Introduction

Anatomic reduction of talar body fractures is critical in restoring congruency to the talocrural joint. Previous studies have indicated a maximum of 25% talar body exposure without malleolar osteotomy. The aim of this study was to investigate the percentage talar body exposure when using the lateral transligamentous approach.

Introduction

The current treatment for Freiberg's osteochondrosis centres around either: simple debridement or debridement osteotomy. The main principle of the osteotomy is to rotate normal articular cartilage into the affected area. We recommend the use of CT scanning to delineate the amount of available, unaffected cartilage available to rotate into the affected space.

Introduction

Ankle fractures in the elderly are an increasing problem with our aging population. Options for treatment include non-operative and operative with a range of techniques available. Failure of treatment can lead to significant complications, morbidity and poor function. We compared the outcomes of two operative techniques, intramedullary hindfoot nailing (IMN) and fibular-pro-tibia fixation (FPT). This is the largest analysis of these techniques and there are no comparative studies published.

Aims

Total femoral arthroplasty (TFA) is a rare procedure used in cases of significant femoral bone loss, commonly from cancer, infection, and trauma. Low patient numbers have resulted in limited published work on long-term outcomes, and even less regarding TFA undertaken for non-oncological indications. The aim of this study was to evaluate the long-term clinical outcomes of all TFAs in our unit.

The primary aim of this study was to compare the clinical outcomes of osteoid osteoma (OO) between the group of patients with the presence of nidus on biopsy samples from radiofrequency ablation (RFA) with those without nidus. Secondly, we aimed to examine other factors that may affect the outcomes of OO reflecting our experience as a tertiary orthopaedic oncology centre.

We retrospectively reviewed 88 consecutive patients diagnosed with OO treated with RFA between November 2005 and March 2015, consisting of 63 males (72%) and 25 females (28%). Sixty-six patients (75%) had nidus present in their biopsy samples. Patients’ mean age was 17.6 years (4-53). Median duration of follow-up was 12.5 months (6-20.8). Lesions were located in the appendicular skeleton in seventy-nine patients (90%) while nine patients (10%) had an OO in the axial skeleton. Outcomes assessed were based on patients’ pain alleviation (partial, complete, or no pain improvement) and the need for further interventions.

Pain improvement in the patient group with nidus in histology sample was significantly better than the group without nidus (OR 7.4, CI 1.35-41.4, p=0.021). The patient group with nidus on biopsy demonstrated less likelihood of having a repeat procedure compared to the group without nidus (OR 0.092, CI 0.016-0.542, p=0.008). Our study showed significantly better outcomes in pain improvement in appendicular lesions compared to the axially located lesions (p = 0.005). Patients with spinal lesions tend to have relatively poor pain relief than those with appendicular or pelvic lesions (p=0.007).

Patients with nidus on histology had better pain alleviation compared to patients without nidus. The histological presence of nidus significantly reduces the chance of repeat interventions. The pain alleviation of OO following RFA is better in patients with appendicular lesions than spinal or axially located lesions.

Abstract

Introduction

Prosthetic joint infection (PJI) is the leading cause of failure of primary and revision hip and knee arthroplasty. It is challenging condition which represents a growing burden on hospital resources. In-patient hospital stay for antibiotic therapy post-operatively is costly and access to out-patient IV therapy (OPAT) varies between regions. In a tertiary referral centre for revision and infection, the suitability and cost-effectiveness of Dalbavancin was reviewed as a “single-shot” therapy following DAIR or revision lower limb arthroplasty for PJI.

Introduction

Standard teaching of dislocated ankles was always reduce then x-ray. However the 2016 BOAST guidelines stated “Reduction and splinting should be performed urgently for clinically deformed ankles. Radiographs should be obtained before reduction unless this will cause an unacceptable delay”. We aimed to audit our practice against the BOAST guidelines and look at time from attendance to reduction.

