Autologous osteochondral transplantation (AOT) is an effective treatment for large Osteochondral Lesions of the Talus (OLT), however little is reported on an athletic population, who are likely to place higher demands on the reconstruction. The aim is to report the outcomes of large OLT (>150mm²) within an athletic population. The study population was limited to professional or amateur athletes (Tegner score >6) with an OLT of size 150mm² or greater. The surgical intervention was AOT with a donor site from the lateral femoral condyle. Clinical outcomes at a minimum of 24 months included Return to Sport, VAS and FAOS Scores. In addition, graft incorporation was evaluated by MRI using MOCART scores at 12 months post-surgery. 38 athletes including 11 professional athletes were assessed. Mean follow-up was 46 months. Mean lesion size was 249mm². 33 patients returned to sport at their previous level and one did not return to sport (mean return to play 8.2 months). Visual analogue scores improved from 4.53 pre-operatively to 0.63 post-operatively (p=0.002). FAOS Scores improved significantly in all domains (p< 0.001). Two patients developed knee donor site pain, and both had three osteochondral plugs harvested. Univariant analysis demonstrated no association between pre-operative patient or lesion characteristics and ability to return to sport. However, there was a strong correlation between MOCART scores and ability to return to sport (AUC=0.89). Our study suggests that AOT is a viable option in the management of large osteochondral talar defects in an athletic population, with favourable return to sport levels, patient satisfaction, and FAOS/VAS scores. The ability to return to sport is predicated upon good graft incorporation and further research is required to optimise this technique. Our data also suggests that patients should be aware of the increased risk of developing knee donor site pain when three osteochondral plugs are harvested.

Background

Lateral ankle instability is a common problem, but the precise role of the lateral ankle structures has not been accurately investigated. This study aimed to accurately investigate lateral ankle complex stability for the first time using a novel robotic testing platform.

The management of symptomatic osteochondral lesions of the talus (OLTs) can be challenging. The number of ways of treating these lesions has increased considerably during the last decade, with published studies often providing conflicting, low-level evidence. This paper aims to present an up-to-date concise overview of the best evidence for the surgical treatment of OLTs. Management options are reviewed based on the size of the lesion and include bone marrow stimulation, bone grafting options, drilling techniques, biological preparations, and resurfacing. Although many of these techniques have shown promising results, there remains little high level evidence, and further large scale prospective studies and systematic reviews will be required to identify the optimal form of treatment for these lesions.

Cite this article: Bone Joint J 2021;103-B(2):207–212.

Introduction

Injections are used to treat a wide variety of pathologies. Our aim was to evaluate the efficacy and safety of foot and ankle injections in our clinic.

Introduction

Survival rates of recent total ankle replacement (TAR) designs are lower than those of other arthroplasty prostheses. Loosening is the primary indication for TAR revisions [NJR, 2014], leading to a complex arthrodesis often involving both the talocrural and subtalar joints. Loosening is often attributed to early implant micromotion, which impedes osseointegration at the bone-implant interface, thereby hampering fixation [Soballe, 1993]. Micromotion of TAR prostheses has been assessed to evaluate the stability of the bone-implant interface by means of biomechanical testing [McInnes et al., 2014]. The aim of this study was to utilise computational modelling to complement the existing data by providing a detailed model of micromotion at the bone-implant interface for a range of popular implant designs, and investigate the effects of implant misalignment during surgery.

This study investigated athletes presenting with grade II syndesmosis injuries and identified the clinical and radiological factors important in differentiating a stable from dynamically unstable injury and those findings associated with a longer recovery and return to sport.

Sixty-four athletes were prospectively assessed with an average follow-up of 37 months (range 24–66 months). Athletes with an isolated distal syndesmosis (+/− medial deltoid ligament) injury were included. Those athletes with a concomitant ankle fracture were excluded. Those considered stable (grade IIa) were treated conservatively with a boot and progressive rehabilitation. Those with clinical signs of instability underwent arthroscopy and if instability was confirmed (grade IIb) the syndesmosis was stabilized surgically. The clinical assessment of injury to individual ligaments of the ankle and syndesmosis were recorded along with MRI findings, complications and time to return to play.

All athletes returned to the same level of professional sport – 28 with IIa injuries returned at a mean of 45 days whereas the 36 with grade IIb injuries returned to play at a mean of 64 days (p< 0.001). Clinical assessment of injury to the ligaments of the syndesmosis correlated well with MRI findings. Those with a positive squeeze test were 9.5 times as likely and those with a deltoid injury 11 times more likely to have an unstable syndesmosis confirmed arthroscopically. The combination of injury to the AITFL and deltoid ligament was associated with a delay in return to sport. Concomitant injury to the ATFL indicated a different mechanism of injury with the syndesmosis less likely to be unstable and was associated with an earlier return to sport.

Clinical and MRI findings may differentiate stable from dynamically unstable grade II injuries and identify which athletes may benefit from early arthroscopic assessment and stabilization. It also suggests the timeframe for expected return to play.

Background:

Achilles pathology is a serious and frequently occurring problem, especially in elite athletes. Recent research has suggested a role for the plantaris tendon in non-insertional achilles tendinopathy. We report on the outcomes after excision of the plantaris tendon in elite athletes.

Background

Lateral ligament injuries of the ankle are common. They account for up to 50% of all sporting injuries. Recovery times vary, leading to time away from sport and training for the professional athlete. Predicting this time is important for the treating surgeon, the athlete and the rehabilitation team. This can be difficult as associated ankle injuries occurring at the time of the trauma may alter recovery and rehabilitation.

