The Cobb Stainsby forefoot arthroplasty for claw and hammer toes combines excision arthroplasty (Stainsby) with extensor tendon transfer to the metatarsal head (Cobb). We present a retrospective, three surgeon case series of 218 toes in 128 patients over four years. Clinical notes were reviewed for all patients and 77 could be contacted for a telephone survey. Follow up ranged from 12–82 months.

All patients presented with pain and shoe wear problems from dislocated metatarsophalangeal joints either from arthritis, hallux valgus, Freiberg's disease or neurological disorders. Ipsilateral foot procedures were performed simultaneously in 24 (30%) patients. Seventy-two patients (94%) were satisfied, 72 (94%) reported pain relief, 55 (71%) were happy with toe control, 61 (79%) were pleased with cosmesis, 59 (77%) returned to normal footwear and 56 (73%) reported unlimited daily activities. Minor complications occurred in 17 (13%) and 3 (2%) developed complex regional pain syndrome. Four (5%) developed recurrent clawing.

The Stainsby procedure permits relocation of the plantar plate under the metatarsal head for cushioned weight-bearing but can create a floppy, unsightly toe. By combining this with the Cobb procedure, our case series demonstrates improved outcomes from either procedure alone with benefits over alternatives such as the Weil's osteotomy.

Oxford Level 4 evidence – retrospective case series.

Lisfranc fracture dislocations of the midfoot are uncommon but serious injuries, associated with posttraumatic arthrosis, progressive deformity, and persistent pain. Management of the acute injury aims to restore anatomic tarsometatarsal alignment in order to minimise these complications. Reduction and stabilisation can be performed using image-guided percutaneous reduction and screw stabilisation (aiming to minimise the risk of wound infection) or through open plating techniques (in order to visualise anatomic reduction, and to avoid chondral damage from transarticular screws). This retrospective study compares percutaneous and open treatment in terms of radiographic reduction and incidence of early complications.

Case records and postoperative radiographs of all patients undergoing reduction and stabilisation of unstable tarsometatarsal joint injuries between 2011 and 2014 in our institution were reviewed. Dorsoplantar, oblique and lateral radiographs were assessed for accuracy of reduction, with malreduction being defined as greater than 2mm tarsometatarsal malalignment in any view. The primary outcome measure was postoperative radiographic alignment. Secondary outcome measures included the incidence of infection and other intra- or early postoperative complications.

During the study period, 32 unstable midfoot injuries were treated, of which 19 underwent percutaneous reduction and screw stabilisation and 13 underwent open reduction and internal fixation. Of the percutaneous group, no wound infections were reported, and there were four (21.1%) malreduced injuries. Of the open group, two infections (15.4%) were observed, and no cases of malreduction.

In conclusion, our study shows a strong trend towards increased risk of malreduction when percutaneous techniques are used to treat midfoot injuries, and an increased risk of infection when open surgery is used. Whilst conclusions are limited by the retrospective data collection, this study demonstrates the relative risks to consider when selecting a surgical approach.

The International Commission on Radiological Protection has established standards for radiation protection. This study aims to determine actual and perceived radiation dose and audit safe practice when using image-intensifiers in theatre.

Between September 2012 and March 2013, 50 surgeons were surveyed during 39 procedures. Information collected by radiographers included the number of images the surgeons thought they used, actual number used, dose, screening time, number of people scrubbed, wearing thyroid collars and standing within 1m of the image-intensifier when in use.

The primary surgeon was more likely to estimate the number of images used correctly compared to the assistant. Supervising consultants were most accurate, followed by registrars as primary surgeons, consultants as primary surgeons then assisting registrars, and lastly SHOs. Most surgeons underestimated the number of images used. 87.5% of scrubbed staff were standing within 1m of the image-intensifier during screening and 36.5% were wearing thyroid protection. Three surgeons stated they were not wearing collars as they were unavailable.

We conclude that surgeons have a reasonable estimation of the x-rays used but are not undertaking simple steps to protect themselves from radiation. We plan to initiate an education program within the department and have ordered new, lightweight thyroid collars.

Recent reports observe that orthopaedic surgeons lack essential knowledge about ionising radiation. We aim to demonstrate perceived use of image-intensifiers by surgeons and awareness of radiation doses used during fractured neck of femur surgery.

