Tendinopathy can commonly occur around the foot and ankle resulting in isolated rupture, debilitating pain and degenerative foot deformity. The pathophysiology and key cells involved are not fully understood. This is partly because the dense collagen matrix that surrounds relatively few resident cells limits the ability of previous techniques to identify and target those cells of interest. In this study, we apply novel single cell RNA sequencing (CITE-Seq) techniques to healthy and tendinopathic foot/ankle tendons. For the first time we have identified multiple sub-populations of cells in human tendons. These findings challenge the view that there is a single principal tendon cell type and open new avenues for further study. Healthy tendon samples were obtained from patients undergoing tendon transfer procedures; including tibialis posterior and FHL. Diseased tendon samples were obtained during debridement of intractable Achilles and peroneal tendinopathy, and during fusion of degenerative joints. Single cell RNA sequencing with surface proteomic analysis identified 10 sub-populations of human tendon derived cells. These included groups expressing genes associated with fibro-adipogenic progenitors (FAPs) as well as ITGA7+VCAM1- recently described in mouse muscle but, as yet, not human tendon. In addition we have identified previously unrecognised sub-classes of collagen type 1 associated tendon cells. Each sub-class expresses a different set of extra-cellular matrix genes suggesting they each play a unique role in maintaining the structural integrity of normal tendon. Diseased tendon harboured a greater proportion of macrophages and cytotoxic lymphocytes than healthy tendon. This inflammatory response is potentially driven by resident tendon fibroblasts which show increased expression of pro-inflammatory cytokines. Finally, identification of a previously unknown sub-population of cells found predominantly in tendinopathic tissue offers new insight into the underlying pathophysiology. Further work aims to identify novel proteins targets for possible therapeutic pathways.
Acetabular component loosening with associated bone loss is a challenge in revision hip arthroplasty. Trabecular Metal (TM) by Zimmer Biomet has been shown to have greater implant survivorship for all-cause acetabular revision in small cohort retrospective studies. Our study aims to review outcomes of acetabular TM implants locally. This is a retrospective observational study using data from Auckland City and North Shore Hospitals from 1st of January 2010 to 31st of December 2020. Primary outcome is implant survivorship (re-revision acetabular surgery for any cause) demonstrated using Kaplan-Meier analysis. Secondary outcome is indication for index revision and re-revision surgery. Multivariate analysis used to identify statistically significant factors for re-revision surgery.Introduction
Method
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
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.
Ankle fusion presents a difficult problem in the presence of infection, inadequate soft tissue, poor bone stock and deformity. Nonunion and infection remains a problem even with internal fixation. Ilizarov frame provides an elegant solution to the problem with stable remote fixation while allowing lengthening, deformity correction and weight bearing. Twenty-one consecutive patients were studied. The mean age at onset of disease was 52 years (range 4-70). Mean duration of the problem was 59.9 months (6-372). Aetiology included traumatic arthritis in 5, traumatic arthritis with osteomyelitis in 1, failed ankle fusion in 8, septic arthritis in 1, infected ankle fracture nonunion in 1, avascular necrosis of talus in 1, congenital deformity in 3 and failed ankle arthroplasty in 1. 15 patients had deformity of the ankle at the time of presentation. 15 of the 21 patients had either clinical or radiological evidence of infection. Treatment principles involved local excision, deformity correction with good alignment and soft tissue management. Static Compression was achieved with an Ilizarov frame while dynamic fixation was performed in 3 cases for lengthening. Antibiotics treatment was continued until union in the infected cases. On achieving union the frame was removed and a below knee cast was applied for 4 weeks.Introduction
Patients and methods
Acetabular bone loss is a problem in primary and revision Total Hip Joint Replacement (THJR). Impaction bone grafting is one method of dealing with this problem. We looked at the results of two surgeons who use this method at North Shore Hospital, Auckland. A retrospective study was carried out on all patients who had acetabular impaction bone grafting carried out as part of THJR, whether primary or revision. All operations were performed by two surgeons, Mr Rob Sharp and Mr Bill Farrington. Patients were assessed in clinic at varying time intervals post grafting, and were functionally scored. 33 patients underwent impaction grafting, a total of 35 acetabular grafts. Of these the male to female ratio was 16:17, and the mean age range was 46–82 years. Average Harris hip score was 79 (Min 54 Max 95), and the average Oxford score was 39 (min 13 Max 48). There was one failure, 3 dislocations, and1 sciatic nerve palsy. Impaction bone grafting is one method, which can be utilised to reconstruct acetabular bone loss, with the additional advantage of restoring bone stock. We found high rates of patient satisfaction, and a low failure rate.
According to the National Institute of Clinical Excellence (NICE) Guidelines, some foot and ankle patients are, by definition, at high risk of DVT/PE. Despite NICE guidance, DVT recommendations are still controversial, and are being reviewed by the BOA to be more operation and context specific. One consultant at our institution therefore initiated a 6 week medical DVT prophylaxis regimen for all his post-operative hind–foot surgery patients who were placed in plaster. From January 2007 to February 2008 we audited 97 hind-foot patients to measure their compliance rate, complications and DVT/PE rate. Compliance was excellent (97%) particularly with regard to Low Molecular Weight Heparin (LMWH), but only 70% had medication prescribed for the 6 weeks, and 3% developed a DVT. Self administered LMWH is acceptable and compliance is excellent in post operative orthopaedic patients, but not necessarily effective.
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.
