(iii) Arthroscopy of the foot and ankle

The role of arthroscopy in the management of articular pathology is now well established. Its use in the management of foot and ankle pathology is relatively new, but with innovative techniques and modern equipment, the indications are expanding. Procedures that were previously performed through an open approach can now be done using a pure arthroscopic, or arthroscopically assisted, method with the aim of earlier rehabilitation, reducing complications and scarring, and improving outcome. We describe the history, current role and potential future uses of arthroscopy in the treatment of foot and ankle conditions.     

(iii) Lateral ankle instability

Ankle sprains are the most common sports-related injury and are caused by forced plantar flexion and inversion. Most involve the lateral ligamentous complex and recover with conservative management, but 20% go on to develop biomechanical or functional instability. This article focuses on clinical symptoms, signs, conservative and surgical management of acute lateral ankle sprains and lateral ankle instability.     

(iv) Imaging of foot and ankle disorders

This article gives an overview of the imaging modalities used in the assessment of acute and chronic foot and ankle disorders in the adult patient. The relative merits of each imaging modality are explained and examples are given of the common conditions.     

(i) The principles of foot and ankle arthrodesis

Successful arthrodesis of a diseased joint for pain relief and stability in the appropriate patient is achieved by thorough pre-operative planning and attention to risk factors for non-union, meticulous surgical technique including respect for soft tissues, adequate joint surface preparation and co-aptation of joint surfaces with stable fixation in the position of most useful function. Here we outline how these principles are applied in the foot and ankle.     

Imaging of the foot and ankle

There are a number of imaging modalities available to assist in assessment of the foot and ankle. The variety of techniques will be described with emphasis on the particular advantages and limitations of each. Recent advances and variations relating to the individual modalities are reviewed together with specific clinical scenarios.     

(iii) Osteochondritis

In this article the presentation, pathogenesis, diagnosis and management of osteochondritis dissecans are reviewed and compared with the osteochondroses and avascular bone necrosis.     

The diabetic foot and ankle

Diabetes mellitus is a common malady of our time with ever increasing numbers of patients presenting with diabetic foot and ankle pathology. Diabetes requires treatment by a multidisciplinary team and vascular disease requires management involving vascular surgeons. There is, however, an increasing burden on the orthopaedic surgeon with ulceration, foot deformity, osteomyelitis and Charcot osteo-arthropathy being direct complications of diabetes. Potential severe complications following fracture and elective surgery require an understanding of diabetes and its effects on soft tissue and bone. The key topics are: Pathophysiology - effects of hyperglycaemia on vascular, neuronal and immune systems, Assessment - examination of diabetic foot pathology and how to spot the ‘at risk foot’, Ulceration - management of foot and ankle ulceration and indications for intervention, Charcot osteo-arthropathy - brief overview of Charcot-type foot and ankle disease, and Management of ankle fractures - overview of current trends in options for conservative and surgical intervention.     

Management of tendinopathies of the foot and ankle

Foot and ankle tendinopathies are a significant problem in orthopaedic practice. They represent a failed healing response. Such tendons show increased matrix remodelling, leading to a mechanically less stable tendon which is more susceptible to damage. Diagnosis is based on a careful history and detailed clinical examination and investigations. Initially treatment is by relative rest and modification of physical activity, use of rehabilitative exercises, evaluation and correction of intrinsic and extrinsic causes of injury. Surgical management is indicated if conservative management fails, in stage 3 tendinopathy or if tendon rupture occurs. Randomized controlled trials are awaited to clarify the best therapeutic options.     

(iii) Hand infections

Infections of the hand and upper limb present in large numbers to medical practitioners and represent 20% of admissions to hand surgery units. Infection can manifest in many different forms due to differing aetiological insults and the unique anatomical arrangement and compartmentalization within the hand. As a result, the significance and severity of these conditions at presentation are often not appreciated by both patients or medical staff.Prompt recognition and timely institution of appropriate treatment with splintage, elevation, antibiotics, and aggressive surgical intervention when indicated, can prevent permanent impairment, rapidly returning patients to their pre-morbid level of function. Time is particularly important as infection can spread rapidly, irreversibly damaging complex specialized tissues such as synovium and articular cartilage necessary for unrestricted hand function.Despite the advent and development of antibiotics, delay in presentation, diagnosis or treatment still results in increased morbidity and on occasion mortality, disability resulting from pain, stiffness, contracture or amputation.     

(iii) Bearing surfaces

Alternative bearings surfaces to polyethylene have reduced wear and have led to improved patient outcomes, allowing younger and more active patients to be considered for joint replacements. These bearing surfaces have been developed largely as a response to osteolysis and loosening associated with polyethylene particulate debris. This has led to the evolution of various forms of cross-linked polyethylene and to the greater use of hard-on-hard bearings. The use of metal-on-metal led to resurfacing hip replacements and to the use of large head metal-on-metal hip replacements. Although metal-on-metal bearings have a number of theoretical advantages, the release of metal debris and ions from some designs has been catastrophic. In the future new bearing surfaces must be more thoroughly tested pre-clinically and in well-designed clinical series.     

(iii) Biomechanics of the knee and TKR

The principal aim of a total knee replacement (TKR) is to restore painless movements of the knee joint. Osteoarthritis, along with other pathologies that damage the articular surface of the knee, results in painful limitation of knee movement and alteration of shape and alignment of the joint. Restoration of the functional anatomy of the knee, including alignment, soft tissue balancing and restoration of the joint line, are integral to improving function. Factors that ensure long-term survival of the replaced knee have to be addressed while performing this procedure. Biomechanics of the knee and its restoration are key to improving both function and survival of a total knee replacement. Screw home movement in terminal extension and femoral roll back in flexion are unique to the knee joint. The patella improves extensor function by increasing its lever arm. Implant designs available include femoral components of fixed or multiple radii, high flexion knee replacements, posterior cruciate retaining or substituting designs and fixed or mobile tibial inserts. Computer navigation has been used to achieve accurate bone alignment and soft tissue balancing. Further research on these advances is essential to define their role in improving the results of TKR.     