Surgeons at a regional trauma centre were sent an online questionnaire. They were shown two neck of femur fracture radiographs and asked the total number of images they would use to reduce and fix the fracture with a dynamic-hip-screw / inter-medullary nail respectively. They were asked the maximum safe radiation dose, and that of ‘hip pining’ compared to CXR as outlined by the Ionising Radiation Regulations 1999.

For a DHS, consultants and registrars estimate their image use similarly. For IM nailing, consultants estimated higher image use than registrars, and double the number of X-rays taken for IM nailing compared to DHS. Knowledge levels regarding radiation doses during orthopaedic hip procedures are very low.

There is an expectation that more images will be used in IM nailing procedures. We plan to educate orthopaedic surgeons about radiation dose and safety. Correlating our findings with actual use of image in theatre when performing hip fracture surgery would extend the use of this study.

Background

During cephalomedullary nail stabilisation of subtrochanteric femoral fractures, damage to the distal anterior femoral cortex by the nail is a recognised cause of periprosthetic fracture. Currently available cephalomedullary devices vary widely in anteroposterior curvature, though all are less curved than the mean anatomic human femur. This study tests the hypothesis that a cephalomedullary device with greater anteroposterior curvature will achieve a more favourable position in the distal femur, with greater distance of the nail tip from the anterior cortex, and therefore lower risk of cortical damage.

Introduction

Shoes with a rocker sole are commonly prescribed following forefoot surgery to redistribute pressure towards the heel. By shifting the body weight backwards, does the rocker shoe adversely effect balance and so disturb normal muscle activity? This study investigated the effects of the Darco post-operative shoe, and the impact of a contralateral shoe raise, on forefoot pressure, posture and balance.

We present the clinical and radiological outcome of a prospective series of 22 Buechel-Pappas Total Ankle Replacements (TAR) implanted in 19 patients with a mean follow-up of 9 years (range 6 to 13). The only published long term results of this prosthesis in the literature are from the originators' unit.

Patients have been prospectively reviewed yearly since 1991. None was lost to follow-up. The primary diagnosis was rheumatoid arthritis in 11 and osteoarthritis in 8 patients. 12 patients were female. Mean patient age was 64 (range 39 to 81). At the time of review 4 patients (6 ankles) had died between 12 and 69 months post-operatively of unrelated causes with their prostheses in situ. One patient had a below knee amputation for chronic venous ulceration 11 years after a TAR which until that point had continued to function well. One patient with severe rheumatoid arthritis had the implant removed at 8 weeks for deep infection. Another patient with rheumatoid arthritis had the TAR revised to a tibio-talar-calcaneal fusion 59 months post-operatively for talar avascular necrosis. One patient has pain from impingement and another patient with rheumatoid arthritis has intermittent pain at 8 years following her TAR. Every other implant continues to function well. The New Jersey LCS ankle assessment scores increased from a mean of 35 pre-operatively to 82 post-operatively. The increases were largely due to pain relief and improved function with the pre-operative range of motion being preserved. These scores have been maintained in the long term. No surviving implant is radiologically loose.

Our results suggest that the Buechel-Pappas TAR offers good clinical and radiological long-term results to patients with often disabling ankle arthritis

Summary: A large number of review appointments in elective clinics are to discuss results. In well-informed patients, investigations and treatment plans can be discussed by telephone, avoiding the need for a face-to-face consultation. This saves resources, assists in achieving treatment pathway targets, and is financially viable and acceptable to patients.

Background: An audit of the Plymouth foot & ankle service highlighted a long patient wait to discuss the outcome of investigations and plan treatment. Not only is this unacceptable for patients, it adversely affects the flow of the RTT pathways.

Derriford Hospital has a wide catchment area and the foot & ankle service has a military catchment area from Cornwall to Buckinghamshire.

Method: During the initial outpatient consultation, if the clinician feels that the patient is suitable, an arrangement is made to discuss the results of investigations and subsequent treatment plan by telephone. The treatment options are re-iterated in a summary letter of the consultation to the patient.

Conclusion: The preliminary 3 month results are presented and as a concept the clinic has been successful, being acceptable to all patients involved and reducing the requirement to provide additional clinics.

