British Orthopaedic Foot & Ankle Society (BOFAS)
3rd – 5th November 2010
Nottingham, England
President: Sunil Dhar, MS, MCh Orth, FRCS Ed Orth
Correspondence should be sent to: Mrs Rosemarie Ricciardi,
Royal College of Surgeons, 35-43 Lincoln’s Inn Fields
London WC2A 3PE
Email: [email protected]
LENGTHENING OF THE SHORT METATARSAL
D. Singh, Consultant Orthopaedic Surgeon, Foot and Ankle Unit
Royal National Orthopaedic Hospital, UK
One of the complications of hallux valgus surgery is shortening of the first metatarsal and this becomes
particularly symptomatic in patients with a pre existing short metatarsal (Morton’s foot or Greek foot). Initial
treatment consists of appropriate insoles which incorporate not only relief of pain due to pressure
metatarsalgia under the lesser metatarsal heads but also a Morton type extension under the big toe. Insoles
with metatarsal relief are, however, not always well tolerated and surgery becomes necessary. The options are
to shorten the lesser metatarsal heads or lengthen the previously shortened first metatarsal. Arthrodesis of the
great toe metatarso-phalangeal joint can provide functional length to the first metatarsal.
We have achieved good results in lengthening of the first metatarsal and believe that it is a safe option
which avoids trauma to the lesser metatarso-phalangeal joints. The technique is presented and depends on
whether there is a residual hallux valgus or whether the toe is well aligned. The operation should address the
plane of the deformity and reverse the cause of the lengthening.
Emphasis should however be placed in not getting the complication in the first instance and the
incidence of the problematic short first metatarsal has significantly reduced since the decrease in popularity of
the Wilson osteotomy.
HALLUX VARUS FOLLOWING HALLUX VALGUS CORRECTION
S. Haddad Associate Professor of Clinical Orthopaedic Surgery
University of Chicago Pritzker School of Medicine
Congenital hallux varus had been a well-described condition for many years before acquired hallux varus as a
condition arising from bunion correction was not described until 1935. In that year, McBride discussed this
potential problem when describing this as a potential problem from his described technique, identifying
possible mechanisms to prevent the disorder from occurring. Authors such as Joplin and Kelikian echoed the
concept in the early 1960’s, spawning a series of corrective procedures. Miller brought this to common
practice in 1975, describing the tendon imbalance seen across the precarious 1st MTP joint.
The first metatarsophalangeal joint moves in the sagittal plane, dorsiflexion and plantarflexion only.
Four intrinsic muscles stabilize the digit, with the abductor and adductor hallucis taking the lion share of this
function. The abductor tendon actually functions primarily as a plantarflexor of the first metatarsophalangeal
joint 83% of the time (Thompson) due to its primary plantar location. This fact, in combination with the
pronation generally seen in severe bunion deformities, contributes to acquired hallux varus following bunion
correction. Besides the obvious cause of over-correction of the metatarsal osteotomy creating hallux varus,
imbalance of the tendon complex post-operatively can create an equally catastrophic circumstance. Hawkins
demonstrated that severing the adductor tendon complex (the conjoined tendon) will not product hallux varus
when the hallux is not rotated. However, in more severe hallux valgus, pronation of the hallux may be
proportional to the deformity of the hallux itself. This rotational deformity places the insertions of the
abductor (and medial insertion of the flexor brevis) more plantarward and lateral, increasing the valgus
deformity. If the entire conjoined tendon is sectioned and the internal rotation deformity corrected the
insertion of the contracted abductor moves medially, pulling the toe into varus. If the center of the base of the
proximal phalanx is brought beyond the mid-point of the first metatarsal head, the extensor hallucis longus
will bowstring, pulling the great toe into varus while creating a hallux flexus deformity. Finally, if the lesser
toes are in varus and not corrected, this deforming force will create hallux varus following bunion correction
with a lateral release. The message is clear: not all patients require a lateral release, and, if done, should be
done with caution.
Once present, correction can be difficult. Tendon transfers utilizing the extensor hallucis longus
(Johnson) or extensor hallucis brevis (Myerson) only have beneficial effects in non-arthritic, mobile first
metatarsophalangeal joints. In addition, if metatarsal deformity is not corrected, the deformity will recur.
Thus, in many circumstances, arthrodesis of the first metatarsophalangeal joint becomes the treatment of
choice, and is commensurate with a disappointed patient who underwent a primary bunion correction and was
left with a fused great toe.
This lecture will explore the above mechanism and salvage situations, in hopes of eliminating this
unwelcomed outcome from your practice.
FAILED MORTON’S NEUROMA SURGERY
M. S. Davies
The London Foot & Ankle Centre
A Morton’s neuroma is a compressive neuropathy most commonly affecting the common digital nerve of the
third inter-space. Symptoms are variable but usually the diagnosis can be made quite easily and the diagnosis
is essentially a “clinical” one. When symptoms relate to the second inter-space the clinician needs to be alert
to mechanical causes of metatarsalgia leading to secondary irritation of the nerve. Imaging with MRI scanning
and/or ultrasound can be helpful but equally can be misleading, as there may be false positives and false
negatives. In the case of ultrasound the accuracy of imaging depends on the experience and expertise of the
radiologist.
Morton’s neuroma surgery is usually associated with high levels of success but some reports suggest
as many as 30% of patients under-going such surgery are dissatisfied with the outcome. The reasons for failed
surgery can be broadly divided into three groups: a) wrong diagnosis b) wrong surgery and c) right diagnosis
and right operation but unfavourable outcome. Wrong diagnosis is most commonly encountered in second
space pathology when there is an underlying mechanical reason for the symptoms such as second MTP joint
synovitis. This is usually secondary to joint overload associated with first ray insufficiency eg hallux valgus.
This is the so-called Moron’s neuroma. Wrong surgery occurs when the wrong space is operated upon, when
mechanical causes are overlooked or when a plantar incision is made over the weight-bearing part of the
forefoot, leading to painful scar formation. Wrong surgery can also involve failure to recognise anomalous
anatomy within the space or insufficient nerve resection. Unfavourable outcomes include infection, stump
neuroma formation or the onset of CRPS. Occasionally despite an appropriate assessment and operation a
patient will derive no relief of symptoms and the cause of the pain remains totally unexplained.
Careful history and examination and careful pre-operative planning can reduce the incidence of failed
Morton’s neuroma surgery. The role of imaging is probably greater in such cases compared with those
presenting with a primary Morton’s neuroma but the diagnosis remains essentially clinical. Stump neuroma
resection should be considered in patients presenting with repeat symptoms especially if there is initial
surgical success followed by recurrent symptoms. If two explorations result in no success then a third
exploration is unlikely to resolve the problem. Some patients are left with intractable symptoms and should be
referred to a pain specialist, as further surgery often has nothing more to offer.
MINIMALLY INVASIVE SURGERY – WHAT GOES WRONG?
D. Redfern
Brighton & Sussex University Hospitals
I consider the term ‘minimally invasive surgery’ (MIS) to represent a wide range of techniques directed at
achieving a surgical objective with less collateral tissue damage. The surgeon choosing to employ such
techniques may aspire to achieve improved or more consistent outcome for their patients but is this so? What
are the complications? In certain areas of surgery the concept of MIS is well established (e.g. knee and ankle
arthroscopy). In forefoot surgery the concept has been met with interest but also skepticism. Much of this
skepticism pivots around concerns that the loss of direct vision (maintained in arthroscopic techniques) may
increase the risk of complications. In other words, there is a concern that due to the loss of direct visualization
(replaced by intra-operative xray imaging), any benefit that might arise from the less invasive technique of the
operation will be negated by either poorer quality of surgical correction or higher risk of injury to adjacent
structures. All surgery is associated with a degree of risk and in considering the complications specifically
associated with MIS of the forefoot we must try to separate out those complications related to the specific
MIS technique involved and those that are not. In other words, we need to identify whether the complication
has occurred as a result of incorrect surgical planning (e.g. wrong choice of osteotomy/flaws in surgical
objective), poor execution of the surgical technique, or as a result of the MIS instrumentation/equipment. I
will discuss the above in relation to my experience of complications encountered whilst employing minimally
invasive surgical techniques in the treatment of forefoot pathology over the last 2 years.
TREATMENT OF FOR END-STAGE MTP1 OA WITH
HEMIARTHROPLASTY OR INTERPOSITIONAL ARTHROPLASTY
C. Saltzman
University of Utah
Fusion remains the standard of care and is associated with a high satisfaction rate. But…. fusion generally
requires 6 weeks of restricted weight bearing or immobilization. Potential problems include 1) nonunion, 2)
malunion, 3) sesamoid pain (from DJD), 4) late onset IP1 DJD.
Complete joint replacement has been performed with a number of different designs since the early
1970’s. The metal and poly designed implants are associated with a high failure rate, presumably from high
shear loads, eccentric axial loads, poor fixation and bone stock problems. Resurfacing of both sides of the
joint with a one piece silicone based crosslinked rubber {“silastic”} in rheumatoid patients appears to function
better with use of metal grommets to reduce generation of particle debris and foreign body reaction. These
silastic implants are still used by surgeons in select low-demand rheumatoid patients. Salvage after failure of
any of these total joint replacements can be challenging because of loss of bone stock.
3 other methods are used to resurface the joint in severe OA: 1) resurfacing the proximal phalangeal
side only, 2) resurfacing the metatarsal head only and 3) resurfacing the joint with and interposition
arthroplasty. 1) advantage of the proximal phalangeal side resurfacing is simplicity of geometry; the
disadvantage is disruption of the FHB attachment and the relative scarcity of severe cartilage damage at that
side of the joint. 2) Advantage of the metatarsal head side for resurfacing is that is the typical location of the
arthritic change; the disadvantage is potential interference with the sesamoid complex and bulkiness of
fixation could lead to a more difficult salvage. 3) The advantage of interposition arthroplasty is the
maintenance of bone stock; disadvantages include inconsistent local tissue and somewhat less predictable
outcomes.
In this talk I will focus primarily on the technique and results of a proximal phalangeal resurfacing
approach for OA of the MTP1 joint.
THE MISSED LIGAMENTOUS LISFRANC
C. Saltzman, Professor and Chair University of Utah
1.
Diagnosis
a. History and exam
i. True Lisfranc fracture dislocations are NOT difficult to diagnose
b. Midfoot sprains or subtle injuries
i. These are DIFFICULT to diagnose
- subtle x-ray findings with minimal displacement
i) Exam:
- be “suspicious” of midfoot sprains
- TMT tenderness, swelling
- inability to WB
ii) Mechanism of injury:
- indirect twisting injury (athletic)
- crush injury of the foot (trauma)
- axial forefoot loading (dancers, jumpers)
iii) Investigations:
- X-rays usually normal or subtle widening
need to assess all 3 views in detail
standing AP compare to the other side
-Stress x-rays: - if clinical symptoms indicate - severe injury + pain but x-ray
looks normal
- MRI useful for anatomic/ instability correlation
- CT scan good for subtle injuries/fractures and displacement
- Bone scan positive in subacute / chronic pain situation
2. Treatment
a) Surgical Indications
i) Any displacement / positive stress xrays/ test
ii) Surgical technique
- open reduction or closed and percutaneus fixation
- anatomic reduction essential
- NWB period up to 6 weeks
- WB with protection for another 4-6 weeks
iii. Screw vs tightrope fixation
iv. Hardware removal
b) Non-operative
i) Stable non-displaced sprain (need to make sure this is stable , ie stress views)
- 6 to 8 weeks NWB
- expect prolonged recovery up to 6 months with
proper treatment
3. Controversial Issues:
a. Do all injuries with mild displacement have to be fixed operatively?
b. Arthrodesis vs fixation for soft tissue lisfranc with mild displacement?
c. Arthrodesis vs fixation subacute or chronic presentation?
d. Hardware removal?
COMPLICATIONS OF MIDFOOT SURGERY
P. Cooke
Nuffield Orthopaedic Centre, Oxford
Surgery to the midfoot (usually fusion) may be performed for trauma, arthritis, deformity or combinations.
There are reports of good results, meaning primary fusion rates of 90+percent, 12 % serious
complication rates and need for hardware removal 1n 25% of cases from specialist centres (Nemec et al
AOFAS 2010). But even these good results mean 10% of patients needing lengthy revision surgery, and a
third needing some additional intervention.
Surgery to the midfoot, like all surgery has both consequences (which everyone experiences) and
complications (which some peolple get).
The consequences of midfoot surgery are time in hospital, long periods in cast (often non-weight
bearing) and long rehabilitation periods leading to a “second best” result where pain is relieved, but
mechanics and full function are not restored, and longterm stiffness and swelling are comon. Usually the
patient still needs to restrict activities and wear orthotics or adaptive footwear.
The commonest complication is probably a failure to inform patients of the consequences of surgery –
inevitably leading to disappointment with result and outcome.
Common complications include:
Wound, nerve and vascular problems.
Delayed union, malunion and non-union.
General complications such as DVT and embolism.
All these complications are more common in patients who smoke, are diabetic or have a BMI over 30.
By showing examples of problems seen in the last 15 years of tertiary referral ( and the authors own
cases), a system to minimise complications, and to address them when they occur, will be presented, based on
:
Good preparation and timely accurate information
Planning surgery (approach, execution and post operative management)
Rehailitation and after surgery care.
These can usually only be brought together by a surgeon performing this surgery on a regular basis,
and with the support of an equally experienced multi-disciplinary team.
CURRENT CONTROVERSIES IN THE ADULT ACQUIRED FLATFOOT
MANAGEMENT
S. Haddad, Associate Professor of Clinical Orthopaedic Surgery
University of Chicago Pritzker School of Medicine
Most of the controversy surrounding management of the adult acquired flatfoot deformity revolves around the
correction of Stage 2 deformity. Stage 1 deformity, uncommonly corrected surgically, involves tenosynovitis
with preservation of tendon length and absence of structural deformity. Attempts at tenosynovectomy in light
of structural deformity leads to operative failure, found in 10% of Teasdall and Johnson’s 1992 patient
population. Thus, with tenosynovectomy rarely becoming an operative situation, Stage 2 deformity becomes
the mainstay of operative treatment of the adult flatfoot. Stage 2 deformity patients present with swelling
medially, the inability to do a single heel raise, with a passively correctable subtalar joint. The tendon is
functionally torn. In recent years, authors have subdivided Stage 2 deformity even further into A and B
subcategories, where A involves less than 50% uncovering of the talonavicular joint, and B patients more than
50%. Recently, Anderson has added a C subtype, which may be applied to either A and B patients, in patients
who have forefoot varus. Thus, Stage 2 patients suffer from pain that begins medially and progresses to the
subfibular region over time. Most important, recognition of the continued sub classification in Stage 2
disease echoes the fact that this disorder is on a continuum, challenging the surgeon to recognize subtleties
that, if unrecognized, lead to a poor patient outcome. The mainstay of treatment in Stage 2 disease is the
medial slide calcaneal osteotomy, which realigns the hindfoot axis reducing valgus, improves the medial arch,
protects the FDL tendon transfer, and allows the Achilles tendon to become a strong inverter. Over shift of
the calcaneus can compromise the outcome, as will a lack of recognition of the congenital subtleties such that
a valgus hindfoot can have a varus orientation to the calcaneus, both leading to lateral overload. A pure
medial slide of a calcaneus that has a varus orientation does not correct deformity, rather, it creates it. Thus,
an axial calcaneal view must be studied carefully, for a varus orientation may be corrected via a closing
wedge osteotomy commensurate with the medial shift of the tuberosity. As noted above, the flexor digitorum
longus tendon transfer is the staple procedure to replace the damaged posterior tibial tendon. This transfer
balances the eversion power of the peroneal tendons, works in phase with the former posterior tibial tendon in
the stance phase of gait, and replaces a painful diseased posterior tibial tendon. However, over tensioning the
transfer results in a tenodesis rather than a functional tendon transfer, the relative weakness of the FDL tendon
(30% as strong as the PTT) creates difficulty with heel raise, and inappropriate transfer to distal tarsal bones
may compromise the result by limiting torque from the transferred tendon. Preservation of the posterior tibial
tendon in combination with the transferred FDL tendon remains a consideration without answer, though
Rosenfeld (2005) suggests a substantial improvement in strength through PTT preservation. Failure of the
above protocol for treating Stage 2 disease most often revolves around the insufficient corrective power of the
tandem procedures in longstanding ruptures. According to Guyton (2001), only 50% of patients report a
perception in deformity improvement following FDL/calcaneal osteotomy procedures, and only 4% report a
significant improvement in pre-existing deformity. Sangeorzan (2001) found such patients could not achieve
a painless plantigrade foot due to acquired ligament laxity (primarily the Spring Ligament). Sangeorzan
applied Evans’ pediatric procedure to adults without confirming the pathomechanics of correction. Some
speculate the windlass effect on the plantar fascia creates correction (refuted by Horton, 1998, finding the
plantar fascia is loosened by a lateral column lengthening), others believe tightening the peroneus longus
through lateral column lengthening increases first ray plantarflexion, restoring the medial arch. Controversy
also remains in answering Cooper’s (1997) claim that lengthening through the calcaneus creates static
increase in pressure about the calcaneocuboid joint (1.4mPa total) that may lead to an arthritic joint long term.
Painful lateral overload following lateral column lengthening remains difficult problem to both prevent and
correct. This last point leads to some focusing their efforts on restoration of the medial column. This group
focuses on the “C” type deformity noted by Anderson, those with forefoot varus. It is known that the medial
column is supported by the navicular, the cuneiforms, and the first, second, and third metatarsals. While a
Cotton (opening wedge medial cuneiform) osteotomy, a first tarsometatarsal joint arthrodesis, or a metatarsal
osteotomy has value, the surgeon must note that this only corrects the first ray. Complete correction of the
medial column is best achieved through naviculocuneiform joint arthrodesis. Standing radiographs
commonly reveal collapse at that level; however, surgeons are reticent to perform such fusions in light of the
higher nonunion rate.
BIOLOGY AND TREATMENT OF DIABETIC CHARCOT ARTHROPATHY
C. Saltzman
Professor and Chair University of Utah
In developed nations Charcot arthropathy is most commonly caused by diabetes mellitus. Worldwide, leprosy
remains the primary cause. All evidence points to a relationship between neurologic loss, continued loading
activities and the development of unrecognized bone fragmentation. In type 2 diabetes, dysregulation of leptin
biology causes bone loss and may be an important factor in precipitating Charcot events. Bone density studies
show massive loss of bone in patients with ankle and hindfoot Charcot problems, but not midfoot problems.
