Background. Masses are not uncommon in the foot and ankle. Most of these masses are benign, often leading clinicians to underestimate their potential for malignancy. Methods. We conducted a retrospective review of our clinical records, on patients with histologically confirmed musculoskeletal tumours of the foot and ankle, treated in a single nstitution between 2010 and 2019. The maximum diameter of each lesion was determined through MRI or Ultrasound analysis in centimeters. To develop a scoring system we compared the risk of malignancy with five criteria: site (proximal or distal to the first TMTJ), gender, age, composition and the diameter as observed. Results. Our study included 496 patients, of whom 39 (7.9%) were identified as having malignancies. The incidence of malignancy demonstrated an increased propensity among male patients, patients over 50 years of age and lesions located proximal to the TMTJ. A ROC Analysis determined that lesions measuring over 2.85 cm had an increased risk of malignancy, with a PPV of 31.1%, a NPV of 94.2%, a Sensitivity of 0.82, and a Specificity of 0.62. These identified patterns of risk were employed to formulate a scoring system, aimed at facilitating informed clinical judgment in the referral of patients to regional tumor services. Conclusion. The new OxFAT scoring system highlights the importance of lesion size, site, age and gender of the patient in determining the risk of malignancy in lump in the foot and ankle. We propose this new scoring system to aid health care professionals in managing these patients. Based on our results any patient with a foot or ankle mass of less than 2.85cm, an OxFAT score < 4/7 and no malignant or sinister features on MRI or USS can be managed locally with excision biopsy. All other patients should be referred urgently to a Regional Tumour Service

Introduction. Osteoarthritis in the foot and ankle affects approximately 30,000 patients annually in the UK. Evidence has shown that excess weight exacerbates foot pain, with significant increases in joint forces. However, despite the current trend for Clinical Commissioning Groups to ration surgery for obese patients, studies have not yet determined the effect of weight loss in obese patients with foot and ankle arthritis. Aim. Pilot study to investigate the effect of simulated weight loss on pain scores in obese patients with symptomatic foot and ankle arthritis. Methods. Following ethical approval, a prospective study of 17 obese patients (mean BMI 39.2, range 31.2 – 50.3) with foot and ankle arthritis was undertaken (BOFAS funded). Under physiotherapist supervision, patients walked for one minute on an anti-gravity treadmill, which allowed simulated weight reduction. Following baseline assessment, reduced BMI was simulated, starting at 20, rising in increments of 5, until each patient's usual BMI was reached. Pain was assessed using a Visual Analogue Scale (VAS). Repeated measures ANOVA was used to assess for significant changes in pain, comparing baseline with each simulated BMI category (significance set at p< 0.05). Results. Simulated weight loss caused a significant reduction in pain (p=0.005, power 0.91). Mean VAS pain scores improved by 24% (p=0.003) and 17% (p=0.040) for BMI categories 20 and 25, compared with baseline. Pain scores were not significantly different comparing BMI categories of 25 and 20. Conclusion. Simulated weight loss to normal BMI significantly decreased pain in obese patients with foot and ankle arthritis. The use of the anti-gravity treadmill to demonstrate the feeling of normal BMI has also provided motivation to several patients to lose weight. The current study could be used to power future studies to investigate the effects of weight loss in foot and ankle patients

Aims. The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. Methods. This UK-based multicentre retrospective national audit studied foot and ankle patients who underwent surgery between 13 January and 31 July 2020, examining time periods pre-UK national lockdown, during lockdown (23 March to 11 May 2020), and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included. A total of 43 centres in England, Scotland, Wales, and Northern Ireland participated. Variables recorded included demographic data, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. Results. A total of 6,644 patients were included. Of the operated patients, 0.52% (n = 35) contracted COVID-19. The overall all-cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n = 9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n = 3 deaths). Matching for age, American Society of Anesthesiologists (ASA) grade, and comorbidities, the odds ratio of mortality with COVID-19 infection was 11.71 (95% confidence interval 1.55 to 88.74; p = 0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and among patients with and without COVID-19 infection. After lockdown the COVID-19 infection rate was 0.15% and no patient died of COVID-19. Conclusion. COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and postoperative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions. Cite this article: Bone Joint Open 2021;2(4):216–226

