Avascular necrosis (AVN) of the talus is a painful condition caused by trauma, steroids, alcoholism and haematological disorders. It is difficult to treat and at present there is insufficient evidence in favour of any particular strategy. The aim of operative therapy should be to relieve symptoms, maintain the normal architecture of the talus and treat associated arthritis. Small case series have described early core decompression, retrograde tibiotalocalcaneal arthrodesies and open tibio-calcaneal arthrodesis. Open procedures risk further talar collapse by disrupting its blood supply, and tibiotalocalcanal fusion sacrifices both the ankle and subtalar joints. The hypothesis is that arthroscopic ankle fusion relieves symptoms of AVN talus while preserving the subtalar joint and preventing further collapse. A case study was performed of 16 patients with AVN who underwent arthroscopic ankle fusion at the Nuffield Orthopaedic Centre, Oxford, UK between 1998 and 2012. Clinical notes, radiographs and MRI was used to investigate the cause, co-morbidities and treatment outcomes following arthroscopic ankle fusion. Our primary outcome was fusion rate. Secondary outcomes included peri-operative complications, ongoing pain and subsequent operative intervention.Background:
Methods:
Vitamin D plays an important role in bone turnover. Deficiency (including borderline deficiency, or insufficiency) has a known association with fractures and has been linked to delayed or nonunion of fractures. We therefore routinely test vitamin D in cases of nonunion. Noting a high rate of vitamin D deficiency in this group, we instituted a policy to routinely screen for and treat vitamin D deficiency in both post-operative and pre-operative patients. We hypothesised that, in the post-operative patients, levels would correlate with rates of union. We sent serum vitamin D levels on consecutive post-operative patients seen in clinics between January and May 2014. They included those with an arthrodesis of the ankle, triple joint or first MTPJ. Union was deemed to have occurred when the patient was comfortable full weight bearing and radiographs showed trabeculae crossing the fusion site. Nonunions were all confirmed with computed tomography.Introduction:
Methods:
Calcaneal osteotomy is an established technique in correcting hind foot deformity. Patients have traditionally received an open osteotomy through Atkins lateral approach. In order to reduce the rate of wound complications associated with the Atkins approach, a minimally invasive surgical (MIS) technique has been adopted since 2011. This uses a low-speed, high-torque burr to perform the same osteotomy under radiographic guidance. The results of the new MIS technique, including post-operative complication rates, are compared to the standard open approach. The safety of the new MIS technique was investigated by conducting a case controlled study on all patients who underwent displacement calcaneal osteotomy at the Nuffield Orthopaedic Centre, Oxford from 2008 to 2014. The primary outcome measure was 30 day post-operative complication rate. Secondary outcome measures included operating time, duration of stay, fusion rates and amount of displacement achieved.Background:
Methods:
TTC fusion for the salvage of failed TARs with significant bone loss using a hindfoot nail and femoral head allograft has been reported in a number of small series. We present our experience of this procedure. Review of the theatre records from 2006 to July 2011 identified twenty four cases using this technique. The case notes and imaging were retrospectively reviewed.Introduction:
Method:
Evaluation of outcomes and satisfaction following hallux valgus (HV) surgery is usually retrospective and rarely uses patient-reported outcome measures (PROMs). Prospective Cohort Study. Postal evaluation survey of patients who had provided pre-operative PROMs data.Background
Design
Ankle replacement is now common in the UK. In a tertiary referral NHS practice, between 1997–2011 we implanted two types of cementless mobile bearing total ankle replacements (TAR). We reviewed our operative database and electronic patient records and confirmed the number of prosthesis with our theatre records. All case notes and radiographs were reviewed. Failure was taken as revision, and patients were censored due to death or loss to follow-up. The survivorship was calculated using a life table (the Kaplan-Meier method), with 95% confidence intervals.Introduction
Methods
The Manchester–Oxford Foot Questionnaire (MOXFQ) is a validated
16-item, patient-reported outcome measure for evaluating outcomes
