The importance of total ankle replacement (TAR) implant orientation in the axial plane is poorly understood with major variation in surgical technique of implants on the market. Our aims were to better understand the axial rotational profile of patients undergoing TAR. In 157 standardised CT Scans of end-stage ankle arthritis patients planning to undergo primary TAR surgery, we measured the relationship between the knee posterior condylar axis, the tibial tuberosity, the transmalleolar axis(TMA) and the tibiotalar angle. The foot position was measured in relation to the TMA with the foot plantigrade. The variation between medial gutter line and the line bisecting both gutters was assessed.Background
Methods
Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty (TAA) fails, it can either undergo revision to another ankle replacement, revision of the TAA to ankle arthrodesis (fusion), or amputation. Currently there is a paucity of literature on the outcomes of these revisions. The aim of this meta-analysis is to assess the outcomes of revision TAA with respect to surgery type, functional outcomes, and reoperations. A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Medline, Embase, Cinahl, and Cochrane reviews were searched for relevant papers. Papers analyzing surgical treatment for failed ankle arthroplasties were included. All papers were reviewed by two authors. Overall, 34 papers met the inclusion criteria. A meta-analysis of proportions was performed.Aims
Methods
A multicentre, randomized, clinician-led, pragmatic, parallel-group orthopaedic trial of two surgical procedures was set up to obtain high-quality evidence of effectiveness. However, the trial faced recruitment challenges and struggled to maintain recruitment rates over 30%, although this is not unusual for surgical trials. We conducted a qualitative study with the aim of gathering information about recruitment practices to identify barriers to patient consent and participation to an orthopaedic trial. We collected 11 audio recordings of recruitment appointments and interviews of research team members (principal investigators and research nurses) from five hospitals involved in recruitment to an orthopaedic trial. We analyzed the qualitative data sets thematically with the aim of identifying aspects of informed consent and information provision that was either unclear, disrupted, or hindered trial recruitment.Aims
Methods
This is a multicentre, non-inventor, prospective observational study of 503 INFINITY fixed bearing total ankle arthroplasties (TAAs). We report our early experience, complications, and radiological and functional outcomes. Patients were recruited from 11 specialist centres between June 2016 and November 2019. Demographic, radiological, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Questionnaire, and EuroQol five-dimension five-level score) were collected preoperatively, at six months, one year, and two years. The Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system was used to stratify deformity. Early and late complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts, and/or subsidence.Aims
Methods
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. Patients ≥18 years with Coughlin hallux rigidus grade 2, 3, or 4 were treated with implant MTPJ1 hemiarthroplasty or arthrodesis. Pain VAS, Foot and Ankle Ability Measure (FAAM) Sports and ADL, and SF-36 PF scores were obtained preoperatively, and at 2, 6, 12, 24, 52 and 104 weeks postoperatively. Final outcomes, MTPJ1 active peak dorsiflexion, secondary procedures, radiographs and safety parameters were evaluated for 129 implant hemiarthroplasties and 47 arthrodeses. Composite primary endpoint criteria for clinical success included pain reduction ≥30%, maintenance/improvement in function, and no radiographic complications or secondary surgical intervention at 24 months. Predictor variables included: grade; gender; age; BMI; symptom duration; prior MTPJ1 surgery; preoperative hallux valgus angle, ROM, and pain. Two-sided Fisher's Exact test was used (Introduction
Methods
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. There is little credible research comparing GT in people with and without foot and ankle pathology. There is no normative data for ankle dorsiflexion range measured using a Lunge test and prevalence of GT in the normal population. 97 ankles with foot and ankle (FA) pathology and 89 ankles of healthy volunteers (HV) without FA pathology were recruited from the royal national orthopaedic hospital (RNOH). Degrees of ankle dorsiflexion range were measured using an inclinometer and a version of the lunge test with the knee flexed and extended. These findings were then compared between groups.Rationale
Methodology
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. 77 patients admitted for an osteotomy or arthrodesis procedure between September 2013 and May 2014 agreed to participate in this study. A questionnaire was completed and a urine sample was obtained and tested for cotinine, a metabolite of nicotine, by 2 techniques: a dipstick, the COT One Step Cotinine Test, yielding a positive result when the cotinine in the urine exceeds 200 ng/mL and the Concateno laboratory assay test, providing a mean value to give a qualitative reading whereby the cut off for non-smokers is 500ng/ml.Introduction:
Method:
