Abstract

Background

Fractures of the metatarsal bones are the most frequent fracture of the foot. Up to 70% involve the fifth metatarsal bone, of which approximately eighty percent are located proximally. Low-intensity pulsed ultrasound (LIPUS) has been shown to be a useful adjunct in the treatment of delayed fractures and non unions. However, there is no study looking at the success rate of LIPUS in fifth metatarsal fracture delayed unions.

Introduction:

All reported RA forefoot deformities in the literature so far have arisen from shoe wearing populations. Our aim in this study was to compare hallucal deformities seen in a shod to a non-shod population.

Introduction:

There are concerns with the use of the Shannon burr in calcaneal osteotomies entered from the lateral side, with the medial structures possibly at risk when performing the osteotomy of the medial calcaneal wall. Our aims with this study were to investigate the neurovascular relationships with the calcaneal osteotomy performed using a Shannon burr.

The incidence of venous thromboembolism (VTE) is unknown in elective foot and ankle surgery. In March 2010 we surveyed the current practice in VTE prophylaxis in elective foot and ankle surgery amongst members of the British Orthopaedic Foot and Ankle Society (BOFAS).

The response rate was 53%. The total the number of elective foot and ankle operations performed by the surveyed group was 33,500 per annum. The perceived incidence of DVT, PE and fatal PE was 0.6%, 0.1% and 0.02%. In our study the number of patients needed to treat to prevent a single fatal PE is 10,000 although this figure is open to significant bias.

The National Institute for Health and Clinical Excellence (NICE) recently published guidelines on reducing the risk of venous thromboembolism in surgical patients. These guidelines cover all surgical inpatients and uses data extrapolated from other groups of patients. We question the applicability of these guidelines to patients undergoing elective foot and ankle surgery. We consider that this data justifies the prospective study of the incidence of VTE in patients undergoing elective foot and ankle surgery, without the use of chemical thromboprophylaxis.

The aetiology of hallux valgus is well published and largely debated. Hypermobility at the TMTJ was initially described by Morton, but it was not till Lapidus that its association with hallux valgus was hypothesized. However, little has been published on the anatomy of the tarsometatarsal joint. Our aim was to determine whether there was an anatomical basis for the coronal hypermobility in hallux valgus.

Equinus contracture of the ankle due to a tight Gastrocnemius has been implicated in the pathogenesis of a number of foot and ankle conditions. There are numerous described procedures for release of the Gastrocnemius such as the Strayer procedure.

Our indications for release are in patients with a symptomatic forefoot and an equinus contracture of 5 degrees or more in extension as defined by the Silfverskiöld test. The release is usually combined with a reconstructive procedure. The advantages of our technique are its simplicity, excellent visualisation of the tendon and sural nerve, good wound healing and patient comfort post-operatively.

The procedure can be performed without tourniquet. A 2.5cm incision is made over the medial calf, just distal to the Gastrocnemius muscle indentation. The deep fascia is incised and the edge of the tendon can be visualised. Blunt digital dissection is performed on either side of the tendon to develop a plane. A metal Cusco speculum is inserted to visualise the full width of the tendon. The tenotomy is performed starting medially and the last 5mm of the lateral tendon is left uncut. This reduces the chance of iatrogenic injury to the nerve. The tendon bridge can be left if correction is sufficient, otherwise passive dorsiflexion of the ankle results in completion. Post-operatively, patients are able to mobilise fully with crutches and passive ankle physiotherapy is commenced immediately.

We performed 22 MAGS procedures in 17 patients. There were no Sural nerve injuries and no wound complications. All patients were delighted with cosmesis. Average pre-operative equinus contracture with the leg extended was 18 degrees. Average intra-operative correction of 24 degrees was obtained and at 3 months follow-up, all patients were able to dorsiflex past neutral.

Most high-energy trauma to lower legs, ankles and feet result in severe crush injuries. We performed a retrospective case series study

Eight patients (7M: 1F) with mean age of 28 years (range -18 -35 years) were included. Four had Grade 3 open fractures of the distal tibia and 5 had open foot fractures. Two had neurovascular injuries. Four patients had associated injuries with mean ISS of 9 (range 8-16) and a mean MESS score of 3.5 (3-7). All had undergone some form of internal and external fixation within approximately 24 hours (8 hrs to 4 days). The mean follow-up period was two years (range 1-4 years). At final follow-up patients' health was measured using SF-36 questionnaire.

