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.

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.