Purpose: The growing use of foot surgery includes many innovating techniques which require adequate evaluation. To facilitate evaluation, the Association Française de Chirurgie du Pied (AFCP) elaborated a computer program for acquisition of clinical and radiological data on foot surgery. The data collected were centralised and analysed to assess surgical procedures. Material and methods: Clinically. Signs of forefoot disorders were reviewed and classed by surgeons with extensive experience in forefoot surgery. Signs were classed by topic then formulated for the computer display to facilitate input during consultations. A system of profiles was designed to limit the data input filed and shorten input time. The program includes an automatic calculation of the Kitaoka forefoot score. Radiologically: The system includes a tool for analysing radiographs using a vectorial drawing software integrated in the database. This system uses remarkable landmarks chosen by clicking on the radiographs: angles and lengths for preoperative planning are calculated automatically. These values are automatically integrated into the database and can be retrieved for file studies. Operation report: Procedures performed on the forefoot are presented in picture form with clinical data. A profiles system is used to choose the items for input and reduce entry time. Printout: Printouts can be made to include in the patient’s files. Exploitation: Data can be exported for processing with another programme. This function was tested with a dissertation written on Weil osteotomies. Conclusion: This freely distributed software is a first step toward a computer evaluation system for foot surgery. Our hope is that sufficient data can be collected to validate the reliability of our surgical techniques

Introduction: There are no guidelines for the use of any particular tourniquet in foot surgery. We undertook this prospective randomised study to assess the efficacy of the S-MART . TM. tourniquet in foot surgery as compared to the pneumatic tourniquet. A literature review confirms this is the first randomised controlled study objectively measuring the outcomes of this tourniquet system. Material and Methods: We included 40 consecutive patients who had foot surgery from May 2006 to August 2006. Informed consent with local medical ethics committee approval was obtained. We excluded patients with history of diabetes mellitus, deep vein thrombosis, fractures, limb circumference more than 40 centimetres and smokers. The ease of application of tourniquet, intraoperative bloodless field and ease of removal was scored on a scale of 1–10. Patients were followed up at 2 weeks. Results: 20 patients were randomised into group one with pneumatic tourniquet (average age 63.36) and 20 patients in group two with S-MART . TM. tourniquet (average age 61.25). The average tourniquet placement time in-group one was 144.36 seconds as compared to 12 seconds ingroup two. The mean ease of application scores was 4.27 in-group one as compared to 1.46 in-group two. Total tourniquet time was more in-group one. Intraoperative haemostasis was rated higher in-group two. Discussion: SMART . TM. tourniquet provides a good intraoperative haemostasis and is easy to apply. This tourniquet helps to exsanguinate; this frees up theatre personnel, saves resources and decreases tourniquet time for surgery. The limitation is it cannot be reinflated and cannot be used in patients with fractures. Conclusion: S-MART tourniquet is a good for foot surgery, provides a good operative field, is easy to apply and saves precious theatre time and resources

Introduction. We hereby present results of controlled randomized trial of use of popliteal block for pain relief in ankle and hind foot surgery. Materials and methods. We have studied 63 patients over period of 9 months. Patients who needed ankle or hind foot procedure were selected for trial. Patients were explained about the trial and popliteal block along with leaflets at preoperative clinics. Patients were randomized on the day of surgery. A sealed envelop stating whether patient will go to block group (A) or no block group (B) was opened in the anaesthetic room before the patient was anaesthetized. Patients were evaluated for subjective pain scores at 30 min, 6 hrs, 12 hrs and 24 hrs after surgery. Amount of anaelgesic required and time to first dose was documented. Popliteal blocks were given by one foot and ankle consultant and one trained fellow. The block was administered in lateral position at 0.8 mA stimulus to detect the nerve. The data was compared statistically between group A and B. Results. The average pain scores in Group A (33 pts) were 0.72, 1.60, 1.51 and 1.03 at 30 min, 6 hrs, 12 hrs and 24 hrs respectively. While in Group B (30 pts) it was 2.73, 5.5, 6.03 and 3.33 at 30 min, 6 hrs, 12 hrs and 24 hrs respectively. There was statistically significant difference in pain scores at 6 and 12 hrs. There was no statistically significant difference in pain scores at 30 min and 24 hrs. Time to the request for first analgesic was statistically longer in Group A. Conclusion. Popliteal block offers an effective way of pain relief in ankle and hind foot surgery. We believe that it may reduce amount of anaesthetic or anaelgesic drug requirement as well

