Foot Surgery BOA Blue Book

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Disclaimer Steering Group Sections 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

Introduction Indications for referral for Operation The Outpatient Consultation Waiting for the Operation Pre-Admission Assessment Hospital Admission Hospital Facilities Operating Theatre Resources The Surgeon and the Surgical Team The Anaesthetist and Anaesthetic Technique Clinical Record The Operative and Post-Operative Records Implants Prophylaxis against Venous Thrombo-embolism Prophylaxis against Infection Surgical Options - Disorders of the first ray - Arthritis of the first MTP joint or hallux rigidus Surgical options – Disorders of the first ray – Hallux valgus Surgical options – Disorders of the first ray – Sesamoid disorders Surgical options – Lesser toe problems Surgical options – The rheumatoid forefoot Surgical options – Morton’s interdigital neuroma Surgical options – In-growing toe nails Post-Operative Management Follow-up of Patients



Elective forefoot surgery is generally highly successful, but examples of poor selection of patients and poor surgical management continue to occur. I was given the task of coordinating the writing of this document so that it represents a consensus statement that is acceptable to both the British Orthopaedic Association (BOA) and the British Orthopaedic Foot and Ankle Society (BOFAS). I have used and adopted many sections of the guide ‘Primary Total Hip Replacement, A Guide to Good Practice’, 2nd edition, published in 2006 by the BOA, as the general principles are also applicable to forefoot surgery. This good practice guide is intended to inform surgeons, primary and secondary healthcare providers and commissioners about current good practice in forefoot surgery. It is not designed to be a textbook. Nor is it designed to educate patients but it may form the basis for patient-focussed information. The guide will require revision in 5 years’ time. Forefoot surgery as described in this document includes elective surgery for hallux valgus and other disorders of the first ray, lesser toe deformities, nail disorders, forefoot disorders specific to inflammatory arthritis, and Morton’s (interdigital) neuroma. It does not cover trauma. The standards laid down in this document apply to the practice of forefoot surgery in any setting, be it National Health Service (NHS), Private Practice or elsewhere. The creation of such a consensus document involves help from many experts. Those who have made this task possible are acknowledged below.

Brigitte Scammell


Kartik Hariharan


Steve Bendall Mark Davies Steve Hepple Nilesh Makwana Anthony Sakellariou Dishan Singh

DISCLAIMER This good practice guidance is of a general nature and is not intended to be a substitute for professional medical advice, diagnosis, treatment or care. This guidance is intended for suitably qualified medical practitioners. The British Orthopaedic Association and the British Orthopaedic Foot and Ankle Society disclaim any and all liability from any injury, loss, or damage of any kind resulting from actions taken or omissions made by any person relying on this guidance.

1. INTRODUCTION 1.1 This document is a statement of current good practice in forefoot surgery in the United Kingdom (UK) in all settings. It has been approved by the Council of the British Orthopaedic Association (BOA) and by the Executive and Members of the British Orthopaedic Foot and Ankle Society (BOFAS). 1.2 The disorders included in this document are: Disorders of the first ray including arthritis of the first metatarso-phalangeal (MTP) joint, hallux valgus, sesamoid disorders; Lesser toe problems including lesser toe deformities and MTP joint subluxation/dislocation. Other disorders including the rheumatoid forefoot, Morton’s (interdigital) neuroma and nail problems. 1.3 This document attempts to identify best practice in general terms, using available evidence. It does not claim to apply to all patients, in all circumstances. Each consultant, or those within a surgical team, must continue to take into account the individual requirements of a patient. 1.4 This document should be read in conjunction with the Advisory Book on Consultant Trauma and Orthopaedic Services (BOA 2007). 1.5 The patient’s treatment should be in a setting wherein satisfactory standards of Clinical Governance are applied.

2. THE INDICATIONS FOR REFERRAL FOR OPERATION 2.1 Pain and disability are the indications for operative management. In many cases other non-operative treatment, such as footwear modification and insoles have failed or have proven to be futile. 2.2 Deformity alone can be an indication for operation if skin integrity is compromised and/or it is not possible to accommodate the deformity comfortably in good quality footwear. 2.3 Referral guidelines should be developed to help identify appropriate referral of patients to the orthopaedic service. 2.4 The General Practitioner (GP) should be aware of the general health of any patient before referring to the local orthopaedic service, and any significant health problems should be corrected as far as possible, before that referral is made.

3. THE OUTPATIENT CONSULTATION 3.1 Usually the patient will have attended their GP who will seek the opinion of a Consultant Orthopaedic Surgeon. Patients expect to be seen promptly, ideally within one month of referral by the GP (BOA 2006).

