Introduction

Total ankle arthroplasty (TAA) is an increasingly popular treatment option for patients with end-stage ankle arthritis. However, for most implant systems, failure rates of 10–20% have been reported within the first 10 years after primary TAA. Pain is the primary symptom that indicates failure of TAA but cause of it can be difficult to establish.

Introduction

Total ankle replacement as a valid treatment for end stage ankle arthritis, is gaining popularity and every year there is an increasing number of procedures. With revision rates as high as 21% at 5 years and 43% at 10 years there is a need for understanding and reporting the outcome of revision ankle replacement. Our aim was to study the patient reported outcomes following revision TAR with a minimum of 2 year follow up.

Aims

A multicentre, randomized, clinician-led, pragmatic, parallel-group orthopaedic trial of two surgical procedures was set up to obtain high-quality evidence of effectiveness. However, the trial faced recruitment challenges and struggled to maintain recruitment rates over 30%, although this is not unusual for surgical trials. We conducted a qualitative study with the aim of gathering information about recruitment practices to identify barriers to patient consent and participation to an orthopaedic trial.

The effect of BMI on patient-reported outcomes following total ankle replacement (TAR) is uncertain and the change in BMI experienced by these patients in the 5 years following surgery has not been studied. We report a series of 106 patients with complete 5-year data on BMI and patient-reported outcome scores.

Patients undergoing TAR between 2006 and 2009, took part in the hospital joint registry, which provides routine clinical audit of patient progress following total joint arthroplasty; therefore, ethics committee approval was not required for this study. Data on BMI, Foot and Ankle Score (FAOS) and SF-36 score were collected preoperatively and annually postoperatively.

Patients who were obese (BMI >30) had lower FAOS scores pre-operatively and at 5 years, however this did not reach significance. Both obese (p = 0.0004) and non-obese (p < 0.0001) patients demonstrated a significant improvement in FAOS score from baseline to 5 years. This improvement was more marked for the non-obese patients. No significant differences were seen for SF36 scores between obese and non-obese patients either at baseline or 5 years. There was a trend for improved score in both groups.

Mean pre-operative BMI was 28.49. Mean post-operative BMI was 28.33. The mean difference between pre- and post-operative BMI was −0.15, which was not statistically significant (p=0.55). There were no significant differences in revisions in the obese (2) and non-obese (1 and one awaited) groups at 5 years.

This data supports use of TAR in the obese population, as significant increases in mean FAOS score were seen in this group at 5 years. Obesity did not have a significant influence on patients' overall health perceptions, measured by the SF36 and a trend for improvement was seen in both obese and non-obese patients. TAR cannot be relied upon to result in significant post-operative weight-loss without further interventions.

Introduction:

Ankle arthritis is a leading cause of pain and disability. The effect of this condition on physical and mental health is similar to end stage hip arthritis. There is paucity of literature on PROMS following total ankle replacements (TAR) in comparison to total hip replacement (THR) or knee replacement (TKR). We aimed to study 5 year outcomes of TAR in comparison with TKR and THR.

Introduction:

There is paucity of literature on Gait analysis following Total Ankle Replacement (TAR). We aimed to study changes to gait after successful Mobility TAR.

Introduction:

Peroneal muscle weakness is a common pathology in foot and ankle surgery. Polio, charcot marie tooth disease and spina bifida are associated with varying degrees of peroneal muscle paralysis. Tibialis Posterior, an antagonist of the peroneal muscles, becomes pathologically dominant, causing foot adduction and contributes to cavus foot posture. Refunctioning the peroneus muscles would enhance stability in toe off and resist the deforming force of tibialis posterior. This study determines the feasibility of a novel tendon transfer between peroneus longus and gastrocnemius, thus enabling gastrocnemius to power a paralysed peroneus tendon.

Introduction:

The aim of this study was to assess patients reported fitness to return to work and to driving after ankle replacement.

Introduction:

Total Ankle Replacement is proving to be a viable option for younger patients with Post Traumatic Osteoarthritis of the Ankle. The aim of our study was to study the clinical and patient reported outcomes between patients of < 60 and > 60 years who underwent TAR.

Aim

We aimed to study the effect of BMI on clinical and patient-reported outcomes in patients with TAR with a minimum follow-up of three years.

Introduction

Postoperative pain following the 3 component ankle arthroplasty (AA) (Mobility™) is a recognised problem without any apparent cause. This study aimed to determine pattern of postoperative pain following Total Ankle Arthroplasty (TAA) and its management options.

Aim

A prospective cohort of patients undergoing total ankle arthroplasrty for arthritis following pilon fractures was included in the present study. This group of patients generally have poor soft tissue envelope and have had previous surgical interventions prior to the ankle arthroplasty, making the arthroplasty more difficult as well as prone to complications.

Background and objective

Metatarsals stress fractures are common in athletes and dancers. Occasionally, such fractures could occur without trauma in peripheral neuropathic patients. There is no published series describing outcome of stress fractures in these patients. This study analyse these fractures, treatment and outcome.

