Introduction

Pes cavovarus is a foot deformity that can be idiopathic (I-PC) or acquired secondary to other pathology. Charcot-Marie-Tooth disease (CMT) is the most common adult cause for acquired pes cavovarus deformity (CMT-PC). The foot morphology of these distinct patient groups has not been previously investigated. The aim of this study was to assess if morphological differences exist between CMT-PC, I-PC and normal feet (controls) using weightbearing computed tomography (WBCT).

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.

Aims

Cone beam CT allows cross-sectional imaging of the tibiofibular syndesmosis while the patient bears weight. This may facilitate more accurate and reliable investigation of injuries to, and reconstruction of, the syndesmosis but normal ranges of measurements are required first. The purpose of this study was to establish: 1) the normal reference measurements of the syndesmosis; 2) if side-to-side variations exist in syndesmotic anatomy; 3) if age affects syndesmotic anatomy; and 4) if the syndesmotic anatomy differs between male and female patients in weight-bearing cone beam CT views.

Aims

Gastrocnemius tightness predisposes to musculoskeletal pathology and may require surgical treatment. However, it is not clear what proportion of patients with foot and ankle pathology have clinically significant gastrocnemius tightness. The aim of this study was to compare the prevalence and degree of gastrocnemius tightness in a control group of patients with a group of patients with foot and ankle pathology.

Introduction

Studies have compared outcomes of first metatarsophalangeal joint (MTPJ1) implant hemiarthroplasty and arthrodesis, but there is a paucity of data on the influence of patient factors on outcomes. We evaluated data from a prospective, RCT of MTPJ1 implant hemiarthroplasty (Cartiva) and arthrodesis to determine the association between patient factors and clinical outcomes.

Aims

Smoking is associated with post-operative complications but smokers often under-report the amount they smoke. Our objective was to determine whether a urine dipstick test could be used as a substitute for quantitative cotinine assays to determine smoking status in patients.

Patients with advanced stage hallux rigidus from 12 centers in Canada and the UK were randomized (2:1) to treatment with a small (8/10 mm) hydrogel implant (Cartiva) or 1^st MTP arthrodesis. VAS pain scale, validated outcome measures (FAAM sport scale), great toe active dorsiflexion motion, secondary procedures, radiographic assessment and safety parameters were evaluated.

236 patients were initially enrolled, 17 patients withdrew prior to randomization, 17 patients withdrew after randomization and 22 were non-randomized training patients, leaving 152 implant and 50 arthrodesis patients. Standard demographics and baseline outcomes were similar for both groups.

Mean VAS pain scores decreased from 6.8 and 6.9 respectively for the implant and arthrodesis groups from baseline to 1.4 and 0.7 at 24 months. Similarly, the FAAM sports score improved significantly from baseline levels of 37 and 36 to 24 months level of 77 and 82 respectively for the implant and arthrodesis groups. First MTP active dorsiflexion motion improved an average of 4° at 3 months after implant placement and was maintained at 24 months.

Secondary surgeries occurred in 17 (11.2%) implant patients and 6 (12.0%) arthrodesis patients. Fourteen (9.2%) implants were removed and converted to arthrodesis and 6 (12.0%) arthrodesis patients had painful hardware requiring removal. There was no case of implant fragmentation, wear, or bone loss. Analysis of a single composite endpoint utilizing the three primary study outcomes (pain, function, and safety) showed statistical equivalence between the2groups.

This study used the lunge test to measure the difference between ankle dorsiflexion with the knee flexed and extended in persons with and without foot and ankle pathology. This may help us devise a weight bearing test for GT.

Introduction:

Wound healing and poor bone healing are complications seen in patients who smoke and some surgeons prefer not to operate on smokers. However, self reporting of smoking by patients may be biased. This study compares self-reporting of smoking habits and cotinine levels in the urine of our patients.

Aims:

With the advent of standing CT and MRI scans, there is increasing interest in establishing the role and usefulness of these investigations. When ordering a standing investigation, we assume that 100% of body weight is loaded through the limb, but most machines have handlebars for support and some have seats to allow patients the opportunity to sit. The aim of this study was to evaluate the amount of load going through the lower limbs in various positions supported and unsupported, to explore the range and variation in measurements obtained.

