We report a systematic review and meta-analysis of published randomised and quasi-randomised trials evaluating the efficacy of pre-operative skin antisepsis and cleansing techniques in reducing foot and ankle skin flora. The post-preparation culture number (Post-PCN) was the primary outcome. The data were evaluated using a modified version of the Cochrane Collaboration’s tool. We identified eight trials (560 participants, 716 feet) that met the inclusion criteria. There was a significant difference in the proportions of Post-PCN between hallux nailfold (HNF) and toe web spaces (TWS) sites: 0.47 vs 0.22, respectively (95% confidence interval (CI) 0.182937 to 0.304097; p < 0.0001).

Meta-analyses showed that alcoholic chlorhexidine had better efficacy than alcoholic povidone-iodine (PI) at HNF sites (risk difference 0.19 (95% CI 0.08 to 0.30); p = 0.0005); a two-step intervention using PI scrub and paint (S& P) followed by alcohol showed significantly better efficacy over PI (S& P) alone at TWS sites (risk difference 0.13 (95% CI 0.02 to 0.24); p = 0.0169); and a two-step intervention using chlorhexidine scrub followed by alcohol showed significantly better efficacy over PI (S& P) alone at the combined (HNF with TWS) sites (risk difference 0.27 (95% CI 0.13 to 0.40); p < 0.0001). No significant difference was found between cleansing techniques.

Cite this article: Bone Joint J 2013;95-B:498–503.

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

Introduction. Hindfoot intramedullary nail fixation (HFN) or fibula pro-tibial screw fixation (PTS) are surgical options for ankle fractures in patients with multiple co-morbidities; we compared their outcomes. Methods. A retrospective review of 135 patients who underwent HFN fixation (87 patients) or PTS fixation (48 patients) for ankle fractures (AO/OTA A/B/C) from 5 major trauma centres. Patient demographic data, co-morbidities, Charlson Co-morbidity Index Score (CCIS), weight-bearing, and post-operative complications were recorded. Radiographs were assessed for non-union and anatomical reduction. Results. HFN estimated 10-year survival was 27±31% and was 48±37% for PTS (p<0.001). Average time to full weightbearing (FWB) in the HFN group was 1.7±3.3 weeks compared to 7.8±3.8 weeks in the PTS group (p<0.001). Despite this, HFN fixation carried a greater VTE risk (p=0.02). HFN accompanied by joint preparation had greater risk of infection (p=0.01), metalwork failure (p=0.02) and wound breakdown (p=0.01). The overall complication rate in diabetic patients was 56%, but 76% in HFN patients. In the HFN group 17 (20%) patients died at 1 year. Patients with open fractures(p=0.01), dementia (p<0.05), and a higher CCIS (p=0.04) were more likely to die after HFN surgery. Age and co-morbidity matched data showed a higher rate of complications and mortality in those above 75 years fixed with a HFN, irrespective of CCIS. In those between 60–75 years, there was a greater risk of superficial infection and mortality after HFN, irrespective of CCIS. These complications were not seen after PTS. Conclusion. HFN carries a greater risk of superficial infections, VTE and mortality compared to PTS, independent of age and CCIS. Diabetes leads to a greater comparative risk of deep infections, wound breakdown and non-union in HFN. Alternative methods of fixation (e.g. PTS) should be considered before HFN. HFN may be suitable in selective indications where other methods are not appropriate

Aims. Arthroplasty has become increasingly popular to treat end-stage ankle arthritis. Iatrogenic posterior neurovascular and tendinous injury have been described from saw cuts. However, it is hypothesized that posterior ankle structures could be damaged by inserting tibial guide pins too deeply and be a potential cause of residual hindfoot pain. Methods. The preparation steps for ankle arthroplasty were performed using the Infinity total ankle system in five right-sided cadaveric ankles. All tibial guide pins were intentionally inserted past the posterior tibial cortex for assessment. All posterior ankles were subsequently dissected, with the primary endpoint being the presence of direct contact between the structure and pin. Results. All pin locations confer a risk of damaging posterior ankle structures, with all posterior ankle structures except the flexor hallucis longus tendon being contacted by at least one pin. Centrally-aligned transcortical pins were more likely to contact posteromedial neurovascular structures. Conclusion. These findings support our hypothesis that tibial guide pins pose a considerable risk of contacting and potentially damaging posterior ankle structures during ankle arthroplasty. This study is the first of its kind to assess this risk in the Infinity total ankle system. Cite this article: Bone Jt Open 2021;2(7):503–508