3.2 Patients expect the consultation to include the orthopaedic surgeon who will be performing the operation (BOA 2006). The consultation should include history taking, examination, and provision of 2 or 3 good quality x-ray images: dorso-posterior (DP), lateral and oblique of the foot. The DP and lateral x-rays should be taken standing weight bearing. 3.3 The BOA regards 20-30 minutes as the minimum time allowable for a first consultation. The patient must feel that adequate time has been allowed for this consultation. 3.4 A suitable environment for discussion with the patient and relatives should be present, and all relevant notes and investigations, including imaging, should be available. The consulting area must be private and have an examination couch. Suitably trained nursing staff should be available to assist the surgeon and to chaperone if required. 3.5 Patients expect further investigations such as MRI or CT scanning and treatment to be completed within two months of the initial outpatient consultation (BOA 2006). 3.6 Discussion regarding the possibility of operative management of the forefoot disorder should involve a consultant who has a Certificate of Completion of Training (CCT in Trauma and Orthopaedics) and is on the General Medical Council (GMC) Specialist Register for Trauma and Orthopaedics. Such discussion should take place before the patient is offered the operation. Then with their agreement their name is then placed on the waiting list for the operation. 3.7 Some centres have a process whereby other practitioners (for example a Fellow, Specialist Registrar or Surgical Podiatrist) may place a patient’s name on the waiting list for operation. Such an arrangement should involve a team approach and it is essential that a Consultant Orthopaedic Surgeon meeting the standards in 3.6 is involved in the process. This process should be reviewed regularly. 3.8 Patients should have the risks and benefits of the operation explained in understandable language. An individual patient may have added risk factors present (such as cardio-vascular disease, obesity, predisposition to venous thrombo-embolism, neurological disease, inflammatory arthritis or diabetes) and that patient should be made aware of the added risks when these factors are present. The surgeon should try to verify that the patient has understood the information. 3.9 Patients should be aware that they, and not the surgical team, make the decision whether or not to undergo surgery. 3.10 The patient should be made aware that there is the option of not having an operation, and other treatment may be possible in appropriate cases, such as shoe modification or orthoses. 3.11 Patients expect surgical units to provide audit data on outcomes using a validated outcome questionnaire and procedure and/or surgeon specific readmission rate (BOA 2006).

4. WAITING FOR THE OPERATION 4.1 Consultants and their managers are expected to manage their waiting lists ethically and patients should be admitted for operation according to clinical priority and length of time on the waiting list. Social circumstances may occasionally be a factor to be borne in mind in assessing priority. 4.2 A few patients will require immediate admission for control of infection and/or ischaemia following the initial consultation. 4.3 Providing written information about the proposed surgery at the time of listing for the operation is best practice which facilitates the patient’s understanding and may reduce anxiety. 4.4 Patients can expect to be consulted about key dates including the pre-operative assessment, the operation itself and any planned time in hospital.

5. PRE-ADMISSION ASSESSMENT 5.1 A managed system of pre-admission assessment is best practice. This assessment should take place within four weeks of the operation. 5.2 Pre-admission clinics should be staffed by doctors and other clinicians (usually nurses) working to agreed protocols. The presence of anaesthetists and Allied Health Professionals (AHPs), such as physiotherapists, occupational therapists and social workers, helps to prevent cancellations, identify co-morbidities and risk factors and permit discharge planning. There is also an opportunity for patient education, particularly with regard to the risks and benefits of the operation. At this stage identification of goals for that patient can be discussed. 5.3 Fully-informed consent for the procedure and for collection of patient details for local audit or national registries is best obtained at this stage by the surgeon or a member of the team trained to do so. 5.4 Routine investigations of blood, urine, blood pressure and relevant microbiological assessment (including MRSA screening) are carried out. 5.5 General health screening by the general practitioner will help to detect significant clinical problems before the pre-admission assessment and will help to identify those patients that may require additional investigation at that time. 5.6 Provisional discharge planning should take place. This takes into consideration age, co-morbidities, home circumstances and availability of carers after discharge from hospital. 5.7 With the move towards same-day admission, day surgery and early discharge, these arrangements become vital for the safe passage of the patient through the service. 5.8 Information about the operation may be given to the patient or relatives in leaflet or pamphlet form. It should be written in language that is understandable to the patient. 5.9 A process should be in place to ensure that all patient-related information is available at the time of admission. This applies especially to any investigations that may have been deemed necessary at the pre-admission assessment. 5.10 Patients considered unfit to undergo the operation and who require further treatment or investigation should be suspended from the active surgical waiting list according to agreed national guidelines.

6. HOSPITAL ADMISSION 6.1 Patients should be admitted to hospital with adequate time before operation to allow routine pre-operative and pre-anaesthetic procedures to be completed. 6.2 The limb on the operation side should be indelibly marked by the operating surgeon in an area which should be visible during preparation in the operating theatre. If operating on the toes, each toe must be marked separately. 6.3 Pre-operative visiting by a member of the anaesthetic team is necessary to explain details of the anaesthetic and to obtain consent for anaesthesia. If the operation is being carried out under local anaesthesia, then at times the person operating and administering the local anaesthetic will be the same individual. He/she must then obtain consent for both the surgery and the anaesthetic. If the operating surgeon also administers local anaesthesia, he/she should have documented evidence of achieving locally agreed competencies. 6.4 The patient must give written consent to the operating surgeon or senior medical member of the team and this consent is best given at the preadmission assessment.

7. HOSPITAL STAFF AND IN-PATIENT FACILITIES 7.1 The operation is most safely carried out in hospitals where consultant support from other medical and surgical disciplines is readily available. 7.2 Access to a high dependency unit (HDU) or intensive care unit (ICU) is seldom required for forefoot surgery, but all patients must have access to 24 hour, 7 day a week emergency medical cover. 7.3 Adequate numbers of trained orthopaedic nurses and members of AHPs, especially physiotherapists and plaster technicians, must be available. 7.4 Patients should be nursed in dedicated elective wards, staffed by a team experienced in the management of patients with musculoskeletal disease. 7.5 The risk of cross-infection in hospital should be reduced to a minimum. Facilities must be available for isolating patients known to be infected with, or carrying pathogenic organisms.

8. OPERATING THEATRE RESOURCES 8.1 Infection following operation can be catastrophic for the patient. 8.2 The use of ultra-clean air theatres is advised particularly when implants are used. 8.3 The operating theatre should be dedicated to elective orthopaedic surgery as far as is possible. Sharing these facilities with other elective clean surgical disciplines is acceptable,. 8.4 There should be a clear and agreed sterile technique protocol in the orthopaedic theatre. Adherence to this should be mandatory. 8.5 The surgeon must have a trained scrub nurse who is fully familiar with the instrumentation. If required, in the absence of junior medical staff, additional assistance must be available. Specific training should be received by any assistant. 8.6 A full range of implants and instruments must be readily available. 8.7 Appropriate impenetrable clothing and sheets/drapes are essential. 8.8 A Hospital Sterile Supply Department (HSSD) should be located near the operating theatre. It must be able to process used instruments and provide packs in an efficient and timely manner. Tracking mechanisms should be in place to ensure efficient and accountable sterilisation procedures. (BOA 2008) 8.9 A range of casting materials must be readily available. 8.10 A fully equipped and adequately staffed recovery area must be provided.

