Aim

Young patients with ankle arthritis that remains symptomatic in spite of conservative treatment and following arthroscopic debridement are usually offered either ankle fusion or ankle replacement. Both these options are far from ideal in this age group. The aim of this study was to evaluate functional outcomes following ankle distraction to determine whether it is a reliable alternative for the treatment of ankle arthritis in young adults.

Material and methods

Data was collected prospectively for 15 patients (9 males and 6 females, mean age 31.9 years) with “stage 2” ankle arthritis who failed conservative treatment and continued to be symptomatic following arthroscopic ankle debridement. Distraction of 8 mm was done using a dynamic constrained ankle circular frame and all patients were allowed full weight bearing all through the distraction process. The subjective functional evaluation was based on the American Orthopaedic Foot and Ankle Score (AOFAS), the Foot Disability Index (FADI) and the Visual Analogue Score (VAS). In 10 patients the Manchester Oxford Foot questionnaire (MOXFQ) and the Short Form (SF) 12 patient satisfaction questionnaire were also filled preoperatively and at final follow up.

Introduction

Post-traumatic arthritis is the commonest cause of arthritis of the ankle. Development of arthritis is dependent on the restoration of pre-injury anatomy. To assess the effect of grade of lead surgeon on the accuracy of surgical reduction, we performed a retrospective radiographic analysis of all ankle fractures undergoing open reduction and internal fixation, in a single institution.

Method

All patients treated by surgical intervention in an 11 month period (January to November 2011) were included, with the grade of lead surgeon performing the operation recorded.105 patients, 48 males and 53 females, were included with a mean age of 41 years (range: 17–89). Standard antero-posterior (AP) and mortise views were analysed for tibiofibular overlap, ankle clear space and talocrural angle and compared to standardised values from the literature. Lead surgeon grade was stratified as either, trauma consultant, senior registrar (years 4+) or junior registrar (years 1–3).

Introduction

Postoperative pain following the 3 component ankle arthroplasty (AA) (Mobility™) is a recognised problem without any apparent cause. This study aimed to determine pattern of postoperative pain following Total Ankle Arthroplasty (TAA) and its management options.

Materials and methods

In prospective observational study 167 patients who had (AA) and minimum follow-up of 24 months were included. FAOS ankle score, patients' satisfaction, SF36 and diagrammatic mapping of postoperative pain among other parameters were collected preoperatively and postoperatively at 3 months, 6 months and the annually. 20 Patients (12%) had moderate to severe postoperative ankle pain following the ankle arthroplasty.

Introduction

Longstanding complex muliplanar foot deformities represent a significant challenge. The traditional surgical techniques involve excessive dissection and excision of large bony wedges or modifications of the triple fusion to correct the deformity. The majority of the reports in the literature present collective data on different deformity patterns and also mix paediatric and adult patients, even with multiple correction techniques. The aim of this study was to evaluate the clinical, radiological and functional outcomes of the gradual correction of a single common deformity pattern of equino-cavo-varus using a single correction technique of the V-osteotomy and the Ilizarov frame.

Material and methods

We present prospectively collected data on 40 feet in 35 adult patients with stiff longstanding equino-cavo-varus deformity. All patients had a V-osteotomy and gradual correction using an Ilizarov frame, with a mean follow-up of 20 months. We collected the American Orthopaedic Foot and Ankle Scocity score (AOFAS), the Foot and Ankle Disability Index (FADI) and a Visual Analogue Pain score (VAS) for all ptients preoperatively and between 1 and 2 years following frame removal.

Aim

A prospective cohort of patients undergoing total ankle arthroplasrty for arthritis following pilon fractures was included in the present study. This group of patients generally have poor soft tissue envelope and have had previous surgical interventions prior to the ankle arthroplasty, making the arthroplasty more difficult as well as prone to complications.

Methods

The data collected included patient demographics, American Orthopaedic Foot and Ankle Score (AOFAS) and patient reported outcomes (FAOS, SF-36, patient satisfaction) The data was collected preoperatively and at 1 & 2 years postoperatively. The minimum follow-up period was 2 years post-operatively.

Background

Despite the suggestion by Virchow in 1856 that thrombosis was the result of venous stasis, endothelial dysfunction and hypercoagulability there are some fundamental questions which remain to be answered. The published studies fail to provide specific details such as cast type and anatomical location of the thrombosis, but instead focus on the incidence of VTE and which chemical thromboprophylaxis is most effective. Previous studies of VTE in trauma patients have involved small numbers of patients and have not look at the risk medium to long term risk. Most importantly they have not looked at the site of the VTE. This makes interpretation of the link between cast and VTE even more complex.