The National Joint Registry (NJR) was established in 2003, and was extended to include ankle arthroplasty on 1st April 2010, and shoulder and elbow arthroplasty in April 2012. The aim of this study was to evaluate the uptake of the NJR for ankle arthroplasty over its first 3 years. This is compared to the first 3 years of hip and knee data, and the first year of shoulder and elbow data. The methods of measuring compliance are also evaluated. NJR compliance is measured by comparing the number of procedures submitted to the NJR, against the number of levies raised through implant sales. This applies to all of the UK, and both independent and NHS providers. However, compliance can also be measured by comparing NJR submissions with data submitted to the Hospital Episode Statistics (HES) database. This only relates to NHS institutions in England. The NJR ankle data was compared to implant data, and adjusted to compare to HES data, to evaluate the different methods of measuring compliance. We also compared these figures with the first 3 years for hip and knee arthroplasties and the first year for shoulder and elbow arthroplasties. In 2011 there were 493 arthroplasties and the compliance was 64% against industry data. In 2012 there were 590 procedures with compliance improved to 77% against industry data. When adjusting NJR to compare with HES data, the compliance was 87% in 2012., with 507 ankle arthroplasties registered with the NJR and 582 on HES data. The reasons for this discrepancy are discussed. The specific difficulties of capturing ankle revisions are discussed, as some get revised to arthrodeses. The uptake is significantly higher than the first year for all other joints (shoulders 52%, hips 57%, knees 57%, and elbows 60%).Results:
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. Following ethics and local IRB approval, 40 healthy volunteers were asked to stand on an electronic weighing scales and be measured for height. They were then asked to stand on an identical electronic weighing scale on the PedCAT standing CT. Their weight was measured single and double leg stance, with the hands supported and unsupported on the side bars. The subjects were then asked to sit with a single and then both legs on the scale.Aims:
Methods:
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. A review of the first 100 CBCT scanning in our unit has been performed to assess ease of scanning, imaging time, radiation dose and value of imaging as opposed to conventional imaging.Introduction:
Method:
We performed a systematic review and meta-analysis
of modern total ankle replacements (TARs) to determine the survivorship,
outcome, complications, radiological findings and range of movement,
in patients with end-stage osteoarthritis (OA) of the ankle who
undergo this procedure. We used the methodology of the Cochrane Collaboration,
which uses risk of bias profiling to assess the quality of papers
in favour of a domain-based approach. Continuous outcome scores
were pooled across studies using the generic inverse variance method
and the random-effects model was used to incorporate clinical and
methodological heterogeneity. We included 58 papers (7942 TARs)
with an interobserver reliability (Kappa) for selection, performance,
attrition, detection and reporting bias of between 0.83 and 0.98.
The overall survivorship was 89% at ten years with an annual failure
rate of 1.2% (95% confidence interval (CI) 0.7 to 1.6). The mean
American Orthopaedic Foot and Ankle Society score changed from 40 (95%
CI 36 to 43) pre-operatively to 80 (95% CI 76 to 84) at a mean follow-up
of 8.2 years (7 to 10) (p <
0.01). Radiolucencies were identified
in up to 23% of TARs after a mean of 4.4 years (2.3 to 9.6). The
mean total range of movement improved from 23° (95% CI 19 to 26)
to 34° (95% CI 26 to 41) (p = 0.01). Our study demonstrates that TAR has a positive impact on patients’
lives, with benefits lasting ten years, as judged by improvement
in pain and function, as well as improved gait and increased range
of movement. However, the quality of evidence is weak and fraught
with biases and high quality randomised controlled trials are required
to compare TAR with other forms of treatment such as fusion. Cite this article:
Surgeons, commissioners and patients are increasingly seeking more in depth details on outcomes of total ankle replacement (TAR). We set out to perform a detailed and up to date meta-analysis of the outcomes of TAR, with a focus on PROMS. We searched MEDLINE, Cochrane, EMBASE, CINAHL and the Science Citation Index databases using the terms “total”; “ankle”; “arthroplasty” or “replacement” to April 2012. We included all languages; series with greater than 20 TAR; minimum 2 years follow-up. We excluded papers on revisions; prostheses no longer marketed; and kin studies. We worked with the Cochrane Collaboration to adopt their methodology including the creation of a risk profile assessing all forms of bias.Introduction
Methods
Axial musculoskeletal control (AMC) is a widely used concept and has been shown to be an important factor in physical performance, the pathophysiology of back pain and other MSK conditions. However, there is no agreement on a definition of AMC, nor a validated test for AMC and its application in clinical practice. Our aim was to develop a test for AMC using the Delphi method from a panel of experts with video and analysis of the footage. We found that the most commonly used tests were the maintenance of neutral pelvic position in single leg stance, single leg stance with eyes closed and single leg squat. We aim to further validate our findings by comparing this to surface EMG recordings and centre of gravity measurements in stress situations.
