Informed consent is integral to good-practice. It protects the patient and offers proof of discussion and interaction between the surgeon and the patient. We compare efficacy of last clinic consent, specialised consent clinic with or without provision of patient specific literature. Group A patients underwent written consent at their last outpatient clinic and conformation of consent on the morning of surgery. Group B underwent consent in designated pre-admission clinic in the week prior to surgery. Group (C) attended the same preadmission clinic and were provided with a surgeon dictated written explanation of their surgery and particular risks. This included a explanation of the procedure, complications, risks and rewards in layman's terms, aimed at patients with a reading age of 14 years, with advice concerning alternative procedures and the consequences of taking no action. The risks are graded: common, less common and rare. All patients undertook a pre-surgery questionnaire on the morning of surgery by an independent observer prior to any contact with the surgical team. Questions focused on their planed procedure, post-operative instructions and possible complications in order to assess the recall of the consent process. A VAS-scale was added to assess overall satisfaction. Statistical analysis was undertaken by a T-test. In total 162-patients were assessed, the response rate was 68.5% (n=111). In-group A (n=16) 18.8% patients remembered 3 relevant complications, 56.2% recalled their post-operative considerations their overall satisfaction was 4/10. In-group B (n=57) 45.5% remembered three complications, 63.7% recalled their postoperative considerations and had a patient satisfaction of 5/10. In-group C (n=38) 48.3% remembered three complications, and 70.7% recalled postoperative considerations, the overall satisfaction improved to 6/10. We observed that the consent process is improved by the use of routine pre-operative consent clinics; however the addition of patient specific literature is observed to further improve recall and satisfaction.
Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency. We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery.Background
Methods
Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency. We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery.Background
Methods
The use of effective pre-operative preparation solution is an important step in limiting surgical wound contamination and preventing infection, particularly in forefoot surgery. The most effective way is unknown. In recent studies, >
70% of aerobic bacterial cultures of specimens taken from the nail folds following skin preparation with povidine iodine were positive. The aim of the study was to determine the effectiveness of pre-operative Triclosan (Aquasept) shower, skin preparation using povidone iodine and ethyl alcohol in reducing post-operative forefoot infection. Between February 2005 and August 2005, all patients undergoing forefoot surgery under the care of the senior author were followed prospectively. There were 50 women and 10 men with an average age of 55 years (17–92 years), who underwent 92 forefoot procedures. The surgeries included 35 (38%) osteotomies, 31 (34%) arthrodeses, and 9 (10%) Morton’s neuroma excisions and 17 (18%) soft tissue procedures. As a standard protocol, pre-operatively all patients had Triclosan shower on the day of surgery, the foot/feet were painted with povidone iodine and was covered with a sterile towel in the ward. At induction, everyone received cefuroxime 1.5gm (IV); the feet were prepared using povidone iodine and then ethyl alcohol and dried. Patients were followed up in the clinic at 2weeks, 6weeks and 3months, further follow-up if necessary. None of the patients in the study developed deep infection. Two patients required oral antibiotics for superficial infection (one pin track infection after distal inter-phalangeal joint fusion of second toe, one following scarf osteotomy) We conclude that the method used in this study was very effective in preventing infection following forefoot surgery.
Scarf osteotomy is a z-osteotomy of the 1st metatarsal and is proposed to correct anatomical and functional deformities of hallux valgus. This procedure allows early ambulation and early return of function. This study was conducted to evaluate clinical and paedobarographic results following this procedure in a district general hospital. From August 2000, we prospectively collected the data on 43 feet (32 consecutive patients) followed up for 12 months. We collected the data pre-operatively, 3,6 and 12 months post-operatively using AOFAS score, weight-bearing radiographs and paedobarographs. From the paedobarographs (Musgrave), the forefoot function was evaluated using peak pressure, force time integral and pressure time integrals. Mean total AOFAS score increased from 45.13 pre-operatively to 94.5 post-operatively (p<
0.001). Postoperatively, the hallux valgus angle decreased from 29.83° to 11.79° and 1–2 intermetatarsal angle decreased from 12.48° to 6.37° (p<
0.001). Post-operatively, peak pressure has increased under the 1st metatarsal head and decreased under the 2nd metatarsal head. Force time integral and pressure time integrals also showed similar changes. We have not noticed significant alteration of forefoot pressures under the lateral part of forefoot. Using scarf osteotomy, we achieved good correction of the hallux valgus deformity and significant improvement of AOFAS scores. We also noted alteration of the forefoot function with increased pressure under the 1st metatarsal and reduced pressure under the 2nd metatarsal head.
