Review of Classification Systems for Adult Acquired Flatfoot Deformity/Progressive Collapsing Foot Deformity and the Novel Development of the Triple Classification Delinking Instability/Deformity/Reactivity and Foot Type.

Background: Classifications of AAFD/PCFD have evolved with an increased understanding of the pathology involved. A review of classification systems helps identify deficiencies and respective contributions to the evolution in understanding the classification of AAFD/PCFD. Methods: Using multiple electronic database searches (Medline, PubMed) and Google search, original papers classifying AAFD/PCFD were identified. Nine original papers were identified that met the inclusion criteria. Results: Johnson's original classification and multiple variants provided a significant leap in understanding and communicating the pathology but remained tibialis posterior tendon-focused. Drawbacks of these classifications include the implication of causality, linearity of progression through stages, an oversimplification of stage 2 deformity, and a failure to understand that multiple tendons react, not just tibialis posterior. Later classifications, such as the PCFD classification, are deformity-centric. Early ligament laxity/instability in normal attitude feet and all stages of cavus feet can present with pain and instability with minor/no deformity. These may not be captured in deformity-based classifications. The authors developed the 'Triple Classification' (TC) understanding that primary pathology is a progressive ligament failure/laxity that presents as tendon reactivity, deformity, and painful impingement, variably manifested depending on starting foot morphology. In this classification, starting foot morphology is typed, ligament laxities are staged, and deformity is zoned. Conclusions: This review has used identified deficiencies within classification systems for AAFD/PCFD to delink ligament laxity, deformity, and foot type and develop the 'Triple classification'. Advantages of the TC may include representing foot types with no deformity, defining complex secondary instabilities, delinking foot types, tendon reactivity/ligament instability, and deformity to represent these independently in a new classification system. Level of Evidence: Level V.

Evaluation of first ray instability using the double dorsiflexion test: A prospective observational case-controlled study.

BACKGROUND: First-Ray (FR) stability allows for foot propulsion in-stance, taking 60% weight. First-ray instability (FRI) is associated with middle column overload, synovitis, deformity and osteoarthritis. Clinical detection can still be challenging. We propose to develop a clinical test that helps identify FRI using two simple manual manoeuvres. METHODS: 10 patients with unilateral FRI were recruited. Unaffected contralateral feet were used as controls. Stringent exclusion criteria were applied including hallux MTP pain, laxity, inflammatory arthropathy and collagen disorders. A Klauemeter directly measured the sagittal plane dorsal first metatarsal head translation of affected vs unaffected feet. Maximum passive proximal phalanx 1st MTP joint dorsiflexion was measured using a video capture and Tracker motion software analysis with and without applying a dorsal force at the 1st metatarsal head using a Newton meter. Proximal phalanx motion was compared in affected vs unaffected feet with and without dorsal metatarsal head force application and compared to direct measurements using the Klaumeter. P value of < 0.05 was considered significant. RESULTS: FRI feet had dorsal translation greater than 8 mm (median, 11.94; interquartile range [IQR], 10.23-13.81) vs 1.77 for unaffected control feet was (median, 1.77; interquartile range [IQR], 1.23-2.96) using the Klauemeter. The percentage reduction in 1st MTP joint dorsiflexion ROM when applying the double dorsiflexion test FRI (mean reduction of 67.98%) when compared to control feet (mean reduction of 28.44%)(P < 0.01). Receiver operating characteristic (ROC) analysis showed that a 50% reduction in dorsiflexion ROM of 1st MTPJ when performing the double dorsiflexion test achieved a specificity of 100% and sensitivity of 90% (AUC =0.990, 95%CI [0.958-1.000], P > 0.0001). CONCLUSION: The double dorsiflexion (DDF) is easy to perform with two relatively simple manual manoeuvres that avoids the need for complex instrumented and radiation-based assessment. Greater than 50% decrease in proximal phalanx motion has an over 90% sensitivity in identifying feet with FRI. LEVEL OF EVIDENCE: This was a prospective case-controlled study of consecutive cases of a level II evidence.

Spring ligament insufficiency and hallux valgus as an independent risk factors for first ray instability.