Aims. Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis. Methods. We retrospectively reviewed all the patients who underwent closed ankle arthrodesis (CAA) in Ilizarov Scientific Centre from 2013 to 2018 (Group A) and compared them with a similar group of patients (Group B) who underwent open ankle arthrodesis (OAA). We then divided the neuropathic patients into three arthritic subgroups: Charcot joint, Charcot-Maire-Tooth disease, and post-traumatic arthritis. All arthrodeses were performed by using an Ilizarov ring fixator. All patients were followed up clinically and radiologically for a minimum of 12 months to assess union and function. Results. The union rate for Group A was 81% (17/21) while it was 84.6% (33/39) for Group B. All the nonunions in Group A underwent revision with an open technique and achieved 100% union. Mean duration of IRF was 71.5 days (59 to 82) in Group A and 69 days (64.8 to 77.7) in Group B. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was similar in both groups. The postoperative hospital stay was shorter in Group A (21 days (SD 8)) than Group B (28 days (SD 9)). In the latter Group there were more problems with wound healing and greater requirement for antibiotic treatment. The mean operating time was 40 minutes (SD 9) in Group A compared to 80 minutes (SD 13) in Group B. Recurrence of infection occurred in 19% (4/21) and 15.5% (6/39) for Group A and Group B respectively. Conclusion. We found CAA using an IRF to be an effective method for ankle arthrodesis in infected neuropathic foot and ankle cases and afforded comparable results to open methods. Due to its great advantages, Ilizarov method of CAA should always be considered for neuropathic ankles in suitable patients. Cite this article: Bone Joint J 2020;102-B(4):470–477

We present a series of 23 total ankle replacements revised for balloon osteolysis and aseptic loosening with a hind-foot fusion nail without the use of bone graft. This is the largest series of total ankle replacements revised to a hindfoot fusion with a nail presented in the literature. Initial assessment involved investigations to rule out infection and a CT scan of the ankle to assess the size of cysts. Patients underwent surgery in a single stage procedure. The surgery involved excision of the fibula and preparation of the sub-talar joint through a lateral incision; removal of the implant and preparation of the talar and tibial surface with flat cuts through an anterior incision and safe excision of the medial malleolus aided by a medial incision. The prepared surfaces were then compressed and fixed using a Biomet Phoenix Nail. Patients were then followed up to assess for clinical and radiographic union. This study involved 18 male and 4 female patients with an average age of 67. All patients had AES ankle replacements (Biomet) in-situ, undergoing revision surgery for aseptic loosening with balloon osteolysis. At a mean follow up of 13.9 months, 96% (22/23) of ankles achieved osseous union across the tibio-talar joint with 1 patient achieving a partial union. 91% (21/23) of patients achieved union across the subtalar joint with 2 patients identified as having a non-union. 1 patient with a subtalar non-union suffered a broken nail and required revision surgery. The only other identifiable complication was a single patient sustained a stress fracture at the proximal tip of the nail, which was treated conservatively. We believe this method is a reliable and reproducible method of achieving osseous union following a failed total ankle replacement without using graft. Although patients may have a leg length discrepancy, none have requested leg lengthening

Aims

In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method.

Isolated talonavicular arthrodesis is a common procedure particularly for posttraumatic arthritis and rheumatoid arthritis. Two surgical approaches are commonly used: the medial approach and the dorsal approach. It is recognized that access to the lateral aspect of the talonavicular joint can be limited when using the medial approach and it is our experience that using the dorsal approach addresses this issue. We performed an anatomical study using cadaver specimens, to compare the amount of articular surface that can be accessed, and therefore prepared for arthodesis, by each surgical approach. Medial and dorsal approaches to the talonavicular joint were performed on each of 10 cadaveric specimens. Distraction of the joint was performed as standard for preparation of articular surfaces during talonavicular arthrodesis. The accessible area of articular surface was marked for each of the two approaches. Disarticulation was performed and the marked surface area was quantified using a digital Microscribe allowing a three dimensional virtual model of the articular surfaces to be assessed. This study will provide quantifiable measurements of the articular surface accessible by the medial and dorsal approaches to the talonavicular joint. These data may provide support for the use of the dorsal approach for talonavicular arthrodesis

Aims

We report the medium-term outcomes of a consecutive series of 118 Zenith total ankle arthroplasties (TAAs) from a single, non-designer centre.

Patient reported outcomes and satisfaction as a measure of service quality is becoming an increasingly important tool in local service assessment as well as a quality indicator within commissioning frameworks. We analyse the introduction of SCP led MDT facilitated patient group meetings addressing the education and preparation of patients listed for ankle and hindfoot surgery at WSH HYPOTHESIS- To identify the outcome benefits to patients from this type of quality initiative. This has been previously demonstrated in other specialities in the trust such as hip and knee replacement resulting in mandatory attendance as part of the care pathway. Feedback was gathered via a patient questionnaire from 60 patients invited to meetings over an 18 month period. Two groups of patients who have undergone hindfoot/ankle surgery at WSH were compared. Group 1 attended a 1 hour MDT meeting preoperatively designed to educate the patient on all aspects of their surgery from pre assessment through to post operative management. Group 2 did not attend any such meeting whether invited or not. Results. Group 1 found the meetings beneficial in preparing them for surgery and improved their knowledge of disease, treatment options and recovery. Group 2 felt less prepared with less knowledge of post op limitations, and available support. No significant difference in length of stay was observed. Recommendations. Additional to their consultant examination, patients undergoing major foot surgery benefit from receiving additional information provided by a mixed group of professionals involved in their care. Physiotherapists and occupational therapists as well as volunteer post operative patients at these meetings provided valuable advice and instruction in preparing for and recovering from this type of surgery

