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

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

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.

The patient-reported Manchester-Oxford Foot Questionnaire (MOXFQ), with 3 dimensions (Walking/standing(W/S), Pain, Social interaction(SI)) has previously been validated in patients undergoing hallux valgus surgery. A preliminary cross-sectional evaluation of its measurement properties relating to surgery on different regions of the foot and ankle is presented here.

Within 4 weeks prior to foot or ankle surgery, 671of 764 consecutive eligible patients (87.8% response rate) were assessed with the: (i) MOXFQ questionnaire, (ii) SF-36 general health survey (iii) American Orthopaedic Foot & Ankle Society (AOFAS) scales. Sample characteristics: mean age 53 years 427 (63.6%) female. Patients were booked for (main) surgery on Hallux (210, 31.3%), Lesser Toes (119, 17.7%), Mid foot (22, 3.3%), Ankle/Hind foot (311, 46.3%) and whole foot/multiple regions (9, 1.3%)

MOXFQ item response rates were high (<2% missing on any one item) with responses generally well distributed across response categories. Item-total correlations within each dimension were generally above recommended levels. Internal consistency, as assessed by Cronbach's alpha, were 0.93, 0.84 and 0.71 for the W/S, Pain and SI dimensions, respectively. Within Hallux, Lesser toes and Ankle/hind foot surgical subgroups (low numbers precluded mid foot and whole/multiple region analyses), alphas for these subscales were similar. Convergent validity of MOXFQ was demonstrated by correlations between the 3 dimensions (W/S, Pain, SI) with similar dimensions of the SF-36 and relevant AOFAS scales. A priori hypotheses were generally supported.

The MOXFQ demonstrates good baseline measurement properties in patients undergoing a range of foot and ankle surgery, suggesting its suitability as an outcome measure for clinical trials of foot and ankle surgery in general. The SI dimension, concerned with cosmesis and social participation has somewhat weaker properties but remains useful. Evidence for the MOXFQ's responsiveness across the range of foot and ankle surgery is yet to be assessed.

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: The first line treatment in our centre for Morton’s neuroma (MN), sufficient to warrant intervention, is a peri-neural Ultrasound guided injection of corticosteroid (USI).

The NHS will soon implement 18 week referral to treatment targets.

A prospective study was performed whereby from 2004–6, referral letters from General Practitioners suggesting a diagnosis specifically of Morton’s neuroma, resulted in randomised assignment to either direct referral for USI or to the specialist Foot and Ankle outpatient clinic.

Patients with less specific referral letters were evaluated in clinic and referred for USI as appropriate.

A comparison was made of the sensitivity and specificity of the referral pathways, financial implications and the time to treatment (TTT).

Results: 121 patients were referred for USI.

Of 57 patients for whom the GP had diagnosed a MN, 40 (70%) had the diagnosis confirmed on USI (other diagnoses were: 7 NAD, 3 ganglions, 2 bursae, 2 degenerative change, 1 glomus tumour, 1 angioleiomyoma, 1 SOL); this was comparable to the overall number referred to radiology with a suspected MN (69%).

In the directly referred group, the mean TTT was 115 days (95%CI = 89 – 141), compared to 241 days (95%CI = 223 – 259) for those patients who went via a Foot and Ankle clinic. P< 0.0001.

Conclusion: For patients with features highly suggestive of a Morton’s neuroma, direct referral from primary care for USI has a similar sensitivity and specificity to referral from a specialist hospital clinic and the TTT is significantly shorter.

The mean wait of this group is within the 18 week government target without any changes to our current radiology protocols. Using this direct referral protocol we saved 29 outpatient appointments; if followed for all eligible patients we would have saved 57 outpatient appointments.

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 SCARF osteotomy is a three dimentional osteotomy for hallux valgus. It combines a lateral release of the adductor hallucis with a lateral and plantar displacement of the first metatarsal. The osteotomy is ‘z’ shaped in the lateral view and displacement of the distal fragment is followed by internal fixation.

In this study we set out to determine whether the SCARF osteotomy was an effective method in the correction of moderate to severe hallux valgus deformity. A prospective radiographic study was performed on 22 cases of SCARF osteotomy with an average age of 52 years (range 25–78). Standardised weight bearing anterior-posterior radiographs were taken preoperatively and at six months post operatively.

The American Foot and Ankle Society guidelines were used for all measurements. Measurements were made using overlay acetate sheets to minimise inter and intra observer error.

These were compared to determine changes in the intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA) and joint congruency angle (JCA). Correction of sesamoid position and metatarsal length changes were also assessed.

The results showed a median reduction of IMA of 6 degrees, HVA of 16 degrees, DMAA of 6 degrees and an improvement in JCA of 11 degrees. Improvement of the lateral sesamoid displacement from beneath the first metatarsal head was seen postoperatively. Metatarsal length was assessed by comparing the ratio of the length of the first to second metatarsal pre and post operatively. No shortening was found. There was no incidence of avascular necrosis or non-union. This study indicates that the SCARF osteotomy produces effective radiological correction of hallux valgus where there is moderate to high degree of deformity. It also improves sesamoid displacement and avoids shortening of the first metatarsal.