Introduction

Ankle fractures are common injuries presenting to trauma departments and ankle open reduction and internal fixation (ORIF) is one of the first procedures targeted in early orthopaedic training. Failure to address the fracture pattern with the appropriate surgical technique and hardware may lead to early failure resulting in revision procedures or premature degenerative change. Patients undergoing revision ORIF are known to be at much greater risk of complications, and many of these secondary procedures may be preventable.

Introduction

Arthroscopic ankle fusion is an effective treatment for end stage ankle arthritis. It reliably improves pain but at the expense of ankle motion. Development of adjacent degenerative joint disease in the foot is thought to be a consequence of ankle fusion due to altered biomechanics. However, it has been reported to be present on pre-operative radiographs in many patients. There is very little evidence reporting the long-term outcomes of patients undergoing arthroscopic ankle fusion and particularly those requiring secondary procedures for adjacent joint disease.

Background

Total ankle replacement (TAR) design has evolved greatly in recent years and offers a reasonable alternative to ankle arthrodesis in a select patient population with end-stage arthritis. Originator series’ report good longevity and excellent patient reported outcomes (PROMs). We report our outcomes in an independent, non-inventor cohort.

Hammer toe involves metatarsophalangeal joint (MTPJ) hyperextension and proximal interphalangeal joint (PIPJ) flexion. Surgery commonly involves excision arthroplasty or fusion of the PIPJ with MTPJ soft tissue release if necessary. Previous series record that MTPJ release was carried out “as required” but not how often release is necessary. Myerson and Shereff's (1989) cadaver study found release of the extensors, MTPJ capsule and collateral ligaments necessary for full hammertoe correction. Hossain (2002) found the clinical results of this procedure were no better than simple PIPJ fusion. We release the MTPJ if hyperextension persists after PIPJ correction and release the components sequentially. We studied how often and how extensive a release was required, and how this corelated with pre-operative assessment.

We reviewed the records of 164 patients who had hammer toe correction under one consultant surgeon. Patients with complex corrections were excluded. The severity of the pre-operative deformity was classified as type 1 (PIPJ and MTPJ correctable), 2 (PIPJ fixed, MTPJ correctable) or 3 (neither joint correctable). We recorded the extent of release required for each toe.

Introduction: Current evidence for treatment of Achilles tendon rupture suggests that open surgical repair reduces the re-rupture rate compared to conservative treatment, but with a higher risk of infection. Modern non-surgical treatment and surgical aftercare involves early weight-bearing in functional orthoses. It is therefore appropriate to measure the re-rupture rates and outcomes in patients treated in this manner.

Materials and methods: Between 2002 and 2008 our unit prospectively collected data on 80 patients treated with a below-knee functional orthoses for complete Achilles tendon rupture. Patients made their own choice of treatment following evidence-based counselling. The patients were treated either surgically or conservatively and entered the appropriate arm of the standard orthotic and early weight-bearing treatment protocol. Patients were contacted by telephone or post for follow-up and completed a VISA-A and Achilles Total Rupture Score (ATRS) questionnaire.

Results: There were 61 Males, 19 Females with an age range of 24–80 (median 42). The median time in the functional brace was eight weeks. 51 patients were treated conservatively and 29 patients surgically. The conservative group were a decade older (median age 47y, range 27–80) than the surgical group (median age 37y, range 24–55y). In the non-operative treatment group the re-rupture rate was 3.9% (2/51, 95% confidence interval 0.5–13.5%). In the surgical group it was 3.4% (1/29, 95% confidence interval 0–17.8%), in this group the wound infection rate was 6.8% (2/29, 95% confidence interval 0.9–22.8%) with no nerve injuries reported. The median ATRS was 82 in the conservative group and 95 in the surgical group. The median VISA-A scores were 57 and 92 respectively.

Discussion: Our case series shows comparable low re-rupture rates in both groups. Functional scores, using the newly validated ATRS score, were lower in the non-surgical, older group.

Conclusion: Functional care after surgical and non-surgical treatment of Achilles rupture produces similar re-rupture rates.