This suggests a different mechanism for collapse. Stable collapse with ulcer development in the midfoot can
be treated with exostectomy. Realignment and fusion remain the mainstays of treatment for diabetic Charcot
neuropathy, especially in the ankle and hindfoot. Bone mineralization deficiencies require special
consideration of fixation techniques. Thin wire external fixation – either as primary fixation or to
reinforce/neutralize other methods can be very helpful. Large bridging screws and carefully selected bridging
plates are frequently also valuable to consider. Excessive immobilization periods (often double the normal
amount of time) are generally required. The goal may be limited to a braceable, plantigrade foot.
BODY IMAGE PROBLEMS AND BODY DYSMORPHIC DISORDER
D. Veale
Consultant Psychiatrist in Cognitive Behaviour Therapy
South London and Maudsley Trust and The Priory Hospital North London
Body Image is defined as our internalised sense of what we look like. For most of us, there is a relatively good
match between what we think we look like and how we appear to other people. Body image can also be
studied in terms of what you look like in the eyes of an observer and the pressures that occur to look a certain
way. Body Dysmorphic Disorder (BDD) is the most extreme type of body image problem and consists of a
preoccupation with one or more features that is not noticeable to others or the person’s concern is markedly
excessive. The preoccupation is associated with many time consuming rituals such as mirror gazing or
constant comparing. It is associated with a poor quality of life, social isolation, depression and a high risk of
committing suicide. Any part of the body may be involved but the foot is an uncommon focus for people with
BDD. Such individuals often have needless dermatological treatment and cosmetic surgery. Body image
problems and especially BDD is easily trivialised and stigmatised. People with BDD can benefit from
cognitive behaviour therapy and certain types of medication.
Speaker: David Veale is Consultant Psychiatrist in Cognitive Behaviour Therapy at the South
London and Maudsley Trust and The Priory Hospital North London and an Honorary Senior Lecturer at the
Institute of Psychiatry, Kings College London. He runs a national specialist service for people with BDD and
obsessive-compulsive disorder. He has published about 70 articles and co-authored five books including
“Overcoming Body Image Problems (including Body Dysmorphic Disorder” published by Robinson and a
treatment manual for BDD. He is a past President of The British Association of Behavioural and Cognitive
Psychotherapies. His website is www.veale.co.uk
TENDINOPATHY OF THE MAIN BODY OF THE ACHILLES TENDON
U. G. Longo
Consultant, Campus Biomedico University, Italy
Achilles tendinopathy is a common cause of disability. Despite the economic and social relevance of the
problem, the causes and mechanisms of Achilles tendinopathy remain unclear. Tendon vascularity,
gastrocnemius-soleus dysfunction, age, gender, body weight and height, pes cavus, and lateral ankle
instability are considered common intrinsic factors. The essence of Achilles tendinopathy is a failed healing
response, with haphazard proliferation of tenocytes, some evidence of degeneration in tendon cells and
disruption of collagen fibres, and subsequent increase in non-collagenous matrix. Tendinopathic tendons have
an increased rate of matrix remodelling, leading to a mechanically less stable tendon which is more
susceptible to damage. The diagnosis of Achilles tendinopathy is mainly based on a careful history and
detailed clinical examination. The latter remains the best diagnostic tool. Over the past few years, various new
therapeutic options have been proposed for the management of Achilles tendinopathy. Despite the morbidity
associated with Achilles tendinopathy, many of the therapeutic options described and in common use are far
from scientifically based. New minimally invasive techniques of stripping of neovessels from the Kager’s
triangle of the tendo Achillis have been described, and seem to allow faster recovery and accelerated return to
sports, rather than open surgery. A genetic component has been implicated in tendinopathies of the Achilles
tendon, but these studies are still at their infancy.
Plantar Fascia Pathology
PLANTAR FASCIITIS
M. Solan
ATYPICAL PLANTAR FASCIOPATHY
A. Carne
Royal Surrey County Hospital, Guildford
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.
COMMON TREATMENT STRATEGIES – ECCENTRIC CALF TRAINING
J. Rees
Defence Medical Rehabilitation Centre, Headley Court
Degenerative disorders of tendons present an enormous clinical challenge. They are extremely common, prone
to recur and existing medical and surgical treatments are generally unsatisfactory.
Eccentric, but not concentric, exercises have been shown to be effective in managing tendinopathy of the
Achilles tendon and of the mid-portion of the Achilles tendon in particular.
There has been much speculation on why eccentric exercises are effective. This talk will highlight the
theories and evidence behind why eccentric exercises are effective. An understanding of why eccentric
exercises are effective should inform best clinical practice on rehabilitation of tendinopathy. This talk will
also discuss limitations of eccentric exercises and highlight areas where future research is needed.
Dr Jonathan Rees BSc, MSc, FRCP (UK), FFSEM (UK), MD
Dr Jonathan Rees is a Consultant Rheumatologist at the Defence Medical Rehabilitation Centre, Headley
Court and Honorary Consultant Rheumatologist and Guy’s and St Thomas’ Hospitals. He has wide experience
in Musculoskeletal Rehabilitation and Sport and Exercise Medicine, and was a Medical Officer to the 2008
Beijing Great Britain Paralympic Team. Tendinopathy was the subject of his Medical Doctorate which was
awarded from University College London in 2010.
CONSERVATIVE MANAGEMENT OF ACUTE RUPTURE OF THE
ACHILLES TENDON
R. Wallace
Consultant Orthopaedic Surgeon
The best management for acute rupture of the Achilles tendon remains controversial. An unacceptably high
re-rupture rate following conservative management has been quoted as a reason for surgical management,
however, many of these studies do not stand up to critical scrutiny. Since 1989 I have personally treated over
1600 consecutive patients with acute rupture of the tendo-achilles using a conservative functional
management protocol. This protocol was developed in the light of experience over a number of years. I will
present an independent review of 1044 consecutive patients presenting to my tendo-achilles clinic between
1996 and 2008. After examination, 975 patients were found to have an acute tendon rupture, the rest being
gastrocnemius muscle tears, painful Achilles tendonopathy or mis-referrals. Of these 975 patients 29 were
late presenters in whom the tendon ends did not approximate well on plantar flexion. These patients were
therefore treated surgically. One patient was too obese to be included in the standard protocol, although he
was still treated conservatively. With a minimum follow up of two years, the overall re-rupture rate was
2.9%. The re-rupture rate using this management protocol is similar to or better than the published operative
re-rupture rates. The protocol, complications and outcome will be discussed and I recommend a well defined
and tested non operative functional management protocol for treatment of acute tendo-achilles rupture. This
protocol is suitable for all ages including those with significant sporting demands. It is essential that patients
have assessment and follow up carried out by a senior and experienced surgeon.
REHABILITATION FOR ACHILLES TENDON REPAIR
U. G. Longo
Consultant, Campus Biomedico University, Italy
Evidence-based orthopaedic surgery emphasizes the need to properly design and perform high-quality
randomized controlled trials to minimize bias and to truly ensure the effectiveness of orthopaedic
interventions. The currently available best evidence suggests to load and move the Achilles tendon after an
open or percutaneous repair for an acute rupture.
Following repair of the torn AT, patients are immobilized with their ankle in gravity equines. They are
encouraged to bear weight on the operated limb as soon as possible to full weightbearing, and discharged
home on the day of the procedure. All patients are given an appointment for review 2 weeks postoperatively,
when they receive a single cast change, with the ankle accommodated in a removable anterior splint in a
plantigrade position, secured to the lower leg and foot with Velcro straps. Removal of the foot straps under
supervision of a physiotherapist allowes the ankle to be plantar flexed fully but not dorsiflexed. These
exercises are performed against manual resistance. At 6 weeks postoperatively, the anterior splint is removed,
and the patient referred to physiotherapy for active mobilization.
At 12 weeks postoperatively, patients are assessed as to whether they are able to undertake more vigorous
physiotherapy, and encouraged to gradually return to their normal activities. Progressive activities are
incorporated as strength allowed, with the aim to return to unrestricted activities 6 months following surgery.
SUBTALAR ARTHRODESIS FOLLOWING CALCANEAL FRACTURE
M. Jackson
Consultant Orthopaedic Surgeon, Bristol Royal Infirmary
Persistent pain is a common cause of disability in patients after fractures of the calcaneum. Amongst the
possible causes for post traumatic pain is the development of degenerative osteoarthritis of the posterior facet
of the subtalar joint. However there are many other causes of post-traumatic hindfoot pain which require
consideration prior to treatment. Knowledge of the patho-anatomy of calcaneal fractures is required to reach
an accurate diagnosis. Significant symptoms and disability may be treated by arthrodesis of the subtalar joint.
Post-traumatic arthritis in the non-operatively treated calcaneal fracture is however usually associated
with deformity of the hindfoot, disordered hindfoot biomechanics, lateral wall fibular impingement and fibular
tendon dysfunction.
Fractures treated by primary open reduction and fixation should be well aligned but despite anatomic
reduction may also develop posterior facet arthritis. Symptoms may also be caused by prominence or
impingement of the implant, particularly of locked perimeter plates on the lateral wall.
Patients therefore require careful assessment prior to surgery and any operative measures have to
address these key features in order to produce a satisfactory clinical result.
This lecture will address the potential problems of this type of surgery and key features in the clinical
assessment and imaging of these patients.
Subtalar arthrodesis in the presence of deformity is technically complex and requires careful planning in order
to correct the deformity and to produce a well aligned hindfoot to allow corrected biomechanics without
impingement and the fitment of suitable footwear.
The surgical techniques and different types of surgery required to adequately manage the posterior
facet and deformity will be covered and will include arthroscopically assisted in-situ fusion, the safe
approaches for open surgery and techniques to reconstruct the lateral wall, fibular tendon function and
osteotomies required to restore calcaneal height and alignment.
HINDFOOT MALUNION
S. Haddad
Associate Professor of Clinical Orthopaedic Surgery
University of Chicago Pritzker School of Medicine
Arthrodesis of both the ankle and the hindfoot has been discussed in the literature since the early part of the
last century. Techniques have been modified substantially since these early discussions, though
complications remain a frustrating element in patient management. Early procedures relied on molded plaster
casts to hold fixation in corrected positions. Successful outcomes were hampered by loss of reduction in
these casts and subsequent malunions. In addition, motion within these casts lead to a high rate of nonunion
between the opposed bony surfaces. The era of internal fixation allowed compression across arthrodesis sites,
enhancing union but creating a host of technical errors leading to unsatisfying results.
Malunion is also seen in post-traumatic situations. In particular, non-operative management of
calcaneus fracture (or other hindfoot fractures) leads to not only arthritis of the involved joint surfaces, but
malunion complicating successful fusion. Fusion in-situ leads to a high level of patient dissatisfaction,
leading surgeons to challenging deformity correction while trying to achieve successful arthrodesis in
compromised joints.
This lecture will focus on two types of malunion, one iatrogenic, one acquired. Revision triple
arthrodesis (iatrogenic) can range from simple to challenging. A variety of studies document patient
dissatisfaction following correction via this technique, ranging from Graves and Mann (1993) where the
highest dissatisfaction rate was in highest in valgus malunion, to Sangeorzan and Hansen (1993), who found a
9% failure rate, most with varus malunion. The precarious balance required to create a plantigrade foot via
triple arthrodesis with pre-existing deformity leaves even the most skilled surgeon challenged. As such, this
component of the lecture will focus on recognition and correction of malunion based on a structured
algorithmic approach we first presented in 1997. This algorithm is based on recognition of the apex of the
deformity, and creating osteotomies to achieve balance.
We reviewed 28 patients who returned for follow-up examination who received treatment through
this algorithm and found a statistically significant improvement in pre- and postoperative AOFAS
ankle/hindfoot score, from an average of 31 points preoperatively to 59 postoperatively (p<0.01). All patients
united, and all stated they would undergo the revision procedure again. Comparisons of pre- and
postoperative shoe wear modification demonstrated a statistically significant improvement (p=0.01).
Preoperatively, 20 patients required restrictive devices such as ankle foot orthoses and orthopaedic shoes.
Postoperatively, only 1 patient required such a restrictive device. In fact, 17 patients required no
modifications to their shoe wear at all.
The second component to this lecture will assess acquired hindfoot deformity, from malunion created by
calcaneus fractures. A 2005 JBJS study by Brauer, et.al. found operative management resulted in a lower rate
of subtalar arthrodesis with a shorter time off work compared to non-operative management. Removing the
expense of time off work still netted a $2800 savings for operative management over non-operative
management. Sanders echoed these thoughts in a JBJS 2006 paper, suggesting patients with displaced intraarticular calcaneal fractures may benefit from acute operative treatment given the difficulty encountered in
restoring the calcaneal height and the talo-calcaneal relationship in symptomatic calcaneal fracture malunion.
Thus, with these challenges in mind, the goal of this component of the lecture is to introduce methods to
achieve balance and union with calcaneus fracture malunion. Vertically oriented multiplanar calcaneal
osteotomy may assist the surgeon in avoiding the higher non-union rate associated with bone-block
arthrodesis procedures. In this vein, the challenges associated with bone block subtalar arthrodesis will be
explored.
POST-TRAUMATIC ANKLE OSTEOARTHRITIS AND JOINT DISTRACTION
C. Saltzman
Professor and Chair
University of Utah
Osteoarthritis (OA) is a disease of the joints stemming from a variety of factors, including joint injuries and
abnormally high mechanical loading. Although the traditional treatment alternatives for end-stage OA are
arthroplasty in the case of the hip and knee, and arthroplasty or arthrodesis in the case of the ankle, these
options are not ideal for younger, more active patients. For these patients, joint prostheses would be expected
to fail relatively quickly, and ankle fusion is not amenable to maintaining their active lifestyles. In these
cases, joint distraction has attracted investigative attention as a conservative OA treatment for younger
patients 9-14.
Based on the principle that decreasing the mechanical load on cartilage stimulates its regeneration 15,
distraction treatment calls for reduced loading of the joint during a period of typically 3 months, during which
time the load customarily passing through the joint is taken up by an external fixator spanning the joint . By
mounting the fixator components to the bone on each side of the joint, and then lengthening the rods
connecting the proximal and distal portions of the fixator, the joint is distracted. Assuming the fixation is
appropriately stiff, any load passes through the fixator instead of the joint, and the two articular surfaces will
not be allowed to contact each other under physiologic loading. The exact mechanisms leading to cartilage
regeneration during distraction are not yet understood.
A possible negative consequence of joint fixation is cartilage degeneration due to immobilization
during the treatment. It has been shown by Haapala et al. and others that long-term immobilization can be
detrimental to articular cartilage 16-18.
Conversely, joint motion during fixation (even passive motion) is thought to stimulate or encourage
cartilage regeneration 19-22. Toward this end, considerable effort has been invested in the application of hinges
to external fixation for joints Joint motion has also been suggested as a potentially beneficial factor in
distraction treatment, as well 10. This is borne out by data from an RCT comparing the use of a rigid vs motion
external fixator. Change in joint biology due to resorption of cysts may be responsible for reversal of
symptoms.
ANKLE ARTHRODESIS VS. REPLACEMENT
Charles Saltzman
Professor and Chair
University of Utah
Data is scant on the critical question of whether patients with endstage ankle arthritis are better served by a
fusion or a replacement.
The STAR trial, a prospective case control study, comparing safety and efficacy of STAR ankle
replacement at 24 months for 158 replacements and 66 fusions:
This FDA trial showed the STAR ankle replacement had better function, equivalent pain relief and a
higher rate of complications and secondary procedures as ankles treated with fusion. A separate prospective
cohort comparison of 200 ankle replacements vs. 94 ankle fusions performed by the collaborative consortium
of Canadian Orthopaedic Foot and Ankle Surgeons (COFAS) suggests similar patient oriented outcomes at 24
months. Patients’ self-assessment questionnaires do not show significant differences between the two groups.
The main medium/long-term concerns with ankle replacement remain component subsidence
(especially talar subsidence) and polyethylene wear. Forces across the ankle are considerable, and the
orientation of those forces to the underlying trabecular structure are a concern. Whether 2 or 3 part ankles will
provide better bearing wear results remains unknown. With older designs, at 10 years the Swedish registry
found approximately 60% survivorship. This registry has also shown better survivorship in patients with
rheumatoid disease and with increased surgeon experience. More recent results related to the Hintegra and
AES components show better midterm (5 year) revision rates in selected surgeons hands, than seen with older
designs.
A large meta-analysis of ankle fusion and replacement published data by Haddad et al reported a
mean nonunion rate of 10%. The main long-term concerns with ankle fusion are limitations of motion, and the
development of premature arthritis in adjacent foot joints. In a study of an average of 9 year outcome of the
Agility ankle replacement suggested that the incidence secondary arthritis is halved by replacement as
compared to fusion.
THE PERSISTENTLY PAINFUL OSTEOCHONDROL LESION OF THE
TALAR DOME
Ian Winson
Avon Orthopaedic Centre, Bristol
The diagnosis of Osteochondral Chondral Lesion of the talar dome is ever more regularly made. Though
algorithms of management have emerged by recognising the position, size and the most reliable treatment
options, the problem of the failed or relapsed case has only been considered in limited publications.
When considering the failed case a variety of possibilities have to be considered.
The characteristics of the patient have to be considered. The nature of the original presentation and the history
of the present as opposed to the past compliant are worth noting. Patients who have no history of trauma do
seem to have a different natural history and response to treatment. The young and the old may well respond
differently.
Factors preventing recovery from surgery such as ongoing instability of the ankle or hindfoot
deformity creating on going abnormal pressures on the joint surface should be looked for.
The possibility that the surgery undertreated or missed the full nature of the lesion has to be
considered. The possibility of an untreated further pathology should be reviewed.
The severity of the original lesion and it’s likely response to treatment should be considered. Larger
cystic lesions would be more likely to have a poorer outcome. Ultimately if there are persistent symptoms and
evidence of ongoing unresolved pathology on the joint surface alternative techniques to resurface the joint
should be considered.
WALKING ON A TIGHTROPE – THE UNSTABLE SYNDESMOSIS
C. Saltzman
Professor and Chair University of Utah
Ankle sprains in the athlete are one of the most common injuries, and syndesmosis type sprains seem to
becoming diagnosed at an increasing rate. There still exists a paucity of information on optimal conservative
and operative management.
Treatment

Because of the spectrum of injury, there is a spectrum of treatment.
o if there is mortise widening, operative stabilization is required
o if the mortise is normal, even with external rotation stress test positive, conservative treatment
has been employed.
 staged conservative regimen directed at reducing pain and swelling acutely, at
regaining range of motion and strength subacutely, and then progressed to functional
training and finally return to sport. The timeframe for these was in the range of 2 to 6
weeks without very specific progression criteria.
 In the athlete , pain with rotational stress , greater severity of sprain, may treat
operatively to stabilize the syndesmosis and aggressive rehab with earlier return to
sport
 Tightrope vs screw fixation vs both
 Use of arthroscopy
o Chronic sprains with recalcitrant pain and functional instability usually require operative
treatment.
 very poor evidence exists as to the timing or type of procedure. Arthroscopy is
required to confirm the diagnosis, treat intraarticular problems, and provide fixation
of the distal tibiofibular syndesmosis. The postoperative regimen used is generally the
same as the one used when treating an acute syndesmosis disruption.