INTRODUCTION: First ray instability (FRI) arising from failed plantar/interosseous ligaments is strongly associated with planovalgus, leading to synovitis and deformity. Our hypothesis is that proximal spring ligament insufficiency (SLI) drives secondary FRI in the absence of hallux valgus (HV) and may be an independent risk factor. METHODS: Patients with FRI, screened by Klaue's test, were recruited. Patients' normal contralateral feet with previous radiographs were included as controls. First ray dorsal translation was measured with a digital Klauemeter. Spring ligament integrity was assessed using lateral translation distance as an indirect measure of spring ligament strain. Intermetatarsal angle and hallux valgus angle were recorded to classify the severity of HV. RESULTS: Seventy feet included, 54 had symptomatic FRI and 16 were asymptomatic contralateral feet included as control. Twenty-three feet had moderate/severe HV and 47 had mild/normal HV. Moderate/severe HV was associated with FRI (OR, 10.31; p = 0.029). Forty-five feet with SLI had a strong association with FRI (OR, 100.7; p < 0.0001). SLI without moderate/severe HV was the most prevalent group (31/54), followed by SLI with moderate/severe HV, 29.63% (16/54). Moderate/severe HV without SLI was prevalent in 11.1% (6/54) and 1.85% (1/54) had no SLI or moderate/severe HV. In a multivariate logistic regression analysis model, both SLI and severe/moderate HV were independent predictors of FRI. CONCLUSION: This is the first study that links SLI and HV as independent risk factors to FRI. 98.15% of FRI can be attributed to SLI, HV or both. First ray instability may allude to the strong presence of spring ligament insufficiency in the absence of hallux valgus. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

High incidence of spring ligament laxity in ankle fractures with complete deltoid ruptures and secondary first ray instability.

AIMS: To assess the incidence of spring ligament failure in patients who have complete deltoid ruptures. PATIENTS AND METHODS: The authors retrospectively analysed ankle fractures in our trauma database from January 2015 to January 2019. 61 patients who sustained ankle fractures with complete deltoid ligament ruptures based on an AP ankle radiographs with increased medial joint space were identified. 25 patients attended clinic for assessment. Of these, 5 were found to have gross planovalgus with pre-existing spring ligament laxity in the uninjured control foot and these were excluded from the analysis. 20 patients were assessed for spring ligament failure /laxity. For each patient, the uninjured foot was used as the control. RESULTS: The TMT instability score and the lateral translation score showed statistically significant increases in the injured compared to the uninjured foot. The ratio of increase in both TMT instability and lateral translation scores (strain) in the injured versus the uninjured foot was assessed. A strong correlation (+0.62 pearson correlation coefficient) was found between the two ratios. CONCLUSION: All 20 patients showed increased spring ligament laxity and 19 patients showed increased TMT instability. Our results show that with complete deltoid rupture, there is likely greater disruption of the medial ligamentous structures of the foot than previously recognised. The degree of increase in the spring ligament strain also correlates with the degree of strain at the plantar TMT joint ligaments, and thus first ray instability. This finding has significant implications for the long-term assessment and management of ankle fractures involving complete deltoid disruption. Early intervention with orthotics in this cohort may prevent progressive destabilisation of the midfoot and the first ray. This evolving understanding may lead to the prospect of earlier surgical intervention to reconstitute the integrity of the spring ligament and protect the foot progressing to stage 2 AAFD.

Plantar fasciitis: Talonavicular instability/spring ligament failure as the driving force behind its histological pathogenesis.

The aetiology of plantar fasciitis (PF) remains uncertain and to date, it is not known if there is an association with spring ligament laxity. In this study, 28 patients with unilateral plantar fasciitis were evaluated. A digital Klaumeter was used to assess first ray for instability and lateral plane translation was used as a measure of spring ligament laxity in the affected vs unaffected foot (internal control). Retromalleolar tenderness as a sign of a reactive tibialis posterior tendon was also assessed. The mean lateral translation score for symptomatic feet was 67.2 (95% CI [63.26-71.14]), compared to asymptomatic feet mean of 33.0 (95% CI [27.35-38.65] p < 0.05). The mean TMT instability score for symptomatic feet was 11.3 (95% CI [10.29-12.3]), compared to the asymptomatic feet mean of 5.9 (95% CI [4.49-7.31] p < 0.05). 100% of symptomatic feet had a retromalleolar tenderness over the tibialis posterior compared to 14% of asymptomatic feet. This is the first study to demonstrate a statistically significant increase in spring ligament strain in feet affected with PF using internal controls. The study postulates that tensile overload at the medial plantar fascia develops secondary to spring ligament failure regardless of foot shape. Furthermore, this condition can be regarded as an early warning sign of adult acquired flat foot disorder (AAFD). Future treatments for PF should not further destabilise the medial arch. This understanding may allow development of new treatment strategies in restoring spring ligament integrity to offload the plantar fascia strain.

Complex regional pain syndrome: an evolving perspective.