Introduction:

Cone Based CT (CBCT) scanning uses a point source and a planar detector with parallel data acquisition and volumetric coverage of the area of interest. The pedCAT (Curvebeam USA) scanner is marketed as a low radiation dose, compact, faster and inexpensive CT scanner that can be used to obtain both non- weightbearing and true 3 dimensional weightbearing views.

Introduction

Bone Marrow Oedema Syndrome (BMOS) is an unusual and poorly understood condition. It commonly affects the hips and knees and is reported to have a tendency to recur. The foot and ankle are less frequently involved but nevertheless patients can be severely impaired. Only case reports of BMOS of the foot and ankle have been published.

The aim of this study is to evaluate the sites of occurrence, risk factors, efficacy of immobilisation, response to intravenous biphosphonates and local or remote recurrence over the following years.

Background

The focus on evidence-based medicine has led to calls for increased levels of evidence in surgical journals. The purpose of the present study was to review the levels of evidence in articles published in the foot and ankle literature and to assess changes in the level of evidence over a decade.

Introduction

The Z or “scarf” osteotomy was first described by Meyer in 1926 and then by Burutaran in 1976. It was later popularised by Weil in the USA and Barouk in Europe in the 1990's and is now an accepted technique that forms part of a surgeons' armamentarium. The theory of Diffusion of Innovations was described by Rogers in 1962 to explain how novel ideas are accepted into practice across different industries, including medicine. It has never previously been used to study the adoption of ideas in foot and ankle surgery.

Introduction

Calcaneal osteotomy is often performed together with other procedures to correct hindfoot deformity. There are various methods of fixation ranging from staples, headed or headless screws or more recently stepped locking plates. It is not clear if one method is superior to the other. In this series we compare the outcome of various methods of fixation with particular attention to the need for subsequent hardware removal.

Background

The recent emphasis on using “evidence based medicine” for decision-making in patient care has prompted many publishers to mention the level of evidence of articles in their journals. The “quality” of a journal may thus be reflected by the proportion of articles with high levels of evidence and assist it achieve citations and therefore an Impact Factor.

The purpose of this study was to survey published Foot and Ankle literature to evaluate changes in the level of evidence over ten years.

Introduction

Bone marrow oedema syndrome (BMES) of the foot and ankle is an uncommon and often misdiagnosed condition. It is usually thought to be a benign self limiting condition, without any sequelae. However, it can cause disabling pain for a prolonged period of time.

Single stage total talectomy with tibio-calcaneal arthrodesis in adult patients has been rarely reported in the literature. In patients with severe rigid, unbraceable equinovarus deformities, talectomy can offer excellent correction.

We performed single stage total talectomy with tibiocalcaneal arthrodesis on 11 feet in 10 patients (6F; 5M) of average age 67 years (range 54–77 years). 6 patients had neuropathic deformity, 2 had failed fusion procedures and 2 had severe Rheumatoid hindfoot disease. The fusion was undertaken using a hindfoot nail and screws in 5 patients, plate and screws in 4 patients, a hindfoot nail in 1 and cancellous screws in 1 patient. All patients followed the standard post operative protocol and were reviewed at 2, 6 and 12 weeks and thereafter every 4 weekly till union. All patients were mobilised strictly non weight bearing for the first 6 weeks and thereafter, touch weight bearing was allowed with the leg in a protective cast. Full weight bearing was allowed once the fusion had consolidated.

Fusion was achieved in 7 feet (64%) at an average time of 17 weeks. In 4 patients, non-union persisted but they were pain free at latest review and would not consider further surgery. Average duration of follow-up was 20 months (range 6–24 months). All patients had stiff hindfeet with a jog of movement at the tibio navicular articulation. All patients had a stable, plantigrade, braceable foot and were community ambulators. All patients were satisfied with the outcome.

Total talectomy with tibiocalcaneal arthrodesis is a useful procedure to correct severe rigid equinovarus deformities in adults. The tibionavicular articulation forms a pseudarthrosis and retains a jog of movement. Retention of the head of the talus with talotibial arthrodesis is unnecessary. We recommend this procedure as a salvage option in this difficult problem.

Introduction

Debate remains which surgical technique should be used for ankle arthrodesis. Several open approaches have been described, as well as the arthroscopic method, using a variety of fixation devices.

Both arthroscopic and open procedures have good results with union rates of 93–95%, 3% malunion rate and patient satisfaction of 70–90%, although some report complication rates as high as 40%.

