Audit of foot and ankle surgeons’ management of acute peroneal tendon tears and review of management protocols

IntroductionThe aim of this audit was to identify whether there is consistent and successful management of acute peroneal tendon tears within orthopaedic foot and ankle consultants in the Wessex area of the UK. It was suspected that there was an absence of consistency between surgeons’ practices and a more evidenced based management protocol could be developed.Materials and methodsA questionnaire of the orthopaedic surgeons in Wessex investigated whether there was consistency in surgical management of peroneal tears.ResultsOur results demonstrate that each of the nine surgeons’ management of acute peroneal tendon tears varied greatly.ConclusionThe evidence in the literature was examined in an attempt to produce a protocol to aid surgical decision-making. A randomised controlled trial is required for consistent evidenced based surgical management of peroneal tendon tears.     

☆Diagnostic and therapeutic injections of the foot and ankle—An overview

Foot and ankle injections are useful diagnostic and therapeutic tools, particularly when the pain etiology is uncertain. A variety of foot and ankle injuries and pathologies, including degenerative joint disease, plantar fasciitis and different tendinopathies are amenable to injections. Understanding the foot and ankle anatomical landmarks, a thorough physical exam and knowledge of the different injection techniques is key for a successful approach to different pathologies. The objective of this study is to review the use of foot and ankle injections in the orthopaedic literature, present the readers with the senior author's experience and provide a comprehensive clinical guideline to the most common foot and ankle diagnostic and therapeutic injections.     

The importance of the early appropriate management of foot and ankle soft tissue sarcomas – experiences of a regional sarcoma service

IntroductionSoft tissue sarcomas (STS) are a group of rare malignant tumours that can occur at almost any anatomical location in patients of any age, which often present to health care professional working outside a recognised sarcoma service. A review of foot and ankle STSs was conducted, reporting on patient and tumour characteristics, and patient outcome following surgery performed within and outside our sarcoma service.Patients and methodsA retrospective review of all foot and ankle STSs managed by our sarcoma service over a 14 year period was performed. Patient demographics, tumour characteristics, management and patient outcomes including recurrence rates and survival were analysed.ResultsTwenty-six patients were analysed (16F:10M) with a mean age of 57.7 years (range 17–87). The mean follow-up was 6.3 years (range 1–16). Sixteen tumours involved the foot, nine the ankle, and one spanned the foot and ankle. Mean tumour size was 4.3 cm (range 0.8–15), although 61% of cases were smaller than 4 cm, and almost one third of cases smaller than 1 cm. Seven of 26 (27%) cases were diagnosed after an unplanned excision performed by non sarcoma surgeons. These patients were more likely to undergo an incomplete tumour excision (p < 0.001), suffer local recurrence (p = 0.001), and eventually undergo a secondary amputation (p = 0.034) than those patients managed exclusively by a sarcoma service. Overall, 12 (46%) patients died of their disease during follow up, equating to a five-year survival rate of 69%.ConclusionOur data shows that unplanned excisions continue to be performed on foot and ankle STSs, and that these have detrimental effects on patients. Despite this, our results also show that these complex patients can be managed successfully when referred appropriately to a sarcoma service, prior to any surgical treatment. This highlights the importance of vigilance amongst all health care professionals managing any foot or ankle lumps, regardless of their size.     

The forgotten foot – An assessment of foot and ankle radiograph pathology in final year medical students

IntroductionIt has been shown that doctors in Emergency Departments (EDs) have inconsistent knowledge of musculoskeletal anatomy. This is most likely due to a deficiency in focused musculoskeletal modules at undergraduate level in medical school. The aims of this study were to evaluate the knowledge of final year medical students on foot anatomy and common foot and ankle pathology as seen on radiographs.MethodsFinal year medical students were asked to complete our short examination on a handout. The handout was anonymous and non-mandatory. There were four images. The first image is the anatomical section and the remaining images are the pathological section.ResultsAll 235 students responded. 57% were females. For the identification of the normal bones of the foot as shown on an X-ray, the average score for the group was 2.69 (out of a maximum of 6) {SD 1.67}7. Only 8.3% achieved a 6/6 or 100% grade i.e. recognising all six bones correctly. A further 8.3% achieved 5/6 (83%). 8.3% failed to correctly identify any bone seen on the X-ray, a corresponding score of 0.DiscussionThis quick test showed normal anatomy of the foot and common pathology. One would expect final year medical students to be familiar with, especially two weeks before their finals in surgery. The curriculum should address the paucity of time spent in educating students in foot and ankle pathology.     

Correction of ankle and hind foot deformity in Charcot neuroarthropathy using a retrograde hind foot nail—The Kings’ Experience

Background

Corrective fusion for the unstable deformed hind foot and mid foot in Charcot Neuroarthropathy (CN) is quite challenging and is best done in tertiary centres under the supervision of multidisciplinary teams.

