BOA2015 Posters. Foot & Ankle Surgery

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1 BOA2015 Posters Foot & Ankle Surgery 77 First metatarsal resurfacing for the management of hallux rigidus and its effect on joint range motion Ballal M. 1, Roche A. 1, Calder J. 1 1 Chelsea and Westminster Hospital, Orthopaedics, London, United Kingdom Background: Arthrodesis is the gold-standard surgery for significant hallux rigidus. Some patients are reluctant to consider this, wishing to maintain their metatarsophalangeal joint (MTPJ) motion. Total joint arthroplasty has shown mixed results and failure results in challenging revisions. Metatarsal hemiarthroplasty potentially preserves native bone and is gaining popularity but little data supporting the implants exists. This prospective study reports 18 patients 2-year outcomes following Hemicap replacement. Methods: 1 st MTP Hemicaps implanted between were prospectively analysed. Preoperative assessment included examination, AOFAS, AOS score and radiographs. Peri-operative complications and a minimum 2-year follow-up scores and radiographs were assessed. Results: 18 patients were reviewed. No patients smoked, had diabetes, rheumatoid arthritis or gout. One patient underwent a simultaneous Moberg osteotomy. Mean age was 52 years. At 2-year followup, the mean AOFAS score improved from 53.9 to 77.9 [p< 0.01]. The AOS score improved from 54.8 to 25 [p< 0.01]. 10 were very satisfied, 6 satisfied, 1 partly satisfied and 1 dissatisfied. The average 1 st MTP arc of movement improved from 40 pre-operatively to 44 post-operative. There were no cases of significant radiographic lucency or subsidence. There were no other peri-operative complications and no-one required implant removal. Conclusion(s): Early results suggest Hemicap implants are safe and provide good pain relief for hallux rigidus. Patients should be warned that movement may be maintained but not improved. Implications: Our early results demonstrate that 1st MTPJ hemicaps are good for pain relief with no improvements in range of motion. 171 Preliminary results of the EXOGEN low intensity pulsed ultrasound system in the management of delayed and non-unions in foot and ankle elective fusions Leonidou A. 1, Gorbacev D. 1, Tawfiq O. 1, Jahnich H. 1 1 Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, United Kingdom Background: Non-union is a recognised complication of elective foot and ankle fusions. EXOGEN is a non-invasive self- administered treatment, which delivers low-intensity pulsed ultrasound when applied on the skin over the fusion, aiming to promote healing. This study presents the results of the EXOGEN system in patients with non-unions following foot and ankle elective fusions from our Institution. Methods: Patients were prospectively studied. Demographics, length of treatment, complications as well as final outcome were recorded. Union of the fusion was assessed both clinically and radiologically. Results: Between July 2012 and September 2014, 8 patients received EXOGEN treatment in our institution for delayed or non-unions of elective foot and ankle fusions. 2 patients (25%) achieved union and 6 (75%) did not. 3 patients were female and 5 male. Their mean age was 65 years (range 47-81). 5 patients had previous 1 st metatarsophalangeal joint (MTPJ) fusion, 1 ankle arthrodesis, 1 calcaneo-cuboid fusion and 1 navicular - cuneiform fusion. The mean time for EXOGEN application following the initial operation was 8.5 months (range 4-12 months). The 2 cases that reached union

