Background

Supination-external rotation (SER) injuries make up 80% of all ankle fractures. SER stage 2 injuries (AITFL and Weber B) are considered stable. SER stage 3 injury includes disruption of the posterior malleolus (or PITFL). In SER stage 4 there is either medial malleolus fracture or deltoid injury too. SER 4 injuries have been considered unstable, requiring surgery. The deltoid ligament is a key component of ankle stability, but clinical tests to assess deltoid injury have low specificity. This study specifically investigates the role of the components of the deep deltoid ligament in SER ankle fractures.

Patients with advanced stage hallux rigidus from 12 centers in Canada and the UK were randomized (2:1) to treatment with a small (8/10 mm) hydrogel implant (Cartiva) or 1^st MTP arthrodesis. VAS pain scale, validated outcome measures (FAAM sport scale), great toe active dorsiflexion motion, secondary procedures, radiographic assessment and safety parameters were evaluated.

236 patients were initially enrolled, 17 patients withdrew prior to randomization, 17 patients withdrew after randomization and 22 were non-randomized training patients, leaving 152 implant and 50 arthrodesis patients. Standard demographics and baseline outcomes were similar for both groups.

Mean VAS pain scores decreased from 6.8 and 6.9 respectively for the implant and arthrodesis groups from baseline to 1.4 and 0.7 at 24 months. Similarly, the FAAM sports score improved significantly from baseline levels of 37 and 36 to 24 months level of 77 and 82 respectively for the implant and arthrodesis groups. First MTP active dorsiflexion motion improved an average of 4° at 3 months after implant placement and was maintained at 24 months.

Secondary surgeries occurred in 17 (11.2%) implant patients and 6 (12.0%) arthrodesis patients. Fourteen (9.2%) implants were removed and converted to arthrodesis and 6 (12.0%) arthrodesis patients had painful hardware requiring removal. There was no case of implant fragmentation, wear, or bone loss. Analysis of a single composite endpoint utilizing the three primary study outcomes (pain, function, and safety) showed statistical equivalence between the2groups.

The MediShoe (Promedics Orthopaedics Ltd, Glasgow) is a specific post-operative foot orthosis used by post-operative foot and ankle patients designed to protect fixations, wounds and maximise comfort. The use of rigid-soled shoes has been said to alter joint loading within the knee and with the popular use of the MediShoe at our centre in post operative foot and ankle surgery patients, it is important to ascertain whether this is also true.

An analysis of the knee gait kinetics in healthy subjects wearing the MediShoe was carried out. Ten healthy subjects were investigated in a gait lab both during normal gait (control) and then with one shoe orthosis worn. Force plates and an optoelectronic motion capture system with retroreflective markers were used and placed on the subjects using a standardised referencing system. Three knee gait kinetic parameters were measured:- knee adduction moment; angle of action of the ground reaction force with respect to the ground in the coronal plane as well as the tibiofemoral angle. These were calculated with the Qualisys software package (Gothenburg, Sweden).

A two-tailed paired t-test (95% CI) showed no significant difference between the control group and the shoe orthosis-fitted group for the knee adduction moment (p = 0.238) and insignificant changes with respect to the tibiofemoral angle (p = 0.4952) and the acting angle of the ground reaction force (p = 0.059).

The MediShoe doesn't significantly alter knee gait kinetics in healthy patients. Further work, however is recommended before justifying its routine use.

Background

Most patients with Achilles tendinopathy (AT) are treated successfully with physiotherapy ie eccentric calf training. In some patients gastrocnemius contracture persists. Three other publications have reported improvement in AT following gastrocnemius release, but this is the first series of patients to have proximal medial gastrocnemius release (PMGR) for AT. The purpose of this study was to review patients with refractory non-insertional and insertional AT treated by PMGR with a minimum followup of 18 months.

Introduction

Entry into orthopaedic higher surgical training remains extremely competitive, however little evidence exists regarding the validity of short-listing and interviewing for selection. This paper assesses the relative correlations of short-listing and interview scores in predicting subsequent performance as an orthopaedic trainee.