9. THE SURGEON AND THE SURGICAL TEAM 9.1 Any Consultant Orthopaedic Surgeon within the team should possess a CCT and be enrolled on the Specialist Register of the GMC or, hold another acceptable international qualification. 9.2 The operative credentials of any member of the team should relate to regular performance of the operation. It is impossible to be dogmatic on the number of such procedures performed, but occasional performance is not acceptable. 9.3 The knowledge and practical skills of a Consultant Orthopaedic Surgeon and the team performing the operation must be maintained by continuing medical education (CME), audit of complications and outcomes, and a continuing appraisal process. 9.4 Operations performed by surgeons in training must be supervised by consultants meeting the criteria in 9.1. Operating theatre time must be made available when required for surgical training as part of a Surgical Training programme. The level of supervision should be in accordance with the experience of the trainee. In the absence of consultant supervision in theatre, arrangements should be made for on-site consultant cover.

10. THE ANAESTHETIST AND THE ANAESTHETIC TECHNIQUE 10.1 The anaesthetist and anaesthetic team are essential, highly-trained and skilled members of the operating team. 10.2 The Royal College of Anaesthetists has developed standards of training and practice in this Specialty which must be followed. 10.3 Such standards will change in time and all staff should update their skills and knowledge regularly through CME and CPD. 10.4 The activity of the Consultant Anaesthetist may include supervision of Extended Role Practitioners such as Nurse Anaesthetists. This should follow nationally agreed standards. 10.5 The involvement of the anaesthetic team is desirable in the Pre-Admission Assessment. The team should, as far as possible, help to identify and assess increased medical risk factors and advise on reduction of risk where possible. This may require postponement of the scheduled operation. 10.6 The team must be involved in the process of informed consent and immediate preoperative visiting. 10.7 The Anaesthetic Record should be part of the Clinical Record and meet nationally agreed standards. 10.8 The activity of the anaesthetic service must be within the setting of Clinical Governance.

11. CLINICAL RECORD 11.1 Good records are a basic tool of clinical practice and should be typewritten or produced on computer. 11.2 The record must include the name, date of birth and the address of the patient, and the referring practitioner should be identified. The hospital number should be clear, and the hospital and surgeon with responsibility for care of the patient should be named. Increasingly the patient will be admitted under the care of a team and, if so, this should be specified. 11.3 Within the record, the general medical condition of the patient as well as fitness for operation should be recorded. It should contain the clinical history, full clinical examination findings, pre-existing medical history and all current disabilities and complaints. The diagnosis of the condition and the purpose of the operation should be stated and all medication should be listed. There should be a multi-disciplinary clinical record which may be part of a local Integrated Care Pathway (ICP). 11.4 The process of fully-informed consent should be recorded correctly and the patient’s signature witnessed as appropriate. The process should ensure that the patient is aware of the risks and benefits of the procedure being offered, as well as the option of not performing any procedure. The operating surgeon or another appropriately trained member of the surgical team should complete the consent form with the patient and all of the above should be in compliance with guidelines. 11.5 The Anaesthetic Record is part of this record. 11.6 Records and images should be retained to permit long-term follow-up, particularly in joint replacement surgery.

12 THE OPERATIVE AND POST-OPERATIVE RECORDS 12.1 The operative note should be made in writing or dictated by the operating surgeon or other member of the surgical team for immediate typing. A proforma may be available and the surgeon should complete this. 12.2 The record of the operation should be made as soon as possible following surgery and should include: •

Patient identification

The name of the operating surgeon, assistants and the name of the consultant or team responsible

The diagnosis

The procedure performed

The position of the patient on the operating table

The name of the anaesthetist

The type of anaesthesia employed

Tourniquet pressure and time (if used)

The surgical incision or approach used, and the reason for doing so, if necessary

Description of any other procedures performed such as catheterisation or the use of calf stimulators or foot pumps

Description of the findings including major structures seen

Details of tissues removed, altered or added

Details of serial numbers of prostheses inserted

Details of bone grafting if used

Details of sutures or wound repair materials used

An accurate description of any difficulties or complications encountered and how these were overcome

Details of antibiotic prophylaxis [See section 15]

Details of venous thrombo-embolism prophylaxis [See section 14]

Details of the reduction and stability of joints if relevant at completion of the procedure

Immediate post-operative instructions and, in particular, any variance from any agreed care pathway or rehabilitation programme

The surgeon’s signature or computer equivalent

Date of the operation

12.3 Post-operative progress should be documented, particularly noting any complications. The date of discharge and arrangements for further care should be

recorded. The existence of an ICP should be specified, if present in an institution, and any variance from that pathway should be recorded. 12.4 All notes should be contemporaneous and should not be altered; errors should be identified. Orthopaedic records within the hospital records should be readily identifiable within the case note. 12.5 Follow-up notes should allow another clinician to assume the care of the patient at any time. The following standards should apply: • All clinicians mentioned in the record must be identified by name and designation. • Details of written and verbal information given to the GP, patients, relatives and carers must be recorded. • Details of all investigations considered and requested should be noted. • There should be a daily entry of the patient’s progress in the record. Any change in the patient’s management or any further procedures should be recorded. • An entry should be made whenever a doctor is called to see the patient. • Deletion should be made with a single line and signed and dated. 12.6 All patients should have good quality radiographs of the foot before discharge from hospital. 12.7 There should be agreed protocol for the retention of all documents and images. 12.8 The Anaesthetic Record should comply with standards laid down by that specialty. 12.9 The clinical record in all settings (NHS, Private Practice or Independent Sector Treatment Centres) should follow the same high standard as laid down in this document.

