Introduction:

Instability and synovitis of the lesser metatarsalphalangeal (MTP) joints is a significant cause of forefoot pain. Plantar plate imaging traditionally has been through MRI and fluoroscopic arthrography. We have described ultrasound arthrography as a less resource-intensive technique without radiation exposure. We report the correlation between ultrasound arthographic and surgical findings.

The most important determinant in the treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement. Weber (2010) showed that weightbearing radiographs predicted stability in patients with undisplaced ankle fractures.

We developed clinical criteria for potential instability and applied them to a prospective series of patients. Criteria included: medial clear space of < 4mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; a high-energy fracture mechanism. A consecutive, prospectively documented series of 37 patients chose functional brace treatment of potentially unstable fractures. Weightbearing radiographs were performed in the brace before treatment, and free of brace at clinical union (6–9 weeks in all patients). Patients were encouraged to bear full weight and actively exercise their ankles in the brace.

All fractures healed without displacement. The risk of displacement was 0% (95% CI 0–11.2%). This preliminary series gives support for the use of weightbearing radiographs to guide treatment of undisplaced ankle fractures.

Hammer toe involves metatarsophalangeal joint (MTPJ) hyperextension and proximal interphalangeal joint (PIPJ) flexion. Surgery commonly involves excision arthroplasty or fusion of the PIPJ with MTPJ soft tissue release if necessary. Previous series record that MTPJ release was carried out “as required” but not how often release is necessary. Myerson and Shereff's (1989) cadaver study found release of the extensors, MTPJ capsule and collateral ligaments necessary for full hammertoe correction. Hossain (2002) found the clinical results of this procedure were no better than simple PIPJ fusion. We release the MTPJ if hyperextension persists after PIPJ correction and release the components sequentially. We studied how often and how extensive a release was required, and how this corelated with pre-operative assessment.

We reviewed the records of 164 patients who had hammer toe correction under one consultant surgeon. Patients with complex corrections were excluded. The severity of the pre-operative deformity was classified as type 1 (PIPJ and MTPJ correctable), 2 (PIPJ fixed, MTPJ correctable) or 3 (neither joint correctable). We recorded the extent of release required for each toe.

Introduction

Many common fractures are inherently stable, will not displace and do not require plaster casting to achieve union in a good position. Nevertheless, many patients with stable fractures are advised that they need a cast, despite the potential for stiffness, skin problems and thromboembolism. Attempts to challenge this practice often meet the argument that patients prefer a cast for pain relief. We analysed five years of a single consultant's fracture clinic to see how many patients with stable foot and ankle fractures chose a cast after evidence-based counselling.

Introduction: Lesser metatarsophalangeal joint (MTPJ) instability is a common cause of forefoot pain. Instability is probably caused by tears of the plantar plate and collateral ligaments. We prospectively compared MRI and ultrasound with and without arthrography in the assessment of patients with MTPJ instability.

Materials and Methods: MTPJ instability was diagnosed by the draw test. Nineteen patients underwent imaging with consent. One musculoskeletal radiologist performed MRI arthrography and a different musculoskeletal radiologist performed ultrasonography supplemented with arthrography. Each radiologist reported his own study, blinded to the results of the other modality. Where possible, the radiological diagnosis was evaluated at surgery.

Results: MRI identified four full thickness plantar plate tears. In five studies no contrast was seen in the MTP joint and in 10 contrast was contained within the joint.

Ultrasound identified six full thickness plantar plate tears as hypoechoic zones that extended through the whole thickness of the plate. Eleven studies showed partial thickness tears. Two studies showed thinning of the plate. Ultrasound arthrography identified seven full thickness tears by extravasation of injected fluid into the flexor tendon sheath. Eleven studies showed partial thickness tears and one was normal. Ultrasound and ultrasound arthrography agreed in 14/19 patients. MRI agreed with ultrasound on 3 of 6 full thickness tears and with ultrasound arthrography in 4 of 6 full thickness tears. MRI gave additional information about the articular surfaces in four patients. Surgical comparison was available in 11/19 patients. Ultrasound with and without arthrography correctly predicted four partial thickness tears. Ultrasound arthrography correctly predicted 6/7 full thickness tears, MRI 3/7 and ultrasound 3/7.

Discussion: Ultrasound with arthrography appears the best modality to distinguish between partial and full-thickness tears. It is cheaper, simpler and can be performed in the outpatient setting. Larger studies with surgical confirmation are required to assess its value more precisely.

