Introduction. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to perform major foot/ankle operations as day-case. This could have significant impact on length of stay, saving resources and is in keeping with government policy. However, there are theoretical concerns about complications and low patient satisfaction due to pain. Methods. The survey was developed following review of the literature and was approved for distribution by the BOFAS (British Orthopaedic Foot & Ankle Society) scientific committee. An online survey (19 questions) was sent to UK foot and ankle surgeons via the BOFAS membership list. Major foot/ ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge, with day surgery as the intended pathway. Results. A total of 132 surgeons responded, 80% from Acute NHS Trusts. The majority (78%) thought that more procedures could be performed as day-case at their centre. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. Despite post-operative pain and patient satisfaction being theoretical concerns for day-case surgery in this population; these outcomes were only measured by 34% and 10% of respondents respectively. The top perceived barriers to performing more major foot and ankle procedures as day-case were: Lack of physiotherapy input pre/post-operatively (23%), Lack of out of hours support (21%). Conclusions. There is consensus among surgeons to do more major foot/ ankle procedures as day-case. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. There is a need to scope the provision of physiotherapy pre/post-operatively and out of hours support at sites where this is a perceived barrier

Lisfranc fracture dislocations of the midfoot are uncommon but serious injuries, associated with posttraumatic arthrosis, progressive deformity, and persistent pain. Management of the acute injury aims to restore anatomic tarsometatarsal alignment in order to minimise these complications. Reduction and stabilisation can be performed using image-guided percutaneous reduction and screw stabilisation (aiming to minimise the risk of wound infection) or through open plating techniques (in order to visualise anatomic reduction, and to avoid chondral damage from transarticular screws). This retrospective study compares percutaneous and open treatment in terms of radiographic reduction and incidence of early complications. Case records and postoperative radiographs of all patients undergoing reduction and stabilisation of unstable tarsometatarsal joint injuries between 2011 and 2014 in our institution were reviewed. Dorsoplantar, oblique and lateral radiographs were assessed for accuracy of reduction, with malreduction being defined as greater than 2mm tarsometatarsal malalignment in any view. The primary outcome measure was postoperative radiographic alignment. Secondary outcome measures included the incidence of infection and other intra- or early postoperative complications. During the study period, 32 unstable midfoot injuries were treated, of which 19 underwent percutaneous reduction and screw stabilisation and 13 underwent open reduction and internal fixation. Of the percutaneous group, no wound infections were reported, and there were four (21.1%) malreduced injuries. Of the open group, two infections (15.4%) were observed, and no cases of malreduction. In conclusion, our study shows a strong trend towards increased risk of malreduction when percutaneous techniques are used to treat midfoot injuries, and an increased risk of infection when open surgery is used. Whilst conclusions are limited by the retrospective data collection, this study demonstrates the relative risks to consider when selecting a surgical approach

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.

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

Introduction. Major ankle and hindfoot surgery has traditionally been performed as an inpatient. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to contemplate performing major ankle and hindfoot operations as a day-case. This could have a significant impact on length of stay for these major cases, saving resources and in keeping with government policy. In this study, we prospectively audited the outcome of the first cohort of patients undergoing major ankle and hindfoot surgery as a day-case against a series of standards. Methods. Twenty four consecutive patients who underwent ankle or hindfoot surgery between August 2009 and April 2010 were considered for day surgery. Seven patients were deemed not suitable due to co-existing medical conditions or insufficient help at home. This left 17 patients who had ankle or hindfoot surgery as a day case. All patients received an ultrasound-guided regional nerve block and spinal or general anaesthesia. The data was collected on patient demographics, diagnosis, and type of surgical procedure. Patients received the standard follow-up regimen for a particular procedure. Patient satisfaction was assessed using a standard questionnaire which included self-monitoring of post-operative pain at 6, 24 and 48 hrs. In addition, any adverse outcomes were recorded. Results. The average age was 48 (range 23-67) years. There were 7 males and 10 females. The surgical procedures included arthroscopic ankle fusion (5), subtalar fusion (5), talonavicular fusion (1) midfoot fusion with calcaneal osteotomy (1), tibialis posterior reconstruction (3) tendo-achilles reconstruction (1) and arthroscopy and lateral ligament reconstruction (1). 93% patients reported that they were given enough information and advice about their operation as a day case. No patients reported severe pain at 6 hrs. One patient had severe pain at 24 hrs post-op. Four patients (23%) had significant pain at 48 hrs and required strong analgesia. Thirteen (77%) patients stated that they would recommend having this surgery as a day-case if they were having it again whereas four (23%) would prefer staying in overnight. The average length of stay for the patients deemed unsuitable for day surgery was 3.8 (range 1-6) days. Conclusions. Our initial results of performing major ankle and hindfoot procedures as day surgery are encouraging but pain control at 48 hrs still remains an unsolved issue and further optimisation is needed

Introduction. Patients who present with atypical foot pain in a non specific sensory distribution may benefit from having nerve conduction studies (NCS). The aim of this study was to confirm whether NCS is a useful tool. Methods. Between July 2005 and March 2011, 78 patients had NCS to investigate foot pain. The management following NCS was compared with the initial management plan. Results. Complete data was available for 60 patients, of whom 31 were male. The mean age at presentation was 54.4 years (range 18–89.7). Eighteen patients had bilateral symptoms. The predominant symptom was pain in 47 patients. Aching, burning, throbbing, shooting, pins and needles, proximal/distal radiation, numbness, and paraesthesia were also described in 23 patients. Twenty patients had a history of trauma and five developed symptoms following elective lower limb surgery. Eight patients had a cavovarus foot. There were 22 normal results. The NCS diagnosed peripheral nerve (13)/nerve root (8) pathology, Charcot-Marie-Tooth (1), amyotrophic lateral sclerosis (1), tarsal tunnel syndrome (3), and nonspecific neuropathy (12). Surgery was initially considered for 9 patients. Following a normal result, 4 out of 7 had surgery. One patient with an abnormal result proceeded to surgery. The NCS was abnormal in 70.1% (36/51) of patients who were for nonoperative management, 4 of whom proceeded to have surgery. None of the patients who had a normal NCS had an operation. Conclusion. NCS provided a diagnosis for 63.3% of the patients. Following NCS, the management plan changed in 44% of patients who were initially considered for surgery (4/9) and in 7.8% of patients who were initially considered for nonoperative management (4/51). This investigation is a useful adjunct in guiding the management of patients who present with atypical non specific foot pain