Patients' perspective and experience is heavily modulated by their understanding of their pre-operative disability along with their overall coping strategy and life philosophy. Given that evidence-based practice is relying on patient-reported outcomes more and more, the orthopaedic community must be diligent in differentiating patients that may have the same objective outcome but vary widely on a patient-reported subjective basis. In clinical practice, patient selection is often a sensitive, experience-based decision process that screens for catastrophization, recognizing that certain patients will not benefit from a simple surgery. It is well appreciated that patient's catastrophization can affect their subjective outcome but there is little reported literature on this abstract concept. The study set out to determine if post-operative outcomes correlated with pre-operative catastrophization scales.

This current study set out to look at a cohort of complex consecutive foot and ankle cases and describe the relationship between Patient Catastrophizing Score (PCS) and multiple functional outcomes that are used commonly in foot and ankle specifically (SF-12 & FAOS). The PCS has three subcategory rumination, helplessness and magnification. A single institution undertook recruitment in consecutive patients within three surgeon's practice. In the end, 46 patients were found to be eligible in the study with an average age of 54.72 ± 14.41 years-old, a majority female 30 / 46 (65.22%), a minority employed at the pre-operative visit 19/46 (41%) and with an average BMI of 26.2 ± 5.56.

We found that the mental component of the SF12 had a statistically significant negative effect with the rumination score (r=−1.03) (p = 0.01) and the helplessness score (r=−1.05) (0.001). There was no statistically significant effect for the physical component of the SF-12. Looking at the FAOS Pain component, it correlated was significantly with the PCS rumination (Multivariate : r= −7.6 (p=0.002) Univariate: r=−2 (0.03)) and helplessness (Multivariate : r=−6.73 (p=0.01) Univariate: r=−1.5 (p=0.03)). Otherwise the FAOS ADL component showed correlation as well with the PCS rumination (Multivariate: r=−4.67 (p=0.02) Univariate : r=−1.85 (p=0.01)), helplessness (Multivariate r=−5.89 (p = 0.01) Univariate r=−1.81 (p = 0.001)) and total score (Multivariate : r=3.74 (p=0.02) Univariate r=−0.75 (p=0.01)). The FAOS Quality of life component was statistically significant for the rumination score (Univariate r=−11.59) (p < 0.05) and the helplessness score (Univariate r=−9.65) (p = 0.002) also the PCS total (Univariate r=8.54) (p = 0.0003).

As layed out in our hypothesis, this study did show an association between an increase patient catastrophizing score pre-operatively and a worse outcome in the following scores: Mental component of SF12, FAOS Pain, FAOS ADL and FAOS Quality of life components. This is an association and no causality can be proven within the limits of this current pilot study, but remains alarming. In elective surgeries, catastrophization should be screened for using the PCS form and potentially modulated pre-operatively with the help of allied health therapist while a patient is on the waitlist.

Lower-extremity orthopaedic procedures may be performed under either regional or general anaesthesia, or a combination of both techniques. There is a growing body of evidence supporting the benefits of regional anaesthesia, with meta-analyses of randomised controlled trials and registry data suggesting decreases in deep surgical site infections, thromboembolic events, cardiopulmonary complications and length of stay associated with use of regional anaesthesia. In patients undergoing foot and ankle surgery specifically, there is evidence demonstrating decreased post-operative pain, nausea, vomiting, opioid use and unplanned hospital admission. This supports an increased role for the use in regional anaesthesia in patients undergoing foot and ankle surgery. However, the type of anaesthetic used is dependent on surgeon, patient, anaesthesiologist and institutional factors. The purpose of this study is to investigate pre-operative factors that predict the type of anaesthetic used in patients undergoing foot and ankle surgery.

Data was collected prospectively on 888 patients undergoing foot or ankle surgery at a single institution. The primary method of anaesthesia for each procedure was recorded. Ten additional variables were recorded and analysed: age, BMI, gender, diabetes, ASA status, procedure length, procedure start time, elective vs. trauma procedure, primary vs. revision procedure and preoperative anticoagulation. Logistic regression modelling was performed to identify factors that independently predict the type of anaesthetic used.

General anaesthetic was employed in 280 patients (32%), and regional anaesthesia was the primary anaesthetic type used in 608 (68%). Logistic regression modelling demonstrated that factors that independently predict use of general anaesthetic include younger age (p<0.0001; Odds Ratio 0.97/year), male sex (0.0033; 1.618), procedure start time (0.0319; 1.066/hour) and length of procedure (<0.0001; 1.520/hour). Patients who underwent general anaesthetic had a mean length of procedure of 108 +/− 77 minutes, whereas patients provided with regional anaesthesia had a mean length of procedure 83 +/− 64 minutes.