Six patients had their fractures healed at a mean of 4.8 months (4-9 m). Two patients had fully functional foot with occasional complaints of painful ankle. Two patients had CRPS1 undergoing treatment. Two patients are unable to walk due to chronic pain and deformity. Comparison of the SF-36 scores with the age-matched UK normal controls without foot and ankle injuries showed significantly worse scores in physical function (PF: p<0.01) and role physical (RP: p< 0.01) categories.

Our surgical instinct dominates decision-making, favouring salvage rather than amputation in these young groups of patient. They gradually suffer a cocktail of crippling disease characterised by psycho-socio-economic and physical disability. Should we be depleting our resources in salvaging these complex limb injuries?

The aim of this study was to determine the accuracy of Magnetic Resonance Imaging (MRI) scanning compared to arthroscopic findings in patients presenting with chronic ankle pain and/or instability. We reviewed all patients who underwent arthroscopy of the ankle between December 2005 to July 2008 in our institution.

A total of 105 patients underwent arthroscopy for chronic ankle pain and/or instability. Twenty-four patients underwent MRI prior to the procedure. We compared the MRI findings with arthroscopic findings. We specifically examined for the anterior talofibular ligament (ATFL), calcaneofibular cigament (CFL) and osteochondral lesions(OCD). Arthroscopic findings were considered as a gold standard. There were 12 female and 12 male patients with an average age 39 years (11–65). The time interval between the MRI scan and arthroscopy was 7 months (2–18). In our study MRI had 100% specificity for the diagnosis of ATFL and CFL tears and osteochondral lesions. However sensitivity was low particularly for CFL tears. The accuracy of MRI in detecting ATFL tear was 91.7%, CFL tear was 87.5% and osteochondral lesion was 83.3%.

We conclude that MRI scanning has a very high specificity and positive predictive value in diagnosing tears of ATFT, CFL and osteochondral lesions. However sensitivity was low with MRI. In a symptomatic patient negative results on MRI must be viewed with caution and an arthroscopy is advisable for a definitive diagnosis and treatment.

Introduction: The Taylor Spatial Frame (TSFTM, Smith & Nephew, Memphis) has gained international recognition for the fixation of complex long bone fractures and deformity correction. It’s application with transverse wires can be difficult in some anatomic regions, and fixation of frames with half pins is gaining clinical popularity. Half-pins cause minimal transfixion of the surrounding soft tissues and can be inserted into anatomically safe areas.

Aims: This study aimed to compare the stiffness characteristics of a TSF frame fixed with transverse wires to fixation with half pins.

Materials and methods: Experiments were carried out in the biomechanics laboratory at Cardiff university. All mechanical testing was performed with a servo-hydraulic test frame (MTS-858 Mini Bionix II®, MTS Corp., Minneapolis). Custom built mounts were used to attach the bone rigidly to one end of the machine and TSF ring to the other. Rings were fixed with 1.8mm transverse wires or hydroxyapatite coated 6.5mm half pins with 45°, 60°, 75° and 90° divergence angles. Bone was loaded with axial load to 400N and torque to 20Nm. Load/displacement curve data were analyzed for slope and displacement.

Results: For larger diameter rings (180mm) there was no statistically significant difference in axial stiffness between the transverse wires (with 2 rings) and the half pins (p> 0.05). For 155mm diameter rings half pins provided statistically higher axial stiffness than transverse wires (p= 0.036). Half pins gave significantly more torsional stiffness for both ring diameters when compared to transverse wires (p< 0.05). As in axial stiffness, small diameter rings showed increased stiffness in torsion. There was an increase in axial and torsional stiffness as the divergence angle between the wires or pins increased (p< 0.05).

Conclusion and clinical relevance: Half pins provide greater stiffness to TSF frames and allow axial micro-motion as well. This work provides a rationale for clinical decision making in construction of a TSF frame.

Introduction: The transverse metatarsal arch is the subject of some controversy as there isn’t a clear consensus as to whether there is a transverse arch (TMA) in stance phase. The current treatment options of forefoot pathology focus on the need to harmonise the TMA by the use of osteotomies such as the Weil osteotomy.