of foot or ankle surgery. The original development of the instrument
identified three domains. This present study examined whether the
three domains could legitimately be summed to provide a single summary
index score. The MOXFQ and Short-Form (SF)-36 were administered to 671 patients
before surgery of the foot or ankle. Data from the three domains
of the MOXFQ (pain, walking/standing and social interaction) were
subjected to higher order factor analysis. Reliability and validity
of the summary index score was assessed.Objectives
Methods
In 1927, Lambrinudi described a variant triple fusion for the treatment of paralytic “drop foot”. This involved closing wedge We describe a series of 14 complex corrective triple Introduction
Surgery to the midfoot (usually fusion) may be performed for trauma, arthritis, deformity or combinations. There are reports of good results, meaning primary fusion rates of 90+percent, 12 % serious complication rates and need for hardware removal 1n 25% of cases from specialist centres (Nemec et al AOFAS 2010). But even these good results mean 10% of patients needing lengthy revision surgery, and a third needing some additional intervention. Surgery to the midfoot, like all surgery has both consequences (which everyone experiences) and complications (which some peolple get). The consequences of midfoot surgery are time in hospital, long periods in cast (often non-weight bearing) and long rehabilitation periods leading to a “second best” result where pain is relieved, but mechanics and full function are not restored, and longterm stiffness and swelling are comon. Usually the patient still needs to restrict activities and wear orthotics or adaptive footwear. The commonest complication is probably a failure to inform patients of the consequences of surgery – inevitably leading to disappointment with result and outcome. Common complications include: Wound, nerve and vascular problems. Delayed union, malunion and non-union. General complications such as DVT and embolism. All these complications are more common in patients who smoke, are diabetic or have a BMI over 30. By showing examples of problems seen in the last 15 years of tertiary referral (and the authors own cases), a system to minimise complications, and to address them when they occur, will be presented, based on: Good preparation and timely accurate information Planning surgery (approach, execution and post operative management) Rehailitation and after surgery care. These can usually only be brought together by a surgeon performing this surgery on a regular basis, and with the support of an equally experienced multi-disciplinary team.
Juvenile Chronic Arthritis results in the early degeneration of multiple joints with severe pain and deformity. Treatment of ankle arthritis is complex and ankle replacement is indicated because of adjacent and distant joint involvement. We reviewed 25 total ankle replacements in 13 young adults suffering the generalised consequences of Juvenile Chronic Arthritis (JCA) between 2000 and 2009. 12 had bilateral disease, 20 had anklylosis or prior fusion of the hind- or midfoot, and 16 had substantial fixed inversion of the hindfoot. All had previous prosthetic arthroplasty of between 1 and 15 joints. Surgery comprised corrective triple fusion where required, with staged total ankle arthroplasty at an interval of 3 or more months. All patients reported significant reduction in pain, and increased mobility with increased stride length, however severe co-morbidity limited the usefulness of routine outcome scores. No ankles have required revision to date. We noted that the dimensions of the distal tibia and talus are markedly reduced in patients with JCA, and as a result of this and bone fragility, the malleoli were vulnerable to fracture or resection. JCA is also associated with cervical spondilitis and instability, micrognathia, temporomandibula arthritis and crico-arytenoid arthritis, resulting in challenging anaesthesia.Materials and Methods
Results
Changes in armour reinforcement of military vehicles have resulted in a changed injury pattern. Injuries which would previously have resulted in amputation are now less severe, and after initial debridement and temporary fixation the foot can now be saved. New patterns of injuries are emerging often as a part of potentially survivable poly-trauma. We describe a small series of these injuries. The techniques and results of late reconstruction are presented. We also discuss specific problems of managing patients with potential contamination with unusual organisms.