With increasing evidence supporting the benefits of regional anaesthesia in patients undergoing lower extremity surgery, it is important to identify modifiable factors that contribute to patients receiving alternative treatments. Since later procedure start time was identified as an independent predictor of general anaesthetic use, there may be a role for identifying patients at increased risk of complications associated with general anaesthesia and scheduling earlier start times. Furthermore, while it is logical that extended length of procedure may be a contraindication to regional anaesthesia, the mean procedure time of 108 minutes in the general anaesthesia group indicates that many of these patients should still be considered candidates for regional anaesthesia.

In the current health care climate, there is an increasing focus on cost savings and resource management. As such, there is an emphasis on decreasing length of stay and performing surgery on an outpatient basis. Consequently, some patients will have unanticipated intra-operative or post-operative adverse events that will necessitate an unplanned post-operative hospital admission or a readmission after discharge. These unplanned admissions or readmissions represent an increased burden on health care systems and can cause cancellation of other scheduled procedures. The purpose of this study is to investigate whether pre-operative patient risk factors or intra-operative events could predict unplanned admission or readmission following discharge in patients undergoing either elective or emergency foot and ankle surgery.

Data was prospectively collected on a total of 889 patients. The patients were divided into two groups: patients without readmissions (N=791) and patients who had an unplanned admission or readmission (N=98). We also collected and analysed the following variables: age, gender, BMI, diabetes, ASA class, surgery start time, length of surgery, regional vs. general anesthetic, elective vs. trauma surgery and type of procedure. Logistic regression models were used to identify risk factors that could independently predict unplanned admissions or readmissions to hospital following foot and ankle surgery.

Factors that could be used to independently predict readmission were length of surgery (p 0.0154, Odds Ratio 1.004) and trauma surgery (0.0167; 1.978). For every 1-hour increase in length of surgery, the odds of unplanned admission/readmission increase by 1.27 times. The odds of patients undergoing surgery for acute traumatic injuries getting readmitted are 1.978 times higher than for elective surgery patients.

In conclusion, our study showed that pre-operative patient risk factors including BMI, diabetes, and ASA status were unable to predict whether patients would have an unplanned admission or readmission. The two factors that were able to predict whether patients would have an unplanned admission or readmission were length of the procedure and trauma surgery – both of which are not readily modifiable. Our results showed that in spite of institutional measures to ensure timely discharge, only 11% of patients required an unplanned admission or readmission.

The Weil osteotomy has gained popularity for surgically treating patients with metatarsalgia, intractable plantar keratosis and/or metatarsophalangeal joint dislocation because of its simplicity and lack of complications. Different geometric configurations of the Weil osteotomy have been proposed to reduce plantar pressure. In a dynamic cadaver model, these different geometric configurations of the Weil osteotomy did not significantly alter plantar pressure. Metatarsal head resection was required to significantly reduce plantar pressure.

The purpose of this study was to evaluate the effect of different geometric configurations of the Weil osteotomy on the plantar pressures in a dynamic cadaver model.

Different geometric configurations of the Weil osteotomy have been proposed to decrease plantar pressure, but in a dynamic cadaver model, these modifications did not significantly alter plantar pressure. Metatarsal head resection was required to significantly reduce plantar pressure.

The plantar translation of the metatarsal head occurring with a more oblique Weil osteotomy compared to a standard Weil osteotomy did not significantly increase plantar pressure in a dynamic cadaver model. The addition of a 4 mm slice resection did not significantly reduce pressure. Metatarsal head resection was required to significantly reduce pressure (p=0.02).

Ten specimens (5 matched pairs of cadaver lower extremities) were tested. Each pair of specimens had an oblique Weil osteotomy performed on one side, and a standard (parallel) Weil osteotomy on the other. Then, a 4 mm slice resection, and metatarsal head resection were performed sequentially. The plantar pressures were measured with an F scan in-shoe sensor while cyclically loaded to 700 N at a frequency of 1 Hz in intact specimens, and after each intervention.

The different geometric configurations of the Weil osteotomy did not significantly alter plantar pressure; metatarsal head resection was required to significantly reduce pressure. The Weil osteotomy reliably reduces dislocated metatarsophalangeal joints. The angle of the osteotomy does not affect plantar pressure. Further study in a dynamic model is required to identify other factors, which affect plantar pressure.

Purpose: To assess patients quality of life, pain, and functional limitations with with endstage ankle arthritis (EAA) and compared this to a similar cohort of patients with endstage hip arthritis (EHA).

Methods: Preoperative data (Short Form SF36) was collected prospectively from patients (n=130) with end stage ankle arthritis and compared to a similar cohort of patients (n=130) with end stage hip arthritis. Patients with ankle arthritis were registered in the Canadian Orthopedic Foot and Ankle Society (COFAS) multi-center study investigating the clinical outcome of ankle arthroplasty and fusion and patients with hip arthritis were randomly selected from the Halifax Joint Replacement Registry Database.

