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

Background. Patients presenting with an acute tendoachilles (TA) rupture are managed in a dedicated clinic led by a Foot & Ankle Consultant and specialist physiotherapist. The diagnosis is made clinically and no ultrasound scan is performed. All management, rehabilitation and follow-up is undertaken within this clinic by the specialist physiotherapist, with Consultant support as required. Patients are offered a choice of conservative or surgical management (percutaneous TA repair). Both groups undergo a standardised functional rehabilitation regimen. Methods. All patients treated through our dedicated clinic between May 2010 and April 2016 were identified. Patient outcomes were reported using the validated Achilles Tendon Repair Score (ATRS). ATRS scores were collected at 3, 6 and 12 months post-injury. Re-rupture and complication rates were also documented. Results. 167 patients were identified. 79 patients underwent a percutaneous repair and 88 patients opted for conservative management. Mean age of patients undergoing percutaneous repair was 46 years (21–77 years) and 52 years (19–88 years) in the conservatively managed group. Male to female ratios were equal between both groups. Mean ATRS scores at 3, 6 and 12 months were 41.6, 69.5 and 85.3 respectively for the percutaneous repairs and 45.4, 69.0 and 77.1 respectively for the conservatively managed group. The re-rupture rate was 4.2% (3 patients) in the conservative group and 0% in our surgical group. In the surgical group, 1 patient developed a PE and 1 had a wound complication. Discussion. Our dedicated clinic for managing TA ruptures has proved popular with patients, with a patient satisfaction score of 98.7%. By standardising our rehabilitation regimen we believe our outcomes have improved. Our percutaneous repair group has an improved ATRS score compared to our conservative group at 12 months post injury. We believe that any fit active individual should be offered a percutaneous repair irrespective of age

Aims

This prospective cohort study aims to determine if the size of the tendon gap following acute rupture of the Achilles tendon shows an association with the functional outcome following non-operative treatment.

Introduction. Acute ankle injuries are commonly seen in musculoskeletal practice. Surgical management is the gold standard for lateral ligament injury in those with failed conservative treatment for a minimum of six months. Several studies have shown good functional outcome and early rehabilitation after MBG repair with an internal brace augmentation which is a braided ultrahigh molecular weight polyethylene ligament used to enhance the repair that acts as a secondary stabiliser. Hence the aim of the study was to compare the results with and without augmentation. Methods. A single centre retrospective review conducted between November 2017 and October 2019 and this included 172 patients with symptomatic chronic lateral ligament instability with failed conservative management. The diagnosis was confirmed by MRI. All patients had an ankle arthroscopy followed by open ligament repair. Patients were grouped into isolated MBG and internal brace groups for analyses and all had dedicated rehabilitation. Results. A total of 148 patients were available for final follow up with 87 patients in the MBG group and 61 patients in the IBA group. Mean Age was 38 years and mean follow up was 22 months. The internal brace group showed better Manchester Oxford foot and ankle score (19.7 vs 18.2) and more patients returning to preinjury activity levels (73 vs 55) as compared to isolated repair. Conclusion. Internal brace augmentation with MBG repair facilitated early rehabilitation and return to pre injury activity level in majority of patients compared to isolated MBG repair

Introduction. Charcot neuroarthropathy (CN) of foot and ankle presents significant challenges to the orthopaedic foot and ankle surgeon. Current treatment focuses on conservative management during the acute CN phase with offloading followed by deformity correction during the chronic phase. However, the deformity can progress in some feet despite optimal offloading resulting ulceration, infection, and limb loss. Our aim was to assess outcomes of primary surgical management with early reconstruction. Methods. Between December 2011 and December 2019, 25 patients underwent operative intervention at our specialist diabetic foot unit for CN with progressive deformity and or instability despite advanced offloading. All had peripheral neuropathy, and the majority due to diabetes. Twenty-six feet were operated on in total - 14 during Eichenholtz stage 1 and 12 during stage 2. Fourteen of these were performed as single stage procedures, whereas 12 as two-stage reconstructions. These included isolated hindfoot reconstructions in seven, midfoot in four and combined in 14 feet. Mean age at the time of operation was 54. Preoperative ulceration was evident in 14 patients. Results. Mean follow up was 45 months (Range 12–98). There was 100% limb salvage. One-year ambulation outcomes demonstrate FWB in bespoke footwear for 17 patients and in an ankle foot orthosis (AFO), Charcot restraint orthopaedic walker (CROW) or bivalve cast for seven. All preoperative ulceration had healed. Union was achieved in 18/21 hindfoot reconstructions and 7/18 midfoot reconstructions. There were nine episodes of return to theatre, of which five were within the first 12 months. There was one episode of new ulceration. Conclusion. Surgical management of acute CN (Eichenholtz one and two) of the foot provides functional limb salvage. In particular, hindfoot reconstruction shows good rates of bony union. It should be considered in ‘foot at risk’ presentations of acute CN foot

