Introduction

Traditional treatment of idiopathic flatfoot in the adult population include calcaneal neck lengthening or fusions. These surgical methods result in abnormal function with significant complication rates. Our prospective study aimed to quantify the functional and radiological outcome of a new technique for spring ligament reconstruction using a hamstring graft, calcaneal osteotomy and medial head of gastrocnemius recession if appropriate.

Methods

22 feet were identified from the senior authors flatfoot reconstructions over a 3 year period (Jan 2013 to Dec 2015). 9 feet underwent a spring ligament reconstruction. The control group were 13 feet treated with standard tibialis posterior reconstruction surgery. Follow up ranged from 8 to 49 months. Functional assessment comprised VAS heath and pain scales, EQ-5D and MOXFQ scores. Radiographic analysis was performed for standardised parameters.

Introduction

Injections are used to treat a wide variety of pathologies. Our aim was to evaluate the efficacy and safety of foot and ankle injections in our clinic.

Materials and methods

We performed a retrospective review of notes and a telephone questionnaire audit into the clinical outcome of all patients who underwent an injection of the foot or ankle in a year. All procedures were performed in an out-patient setting by a consultant musculoskeletal radiologist using either ultrasound or X-ray guidance, with a minimum of two year follow-up. According to the pathology treated, the type of injection included depomedrone, hyaluronic acid and high volume saline injections.

Results

Patients were followed for an average of three years following the procedure (range 1 – 7 years). Patients rated their pain on a visual analogue pain scale as an average of 8 (range 6–9) prior to surgery and an average of 2 postoperatively (range 0–4). The AOFAS scores improved from a mean of 29 (range 25 – 35) preoperatively to a mean of 79 (range 75–88) postoperatively. Hindfoot range of motion remained and the extent of arthritis of the navicular complex was unchanged. No patient has since required an arthrodesis.

Since the majority of MWD patients respond to an orthotic support which changes the load of the hindfoot and forefoot, we believed that patients would respond positively to a calcaneal osteotomy as an alternative treatment.

Background

Cheilectomy and arthrodesis are accepted procedures for symptomatic hallux rigidus. Although good functional outcomes have been reported, there is little data available on post-operative sporting ability for these patients.

Aims

We investigated sporting ability and functional outcomes of two cohorts of patients, the first underwent dorsal cheilectomy and the second arthrodesis.

Aim

To examine the mid-term survival, clinical and patient reported outcomes of the silastic 1^st metatarsophalangeal joint replacement for the treatment of end stage hallux rigidus.

Methods

We reviewed 83 consecutive silastic arthroplasties performed in 79 patients for end stage hallux rigidus. There were 3 men and 76 women; mean age 63 years (range 45–78 years). No patient was lost to follow up. Average follow-up was 5.3 years (1.1–11.3 years). The EQ 5D–5L Health index, Manchester-Oxford Foot Questionnaire (MOXFQ), visual analogue scale (VAS) of pain and overall satisfaction rate (Likert scale) were collected for patient reported outcomes.

Aim

We describe a case series using adjuvant calcium sulphate bio composites with antibiotics in treating infected metalwork in the foot and ankle.

Method

11 patients aged 22–81 (9 males, 2 females) were treated with clinical evidence of infected limb metal work from previous orthopaedic surgery. Metal work removal with intra osseous application of either cerement in 8 cases (10–20ml including 175mg–350mg gentamycin) or stimulan in 3 cases (5–12ml including 1g vancomycin) into the site was performed. Supplemental systemic antibiotic therapy (oral/intravenous) was instituted based on intraoperative tissue culture and sensitivity.

Introduction

Corrective fusion for the unstable deformed hind foot in Charcot Neuroarthropathy (CN) is quite challenging and is best done in tertiary centres under the supervision of multidisciplinary teams.

Patients and methods

We present our results with a series of 42 hind foot deformity corrections in 40 patients from a tertiary level teaching hospital in the United Kingdom. The mean patient age was 59 (33–82). 16 patients had type1 diabetes mellitus, 20 had type 2 diabetes and 4 were non-diabetic. 18 patients had chronic ulceration. 17 patients were ASA 2 and 23 were ASA grade 3. All patients had acute single stage correction and Trigen hind foot nail fusion performed through a standard technique by the senior author and managed peri-operatively by the multidisciplinary team. Our outcome measures were limb salvage, deformity correction, ulcer healing, weight bearing in surgical shoes and return to activities of daily living (ADL).

