Introduction

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

Determination of ankle stability is straightforward when the injury involves both the medial and lateral malleolus. However it can be challenging when the medial injury involves the deltoid ligament. Radiographic diagnosis of ankle instability highly depends on the measurement of medial clear space. As the shape of talus has been postulated akin to a trapezoid, the medial clear space may be influenced by the portion of talus occupying the mortise. Hence the medial clear space may be influenced by the position of the ankle. We sought to evaluate the impact of ankle plantarflexion and division of the deltoid ligament on the medial clear space.

For the study 10 fresh-frozen cadaveric lower limbs were used. Mortise radiographs were taken at neutral, 15 and 30 degrees of plantarflexion and neutral external rotation. These measurements were repeated after dividing the deltoid ligament. To ensure consistent ankle position, the ankle was placed in a specially constructed rig, which recreated the above positions. The medial clear space and talar tilt were measured. Differences in the means between the groups were determined with the paired ‘t’ test and ANOVA within the groups. Statistical significance was set a p-value of 0.05.

Increasing the plantarflexion from neutral to 30 degrees in both groups resulted in increase in the medial clear space and talar tilt. The mean increase in medial clear space became statistically significant at 30 degrees when compared to neutral. Between the groups there was a significant difference in medial clear space at 30 degrees plantarflexion. Dividing the deltoid ligament also had a significant effect on talar tilt.

Plantarflexion has an influence on the medial clear space in ankle mortise views therefore pre and post ankle fixation radiographs must be interpreted with caution.

MIS (minimally invasive surgery) aims to improve cosmesis and facilitate early recovery by using a small skin incision with minimal soft tissue disruption. When using MIS in the forefoot, there is concern about neurovascular and tendon damage and cutaneous burns. The aim of this anatomical study was to identify the structures at risk with the proposed MIS techniques and to determine the frequency of iatrogenic injury.

Introduction

Brachial plexus blocks are used widely to provide intra-operative and post-operative analgesia. Their efficacy is well established, but little is known about discharging patients with a numb or weak arm. We need to quantify the risk of complications for improved informed consent.

Introduction: Tibialis posterior tendon dysfunction is a common cause of foot pain and dysfunction in the middle aged patients. Initially, it presents as medial ankle pain and swelling, with or without a flexible flat foot, later progressing on to a fixed deformity. Operative management for the early stages of tendon dysfunction poses a significant workload on hospitals and physical burden on patients. We have evaluated non-operative management of early tibialis posterior tendon dysfunction (1).

Methods: This is a prospective study on patients with stage I and II tibialis posterior tendon dysfunction treated with a structured physiotherapy protocol. Twelve consecutive patients referred to a foot and ankle consultant with early tibialis posterior dysfunction from July 2008 were included in the study. The physiotherapy regime includes repetitive resisted active dorsiflexion, inversion, eversion, heel rise, and tip toe walking. The intensity of physiotherapy is progressively increased over the period of four months in four phases. Criteria for successful rehabilitation are ability to perform greater than ten single stance heel rises and tip toe walking for more than 100 yards. Patients who cannot achieve the expected progression were re-referred for surgical intervention. All the patients were referred for support with orthoses, however, only a few received the orthoses during the treatment period. The outcome was assessed using the validated outcome score Foot Function Index (FFI) before and after physiotherapy regimen.

Results: The study group consisted of 10 females and two males with 10 unilateral and two bilateral cases. The mean age was 59 years (48 to 79). The average number of physiotherapy visits was five. Prior to treatment the mean number of single stance tip toes performed by the patients was four. Out of 12 patients, ten successfully completed the rehabilitation. The mean FFI before rehabilitation was 55, which improved to 19 at the end of four months rehabilitation. On analysis using a paired t test 95% CI for mean difference: (25.07, 46.93) P < 0.0001. The improvement was consistent with all the three components of FFI (pain, activity and function) (p< 0.0001).

Conclusion: This study suggests early tibialis posterior tendon dysfunction can be treated effectively with structured physiotherapy.

Introduction: A retrospective review was conducted on individuals who have undergone Mitchell osteotomy for mild to moderate hallux valgus deformity. Hallux valgus leads to altered load bearing function of the foot and correction of deformity might result in shortening of the first metatarsal. Transfer metatarsalgia is one of the common postoperative complication. This study aims to look at the restoration of load bearing function of the foot post deformity correction.