Introduction. The conservative management of stable Weber B fibula fractures remains variable. We thought that the current trend in our institution poses an unnecessary burden on fracture clinics. Methods. We reviewed patients referred with Weber B ankle fractures over an 18 month period. Our inclusion criteria were non-diabetic adults, with isolated stable Weber B fractures. Fractures were deemed stable if they had no evidence of talar shift on initial radiographs (< 5mm medial clear space and < 1mm variation between superior and medial clear spaces). Exclusion criteria were unstable fractures on radiographs, or no local follow-up. Management was reviewed from case notes and radiographs. Primary outcome was the stability of the fracture by the end of treatment. Secondary measures were duration of treatment, number of follow up appointments and radiographs, and complications. Results. 182 cases were reviewed. 82 were excluded leaving 100 patients for follow-up. Mean age was 53 (18–99). Mean number of outpatient appointments was 2.63 (1–6), follow up radiographs was 2.34 (0–6). 74 were treated in a walking boot and 15 in a walking cast for a mean of 6 weeks (4–9) and allowed to full weight-bear. 10 were kept non weight-bearing in a cast for 6 weeks and 1 was partially weight-bearing. Mean follow-up time was 7.3 weeks (1–30). No fractures displaced and one patient developed an ulcer from a cast. Conclusion. Our study suggests that in isolated Weber B fractures, with no radiographic instability on initial presentation, further displacement is unlikely. We propose that these injuries can be treated safely in a removable boot with full weight-bearing for 6 weeks then clinical and radiologic assessment if required. Casting or restricted weight-bearing does not confer any additional advantage. We question the necessity and rationale behind weekly clinical and radiological follow-up for such cases

Aims

Achilles tendon re-rupture (ATRR) poses a significant risk of postoperative complication, even after a successful initial surgical repair. This study aimed to identify risk factors associated with Achilles tendon re-rupture following operative fixation.

Freiberg's Infraction; osteonecrosis of the metatarsal head, is the fourth most common intra-articular osteonecrosis in the body. Surgical intervention is usually reserved for late stage of the disease process (III-V) or failure of conservative management. We evaluated the outcomes of patients treated with primary Interpositional Arthroplasty technique using periosteum and fat for adequate surfacing and as a spacer for Freiberg's Disease. Twenty-three cases (21 patients) were performed from February 2009 – March 2016 (18 women, 5 men). Mean age at surgery was 51.1 years (range 19 – 70.5 years) with 91% affecting the second metatarsal. Twenty-one cases were primary and two cases were revision. Five cases were stage III, 10 were in stage IV and 8 were stage V. All patients underwent Interpositional Arthroplasty using periosteum and fat graft from affected metatarsal inserted as joint spacer and secured with sutures. Patients were followed up by postal questionnaires using two validated questionnaires; MOXFQ and AOFAS. Mean follow-up was 3.7 years (0.6 – 7.6 years). Paired two-tailed student t tests were used to assess clinical significance. The left and right foot was affected in 12 and 11 cases respectively. There were no postoperative infections, non-unions or transfer metatarsalgia. Surgery allowed 8 patients to wear normal footwear, 9 wearing fashion shoes, 5 wearing dress shoes and 5 patients returned to sporting activities. Mean pre-operative and post-operative VAS pain scores were 6.7 (range 4–10) and 3.2 (range 0–0) (p< 0.05). Mean peri-operative AOFAS scores were 43.8 (range 14–14) and 71.3 (range 10–10) (p< 0.05). Mean peri-operative MOXFQ scores were 62.9 (range 23–23) and 31.8 (range 0–0) (p< 0.05). We recommend our novel Interpositional Arthroplasty using periosteum and fat spacer for late stage Freiberg's disease as it can result in significant improvement in pain, prevents donor site morbidity and produces significant functional improvement and patient satisfaction