Introduction: Coding systems are important for epidemiology, research, audit, activity analysis and now remuneration. There have been concerns that the existing coding systems do not represent foot and ankle activity accurately.

Materials and Methods: The senior author’s logbook was analysed for 2 years. Each operation descriptor was recorded. A “simple descriptor” described an operation of one component (“scarf osteotomy”). A “multiple descriptor” described multiple instances of one component (“bilateral scarf osteotomy”). A “compound descriptor” described a procedure made up of more than one component (“scarf osteotomy and 2nd toe straightening”). We encoded the logbook using OPCS4.5 and the RCSED Electronic Logbook. We assessed whether simple descriptors could be coded unambiguously (ie there was a one-to-one relationship between descriptor and code so that distinct procedures could be identified) and whether compound descriptors contained ambiguous codes. We also considered whether the overall procedure was adequately summarised by the tabulated codes. Codes were converted to the HRG4 and BUPA payment codes and referenced to chevron osteotomy.

Results: There were 513 procedures with 157 different descriptors (3.27 cases/descriptor, compared with 4.44 in upper limb and 7.69 in lower limb). Fifty-four descriptors (321 patients) were simple, 18 (52 patients) were multiple and 85 (140 patients) were compound. Using OPCS, 57.4% of simple descriptors (46.1% of patients) were ambiguous, as were 82.4% of compound descriptors (85.7% of patients). In 27.1% of descriptors (33.6% of patients) the tabulated codes did not give the overall procedure clearly. Using the eLogbook, 48.1% of simple descriptors (25.2% of patients) and 74.1% of complex descriptors (70.7% of patients) were ambiguous and in 30.6% of descriptors (37.1% of patients) the codes did not summarise the operation well. Most remuneration compared reasonably with chevron osteotomy, with some idiosyncrasies. Overall remuneration was lower than procedures of comparable complexity in other specialties.

Introduction: Lesser metatarsophalangeal instability is a common cause of forefoot pain. Previous studies were small and there is little data comparing surgical with non-surgical treatment.

Patients and Methods: Metatarsophalangeal instability was diagnosed and staged with the draw test. We recorded the clinical presentation, involved toes, severity of instability, presence of toe deformity and management. Patients were followed-up in clinic or by telephone interview with visual analogue pain and satisfaction scores and AOFAS lesser metatarsophalangeal scores. Outcomes were assessed by an independent observer.

Results: We studied 154 patients: 127 (82%) female and 27 (18%) male. The median age was 56 years (range 33–85). One foot was affected in 107 patients (69%) and both feet in 47 (31%). The second toe only was affected in 99 patients (64%) and multiple toes in 52 (34%). Seventy-three patients (47%) had a complaint of generalised forefoot pain. Sixty-eight (44%) had pain and deformity localised to the second toe. Thirteen patients (8%) had toe deformity with significant MTPJ instability. 150 toes (52%) had grade 1 instability, 108 (37%) grade 2 instability and 21 (7%) grade 3 instability. Twelve toes (4%) presented dislocated with a history of instability. Ninety-nine patients (64%) were treated conservatively, using functional taping, shoe modifications, insoles and injections. Fifty-five patients (36%) had surgery, including lesser toe straightening, flexor-extensor transfer, plantar plate repair, Weil and Stainsby procedures. 79% of patients were reviewed at a mean of 65 months (range 14 to 138). Mean pain score was 31mm ± 23.7mm for the conservative group and 23mm ± 24.1mm in the surgical group. Mean AOFAS score was 69 ± 16.3 for the conservative group and 67 ± 17.8 in the surgical group. 39 (52%) conservatively treated patients were either satisfied or very satisfied compared to 31 (66%) surgically treated patients. No differences were statistically significant.

The most important determinant of treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement.

We developed clinical criteria for potential instability and applied them to a prospective series of patients. Criteria included: a medial clear space of < 4mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; a high-energy fracture mechanism. Patients with a medial clear space of < 4mm and none of these criteria were considered to have stable fractures, while those with a medial clear space of > 4mm were considered to have a displaced fracture.

We studied 152 consecutive skeletally mature patients with undisplaced, potentially unstable malleolar fractures treated by the senior author between 1st January 1998 and 31st December 2007. Patients were treated in a below-knee walking cast (136 patients) or a functional ankle brace (16 patients) for six weeks. Weight bearing was encouraged throughout. Weight bearing radiographs were obtained at one week and six weeks. Displacement was defined as talar displacement with a medial clear space > 4mm. Demographic, clinical and radiological data were collected prospectively.

