Introduction

Medial column insufficiency in patients with painful acquired flatfoot can be difficult to appreciate. The reverse Coleman block test is used in this study to predict medial column instability.

Introduction

Medial column insufficiency in patients with painful acquired flatfoot can be difficult to appreciate. The reverse Coleman block test (as described and published by Mr E Wood in 2009) is used in this study to predict medial column instability.

The aim of the study was to assess the clinical, radiological and paedobarographic outcome following modified Silver’s McBride’s procedure, in the treatment of Hallux Valgus. Between 1997 and 1999, Modified Silver’s McBrides procedure for Hallux Valgus was performed on 38 foot in 28 patients (18 unilateral and 10 bilateral). The median age was 60 years. The median follow up was 26 weeks. Clinical outcome measures consisted of pain, deformity, mobility, walking ability and shoe wear. Radiological outcome measures were Hallux Valgus angle, Intermetatarsal angle, 1st to 5th Metatarsal distance, 1st to 2nd metatarsal distance, and the DMAA (Distal Metatarsal Articular Angle). Paedobarographic (Musgrave) outcome of peak pressure, total force, time from heel strike to toe lift off post operatively were analysed. Preoperative visual analogue pain score was 5–8 and 0–4 postoperatively (p< 0.001). 34 feet had pain on walking preoperatively and only 11 had pain post-operatively. 12 were wearing special shoes pre- operatively and 5 post-operatively. Hallux Valgus angle was 34 pre-operatively and 19 post-operatively (p< 0.001). IMT angle was 14.53 pre-op and 10.88 postop (p< 0.001). 1st-5th MT distance was 67mm pre- op and 63mm post-op (p=0.001). 1st-2nd MT distance was 15 pre-op and 10 post-op (p=0.004). DMAA was 24.7 degrees. 21 foot an obliquity of the 1st tarsometatarsal joint was seen indicating an anatomical cause of metatarsus varus. Foot pressure studies showed a peak pressure of 1.37kg/cm2 , heel to toe off- time was 936.9ms and maximum load was 65.2 kg. There were 3 cases of superficial wound problems. One patient developed Hallux varus deformity, with no functional disability.

Conclusion: Modified Silver’s McBride procedure for the treatment of Hallux Valgus is a soft tissue procedure and is a safe alternative to the commonly practiced osteotomies for correction of this disorder.

Background and Aim: It was observed by the senior author over 15 years that if the foot became dependant in the 1st 48 hours after foot surgery, the patient suffered marked swelling and pain. This effect seemed less after about 48 hours. The practice was adopted of keeping the foot elevated for at least 48 hours. Aware of the work of John Tooke and Gerry Rayman with postural effects on laser Doppler skin flow, we set out to see if there was a demonstrable scientific basis for this practice.

Materials and Method: Laser Doppler flow meter was used to assess blood flow in 14 patients, (16 feet), undergoing foot and ankle surgery. Flow was recorded in the big toe, at heart level and on dependency, preoperatively, and then sequentially at 24, 48, 72 and 96 hours post operatively. Postural vasoconstriction was calculated using the formula; Postural Vas.(%)=Blood flow at heart level – Blood flow on depend./ X 100 Blood flow at heart level The time taken for blood flow in the toe to get back to the pre-operative values was assessed. Room temperature, patient temperature and patient position were all kept constant.

Results: Postural vasoconstriction was recorded for all 14 patients at 48 hours, for 7 patients at 72 hours, and for 2 patients at 96 hours post operatively. All patients had an ankle block, except 2 patients who had a popliteal block. The mean postural vasoconstriction preoperatively was 51.31%; mean at 24 hours post op. was 23.05% mean at 48 hours post op. was 36.62% and mean at 72 hours post op. was 44.24%. The mean operative time was 87.25 minutes. There was a significant difference between the pre-op levels and the 24, 48 and 72 hours post-op levels (p< 0.05). At 96 hours post-op, the difference wasn’t significant. Greater operative time was associated with less postural vasoconstriction at the 72 hours postoperatively.

Conclusion: Results showed that it takes longer than 72 hours for microcirculation to get back to normal rather than 48 hours, but the return towards normality was evident by that time. The results emphasised the importance of post-operative foot elevation for at least 48 hours due of this phenomenon. With increasing operative time, it took longer for the microcirculation to get back to normal. The longer the surgery the longer the period of elevation required. We believe that this practice minimises post operative complications; such as oedema, wound breakdown, pain on dependency. No patients suffered DVT’s or PE’s. However, patients did start with active and passive foot and lower limb physiotherapy soon after surgery.

Aim The senior author observed over 15 years that if the foot became dependant during the first 48 hours following foot surgery, the patient suffered marked swelling and pain. This effect seemed less after about 48 hours. Aware of the work of Tooke and Rayman (1986) with postural effects on laser Doppler skin flow, we set out to see if there was a demonstrable scientific basis for this practice.