Introduction

Surgical approaches to the dorsum of the foot are common for management of midfoot fracture dislocations and arthritis. The anatomy can be difficult to identify and neurovascular injury can be a serious complication.

Extensor hallucis brevis (EHB) is a consistent and easily identifiable structure encountered in these approaches. This study assesses the close relationship of the EHB musculotendinous junction to the neurovascular bundle for use as a reliable landmark.

Introduction

Fifth metatarsal fractures are a common injury suffered by professional footballers. It is frequently reported in the media that such an injury will result in a 6-week absence from play. The purpose of this study was to assess frequency of media reporting of fifth metatarsal fractures, the time that is predicted by the media before the player will return to soccer and the actual time taken for the player to return to play.

Introduction

Lisfranc joint injuries are increasingly recognised in elite soccer and rugby players. Currently no evidence-based guidelines exist on timeframes for return to training and competition following surgical treatment. This study aimed to see whether return to full competition following surgery for Lisfranc injuries was possible in these groups and to assess times to training, playing and possible related factors.

Introduction

The mainstay of treatment in non-insertional Achilles tendinopathy is non-operative, however between 1/4 and 1/3 of patients fail this. The main symptom is pain which appears to be related to new nerve endings that grow into the tendon with the neovessels from the paratenon. Treatments which strip the paratenon from the tendon are showing promise including formal paratenon stripping via Achilles tendinoscopy. The pain and swelling in Achilles tendinopathy is usually on the medial side leading to the postulation that the plantaris tendon may have a role to play.

Background: Foot injuries represent a small but important proportion of injuries to professional rugby union players. There are no detailed epidemiological studies regarding these injuries.

Purpose: The aim of this study was to describe the epidemiology of foot injuries sustained by a cohort of professional rugby union players and identify areas that may be targeted for injury prevention in the future.

Study design: Descriptive epidemiological study.

Methods: Medical personnel prospectively recorded injuries in professional, premiership rugby union players in England over 4 seasons. Injuries to the foot were identified and the time away from training and playing was reported.

Results: A total of 147-foot injuries were sustained resulting in 3,542 days of absence in total. Acute events accounted for 73% of all foot injuries, with chronic, mostly overuse conditions, accounting for 25% (undiagnosed 2%). Chronic conditions led to proportionately more time away from training and playing (p< 0.001). Specifically, stress fractures in the foot accounted for 8% of the total foot injuries but 22% of the absence. Navicular stress fractures had the longest recovery time with the mean return to training and match play of 188 days.

Conclusions: In collision sports, such as rugby, injury is inevitable, but clinicians should always be seeking ways to minimise their occurrence and impact. This study revealed significant morbidity associated with chronic and overuse foot injuries in these professional athletes. With greater attention paid to risk factors, some of these injuries, and importantly, recurrent injuries may be avoided.

Introduction: Adequately managing post-operative pain following ankle and hindfoot surgery can be difficult. Conventional analgesics have significant side effects including nausea and gastric irritation. The results of a pilot study of continuous infusion v’s single bolus popliteal block encouraged us to perform the full PRCT.

Method: The trial was approved by the local Research and Ethics Committee and registered with the European Clinical Trials Database. Approval was obtained from the Medicines and Healthcare products Regulatory Authority (MHRA) for the use of normal saline infusion as a placebo. The recommendations of Good Clinical Practice in the conduct of clinical trials on medicinal products for human use were respected.

Inclusion criteria were all patients who were undergoing significant hind foot or ankle procedures. Exclusion criteria included coexisting peripheral neuropathy and any inability to fill in the questionnaire.

The pilot study provided a standard deviation of pain scores which allowed us to calculate the sample size required; 25 patients in each group would have 90% power to detect a difference in means VAS scores of 3 which we considered to be clinically significant. A total number of 56 (to allow for 10% loss to follow-up) were recruited. The patients and the assessors were blinded to the treatment allocated. Sealed envelopes contained random allocations and were opened by the anaesthetist. A bolus of 20ml 0.25% bupivacaine was injected and then the catheter was inserted and connected to a pump. Patients were randomly assigned to receive either an infusion of normal saline or bupivacaine over the next 72 hours.

The patients were asked to complete a visual analogue pain chart, three times daily, for 72 hours postoperatively. Data was also recorded regarding supplementary opiate analgesic requirements and any problems or complications.

Statistical analysis was performed using MedCalc for Windows, version 9.6.4 (MedCalc software, Mariakerke, Belgium). A Mann-Whitney U test was used for the non-parametric data sets.

Results: Both groups had very low median VAS pain scores on the day of operation and there was no difference between the two; study 1.167, control 1.000 (p=0.893). On the 3 post operative days studied there were significantly lower pain scores in the study group; day 1: 1.67 v’s 3.67 (p=0.003), day 2: 1.33 v’s 2.83 (p=< 0.001), day 3: 1.11 v’s 2.56 (p=< 0.001).

There was no difference in median milligrams of morphine usage on the day of operation; study = 10, placebo = 10 (p = 0.942). The morphine usage was lower in the study group on all post operative days and this was significant on days 2& 3; day 1: 10 v’s 15 (p=0.054), day 2: 10 v’s 20 (p=< 0.001), day 3: 7.5 v’s 10 (p=0.02). Median total morphine requirements over the 3 post operative days were 30mg for the study group compared to 52.5mg for the control group and this was significant (p=0.012).

The study group on average spent less nights as an inpatient with a median value of 1 compared to 2 for the control but this was not significant (p=0.430).

There were no major complications with the administration of the blocks or with the catheters.

