Abstract

Introduction:

Plantar Fasciitis is an extremely common and challenging problem that presents itself to foot and ankle practitioners. Many different treatment modalities are available for this condition, with little proven benefit. ECSWT was approved for use by the FDA for the treatment of chronic proximal plantar fasciitis in 2002 and NICE published guidance in 2009 recommending its use in refractory cases.

The majority of hip fracture patients receive operative treatment, although the National Hip Fracture Database (NHFD) 2012 suggest 2.6% were treated conservatively. One of only a few published reports on the outcomes of these patients has demonstrated that mortality rates beyond 30 days remain comparable to patients receiving surgery. We have assessed the outcomes of conservatively managed patients in our unit.

Patients treated conservatively at our hospital between 2010 and 2012 inclusive were identified using the NHFD. Data collection included mobility status, ASA grade, Nottingham Hip Fracture Score (NHFS), mortality (30 days and 1 year) and pain scores.

The study group (N=31) had a mean age 85, mean ASA was 4 and mean NHFS mortality risk 21.3%. Morbidity included one case of pneumonia and one infection from another source, however there were no pressure sores or VTE. Three patients later received surgery once their health had improved. Pain control was achieved in 91% patients (21/23) and although mobility decreased, 34.8% of patients were able to mobilise with either two aids or a frame.

Given the selection bias for conservative treatment in unwell patients, the higher mortality figure is not unexpected. Although the 30 day mortality data is higher than the national average for operative management, those patients surviving 30 days have a mortality similar to those managed operatively. Despite mobility decreasing from the pre-admission status, a significant number of patients were pain free and could mobilise. Therefore conservative management can produce acceptable results in these patients.

Introduction

Patients who present with atypical foot pain in a non specific sensory distribution may benefit from having nerve conduction studies (NCS). The aim of this study was to confirm whether NCS is a useful tool.

Introduction

Forefoot deformities are common in the rheumatoid population and lead to abnormal loading, plantar callosities and metatarsalgia. First MTP joint arthrodesis with lesser toe Stainsby procedures has become a popular method of reconstructing the rheumatoid forefoot but there is little data that reviews the clinical or biomechanical results of combining the two procedures.

Background

Salvage procedures on the 1st MTPJ following failed arthroplasty, arthrodesis or hallux valgus surgery are difficult and complicated by bone loss. This results in shortened first ray and transfer metatarsalgia. We present our experience of using tri-cortical interposition grafts to manage this challenging problem.

Damage to the dorsomedial branch of the medial dorsal cutaneous nerve is not uncommon in surgery of the hallux. The resultant morbidity can be disabling. In the light of the senior author’s operative observation of a sentinel vein, we undertook a cadaver study to investigate the anatomical relationships of the dorsomedial branch of the medial dorsal cutaneous nerve. This established that in 14 of 16 cadaver great toes exposed via a modified medial incision, there is an easily identified vein which runs transversely superficial and proximal to the nerve. In a prospective clinical study of 171 operations on the great toe using this approach, we confirmed this anatomical relationship in 142 procedures (83%), with no complaint of numbness or pain in the scar at follow-up. We attribute this to careful identification of the ‘sentinel’ vein and the subjacent sensory nerve, which had been successfully protected from damage. We recommend this technique when operating on the great toe.

We aimed to assess the long term results of patients who underwent Autologous Chondrocyte Implantation (ACI) for osteochondral lesions of the talus. Between 1998 and 2006, 28 patients underwent ACI for osteochondral lesions of the talus. All these patients were prospectively reviewed and assessed for long term results. Outcomes were assessed using satisfaction scores, Mazur ankle score and the AOFAS score, and Lysholm knee score for donor site morbidity.

The 28 patients who underwent the procedure included 18 males and 10 females. Follow up ranged from 1–9 years. In all patients, there was an improvement in the Mazur and AOFAS ankle scores and the Lysholm scores showed minimal donor site morbidity. Improvement in ankle score was independent of age and gender. The better the pre-op score the less the difference in post-op ankle scores. Patients were unlikely to benefit with pre-op ankle scores over 75.

The mid to long term results of ACIs in the treatment of localised, contained cartilage defects of the talus are encouraging and prove that it is a satisfactory treatment modality for symptomatic osteochondral lesions of the talus. Complications are limited. However, in view of limited number of patients, a multi-centre randomised controlled study is required for further assessment.

Introduction: The treatment of stage 3 hallux rigidus is controversial. Cheilectomy, fusion and total joint replacement have all been advocated. No consensus is agreed on the best optimal management. We present our results of a ceramic on ceramic MOJE metatarsophalangeal (MTP) joint replacement.