The June 2013 Foot & Ankle Roundup. 360 . looks at: soft-tissue pain following arthroplasty; pigmented villonodular synovitis of the foot and ankle; ankles, allograft and arthritis; open calcaneal fracture; osteochondral lesions in the longer term; severe infections in diabetic feet; absorbable first ray fixation; and showering after foot surgery

The December 2015 Foot & Ankle Roundup. 360 . looks at: The midfoot fusion bolt: has it had its day?; Ankle arthroplasty: only for the old?; A return to the Keller’s osteotomy for diabetic feet?; Joint sparing surgery for ankle arthritis in the context of deformity?; Beware the subtalar fusion in the ankle arthrodesis patient?; Nonunion in the foot and ankle a predictive score; Cast versus early weight bearing following Achilles tendon repair; Should we plate Lisfranc injuries?

The December 2014 Foot & Ankle Roundup360 looks at: Charcot feet, biomarkers and diabetes; weight bearing following Achilles tendon rupture; endobuttons and mal-reduced diastasis; evidence for stem cell therapies in osteochondral lesions of the talus; syndesmosis fixation in SER ankle fractures; and self-reporting for foot and ankle outcomes

Introduction. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to perform major foot/ankle operations as day-case. This could have significant impact on length of stay, saving resources and is in keeping with government policy. However, there are theoretical concerns about complications and low patient satisfaction due to pain. Methods. The survey was developed following review of the literature and was approved for distribution by the BOFAS (British Orthopaedic Foot & Ankle Society) scientific committee. An online survey (19 questions) was sent to UK foot and ankle surgeons via the BOFAS membership list. Major foot/ ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge, with day surgery as the intended pathway. Results. A total of 132 surgeons responded, 80% from Acute NHS Trusts. The majority (78%) thought that more procedures could be performed as day-case at their centre. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. Despite post-operative pain and patient satisfaction being theoretical concerns for day-case surgery in this population; these outcomes were only measured by 34% and 10% of respondents respectively. The top perceived barriers to performing more major foot and ankle procedures as day-case were: Lack of physiotherapy input pre/post-operatively (23%), Lack of out of hours support (21%). Conclusions. There is consensus among surgeons to do more major foot/ ankle procedures as day-case. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. There is a need to scope the provision of physiotherapy pre/post-operatively and out of hours support at sites where this is a perceived barrier

Abstract. Objectives. Epiphysiodesis is a commonly used treatment for lower limb angular deformities. However, in recent years, distal tibial growth modulation using ‘eight plates’ or screws has emerged as an alternative treatment for paediatric foot and ankle disorders, such as CTEV. Our objective was to assess the efficacy of distal tibial modulation in correcting various paediatric foot and ankle disorders. Methods. This retrospective study analysed 205 cases of paediatric foot and ankle disorders treated between 2003 and 2022, including only cases where the eight plate or screw was fixed on the anterior surface of the distal tibia. Our aim was to measure post-operative changes in dorsiflexion, the distal tibial angle, and the tibiocalcaneal angle by examining clinical records and radiology reports. Results. We identified nine cases (nine feet) meeting the full inclusion criteria, comprising seven cases of CTEV, one case of arthrogryposis, and one case of cavovarus foot. The cohort consisted of five male and four female patients, with a mean age of 10 years and 9 months at the time of surgery. Seven cases involved the left tibia, and two cases involved the right tibia. The mean time between pre-operative X-ray to surgery was 168 days, and the mean turnaround time between surgery and post-operative X-ray was 588 days. A mean change in the distal tibial angle of 4.33 degrees was noted. However, changes in dorsiflexion were documented in only one case, which showed a change of 13 degrees. Notably, our average distal tibial angle was significantly lower than reported in the literature, at 4.33 degrees. Additionally, some studies in the literature used the Oxford Ankle Foot Questionnaire for Children to assess pre- and post-operative outcomes, but it is important to note that it is validated only for children aged 5 to 16. Furthermore, most cases reported an improved tibiocalcaneal angle except for an anomaly of 105 degrees. We assessed satisfactory patient outcomes using patient notes. Out of the 6 procured notes, one has been discharged. The rest are still under yearly or 6-monthly review and are at various stages, such as physiotherapy, removing the eight plate, or requiring further surgery. The most common presentations at review are plantaris deformity and pain. Conclusions. Our study suggests that distal tibial growth modulation can be an effective treatment option for selected paediatric foot and ankle disorders. However, due to the limited number of cases in our study, the lack of documentation of changes in dorsiflexion, and a lack of pre- and post-operative outcomes using a standardised method, further research is needed to investigate this procedure's long-term outcomes and potential complications. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. VTE is a possible complication of foot and ankle surgery, however there is an absence of agreement on contributing risk factors in the development of VTE. The primary outcome of this study was to analyse the 90-day incidence of symptomatic VTE following foot and ankle surgery and to determine which factors may increase the risk of VTE. Methods. This was a national, multi-centre prospective audit spanning a collection duration of 9 months (2022/2023). Primary outcomes included incidence of symptomatic VTE and VTE related mortality up to 90 days following foot and ankle surgery and Achilles tendon rupture, and analysis of risk factors. Results. In total 11,363 patients were available for analysis. 5,090 patients (44.79%) were elective procedures, 4,791 patients (42.16%) were trauma procedures (excluding Achilles ruptures), 398 patients (3.50%) were acute diabetic procedures, 277 patients (2.44%) were Achilles ruptures undergoing surgery and 807 patients (7.10%) were Achilles ruptures treated non-operatively. There were 99 cases of VTE within 90 days of admission across the whole group (Total incidence = 0.87%), with 3 cases of VTE related mortality (0.03%). On univariate analysis, increased age and ASA grade showedhigher odds of 90-day VTE, as did previous cancer, stroke, history of VTE, and type of foot and ankle procedure / injury (p<0.05). However, on multivariate analysis, the only independent predictors for 90-day VTE were found to be the type of foot and ankle procedure (Achilles tendon rupture = Odd's Ratio 11.62, operative to 14.41, non-operative) and ASA grade (grade III/IV = Odd's Ratio 3.64). Conclusion. The incidence of 90-day post procedure VTE in foot and ankle surgery in this national audit was low. Significant, independent risk factors associated with the development of 90-day symptomatic VTE were Achilles tendon rupture management and high ASA grade