Materials and Methods: A retrospective study of 75 feet (62 patients) with a mean follow up of 19 months. Patients underwent clinical, pedobarographic and radiological assessment. ‘Metatarsal skyline Views’ (MSV) were procured to assess the plantar profile of the TMA following Weil osteotomy. The feet were assessed using AOFAS, Foot Function Index, SF-36 and Manchester-Oxford Foot Questionnaires.

Results: 69 feet showed good to excellent results with a normal MSV plantar profile. 6 feet had recurrent meta-tarsalgia with callosities and abnormal MSV profiles. These results correlated well with pedobarography.

Discussion: The angle of Weil osteotomy is usually referenced relative to the floor irrespective of the plantar angulation of metatarsal. As different metatarsals had varying plantar angulations, the weight bearing metatarsal skyline view was used to ascertain the plantar profile of the metatarsals before, during and after surgery. This was also used to determine the amount of dorsal displacement required in addition to shortening in order to harmonise both length and plantar profile.

Conclusion: The use of the Metatarsal skyline view has significantly improved our planning of the angles of the Weil osteotomy.We suggest that the reference for the osteotomy should be the plantar angulation of the metatarsal rather than the floor. It has made the intra-operative assessment of the osteotomy easier and has improved our understanding of the osteotomy and its influence on the forefoot plantar profile.

Introduction: The transverse metatarsal arch is the subject of some controversy as there isn’t a clear consensus as to whether there is a transverse arch (TMA) in stance phase. The current treatment options of forefoot pathology focus on the need to harmonise the TMA by the use of osteotomies such as the Weil’s.

Materials and Methods: A retrospective study of 75 feet (62 patients) with mean follow up of 19 months. Patients underwent clinical, pedobarographic and radiological assessment. ‘Metatarsal skyline Views’ (MSV) were procured to assess the plantar profile of the TMA following Weil osteotomy. The feet were assessed using AOFAS, Foot Function Index, SF-36 and Manchester-Oxford Foot Questionnaires.

Results: 69 feet showed good to excellent results with a normal MSV plantar profile. 6 feet had recurrent metatarsalgia with callosities and abnormal MSV profiles. These results correlated well with pedobarography.

Discussion: The angle of Weil osteotomy is usually referenced relative to the floor irrespective of the plantar angulation of metatarsal. As different metatarsals had varying plantar angulations, the weight bearing metatarsal skyline view was used to ascertain the plantar profile of the metatarsals before, during and after surgery. This was also used to determine the amount of dorsal displacement required in addition to shortening in order to harmonise both length and plantar profile.

Conclusion: The use of the Metatarsal skyline view has significantly improved our planning of the angles of the Weil osteotomy. We suggest that the reference for the osteotomy should be the plantar angulation of the metatarsal rather than the floor. It has made the intraoperative assessment of the osteotomy easier and has improved our understanding of the osteotomy and its influence on the forefoot plantar profile.

To compare the intrinsic foot function and pliability of the foot in shoe and non shoe wearing population, measurement on the right foot of 100 randomly selected non-shoe wearing (Indians) and 100 shoe-wearing (British) population was carried out. They had normal body-mass index, age between 25 to 35 years and no previous injury or disability to the lower extremities.

Using a force gauge, force of extension and flexion at 1st metatarsophalyngeal joint, abduction at 5th meta-tarsophalyngeal joint and adduction between 1st and 2nd toe was measured. Pliability Ratio was calculated as follows:

Maximum weight bearing foot length X maximum weight bearing foot length

Maximum non-weight bearing foot length X maximum non-weight bearing foot length.

Using the student test at 95% confidence interval, there was no statistically significant difference in the intrinsic foot function. Multivariate regression analysis showed that after adjustment for other variables like gender and ethnicity, the shoe condition is significant on the pliability ratio. This study shows that although shoe-wearing does not affect the intrinsic foot function it definitely results in stiffer feet. This difference is more marked in women (p=0.0171).

Shoe-wearing can affect the transmission of forces during locomotion especially if the muscles acting across the foot are normal but the joints across which they act are stiff. Shoes have an inbuilt medial arch support and narrow toe boxes. This result in incomplete movement of the transverse and longitudinal arches of the foot leading to stiffer feet and can affect the biomechanics of shod feet.

