Aims

To describe outcome reporting variation and trends in non-pharmacological randomized clinical trials (RCTs) of distal tibia and/or ankle fractures.

Background. 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. Methods. 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 cadavera, basic-science articles were excluded. Results. For both years 2000 and 2010 combined, 63.5% of the articles were therapeutic, 25.5% were prognostic, 10.6% were diagnostic, and 0.8% were economic. In 2000 the ratings were 1.3% as Level I, 5.8% as Level II, 11.9% as Level III, 44.7% as Level IV and 36.3% as level V. In 2010 the ratings were 2.9% as Level I, 9.6% as Level II, 15.4% as Level III, 38.2% as Level IV and 33.8% as level V. Conclusion. The literature in foot and ankle surgery has responded to the demand for more evidence-based medicine with an increase in level I and II papers but the rate of change has been slow. The majority of evidence remains in the level IV and V

Introduction. Surgeons, commissioners and patients are increasingly seeking more in depth details on outcomes of total ankle replacement (TAR). We set out to perform a detailed and up to date meta-analysis of the outcomes of TAR, with a focus on PROMS. Methods. We searched MEDLINE, Cochrane, EMBASE, CINAHL and the Science Citation Index databases using the terms “total”; “ankle”; “arthroplasty” or “replacement” to April 2012. We included all languages; series with greater than 20 TAR; minimum 2 years follow-up. We excluded papers on revisions; prostheses no longer marketed; and kin studies. We worked with the Cochrane Collaboration to adopt their methodology including the creation of a risk profile assessing all forms of bias. Results. Of 1841 papers identified, 51 remained for analysis, with a pool of 6719 patients. The mean patient age was 59.3(17–95) and mean BMI was 28.8(19.4–44). 53% of patients were male. The most common indication was posttraumatic osteoarthritis. The majority of the studies were level IV and more than half the studies had several forms of bias. Intraoperative complication rate was 9%, with medial malleolar fracture (4.4%) being the most common. The pooled mean pre-op VAS was 7.6 which improved to 1.5 at 4–5 years. The mean pre-op AOFAS was 39.7, improving to 79.9 for up-to 10 years. Range-of-motion increased after TAR from 22.8° preoperatively to 33.6° postoperatively. Radiographic abnormalities were found in 22% of cases with a mean follow up of 53 months, of which 7.9% were re-operated upon. Gait velocity, cadence, stride length and power all improve following TAR. Survival at 8–10 years was 89.4%, with a cumulative failure rate of 1.9%. Conclusion. This is the most comprehensive meta-analysis carried out on TAR to date. TAR provides patients with an increased range of motion and improvement postoperative PROMS maintained up to 10 years

We present a review of litigation claims relating to foot and ankle surgery in the NHS in England during the 17-year period between 1995 and 2012.

A freedom of information request was made to obtain data from the NHS litigation authority (NHSLA) relating to orthopaedic claims, and the foot and ankle claims were reviewed.

During this period of time, a total of 10 273 orthopaedic claims were made, of which 1294 (12.6%) were related to the foot and ankle. 1036 were closed, which comprised of 1104 specific complaints. Analysis was performed using the complaints as the denominator. The cost of settling these claims was more than £36 million.

There were 372 complaints (33.7%) involving the ankle, of which 273 (73.4%) were related to trauma. Conditions affecting the first ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective practice. Overall, claims due to diagnostic errors accounted for 210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery and 149 (13.5%) from alleged mismanagement.

Our findings show that the incorrect, delayed or missed diagnosis of conditions affecting the foot and ankle is a key area for improvement, especially in trauma practice.

Cite this article: Bone Joint J 2014;96-B:1510–14.