Methods: Patients with preoperative intermetatarsal angle of less than 14 degrees were included. Clinical records and radiographs were reviewed. Clinical evaluation done with AOFAS scores and plantar pressures recorded using musgrave system. The foot was divided into 7 regions: first metatarsal head, 2nd & 3rd metatarsal heads, 4th & 5th metatarsal heads, midfoot, heel, hallux and lesser toes. Average pressure, peak pressure distribution and contact time of all seven regions were analysed. A control group of 15 individuals with twenty normal feet were included for comparison. Statistical analysis was done with analysis of variance of the means and Pearson correlation tests.

Results: Seventeen mitchell osteotomy was performed on 13 patients with follow up ranging from 14 to 66 months, a mean of 34 months. Most of our study group were females with an age range of 25 to 71 years, a mean of 53 years. The mean postoperative AOFAS scores were 87 and a median of 90 out of 100. Pedobarograph findings: Statistically significant reduced average pressure, peak pressure and contact time were noted under hallux when compared to the normal control group. The peak pressures were reduced at all forefoot regions but statistically insignificant. Otherwise, the pressure distribution, contact time and center of pressure progression were similar to the normal feet. On analysis of correlation between the parameters observed, reduced pressure distribution under first metatarsal head lead to increased pressures under 4th, 5th metatarsal heads and lesser toes. Significant correlation found between the pressure distribution under hallux and the AOFAS scores, which reveals the outcome of procedure, depends on the load bearing characteristics of hallux and not the first MT head.

Conclusion: Mitchell osteotomy restores the load bearing function of the feet to near normal except hallux, which may affect the outcome of the procedure.

Introduction Hallux valgus (HV) leads to altered load-bearing function of the foot but there is no adequate evidence to show the restoration of load bearing function post-deformity correction where transfer metatarsalgia is the common complication. This study describes a retrospective review conducted on individuals who have undergone Mitchell and Scarf osteotomy for severe HV deformity.

Method Clinical records and radiographs were reviewed. Clinical evaluation was done using American Orthopaedic Foot and Ankle Society (AOFAS) scores and plantar pressures recorded using the Musgrave system analysing the average pressure, peak pressure distribution and contact time of the various regions of foot during the gait cycle. A control group of 15 individuals with 20 normal feet was included for comparison. Statistical analysis was carried out using ANOVA and correlation tests.

Results Twenty-two Mitchell and 22 Scarf osteotomies were performed on 28 patients with follow up ranging from 13 to 62 months. The average postoperative AOFAS scores following Mitchell and Scarf osteotomy were 74 and 84 respectively.

Pedobarograph findings: Post-Mitchell osteotomy, an insufficiency of hallux was seen, which overloads the second and third metatarsal heads. Post-Scarf osteotomy resulted in reduced peak pressures under first, second and third metatarsal heads and hallux with reduced push off during late stance phase. More pressure is transferred through heel, midfoot and lateral metatarsal heads. The centre of pressure progression is central in both the study groups. The outcome of the procedure depends on the load bearing characteristics of hallux and not the first metatarsal head.

Conclusion Mitchell osteotomy leads to abnormal load bearing characteristics of the forefoot with an unfavourable outcome. However, the Scarf procedure does not restore the load bearing characteristics to normal. A prospective study may be more valuable.

Aim: Stainsby and Briggs described a procedure for the correction of þxed claw toes. We studied the results of the Stainsby procedure in non-rheumatoid þxed claw-toes performed between March 1995 and January 2000. Method: All procedures were reviewed independently by the junior authors. The outcome was measured using the American Orthopaedic Foot and Ankle Society lesser toe scale (Kitaoka 1994). Patients were asked about overall satisfaction and whether they would recommend the operation to a family member. Results: Thirty-seven patients were operated on, four of whom died and one moved away, leaving 32 patients (38 feet, 88 toes) for study. The median age of the study patients was 59.5years (16–80 years) and median follow-up was 37 months (12–60 months). Twenty-two patients had hallux valgus, 7 pes cavus and 6 underwent salvage surgery for previous failed forefoot surgery. The median AOFAS score at follow-up was 80 (37–95). Thirty-four feet (89%) were satisfactory and 25 patients (78%) would recommend the operation. Wound problems occurred in 11 feet (29%) and transient paraesthesiae in 9 (24%). Dissatisfaction was usually due to the ßoppiness of the toe. Conclusion: The Stainsby procedure is a good salvage procedure for severe claws toes with good patient perception and function.