Conclusion: The bolus of bupivacaine given to all patients prior to surgery meant that low pain scores were seen in both groups in the immediate post operative period with no significant difference between them. The continuous infusion of bupivacaine via a pain pump provided significantly better analgesia than normal saline with significantly less requirement for supplementary oral analgesic agents over the 72 hours after major ankle or hind foot surgery. This is a safe and effective method of managing post operative pain in these patients.

Introduction: When conservative treatment of posterior ankle impingement syndrome (PAIS) fails, operative intervention is indicated. Traditionally this involved an open approach. More recently posterior ankle arthroscopy has been employed. We report the first series of results from an exclusively elite athlete population.

Method: We looked retrospectively at a prospectively compiled database of a consecutive series of elite professional soccer players on whom we have performed posterior ankle arthroscopy for both bony and soft tissue PAIS over the past 5 years. We reviewed our clinical and operative notes and those of the Football Association medical team. Statistical analysis was performed using MedCalc for Windows, version 9.6.4 (MedCalc software, Mariakerke, Belgium).

Results: One player was lost to follow up leaving 27 out of 28 players in the study.

The mean time to return to training post operatively was 34 days (24–54) and to playing was 41 days (29–72). Significant correlations were found between the length of symptoms and the number of pre operative injections (Spearman’s rank correlation coefficient = 0.806. p< 0.001) and the length of symptoms pre-operatively and return to training (Correlation coefficient = 0.383. p=0.048) and return to play (Correlation coefficient = 0.385. p=0.048). Return to training was significantly faster after soft tissue debridement with FHL release than after bony surgery (p=0.046 Kruskal-Wallis test). There was one surgical complication in the form of a persistent portal leakage. This was successfully treated by resting the ankle in a boot for 2 weeks. One patient had recurrent symptoms 3 months after surgery; this was successfully treated with an ultrasound guided injection. There were no infections and no neurovascular injuries.

Conclusion: Posterior ankle arthroscopy is safe and effective in the treatment of posterior ankle impingement syndrome in the elite soccer player with return to training expected at an average of 5 weeks.

Introduction: The pathogenesis of chronic tendinopathy is unclear. The role of the increased apoptosis of tenocytes has been suggested by high intratendinous levels of glutamate being demonstrated in patients with tendinosis. Nitric oxide is a known mediator of apoptosis and nitric oxide synthase (NOS) isoforms have been shown to be upregulated in rotator cuff tendons as a result of chronic overuse. We found, the same upregulation of NOS in the Achilles tendon in non-insertional Achilles tendinopathy in a previous study.

The purpose of this study was to investigate whether apoptotic cells were present in these tissues with raised eNOS and iNOS levels.

Methods: Samples were obtained from the Achilles Tendons of patients with in non-insertional Achilles tendinopathy who had failed conservative treatment for at least six months and were undergoing a surgical procedure. Consent was obtained preoperatively from all patients and ethical approval was granted by the research ethics committee.

Several biopsies were taken of the visibly abnormal tendon tissue. Control samples were taken from macroscopically normal tendon correlating with areas of normal tissue on MRI.

Standard immunohistochemical techniques were used to identify the expression of endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS).

Apoptotic cells were identified using terminal deoxynucleotidyl transferase-mediated dUTP neck end labelling (TUNEL reaction) with TdT-FragEL and the demonstration of Caspase-3 activation.

A power calculation was performed which showed that 14 patients in each group would be required to show a 50% difference between the two groups using a level of significance of 5%.

Results: Significant differences were found between the diseased tendon and the controls for all of the parameters measured. The mean Caspase-3 cell count for diseased tendon was 51.9 compared to 28.3 for the controls (p=0.000001). The mean TUNEL cell count for diseased tendon was 24.1 compared to 14.8 (p=0.00014). iNOS densitometry revealed a mean of 26.1 for the diseased tissue verses 15.0 for the controls (p=0.000009) and the values for eNOS were 48.3 and 23.7 respectively (p=0.015).

Conclusions: Apoptosis clearly plays a role in the development of non-insertional Achilles tendinopathy and appears to be related to the presence of raised eNOS and iNOS levels.

It is possible that, by blocking the apoptotic pathway, the tendinopathic process could be halted. This may lead to the development of treatments strategies for early Achilles tendinopathy.

Introduction: The pathogenesis of chronic tendinopathy is unclear. A role for increased apoptosis of tenocytes has been suggested. Nitric oxide is thought to be a mediator of apoptosis and nitric oxide synthase (NOS) isoforms have been shown to be up regulated in rotator cuff tendons as a result of chronic overuse. We found, the same up regulation of NOS in the Achilles tendon in non-insertional Achilles tendinopathy in a previous study.

The purpose of this study was to investigate whether apoptotic cells were present in these tissues with raised endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) levels.

Methods: Consent was obtained preoperatively from all patients and the research and ethics committee granted ethical approval. Samples were obtained from the Achilles Tendons of patients with non-insertional Achilles tendinopathy who had failed conservative treatment for at least six months and were undergoing a surgical procedure. Several biopsies were taken of the visibly abnormal tendon tissue. Control samples were taken from macroscopically normal tendon correlating with areas of normal tissue on MRI. Standard immunohistochemical techniques were used to identify the expression of eNOS and iNOS. Apoptotic cells were identified using terminal deoxynucleotidyl transferase-mediated dUTP neck end labelling (TUNEL reaction) with TdT-FragEL and the demonstration of Caspase-3 activation.

Results: Significant differences were found between the diseased tendon and the controls for all of the parameters measured. The mean Caspase-3 cell count for diseased tendon was 51.9 compared to 28.3 for the controls (p=0.000001). The mean TUNEL cell count for diseased tendon was 24.1 compared to 14.8 (p=0.00014). iNOS densitometry revealed a mean of 26.1 for the diseased tissue verses 15.0 for the controls (p=0.000009) and the values for eNOS were 48.3 and 23.7 respectively (p=0.015).