There were 88 male and 64 female patients, with a median age of 43 years. Criteria for possible instability were: medial tenderness, 115 patients; proximal fibular fracture, 29 patients; bimalleolar fracture, 17 patients; other criteria, 15 patients. Three fractures displaced (risk of displacement 2.0%, 95% CI 0.4–5.7%). All displaced within the first week and were treated by open reduction and internal fixation. One bimalleolar fracture developed a symptomatic medial malleolar non-union which was treated by percutaneous screw fixation (risk of non-union 5.9%, 95% CI 0.1%–28.7%). All the other fractures achieved clinical union by 8 weeks.

Introduction: An osteotomy in the proximal first metatarsal corrects the metatarsal head position with much less movement of the fragment than an equivalent distal osteotomy. Most described techniques are technically demanding and reported complications including non-union, mal-union and transfer pain. We present our results of an opening wedge osteotomy with a medial wedge plate. We also present the pitfalls and tips to avoid complications.

Materials and Methods: Thirty-four procedures in 30 patients were performed using the Arthrex wedge plate. Demographic and clinical data, AOFAS scores and radiological measurements of standardised radiographs were collected for all the patients.

Results: All patients were females. The average age was 52 years. Twenty-seven were primary procedures and 7 patients had had previous, failed 1st ray surgery. No bone graft was used. Thirty-two feet showed clinical and radiological signs of union. Four complications occurred and one was treated with metatarsophalangeal joint fusion. One had an infection. Two patients had broken screws. The average hallux valgus angle and inter-metatarsal angle corrections were 200 and 90 respectively. Average increase in AOFAS scores: preoperative 47 to postoperative 81.

Discussion: The spacer in the plate acts as a pillar and obviates the need for a bony strut. Keeping an intact lateral cortex and preventing any shaft displacement was important in avoiding transfer pain. 4.5mm or smaller plates appear to have fewer problems and better scores, al though this was statistically unproven. Screw breakage in the absence of infection had no bearing on overall outcome. Some patients with poor fixation may benefit from non-weight bearing for the first 6 weeks.

Conclusion: The wedge plate osteotomy is a powerful tool to correct moderate to severe hallux valgus. It does not need additional bone graft and has a favorable clinical and radiological outcome. The prelude to optimum result was meticulous technique avoiding the discussed pit falls.

Introduction: Adult acquired flatfoot is a common cause of foot pain. The majority of series describe surgery although important non-surgical series exist. This series of 166 patients gives an overview of the clinical spectrum of the condition and outcomes.

Materials and Methods: Data was collected prospectively on 166 consecutive patients with adult acquired flatfoot between 1995 and 2005. 104 patients were reviewed at a median of eight years (range 3–13). A standardised clinical examination, AOFAS hindfoot and visual analogue satisfaction scores were performed.

Results: There were 40 men (median age 56 years) and 126 women (median age 60 years). 68% had other musculoskeletal problems. Patients were Truro staged at presentation; Stage 1: 26 patients. Stage 2A: 84 patients. Stage 2B: 25 patients. Stage 2C: 23 patients. Stage 3: 6 patients. Stage 4: 2 patients.

Stage 1 patients were younger (p< 0.001). 133 patients had soft-tissue symptoms, but 33 had degenerative problems. Degenerative patients had a higher median age (p=0.0138) and stiffer deformities (p< 0.0001). Most patients (131, 78.9%) were managed conservatively. Surgery was commoner in the arthritic group (p=0.001).

Fifty-two conservatively treated feet were clinically reassessed. In 31 (59%) patients the Truro stage had not changed, 11 (21%) had improved and 10 (20%) had deteriorated. Twenty percent of patients treated with orthoses stopped using them after 18 to 24 months. In non-surgically treated patients, the median AOFAS score was 73/100 and satisfaction score 71/100. In surgically treated patients the median AOFAS score was 74/100 and satisfaction score 83/100.

Discussion: There is a young group of patients with adult acquired flatfoot, with soft tissue symptoms but no progressive deformity. There is a large group with a flexible deformity who can mostly be treated with orthoses, and an older group with stiffer, arthritic deformities who are more likely to need surgery.

Conclusion: Final outcomes and satisfaction were similar in surgically and non-surgically treated patients.

