Objectives

Minimally invasive surgery (MIS) has gained popularity for hallux valgus, compared to the traditional scarf osteotomy (OS). Though evidence suggests similar clinical outcomes, there is paucity of randomised controlled studies. This study aimed to assess the feasibility of conducting a randomised controlled trial comparing the patient recorded and clinical outcomes for the surgical management of Hallux Valgus between OS and MIS Chevron Akin (MICA).

Background

In fixation of the fibula in ankle fractures, AO advocate using a lag screw and one-third tubular neutralisation plate for simple patterns. Where a lag screw cannot be placed, bridging fixation is required. A local pilot service evaluation previously identified variance in use of locking plates in all patterns with significant cost implications. The FAIR study aimed to evaluate current practice and implant use across the United Kingdom (UK) and review outcomes and complication rates between different fibula fixation methods.

Despite advancements, revision rates following total ankle replacement (TAR) are high in comparison to other total joint replacements. This explant analysis study aimed to investigate whether there was appreciable metal particulate debris release from various contemporary TARs by describing patterns of material loss. Twenty-eight explanted TARs (9 designs: 3 fixed and 6 mobile bearing), revised for any reason, were studied. The articulating surfaces of the metal tibial and talar components as well as the polyethylene insert were assessed for damage features using light microscopy. Based on the results of the microscopic analysis, scanning electron microscopy with energy dispersive X-ray spectroscopy was performed to determine the composition of embedded debris identified, as well as non-contacting 3D profilometry. Pitting, indicative of material loss, was identified on the articulating surfaces of 54% of tibial components and 96% of talar components. Bearing constraint was not found to be a factor, with similar proportions of fixed and mobile bearing metal components showing pitting. More cobalt-chromium than titanium alloy tibial components exhibited pitting (63% versus 20%). Significantly higher average surface roughness (Sa) values were measured for pitted areas in comparison to unpitted areas of these metal components (p<0.05). Additionally, metallic embedded debris (cobalt-chromium likely due to pitting of the tibial and talar components or titanium likely from loss of their porous coatings) was identified in 18% of polyethylene inserts. The presence of hard 3^rd body particles was also indicated by macroscopically visible sliding plane scratching, identified on 79% of talar components. This explant analysis study demonstrates that metal debris is released from the articulating surfaces and the coatings of various contemporary TARs, both fixed and mobile bearing. These findings suggest that metal debris release in TARs may be an under-recognised issue that should be considered in the study of painful or failed TAR moving forwards.

Introduction

Following publication of the Ankle Injury Management (AIM) trial in 2016 which compared the management of ankle fractures with open reduction and internal fixation (ORIF) versus closed contact casting (CCC), we looked at how the results of this study have been adopted into practice in a trauma unit in the United Kingdom.

Introduction

This is a multi-centre, prospective, observational study of 503 INFINITY fixed bearing total ankle arthroplasties. We report the minimum two-year results of this prosthesis which was introduced to the UK Market in 2014 and is now the most used ankle arthroplasty in the National Joint Registry of England and Wales.

Background

Surgical intervention for hallux valgus and hallux rigidus is an option for patients presenting with severe pain and deformity. Literature suggest that patients with high Pain Catastrophisation Scores (PCS) have poorer outcomes in spinal and to a lesser extent in arthroplasty surgery. There is however very little evidence pertaining to foot and ankle surgery.

Introduction

When ankle arthroplasty fails the options are revision to arthrodesis or revision to arthroplasty. We report early outcomes of revision procedures for failed total replacement.

Introduction

We report the functional outcome and survivorship of the Hintegra Total Ankle Replacement (TAR), in consecutive cases by multiple surgeons in a single UK institution. Between 2010–2014 the Hintegra TAR held 7.1% UK market share and surgeons should be aware of failure mechanisms.