Conclusions: Apoptosis clearly plays a role in the development of non-insertional Achilles tendinopathy and appears to be related to the presence of raised eNOS and iNOS levels. It is possible that, by blocking the apoptotic pathway, the tendinopathic process could be halted. This may lead to the development of treatments strategies for early Achilles tendinopathy.

Introduction: Sciatic nerve blocks have been used to reduce post-operative analgesia and allow early discharge for patients undergoing foot and ankle surgery. This study aims to identify utilisation of this procedure and to ascertain if there is a consensus amongst surgeons as to best practise with regards to who performs the block and how it is performed.

Method: We surveyed current committee members of the American and members of the British orthopaedic foot and ankle surgery societies (AOFAS and BOFAS).

Results: More than half of those who responded perform over 90% foot and ankle surgery. 77% performed sciatic nerve blockade through the popliteal approach (26% used the subgluteal approach). The most common position was supine with 80% being performed by the anaesthetist. 45% never used ultrasonography to detect the position of the nerve and variable levels of nerve stimulation were used. 30% used an infusion catheter with 20% allowing discharge to home with the catheter. 42% of surgeons where happy to have the block performed under full anaesthesia. The commonest complication cited was prolonged anaesthesia, the majority of which resolved. Performing the block awake or sedated did not seem to alter the number of complications seen.

Discussion: This study represents a current practice review of sciatic nerve blocks performed in foot and ankle surgery and shows a variety of techniques used. Although this is now a widely used block, no consensus has been reached as to the use of ultrasound, level of nerve stimulation or whether the patient needs to be awake for the procedure. The use of infusion catheters (especially after discharge) has not been widely utilised, especially amongst UK surgeons.

Compression staples are a popular form of fixation for osteotomy and arthrodesis. “Mechanical Compression” or “Shape Memory” designs are commercially available. We performed a biomechanical study to assess suitability for their intended functions.

Compression was measured using a load cell mounted within a simulated arthrodesis site. Two designs of mechanical compression and shape memory staples were tested and compared. The effect of altering the length of the staple limb was also assessed.

Both designs of mechanical compression staple had divergence of their fixation limbs causing inconsistent compression or even distraction. The shape memory staples all achieved a consistent compressive force at the fusion site. Staple limb length did not appear to alter the compression force generated.

The limbs of Mechanical Compression Staples splay open with a fulcrum at the intersection bridge. As a result, there is distraction of the far cortex and compression of the proximate cortex. Shape memory staples compress both the near and far cortices leading to stability and compression forces across the arthrodesis site.

Method: This study reports upon 216 patients (97 Minimally invasive and 119 Standard) enrolled into a randomised control trial comparing a standard posterior approach to the hip with a single incision minimally invasive surgery (MIS) posterior approach at 6 weeks and 1 year post-operatively. Primary outcome measures included operative time, blood loss, length of stay and functional hip scores.

Results: The demographics and pre-operative hip scores for both cohorts were statistically similar. Intra-operative blood loss was significantly reduced in the MIS cohort (p=< 0.01). There was no difference in surgical time (p=0.37), time to discharge (p=0.24) or complication rate between the two groups.

Both groups had statistically improved post-operative hip scores, however, at the 1 year follow-up the MIS group were significantly better in terms of WOMAC, Harris Hip, Merle d’Aubigne and SF-12 scores when compared with a standard posterior approach.

Conclusion: This study demonstrates that MIS THA is a safe, reproducible technique in a DGH. We recommend the use of MIS techniques in primary THA and adhere to the principle that an incision need be no longer than necessary to perform the procedure safely.

Introduction: Compression staples are indicated for use in forefoot osteotomies and midfoot and forefoot fusions. The staple design can be divided into “Mechanical Compression” or “Shape Memory”. Although they are becoming increasingly popular because of their ease of use, there is little data published on the effectiveness of the true compression achieved across bony surfaces. There is no data on the optimal limb-length to staple width ratio required for compression. We aimed to compare four commercially available types of compression staple and measure the compression force achieved.

Methods and Materials: Compression in porcine tibia, cancellous bone substitute and perspex was compared using a load cell mounted within a simulated fusion site between two test blocks. The amplified output was continuously recorded using a datalogger and the data analysed. Two designs of “mechanical” compression staple and two designs of “shape memory” staple were tested. The effect of altering limb length on compression was also noted.

Results: The “mechanical” compression staples splayed open with the limbs of both designs causing either no compression or even distraction at simulated fusion site. Distractive forces of up to 23N were recorded. By contrast, the “shape memory” staples all achieved compression at the fusion site of between 5–25N. Limb length did not appear to alter the compression force achieved.

Discussion: “Mechanical” compression staples act in a similar way to basic AO principles of a 2-hole compression plate used without a lag screw technique or pre-bending. Although there is compression of the cis-cortex, the limbs of the staple splay open with a fulcrum around the bridge-limb intersection resulting in distraction of the trans-cortex. “Shape memory” staples compress both the cis- and trans-cortices along the length of the limb leading to adequate stability and compression forces across the fusion site.

Conclusion: This study demonstrates that “mechanical” compression staples cause a distractive force rather than a compressive force and manufacturers should be aware that further design modifications are required to prevent this. We recommend that “shape memory” staples, standard staples or lag screws are used instead. The limb-length to staple width ratio does not appear to be important.