The responsiveness of the Manchester–Oxford Foot
Questionnaire (MOXFQ) was compared with foot/ankle-specific and
generic outcome measures used to assess all surgery of the foot
and ankle. We recruited 671 consecutive adult patients awaiting
foot or ankle surgery, of whom 427 (63.6%) were female, with a mean
age of 52.8 years (18 to 89). They independently completed the MOXFQ,
Short-Form 36 (SF-36) and EuroQol (EQ-5D) questionnaires pre-operatively
and at a mean of nine months (3.8 to 14.4) post-operatively. Foot/ankle
surgeons assessed American Orthopaedic Foot and Ankle Society (AOFAS)
scores corresponding to four foot/ankle regions. A transition item measured
perceived changes in foot/ankle problems post-surgery. Of 628 eligible
patients proceeding to surgery, 491 (78%) completed questionnaires
and 262 (42%) received clinical assessments both pre- and post-operatively. The
regions receiving surgery were: multiple/whole foot in eight (1.3%),
ankle/hindfoot in 292 (46.5%), mid-foot in 21 (3.3%), hallux in
196 (31.2%), and lesser toes in 111 (17.7%). Foot/ankle-specific
MOXFQ, AOFAS and EQ-5D domains produced larger effect sizes (>
0.8)
than any SF-36 domains, suggesting superior responsiveness. In analyses
that anchored change in scores and effect sizes to patients’ responses
to a transition item about their foot/ankle problems, the MOXFQ
performed well. The SF-36 and EQ-5D performed poorly. Similar analyses,
conducted within foot-region based sub-groups of patients, found
that the responsiveness of the MOXFQ was good compared with the
AOFAS. This evidence supports the MOXFQ’s suitability for assessing
all foot and ankle surgery.
In 2004, our centre has changed from the “STAR” to the “Mobility” Total Ankle Replacement device and a study was undertaken in order to ascertain if there was a learning curve to useage of this new device and perform a comparison in terms of survival, function, additional procedures and complications. The indications were 55% osteoarthritis, 30% Rheumatoid and 8% JIA with the remainder being haemophiliac, haemochromatosis and ankylosing spondylitis. One third of TARs in this unit are combined with additional procedures such as subtalar fusion. Only isolated TARs were considered in this study and the tourniquet time, wound problems, length of stay and known complications for the last 20 STAR TARs was compared to the first 20 Mobility TARs. 68 Mobility TARs have been implanted since Oct 2004 and survival data was collected for this entire cohort and compared to a similar number of STARs.
The survival curve of the mobility and STAR shows no loss of the Mobility due to revision at up to 3 years. Clinical outcome scores will be presented.
The early results for this new prosthesis show no cause for concern and surveillance is ongoing.
Between 1998 and 2007, fifteen patients with haemophilia A underwent 21 ankle arthrosco-pies+/− arthroscopic cheilectomy in order to attempt symptomatic relief of arthrosis and to increase the range of motion. All patients had severe degenerative changes radiologically. Perioperative management was shared with our local dedicated Haemophilia service and the management algorithm will be presented. Outcome data for pain and range of motion shows only moderate benefits. Two patients had good relief of symptoms for 6 months. Two patients however chose to return for arthroscopies to the contralateral ankle and two had arthoscopies to the same ankle. Follow up data is not currently available for 4 patients and the rest required fusion with a median time to fusion of 1 year. Two patients had a documented increased range of motion, but one of these patients had an increased level of pain associated with the increased mobility. There was 1 major complication, namely an aneurysm of the tibialis anterior artery. Two patients had recurrent bleeds following surgery requiring ongoing and prolonged factor VIII treatment. Average patient stay was 3.1 days, range 2 to 5 days and this stay is shorter for later years than earlier years. The post-operative requirement for extra factor VIII ranged from 4 postoperative doses to 3 weeks ongoing treatment, median 10 doses. The average cost per dose was approximately £1128, giving a median cost of £11280 per case. In summary, this procedure seems to be expensive in terms of QALY gains and has low rates of success in terms of function and pain relief.
In addition, using the characteristics of the inserted screw as a scaleable marker, it was calculated what would have been the optimum length of screw thread in order to maximise screw thread length in the target bone whilst preventing the screw threads being across the fusion site.
Currently available screws have thread lengths that are either too long (breaching the fusion site) or too short for ideal fixation and we propose a different thread length to those currently available. However, even with current screws, we found no correlation between thread length, thread positioning across the fusion site and non-union.
