Pes cavovarus is a foot deformity that can be idiopathic (I-PC) or acquired secondary to other pathology. Charcot-Marie-Tooth disease (CMT) is the most common adult cause for acquired pes cavovarus deformity (CMT-PC). The foot morphology of these distinct patient groups has not been previously investigated. The aim of this study was to assess if morphological differences exist between CMT-PC, I-PC and normal feet (controls) using weightbearing computed tomography (WBCT). A retrospective analysis of WBCT scans performed between May 2013 and June 2017 was undertaken. WBCT scans from 17 CMT-PC, 17 I-PC and 17 healthy normally-aligned control feet (age-, side-, sex- and body mass index-matched) identified from a prospectively collected database, were analysed. Eight 2-dimensional (2D) and three 3-dimensional (3D) measurements were undertaken for each foot and mean values in the three groups were compared using one-way ANOVA with the Bonferroni correction.Introduction
Methods
Studies have compared outcomes of first metatarsophalangeal joint (MTPJ1) implant hemiarthroplasty and arthrodesis, but there is a paucity of data on the influence of patient factors on outcomes. We evaluated data from a prospective, RCT of MTPJ1 implant hemiarthroplasty (Cartiva) and arthrodesis to determine the association between patient factors and clinical outcomes. Patients ≥18 years with Coughlin hallux rigidus grade 2, 3, or 4 were treated with implant MTPJ1 hemiarthroplasty or arthrodesis. Pain VAS, Foot and Ankle Ability Measure (FAAM) Sports and ADL, and SF-36 PF scores were obtained preoperatively, and at 2, 6, 12, 24, 52 and 104 weeks postoperatively. Final outcomes, MTPJ1 active peak dorsiflexion, secondary procedures, radiographs and safety parameters were evaluated for 129 implant hemiarthroplasties and 47 arthrodeses. Composite primary endpoint criteria for clinical success included pain reduction ≥30%, maintenance/improvement in function, and no radiographic complications or secondary surgical intervention at 24 months. Predictor variables included: grade; gender; age; BMI; symptom duration; prior MTPJ1 surgery; preoperative hallux valgus angle, ROM, and pain. Two-sided Fisher's Exact test was used (Introduction
Methods
Patients with advanced stage hallux rigidus from 12 centers in Canada and the UK were randomized (2:1) to treatment with a small (8/10 mm) hydrogel implant (Cartiva) or 1st MTP arthrodesis. VAS pain scale, validated outcome measures (FAAM sport scale), great toe active dorsiflexion motion, secondary procedures, radiographic assessment and safety parameters were evaluated. 236 patients were initially enrolled, 17 patients withdrew prior to randomization, 17 patients withdrew after randomization and 22 were non-randomized training patients, leaving 152 implant and 50 arthrodesis patients. Standard demographics and baseline outcomes were similar for both groups. Mean VAS pain scores decreased from 6.8 and 6.9 respectively for the implant and arthrodesis groups from baseline to 1.4 and 0.7 at 24 months. Similarly, the FAAM sports score improved significantly from baseline levels of 37 and 36 to 24 months level of 77 and 82 respectively for the implant and arthrodesis groups. First MTP active dorsiflexion motion improved an average of 4° at 3 months after implant placement and was maintained at 24 months. Secondary surgeries occurred in 17 (11.2%) implant patients and 6 (12.0%) arthrodesis patients. Fourteen (9.2%) implants were removed and converted to arthrodesis and 6 (12.0%) arthrodesis patients had painful hardware requiring removal. There was no case of implant fragmentation, wear, or bone loss. Analysis of a single composite endpoint utilizing the three primary study outcomes (pain, function, and safety) showed statistical equivalence between the2groups. In patients requiring surgery for advanced stage hallux rigidus, treatment with a small synthetic cartilage implant resulted in comparable clinically important pain relief and functional outcomes compared to 1st MTP arthrodesis while preserving and often improving great toe motion. Secondary surgical intervention was similar in the implant and arthrodesis groups. Revision from a small implant plug to arthrodesis can be performed if needed.Conclusion
This study used the lunge test to measure the difference between ankle dorsiflexion with the knee flexed and extended in persons with and without foot and ankle pathology. This may help us devise a weight bearing test for GT. There is little credible research comparing GT in people with and without foot and ankle pathology. There is no normative data for ankle dorsiflexion range measured using a Lunge test and prevalence of GT in the normal population. 97 ankles with foot and ankle (FA) pathology and 89 ankles of healthy volunteers (HV) without FA pathology were recruited from the royal national orthopaedic hospital (RNOH). Degrees of ankle dorsiflexion range were measured using an inclinometer and a version of the lunge test with the knee flexed and extended. These findings were then compared between groups.Rationale
Methodology