We have investigated whether a system of four inertial measurement units (IMUs) attached to the segments of the lower limbs could provide useful information about the kinematics of limb segment movement in gait in a healthy population. Four IMUs were attached to participants over their clothes. Participants then walked at their self-selected speed for 10 metres along a corridor and back. IMUs were removed, data downloaded on to a computer and ranges of motion were calculated for thigh, calf and knee, in addition to stride duration. 128 participants were recruited aged 18–97. There was little variation in most angle parameters up to age of 80. The relationships between angle and age are non-linear. There was a slight increase in stride duration with age of about 0.1% per year. The study concentrated on active subjects, with no specific co-morbidities that might affect gait. Results obtained may represent what is achievable for any given age, and approximate to changes that occur due to primary ageing. We propose that, after the age 80, peak muscle power declines below a threshold, such that muscular activity required to move a limb approaches the peak power available, and that it is the decline in peak muscle power that ultimately limits gait in active older people. Walking ability is important in maintaining independence as people age. It would be more effective to encourage exercises to maintain normal gait at a much earlier age. Deviations from the normal range could be identified early, and appropriate intervention given.
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. All articles from the years 2000 and 2010 in Foot and Ankle International, Foot and Ankle Surgery, and all foot and ankle articles from JBJS A and JBJS B were analysed. Animal, cadaveric, basic science, editorials, surveys, letters to Editor and correspondence were excluded. Articles were ranked by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine.Background
Methods
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. This paper uses publication volume as a surrogate marker for adoption, as described previously by the authors. Briefly, a systematic review of the literature was carried out. MESH headings included ‘Hallux Valgus’, and ‘osteotomy’ or ‘SCARF’ or ‘Z osteotomy’ or ‘bunionectomy’. 2818 publications were identified and the abstracts were reviewed excluding 2699 publications for non-relevance. The data was analysed by year of publication, country of origin, as well as for level of evidence.Introduction
Methods
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. Articles from Foot and Ankle International, JBJS Br, JBJS Am, Foot and Foot and Ankle Surgery were used. We looked at the years 2000 and 2010 and ranked the articles by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine. 498 articles were ranked. Studies of animals, studies of Background
Methods
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 We retrospectively reviewed 8 patients with the diagnosis of BMES. There were 6 males and 2 females with an average age of 51 years (38–63 years). All patients had acute onset of severe pain in the foot without any history of trauma. None of the patients had history of excessive alcohol or steroid intake. 5 patients (63%) had bilateral involvement of migratory nature. All patients had characteristic features on MR scans, with involvement of 3 or more bones in the foot.Introduction
Materials and Methods
Knowledge of knee kinetics and kinematics contributes to our understanding of the patho-mechanics of knee pathology and rehabilitation and a mobile system for use in the clinic is desirable. We set out to assess validity and reliability of ambulatory Inertial Motion Unit (IMU) Sensors (Pegasus¯) against an established optoelectronic system (CODA¯). Pegasus¯ uses inertial sensors placed on subjects' thighs and lower leg segments to directly measure orientation of these segments with respect to gravity. CODA¯) models the position of joint centres based on tracked positions of optical markers placed on a subject, providing 3D kinematics of the subject's hips, knees and ankles in all three planes. Intra observer reliability of the Pegasus¯ system was tested on 6 volunteers (4 male; 2 female) with no previous lower limb or knee pathology. IMU's were placed on the long axis of the lateral aspects of both thighs and lower leg segments. A test re-test protocol was used with sagittal data angle collected around a standard circuit. Inter-observer reliability was tested by placement of IMU's by 5 different testers on a single volunteer. To test validity, we collected simultaneous sagittal knee angle data from Pegasus¯ and CODA¯ in two subjects. The presence of IMU's did not compromise positioning of optical markers.Introduction