13. FIXATION DEVICES / IMPLANTS 13.1 Orthopaedic Surgeons have many fixation devices from which to choose. Many of these have not been subject to studies of outcome. Guidance exists from the National Institute of Health and Clinical Excellence (NICE) on the use of joint replacements for the first metatarso-phalangeal joint. 13.2 Many factors determine the surgeon’s preference for an individual implant. These include their training, consultant colleagues’ preference, and a desire to improve their own results. The manufacturers of such devices can have a significant effect on choice through the service they provide. 13.3 The choice of fixation should be governed by evidence of the effective performance of that implant and, if possible, of the operating team using it. 13.4 The choice of implant may be influenced by cost. Surgeons and their teams should ensure that the cost of the implant does not result in the use of an unproven or substandard implant. Managers should ensure that when changes in implant or equipment are introduced, all staff are involved, informed and suitably trained. 13.5 Surgeons should be aware of information published by manufacturers in relation to each implant. This Information for Use (IFU) enclosed with each implant should be read by the surgeon. 13.6 The published results of many implants offer little help to the surgeon wishing to make an informed choice. Most outcome research is short-term, non-comparative and does not take into account the case-mix and variations in the operative technique of the surgeon. There is great variation in the measurement of outcomes following the procedure. Surgeons should be aware of the high quality outcome studies that are published and of the advice from NICE (2005). 13.7 The patient and hospital management must be made aware if any of the surgical or anaesthetic team may gain financially from the use of any device or medicine.

14. PROPHYLAXIS AGAINST VENOUS THROMBO-EMBOLISM 14.1 Few studies exist to guide best practice in thromboprophylaxis in elective forefoot surgery. 14.2 A prospective series of 100 Chevron osteotomies for bunion correction in whom no thromboprophylaxis was given and which excluded patients with previous deep vein thrombosis (DVT), found a prevalence of venographically proven calf DVT of 4%, none of which was symptomatic. The authors concluded that the routine use of thromboprophylaxis was not necessary (Radl et al, 2003). 14.3 Mizel et al (1998) in a prospective multicentre study of 2733 patients undergoing a variety of foot and ankle procedures of which 50% were in the forefoot. The incidence of clinical DVT was 6 in 2733 (0.22%) and that of non-fatal pulmonary embolus (PE) was 4 in 2733 (0.15%). The incidence in the 50% of patients having forefoot procedures is not stated, but all thromboembolic events occurred in patients who were non weight-bearing after surgery. The authors conclude that routine thromboprophylaxis is not warranted after foot and ankle surgery. 14.4 Solis and Saxby (2002) undertook a prospective study of 201 patients having a variety of foot and ankle surgery who all had duplex ultrasound performed at the first postoperative visit. 7 patients had a calf DVT (3.5%), none of which were treated or progressed proximally. Factors associated with an increased risk of DVT were postoperative immobilisation, hindfoot surgery, tourniquet time and age. The authors concluded that the rate and progression of DVT after foot and ankle surgery was low and did not require routine thromboprophylaxis. 14.5 There are well-accepted patient-related factors that increase the risk of DVT or PE. These include: a history of PE or DVT, malignancy, a positive family history, hindfoot surgery, non-weightbearing, and likelihood of prolonged immobility or poor mobilisation. (NICE, 2010). 14.6 NICE (2010) identified that the use of lower limb plaster casts is associated with a risk of DVT between 4-40% without prophylaxis. They compared 6 randomised controlled trials of LMWH with placebo in patients immobilised in a bellow knee cast or cylinder plaster following ankle fracture, Achilles tendon rupture and other lower limb injuries and concluded that LMWH until cast removal was associated with a significant reduction in DVT but not PE. The weightbearing status of the leg in cast is not stated in any of the 6 papers and as all papers refer to hindfoot surgery, the results cannot be extrapolated to forefoot surgery where cast immobilisation and non-weightbearing are seldom practiced. 14.7 Nevertheless, the surgeon, anaesthetist and clinical team should identify any risk factors in an individual patient at pre-admission assessment, using a risk assessment tool such as that recommended by NICE or one used locally by the surgeon’s employing NHS Trust. (NICE, 2010). Despite risk assessment tools being available, there are none that are validated to date. 14.8 The BOA’s view is that an orthopaedic surgeon using a risk assessment tool of their Trust is complying with the NICE guidelines. 14.9 For most patients undergoing elective forefoot surgery, early mobilisation is all that is required. 14.10 Debate continues regarding the use of chemical prophylaxis.

14.10 There is evidence that the use of spinal anaesthetic technique significantly reduces the incidence of DVT. Anaesthetists should be aware of the potential risk of spinal haematoma with concurrent chemical prophylaxis and neuraxial anaesthesia. An indwelling epidural catheter, if used, should be removed before such chemical prophylaxis is commenced, and guidelines should be regularly updated. 14.12 There is strong evidence for the effectiveness of low molecular weight Heparin, rivaroxaban, dabigatran or Warfarin in reducing radiological or Doppler detected DVT by 40 to 60% in hip and knee arthroplasty. However, there is also concern regarding possible bleeding complications which may put the surgical wound at risk. There is little current evidence for the use of such prophylaxis in forefoot surgery. 14.13 To be effective, prophylaxis should be given as close as possible to the time of surgery. Mechanical devices (foot pumps, pneumatic compression, calf stimulators) may be used in the perioperative period and there is good evidence that these reduce the risk of DVT following hip or knee replacement surgery. These are, by and large, free of significant side effects.