Aim: To find out the medium to long term outcome following MOJE MTP joint replacement.

Material and Methods: A sample of 95 patients was identified, between January 1999 to July 2006 from our data base who underwent MOJE metatarsophalangeal joint replacement. We divided these patients into three groups. First group had screw fit ceramic MOJE joint replacement; second group Mark 1 ceramic on ceramic press fit MOJE joint replacement and third group Mark 2. Indications of the surgery were osteoarthritis (primary or secondary), osteochondral defects, inflammatory arthropahty, previous infections and previously failed surgery. The outcome was analysed clinically, radiologically and functionally (using AOFAS and QALY scoring system).

Results: This study shows that the early results are promising but the medium and long term results show early radiological loosing. The significance of this is not known but based on these results we would advice caution on the use of these implants and further long term studies are required.

Aim: Concerns have been expressed that DMARDS may interfere with bone healing. Previous studies give conflicting advise and no consensus exist in current practise especially with the newer DMARDS such as Leflunomide, Etanercept, and Infliximab. The aim of this study was to assess the in-vitro effect of DMARDS and cox-2 inhibitors on Osteoblast activity.

Method: Osteoblasts were cultured from femoral heads obtained from five young otherwise healthy patients undergoing total hip replacement The cells were cultured using techniques that have been previously described. A computer aided design of experiment was used as a model for setting up the experiment on samples obtained from the five patients. Normal therapeutic concentration of the various DMARDS was added alone and in combination to the media. The cell growth was estimated after two weeks using spectrophotometric technique using Roche Cell proliferation Kit. Multiple regression analysis was used to estimate the best predictor of the final result.

Results: The most significant factor (p< 0.001) in predicting the ultimate response was the patient themselves. Cox-2 inhibitor (Etoricoxib) was found to have the most consistent effect although always in combination with some other drug which varied amogst different patients. Etoricoxib in fact had a stimulatory effect (R=0.219) on the osteoblast growth.

Conclusion: Different patients respond differently to the drugs. None of the DMARDS tested inhibit osteoblast proliferation and differentiation in-vitro. If osteoblastic activity is considered to be the primary factor responsible for bone healing, then an inhibition should not result in patients who are on these drugs.

Methotrexate and Cox-2 inhibitors are thought to interfere with bone healing. There have been controversial results published in the literature. The effect of newer antirheumatoids (Leflunomide, Etanercept, Infliximab) has not been studied. The aim of this study was to find the in-vitro effect of methotrexate, newer anti-rheumatoids, steroids and cox-2 inhibitors on Osteoblasts. Osteoblasts were cultured from femoral heads obtained from young otherwise healthy patients undergoing total hip replacement. The cells were cultured using techniques that have been previously described. A computer aided design of experiment was used as a model for setting up the experiment on samples obtained from five patients. Normal therapeutic concentration of the various antirheumatoids was added alone and in combination to the media. The cell growth was estimated after two weeks using spectrophotometric technique using Roche Cell proliferation Kit. Multiple regression analysis was done to estimate the best predictor of the final result. Patient was found to be the most significant factor (p< 0.001) in predicting the ultimate response. Cox-2 inhibitor (Etoricoxib) was found to be the next best predictor (p=0.043). Etoricoxib in fact had a stimulatory effect (R=0.219) on the osteoblast growth, which was accentuated in the presence of other agents that varied amongst different patients. Different patients respond differently to the drugs. None of the antirheumatoids inhibit osteoblast proliferation and differentiation in-vitro. If osteoblastic activity is considered to be the primary factor responsible for bone healing, then an inhibition should not result in patients who are on these drugs.

Aims: Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all structurally unstable joints require stabilisation. The aim of this study was to find out the role of EUA & Arthroscopy in the management of these problems.

Methods: We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation programme. All patients underwent an examination under anaesthesia with stress views to determine instability proceeded by arthroscopic examination of the ankle.

Results: Intra-articular bony lesion was seen in 41.8% of cases. 79.1% had fibrosis in the anterolateral gutter, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%. Arthroscopy demonstrated attenuation of the Anterior Talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14(32.5%). 23 patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction.

Conclusion: Arthroscopic assessment and treatment of intraarticular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction.