Introduction

There is less literature reporting outcomes following total ankle replacement (TAR) in patients presenting with a coronal plane deformity preoperatively. This study compares clinical and patient reported outcomes at 1 year between TAR patients with and without coronal plane deformity.

Background

The recommended indications for total ankle replacement (TAR) are limited, leaving fusion as the only definitive alternative. As longer-term clinical results become more promising, should we be broadening our indications for TAR?

Introduction

There is no published series described change in bone mineral density (BMD) after ankle replacement. We present the results of a prospective study examining the effect of total ankle replacement (TAR) upon local bone mineral density (BMD).

Total ankle replacement (TAR) is increasingly offered as an alternative to ankle fusion for the management of severe ankle arthritis. As with all other types of joint arthroplasty, there are risks involved and complications that occur; these increase with case complexity. We present the complications and management from a single-centre series.

Since 2006, we have performed 150 Mobility TARs with up to 4 years' follow-up. We have excluded 16 that are part of a separate RCT and 10 with less than 3 months' follow-up. 124 TARs were included in our study (117 patients). Three ankles (2.4%) had superficial wound infections treated successfully with antibiotics. One ankle (0.8%) required an arthroscopic washout and debridement but the implant was retained. 11 ankles (8.9%) had a periprosthetic fracture: One was intraoperative; 10 were postoperative (2 fixed). Four patients (3.2%) developed CRPS. One ankle required fusion surgery (following subsidence of the talar component) with another one pending revision (ligament instability causing implant displacement). No patient had a symptomatic deep vein thrombosis or thromboembolic event.

Our figures are comparable with other series. Our complication rate has not changed significantly over time. Our results, at present, suggest that most complications (98%) with the Mobility TAR can be satisfactorily managed without having a detrimental effect on the implant.

There have been proven and promising results with total ankle replacement. However, there is a significant complication rate that must be made clear to the patient via informed consent; the rate still remains higher than for hip and knee arthroplasty.

This project highlights the red flags in postoperative rehabilitation of total ankle replacement (TAR) patients managed with two different postoperative rehab regimes.

20 TAR patients were recruited for a pilot RCT between 2008 and 2011; they were randomized to 2 groups (immobilisation in a below knee plaster cast for 6 weeks vs. early mobilisation following TAR); all patients underwent a graded outpatient Physiotherapy program until 12 weeks postoperatively. Assessments included questionnaires, complications, American Orthopaedic Foot and Ankle Score (AOFAS) done preoperatively, 3 and 6 months after surgery

Background

Postoperative pain following (Mobility TM) ankle arthroplasty (AA) is recognised problem. This study aimed to determine pattern of postoperative pain following Ankle arthroplasty (AA).

Introduction

The standard practice of uncomplicated total ankle replacement (TAR) involves postoperative immobilisation. Periprosthetic fracture is a well-recognised complication following ankle arthroplasty. It occurs predominantly as a stress reaction on the medial tibial metaphysis during the postoperative rehabilitation period. Occasionally it occurs during surgery. We present fractures from a single-centre series of Mobility TARs.

Introduction

The standard practice of uncomplicated total ankle replacement (TAR) involves post-operative immobilisation. Periprosthetic fracture is a well-recognised complication following ankle arthroplasty. It occurs predominantly as a stress reaction on the medial tibial metaphysis during the post-operative rehabilitation period. Occasionally it occurs during surgery. We present fractures from a single-centre series of Mobility TARs.

Background

Total ankle replacement (TAR) is increasingly offered as an alternative to ankle fusion for the management of severe ankle arthritis. As with all other types of joint arthroplasty, there are risks involved and complications that occur; these increase with case complexity. We present the complications and management from a single-centre series.

Introduction

Ankle replacement is a major surgery with significant soft tissue dissection and bleeding. The skin quality is often poor in these patients due to age, edema, venous congestion, arteriopathy or previous procedures and soft tissue injury. The chances of wound infection increase with delayed wound healing. Absorbent non-adherent dressing (ABD) and VAC dressing applied in theatre after ankle replacement were assessed in a cohort of 147 patients with wound complications, pain, satisfaction and length of stay as outcome measures.

Introduction

This project reports differences in outcome measures after total ankle arthroplasty (TAA) for patients with Osteoarthritis (OA), Rheumatoid Arthritis (RA) and Post-traumatic Osteoarthritis (PTOA).

Introduction

Peri prosthetic fracture is a recognised complication following Total ankle arthroplasty (TAA). There is limited literature on post operative management following TAA and controversies exist based on surgeon preferences. This project reports the incidence of peri- prosthetic fractures in patients managed with 2 different post-operative protocols.

TMTJ fusion is performed for arthritis or painful deformity. K-wire and trans-articular screws are usually used to stabilize the joints. We present our experience with LP for TMTJ fusion in first 100 joints.

Introduction: A Rose calcaneal osteotomy and Cobb procedure for treatment of acquired pes planus is gaining in popularity as a result of the advantages of anatomical reconstruction and reduced graft site morbidity. Although, its ability to provide long term dynamic function and effect on patient’s symptoms remains to be seen.