Aims: Traditionally in surgery, and this is especially true in orthopaedic foot surgery, is not paid much attention to patient’s emotions, not considering how specific personality traits could affect pre and post surgical management. Following the guidelines of WHO about the treatment of pain and in order to optimize the clinical management of patients who complain of painful foot disorders such as hallux valgus, we studied the relation between level of anxiety, perception of pain and memory pain before and after the surgical procedure. Methods: In the period 2000 and 2004 we studied 88 patients who were treated with distal metatarsal osteotomy for correction of hallux valgus. In order to evaluate anxiety trait level we selected one of the most frequently employed tests in clinical medicine (S.T.A.I. Y2). To quantify the amount of pain, due to such pathology in the pre and post surgical period, FFI test (visual analogous) and a questionnaire on pain memory, were employed. Pain was studied longitudinally, in the following steps: presurgery, immediately postsurgery, daily in the first four days, and at one and two weeks interval after the procedure. The use of analgesic drugs in the first two weeks was recorded. Two years later the same patient were recalled in order to collect data related to the clinical outcome and pain memory persistence. Results: A subgroup of 33 patients showed an high anxiety trait level (score > 43), the remaining 50 patients had a score in the normal range. The statistical analysis of the data shows a direct correlation between anxiety level and pain perception in the pre surgical period. Furthermore, patients with higher level of anxiety showed an increased use of analgesic drugs in the post surgical period (the higher dosage prescribed on demand). The unpleasant memory persistence is however mitigated in the same group, possibly due to much drug assumption. Conclusions: A correct management of patients with painful diseases candidated to surgical procedures should include a comprehensive psychological evaluation in order to identify their emotional state. Especially in clinical situations requiring bilateral surgical approaches is mandatory to avoid that pain could become a traumatic experience