Background

Avulsion fractures of the base of the fifth metatarsal are some of the commonest foot injuries. The robust scientific evidence on the optimal non-operative treatment of these fractures is scant. We designed and conducted a prospective randomised non-inferiority controlled trial of symptomatic treatment versus cast immobilisation with the null hypothesis that cast immobilisation gave substantial benefit over the symptomatic treatment in terms of patient reported outcome measures(PROMs). The alternative hypothesis was that symptomatic treatment was not inferior.

Background

Patients suffering a distal femoral fracture are at a high risk of morbidity and mortality. Currently this cohort is not afforded the same resources as those with hip fractures. This study aims to compare their mortality rates and assess whether surgical intervention improves either outcome or mortality following distal femoral fractures.

Aims

Although infrequent, a fracture of the cuboid can lead to significant disruption of the integrity of the midfoot and its function. The purpose of this study was to classify the pattern of fractures of the cuboid, relate them to the mechanism of injury and suggest methods of managing them.

Most of current literatures advise on thromboprophylaxis with injectable LMWH for trauma patients. Injectable anticoagulants have got inherent problems of pain, bruising and difficulty in administering the drug, which leads to low compliance. Clexane is derived from a pig's intestinal mucosa, hence could be objectionable to certain proportion of patients because of their religious beliefs. Oral anticoagulants have been used as thromboprophylactic agents in hip and knee arthroplasty. However there is not enough literature supporting their use as thromboprophylactic agent in ambulatory trauma patients with ankle fracture being managed non-operatively as out-patient.

This study looks into the efficacy of oral anticoagulant in preventing VTE in ambulatory trauma patients requiring temporary lower limb immobilisation for management of ankle fracture. The end point of this study was symptomatic deep vein thrombosis (either proximal or distal) and pulmonary embolism.

Routine assessment with a VTE assessment risk proforma for all patients with temporary lower limb immobilisation following lower limb injury requiring plaster cast is done in the fracture clinic at this university hospital. These patients are categorised as low or high risk for a venous thromboembolic event depending on their risk factor and accordingly started on prophylactic dose of oral anticoagulant (Rivaroxaban - Factor Xa inhibitor). Before the therapy is started these patients have a routing blood check, which includes a full blood count and urea and electrolyte. Therapy is continued for the duration of immobilisation. Bleeding risk assessment is done using a proforma based on NICE guideline CG92. If there is any concern specialist haematologist advice is sought. A total of 200 consecutive patients who presented to the fracture clinic with ankle fracture, which was managed in plaster cast non-operatively, were included in this study. They were followed up for three months following injury. This was done by checking these patients’ radiology report including ultrasound and CT pulmonary scan (CTPA) test on hospital's electronic system. Fracture of the lateral malleolus which include Weber-A, Weber-B and Weber-C fractures were included in the study. Also included were bimalleolar fractures and isolated medial malleolus fractures. Complex pilon fractures, polytrauma and paediatric patients were excluded from the study.

Only one case of plaster associated isolated distal deep vein (soleal vein) thrombosis was reported in this patient subgroup. There was no incidence of proximal deep vein thrombosis or pulmonary embolism. No significant bleeding event was reported.

Injectable low molecular weight heparin (LMWH) rather than oral anticoagulant has been recommended by most of the studies and guidelines as main thromboprophylactic agent for lower limb trauma patients.

Introduction:

The surgical treatment of intractable metatarsalgia has been traditionally been an intra-articular Weil's type of metatarsal osteotomy. In such cases, we adopted the option of performing a minimally invasive distal metaphyseal metatarsal ostetomy (DMMO) to decompress the affected ray. The meta-tarsophalangeal joint was not jeopardised. We present our outcomes of Minimally Invasive Surgery for metatarsalgia performed at our teaching hospital.

Introduction:

Prompted by the success of hip and knee arthroplasty, total ankle replacement (TAR) has become increasingly popular as a treatment for end stage arthritic complaints of the ankle. Glazebrook et al proposed a three grade classification of complications to assist prediction of early implant failure. We have compared the experience of a tertiary referral centre in the UK to Glazebrook's proposed system.