Materials and Methods: Twenty-two patients with stage two and three Posterior tibialis tendon dysfunction underwent surgical reconstruction with a Cobb procedure and Rose calcaneal osteotomy between 2003 and 2008. The average age was 59 years (range: 20–80 years). There were 18 females and four males.

Results: We evaluated the dynamic function of the Tibialis posterior muscle tendon function by ultra-sonograms postoperatively at mean follow-up time of 36 months. Eighty three per cent of patients achieved a single heel raise. Seventy-three percent of the patients showed an intact and mobile tibialis posterior tendon on supination and pronation movements. There was no difference in the satisfaction of patients with a tenodesis or non tenodesis.

Conclusion: Our results suggest that Cobb procedure does provide dynamic Tibialis posterior function in majority of patients.

The surgical correction of hammertoe deformity of the lesser toes is one of the most commonly performed forefoot procedures. In general, percutaneous Kirschner wires are used to provide fixation to the resected proximal interphalangeal joint. Although these wires are effective, issues such as pin tract infection as well as difficult postoperative management by patients make alternative fixation methods desirable.

The biomechanical studies suggested that the bioabsorbable implant would be a suitable fixation device for the hammer toe procedure. These wire are made of a copolymer of 82% poly-L-lactic acid and 18% polyglycolic acid.

The aim of our study was to assess the clinical outcome of these two implants. We compared 100 consecutive proximal interphalangeal joint fusions performed with each implant. There was no statistically significant difference in the fusion rate at six months using either implant. However, there was significant statistical difference in cost, rate of infection, implant migration, recurrence of deformity, patient’s return to driving, walking with routine foot wear and satisfaction. There was 11% rate of reactive inflammation in the absorbable wire group but no infection.

The study shows the absorbable wires are safe for fusion of proximal inter phalangeal joints.

Introduction: Tarsometatarsal joint (TMTJ) fusion is performed for arthritis or painful deformity. First TMTJ fusion may be performed as a part of corrective surgery for hallux valgus deformity. K-wires and trans-articular screws are often used to stabilize the joints. We present our experience with the use of locking plates (LP) for TMTJ fusion.

Patients and Methods: Thirty-three TMTJ’s in 19 patients were fused and stabilised with LP’s between January and September 2008. The procedure was performed for Lisfranc arthritis in 13 patients and Lapidus procedures in six. Two out of 6 were revisions after failed fusion using transarticular screws. Iliac crest bone autograft was used in 26 joints in 12 patients. All patients post-operatively had below knee plaster immobilization and protected weight bearing walking for first 6 weeks. Clinical and radiological surveillance continued until bone union. AOFAS midfoot scale was used as outcome measure.

Results: There were 7 male and 12 female patients with average age of 51 (14–68). The American orthopaedic foot and ankle surgery society (AOFAS) midfoot score showed a 42% improvement in pain, 30% improvement in function and 53% improvement in alignment. The average AOFAS overall score improved from 30 preoperativley to 67 postoperativley. All except one joint in one patient had clinically and radiologically fused joints. One patient underwent removal of the metalwork and four had delayed wound healing. The average satisfaction score was 7 out of 10. 86% said of patients said that they would recommend the surgery to a friend, and 91% would undergo the surgery again.

Discussion: Locking plates have been recently introduced for ankle and foot surgery. Biomechanical studies have shown that the plates are not as strong or stiff as trans-articular screw fixation, however, they are easy to use, have more flexibility for realignment and can act as a buttress for bone graft. In our series all, except one, patients achieved bony union without loss of alignment.

Conclusion: Locking plates provide satisfactory stability for TMTJ fusion, without complications.

Introduction and Aims: Morbid obesity (BMI> 40) has been shown to cause increased perioperative morbidity and poorer long-term implant survivorship following total knee arthroplasty (TKA). The aim of this study was to determine the impact of morbid obesity on patient-reported outcomes following TKA.

Methods: Patients undergoing primary TKA were invited to complete questionnaires preoperatively and one year after surgery. Questionnaires include the WOMAC and SF-36 health status measures, demographics, self-reported comorbid medical conditions, height and weight. At follow-up, satisfaction with results of TKA is included. Patients were categorised by their preoperative BMI categories as ideal weight (20–25), overweight (> 25–30), obese (> 30–40) or morbidly obese (> 40). We used multivariate analysis to adjust for known significant correlates of WOMAC and SF-36, namely age, gender and comorbid medical conditions. Adjusted mean scores for each assessment were compared by BMI category.

Results: A total of 769 patients were included in the study which included 27 morbidly obese, 280 obese, 314 overweight and 148 ideal weight patients. Morbidly obese patients when compared with non-obese patients had significantly worse preoperative WOMAC pain and function and a trend for worse SF36 scores (Vitality significantly worse, p=0.04). There was no significant difference between the BMI categories at one year for WOMAC or SF-36 scores (trend for the Physical Functioning score to be lower, p=0.052). Morbidly obese patients were all satisfied with pain relief after surgery but were less satisfied with functional results when compared to the non-obese groups.