Tight rope vs Screw Fixation
 clinical studies tightrope fixation has been acceptable and comparable to screw fixation
 laboratory studies demonstrate comparable construct stability in the laboratory/cadaveric setting
 indications for tightrope fixation are becoming more clear with more experience
 my indications:
o syndesmotic sprains with complete or incomplete disruption
o fractures with syndesmotic disruption augment with screws, leave in place following screw
removal
Summary and Controversies:
 Syndesmotic or high ankle sprains continue to be a common injury that result in significant time lost
from sport
 The conclusion that can be drawn from the current evidence is that the current diagnostic process
probably fails to clearly assess the severity of the injury, which reduces the likelihood of accurately
predicting the time lost from sport.
 Syndesmosis sprains can be a significant injuries that result in an inability to play sports for
significant periods of time(up to 137 days).
 We need to be able to identify the more severe ones earlier in order to improve their treatment ,
perhaps lead to operative stabilization
 Tightrope fixation avoids screw removal, minimally invasive , permanent stabilization
DELTOID LIGAMENT RECONSTRUCTION
S. Haddad
Associate Professor of Clinical Orthopaedic Surgery
University of Chicago Pritzker School of Medicine
Deltoid ligament insufficiency has been shown to decrease tibiotalar contact area and increase peak pressures
within the lateral ankle mortise. Sectioning of the deltoid ligament has been shown to decrease tibiotalar
contact area by 43%. This detrimental effect may create an arthritic ankle joint if left unresolved.
Reconstructive efforts thus far have been less than satisfactory. Pankovich and Shivaram described the deltoid
ligament as having superficial and deep components based on insertion sites. The superficial layer originates
from the anterior colliculus of the medial malleolus and inserts on the navicular, calcaneus and talus. The deep
layer originates from the intercollicular groove and posterior colliculus and inserts on the talus. Boss and
Hintermann noted that the most consistent and strongest bands of the deltoid were the tibiocalcaneal and
posterior deep tibiotalar ligaments. Chronic deltoid ligament insufficiency may be seen in several disorders
including trauma and sports injuries, posterior tibial tendon disorders, prior triple arthrodesis with valgus
malunion, or total ankle arthroplasty with improper component positioning or pre-existing ligament laxity.
The reconstruction of the deltoid ligament in these settings may be critical to the prevention of tibiotalar
arthrosis or failure of ankle prostheses from edge loading and polyethylene wear.
The reconstructive technique we describe, under low torque, was able to restore eversion and external
rotation stability to the talus, which was statistically similar to the native deltoid ligament. In addition, though
we maximally tension this graft to give the most secure repair possible, we did not note any increased stiffness
in the ankle joint through our measurement techniques. This unusual, positive secondary effect is different
from that noted in studies of lateral ligament reconstruction, where ligament tensioning by all methods
attempts to reproduce the native tension and not exceed it. All medial ankle ligament repairs of substance
involve some type of tendon-weave (whether autograft or allograft) to achieve reconstruction. Our technique
develops its strength not only from the anatomic orientation of the reconstructed ligament, but the strength of
the components chosen to fix the tendon graft to the bone. The use of Endobuttons allows the entire graft to sit
within the tunnels, without the potential violation of the graft ends achieved through techniques utilizing
interference screw fixation. Tensioning the graft proximally through the tibia against a rigid distal construct
allows greater tension to be placed on the graft at the deltoid ligament site itself than techniques which employ
distal tensioning while holding the ankle into inversion. Finally, the use of a looped graft proximally secured
with a post that may be moved even further proximally at the surgeon’s discretion creates superior tension to
achieve medial column rigidity in grossly unstable situations. Thus, given the critical importance of the
deltoid ligament and the relative paucity of repair/reconstruction options available, we believe this novel
approach will assist the clinician in anatomically reconstructing this challenging condition.
Deltoid ligament reconstruction technique using semitendinosis allograft, with superimposed line
drawing demonstrating orientation of looped graft.
CTEV TREATMENT WITH THE PONSETI METHOD, INCLUDING RECURRENCE
C. Saltzman
Professor and Chair, University of Utah
Clubfoot deformity is the most common congenital musculoskeletal disorder (1). Approximately one in one
thousand people are born with at least one clubfoot; between 150,000 and 200,000 babies are born with a
clubfoot each year (2). Eighty percent of these cases occur in developing countries, and the majority is left
untreated. When infants are treated with a non-invasive casting technique pioneered by Ignacio Ponseti M.D.,
they generally can be “cured” with relative ease. In the United States, 97% of patients given this treatment
can walk successfully and are able to live normal lives (3). The Ponseti Method requires several plaster casts
but either no or minimal surgery, can be taught fairly easily not only to doctors but also to healthcare workers,
nurses, and other people who have some knowledge and training in healthcare. Also, it requires plaster
casting, making it an inexpensive treatment.
Dr. Ignacio Ponseti first performed his non-invasive treatment in 1949, but didn’t publish his results
until 1963. Two more papers, published in 1979 and 1995 described the long-term outcomes of treatment. In
1996 Oxford Press published a book detailing his approach. Although the treatment has always had high
success rates, a lack of publicity prevented it from becoming more widely used until the late 1990s.
Its basic mechanism consists of a series of plaster casts and manipulations that gradually reshape the
foot around a fixed talus to obtain correction. Generally, between five and seven casts are required. The casts
extend from the toes to the upper thigh and hold the knees at a right angle. One of the most important aspects
of this method is timing: infants can be given treatment starting at seven days old and ideally should begin
treatment before reaching eight months of age.
Brazil, Uganda, Malawi and Chile now have official national programs, which are sponsored by each
country’s Ministries of Health, in which clinics in each country treat clubfoot disorder using the Ponseti
Method. China set up a national program in 2005, but with a population of 1.3 billion people, it will take
several years to complete the training. The prevalence of the Ponseti Method varies in the sixty other
countries with healthcare workers trained in the treatment.
This talk will review the principles of treatment and focus on results of recurrence after initial
treatment with the Ponseti Method.
NEW FRONTIERS IN FOOT AND ANKLE SURGERY
C. Saltzman
Professor and Chair University of Utah
Technique, inducations, complications and early outcomes with posterior ankle and subtalar
arthroscopy
A.
ANKLE ARTHROSCOPY: Tips and Pearls on Avoiding Complications
a. Introduction
i. understanding of the anatomy of the foot and ankle is critical to safe performance of
arthroscopic procedures and prevention of complications
ii. understanding of the surface and intra-articular anatomy of the ankle/subtalaar region is
essential
iii. topographical anatomy serves as a guide to the successful placement of arthroscopic
portals in the ankle
iv. neurovascular and tendinous structures are most at risk
b. Indications for Posterior / Subtalar Arthroscopy
i. Posterior ankle / ST Impingement
ii. OLT Ankle (usually posteromedial)
iii. Assist operative reduction of calc or post mal fractures
iv. Arthrodesis ankle / ST or both
v.
PL-D
c. Portals
i. Know the anatomy , use blunt dissection, minimize re-entry
ii. Preoperative plan for access , pathology , visualization
d.
Prone Position
a. Posteromedial
b. Posterolateral
c. Accessory posterolateral
e. Set-up/instrumentation
i. Positioning ii. posterior, prone
iii. Distraction- non-invasive vs invasive (trans-calcaneal thin wire)
iv. Equipment - general set-up/ instruments
scopes ( 4.0 for outside joint or fusions; 2.7 otherwise)
irrigation/pump (run at lowest flow possible)
f. Tips on Avoiding Complications
i. Patient selection and education
ii. Careful preoperative planning , evaluation
iii. Know/ respect your anatomy
iv. Meticulous portal placement / care
v. Limit operative time/ distension/ tissue damage
vi. Use mini C-arm to monitor
vii. Plan, plan and plan , if you are prepared , all will work out
viii. Rehabilitation protocol and follow up.
THE TARSOMETATARSAL JOINT AND ITS ASSOCIATION WITH
HALLUX VALGUS
L. Mason, H. Tanaka, K. Hariharan
Royal Gwent Hospital
The aetiology of hallux valgus is well published and largely debated. Hypermobility at the TMTJ was initially
described by Morton, but it was not till Lapidus that its association with hallux valgus was hypothesized.
However, little has been published on the anatomy of the tarsometatarsal joint. Our aim was to determine
whether there was an anatomical basis for the coronal hypermobility in hallux valgus.
Method: Anatomical dissection was completed on 42 feet from 23 bodies. Presence of hallux valgus
was noted (displacement of sesamoids). Measurements and photographs were taken of the first tarsometatarsal
joint and all differences noted.
Observations: The TMTJ articular morphology is variable. There were 3 separate subtypes identified
of the metatarsal articular surface.
Results: The articular subtypes identified were called called A, B and C. Type A, was uni-facet with a
single flat articular surface, Type B was bi-facet with two distinct flat articular surfaces, and Type C was trifacet, with the presence of a lateral eminence on inferolateral surface of metatarsal. Type A was found
exclusively in bodies with Hallux Valgus and Type C exclusively in bodies without Hallux Valgus. Type B
was found in both groups. Type C was more common in males and type B was more common in females.
The third facet was much more common in men. Another anomaly was found; measurements taken
from the lowest to highest point of joint surface (mm) revealed a significantly flatter joint surface in bodies
with hallux valgus.
Conclusion: Coronal plane motion in varus is a consistent feature of hallux valgus. The lateral
eminence acts as a sliding dovetail joint and prevents coronal plane motion and rotation. We believe we have
identified a joint type that is protective of the development of hallux valgus.
DETECTING MALIGNANT TUMOURS OF THE FOOT AND ANKLE WHAT ARE THE RELEVANT CLINICAL FEATURES?
S. Hazarika, S. Murray, C. Gerrand
Freeman Hospital, Newcastle
Aims. Malignant tumours of the foot and ankle are rare, but easily missed. NICE guidelines for bone and soft
tissue tumours may be less appropriate for the foot and ankle than elsewhere. The purpose of this study was to
identify the clinical features and treatment of malignant tumours arising in the foot and ankle to see if
guidelines should be modified.
Patient and Methods. This was a retrospective review of patients presenting to the Bone and Soft
Tissue Tumour Service with a suspected tumour of the foot or ankle. Between March 1998 and July 2009, 132
patients were identified from a prospectively collected database of patients reviewed at a weekly
multidisciplinary meeting.
Results. Of 132 patients, 43 had benign tumours, 26 malignant tumours and 65 tumour like conditions
(eg. ganglions, epidermal cysts, osteophytosis). In the malignant tumour group, the median duration of
symptoms prior to presentation was 24 months, with a painful, small but enlarging mass being the most
common clinical presentation. In 4 of the 26 cases (12%) unplanned excision had been undertaken prior to
referral.
Of the 26 malignant tumours, 4 were primary bone tumours (1 Ewing’s sarcoma, 1 osteosarcoma and
2 chondrosarcomas) and 22 were soft tissue tumours of which 9 (41%) were synovial sarcomas. In 15 of 26
(58%) of cases the malignant tumour was high grade. In 10 of 26 (39%), amputation was required in order to
achieve curative margins and 7 (25%) cases required soft tissue reconstructive surgery following tumour
resection.
Conclusions. The majority of malignant tumours in the foot and ankle are soft tissue in origin and
high grade. Their clinical presentation can make early detection challenging and a high index of suspicion is
required. In this review most malignant tumours presented as longstanding, small but enlarging, painful
masses. Specific guidelines for investigation and referral may be warranted in addition to the current NICE
recommendations.
MECHANICAL STABILITY OF A LOCKED STEP PLATE VERSUS
COMPRESSION SCREW FOR MEDIAL DISPLACEMENT OSTEOTOMY
OF THE OS CALCIS IN A CADAVERIS MODEL
M.J. Oddy, S. Konan, J. Meswania, G.W. Blunn, R.T. Madhav
University College London Hospitals NHS Foundation Trust
& The Centre for Biomedical Engineering, University College London
Medial Displacement Osteotomy (MDO) of the os calcis is used to correct the hind foot valgus in a flat foot
deformity. Screw fixation is commonly used although contemporary locking plate systems are now available.
This study tested the hypothesis that a 10mm MDO would support a higher load to failure with a locked step
plate than with a single cannulated screw.
Materials and Methods. Eight pairs of embalmed cadaveric limbs harvested 10cm below the knee
joint were axially loaded using a mechanical testing rig. Two pairs served as non-operated controls loaded to
4500N. The remaining limbs in pairs underwent a 10mm MDO of the os calcis and were stabilised with a
locked step plate or a 7mm cannulated compression screw. One pair was loaded to 1600N (twice body weight)
as a pilot study and the remaining 5 pairs were loaded to failure up to 4500N. The force-displacement curve
and maximum force were correlated with observations of the mechanism of failure.
Results. In one pair of control limbs, failure occurred with fractures through both os calcis bones,
whilst the other pair did not undergo mechanical failure to 4500N. In the pilot osteotomy, the plate did not fail
whilst loss of fixation with the screw was observed below 1600N. For the remaining five pairs, the median
(with 95% Confidence Intervals) of the maximum force under load to failure were 1778.81N (1099.39 –
2311.66) and 826.13N (287.52 – 1606.67) for the plate and screw respectively (Wilcoxon Signed Rank test
p=0.043). In those with screw fixation loaded to 4500N, the tuberosity fragment consistently failed by rotation
and angulation into varus.
Conclusion. In this model of load to failure with a medial displacement os calcis osteotomy, a locked
step plate supported a significantly higher maximum force than a single large cannulated screw.
INFECTION RATES IN FOOT AND ANKLE SURGERY
M.T. Williams, A.P. Molloy, D.J. Simmonds, C.K. Butcher
University Hospital Aintree
1737 elective foot and ankle cases were prospectively audited from Dec 2005 to end June 2010. All cases
were brought back to a specialist nurse dressing clinic between 10 and 17 days post op. Data was collected at
the dressing clinic with a standardised proforma on the type of surgery, the state of the wound and any
additional management required. Those patients with a pre-existing infection were excluded.
Of the 1737 cases 201 (11.6%) had a minor wound problems such as excessive post op bleeding into
the dressings, suture problems, early removal of K wires, delayed wound healing and minor infection. 42
patients required antibiotics (2.4%) 8 patients had a deep wound infection (0.5%) requiring intravenous
antibiotics and or further surgery.
There were 1185 forefoot procedures 36 of which developed an infection (3%), overall infections of
the mid / hindfoot was 6 (1%).
Practice has changed as a result of the audit (reviewed annually). We have changed our closure
techniques (reducing suture problems). For the past 2 years all of our elective foot and ankle patients now go
to an ultra clean ward (Joint Replacement Unit) and we have shown a reduction in infection rates by over 50%
since. Our infection rate before the JRU was 3.3% with 0.7% deep infection rate (818 procedures) and after
the introduction of the JRU our infection rate has ped to 1.6% superficial and 0.3% deep infection p<.001.
This large series prospective study sets a benchmark for infection rates in elective foot and ankle
surgery. It also highlights the benefit of a dedicated orthopaedic elective unit with rigorous infection control
policy and the need to regularly review our results.
AN AUDIT OF THE PROFITABILITY OF FOOT AND ANKLE SURGERY IN
A UNIVERSITY HOSPITAL FOUNDATION TRUST
A. Roche, S. Bennett, B. Fischer, A. Molloy
Aintree University Teaching Hospitals NHS Foundation Trust
NHS governance demands that services provided are clinically effective and safe. In the current financial
climate and threats over public sector spending cuts, services offered by health care providers should also be
cost-effective and profitable. Surgical specialties are often perceived as expensive with high implant costs.
The aim of this audit was to cost the profit margin for foot/ankle surgery and test the accuracy of coding data
collected.
Materials and Methods. Theatre data between January-April 2010 was retrospectively reviewed.
Equipment inventories, operation notes and radiographs were reviewed for implants used. Clinical coding data
was analysed and coded separately by the surgeon for comparison. Theatre expenses were calculated and
accuracy estimated. Tariff generated and patient expenses were calculated and a final profit margin revealed.
Wilcoxon matched-pair testing compared hospital recorded and surgeon calculated data.
Results. 95 cases were included (51 forefoot, 5 midfoot, 6 arthroscopy, 12 hindfoot, 21 other), 65
female and 30 male patients. Theatre inventories were correct in 11% of cases. Mean inventory costs recorded
were £90 and following surgeon analysis, £319. Total actual inventory cost was £30,306.23 but £8548.58 was
recorded (p<0.0001). OPCS codes were deemed correct in 43% and incorrect in 57% of cases. Operation
profit margin, including theatre, ward and salary costs was recorded as £158,229 but corrected profit margin
with d inventories and OPCS codes was £121,584 (p=0.001).
Discussion. Informed decisions on service provision depend upon the reliability of information
provided. Operative data collection by personnel needs to be improved to provide precise information to
enable more accurate income and expenditure figures.
Conclusion. Elective foot and ankle surgery is a profitable surgical sub-specialty.
METATARSOPHALANGEAL SOFT TISSUE RELEASE IN HAMMER TOE
CORRECTION: HOW MUCH IS NECESSARY?
V. Sinclair, J. Barrie
East Lancs Foot & Ankle Service
Hammer toe involves metatarsophalangeal joint (MTPJ) hyperextension and proximal interphalangeal joint
(PIPJ) flexion. Surgery commonly involves excision arthroplasty or fusion of the PIPJ with MTPJ soft tissue
release if necessary. Previous series record that MTPJ release was carried out “as required” but not how often
release is necessary. Myerson and Shereff’s (1989) cadaver study found release of the extensors, MTPJ
capsule and collateral ligaments necessary for full hammertoe correction. Hossain (2002) found the clinical
results of this procedure were no better than simple PIPJ fusion. We release the MTPJ if hyperextension
persists after PIPJ correction and release the components sequentially. We studied how often and how
extensive a release was required, and how this corelated with pre-operative assessment.
We reviewed the records of 164 patients who had hammer toe correction under one consultant
surgeon. Patients with complex corrections were excluded. The severity of the pre-operative deformity was
classified as type 1 (PIPJ and MTPJ correctable), 2 (PIPJ fixed, MTPJ correctable) or 3 (neither joint
correctable).
We
recorded
the
extent
of
release
required
for
each
toe.
Results. Of 334 type 2 toes in 146 patients, 178 (53.3%) required no MTPJ release, 11 (3.3%)
extensor tenotomy only, 15 (4.5%) extensor tenotomy and MTPJ dorsal capsulotomy and 130 (38.9%)
extensor tenotomy, capsulotomy and collateral ligament release. Of 31 type 3 toes in 18 patients, one (3.2%)
needed no release, 2 (6.5%) tenotomy, one (3.2%) capsulotomy and 27 (87.1%) complete release.
