Background. Procedural sedation (PS) requires two suitably qualified clinicians and a dedicated monitored bed space. We present the results of intra-articular haematoma blocks (IAHB), using local anaesthetic, for the manipulation of closed ankle fracture dislocations and compared resource use with PS. Methods. Patients received intra-articular ankle haematoma blocks for displaced ankle fractures requiring manipulation between October 2020 to April 2021. The technique used 10ml of 1% lignocaine injected anteromedially into the tibiotalar joint. Pain scores (VAS), time from first x-ray to reduction, and acceptability of reduction were recorded. A comparison was made by retrospective analysis of patients who had undergone PS for manipulation of an ankle fracture over the six month period March – August 2020. Results. During the periods assessed, 25 patients received an IAHB and 28 received PS for ankle fractures requiring manipulation (mean age 57.8yr vs 55.1yr). Time from first x-ray to manipulation was 65.9 min (IAHB) vs 82.9 min (PS) (p = 0.087). In the IAHB group mean pain scores pre, during and post manipulation were 6.1, 4.7 and 2.0 respectively (‘pre’ to ‘during’ p < 0.05; ‘pre’ to ‘post’ p < 0.01). In the IAHB group, 23 (92%) had a satisfactory reduction without need of PS or general anaesthetic. In the PS group 23 (82%) had a satisfactory reduction. There was no significant difference in the number of unsatisfactory first attempt reductions between the groups. There were no cases of deep infection post operatively in either group. Conclusion. Intra-articular haematoma block of the ankle appears to be an efficacious, safe and inexpensive means of providing analgesia for manipulation of displaced ankle fractures. Advantages of this method include avoiding the risks of procedural sedation, removing the requirement of designated clinical space and need for qualified clinicians to give sedation, and the ability to re-manipulate under the same block

Manipulation of the metatarsophalangeal joint and injection with steroid and local anaesthetic are widely practised in the treatment of hallux rigidus, but there is little information on the outcome. We report the results of this procedure carried out on 37 joints, with a minimum follow-up of one year (mean, 41.2 months). Patients with mild (grade-1) changes gained symptomatic relief for a median of six months and only one-third required surgery. Two-thirds of patients with moderate (grade-2) disease proceeded to open surgery. In advanced (grade-III) hallux rigidus, little symptomatic relief was obtained and all patients required operative treatment. We recommend that joints are graded before treatment and that manipulation under anaesthetic and injection be used only in early (grades I and II) hallux rigidus

Objectives. Cartiva synthetic cartilage implant (SCI) is licenced for use in management of symptomatic hallux rigidus in several countries including the UK. As for now, there are no independent comparative series for treatment of hallux rigidus utilising polyvinyl alcohol implants. Study design and methods. Patients at a single centre with symptomatic hallux rigidus who underwent Cartiva SCI implant procedure were identified. First metatarsophalangeal joint arthritis was radiographically graded according to the Hattrup and Johnson (HJ) classification. Pre-operative and post-operative patient-reported outcomes were evaluated using the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale and the Manchester-Oxford Foot Questionnaire (MOXFQ). Results. 66 patients (19M, 47F) (43R and 23L) were followed up for an average of 14 months (min=2, max=36). 17 patients suffered from HJ2/moderate arthritis and 49 patients with grade HJ3/severe arthritis. Post-operative mean FAAM scores showed statistically significant improvement (p< 0.0001). Patients reported a 40% increase in functionality during activities of daily living. All 3 MOXFQ Domain scores improved significantly (p< 0.02). The Index score improved by 28 points (p< 0.0001). There was no correlation between length of follow up or age and PROMs (r=0.129). No statistical difference was demonstrated between sexes. However clinically, males and older patients exhibit better outcomes. There was a 89.4% patient satisfaction with the use of Cartiva. Conclusions. Our study shows excellent results with statistically significant improvements in functional outcomes, and promising short-term follow-up with low early revision rates. Pain in particular was significantly reduced. One third of patients developed post-operative stiffness requiring a manipulation under anaesthesia. Patient selection is key. Additional imaging may be required to assess sesamoid osteoarthritis. At 3 years the implant has demonstrated to be safe and efficacious in the management of hallux rigidus. Durability and survivability of the implant will continue to be studied in this cohort