2 were both previous 1 st MTPJ fusions, in male patients. In one case EXOGEN was used for 3 months and in the other for 6 months. For the 6 patients that did not reach union, the mean time EXOGEN was used before stopped was 8.6 months (range 3-24 months). There were no complications from the use of EXOGEN noted. Conclusions and Implications: To the authors knowledge this is the first study in the literature reporting on the EXOGEN low intensity pulsed ultrasound system following elective foot and ankle fusions delayed and non-unions. Our preliminary results report poor union rate following EXOGEN in these patients with only 25% reaching fusion. 198 Complications following surgical fixation of ankle fractures: the impact of a surgical site infection protocol Sudworth O. 1,2, Harrison W. 3, Giotakis N. 3 1 The Pennine Acute Hospitals NHS Trust, Oldham, United Kingdom, 2 The Royal Liverpool & Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom, 3 The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom Background: Ankle fractures are common and often require open reduction and internal fixation (ORIF). Surgical site infection (SSI) is one of the most devastating post-operative complications. The aim of this study was to assess the impact of an SSI protocol on infection rates following ankle fracture fixation. The protocol, developed after 2009, included pre-operative MRSA screening, a formal prophylactic antibiotic regime, clean air theatres, specialist SSI nurses, a formal wound care protocol and an MDT meeting and ward round for SSI cases. Methods: Patients undergoing ankle fracture fixation over a 10-month period were compared, using Fisher's exact test, to a previous study at the same hospital by Thangarajah et al (2009). 1 Results: There were 98 patients (53 male: 45 female), with a mean age of 39 (range 16-84) years. Seven patients (7%) developed an SSI, 6 superficial and 1 deep. Deep infection required debridement and removal of metalwork. In the 2009 study, prior to any SSI protocol, 12/50 patients (24%) developed an SSI, 7 superficial and 5 deep. There was a statistically significant reduction in SSI's (p=0.0077). Host type significantly correlated with SSI rates (p=0.0363). Other variables had no significant impact on SSI rates: delay in presentation (p=0.6307), delay to surgery (p=0.9203), temporary spanning external fixation (p=0.3152) and smoking status (p=1.0). Conclusion(s): It is not clear how each aspect of the protocol impacted the overall SSI rate. However, collectively the protocol significantly reduced SSI rates from 24% to 7%. Implications: We therefore recommend using a similar, focused SSI protocol in all patients undergoing ankle fracture fixation. References: 1. Thangarajah, T, Prasad, P.S.V. and Narayan, B. (2009). Surgical site infections following open reduction and internal fixation of ankle fractures. Open Orthop J. 22, A randomised controlled trial assessing the effect of a continuous subcutaneous infusion of local anaesthetic following elective surgery to the great toe Rose B. 1, Barton T. 1, Walsh J. 1, Fogarty K. 1, Wines A. 1 1 North Sydney Orthopaedic Sports Medicine Centre, Sydney, Australia Background: First ray surgery is the most frequently performed in foot. Patients may experience significant post-operative pain. It is of paramount importance that pain is controlled, especially if surgery is performed as a day case, which is common. A continuous local anaesthetic infusion, administered through a subcutaneous catheter to the wound or a nerve supplying sensation to the

3 surgical site, has been successfully adopted following surgery to other body regions, but has never been trialled for the forefoot. Methods: A double blind randomised controlled trial was performed to assess the effect of a local anaesthetic infusion post-operatively. A previous power analysis showed that 48 people in each group would be sufficient. One hundred patients were prospectively recruited with primary hallux valgus or an arthritic first metatarsophalangeal joint (MTPJ) requiring surgery. Post-operatively, one group received an infusion of 1% ropivacaine hydrochloride through the ON-Q Painbuster device sited anterior to the medial malleolus so as to block the saphenous nerve and medial branches of the superficial peroneal nerve. The second group received a placebo infusion of 0.9% normal saline. Visual Analogue Scores (VAS) were obtained on days one and seven post-operatively. Results: Follow-up was achieved in all patients. There were no significant differences between the two groups demographic characteristics or surgical data. The mean VAS changed from 4.52 to 2.82, with a mean reduction of 1.70 in the treatment group, and from 3.52 to 2.07, with a mean reduction of 1.45 in the control group. There was no significant difference for the change in VAS score between the two groups (p=0.70). Conclusion: We do not support the use of a post-operative local anaesthetic infusion at the ankle as a method of reducing pain in the immediate post-operative period. 556 Joint specific and generic outcome scores in patients undergoing common foot and ankle operations in a district general hospital - the effect of disease and the benefit of surgery Loizou C. 1, Smith G. 1, Loveday D. 1 1 Norfolk and Norwich University Hospital, Norwich, United Kingdom Background: The Manchester Oxford Foot Questionnaire (MOXFQ) and EQ-5D are validated instruments that were developed for the measurement of outcomes in foot and ankle surgery and generic health status, respectively. Our aim was to measure such outcomes in patients undergoing common foot and ankle operations and identify the effect of disease and the benefit in relation to the type of surgery. Methods: Patients attending for arthroscopic ankle fusion for ankle arthritis, 1 st metatarsophalangeal joint (MTPJ) fusion for MTPJ arthritis and Scarf/Akin osteotomies for bunions were included. Patients completed both the MOXFQ and EQ-5D questionnaires pre and post-surgery. Results: 36 of 39 patients (92%) who had pre-op outcome scores completed post-op scores at a minimum of 9 months following surgery. The pre-op MOXFQ scores were worse for the ankle arthritis group (mean 52) compared to the MTPJ arthritis (mean 44) (p< 0.05) and the bunion groups (mean 39) (p< 0.001). The pre-op EQ-5D index scores were better for the bunion group (mean 0.62) compared to the MTPJ arthritis (mean 0.41) (p< 0.01) and the ankle arthritis groups (mean 0.39)(p< 0.01). No significant differences were found in the post-operative scores (MOXFQ,EQ-5D) between the ankle fusion (means 18 and 0.70), the MTPJ Fusion (means 14 and 0.88) and the Scarf/Akin groups (means 21 and 0.69). Both outcome scores showed a significant improvement postoperatively (p< ) except for the EQ-5D scores in the bunion group. Conclusion(s): Patients with ankle arthritis have worse joint specific outcome scores compared to patients with MTPJ arthritis or bunions and hence benefit the most from surgery. Patients with arthritis of the ankle and MTPJ have worse generic health outcome scores compared to those with bunions who also show no improvement following surgery. Implications: These results have significance when it comes to patient consenting and prioritisation of resources in healthcare. 584 Abdominal fat transfer for recreating fat pad in hind foot and forefoot Malhotra A. 1, Dickenson E. 2, Wharton S. 2, Marsh A. 2