BACKGROUND: Complex regional pain syndrome (CRPS) is a heterogenous and poorly understood condition that can be provoked by quite minor injuries. The symptoms and signs of CRPS persist, long after the patient has recovered from the inciting event. In some cases, there is a clear association with a peripheral nerve injury. The degree of disability produced by CRPS is often out of proportion to the scale of the original insult and the condition is associated with protracted recovery times and frequent litigation. METHODS: We have performed a PubMed literature search, referenced landmark papers in the field and included a national expert in peripheral nerve injury and repair in our team of authors. RESULTS AND CONCLUSIONS: The diagnostic criteria for CRPS have changed repeatedly over the last two centuries and much of the historical literature is difficult to compare with more recent research. In this review article, we consider how our understanding of the condition has evolved and discuss its pathogenesis, its apparent heterogenicity and the various investigations and treatments available to the clinician.

Using domiciliary non-invasive ventilator data downloads to inform clinical decision-making to optimise ventilation delivery and patient compliance.

INTRODUCTION: Ventilation parameter data from patients receiving home mechanical ventilation can be collected via secure data cards and modem technology. This can then be reviewed by clinicians and ventilator prescriptions adjusted. Typically available measures include tidal volume (VT), leak, respiratory rate, minute ventilation, patient triggered breaths, achieved pressures and patient compliance. This study aimed to assess the potential impact of ventilator data downloads on management of patients requiring home non-invasive ventilation (NIV). METHODS: A longitudinal within-group design with repeated measurements was used. Baseline ventilator data were downloaded, reviewed and adjustments made to optimise ventilation. Leak, VT and compliance data were collected for comparison at the first review and 3-7 weeks later. Ventilator data were monitored and amended remotely via a modem by a consultant physiotherapist between the first review and second appointment. RESULTS: Analysis of data from 52 patients showed increased patient compliance (% days used >4 hours) from 90% to 96% (p=0.007), increased usage from 6.53 to 6.94 hours (p=0.211) and a change in VT(9.4 vs 8.7 mL/kg/ideal body weight, p=0.022). There was no change in leak following review of NIV prescriptions (mean (SD): 43 (23.4) L/min vs 45 (19.9)L/min, p=0.272). CONCLUSION: Ventilator data downloads, via early remote assessment, can help optimise patient ventilation through identification of modifiable factors, in particular interface leak and ventilator prescriptions. However, a prospective study is required to assess whether using ventilator data downloads provides value in terms of patient outcomes and cost-effectiveness. The presented data will help to inform the design of such a study.

Long-term follow-up of patients undergoing tibialis posterior transfer: Is acquired pes planus a complication?

In this retrospective study, a series of 10 elective patients treated with transfer of the tibialis posterior (TP) tendon for pes cavus and drop foot are described. Since TP transfer completely subtracts the role of this tendon, this cohort of patients provides an opportunity to examine the consequences of tibialis posterior (TP) deficiency. After a mean follow up period of 44.7 months, only one patient showed evidence of strain in the spring ligament but none of the patients in this series developed clinical or radiological evidence of planovalgus deformity. The authors conclude that planovalgus deformity is not an inevitable sequelae of TP Tendon transfer and that established theory underestimates the role of static soft tissue restraints such as spring ligament in hindfoot stability.

Enhanced recovery programme reduces opiate consumption in hip hemiarthroplasty.

INTRODUCTION: The enhanced recovery programme (ERP) is used to improve patient experience before, during and after an operation. Initially designed for colorectal surgery, it has now been adopted by many other disciplines, including orthopaedics. Where applicable, ERP has shown to be associated with less pain, reduced length of hospital stay and increased patient satisfaction in elective orthopaedic procedures. There is, however, a paucity of data regarding the use of ERP in fractured neck of femur (NOF) operations. Our aim was to investigate the effect of ERP on analgesic requirements and hospital length of stay during hemiarthroplasty. METHOD: Consecutive notes of 100 patients who received a hemiarthroplasty for a fractured NOF were reviewed retrospectively. In one group (n = 50), patients received routine pre- and post-operative care; the second (n = 50) were on the ERP. All patients were previously mobile with an abbreviated mental test score of more than eight and lived in their own home. RESULTS: With ERP, oral opiate consumption fell dramatically in the first three post-operative days (4.7 vs. 14.0 mg, p > 0.005). The use of patient-controlled analgesia (PCA) was also significantly reduced (odds ratio 0.16, p > 0.05). Although ERP had no statistically significant effect on length of stay (7 vs. 8.5 days, p = 0.2), it saw a greater proportion of patients being discharged back to their own home (25 vs. 19 patients, p < 0.05). CONCLUSION: The ERP reduces post-operative oral opiates and PCA requirements in fractured NOF cases and by inference reduces pain. It does not appear to affect length of hospital stay in an acute unit.

Research synthesis of recommended acetabular cup orientations for total hip arthroplasty.