Introduction

Scar sensitivity is a recognised complication of foot surgery. However there is very little published about it. This study looks at the incidence and natural history of scar sensitivity following hallux valgus surgery.

Introduction

Plantar fasciopathy is a common cause of heel pain, and is usually treated in primary practice with conservative measures. Intractable cases can prove very difficult to treat. Currently plantar fasciopathy is not routinely imaged and treatment is empirical. At the Royal Surrey County Hospital patients with intractable plantar fasciopathy are managed in a unique ‘one-stop’ Heel Pain clinic. Here they undergo clinical assessment, ultrasound scanning and targeted therapy.

The saphenous nerve is classically described as innervating skin of the medial foot extending to the first MTP joint and thus is at risk in surgery to the medial ankle and forefoot. However, it has previously been demonstrated by the senior author that the dorsomedial branch of the superficial peroneal nerve consistently supplies the dorsomedial forefoot, leading to debate as to whether the saphenous nerve should routinely be included in ankle blocks for forefoot surgery. We undertook a cadaveric study to assess the presence and variability of the saphenous nerve.

29 feet were dissected from a level 10 cm above the medial malleolus, and distally to the termination of the saphenous nerve. In 24 specimens (83%), a saphenous nerve was present at the ankle joint. In 5 specimens the nerve terminated at the level of the ankle joint, and in 19 specimens the nerve extended to supply the skin distal to the ankle. At the ankle, the mean distance of the nerve from the tibialis anterior tendon and saphenous vein was 14mm and 3mm respectively. The mean distance reached in the foot was 5.1cm. 28% of specimens had a saphenous nerve that reached the first metatarsal and no specimens had a nerve that reached the great toe.

The current study shows that the course of the saphenous nerve is highly variable, and when present usually terminates within 5cm of the ankle. The saphenous nerve is at risk in anteromedial arthroscopy portal placement, and should be included in local anaesthetic ankle blocks in forefoot surgery, as a significant proportion of nerves supply the medial forefoot.

Introduction

Foot and ankle is a well-established and growing sub specialty in orthopaedics. It accounts for 20 to 25 per cent of an average department's workload. There are two well established foot and ankle specialist journals but for many surgeons the Journal of Bone and Surgery (JBJS) remains the preeminent journal in orthopaedics and a highly sought after target journal for publication of research. It is our belief that foot and ankle surgery is underrepresented in the JBJS. We undertook a study to test this hypothesis.

The saphenous nerve is classically described as innervating skin of the medial foot to the first MTP joint and thus is at risk in surgery to the medial ankle and foot. However, it has previously been demonstrated that the dorsomedial branch of the superficial peroneal nerve consistently supplies the dorsomedial forefoot, and therefore previous descriptions of the saphenous nerve maybe erroneous.

We undertook a cadaveric study to assess the presence and variability of this nerve.

21 cadaveric feet were dissected from a level 5 cm above the medial malleolus, and distally to the termination of the saphenous nerve. In 16 specimens (76%), a saphenous nerve was present, of which 14 were anterior to the saphenous vein. Two of 16 nerves terminated above the medial malleolus. Therefore, only 14 of 21 specimens (66%) had a saphenous nerve present at the level of the medial malleolus. In seven of these 14 specimens (50%), the nerve terminally branched before the level of the tip of the malleolus. The mean distance reached in the foot was 46mm. Only two nerves reached the forefoot, at 97mm and 110 mm from the ankle joint respectively. At the ankle, the mean distance of the nerve from the tibialis anterior tendon was 9mm, and the saphenous vein 1.2mm.

Heel pain is very prevalent. Pain, especially after a period of rest, is the main symptom. Reduced ability to walk long distances and inability to participate in exercise and sport are other complaints. Plantar heel pain is most commonly caused by plantar fasciitis. Whilst only the recalcitrant cases reach secondary care, this can still be a significant workload. In the Royal Surrey County Hospital, Guildford, we see approximately 200 cases of recalcitrant heel pain each year. The vast majority of cases never come to hospital and are managed in primary care (1500/yr in podiatry alone). Effective primary treatments should reduce the number of long-term sufferers.