Ankle fractures account for 10% of all fractures. Most deformed looking ankles are manipulated in the emergency departments (ED) on clinical judgement in order to improve the outcome and avoid skin complications. It is accepted that significantly displaced ankle injuries with neurovascular (NV) compromise or critical skin should be reduced prior to imaging. However, is it really possible to understand the injury to an ankle without an x-ray or other imaging? The other possible injuries around the ankle, presenting with swelling and deformity of the ankle region, may include a ligamentous, talar, subtalar, Chopart joint or calcaneal injury. Does the risk of waiting for the imaging outweigh the benefit of manipulation of an undiagnosed injury?. This prospective study involved the analysis of all patients with ankle injuries referred to orthopaedics between November 2009 and February 2010. Results: Over the audited period 100 referrals were identified (43 male, 57 female). The average age was 50.4 years (range 5–89). Only 2% of fractures were open. Manipulation in the ED was performed for 44% of patients. Of these, 39% (17 cases) were manipulated and supported in plaster slab without an initial x-ray; 3 due to vascular deficit, 2 due to critical skin and 12 with no documented reason!. Re-manipulation in the ED as well as definitive open reduction and internal fixation (ORIF) were significantly lower in those patients who had an x-ray prior to manipulation (p < 0.05). ORIF was performed in 68% of all patients. Importantly, 80% of ankles manipulated in ED went on to have ORIF which was significantly higher than the 47% in the non-manipulation cohort (p < 0.05). We conclude that taking ankle injury radiographs prior to any attempt at manipulation, in the absence of NV deficit or critical skin, will constitute best practice

Introduction. The Ponseti regime was introduced in Swansea in 2003 for the treatment of congenital talipes equinovarus (CTEV). The aim of this retrospective cohort study was to compare children treated with this regime with a historical group treated traditionally before then. Materials and Methods. Sixty children (89 feet) were treated with the Ponseti regime between 2003 and 2010. Their notes were compared with notes from 12 children (21 feet) treated between 1995 and 2002. Clinic attendance for serial manipulation and immobilisation (strap/cast) was compared using a two-tailed Mann Whitney U test. Major release surgery was compared using a two-tailed Fisher's Exact test. Results. Children in the historical cohort presented when they were 0–174 days old (median 1 day). They attended 3–35 times (median 22) for serial manipulation and strapping/ plasters. Major release surgery was undertaken on 14 feet (66.7%) when the children were 6–39 months old (median 9 months); 7 had revision surgery. The Ponseti cohort presented when they were 0–73 days old (median 10 days) and attended outpatients 2–19 times (median 7) for serial manipulation and casting. An Achilles tenotomy was undertaken in 54 feet (60.7%) when the children were 45–184 days old (median 71 days) and major release surgery in 17 feet (19.1%) when the children were 10–66 months old (median 21 months). Four children had revision surgery. Discussion. There is a significant reduction in outpatient attendances (Ua = 1313, p = <0.0001) for serial manipulation and reduced rate of release surgery (p = 4.56 × 10. −5. ) since the implementation of the Ponseti regime. The rate of revision surgery in both groups was not significant (p = 0.15), although these samples were small. Conclusion. The Ponseti regime is an effective initial treatment for infants with CTEV compared with traditional treatment. It has decreased the number of clinic attendances and the rate of major release surgery

Aims

The number of revision total ankle arthroplasties (TAAs) which are undertaken is increasing. Few studies have reported the survival after this procedure. The primary aim of this study was to analyze the survival of revision ankle arthroplasties using large datasets. Secondary aims were to summarize the demographics of the patients, the indications for revision TAA, further operations, and predictors of survival.

Aims

The Cartiva synthetic cartilage implant (SCI) entered mainstream use in the management of first metatarsophalangeal joint (MTPJ) arthritis following the positive results of large trials in 2016. Limited information is available on the longer-term outcomes of this implant within the literature, particularly when independent from the originator. This single-centre cohort study investigates the efficacy of the Cartiva SCI at up to five years.

Aims

A local injection may be used as an early option in the treatment of Morton’s neuroma, and can be performed using various medications. The aim of this study was to compare the effects of injections of hyaluronic acid compared with corticosteroid in the treatment of this condition.

