P.H. Cooke

Acquired adult flat foot due to isolated plantar calcaneonavicular (spring) ligament insufficiency with a normal tibialis posterior tendon

BACKGROUND We present nine cases of acquired flat foot deformity (AFFD) in adults caused by isolated spring ligament insufficiency. METHODS We present the clinical sign that allows differentiation of this diagnosis from posterior tibialis tendon (PTT) dysfunction namely the ability to single leg tiptoe, but with persistent forefoot abduction and heel valgus. In addition we illustrate the unique radiological features which allow confirmation of the diagnosis. Only a solitary previous case report has documented this alternative aetiology of AFFD; in that case, diagnosis was made intra-operatively. RESULTS Six patients have been managed with orthoses. Three patients underwent surgery; one patient who presented early had isolated repair of the spring ligament complex. The remaining two required a calcaneal osteotomy and flexor digitorum longus transfer as for a PTT reconstruction. CONCLUSION We propose that early diagnosis (with ultrasound confirmation) and management of this condition would offer a better prognosis and allow less interventional surgery.

The Manchester–Oxford Foot Questionnaire (MOXFQ): Development and validation of a summary index score

Objectives 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. Methods 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. Results The mean age of the participants was 52.8 years (sd 15.68; 18 to 89). Higher order principle components factor analysis produced one factor, accounting for 74.7% of the variance. The newly derived single index score was found to be internally reliable (α = 0.93) and valid, achieving at least moderate correlations (r ≥ 0.5, p < 0.001) with related (pain/function) domains of the SF-36. Conclusions Analyses indicated that data from the MOXFQ can be presented in summary form. The MOXFQ summary index score (MOXFQ-Index) provides an overall indication of the outcomes of foot and ankle surgery. Furthermore, the single index reduces the number of statistical comparisons, and hence the role of chance, when exploring MOXFQ data.

The demand incidence of symptomatic ankle osteoarthritis presenting to foot & ankle surgeons in the United Kingdom.

BACKGROUND Ankle arthritis is a cause of major disability; however reports in the literature on the incidence of ankle osteoarthritis are rare. OBJECTIVES To explore the methodological challenges in obtaining an incidence of ankle osteoarthritis and to estimate the incidence of symptomatic osteoarthritis presenting to Foot & Ankle specialists in the UK. METHODS We searched available national diagnosis databases and also sent out a questionnaire-based survey to all Consultant members of the British Orthopaedic Foot & Ankle Society (n=180). RESULTS 123 completed survey questionnaires were returned (68%) with each surgeon seeing on average 160 cases of symptomatic ankle arthritis and performing on average 20 definitive procedures for end-stage ankle osteoarthritis per year. There are no internationally agreed diagnostic or treatment codes specific for ankle osteoarthritis. CONCLUSION There are an estimated 29,000 cases of symptomatic ankle osteoarthritis being referred to specialists in the UK, representing a demand incidence of 47.7 per 100,000. 3000 definitive operations to treat end stage ankle osteoarthritis take place in the UK annually. We recommend that specific codes pertaining to ankle arthritis and its treatment be included in any future revisions of the WHO International Classification of Diseases (ICD) and operative procedure coding systems.

Divot Sign: A New Observation in Anterior Impingement of the Ankle

Anterior impingement of the ankle results from osteophyte formation on the anterior edge of the distal tibia. Classically, subsequent degeneration results in an osteophyte forming on the anterior neck of the talus. This results in limited dorsiflexion and impingement seen in the ankles of athletes. Recent clinical observation in high performance soccer players has revealed a previously unrecognized pattern of a localized divot forming in the talar neck in place of the osteophyte. This accepts the tibial osteophyte during dorsiflexion, which is therefore not limited in these patients.

The use of surgeon-performed ultrasound assessment in a foot and ankle clinic

BACKGROUND We describe the first reported use of ultrasound examination performed by an orthopaedic surgeon in the setting of a foot and ankle clinic. METHODS The senior author attended a course in musculoskeletal ultrasound and performed 100 examinations each checked against the results from a consultant radiologist. Records were kept of all examinations performed in the clinic over a 6-month period with results. RESULTS Of the 622 patients seen, 91 had an ultrasound scan and 36 had guided injections. All patients had one hospital attendance spared, for most two. Time saved on the treatment pathway per patient was on average 6 weeks. CONCLUSION Ultrasound assessment performed by a clinician during an outpatient clinic appointment reduces delay in treatment and cuts costs by reducing patient episodes.

Total Ankle Replacement

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Athroscopic Arthrodesis of the Ankle

Arthroscopic ankle arthrodesis (sometimes also known as arthroscopically assisted) is commonly performed to stabilise the arthritic ankle and provide pain relief.