Aims: The aims of this study were to 1) determine if vacuum assisted closure therapy (VAC) helps assist closure in diabetic foot ulcers and wounds secondary to peripheral vascular disease, 2) if it helps debride wounds and 3) if it prevents the need for further surgery

Materials and Methods: 15 patients were reviewed, average age 49.3yrs at an average of 6.3 months (1–18months). Ten patients had diabetes (8 IDDM) with 5 patients having grade 3 ulcers (Wagner-Meggitt). All wounds were surgically debrided prior to the application of the VAC therapy. The VAC therapy was applied according to the manufacturers instrucrtions. The main outcome measures were 1) time to satisfactory wound closure 2) change in the wound surface area and 3) need for further surgery

Results: Satisfactory healing was achieved in 11 patients (73.3%). 10 were diabetic, 5 patients had peripheral vascular disease and 5 patients had both. The time to satisfactory healing was 2.5 months, average 1–6 months. The average size of the wound ulcer was 7.41cm2 (2–10cm2) prior to treatment and 1.58cm2 (0–2cm2) following treatment in an average of 2.5 months. VAC therapy helped debride all non healing wounds following surgical debridement. In 10 patients, the need for further radical surgery, namely amputation, was avoided.

Conclusion: VAC therapy is a useful adjunct to the standard treatment of chronic wound /ulcers in patients with diabetes with or without periphearl vascular disease. Its use in foot and ankle surgery leads to a quick wound closure and in some cases avoids the need for further surgery with a potential for limb salvage.

Aims Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all structurally unstable joints require stabilisation. The aim of this study was to find out the role of examination under anaesthesia (EUA) and arthroscopy in the management of these problems.

Method We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation programme. All patients underwent an EUA with stress views to determine instability, proceeded by arthroscopic examination of the ankle.

Results Intra-articular bony lesion was seen in 41.8% of cases. Fibrosis in the anterolateral gutter was found in 79.1%, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%. Arthroscopy demonstrated attenuation of the anterior talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14 (32.5%). Twenty-three patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction. Three patients (6.9%) needed supplementary procedures for other associated problems.

Conclusion Arthroscopic assessment and treatment of intraarticular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction.

Background The American Orthopaedic Foot and Ankle Society (AOFAS) score is one scoring system used to evaluate and monitor the progress of patients following foot and ankle surgery. The aim of this study was to evaluate the trend of AOFAS score over a period of time and correlate with quality-adjusted life-year (QALY) score, which is a valid and reliable scoring system.

Method All patients undergoing surgery under one foot and ankle surgeon from a period of January 2001 to July 2003 were reviewed. The pre-operative AOFAS and QALY scores and post-operative at 3, 6, 12 months and yearly were collected prospectively.

Results This study includes 205 surgical procedures in 159 patients. This included 40 patients with 41 feet in the ankle-hindfoot group; 15 patients with 15 feet in the midfoot group; 83 patients with 114 feet in the hallux group and 29 patients with 35 feet in the lesser toes group. The mean age of the patients was 51.9 yrs.

The general trend of the AOFAS graph shows a mean of 45.3 pre-operatively which rises to 72.4 at 3 month and a peak of 77.1 at 6 months only to fall to 75.7 at 12 months. This fall though seemingly marginal was significant (p< 0.001) Kendall’s rank correlation was used to correlate the AOFAS and QALY score. The 6-month AOFAS score was found to have higher correlation with the final QALY score (τ =0.423) than the 12-month AOFAS score (τ =0.236).

Conclusion AOFAS score correlates with subjective and functional results as determined by QALY score. The role of assessing AOFAS at 3 months does not seem to be justified. There is a deterioration in score at 12 months. Post-operative scores at 6 months should be sufficient to assess the outcome.

Introduction and Aims: Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all the structurally unstable joints require stabilisation.

Method: We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation program. All patients underwent an examination under anaesthesia with or without stress views to determine instability and this was preceded by arthroscopic examination of the ankle.

Results: Intra-articular lesion was seen in 41.8% of cases. 79.1% had fibrosis in the anterolateral gutter, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%.

Arthroscopy demonstrated attenuation of the Anterior Talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14 (32.5%). Twenty-three patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction. Three patients (6.9%) were lost to follow-up and three (6.9%) needed further procedures.

Conclusion: Arthroscopic assessment and treatment of intra-articular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction.

