Background:

Avascular necrosis (AVN) of the talus is a painful condition caused by trauma, steroids, alcoholism and haematological disorders. It is difficult to treat and at present there is insufficient evidence in favour of any particular strategy. The aim of operative therapy should be to relieve symptoms, maintain the normal architecture of the talus and treat associated arthritis. Small case series have described early core decompression, retrograde tibiotalocalcaneal arthrodesies and open tibio-calcaneal arthrodesis. Open procedures risk further talar collapse by disrupting its blood supply, and tibiotalocalcanal fusion sacrifices both the ankle and subtalar joints. The hypothesis is that arthroscopic ankle fusion relieves symptoms of AVN talus while preserving the subtalar joint and preventing further collapse.

Introduction:

Vitamin D plays an important role in bone turnover. Deficiency (including borderline deficiency, or insufficiency) has a known association with fractures and has been linked to delayed or nonunion of fractures. We therefore routinely test vitamin D in cases of nonunion. Noting a high rate of vitamin D deficiency in this group, we instituted a policy to routinely screen for and treat vitamin D deficiency in both post-operative and pre-operative patients. We hypothesised that, in the post-operative patients, levels would correlate with rates of union.

Background:

Calcaneal osteotomy is an established technique in correcting hind foot deformity. Patients have traditionally received an open osteotomy through Atkins lateral approach. In order to reduce the rate of wound complications associated with the Atkins approach, a minimally invasive surgical (MIS) technique has been adopted since 2011. This uses a low-speed, high-torque burr to perform the same osteotomy under radiographic guidance. The results of the new MIS technique, including post-operative complication rates, are compared to the standard open approach.

Introduction:

TTC fusion for the salvage of failed TARs with significant bone loss using a hindfoot nail and femoral head allograft has been reported in a number of small series. We present our experience of this procedure.

Background

Evaluation of outcomes and satisfaction following hallux valgus (HV) surgery is usually retrospective and rarely uses patient-reported outcome measures (PROMs).

Introduction

Ankle replacement is now common in the UK.

In a tertiary referral NHS practice, between 1997–2011 we implanted two types of cementless mobile bearing total ankle replacements (TAR).

Objectives

The Manchester–Oxford Foot Questionnaire (MOXFQ) is a validated 16-item, patient-reported outcome measure for evaluating outcomes of foot or ankle surgery. The original development of the instrument identified three domains. This present study examined whether the three domains could legitimately be summed to provide a single summary index score.

Introduction

In 1927, Lambrinudi described a variant triple fusion for the treatment of paralytic “drop foot”. This involved closing wedge osteotomies and fusion to correct the deformities predominantly caused by Polio. The eradication of Polio has seen a shift in its use to the correction of other complex hind foot deformities. The technique has relevance in modern Orthopaedics for other neurological and degenerate conditions. There have been few published series of this technique since 1927.

We describe a series of 14 complex corrective triple arthrodeses to illustrate the power of Lambrinudi's concepts. We believe Lambrinudi's original description has relevance in terms of modern day complex hindfoot deformity correction.

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.

Juvenile Chronic Arthritis results in the early degeneration of multiple joints with severe pain and deformity. Treatment of ankle arthritis is complex and ankle replacement is indicated because of adjacent and distant joint involvement.

Changes in armour reinforcement of military vehicles have resulted in a changed injury pattern. Injuries which would previously have resulted in amputation are now less severe, and after initial debridement and temporary fixation the foot can now be saved. New patterns of injuries are emerging often as a part of potentially survivable poly-trauma. We describe a small series of these injuries. The techniques and results of late reconstruction are presented. We also discuss specific problems of managing patients with potential contamination with unusual organisms.