Methodology

We analysed 1479 consecutive trauma cast applications and the incidence of symptomatic VTE in the six months following the injury. The diagonosis, cast type and site of the VTE was recorded.

Background

The Weil osteotomy is successful in the management of metatarsalgia and toe deformity. The aim is to achieve controlled shortening whilst avoiding plantarflexion. Recognised complications of the Weil osteotomy include a ‘floating toe’ in up to 20% or more of cases.

Aim

Can modification of the Weil osteotomy avoid the metatarsal head plantarflexion and subsequent dorsal subluxation of the interosseous muscle that is implicated in the development of a ‘floating toe’.

Background

The conflict in Afghanistan has been epitomised by the emergence of the Improvised Explosive Device (IEDs). Improvements in protection and medical treatments have resulted in increasing numbers of casualties surviving with complex lower extremity injuries. To date, there has been no analysis of foot and ankle blast injuries as a result of IEDs. Therefore the aims of this study are to report the pattern of injury and determine which factors were associated with a poor clinical outcome.

Methods

Using a prospective trauma registry, UK Service Personnel who sustained lower leg injuries following an under-vehicle explosion between Jan 2006 and Dec 2008 were identified. Patient demographics, injury severity, the nature of lower limb injury and clinical management was recorded. Clinical endpoints were determined by (i)

need for amputation and

Introduction

Minimally invasive Achilles tendon repair has recently gained popularity amongst foot and ankle surgeons. This study aims to quantify the risk of sural nerve injury when using the Achillon device (Integra), as well as delineate its anatomical relationship to the Achilles tendon.

Methods

In 15 cadaveric specimens, the Achilles tendon was transected through a 2cm transverse incision made 4cm proximal to the palpable Achilles tendon insertion point. The Achillon device was inserted beneath the paratenon both proximally and distally and six needle passers mounted with sutures were introduced percutaneously into the tendon (x3 proximal and x3 distal). We dissected around the Achillon jig to determine whether the needle and suture had punctured the sural nerve. We also documented the position of the sural nerve in relation to the Achilles tendon.

Introduction

Total ankle replacement (TAR) surgery remains a reasonable alternative to arthrodesis in a select group of patients with end stage ankle joint arthritis. We describe the early results of a prospective study of the first 50 Zenith total ankle replacements performed by a single surgeon (SKG).

Methods

Demographic details, Visual Analogue Score (VAS) for pain (0, no pain; 10, worst possible pain), AOFAS scores, ‘would have surgery again’ and satisfaction levels were collated, pre-operatively and at their most recent outpatient review. Any post-operative complications were noted. Radiographs were also assessed for evidence of loosening, progressive osteolysis, subsidence and overall alignment of the implant.

Introduction

The Mobility™ prosthesis [Depuy] is the most extensively used TAR in the UK, though there are few published results. We present our complete experience of the Mobility prosthesis in a diverse population.

Methods

From March 2005 to December 2009, 84 consecutive Mobility ankle replacements were performed by the senior author, in 79 patients (28 female, 51 male) with mean age 64.5 years (43–80). This complete cohort included the first and last cases with this implant. Mean follow-up was 50.1±18.2 months (range 14–86).

Patients with ankle replacements in situ, were reviewed clinically and radiologically. Clinical outcome measures were: AOFAS score, MOXFQ (adapted for the ankle), and VAS for pain. Post-operative radiographs were reviewed to assess component position and examine for zones of lucency.

Introduction

Osteoarthritis commonly affects the first metatarsophalangeal joint. Stress across this joint has been postulated to increase the incidence of osteoarthritis. Certain foot structures have been associated with a higher incidence of osteoarthritis of the big toe. Utilizing finite elemental analysis, bone stress across the first metatarsophalangeal joint was calculated during mid stance phase of gait and compared in different foot structures.

Method

A geometrically accurate three dimensional model of the first metatarsophalangeal joint was created utilising a high resolution 7 tesla MRI and Mimics v14 imaging software. Planus, rectus and cavus feet were simulated by varying the metatarsophalangeal declination angle to 10.1, 20.2 and 30.7 degrees, respectively. A non-manfold computer aided design technique in Mimics v14.2 and finite element method in ANSYS v12 FE were utilised to create the boundary conditions, representing the double support stance phase of gait. Using information from 61 asymptomatic patients with different foot types walking over a Novel emed-x plantar pressure measuring system, plantar loading conditions were applied. Finite elemental analysis was used to predict stress in the first metatarsophalangeal joint in the different foot types.