Abstract. Background. Distinction between foot and ankle wound healing complications as opposed to infection is crucial for appropriate allocation of antibiotic therapy. Our aim was to evaluate the diagnostic accuracy of white cell count (WCC) and C-reactive protein (CRP) as diagnostic tools for this distinction in the non-diabetic cohort. Methods. Data were reviewed from a prospectively maintained Infectious Diseases Unit database of 216 patients admitted at Leicester University Hospitals – United Kingdom between July 2014 and February 2020 (68 months). All diabetic patients were excluded. For the infected non-diabetic included patients, we retrospectively retrieved the inflammatory markers (WCCs and CRP) at the time of presentation. Values of CRP 0–10 mg/L and WCC 4.0–11.0 ×109 /L were considered normal. Results. 25 patients met our inclusion criteria. Infections were confirmed microbiologically with positive intra-operative culture results. 7 (28%) patients with foot osteomyelitis (OM), 11 (44%) with ankle OM, 5 (20%) with ankle septic arthritis, and 2 (8%) patients with post-surgical wound infection were identified. Previous bony surgery was identified in 13 (52%) patients. 21 (84%) patients did have raised inflammatory markers while 4 (16%) patients failed to mount an inflammatory response even with subsequent debridement and removal of metalwork. CRP sensitivity was 84%, while WCC sensitivity was only 28%. Conclusion. CRP had good sensitivity, whereas WCC is a poor inflammatory marker in the detection of such cases. In presence of a clinically high level of suspicion of foot or ankle infection, a normal CRP should not rule out the diagnosis of OM