Introduction: Adequate analgesia following hindfoot surgery can be difficult and conventional analgesics have significant side effects. A single bolus popliteal block of the neurovascular bundles is effective but short-lived. We have been using a retained perineural catheter with continuous local anaesthetic infusion for pain relief post-operatively.

Materials and Methods: This 2 cohort observational study compares pain relief following single bolus dose popliteal block and retained continuous infusion peri-neural catheter. With the patient supine in the anaesthetic room a nerve stimulator identified the tibial and peroneal branches of the sciatic nerve which were blocked with 20mls 0.5% marcaine. In 31 patients a perineural catheter was left in situ and connected to a Stryker “Pain Pump” infusing 0.25% bupivacaine at a rate of 4 ml/hour with 1 ml/hour patient controlled boluses. Following discharge the catheter was removed by the district nurse at 72 hours post-operatively.

Results: Patients were asked to fill in Visual Analogue Scores for 72 hours post operatively. The mean pain score for the single block group was 4.9 (range 0–9). The mean pain score for the popliteal catheter group was 1.03 (range 0–5). One patient had an air-lock in the infusion tubing leading to pain once the initial block wore-off. One patient experienced a patch of numbness in the lower leg which resolved by the 2 week follow-up. There were no other complications, such as infection, from placement of the retained popliteal catheter. All patients were satisfied with their post-operative pain control.

Conclusion: We recommend this novel technique as an effective method of pain relief after ankle and hindfoot surgery. To confirm our findings we are running a randomised, double blinded, placebo controlled trial to study this method of pain relief.

Introduction: Open Repair of the Achilles tendon is associated with problems of wound breakdown and infection. Percutaneous methods have been associated with sural nerve injury. The Achillon system avoids these problems. However no studies have assessed the strength of this repair and whether it allows early active rehabilitation.

Materials/Methods: Simulated Achilles tendon ruptures in sheep Achilles tendons were repaired using either the Achillon method or a two strand Kessler technique with a No.2 Ticron Suture. The tendon diameter was measured in all cases, and was matched for both groups (mean 9mm, range 8–10mm). Specimens were loaded to failure using an Instron tensile testing machine.

Results: Mean load to failure for the Achillon method was 153.13N ±59.64 (range 65–270), and the mean load to failure for the Kessler Repair was 123.13N ±24.19 (range 75–150). This difference was not statistically significant p=0.209. A Pearson’s correlation coefficient was carried out for each group to see if mean load to failure was related to tendon diameter. There were statistically significant higher mean loads to failure for wider tendon repaired by the Achillon method p=0.047, however this was not the case with Kessler repairs p=0.231.

Discussion: The Achillon repair had a similar load to failure as the 2 strand Kessler repair. These results support the use of early active rehabilitation following the Achillon repair and we could not demonstrate stretching at the repair site. As this method is minimally invasive and does not grasp the tendon it may also have less effect on disruption of tendon blood supply and allow faster healing.

Conclusion: The Achillon repair has comparable tensile strength to Kessler Repair, and is a biomechanically sound method of repair of the acutely rupture Achilles tendon in suitable Patients.

Introduction: Open Repair of the Achilles tendon is associated with problems of wound breakdown and infection. Percutaneous methods have been associated with sural nerve injury. The Achillon system avoids these problems. However no studies have assessed the strength of this repair and whether it allows early active rehabilitation.

Materials/Methods: Simulated Achilles tendon ruptures in sheep Achilles tendons were repaired using either the Achillon method or a two strand Kessler technique with a No.2 Ticron Suture. The tendon diameter was measured in all cases, and was matched for both groups (mean 9mm, range 8–10mm). Specimens were loaded to failure using an Instron tensile testing machine.

Results: Mean load to failure for the Achillon method was 153.13N ± 59.64 (range 65–270), and the mean load to failure for the Kessler Repair was 123.13N ± 24.19 (range 75–150). This difference was not statistically significant p=0.209. A Pearson’s correlation coefficient was carried out for each group to see if mean load to failure was related to tendon diameter. There were statistically significant higher mean loads to failure for wider tendon repaired by the Achillon method p=0.047, however this was not the case with Kessler repairs p=0.231.

Discussion: The Achillon repair had a similar load to failure as the 2 strand Kessler repair. These results support the use of early active rehabilitation following the Achillon repair and we could not demonstrate stretching at the repair site. As this method is minimally invasive and does not grasp the tendon it may also have less effect on disruption of tendon blood supply and allow faster healing.

Conclusion: The Achillon repair has comparable tensile strength to Kessler Repair, and is a biomechanically sound method of repair of the acutely rupture Achilles tendon in suitable patients.

Introduction: Adequate analgesia following hindfoot surgery can be difficult and conventional analgesics have significant side effects. A single bolus popliteal block of the neurovascular bundles is effective but short-lived. We have been using a retained perineural catheter with continuous local anaesthetic infusion for pain relief post-operatively.

Materials and Methods: This 2 cohort observational study compares pain relief following single bolus dose popliteal block and retained continuous infusion perineural catheter. With the patient supine in the anaesthetic room a nerve stimulator identified the tibial and peroneal branches of the sciatic nerve which were blocked with 20mls 0.5% marcaine. In 31 patients a perineural catheter was left in situ and connected to a Stryker “Pain Pump” infusing 0.25% bupivacaine at a rate of 4 ml/hour with 1 ml/hour patient controlled boluses. Following discharge the catheter was removed by the district nurse at 72 hours post-operatively.