Introduction: Current evidence for treatment of Achilles tendon rupture suggests that open surgical repair reduces the re-rupture rate compared to conservative treatment, but with a higher risk of infection. Modern non-surgical treatment and surgical aftercare involves early weight-bearing in functional orthoses. It is therefore appropriate to measure the re-rupture rates and outcomes in patients treated in this manner.

Materials and methods: Between 2002 and 2008 our unit prospectively collected data on 80 patients treated with a below-knee functional orthoses for complete Achilles tendon rupture. Patients made their own choice of treatment following evidence-based counselling. The patients were treated either surgically or conservatively and entered the appropriate arm of the standard orthotic and early weight-bearing treatment protocol. Patients were contacted by telephone or post for follow-up and completed a VISA-A and Achilles Total Rupture Score (ATRS) questionnaire.

Results: There were 61 Males, 19 Females with an age range of 24–80 (median 42). The median time in the functional brace was eight weeks. 51 patients were treated conservatively and 29 patients surgically. The conservative group were a decade older (median age 47y, range 27–80) than the surgical group (median age 37y, range 24–55y). In the non-operative treatment group the re-rupture rate was 3.9% (2/51, 95% confidence interval 0.5–13.5%). In the surgical group it was 3.4% (1/29, 95% confidence interval 0–17.8%), in this group the wound infection rate was 6.8% (2/29, 95% confidence interval 0.9–22.8%) with no nerve injuries reported. The median ATRS was 82 in the conservative group and 95 in the surgical group. The median VISA-A scores were 57 and 92 respectively.

Discussion: Our case series shows comparable low re-rupture rates in both groups. Functional scores, using the newly validated ATRS score, were lower in the non-surgical, older group.

Conclusion: Functional care after surgical and non-surgical treatment of Achilles rupture produces similar re-rupture rates.

Previous studies of adult acquired flatfoot have reported the results of treatment. No study has described the clinical characteristics of a consecutive series.

In a ten-year period we managed 166 patients with adult acquired flatfoot. Forty were male and 126 female The median age of the men was 56 years and of the women 60 years (p=0.149). Twenty-eight had bilateral problems and 78% had gastrocnemius/soleus tightness.

We used the Truro classification. There were 26 stage 1 patients, with a median age of 45 years. Eight were male and 18 female. Eight had features of enthesopathy but rheumatological investigations were negative. There were 84 stage 2 patients, with a median age of 61 years; 23 were male and 61 female. Twenty-five patients were stage 3, with a median age of 59 years; 5 were male and 20 female. 23 patients were in stage 4, with a median age of 67 years; 4 were male and 19 female. Six patients were stage 5, with a median age of 67.5 years; all were female. There were two patients in stage 6, aged 81 and 85 years, both female. The stage 1 patients were significantly younger than the others (p< 0.001); there were no other significant differences in ages or sex ratios.

Most patients had predominantly soft-tissue problems. However, we identified 33 whose problems related mainly to osteoarthritis. These patients had a higher median age (62.5 years versus 58 years, p=0.0138) and stiffer deformities (p< 0.0001).

Most patients (131, 78.9%) were managed solely with orthotics, shoe adaptations and physiotherapy. Thirty-five patients were offered surgery. Twenty-eight procedures were performed on 23 patients. Surgery was commoner in the arthritic group (15/33 offered surgery versus 20/133, p=0.001).

Plantar fibromatosis is a relatively rare disease compared to its counterpart in the hand. Though it is considered to be a part of Dupuytrens diathesis it has been less exhaustively studied to enable evidence based management strategies.

We followed up all patients presenting with plantar fibromatosis to our institute between 1980 and 2006, identifying 41 patients. 6 patients were lost to followup. Thirty-five patients with 60 involved feet were included in the study. There were 22 males and 13 females, all white Caucasians. The median age at presentation was 45 (19–63 years), and the median follow up was 10 years (2–25 years)

Twenty-one of our patients had palmar Dupuytren’s disease, six had knuckle pads, four had Peyronie’s disease, four had other superficial fibomatoses and two keloids. Six were diabetic, four had epilepsy of whom two took valproate and one phenobarbitone. Eight patients had a family history of fibromatoses.

The most common presentation was a painful lump (20); 13 patients had a painless lump (13) and two had only pain. All patients reported a proliferative phase of enlarging nodule size, often with pain, which lasted 1–4 years (median 2 years). Thereafter most patients reported improvement in symptoms (size of lump and pain) as well as function. As we came to recognise this, we treated most patients with symptomatic measures and observation only. At review, 17 patients considered their symptoms were improving, 14 were stable and only four had noticed deterioration. Seven patients, mostly early in the series, were treated by wide excision; six had recurrence at review although only one was symptomatic.