Introduction

The mid foot joints are usually the first to be affected in Charcot neuroarthropathy (CN). Reconstruction is technically demanding and fraught with complications.

Patients and methods

We present our experience of mid foot fusion in CN from a tertiary diabetic foot centre. We undertook mid foot corrective fusion in 27 feet (25 patients). Twelve of these had concurrent hind foot fusion. Eleven patients had type 1 diabetes, 12 had type 2 and 2 were non-diabetics. 23 patients were ASA grade 3 and 2 were ASA 2. 21 feet had ulcers preoperatively and mean HbA1c was 8.2. 13 patients had diabetic retinopathy and 6 had nephropathy.

Aims

This prospective cohort study aimed to determine if the size of the tendon gap following acute tendo Achillis rupture influences the functional outcome following non-operative treatment.

Patients and methods

All patients presenting with acute unilateral tendo Achillis rupture were considered for the study. Dynamic ultrasound examination was performed to confirm the diagnosis and measure the gap between ruptured tendon ends. Outcome was assessed using dynamometric testing of plantarflexion and the Achilles tendon rupture score (ATRS) six months after the completion of a rehabilitation programme.

Introduction

The dichotomy between surgical repair and conservative management of acute Achilles tendon ruptures has been eliminated through appropriate functional management. The orthoses used within functional management however, remains variable. Functional treatment works on the premise that the ankle/hindfoot is positioned in sufficient equinus to allow for early weight-bearing on a ‘shortened’ Achilles tendon. Our aim in this study was to test if 2 common walking orthoses achieved a satisfactory equinus position of the hindfoot.

Methods

10 sequentially treated patients with 11 Achilles tendon injuries were assigned either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus corrected vacuum brace system (EEB). Weight bearing lateral radiographs were obtained in plaster and the orthosis, which were subsequently analysed using a Carestream PACS system. The Mann-Whitney test was used to compare means.

Introduction

Active patients may benefit from surgical repair of the achilles tendon with the aim of preserving functional length and optimising push-off power. A mini-open device assisted technique has the potential to reduce wound complications, but risks nerve injury. We present the largest published series of midsubstance achilles tendon repairs using the Achillon® device.

Methods

A prospective cohort study was run at the Princess Royal Devon & Exeter Hospital between 2008 and 2015. We included all patients who presented with a midsubstance Achilles tendon rupture within 2 weeks of injury, and device assisted mini-open repair was offered to a young active adult population. All patients in the conservative and surgical treatment pathway had the same functional rehabilitation protocol with a plaster for 2 weeks, and a VACOped boot in reducing equinus for a further 8 weeks.

Background

Patients presenting with an acute tendoachilles (TA) rupture are managed in a dedicated clinic led by a Foot & Ankle Consultant and specialist physiotherapist. The diagnosis is made clinically and no ultrasound scan is performed. All management, rehabilitation and follow-up is undertaken within this clinic by the specialist physiotherapist, with Consultant support as required. Patients are offered a choice of conservative or surgical management (percutaneous TA repair). Both groups undergo a standardised functional rehabilitation regimen.

Methods

All patients treated through our dedicated clinic between May 2010 and April 2016 were identified. Patient outcomes were reported using the validated Achilles Tendon Repair Score (ATRS). ATRS scores were collected at 3, 6 and 12 months post-injury. Re-rupture and complication rates were also documented.

Aim

To determine the influence of tendo achilles (TA) rupture gap distance and location on clinical outcome managed with accelerated functional rehabilitation.

Methods

Twenty six patients with acute complete TA ruptures underwent ultrasound (US) within a week of injury. Measurements included the distance of the rupture from the enthesis and the gap distance between the tendon edges in three positions –

All patients were managed non-operatively in functional weightbearing orthoses. Nineteen patients were followed up at a mean of 6.1 years (range 5.8–6.5). Outcomes included ultrasound confirmation of healing, Achilles Tendon Rupture Score (ATRS) and Modified Lepilahti score (MLS).