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

Bipartite talus is a rare condition of uncertain aetiology, possibly congenital, with only six reported cases in the literature. Previously, these lesions have been successfully managed either conservatively, by excision of the posterior fragment, arthrodesis or one case by internal stabilisation using a postero-anterior screw which failed to lead to bony healing. We report a series of four symptomatic cases of talus partitus in three patients, with a mean follow-up of 47 months (range 25-66 months). All patients had significant pain on presentation warranting surgical management. All three patients were male, with a mean age of 26 years (range 13-55 years) at surgery. Plain radiographs and computed tomography scans were obtained pre-operatively. All patients were reviewed at follow-up by an independent assessor. The youngest patient presented aged 13 with a lesion without sub-talar arthrosis. He represented two years later with a similar lesion on the contralateral side. He was treated twice by internal fixation with two postero-anterior cannulated screws augmented with bone graft following preparation of the bone surfaces. The second patient presented with symptoms of isolated sub-talar osteoarthritis. He was treated with a sub-talar arthrodesis augmented with bone graft through a postero-lateral approach. The final patient presented late (age 55) with severe hind-foot osteoarthritis. His symptoms required treatment with tibio-talar-calcaneal fusion and a hind-foot nail. All patients reported a resolution of their symptoms post-operatively. Evidence of was seen radiographically in all cases. We report the largest series to date of bipartite talus. All four cases were successfully treated surgically with three differing techniques, all of which utilised bone graft and internal fixation to achieve bony healing. We suggest treatment by a fusion of the talar fragments with associated limited fusion if the adjacent joints are markedly degenerate

Aims

The hypothesis of this study was that bone peg fixation in the treatment of osteochondral lesions of the talus would show satisfactory clinical and radiological results, without complications.

Aims

Tibiotalocalcaneal (TTC) fusion is used to treat a variety of conditions affecting the ankle and subtalar joint, including osteoarthritis (OA), Charcot arthropathy, avascular necrosis (AVN) of the talus, failed total ankle arthroplasty, and severe deformity. The prevalence of postoperative complications remains high due to the complexity of hindfoot disease seen in these patients. The aim of this study was to analyze the relationship between preoperative conditions and postoperative complications in order to predict the outcome following primary TTC fusion.

Aims

We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity.

Aims

The traditional transosseus flexor hallucis longus (FHL) tendon transfer for patients with Achilles tendinopathy requires two incisions to harvest a long tendon graft. The use of a bio-tenodesis screw enables a short graft to be used and is less invasive, but lacks supporting evidence about its biomechanical behaviour. We aimed, in this study, to compare the strength of the traditional transosseus tendon-to-tendon fixation with tendon-to-bone fixation using a tenodesis screw, in cyclical loading and ultimate load testing.

Aims

We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.

Aims

Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent.

Aims

Flexor hallucis longus (FHL) tendon transfer is a well-recognized technique in the treatment of the neglected tendo Achillis (TA) rupture.

Talonavicular and subtalar joint fusion through a medial incision (modified triple arthrodesis) has become an increasingly popular technique for treating symptomatic flatfoot deformity caused by posterior tibial tendon dysfunction.

The purpose of this study was to look at its clinical and radiological mid- to long-term outcomes, including the rates of recurrent flatfoot deformity, nonunion and avascular necrosis of the dome of the talus.

A total of 84 patients (96 feet) with a symptomatic rigid flatfoot deformity caused by posterior tibial tendon dysfunction were treated using a modified triple arthrodesis. The mean age of the patients was 66 years (35 to 85) and the mean follow-up was 4.7 years (1 to 8.3). Both clinical and radiological outcomes were analysed retrospectively.

In 86 of the 95 feet (90.5%) for which radiographs were available, there was no loss of correction at final follow-up. In all, 14 feet (14.7%) needed secondary surgery, six for nonunion, two for avascular necrosis, five for progression of the flatfoot deformity and tibiotalar arthritis and one because of symptomatic overcorrection. The mean American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score) at final follow-up was 67 (between 16 and 100) and the mean visual analogue score for pain 2.4 points (between 0 and 10).

In conclusion, modified triple arthrodesis provides reliable correction of deformity and a good clinical outcome at mid- to long-term follow-up, with nonunion as the most frequent complication. Avascular necrosis of the talus is a rare but serious complication of this technique.

Cite this article: Bone Joint J 2015; 97-B:668–74.