Clubfoot is medically defined as luxatio pedis sub talo. The process of dislocation mostly caused by muscular imbalance results in bony deformities and soft tissue contractures, which in the majority of cases – even after meticulous conservative treatment – have to be corrected by surgery. In children before school age, surgical corrections should always address the main pathology. To achieve normal alignment of the fore and hindfoot, a complete reduction of the talus within the acetabulum pedis has to be done by soft tissue release. Analysing the pathomorphology, a clubfoot is characterised by equinus, varus, forefoot adduction, and horizontal subtalar medial rotation. Regarding bony deformation, the medial side of the talus is narrowed by the navicular, the medial malleolus, and the fibrocartilage between. Growth expansion is limited on the medial side and there is more growth expansion on the lateral convex side, leading to external rotation of its body (~ 10-25°) and internal inclination of the neck (~30-50°). The calcaneus is internally rotated 20-30°. Regarding joint dislocation, there is a displacement of the navicular medially and plantarward towards the medial malleolus. The cuboid bone usually follows the position of the navicular and dislocates gradually to the medial side. Soft tissue contractures are located medially (Lacinate Lig., M. Add. hallucis, Spring Lig., talo navicular Lig., Master knot of Henry) and posterior (lat. fibulo calc. Lig, post. capsule of the ankle joint). There is also a shortening of muscles e.g. short plantar flexors, M. tib. post., M. flex. hall. longus., M. flex. digit. comm., M. tib. ant. The method of treatment depends on the severity of a clubfoot, the preoperatively achieved results of conservative treatment, and how extensive a subtalar release has to be performed. If the navicular can be reduced conservatively, a posterolateral surgical approach is indicated. A transversal incision is performed starting laterally at the calcaneal cuboid joint and ending medially below the medial malleolus. A dorso lateral release of the subtalar joint, Tendo Achilles lengthening, and dorsal release of the ankle joint is performed. At the age of three to six months, it is possible to correct subtalar malalignment to move the calcaneus away from the fib. Malleolus by external rotation in relation to the talus (Mini Cincinnati technique). If the talonavicular and the calcaneo-cuboid joint are dislocated, a complete subtalar release has to be done in order to reduce the talo-navicular, calcaneo-cuboid and talo-calcaneal joint. To avoid overcorrection, the talo calcaneal interosseous lig. should be kept intact whenever possible (Mc Kay-Simons procedure). This type of surgery should not be performed before the age of six months. The subtalar release technique described by McKay was introduced in our hospital in 1983. Since then, 362 clubfeet have been treated by the above-mentioned techniques: 249 by the Mini Cincinnati (Group 1) and 113 by the McKay-Simons procedure (Group 2). Age at the time of surgery ranged from 2 to 12 months in Group 1 and 5 to 52 months in Group 2. In Group 1, the results were excellent in 42%, and good (residual forefoot adduction) in 49%. A second surgical intervention had to be done in only 9%. Regarding shape and appearance of the foot in Group 2, results were excellent in 46%, good in 38% and insufficient in 16% (overcorrection 3%, relapse 13 %). Concerning functional outcome, the feet of Group 2 presented much more stiffness than those of Group 1, which was also found pre-operatively. The treatment of clubfoot is still a matter of controversy because of different severity of deformity and different treatment philosophies. According to our experience, the McKay-Simons procedure has proved to be ideal for simultaneous correction of various components of the deformity from one single approach. In particular, correction of subtalar horizontal rotational deformity in the subtalar joint can be easily performed. Based on the survey, the danger of damaging nerves, blood vessels, tendons and joint cartilages can be kept to a minimum by using the Cincinnati approach. In the majority of cases, the foot appears normal, moves without pain, and is flexible enough to enable the child to walk on his toes or heels and to participate in sportactivities. Limitation of mobility is nevertheless the main problem of all extensive soft tissue procedures in clubfoot surgery, and it is not known at this time if this will cause subtalar osteoarthritis in early adulthood. Complete subtalar release develops less osteonecrosis, fewer changes in the navicular, and less cavus and adductus than the use of other surgical techniques. Overcorrection and poor functional results were seen in patients less than six months old at the time of surgery. We recommend that a complete subtalar release be delayed until the child is aged 6 to 12 months. Treatment should ideally be completed by the time the child is ready to walk

Arthordesis of small joints of the foot is a commonly performed procedure in orthopaedics. A variety of fixation devices have been used for this purpose. Nickel-Titanium Memory compression staples for arthrodesis have been used in our institute since June 2003. We report the results of the procedure over a period of 7years involving 252 feet in 232 consecutive patients who underwent arthrodesis or an osteotomy fixation using compression staples. The patients were evaluated to determine the period of immobilization in cast and the time to radiographic joint fusion.

The emphasis of this study was to validate the safety of the implant for fusion of small joints of the foot, as well as to determine whether there is a demonstrable trend in time to fusion and period of immobilization required.

The average time to fusion was 7.2 weeks, the average period of immobilisation was 6.5 weeks. Successful union was achieved in 98% cases. We report the follow up results, finer technical aspects of the procedure and pitfalls to avoid whilst performing the fusions.

Introduction

Surgical reconstruction of Charcot joint deformity is increasingly being offered to patients. In our centre a hybrid type fixation technique is utilised: internal and external fixation. This combined fixation has better wound management and earlier mobilisation in this deconditioned patient group. The aim of this study was to assess clinical, radiological and patient reported outcomes for all patients who underwent this hybrid technique.