Introduction

Operative fixation of ankle fractures is often deferred due to swelling to avoid the risk of wound problems. The routine practice is to admit the patient and operate once the swelling has subsided. We introduced a new pathway to manage these ankle fractures at home preoperatively to improve service efficiency. We studied the impact of home therapy on length of inpatient stay and associated problems.

Methods

A control group was studied from December 2009 to March 2010, where patients were treated normally. The home therapy ankle pathway was then introduced in August 2010. Patients presenting with excess ankle swelling were placed in a back slab following reduction of ankle to a satisfactory position. The patients were provided limb care advice, thromboprophylaxis, an emergency contact number and discharged home on crutches with a predetermined operative slot, usually 6 days following injury. Patients were also contacted by a member of staff to ensure they were coping with the injured limb at home. Patients who are unsafe to be discharged on home therapy were admitted. This cohort of patients was studied between August 2010 and December 2011.

Introduction

Up to 70% of patients with symptomatic Morton's neuroma proceed to surgery having failed non-operative management. The success of surgical excision is up to 85% but carries with it significant morbidity. Radiofrequency ablation (RFA) is a less invasive alternative.

Methods

We studied a consecutive cohort of patients with Morton's neuroma that had failed non-operative treatment. Instead of undergoing surgical excision, these patients were referred for RFA. Under a local anaesthetic nerve block, RFA was performed under ultrasound-guidance, as an out-patient procedure, by a single radiologist. The procedure was repeated after 4 weeks if necessary. We followed patients for a minimum of 6 months to assess their change in visual analogue pain scores (VAS), overall symptom improvement, complications and progression to surgical excision.

Introduction

The aim of this study is to better understand the anatomy of the forefoot to minimise surgical complications following minimally invasive forefoot surgery.

Methods

The study examines the plantar anatomy of the lesser toes in ten cadaver feet. The tendons, nerves and bony anatomy are recorded.

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.

Methods

Between July 2005 and March 2011, 78 patients had NCS to investigate foot pain. The management following NCS was compared with the initial management plan.

Background

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

Design

Prospective Cohort Study. Postal evaluation survey of patients who had provided pre-operative PROMs data.

Introduction

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints.

Methods

Fresh frozen cadaveric specimens without evidence of forefoot deformity were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in positions ranging from 10 degrees of dorsiflexion to 60 degrees of plantarflexion using a MicroScribe, enabling quantitative analyses in a virtual 3D environment.

Introduction

Surgeons, commissioners and patients are increasingly seeking more in depth details on outcomes of total ankle replacement (TAR). We set out to perform a detailed and up to date meta-analysis of the outcomes of TAR, with a focus on PROMS.

Methods

We searched MEDLINE, Cochrane, EMBASE, CINAHL and the Science Citation Index databases using the terms “total”; “ankle”; “arthroplasty” or “replacement” to April 2012. We included all languages; series with greater than 20 TAR; minimum 2 years follow-up. We excluded papers on revisions; prostheses no longer marketed; and kin studies. We worked with the Cochrane Collaboration to adopt their methodology including the creation of a risk profile assessing all forms of bias.

Introduction

We present a consecutive series of 19 patients with 22 intra-articular calcaneal fractures treated by percutaneous arthroscopic fixation (percutaneous arthroscopic calcaneal osteosynthesis “PACO”). Traditional open reduction and fixation regularly has significant wound complications. PACO has the advantage of direct visualization of the joint surface reduction with the benefit of minimal soft tissue trauma and wound complications.

Methods

Between July 2010 & April 2012, 39 isolated closed intra-articular calcaneal fractures were admitted to St Mary's Hospital. All Sanders type 2 and type 3 fractures were included. Undisplaced fractures (13) were treated non-operatively and comminuted type 4 fractures (4) were treated with primary arthroscopic fusion. Surgery was performed on the next list with no delay for swelling. All patients had pre and post op CT scans. Patients were discharged in a temporary cast with routine follow up at 2, 6 and 12 weeks.

Introduction

Whilst most cases of plantar fasciitis can be resolved with existing conservative established treatment options, a few intractable cases can be difficult to resolve. New biologic treatments have been proposed for a variety of soft tissue tendon problems. We evaluated the results of PRP in the treatment of recalcitrant chronic cases of plantar fasciitis.

Methods

Patients with plantar fasciitis that had not responded to a minimum of 8 months standard conservative management (eccentric stretching, physiotherapy, cortisone injection, night splints) were offered PRP therapy. The injection into the tender spot at the proximal plantar fascial insertion was performed in theatre as a day case. Roles Maudsley (RM) scores, Visual analogue scores (VAS) for pain, AOFAS scores and ‘would have injection again’ were collated pre-operatively, at three and six months.