Extracorporeal shock wave treatment in foot and ankle fracture non-unions — A review

BackgroundThe authors reviewed the current evidence and conducted a comprehensive review on the use of extracorporeal shock wave therapy (ESWT) in the treatment of foot and ankle fracture non-unions.MethodsFour databases were searched to identify relevant studies in the available literature.ResultsEight studies were reviewed, demonstrating union rates of 65%–100% and 90–100% at 3- and 6-months following ESWT treatment respectively. No major complications were seen in any of the studies. Minor complications included local soft tissue swelling, petechiae, bruising and pain.ConclusionsThe literature that is currently available is limited to case series of relatively small sample sizes, highlighting the need for a prospective randomised controlled trial to further investigate the efficacy of ESWT in the treatment of foot and ankle fracture non-unions.     

Chondromyxoid fibroma of the foot and ankle: 40 years’ Scottish bone tumour registry experience

Ten cases of histologically proven chondromyxoid fibroma (CMF) of the foot and ankle with a mean follow-up of 6.1 years were retrospectively reviewed using the Scottish Bone Tumour Registry. The patients' mean age was 19 years; there were six males and four females. The anatomical locations were five phalangeal, three metatarsal, one tarsal affecting body of os calcis and one distal tibial. The median delay in presentation was 4.5 months. The modes of presentation were pain only (n=4), painful lump (n=4) and painless lump (n=2). The typical radiological finding was an expansile, lobulated, cystic lesion. Cortical erosion was documented in 80% patients. In four cases, curettage alone was carried out, while five patients underwent curettage along with autogenous bone grafting. One patient with distal phalangeal CMF had a primary toe amputation. Two patients had recurrences 9 and 16 months after their initial curettage. Both of them were males with proximal phalangeal CMF, associated with cortical erosion. Foot and phalangeal CMF initially treated with curettage only should be closely followed up, as we observed a 20% recurrence rate within a 2-year period. Cases featuring cortical erosion require thorough curettage and may require autogenous bone grafting to prevent fracture.     

Minimising negative ankle and foot X-rays in the Emergency Department—Are the Ottawa ankle rules good enough?

ObjectivesTo review fracture rates in patients who had X-rays of either the ankle or foot or both in the Emergency Department of a district hospital.MethodA retrospective review of 2589 Emergency Department patients who had X-rays of the ankle or foot or both over a 12-month period.ResultsThere were 1199 ankle X-rays taken of which 193 (16%) showed a significant fracture. There were 1081 patients who had a foot X-rayed of which 165 (15%) showed a significant fracture. Younger patients had more X-rays but older patients were more likely to have a fracture. There were 309 patients who had an ipsilateral ankle and foot X-rayed at the same time, and of these 42 (14%) showed one fracture and just two (0.6%) showed a significant fracture of both ankle and foot.ConclusionsThe approach to X-raying ankle and feet in this study is probably widespread, and Ottawa Ankle Rules still seem to be of limited use in diagnosing fractures. This low yield of positive X-ray could be accepted or a more sophisticated ankle rule introduced.     

Is there a correlation between static radiographs and dynamic foot function in pediatric foot deformities?

BackgroundIdiopathic flexible flatfeet, congenital clubfeet and pes cavovarus are the most common foot deformities in children. Accurate assessment to quantify the severity of these deformities by clinical examination alone can be challenging. Radiographs are a valuable adjunct for accurate diagnosis and effective treatment. However, static radiographs during relaxed standing may not reflect the dynamic changes in the foot skeleton during functional activities such as walking. Therefore, the aim of this study is to predict dynamic foot movements during walking from planar standing radiographs to reveal the significance of the radiographic analysis for the assessment of foot function.MethodsPatients 8–17 years with flexible flatfeet (FFF, n = 217) recurrent clubfeet (RCF n = 38) and overcorrected clubfeet (OCCF, n = 71) of non-neurogenic or syndromic origin and pes cavovarus due to peripheral neuropathy (PNP, n = 48) were retrospectively included. Patients underwent gait analysis with the Oxford Foot Model and radiographic examination in anterior-posterior and lateral view during standing. Multilinear predictor analysis of selected gait parameters was performed based on radiographic measures.ResultsThe variance that was explained by radiography was greatest for the transverse plane forefoot abduction with 33% for OCCF, 50% for RCF and 59% for PNP. Flatfeet and foot kinematics in the other planes or between rearfoot and tibia showed little or no relation.ConclusionsThe static measures of foot deformities by radiography could explain only a small amount of variance in foot kinematics during walking, in particular for FFF. An explanation may be that the forces during weight bearing bear little resemblance to those during gait in terms of neither magnitude nor direction. These findings suggest that foot function cannot be accurately assessed solely from static radiographic observations of the foot, commonly undertaken in clinical practice.     