Discussion. Nearly 50% of toes needed MTP soft tissue release, partial in 8%. Pre-operative
assessment was not very accurate in predicting the need for release. We have not yet correlated need for
release with clinical outcome.
Conclusion MTP release is required in many hammertoe corrections. Assessment of toe position after
incision of each structure may avoid the need for complete release.
TARSO-METATARSAL JOINT (TMTJ) FUSION – RESULTS OF FIRST 100
JOINTS USING LOW PROFILE DORSAL LOCKING PLATE (LP)
A. Kulkarni, T. Soomro, M. Siddique
Freeman Hospital
TMTJ fusion is performed for arthritis or painful deformity. K-wire and trans-articular screws are usually used
to stabilize the joints. We present our experience with LP for TMTJ fusion in first 100 joints.
Patients and methods. 100 TMTJ in 74 patients were fused and stabilised with LP between January
2007 and December 2010. The indication was Lisfranc arthritis and hallux valgus. Iliac crest bone autograft
was used in 64 joints. Auto graft was used in 22/53 first TMT fusions. All patients post-operatively had
below knee plaster immobilization and protected weight bearing walking for first 6 weeks. Clinical and
radiological surveillance continued until bone. AOFAS midfoot scale was used as outcome measure.
Results. There were 18 male and 56 female patients with average age of 51 (14 -68). AOFAS midfoot
scale improved 42% for pain, 30% for function and 53% for alignment. Average AOFAS overall score
improved from 30 pre-op to 67 post op.
95 joints had clinical and radiological fusion. 1 patient needed removal of metalwork and 3 had
delayed wound healing and 4 had radiological non- . All non- s were in 1st TMTJ where bone graft failed and
were revised. None of the lesser ray TMTJ had non- . Average satisfaction score was 7 out of 10. 86% said
they
would
recommend
it
to
a
friend
and
91%
would
have
it
again.
Discussion. Biomechanical studies has shown plates are not as strong or stiff as trans-articular screw
fixation however they are easy to use, have more flexibility and act as a buttress for autograft. Our results
show that dorsal locking plate has satisfactory clinical out come with or without bone graft for lesser rays. 1st
TMT fusion without bone graft has higher fusion rate compare to 3 failures in 22 1st TMTJ with bone graft.
This is due to multiple factors including LP being not strong enough to sustain the stresses until creeping
substitution through the bone graft.
Conclusion. Locking plates provide satisfactory stability without complications for lesser ray with or
without bone graft. Fusion for 1st TMTJ with auto bone graft has high failure of 13%.
TOTAL ANKLE REPLACEMENT IN JUVENILE CHRONIC ARTHRITIS
G. Wansbrough, R. Sharp, P. Cooke
Nuffield Orthopaedic Centre
Juvenile Chronic Arthritis results in the early degeneration of multiple joints with severe pain and deformity.
Treatment of ankle arthritis is complex and ankle replacement is indicated because of adjacent and distant
joint involvement.
Materials and Methods. We reviewed 25 total ankle replacements in 13 young adults suffering the generalised
consequences of Juvenile Chronic Arthritis (JCA) between 2000 and 2009. 12 had bilateral disease, 20 had
anklylosis or prior fusion of the hind- or midfoot, and 16 had substantial fixed inversion of the hindfoot. All
had previous prosthetic arthroplasty of between 1 and 15 joints. Surgery comprised corrective triple fusion
where required, with staged total ankle arthroplasty at an interval of 3 or more months.
Results. All patients reported significant reduction in pain, and increased mobility with increased
stride length, however severe co-morbidity limited the usefulness of routine outcome scores. No ankles have
required revision to date.
We noted that the dimensions of the distal tibia and talus are markedly reduced in patients with JCA,
and as a result of this and bone fragility, the malleoli were vulnerable to fracture or resection. JCA is also
associated with cervical spondilitis and instability, micrognathia, temporomandibula arthritis and cricoarytenoid arthritis, resulting in challenging anaesthesia.
Discussion. As a result of our experience, we recommend preoperative CT scan to confirm whether standard
or custom implants are required. We also advocate pre-cannulation of both maleoli to reduce the rate of
fractures, and facilitate fixation should this occur.
Conclusion. Surgery for this group of patients requires specialist anaesthetic input as well as surgical
skills.
EARLY RESULTS OF MINIMALLY INVASIVE CHEILECTOMY FOR
PAINFUL HALLUX RIGIDUS
E.C.J. Dawe, T. Ball, S. Annamalai, J. Davis
Torbay Hospital
Minimally Invasive foot surgery remains controversial. Potential benefits include a reduced incidence of
wound complications, faster return to employment and normal footwear. There are no studies published
regarding the results of minimally invasive dorsal cheilectomy.
Patients and Methods. Thirty eight patients with painful grade I hallux rigidus underwent dorsal cheilectomy
between April 2006 and June 2010. Minimally invasive cheilectomy (MIC) was introduced in August 2009.
AOFAS scores, satisfaction, return to normal shoes and employment were assessed.
Results. Twenty two patients had open cheilectomy (OC) whilst 16 had MIC. Mean follow-up was 6
months for the MIC group and 35 months for the OC group. Mean AOFAS score was 75/100 (SD 17) in the
MIC group and 70/100 (SD 18). Patients rated their satisfaction as 9.1/10 for MIC and 8.6/10 for OC. There
was no significant difference in time to return to normal shoes (P = 0.32) or employment (P = 0.07).
Two patients (one MIS, one OC) had a superficial wound infection which resolved with oral
antibiotics. One patient had a first metatarsophalangeal joint fusion in the MIS group. Two patients in the OC
group went on to have a first metatarsophalangeal joint fusion and one underwent joint resurfacing.
Discussion. These results suggest MIC has comparable early results to OC. Larger studies are
required to further establish the benefits of MIC.
Conclusion. Minimally invasive dorsal cheilectomy seems to offer a safe alternative to open
cheilectomy with promising early results. Patient satisfaction with this procedure is very high.
SAFETY AND EFFICACY OF FOREFOOT SURGERY UNDER ANKLE
BLOCK ANAESTHESIA
D. Russell, A. Pillai, K. Anderson, C.S. Kumar
Glasgow Royal Infirmary
Regional anaesthetic for foot surgery has been discussed as a method of post operative analgesia. Ankle block
as the sole anaesthetic for foot surgery has not been extensively reviewed in the literature.
Aim. To describe our experience of forefoot surgery under ankle block.
Methods. 71 consecutive forefoot procedures (65 patients) were carried out under ankle block. A
mixture of 10ml 2% Lidocaine with 10ml 0.5 % Bupivacine was administered to the superficial peroneal,
deep peroneal, sural and saphenous nerves. Ankle tourniquet was employed in all procedures. Patients were
contacted post operatively and completed a standardised questionnaire including an incremented pain
assessment ranging from 0-10 (0 no pain, 10 severe pain).
Results. 61 female and 4 male patients were contacted (age range 33-67y). Procedures included 48
first metatarsal osteotomies, 15 cheilectomies, 2 first MTP joint replacements, and 6 fusions. 17 patients (26
%) reported some discomfort during the block procedure (average pain score 1.2). No patients reported any
pain during their operation(s). 14 patients (22%) required supplementation of the block. Average pain score at
6, 12, 24 and 48 hours following surgery were 0.66, 2.9, 2.4 and 1.3 respectively. All patients were
discharged home and walking on the same day. None complained of nausea or required parentral analgesia.
There were no readmissions. Each patient confirmed they would have surgery under regional block rather than
general anaesthesia and would recommend this technique to family and friends.
Discussion. There are many advantages in being able to perform these small procedures under
regional anaesthesia. Our initial observational study suggests forefoot surgery under ankle block alone may
be safe and effective. Anaesthesia obtained permits the majority of forefoot procedures and provides lasting
post-operative analgesia. Combined with intra-operative sedation, use of ankle tourniquet and same day
discharge it has very high patient acceptance and satisfaction.
DYNAMIC ULTRASOUND ASSESSMENT OF THE EFFECTS OF KNEE
AND ANKLE POSITION ON ACHILLES TENDON APPOSITION
FOLLOWING ACUTE RUPTURE
A.A. Qureshi, T. Ibrahim, W. Rennie, A.J. Furlong
University Hospitals of Leicester NHS Trust
Aim. To determine the effects of knee and ankle position on tendo Achilles (TA) gap distance in patients with
acute rupture using ultrasound.
Methods. Twenty seven patients with twenty-eight acute complete TA ruptures confirmed on ultrasound were
recruited within a week of injury. The mean age at presentation was 42 years (range 23-80 years). Ultrasound
measurements included location of the rupture and the gap distance between the superficial tendon edges with
the ankle in neutral and knee extended. The gap distance was sequentially measured with the foot in
maximum equinus and 0°, 30°, 60° and 90° of knee flexion.
Results. The mean distance of the rupture from the enthesis was 52mm (range: 40-76mm). The mean
gap distance with the ankle in neutral and knee extended was 11.4mm (95%CI: 9.9, 12.9). This reduced to
4.8mm (95%CI: 3.3, 6.4) when the foot was in maximum equinus, 3.8mm (95%CI: 2.5, 5.1) with 30° knee
flexion, 2.6mm (95%CI: 1.7, 3.6) with 60° knee flexion and 1.5mm (95% CI: 0.8, 2.2) with 90° knee flexion.
Expressing the reduction in gap distance with each successive position as a percentage of the gap distance
with the knee extended and ankle in neutral revealed a mean reduction of 58.9%, 66.9%, 77.1% and 85.9%
with maximum equinus and 0°, 30°, 60° and 90° of knee flexion respectively. The difference in gap distance
between each of these positions was statistically significant (p<0.05).
Discussion. Maximum equinus alone significantly reduces the gap distance in acute TA rupture.
Increasing knee flexion demonstrates a lesser effect throughout the initial 90° arc suggesting apposition is
encouraged by use of a below knee maximum equinus cast permitting full knee flexion.
RESURFACING OF THE METATARSAL HEAD
PRESERVATION IN ADVANCED HALLUS RIGIDUS
FOR
MOTION
C.T. Hasselman
University of Pittsburgh Medical Center, St Margaret
Introduction. The literature remains controversial on treatment of advanced stages of first metatarsophalangeal
(MTP) arthritis and frequently favors arthrodesis. However, complications and suboptimal outcomes in active
patients still remain with fusion of the first MTP joint. This study reports results of patients who underwent
metallic resurfacing of the metatarsal side of the MTP joint.
Materials and Methods. Twenty seven patients (31 implants) with stage II or III hallux rigidus
underwent resurfacing with a fourth generation (screw fixation) contoured MTP implant and were willing to
participate in a follow up study comparing pre- and postoperative radiographs, range of motion, AOFAS and
SF-36 scores. The average age of these patients was 51 years (range 35-74) and the average follow up was 54
months (range 45-66).
Results. The postoperative assessment demonstrated statistically significant improvements in range of
motion, AOFAS, and SF-36 scores (P<0.05) when compared to baseline. The mean preoperative AOFAS
scores improved from 51.5(range 35-74) to 94.1 (range 82-100). The mean preoperative active range of
motion improved from 19.7 degrees (range 5-50) to 47.9 degrees (range 25-75). The mean preoperative
passive range of motion improved from 28.0 degrees (range 10-60) to 66.3 degrees (range 40-90). The mean
SF-36 score improved from 71.2 (range 60.6-80.0) to 88.2 (range 69.6-99.1), physical health sub scores
improved from 66.8 (range 40-87) to 90.1 (range 70-98). The average time for return to work was 7 days
(range 3-20). There was one implant revision due to phalangeal disease progression. All other patients were
satisfied and willing to have the procedure performed again.
Conclusion. Current 4 and 5 year results are very promising. Preservation of joint motion, alleviation
of pain and functional improvement data are very encouraging. Because minimal joint resection is performed,
conversion to arthrodesis or other salvage procedures is relatively simple if further intervention is necessary.
DORSAL CLOSING WEDGE OSTEOTOMY, DEBRIEDEMENT AND
MICROFRACTURE FOR THE TREATMENT OF FREIBERG'S DISEASE
S.N. Maripuri, A. Kotecha, P. Brahmabhat, K. Kanakaraj, Y. Nathdwarawala
Nevill Hall Hospital, Abergavenny, Wales
Introduction. Freiberg’s infarction poses a challenge to foot and ankle surgeons. Several surgical and non
surgical treatment methods are described. We performed a dorsal closing wedge osteotomy, debridement and
microfracture of the metatarsal head. Dorsal closing wedge osteotomy helps in bringing the smooth plantar
articular surface of the metatarsal head to articulate with the phalangeal articular cartilage whilst offloading
the damaged dorsal articular cartilage. Debridement and Microfracture of the metatarsal head helps in
regeneration of the damaged cartilaage via subchondral stem cells.
Materials and Methods. Total of 15 patients (12F, 3M) underwent the above surgery between year
2002 and 2008.Mean age was 35yrs (range14-60). All of them had an extraarticular dorsal closing wedge
osteotomy fixed with a single screw along with debridement of the joint and mocrofracture of the damaged
cartilage. Post operatively heel weight bearing was allowed with a special shoe for 6 weeks. Serial
radiological assessments were done to assess healing of the osteotomy and reshaping of metatarsal head.
Patients had a mean follow up of 2.5 yrs (Range 1-6). All patients were assessed using subjective patient
satisfaction scores (scale 0-10) and AOFAS scores.
Results. 2nd metatarsal was involved in 14 and 3rd in one patient. All the osteotomies healed at a
mean period of 10 weeks (range6-18). The mean patient satisfaction score was 8 (range5-10). The mean pre
and post operative AOFAS scores were 54 and 82. One patient developed post operative haematoma which
resolved spontaneously. No other complications noted
Conclusions. A combination of dorsal closing wedge osteotomy, debridement and microfracture is a
simple, reproducible and effective method of treating Freiberg’s disease with no major complications
MINIMALLY INVASIVE HALLUX VALGUS CORRECTION: THE MICA
TECHNIQUE
R.Walker, D. Redfern
Brighton & Sussex University Hospitals
Introduction. We describe our experience with a minimally invasive Chevron and Akin (MICA) technique for
hallux valgus correction. This technique adheres to the same principles as open surgical correction but is
performed using a specialized high-speed cutting burr under image intensifier guidance via tiny skin portals.
Methods. All patients undergoing minimally invasive hallux valgus correction between November
2009 and April 2010 were included in this study and were subject to prospective clinical and radiological
review. Patients were scored using the Kitaoka score as well as radiological review and patient satisfaction
survey. Surgery was performed under general anaesthetic and included distal soft tissue release, Chevron and
Akin osteotomies, with the same indications as for open surgery. All osteotomies were internally fixed with
cannulated compression screws.
Results. 83 operations were performed on 70 patients (2 male 65 female, mean age 54 years (27-78)).
The pre-operative mean HVA was 34° and IMA 14°. Post-operative mean HVA was 9° and IMA 9.5°.
Kitaoka score improved significantly at 3-12 months follow-up. There were no delayed or non- s and no
osteonecrosis. Six M1 osteotomies moved during the postoperative period (3 feet (2 patients) required further
surgery + 3 incomplete corrections without need for further surgery) and the fixation technique was
successfully modified to avoid this problem. Mild transfer metatarsalgia was observed in 4 patients. There
were 2 superficial wound infections. Cutaneous nerve injuries were noted in 3 feet but none painful. No
recurrent deformities observed to date. Overall, 65% patients very satisfied, 29% satisfied, 6% unsatisfied.
Discussion. This study suggests that good results can be obtained in forefoot surgery with the MICA
technique. We believe this technique may offer advantages for some patients in terms of reduced morbidity
and cosmesis. A randomized study is in progress to compare open and minimally invasive techniques.
EXPERIENCE WITH A MINIMALLY INVASIVE DISTAL LESSER
METATARSAL
OSTEOTOMY
FOR
THE
TREATMENT
OF
METATARSALGIA
R. Walker, D. Redfern
Brighton & Sussex University Hospitals
In recent years the Weil osteotomy has become the dominant technique employed by most surgeons for distal
metatarsal osteotomy. This is generally a reliable technique but problems with stiffness can frequently occur
in the operated metatarso-phalangeal joints. We present our experience with a minimally invasive distal
metatarsal extra-articular osteotomy technique. This technique utilises a high-speed burr via a tiny skin portal
to perform a distal metatarsal extra-articular osteotomy under image intensifier guidance without the need for
fixation.
A consecutive series of 55 osteomies in 21 patients were included in the study. All osteotomies were
performed for metatarsalgia / restoration of metatarsal cascade. The mean age was 49 (38-78), and 20/21 were
female. The senior author performed all surgery. All patients were allowed to weight bear immediately in a
postoperative shoe and then an ordinary shoe from 4-6 week post-operatively. Mean follow-up was 8 months
(4-13) and patients were assessed clinically and scored using the AOFAS scoring system and a subjective
outcome score.
The mean AOFAS score improved significantly postoperatively. All patients were very satisfied /
satisfied with the outcome. Two patients had minor superficial portal infections, which resolved with oral
antibiotics. One patient reported irritating numbness and stiffness in toes (1st case performed). Most patients
reported swelling persisting to 3-4 months. There was one symptomatic delayed at 4 months treated
successfully with short air boot immobilisation. There were no mal unions.
This series suggests that MIS distal metatarsal osteotomy results compare well with outcomes
reported with modern open techniques such as the Weil. We now favour an MIS distal metatarsal osteotomy
technique for most indications due to the minimal stiffness observed postoperatively as well as much reduced
surgical time without the need for tourniquet.
LESS INVASIVE SINGLE INCISION FLEXOR HALLUCIS LONGUS
TRANSFER FOR CHRONIC ACHILLES TENDON RUPTURE
R. Walker, D. Redfern
Brighton & Sussex University Hospitals
Introduction. Chronic ruptures of the Achilles tendon pose a significant management challenge to the
clinician. Numerous methods of surgical reconstruction have been described and are generally associated with
a higher complication rate than with immediate repair. We report our results with a single 5cm incision
technique to reconstruct chronic Achilles tendon ruptures with transfer of FHL. This simple technique also
enables easy tensioning of the graft / reconstruction to match the uninjured leg and early mobilisation.
Materials & Methods. All patients undergoing late Achilles tendon reconstruction (over 4 months
from rupture) during the period September 2006 to January 2010 were included in the study. All patients were
treated using a single incision technique and posterior ankle FHL harvest with bio absorbable interference
screw fixation in the calcaneum. Weight bearing was allowed from 2 weeks post operatively with a dynamic
rehabilitation regime identical to that which we use following repair of acute ruptures. A retrospective review
of
the
records
was
performed
and
a
further
telephone
review
undertaken.