Methods
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. We surveyed 90 consecutive patients in three Consultant Foot & Ankle surgeons' new outpatient clinics at our institution. Sixty patients received a copy of the letter sent to their GP (standard practice) and 30 patients received a letter in plain English addressed to the patient and a copy was sent to the GP (new practice). Patients were sent a cover letter explaining the study a copy of their clinic note and also a questionnaire that asked details about their preferred methods of communication. In addition qualitative interviews with 4 GP Partners were carried out to harbour their opinions.Introduction
Methods
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. Seventy consecutive patients receiving foot orthoses at the Royal National Orthopaedic Hospital were retrospectively asked to complete a questionnaire and to bring their shoes and orthotics to research clinic. The inside width of the shoes and corresponding width of the orthotic were measured. A semi-structured interview was carried out on 10 patients, including those that were satisfied or unsatisfied, using qualitative research methods to identify issues that are important to patients.Introduction
Methods
Autologous chondrocyte implantation (ACI) and mosaicplasty are both claimed to be successful for the repair of defects of the articular cartilage of the knee but there has been no comparative study of the two methods. A total of 100 patients with a mean age of 31.3 years (16 to 49) and with a symptomatic lesion of the articular cartilage in the knee which was suitable for cartilage repair was randomised to undergo either ACI or mosaicplasty; 58 patients had ACI and 42 mosaicplasty. Most lesions were post-traumatic and the mean size of the defect was 4.66 cm2. The mean duration of symptoms was 7.2 years and the mean number of previous operations, excluding arthroscopy, was 1.5. The mean follow-up was 19 months (12 to 26). Functional assessment using the modified Cincinatti and Stanmore scores and objective clinical assessment showed that 88% had excellent or good results after ACI compared with 69% after mosaicplasty. Arthroscopy at one year demonstrated excellent or good repairs in 82% after ACI and in 34% after mosaicplasty. All five patellar mosaicplasties failed. Our prospective, randomised, clinical trial has shown significant superiority of ACI over mosaicplasty for the repair of articular defects in the knee. The results for ACI are comparable with those in other studies, but those for mosaicplasty suggest that its continued use is of dubious value.
Mosaicplasty 100 consecutive patients aged 15–45 with a symptomatic articular cartilage lesion in the knee suitable for cartilage repair were randomised at arthroscopic assessment to undergo either mosaicplasty or ACI. 42 patients underwent mosaicplasty, 58 had ACI. Mean age at time of surgery was 31 years and the average defect size 4. 66 cm2. 46% of the defects were post-traumatic, 19% had osteochondritis dissecans, 14% had chondromalacia patella and 16% had lesions of unknown aetiology. 53% had a medial femoral condyle lesion, 25% patella, 18% lateral femoral condyle, 3% trochlea and there was one defect of the lateral tibial plateau. The mean duration of symptoms was 7. 2 years and the average number of previous operations (excluding arthroscopies) was 1. 5. Only 6 patients had no prior surgical interventions to the affected knee. The mean follow-up was 1. 7 years. Patients were evaluated using Modified Cincinnati and Stanmore Functional rating systems, visual analogue scores and clinical assessment. Arthroscopy and biopsy was performed at one year and repair assessed with the International Cartilage Repair Society grading system. Clinical results at one year showed 70% of mosaic-plasty patients and 87% of ACI patients had a good or excellent result. Arthroscopy at one year demonstrated more complete healing in ACI patients. Eleven (26%) of the mosaicplasty group subsequently failed clinically and arthroscopically, with peak failure at 2 years. At one year follow-up, both techniques of articular cartilage repair can be useful in selected patients. ACI is preferred for lesions of the patella. Long-term follow-up is needed to assess the durability of articular cartilage repair using these methods, in particular mosaicplasty which showed signs of progressive failure over 2 years.