Discussion: This study shows that morbidly obese patients report significantly worse health status prior to TKA but their post-operative improvement is greater than the non-obese population. Although morbid obesity should not be an absolute contraindication to TKA, patients should be carefully selected balancing the risk of perioperative complications and earlier failure against the demonstrated marked improvement in quality of life.

Introduction: TMTJ fusion is performed for arthritis or painful deformity. First TMTJ fusion may be performed for Hallux valgus deformity. K-wire and trans-articular screws are usually used to stabilize the joints. We present our audit of experience with LP for TMTJ fusion.

Patients and Methods: 33 TMTJ in 19 patients were fused and stabilised using LP between January and September 2008. The procedure was performed for Lisfranc arthritis in 13 and Lapidus procedure in 6. Two out of 6 were revisions after failed fusion using transarticular screws. Iliac crest bone autograft was used in 26 joints in 12 patients. All patients post-operatively had below knee plaster immobilization and protected weight bearing walking for first 6 weeks. Clinical and radiological surveillance continued until bone union. AOFAS mid-foot scale was also used as an outcome measure.

Results: There were 7 male and 12 female patients with average age of 51 (14–68). AOFAS midfoot scale showed 42% improvement in pain, 30% improvement in function and 53% improvement in alignment. Average total AOFAS score improved from 30 preoperative to 67 postoperative.

All except 1 joint in one patient had clinical and radiological fusion of their joints. 1 patient needed removal of metalwork and 4 had delayed wound healing. Average satisfaction score was 7/10. 86% Patients would recommend it to a friend and 91% would have it again.

Discussion: Locking plates have been recently introduced for ankle and foot surgery. Biomechanical studies have shown plates are not as strong or stiff as trans-articular screw fixation however they are easy to use, have more flexibility for realignment and can act as a buttress for bone graft. In our review all patients except one had bone union without loss of alignment.

Conclusion: TMTJ fusion improves pain and function. Locking plates provide satisfactory stability for TMTJ fusion

Introduction: There is limited literature available looking into circumstances surrounding the development of stress fracture of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of ankle replacement upon local bone mineral density and the phenomenon of stress shielding.

Aim: To assess the effect of ankle replacement loading of the medial and lateral malleoli, by analysing the BMD of the medial and lateral malleoli before and after Mobility total ankle replacement.

Methodology: Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 and 12 months after surgery. The bone mineral density of a 2 cm square area within the medial malleolus and lateral malleolus was measured. The pre-operative and post-operative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed.

Results: The mean preoperative BMD within the medial malleolus improved from 0.58g/cm2 to mean 6 months postoperative BMD of 0.59g/cm2 and 0.60g/cm2 at 12 months. The mean preoperative BMD within the lateral malleolus decreased from 0.40g/cm2 to a mean 6 months postoperative BMD of 0.34g/cm2. However the BMD over the lateral malleolus increased to 0.36g/cm2 at 12 months. The mean alignment of the tibial component was 88.5° varus (85° varus to 94° valgus). There was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865).

Conclusion: The absence of stress shielding around the medial malleolus indicates that TAR implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus.

There is limited literature available looking into circumstances surrounding the development of stress fracture of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of ankle replacement upon local bone mineral density and the phenomenon of stress shielding.

We aimed to assess the effect of ankle replacement loading of the medial and lateral malleoli, by analysing the Bone Mineral Density (BMD) of the medial and lateral malleoli before and after Mobility total ankle replacement.

Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 months after surgery. The bone mineral density of a 2 cm square area within the medial malleolus and lateral malleolus was measured. The pre-operative and postoperative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed.

The mean preoperative BMD within the medial malleolus improved from 0.57g/cm2 to mean 6 months postoperative BMD of 0.62g/cm2. The mean preoperative BMD within the lateral malleolus decreased from 0.39g/cm2 to a mean 6 months postoperative of 0.33g/cm2. The mean alignment of the tibial component was 88.50 varus (range 850 varus to 940 valgus). However, there was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865).

The absence of stress shielding around the medial malleolus indicates that ankle replacements implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus.

Total Ankle Arthroplasty (TAA) using the uncemented three component mobile design has shown encouraging results. There is limited literature on the optimal postoperative management. In our centre, TAA patients are mobilised 48 hours after surgery without a short leg plaster. The aim of this prospective audit was to measure the outcomes of these patients to ascertain if this is a safe and effective protocol.

Patients who underwent primary TAA between March 2006 and March 2008 were invited to participate in the audit. Assessment included patient questionnaires which collected demographics, height and weight, Foot and Ankle Outcome Score (FAOS) and Short-Form-36 (SF-36). Clinical examination collected American Orthopaedic Foot and Ankle Score (AOFAS). Data was collected pre-operatively and at 3 and 6 months after surgery.