Introduction

Fifth metatarsal fracture is a common injury. Current practice supports conservative management, with surgery in the event of non-union. Early fracture clinic review is not perceived to improve patient experience or increased detection of non-union. A new protocol standardises treatment to symptom level and discharges patients from ED with advice but without any routine follow-up arranged. A leaflet advises on management, prognosis and helpline details and there is an open-access policy for those whose symptoms persist to investigate potential non-union.

Method

A prospective audit evaluated the protocol, surveying patients at 8-weeks and 6-months post-injury. A minor injuries unit continued to refer to fracture clinic and was the control group. During 6-months 46 acute fractures were recorded in the new protocol(group 1) and 47 in the control(group 2). 1 patient in each group was known to experience non-union. 31 of group 1 and 22 of group 2 responded to at least one survey.

Introduction

Ankle replacement is now common in the UK.

In a tertiary referral NHS practice, between 1997–2011 we implanted two types of cementless mobile bearing total ankle replacements (TAR).

Methods

We reviewed our operative database and electronic patient records and confirmed the number of prosthesis with our theatre records. All case notes and radiographs were reviewed. Failure was taken as revision, and patients were censored due to death or loss to follow-up. The survivorship was calculated using a life table (the Kaplan-Meier method), with 95% confidence intervals.

Introduction

Periprosthetic cyst formation following ankle replacement, requiring revision surgery, has previously been reported. The exact pathogenesis of cyst formation is unclear but considered to be due to a combination of biological and mechanical factors. Our objective was to review the incidence of periprosthetic cyst formation following Mobility ankle replacement and their outcome.

Patients and methods

We reviewed all the Mobility ankle replacements performed by the senior author from Oct 2005 till May 2012. Serial radiographs were reviewed to identify the presence of cystic lesions in the tibia or the talus.

Introduction

Venous thromboembolism (VTE) represents a major cause of morbidity, mortality and financial burden to the NHS. Acquired risk factors are well documented, including immobilisation, lower limb plaster cast and surgery. NICE guidance on VTE prophylaxis within orthopaedics currently excludes operative ankle fracture fixation (ankle ORIF).

Aims

Ascertain the local incidence of VTE; compare our local VTE rates with published data from other institutions; review guidelines, scientific literature and other hospitals policies; formulate a local policy for VTE prophylaxis.

Introduction

Hallux valgus surgical correction has a variable but significant risk of recurrence. Symptoms result from an iatrogenic first brachymetatarsia following the index surgical procedure. First metatarsal shortening has been shown to correlate with the onset of transfer metatarsalgia. We describe the use of the scarf osteotomy to both correct the recurrent deformity and lengthen the shortened first metatarsal.

Methods

36 lengthening scarf osteotomies were undertaken in 31 patients. Clinical (AOFAS and SF12 scores) and radiographic measures (IMA, HVA) were taken pre- and post-operatively. The maximum theoretical lengthening was 10mm, to prevent first MTP joint stiffness post-operatively. The actual lengthening was determined and measured intra-operatively.

Introduction

With increasing numbers of primary total ankle replacements being performed, the number of revision ankle surgeries is expected to rise also. We present the results of the revision procedures for failed Scandinavian total ankle replacements.

Patients and methods

We retrospectively reviewed all the Scandinavian TAR done by the senior author from March 1999 till Jan 2006. Patients who underwent revision surgery were identified and their data was collected including indications for revision surgery, procedure performed, symptoms and the overall outcome.

Introduction

There are a number of options available for surgical management of hallux rigidus. Ceramic implants of the first metatarsophalangeal joint (MTPJ) have been available for years; however there are no published long-term results existing.

Methods

We performed a retrospective review of all consecutive first MTPJ replacements carried out for later stage hallux rigidus using second generation MOJE ceramic implant with press-fit design. Two specialised foot and ankle surgeons performed these operations at a tertiary referral centre. Patient underwent regular follow ups including clinical review, functional scoring (AOFAS and FFI) and assessment of radiographs. Kaplan Meyer Survival analysis was performed.

Introduction

Hallux Rigidus affects 2–10% of population, usually treated with cheilectomy or arthrodesis, however, for the subclass of patients who refuse to undergo fusion, Arthroplasty is an alternative solution, it maintain some degree of motion and provide pain relief. Toefit; is one of the prostheses being used. It is a total joint replacement with polyethylene insert.

The aim of this study is to find clinical and radiological outcomes of Toefit arthroplasty.