Untreated clubfoot results in serious disability, but mild to moderate residual deformities can still cause functional limitations and pain. Measuring the impact of clubfoot deformities on children's wellbeing is challenging. There is little literature discussing the variability in outcomes and implications of clubfoot based on where geographically the child resides. Although the use of patient reported outcome measures (PROMs) is steadily growing in pediatric orthopaedics, few studies on clubfoot have incorporated them. The most widely used PROM for pediatric foot and ankle pathology is the Oxford Foot and Ankle Questionnaire for Children (OXFAQ-C) that include a physical, school and play, emotional and shoe wear domains. The aim of this study is to evaluate the validity and regional differences in scores of the OXFAQ-C questionnaire to identify functional disability in children with clubfoot in India and Canada. This is a retrospective cohort study of children in Indian and Canadian clubfoot registries aged 5-16 years who completed >1 parent or child OXFAQ-C. The OXFAQ-C was administered once in 01/2020 to all patients in the Indian registry, and prospectively between 06/2019 and 03/2021 at initial visit, 3, 6, 12 months post-intervention, then annually for the Canadian patients. Demographic, clubfoot, and treatment data were compared to OXFAQ-C domain scores. Descriptive statistics and regression analysis were performed. Parent-child concordance was evaluated with Pearson's Coefficient of Correlation (PCC). The cohort had 361 patients (253 from India, 108 from Canada). Non-idiopathic clubfoot occurred in 15% of children in India and 5% in Canada, and bilateral in 53% in India and 50% in Canada. Tenotomy rate was 75% in India and 62% in Canada. Median age at presentation was 3 months in India and 1 month in Canada. Mean Pirani score at presentation and number of Ponseti casts were 4.9 and 6.1 in India and 5.3 and 5.7 in Canada, respectively. Parents reported lower scores in all domains the older the child was at presentation (p Canadians scored significantly lower for all domains (p < 0 .001), with the difference being larger for child-reported scores. The greatest difference was for physical domain. Canadian parents on average scored their child 6.21 points lower than Indian parents, and Canadian children scored a mean of 7.57 lower than Indian children. OXFAQ-C scores differed significantly between Indian and Canadian children despite similar demographic and clubfoot characteristics. Younger age at presentation and tenotomy may improve OXFAQ-C scores in childhood. Parent-child concordance was strong in this population. The OXFAQ-C is an adequate tool to assess functional outcomes of children with clubfeet. Cultural validation of patient reported outcome tools is critical

Tendinopathy can commonly occur around the foot and ankle resulting in isolated rupture, debilitating pain and degenerative foot deformity. The pathophysiology and key cells involved are not fully understood. This is partly because the dense collagen matrix that surrounds relatively few resident cells limits the ability of previous techniques to identify and target those cells of interest. In this study, we apply novel single cell RNA sequencing (CITE-Seq) techniques to healthy and tendinopathic foot/ankle tendons. For the first time we have identified multiple sub-populations of cells in human tendons. These findings challenge the view that there is a single principal tendon cell type and open new avenues for further study. Healthy tendon samples were obtained from patients undergoing tendon transfer procedures; including tibialis posterior and FHL. Diseased tendon samples were obtained during debridement of intractable Achilles and peroneal tendinopathy, and during fusion of degenerative joints. Single cell RNA sequencing with surface proteomic analysis identified 10 sub-populations of human tendon derived cells. These included groups expressing genes associated with fibro-adipogenic progenitors (FAPs) as well as ITGA7+VCAM1- recently described in mouse muscle but, as yet, not human tendon. In addition we have identified previously unrecognised sub-classes of collagen type 1 associated tendon cells. Each sub-class expresses a different set of extra-cellular matrix genes suggesting they each play a unique role in maintaining the structural integrity of normal tendon. Diseased tendon harboured a greater proportion of macrophages and cytotoxic lymphocytes than healthy tendon. This inflammatory response is potentially driven by resident tendon fibroblasts which show increased expression of pro-inflammatory cytokines. Finally, identification of a previously unknown sub-population of cells found predominantly in tendinopathic tissue offers new insight into the underlying pathophysiology. Further work aims to identify novel proteins targets for possible therapeutic pathways

Introduction. Injections are used to treat a wide variety of pathologies. Our aim was to evaluate the efficacy and safety of foot and ankle injections in our clinic. Materials and methods. We performed a retrospective review of notes and a telephone questionnaire audit into the clinical outcome of all patients who underwent an injection of the foot or ankle in a year. All procedures were performed in an out-patient setting by a consultant musculoskeletal radiologist using either ultrasound or X-ray guidance, with a minimum of two year follow-up. According to the pathology treated, the type of injection included depomedrone, hyaluronic acid and high volume saline injections. Results. Overall 410/446 (92%) patients reported a significant improvement in symptoms and 227 (62%) reported complete resolution of their pain, with 127 (28%) remaining asymptomatic at two year follow-up. The mode time of recurrence of pain was three months. 59 (13%) underwent a further injection and 102 (23%) underwent operative intervention within the follow-up period. There were no reported infections. Complications occurred in two percent of patients, including steroid flare, pain and plantar plate ruptures. Conclusion. Injections are a safe and effective option for treating a variety of foot and ankle conditions and reduce the need for surgery. They are particularly effective for the treatment of ankle soft tissue impingement. They appear ineffective in providing significant improvement in pain for longer than three months in conditions such as plantar fasciitis and hallux rigidus