Lateral approach open calcaneal osteotomy is the described gold standard procedure in the management of hindfoot deformity. With development of minimally invasive surgery, a MIS approach has been described, citing fewer wound complications and lower risk of sural nerve injury. This audit compares MIS to the traditional procedure. A retrospective review of all patients undergoing calcaneal osteotomy in Northumbria Trust in the past 5 years was performed. A total of 105 osteotomies were performed in 97 patients; 28 (13M:15F) in MIS group and 77 (40M:37F) had an open approach. The average age was 52.1 (range 16–83) for MIS and 51.5 (range 18–83) in the open group. All patients were followed up for development of wound complication, nerve injury and fusion rate. Wound complications were similar (10.7% in MIS group vs 10.3% in Open group) with no significant difference (p=0.48). Patients were treated for infection in 3(3.8%) cases in the open group and 2(7.1%) in the MIS group. This difference was not significant (p=0.43). 4 (14.3%) patients in the MIS group had evidence of sural nerve dysfunction post-operatively (managed expectantly), compared to 12(15.5%) patients in the open group (p=0.44). Of these, 2 went on to undergo neuroma exploration. There was no difference in nerve dysfunction in varus or valgus correction. Mean translation in the open group was measured as 7.3mm(SD=1.91;3 to 13mm) and 7.5mm(SD=1.25;5 to 10mm) in the MIS group. Translation was similar in varus or valgus correction. Non-union occurred in 2 patients in the MIS group and none in the open group (p= 0.06). MIS calcaneal osteotomy is a safe technique, that works as effectively as osteotomy performed through an open approach. There were lower rates of nerve injury, wound complication and infection, but this was not significantly different comparing groups. There was a higher risk of non-union in MIS technique.

Introduction

Day Case Surgery (defined as same day discharge) is a priority within the National Health Service and has been shown to provide beneficial outcomes for patients and hospitals. We report our experience developing a Day Case Programme for Total Ankle Replacement (TAR).

Background

The use of a knotless TightRope for the stabilisation of a syndesmotic injury is a well-recognised mode of fixation. It has been described that the device can be inserted using a “closed” technique. This presents a risk of saphenous nerve entrapment and post-operative pain.

Background

Traditionally, the extended lateral approach (ELA) was the favoured approch for calcaneal fractures, but has been reported to have high incidence of wound complications. There has been a move amongst surgeons in the United Kingdom towards the sinus tarsi approach (STA) due to its minimally invasive nature, attempting to reduce such complications.

Platelet rich plasma has been advocated for the treatment of plantar fasciitis but there are few good quality clinical trials to support its use. We report a pilot double blind randomised controlled trial of platelet rich plasma versus normal saline.

Introduction

Single photon emission computed tomography (SPECT) can be used to create a three dimensional image of a radiopharmaceutical bone scan. This combined with high resolution CT scan (SPECT-CT) with bone windows allows the linking of the information obtained in both investigations. The multiplanar anatomical information provided by CT is therefore linked with the functional, biological information of bone scintigraphy. The painful total ankle replacement has a number of potential causes of discomfort including impingement and loose components. Correct identification of the source of pain will assist surgeons in treating the source of the pain while avoiding unnecessary surgery. We present our experience of the use of SPECT-CT to investigate patients with ongoing pain following Total Ankle Replacement (TAR).

Background

Ankle arthrodesis results in significantly improved pain and function for patients with end-stage ankle arthritis. Arthroscopic ankle arthrodesis has gained increasing popularity with reports of shorter hospital stays, time to union and equivalent union rates to open arthrodesis. However, there remains a lack of good quality prospective data.

Background: Diagnostic and operative codes are routinely collected on every patient admitted to National Health Service (NHS) hospitals in England and Wales (hospital episode statistics, HES). The data allows for linkage of post-operative complications and primary operative procedures, even when patients are re-admitted following a successful discharge. Morbidity and mortality data on foot and ankle surgery (F& A) has not previously been available in large numbers for NHS patients.

Methods: All HES data for a 44-month period prior to August 2008 was analysed and divided into four groups – hindfoot fusion, ankle fracture surgery, ankle replacement and a control group. The control group was of first metatarsal osteotomy, which is predominantly day case surgery where no above ankle cast is used. The incidence of pulmonary embolism (PE) and all cause mortality (MR) within 90 days, and a return to theatre (RTT, as a complication of the index procedure) within 30 days was calculated for each group.

Results: 7448 patients underwent a hindfoot fusion. PE, RTT and MR were 0.11%, 0.11% and 0.12% respectively. 58732 patients had operative fixation of an ankle fracture. PE, RTT and MR were 0.16%, 0.08% and 0.35%. 1695 patients had an ankle replacement. PE, RTT and MR were 0.06%, 0.35% and zero. 35206 patients underwent a first metatarsal osteotomy. PE, RTT and mortality rates were 0.02%, 0.01% and 0.03%.

Discussion: There is controversy regarding the use of venous thrombo-embolic (VTE) prophylaxis in foot and ankle surgery. Non-fatal PE in F& A surgery has previously been reported as 0.15%. NICE guidelines recommend low molecular weight heparin (LMWH) for all inpatient orthopaedic surgery. 94% of F& A surgeons prescribe LMWH to post operative elective inpatients in plaster according to a previous British Orthopaedic foot and ankle society survey. VTE events, RTT and mortality rates for all groups were extremely low, including inpatient procedures requiring prolonged immobilisation. We question the widespread use of LMWH.