Results. 15 ‘late’ Achilles tendon reconstructions were undertaken in the study period. Their mean
age was 55 years (38-80). Mean time from rupture was 16 months (5-96). Significant co-morbities included
diabetes, chronic renal failure, multiple schlerosis and Parkinson’s disease. The mean duration of follow-up
was 20 months (7–38). There were no post-operative complications. AOFAS score improved significantly in
all patients and all reported good or excellent improvement in strength and return to pre-injury function
(including sport in 2 cases).
Conclusion. This less invasive single incision technique of FHL transfer reconstruction of chronic
Achilles tendon ruptures as previously published from our unit seems to be a safe and reliable undertaking in
patients with symptomatic chronic Achilles ruptures and is our preferred technique for all chronic ruptures
especially in the presence of significant co-morbities.
THE ANTERIOR EXTENSILE APPROACH FOR TALAR NECK
FRACTURES - A CADAVERIC AND CLINICAL STUDY
A. Pillai, M. Mullen, Q. Fogg, S. Kumar
Ninewells Hospital Dundee / Artculations reserch Lab-University of Glasgow
Background: Talar neck fractures occur infrequently and are associated with high complication rates.
Anatomical restoration of articular congruity is important. Adequate exposure and stable internal fixation of
these fractures are challenging.
Aims: We investigate the use of an anterior extensile approach for exposure of these fractures and
their fixation by screws introduced through the talo-navicular articulation. We also compare the quality and
quantity of exposure of the talar neck obtained by this approach with the commonly described combined
medial / lateral approaches.
Materials and Methods: An anterior approach to the talus between the tibialis anterior and the extensor
hallucis longus tendons protecting both the superficial and deep peroneal nerves was performed on 5 fresh
frozen cadaveric ankles . The surface area of talar neck accessible was measured using an Immersion Digital
Microscibe and analysed with Rhinoceros 3D graphics package. Standard antero-medial and antero –lateral
approaches were also carried out on the same ankles, and similar measurements taken. Seven patients with
talar neck fractures (4 Hawkins Type II and 3 Hawkins Type III) who underwent operative fixation using this
approach with parallel cannulated screws through the talo-navicular joint were followed and the clinical
radiological outcomes were recorded.
Results: 3D mapping demonstrated that talar surface area visible by the anterior approach (mean
1200sqmm) is consistently superior to that visible by either the medial or lateral approaches in isolation or in
combination (mean medial 350sqmm, mean lateral 600sqmm). Medial malleolar osteotomy does not offer any
additional visualisation of the talar neck. 3D reconstruction of the area visualised by the three approaches
confirms that the anterior approach provides superior access to the entirety of the talar neck. 5 male and 2
female patients (mean age -) were reviewed at a mean follow up period of 6 months. All had anatomical
articular restoration, and no wound problems. None developed non or AVN. There were no symptoms
referable to the talo-navicular joints which showed no evidence of any secondary changes on the radiographs.
Discussion: The anterior extensile approach offers superior visualisation of the talar neck in
comparison to other approaches for anatomical articular restoration. Surgical morbidity with this approach is
low, and introduction of screws through the talo-navicular joint allows stable fixation of talar neck fractures
along the axis of the bone. We argue that this approach is safe, adequate and has the potential to cause least
vascular disruption.
FOLLOW-UP OF A SERIES OF 33 ARTHROSCOPIC SUBTALAR FUSIONS
L. Jeavons, M. Butler, M. Shyam, S. Parsons
Royal Cornwall Hospital
We report a single surgeon series of 33 arthroscopic subtalar fusions performed through a 2-portal sinus tarsi
approach on 32 patients between March 2004 and February 2009. Background pathologies included primary
arthrosis, post-traumatic arthritis, planovalgus foot, rheumatoid disease, sinus tarsi syndrome and CTEV.
97% [32/33] of fusions as assessed by both clinical and radiological means were achieved within 16
weeks [76% [25/33] within 12 weeks] with only a single outlier which had fused by 22 weeks. There were no
deep infections, thrombotic events or neuromas. Five patients suffered complications of which four were
successfully treated with a satisfactory outcome. One patient developed persistent pain and was eventually
referred to another centre for further management.
In our experience arthroscopic subtalar fusion surgery has been demonstrated to give excellent outcomes with
minimal complications. Furthermore, it is a technique allowing surgery even in patients with significant
hindfoot deformity. It is a suitable operation even for patients with a compromised soft tissue envelope which
would normally preclude an open procedure.
PROSPECTIVE RANDOMISED CONTROLLED TRIAL COMPARING
CORTICAL SCREW AND TIGHTROPE FIXATION IN ACUTE
SYNDESMOSIS INJURIES OF THE ANKLE JOINT – EARLY RESULTS
R.S. Kotwal, V. Paringe, N.K. Rath, K. Lyons
University Hospital of Wales, Cardiff
Injury to the syndesmosis occurs in approximately 10% of all patients with ankle fractures. Anatomic
restoration of the syndesmosis is the only significant predictor of functional outcome. Several techniques of
syndesmosis fixation are currently used such as cortical screws, bioabsorbable screws and more recently
introduced suture-button fixation. No single technique has been shown to be superior to the others.
The objective of this research project is to investigate whether treatment with a tightrope (suturebutton fixation) gives superior results than the use of a cortical screw in the treatment of acute syndesmotic
ankle injuries with regards to function, pain, satisfaction and return to normal activities.
Research Ethics Committee approval was obtained. 40 patients with syndesmotic ankle injuries
associated with diastasis were prospectively recruited, 20 in each group. Patients were randomized to one of
the 2 groups. At 12 weeks, American Orthopaedic Foot and Ankle Society (AOFAS) scores and a
computerized tomography (CT) scan of both the ankles was obtained. At 1 year, AOFAS scores and
satisfaction was assessed.
32 patients have been recruited so far, 20 in the tightrope group and 12 in the cortical screw group.
Mean AOFAS scores at 3 months post-op were 90.67 in the Tightrope group and 84 in the screw group. The
difference was not significant (p= 0.096). CT scans revealed that the quality of syndesmosis reduction was
equally good with both the techniques. Metalwork prominence was common with both the devices.
Discussion and Conclusion. Both the devices achieved good reduction of the syndesmosis. Our CT
scan protocol has insignificant radiation risk and allows more accurate assessment of the syndesmosis. Early
clinical results do not show a significant difference in the functional outcome with the use of either device.
Long-term (1 year) follow-up has been planned.
THE MOXFQ PATIENT-REPORTED QUESTIONNAIRE: ASSESSMENT OF
DATA QUALITY, RELIABILITY AND VALIDITY IN RELATION TO FOOT
AND ANKLE SURGERY
J. Dawson, I. Boller, H. Doll, G. Lavis
Oxford University & Nuffield Orthopaedic Centre
The patient-reported Manchester-Oxford Foot Questionnaire (MOXFQ), with 3 dimensions
(Walking/standing(W/S), Pain, Social interaction(SI)) has previously been validated in patients undergoing
hallux valgus surgery. A preliminary cross-sectional evaluation of its measurement properties relating to
surgery on different regions of the foot and ankle is presented here.
Within 4 weeks prior to foot or ankle surgery, 671of 764 consecutive eligible patients (87.8% response rate)
were assessed with the: (i) MOXFQ questionnaire, (ii) SF-36 general health survey (iii) American
Orthopaedic Foot & Ankle Society (AOFAS) scales. Sample characteristics: mean age 53 years 427 (63.6%)
female. Patients were booked for (main) surgery on Hallux (210, 31.3%), Lesser Toes (119, 17.7%), Mid foot
(22, 3.3%), Ankle/Hind foot (311, 46.3%) and whole foot/multiple regions (9, 1.3%)
MOXFQ item response rates were high (<2% missing on any one item) with responses generally well
distributed across response categories. Item-total correlations within each dimension were generally above
recommended levels. Internal consistency, as assessed by Cronbach’s alpha, were 0.93, 0.84 and 0.71 for the
W/S, Pain and SI dimensions, respectively. Within Hallux, Lesser toes and Ankle/hind foot surgical
subgroups (low numbers precluded mid foot and whole/multiple region analyses), alphas for these subscales
were similar. Convergent validity of MOXFQ was demonstrated by correlations between the 3 dimensions
(W/S, Pain, SI) with similar dimensions of the SF-36 and relevant AOFAS scales. A priori hypotheses were
generally
supported.
The MOXFQ demonstrates good baseline measurement properties in patients undergoing a range of foot and
ankle surgery, suggesting its suitability as an outcome measure for clinical trials of foot and ankle surgery in
general. The SI dimension, concerned with cosmesis and social participation has somewhat weaker properties
but remains useful. Evidence for the MOXFQ’s responsiveness across the range of foot and ankle surgery is
yet to be assessed.
AN AUDIT OF THROMBOEMBOLIC DISEASE IN ELECTIVE FOOT AND
ANKLE SURGERY WITH AND WITHOUT THE USE OF ASPIRIN AS
CHEMICAL THROMBOPROHYLAXIS
C. Pearce, J. Griffiths, L. Matthews, M. Forsbrey
Basingstoke and North Hampshire NHS Foundation Trust
Thromboembolic disease is associated with a high degree of morbidity and mortality. There is increasing
pressure for elective orthopaedic patients, including those undergoing foot and ankle surgery, to be prescribed
chemical thromboprophylaxis post-operatively in order to reduce the risk of a thromboembolic event. The
risks of chemical thromboprophylaxis in terms of increased bleeding, wound problems and HIT are well
documented. The aim of this study was to determine the incidence of clinically significant thromboembolic
events in patients undergoing elective foot and ankle surgery with and without the use of aspirin.
We audited a consecutive series of 1625 patients undergoing elective foot and ankle surgery between
2003 and 2010. Between 2003 and 2006 inclusive, aspirin was used post operatively as chemical
thromboprohylaxsis. Between 2007 and 2010, no chemical thromboprohylaxsis was used. The follow-up
period for all patients was at least three months post-operatively. Most patients were reviewed at 3 months by
the senior surgeon. Those who were reviewed less than 3 months (patients undergoing minor procedures)
were contacted via telephone to confirm whether a thromboembolic event had been diagnosed.
There was no loss to follow up. Of the 1625 patients, 555 patients received aspirin and 1070 patients
received no chemical thromboprohylaxsis. 5 of 1625 (0.31%) patients developed a clinically significant
thromboembolic event. 3 patients developed a DVT at an average time of 5 weeks post operatively. 2 patients
developed non-fatal PE at an average time of 7 weeks post operatively. 3 of the 5 thromboembolic events
occurred in the aspirin group (all DVT’s) whereas 2 of the 5 (all PE) developed in the non aspirin group.
The incidence of clinically significant thromboembolic events is low in elective orthopaedic foot and
ankle surgery. We suggest that the benefit of chemical thromboprophylaxis does not outweigh its potential
risks in foot and ankle surgery.
IS IT POSSIBLE TO DO MAJOR HINDFOOT AND ANKLE OPERATIONS
AS DAY SURGERY?
J. Mangwani, D. Williamson, T. Allan
Great Western Hospital, Swindon
Introduction. Major ankle and hindfoot surgery has traditionally been performed as an inpatient. Recent
advances in minimally invasive surgery and improved post-operative pain management make it possible to
contemplate performing major ankle and hindfoot operations as a day-case. This could have a significant
impact on length of stay for these major cases, saving resources and in keeping with government policy.
In this study, we prospectively audited the outcome of the first cohort of patients undergoing major ankle and
hindfoot surgery as a day-case against a series of standards.
Methods. Twenty four consecutive patients who underwent ankle or hindfoot surgery between August
2009 and April 2010 were considered for day surgery. Seven patients were deemed not suitable due to coexisting medical conditions or insufficient help at home. This left 17 patients who had ankle or hindfoot
surgery as a day case. All patients received an ultrasound-guided regional nerve block and spinal or general
anaesthesia. The data was collected on patient demographics, diagnosis, and type of surgical procedure.
Patients received the standard follow-up regimen for a particular procedure. Patient satisfaction was assessed
using a standard questionnaire which included self-monitoring of post-operative pain at 6, 24 and 48 hrs. In
addition,
any
adverse
outcomes
were
recorded.
Results. The average age was 48 (range 23-67) years. There were 7 males and 10 females. The
surgical procedures included arthroscopic ankle fusion (5), subtalar fusion (5), talonavicular fusion (1)
midfoot fusion with calcaneal osteotomy (1), tibialis posterior reconstruction (3) tendo-achilles reconstruction
(1) and arthroscopy and lateral ligament reconstruction (1). 93% patients reported that they were given enough
information and advice about their operation as a day case. No patients reported severe pain at 6 hrs. One
patient had severe pain at 24 hrs post-op. Four patients (23%) had significant pain at 48 hrs and required
strong analgesia. Thirteen (77%) patients stated that they would recommend having this surgery as a day-case
if they were having it again whereas four (23%) would prefer staying in overnight. The average length of stay
for the patients deemed unsuitable for day surgery was 3.8 (range 1-6) days.
Conclusions. Our initial results of performing major ankle and hindfoot procedures as day surgery are
encouraging but pain control at 48 hrs still remains an unsolved issue and further optimisation is needed.
CLINICAL THROMBOEMBOLIC EVENTS AFTER ACUTE ACHILLES
TENDON RUPTURE MANAGEMENT: NON WEIGHT BEARING IN
PLASTER VERSUS FUNCTIONAL WEIGHT BEARING MOBILISATION
C. Walker, G. Aashish, M. Bhatia
Leicester Royal Infirmary
Introduction/ Aim. Thromboembolism is a significant cause of patient morbidity and mortality, the risk of
which increases in orthopaedic patients with lower limb immobilisation. It was therefore, our aim to identify
a difference in symptomatic thromboembolism by treating acute Achilles tendon rupture patients with
conventional non- weight bearing plaster versus functional weight bearing mobilisation.
Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were reviewed.
The patients’ demographics, treatment modality (non- weight bearing plaster versus weight bearing boot), and
predisposing risk factors were analysed. From the 91 patients, 50 patients with acute Achilles tendon rupture
were treated conservatively in a non- weight bearing immobilisation cast. From these 50 patients, 3 then
underwent surgery and were therefore excluded from the results. 41 patients were treated with functional
weight bearing mobilisation. Patients who did have a symptomatic thromboembolic event had an ultrasound
scan to confirm a deep vein thrombosis of the lower limb, or a CT-scan to confirm pulmonary embolism.
Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9
patients (19.1 %) had a thromboembolic event. Out of the 41 patients who were treated with functional
weight bearing mobilisation, 2 patients (4.8%) had a thromboembolic event. Thus, patients who were treated
in a non-weight bearing plaster had a significantly higher risk of developing thromboembolism (p value of
<0.05) and an increased risk ratio of 24% compared to those who were treated with functional weight bearing
mobilisation.
Conclusion. There is a significant decrease in the clinical incidence of thromboembolic events in
patients treated conservatively with early mobilisation in the functional weight bearing boot compared to
those treated in a non- weight bearing cast.
IS LAG SCREW FIXATION REALLY NECESSARY WITH PLATE
FIXATION OF OBLIQUE FRACTURES OF LATERAL MALLEOLUS?
S. Sidharthan, A. Jarvis
Western Sussex Hospitals NHS Trust, Worthing Hospital
Lag screw fixation with plate osteosynthesis is the usual recommendation for oblique non-comminuted lateral
malleolus fractures. Lag screw fixation may sometimes pose varying difficulties depending on the orientation
of the fracture and in osteoporotic bones where the process may cause disintegration of the bone.
The purpose of this study was to evaluate whether additional lag screw fixation with plate
osteosynthesis offered any advantage over plate only fixation in non-comminuted oblique fractures of the
lateral malleolus. A simple method of fixation was employed where the fracture was reduced and held
temporarily with a K wire. After fixation with plate the K wire was removed. A total of 20 patients who had
non-comminuted unstable oblique fractures of their lateral malleolus that had been surgically fixed plate only
fixation were retrospectively evaluated. The patients were aged between 17 and 70 yrs. Evaluation of the
success of fixation, complications, resultant mobility and patient satisfaction was based on information
gathered from X-ray findings and clinic notes. These results were compared to an agematched group of 20
consecutive patients treated with lag screw fixation and plate osteosynthesis. There was no significant
difference in the rate of or functional outcomes in either groups. Lag screw fixation offers no additional
advantage when combined with plate synthesis of non-comminuted oblique lateral malleolus fractures.
SURFACE ASSESSMENT AND RECONSTRUCTION OF THE INTRAOSSEOUS ARTERIAL SUPPLY OF THE TALUS
C. Senthil Kumar, R. Miller, A. Lomax, S. Kapoor, Q.A. Fogg
University of Glasgow and Glasgow Royal Infirmary
The arterial supply of the talus has been studied extensively in the past. These have been used to improve the
understanding of the risk of avascular necrosis in traumatic injuries of the talus. There is, however, poor
understanding of the intra-osseous arterial supply of the talus, important in scenarios such as osteochondral
lesions of the dome. Previous studies have identified primary sources of arterial supply into the bone, but have
not defined distribution of these sources to the subchondral regions.
This study aims to map the arterial supply to the surface of the talus. Cadaveric limbs (n=10) were
dissected to identify source vessels for each talus. The talus and navicular were removed, together with the
source vessels, en bloc. The source vessels were injected with latex and processed using a new, accelerated
diaphanisation technique. This quickly rendered tissue transparent, allowing the injected vessels to be
visualised. Each talus was then reconstructed using a digital microscribe, allowing a three dimensional virtual
model of the bone to be assessed. The terminal points of each vessel were then mapped onto this model,
allowing
the
distribution
of
each
source
vessel
to
be
determined.
This study will provide quantifiable evidence of areas consistently restricted to single-vessel supply,
and those consistently supplied by multiple vessels. These data may help to explain the distribution and
mechanisms behind the development of the subchondral cysts of the talus.
THE EXTRA AND INTRA-OSSEOUS ARTERIAL SUPPLY OF THE
NAVICULAR
C. Senthil Kumar, R. Miller, A. Lomax, S. Kapoor, Q.A. Fogg
University of Glasgow and Glasgow Royal Infirmary
There is a paucity of information on the arterial supply of the navicular, despite its anatomic neighbours,
particularly the talus, being investigated extensively. The navicular is essential in maintaining the structural
integrity of the medial and intermediate columns of the foot, and is known to be at risk of avascular necrosis.
Despite this, there is poor understanding of the vascular supply available to the navicular, and of how this
supply is distributed to the various surfaces of the bone.
This study aims to identify the key vessels that supply the navicular, and to map the arterial supply to
each surface of the bone. Cadaveric limbs (n=10) were dissected to identify source vessels for each navicular.