Purpose: To evaluate the outcome of salvage surgery with external fixation in these rare and severe lower limb injuries

Methods: Eight patients (7M: 1F) with mean age of 28 years (range −18 −35 years) were included. Four had Grade 3 open fractures of the distal tibia and 5 had open foot fractures. Two had neurovascular injuries. Four patients had associated injuries with mean ISS of 9 (range 8–16) and a mean MESS score of 3.5 (3–7). All had undergone some form of internal and external fixation within approximately 24 hours (8 hrs to 4 days). The mean follow up period was two years (range 1 – 4 years). At final follow-up patient’s health was measured using SF-36 questionnaire.

Results: Six patients had their fractures healed at a mean of 4.8 months (4–9 m). Two patients had fully functional foot with occasional complaints of painful ankle. Two patients had CRPS1 undergoing treatment. Two patients are unable to walk due to chronic pain and deformity. Comparison of the SF -36 scores with the age-matched UK normal controls without foot and ankle injuries showed significantly worse scores in physical function (PF: p< 0.01) and role physical (RP: p< 0.01) categories

Conclusions: Our surgical instinct dominates the decision-making favoring salvage with external fixation primarily rather than amputation in these young groups of patient. Should we be depleting our resources in salvaging these complex limb injuries?

Aims: To show that ankle fusion using an intra-medullary nail is effective with low morbidity and high patient satisfaction and improvement in postoperative AOFAS scores in selected patients. Methods: The þrst twenty ankle fusions performed with the Biomet intra-medullary nailing system by one surgeon were reviewed over a two year period. The Biomet system offers superior advantages, allowing longitudinal compression and posterior to anterior distal locking in the calcaneus.

Data sets were recorded for each patient. Information with regard to each patients age, sex, occupation, presenting complaint, mechanism of injury if applicable, index procedure if applicable, diabetic status, associated comorbidities and smoking habitus were recorded. The pre-operative and post-operative AOFAS score was also recorded for each patient. Results: All patients except one showed a marked improvement in their AOFAS score when treated with intra-medullary nail for ankle fusion. The average improvement in score was 150%. Morbidity from the procedure was low. There was one case of mortality not attributed to the nail. 19 out of 20 patients went on to solid fusion. Conclusion: The use of an intra-medullary nail for fusion of the ankle is a reliable technique in selected cases. AOFAS scores consistently improve, morbidity is low and fusion is usually successful. We would advocate this technique for fusion.

Aims: To assess the difference in muscle function and pliability between shoe wearing and non shoe-wearing feet. Methods: Using a basic force gauge, force of extension and ßexion at 1st metatarsophalyngeal joint, abduction at 5th metatarsophalyngeal joint and adduction between 1st and 2nd toe was measured on the right foot of 100 (50 male and 50 female) randomly selected human population. They had normal body-mass index and age between 25 to 35 years. People with previous injury or disability to the right lower extremity were excluded. Measurement on non-shoe wearing population was carried out on Indian population. Measurements on shoe-wearing population were carried out on the British population. Maximum length and breadth of full weight bearing and non-weight bearing foot was measured. Pliability Ratio of weight bearing length and breadth of the foot by the non-weight bearing length and breadth of the foot was calculated. Results: There was no statistically different muscle force in the small joints of the feet. Pliability ratio showed that the shoe wearing feet were stiffer than non-shoe shoe wearing feet. Conclusions: Shoe wearing does not affect the intrinsic foot function. It may result in slightly stiffer feet. This can result in improper distribution of force while weight bearing Pediatric hip

This small study was a pilot for a larger ongoing study to look at the long-term results of Wilson’s osteotomy.

Eight patients and thirteen feet were reviewed at a minimum of twelve years post operatively (twelve to eighteen years).

Photographs were obtained of their feet, also pedographs, and pre and post op X-rays. Clinical assessments were done and the patient outcome was quantified using the American Academy of Foot and Ankle Surgeons scoring system which includes a shoe comfort score.

The findings show that in the younger population (less than 40 years old) there were minimal symptoms (pain and stiffness), all showed callosity formation and none had a recurrence. The older group (over 40 at operation) were more symptomatic, all showed callosity formation and there was a recurrence rate of more than 40%.