Locked plates confer angular stability across fusion sites, and as such are more rigid than either screws or intramedullary nails. This gives the advantage of reducing motion to enhance union rates and potentially allowing early weight bearing. The Philos plate (Synthes) is a contoured locking plate designed to fix humeral fractures but which also fits the shape of the hindfoot and provides strong low profile fixation. Its successful use for tibiotalocalcaneal (TTC) arthrodesis has been reported.

Our aim was to prospectively evaluate the use of the Philos plate in hindfoot arthrodesis Twenty-one hindfoot arthrodeses were performed using the Philos plate between Oct 2008 and Jan 2010. Patients were followed up for a minimum of 1 year and had preoperative and 6 monthly AOFAS hindfoot scores and serial radiographs until union. Overall there were 15 ankle fusions, 5 tibiotalocalcaneal fusions and 1 subtalar fusion. At 6 months there were 13 unions and 9 non-unions (4 ankle, 5 TTC) giving a non-union rate of 38% overall and 25% for ankle fusions in isolation. Mean AOFAS scores at 6 months were 74/100 for the union group and 47 for non-unions (chi squared p < 0.001). No patient in the non-union group went on to fuse within a year without further surgery. Both groups had similar case mixes including osteoarthritis, AVN of the talus and failed arthroplasty. They also had similar co-morbidities, rates of smokers and bone grafting.

Our conclusion is that the high non-union rates are probably due to the lack of compression conferred across the join by the Philos plate as there is no compression hole and we did not supplement the fixation with a lag screw. We recommend using locked plates for hindfoot arthrodesis only with additional compression.

Introduction

Growing evidence in the literature suggests better clinical and functional outcomes and lower re-rupture rates with repair compared to non-operative treatment of ruptured Achilles tendon. There are however, concerns of wound infection, nerve injury and scar tenderness with the standard open and percutaneous techniques of repair. We aim to evaluate clinical and functional outcomes and complications in patients treated with minimally invasive Achillon device.

There is mixed evidence in the literature regarding increasing age, ASA and BMI as risk factors for surgical site infection in orthopaedic surgery. To investigate the matter further, we examined 1055 wounds in 1008 patients in the Department of Trauma and Orthopaedic Surgery at University College London Hospital between 2000 and 2006. All patients with a minimum two-night stay were included. Data was collected by four designated research nurses. The age, height, weight and ASA status of each patient was recorded. All wounds were classified using ASEPSIS. This is a quantitative wound scoring method which is a summation of scores calculated from visual wound characteristics and the clinical consequences of infection.

Our results showed a strong linear association between age and ASEPSIS scores. Single variable regression analysis showed a t value of 3.32 and p value of 0.001. A similar linear association was seen between ASA grading and ASEPSIS scores. Single variable regression analysis showed a t value of 2.75 and p value of 0.006. The association between BMI and ASEPSIS scores was markedly different from that seen with age and ASA. The graph was U-shaped with patients with a BMI of 25-30 having the lowest average ASEPSIS scores. Patients with a lower and a higher BMI had higher average ASEPSIS scores. Single variable regression analysis was not significant since the relationship between BMI and ASEPSIS scores is not linear.

In conclusion, there are clearly defined patient groups who are at increased risk of developing a surgical site infection: older patients, patients with a higher ASA, and patients with both a low and high BMI. These patients should be targeted to reduce overall infection rates. This can be achieved by ensuring adequate antibiotic prophylaxis, having a low threshold to treat suspected infection and arranging regular follow-up.

Introduction: Several methods for the management of syndesmosis disruption during ankle fracture fixation have been documented The Tightrope anchor is a relatively new technique consisting of two buttons and a strand of Fiber-wire which is looped twice though the buttons to create a pulley effect between the fibula and tibia, thereby stabilising the ankle syndesmosis. We have reviewed the outcomes in 38 patients treated with this technique.

Materials and Methods: Data including nature of operation, complications and the need for subsequent surgery were recorded for all patients receiving a Tightrope from May 2006 to September 2008.