The talus and navicular were removed, together with the source vessels, en bloc. The source vessels were
injected with latex and processed using a new, accelerated diaphanisation technique. This quickly rendered
tissue transparent, allowing the injected vessels to be visualised. Each navicular was then reconstructed using
a digital microscribe, allowing a three dimensional virtual model of the bone to be assessed. The terminal
points of each vessel were then mapped onto this model, allowing the distribution of each source vessel to be
determined.
This study will provide the as yet unpublished information on the arterial supply of the human
navicular bone. The data will also give quantifiable evidence of any areas consistently restricted to singlevessel supply, and those consistently supplied by multiple vessels. This may help to explain the propensity of
this bone to develop disorders such as osteochondritis, avascular necrosis and stress fractures which often
have a vascular aetiology.
PERONEAL SPASTIC FLATFEET WITHOUT TARSAL COALITION AND
PRESENCE OF ACCESSORY SUBTALAR FACET - CLINICAL AND
RADIOLOGICAL FINDINGS
S. Chaudhry, H. Prem
Royal Orthopaedic Hospital, Birmingham
Painful peroneal spastic flatfeet without coalition or other known etiologies in adolescence, remains a difficult
condition to treat. We present eight such cases with radiological and surgical evidence of bony abnormalities
in the lateral subtalar region just anterior to the posterior facet.
All patients had presented as tertiary referrals with recalcitrant pain and had undergone a trial of orthotics and
physiotherapy. Diagnostic workup included a clinical and radiographic evaluation. Clinical examination
consisted of gait examination, foot alignment, range of motion, torsional profile of the lower limbs and
marking of symptomatic foci. All patients had standing weightbearing anteroposterior and lateral projections
of the foot and ankle, CT and/or MRI scans of the foot. Coalitions and other known intra-articular pathologies
like subtalar arthritis were ruled out. All patients had bilateral flatfeet but unilateral peroneal spasm.
All patients had an accessory anterolateral talar facet (ATF) which was arising as an anterior and distal
extension of the lateral process of the talus. This caused lateral impingement between the facet and the
calcaneum, confirmed by bone edema around the sinus tarsi and marked at the apex of the angle of Gissane on
MRI scans. All patients had stiff subtalar joints with very limited movement under anaesthesia, indicating
peroneal muscle contracture. Patients were treated with a combination of facet excision, fractional peroneal
and gastrosoleus lengthening and calcaneal lengthening to correct the flatfoot and prevent lateral
impingement.
DO PATIENTS WITH STABLE FOOT AND ANKLE FRACTURES WANT A
CAST?
S. Dalal, J.L. Barrie
East Lancs Foot & Ankle Service
Introduction. Many common fractures are inherently stable, will not displace and do not require plaster casting
to achieve union in a good position. Nevertheless, many patients with stable fractures are advised that they
need a cast, despite the potential for stiffness, skin problems and thromboembolism. Attempts to challenge
this practice often meet the argument that patients prefer a cast for pain relief. We analysed five years of a
single consultant’s fracture clinic to see how many patients with stable foot and ankle fractures chose a cast
after evidence-based counselling.
Materials and methods. All patients with stable fractures of the ankle or metatarsals seen between 1st
June 2005 and 31st May 2010 were included. Displaced or potentially unstable ankle fractures, Jones fractures
and fractures involving the Lisfranc joint were excluded. Patients were advised functional treatment but
offered a cast if they wished. Patients were documented prospectively as part of a larger audit, including
demographics, diagnosis and treatment in the emergency department and fracture clinic.
Results. 93 patients had stable ankle fractures. One (1%) chose a cast, 77 an ankle brace and 14 the
RICE regime. One was advised a cast for neurological deformity. 105 patients had fifth metatarsal fractures
outside the “non-” zone. 19 (18%) chose casts and 86 followed the RICE regime. 50 patients had other stable
metatarsal fractures 15 (30%) chose casts. 86% of patients had casts applied in the emergency department.
Discussion. The majority of patients with stable foot and ankle fractures do not wish to wear a cast
once they understand it will not affect their outcome. In many cases this decision could have been reached in
the emergency department with appropriate guidelines and education, preventing patient inconvenience and
possible adverse events.
Conclusion. Most patients are happy with evidence-based functional treatment of stable fractures.
ULTRASOUND GUIDED DRY NEEDLING FOR RESISTANT PLANTAR
FASCITISI – IS IT EFFECTIVE?
C. Heaver, A. Sinha, A. Marsh, R. Shave
Russells Hall Hospital, Dudley, West Midlands
Background. Plantar fasciitis is a frequently chronic and disabling cause of foot pain in adults. This
prospective study aims to evaluate the analgesic effect of ultrasound guided dry needling in patients with
chronic plantar fasciitis, refractory to conservative treatment.
Method and Materials. Patients undergoing dry needling for plantar fasciitis, followed by perifascial
injection between Jan ’09 and Feb ’10 were identified.
Pain scores were recorded on a visual analogue scale from 0 (no pain) to 10 (worst pain possible) before the
procedure, 2 weeks and 6 weeks post procedure. Patients were also contacted in April to assess their current
pain level.
Responses were graded as excellent (> 75% pain score improvement), good (50-74%), fair (25-49%) and poor
(<25% relief).
Any complications or need for any further intervention were recorded.
Results. 55 feet (46 patients) were identified. All patients had had no relief with previous treatment.
24 feet who had calf tightness had undergone a gastrocnemius muscle lengthening. All patients had
radiological confirmation of diagnosis prior to undergoing the procedure.
At 2 weeks: 1 foot lost to follow-up. 43/54 feet had excellent or good pain relief.
At 6 weeks: 5 feet (4 patients) were lost to follow up. 37 feet (28 patients) reported excellent or good pain
relief. 11/13 feet patients with fair to poor response underwent a repeat procedure.
Redo-Procedure. Using the same outcome measures, 8/11 and 9/11 feet had excellent or good
response at 2 and 6 weeks respectively.
Long-term follow-up:
42 feet (34 patients) were contacted. 13 feet (12 patients) lost to follow-up.
Follow-up duration from 2 to 13 months. Mean F/U = 7 months.
23 feet (5 redos) had excellent or good outcome 19 feet (6 redos) had fair or poor outcome.
If symptoms reoccurred, average duration of total analgesic effect was 3 months.
Conclusion. 80% and 74% of patients had excellent or good outcome at 2 and 6 weeks respectively.
After an average of 7 months follow-up, 55% patients had excellent or good results. In those patients in
whom symptoms recurred, the average duration of total analgesic effect was 3 months. We believe that
ultrasound guided dry needling is an effective treatment method for plantar fasciitis.
ACHILLES TENDINOSCOPY AND PLANTARIS TENDON RELEASE IN
THE TREATMENT OF NON- INSERTIONAL ACHILLES TENDINOPATHY
C. Pearce, J. Carmichael, J. Calder
BNHFT
Introduction. The mainstay of treatment in non-insertional Achilles tendinopathy is non-operative, however
between ¼ and 1/3 of patients fail this. The main symptom is pain which appears to be related to new nerve
endings that grow into the tendon with the neovessels from the paratenon. Treatments which strip the
paratenon from the tendon are showing promise including formal paratenon stripping via Achilles
tendinoscopy. The pain and swelling in Achilles tendinopathy is usually on the medial side leading to the
postulation that the plantaris tendon may have a role to play.
Methods. We report a consecutive series of 11 patients who underwent Achilles tendinoscopy with
stripping of the paratenon and division of the plantaris tendon, above the level of the tendinopathic changes in
the Achilles. All patients had failed conservative treatment for at least 6 months and requested surgical
intervention. The patients were scored with the SF-36, AOS and AOFAS hindfoot questionnaires preoperatively and at a minimum of 2 years post operatively. They also recorded their level of satisfaction with
the treatment at final follow up.
Results. The mean AOFAS scores significantly improved from 68 pre-op to 92 post op (p = 0.0002)
as did the AOS scores for both pain (28% pre-op to 8% post op (p=0.0004)) and disability (38% pre-op to
10% post op (p=0.0005). The mean SF-36 scores also improved but were not statistically significant (pre-op
76 post op 87 (P = 0.059).
There were no complications. 8 of the 11 patients were satisfied, the other 3 somewhat satisfied.
Conclusion. The results of Achilles tendinoscopy and division of the plantaris tendon are encouraging
but further studies are required to compare it to other treatments. It is minimally invasive and low risk so
should not affect the ability to perform a formal open procedure if unsuccessful.
EARLY MOBILISATION VS. IMMOBILISATION IN A PLASTER CAST
AFTER TOTAL ANKLE ARTHROPLASTY – DOES IT AFFECT THE
INCIDENCE OF PERI-PROSTHETIC FRACTURES
J. Ramaskandhan, E. Lingard, M. Siddique
Freeman Hospital, Newcastle upon Tyne
Introduction. Peri prosthetic fracture is a recognised complication following Total ankle arthroplasty (TAA).
There is limited literature on post operative management following TAA and controversies exist based on
surgeon preferences. This project reports the incidence of peri- prosthetic fractures in patients managed with 2
different post-operative protocols.
Materials and Methods. Patients undergoing primary TAA with a diagnosis of Osteoarthritis (OA) or
Post-traumatic Osteoarthritis (PTOA) were recruited into a randomized controlled trial. These patients did not
require any additional procedures.
Patients were consented for the trial and randomized to one of two treatment groups (Early
mobilisation after surgery vs. immobilisation in a plaster cast for 6 weeks post operatively). Plaster group
patients underwent a graduated physiotherapy program from 6-12 weeks and early mobilisation group patients
from 1-12 weeks. Complications any were recorded at 2, 4, 6 and 12 weeks post-operatively.
Results. A total of 16 ankle replacements were done for a diagnosis of OA (10) and PTOA (6). Mean
age was 58 years (±11.75) for the plaster group and 64 years (± 9.32) for the early mobilisation group. 7
patients were randomized to the plaster group and 9 patients were randomized to the early mobilisation group.
Of the plaster group 1 patient sustained an intra-operative fracture tibia and 2 patients reported with a
fractured medial malleolus. Of the early mobilisation group, 1 patient reported with a peri prosthetic fracture
tibia at 6 weeks and 3 patients reported a fractured medial malleolus at 3 months follow up.
The percentage of fracture incidence between plaster versus early immobilisation group was 42.8%
and 44.4 % respectively
Conclusions. These early results demonstrate no significant differences in the incidence of fracture
rates between groups. Further studies of post-operative management are needed to study the correlation with
peri-prosthetic fracture rates after TAA
THE INCIDENCE AND SIGNIFICANCE OF POSTERIOR TALOFIBULAR
LIGAMENT INJURY ON MAGNETIC RESONANCE IMAGING
T. Fursdon, S. Platt
Wirral University Teaching Hospital NHS Foundation Trust
Injuries to the lateral ligamentous complex of the ankle are common. The most commonly injured ligament is
the anterior talofibular ligament (ATFL) followed by the calcaneofibular ligament (CFL). The posterior
talofibular ligament (PTFL) is less commonly injured. There are few studies reporting the incidence of PTFL
injury and less data available which describes the significance of this injury. We aim to establish an incidence
of
PTFL
injury
and
allude
to
the
possible
significance
of
such
an
injury.
Methods. A retrospective review of patient notes and magnetic resonance (MR) scans dating from
September 2007 to present day was undertaken. Patients complaining of acute or chronic ankle pain, swelling,
and instability were included in the study. Exclusion criteria consisted of patients that had undergone previous
surgery to the ankle. Routine MR was performed on all patients with oblique axial, coronal and sagittal views
taken.
Results. 312 patients were included in the study. The incidence of PTFL injury was 10.9%. The PTFL
never ruptured in isolation. In 12.3% of patients the PTFL had ruptured with the ATFL and in 28.6% of
patients it had ruptured with the CFL. Osteochondral defects were also present in the majority of patients with
PTFL failure (57.1%).
Conclusion. This study confirms that the PTFL rupture is rare. It is never injured in isolation. The
frequency of incidental findings in those patients with PTFL injury is high. The commonest associated injury
was an osteochondral lesion of the talus. The inference of our findings is that patients with a PTFL rupture
have sustained a more significant ankle injury.
IMPINGEMENT LESIONS AND CHONDRAL DEFECTS IN CHRONIC
ANTEROLATERAL INSTABILITY – MRI AND ARTHROSCOPIC STUDY
A. Mahmood, D.G. Shivarathre, S.R. Platt, M.S. Hennessy
Wirral University Hospitals NHS Trust
Background. Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates
mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable
ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less
recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence
of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency.
Methods. We performed a retrospective study of all consecutive patients who underwent modified
Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to
surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven
patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory
arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings
were recorded in detail during the surgery.
Results. The mean age was 29.8 years (Range 18.2 – 58 yrs). There were 44 females and 34 males
in the study. The incidence of chondral lesions were 11.5% (9 out of 78 ankles). The commonest site for
chondral defect was the anteromedial talar dome. The incidence of anterolateral impingement which required
arthroscopic debridement was 48.7 %( 38 ankles). A further 10 ankles revealed non-specific synovitis and
scarring which was debrided. The sensitivity and specificity of the MRI scans in the assessment of chondral
lesions is 91% and 100%.
Conclusion. The incidence of chondral lesions in chronic ankle instability is lower than previously
published literature. However, soft tissue impingement lesions have a much higher incidence and require
debridement. Arthroscopic examination and debridement of impingement prior to lateral ligament
reconstruction of the ankle is quintessential in the management of chronic anterolateral instability.
IS A SHORT SCREW BETTER? TRENDS IN MEDIAL MALLEOLUS
FRACTURE FIXATION AND SUPERIOR EFFICACY OF SHORTER FULLYTHREADED CANCELLOUS SCREWS
L. Parker, P. Smitham, I. McCarthy, N. Garlick
Royal Free Hospital
Conventionally, medial malleolus fractures are treated surgically with anatomical reduction and internal
fixation using screws. There seems to be no consensus, backed by scientific study on the optimal screw
characteristics in the literature.
We retrospectively examined case notes and radiographs of 48 consecutive patients taken from our
trauma database (21 male, 27 female) with an average age of 50 years (range 16-85) who had undergone
medial malleolus fracture fixation with screws at the Royal Free Hospital, London between January 2009 and
June 2010.
The most commonly used screw was the AO 4.0 mm diameter cancellous partially-threaded screw in 40, 45
and 50 mm lengths (40 mm n = 28, 45 mm n = 26, 50 mm n = 23) with the threads passing beyond the physeal
scar in all cases. Incomplete reduction defined as > 1mm fracture displacement was observed on postoperative x-rays in 12 out of 48 cases (25%), all of which relied on partially-threaded screw fixation. In 5
cases where AO 4.0 mm diameter fully-threaded screws engaging the physeal scar had been used, no loss of
reduction was observed.
This unusual, occasional use of fully-threaded screws prompted us to investigate further using a
porcine model and adapted pedo-barographic transducer. We compared pressures generated within the
fracture site using AO 4.0 mm partially-threaded cannulated screws, 4.0 mm partially-threaded cancellous
screws and 4.0 mm fully-threaded cancellous screws.
Fully-threaded cancellous 4.0 mm diameter screws generated almost 3 times the compression of a
partially-threaded cancellous screw with superior stability at the fracture. Partially-threaded screws quickly
lost purchase, compression and stability particularly when they were cannulated. We also observed that screw
thread purchase seemed enhanced in the physeal region.
We conclude that fully-threaded cancellous 4.0 mm AO screws are superior to longer partiallythreaded screws and that use of cannulated 4.0 mm partially-threaded screws should be avoided in fixation of
medial malleolus fractures.
PROSPECTIVE RANDOMISED CONTROL TRIAL COMPARING THE
EFFICACY OF EXTRACORPOREAL SHOCKWAVE THERAPY AGAINST
PHYSIOTHERAPY
FOR
NON
INSERTIONAL
TENDOACHILLIS
TENDONITIS
V. Paringe, Ni Vannet, N. Ferran, A. Gandour
University Hospital of Wales
ECSWT has been on the medical horizon for last 30 years mainly in urology for urolithiasis and has found a
parallel use in orthopaedics for various chronic soft tissue conditions like Tendoachilles tendinoses and
plantar fasciitis etc. ECSWT acts a piezoelectric device releasing acoustic energy and causing micro-trauma
activating cytokine mediated response stimulating local angiogenesis and tissue repair.
Methodology. 56 patients were recruited for the trial after ethics approval was achieved. The
diagnosis was confirmed with ultrasound scan and measuring the width of the swelling and the local
hypervascularity. The cohort of the patients was randomised in groups for physiotherapy [n=23] and
shockwave therapy [n= 23]. The patient groups with shockwave therapy received a 3-week treatment with
typical 2000 impulses per session once a week and physiotherapy group was subjected to eccentric loading
exercises. Patients were assessed at 12 week with AOFAS, VISA-A scores and repeat ultrasound scan.
Results. The average age of the average age was 51 years [36- 73 years] Mean duration of symptoms
prior to treatment was 25 months (range 6-60 months). AOFAS scores increased in both groups: from 64⇒86
in the ECSWT group and 72⇒79 in the physiotherapy group. VISA-A scores also increased in both groups
from 39⇒73 in the ECSWT group and from 36⇒56 in the physiotherapy group. Scores were significantly
higher in the ECWST group post treatment. The ultrasound scan findings suggested the tendon girth receding
from 10.9 mm⇒9.9 mm in physiotherapy group while 9.8 mm⇒8.7 mm in the ECSWT group with
hypervascularity decreasing from marked to mild in both groups. Statistical significance was established using
SPSS 16 p < 0.001in post treatment group.
Conclusion. Clinically significant improvement was found in the patients treated with ECSWT as
compared to the physiotherapy sessions while radiological evidence showed parallel improvement in both the
groups.
AN AUDIT OF 1088 ANKLE TRAUMA PATIENTS: A DESCRIPTIVE
ANALYSIS OF PICK UP RATES AND UNWARRANTED RADIOGRAPHS
N. Morris, F. Wadia, M.R. Lovell
University Hospital of South Manchester
Introduction. Ottawa ankle rules originally described in 1992 have been shown to improve the pick-up rates of
ankle fractures and avoid the need for unnecessary X-rays, thus minimising cost and radiation to the patient.
We decided to carry out an audit at our hospital to look at the pick-up rates of ankle fractures and
ways to minimise x-rays for the patient both in A& E and in the orthopaedic department.
Methods. Ankle x-rays of 1088 trauma patients over a 7 month period from Dec 2009 to June 2010
(inclusive) were reviewed. Patients with ankle fractures were classified according to Weber type, and whether
they were treated surgically or non-operatively. Non-operatively treated ankle fractures then formed the main
sub-group of our study, looking at the number of follow-up X-rays and the amount of subsequent
displacement. The amount of displacement was classified into non-displaced (0 mm), minimally displaced
(<2mm) and displaced (>2 mm).