Introduction

Children with early-onset scoliosis (EOS) with rib hump chest-wall distortion or fused/absent ribs have thoracic insufficiency syndrome (TIS). Commonly, respiration is adversely affected by loss of lung volume from chest-wall constriction and clinical loss of active rib cage expansion. The dynamic thoracic components of diaphragm or rib cage lung expansion during respiration is poorly characterised by radiograph or CT scan. Pulmonary function tests indicate only hemithorax performance. Dynamic lung MRI, however, can visualise both chest-wall and diaphragm motion, allowing assessment of each individual hemithorax performance, so that a dynamic classification system of the thoracic function can be developed.

Introduction

Following recommendations in the NHS Plan, all Trusts in the UK now send copies of correspondence to patients as standard practice. It is not clear whether patients wish to receive such correspondence, nor whether this practices an additional workload on the NHS as patients seek clarification on the medical terminology used in their letters.

Introduction

There are approximately 1.2 million patients using orthotics in the UK costing the NHS in excess of £100 million per annum. Despite this, there is little data available to determine efficacy and patient compliance. There have been a few reports on patient satisfaction, which indicate that between 13-50% of patients are dissatisfied with their orthotics. Our aim was to evaluate patient reported satisfaction with orthotics prescribed and to investigate the reasons behind patient dissatisfaction.

One of the complications of hallux valgus surgery is shortening of the first metatarsal and this becomes particularly symptomatic in patients with a pre existing short metatarsal (Morton's foot or Greek foot). Initial treatment consists of appropriate insoles which incorporate not only relief of pain due to pressure metatarsalgia under the lesser metatarsal heads but also a Morton type extension under the big toe. Insoles with metatarsal relief are, however, not always well tolerated and surgery becomes necessary. The options are to shorten the lesser metatarsal heads or lengthen the previously shortened first metatarsal. Arthrodesis of the great toe metatarso-phalangeal joint can provide functional length to the first metatarsal.

We have achieved good results in lengthening of the first metatarsal and believe that it is a safe option which avoids trauma to the lesser metatarso-phalangeal joints. The technique is presented and depends on whether there is a residual hallux valgus or whether the toe is well aligned. The operation should address the plane of the deformity and reverse the cause of the lengthening.

Emphasis should however be placed in not getting the complication in the first instance and the incidence of the problematic short first metatarsal has significantly reduced since the decrease in popularity of the Wilson osteotomy.

Background: Non-operative treatment for plantar fasciitis varies widely and includes the use of night ankle-foot orthoses (AFO’s). Some studies have shown that this is more effective in the initial management of plantar fasciitis than anti-inflammatory therapy. During sleep the foot and ankle tend to assume a plantarflexed position, which results in tightness of the calf muscle group, accounting for the stiffness and pain experienced by patients as they take their first weight bearing steps in the morning. However, when the foot and ankle are kept in a dorsiflexed stretched position at night, stress relaxation occurs and the plantar fascia relaxes.

Aim: Compliance with night AFO’s that dorsiflex the foot/ankle has always been a problem. This study compares the effectiveness of a posterior AFO, which dorsiflexes the foot, with an anterior AFO, which maintains the foot in plantigrade, asking whether it is absolutely necessary to dorsiflex the foot and ankle during the night to avoid early morning pain and stiffness, or whether it is it sufficient just to maintain the foot in plantigrade.

Methods: 18 participants were recruited on a voluntary basis and at random from among those patients referred to the Orthotics department with plantar fasciitis to be provided with a night orthosis. The inclusion criterion was that the diagnosis was purely plantar fasciitis with no secondary diagnosis, symptoms or complications. Each participant was given a questionnaire to fill in; this evaluated how satisfied the participants were with the orthosis with regards to comfort, ease of use and appearance, and whether the pain in the foot was reduced and at what stage was it reduced. The two types of AFO’s used in this study were:

A posterior AFO that holds the foot in dorsiflexion. The amount of dorsiflexion could be adjusted.

Results: 67% of the participants confirmed that morning pain and stiffness was less after wearing the AFO; this included 78% of those that wore the anterior AFO and 56% of those that used the posterior orthosis. 56% of all participants reported that the orthoses were uncomfortable and disrupted sleep. The most uncomfortable was the posterior AFO (89%), as opposed to the anterior one (22%). Both types of orthoses were reported to be relatively easy to don and doff (89% anterior AFO and 78% posterior AFO). On a scale of 1 to 10, the participants were asked to grade the pain before starting the orthosis treatment regime, after 6 weeks of wearing the AFO and again 6 weeks later. On average, the anterior AFO reduced the pain from 7 to 2.1, while the posterior orthosis only reduced the pain from 8.1 to 6.7.