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Introduction. Standard teaching of dislocated ankles was always reduce then x-ray. However the 2016 BOAST guidelines stated “Reduction and splinting should be performed urgently for clinically deformed ankles. Radiographs should be obtained before reduction unless this will cause an unacceptable delay”. We aimed to audit our practice against the BOAST guidelines and look at time from attendance to reduction. Methods. We retrospectively reviewed all case notes of patients admitted via A&E at the Northern General Hospital with a fractured ankle between August 2016 and January 2017. Time of arrival, time to x-ray and time to reduction were recorded in a database for analysis. Results. 65 patients with acute ankle fractured dislocations were identified from 140 acute fractured ankle referrals to the orthopaedic on-call team. 55 of these had a pre-reduction x-ray. Time from arrival to a radiograph of a reduced ankle in cast was 3hrs 59 minutes for those who had a pre-reduction radiograph compared with 1hr 3 minutes for those who didn't have a pre-reduction radiograph. 12.5% of those with no pre-reduction radiograph required re-manipulation compared with 31% of those who did have a pre-reduction radiograph. Conclusion. Having a pre-reduction x-ray significantly increases the time until there is radiological evidence of a reduced ankle. There was an associated higher risk of requiring a further manipulation in those who had a pre-reduction radiograph. A larger review is currently being undertaken to better understand the possible reasons for this

Rocker bottom deformity may occur during the conservative treatment of idiopathic congenital clubfoot. Between 1975 and 1996, we treated 715 patients (1120 clubfeet) conservatively. A total of 23 patients (36 feet; 3.2%) developed a rocker bottom deformity. It is these patients that we have studied. The pathoanatomy of the rocker bottom deformity is characterised by a plantar convexity appearing between three and six months of age with the hindfoot equinus position remaining constant. The convexity initially involves the medial column, radiologically identified by the talo-first metatarsal angle and secondly by the lateral column, revealed radiologically as the calcaneo-fifth metatarsal angle. The apex of the deformity is usually at the midtrasal with a dorsal calcaneocuboid subluxation. Ideal management of clubfoot deformity should avoid this complication, with adequate manipulation and splinting and early Achilles’ percutaneous tenotomy if plantar convexity occurs. Adequate soft-tissue release provides satisfactory correction for rocker bottom deformity. However, this deformity requires more extensive and complex procedures than the standard surgical treatment of clubfoot. The need for lateral radiographs to ensure that the rocker bottom deformity is recognised early, is demonstrated

Aims

To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle.

Introduction:. The Best Practice Tariff (BPT) for hip fractures was introduced in April 2010 to promote a number of quality markers, including surgery within 36 hours. We conducted an audit to see whether the introduction of the BPT has had an inadvertent adverse effect on delay to fixation of unstable ankle fractures. Method:. We compared the delay to surgery for 50 consecutive patients with unstable ankle fractures in the 2009 financial year with another 50 patients treated in the 2011 financial year, ie one year after the introduction of the BPT. There were no other changes in service in our department in this period. All radiographs were reviewed and classified using the Lauge-Hansen system by 2 surgeons. Excel was used for data analysis using unpaired T-Test and chi-squared test to assess significance. Results:. 2 patients with pilon fractures were excluded from each group. Demographics and fracture pattern between the remaining 48 patients in each group were similar. The mean delay to surgery before BPT was 2.2 days compared with 3.8 days after its introduction (p = 0.01). 7 patients waited more than 5 days for surgery before BPT compared with 17 patients after its introduction (p < 0.001). There was 1 manipulation under anaesthetic (MUA) before BPT and 8 MUAs in 7 patients after its introduction (p < 0.001). Conclusion:. There is a significant association between the introduction of BPT for hip fractures and an increase in the delay to surgery for patients with unstable ankle fractures by an average of 1.6 days. More patients waited more than 5 days for surgery and there were more MUAs. We postulate that in a resource-limited NHS, prioritizing one patient group inevitably disadvantages others. Orthopaedic trauma services must adapt to national guidance to ensure all patients are treated in a timely fashion

Aims

The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice.

Aims

Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°.

Clubfoot deformity is the most common congenital musculoskeletal disorder (1). Approximately one in one thousand people are born with at least one clubfoot; between 150,000 and 200,000 babies are born with a clubfoot each year (2). Eighty percent of these cases occur in developing countries, and the majority is left untreated. When infants are treated with a non-invasive casting technique pioneered by Ignacio Ponseti M.D., they generally can be “cured” with relative ease. In the United States, 97% of patients given this treatment can walk successfully and are able to live normal lives (3). The Ponseti Method requires several plaster casts but either no or minimal surgery, can be taught fairly easily not only to doctors but also to healthcare workers, nurses, and other people who have some knowledge and training in healthcare. Also, it requires plaster casting, making it an inexpensive treatment. Dr. Ignacio Ponseti first performed his non-invasive treatment in 1949, but didn't publish his results until 1963. Two more papers, published in 1979 and 1995 described the long-term outcomes of treatment. In 1996 Oxford Press published a book detailing his approach. Although the treatment has always had high success rates, a lack of publicity prevented it from becoming more widely used until the late 1990s. Its basic mechanism consists of a series of plaster casts and manipulations that gradually reshape the foot around a fixed talus to obtain correction. Generally, between five and seven casts are required. The casts extend from the toes to the upper thigh and hold the knees at a right angle. One of the most important aspects of this method is timing: infants can be given treatment starting at seven days old and ideally should begin treatment before reaching eight months of age. Brazil, Uganda, Malawi and Chile now have official national programs, which are sponsored by each country's Ministries of Health, in which clinics in each country treat clubfoot disorder using the Ponseti Method. China set up a national program in 2005, but with a population of 1.3 billion people, it will take several years to complete the training. The prevalence of the Ponseti Method varies in the sixty other countries with healthcare workers trained in the treatment. This talk will review the principles of treatment and focus on results of recurrence after initial treatment with the Ponseti Method