4 1 The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom, 2 Dudley Group of Hospitals, Dudley, United Kingdom Background: Primary functions of heel and forefoot fat pad - shock absorber at heel strike, energy dissipation, load bearing, grip and insulation. Reliability of weight bearing heel pad thickness measurements by ultrasound has been determined by Rome et al. Importance of soft tissue fillers has been recently popularised by Coleman. Methods and Materials: Harvesting done by standard low pressure liposuction using small cannula. Grafting using small needle depositing the small globules of fat in multiple layers of soft tissue. There is an expectation that up to 50% of the fat will be lost and so up to 19mls of fat placed per foot. Patients were kept NWB for 4-6 weeks post op and then allowed to mobilise fully. Case notes were prospectively collated and analysed. Pre and post-op ultrasound scans were performed to document the depth of the heel/forefoot fat pad. Clinical pictures were taken and post-op patient satisfaction scores were done as well. Results: We treated 9 feet in 5 patients. 5 heel fat pad transfers and 4 forefoot. Pain completely relieved in all feet. No complications. Average pre-op VAS - 3/ Post-op - 9. Average pre-op AOFAS score - 70/ post-op Follow-up 6 months - maximum 23 months. Conclusion: Fat transfer is usually used for cosmetic reasons and occasionally to improve scars. Very few reports from South America have been published for patients using high heels giving pain but none for patients with a pathological anomaly. The technique seems to highly effective with no complications so far. It is currently being used on other painful problems in other areas of the sole with equal success. Abdominal fat transfer is an innovative technique aimed at getting rid of the heel pad syndrome. 603 A cadaveric analysis: the study of a previously undescribed tendinous bridge in the foot Thomas R.L. 1, Knight T. 2 1 Royal Navy, General Duties Afloat, Naval Command HQ, Portsmouth, United Kingdom, 2 The Robert Jones and Agnes Hunt Orthopaedic Hospital, Musculoskeletal Histopathology, Oswestry, United Kingdom Background: Dissection has underpinned our wider anatomical knowledge as a means of discovery and research since the dawn of curiosity. In current times, it is uncommon to find anything which has not been previously referred to. Whilst pursuing undergraduate study, a collagenous structure was observed in the fore-foot that was not mentioned in standard anatomical texts. The tissue adjoined the metatarsophalangeal and interphalangeal plantar plates of the hallux and appeared to be similar in the three available specimens. An exhaustive review of the literature failed to find the structure described; therefore further, more systematic investigation was warranted. Methods: Eight fresh-frozen feet from four cadavers were dissected and the structure identified and isolated. Two specimens were subject to histological section and H&E staining while the remaining specimens were subject to cyclic longitudinal stress assessment. Results: Longitudinal tensile strength analysis revealed that there was variability between specimens but that a significant ability to withstand force was inherent in several. Histological analysis showed

5 that there was an organised collagenous arrangement with an inner tendinous layer apparent, although there was no macroscopic sheath. Conclusion(s): The results of this study indicate that there is a previously undescribed tendon in the foot. This raises the questions of why this structure has not been previously described, its clinical significance; and the epidemiology of the differences in tensile strength between specimens. Implications: Its presence has biomechanical ramifications relevant to reinforcement of the windlass mechanism during gait. The clinical implications of pathology here relate to first ray hypermobility and metatarsalgia, with predisposition to acquired pes planus deformity being a consideration. Conflict of Interest: Presentation of this work is also pending approval at the Combined Services Orthopaedic Society conference in May 2015.