A total of 48 ankle replacements in 46 patients were included. Primary diagnosis was osteoarthritis (25), post-traumatic osteoarthritis (9), and rheumatoid arthritis (12). Mean age was 63 years (range 33 to 83) and the majority were males (29, 60%). The average body mass index was 28 (SD 5.3). There were significant improvements to 3-months after surgery for AOFAS (mean 29 to 76, p< 0.0001), FAOS (mean scores changes: Pain 36 to 72, Function 41 to 68, Stiffness 38 to 65, p< 0.001) and physical domains of the SF-36 (means score changes: Physical Functioning 25 to 39, Role Physical 27 to 40, Bodily Pain 29 to 48 and Vitality 42 to 50, p< 0.05). All outcome scores were maintained with a non-significant trend for better scores from 3 to 6 months.

These early results demonstrate encouraging outcomes for TAA patients who are mobilised early after surgery without a short leg plaster. Further studies of post-operative management are needed to compare outcomes after TAA between patients undergoing this protocol and patients who are immobilised in plaster.

Introduction: The Scarf osteotomy for the treatment of hallux valgus is achieving popularity, but no comparative study has proven the efficacy of this procedure over other first metatarsal osteotomies.

We present a retrospective comparative review of the radiological outcomes of Chevron and Scarf with Akin osteotomy in the treatment of hallux valgus.

Materials and Methods: The radiological outcomes of 40 first metatarsal osteotomies, 20 Chevron and 20 Scarf with Akin are presented. The radiological parameters studied included hallux valgus angle, hallux inter-phallangeus, intermetatarsal angle, sesamoid station and foot width.

Results: The mean post-operative hallux valgus angles (HVA’s) were: Chevron mean HVA 17.90, standard deviation 7.360, standard error 1.65. Scarf with Akin osteotomy mean HVA 9.550, standard deviation 6.60, standard error 1.4. The difference in postoperative HVA between the two operations was statistically significant (p< 0.001).

The mean post-operative intermetatarsal angles (IMA) were: Chevron mean 8.050, standard deviation 2.560, standard error 0.57. Scarf with Akin mean 7.220, standard deviation 2.56, standard error 0.57. The difference in postoperative IMA between the two groups did not achieve statistical significance.

The mean change in IMA for each was: Chevron mean increment 4.90 Standard deviation 2.290, standard error 0.51. Scarf with Akin mean increment 6.680, standard deviation 4.130, and standard error 0.88. The difference in alteration of IMA between the two groups did not achieve statistical significance.

Discussion and Conclusion: We conclude that as there was no difference in the distribution of post-op IMA for Scarf and Chevron osteotomies that the added affect of an Akin osteotomy may contribute to the Scarf to produce the better correction in hallux valgus angle.

Introduction: There is limited literature available looking into circumstances surrounding the development of stress fracture of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of ankle replacement upon local bone mineral density and the phenomenon of stress shielding.

Aim: To assess the effect of ankle replacement loading of the medial and lateral malleoli, by analysing the BMD of the medial and lateral malleoli before and after Mobility total ankle replacement.

Methodology: Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 months after surgery. The bone mineral density of a 2 cm square area within the medial malleolus and lateral malleolus was measured. The pre-operative and post-operative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed.

Results: The mean preoperative BMD within the medial malleolus improved from 0.57g/cm2 to mean 6 months postoperative BMD of 0.62g/cm2. The mean preoperative BMD within the lateral malleolus decreased from 0.39g/cm2 to a mean 6 months postoperative BMD of 0.33g/cm2. The mean alignment of the tibial component was 88.50 varus (range 850 varus to 940 valgus). However, there was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865).

Conclusion: The absence of stress shielding around the medial malleolus indicates that ankle replacements implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus.

Introduction: Lisfranc injuries account for 0.2% of all fractures. Around 20% of these injuries are missed or misdiagnosed leading to long term problems with the foot. Early recognition and treatment of these injuries are crucial in restoring the function of the foot.

Aim: To review the functional outcome of patients following surgery for lisfranc injuries.

Methodology: This is a retrospective review of patients treated surgically for lisfranc injury in our hospital between January 2000 and January 2007. There were 13 patients whose records were reviewed and data including age, mechanism of injury, associated injuries, surgery performed, and peri-operative complications were collected. A telephonic survey was conducted to find out the current functional and employment status. AOFAS mid-foot score was used to evaluate the outcome.

Results: 13 patients were included in the study. Mean age was 31 years at the time of injury. 5 patients were female and 8 male. 10 had injury on the left foot while 3 had on the right. 11 were closed lisfranc injury. 10 patients had isolated lisfranc injury. Seven patients had sustained lisfranc injury following a fall, while three had a road traffic accident. Six patients had a homo-lateral, four had isolated and two had divergent type. Nine patients had trans-articular fixation, seven of whom had open reduction and internal fixation while two had K-wire fixation. Extra-articular fixation was done in four patients. Average AOFAS mid foot scoring was 80 ranging from 47 to 100. Lower scores were related to pain. Nine patients were pain free at follow up and returned to work. Average follow-up period was 32.6 months (range5–77 months)

Conclusion: Two thirds of patients with a Lisfranc fracture dislocation return to work and extra-articular fixation may result in superior outcomes compared with the traditional methods.