Purpose: An audit was undertaken to evaluate the patients’ experience of foot surgery at the great Western Hospital in 2004 following the appointment of a podiatric surgeon to the orthopaedic department. Method: The first 100 patients that were operated on by the podiatric surgeon (Group 1) were matched by OPCS code to a randomly selected patient cohort that had been operated on by orthopaedic surgeons (Group 2). All patients were at a minimum of 6 months post-surgery (range 6–10 months Gp. 1, 11–20 months Gp. 2). The audit department sent out an anonymous questionnaire relating to the patients’ experience both before and after their surgery as well as current levels of satisfaction with the outcome of their surgery. Results: The response rate was 64% in Gp.1 and 68% in Gp.2. The patients’ overall satisfaction with the result of their foot surgery was determined using a Likert scale and the results can be seen in Table 1. Patients in the podiatric surgical group were significantly more satisfied with the result of their foot surgery than those in the orthopaedic group (p< 0.008; Mann Whitney U test). Similar statistically significant differences were also seen between the two groups relating to patient satisfaction with their pre and post-operative consultations and information concerning their proposed surgery and its outcome. Conclusion: The results of this audit suggest that the satisfaction of patients following foot surgery can rise significantly following the appointment of a podiatric surgeon to a general hospital orthopaedic department

Introduction: Every ten seconds, somewhere in the world, someone dies of tobacco-related causes. The adverse effects of smoking on the cardiovascular, respiratory, and immune systems have been well documented. Results of foot surgery are also gravely affected by cigarette smoking, with poorer clinical outcomes, lower rates of osteotomy union, bony fusion and higher rates of postoperative infection. However, data on surgeon’s awareness and their practices to overcome the adverse effects of smoking in elective foot surgery is limited. Aim: The purpose of this study was to report the results of a survey of experienced foot and ankle surgeons regarding their awareness about detrimental effects of smoking and the measures they take in their practice to prevent them. Methods: A survey of members of British Foot and Ankle Society was done to document surgeon’s awareness and attitudes towards detrimental effects of smoking in patients undergoing elective foot surgery and the measures they take to prevent these problems. Survey was returned by 104 of the 225 surgeons (47%). Results: One hundred and two (99%) of the surgeons were aware of the damaging effects of smoking in foot and ankle surgery. Eightynine (84%) of these recorded the smoking habits of their patients in their dictated notes. However, only 9% respondent admitted recording the smoking habits of their patients in consent form and warn them about forthcoming risk of complications at the time of consenting. Only twentyfour (23%) had varying protocol’s to prevent smoking related operative complications. Conclusions: Most of the surgeons appreciate the harmful effects of smoking. However they are unaware of the extent to which it causes problems. Majority of the members would like the society to propose a unified policy or evidence based guidelines to deal with smoking related problems in foot surgery

The October 2024 Foot & Ankle Roundup³⁶⁰ looks at: Hemiarthroplasty for hallux rigidus; Fixed or mobile-bearing ankle arthroplasty? A meta-analysis; Bone grafting for periprosthetic bone cysts following total ankle arthroplasty; Diabetic foot ulcer after first-ray amputation; Early motion after ankle surgery: the path to faster recovery?; Are podiatrists and orthopaedic surgeons approaching zone 2 fifth metatarsal fractures in the same way?.

Aims

Treatment of Weber B ankle fractures that are stable on weightbearing radiographs but unstable on concomitant stress tests (classified SER4a) is controversial. Recent studies indicate that these fractures should be treated nonoperatively, but no studies have compared alternative nonoperative options. This study aims to evaluate patient-reported outcomes and the safety of fracture treatment using functional orthosis versus cast immobilization.

Cigarette smoking prior to and following foot surgery is well recognised as resulting in a higher complication rate. The purpose of this study was to determine the effectiveness of pre-operative counselling prior to elective hallux valgus surgery. A prospective record of smoking histories was taken in all patients prior to surgery. They were counselled as to the increased complication rate and advised to stop prior to surgery and in the immediate peri-operative period. The mechanism of the increased complication rate was explained to improve their understanding to stop smoking. They were advised to see their GP for specific strategies and medications. Further smoking history was taken on admission and in review clinics. A telephone survey was then conducted to ascertain their smoking pattern following discharge from follow-up. Forty-two patients underwent hallux valgus surgery over a 12 month operating period. Ten (23%) were recorded as smokers at the time of initial consultation. Most patients (80%) were unaware of the detrimental effects of smoking following foot surgery. Patient education was effective in providing an impetus to stop or reduce smoking in 6 (60%) patients pre-operatively. One further patient subsequently desisted from smoking following surgery. Only two patients had re-commenced smoking following surgery implying a long term change of behavior. Only one complication of a DVT occurred in a patient who continued to smoke. This small study has shown the effectiveness of educating our patients in the importance of giving up smoking prior to elective foot surgery

