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

Background. Disability and slow return to sport and work after tendon rupture are major challenges. Platelet Rich Plasma (PRP) is an autologous supraphysiological concentration of platelets from whole blood that has demonstrated positive cellular and physiological effects on healing in laboratory conditions but evidence from adequately powered robust clinical trials is lacking. We aimed to determine the clinical efficacy of PRP for treatment of acute Achilles tendon rupture. Methods. In a placebo-controlled, participant- and assessor-blinded, trial at 19 NHS hospitals we randomly assigned 230 adults starting acute Achilles rupture non-surgical management to PRP injection or dry-needle insertion (placebo) to the rupture gap under local anaesthetic. Patients with confounding or contraindicated concurrent medical conditions were excluded. The primary outcome was muscle-tendon function, assessed by the limb symmetry index (LSI, uninjured limb/injured limb × 100, higher scores better) of the work (Joules) performed during the heel-rise endurance test at 24 weeks. Secondary outcomes were: Achilles Tendon Rupture Score (ATRS, 0–100, higher scores better), quality of life (SF-12), pain, and goal attainment. Trial registration: ISRCTN54992179. Results. Participants were aged mean 46 years and 57 (25%) were female. 103/114 (90%) of the PRP group and all (n=116) in the placebo group received allocated treatment. At 24 weeks, mean LSI was 34.4 for the PRP group and 38.8 for placebo (adjusted mean difference −4.4 95% CI −11.2 to 2.5, n=201) and ATRS was mean 65.2 PRP vs 65.8 (adjusted mean difference −0.6, 95% CI −4.9 to 3.7, n=224). There were no differences between groups in the other secondary outcomes. Conclusion. We found no evidence of PRP efficacy for improving muscle-tendon function or patient-reported recovery after acute Achilles tendon rupture. Our findings challenge the increasing global use of PRP for acute tendon injury and indicate that robust evaluations are required in other applications

The aim of this study was to compare the outcome of bilateral sequential total ankle replacement (TAR) with that of unilateral TAR. We reviewed 23 patients who had undergone sequential bilateral TAR under a single anaesthetic and 46 matched patients with a unilateral TAR. There were no significant pre-operative differences between the two groups in terms of age, gender, body mass index, American Society of Anaesthesiologists classification and aetiology of the osteoarthritis of the ankle. Clinical and radiological follow-up was carried out at four months, one and two years. After four months, patients with simultaneous bilateral TAR reported a significantly higher mean pain score than those with a unilateral TAR. The mean American Orthopaedic Foot and Ankle Society hindfoot score and short-form 36 physical component summary score were better in the unilateral group. However, this difference disappeared at the one-and two-year follow-ups. Bilateral sequential TAR under one anaesthetic can be offered to patients with bilateral severe ankle osteoarthritis. However, they should be informed of the long recovery period

Purpose. Ankle and hindfoot surgery is associated with severe post-operative pain, leading to a reliance on opiate analgesia and its side effects, longer hospital stays, and patient dissatisfaction. Popliteal sciatic nerve blockade has the potential to resolve these issues. We present our experience with using a continuous local anaesthetic nerve block delivered by an elastomeric pump in patients undergoing major foot and ankle surgery. Methods. All patients undergoing major ankle or hindfoot surgery during a one-year period under a single surgeon were eligible for a continuous popliteal block. An ultrasound-guided popliteal nerve catheter was inserted immediately before surgery and a bolus of bupivacaine infiltrated. Using a 250ml elastomeric pump, a continuous infusion was started immediately post operatively and terminated 48 hours later. Prospective data including post-operative analgesia, nausea and vomiting (PONV), length of stay (LOS), pain scores, and patient satisfaction were recorded daily for 48 hours post operatively. Results. Eighty-one patients (53 male, 28 female) with a mean age 60 years (24–84 years) were included. 66 patients received spinal anaesthesia with 15 having general anaesthetics. There were no complications associated with the nerve catheters. At day 1 post op, 49 (60%) patients reported having no or mild pain. 68 (84%) patients had no PONV. 27 (33%) patients did not require any opiate analgesia during their post op period. Average LOS for all patients was 54 hours, with 41 (51%) discharged within 48 hours. 74 (91%) reported good or excellent pain management in the post operative period. Conclusions. Continuous popliteal sciatic nerve blockade is a safe and effective method for controlling post-operative pain, reducing opiate-induced side effects, and optimising length of stay. Patient-reported outcomes support its use in major ankle and hindfoot surgery. Furthermore, reduced costs from early discharge in combination with a daycase tariff uplift can bring significant financial savings