Introduction: There is relatively little known about patient-reported health status in patients with ankle arthritis awaiting arthroplasty. This study aims to compare the preoperative health status of patients awaiting ankle, hip and knee arthroplasty.

Materials and Methods: Patients admitted for primary ankle, hip or knee arthroplasty to an NHS teaching hospital were invited to participate. Preoperative questionnaire included the WOMAC, SF-36 and self-reported height and weight providing body mass index (BMI). Comparisons of WOMAC and SF-36 data were adjusted for age, gender and BMI.

Results: A total of 2,196 patients were recruited between July 2003 and May 2007; including 35 ankle arthroplasty (TAA), 899 hip arthroplasty (THA) and 1,262 total arthroplasty (TKA) cases. There was no significant difference in age across the 3 groups but a significantly higher proportion of TAA patients were male (69 percent vs. 38 percent for THA and 43 percent for TKA, p=0.0002). BMI of the TKA patients was significantly higher than the THA patients (29.4 vs. 27.3, p< 0.0001). Multivariate analysis which adjusted for age, gender and BMI demonstrated that THA patients were significantly worse (p< 0.05) than the TKA patients on all domains except for WOMAC stiffness and the SF-36 general health and mental health domains. TAA patients were not significantly different from either group on any measure.

Conclusions: Patients awaiting TAA reported similar WOMAC and SF-36 scores as the TKA patients. Patients awaiting THA report worse pain and function related to their hip and worse SF-36 scores except for general health and mental health domains.

Aim: To validate the accuracy of the MobilityTotal Ankle Replacement alignment jig.

Method: The early radiological alignment outcomes (angles ‘A, B, C’) of 35 Mobility ankle replacements were determined from weight bearing X rays.

These radiological outcomes were compared with alignment outcomes for ‘Star’ total ankle replacement, as published by PLR Wood. (Total Ankle Replacement JBJS April 2003 85B, pg 334)

Results: Indication: osteoarthritis 25, posttraumatic osteoarthritis 6, rheumatoid arthritis 4.

32/35 Angle A were within the published accepted range (850–950).

No statistical difference between the distribution of angle A, B and C and the means for A, B and C for the published results.

Discussion: Results for angle B are skewed toward the upper limit of the current accepted range (800–900). The author (MSS) attempts to reproduce this, to place the anterior margin of the tibial component on subchondral bone.

A lower angle B positions the implant on metaphyseal bone with a risk of subsidence. Comparing Angle B with a modified acceptable range (850–950) 31/35 fell in the new range.

Conclusion: Early radiological alignment for Mobility is reproducible and compares favourably with published data.

Background: Ankle fractures are the second commonest lower limb fractures after hip fractures and as opposed to the latter occur commonly in younger population of working age. Due to a host of different factors including the state of soft tissues and delayed presentation, there is often a delay of several days between fracture and operation, resulting in longer admissions. It is hypothesised that early intervention may shorten hospital stay and hence save on hospital resources.

Aims: To ascertain the impact of timing of ankle fracture surgery on length of post operative and total hospital stay and its implication on resources.

Methodology: Consecutive ankle fractures that underwent open reduction and internal fixation at Newcastle General Hospital over a 4-year period were studied as a retrospective cohort. Data collection from Theatre records, PAS system, case notes and radiographs was undertaken and entered in SPSS database.

Results: 431 cases of ankle fracture open reduction and internal fixation were included in the study. 41% were female and 59% were male patients, with a mean age of 39.1 years (SD±17.8), with age range from 16 to 89 years.

298 patients were operated within 48 hours of admission (early surgery group), and 136 patients after 48 hours (delayed surgery group). The mean hospital stay in the early operation group was mean 5.3 days (SD±4.9) and in the delayed surgery group it was 12.2 days (SD±8.4). The patients who were operated early had shorter total hospital stay (p< 0.001) and also had shorter post-operative stay (p< 0.05). Increasing age and female gender appeared to predispose to longer hospital stay but this was not statistically significant. Mean age, gender and ASA grade, fracture class and operating surgeon’s grade distribution were not significantly different in the early and late surgery groups.

Each patient in delayed surgery group spent an extra 6.9 days in hospital stay compared to the early surgery group, translating into an extra 937 hospital bed days. The average extra cost of hospital stay per case in the delayed surgery group (£1414) exceeds the average expense of surgery per case in that group. The delayed surgery group resulted in added expenditure of £192085 to the trauma division solely for extra hospital stay.

Conclusion: Timing of surgery in ankle fracture appears to be the most significant determinant affecting the hospital stay. This has a significant resource implication, financially and in freeing up of hospital resources, as well as impacting on the lives of this large group of patients.

Purpose: The purpose of this study was to assess the subjective, clinical and radiological improvement in patients with moderate to severe hallux rigidus undergoing Proximal Phalangeal Dorsomedial Closing-wedge Osteotomy with Cheilectomy.

Methods: Between March 2003 and November 2004, 17 patients (18 feet) underwent Proximal Phalangeal Dorsomedial Closing-wedge Osteotomy with Cheilectomy, 14 were available for clinical follow-up; pre and post-operative X-rays were available for all of them.