Introduction We report the experience of a district general hospital foot and ankle service, in performing a modified excision arthroplasty and tendon transfer to the metatarsophalangeal (MTP) joints of the lesser toes in both rheumatoid and non-rheumatoid patients. The procedure was carried out on 114 toes, in 58 feet of 55 patients over a 5-year period.

Background Historically, partial proximal phalangectomy was complicated by recurrence of the extension deformity. Stainsby (1990) described a technique of 7/8ths phalangectomy, repositioning of the plantar plate, extensor to flexor attachment and K-wire stabilisation to treat dislocated MTP joints of the lesser toes. However, it is recognised that the use of K-wires can be complicated by infection or premature removal. Angel reported the re-routing of the extensor tendon through a drill hole in the metatarsal head for MTP joint instability; this technique was attributed to Nigel Cobb. We have utilised the Stainsby technique and combined it with a Cobb tendon transfer to impart immediate stability to the toe, allowing K-wire fixation to be discarded.

Technique Following a percutaneous proximal extensor tenotomy, a radical partial proximal phalangectomy (via a dorsal incision) reduces a dislocated MTP joint and the plantar plate is repositioned beneath a mobilised metatarsal head. A drill hole is then placed in the metatarsal head and the extensor tendon is re-routed from a plantar to dorsal direction. This maintains the reduction of the toe and provides interposition between the cut end of the proximal phalanx and the metatarsal head.

Conclusion We believe that this modified combined technique is a reproducible alternative to the Stainsby procedure but, in addition, provides immediate stability of the MTP joint without the need for K-wire fixation.

Many techniques exist for reduction of anterior dislocation of the shoulder. The two commonest methods are the Hippocratic and Kocher. Iatrogenic complications have been linked to both techniques; though reports of brachial plexus traction-injury from the Hippocratic method are rare compared to the more common complication of surgical neck of humerus fracture secondary to the Kocher technique.

Method Questionnaires were sent to 125 Orthopaedic and 125 A& E departments in the UK, asking staff to independently comment on their preferential reduction technique in anterior dislocation of the shoulder.

Results Overall 62% performed the Kocher method and 29% performed a Hippocratic reduction. However, 64% of Orthopaedic consultants performed a Hippocratic reduction (34% performing Kocher) compared to only 14% of A& E consultants, (70% of whom performed a Kocher reduction).

Conclusion The significant risk of humeral neck fracture in performing a Kocher reduction, especially in an inadequately anaesthetised patient in the A& E setting, and the overwhelming preference of Orthopaedic consultants to perform a Hippocratic reduction, indicate that the Kocher method should not be employed.

Introduction The Buechel-Pappas Total Ankle Replacement (BP TAR) has been used in Cornwall since 1991. The early results were presented to the Foot Society in 1997. The only published long term results of this pros-thesis are from the designer’s unit.

Method We present the clinical and radiological outcome of a prospective series of 22 BP TARs implanted in 19 patients with a mean follow-up of 9 years (range 6–13). The primary diagnosis was rheumatoid arthritis (RA) in 11 and osteoarthritis in eight patients. Twelve patients were female. Mean patient age was 64 years (range 39–81). Patients were reviewed at yearly intervals. None were lost to follow-up.

Results At the time of review, four patients (six ankles) had died between 12 and 69 months post-operatively of unrelated causes with their prostheses in situ. One patient had a below knee amputation for chronic venous ulceration, 11 years after a BP TAR which was functioning well. One patient with severe RA had the implant removed at 8 weeks for deep infection. A second patient with RA had the TAR revised to a tibiotalocalcaneal fusion 59 months post-operatively for talar avascular necrosis. One patient has pain from impingement and another patient with RA has intermittent pain at 8 years following TAR. Every other implant remains asymptomatic. The New Jersey LCS ankle assessment scores increased from a mean of 35 pre-operatively to 82 post-operatively. The increases were largely due to pain relief and improved function with the pre-operative range of motion being preserved. These scores have been maintained in the long term. No surviving implant is radiologically loose.

Conclusion Our results suggest that the BP TAR offers good clinical and radiological long-term results to patients with often disabling ankle arthritis.

We wish to report a technique for the reconstruction of the late presenting Achilles tendon rupture.