Aims

Arthroplasty for end-stage hallux rigidus (HR) is controversial. Arthrodesis remains the gold standard for surgical treatment, although is not without its complications, with rates of up to 10% for nonunion, 14% for reoperation and 10% for metatarsalgia. The aim of this study was to analyze the outcome of a double-stemmed silastic implant (Wright-Medical, Memphis, Tennessee, USA) for patients with end-stage HR.

The last decade has seen a considerable increase in the use of in total ankle arthroplasty (TAA) to treat patients with end-stage arthritis of the ankle. However, the longevity of the implants is still far from that of total knee and hip arthroplasties.

The aim of this review is to outline a diagnostic and treatment algorithm for the painful TAA to be used when considering revision surgery.

Cite this article: Bone Joint J 2017;99-B:5–11.

Pigmented villonodular synovitis (PVNS) is a rare benign disease of the synovium of joints and tendon sheaths, which may be locally aggressive. We present 18 patients with diffuse-type PVNS of the foot and ankle followed for a mean of 5.1 years (2 to 11.8). There were seven men and 11 women, with a mean age of 42 years (18 to 73). A total of 13 patients underwent open or arthroscopic synovectomy, without post-operative radiotherapy. One had surgery at the referring unit before presentation with residual tibiotalar PVNS. The four patients who were managed non-operatively remain symptomatically controlled and under clinical and radiological surveillance. At final follow-up the mean Musculoskeletal Tumour Society score was 93.8% (95% confidence interval (CI) 85 to 100), the mean Toronto Extremity Salvage Score was 92 (95% CI 82 to 100) and the mean American Academy of Orthopaedic Surgeons foot and ankle score was 89 (95% CI 79 to 100). The lesion in the patient with residual PVNS resolved radiologically without further intervention six years after surgery. Targeted synovectomy without adjuvant radiotherapy can result in excellent outcomes, without recurrence. Asymptomatic patients can be successfully managed non-operatively. This is the first series to report clinical outcome scores for patients with diffuse-type PVNS of the foot and ankle.

Cite this article: Bone Joint J 2013;95-B:384–90.

We investigated 60 patients (89 feet) with a mean age of 64 years (61 to 67) treated for congenital clubfoot deformity, using standardised weight-bearing radiographs of both feet and ankles together with a functional evaluation. Talocalcaneal and talonavicular relationships were measured and the degree of osteo-arthritic change in the ankle and talonavicular joints was assessed. The functional results were evaluated using a modified Laaveg-Ponseti score. The talocalcaneal (TC) angles in the clubfeet were significantly lower in both anteroposterior (AP) and lateral projections than in the unaffected feet (p < 0.001 for both views). There was significant medial subluxation of the navicular in the clubfeet compared with the unaffected feet (p < 0.001). Severe osteoarthritis in the ankle joint was seen in seven feet (8%) and in the talonavicular joint in 11 feet (12%). The functional result was excellent or good (≥ 80 points) in 29 patients (48%), and fair or poor (< 80 points) in 31 patients (52%). Patients who had undergone few (0 to 1) surgical procedures had better functional outcomes than those who had undergone two or more procedures (p < 0.001). There was a significant correlation between the functional result and the degree of medial subluxation of the navicular (p < 0.001, r² = 0.164), the talocalcaneal angle on AP projection (p < 0.02, r2 = 0.025) and extent of osteoarthritis in the ankle joint (p < 0.001).

We conclude that poor functional outcome in patients with congenital clubfoot occurs more frequently in those with medial displacement of the navicular, osteoarthritis of the talonavicular and ankle joints, and a low talocalcaneal angle on the AP projection, and in patients who have undergone two or more surgical procedures. However, the ankle joint in these patients appeared relatively resistant to the development of osteoarthritis.