Results: Patients were asked to fill in Visual Analogue Scores for 72 hours post operatively. The mean pain score for the single block group was 4.9 (range 0–9). The mean pain score for the popliteal catheter group was 1.03 (range 0–5). One patient had an air-lock in the infusion tubing leading to pain once the initial block wore-off. One patient experienced a patch of numbness in the lower leg which resolved by the 2 week follow-up. There were no other complications, such as infection, from placement of the retained catheter. All patients were satisfied with their post-operative pain control.

Conclusion: We recommend this novel technique as an effective method of pain relief after ankle and hindfoot surgery. To confirm our findings we are running a randomised, double blinded, placebo controlled trial to study this method of pain relief.

Introduction: A recent clinical study has suggested that topical GTN may improve the outcome of non-insertional Achilles tendinopathy. The mechanism for this improvement is obscure but is thought to be due to modulation of local nitric oxide (NO) levels. The purpose of this study was to assess the clinical and histological results of topical GTN for non-insertional Achilles tendonitis.

Methods: 40 patients with non-insertional Achilles tendonitis underwent standard non-operative therapy. 20 patients also used topical GTN daily. AOFAS, AOS visual analogue scores and SF36 forms were completed pre-treatment and 3 months later.

Patients who failed conservative treatment and underwent surgery had histological examination of achilles tendon and histochemical analysis for isomers of NOS (eNOS and iNOS) as a marker of NO production.

Results: There was an overall improvement in symptoms in both groups but no significant difference in the improvement bewtween them – there was no additional benefit in using GTN patches. 4 patients also had to stop using patches within 3 weeks because of headaches.

Histological examination did not show any difference in collagen synthesis or remodelling between the 2 groups and there was no evidence of stimulated wound fibroblasts in the GTN group. There was no difference between the groups in the expression of eNOS or iNOS.

Conclusion: This study fails to demonstrate any improvement in symptoms when using GTN patches. There is no histological evidence that GTN promotes degenerate tendon to stimulate wound fibroblasts and increase collagen synthesis and remodelling. GTN patches do not appear to modulate the expression of NOS enzymes in diseased Achilles tendon. The use of GTN patches in the treatment of non-insertional Achilles tendonitis remains questionable and the role of NO as a mediator of inflammatory response remains elusive.

Introduction: A recent clinical study has suggested that topical GTN may improve the outcome of non-insertional Achilles tendinopathy. The mechanism for this improvement is obscure but is thought to be due to modulation of local nitric oxide (NO) levels. The purpose of this study was to assess the clinical and histological results of topical GTN for non-insertional Achilles tendonitis.

Methods: 40 patients with non-insertional Achilles tendonitis underwent standard non¬operative therapy. 20 patients also used topical GTN daily. AOFAS, AOS visual analogue scores and SF36 forms were completed pre-treatment and 3 months later. Patients who failed conservative treatment and underwent surgery had histological examination of the Achilles tendon and histochemical analysis for isomers of NOS (eNOS and iNOS) as a marker of NO production.

Results: There was an overall improvement in symptoms in both groups but no significant difference in the improvement between them – there was no additional benefit in using GTN patches. 4 patients also had to stop using patches within 3 weeks because of headaches.

Histological examination did not show any difference in collagen synthesis or remodelling between the 2 groups and there was no evidence of stimulated wound fibroblasts in the GTN group. There was no difference between the groups in the expression of eNOS or iNOS.

Conclusion: This study fails to demonstrate any improvement in symptoms when using GTN patches. There is no histological evidence that GTN promotes degenerate tendon to stimulate wound fibroblasts and increase collagen synthesis and remodelling. GTN patches do not appear to modulate the expression of NOS enzymes in diseased Achilles tendon. The use of GTN patches in the treatment of non-insertional Achilles tendonitis remains questionable and the role of NO as a mediator of inflammatory response remains elusive.

Rotator cuff tears are an increasingly recognizable and common problem amongst the elderly. We undertook this review to assess outcome from open surgical rotator cuff repair and acromioplasty in patients over the age of 70 years.

A retrospective review of 61 patients with 64 full thickness rotator cuff tears treated with open repair and decompression acromioplasty between 1/1/92 and 30/6/04.To evaluate the current functional state and satisfaction (mean time from surgery 46.3 months) 50 patients were contacted and invited to attend for clinical evaluation using Constant and Murley’s functional score and/or answer a modified subjective 12 point Simple Shoulder Test. Eleven patients were not contactable despite attempts through post and phone.

All grades of tears were reparable with 48 being good tendon to bone. All the patients underwent a six week supervised physiotherapy programme. Complications included 6 frozen shoulder and seven cases of re- rupture .One patient each developed pulmonary embolism and reflex sympathetic dystrophy. Based on the definitive scoring of Constant and Murley’s 31 were rated as excellent (80–100 points) 9 good (65–79), 2 fair (50–64) and 2 poor (less than 50). Out of the total 43 patients (44 shoulders) examined and scored 90% showed excellent and good results.

Symptomatic rotator cuff tears in the elderly, active and healthy patients treated by a surgical repair results in good and early functional return, lasting pain relief and excellent patient satisfaction and should be actively considered as a definitive mode of treatment in this age group.

Aspetic loosening is a major problem of total hip arthroplasty, especially in young and/or active patients. This study was performed to assess the clinical performance of non-cemented, metal-on-metal implant and complications including loosening and osteolysis at medium-term follow-up.

Between 1994 and 1998, 38 patients (45 hips) had a THA with a Metasul articulation. Thirty-two patients (39 hips) were available for follow up an average of 5.3 years following the operation. Patients were independently assessed by clinical examination, with use of the Harris Hip Score, patient self-assessment forms and radiographs.