15. PROPHYLAXIS AGAINST INFECTION 15.1 Patients should be clinically screened for infection prior to the operation. Fungal skin and nail infections should be treated prior to elective forefoot surgery. 15.2 All patients who will have an implant should receive, intravenously, an antibiotic at induction of anaesthesia. Each unit performing the operation should have a locallyagreed policy which should include advice from microbiologists. 15.3 Surgery requiring implants should be performed in ultra clean air theatres if possible.

16. SURGICAL OPTIONS – DISORDERS OF THE FIRST RAY - ARTHRITIS OF THE FIRST MTP JOINT OR HALLUX RIGIDUS 16.1 Hallux rigidus is a painful, progressive, degenerative condition of the hallux MTPJ characterised by restricted motion of that joint and osteophyte formation. It is a common disorder that has been reported to affect 2% of individuals who are more than 50 years of age (Gould, 1981). 16.2 Clinical examination of the foot should include assessment of the condition of the soft tissues, skin, and for the presence or otherwise of gastroc-soleus contracture; the degree of deformity and correctability of the hallux; the mobility of the IP, MTP and TMT joints; the presence of pathology or deformity of the lesser rays; the presence of concurrent abnormalities of structure and function of the whole foot, ankle and lower limb; the neurovascular status of the limb. 16.3 Radiological assessment should include 2 views: D-P and lateral taken weightbearing. In addition, further views such as an oblique and/or sesamoid view can be considered. 16.4 Clinical and radiological assessment should allow assessment of the degree of the degenerative process. 16.5 Patient management is dictated by the summation of a patient’s symptoms and expectations, and the degree of the degenerative process. The objectives of treatment are patient education, relief of pain and deformity, plus improvement in function. 16.6 Conservative management consists of accommodative footwear, use of orthotics and proprietary analgesia and NSAIDs (Thompson et al., 1992). 16.7 Manipulation and steroid injection can be of benefit in hallux rigidus. Repeated injections are to be discouraged. (Solan et al., 2001). 16.8 Indications for operative treatment are: pain not adequately controlled by nonoperative means, with disability, and major problems with footwear. 16.9 The objectives of operative treatment include the relief of pain from the 1st MTPJ and correction of any deformity. These objectives can be achieved by operations that preserve motion at this joint and fusion, which does not. Whatever procedure is selected, it should not further dysfunction the first ray by excessive shortening or elevation. 16.10 Cheilectomy is the first surgical procedure that should be considered in any patient with restricted ROM but whose mid-range motion is painless and who has radiologically obvious, dorsal and lateral metatarsal head and proximal phalangeal osteophytes. Cheilectomy aims to increase motion, decrease pain, and facilitate an early return to activity. Nawoczenski et al. (2008) showed that cheilectomy was effective in maintaining balanced plantar loading with increased ROM, although normal kinematics were not restored completely and joint degeneration could continue progressing. Results of a recent study (Canseco 2009) showed significant improvements in walking speed, cadence, stride length, and stance/swing ratio from preoperative to postoperative state. Altered hallux and forefoot positions preoperatively, showed shifts towards normal after cheilectomy. Also, the study by Coughlin and Shurnas (2004) showed that performing cheilectomy in 93 patients with hallux rigidus grades I, II and (selected) III, offered a 92% good or excellent subjective result after a mean follow-up of 9.6 years. Age, should also not be a contra-indication to cheilectomy (Feltham et al., 2001). 16.11 For severe arthritis of the MTP joint, arthrodesis remains the gold standard. The reported success rates range from 77-100%. Internal fixation is recommended. Use of

a single screw is bio-mechanically unsound and is discouraged (Coughlin & Shurnas 2004). 16.12 The Keller’s procedure (excision arthroplasty) has been shown to de-function the first ray of the foot. Push-off becomes weak and re-distribution of forefoot loading causes secondary deformities and metatarsalgia (Lau and Daniels, 2001). Current evidence suggests that this procedure should only be considered in elderly persons with extremely low functional demands and with advanced degenerative changes in the 1st MTPJ, who are at high risk of developing complications such as infection, if fusion is undertaken (Keiserman et al., 2005). 16.13 Implant arthroplasties are not recommended according to current evidence (Keiserman et al., 2005). Also hemi-arthroplasties of the 1st MTPJ have proven less successful than arthrodesis (Raikin and Ahmad, 2008). As such, replacement of the 1st MTPJ is a procedure to be approached with caution. It is accepted that all orthopaedic implants are subject, ultimately, to mechanical failure. Therefore, surgeons who choose to implant such devices outside of a trial approved by an ethics committee, should, prior to implantation, fully inform their patients of the expected longevity of the device and the consequences of implant failure.

