent results in terms of patient satisfaction and pain relief

Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems including combined arthritis of the ankle and subtalar joints, complex hindfoot deformities and failed total ankle arthroplasty. The aim of this study was to report the elective results of combined subtalar and ankle arthrodesis using one design of dynamic retrograde intramedullary compression nail-the T2 Ankle Arthrodesis Nail(Stryker). Retrospective review identified 53 consecutive patients who had 55 tibiotalocalcaneal arthrodesis procedures by two surgeons(ITS and NJT) using T2 Ankle nail fixation. 3 patients died of unrelated causes before follow up was complete which left 50 patients(52 nails); the largest consecutive series in the use of this device. Mean follow up was 23.5(3-72) months with the average age of patients being 61(range 22-89) years. An 84% response was achieved to a function and patient satisfaction questionnaire. Main indications for treatment were combined ankle and subtalar arthritis(63%-33/52) or complex hindfoot deformities(23%-12/52). Outcome was assessed by a combination of Clinical notes review, clinical examination, and telephone questionnaire. 46 patients(83.6%) achieved union at a mean time of 3.7 months. 8 patients required an allograft(femoral head) bone block procedure. 4 patients(10%) subjectively thought that the procedure was of no benefit or had a poor result whilst 35(83%) had a good or excellent result. The mean visual analog scale(VAS) score for preoperative functional pain was 7.1 compared to the mean post operative (VAS) score of 1.9(p<0.001). Complications consisted of 2 amputations, 2 deep infections and 5 removals of broken or painful screws. The use of preoperative functional aids and orthotics dropped from 32% to 18% and 22% to 18% respectively. This device and technique is a safe and effective treatment of hindfoot arthrosis and deformity giving reliable compression and subsequent fusion with excellent results in terms of patient satisfaction and pain relief

Purpose. Management of early onset scoliosis (EOS) can be very challenging. Surgery is indicated when orthotics and casting fail. Growing rod instrumentation has become an effective approach in controlling the deformity while allowing spinal growth. However, as with any surgery, there are known complications including failure of the proximal foundation. We analyzed our patients who underwent growing rod instrumentation and identified factors that were correlated with proximal foundation failure. Method. Our Pediatric Orthopaedic Spine Database (1992–2010) was reviewed for all patients who underwent growing rod instrumentation. Sixty-six patients with EOS were identified and divided into two groups: Group 1 – proximal foundation failure; and Group 2 – no incidents of proximal failure. The two groups were evaluated for differences in age, sex, weight, upper vertebral level in construct, presence of apical fusion, and pre-operative curve magnitude. Results. Eight of the 66 patients (12%) had proximal foundation failure. When comparing Group 1 and Group 2, only age, pre-operative kyphosis, and presence of apical fusion were significant differences between the two groups. The mean age of Group 1 patients was 4.9 years (range, 2.6 to 9.2 years) and the mean age of Group 2 patients was 7.5 years (range, 2.4 to 11.6 years) (p <0.006). The mean pre-operative kyphosis in Group 1 was 71 degrees compared to 50 degrees in Group 2 (p=0.049). Among the 12 patients with apical fusion, four (33%) had proximal failure. The presence of apical fusion was also a significant difference between the groups (p=0.003). Linear regression demonstrated a significant correlation between kyphosis and failure (k=0.005, p-value 0.016) as well as age and pullout (k=−0.005, p-value <0.01). Conclusion. Our data indicates that younger patients with increased pre-operative kyphosis are at a higher risk for proximal failure of their growing rods resulting in increased incidence of unplanned surgeries. The presence of an apical fusion was also correlated to increased failure rates possibly due to stress at the proximal construct. Further research is needed to determine if stronger constructs decrease the pullout rate in the at-risk patients

Aims

To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population.

Aims

Single-event multilevel surgery (SEMLS) has been used as an effective intervention in children with bilateral spastic cerebral palsy (BSCP) for 30 years. To date there is no evidence for SEMLS in adults with BSCP and the intervention remains focus of debate.