Wound healing and poor bone healing are complications seen in patients who smoke and some surgeons prefer not to operate on smokers. However, self reporting of smoking by patients may be biased. This study compares self-reporting of smoking habits and cotinine levels in the urine of our patients. 77 patients admitted for an osteotomy or arthrodesis procedure between September 2013 and May 2014 agreed to participate in this study. A questionnaire was completed and a urine sample was obtained and tested for cotinine, a metabolite of nicotine, by 2 techniques: a dipstick, the COT One Step Cotinine Test, yielding a positive result when the cotinine in the urine exceeds 200 ng/mL and the Concateno laboratory assay test, providing a mean value to give a qualitative reading whereby the cut off for non-smokers is 500ng/ml.Introduction:
Method:
With the advent of standing CT and MRI scans, there is increasing interest in establishing the role and usefulness of these investigations. When ordering a standing investigation, we assume that 100% of body weight is loaded through the limb, but most machines have handlebars for support and some have seats to allow patients the opportunity to sit. The aim of this study was to evaluate the amount of load going through the lower limbs in various positions supported and unsupported, to explore the range and variation in measurements obtained. Following ethics and local IRB approval, 40 healthy volunteers were asked to stand on an electronic weighing scales and be measured for height. They were then asked to stand on an identical electronic weighing scale on the PedCAT standing CT. Their weight was measured single and double leg stance, with the hands supported and unsupported on the side bars. The subjects were then asked to sit with a single and then both legs on the scale.Aims:
Methods:
Cone Based CT (CBCT) scanning uses a point source and a planar detector with parallel data acquisition and volumetric coverage of the area of interest. The pedCAT (Curvebeam USA) scanner is marketed as a low radiation dose, compact, faster and inexpensive CT scanner that can be used to obtain both non- weightbearing and true 3 dimensional weightbearing views. A review of the first 100 CBCT scanning in our unit has been performed to assess ease of scanning, imaging time, radiation dose and value of imaging as opposed to conventional imaging.Introduction:
Method:
Bone Marrow Oedema Syndrome (BMOS) is an unusual and poorly understood condition. It commonly affects the hips and knees and is reported to have a tendency to recur. The foot and ankle are less frequently involved but nevertheless patients can be severely impaired. Only case reports of BMOS of the foot and ankle have been published. The aim of this study is to evaluate the sites of occurrence, risk factors, efficacy of immobilisation, response to intravenous biphosphonates and local or remote recurrence over the following years. A retrospective review of 25 adult patients who have been diagnosed with BMOS have been followed-up for an average of 5.8 years (range: 2–11). Six patients have not been traced.Introduction
Methods
The focus on evidence-based medicine has led to calls for increased levels of evidence in surgical journals. The purpose of the present study was to review the levels of evidence in articles published in the foot and ankle literature and to assess changes in the level of evidence over a decade. All articles from the years 2000 and 2010 in Foot and Ankle International, Foot and Ankle Surgery, and all foot and ankle articles from JBJS A and JBJS B were analysed. Animal, cadaveric, basic science, editorials, surveys, letters to Editor and correspondence were excluded. Articles were ranked by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine.Background
Methods
The Z or “scarf” osteotomy was first described by Meyer in 1926 and then by Burutaran in 1976. It was later popularised by Weil in the USA and Barouk in Europe in the 1990's and is now an accepted technique that forms part of a surgeons' armamentarium. The theory of Diffusion of Innovations was described by Rogers in 1962 to explain how novel ideas are accepted into practice across different industries, including medicine. It has never previously been used to study the adoption of ideas in foot and ankle surgery. This paper uses publication volume as a surrogate marker for adoption, as described previously by the authors. Briefly, a systematic review of the literature was carried out. MESH headings included ‘Hallux Valgus’, and ‘osteotomy’ or ‘SCARF’ or ‘Z osteotomy’ or ‘bunionectomy’. 2818 publications were identified and the abstracts were reviewed excluding 2699 publications for non-relevance. The data was analysed by year of publication, country of origin, as well as for level of evidence.Introduction
Methods