Background. Forefoot surgery is often performed under regional anaesthesia (ankle block) in awake patients, using tourniquet or esmarch bandage to obtain bloodless field. The purpose of this study was to examine the value and need for local tourniquet pain control using local subcutaneous analgesic mixture in patients undergoing forefoot surgery under regional anaesthesia. We prospectively randomized 56 patients who underwent forefoot surgery under ankle block to receive subcutaneous local anaesthetic mixture under the tourniquet. We checked for local tourniquet pain score (VAS 0–100) and skin condition during and after the procedure. Results. Tourniquet was quite tolerable in both groups, with an average VAS score of 7–21. No difference was observed between groups throughout most of the procedure. No correlation between VAS scores and procedure length or patient's age or gender. Conclusion. Ankle tourniquet is well tolerated by patients without need for local anaesthetics

Regional anaesthetic for foot surgery has been discussed as a method of post operative analgesia. Ankle block as the sole anaesthetic for foot surgery has not been extensively reviewed in the literature. Aim. To describe our experience of forefoot surgery under ankle block. Methods. 71 consecutive forefoot procedures (65 patients) were carried out under ankle block. A mixture of 10ml 2% Lidocaine with 10ml 0.5 % Bupivacine was administered to the superficial peroneal, deep peroneal, sural and saphenous nerves. Ankle tourniquet was employed in all procedures. Patients were contacted post operatively and completed a standardised questionnaire including an incremented pain assessment ranging from 0-10 (0 no pain, 10 severe pain). Results. 61 female and 4 male patients were contacted (age range 33-67y). Procedures included 48 first metatarsal osteotomies, 15 cheilectomies, 2 first MTP joint replacements, and 6 fusions. 17 patients (26 %) reported some discomfort during the block procedure (average pain score 1.2). No patients reported any pain during their operation(s). 14 patients (22%) required supplementation of the block. Average pain score at 6, 12, 24 and 48 hours following surgery were 0.66, 2.9, 2.4 and 1.3 respectively. All patients were discharged home and walking on the same day. None complained of nausea or required parentral analgesia. There were no readmissions. Each patient confirmed they would have surgery under regional block rather than general anaesthesia and would recommend this technique to family and friends. Discussion. There are many advantages in being able to perform these small procedures under regional anaesthesia. Our initial observational study suggests forefoot surgery under ankle block alone may be safe and effective. Anaesthesia obtained permits the majority of forefoot procedures and provides lasting post-operative analgesia. Combined with intra-operative sedation, use of ankle tourniquet and same day discharge it has very high patient acceptance and satisfaction

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

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.

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

Introduction. Up to 70% of patients with symptomatic Morton's neuroma proceed to surgery having failed non-operative management. The success of surgical excision is up to 85% but carries with it significant morbidity. Radiofrequency ablation (RFA) is a less invasive alternative. Methods. We studied a consecutive cohort of patients with Morton's neuroma that had failed non-operative treatment. Instead of undergoing surgical excision, these patients were referred for RFA. Under a local anaesthetic nerve block, RFA was performed under ultrasound-guidance, as an out-patient procedure, by a single radiologist. The procedure was repeated after 4 weeks if necessary. We followed patients for a minimum of 6 months to assess their change in visual analogue pain scores (VAS), overall symptom improvement, complications and progression to surgical excision. Results. 30 feet in 25 patients were studied. There were 4 males and 21 females with an average age of 55 years (range 33–73 y). All had tried previous methods of non-operative management. 40% presented with 2. nd. space neuromas and 60% with 3. rd. space. The average number of treatment sessions was 1.6 (range 1–3, mode 1). Prior to treatment, all patients had pain on activity (VAS average: 6.0, range 3–9). At 6 months post treatment, there was a statistically significant reduction in pain scores (post RFA VAS average: 1.7, range 0–8, p<0.001). The average overall symptom improvement was 76%. There was one minor complication of temporary nerve irritation. 3 neuromas (10%) have progressed to surgical excision. 1 patient has ongoing, unchanged pain with no obvious cause. At 6 months, 26 out of 30 feet had a satisfactory outcome. Conclusion. RFA has potentially reduced the need for surgical excision of Morton's neuromas by >85%