To investigate the incidence of PTS in patients with veno-graphically proven DVT following hip or knee replacement surgery, patients were derived from a randomised controlled trial of LMWH versus unfractionated heparin prophylaxis in 500 total hip or knee replacement patients. Surveillance venogram at 10 days detected DVT in 93 patients, and these were warfarinised for 3–6 months. At a minimum follow-up of 7 years, patients were assessed by clinical examination, questionnaire and application of two scoring systems; a modified PTS score based on the Browse score, and the clinical component of the International Consensus Committee on Chronic Venous Disease classification (ICC-CVD). 70 patients (21 deaths and 2 non-responders, follow-up rate 97%) with 32 THR and 38 TKR were studied. 63% patients were female, and average age was 74 years. Leg ache (46%) and swelling (42%) were the most common subjective complaints, but 40% patients had no complaints. Objectively, leg swelling was observed in 52% of patients, varicose veins in 26%, but ulceration was seen in only 3% of patients. The modified PTS score showed 14% patients had no symptoms, 64% mild symptoms, 19% moderate and 3% severe symptoms of PTS. The ICC-CVD score revealed 27% with no symptoms, 53% mild symptoms, 17% moderate and 3% severe symptoms of PTS. There was good correlation between the scoring systems for moderate and severe disease, but the modified PTS may have overestimated the incidence of mild PTS. Severe symptomatic PTS is rare following early detection and treatment of DVT after total hip and knee replacement.
Autologous Chondrocyte Implantation’ (ACI) is a cartilage repair technique that involves implantation of cultured chondrocytes beneath a membrane of autologous periosteum. In this study a porcine biodegradable membrane was also used to assess its effectiveness. The aim is to restore articular cartilage to symptomatic defects, rather than initiating a fibrocartilagenous repair. We undertook a prospective study of 125 consecutive patients who underwent ACI. Average age at the time of surgery was 30. 9 years (range 14 – 49), 55% of patients were male. The average size of the defect was 4. 35 cm². 44% of defects were attributable to known traumatic incidents, 2 1 % had osteochondritis dessicans, 18% chondromalacia patella, 12% had defects of unknown aetiology and 5% other. The average duration of symptoms prior to this surgery was 7. 16 years. The mean number of previous operations (excluding arthroscopies) was 1. 6. Only 9 patients had no previous major surgery to the affected knee. 44% had defects of the medial femoral condyle, 31% patella, 20% lateral femoral condyle and 5% had a trochlea lesion. 26% of the defects were covered with periosteum and 74% with a porcine collagen membrane (chondrogide) Minimum follow-up was six months, 70 patients had minimum follow-up of one year. Mean follow-up 18 months. Patients were assessed using Modified Cincinnati and Stanmore Functional rating systems, visual analogue scores and clinical evaluation. Arthroscopy and biopsy was performed at one year and the repair assessed using the International Cartilage Research Society grading system. At one year follow-up overall 41 % patients had an excellent result, 48% good, 8% fair and 3% poor. For defects of the medial femoral condyle, 88% had a good or excellent result, 85% for the lateral femoral condyle and 80% for the patella. 61 patients were arthroscopically assessed at one year. 50/61 (82%) demonstrated ICRS grade 1 or 2 repair. Healing of the defect occurred with either a periosteum or chondrogide defect cover. Results at one year suggest that ACI is a successful articular cartilage repair technique in selected patients. Long-term follow-up is required to assess the durability of the repair.
Many methods have been described over the past 5 years for repair of articular cartilage defects. The best reported results have been from the use of autologous chondrocyte transplantation (ACT)(1) and mosaicplasty.(2) There have, however, been no prospective clinical trials of these two methods. In this trial 70 patients were prospectively randomized to receive either autologous chondrocyte transplantation (37) or mosaicplasty (33) in the knee. 37 patients were female and 33 male. The average age was 32 years (16 – 44). The indications for surgery were persistent pain and mechanical symptoms in the knee with an isolated defect of the articular cartilage. 38 (56%) were post-traumatic, 12 (16%) due to osteochondritis dissecans, 10 (14%) due to previous meniscectomy, and 10 (14%) due to chondromalacia patellae. The size of the defects ranged from 2cm2 to 12cm2 (mean 4.8cm2). There were 35 defects on the medial femoral condyle, 13 on the lateral femoral condyle, 17 on the patella and 5 on the trochlear. 31 patients were undergoing primary surgery and 39 secondary surgery. All were independently reviewed using the Visual Analogue Pain Score, the Cincinatti Pain Score and the Stanmore Score. Patients were arthroscoped at one year with MRI scan and biopsies where possible.