A proximal intra muscular Z lengthening through a separate incision facilitates distal translation of the proximal tendon stump, allowing direct repair distally with minimum tension. Post operatively, a below knee cast is applied for six weeks, with progressive dorsiflexion at two weekly intervals. A dorsiflexion restriction splint accompanies early physiotherapy for a further six weeks, with unprotected weight bearing commencing at three months.

There were eleven patients in the study group with an average follow up of 24 months. All tendons united. There were no re-ruptures. Two distal wound breakdowns occurred and one of these healed by secondary intention. Good single stance power returned in patients with smaller separations but greater calf wasting and weakness was observed in those patients with large separations.

We conclude that this technique can be employed for the reconstruction of late presenting Achilles tendon ruptures, but great care is required with soft tissue dissection distally. Consideration could be given to deep flexor transfers in the widely separated case.

We wish to report a technique for the reconstruction of the late presenting Tendo Achilles rupture.

A proximal intra muscular Z lengthening through a separate incision facilitates distal translation of the proximal tendon stump, allowing direct repair distally with minimum tension.

Post operatively, a below knee cast is applied for six weeks, with progressive dorsiflexion at two weekly intervals.

A dorsiflexion restriction splint accompanies early physiotherapy for a further six weeks, with unprotected weight bearing commencing at three months.

There were eleven patients in the study group with an average follow up of 24 months. All tendons united. There were no re-ruptures. Two distal wound breakdowns occurred and one of these healed by secondary intention.

Good single stance power returned in patients with smaller separations but greater calf wasting and weakness was observed in those patients with large separations.

We conclude that this technique can be employed for the reconstruction of late presenting Achilles tendon ruptures, but great care is required with soft tissue dissection distally.

The operative and non-operative treatment options for acute tendo achilles rupture are well documented in the literature. The management of late presenting tendon rupture is usually operative, and can be complicated by acute shortening of the muscle-tendon unit and leave repairs under tension, which may lead to re-rupture. We report the use of the sliding graft technique for reconstruction of late presenting rupture.

A proximal intra muscular Z lengthening through a separate incision facilitates distal translation of the proximal tendon stump, allowing direct repair distally with minimum tension.

Post operatively a below knee cast is applied for six weeks with progressive dorsiflexion at two weekly intervals.

A dorsiflexion restriction splint accompanies early physiotherapy for a further six weeks with unprotected weight bearing commencing at three months.

There were eleven patients in the study group with an average follow up of 13 months. All tendons united. There were no re-ruptures. Two distal wound breakdowns occurred and one of these healed by secondary intention.

Good single stance power returned in patients with smaller separations but greater calf wasting and weakness was observed in those patients with large separations.

We conclude that this technique can be employed for the reconstruction of late presenting tendo achilles ruptures but great care is required with soft tissue dissection distally.

Consideration could be given to deep flexor transfers in the widely separated case.

The interaction of a blast wave with the thorax produces primary pulmonary blast injury by releasing energy at biological interfaces of differing acoustic impedance. This process is known as coupling. It was hypothesised that protective armour designed on the basis of an acoustic decoupler, may modulate the effect of thoracic blast.

Anaesthetised, spontaneously breathing male pigs (n=18) were allocated into two equal groups and exposed to whole body blast in free field conditions. All animals were provided with Kevlar® protection, but in addition animals in group 2 were provided with protective thoracic armour. Blood gas analysis was performed prior to and up to 1 h post-blast. The animals were killed at 1 h post-blast and a post-mortem carried out. Severity of lung injury, called the quotient of injury (QI) was calculated by comparing masses of injured lung with standardised uninjured lung masses.

All procedures complied with the Animals (Scientific Procedures) Act 1986.

In group 1, PaO2 was reduced from a pre-blast mean of 9.7 kPa to a post-blast mean of 6.6 kPa, whereas in group 2 PaO2 fell from a pre-blast mean of 10.5 kPa to a post-blast mean of 8.3 kPa. The difference between the groups was statistically significant (p< 0.05). The mean QI in group 1 was 1.7 compared to a group 2 mean of 1.12, indicating severe injury in the unprotected animals (p< 0.01).

Decoupling protective thoracic armour ameliorated the effects of thoracic blast in this animal model. This will lead to the development of personal protective thoracic armour for frontline servicemen.