Results: All symptom and functional SF36 subscales for patients with EAA or EHA, were approximately two standard deviations below normal population scores. All differences between ankle and hip SF36 subscales scores were less than 4 points (40% of STD) in both direct and adjusted comparisons. A direct comparison of SF36 scores revealed that patients with EAA had significantly worse mental health according to the SF36 Mental Component Summary Score (MCS) (p= 0.0059), physical limitations with work and daily activities - role physical score (p= < 0.0001), and general health (p= 0.0004). Patients with EHA reported poorer physical function (p= 0.0007) although the Physical Component Summary Score (PCS) for the SF36 was not significant (p= 0.0510). Total Summary SF36, Physical Component Summary (PCS), bodily pain, vitality, role-emotional, social functioning, and mental health subscales were all not significantly different between cohorts (p> 0.05).

Conclusions: Patients with EAA have devastating losses of quality of life, which are comparable to patients with EHA. These findings suggest that increased resources should be directed towards alleviating the severe pain and disability associated with ankle arthritis.

In this paper, a retrospective review was undertaken of a large musculoskeletal tumour database to identify patients who presented with tumours of the foot and ankle. Soft tissue tumours occurred more frequently than bone tumours, and were also more frequently malignant than bone tumours. In contrast to the more recent trend towards limb-preserving surgery in other anatomic areas, malignant tumours of the foot and ankle were frequently unresectable and were treated with amputation.

Although the majority of extremity tumours that present to the orthopaedic surgeon are found in the proximal limbs or around the knee, tumours of the ankle and foot are also relatively common. The purpose of this study is to identify the frequency with which benign and malignant bone and soft tissue tumours occur in the foot and ankle and the oncologic and surgical outcomes of these patients.

A retrospective review of a large musculoskeletal tumor database in a tertiary referral center from the years 1986–2002 was undertaken. For oncologic outcomes, a minimum two-year follow up was considered.

A total of one hundred and sixteen bone and one hundred and seventy-one soft tissue tumours were identified. Seventy-seven bone tumours were benign and thirty-nine were malignant. Sixty-six soft tissue tumours were benign and one hundred and five were malignant. The most common benign bone tumour was giant cell tumour and osteosarcoma was the most common malignancy. Malignant fibrous histiocytoma was common in the distal leg but synovial sarcoma and clear cell sarcoma were more common in the foot. Twenty patients with bone malignancies (51%) and twenty-four with soft tissue sarcomas (23%) had amputation as definitive surgical management. Death from metastases occurred in 25% of patients with bone malignancies and 10% of soft tissue sarcomas.

At this center, the majority of bone tumours treated are benign but the majority of soft tissue tumours are malignant. Limb salvage is often not possible and amputation for local tumour control is necessary far more often than in other anatomic sites.

Aims: To evaluate the effect of different geometric conþgurations of the Weil osteotomy on the plantar pressures in a dynamic in vitro cadaver model. Methods: Ten specimens consisting of 5 matched pairs of cadaver lower extremities were tested. Each pair of specimens had an oblique Weil osteotomy with 5 mm shift performed on one side, and a standard (parallel) Weil osteotomy with 5 mm shift on the other. Then, a 4 mm slice resection, and metatarsal head resection were performed sequentially on each specimen. The plantar pressures were measured while cyclically loaded to 700 N at a frequency of 1 Hz with a F scan in-shoe sensor in intact specimens, and after each intervention. Results: This is the þrst study to demonstrate that the plantar translation of the metatarsal head occurring with a more oblique Weil osteotomy compared to a standard (parallel) Weil osteotomy did not signiþcantly increase plantar pressure in a dynamic in vitro cadaver model. Furthermore, the addition of a 4 mm slice resection did not signiþcantly unload the metatarsal head. Metatarsal head resection was required to signiþcantly unload the metatarsal head (p=0.02). Conclusions: The different geometric conþgurations of the Weil osteotomy did not signiþcantly alter plantar pressures in a dynamic cadaver model. Metatarsal head resection was required to signiþcantly unload the metatarsal head. Future studies of the effect of metatarsal osteotomies on plantar pressure should include evaluation in a dynamic in vitrocadaver model to account for all factors, which determine the distribution of plantar pressure.

A retrospective study was made of the results of surgical treatment of subluxation or dislocation of the hip in patients who had suffered from poliomyelitis. Good results were achieved in 46% and satisfactory results in 24%. The key factors for success are muscle balance, the femoral neck-shaft and anteversion angles, and the acetabular geometry. Iliopsoas transfer can augment the hip abductor power by an average of one MRC grade. Varus derotation femoral osteotomy is important to re-establish a normal neck-shaft angle and anteversion. The results of pelvic osteotomy are variable and the importance of a posterior acetabular defect is emphasised.