Conclusion: In general, plantar fasciitis night AFO’s are poorly tolerated orthoses, however, their use can be justified in that the pain levels are reduced. The anterior AFO seems to be more effective in achieving this, without dorsiflexing the foot/ankle beyond plantigrade. Thus, one could argue that there is no need to dorsiflex to achieve the goal. However, further investigation is necessary with a larger patient cohort.

Metatarsalgia is a recognised complication following iatrogenic shortening of the first metatarsal in the management of hallux valgus. The traditional surgical treatment is by shortening osteotomies of the lesser metatarsals.

We describe the results of lengthening of iatrogenic first brachymetatarsia in 16 females. A Scarf-type osteotomy was used in the first four cases and a step-cut of equal thicknesses along the axis of the first metatarsal was performed in the others.

The mean follow-up was 21 months (19 to 26). Relief of metatarsalgia was obtained in the six patients in whom 10 mm of lengthening had been achieved, compared to only 50% relief in those where less than 8 mm of lengthening had been gained.

One-stage step-cut lengthening osteotomy of the first metatarsal may be preferable to shortening osteotomies of the lesser metatarsals in the treatment of metatarsalgia following surgical shortening of the first metatarsal.

Scarf osteotomy is widely used as a surgical treatment for hallux valgus. It is a versatile osteotomy, allowing shortening, depression or medial displacement of the capital fragment but it remains uncertain how stresses within the bone subsequently vary. The aim of this study was to design a computerised model to explore the effect on bone stress of changing the position of bony cuts for a scarf osteotomy.

A computerised image was constructed using finite element analysis. This utilises a mathematical technique to form element equations which represent the effect of applied force to the object appropriate to each finite element. Maximum bone stresses were then measured using different osteotomy variables. The osteotomy variables studied were the length of the longditudinal cut, apex of the distal cut to articular cartilage, resection level of the longditudinal cut and combinations of these variables. A saw bone model was used to test the findings of the study.

The results of this study show that lowering the longditudinal resection level and shortening via the distal cut beyond 6 mm will decrease bone stress. Additionally, raising the longditudinal resection level and shortening via the proximal cut caused an increase in bone stress. A saw bone model confirmed the findings of the study.

In conclusion, our experience is that finite element analysis is a very useful model in studying the bony stresses for a scarf osteotomy and assists in optimising the direction and angle of bony cuts used.

In the belief that many of the barriers that patients face when deciding upon an ankle or hindfoot fusion procedure stem from inadequate information about the procedure and its outcomes, the novel concept of a “Fusion forum” has been developed: a nurse-led informal group meeting to facilitate patients’ understanding and perception of fusion procedures. The aims were to provide more in-depth information than it is possible to deliver during the limited time of an initial doctor-patient consultation, to get the patient to meet and question a guest (an expatient who has previously had a fusion procedure) and to allow patients time to reflect upon their choices.

The value of the fusion forum has been evaluated by a questionnaire which was completed by the first 48 patients who attended the forum. 96% (46/48) of respondents felt that the quality of information that they were given was excellent or good. No respondent thought that the information was unsatisfactory. Patients were asked how valuable they had found meeting the guest. Four patients did not respond to this question. All of the respondents thought that meeting another patient who had already undergone the procedure was excellent or good

The mechanics of setting up a foot and ankle fusion forum is discussed, along with the lessons learnt from the first cohort of patients. This process has been found to greatly increase patient understanding of arthrodesis. It has been found during the consent process in pre-admission clinic that patients demonstrate a more in-depth understanding of the operative procedure, a more comprehensive knowledge of what the whole process involves, as well as the relative risks and benefits and the expected time of recovery.

Purpose: Evaluation of a hands free crutch. This interesting device is intended for patients who have undergone foot and ankle surgery and should be non-weight bearing. It involves a knee tray attached to a vertical beam with a rubber foot. The crutch is strapped to the lower limb and weight is transferred though the proximal tibia.

Methods: Five Volunteers were assessed using the crutch, the K9 walker and 2 standard crutches in a simulated environment.

A comparison was made between this device and the K9 walker which has been shown to be a liberating walking aid indoors. Tasks from activities of daily living, productivity and transfers were included. Assessment was undertaken by the Occupational Therapy Team.