The UK foot and ankle COVID-19 national (FAlCoN) audit – Regional variations in COVID-19 infection and national foot and ankle surgical activity

AimsThis paper details the impact of COVID-19 on foot and ankle activity in the UK. It describes regional variations and COVID-19 infection rate in patients undergoing foot and ankle surgery before, during and after the first national lock-down.Patients & methodsThis was a multicentre, retrospective, UK-based, national audit on foot and ankle patients who underwent surgery between 13th January and 31st July 2020. Data was examined pre- UK national lockdown, during lockdown (23rd March to 11th May 2020) and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Regional, demographic and COVID-19 related data were captured.Results6644 patients were included. In total 0.53% of operated patients contracted COVID-19 (n = 35). The rate of COVID-19 infection was highest during lockdown (2.11%, n = 16) and lowest after lockdown (0.16%, n = 3). Overall mean activity during lockdown was 24.44% of pre-lockdown activity with decreases in trauma, diabetic and elective foot and ankle surgery; the change in elective surgery was most marked with only 1.73% activity during lock down and 10.72% activity post lockdown as compared to pre-lockdown. There was marked regional variation in numbers of cases performed, but the proportion of decrease in cases during and after lockdown was comparable between all regions. There was also a significant difference between rates of COVID-19 and timing of peak, cumulative COVID-19 infections between regions with the highest rate noted in South East England (3.21%). The overall national peak infection rate was 1.37%, occurring during the final week of lockdown. General anaesthetic remained the most common method of anaesthesia for foot and ankle surgery, although a significant increase in regional anaesthesia was witnessed in the lock-down and post-lockdown periods.ConclusionsNational surgical activity reduced significantly for all cases across the country during lockdown with only a slow subsequent increase in elective activity. The COVID-19 infection rate and peaks differed significantly across the country.     

Home therapy pathway – Safe and streamlined method of initial management of ankle fractures

BackgroundAnkle fractures requiring operative fixation often swell up after 24 h and surgery during this period is not feasible as there are several associated risks including infection and wound breakdown. The affected limb is kept elevated usually in hospital and once the swelling has sufficiently subsided then the operation takes place. We conducted a study looking at the impact of a home therapy ankle pathway on the length of stay and safety of patients with ankle fractures requiring surgical fixation.MethodsThe length of stay of a control group was studied from December 2009 to March 2010. The home therapy ankle pathway was then introduced in August 2010. If patients could not have their operation within 24 h then they were placed in a Plaster of Paris back slab in casualty with the ankle reduced, limb care advice given – elevation, cooling and DVT thromboprophylaxis – and the patient was discharged home on crutches after a slot was determined on the trauma list typically six days later. The patient was also given an emergency contact number in case an untoward event occurred, and they were called at least once during their home stay by hospital staff to ensure all was well. Patients who were unsafe to be discharged on home therapy were admitted. This cohort of patients was studied between August 2010 and December 2011ResultsIn the control group, 49 ankle fractures required operative intervention. The mean pre-operative length of stay was 2.88 days and the mean post op length of stay was 5 days. Between August 2010 and December 2011, after implementation of the pathway, 176 ankle fractures requiring operative treatment presented to the orthopaedic department. Of these, 105 were eligible for home therapy on the ankle pathway prior to surgery. The average pre-operative length of stay on the pathway was 0.17 days. The average post op length of stay was 1.72 days (P < 0.001 in all modalities). Home therapy was carried out for an average of 6.63 days. Challenges of home therapy included persistent swelling and blistering (11), loss of reduction (4), poor pain management whilst at home (4) and cancellation due to lack of availability of a theatre slot (6).ConclusionWith patients in whom it is indicated, the home therapy ankle pathway has proved to be a safe and resource sparing method of managing ankle fractures prior to surgery.     

Off-label use and prescribing: what does it mean for the foot and ankle surgeon?

Drugs and medical devices obtain specific on-label indications for use by the Food and Drug Administration. Physicians are able to use such devices and drugs off label as part of the practice of medicine, but is this is good thing? This edition of In the Profession examines what it means to be off label in terms of regulations, clinical studies, industry marketing, and common areas of use.     

Is there a learning curve in foot and ankle surgery?

BackgroundPrevious studies of orthopaedic learning curves have largely described the introduction of new techniques to experienced consultants. End points have usually involved technical considerations. A paucity of evidence surrounds foot and ankle surgery. This study investigates the learning curve during a foot and ankle surgeon's first year, defined by functional outcome.Methods150 patients underwent elective foot or ankle surgery during the whole period. Preoperative and 6 month postoperative functional scores were compared between the first and second 6 month groups.ResultsFunctional improvement was greater, approaching significance, in the second group (p = 0.0605). There was no difference for forefoot cases (p = 0.345). Functional improvement was significantly greater in the second group with forefoot cases removed (p = 0.0333).ConclusionsA learning curve exists in the first year of practice of foot and ankle surgery, demonstrated by functional outcome. This is confined to ankle, hindfoot and midfoot, but not forefoot surgery.