Introduction: Surgical treatments for ankle arthritis include arthrodesis and total ankle replacement (TAR). Whilst arthrodesis has reasonable midterm results, longer term data has identified concerns, such as progressive arthritis of adjacent joints. There are more than 10 TAR designs available in Europe alone, each with limited published outcomes. In order to understand current practice and perceptions in relation to ankle replacement, a questionnaire based survey was carried out by email and post to all Consultant members of BOFAS based in the UK (n=180).

Results: 123 completed questionnaires were returned (68%). Thirty Seven (30%) respondents said they were not currently carrying out joint replacement. There was wide variation amongst surgeons in the types of prosthesis used. A small number of surgeons were responsible for the majority of the volume of TAR surgery carried out in the UK. The median number of ankle replacements carried out per year, by surgeons who are performing ankle replacement was 8 (range 1–55) compared to 13 (range 3–55) for ankle arthrodesis. 97.5% of respondents supported the creation of a national joint register for ankle replacements.

Conclusion: This is the first report of the current status quo in the UK with regards the use of total ankle replacement. It is estimated that at least 1281 ankle replacements are carried out per year in the UK. 72% of surgeons that are performing ankle replacements in the UK carry out less than 8 ankle replacements per year. Single surgeon reported series with such small numbers is unlikely to yield meaningful data. An increase in the number of surgeons performing ankle replacements coupled with a rapid proliferation in the number of available implants might lead to early failure and poor outcomes and this would point to the necessity for a National Joint Register for ankle replacements.

Introduction: Acquired pes planus is caused by mechanical uncoupling of the bones of the tarsus due to failure of the osseoligamentous complex that maintains the medial longitudinal arch of the foot. The most common cause of acquired flat foot deformity in adults is posterior tibialis tendon dysfunction. A solitary previous case report has documented an alternative aetiology of acquired flat foot in adults due to isolated spring ligament rupture; in that case diagnosis was made intra-operatively.

Materials and Methods: We present 9 cases of acquired flat foot deformity that were caused by isolated spring ligament insufficiency, mainly presenting after an eversion injury of the ankle. We present the clinical sign of ability to single leg tiptoe, but with persistent forefoot abduction and heel valgus, that allows differentiation of this diagnosis from posterior tibialis tendon dysfunction. In addition we illustrate the radiological features of this condition which have not been previously described and allow confirmation of the diagnosis non-operatively.

Results: Six patients have been managed with orthotics and three underwent surgery; one patient who presented early had an isolated repair of the spring ligament complex and has done well. The remaining two patients required a calcaneal osteotomy and Flexor Digitorum Longus transfer as for a PTT reconstruction. In all these three patients the spring ligament was found to be completely ruptured during surgery.

Discussion: This type of injury may not be as rare as previously thought and demonstrates the importance of the spring ligament on its own in maintaining the medial longitudinal arch. Awareness of this condition could lead to earlier diagnosis and better prognosis with earlier treatment.

Conclusion: We propose that early diagnosis (with ultrasound confirmation) and management of this condition would offer a better prognosis and allow less interventional surgery.

Introduction: In June 2006, the post-operative plaster immobilisation protocol for patients undergoing foot and ankle surgery at our institution changed from multiple plaster changes to the immediate application of a definitive reusable split synthetic cast. This study aims to assess the savings following this change in practice.

Materials and Methods: A retrospective analysis of plaster room records from June 2005 to June 2007 was performed.

The original procedure involved application of a plaster backslab following surgery, change of cast on day 1 post operatively, suture removal and plaster change at two weeks post-operation and cast removal or bivalving six weeks post-operation, following outpatient review.

The new procedure utilised a reusable cast applied in theatre which allowed suture removal and wound inspection in the community and outpatient review at six weeks without plaster change.

Results: Two hundred and twenty-two patients from 2005–6 were managed with the plaster procedure at a cost of £344.98 per patient and a total cost of £76,586.56. While 203 patients from 2006–7 were managed with the new procedure at a cost of £147.10 per patient and a total cost of £29,861.30. The net saving to the hospital of this change in practice was £197.88 per patient and £40,169.64 in total. There were no referrals back to the hospital as a consequence of this change in practice.

Discussion: Plaster changes and hospital outpatient appointments add cost to surgical procedures. This simple change in the post-operative casting of foot and ankle patients resulted in less outpatient visits and plaster changes without compromising the standard of medical care.

Conclusions: In the current political and financial climate it is important that economic efficiency, at a local level. This study demonstrates how small changes in local practice can result in significant financial savings for hospitals.

Introduction: The first line treatment in our centre for Morton’s neuroma (MN), sufficient to warrant intervention, is a peri-neural Ultrasound guided injection of corticosteroid (USI).

The NHS will soon implement 18 week referral to treatment targets.

A prospective study was performed whereby from 2004–6, referral letters from General Practitioners suggesting a diagnosis specifically of Morton’s neuroma, resulted in randomised assignment to either direct referral for USI or to the specialist Foot and Ankle outpatient clinic.

Patients with less specific referral letters were evaluated in clinic and referred for USI as appropriate.

A comparison was made of the sensitivity and specificity of the referral pathways, financial implications and the time to treatment (TTT).

Results: 121 patients were referred for USI.

Of 57 patients for whom the GP had diagnosed a MN, 40 (70%) had the diagnosis confirmed on USI (other diagnoses were: 7 NAD, 3 ganglions, 2 bursae, 2 degenerative change, 1 glomus tumour, 1 angioleiomyoma, 1 SOL); this was comparable to the overall number referred to radiology with a suspected MN (69%).