The Clinical assessment was based on modified American Orthopaedic Foot and Ankle Society’s hallux-metatarsophalangeal scale. The subjective assessment was done by a questionnaire and radiological assessment was done by using digital radiographs.

Results: Out of the 18 feet we studied, 1 was of Grade 1, 9 of Grade 2 and 8 of Grade 3. 12 out of 14 patients (85%) were satisfied with the outcome after an average follow-up period of 14 months. There was an increase in the Mean mAOFAS score of 49.6 (from a mean score of 26.2 to 75.8); the improvement in pain score was 27.4. With a mean osteotomy thickness of 1.78 mm, the proximal phalangeal length was decreased by a mean of 3.7mm. The medialization achieved in the men M1-P1 angle was 6.8 degrees. There was a highly significant gain of 25 degrees in Mean Dorsiflexion which cannot be explained by a mean increase of only 0.9 mm in the lateral dorsal joint space attributable to cheilectomy.

Conclusion: Dorsomedial Proximal Phalangeal Closing-wedge Osteotomy combined with Cheilectomy gives good subjective and clinical results regarding satisfaction, pain relief and gain in dorsiflexion; at least in the short-term. This gain in movement might be explainable by an improved EHL lever-arm resulting from dorsome-dial nature of the phalangeal osteotomy.

Interventional MRI provides a novel non-invasive method of in-vivo weight-bearing analysis of the talo-calcaneal joint. Six healthy males (mean 28.8 years) underwent static right foot weight bearing MRI imaging at 0o, 15o inversion, and eversion. Using known radiological markers the motion of the talus and calcaneum were analysed.

The calcaneum externally rotates, plantar-flexes and angulates into varus. The talus shows greater plantarflexion with similar varus angulation, with variable axial rotation. Relative talo-calcaneal motion thus involves, 6o relative talar internal rotation, 3.2o flexion and no motion in the frontal plane. Concurrently the talus moves laterally on the calcaneum, by 6.5mm, with variable translations in other planes.

The calcaneum plantar-flexes, undergoes valgus angulation, and shows variable rotation in the axial plane. The talus plantar-flexes less, externally rotates, and shifts into varus. Relative motion in the axial and saggital plane reverses rotations seen during inversion. The 8o of relative valgus talo-calcaneal angulation is achieved through considerable varus angulation of the talus, in a direction opposite to the input motion. This phenomenon has not been previously reported. From coronal MRI data, comparative talo-calcaneal motion in inversion is prevented by high bony congruity, whereas during eversion, the taut posterior tibio-talar ligament appears to prevent talar valgus angulation.

We have demonstrated that Interventional MRI scanning is a valuable tool in analysing the weight-bearing motion of the talo-calcaneal joint, whilst approaching the diagnostic accuracy of stereophotogammetry. We have also demonstrated consistent unexpected talar motion in the frontal plane. Talo-calcaneal motion is highly complex involving simultaneous rotation and translation, and hence calculations of instantaneous axes of rotation cannot effectively describe talo-calca-neal motion. We would suggest that relating individual and relative motion of the talus / calcaneum better describes subtalar kinematics.

Background: Interventional MRI provides a novel non-invasive method of in-vivo weight-bearing analysis of the subtalar joint. Preceding in-vivo experimentation with stereophotogammetry of volunteers embedded with tantalum beads has produced valuable data on relative talo-calcaneal motion (Lundberg et al. 1989). However the independent motion of each bone remains unanswered.

Materials and Methods: Six healthy males (mean 28.8 years), with no previous foot pathology, underwent static right foot weight bearing MRI imaging at 0°, 15° inversion, and 15° eversion. Using identifiable radiological markers the absolute and relative rotational and translational motion of the talus and calcaneum were analysed.

Results and Discussion: Inversion: The calcaneum externally rotates, plantar-flexes and angulates into varus. The talus shows greater plantar-flexion with similar varus angulation, with variable axial rotation. Relative talo-calcaneal motion thus involves, 6° relative talar internal rotation, 3.2° flexion and no motion in the frontal plane. Concurrently the talus moves laterally on the calcaneum, by 6.5mm, with variable translations in other planes. This results in posterior facet gapping and riding up of the talus at its posterolateral prominence. Eversion: The calcaneum plantar-flexes, undergoes valgus angulation, and shows variable rotation in the axial plane. The talus plantar-flexes less, externally rotates, and shifts into varus. Relative motion in the axial plane reverses rotations seen during inversion (2.5° talar external rotation). The 8° of relative valgus talo-calcaneal angulation is achieved consistently through considerable varus angulation of the talus, in a direction opposite to the input motion. This phenomenon has not been previously reported. From coronal MRI data, comparative talo-calcaneal motion in inversion is prevented by high bony congruity, whereas during eversion, the taut posterior tibio-talar ligament prevents talar valgus angulation.