Introduction

Patients with neglected rupture of the Achilles tendon typically present with weakness and reduced function rather than pain. Shortening of the musculotendinous unit and atrophy of the muscle belly in chronic rupture potentially leads to poorer recovery following tendon transfer. Few papers have looked at the outcomes of FHL reconstruction specifically in neglected TA rupture. Of those that have none report functional outcomes following a transtendinous repair.

Methods

Twenty patients with irreparable unilateral tendoachilles ruptures treated with transtendinous FHL reconstruction between 2003 and 2011 were reviewed. Achilles Tendon Rupture Score (ATRS), AOFAS hindfoot score, Tegner score and SF12 were recorded. Standard isokinetic assessment of ankle plantarflexion was performed with a Cybex dynamometer. Great toe flexion strength was tested clinically.

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.

Method

A retrospective analysis of all patients attending our unit for ankle ORIF over a two year period was undertaken. Patients were identified from our Bluespier database and a review of X rays was undertaken. All patients undergoing re-operation within eight weeks of the primary procedure were studied. The cause of primary failure was established and potential contributing patient and surgical factors were recorded.

Introduction

We performed a longitudinal outcome study involving the operative management of ankle fractures at two university teaching hospitals. This was a retrospective review of the quality of reduction and a prospective study into the functional outcome.

Methods

All patients undergoing open reduction internal fixation of the ankle between November 2006 and November 2007 at one centre, and January to December 2009 at the other were included. Adequacy of reduction was assessed on the initial post-operative radiographs using Pettrone's criterion. The post-operative functional outcome was recorded using the Lower Extremity Functional Scale (LEFS), completed by postal or telephone follow-up at 64 months post injury (60–74 months).

Introduction

Fixation of posterior malleolar fragments associated with ankle fractures aims to stabilise the syndesmosis and prevent posterior subluxation. Haraguchi described 3 types of posterior malleolar fractures, with type 2 being a medial extension injury, these fractures often involve medial and posterior fragments. We describe the techniques and outcomes for a double window posteromedial approach allowing optimal reduction and stabilisation.

Methods

A retrospective review was performed at 2 units, Bristol Royal Infirmary and QE Hospitals Birmingham, between August 2014 and April 2016. Inclusion criteria were all patients having this posteromedial approach for closed ankle fracture fixation. Patients were assessed for complications and postoperative ankle function with the Olerud and Molander scoring system.

Background

There have been multiple techniques described to determine hindfoot alignment radiographically. The 2-dimensional nature of radiographs fails to take into account the contribution of the remainder of the foot to overall alignment. A new radiographic technique has been published in which the hindfoot alignment is calculated using the Ground Reaction Force Calcanea Offset. This technique accounts for the individual forefoot contribution to alignment, but is still limited by it´s 2-dimensional nature. The purpose of this study was to compare the hindfoot moment arm (HMA) described by Saltzman and the hindfoot alignment angle (HAA) described by Williamson, with a technique determining the ground reaction force calcaneal offset (GRF-CT) using 3-dimensional weight bearing CT Scans.

Methods

The HMA, HAA, and GRF-CT 3-D weight bearing CT scans were measured by three different investigators. Each of these measurements were calculated twice on separate occasions by each investigator to determine the intra- and inter-observer reliability.

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.

Material and methods

We reviewed the operative records of 149 patients who had undergone arthroscopic ankle fusion under the care of two consultant foot and ankle surgeons between 2002 and 2006. We contacted patients by telephone to determine whether they had required further investigation or surgery on the same foot after their index procedure. Secondary outcome measures included a Manchester Oxford Foot Questionnaire (MOQFQ) score and a patient satisfaction score.

Background

Revision total ankle arthroplasty (TAA) can be extremely challenging due to bone loss and deformity. We present the results examining the preliminary indications and short term outcomes for the use of the Salto XT revision prosthesis.

Material and methods

We conducted an IRB approved prospective review revision TAA performed in two institutions using the Salto XT. There were 40 patients (24 females and 16 males with an average age of 65 years (45–83), who had undergone previous TAA (Agility 27, Salto 4, STAR 4, Buechal Pappas 1), and 4 patients who underwent staged procedures for infection. The primary indications for the revision were loosening and subsidence (34), malalignment (17), cyst formation (8), infection (4).