17. SURGICAL OPTIONS – DISORDERS OF THE FIRST RAY – HALLUX VALGUS 17.1 Hallux valgus is deformity of the first ray comprising of medial deviation of the 1st MT with uncovering of the underlying sesamoid bones combined with lateral deviation of the hallux at the MTP joint and pronation, usually, but not invariably, associated with subluxation of the MTP joint. 17.2 Hallux valgus interphalangeus is a variant associated with a deformity at the interphalageal joint without deformity per se of the MTP joint. 17.3 Clinical assessment must include the patient’s expectations of outcome of treatment as only 60% of patients are able to wear unlimited shoes following surgery (Mann and Pfeffinger, 1991). 17.4 Clinical examination of the foot should assess the condition of the soft tissues, skin, and the presence or otherwise of gastroc-soleus contracture; the degree of deformity and correctability of the hallux; the mobility of the IP, MTP and TMT joints; the presence of pathology or deformity of the lesser rays; the presence of concurrent abnormalities of structure and function of the whole foot, ankle and lower limb; the neurovascular status of the limb. 17.5 Radiological assessment should include 2 or 3 views: DP and lateral taken weightbearing and an optional oblique view to assess the deformity and assist in pre-operative planning. The hallux valgus angle (HVA) (normal < 15°) and intermetatarsal angle (IMA) (normal < 9°) are assessed. The congruency of the MTP joint, distal metatarsal articular angle (DMMA), hallux valgus interphalangeus angle, the relative length of the first and second metatarsals to one another, MTP joint arthrosis and degree of uncovering of the sesamoids are also assessed, as are deformities and pathology affecting the lesser rays and the whole foot. 17.6 The objectives of surgical treatment are restoring the function of the first ray, relief of pain and deformity, improvement in function and improved footwear. 17.7 Conservative management consists of accommodative footwear. Orthoses do not affect the progression of hallux valgus. 17.8 Indications for surgery are pain not adequately controlled by non-operative means, with disability and major problems with footwear. Ulceration may also be an indication, but many of these cases have vascular or neurological deficit, and the treatment of such cases is beyond the remit of this document. 17.9 The mid-medial incision is preferred to avoid iatrogenic neuroma formation. 17.10 For severe arthritis of the MTP joint with hallux valgus, arthrodesis remains the gold standard. The Keller’s procedure (excision arthroplasty) is only rarely required, for example in an elderly person with extremely low functional demands and in those patients with a high risk of infection. 17.11 For hallux valgus without arthritis the surgical technique must aim to preserve relative metatarsal length, restore metatarsal and sesamoid alignment, and correct MTP joint subluxation if present. 17.12 Internal fixation should be used for the stabilisation of osteotomies and the technique should be sufficiently robust to allow early weight bearing and mobilisation. The post-operative regimen should be aimed at restoring motion and function of the joint as rapidly as possible without causing problems related to excessive swelling, stress fracture or under/over correction of the deformity. Post-operative footwear, splintage and physiotherapy should be provided to meet the individual requirements of the

patient. Recovery from surgery and restoration of normality will take between six and twelve months from surgery. 17.13 There is no reason why surgery for bilateral deformity should not be carried out simultaneously (Lee et al., 2009).

18. SURGICAL OPTIONS – DISORDERS OF THE FIRST RAY – SESAMOID DISORDERS 18.1 Appropriate consideration of the anatomy and pathology of the sesamoid bones should be made in all disorders of the 1st MTPJ, especially when plantar pain is a major feature. 18.2 Diagnosis and differentiation of sesamoid pathology is difficult but may be aided by plain radiography, CT scanning, MRI scanning and nuclear bone scans (Sanders, Rathur 2008). 18.3 Acute injuries may be due to sesamoid fractures or soft tissue injuries to the metatarso-sesamoid-phalangeal complex (e.g. turf toe). Plain radiographs and MRI scanning may be helpful in acute hyperextension injuries and early surgical intervention is indicated in significant injuries, whereas less serious injuries can be managed conservatively with appropriate taping, orthoses and footwear modification (Cohen, 2009). 18.4 Chronic pain in the sesamoid area may be due to undiagnosed acute trauma, repeated injury, osteonecrosis, and arthritis or peri-sesamoid inflammation. The term sesamoiditis itself is not defined and a differential diagnosis should be sought by appropriate plain radiography, MRI scanning, CT scanning or radioisotope imaging. In most cases, initial therapy should consist of prolonged conservative management with modification of activity, splintage, insoles, footwear modification and immobilisation. 18.5 Isolated excision of one sesamoid bone should only be considered in cases failing to respond to appropriate conservative measures, and then only once due consideration and explanation of the potential complications of excision have been undertaken (Aper et al., 1996). 18.6 Removal of both sesamoids is generally contraindicated (Aper et al., 1996). 18.7 Inappropriate or incomplete repair of the capsular structures after sesamoidectomy will invariably lead to poor function and or deformity.

19. SURGICAL OPTIONS – LESSER TOE PROBLEMS 19.1 Assessment of the lesser toe pathology must include the first ray and an appreciation of contributions of MTPJ, PIPJ and DIPJs to the pathology/deformity. 19.2 Systemic diagnoses such as inflammatory arthritis or neuromuscular disease can present to the surgeon with deformity or pathology affecting one or more lesser toes. 19.3 Examination of the lesser toes must differentiate between a flexible and fixed deformity. Multiple claw toes necessitates consideration of an underlying neurological disorder. 19.4 The principles of any intervention are to maintain toe alignment or correct alignment when deformity exists. Dislocation and subluxation of the MTPJs should be reduced. Toe contact should be maximised with the ground in order to distribute forefoot load evenly (Coughlin MJ, 2003). 19.5 Treatment options range from conservative through joint sparing procedures to joint sacrificing procedures. In principle joint sparing procedures should be favoured over joint sacrificing. Surgery to lesser toe MTPJs can result in stiffness and, therefore, physiotherapy in the early post-operative period should be considered (Espinosa N et al. 2008). 19.6 The surgeon should be prepared to address deformity of the lesser toes at several levels. Any surgical procedure needs to take into consideration the neurovascular status of the foot. 19.7 Most osteotomies of the metatarsals should be stabilised with internal fixation.