Conclusion: We have demonstrated that Interventional MRI scanning is a valuable tool to analysing the weight bearing motion of the talo-calcaneal joint, whilst approaching the diagnostic accuracy of stereophoto-gammetry. We have also demonstrated consistent unexpected talar motion in the frontal plane. Talo-calcaneal motion is highly complex involving simultaneous rotation and translation, and hence calculations of instantaneous axes of rotation cannot effectively describe talo-calcaneal motion. We would suggest that relating individual and relative motion of the talus / calcaneum better describes subtalar kinematics.

Aims: To study whether re-transfusion of autologus blood from solcotrans drains reduced banked blood transfusion requirement in primary total knee arthroplasty (TKR). Methods: 195 patients with unilateral primary TKR using the same surgical technique and implants were prospectively reviewed. Group 1: In 120 cases, solcotrans drain system used for postoperative blood salvage and reinfusion. Group 2: 75 cases had standard redivac drains. Homologous blood transfusions used if post-operative haemoglobin < 9 gm. Factors like weight and height, and pre-operative haemoglobin levels were also studied. Results: Group 1: Average blood loss: 598 ml. 88 cases (71%) had reinfusion of autologous salvaged blood, average re-transfusion: 271 ml (range: 200 Ð 1160 ml). In 29% (32 cases), there was not enough blood in solcotrans drains for re-transfusion. 29 patients (23%) required banked blood transfusion in whom average blood loss was 720 ml, average number of units transfused: 1.6. In 10 of the 29 cases, there was not enough blood in solcotrans drains for re-transfusion. Group 2: Average blood loss: 588 ml. 20 cases (26%) required banked blood transfusion in whom average blood loss was 758 ml. Average number of units transfused: 1.9. Conclusions: In our study, solcotrans system did not reduce the requirement of banked blood transfusion signiþcantly in TKR. In both groups, low levels of preop-erative haemoglobin, low weight and amount of blood loss inßuenced banked blood requirement (p< 0.05).

Aims: To study functional outcome and survivorship of custom designed knee implants for primary and revision TKR where off-the-shelf prostheses were unsuitable. Methods: Clinical and radiological results of twenty-three custom-designed total knee prosthesis in twenty patients were prospectively reviewed. The indications were bone loss following multiple revisions of total knee prosthesis and debridement for infection, periprosthetic fractures, bone deformity with rickets and small bones with juvenile chronic arthritis. All implants designed and manufactured at Centre for Biomedical Engineering, Stanmore, U.K. Four different designs of knee prosthesis used: Condylar knee of miniature size, CAD-CAM knee, Superstabiliser and Rotating Hinges. Hospital for Special Surgery (HSS) score taken preoperatively, at 3 months, and yearly by an independent research physiotherapist. Duration of follow up: 62.5 months (28–126 months) Results: Average HSS score improved from 13.5 points (range 0–48) pre-operatively to 86.5 points postoperatively (range 62–96) (p=0.025). Average maximum flexion post operatively: 86.4° (range 60°–122°). Sixteen knees had excellent, five good and two poor results. Extension lag of 15°–25° in three patients. One patient with juvenile chronic arthritis needed revision at five years after index arthroplasty. Conclusions: Clinical and radiological results for custom designed prostheses compare favourably with standard knee prosthesis for similar indications. Our results support the use of a custom designed knee implant as salvage prosthesis and also as an alternative to arthrodesis or amputation.

Clinical investigations and tests need to be validated by studying their inter-observer and intra-observer errors, but there has been no documentation of such verification in diagnostic knee arthroscopy. We performed a prospective study to find out to what extent the findings in knee arthroscopy differ between two different surgeons.

Two senior specialist registrars (M.S. and A.J.) who took part in this study worked with the senior author (ACW) for a period of eight and seven months respectively. A total of 78 knee arthroscopies admitted from routine waiting list were studied. The specialist registrar first performed arthroscopy when the supervising consultant stayed away from the operating room. His findings were recorded on a proforma by an independent third person before the consultant returned to the operating room and repeated the EUA and arthroscopy without prior knowledge of the trainee findings. Findings from the consultant arthroscopy were then recorded separately on the same proforma.

The following findings were recorded:

Examination under anaesthesia

The inter-observer variations in diagnostic knee arthroscopy were found to be high. Given the seniority and experience of the two trainee senior registrars involved in the study, and allowing for the Hawthorne effect, the results of the study cast doubt on this procedure being performed un-supervised. It also questions the validity of any therapeutic intervention based on the findings of un-supervised arthroscopies.

We carried out a prospective study in order to establish to what extent the intra-articular evaluation undertaken during arthroscopy of the knee differed between surgeons. Two senior specialist registrars and a consultant orthopaedic surgeon with a special interest in knee surgery were involved. A total of 78 knee arthroscopies (78 patients) was studied. Arthroscopy was first carried out by the trainee and then by the senior author (ACWH). The intra-articular evaluation during the arthroscopy was recorded independently by a third person in the operating theatre. Data were collected to record variations in examination under anaesthesia, the morphology and pathology of the menisci and anterior cruciate ligament and the state of the articular surfaces.

The overall interobserver variation was 20% in all categories. We question the published results of intra-articular evaluation during knee arthroscopy when surgeons of different levels of experience are involved in a single study.