The average age was 53.5 years (range 29 to 68) with a diagnosis of primary OA accounting for 34 hips and other diagnoses for 5 hips. The average Harris Hip Score for those patients without a revision was 94.7 points (range 71 to 100). One patient had a revision of a loose femoral component at 16 months, at last review he had a Harris Hip Score of 99.7 points. No patient had a loose or revised acetabular component. Two patients had an early dislocation without sequelae. Thirty-six hips were rated as very good or excellent. There was no radiological evidence of progressive radiosclerotic lines and no other evidence of loosening.

This group of young and/or active patients with Metasul articulations has clinical results equivalent to metal-on-polyethylene articulations. There is no evidence to suggest that the rate of loosening is higher as was documented by previous metal-on-metal designs. At medium term follow up there is no evidence that the metal-on-metal articulation gave rise to any new problems or complications.

The aim of this study was to investigate the long-term outcome of isolated, displaced Lisfranc injuries requiring operative intervention and identify whether results of treatment are influenced by workers compensation.

This retrospective study reviewed all patients who underwent operative intervention for Lisfranc injuries. Patients with concomitant injuries were excluded from further investigation so that the outcome of purely isolated Lisfranc injuries could be assessed. The minimum follow-up was two years and the senior author performed all the operations. Patients were contacted and their employment status recorded. Ordinal regression analysis was performed to identify which factors influenced the outcome.

Forty-six patients were studied and 24 had pursued medico-legal claims. The average Workcover payment was Aus$25,000 (£10,000). Thirteen of forty-six patients had a poor outcome. Eleven of these patients had compensation claims (p< 0.01) and 11 had greater than a three month delay in treatment following diagnosis (p< 0.05). Although 12/33 men and 1/13 women had a poor outcome this difference was not statistically significant. The need for secondary fusion was not associated with a poor outcome. There was no significant difference between outcome and mechanism of injury or previous occupation. There was no correlation between the outcome and age at the time of injury.

This series of 46 patients has a long follow-up of a rare injury. We believe that this study has medico-legal implications on reporting prognosis for such injuries and highlights the importance of prompt diagnosis and treatment for such injuries.

Percutaneous repair of a ruptured Achilles tendon has been shown to reduce wound healing problems but it has a high incidence of injury to the sural nerve. The Achillon Suture System is a new method utilising a small longitudinal incision. It passes a suture through the Achilles tendon leaving the suture purely within the tendon. The aim of this prospective study was to investigate the results of a new mini-open technique utilising a horizontal incision and early active mobilisation.

Following ethical committee approval 25 patients underwent repair of their ruptured Achilles tendon using the Achillon System. Rather than the longitudinal incision we used a horizontal incision and an accelerated rehabilitation program with a brace for six weeks post-operatively. Patients were followed up at six weeks, three and six months and one year post-op using the AOFAS and Leppilahti scoring systems.

There were no wound complications, re-ruptures or sural nerve injuries. All patients returned to work or their previous daily activities by six weeks (mean 22 days) post op. All patients had returned to driving by six weeks. One patient had 10° restriction in dorsiflexion at three months, which prevented her return to running. She was back to running and had a full range of movement at six months. All other patients returned to sporting activities at three months but jumping sports such as basketball were discouraged until six months post-op.

We suggest that this modification of using a horizontal incision and early mobilisation enhances wound healing and allows early return to normal activities and sports. It is technically simple, utilises a small incision (still enabling visual confirmation that the tendon ends have been approximated) and reduces the risk of sural nerve injury seen in other mini-open or percutaneous techniques.

Percutaneous repair of a ruptured Achilles tendon has been shown to reduce wound healing problems but it has a high incidence of injury to the sural nerve. The Achillon Suture System is a new method utilising a small longitudinal incision. It passes a suture through the Achilles tendon leaving the suture purely within the tendon. The aim of this prospective study was to investigate the results of a new mini-open technique utilising a horizontal incision and early active mobilisation.

Following ethical committee approval 25 patients underwent repair of their ruptured Achilles tendon using the Achillon System. Rather than the longitudinal incision we used a horizontal incision and an accelerated rehabilitation program with a brace for 6 weeks post-operatively. Patients were followed up at 6 weeks, 3 months and 6 months post-op using the AOFAS and Leppilahti scoring systems.

There were no wound complications, re-ruptures or sural nerve injuries. All patients returned to work or their previous daily activities by 6 weeks (mean 22 days) post op. All patients had returned to driving by 6 weeks. One patient had 10° restriction in dorsiflexion at 3 months which prevented her return to running. She was back to running and had a full range of movement at 6 months. All other patients returned to sporting activities at 3 months but jumping sports such as basketball were discouraged until 6 months post-op.

We suggest that this modification of using a horizontal incision and early mobilisation enhances wound healing and allows early return to normal activities and sports. It is technically simple, utilises a small incision (still enabling visual confirmation that the tendon ends have been approximated) and reduces the risk of sural nerve injury seen in other mini-open or percutaneous techniques.

Assessment of the appropriateness of tendon transfer procedures and the necessity for excising the posterior tibial tendon (PTT) in stage II PTT dysfunction.

12 patients undergoing surgical treatment for unilateral PTT dysfunction underwent magnetic resonance imaging of the tibialis posterior (TP) and flexor digitorum longus (FDL) muscle bellies.

All patients had atrophy of the TP muscle compared to the normal leg (mean 10.7%, p = 0.008). In those patients with a complete rupture of PTT there was replacement of the TP muscle by fatty infiltration. Conversely, the FDL muscle showed a compensatory hypertrophy (mean 17.2%, p< 0.002).