Total hip arthroplasty (THA) is regarded as one of the most successful surgical procedures of modern times yet continues to be associated with a small but significant complication rate. Many early failures may be associated with poor component positioning with, in particular, acetabular component orientation dependent on the subjective judgement of the surgeon. In this paper, we compare the manufacturers' instructions on acetabular cup orientation with the literature-based recommended safety zones and surgical technique, by transforming them onto a single, clinically-relevant framework in which the different reference systems, safety guidelines and current instrumentation surgical techniques can be evaluated. The observed limited consensus between results reflects ongoing uncertainty regarding the optimum acetabular component positioning. As malpositioning of the acetabular cup increases the risk of revision surgery, any ambiguity over the correct position can have a causal effect. Our analysis highlights the need for a surgical reference system which can be used to describe the position of the acetabular cup intra-operatively.

The management of soft tissue sarcomas.

BACKGROUND: Soft tissue sarcomas are a rare and heterogenous group of malignancies that are derived from the mesenchymal cell lines. In the last few decades, the management of these lesions has been improved by the introduction of dedicated Multi Disciplinary Teams (MDTs) where most bone and soft tissue tumours are now treated.(1) Following the recent changes to management outlined by the NICE/IOGs, we believe it is pertinent to review the current thinking on soft tissue tumour management.(2) We also discuss the principles of diagnosis and treatment and the role of adjuvant therapy. METHODS: This is a retrospective review. In the preparation of this paper, we have referred to recent NICE guidelines in this field and have performed a Medline search of the existing literature. RESULTS: The key to the success is early and appropriate patient referral. Whilst the responsibility for performing surgery has shifted away from the generalist and towards the super specialist, improvements in survivability can be achieved by promoting basic knowledge within the medical profession as a whole. CONCLUSIONS: Both excision and biopsy of a soft tissue sarcoma by a non-specialist surgeon have been shown to increase the risk of tumour recurrence and all invasive procedures should now be performed within the MDT setting.

Choosing the optimum swab for canal drying in cemented total hip replacement.

During total hip replacement, the reamed medullary canal of the femur should represent a clean, dry surface. We compared the effectiveness of 4 different cotton swabs in a synthetic femur that had been reamed to receive a size 1 Exeter trial prosthesis. Swab sizes included a 2.5 cm and a 7.5 cm diameter ribbon gauze, a pair of 10 x 7.5 cms square swabs and a larger surgical packing swab (20 x 22 cms). The ability of the swabs to pack the femur was assessed using both plain radiographs and colour photography (after femoral section). After retrieval from the canal, the total dry weight of the cotton inserted was recorded as was the time required to withdraw each swab type. Only the narrowest (2.5 cm diameter) ribbon gauze was found to achieve comprehensive packing as far as the cement restrictor but it required a longer time for removal, and there may be a case for using larger ribbon gauze in larger femora. The mass of cotton delivered to the canal using small square swabs was half of that delivered using narrow ribbon gauze.

Anterior shoulder dislocation.

INTRODUCTION: Anterior dislocation of the shoulder is commonly seen in accident and emergency (A&E) and trauma clinics. In this article, we review the existing literature on the injury and the recent trends in management. MATERIALS AND METHODS: We have discussed this condition with our colleagues and performed a Medline search ('anterior shoulder dislocation') of the relevant papers. We also describe key historical publications and recent developments regarding immobilisation of the joint. RESULTS: Management decisions regarding this condition continue to vary between units, especially for recurrent and posterior dislocation. This paper lays some emphasis on the choice of analgesic agent when attempting shoulder reduction in the A&E setting. A summary of the data from our own department has provided a graphical representation of the classical age and sex distribution for this condition. CONCLUSIONS: Shoulder dislocation is a common injury. Delays in diagnosis remain the single biggest obstacle to optimum results in this group of patients. A significant proportion will require eventual surgery and up to a third of these patients will go on to develop long-term shoulder arthritis. Even patients who have experienced a single episode of dislocation may go on to develop long-term sequelae.

Cubital tunnel syndrome.

Cubital tunnel syndrome is the second most common peripheral nerve entrapment syndrome in the human body. It is the cause of considerable pain and disability for patients. When appropriately diagnosed, this condition may be treated by both conservative and operative means. In this review, the current thinking on this important and common condition is discussed The recent literature on cubital tunnel syndrome was reviewed, and key papers on upper limb and hand surgery were discussed with colleagues.

Hip resurfacing: a technology reborn.

In recent years there has been a resurgence of interest in the concept of hip resurfacing. Much of this interest has stemmed from the work of McMinn in the West Midlands. Hip resurfacing is now emerging as a viable alternative to conventional hip replacement. In this article, we discuss the conceptual advantages offered by hip resurfacing and review the early clinical results and the ongoing clinical concerns regarding this technology.