Consent in foot and ankle surgery

The process of consent for surgical procedures has undergone a fundamental change since the landmark Montgomery vs Lanarkshire Health Board Case. The judge in that case determined that consent should focus on the risks that are material to the patient, and not purely those that a body of expert opinion feels are prudent to mention. This is a change from a paternalistic to a patient-centred approach. Ideally the consenting process should be done by the operating surgeon, or other doctor who has adequate knowledge of the risks and potential complications of the procedure. Taking consent is a process that occurs over several patient contacts, rather than being a singular consenting event. In this article we discuss several of the particular risks of each foot or ankle procedure and their relative incidence, as well as providing guidance regarding optimizing the consent process.     

(iii) Fractures of the tibial pilon

Pilon fractures are severe injuries, with potential to cause long term disability. Outcome depends on the soft tissue injury sustained and the quality of skeletal reconstruction. The evolution of management strategies is discussed, based on understanding the anatomy and classification of this heterogeneous group of injuries. They are approached with a view to formulating a safe management plan to minimize complications associated with treatment, whilst optimizing the outcome by careful soft and hard tissue handling.     

(iii) Patient selection and consent

Appropriate patient selection and consent for a total hip replacement or hip resurfacing is a serious undertaking and one that should not be taken lightly.From the patients’ first presentation, we cover the common pitfalls that can be encountered in the patients’ history and examination as well as specific indications and contraindications to hip resurfacing and hip replacement.Possible alternatives to arthroplasty are discussed ranging from simple analgesia to the more controversial treatments such as hyaluronic acid injections.The different options available for a total hip replacement are considered including the choice of a cemented or uncemented implant, the bearing surface and the reasons for making those choices.Unfortunately hip arthroplasty is not without risk and these potential complications are discussed. The incidence of a lower extremity thrombosis has been quoted as high as 70% but this can be mitigated with thromboembolic prophylaxis. The risk of infection varies from approximately 0.4 to 1.5%.The risk of dislocation between 0 and 2% and fracture less than 1%. Nerve injury can be as high as 3% but is commonly quoted nearer to 1%, and is higher in revision operations at up to 4 %.As well as possible complications, patients should also be made aware of the normal post-operative course from what to expect when they wake up to the type of tests they will have in their immediate post-operative recovery.With the pressures of clinic and operating lists it can be all to easy to rush through these important issues, however, time invested at this stage of the proceedings is well spent.     

(iii) Developmental dysplasia of the hip

Developmental dysplasia of the hip (DDH) is a spectrum of pathologies affecting the infant hip ranging from asymptomatic subtle radiographic signs through mild instability to frank dislocations with an abnormal acetabulum.Patients with developmental hip dysplasia account for around 10% of all primary hip arthroplasties, and around 30% in those under sixty. Early detection and appropriate management can prevent or delay the requirement for total hip replacement.In this article we aim to provide a broad overview of the aetiology, natural history, pathology and management of developmental dysplasia of the hip.     

Reconstruction of pediatric foot and ankle trauma

Although reconstruction of complex distal lower extremity trauma has been studied extensively, the subject has rarely been evaluated in the pediatric population. The authors review their experience with 18 patients ranging from 2 to 18 years of age, who were admitted to the trauma service of the Children's Hospital of the University of Pittsburgh between 1991 and 1999 and required plastic surgery evaluation for the management of foot and ankle injuries. The mechanism of injury included motor vehicle accidents (6), lawnmower injuries (6), gunshot wounds (2), crush injuries (2), burns (1), and complex soft tissue injuries (1). The average hospitalization was 14.3 days, and, on average, 3.1 surgical procedures were required per patient. Most of the cohort required microvascular free tissue transfer (11). One patient was managed conservatively, whereas the remainder underwent surgical reconstruction by primary wound closure (1), skin graft (2), or local flap (3). No patient has required treatment of growth disturbance or late functional problems, and the entire population was ambulatory by their 3-month postoperative evaluation. Despite the severity of these injuries, with reliance on microvascular free tissue transfer, an acceptable outcome can be achieved with preservation of the ability to ambulate.     

(iii) Extensor tendon injuries

Extensor tendon injuries are more common in presentation than flexor injuries. They are often viewed as the poorer cousins on whom the more junior doctor can practice the art of tendon repair without significant risk of morbidity and poor functional outcome. Unfortunately this is not the reality. Understanding of the extensor anatomy helps predict associated injuries and guide subsequent management resulting in decreased morbidity and improved functionality.     

Correction of neurological deformity in the foot and ankle

Deformities of the foot and ankle in neuromuscular conditions are often complex and occur at multiple levels. Careful examination of the patient is key to identifying the deformity, and whether it is flexible or fixed. This will help to guide management options. This paper outlines treatment options for the common deformity patterns seen in clinical practice.     

(iii) Proximal ulna fractures

Fractures to the proximal ulna account for only 1% of all fractures. However, appreciation of the pathoanatomy of the different fracture patterns is essential for the treating surgeon. This review discusses the classification, injury patterns, treatment and outcome of fractures to the olecranon, coronoid process and adult Monteggia fracture dislocations.