Results: The mean patient age was 35 years, and 23 were male. 30/38 patients required no further surgery and had a good functional outcome. Two patients had prominent fibula plates removed but achieved good functional outcomes. For one patient a Tightrope was performed following diastasis screw failure: an improved but suboptimal outcome was achieved. A patient with fibromyalgia had a good range of movement but complained of discomfort. One patient with Poland sequence, who fell post operatively, needed tightrope removal and syndesmosis debridement resulting in a good but painful range of movement. Another patient developed a pulmonary embolus following surgery and prolonged swelling and discomfort limited her functional capacity. Two patients required tightrope removal and significant wound debridement following osteomyelitis of the fibula and tibia.

Discussion and Conclusion: The Tightrope is an effective method of ankle syndesmosis repair, with a reduced need for subsequent diastasis related surgery (35/38) when compared to our diastasis screw method (100%). However, our significant rate of osteomyelitis is disturbing, warranting further investigation.

Background: A novel method for harvesting the flexor digitorum longus (FDL) tendon has previously been described via a plantar approach based on a surface coordinate. The aim of this investigation is to provide a comparison with the traditional medial midfoot dissection for tendon harvest.

Methods: The FDL tendon was exposed in 10 cadaveric feet via a limited plantar approach and also medially as far as could be accessed via the knot of Henry. The FDL was marked with a metal clip in each approach. The lengths of the skin incisions were recorded and the distance between the two markers was measured. The morphology of the FDL tendon was observed including interconnections with the flexor hallucis longus (FHL) tendon.

Results: The mean additional length of tendon accessed via the plantar approach was 22.9 mm with a mean reduction in skin incision length of 15.6 mm. The FDL tendon showed some division at the site of the plantar exposure and there were FDL - FHL interconnections in nine of the feet with three distinct patterns observed.

Conclusion: Using the plantar exposure, a longer length of tendon can be obtained through a smaller skin incision, which has been quantified here. Observations on FDL tendon morphology and interconnections may have clinical significance.

Introduction: The assessment of quality in the provision of healthcare is one of the core features of the National Health Service in the 21st Century. From April 2009 Patient Reported Outcome Measure (PROM) data are being collected for the Department of Health for elective hip and knee arthroplasty using generic and disease specific measures of health status. The perceived uses of these data may be for research, assessment of procedural outcome, measures of health inequalities and to aid commissioning groups in selecting their secondary care providers. Foot and ankle surgery covers a wide spectrum of operative procedures with patient responses less predictable than with major joint arthroplasty. We report the use of a sixteen point satisfaction-based questionnaire in order to investigate the nature of patient outcome after the processes of foot and ankle surgery.

Methods: A prospective series of 100 two-part Visual Analogue Scale (VAS) questionnaires was distributed to patients undergoing elective foot and ankle surgery at the Northern General Hospital under the care of four foot and ankle surgeons over a three-month period. The questionnaires were numbered to allow patient anonymity. The first part of nine questions enquired about pre-operative preparation and information and was distributed before surgery. The second part of seven questions, distributed at the first post-operative clinic sought to investigate their hospital and operative experience. Free text comments were requested in addition to the VAS responses, which were expressed as percentages.

Results: 97% of part one and 85% of part two questionnaires were returned completed. 82% had both parts completed and matched. The day case to inpatient ratio was 55: 45. For part one, all clinically related questions scored more than 90% satisfaction, with only two scores for administration-based questions falling below this level. For part two, satisfaction for clinical questions again scored more than 90% and overall, all scored more than 80% satisfaction. Only 23% of pre-operative and 28% of post-operative questionnaires were returned with free-text comments.

Conclusions: A simple patient satisfaction-based questionnaire may be as useful as existing non-validated generic scoring systems used in foot and ankle surgery when assessing quality in the health service, particularly where regional demographics or referral patterns may be important factors influencing patient outcomes. Active dialogue with the surgical colleges and Department of Health should be pursued to avoid inappropriate outcome measures being imposed in foot and ankle surgery.