Recalcitrant cases of plantar fasciitis often have atypical symptoms. Radiological imaging is extremely useful in clarifying the diagnosis. Ultrasound is our preferred modality. There is a spectrum of pathology that affects the plantar fascia, and this is less well classified than for the achilles tendon, where the distinction between insertional tendinopathy and tendinopathy of the main body of the tendon is helpful in guiding treatment.

The evidence for many forms of treatment for plantar fasciitis is weak. Currently, the use of formal calf stretching programs is widely considered to be the best first-line treatment. There are additional benefits with stretches to the fascia itself. The mechanism by which these stretches help is not well established. Calf contracture is, however, associated with a variety of clinical problems in the foot and ankle. This is especially true for isolated gastrocnemius contracture. There is also laboratory evidence that increased plantar fascia strain is seen with increased calf muscle tension. Surgery to release a gastrocnemius contracture improves biomechanics and has been used in refractory cases of heel pain with good effect.

Radial extracorporeal shock wave lithotripsy is the latest version of this non-invasive treatment. Results in our centre are encouraging. For selected cases of atypical plantar fasciopathy injection treatments are effective.

Background: Isolated Gastrocnemius contracture has been implicated as the cause of a number of foot and ankle conditions. Plantar Fasciitis (PF) is one such condition that can be secondary to altered foot biomechanics as a result of gastrocnemius contracture. We perform an isolated proximal medial head of gastrocnemius release (PMGR) as a day-case procedure. This is to report our results of this procedure in the treatment of recalcitrant PF.

Material and Methods: We prospectively followed a consecutive series of 22 heels in 18 patients following a PMGR. To be included, at least one year of conservative treatment must have been tried and isolated Gastrocnemius contracture confirmed clinically using Silfverskiold’s test pre-operatively. Outcome measures included the visual analogue pain score (VAS) and a 5-point Likert scale of postoperative success. Subjective and objective calf weakness was also evaluated. Final follow up was at an average of 25 months (range: 12 to 36 months) after the surgery.

Results: Two patients were lost to follow up. In the remaining 20 heels the average VAS for pain had improved from 9.4 to 1.8 (P< 0.001). Fourteen heels (70%) were pain free or significantly better at final follow up. There was no objective evidence of calf weakness and only one patient (5%) felt subjectively weaker on the released side. There were no ‘major’ complications and only 2 cases (10%) suffered a ‘minor’ complication. One was a case of superficial wound sepsis and the other was of prolonged calf pain following the surgery. Both resolved spontaneously and without further intervention.

Conclusions: A PMGR is a simple way of treating patients with PF who fail to respond to conservative management. The results, in our series, have been favorable and the morbidity low. We recommend the use of gastrocnemius release once non-operative management has failed.

Background: Neglected ruptures of the tendoachilles pose a difficult surgical problem. Intervening scar tissue has to be excised which cannot be repaired by end-to-end anastamosis. Several techniques for reconstruction of chronic ruptures have been described. The flexor hallucis longus (FHL) tendon transfer is considered advantageous over other tendon transfers. One disadvantage of FHL is it has limited excursion. There are no data to determine the optimal positioning of the FHL tendon to the calcaneum.

Materials and Methods: Two computer programmes (MSC.visualNastran Desktop 2002™ and Solid Edge® V19 were used to generate a human ankle joint model. This model is able to reproduce dorsi- and plantarflexion. Different attachment points of FHL tendon transfer to the calcaneum were investigated.

Results: The lowest muscle force to produce plantarflexion (single stance heel rise) was 1355N. Plantarflexion increased for a more anterior attachment point. The maximal plantarflexion was 33.4° for anterior attachment and 24.4° for posterior attachment. There was no significant difference in these figures when the attachment point was moved to either a medial or lateral position.

Clinical relevance: Optimal FHL tendon transfer positioning is a compromise between achieving plantarflexion for normal physiological function versus the force generating capacity and limited excursion of FHL. A more posterior attachment point is advantageous in terms of power. The range of motion is 10° less than when attachment is more anterior, the arc of motion (24.4°) is still physiological. We recommend that FHL is transferred to the calcaneum in a posterior position.