Introduction. The dichotomy between surgical repair and conservative management of acute Achilles tendon ruptures has been eliminated through appropriate functional management. The orthoses used within functional management however, remains variable. Functional treatment works on the premise that the ankle/hindfoot is positioned in sufficient equinus to allow for early weight-bearing on a ‘shortened’ Achilles tendon. Our aim in this study was to test if 2 common walking orthoses achieved a satisfactory equinus position of the hindfoot. Methods. 10 sequentially treated patients with 11 Achilles tendon injuries were assigned either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus corrected vacuum brace system (EEB). Weight bearing lateral radiographs were obtained in plaster and the orthosis, which were subsequently analysed using a Carestream PACS system. The Mann-Whitney test was used to compare means. Results. Initial radiographs of all patients in cast immobilization showed a mean tibio-talar angle (TTA) of 55.67° (SD1.21) and a mean 1. st. metatarsal-tibia angle (1MTA) of 73.83° (SD9.45). There were 6 Achilles tendons treated in the FAWW. Their measurements showed a mean TTA of 27.67°(SD7.71) and 1MTA 37.00 (5.22). 5 tendons were treated using an EEB; there was a statistically significant (p< .05) increase in both the TTA 47.6° (SD5.90) and 1MTA 53.67 (SD5.77) compared to the FAWW group. Discussion. Plantar-flexion at the ankle was significantly greater in the EEB comparative to the FAWW, and very similar to the initial equinus cast. The use of wedges produced an equinus appearance through the midfoot, without producing equinus in the hindfoot as the heel pad rests on the top wedge. We express caution in the use of wedges for Achilles treatment as they do not shorten the Achilles tendon and may result in a lengthened tendon and reduced plantar-flexion power in the long-term

Platelet rich plasma has been advocated for the treatment of plantar fasciitis but there are few good quality clinical trials to support its use. We report a pilot double blind randomised controlled trial of platelet rich plasma versus normal saline. Methods. Patients with more than 6 months of MRI proven plantar fasciitis who had failed conservative management were invited to participate in this study. Patients were block randomised to either platelet rich plasma injection (intervention) or equivalent volume of normal saline (control). The techniques used for the injection and rehabilitation were standardised for both groups. The patient and independent assessor were blinded. Visual analogue scale for pain (VAS) and painDETECT were recorded pre-op and at 6 months. Results. Twenty-eight patients (19 females, mean age 50 years) were recruited, with 14 randomised to each arm. At 6 month follow-up, 8 patients (28.6%) were lost to follow-up. There was a significant change in VAS score from baseline to follow-up in both intervention (mean change 37.2, p = 0.008) and control (mean change 42.2, p = 0.003) groups. However there was no difference between the arms in terms of the change in VAS score from baseline to follow-up (p = 0.183). There was no correlation between pre-op PainDETECT score and change in VAS. Conclusion. This pilot study has failed to show a significant benefit of platelet rich plasma compared to saline injection, although both treatments have shown a significant improvement in symptoms. This may be due to the needling effect of injections. A larger study is required to demonstrate a meaningful change. Loss to follow in this patient group should be considered