Introduction. Foot and ankle is a well-established and growing sub specialty in orthopaedics. It accounts for 20 to 25 per cent of an average department's workload. There are two well established foot and ankle specialist journals but for many surgeons the Journal of Bone and Surgery (JBJS) remains the preeminent journal in orthopaedics and a highly sought after target journal for publication of research. It is our belief that foot and ankle surgery is underrepresented in the JBJS. We undertook a study to test this hypothesis. Methods. We analysed all JBJS (British and American editions) volumes over a 10 year period (2001 to 2010). We recorded how many editorials, reviews, original papers and case reports were foot and ankle related. Results. of 2197 original papers published in JBJS Br only 114 (5%) were foot and ankle related. Nine out of 181 (5%) case reports, 2 out of 71 (3%) aspects of current management, none of the 51 editorials and only 3 out of 97 (3%) of reviews were foot and ankle related. In the JBJS American edition 174 out of 2117 original papers (8%), 28 out of 401 (7%) case reports, 4 out of 103 (4%) current concept reviews, 8 out of 115 (7%) instructional course lectures were foot and ankle related. Of 35 Editors on the JBJS British edition only 2 were dedicated foot and ankle surgeons, one of whom is retired. Our study reveals that foot and ankle related research accounts for a very small proportion of JBJS publications. Foot and ankle surgery needs to be proportionally represented at the editorial board level to reflect the fast growing interest in foot and ankle conditions and related research

The February 2015 Foot & Ankle Roundup. 360. looks at: Syndesmosis screw removal in randomised controlled trial; Diagnostic value of Hawkins sign; Chevron rules supreme?; Diabetes and ankle replacement; Fixed-bearing ankle replacement; Fusion for osteomyelitis of the ankle; ‘Reformed’ fallers

Objectives. The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. Design. Multicentre retrospective national audit. Setting. UK-based study on foot and ankle patients who underwent surgery between the 13. th. January to 31. st. July 2020 – examining time periods pre- UK national lockdown, during lockdown (23. rd. March to 11. th. May 2020) and post-lockdown. Participants. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Main Outcome Measures. Variables recorded included demographics, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. Results. 6644 patients were included. In total 0.52% of operated patients contracted COVID-19 (n=35). The overall all cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n=9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n=3 deaths). Matching for age, ASA and comorbidities, the OR of mortality with COVID-19 infection was 11.71 (95% CI 1.55 to 88.74, p=0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and amongst patients with and without COVID-19 infection. After lockdown COVID-19 infection rate was 0.15% and no patient died of COVID-19 infection. Conclusions. COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and post-operative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions

The April 2014 Foot & Ankle Roundup. 360 . looks at: Hawkins fractures revisited; arthrodesis compared with ankle replacement in osteoarthritis; mobile bearing ankle replacement successful in the longer-term; osteolysis is an increasing worry in ankle replacement; ankle synostosis post-fracture is not important; radiofrequency ablation for plantar fasciitis; and the right approach for tibiotalocalcaneal fusion

The June 2015 Foot & Ankle Roundup. 360 . looks at: Syndesmosis and outcomes in ankle fracture; Ankle arthrodesis or arthroplasty: a complications-based analysis; Crosslinked polyethylene and ankle arthroplasty; Reducing screw removal in calcaneal osteotomies; Revisiting infection control policies; Chevron osteotomy: proximal or distal?; Ankle distraction for osteoarthritis

The April 2015 Foot & Ankle Roundup. 360 . looks at: Plantar pressures linked to radiographs; Strength training for ankle instability?; Is weight loss good for your feet?; Diabetes and foot surgery complications; Tantalum for failed ankle arthroplasty?; Steroids, costs and Morton’s neuroma; Ankle arthritis and subtalar joint

The October 2015 Foot & Ankle Roundup. 360 . looks at: TightRope in Weber C fractures; A second look at the TightRope; Incisional VAC comes of age?; Platelet-derived growth factor and ankle fusions; Achilles tendon rehab in the longer term following surgery; Telemedicine for diabetic foot ulcer