Juvenile Chronic Arthritis results in the early degeneration of multiple joints with severe pain and deformity. Treatment of ankle arthritis is complex and ankle replacement is indicated because of adjacent and distant joint involvement. Materials and Methods. We reviewed 25 total ankle replacements in 13 young adults suffering the generalised consequences of Juvenile Chronic Arthritis (JCA) between 2000 and 2009. 12 had bilateral disease, 20 had anklylosis or prior fusion of the hind- or midfoot, and 16 had substantial fixed inversion of the hindfoot. All had previous prosthetic arthroplasty of between 1 and 15 joints. Surgery comprised corrective triple fusion where required, with staged total ankle arthroplasty at an interval of 3 or more months. Results. All patients reported significant reduction in pain, and increased mobility with increased stride length, however severe co-morbidity limited the usefulness of routine outcome scores. No ankles have required revision to date. We noted that the dimensions of the distal tibia and talus are markedly reduced in patients with JCA, and as a result of this and bone fragility, the malleoli were vulnerable to fracture or resection. JCA is also associated with cervical spondilitis and instability, micrognathia, temporomandibula arthritis and crico-arytenoid arthritis, resulting in challenging anaesthesia. Discussion. As a result of our experience, we recommend preoperative CT scan to confirm whether standard or custom implants are required. We also advocate pre-cannulation of both maleoli to reduce the rate of fractures, and facilitate fixation should this occur. Conclusion. Surgery for this group of patients requires specialist anaesthetic input as well as surgical skills

The saphenous nerve is classically described as innervating skin of the medial foot to the first MTP joint and thus is at risk in surgery to the medial ankle and foot. However, it has previously been demonstrated that the dorsomedial branch of the superficial peroneal nerve consistently supplies the dorsomedial forefoot, and therefore previous descriptions of the saphenous nerve maybe erroneous. We undertook a cadaveric study to assess the presence and variability of this nerve. 21 cadaveric feet were dissected from a level 5 cm above the medial malleolus, and distally to the termination of the saphenous nerve. In 16 specimens (76%), a saphenous nerve was present, of which 14 were anterior to the saphenous vein. Two of 16 nerves terminated above the medial malleolus. Therefore, only 14 of 21 specimens (66%) had a saphenous nerve present at the level of the medial malleolus. In seven of these 14 specimens (50%), the nerve terminally branched before the level of the tip of the malleolus. The mean distance reached in the foot was 46mm. Only two nerves reached the forefoot, at 97mm and 110 mm from the ankle joint respectively. At the ankle, the mean distance of the nerve from the tibialis anterior tendon was 9mm, and the saphenous vein 1.2mm. Discussion. Our study shows that the course of the saphenous nerve is highly variable, and when present usually terminates within 40mm of the ankle. Only 10% reach the first MTP joint. These findings are inconsistent with standard surgical text descriptions. The saphenous nerve is at risk in distal tibial screw placement and arthroscopy portal placement, and should be included in local anaesthetic ankle blocks in forefoot surgery, as a small proportion of nerves supply sensation to the medial forefoot

Introduction. 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 sequelae. However, it can cause disabling pain for a prolonged period of time. Materials and Methods. 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. Results. All patients had their limbs immobilised in a below knee cast and asked to mobilise non weight bearing for 6–8 weeks. Thereafter, they were allowed to mobilise with a pneumatic walker, increasing weight bearing as pain allowed. The walker was discarded at an average of 26 weeks. All 8 patients had complete relief of pain after an average of 14 months (4–22 months). All were able to return to their work environment but 2 complained of occasional aching and swelling of their feet, at the end of their shift at work. 2 patients were treated with bisphosphonates and 2 had targeted local anaesthetic injections with good pain relief. None were treated with Iloprost. Conclusions. BMES affecting the foot and ankle is an uncommon condition. Symptoms tend to be prolonged and may result in chronic swelling and aching around the ankle. Symptoms do tend to improve with time with or without intervention