Background

Subtalar nonunion has a detrimental effect on patients' function, and pose a significant challenge for surgeons particularly in the setting of higher risk factors.

Methods

We retrospectively analyzed a consecutive series of 49 subtalar nonunions between October 2001 and July 2013. Patient records and radiographs were reviewed for specific patient demographics and comorbidities, subsequent treatments, revision fusion rate, use of bone graft, complications, and clinical outcome.

Background

Previous studies have individually shown extracorporeal shockwave therapy (ESWT) to be beneficial for mid-substance Achilles tendinopathy, insertional Achilles tendinopathy or plantar fasciitis. The purpose of this pragmatic study was to determine the efficacy of ESWT in managing the three main causes of refractory heel pain in our routine clinical practice.

Methods

236 patients (261 feet) aged between 25 – 81 years (mean age 50.4) were treated in our NHS institute with ESWT between April 2014 and May 2016. They all underwent a clinical and radiological assessment (ultrasonography +/− magnetic resonance imaging) to determine the primary cause of heel pain. Patients were subsequently categorized into three groups, mid-substance Achilles tendinopathy (55 cases), insertional Achilles tendinopathy (55 cases) or plantar fasciitis (151 cases). If their symptoms were recalcitrant to compliant first line management for 6 months, they were prescribed three consecutive ESWT sessions at weekly intervals. All outcome measures (foot & ankle pain score, EQ-5D) were recorded at baseline and 3-month follow-up (mean 18.3 weeks, range 11.4 to 41).

Methods

Patients with more than 6 months of MRI proven plantar fasciitis who had failed conservative management were invited to participate in this study. Patients were block randomised to either platelet rich plasma injection (intervention) or equivalent volume of normal saline (control). The techniques used for the injection and rehabilitation were standardised for both groups. The patient and independent assessor were blinded. Visual analogue scale for pain (VAS) and painDETECT were recorded pre-op and at 6 months.

Results

Twenty-eight patients (19 females, mean age 50 years) were recruited, with 14 randomised to each arm. At 6 month follow-up, 8 patients (28.6%) were lost to follow-up. There was a significant change in VAS score from baseline to follow-up in both intervention (mean change 37.2, p = 0.008) and control (mean change 42.2, p = 0.003) groups. However there was no difference between the arms in terms of the change in VAS score from baseline to follow-up (p = 0.183). There was no correlation between pre-op PainDETECT score and change in VAS.

Introduction

We aimed to retrospectively identify risk factors for delayed / non-union for first metatarsophalangeal joint fusion.

Methods

Case notes and radiograph analysis was performed for operations between April 2014 and April 2016 with at least 3 months post-operative follow up. Union was defined as bridging bone across the fusion site on AP and lateral radiographic views with no movement or pain at the MTPJ on examination. If union was not certain, CT scans were performed. All patients operations were performed/supervised by one of three consultant foot surgeons. Surgery was performed through a dorsal approach using the Anchorage compression plate. Blinded pre-operative AP radiographs were analysed for the presence of a severe hallux valgus angle equal or above 40 degrees. Measurement intra-observer reliability was acceptable (95%CI:1.6–2.3 degrees). Smoking and medical conditions associated with non-union underwent univariate analysis for significance.

Introduction

Metatarsus adductus (MA) increases the risk of recurrence following surgery for hallux valgus (HV). The goal of this study was to analyze patients with severe MA and identify clinical/surgical factors that are associated with a lower rate of recurrent deformity.

Methods

587 patients underwent correction of HV deformity. The rate of recurrence of HV was 15% (63 out of 414 patients) in patients without MA (MA angle < 20°) and 29.6% (50 out of 173 patients) in patients with MA. 19 patients with severe MA (>31°) were identified; 8 of 19 had associated tarsometatarsal arthritis, and two patients had a skew foot deformity. Ten patients had severe valgus lesser toe deformities. Clinical information collected included associated diagnoses, the presence of arthritis of the tarsometatarsal joints, the presence and degree of lesser toe valgus deformities and surgical procedures performed. Radiographic recurrence was defined as a postoperative HVA > 20°.