In the directly referred group, the mean TTT was 115 days (95%CI = 89 – 141), compared to 241 days (95%CI = 223 – 259) for those patients who went via a Foot and Ankle clinic. P< 0.0001.

Conclusion: For patients with features highly suggestive of a Morton’s neuroma, direct referral from primary care for USI has a similar sensitivity and specificity to referral from a specialist hospital clinic and the TTT is significantly shorter.

The mean wait of this group is within the 18 week government target without any changes to our current radiology protocols. Using this direct referral protocol we saved 29 outpatient appointments; if followed for all eligible patients we would have saved 57 outpatient appointments.

Correction of valgus deformity of the hindfoot using a medial approach for a triple fusion has only recently been described for patients with tight lateral soft tissues which would be compromised using the traditional lateral approach. We present a series of eight patients with fixed valgus deformity of the hindfoot who had correction by hindfoot fusion using this approach.

In addition, we further extended the indications to allow concomitant ankle fusion. The medial approach allowed us to excise medial ulcers caused by the prominent medial bony structures, giving simultaneous correction of the deformity and successful internal fixation.

We had no problems with primary wound healing and experienced no subsequent infection or wound breakdown. From a mean fixed valgus deformity of 58.8° (45° to 66°) pre-operatively, we achieved a mean post-operative valgus angulation of 13.6° (7° to 23°). All the feet were subsequently accommodated in shoes. The mean time to arthrodesis was 5.25 months (3 to 9).

We therefore recommend the medial approach for the correction of severe fixed valgus hindfoot deformities.

Advances in the design of the components for total ankle replacement have led to a resurgence of interest in this procedure.

Between January 1999 and December 2004, 16 patients with a failed total ankle replacement were referred to our unit. In the presence of infection, a two-stage salvage procedure was planned. The first involved the removal of the components and the insertion of a cement spacer. Definitive treatment options included hindfoot fusion with a circular frame or amputation. When there was no infection, a one-stage salvage procedure was planned. Options included hindfoot fusion with an intramedullary nail or revision total ankle replacement. When there was suspicion of infection, a percutaneous biopsy was performed. The patients were followed up for a minimum of 12 months.

Of the 16 patients, 14 had aseptic loosening, five of whom underwent a revision total ankle replacement and nine a hindfoot fusion. Of the two with infection, one underwent fusion and the other a below-knee amputation. There were no cases of wound breakdown, nonunion or malunion.

Management of the failed total ankle replacement should be performed by experienced surgeons and ideally in units where multidisciplinary support is available. Currently, a hindfoot fusion appears to be preferable to a revision total ankle replacement.

We investigated 29 cases, diagnosed clinically as having Morton’s neuroma, who had undergone MRI and ultrasound before a neurectomy. The accuracy with which pre-operative clinical assessment, ultrasound and MRI had correctly diagnosed the presence of a neuroma were compared with one another based on the histology and the clinical outcome.

Clinical assessment was the most sensitive and specific modality. The accuracy of the ultrasound and MRI was similar and dependent on size. Ultrasound was especially inaccurate for small lesions.

There was no correlation between the size of the lesion and either the pre-operative pain score or the change in pain score following surgery.

Reliance on single modality imaging would have led to inaccurate diagnosis in 18 cases and would have only benefited one patient. Even imaging with both modalities failed to meet the predictive values attained by clinical assessment.

There is no requirement for ultrasound or MRI in patients who are thought to have a Morton’s neuroma. Small lesions, < 6 mm in size, are equally able to cause symptoms as larger lesions. Neurectomy provides an excellent clinical outcome in most cases.

Patient warming systems are used routinely to prevent hypothermia under anaesthetic, the benefits of which have been clearly shown in the anaesthetic literature. We were concerned that since these systems take ‘dirty’ air from floor level and distribute it over the patient, bacterial counts could be increased. Also, airflow under the blanket itself could disturb the patients’ own skin cells and thereby influence bacterial counts.

With slit air sampling we analysed air quality at the simulated operative site by passing a known volume of air over an agar plate (tryptone glucose yeast). Using probability curves we were able to calculate the volume of air required to detect 1 colony forming unit (CFU) per m³ with 97% confidence. All tests were performed in an ultra clean air laminar flow theatre.

We assessed the effect of varying degrees of skin shedding under the warming blanket using volunteer patients with Psoriasis. We also simulated activity outside the lamina flow to determine whether counts on the table were influenced.

No colonies were grown in any of the study groups. Plates exposed outside the laminar flow area at floor level showed a relatively high level of contamination. We therefore conclude that the WarmTouch warming system does not influence bacterial counts at the operative site in ultraclean air ventilated theatres.

Patient warming systems are used routinely to prevent hypothermia under anaesthesia. Airflow from warming blankets may potentially influence bacterial counts either by pumping ‘dirty air’ from floor level to the operating area or by blowing the patients’ skin cells into the operating field from airflow under the blanket. Using slit-air sampling we analysed the air quality within a laminar-flow theatre at a simulated operating site. We assessed the effect of ‘high shedding of skin’ under the blanket using volunteer patients with psoriasis. We also simulated general theatre activity outside the laminar-flow area in order to determine whether the bacterial counts in the operating field were affected.

No colonies were grown in any of the groups tested and our results suggest that the patient warming system does not influence bacterial counts at the operating site in an ultraclean air-ventilated theatre, even with patients who have high shedding of skin cells.