The responsiveness of the Manchester–Oxford Foot Questionnaire (MOXFQ) was compared with foot/ankle-specific and generic outcome measures used to assess all surgery of the foot and ankle. We recruited 671 consecutive adult patients awaiting foot or ankle surgery, of whom 427 (63.6%) were female, with a mean age of 52.8 years (18 to 89). They independently completed the MOXFQ, Short-Form 36 (SF-36) and EuroQol (EQ-5D) questionnaires pre-operatively and at a mean of nine months (3.8 to 14.4) post-operatively. Foot/ankle surgeons assessed American Orthopaedic Foot and Ankle Society (AOFAS) scores corresponding to four foot/ankle regions. A transition item measured perceived changes in foot/ankle problems post-surgery. Of 628 eligible patients proceeding to surgery, 491 (78%) completed questionnaires and 262 (42%) received clinical assessments both pre- and post-operatively. The regions receiving surgery were: multiple/whole foot in eight (1.3%), ankle/hindfoot in 292 (46.5%), mid-foot in 21 (3.3%), hallux in 196 (31.2%), and lesser toes in 111 (17.7%). Foot/ankle-specific MOXFQ, AOFAS and EQ-5D domains produced larger effect sizes (> 0.8) than any SF-36 domains, suggesting superior responsiveness. In analyses that anchored change in scores and effect sizes to patients’ responses to a transition item about their foot/ankle problems, the MOXFQ performed well. The SF-36 and EQ-5D performed poorly. Similar analyses, conducted within foot-region based sub-groups of patients, found that the responsiveness of the MOXFQ was good compared with the AOFAS.

This evidence supports the MOXFQ’s suitability for assessing all foot and ankle surgery.

Introduction: Severe haemophilia affects 1 in 10,000 men. The ankle along with the hip and knee are commonly affected. Ankle fusion is the preferred surgery for end stage arthritis in the younger patient although debate exists as to the preferred technique. We conducted a retrospective review of the arthroscopic ankle fusions on haemophiliacs from Oxford and compared data with that of a specialist unit in London using an open technique.

Materials and Methods: We reviewed 22 ankles (22 patients) from Oxford and 10 ankles (8 patients) from London. 90% had Type A haemophilia with similar regular monthly Factor VIII usage: 17941 U/month (Oxford) compared with 17992 (London). 73% of patients in the Oxford Group and 100% of the London group had Hepatitis C and/or HIV.

Results: Union was achieved in all patients. The mean time to union in the open group was 9.1 weeks (Mode- 8 weeks, Range 7–14) compared to 12.2 weeks (Mode- 12 weeks, Range 8–24) in the arthroscopic group. Screw removal was required in 4 patients (3 arthroscopic v’s 1 open). 1 patient in the arthroscopic group suffered a pseudoaneurysm of the dorsalis pedis artery. The arthroscopic group spent less time in hospital- 5.7 days compared to 9.5. Factor VIII usage was less in the arthroscopic group- 32,882 Units compared to 40013.

Discussion: Patients of this nature should be managed in centres used to dealing with their complex needs. Arthroscopic ankle fusion in haemophiliacs is safe for these patients. Although arthroscopic fusion may take slightly longer to unite, there are benefits in terms of reduced patient stay and factor VIII requirement and therefore costs.

Background: Total ankle replacement (TAR) has become an established surgical procedure for the management of end-stage ankle arthropathy offering an alternative to ankle fusion. Controversy exists over whether to correct concomitant hindfoot arthropathy or malalignment as a separate procedure or simultaneously with TAR. Simultaneous surgery confers the advantage of one operation and recovery period, however, many authors believe complication rates may be higher and long-term function compromised.

Method: A retrospective review of all patients, between January 2003 and January 2007, who had undergone simultaneous bony hindfoot or midfoot corrective surgery and TAR, at our institution was performed. A matched group of primary TAR patients were included as controls. Mean follow-up was 38 and 39 months respectively. Data collected included demographics and indications, details of operative procedure, and complications with outcomes assessed by patient satisfaction, range of movement, walking distance and Visual Analogue Score (VAS) for pain.

Results: The two groups were matched for age, sex, follow-up, prostheses and diagnosis. The underlying pathology was predominantly osteoarthritis. Mean VAS improved by 7.66 points in the TAR alone group and 8 points in the TAR and adjuvant surgical procedure group. There was no statistical difference in infection, delayed wound healing, malleolar fracture or re-operation rates between the two groups.

Conclusion: We believe that an experienced Foot and Ankle surgeon can perform corrective hindfoot or mid-foot surgery simultaneously with TAR without significantly compromising outcome.

In 2004, our centre has changed from the “STAR” to the “Mobility” Total Ankle Replacement device and a study was undertaken in order to ascertain if there was a learning curve to useage of this new device and perform a comparison in terms of survival, function, additional procedures and complications.