20. SURGICAL OPTIONS – THE RHEUMATOID FOREFOOT 20.1 The foot and ankle is the initial presentation of rheumatoid arthritis (RA) in 16-19% of cases (Jaakkola and Mann 2004). RA is a systemic disease and patients require a multidisciplinary management strategy involving the rheumatologist, orthopaedic surgeon, physiotherapist, occupational therapist, podiatrist and orthotist. 20.2 The forefoot is frequently symmetrically affected by rheumatoid arthritis. In chronic disease the prevalence can be as high as 90% (Vainio, 1956). 20.3 The hallux is often involved early with resulting dysfunction of the 1st ray. This is characterised in its later stages by joint destruction and development of deformity, both in valgus and varus. 20.4 The lesser metatarsophalangeal joints dislocate as a result of destruction of the ligaments and capsule causing severe plantar callosities, clawing of the lesser toes, ulceration and footwear problems. 20.5 The rheumatoid forefoot usually presents with a combination of great toe deformity with secondary degeneration. There may be intephalangeal and 1st tarsometatarsal joint involvement, lesser metatarsalgia with painful plantar callosities, disease of the soft tissues of the forefoot and often compounded by midfoot/ hindfoot disease and deformity. Often other lower limb joints will contribute to the complexity of diagnosis and treatment. 20.6 Clinical examination includes careful assessment of the soft tissues including the neurological (neuropathy) and vascular structures (vasculitis), tendinous integrity (rupture), sole of the foot (callosity, ulcer), gastroc-soleus (contracture), hindfoot and midfoot (disease, deformity, instability). It is essential for the patient as a whole to be assessed preferably in conjunction with rheumatologic review to grade the systemic manifestations of the disease and initiate / alter treatment appropriately. 20.7 Radiological examination should involve the foot and the ankle with routine DP and lateral weight bearing radiographs. A subtalar view and oblique views of the midfoot may also be required. Doppler assessment of vasculature may be required if the vascular status is difficult to assess due to deformity. Rarely MRI may be required in a diagnostic conundrum (Morton’s neuroma vs rheumatoid nodule). 20.8 Treatment options are based on patient’s symptomatology, stage of disease, general status and expectations. 20.9 The objectives of treatment are to restore pain free ambulation, correct deformity if necessary, treat ulcers and other soft tissue disorders (bursae, tarsal tunnel syndrome, tendon rupture etc). Early treatment is often rewarding (Cracchiolo, 1984). 20.10 Conservative measures include selective steroid injection of inflamed joints, use of orthoses to reduce shear, redistribute weight bearing, support unstable joints, decrease attrition (interdigital appliances), and the use of custom made footwear to accommodate abnormal foot shapes (Gould, 1982). 20.11 Indications for surgical management include failure of conservative treatment to control pain, rapidly progressive deformity and disability. Ulceration and infection may also require surgical treatment. Hindfoot pathology and deformity should be addressed first,. 20.12 RA patients requiring intubation may need clinical and radiographic assessment of the cervical spine.

20.13 Disease modifying anti-rheumatoid drugs (DMARDs) such as the cytokine inhibitors should be withheld after discussion with the rheumatologist for 2-4 weeks prior to major surgery, and may be restarted post-operatively if there is no evidence of infection and once wound healing is satisfactory (British National Formulary). Methotrexate does not need to be stopped preoperatively (Grennan et al., 2001). 20.14 Vascular examination should be undertaken and documented. A formal vascular assessment should be obtained if indicated. 20.15 Skin incisions should be carefully planned with careful soft tissue handling to reduce wound complications. 20.16 RA patients often require a longer length of stay and rehabilitation. 20.17 The principles of operative treatment include stabilisation and re-functioning of the 1st ray, correction of lesser toe deformity, to allow the foot to be shod appropriately. As the 1st ray and the lesser toes are often involved in conjunction, a reconstructive approach to the whole forefoot is often required. 20.18 Synovectomy may be useful in the early stages of the disease. Similarly, MTP release, flexor extensor transfer with PIP release/excision etc may be used in earlier stages of the disease. 20.19 Isolated 1st ray pathology is dealt with by arthrodesis of the MTP, IP or TMTJ as appropriate. This serves to stabilise the first ray and thereby improving weight bearing. 20.20 The Stainsby procedure (Briggs and Stainsby 2001) is a lesser toe procedure saving the MTP joint by releasing and repositioning the plantar plate and the plantar fat pad, excising most of the proximal phalanx, and stabilising the 1st metatarsophalangeal joint. 81% symptom free status has been reported by Briggs and Stainsby. 20.21 Others report patient dissatisfaction with the cosmetic appearance of the toe (Mangaleshkar et al 2001) and the patient requires appropriate counselling as to the appearance of the toe. 20.22 Arthrodesis of the 1st MTPJ and excision of the lesser metatarsal heads, with PIPJ fusion/excision arthoplasty is a successful method of treatment of severe rheumatoid forefoot deformity. It stabilises the 1st ray and de-profiles the sole of the foot by removing the dislocated metatarsal heads. This form of reconstruction is often combined with lesser toe corrective operations including PIPJ fusions, excision arthroplasty and flexor to extensor transfer (Coughlin (2000) and Kadambande et al (2007)). Metatarsal head excision can be dorsal or plantar. Patient has to be counselled on the potential recurrence of callosities in the long term. 20.23 Pan-metatarsal head excision (Hoffman procedure) has also been advocated as a satisfactory method of treating the rheumatoid forefoot (Thomas et al 2006). The Hoffman procedure may result in further defunctioning of the first ray with recurrence of callosities, failure to maintain a plantigrade hallux, decreased arthroplasty space etc (Patsalis et al., 1996) and patients should be counselled appropriately. 20.24 Other procedures such as the Keller’s arthroplasty, joint replacement of the 1st MTP joint and Weil osteotomy of the lesser and 1st MTP joints lack evidence for their efficacy in the treatment of the rheumatoid forefoot and as such will not be included in the treatment options at the present stage until such evidence becomes available.