A screw that has any thread across the fusion site can not offer any compression and may be postulated to lower the rate of fusion. Similarly, maximal screw thread in the target bone would optimise fixation. This retrospective study calculates the ideal characteristics of a screw used for ankle arthrodesis, and assesses the correlation between the lack of compression and non-union.
Of the 64 ACE screws, 8(12.5%) had threads across the TT joint, representing 7(21.9%) of all posterior screws and 1(3%) of all anterior screws in the study. The mean length of screw-threads into the TT joint was 2.1mm(range 0.53 to 4.06 mm). The ST joints were breached by 4(6.25%) screws(all posterior). The mean length of protrusion was 1.8mm(range 0.28 to 3.89mm). No screw thread crossed both TT and ST joints simultaneously. No non-unions were recorded in either group.
The purpose of this study was to investigate the functional outcome of a group of patients following completely neglected tendo-achilles ruptures. Between July 2001 and July 2002 we identified 6 patients who presented to the Foot and Ankle Service in Oxford with 7 chronic untreated complete ruptures of the tendo-achilles. There were 4 males and 2 females and the average age was 65 years (range 52 to 79). The average time since injury was 12.2 months (range 7 to 24). None of them had undergone any modality of treatment for this condition. From the history, a definite acute injury was confirmed in each patient. All patients had a palpable defect in the tendo-achilles between 4 and 8 cm from the insertion and the defects measured from 10 to 32 mm. In all case the Thompson test confirmed ongoing discontinuity and single leg heel raise was not possible on the affected side. Each patient was assessed using the scoring system of Leppilahti and concentric and eccentric power were assessed using the Kin-Com Dynamometer. The results indicate an average Leppilahti score of 65/100 with 1 excellent, 0 good, 3 fair and 2 poor. The isokinetic strength measurements demonstrated that plantar flexor power was on average 36% weaker than the normal side. These differences were most marked at the higher test speeds, which were on average 16% weaker than at the lowest test speed in the affected leg. Five out of 6 patients were pain free, with only one reporting mild pain. Objective testing demonstrated no differences in the range of movement between the injured and the normal side. All patients were satisfied with the outcome; however, most had some reservations, which related to ongoing weakness that prevented recreational activity.
The resurgency of ankle replacement in the last 10 years has prompted a need for effective management of failing prostheses. We present the early to mid-term results for revision surgery of 17 arthroplasties in 17 patients from our tertiary referral centre. Between 1999 and 2004, two Consultant Foot and Ankle Surgeons revised failing ankle arthroplasties in 17 patients (age range 51–74 years). All patients were assessed with tissue cultures and histology that were harvested at the time of surgery and managed in conjunction with a specialist Bone Infection Unit. Intraoperative frozen section was used to aid management, but usually pre-operative decisions had been made which included
one or two stage reimplantation fusion with an intramedullary nail or Ilizarov frame amputation, and Ilizarov fusion combined with proximal tibial lengthening for excessive bone loss. Many of the patients had had previous “revision surgery” such as change of meniscal components, arthroscopic debridements and excision of impingeing osteophytes. Indications for implantation had been osteoarthritis in 59%, rheumatoid arthritis in 18% and post-trauma in 23%. Heel shift procedures to correct malalignment had been performed in 12%. The implants comprised 15 Scandinavian Total Ankle Replacements (STAR), one Agility and one Buechel-Pappas. Three patients had fractured malleoli secondary to bone loss. Cultures and histology confirmed the presence of infection in 24% (defined as positive histology and more than 2/6 positive cultures) with aseptic loosening in the remainder. One infected patient underwent amputation at his request. Six non-infected patients had successful revision of two or three components, one infected patient had Ilizarov fusion and lengthening. The remainder underwent successful hindfoot fusion over a locked intramedullary nail, even in the presence of infection, with suppression to union.
To determine the prevalence and distribution of pain in patients with Charcot-Marie-Tooth disease and the effects of surgery on this pain.