Hallux Valgus was thought to alter the forefoot function with defuctioning of the first ray with a resulting overloading of the second ray. The scarf osteotomy is a z-osteotomy of the first metatarsal and is proposed to correct anatomical and functional deformities of hallux valgus. This study was conducted to evaluate forefoot pressures using the Musgrave foot print system following this procedure in a district general hospital.
We prospectively collected the data from 43 feet in 31 consecutive patients. We evaluated the forefoot function using peak pressure, force time integral and pressure time integral parts of pedobarographs (Musgrave) pre-operatively, three and six months postoperatively.
The mean peak pressure under the first metatarsal head was reduced from 3.09 (95% CI 2.49 −3.70) to 2.25 (95% CI1.80–2.71) at six months. The mean peak pressure under the second metatarsal head was reduced from 6.29 (95% CI 5.44–7.13) to 5.01 (95% CI 3.98–6.05) at six months. Force time integral under the first metatarsal head was reduced from 1.34 (95% CI 1.06–1.62) to 0.97 (95% CI 0.74–1.19)) at six months. Force time integral under the second metatarsal head also reduced from 2.66 (95% CI 2.27–3.06) to 2.41(95% CI 1.98–2.85). Pressure time integrals also showed similar changes.
Scarf osteotomy produced decrease in the forefoot pressures under the medial part of forefoot. We have not noticed significant alteration of forefoot pressures under the lateral part of forefoot.
To achieve tibiotalocalcaneal arthodesis, implants described range from external fixator, compression screws and anterior plate and the more recent retrograde calcaneal locked intramedullary nail. Our aim is to assess the outcome of the AO cannulated blade plate for tibiotalocalcaneal arthrodesis.
Four tibiotalocalcaneal arthrodeses were performed in three patients. The operative technique involves lateral approach to the distal fibula that was osteotomised and used as bone graft. The articular cartilage of ankle and subtalar joint was removed using an osteotome and congruent surfaces achieved. AO cannulated blade plate was applied on the lateral aspect to achieve compression. The postoperative protocol included a plaster cast for three months, followed by mobilization out of plaster.
At the mean follow up of 10 months (range five to fourteen months) all patients were pain free on full weight bearing. The union was achieved at three months which was confirmed clinically and radiologically. There was no infection, wound breakdown, or loss of position at the ankle or subtalar joints. Mean preoperative American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 21 and postoperative score 83. We conclude that the cannulated blade plate is an alternate technique for tibiotalocalcaneal arthodesis, with no moulding of the implant required to attain satisfactory alignment.
The scarf osteotomy is a z-osteotomy of the first metatarsal. This is a technically demanding procedure which allows early ambulation without cast and early return of function. This study was conducted to evaluate clinical results following this procedure in a district general hospital.
We prospectively collected the data from 67 feet in 53 consecutive patients followed up for six months. Four patients were lost to follow up. We collected the AOFAS score preoperatively, and at three and six months. Hallux valgus angle, first-second intermetatarsal angle and sesamoid subluxation were measured from weight bearing radiographs taken preoperatively and at six weeks and six months.
Total AOFAS score increased from 43.1 preoperatively to 85.0 at three months postoperatively (p<
0.0001, 95% CI of 44.5 to 35.5). The AOFAS scores at three and six months also showed significant difference (p<
0.0001, 95% CI of 4 to 10). All the components of AOFAS showed similar improvement postoperatively. The hallux valgus angle decreased from 30.1 to 9.9 degrees at six weeks post operatively (p<
0.0001, 95% CI of 22.21 to 18.27). The first-second intermetatarsal angle decreased from 12.6 to 6.4 at 6 weeks post operatively (p<
0.0001, 95% CI of 5.1 to 7.14). Sesamoid subluxation was reduced in the majority of cases. We had two fractures of the metatarsal head, three wound infections and six cases of transient neuropraxia of the cutaneous nerves.
With Scarf osteotomy, we achieved good correction of the hallux valgus deformity and significant improvement of AOFAS score. It is a versatile and reliable procedure in the management of hallux valgus.
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.
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.
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.
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.
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.