Results. 171 patients (out of 1088) were found to have fractured their ankle giving a pick up rate of
16%. (cf a pickup rate of 26% described in literature with implementation of Ottawa rules). The pick up rate
fluctuated each month from 31% in December to a meagre 6% fractures in June and this could be due to
summertime sports injuries causing less fractures and more sprains. We noted a third more x-rays were
ordered in Spring than Winter. There were no changes in junior staff in either the A&E or the orthopaedic
department to account for the monthly variations.
Conservatively managed fractures were followed up in the fracture clinic (n = 95, 56%) 16% (n = 11)
of the conservatively managed patients were classified as Weber A fractures 84% (n=58) as Weber B
fractures. No Weber C fractures were conservatively managed. Of the eleven Weber A fractures only one was
minimally displaced. Conservatively managed Weber A fractures received an average of 1.36 x-rays on
follow up in the Orthopaedic department. Of the Weber B fractures 42 were non-displaced whilst 16 were
minimally displaced, and these received an average of 3.23 x-rays on follow up. None of these progressed to
displacement > 2mm.
Conclusion. Based on our audit, we have introduced a policy to limit the number of follow-up of Xrays for minimally displaced and undisplaced Weber A & B fractures to one. We have also re-emphasized the
importance of Ottawa rule implementation in our A & E department
THE ROLE OF PLANTARIS LONGUS IN ACHILLES TENDINOPATHY:
A BIOMECHANICAL STUDY
F. Lintz, M. Millett, T. Barton, M. Adams
AOC Bristol, Southmead Hospital
Background. The Plantaris Longus Tendon (PLT) may be implicated in Achilles (AT) tendinopathy. Different
mechanical characteristics may be the cause. This study is designed to measure these.
Methods. Six PLT and six AT were harvested from frozen cadavers (aged 65-88). Samples were
stretched to failure using a Minimat 2000™ (Rheometric Scientific Inc.). Force and elongation were recorded.
Calculated tangent stiffness, failure stress and strain were obtained. Averaged mechanical properties were
compared using paired, one-tailed t-tests.
Results. Mean stiffness was higher (p<0.001) in the PLT, measuring 5.71 N/mm (4.68-6.64),
compared with 1.73 N/mm (1.40-2.22) in AT. Failure stress was also higher (p<0.01) in PLT: 1.42 N/mm²
(0.86-2.23) AT: 0.20 N/mm² (0.16-0.25). Failure strain was less (p<0.05) in PLT: 14.1% (11.5-16.8) than AT:
21.8% (14.9-37.9).
Conclusions. The PLT is stiffer, stronger than AT, demonstrating potential for relative movement under load.
The stiffer PLT could tether AT and initiate an inflammatory response.
THROMBOPROPHYLAXIS IN ELECTIVE FOOT AND ANKLE PATIENTS
– CURRENT PRACTICE IN THE UNITED KINGDOM
P.D. Hamilton, K. Hariharan, A.H.N. Robinson
Addenbrooke’s Hospital
The incidence of venous thromboembolism (VTE) is unknown in elective foot and ankle surgery. In March
2010 we surveyed the current practice in VTE prophylaxis in elective foot and ankle surgery amongst
members of the British Orthopaedic Foot and Ankle Society (BOFAS).
The response rate was 53%. The total the number of elective foot and ankle operations performed by
the surveyed group was 33,500 per annum. The perceived incidence of DVT, PE and fatal PE was 0.6%, 0.1%
and 0.02%. In our study the number of patients needed to treat to prevent a single fatal PE is 10,000 although
this figure is open to significant bias.
The National Institute for Health and Clinical Excellence (NICE) recently published guidelines on
reducing the risk of venous thromboembolism in surgical patients. These guidelines cover all surgical
inpatients and uses data extrapolated from other groups of patients. We question the applicability of these
guidelines to patients undergoing elective foot and ankle surgery. We consider that this data justifies the
prospective study of the incidence of VTE in patients undergoing elective foot and ankle surgery, without the
use of chemical thromboprophylaxis.
SALVAGE PROCEDURE FOR THE 1ST METATARSOPHALANGEAL
JOINT - OUR EXPERIENCE USING TRI-CORTICAL INTERPOSITION
GRAFTS, MID TERM RESULTS
A. Malhotra, P. Gallacher, N. Makwana, P. Laing, S. Hill, A. Bing
The Robert Jones and Agnes Hunt Orthopaedic Hospital
Background. Salvage procedures on the 1st MTPJ following failed arthroplasty, arthrodesis or hallux valgus
surgery are difficult and complicated by bone loss. This results in shortened first ray and transfer
metatarsalgia. We present our experience of using tri-cortical interposition grafts to manage this challenging
problem.
Methods. Between 2002 and 2009 our department performed 21, 1st MTPJ arthrodeses using a tricortical iliac crest interposition graft. Surgical fixation was achieved with a compact foot plate. We performed
a retrospective review from the medical notes and radiographs along with American Foot and Ankle scores
which were collected prospectively.
We analysed the following parameters: time to radiological, requirement for further surgery,
lengthening of 1st ray and any post operative complications.
Results. 1. Patient Demographics – Male: Female = 4:16
2. Mean age – 58 years (38-78 years)
3. Mean follow up – 35 months (4-94 months).
4. Indication for surgery –
Failed arthroplasty 8
Failed fusion 9
Previous Keller’s 1
Failed Scarfe Osteotomy 1
Avascular Necrosis 2
Total 21
5. Arthrodesis achieved – 18 patients (90%) at 4 months post surgery (2-12 months).
6. Mean AOFAS – 45 pre op, 75 post op.
7. Lengthening of 1st Ray achieved – 6 mm average (5mm – 10mm)
8. Complications – 7 (35%)
9. Major – 3 (15%) – 2 non s, 1 varus overcorrection
10. Minor – 4 (20%) – 2 superficial infection, 2 painful hardware
Conclusions. Using interposition arthrodesis for the salvage of 1st MTPJ surgery we can achieve in
90% of patients. However, the rate of complications is not low and hardware often causes irritation, requiring
removal.
TRANSMETATARSAL AMPUTATION FOR DEEP FOREFOOT
INFECTIONS IN DIABETIC PATIENTS
T.A. Ball, C.F. Taylor, R. Gornall, R. McCarthy, R.B. Paisey, J.R. Davis
South Devon Healthcare Trust, Torbay Hospital
Introduction. Uncontrolled deep sepsis in the diabetic foot often leads to below knee amputation (BKA).
However, for deep sepsis in the forefoot, a transmetatarsal amputation can be curative while preserving the
native ankle and hindfoot and allowing mobility without a prosthesis. We critically examined the outcome of
transmetatarsal amputation in our diabetic patients with forefoot ulceration and proven osteomyelitis.
Materials and Methods. Data were collected prospectively at the multidisciplinary diabetic foot clinic.
We recorded demographic details, duration of diabetes, comorbidities, nature of ulceration, radiological
findings, Texas wound score and details of surgery. Patients were followed up regularly in the diabetes clinic.
Medical records were reviewed and complications recorded.
Results. Between January 2005 and December 2008, eleven patients (nine male, two female)
underwent transmetatarsal amputation for osteomyelitis resistant to antibiotic therapy. Mean age was 58.5
years. Of the ten followed up, six had an intact hindfoot stump in Feburary 2010 (mean 36 months, range 3246). One patient died with the stump intact at 21 months. Five patients remained ambulatory, while two had
already been using a wheelchair. Three patients required BKA for continued sepsis and ischaemia.
Discussion. Given the high comorbidities of our patients, it is encouraging that 7 out of 10 patients
had successful transmetatarsal amputations. Numbers are small, as the procedure has a relatively narrow
indication (severe sepsis confined to the forefoot). In retrospect, pre-operative MRI might have helped to
delineate the extent of necrosis, and might have led to better patient ion and a lower re-operation rate.
Conclusions. BKA is not necessary for all diabetic feet with uncontrolled deep sepsis. Transmetatarsal
amputation can preserve the hindfoot and maintain ambulatory function for three years or more, even in
complex patients with comorbidities. Decision-making and perioperative care are challenging and require a
dedicated multidisciplinary team.
TALUS BIPARTITUS: THE EAST KENT EXPERIENCE
B. Rose, L. Louette
East Kent Hospitals NHS Trust
Bipartite talus is a rare condition of uncertain aetiology, possibly congenital, with only six reported cases in
the literature. Previously, these lesions have been successfully managed either conservatively, by excision of
the posterior fragment, arthrodesis or one case by internal stabilisation using a postero-anterior screw which
failed to lead to bony healing.
We report a series of four symptomatic cases of talus partitus in three patients, with a mean follow-up
of 47 months (range 25-66 months). All patients had significant pain on presentation warranting surgical
management. All three patients were male, with a mean age of 26 years (range 13-55 years) at surgery. Plain
radiographs and computed tomography scans were obtained pre-operatively. All patients were reviewed at
follow-up by an independent assessor.
The youngest patient presented aged 13 with a lesion without sub-talar arthrosis. He represented two
years later with a similar lesion on the contralateral side. He was treated twice by internal fixation with two
postero-anterior cannulated screws augmented with bone graft following preparation of the bone surfaces. The
second patient presented with symptoms of isolated sub-talar osteoarthritis. He was treated with a sub-talar
arthrodesis augmented with bone graft through a postero-lateral approach. The final patient presented late (age
55) with severe hind-foot osteoarthritis. His symptoms required treatment with tibio-talar-calcaneal fusion and
a hind-foot nail. All patients reported a resolution of their symptoms post-operatively. Evidence of was seen
radiographically in all cases.
We report the largest series to date of bipartite talus. All four cases were successfully treated
surgically with three differing techniques, all of which utilised bone graft and internal fixation to achieve bony
healing. We suggest treatment by a fusion of the talar fragments with associated limited fusion if the adjacent
joints are markedly degenerate.
IS NERVE CONDUCTION REALLY USEFUL FOR DIAGNOSING TARSAL
TUNNEL SYNDROME? AN AUDIT OF OUR EXPERIENCE (1998-2008)
K. Tsang, C. Fisher, P. Mackenney, A. Adedapo
James Cook University Hospital
Purpose. Tarsal Tunnel Syndrome (TTS) was first reported by Keck and Lam separately in 1962. It has been
regarded as the lower limb equivalent to Carpal Tunnel Syndrome (CTS). The gold standard of diagnosis
proposed over the years is nerve conduction study (NCS). In reality, TTS is much harder to diagnose and treat
compared to CTS. Signs and symptoms can be mimicked by other foot and ankle conditions. Our unit had not
seen a single positive nerve conduction result of TTS in clinically suspicious cases. We have therefore audited
our 10 year experience.
Methods and Results. This is a retrospective audit. Patient list retrieved from neurophysiology. 42
patients were identified. All were referred with a clinical suspicion of TTS. There was no single positive nerve
conduction result showing tarsal tunnel compression. Of these, 27 case notes were retrieved (64%). The
demographics are: A) age (23 to 78), B) 12 males, 15 females, and C) 12 involving left side, 4 right side and
11 bilateral. These studies were conducted according to national guidelines. There were 8 abnormal studies: 4
showing spinal radiculopathy, 3 showing higher peripheral neuropathy and 1 showing tibial nerve irritation
following previous decompression. 4 cases were operated on. These are: 2 for removal of lumps, 1 for partial
plantar fascia release, and 1 for redo-decompression. As for the rest: 16 had no change in the symptoms and
were discharged, 6 were referred to other disciplines, 2 resolved spontaneously, 2 lost to follow up and 1
resolved after a total knee replacement.
Conclusion. Our result does not reflect the findings reported in the literature in the past. Our
neurophysiologist also agreed it is very rare to see one positive test. We feel that our understanding of TTS is
not complete. The routine NCS done at resting position may not be able to replicate the clinical situations
which bring on the symptoms in the first place. Changing lifestyle and improved footwear designs may also
have contributed to a change in disease presentation. Further studies are required to clarify the situation.
MEDIAL COLUMN INSUFFICIENCY
D.T. Loveday, N.P.J. Geary
Wirral University Teaching Hospital NHS Foundation Trust
Introduction. Medial column insufficiency in patients with painful acquired flatfoot can be difficult to
appreciate. The reverse Coleman block test (as described and published by Mr E Wood in 2009) is used in this
study to predict medial column instability.
Methods. Patients who underwent a procedure for medial column insufficiency with use of the reverse
Coleman block test pre-operatively were investigated. Weight bearing radiographs were used to determine the
joints in the medial column contributing to the deformity and also to estimate the angle which the first ray
must be depressed to re-establish hindfoot neutrality. The reverse Coleman block test corrects a mobile valgus
heel to a neutral position by placing a block, of appropriate height, under the first metatarsal head. With the
heel in neutral and the relative forefoot supination compensated the foot returns to a neutral anatomic position.
Gender, age, complications and radiological outcomes were investigated.
Results. Over the last three years 25 medial column procedures were performed for painful
insufficiency on 17 females and five males by the senior author. Three patients underwent staged bilateral
procedures. The average age was 62 years old. Three feet had been on operated on the medial column
previously. The pre-operative weight bearing lateral radiographs showed instability in the medial column
greater than 5° in 12 cases. With the reverse Coleman block test instability was seen in 25 cases and the
deformity increased from an average of 7° (range 0° to 25°) to 14° (range 5° to 30°). Post-operative weight
bearing radiographs, with fusion of the unstable joint, the average medial column alignment was 1° (range 10° to 10°). Three patients developed superficial infections requiring oral antibiotics for treatment. One
patient
had
a
non-requiring
revision
surgery.
Discussion. The reverse Coleman block test revealed instability in 13 out of 27 cases not seen with
simple weight bearing lateral radiographs. The test also on average doubled the size of any deformity seen.
This aided pre-operative planning to predict the scale of deformity correction required.
Conclusion. The reverse Coleman block test is a useful test to determine medial column insufficiency
and assist with pre-operative planning.
COCHRANE DATABASE OF SYSTEMATIC REVIEWS: INTERVENTIONS
FOR TREATING OSTEOCHONDRAL DEFECTS OF THE TALUS IN
ADULTS
D.T. Loveday, R. Clifton, A.H.N. Robinson
Addenbrooke's Hospital, Cambridge
Introduction. Osteochondral defects of the talus are usually a consequence of trauma. They can cause chronic
pain and serious disability. Various interventions, non-surgical and surgical, have been used for treating these
defects. The objective of this Cochrane systematic review of randomised control trials is to determine the
benefits and harms of the interventions used for treating osteochondral defects of the talus in adults.
Methods. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the
Cochrane Central Register of Controlled Trials, MEDLINE, MEDLINE In-Process, EMBASE, Current
Controlled Trials, the WHO International Clinical Trials Registry Platform and reference lists of articles. Date
of last search: December 2009. Eligible for inclusion were any randomised or quasi-randomised controlled
clinical trials evaluating interventions for treating osteochondral defects of the talus in adults. Our primary
outcomes included pain, ankle function, treatment failure (unresolved symptoms or reoperation) and healthrelated quality of life. Preference was given to validated, patient-reported outcome measures. Two review
authors independently evaluated trials for inclusion and, for the included trial, independently assessed the risk
of bias and extracted data.
Results. One small trial with 15 participants and six months follow-up was included. This trial was
published only as a conference abstract, which provided inadequate information to judge the trial's methods
and no numerical results. The trial reported that a series of three intra-articular hyaluronan injections started
three weeks after arthroscopic microfracture did not improve pain but may have improved one aspect of
mobility. There were no available data to check this claim. An important finding of this review is that one
allegedly randomised trial, which compared three surgical interventions, was not randomised or quasirandomised. Upon further clarification from contacting the lead trial author, it became clear that this was a
comparative study only. The only other randomised trial found was an ongoing trial with a published protocol.
This is studying pulsed electromagnetic fields after arthroscopic treatment for osteochondral defects of the
talus.
Conclusions. There is insufficient evidence from randomised trials to determine which interventions
are best for osteochondral defects of the talus in adults. High quality randomised trials are required to guide
non-surgical and surgical treatment decisions for these injuries.
THE EFFECT OF A DARCO POST-OPERATIVE SHOE ON POSTURE,
BALANCE, FOREFOOT PRESSURES AND MUSCLE ACTIVITY
K. Thomason, J. Paton, K. Trimble, J.E. Metcalfe, J. Marsden
Derriford Hospital, University of Plymouth
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.
Materials and Methods. Fourteen healthy volunteers were investigated (age 36 ±10.8 yrs 11 females)
either wearing (1) left Darco shoe and right standard shoe with/without a 5cm temporary shoe raise (Algeos
Ltd) (2) two standard shoes. Postural sway was measured while standing with eyes open /closed and on / off a
foam block. Dynamic balance was measured while stepping forwards/backwards and walking. Measurements
of foot pressure (TECSKAN Inc USA), 3D body motion (Codamotion, UK) and surface electromyography of
lower limb muscles were taken. Results were analysed using a repeated measures ANOVA.
Results. The rocker shoe was associated with a 84% (±14) decrease in mean peak medial forefoot
pressure a posterior shift of 0.9 cm (±1) in the centre of pressure (COP) and a 223% (±127) increase in
tibialis anterior activity (P<0.05). Postural sway and whole body motion while stepping did not change. The
shoe raise decreased peak loading in the Darco shoe and resulted in a smaller shift in the COP.
Discussion and Conclusions. The increase in tibialis anterior activity helps maintain balance by
compensating for the posterior shift in the centre of pressure. In people with weakness in the anterior muscles
a rocker shoe may adversely affect balance. A contralateral shoe raise reduces the posterior shift in the COP
but, due to a decrease in total loading through the whole foot, forefoot offloading is similar. A contralateral
shoe raise may therefore aid balance while maintaining forefoot offloading.
THE FINANCIAL IMPACT OF DIASTASIS SCREW VERSUS TIGHTROPE
FIXATION OF UNSTABLE SYNDESMOSIS INJURIES OF THE ANKLE
J.D. Craik, S. Rajagopalan, J. Lloyd, A. Sangar, H.P. Taylor
Poole Hospital NHS Foundation Trust
Introduction. Syndesmosis injuries are significant injuries and require anatomical reduction. However,
stabilisation of these injuries with syndesmosis screws carries specific complications and many surgeons
advocate a second operation to remove the screw. Primary Tightrope suture fixation has been shown to be an
effective treatment for syndesmotic injuries and avoids the need for a second operation.
Materials and Methods. A retrospective audit identified patients who were treated for syndesmosis
injuries over a two year period. Theatre and clinic costs were obtained to compare the cost of syndesmosis
fixation using diastasis screws with the estimated cost of primary syndesmosis fixation using a Tightrope
suture.