Method

A prospective study. Ethical committee approval was obtained. Patient who have received Toefit Arthroplasty with at least 12 months follow-up and were willing to participate in the study were included. Patients were reviewed by independent surgeon. Questionnaires were completed followed by clinical examination. This followed by radiographic assessment. Patients, who were willing to take part in the study but could not attend a clinical review, were invited to participate in telephone questionnaire. Pre and postoperative AOFAS scores were compared, patients' satisfaction and clinical and radiological outcome were assessed using descriptive statistics, t-test and survivalship analysis were done.

Background

Lisfranc/midfoot injuries are complex injuries with a reported incidence of 1 in 55000 in literature and frequently overlooked. But, recently they are becoming more commonly diagnosed with advent of CT scan and examination under anaesthesias (EUA) for suspicion fractures. Here we present a case series results of a single surgeons experience over the last 6 years.

Methods

Retrospective review of 68 patients treated by a single surgeon over the last 6 years. Injuries were diagnosed on plain Xrays, clinic examination. Any suspicious injury were further assessed by a CT scan, all injuries were confirmed by EUA and treated with open reduction and internal fixation within 4 weeks of injury. Post-operative immobilisation in full cast for 6 weeks then a removal boot with non-weight bearing for a total of 3months. They were followed up regularly initially at 3, 6 and 12months. At final review the following data was collected: clinical examination, plain x-ray looking for: late deformity, signs of OA in Lisfranc joint, Auto fusion rate, rate of metal work failure. The x-rays findings were correlated with: (1) type of fixation. (2) The following scores: FAOS, AOFAS-M, specially designed new foot and ankle score.

Introduction

Excision of prominent metatarsal heads for severe rheumatoid forefoot deformity is well established in clinical practice but results may deteriorate with time. The Stainsby forefoot arthroplasty however, recognises the pathological anatomy of the deformity and is designed to preserve the metatarsal heads by repositioning the plantar plates and forefoot fat pad underneath them.

Design

A prospective case series observing the clinical outcomes and changes in pedobarograph patterns in rheumatoid arthritis patients with severe deformity undergoing Stainsby forefoot arthroplasty.

Introduction

Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, a review of literature suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomittant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes.

Methods

Thirteen consecutively treated patients (eighteen feet) were retrospectively reviewed from the senior author's practice. Clinical examination, American Orthopaedic foot and Ankle Society (AOFAS) hindfoot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction.

Aim

We aimed to study the effect of BMI on clinical and patient-reported outcomes in patients with TAR with a minimum follow-up of three years.

Method

Patients who underwent a TAR between March 2006 and May 2009 were invited to take part in the hospital patient registry. Patients were divided into two groups based on BMI (Group A – BMI <30 and Group B – BMI >30). Patient demographics, co-morbidities, clinical (AOFAS), patient reported outcomes (FAOS, SF-36, patient satisfaction) and complications were collected pre-operatively and at 1, 2 and 3 years and comparison made between groups.

Introduction

Stress fractures in the foot are common; the common practice is to look for any factor in the history or for any foot deformity that could cause the fracture. Once found, it is common to treat the fractures without further investigations. The aim of this study is to assess if we are missing any underlying metabolic disorder associated with such injury.

Materials and methods

We studied 34 sequential cases referred for chronic foot pain. Stress fractures were confirmed either by classic x-ray's features or MRI. Clinical examination and further tests were performed for Vitamin D levels, Thyroid function, PTH, DEXA scan, Biochemical and bone profile. All stress fractures were treated conservatively.

Introduction

Mesenchymal stem cells (MSCs) are a potential source of cells for the repair of articular cartilage and osteochondral defects (OCD) in the ankle. Synovial tissue has been shown to be a rich source of MSCs with the ability to undergo chondrogenic differentiation. Although these cells represent a heterogenous population, clonal populations have not been previously studied.

Methods

MSCs were isolated from synovial tissue of a patient undergoing joint arthroplasty and expanded in culture. Six clonal populations were also isolated and expanded. The cells from the mixed parent population and the derived clonal populations were characterised for stem cell surface epitopes, and then cultured in chondrogenic mediums. Various assays were determined to analyse for features of differentiation.

Introduction

Bone Marrow Oedema Syndrome (BMOS) is an unusual and poorly understood condition. It commonly affects the hips and knees and is reported to have a tendency to recur. The foot and ankle are less frequently involved but nevertheless patients can be severely impaired. Only case reports of BMOS of the foot and ankle have been published.

The aim of this study is to evaluate the sites of occurrence, risk factors, efficacy of immobilisation, response to intravenous biphosphonates and local or remote recurrence over the following years.

Methods

A retrospective review of 25 adult patients who have been diagnosed with BMOS have been followed-up for an average of 5.8 years (range: 2–11). Six patients have not been traced.