Treatment of stage II posterior tibial tendon (PTT) dysfunction remains controversial. These findings support the use of FDL as the tendon of choice for augmentation of PTT in stage II disease. This study also demonstrates that in the presence of a complete rupture, excision of the PTT is a reasonable surgical procedure and pure tenodesis will fail because the TP muscle belly undergoes fatty infiltration. In patients with a diseased but intact PTT there was no fatty infiltration and the TP muscle volume was at least 83% of the normal side in all cases. We therefore suggest that in the presence of an intact PTT the TP muscle may provide some useful function if used to augment the FDL transfer when the diseased tendon is excised.

To evaluate how much tendon may be safely excised in insertional Achilles tendonitis without predisposing the patient to Achilles tendon rupture.

Insertional Achilles tendonitis commonly affects runners and is frequently managed by general orthopaedic surgeons. Most patients may be managed non-operatively but those who do not respond to conservative measures may require excision of the diseased tendon. Currently, there are no clinical studies indicating how much of the tendon may be excised without predisposing the patient to Achilles tendon rupture.

This chart review reports on 52 heels treated surgically for this condition and followed for a minimum of 6 months post-operatively. When less than 50% of the tendon was excised (49 heels) patients were immediately mobilised free of a cast.

There were two failures using this regimen. One patient had inflammatory arthritis and was taking significant immunosuppressive therapy. The second patient was keen for simultaneous bilateral procedures. In retrospect the senior surgeon acknowledges that this was somewhat enthusiastic as even with the most compliant of patients true partial weight-bearing in such a situation is extremely difficult.

This review supports biomechanical data which demonstrates up to 50% of the tendon may be safely resected. We suggest that it is not necessary to immobilise all patients in a cast following surgery for insertional Achilles tendonitis when less than 50% of the tendon is excised. We recommend that patients with inflammatory arthritis or recent immunosuppressive therapy and those in whom greater than 50% of the tendon has been excised should be immobilised in a cast for six weeks. We do not recommend that simultaneous bilateral procedures are performed.

Hallux rigidus is the second most common pathological condition of the first metatarsophalangeal joint, after hallux valgus. Manipulation of the joint and injection with steroid and local anaesthetic (MUA and Injection) is widely practiced, but the literature contains little information on the results of such treatment. We report the results of this procedure performed on thirty-seven joints, with a minimum follow-up of 1 year (mean 41.2 months). Patients with mild (Grade I) changes gained symptomatic relief for a mean of 6 months and only one third required further surgery. Two thirds of patients with moderate (Grade II) disease proceeded to open surgery. In advanced (Grade III) hallux rigidus little symptomatic relief was obtained and all patients required operative treatment. We recommend that joints are Graded before treatment and that MUA and injection be used only in early (Grades I and II) hallux rigidus.

To investigate the incidence of complications arising from clavicle fractures in children and the need for multiple review in fracture clinic.

Retrospective analysis of 200 children with isolated clavicle fractures. The number of clinic visits was documented along with the mechanism of injury and any complications attributable to the fracture. Plain radiographs allowed classification of the fractures both in terms of site and type of fracture.

Retrospective review failed to provide any evidence of long term complications from isolated clavicle fractures. Two patients complained of a non-specific tingling in the arm which had settled within 2 weeks. No intervention other than rest in a broad arm sling was deemed necessary in any of the 200 children. Despite this, the average number of clinic appointments was 2.8.

In the prospective study there were no complications arising from an isolated clavicle fracture. Two patients returned (one at 6 weeks and one at 12 weeks) with concerns about the cosmetic appearance of the fracture site - both patients were reassured and discharged. All patients were satisfied with the cosmetic appearance and function of their shoulder when reviewed at a mean of 7.3 months post injury (range 6–10 months). All patients and/or guardians were satisfied with the patient information sheet.

Isolated clavicle fractures in children are rarely complicated by injuries such as skin necrosis or a neuro-vascular deficit. Despite this, children are commonly reviewed many times by juniors in a busy fracture clinic. We suggest that such review is unnecessary and that uncomplicated fractures may be safely discharged with a patient information sheet after the first clinic appointment.

To investigate the underlying mechanism of osteocyte death in osteonecrosis of the femoral head (ONFH).

Although there are a plethora of conditions that predispose to ONFH the underlying mechanism that results in the death of osteocytes is poorly understood. Consequently, treatment for early disease has a variable outcome. Recent investigation has focussed on the role of nitric oxide (NO) in the local control of bone turnover. NO is central to bone cell metabolism and has been implicated in the development of apoptosis.

Bone samples were harvested from the femoral heads of 40 patients undergoing total hip arthroplasty – 20 for advanced ONFH and 20 for osteoarthritis (control group). Immunocytochemical techniques were used to demonstrate evidence of NO synthase (iNOS and eNOS) as a marker of NO production and for evidence of apoptosis.

There was a marked increase in the expression of both eNOS and iNOS in the bone marrow and osteocytes from patients with ONFH secondary to steroids and alcohol with a correspondingly high proportion of apoptotic cells. Very little evidence of either eNOS or iNOS could be demonstrated in the control group and no significant apoptosis could be demonstrated. Samples from patients with ONFH secondary to sickle cell disease likewise had little evidence of apoptosis and a less marked increase iNOS production.

Our findings suggest that sickle cell disease may cause infarction of bone which subsequently leads to osteonecrosis. However, steroids and alcohol, or their metabolites, may have a direct cytotoxic effect upon bone leading to an increased NO production and NO-mediated apoptosis rather than necrosis. Our findings may provide important clues as to the underlying pathway leading osteocyte death. Therapeutic measures aimed at preventing production of toxic levels of NO or by blocking specific pathways in apoptosis may provide effective an treatment during the early stages of ONFH by halting disease progression.