Category: Hindfoot, Midfoot/Forefoot Introduction/Purpose: Maintenance of the medial longitudinal arch is crucial to efficient kinematics in gait. It is supported by as complex interplay of osseous structures, ligaments, extrinsic tendons and plantar fascia. Two ligaments critical to stabilising the medial longitudinal arch are the Spring (Calcaneofibular) and Naviculocuneiform ligaments. The Spring Ligament serves as a sling within the “Acetabulum Pedis” to orientate the Talus relative to the Calcaneus and Navicular. The Naviculocuneiform ligament is an important plantar tension band and a separate entity to the Posterior Tibial Tendon (PTT) insertion. Attenuation of these ligaments leads to Pes Planus deformity and subsequent defunctioning of the PTT. This study evaluates the functional and radiological outcomes of Spring and Naviculocuneiform ligament reconstruction using Hamstring (Semitendinosis) Allograft and Synthetic ligament (Internal BraceTM, Arthrex). Methods: 33 consecutive Pes Planus reconstructions were performed between 11/11/2013 and 06/03/2018. All patients were followed up prospectively with serial radiographs and functional scores including; MOXFQ, EQF5D and VAS. Minimum follow up was six months. At the midpoint during the study there was transition to using Synthetic Ligament instead of allograft. This was due to availability and ease of use. Surgical technique for both reconstructions included a proximal medial gastrocnemius recession and medialising calcaneal osteotomy. For allograft reconstructions, a pre-tensioned Semitendinosis allograft was fixed proximally to Talar neck using a tenodesis screw and passed plantar to PTT and through a bone tunnel in the medial cuneiform. Synthetic ligaments were inserted from the Sustentaculum Tali to the medial cuneiform in a hammock fashion. In both reconstructions tendinopathic PTTs were excised and a Flexor Digitorum Longus transfer used. Results: There were 17 synthetic ligament reconstructions (6 male, 11 female) and 16 allograft reconstructions (6 male, 10 female). Groups were matched pre-operatively for age, functional scores and radiological markers (T test P values >0.05). At six months significantly better improvements were observed in the synthetic ligament group compared to allograft group with regards to VAS, MOXFQ pain score, Meary’s line, 1st metatarsal Talus angle, Talonavicular uncoverage angle and Hindfoot alignment (T test P < 0.05). Statistical significance was maintained at 12 months with the synthetic ligament providing a significantly better reduction of Meary’s line 1st Metatarsal Talar angle, Talonavicular uncoverage and hindfoot alignment. 2 patients were revised to double fusions in the allograft group and 1 patient revised in the synthetic ligament group. Conclusion: Statistically significant improved functional scores and radiological appearance can be found up to 1 year following Synthetic ligament reconstruction of the Spring and Naviculocuneiform ligaments when compared to Hamstring allograft.
Category: Ankle, Trauma Introduction/Purpose: With the increase in the use of CT scanning and fragment specific fixation for complex ankle fractures, utilisation of multiple surgical approaches has increased. The posterolateral approach has been advocated by many, however in our experience, a large proportion of these fractures are not attainable by this approach. Our aim in this study was to analyse three posterior ankle approaches to find their use and efficacy in accessing the posterior tibia in the fixation of posterior malleolar fractures. Methods: We examined 5 fresh frozen cadaveric lower limbs. Three posterior ankle approaches (posterolateral (PL), posteromedial (PM) and medial posteromedial (MPM) approaches were performed, using a consistent repeatable incision of 7 cm extended proximal from the palpable distal extent of the medial malleolus. In both the PL and PM approaches, the flexor hallucis longus (FHL) was taken medially. In the MPM approach, the access was anterior to tibialis posterior (TP). K-wires were then placed parallel to one another at the 4 extremities of the approach. The ankles were imaged using an image intensifier and the distances measured. Our database of 172 consecutively treated posterior malleolar fractures in our department, was used to analyse the fracture fragment size and compare these fracture patterns to the approaches. The fractures were categorised using the Mason and Molloy classification. Only type 2 and 3 fractures were included, leaving 101 in the study. Results: On radiographic analysis, the type 2B and type 3 fractures incorporate 100% and 83% of the posterior width of the tibia respectively. Considering the PL approach only allows access to 40% of the posterior width of the tibia, another approach is required for these fracture patterns. Only 65% of fractures could be adequately exposed using the PL incision. In comparison, 78% of fractures could be exposed using the PM incision. The MPM incision gave the largest area for access to the posterior tibia, however it did not allow access to the constant posterolateral fragment. Only 35% of patients had posteromedial fractures that could be dealt with using the MPM incision, thus its usage is primarily as a supplementary incision, in conjunction with the PL incision. Conclusion: We conclude that the most commonly used approach (the PL approach) gives the least amount of access to the posterior tibia. In comparison to fracture fragment size, almost half of fractures would not be adequately exposed through the PL approach, and if fixing such fractures the surgeon should be comfortable with multiple approaches.