Introduction:. Historically the incidence of Achilles re-ruptures has been described as around 5% after surgical repair and up to 21% after conservative management. In 2008 we commenced a dedicated Achilles tendon rupture clinic for both conservative and surgically managed patients using new standardised operating procedures (SOP). We have evaluated the impact of this new service, particularly with regard to re-rupture rate. Materials and methods:. The SOP was stage dependent and included an initial ultrasound examination, functional orthotics with early weight bearing, accelerated exercise and guidelines for the return to work and sport. Evaluation included re-rupture rate, complication rate, and outcome measured by the Achilles Tendon Total Rupture Score (ATRS) and Achilles Tendon Repair Score (AS). A basic cost evaluation was performed to assess any potential savings. Results:. A total of 213 patients (151 treated conservatively and 62 surgically) were included. Re-rupture occurred in two patients (1 conservative and 1 surgically managed). There were 16 major complications e.g. DVT, wound infection. The mean ATRS was 54.79, 67.66 and 71.05 at 4, 6 and 9 months respectively and the mean AS was 64.67, 73.96 and 71.05 at 4, 6 and 9 months respectively. The reduction in re-rupture compared to the literature was 4.1% and 19.1% for surgical and conservatively treated patients respectively. Cost savings achieved were £50,000 each annum. This was due to both a decrease in the number of re-ruptures as well as a decrease in the number of patients being managed operatively. Conclusion:. A dedicated follow up Achilles clinic treating acute Achilles tendon ruptures using monitored SOP's, provides an exceptionally low re-rupture rate (0.9%), excellent patient outcome and potential cost savings compared to a traditional fracture clinic approach. The reduction in re-rupture rate, and therefore cost savings, is greater in conservatively managed patients

Numerous procedures have been reported for the hallux valgus correction of the great toe. Scarf osteotomy is a versatile osteotomy to correct varying degrees of mild to moderate hallux valgus deformity. It can also be used for lengthening of the 1st ray as a revision procedure to treat metatarsalgia in patients who had previous shortening osteotomy. We wish to report a patient who had lengthening SCARF osteotomy for the metatarsalgia following previous hallux valgus correction and developed arthritis of the 1st MTPJ in a short term which required fusion. A 49 year old female patient was seen with pain and tenderness over the heads of the 2nd and3rd metatarsal of the right foot. She had hallux valgus correction 10years ago with a shortening osteotomy of the 1st metatarsal. She developed metatarsalgia which failed to conservative management. She had a lengthening SCARF osteotomy for the metatarsalgia in 2004. She had good symptomatic relief for two years and then started having pain over the 1st MTPJ. On examination she had limited movements of the 1st MTPJ and tenderness over the dorsolateral aspects of the 1st MTPJ suggestive of arthritis. Radiographs of the foot showed healed osteotomy with no evidence of AVN of the 1st MT head but features suggestive of osteoarthritis. She had fusion of the 1st MTPJ performed in 2008 for the arthritis following which symptoms resolved. This case highlights that arthritis of the 1st MTPJ can occur in the absence of an AVN of the metatarsal head and patients need to be warned of this potential complaining when having the lengthening SCARF osteotomy for metatarsalgia following a previous shortening osteotomy of the 1st ray

Introduction. Fifth metatarsal fracture is a common injury. Current practice supports conservative management, with surgery in the event of non-union. Early fracture clinic review is not perceived to improve patient experience or increased detection of non-union. A new protocol standardises treatment to symptom level and discharges patients from ED with advice but without any routine follow-up arranged. A leaflet advises on management, prognosis and helpline details and there is an open-access policy for those whose symptoms persist to investigate potential non-union. Method. A prospective audit evaluated the protocol, surveying patients at 8-weeks and 6-months post-injury. A minor injuries unit continued to refer to fracture clinic and was the control group. During 6-months 46 acute fractures were recorded in the new protocol(group 1) and 47 in the control(group 2). 1 patient in each group was known to experience non-union. 31 of group 1 and 22 of group 2 responded to at least one survey. Results. Satisfaction with information provided at initial presentation was high for both protocols. 87%(27/31) satisfied in group 1 and 90%(20/22) group 2(p=1.0000). At 8-weeks 82%(19/23) were satisfied with their progress following the new protocol compared to 89%(17/19) in the control(p=0.6729). At 6-months 88%(22/25) were satisfied compared to 76%(13/17) respectively(p=0.4133). The new protocol is not associated with a significant symptoms increase. At 8 weeks 22%(5/23) described their pain severity as >5/10 reducing to 8%(2/25) by 6-months. Compared to 10%(2/19) of the control at 8-weeks and 6%(1/17) at 6-months. Patients rating fracture management overall as ‘good or excellent’ were comparable between both new, 67%(21/31) and traditional, 77%(17/22) protocols(p=0.5441). Conclusion. No significant difference in patient satisfaction and symptom levels between the old and new protocol was found. The new protocol reduces unnecessary patient appointments. This reduces demands on fracture clinic while maintaining a safe, resource efficient service