Plantar fibromatosis is a benign condition which stabilises and may improve after an initial proliferative phase lasting about two years Most patients require no intervention.

Primary care trusts (PCTs) are encouraged to create musculoskeletal services to improve access and reduce pressure on orthopaedic clinics. Previous reports have suggested problems can arise.

A PCT with a population of 100,000 launched a musculoskeletal service in July 2004. The foot and ankle component was in partnership with the local secondary care foot team. Treatment and referral guidelines were agreed. The PCT staff reviewed GP referrals to orthopaedic clinics. They could forward letters to the acute trust orthopaedic department or initially treat the patients in primary care.

We audited referrals from October-December 2004, allowing 3 months to establish the service and 6 months follow-up.

617 orthopaedic referrals were received, including 123 (19.9%) adult foot and ankle problems. 82 patients were treated initially in primary care: 54 by the podiatrist, 20 by the physiotherapist and 8 by the specialist GP. Commonest problems were metatarsalgia (12), hallux valgus (10), Achilles tendonopathy (9), plantar heel pain (9), generalised foot pain (8) and arthritis (6). The commonest intervention was attendance at a physiotherapy programme (26) followed by advice (22), usually about shoewear, insoles (14) and injections (8). Ten patients were referred to secondary care after initial treatment in the community, all in accordance with guidelines; four were listed for surgery. Four patients failed to attend and information was missing on six.

31 referrals were sent directly to secondary care, 29 of which were according to guidelines. 9 were offered surgery, 9 had other specialist care, 6 required services which could not be accessed directly by the PCT team and 3 failed to attend.

Primary and secondary care can work together successfully to deliver services for patients with foot and ankle problems, though waiting time remains a challenge.

Aim and method We report the outcomes of 100 consecutive diabetic patients who had been prescribed diabetic footwear for 10 years. A podiatrist and orthotist reviewed them at a dedicated clinic. The study aim was to assess footwear efficacy and prevention of ulcers, re-ulceration and amputations.

Conclusion Protective footwear is essential in maintaining healthy diabetic feet. Amputations were only due to vascular complications. All 56 patients who attended remained intact at 2 years. Of the seven ulcerations at 5 years, three went onto below-knee amputation. At 10 years, there were a further three ulcerations, resulting in one minor black toe and one further BK amputation.

Adherence with follow up including footwear review minimises risk. Re-ulceration at 5 years is associated with risk of amputation. Ten-year mortality is high due to vascular complications.

Summary Continued patient adherence with Orthotic therapy confers benefit and minimised re-ulceration. Follow up by Orthotists is an under-utilised resource.

Between 1st March 1995 and 31st December 2002 we treated 69 patients for pedal ganglia. Review was carried out through a research clinic or by questionnaire by an independent reviewer. One patient had died of unrelated causes and one was housebound and deaf. Fourteen were lost to follow-up; final results are pending in 15.

Of the patients reviewed, 13 were treated by observation. Six were male, seven female, aged 16–76, median follow-up 59 months (range 40–106). Eight had no pain and five had occasional pain. None had interference with activities of daily living (ADL). Four chose shoes for comfort and nine could wear any. All had residual ganglia 3–5 mm in diameter but only five were bothered by them. One patient had undergone excision of the ganglion.

Twenty-one had aspiration and injection of ganglia. Eleven were male and ten female, aged 33–80, median follow-up 58 months (range 20–92). Ten had no pain and 11 occasional pain. Sixteen had no problems with ADL, four had interference with recreational activities and one interference with all ADL. Fourteen could wear any shoe and seven chose shoes for comfort. Eighteen were not bothered by their ganglion, two were occasionally bothered and one bothered often. Ten had no treatment other than aspiration and injection, four had repeat aspiration (one twice) and nine had the ganglion excised (two repeat excisions). Five had residual ganglia (three after surgery), two had tender scars and two altered sensation.

Four patients had primary excision. None had any pain, problems with ADL or shoe wear restrictions; one was occasionally bothered by the ganglion site. There were no recurrent ganglia but two had uncomfortable scars.

Many ganglia can be managed by simple treatment and surgery is often followed by minor residual symptoms.