The hands free crutch was also compared with non weight bearing using two crutches to gauge performance outdoors. Assessment of ease of use and safety was undertaken by the Physiotherapy Team.

Results: Domestic chores including cleaning, cooking and shopping were possible using this device. Sitting activities were noted to be more difficult, because of the necessity to remove the crutch on each occasion.

Although speed was significantly greater (p< 0.0001.) using two crutches, the hands free crutch permitted safe outdoor mobilisation on even or uneven ground, up and down slopes with a gradient of 1 in 10 and up and down stairs. Good single leg stance stability was predictive of ease of use and safety for the hands free crutch.

Discussion: The hands free crutch is suited to motivated and physically able patients. Other lower limb pathology contraindicates the use of this device, but in patients with upper limb pathology it would permit non-weight bearing mobilisation. Good balance is paramount and perhaps a falls risk assessment should be performed prior to use.

Introduction: Adolescent peroneal spastic flatfoot (PSF) is often regarded as synonymous with tarsal coalition. Inflammatory arthropathies, infections and tumours may, however, all present in this way, and in a few patients with PSF no definitive pathology may be identified.

We aim of to evaluate the causes of adolescent PSF and to develop an an algorithm for its investigation and the management of those patients in whom no underlying pathology is identified.

Methods: All adolescent patients presenting to the senior author with PSF over a two year period were evaluated first for tarsal coalition by means of clinical examination, plain x-rays and CT scanning. If this proved inconclusive an MRI scan was performed and bloods sent for inflammatory and infective markers. If these too identified no treatable cause the patients were treated with a manipulation under anaesthetic, injection of steroid and local anaesthetic into the subtalar joint and immobilization in a below knee cast for 4 weeks. They then received physiotherapy and a talar neutral orthosis. Follow-up was at 4 weeks post-injection and continued until symptoms resolved.

Results: Five patients were found to have PSF with no identifiable cause. All were male, aged 12–17 at presentation. Four completed the treatment. Mean final follow-up was at 10 months post-procedure. All patients reported relief of pain following the procedure and returned to normal activity. At final follow-up, three were still participating in regular sport. One patient suffered a recurrence of his pain.

Conclusion: Adolescent peroneal spastic flatfoot is often, but not always due to tarsal coalition.

If this and other treatable causes have been excluded, treatment with the regime described may give good symptomatic relief in the short to medium term.

Introduction: Many mini compression screws are now available for fixation in procedures such as metatarsal osteotomies or arthrodeses of the foot.

The aim of the current study is to compare the compression forces achieved by mini compression screws on cortical and cancellous bone models.

Material and Methods: The screws that were tested are listed in the table below. The compression forces were tested by inserting a pressures load measurement cell between longitudinally-split sheep tibia as a cortical bone model and longitudinally split retrieved femoral heads as a cancellous bone model.

Results: The Headed AO 3.5 mm cortical screw gave the best compression force and the Bold was the weakest, both in cortical and cancellous bone. The relative compression forces of the other tested screws were different between cortical and cancellous bone. Compression with the headless screws was lost as soon as the screw penetrated through the cortex in the cortrical bone model.

Conclusions: The indications for using headless self-tapping screws should be reserved for fixation of cancellous bone or of metatarsal or Akin osteotomies where compression is not required for union. When compression is important, such as in MPJ, tarso-metatarsal or talonavicular arthrodeses, Headed AO 3.5 mm or 2.7 mm cortical or 4 mm cancellous screws, which give better compression, should be used.

Morton’s Metatarsalgia is a painful condition and can often be debilitating. The value of surgical exicion has been doubted due to low success rate of surgical intervention.

Objective: The purpose of this study is to examine the variation in the management steps of Morton’s Metatarsalgia.

Methods: Several Surgeons from different European countries answered a questionnaire in regard to their routine management of a typical Morton’s Neuroma patient.

Results: 25 surgeons (100%) stated they would routinely elicit intermetatarsal tenderness in comparison to 14(56%) and 10 (40%) surgeons who would routinely elicit Intermetatrsal tenderness and Mulder’s click respectively. The majority of them (84%) will routinely request plain foot radiograph, while 7 surgeons(28%) uses ultrasound routinely. Coservative management is initiated by 16 surgeons(64%). Local injection was first line of treatment among 13 surgeons (56%). Surgical treatment is favoured by 10 surgeons(40%), while only one surgeon (4 %) would use ultrasound guided injection routinely. The popular surgical approach is dorsal incision (75%). If surgical option was chosen then neurectomy is attempted by 17 (68%) surgeons.