Introduction. Whilst most cases of plantar fasciitis can be resolved with existing conservative established treatment options, a few intractable cases can be difficult to resolve. New biologic treatments have been proposed for a variety of soft tissue tendon problems. We evaluated the results of PRP in the treatment of recalcitrant chronic cases of plantar fasciitis. Methods. Patients with plantar fasciitis that had not responded to a minimum of 8 months standard conservative management (eccentric stretching, physiotherapy, cortisone injection, night splints) were offered PRP therapy. The injection into the tender spot at the proximal plantar fascial insertion was performed in theatre as a day case. Roles Maudsley (RM) scores, Visual analogue scores (VAS) for pain, AOFAS scores and ‘would have injection again’ were collated pre-operatively, at three and six months. Results. Prospective data was collected on 39 patients (44 heels – 15 males, 24 females; mean age 51 years, range 25–79 years). No complications were noted. At six months review RM score improved from 3.8 to 2.5 (p<0.001), VAS improved from 7.7 to 4.2 (p<0.001) and AOFAS improved from 61 to 82 (p<0.001). 21 patients had complete relief of symptoms on 3 months review. 25 patients were very satisfied with the clinical improvement and would have the injection again. Whilst there was a slight improvement in scores from 3 to 6 months, this was not significant. 3 patients with bilateral injections on the same sitting did not improve, though 2 patients with bilateral injections on separate sittings did improve. Conclusion. In this series of chronic intractable cases, PRP injection produced a 64% satisfaction rate from patients. The procedure was safe with no reported complications. The authors feel PRP for plantar fasciitis may have some role in treatment and merits further study with a prospective randomised trial

Aims

Postoperative rehabilitation regimens following ankle arthrodesis vary considerably. A systematic review was conducted to determine the evidence for weightbearing recommendations following ankle arthrodesis, and to compare outcomes between different regimens.

Aims

Limb salvage for diabetic foot infections often require multiple procedures. Some patients will eventually end up with below knee amputation (BKA) when all limb salvage attempts fail. We seek to study the patients’ ability to return to normal life, functional status, prosthesis usage and perspectives on multiple limb salvage procedures that culminated in BKA to review if they would undertake a similar path if their situation was repeated.

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration.

In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:1299–1311.

Objectives

To evaluate the applicability of MRI for the quantitative assessment of anterior talofibular ligaments (ATFLs) in symptomatic chronic ankle instability (CAI).

The Swansea Morriston Achilles Rupture Treatment (SMART) programme was introduced in 2008. This paper summarises the outcome of this programme. Patients with a rupture of the Achilles tendon treated in our unit follow a comprehensive management protocol that includes a dedicated Achilles clinic, ultrasound examination, the use of functional orthoses, early weight-bearing, an accelerated exercise regime and guidelines for return to work and sport. The choice of conservative or surgical treatment was based on ultrasound findings.

The rate of re-rupture, the outcome using the Achilles Tendon Total Rupture Score (ATRS) and the Achilles Tendon Repair Score, (AS), and the complications were recorded. An elementary cost analysis was also performed.

Between 2008 and 2014 a total of 273 patients presented with an acute rupture 211 of whom were managed conservatively and 62 had surgical repair. There were three re-ruptures (1.1%). There were 215 men and 58 women with a mean age of 46.5 years (20 to 86). Functional outcome was satisfactory. Mean ATRS and AS at four months was 53.0 (sd 14), 64.9 (sd 15) (n = 135), six months 67.8 (sd 16), 73.8 (sd 15) (n = 103) and nine months (72.4; sd 14) 72.3 (sd 13) (n = 43). The programme realised estimated cost savings exceeding £91 000 per annum.

The SMART programme resulted in a low rate of re-rupture, a satisfactory outcome, a reduced rate of surgical intervention and a reduction in healthcare costs.

Cite this article: Bone Joint J 2015; 97-B:510–15.

We reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release.

The mean hallux valgus angle improved from −11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from −0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean American Orthopaedic Foot and Ankle Society score improved from 77 to 95 points.

In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications.

We consider that distal chevron metatarsal osteotomy with a medial wedge osteotomy and medial capsular release is a useful procedure for the correction of hallux varus after surgery for hallux valgus.