The indications were 55% osteoarthritis, 30% Rheumatoid and 8% JIA with the remainder being haemophiliac, haemochromatosis and ankylosing spondylitis.

One third of TARs in this unit are combined with additional procedures such as subtalar fusion. Only isolated TARs were considered in this study and the tourniquet time, wound problems, length of stay and known complications for the last 20 STAR TARs was compared to the first 20 Mobility TARs.

68 Mobility TARs have been implanted since Oct 2004 and survival data was collected for this entire cohort and compared to a similar number of STARs.

Results: There was no significant difference in operative time (63 vs 65 mins) between the prostheses, no difference in intra-operative complications (0), no difference in deep infections (0% ) and a minimal difference in hospital stay (4.3 vs 5.1 days) due to non-surgeon factors.

The survival curve of the mobility and STAR shows no loss of the Mobility due to revision at up to 3 years.

Clinical outcome scores will be presented.

Summary: There is no learning curve for an experienced Foot and Ankle Surgeon in changing prosthesis and no apparent effect on morbidity for the patient. All 40 TARs are in situ and functioning acceptably at up to 3 years.

The early results for this new prosthesis show no cause for concern and surveillance is ongoing.

Between 1998 and 2007, fifteen patients with haemophilia A underwent 21 ankle arthrosco-pies+/− arthroscopic cheilectomy in order to attempt symptomatic relief of arthrosis and to increase the range of motion. All patients had severe degenerative changes radiologically.

Perioperative management was shared with our local dedicated Haemophilia service and the management algorithm will be presented.

Outcome data for pain and range of motion shows only moderate benefits.

Two patients had good relief of symptoms for 6 months. Two patients however chose to return for arthroscopies to the contralateral ankle and two had arthoscopies to the same ankle.

Follow up data is not currently available for 4 patients and the rest required fusion with a median time to fusion of 1 year.

Two patients had a documented increased range of motion, but one of these patients had an increased level of pain associated with the increased mobility.

There was 1 major complication, namely an aneurysm of the tibialis anterior artery.

Two patients had recurrent bleeds following surgery requiring ongoing and prolonged factor VIII treatment.

Average patient stay was 3.1 days, range 2 to 5 days and this stay is shorter for later years than earlier years.

The post-operative requirement for extra factor VIII ranged from 4 postoperative doses to 3 weeks ongoing treatment, median 10 doses. The average cost per dose was approximately £1128, giving a median cost of £11280 per case.

In summary, this procedure seems to be expensive in terms of QALY gains and has low rates of success in terms of function and pain relief.

Introduction: An ideal screw for subtalar fusion would be designed such that screw thread length in the distal bone would be maximised but without distal perforation, whilst having no threads across the fusion site that would inhibit compression.

Method: Radiographs and clinical assessment of 100 patients who had undergone subtalar fusion were analysed and correlated with the presence or absence of non-union.

In addition, using the characteristics of the inserted screw as a scaleable marker, it was calculated what would have been the optimum length of screw thread in order to maximise screw thread length in the target bone whilst preventing the screw threads being across the fusion site.

Results: There is no correlation between the presence of screw threads across the fusion site and non-union.

Currently available screws have thread lengths that are either too long (breaching the fusion site) or too short for ideal fixation and we propose a different thread length to those currently available.

However, even with current screws, we found no correlation between thread length, thread positioning across the fusion site and non-union.

Introduction: Arthroscopic ankle arthrodesis is an effective treatment for end-stage arthritis.

A screw that has any thread across the fusion site can not offer any compression and may be postulated to lower the rate of fusion. Similarly, maximal screw thread in the target bone would optimise fixation.

This retrospective study calculates the ideal characteristics of a screw used for ankle arthrodesis, and assesses the correlation between the lack of compression and non-union.

Method: Fifty-one consecutive patients(102 screws) who have had arthroscopic ankle fusions were studied. Either AO(n=38) or ACE(n=64) screws were used. We calculated the screw-thread distance that crossed the talotibial(TT) or the subtalar(ST) joints on digitised images, and recorded the outcomes of the fusions.