Autologous chondrocyte implantation (ACI) has been used most commonly as a treatment for cartilage defects in the knee and there are few studies of its use in other joints. We describe ten patients with an osteochondral lesion of the talus who underwent ACI using cartilage taken from the knee and were prospectively reviewed with a mean follow-up of 23 months. In nine patients the satisfaction score was ‘pleased’ or ‘extremely pleased’, which was sustained at four years. The mean Mazur ankle score increased by 23 points at a mean follow-up of 23 months. The Lysholm knee score returned to the pre-operative level at one year in three patients, with the remaining seven showing a reduction of 15% at 12 months, suggesting donor-site morbidity. Nine patients underwent arthroscopic examination at one year and all were shown to have filled defects and stable cartilage. Biopsies taken from graft sites showed mostly fibrocartilage with some hyaline cartilage. The short-term results of ACI for osteochondral lesions of the talus are good despite some morbidity at the donor site.

Patients with osteochondral lesions of the talus have traditionally been difficult to treat. Autologous chondrocyte implantion (ACI) may provide predictable repair through restoring an articular surface. We reviewed our results of Ankle ACI in eight ACI plus two ACI and mosaicplasty combined with an average age of 40 years (32 to 62) performed over four years.

The patients were assessed with a modified Mazur ankle score, patient satisfaction score and Lysholm knee score, pre- and post-operatively. Ankle arthroscopic assessment was performed in patients at 12 months post surgery. The average time to follow up was 24 months (range two to 52). The osteochondral lesions were post traumatic in seven cases, with seven lesions situated medially and three anterolaterally. The average size of the talar defects at surgery was 2.25cm (range 1 to 4 cm.)

Patient satisfaction scores in eight patients were either “extremely pleased” or “pleased” with the operation which was sustained in the patients at up to four years follow up. The Mazur scores increased by 23 points at mean 24 months follow up. Six patients with over 12 months follow up maintained a markedly improved ankle score. Patients were noted to rehabilitate twice as quickly as patients receiving ACI to the knee.

The Lysholm knee scores returned to the preoperative level in four patients, with the remaining six patients showing a reduced score (mean 12 points), suggesting there may be some donor site morbidity. Five had ankle arthroscopy at one year and were shown to have filled defects and stable cartilage. A biopsy taken from the graft site showed hyaline like cartilage and fibrocartilage to be present These early results suggest that ankle ACI is an appropriate treatment for large symptomatic osteochondral lesions in the talus.

Aims

The aims of this study were to determine if vacuum assisted closure (VAC) therapy affords quicker wound closure in diabetic and ischaemic wounds or ulcers than standard treatment, if it helps debride wounds and if it prevents the need for further surgery.

Materials and methods

We retrospectively reviewed 12 patients, average aged 52.1 yrs (22 to 67) at an average of 6.3 months (1 to12 months). Seven had diabetes and three had chronic osteomyelitis. All wounds or ulcers were surgically debrided prior to application of the VAC therapy. The VAC therapy was applied according to the manufacturers instructions. The main outcome measures were the time to satisfactory healing and the change in the wound surface area.

Results

Satisfactory healing was achieved in six patients (50%), seven were diabetic and one patient had peripheral vascular disease. The average time to satisfactory healing was 2.5 months, (1 to 6 months). The average size of the wound /ulcer was 7.41 cm2 prior to treatment and 1.58 cm2 following treatment for an average 2.5 months in those in whom the wound/ulcer was still present. VAC therapy helped debride all wounds which remained sloughy following surgical debridement. In 8 patients the need for further surgery, such as soft tissue flaps or more radical surgery was avoided.

Conclusion

VAC therapy is a useful adjunct to the standard treatment of chronic wound /ulcers in patients with diabetes or peripheral vascular disease. Its use in foot and ankle surgery leads to a quicker wound closure and in some cases, avoids the need for further surgery. There are significant economic cost savings with its use in foot and ankle surgery.

Twelve patients with an osteochondral lesion of the talus were treated with local osteochondral autogenous grafting. The graft was harvested locally from the medial or lateral talar articular facet. The procedure was combined with an osteotomy of the anterior tibial plafond modifying the technique of Flick and Gould. The average age of the patients was 41 years (range 19 to 68) with an average duration of symptoms of 90 months (range 3 – 240 months). There were six males and six females with the right talus involved in eight and the left in four patients.

Results showed an improvement in the AOFAS score from an average of 69 pre-operatively to 90.2 post-operatively, at an average follow up of 15 months (range 6 to 31 months). The results tended to improve with time and was higher for patients under 40 years of age and in those without pre-existing joint arthritis. All patients were very satisfied with the procedure. Arthroscopy performed in two patients at six and 12 months following surgery showed good graft incorporation. No complications were seen from the donor site or from the osteotomy site on the distal tibia. Our results show that stage III and IV talar lesions can be treated successfully using local autogenous osteochondral graft from the medial or lateral talar articular facet.