Conclusion: Considerable variation exists among continental surgeons in their initial management of a typical Morton’s Neuroma patient. This is probably due to lack of understanding of the true aetiology of the Morton’s “Neuroma”.

Objective of the Study: To assess the clinical effectiveness of ultrasound guided injection in the management of Morton’s Metatarsalgia.

Patients and Methods: Patients, that were clinically diagnosed to with interdigital Morton’s neuroma were treated with ultrasound guided injection of local anaesthetic and steroid. Fifty three patients were available for follow-up, and all had detailed telephone questionnaires completed. These questionnaires included a pre and post injection symptom score, as well as a Johnson Satisfaction score.

Results: 69% of patients had ultrasound diagnosis of Morton’s neuroma and 31% had an ultrasound diagnosis of intermetatarsal bursa. Mean follow up was11.4 months (Range: 3-23 months).67% of the patients were satisfied with the results of treatment. At follow up 63% of patients had no limitation in activity levels, and had no need to modify their shoe wear. Of all patients included in the study, only 3 patients have gone on to require surgery for ongoing symptoms.

Conclusion: Some studies have suggested that neither injection nor imaging have a role in the treatment of Morton’s neuroma. This study, however, demonstrate that ultrasound guided placement of local anaesthetic and steroid in either an intermetatarsal bursa or Mor-ton’s neuroma gives a good short and medium term symptom relief and in the majority of cases avoids the need for surgery.

Introduction: Many mini compression screws are now available for fixation in procedures such as metatarsal osteotomies or arthrodeses of the foot.

The aim of the current study is to compare the compression forces achieved by the relatively new commercial mini compression screws on cortical and cancellous bone models.

Material and Methods: The screws that were tested are listed in the table below. All screws apart from the AO screws are headless and cannulated; and all screws apart from the AO cortical screw are self-tapping. The compression forces were tested by inserting a pressures load measurement cell between longitudinally-split sheep tibia as a cortical bone model and longitudinally split retrieved femoral heads as a cancellous bone model. The screws were inserted across the 2 halves with gradual compression after allowing the reading of the cell to settle.

Results: The Headed AO 3.5 mm cortical screw gave the best compression force, both in cortical and cancellous bone and the Bold was the weakest both in cortical and cancellous bone. The relative compression forces of the other tested screws were different between cortical and cancellous bone. Compression with the headless screws was lost as soon as the screw penetrated through the cortex in the cortrical bone model.

Conclusions: The indications for using headless self-tapping screws should be reserved for fixation of cancellous bone or of metatarsal or Akin osteotomies where compression is not required for union. When compression is important, such as in MPJ, tarso-metatarsal or talo-navicular arthrodeses, Headed AO 3.5 mm or 2.7 mm cortical or 4 mm cancellous screws, which give better compression, should be used.

Introduction: One of the complications of first metatatarsal osteotomies is metatarsalgia secondary to shortening of the first metatarsal. Conservative treatment with insoles is not acceptable to all patients and the traditional treatment of this condition is by shortening osteotomies of the lesser metatarsals (eg Weil, Helal)- the latter osteotomies themselves have complications of causing pain or stiffness in the lesser toes.

Purpose: The aim of this work is to report our results of step cut metatarsal lengthening of iatrogenic first brachymetatarsia.

Patients and Methods: 16 female patients had metatarsal lengthening of iatrogenic first brachymetatarsia. A typical Scarf type osteotomy was used in the first 4 cases and a simple step cut of equal thicknesses along the axis of the first metatarsal was performed in the next 12 procedures.

Results: When 10mm lengthening was done, the metatarsalgia was relieved in all of the 6 patients, in contrary to only 50% relief of symptoms in the patients when less then 8mm lengthening was achieved.

Conclusions: One stage step cut lengthening osteotomy of the iatrogenic short first metatarsal, when over 8mm length is achieved, is safe with good results and is a preferable alternative to shortening osteotomies of the lesser metarsals in the treatment of metarsalgia due to inappropriate shortening of the first metatarsal.

Objective To survey current antithrombotic prophylaxis regimes of foot and ankle surgeons in the UK, and their self-reported rates of deep vein thrombosis (DVT) and pulmonary embolism (PE).