Results. 79 patients received diastasis screw fixation of syndesmosis injuries between January 2007
and January 2009. The mean number of follow up clinic appointments was 3.7 following initial surgery, and
2.2 following diastasis screw removal. Allowing for device, theatre time and clinic appointment costs, and an
estimated average of 4 follow up appointments following Tightrope syndesmosis fixation, primary fixation
with this device could a saving of 34 theatre slots, 68 outpatient clinic appointments, and £12,138 per year at
our hospital.
Discussion. Biomechanical studies have demonstrated a reduction in normal tibiotalar external
rotation with the presence of a diastasis screw, and there are several published reports of complications when
these screws are retained. The Tightrope suture provides reduction of the syndesmosis whilst allowing normal
physiological movement at the distal tibiofibular joint and negates the need for a second operation to remove
the implant. In addition there may be improvements in foot and ankle scores and a faster return to work when
these devices are used compared with traditional screw fixation.
Conclusion. In addition to the patient benefits, our audit suggests that there may be significant
financial benefits associated with primary syndesmosis fixation with Tightrope sutures.
WHAT DO PATIENTS WANT? EVALUATION OF DEPARTMENT OF
HEALTH’S POLICY OF COPYING GP LETTERS TO PATIENTS
H. Molvik, P. Smitham, N. Cullen, D. Singh, A. Goldberg
Royal National Orthopaedic Hospital, Stanmore
Introduction. Following recommendations in the NHS Plan, all Trusts in the UK now send copies of
correspondence to patients as standard practice. It is not clear whether patients wish to receive such
correspondence, nor whether this practices an additional workload on the NHS as patients seek clarification
on the medical terminology used in their letters.
Methods. We surveyed 90 consecutive patients in three Consultant Foot & Ankle surgeons’ new
outpatient clinics at our institution. Sixty patients received a copy of the letter sent to their GP (standard
practice) and 30 patients received a letter in plain English addressed to the patient and a copy was sent to the
GP (new practice). Patients were sent a cover letter explaining the study a copy of their clinic note and also a
questionnaire that asked details about their preferred methods of communication. In addition qualitative
interviews with 4 GP Partners were carried out to harbour their opinions.
Results. 72 (80%) patients responded to the questionnaire. The majority (95%) wanted a letter about
their care, but 76% preferred a letter in plain English addressed to them (new practice) rather than a copy of
the letter sent to their GP (standard practice).
27% of respondents who received a copy of their GP letter stated that there were one or more words that they
did not understand compared to 8.3% of respondents who received letters in simple English. Many of the
patients
seeking
clarification
identified
barriers
in
obtaining
explanation.
GP’s interviewed welcomed the concept of writing directly to patients and felt that this process could lead to
improvements to patient care.
Conclusion. The practice of copying GP letters to patients is flawed, and is not consistent with what
patients’ want. Central NHS dictums should receive the same level of evidenced-based scrutiny applied to
clinical pathways.
RADIOLOGICAL OUTCOME OF PATIENTS WITH SPLAY FOOT
FOLLOWING 1ST AND 5TH METATARSAL OSTEOTOMIES PERFORMED
SIMULTANEOUSLY ON THE SAME FOOT
M. Hadi, C. Walker, R. Sheriff, F. Attar, G. Attar
Leicester Royal Infirmary
Background & aim. There have been many operations described for the treatment of hallux valgus deformities
and b ette done separately with variable success rates. Our aim is to radiologically assess the outcome
following simultaneous osteotomies to the 1st and 5th metatarsals in symptomatic patients with splay foot. To
our knowledge, this procedure has not been described in the literature yet.
Materials & method. 9 symptomatic patients (12 feet) were included in the study. The pre-operative
and post-operative X-rays were assessed and the hallux valgus angles, 1st and 2nd intermetatarsal angles,
distal metatarsal articular angles (DMAA), 4th and 5th intermetatarsal angles, maximum widths of the 1st and
5th metatarsal heads and the maximum distance between 1st and 5th metatarsals were calculated. The
improvement in the angles and distances post-operatively were then assessed for statistical significance using
Non-parametric paired T tests.
Results. Hallux valgus angles( pre op mean of 28.17o (range, 20o-40o), post-op. mean of 16.33o
(range, 4o-30o)), inter-metatarsal angles (mean of 14o (range, 9o-20o) and a post-op. mean of 9.29o (range,
4o-14o)), 1st and 5th metatarsal head widths (pre-op mean of 2.27cm and 1.27cm respectively and a post-op.
width of 1.87cm and 1.09cm respectively), and maximum distance between 1st and 5th metatarsals head (preop mean of 8.05cm (range, 7.4cm-9.1cm) and post-op mean of 7.15cm (range, 6.8cm-7.7cm) all have
significantly
decreased
post-operatively
(p<
0.05).
Conclusion. The results suggest a very good outcome in symptomatic patients following simultaneous
1st and 5th metatarsal osteotomies. All the angles measured except for the DMAA showed a statistically
significant reduction post-operatively.
ABSORBABLE NON-ADHERENT DRESSING (ABD) VS. VACUUM
ASSISTED CLOSURE (VAC) DRESSING AFTER ANKLE REPLACEMENT
SURGERY FOR PRIMARY WOUND HEALING – A RETROSPECTIVE
COHORT STUDY
A. Kulkarni, J. Ramaskandhan, F. Pagnamenta, M. Siddique
Freeman Hospital, Newcastle upon Tyne
Introduction. Ankle replacement is a major surgery with significant soft tissue dissection and bleeding. The
skin quality is often poor in these patients due to age, edema, venous congestion, arteriopathy or previous
procedures and soft tissue injury. The chances of wound infection increase with delayed wound healing.
Absorbent non-adherent dressing (ABD) and VAC dressing applied in theatre after ankle replacement were
assessed in a cohort of 147 patients with wound complications, pain, satisfaction and length of stay as
outcome measures.
Patients and methods. 71 consecutive patients were treated with ABD post-operatively after ankle
replacement. The practice was then changed to VAC dressings for 76 consecutive patients. 44 patients had
additional procedures performed with ankle replacement (11 from ABD group and 33 from VAC group).
Retrospective analysis of prospectively collected data was performed. All patients had daily pain score,
wound
status,
hospital
stay,
satisfaction
and
range
of
movement
recorded.
Results. Patients with VAC had mean pain score of 3/10 post operatively compared with 6/10 with
ABD. There was a significant difference between the length of stay between the groups (p=0.02). The average
stay of stay was 9 days with ABD and 7 days with VAC dressing. One of the patients with VAC dressing had
blisters and 1 patient developed a superficial wound infection. Of the ABD group, 3 patients developed
blisters and 7 patients had wound complications after ABD. Range of movement was similar in both groups
of
patients.
Patient’s
satisfaction
with
VAC
dressing
was
8/10.
Conclusion. VAC is better than ABD as primary dressing after ankle replacement.
OBLIQUE SHORTENING OSTEOTOMY OF LESSER METATARSALS: A
NEW TECHNIQUE
S. Morgan, J. Footee
Worthing and Southland Hospitals
Introduction. Second ray problems are common, especially chronic MTP joint dislocation, and intractable
metatarsalgia caused by a relatively long second ray we describe a new extra-articular technique that allows
considerable shortening
Patients. We retrospectively reviewed 19 patients who underwent this type of osteotomy between
2006 and 2008. Mean age at operation was 62 years (43-78). All patients were. The indications for the
operation were either MTP joint dislocation, or metatarsalgia caused by a relatively long metatarsal. This in
turn was usually due to length lost on the first ray. Functional outcome was evaluated using the ManchesterOxford foot and ankle score (MOXF), which is a validated outcome measure, the score being from zero to 64.
A low numerical score indicates a good outcome. It assesses three main domains, walking, pain and social
interaction. Range of motion, patient satisfaction and complication rates were also recorded. All patients had
AP and lateral weight bearing radiographs.
Results. At an average follow up of 20 months (5 -42) the mean total MOXF score was 17 (SD16).
The metric scores for pain was15, walking 20 and social 15. Radiographically all patients showed sound
bone. The majority of patients (16 of 19) reported that they are either ‘better’ or ‘much better’ following
surgery, in terms of pain, function and quality of life. No patient developed transfer or recurrent
metatarsalgia. No significant MTP joint stiffness was seen, and none of our patients developed osteonecrosis
of the metatarsal head.
Conclusion. Our new technique allows a planned, controlled shortening of the metatarsal with a stable
fixation. The ‘long oblique’ osteotomy heals well, and is extra-articular. This avoids the joint stiffness which
can follow the Weil osteotomy. We believe this technique makes a useful contribution to the surgical
treatment of metatarsalgia and chronic MTP joint sublu
THE USE OF LOCKING PLATES IN COMPLEX MID-FOOT FRACTURES
E. Bayley, N. Duncan, A. Taylor
Queen's Medical Centre, Nottingham
Introduction. Comminuted mid-foot fractures are uncommon. Maintenance of the length and alignment of
the medial column, with restoration of articular surface congruity, is associated with improved outcomes.
Conventional surgery has utilised open or closed reduction with K-wire fixation, percutaneous techniques,
ORIF,
external
fixation
or
a
combination
of
these
methods.
In 2003 temporary bridge plating of the medial column was described to reconstruct and stabilise the
medial column. The added advantage of locking plates is the use of angle-stable fixation. We present our
experience
with
temporary
locking
plates
in
complex
mid-foot
fractures.
Materials and methods. Prospective audit database of 12 patients over a 6 year period (2003-2009).
5 males 7 females mean age 41.9.
Mechanism of injury: 11 high-energy injuries (6 falls from height, 5 RTCs), 1 low energy injury.
Fracture type: All involved the medial column - 12 fracture dislocations of the medial column.
4 concomitant injuries to the lateral column.
All underwent ORIF, realignment, and stabilisation with locking plates across the mid-foot.
Results. Median length of time to plate removal: 3 months (range 2-6).
Prior to removal of the metalwork, there was no loss of reduction, no infections, and no implant breakage.
10 out of 12 required plate removal at 3 months.
Long-term follow-up (Mean 12.4 months, range 4-32): 11 have minimal symptoms of swelling or discomfort
from the midfoot which does not restrict their ADLs, whilst 1 patient developed post-traumatic arthritis with
medial arch collapse. No secondary procedures following plate removal.
The two patients with the plate in-situ were asymptomatic with regards to the metalwork at final
follow-up.
Conclusion. Locking plates provide adequate stabilisation following open reduction and internal
fixation of complex and unstable midfoot fracture dislocations. However, the majority will require removal of
the metalwork.
Following removal of the metalwork, satisfactory length and alignment, and stability of the midfoot,
is maintained.
A PATIENT DERIVED OUTCOME STUDY FOLLOWING SURGICAL
EXCISION OF MORTONS NEUROMA OF THE FOOT
M. Ciapryna, S. Palmer, J. Alvey
Brighton and Sussex Medical School
Background. Morton’s Neuroma is a proximal neuralgia that affects the web spaces of the toes and is
currently of unknown aetiology. Currently surgical excision is considered the gold standard treatment based
on RCT and cohort studies. However patient derived outcomes have not previously been assessed. We
addressed these aspects with our study.
Methods. The validadated patient derived Manchester Oxford Foot and Ankle Questionnaire
(MOXFQ) was used to assess patient derived outcomes of surgery prospectively. The MOXFQ enables the
generation of four scores, a combined global score as well as a pain, walking and social score. Participants
were asked to fill out the 16 item questionnaire prior to surgery and were followed up after a minimum of 6
months.
All participants were treated with neurectomy following clinical diagnosis.
Results. 3 patients (13.6%) were lost to follow up. Final Cohort: 19 feet from 17 participants (F=16,
M=1), mean age of 56. The mean reduction in the total MOXFQ score was significant (p=0.001). The pre
surgical mean score was 38.1 (95% confidence interval = 33.4 - 42.8) and after a mean follow up period of 20
months was 13.1 (95% confidence interval = 7.5 – 18.6). The reductions observed in the three metric scores
of pain, walking and social were all significant (p=0.005, p=0.008, p=0.006 respectively). Eighty four percent
of patients in the study experienced a clinically significantly improved pain domain, 95% in the walking
domain and 58% in the social domain of the MOXFQ.
Conclusions. Surgical excision is an effective intervention for treating Morton’s interdigital Neuroma
with improvements seen in all three domains of the MOXFQ. The pain metric scores were consistent with
previous studies. Neurectomy produces excellent functional improvements for patients. However patient
derived social outcomes from surgical excision were slightly more modest than for those of pain and walking.
SHORT TERM OUTCOMES OF MOBILITY TOTAL ANKLE
ARTHROPLASTY
J.R. Ramaskandhan, E.A. Lingard, M.S. Siddique
Freeman Hospital, Newcastle upon Tyne
Introduction. This project reports differences in outcome measures after total ankle arthroplasty (TAA) for
patients with Osteoarthritis (OA), Rheumatoid Arthritis (RA) and Post-traumatic Osteoarthritis (PTOA).
Materials and Methods. Patients who underwent TAA between March 2006 and May 2010 were
included. Assessments including questionnaires (height, weight, Foot and Ankle Outcome Score, SF-36) and
American Orthopaedic Foot and Ankle Score (AOFAS) were completed pre-operatively, 3, 6, and 12-months
after surgery.
Analyses of outcomes by diagnosis were adjusted for age, gender and BMI.
Results. A total of 114 TAAs performed for OA (59), PTOA (35), and RA (20). OA patients were
significantly older than PTOA (64 vs. 56, p=0.002) and more likely to be male than either RA or PTOA (78%
vs. 35% and 54%, p=0.001). PTOA and OA patients had significantly higher BMI (30 and 29) than RA (25,
p=0.002).
There were significant improvements at 12-months for AOFAS scores for all groups 31 to 75 (OA),
29 to 77 (PTOA) and 24 to 80 (RA). No significant difference in AOFAS scores between the groups at any
time.
Despite no significant difference in preoperative patient-reported measures between groups, OA
patients reported worse ankle-related pain and function outcomes compared to the RA and PTOA patients.
This trend increases at each follow-up period and was significant at 1-year for pain (p=0.03) and function
(p=0.018). PTOA patients had significantly better SF-36 scores at 1 year (p<0.05 for 5 domains).
Conclusion. These early results comparing outcomes by diagnostic groups demonstrate that PTOA and RA
patients have superior outcomes compared to patients with primary OA.
A REVIEW OF ORTHOTIC DESIGN, PATIENT COMPLIANCE AND
SATISFACTION IN AN NHS OUTPATIENT SERVICE
P. Smitham, H. Molvik, K. Smith, J. Attard, N. Cullen, D. Singh, A. Goldberg
UCL, Institute of Orthopaedics and Musculoskeletal Sciences
Royal National Orthopaedic Hospital NHS Trust
Introduction. There are approximately 1.2 million patients using orthotics in the UK costing the NHS in
excess of £100 million per annum. Despite this, there is little data available to determine efficacy and patient
compliance. There have been a few reports on patient satisfaction, which indicate that between 13-50% of
patients are dissatisfied with their orthotics. Our aim was to evaluate patient reported satisfaction with
orthotics prescribed and to investigate the reasons behind patient dissatisfaction.
Methods. Seventy consecutive patients receiving foot orthoses at the Royal National Orthopaedic
Hospital were retrospectively asked to complete a questionnaire and to bring their shoes and orthotics to
research clinic. The inside width of the shoes and corresponding width of the orthotic were measured. A semistructured interview was carried out on 10 patients, including those that were satisfied or unsatisfied, using
qualitative research methods to identify issues that are important to patients.
Results. Forty out of 70 patients (57%) completed the questionnaire either by telephone or in the
clinic. There was a statistically significant difference between the width of the orthotics and the inside
diameter of the shoes that the orthotic was meant to fit in. Dissatisfaction with the new custom made insoles
was reported in 28% of patients. Half of these patients reported that the insoles did not fit with their feet into
their shoes, and 30% indicated a preference for cosmetic issues over function. The majority of patients had
tried numerous homemade or off the shelf versions prior to attending the orthotic department.
Conclusion. There is a high level of patient dissatisfaction with orthotics. This dissatisfaction was due
to a disconnection between prescribed foot orthoses and shoes purchased by patients. There is an urgent need
to join up these two industries to prevent financial waste and improve the cost-effectiveness of orthotic
services.
LIFE AFTER 1. MTPJ ARTHRODESIS – DR SCHOLL VS MANOLO?
M. Goss, A.H. Sott
Epsom & St Helier University Hospital NHS Trust
Background. There is a general assumption amongst many patients – and some Surgeons- that 1.
Metatarsophalangeal Joint Arthrodesis “in neutral plantigrade position” will postoperatively restrict the choice
of shoes and heels in particular.
To our knowledge no studies have been carried out to assess this further.
Methods. A review of a single Surgeon’s series of 25 patients and Radiographs following neutral
1.MTPJ Arthrodesis after 14 – 38 months follow up to assess the type of shoe and height of heel comfortably
worn.
Results. Out of 18 women whose 1. MTPJ was fused in neutral 12 were able to wear at least a 2 inch
(5 cm) heel comfortably the remaining 6 wore mainly flat shoes because of contralateral disease or unrelated
reasons. All men interviewed wore a wide range of different comfortable shoes.
Conclusion. 1. MTPJ Arthrodesis in neutral does not restrict the choice of shoes/heels postoperatively.
Our findings might further strengthen the argument in favour of Arthrodesis vs Joint replacement.
THE FOREFOOT-OFFLOADING SHOE AS AN EFFECTIVE, FUNCTIONAL
AND CHEAP TREATMENT FOR METATARSAL FRACTURES
J. Young, A.H. Sott, N. Robertson, J. Hendry, J. Jacob
Epsom & St Helier University Hospital NHS Trust
Metatarsal fractures are extremely common injuries accounting for 10% of all fractures seen in our accident
and emergency departments (3). The vast majority can be treated conservatively. There is no standardised
treatment, but it is commahplace to immobilise the foot and ankle joint in a below-knee back-slab, full cast or
functional brace for a period of up to 6 weeks, weight-bearing the patient as pain allows. This practice is timeconsuming and expensive, not to mention debilitating, and carries a morbidity risk to the patient.
We describe a simple, effective and cheap treatment method for metatarsal fracture management
using the functional forefoot-offloading shoe (FOS). This is clinically proven to offload pressure on the
metatarsals and is commonly used in both elective forefoot surgery and in diabetic patients.#
Between January and September 2009, we identified 57 patients attending our fracture clinic with new
metatarsal fractures. 28 met our inclusion criteria.
All patients reported a significant improvement in their pain
At Injury – mean 8.21 out of 10 (range 4-10)
After FOS fitting - mean 2.92 out of 10 (range 0-6)
The forefoot-offloading shoe is an excellent alternative to plaster casting or functional boot
immobilisation, offering high patient satisfaction, an excellent outcome and a considerable cost-saving to the
hospital trust.