Calcaneal osteotomy is often performed together with other procedures to correct hindfoot deformity. There are various methods of fixation ranging from staples, headed or headless screws or more recently stepped locking plates. It is not clear if one method is superior to the other. In this series we compare the outcome of various methods of fixation with particular attention to the need for subsequent hardware removal. A retrospective review of the records of a consecutive series of patients who had a calcaneal osteotomy performed in our unit within the last 5 years was undertaken. All patients had had their osteotomy through an extended lateral approach to their calcaneous. The subsequent fixation was performed using one of three methods; a lateral plate placed through the same incision; a ‘headless’; or a ‘headed’ screw through a separate stab incision inserted through the infero-posterior heel. Records were kept of subsequent symptoms from the hardware and need for metalwork removal as well as any complications. When screws were inserted the entry point in relation to the weight-bearing surface of the calcaneous was also recorded.Introduction
Patients and Methods
The recent emphasis on using “evidence based medicine” for decision-making in patient care has prompted many publishers to mention the level of evidence of articles in their journals. The “quality” of a journal may thus be reflected by the proportion of articles with high levels of evidence and assist it achieve citations and therefore an Impact Factor. The purpose of this study was to survey published Foot and Ankle literature to evaluate changes in the level of evidence over ten years. Articles from Foot and Ankle International, JBJS Br, JBJS Am, Foot and Foot and Ankle Surgery were used. We looked at the years 2000 and 2010 and ranked the articles by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine. 498 articles were ranked. Studies of animals, studies of Background
Methods
Bone marrow oedema syndrome (BMES) of the foot and ankle is an uncommon and often misdiagnosed condition. It is usually thought to be a benign self limiting condition, without any We retrospectively reviewed 8 patients with the diagnosis of BMES. There were 6 males and 2 females with an average age of 51 years (38–63 years). All patients had acute onset of severe pain in the foot without any history of trauma. None of the patients had history of excessive alcohol or steroid intake. 5 patients (63%) had bilateral involvement of migratory nature. All patients had characteristic features on MR scans, with involvement of 3 or more bones in the foot.Introduction
Materials and Methods
Single stage total We performed single stage total Fusion was achieved in 7 feet (64%) at an average time of 17 weeks. In 4 patients, non-union persisted but they were pain free at latest review and would not consider further surgery. Average duration of follow-up was 20 months (range 6–24 months). All patients had stiff hindfeet with a jog of movement at the Total
Debate remains which surgical technique should be used for ankle arthrodesis. Several open approaches have been described, as well as the arthroscopic method, using a variety of fixation devices. Both arthroscopic and open procedures have good results with union rates of 93–95%, 3% malunion rate and patient satisfaction of 70–90%, although some report complication rates as high as 40%. To identify union, complication and patient satisfaction rates with open ankle fusions (using the plane between EHL and tibialis anterior).Introduction
Aims
Children with early-onset scoliosis (EOS) with rib hump chest-wall distortion or fused/absent ribs have thoracic insufficiency syndrome (TIS). Commonly, respiration is adversely affected by loss of lung volume from chest-wall constriction and clinical loss of active rib cage expansion. The dynamic thoracic components of diaphragm or rib cage lung expansion during respiration is poorly characterised by radiograph or CT scan. Pulmonary function tests indicate only hemithorax performance. Dynamic lung MRI, however, can visualise both chest-wall and diaphragm motion, allowing assessment of each individual hemithorax performance, so that a dynamic classification system of the thoracic function can be developed. Ten patients with TIS underwent dynamic lung MRI testing as part of the routine clinical preoperative work-up. Each hemithorax was graded: 1=intact motion of both chest wall and diaphragm; 2=primarily loss of chest-wall motion with minimal diaphragm abnormality; 3=substantial loss of diaphragm excursion with minimal loss or compensatory hyperkinesis of chest wall; and 4=substantial loss of both diaphragm and chest-wall motion. The grades for each hemithorax were added and averaged to form the thoracic function score. Ranges of scores were grouped into levels of clinical thoracic performance: level I (score 1–1·5); level II (>1·5–2·5); level III (>2·5–3·5); and level IV(>3·5–4·0).Introduction
Methods
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. 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.Introduction
Methods
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. 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 semi-structured 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.Introduction
Methods
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.
A posterior AFO that holds the foot in dorsiflexion. The amount of dorsiflexion could be adjusted. An anterior AFO that keeps the ankle and foot in plantigrade, with no adjustment to the amount of dorsiflexion.