Category: Other Introduction/Purpose: There is wide variation in the threshold and provision of thromboprophylaxis in the treatment of foot and ankle conditions. One of the difficulties in affecting change in practice in this area is the low incidence of postoperative, symptomatic VTE. Therefore, a large number of patients need to be included in any series for meaningful conclusions to be drawn. Primary objective To observe the UK-wide variation in post-operative thromboprophylaxis, and to analyse the 90-day incidence of symptomatic venous thrombo-embolism related to: -Elective foot and ankle surgery -Trauma foot and ankle surgery -Treatment of Achilles tendon ruptures (operative and non-operative) Methods: This was a multi-centre prospective audit spanning a collection duration of 9 months. Primary outcomes included symptomatic VTE up to 90 days following foot & ankle surgery and Achilles tendon rupture and VTE related mortality up to 90 days following treatment. Secondary outcomes included methods of thromboprophylaxis used, and possible confounding variables and influencing factors for VTE. Results: A total of 10,983 patients were included from 56 sites in the UK. This was split into 51.72% trauma (n=5571), 3.78% diabetic surgery (n=415) and 45.18% elective surgery (n=4962). There was 95 VTE events across the whole cohort (0.86%). Diabetic foot disease surgery had the highest rate of VTE (Below knee amputation 5.3% and acute foot debridement 2.6%). The trauma diagnosis with the highest rate of VTE was Achilles tendon rupture (3.7%). All elective foot procedures had a VTE rate < 1% except elective tendon procedure (1.1%). Factors with statistically significant association with VTE included trauma surgery where prophylaxis stopped greater than 1day pre surgery (p=.027), non-compliance with prophylaxis (p=.001), post-surgical infection (p=.005), and the comorbidities asthma (p=.014), cancer (p=.014), dementia (p=.001), diabetes (p=.005), stroke (p < 0.001) and recent long-distance travel (p=.048). Conclusion: This is a large-scale multicentre study which recorded multiple possible confounding variables. There were 12 different chemical prophylaxis used across the study, with the highest rate of VTE in patients administered Apixaban (4.9%). The most common chemical prophylaxis used in the study was Enoxaparin (27.19%) followed by Dalteparin (20.38%). There was no evidence of a decrease in VTE if mechanical prophylaxis was used. The study identified specific diagnosis with increased risk of VTE and comorbidities.
Abstract Background Medial Malleolus Fractures (MMF) are frequently managed by orthopaedic surgeons and are one of the most treated fractures of the ankle. Many approaches to management are described in the literature however, their morphology is under investigated. Method Patients who had surgical fixation of their MMF were identified from 2012 to 2022. Analysis of their pre-operative, intra-operative and post-operative radiographs was performed. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology. Results A total of 647 patients were identified across a 10-year period who had sustained a medial malleolar fracture. The most common Herscovici fracture in Supination Adduction injuries was a Herscovici D (43.9%, 17/39), in supination external rotation injuries was Herscovici C (52.75%, 259/491), in pronation external rotation injuries was Herscovici C (48.81%, 41/84) and in pronation abduction injuries was Herscovici B (45.45%, 12/33). Medial wall blowout occurred in 19.23%, occurring in supination adduction injuries most commonly (51.28%, 20/39). Herscovici A fractures were significantly more malreduced at time of surgery compared to other fracture types (21.88%, 7/32, p = .003). There was no significant difference in union rates across the classification groups (range 11.67% Herscovici D to 22.86% for Herscovici B). Conclusions Knowledge of the medial malleolar morphology allows greater assessment and planning in their surgical treatment. There was a high rate of medial wall blowout even in the non-adduction fracture types, and this should be assessed to prevent over compression during surgical treatment. Herscovici A fracture malunions may need further investigation and different methods of fixation.
Ankle fracture malreduction has been shown to result in poor long-term functional outcomes. Varying methods can be used to change practice and thereby outcomes. We present over four years' worth of results with the effects of different techniques for change.Two audit cycles were performed incorporating three audit data collections; an initial standard setting audit in 2013, with re-audits in 2015 and 2017. Between the first and second audit was a period of education and reflection. Between the second and third audit there was a change in process in ankle fracture management supported by education. Image intensifier films were reviewed on the hospital picture archiving and communication system, by at least two blinded observers in each cycle. These were scored based on the criteria published by Pettrone et al.In the initial audit in 2013, there were 94 patients, with a malreduction rate of 33%. In the second audit in 2015, there were 68 patients, with an increase in malreduction rate to 43.8%. In the third audit in 2017, there were 205 patients, with a significant decrease in malreduction rate to 2.4%. The final major complication rate was 0.98%. The rate of deep infection was 0.5%.By recognising and addressing the need to improve the quality of ankle fracture fixation, we have made significant improvements in radiological outcomes. Education alone, without system change, was not successful in our department in achieving improved outcomes.
Category: Midfoot/Forefoot Introduction/Purpose: The incompetence of both dynamic and static structures in the foot is responsible for acquired pes planus deformity. The aim of this study was to identify the anatomical location of the midfoot break in symptomatic pes planus deformity, and its relationship with other pes planus radiographic foot measurements. Methods: We completed the radiographic evaluation of 75 feet diagnosed with symptomatic pes planus. The break in the medial column line (Meary’s line) was measured on the lateral radiograph at the intersection of the anatomical axis of the talus and the first metatarsal. Pes planus measurements were performed on each the weight-bearing AP and lateral radiographs, including talonavicular coverage angle, talar – first/ second metatarsal angle, talar uncoverage, talocalcaneal angle, Meary’s angle line break, calcaneal and talar inclination, talocalcaneal angle, cuneiform - metatarsal, tarsal joints angles and distances. Due to Gaussian distribution, unpaired t-test and ANOVA tests were used. Results: The medial column line collapse was at the talonavicular joint in 77.3%, naviculocuneiform in 20%, and cuneiform metatarsal in 2.6%. The line angle severity was proportional to the talonavicular coverage angle and talar uncoverage (p 0.001, R2 0.4915 and P 0.003, R2 0.223). On comparison of the 3 line-break groups, the talocalcaneal angle was significantly higher when the line break was at talonavicular joint (P 0.001) although Meary’s angle was not significantly more severe. Conclusion: The apex of the medial column collapse occurs not only at the talonavicular joint but also distal to the spring ligament and tibialis posterior insertion. Foot abduction increases with the increase in the line collapse regardless of the breaking point. Talus flexion is worse if the arch collapse is at the talonavicular joint, suggesting incompetency of the spring ligament. Assessing the apex of deformity is essential to decide the correct operative strategy.
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