Cigarette smoking is well recognised as contributing to a higher complication rate following foot surgery. The efficacy of pre-operative counselling to stop smoking has not been evaluated following foot surgery. The purpose of this study was to determine the effectiveness of pre-operative counselling prior to elective forefoot surgery. A record of smoking status was taken in all patients prior to surgery. Counselling as to the increased complication rate was undertaken by the lead surgeon at the initial outpatient visit and repeated at pre-operative assessment, with patients advised to see their GP for specific strategies and medications. Further smoking history was taken on admission and in review clinics. A telephone survey was then conducted to ascertain smoking patterns following surgery. Ninety-eight patients underwent forefoot osteotomy or fusion surgery, over an eighteen-month period, by a single surgeon. Of these, twenty-four were recorded as smokers, with follow-up, at a mean interval of twelve months, achieved in twenty-two. Sixteen stopped smoking pre-operatively, with a further four reducing their daily intake as a direct consequence of the counselling. The majority of patients were unaware of the detrimental effects of smoking following foot surgery. Only four patients re-commenced pre-operative smoking patterns following surgery implying long-term behaviour change in the remainder. One complication of a DVT was recorded in a persistent smoker. This small study has illustrated the benefit of utilizing the pre-operative clinic consultation to educate our patients of the importance of giving up smoking prior to elective surgery. Counselling has been shown to provide an incentive for smoking cessation, which has been maintained after the peri-operative period. Although forefoot fusions and arthrodeses were used to provide the figures in our study, the results are transferable to other branches of foot and ankle surgery. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon

Aims

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

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

Aims

Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

The aim of this study was to correlate two outcome measurements of clubfoot surgery. A modified, partially subjective, clinical scoring system was compared with an objective biomechanical assessment, using the optical Dynamic Pedobarograph foot pressure system. The outcomes of the latter method were developed into a classification system for future prospective studies and to complement clinical evaluation of patients, especially those with relapse. Many different functional outcome measures have been designed. Differing number of points are allocated to various subjective and objective items of relevance. The weighting given to each item in the overall score depends entirely on the importance the surgeon believes that particular item has on what he believes constitutes a good corrected clubfoot. This makes the scoring systems arbitrary and therefore results of clubfoot surgery between various centres impossible to compare. Sixteen patients [21 feet] were randomly selected from a poll of patients that had undergone clubfoot surgery. The operations were carried out by a single surgeon and consisted of a lateral-posteromedial peritalar release utilising the Cincinnati incision. Post-operatively, all feet were independently classified using a modified scoring system, based on the ones designed by Laaveg and Ponseti and the one by McKay, which scores both objective and subjective findings. This system has a good interobserver reproducibility. After finalisation of treatment, patients were referred to the Foot Pressure Analysis Clinic in Dundee where a novel method has been developed for the evaluation of clubfeet, using a static and dynamic foot pressure analysis system which provides both a graphical and analytical model for comparison. A pedobarographic classification system was developed. An excellent result entails that the patient does not require further treatment. A good result has been achieved if a near normal posture and pressure distribution is recorded. However, this means that there are still functional problems, which, as the foot matures, may lead to future relapse. These feet may therefore require long-term treatment with an orthotic support to let the foot develop its normal shape. A fair result requires major orthotic support of shoe adaptation, or further surgical releases. The correlation between clinical and biomechanical outcomes in the 21 feet was calculated using Kendall’s tau rank test for non-parametric data. The r value was 0.3524, which was significant [p< 0.05]. There is a significant correlation between the above mentioned outcome measurements. Biomechanical assessment cannot replace clinical evaluation, but can complement it and perhaps give a more subtle and earlier prediction of the need for further additional treatment. This technique has not only proven to be objective but also clinically valuable and cost effective. A prospective study to refine this biomechanical classification system into a reliable predictor of relapse in surgically corrected clubfeet is currently being considered