Aim: Myerson and Sheriff described an anatomical basis for the correction of hammertoe deformity. Based on this model we performed a metatarsophalangeal soft tissue release and proximal interphalangeal arthroplasty. Method: Patients operated between March 1995 and January 2000 were retrospectively reviewed using the American Orthopaedic Foot and Ankle Society Scores (AOFAS) by independent assessors. Results: There were 84 patients with 99 feet and 179 hammertoes with a median follow-up of 28 months. The median AOFAS score was 83 and 87% of patients had a score of more than 60 points. Eighty-three percent of patients were satisþed while 17% were dissatisþed with the procedure. Pain at the metatarsophalangeal joint was the commonest cause of dissatisfaction with 14% having moderate or severe pain. Only 2.5% had metatarsophalangeal joint instability and 9% had callus formation. There was no statistical difference regarding the age and sex of the patient, number of toes operated on, associated hallux valgus surgery and follow-up of less than or greater than 2 years. Conclusions: This study is based on an anatomical model and shows a good result with no recurrence of hammertoe correction.

A retrospective analysis was done on 20 cases of interphalangeal joint fusion of the great toe utilizing longitudinal cortical screw fixation. The purpose of this study was to present a series of interphalangeal joint fusion great toe done in both paediatric and adult patients using 3.5mm cortical screws. Most of the patients had interphalangeal joint fusion along with Jones transfer and other associated procedures with a mean follow up period of 19 months. Arthrodesis was successfully achieved in all the patients. No one had pain at the interphalangeal joint of the great toe. A literature review on interphalangeal joint arthrodesis was done and advantages of cortical screw fixation over other techniques have also been presented.

The use of peripheral nerve blocks for postoperative pain relief following foot & ankle surgery is not widespread. We conducted a prospective study evaluating the efficacy and safety of such blocks in 30 patients who underwent foot & ankle surgery over a period of three months. Sciatic/popliteal nerve blocks were carried out for hindfoot operations and ankle blocks were used in forefoot surgery. All the ankle blocks were administered preoperatively by us while the sciatic nerve blocks were administered by the anaesthetist. Postoperative pain was assessed using visual analog scales and a record was also made of the analgesic requirements at fixed time intervals. Ninety-three percent of the patients were satisfied with their pain control and recorded a pain score of 0 – 1. Only seven percent required analgesics in the immediate postoperative period and a further 30% requested analgesia after 7 – 12 hours. Sixty-three percent had good pain relief at an average of 18 hours postoperatively and did not use any additional analgesics.

We conclude that peripheral nerve blocks are very effective in post- operative pain management and this may allow many of the commonly performed foot and ankle procedures to be done as day case surgeries.

Myerson and Shereff described an anatomical basis for the correction of hammertoe deformity. Based on this model we added a metatarsophalangeal soft tissue release to a proximal interphalangeal arthroplasty as our routine method of correction of hammertoes with fixed PIP joint flexion and flexible MTP joint hyperextension.

Patients operated between March 1995 and January 2000 were retrospectively reviewed using the American Orthopaedic Foot and Ankle Society Scores (AOFAS) by independent assessors. There were 84 patients with 99 feet and 179 hammertoes with a median follow-up of 28 months. The median AOFAS score was 83. Eighty-three percent of patients were satisfied while 19% were dissatisfied with the procedure. Pain at the metatarsophalangeal joint was the commonest cause of dissatisfaction with 14% having moderate or severe pain. Nine percent had callus formation and 4% of toes were over-corrected.

There was no statistical difference in results related to the age and sex of the patient, number of toes operated on, associated hallux valgus surgery and follow-up of less than or greater than two years.

This study is based on an anatomical model and shows results comparable with other series with no recurrence of hammertoe deformity.