Introduction: Thromboprophylaxis in Orthopaedic practice has long been a debated issue. The recent NICE guidelines have recommended low molecular weight heparins (LMWH) for all orthopaedic patients, although a number of authors have highlighted the low risk of thromboembolism in foot and ankle practice. We looked at our series of total ankle replacements (TAR) to identify the incidence of thromboembolism and any complications associated with chemical thromboprophylaxis.

Methods: All patients who had undergone TAR were reviewed retrospectively. Risk factors according to the NICE guidelines were identified as was the type of chemical thromboprophylaxis, if given. Complications including thromboembolism, wound ooze, swelling and delay in discharge were recorded.

Results: There were 45 TAR’s in 45 patients. 20 patients (44%) had been given some form of chemical thromboprophylaxis. There were no cases of thromboembolism in either group. In the group receiving chemical thromboprophylaxis, nine patients (45%) had a wound complication. In the group receiving no chemical thromboprophylaxis only one patient (4%) had a wound complication.

Discussion: Thromboprophylaxis in total ankle replacement may significantly increase the risk of wound complications. We would recommend caution when prescribing chemical prophylaxis for patients undergoing total ankle replacement.

Diagnostic and operative codes are routinely collected for every patient admitted to hospital in the English NHS. Data on post-operative complications following foot and ankle surgery have not previously been available in large numbers. Data on symptomatic venous thromboembolism events and mortality within 90 days were extracted for patients undergoing fixation of an ankle fracture, first metatarsal osteotomy, hindfoot fusions and total ankle replacement over a period of 42 months. For ankle fracture surgery (45 949 patients), the rates of deep-vein thrombosis (DVT), pulmonary embolism and mortality were 0.12%, 0.17% and 0.37%, respectively. For first metatarsal osteotomy (33 626 patients), DVT, pulmonary embolism and mortality rates were 0.01%, 0.02% and 0.04%, and for hindfoot fusions (7033 patients) the rates were 0.03%, 0.11% and 0.11%, respectively. The rate of pulmonary embolism in 1633 total ankle replacement patients was 0.06%, and there were no recorded DVTs and no deaths. Statistical analysis could only identify risk factors for venous thromboembolic events of increasing age and multiple comorbidities following fracture surgery.

Venous thromboembolism following foot and ankle surgery is extremely rare, but this subset of fracture patients is at a higher risk. However, there is no evidence that thromboprophylaxis reduces this risk, and these national data suggest that prophylaxis is not required in most of these patients.

Purpose: Recent animal evidence has suggested that Bupivicaine may be harmful to articular cartilage. The purpose of this study was establish whether, following arthroscopy of the knee, infiltration of Bupivicaine around the portals is as effective as intra-articular infiltration for post-operative analgesia.

Method: Consecutive patients attending for knee arthroscopy were consented and randomised to one of two groups. Following arthroscopy, Group I received 20mls 0.5% Bupivicaine infiltrated into the joint; Group II received 20mls 0.5% Bupivicaine infiltrated around the portals. A Visual Analogue Score (VAS) was collected at one hour post-operatively and rescue analgesia recorded. A power calculation was performed. Ethical approval was granted.

Results: There were 68 patients in Group I (intra-articular) and 69 patients in Group II (portal). There was no significant difference in the age or sex distribution of patients in either group. The mean VAS score was 3.04 in Group I and 3.24 in Group II. There was no significant difference between the two groups (p=0.619). There was also no significant difference in the need for rescue analgesia (p=0.930). The study has demonstrated equivalence between the two groups, within one VAS point (Power = 80%).

Conclusion: We would recommend that following knee arthroscopy, Bupivicaine should be infiltrated around the portals, avoiding intra-articular infiltration.

The administration of intra-articular local anaesthetic is common following arthroscopy of the knee. However, recent evidence has suggested that bupivacaine may be harmful to articular cartilage. This study aimed to establish whether infiltration of bupivacaine around the portals is as effective as intra-articular injection.

We randomised 137 patients to receive either 20 ml 0.5% bupivacaine introduced into the joint (group 1) or 20 ml 0.5% bupivacaine infiltrated only around the portals (group 2) following arthroscopy. A visual analogue scale was administered one hour post-operatively to assess pain relief. Both patients and observers were blinded to the treatment group. A power calculation was performed.

The mean visual analogue score was 3.24 (sd 2.20) in group I and 3.04 (sd 2.31) in group 2. This difference was not statistically significant (p = 0.62).

Infiltration of bupivacaine around the portals had an equivalent effect on pain scores at one hour, and we would therefore recommend this technique to avoid the possible chondrotoxic effect of intra-articular bupivacaine.