Introduction: Gastrocnemius contracture, as demonstrated by Silfverskiold’s test, is increasingly recognised as an underlying cause of painful disorders of the foot and ankle. Elevated pressure beneath the forefoot and symptoms in the hindfoot and ankle are produced as a result of the biomechanical imbalance. Adaptive shortening of the gastrocnemius can be treated by a supervised stretching program. Night splintage and serial casting are other useful non-operative treatments. Refractory cases may be considered for surgical release of the gastrocnemius.

Materials and Methods: The purpose of this study was to follow-up all those patients who were treated with a medial proximal gastrocnemius release with a minimum follow-up of six months.

Results: Eighty procedures were performed in sixty-five patients. There was one post operative infection. One patient has diminished sensation in the distribution of a branch of the saphenous nerve. There was an improvement in ankle dorsiflexion with the knee extended in all patients. Those patients with heel pain felt their symptoms had improved in the majority of cases.

Discussion: Release of the gastrocnemius aponeurosis at the gastrosoleus junction may be performed open or endoscopically. Both techniques place the sural nerve at risk of injury. Proximal release of the gastrocnemius is an alternative technique. Proponents of this method release both the medial and lateral heads through a single transverse skin incision over the popliteal fossa. It has been postulated that release of the medial head alone is sufficient to overcome the muscle contracture. Advantages of this approach include a smaller skin incision and a surgical field more distant from neurovascular structures.

Conclusion: The proximal medial gatrocnemius release is a safe, well tolerated, and effective procedure for those patients who fail an appropriate stretching program. In selected patients it can be preformed under local anaesthetic and light sedation.

Chronic infections and ulceration around the tendo Achillis are difficult to manage. Split-skin grafts do not survive even on healthy exposed tendon. Refractory cases may require plastic surgical intervention with the use of free flaps. Patients with significant vascular disease are not suitable for such techniques. Flexor hallucis longus tendon transfer is an established treatment for chronic ruptures of the tendo Achillis.

We report the successful treatment of an infected tendo Achillis with excision and reconstruction with flexor hallucis longus transfer. The muscle belly of this tendon allowed later skin grafting while the tendon transfer provided good functional recovery.

This study reviewed the subjective, clinical, and radiological outcome of 24 patients (31 feet) treated by basal metatarsal osteotomy with a modified McBride procedure for severe (intermetatarsal angle > 150) hallux valgus, carried out at our institution with an average follow-up time of 29 months.

At the time of follow-up, 40% of the patients were very satisfied, 45% were satisfied, and 15% were not satisfied. The mean Hallux – Metatarsophalangeal – Interphalangeal scale score raised significantly from 39 points (17 – 64) pre-operatively, to 82 (39 – 96) points at follow-up (p < 0.001). The Lesser - Metatarsophalangeal – Interphalangeal scale score raised significantly from 46 points (26 – 69) pre-operatively, to 84 (33 – 97) points at follow-up (p < 0.001). The radiological angles, including M1-M2, M1-P1, M1-M5, and DMAA improved significantly (p < 0.001). 12 of these cases had a M1-M2 angle post correction > 15°. Among the 9 complications recorded, 7 were minor and 2 required an additional procedure.

The basal metatarsal osteotomy coupled with a modified McBride procedure resulted in an overall high satisfaction rate, as well as significant clinical and radiological improvements in our series. Nevertheless, the range of motion of the first MTP joint remained low: 30 – 75° in 67% and < 30° in 6%. Furthermore, the failure to correct the M1-M2 angle to < 15° in 12 cases was probably due to the severe nature of the M1-M2 angle in these patients pre-operatively (21–33°).

Basal metatarsal osteotomy with a modified McBride procedure remains a safe procedure with excellent results, both subjectively and objectively, in patients with severe hallux valgus

Traditionally, immobilisation following achilles tendon rupture has been for 10 to 12 weeks.

We have previously published a series of 71 consecutive repairs with no re-ruptures, using a lateral surgical approach. The latter part of this cohort were immobilised for six weeks instead of 12, with early weight bearing. The lack of any re-ruptures encouraged us to pursue the accelerated rehabilitation.