Method Laser Doppler flow meter was used to assess blood flow in 14 patients (16 feet), peri-operatively. Flow was recorded in the big toe, at heart level and on dependency, pre-operatively, and at 24, 48, 72 and 96 hours post-operatively. Postural vasoconstriction (PV) was calculated using the formula:

\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \[PV\ (\%)\ =\ Blood\ flow\ at\ heart\ level\ {-}\ Blood\ flow\ on\ dependency\ {\times}\ 100\] \end{document}

Blood flow at heart level

Results PV was recorded for all 14 patients at 48 hours, for seven at 72 hours, and for two at 96 hours post-operatively. The mean PV pre-operatively was 51.31%; at 24 hours post-op. was 23.05%; at 48 hours post-op. was 36.62%; and at 72 hours post-op. was 44.24%. There was a significant difference between the pre-op. levels and the 24, 48 and 72 hours post-op. levels (p< 0.05).

Significance of work It takes longer than 72 hours for microcirculation to get back to normal rather than 48 hours, but the return towards normality was evident by that time. This emphasised the importance of postoperative foot elevation for at least 48 hours due of this phenomenon. We believe that this practice minimises post-operative complications, such as oedema, wound breakdown and pain on dependency.

Up to 75% of patients develop metalwork related problems following ankle fracture fixation and require further open surgery to remove them. This second procedure can lead to significant morbidity. To minimise these complications, we developed a technique, for removing the metalwork percutaneously. This technique was used in 12 patients with metalwork problems related to malleolar implants. The majority of problems occurred with the distal fibular plate and the screws.

One stab incision was placed mid way between every two screws so that two screws could be removed though one incision. The plate was stripped from the distal fibula using a narrow osteotome and extracted through the distal or proximal stab wound. Lag screws were also removed through an anterolateral stab incision. When we were unable to palpate the screw head, we used a guide wire under image intensifier to locate the screw head and railroaded a cannulated screwdriver over the wire to lock into the head of the screw. Medial malleolar screws were removed in a similar fashion. The technique was undertaken as day case surgery. No complications were encountered. All patients remained symptom-free postoperatively.

We conclude that percutaneous removal of metalwork around ankle joint is a safe and effective technique, allowing the patient to quickly regain their preoperative level of activity.

Numerous techniques have been described for ankle arthrodesis. Arthroscopic arthrodesis with internal fixation has evolved to reduce the complications associated with open arthrodesis. We present our technique of arthroscopic ankle fusion using two medial cannulated screws with specially designed dished washers

The tibiotalar joint is debrided arthroscopically and internal fixation is achieved with two medial cannulated screws with designed dished washers. Seven ankle arthrodeses were performed on six patients; one underwent bilateral arthrodesis.

All the patients suffered from OA (four post traumatic) and were aged between 53–61 (mean 55.4). There were four males and two females. The follow up ranged from 8–18 months (mean 10).

All the patients achieved ankle fusion. Time for fusion ranged from 6 to 18 weeks, five fused within 12 weeks. Pre operative pain scores improved from 6–10 out of 10 (mean 7.2) to 1–3 out of 10 (mean 1.4) post-operative. Post-operative AAFOS ankle hind foot score ranged from 74–89 out of 100 (mean 81.8). One patient required further operations for adjustment of fixation and one suffered a stress fracture at the level of the proximal screw.

This method of arthroscopic ankle fusion provides an effective alternative to open arthrodesis for selected patients with OA achieving good initial results.

Introduction

The existence of various techniques of ankle arthrodesis shows that there are pros and cons in each method. We describe our experience of ankle arthrodesis using a paediatric angle blade plate.

Materials and methods

10 ankle arthrodeses were performed in nine patients. All patients were reviewed independently in special clinics. The objective assessment was performed by detailed clinical examination and the subjective assessment was made including overall patient satisfaction. The American Orthopedic Foot and Ankle Society ankle/hind foot scoring system was used. The technique of ankle arthrodesis was similar in all patients using an anteromedial or anterolateral incision, preparation of articular surface and paediatric angle blade plate fixation with or without bone grafting. Time to union was assessed by clinical and radiological examinations.

Results

Radiological union was achieved in nine patients in a mean time of 16 weeks. Fibrous union occurred in one patient. Eight patients were very satisfied with their treatment. The patient with fibrous union had a marginal improvement of symptoms with pain score improved from nine to seven. The mean AOFAS score was 84.

Conclusion

Ankle arthrodesis with a paediatric angle blade plate is a useful method of managing intractable cases of ankle arthritis. The technique is simple and effective with excellent success rate.

Two cases are reported of the late diagnosis of compartment syndrome secondary to alcohol and drug overdose. Surgical decompression at two and a half days and at six days, respectively, produced worthwhile recovery. Other reports are reviewed and a case is made for the value of decompression even when performed late, and for delayed and minimal excision of apparently necrotic muscle.