Method A postal questionnaire was sent to 180 members of the British Orthopaedic Foot and Ankle Society requesting regime and types of antithrombotic prophylaxis (if any) used for elective forefoot, elective midfoot, open elective ankle, elective ankle arthroscopy and ankle trauma surgery, and numbers of cases of DVT and PE.

Results Ninety surgeons responded (50%). Surgeons had been practising as consultants with a special interest in foot and ankle surgery for an average of 8.9 years, and performed an average of 24 foot and ankle cases per month. Ten per cent never used antithrombotic prophylaxis in foot and ankle surgery, 64/90 used it routinely for certain cases, and 17/90 used it routinely in all patients. The most common types of prophylaxis were low molecular weight heparin, aspirin and TED stockings. In an approximate overall total of 223,500 foot and ankle cases, the self reported DVT rate was 0.1%. There were 45 reported PEs (0.02%). There was no significant difference in the rate of DVT between those who never, sometimes or always used prophylaxis. Only 5.5% surgeons employed a specific screening protocol to identify high risk patients.

Discussion There is widely varying clinical antithrombotic practice among foot and ankle surgeons in the UK, with no significant difference in reported DVT rates. This has implications for clinical practice and medicolegal issues.

Although the use of split tibialis anterior tendon transfer (combined with the Rose calcaneal osteotomy and reinforcement of the spring ligament) is a recognised procedure in the treatment of stage II tibialis posterior dysfunction, there is a paucity of data regarding its results. Forty-three patients who underwent reconstruction between 1997 and 2003 were evaluated pre- and postoperatively using the AHS scoring system. The average age was 57, and the mean follow-up time was 51 months (range 10–83).

The average AHS score pre-op. was 58 and post-op. was 85. Sixty-six per cent of patients achieved single heel raise. Eighty-four per cent expressed a subjective satisfaction rate, whilst 16% had no improvement. Seventy-eight per cent were able to use normal shoes and 58% did not require the use of any orthotics. The minor complication rate was 16% with no major complications. All osteotomies united uneventfully. Two patients have developed subtalar osteoarthritis, and six calcaneal screws had to be removed for prominence and tenderness.

Our results compare very favourably with other less anatomical reconstructions, but without the donor site morbidity and very low complication rates. A subjective satisfaction rate of 84% has been achieved.

Whilst a few studies have associated various symptoms with the presence of a peroneus quartus muscle in the peroneal compartment of the leg, little is known of the clinical relevance of this muscle.

We dissected 102 cadaver legs and reviewed the magnetic resonance images of 80 patients with symptoms from the ankle. The peroneus quartus, with a number of different attachments, was present in 6.6% of the legs. It most commonly arose from the peroneus brevis muscle and inserted into the retrotrochlear eminence of the calcaneum. Associated pathology included a longitudinal tear in the tendon of peroneus brevis, possible peroneal tendon subluxation or dislocation, and a prominent retrotrochlear eminence. On the MR scans its presence was associated with pain and weakness of the ankle.

Orthopaedic surgeons and radiologists should be aware of the possible presence of the peroneus quartus muscle, not only because of possible associated pathology, but also for its potential use for surgical reconstruction.

Background

Various clinical outcome studies have consistently reported high dissatisfaction rate (25–33%) among the patients after hallux valgus surgery. We believe that a patient’s pre-operative expectations may play a major role in post-operative satisfaction.

Patients & Methods

Questionnaires were sent to 104 patients anonymously who were given a list of reasons and asked which they hoped to improve by having the surgery. They were also asked to list, in the order of priority, goals that they hoped to achieve from surgery.

Results

Overall, improvement in the ability to walk was the most important reason. Most patients also wished to reduce pain over bunion and to regain the ability to wear daily shoes. However, the expectations of patients vary significantly according to age. Patients under 40 placed more importance on their ability to wear dress shoes and improvement in functional activities. Patients between the age of 40 and 60 were more interested to improve physical appearance. Pain on other toes, and the abilities to squat and climb stairs are the main concerns for patients above 60. For the male patients, to be able to continue work is the second most important reason after improvement in walking ability. This is in contrast to the female group where the ability to wear shoes of their choice is more important. Occupation did not make any significant difference.

Conclusions

This study shows that patients have different expectations that can influence the choice of operation. We believe that understanding patients preoperative expectation is crucial in achieving better patient satisfaction, and it should be an important consideration in planning appropriate operation for the patients.