This study documents a further 34 cases followed prospectively for 6–24 months (mean 15.9 months). All were repaired with a single Kessler-type suture using loop PDS, through a lateral approach. Patients were partial weight-bearing immediately in an Aircast boot with three cork heel wedges. At two-weekly intervals the wedges were reduced, and the boot abandoned after six weeks.

There have been no re-ruptures. Thirty of the 34 patients returned to pre-injury activity levels. All patients were satisfied or very satisfied with the immobilisation device and the accelerated rehabilitation regime. Cost savings were also made through use of a single removable orthosis rather than sequential casts.

We advocate this regimen of careful operative achilles tendon repair and accelerated weight bearing rehabilitation with a removable orthosis.

Traditionally, immobilisation following Achilles tendon rupture has been for 10 to 12 weeks.

We have previously published a series of 71 consecutive repairs with no re-ruptures, using a lateral surgical approach. The latter part of this cohort were immobilised for six weeks instead of 12, with early weight bearing. The lack of any re-ruptures encouraged us to persue the accelerated rehabilitation.

This study documents a further 34 cases followed prospectively for 6–24 months (mean 15.9 months). All were repaired with a single Kessler-type suture using loop PDS, through a lateral approach. Patients were partial weight-bearing immediately in an Aircast boot with three cork heel wedges. At two-weekly intervals the wedges were reduced, and the boot abandoned after six weeks.

There have been no re-ruptures. Thirty of the 34 patients returned to pre-injury activity levels. All patients were satisfied or very satisfied with the immobilisation device and the accelerated rehabilitation regime. Costs savings were also made through use of a single removable orthosis rather than sequential casts.

We advocate this regimen of careful operative achilles tendon repair and accelerated weight bearing rehabilitation with a removable orthosis.

Aims and methods

To compare the mechanical stability of an intramedullary (IM) screw with two crossed interfragmentary compression screws for fixation of the 1st MTPJ in ten pairs of cadaveric feet. One foot underwent fixation with two crossed 4.0-mm cannulated cancellous screws. The contralateral foot was fixed with an IM 1.6-mm Kirschner wire and an IM 6.5-mm partially threaded cancellous lag screw. A plantar-to-dorsal load was applied to the distal end of the proximal phalanx at a rate of 1 mm/sec. Failure was defined as gross actuator displacement of 5 mm. Stiffness was defined as the slope of the force versus deformation curve between 10 and 60 N. Strength was defined as the load at failure. The differences in stiffness and strength parameters between the two fixation techniques were checked for significance (P < 0.05) with a paired t-test.

Results

The intramedullary MTP joint fixation was significantly stiffer (18.7 ± 10.1 N/mm) than control group fixation (10.2 ± 6.1 N/mm). Similarly MTP joint fixation in the IM group was stronger (149.2 ± 88.2 N) than that of the control group (100.2 ± 70.8 N), but this was not significant (P = 0.07).

Conclusions

The IM technique resulted in a stronger stiffer fixation when compared with the standard crossed lag screw technique.

In 1996 the quality of the early management of 100 consecutive patients referred to a regional pelvic and acetabular unit between 1989 and 1992 was studied. The management of these patients was assessed in four specific areas, and guidelines were laid down. It was found that in 56% of patients the early management did not meet these suggested standards, with 34% having deficiencies in more than one area. These results were presented, published and circulated to referring hospitals.

Five years later, the early management of a further 100 consecutive referrals was assessed using these same guidelines. The treatment of 57% of patients still did not reach the guideline standards, but the number with problems in more than one area fell to 20%.

There has been some improvement in the early management of pelvic and acetabular injuries. The use of external fixators to control severe haemorrhage increased, but frames were often poorly applied. Wider access to CT scanners has reduced delays in definitive imaging.

Associated injuries are still regularly overlooked, and occasionally treatment of ipsilateral hip or femur fractures compromises pelvic surgery. Early communication with the specialist centre is encouraged but unfortunately delays in referral are still common.