Result: Of the 38 AO screws, only one (2.6%) had threads across the TT joint(thread-length into the joint = 1.2mm). None of the ST joints had been breached.

Of the 64 ACE screws, 8(12.5%) had threads across the TT joint, representing 7(21.9%) of all posterior screws and 1(3%) of all anterior screws in the study. The mean length of screw-threads into the TT joint was 2.1mm(range 0.53 to 4.06 mm). The ST joints were breached by 4(6.25%) screws(all posterior). The mean length of protrusion was 1.8mm(range 0.28 to 3.89mm). No screw thread crossed both TT and ST joints simultaneously.

No non-unions were recorded in either group.

Discussion: In our study the use of ACE screws for arthroscopic arthrodesis increases the risk of screw-threads breaching either the TT or ST joints when compared to the use of AO screws.

Conclusion: We conclude a thread length of 19–20mm would optimise fixation/compression. However no clinical correlation was demonstrated between reduced compression and non-union in this study.

Introduction: Lesser toe deformities which require surgery are often treated using a technique of interphalyngeal joint fusion. This procedure is an effective way of reducing the deformity and pain associated with lesser toe deformity but necessitates internal fixation until fusion is achieved. The Kirschner wire used to provide peri-operative stability is undesirable for a number of reasons, most importantly, the risk of interosseous infection and the lack of patient satisfaction due to the need for a second procedure for the wires removal. The ‘Oxford’ procedure was developed by the senior author (PHC) both in an attempt to remove the need for Kischner wire fixation and to maintain some mobility at the interphalyngeal joint.

Patients and methods: Between January and October 1994, 14 patients underwent ‘Oxford’ procedures on isolated lesser toe deformities. Their mean age was 59 at the time of surgery (range 26 – 79, 3 male and 11 female). Each patient was reviewed in November 1995 and an assessment was made of their post-operative pain levels, function, footwear, cosmetic appearance, time to return to work and any complications they had experienced. In March 2005 (ie: at least 10 years postop) an attempt was made to review these patients and make assessments of their pain in the operated toe, any subsequent surgery in that, or other toes, and the stability of the toe. In addition, an assessment was made of the patients view of the cosmetic outcome and their satisfaction levels. 12 patients were successfully contacted and reviewed.

Results: All 12 patients were satisfied with their long term results in terms of pain relief and cosmesis.

Conclusion: The ‘Oxford’ proceedure for lesser toe deformities has good long term clinical results and avoids k-wire fixation.

The purpose of this study was to investigate the functional outcome of a group of patients following completely neglected tendo-achilles ruptures.

Between July 2001 and July 2002 we identified 6 patients who presented to the Foot and Ankle Service in Oxford with 7 chronic untreated complete ruptures of the tendo-achilles. There were 4 males and 2 females and the average age was 65 years (range 52 to 79). The average time since injury was 12.2 months (range 7 to 24). None of them had undergone any modality of treatment for this condition. From the history, a definite acute injury was confirmed in each patient. All patients had a palpable defect in the tendo-achilles between 4 and 8 cm from the insertion and the defects measured from 10 to 32 mm. In all case the Thompson test confirmed ongoing discontinuity and single leg heel raise was not possible on the affected side. Each patient was assessed using the scoring system of Leppilahti and concentric and eccentric power were assessed using the Kin-Com Dynamometer. The results indicate an average Leppilahti score of 65/100 with 1 excellent, 0 good, 3 fair and 2 poor. The isokinetic strength measurements demonstrated that plantar flexor power was on average 36% weaker than the normal side. These differences were most marked at the higher test speeds, which were on average 16% weaker than at the lowest test speed in the affected leg. Five out of 6 patients were pain free, with only one reporting mild pain. Objective testing demonstrated no differences in the range of movement between the injured and the normal side. All patients were satisfied with the outcome; however, most had some reservations, which related to ongoing weakness that prevented recreational activity.

Conclusion: At one year after injury the completely neglected tendo-achilles rupture in the older population is likely to be pain-free, to have full active ankle movement and to recover two-thirds of the power of plantar flexion compared to the unaffected limb. Ongoing weakness will prevent recreational activity but has minimal affect on activities of daily living including stair-climbing ability. We have established a benchmark of the natural history of this condition in the older patient against which the results of surgical treatment can be compared.