Method. A questionnaire was given to delegates at the British Orthopaedic Foot & Ankle Society (BOFAS) annual scientific meeting 3rd–5th November 2010. A total of 75 questionnaires were included within the analysis. The questionnaire asked delegates for their most commonly performed procedure for a variety of common foot and ankle conditions. Results. Which procedure do you most commonly perform?. Hallux valgus mild;. Chevron 60.0%. Scarf 28.0%. Hallux Valgus Moderate;. Scarf 85.3%. Chevron 12.0%. Hallux Valgus Severe;. Scarf 65.3%. Basal Osteotomy 29.3%. 1st MTPJ OA Fusion;. crossed screws 54.7%. Plate 26.7%. Lesser toe Metatarsalgia;. Weil 48.6%. BRT 22.8%. Hammer second toe;. PIPJ Fusion 62.7%. Oxford Procedure 15%. Tib Post stage 1;. Debridement 60.0%. Conservative 24.0%. Tib Post stage 2;. FDL Transfer 76.0%. Calc. osteotomy 78.7%. Achilles tendon rupture. Open Repair 61.5%. Percutaneous 13.8%. In delegates' normal practice they would fuse an osteoarthritic ankle 90% and perform a Total Ankle replacement 10% of the time. The method of fusion is split 50/50 between arthroscopic and open. Regarding the anaesthetic used for forefoot surgery most are using GA + Regional Block (mean 60%) only occasionally using regional anaesthesia alone (mean 8%). Only 12.3% of delegates have tried minimally invasive [forefoot] surgery (MIS), 17.3% of delegates think they will do more MIS in the future. The practice of British orthopaedic foot and ankle surgeons is broadly in line with an evidence-based approach. Knowledge of current practice may help trainees make sense of the myriad foot and ankle operations described in the literature

Introduction. We describe our experience with a minimally invasive Chevron and Akin (MICA) technique for hallux valgus correction. This technique adheres to the same principles as open surgical correction but is performed using a specialized high-speed cutting burr under image intensifier guidance via tiny skin portals. Methods. All patients undergoing minimally invasive hallux valgus correction between November 2009 and April 2010 were included in this study and were subject to prospective clinical and radiological review. Patients were scored using the Kitaoka score as well as radiological review and patient satisfaction survey. Surgery was performed under general anaesthetic and included distal soft tissue release, Chevron and Akin osteotomies, with the same indications as for open surgery. All osteotomies were internally fixed with cannulated compression screws. Results. 83 operations were performed on 70 patients (2 male 65 female, mean age 54 years (27-78)). The pre-operative mean HVA was 34° and IMA 14°. Post-operative mean HVA was 9° and IMA 9.5°. Kitaoka score improved significantly at 3-12 months follow-up. There were no delayed or non- s and no osteonecrosis. Six M1 osteotomies moved during the postoperative period (3 feet (2 patients) required further surgery + 3 incomplete corrections without need for further surgery) and the fixation technique was successfully modified to avoid this problem. Mild transfer metatarsalgia was observed in 4 patients. There were 2 superficial wound infections. Cutaneous nerve injuries were noted in 3 feet but none painful. No recurrent deformities observed to date. Overall, 65% patients very satisfied, 29% satisfied, 6% unsatisfied. Discussion. This study suggests that good results can be obtained in forefoot surgery with the MICA technique. We believe this technique may offer advantages for some patients in terms of reduced morbidity and cosmesis. A randomized study is in progress to compare open and minimally invasive techniques

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In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method.

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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.

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The aim was to compare long-term patient-reported outcome measures (PROMs) after operative and nonoperative treatment of acute Achilles tendon rupture in the context of a randomized controlled trial.

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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.