Aim: Stainsby and Briggs described a procedure for the correction of þxed claw toes. We studied the results of the Stainsby procedure in non-rheumatoid þxed claw-toes performed between March 1995 and January 2000. Method: All procedures were reviewed independently by the junior authors. The outcome was measured using the American Orthopaedic Foot and Ankle Society lesser toe scale (Kitaoka 1994). Patients were asked about overall satisfaction and whether they would recommend the operation to a family member. Results: Thirty-seven patients were operated on, four of whom died and one moved away, leaving 32 patients (38 feet, 88 toes) for study. The median age of the study patients was 59.5years (16–80 years) and median follow-up was 37 months (12–60 months). Twenty-two patients had hallux valgus, 7 pes cavus and 6 underwent salvage surgery for previous failed forefoot surgery. The median AOFAS score at follow-up was 80 (37–95). Thirty-four feet (89%) were satisfactory and 25 patients (78%) would recommend the operation. Wound problems occurred in 11 feet (29%) and transient paraesthesiae in 9 (24%). Dissatisfaction was usually due to the ßoppiness of the toe. Conclusion: The Stainsby procedure is a good salvage procedure for severe claws toes with good patient perception and function.

Aim: Myerson and Sheriff described an anatomical basis for the correction of hammertoe deformity. Based on this model we performed a metatarsophalangeal soft tissue release and proximal interphalangeal arthroplasty. Method: Patients operated between March 1995 and January 2000 were retrospectively reviewed using the American Orthopaedic Foot and Ankle Society Scores (AOFAS) by independent assessors. Results: There were 84 patients with 99 feet and 179 hammertoes with a median follow-up of 28 months. The median AOFAS score was 83 and 87% of patients had a score of more than 60 points. Eighty-three percent of patients were satisþed while 17% were dissatisþed with the procedure. Pain at the metatarsophalangeal joint was the commonest cause of dissatisfaction with 14% having moderate or severe pain. Only 2.5% had metatarsophalangeal joint instability and 9% had callus formation. There was no statistical difference regarding the age and sex of the patient, number of toes operated on, associated hallux valgus surgery and follow-up of less than or greater than 2 years. Conclusions: This study is based on an anatomical model and shows a good result with no recurrence of hammertoe correction.

Introduction

Mallet toe is a flexion deformity of the distal interphalangeal joint of the lesser toe. It causes pain and callosity in the toe tip and the dorsum of the distal interphalangeal joint. Campbell refers to the “terminal Syme’s amputation” for this condition but the results of this have not previously been reported.

Material and Methods

This is a retrospective review of 35 toes in 22 patients that underwent distal phalangectomy. Sixteen patients were aged over 70. Patients were interviewed by an independent observer regarding the pain relief, cosmetic acceptability and satisfaction with the procedure and were examined for callosity, stump tenderness, sensitivity and neuroma.

Results

All patients were satisfied including pain relief and cosmetic acceptability at an average follow up of 4.6 years. One patient had mild wound infection. One patient had asymptomatic nail growth. No stump tenderness, sensitivity or neuroma was noted.

Discussion and Conclusion

Coughlin reported a satisfaction rate of 89% and 86% following successful fusion and excision arthroplasty respectively. In this series all patients were satisfied. We feel that distal phalangectomy is an option in a selected group of elderly patients where pain relief and functional outcome is the priority.

Charcot neuroarthropathy is a progressive, destructive process occurring in the presence of neuropathy. We report the outcome of neuropathic foot joints presenting to our clinic over a 12 year period.

Methods

Cases were identified from the Diabetic Foot Clinic Register, 1989–2001. We studied patient demographics, clinical presentation, distribution, treatment and outcome.

Results

Twenty-eight episodes of arthropathy occurred in 23 patients. Age at onset ranged from 40 to 79 years. Presentation was acute in 14 and subacute in the others. Sites affected included 23 mid foot, 4 ankle and 1 MTP. Nine feet were ulcerated at presentation, eight had a history of ulcer, nine have no ulcer history. Infection complicated the Charcot process in 15. Mean Hba1c at presentation was 9.3%.

Treatments

Total contact casting 23, 4 “scotch cast” boots and 1 Air-cast walker. Pamidronate was given to 10 patients.

Outcomes

Three patients died. Two had below knee amputations. Casts were required for up to 12 months. Three required orthopaedic foot reconstructions. All ulcers present initially healed.

Conclusion

Charcot arthropathy remains uncommon. In our series treatment was successful in all but two patients in terms of preserved limbs, mobility and freedom from ulceration.