21. SURGICAL OPTIONS – MORTON’S INTERDIGITIAL NEUROMA 21.1 Interdigital neuroma is a painful condition of the forefoot. It is thought to be a mechanically induced neuropathy. It is characterised by extremely variable clinical symptoms and signs. 21.2 A general assessment of the foot is mandatory and should include an assessment of the skin, neurovascular status and whether or not there is any contributory hindfoot or forefoot deformity. 21.3 Positive clinical findings on examination of the foot might include tenderness in the web-space, which is exacerbated by side-to-side pressure (positive squeeze test). There may be an associated ‘click. Mulder described a click associated with recognisable pain (Mulder, 1951). Plantar percussion of the suspect web-space may also reproduce pain. Examination of the MTPJs and toe flexor tendons should be performed to exclude pathology of these. 21.4 Investigation might include plain radiography (to help exclude MTPJ articular pathology) and ultrasound or MRI (depending on local availability and expertise), for localisation of the neuroma and assessment of size. 21.5 Objectives of management should include patient education as well as relief of pain. 21.6 Conservative treatment should include correction of any contributory hindfoot or forefoot deformity, accommodative footwear and/or appropriate orthotic device, plus/minus NSAIDs. 21.7 Steroid/local anaesthetic infiltration (no more than 1.5 ml total volume), with or without ultrasound guidance, can be of benefit, especially if the neuroma is small (less than 5mm). The longevity of any positive effect of steroid infiltration is less predictable with larger neuromas. 21.8 Sequential absolute alcohol injections are not widely practised and should only be undertaken in the context of a trial until further peer reviewed data becomes available. 21.9 Open excision of a symptomatic neuroma is the commonest surgical procedure undertaken although neurolysis (both endoscopic and open) is also practised. 21.10 The standard ‘open’ surgical approach can be either plantar or dorsal. Both approaches have advantages and disadvantages and there is no evidence that either is better. In fact, “there is insufficient evidence on which to assess the effectiveness of surgical and non-surgical interventions for Morton’s neuroma” (Thomson et al., 2004). 21.11 Over 80% good or excellent outcomes should be achieved after surgical excision.

22. SURGICAL OPTIONS – IN-GROWING TOENAILS (ONYCHOCRYPTOSIS) 22.1 In-growing toenails often cause pain and disability. They occur when the nail plate traumatises the lateral nail fold giving rise to pain, inflammation or infection. 22.2 Inflammation is often caused by a hook of nail being left when the toenail is torn during an inappropriate toenail cutting procedure. The inflammation can often be settled by tepid salt baths, gentle retraction of the inflamed tissue and trimming of the sharp hook of nail. 22.3 Surgical treatment should be considered for patients with recurrent episodes of inflammation or infection. 22.4 Enquiries should be made about the patient’s medical history (e.g. diabetes) and a physical examination for circulation (pulses and capillary profusion) is mandatory. Physical examination should exclude palpation for subungual exostosis and radiographs should be performed when subungual exostosis are suspected. 22.5 A Cochrane Database Systemic Review (Rounding and Bloomfield 2002) has demonstrated that temporary measures such as simple nail avulsion or wedge excision of the nail without matricectomy have a recurrence rate of over 50%. They are not recommended. 22.6 The same Cochrane database review has shown that chemical matricectomy (such as phenol ablation) have a lower recurrence rate than surgical matricectomy (e.g. Zadik or Winograd). Patients with recurrent problems with in-growing toenails should, therefore, be managed by chemical matricectomy rather than surgical procedures; the added advantage of the chemical procedures is that they can be performed at the time of infection whereas the surgical procedures have to be delayed until infection has settled often, with antibiotic treatment. There is no need to combine surgical and chemical matricectomy as chemical matricectomy works just as well. 22.7 Chemical matricectomy can be carried out in a clean environment (e.g. an outpatient clinic) and does not need to be carried out in a sterile operating theatre environment. 22.8 Surgical procedures, particularly those involving dissection down to bone, are best carried out in a sterile operating theatre environment. 22.9 The surgeon should pay particular attention to the type of tourniquet used and should ensure that the tourniquet is removed at the end of the procedure. 22.10 The ring block should be performed with plain local anaesthetic as ring blocks performed with anaesthetic plus adrenaline can lead to circulatory problems. 22.11 Cases of inadvertent phenol injection into the tissues have been reported and can be avoided with the use of pre-packed phenol swabs.

23. POST-OPERATIVE MANAGEMENT AND DISCHARGE FROM HOSPITAL 23.1 All patients should be made aware of the expected interventions following surgery. This should be part of any locally developed ICP. 23.2 Mobilisation following the operation should include significant input from the orthopaedic team, and patients should only be discharged from hospital when they are considered capable of coping in the environment at their destination. 23.3 Discharge planning should be in place following pre-admission assessment. 23.4 Patients should be given information about telephone numbers or other methods of contacting the hospital or the orthopaedic service, should problems occur. 23.5 Patients should be informed of the likely early review date following surgery; this will usually be within 2 weeks of the operation.

24. LONG-TERM FOLLOW-UP OF PATIENTS 24.1 For best practice, patients with MTP joint replacements should be followed up clinically and radiologically in the longer term. The minimum requirements include taking a history of any complaints, use of an outcome score and yearly clinical and radiological examination. 24.2 Failure from aseptic loosening of the prosthesis is often silent; the patient may not complain. Regular follow-up with x-ray examination identifies the patient at risk of failure. Revision procedures should be planned and performed before massive bone destruction occurs. Such operations are usually less successful than primary procedures. 24.3 It is recommended that part of the contractual agreement with purchasers/commissioners is to require follow-up to identify premature failure.

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Steering Group 2009 Chairman Members