Members of the Charcot -Marie -Tooth International support group were sent a pain questionnaire. Data about the site, nature, frequency, severity of pain, pain triggers, methods of pain relief and the response to surgery were collected.
There were 399 respondents (233 women and 166 men). The most frequently reported sites of pain were the legs (79%) and feet (77%). Ankle pain was reported by 57%. Walking and exercise were the most frequent pain triggers. Rest was the most common method of modifying pain (60 % of respondents). 32 % found analgesics effective and 39% used heat to relive their pain. The most common sites for surgery were the foot (36%) and ankle (26%). In 43% of patients undergoing foot surgery and 54% of patients undergoing ankle surgery, pain had been increased or introduced following surgery.
Patients with Charcot-Marie-Tooth disease experience significant inherent, and probably neuropathic, pain in addition to pain from mechanical causes. Surgery is unlikely to improve or eliminate pain in these patients. It may introduce pain in some. Surgery should be confined to the treatment of structural problems, as it is often ineffective at relieving pain.
Giant Cell Tumour of the Tendon Sheath is a benign tumour of synovial origin most frequently affecting the upper limb. Up to 11% exhibit radiographic evidence of cortical erosion and intra-osseous expansion. In the upper limb recurrence rates of between 10–50% following excision have been reported. However, GCT-TS is rarely described in the foot and ankle and its behaviour is ill understood. 17 cases of this rarely described tumour in the foot and ankle are presented, describing their clinical presentation, histopathology, treatment and outcome. Analysis of all cases of histopathologically proven GCT-TS of the foot and ankle from the Oxford Tumour Registry, was conducted between the periods of January 1984 to December 1999. 22 cases were identified of which 17 cases had adequate records to allow analysis of patient demographics, duration of symptoms, preoperative investigations, presumed diagnosis, precise site of origin, post operative complications and recurrence rates The mean age of presentation was 28 (8–53). 10 cases were female and 7 male. 76% cases occurred in the foot, all of which arose adjacent to the phalanges or heads of the metatarsals. 14% occurred in relation to the ankle or sub-talar joint. 82% presented with a painless swelling. The duration of symptoms ranged from 6 months to 8 years. Only one patient complained of sensory symptoms. Pre-operative investigations included radiographs in 64% with 3 cases having an additional MRI scan. The MRI scans of GCT-TS have characteristic changes on T1 and T2 images. The presumed preoperative diagnosis was incorrect in 82%. 36% of radiographs taken showed changes including cortical erosion and speckled calcification. A local excision was performed in 15 cases, an amputation in one and a wide local excision in one case only. There have been no recurrences during the follow up period of between 1–12 years. GCT-TS of foot and ankle is rare and is commonly misdiagnosed. Despite only a local excision being performed in more than 80% of this series there were no recurrences. Plain radiographs may show cortical erosion or speckled calcification in up to 36% and MRI is helpful in further defining the anatomy of the lesion, allowing planned excision and reducing the risk of recurrence.
To determine the natural history of dislocation of the hip in cerebral palsy, and to evolve methods to predict dislocation, the notes and radiographs of 462 patients with cerebral palsy were reviewed. Dislocation occurred in 10% of patients by progressive migration and subluxation of the proximal femur in the presence of acetabular dysplasia. Statistical analysis identified the radiographic features that helped to predict dislocation. Measurement of acetabular index, by a method that allows for rotation of the acetabulum, was the most powerful single predictor. Measurement of this index at two and four years of age could identify patients who would dislocate unless effective treatment was undertaken, those at risk of dislocation only if scoliosis developed, and those who would not dislocate. On the basis of this method of screening for dislocation, a logical system of surgical prophylaxis is proposed.
We have reviewed the results of treating 75 fractures of the proximal femoral shaft in the presence of a cemented femoral prosthesis. A simple radiographic classification into four types is proposed, and suggestions are made on the appropriate management of each. Comminuted fractures around the implant need early revision, whilst spiral fractures in this region may be treated conservatively or by operation. Transverse fractures at the level of the tip of the prosthesis are difficult to manage, and may require open reduction and internal fixation.