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Foot Print
November 2026
Bulletin of the British Orthopaedic Foot and Ankle Society
CONTENTS 5 FROM THE PRESIDENT HIRO TANAKA
12 How to avoid trouble in negligence litigation Advice from former BOFAS President Robert Clayton
8
7 FROM THE EDITOR Jitendra Mangwani
14 changes to the foot and ankle forms A joint update from the National Joint Registry (NJR) and the British Orthopaedic Foot & Ankle Society (BOFAS)
8 Should elevated HbA1c delay diabetic foot surgery? Foot Print seeks to answer the question
20 From Surgical Training to National Data A journey through the GIRFT academic fellowship 26 Understanding the Portfolio Pathway for entry onto the T&O Specialist Register A guide to the process of PP
36 Tackle big challenges, leave tiny footprints! Taking a look into how advances in instrumentation and surgical techniques have opened exciting new frontiers in Minimally Invasive Surgery (MIS) of the foot and ankle
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30 New guidelines summary 32 Diabetes epidemic in Asia (especially India) An emerging explosion of unrecognised Charcot feet
Edited by Professor Jitendra Mangwani. Associate Editors - Miss Verity Currall, Mr Munier Hossain and Mr Kailash Devalia. Assistant Editors - Mr Rajiv Limaye and Mr Miguel Fernandez.
38 EVIDENCE CORNER Newly published research between June and October 2026
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18 Finite element modelling Discover how foot and insole models can connect external loading with stresses and strains inside the foot
34 Bridging the gap in diabetic foot care A report from the UK India Diabetic Foot Foundation
32
Foot Print is the Bulletin of the British Orthopaedic Foot and Ankle Society
16 PUZZLE CORNER
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Foot Print
November 2026
Bulletin of the British Orthopaedic Foot and Ankle Society
WELCOME
BOFAS President, HIRO TANAKA
Dear friends,
T
his week, I attended a meeting where the scale of the NHS's challenge in addressing elective waiting lists was presented in colourful charts. Throughout the presentation, I was struck by the thought that each one of those blips represented someone's grandmother, waiting years in pain for her operation. It's so easy for us to get lost in the vastness of the numbers and lose sight of the humanity in our profession. And then my thoughts turned to BOFAS. A society founded on the principles of improving education and research, as well as influencing policy. I feel there's a paradigm shift in the air, where policymakers genuinely recognise that a
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clinically led NHS works to the benefit of patients and the system as a whole. For us, it means a different way of working. We know that our voice can be heard. Take for example, the protection of patient services in Hampshire and the Isle of Wight ICB. Thousands of patients can now receive treatment that would otherwise have been denied, due to our intervention and data from the registry. A review of how tariffs are remunerated means that some trusts will no longer be financially penalised when their surgeons perform total ankle replacements. It means that someone's relative gets the treatment they deserve. We have a real opportunity to make a difference. Not just in education and
research, but in shaping the very services our patients depend upon It requires us to learn to be politically astute, because we're not the only organisation trying to improve services. For our voice to be most effective, we must collaborate with the BOA, Royal Colleges, GIRFT, MHRA, ODEP, SAC and the devolved nations. Despite the systemic challenges we face every day at work, I remain optimistic that our society has the passion, resilience and determination to protect what matters to us all. And on that note, I'm very much looking forward to welcoming you to Wales soon. I'll be at registration all morning for a high five! n
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November 2026
Foot Print
Bulletin of the British Orthopaedic Foot and Ankle Society
FROM THE EDITOR Council and Committees Council Membership: President: Hiro Tanaka President Elect: Callum Clark Immediate Past President: Robert Clayton Honorary Secretary: Jitendra Mangwani Treasurer: Dave Townshend Media & Comms Director: Karan Malhotra Education Committee Chair: Anna Chapman Clinical Practice Committee Chair: Joel Humphrey Scientific Committee Chair: Sarah Johnson-Lynn Chief Operating Officer: Jo Millard Trustee: Steve Hepple Trustee: Steve Bendall EFAS Representative: James Ritchie EDI Lead: Lauren Thomson
Clinical Practice Committee Membership: Chair: Joel Humphrey Secretary: Ben Hickey Caldicott Guardian: Jitendra Mangwani Data Protection Officer: Jo Millard Member: Tim Clough Member: Shariff Hazarika Member: Robbie Ray Member: Peter Rosenfeld Co-opted Registry Lead: Lyndon Mason Co-opted Registry Lead: Ed Wood Co-Opted: Andy Goldberg Co-Opted: Nilesh Makwana
Education Committee Membership: Chair: Anna Chapman BOFAS Global Lead: Graham Chuter Secretary: Maneesh Bhatia Member: Jim Carmichael Member: Verity Currall Member: Yaser Ghani Member: Annabel Hayward Member: Nikki Kelsall Member: Julie Anne Kohls Member: May Labidi Member: Nijil Vasukutty Member: Krishna Vemulapalli Member: Matthew Welck Simulation Working Group: Togay Koç MIS Working Group: Robbie Ray BOTA Representative: Meg Baker Co-Opted: Vivek Dhukaram
Media & Communications Committee Membership: Chair: Karan Malhotra Secretary: Togay Koç Member: Edward Dawe Member: Conrad Lee Member: Joseph Ring Webinar Fellow: Peter Cay
Wisdom in practice emerges when we combine evidence with experience, reflection, and a clear understanding of the realities faced by our patients and colleagues.
C
ollaboration lies at the heart of Foot Print, the BOFAS Bulletin, and is reflected in the breadth and diversity of contributions to each issue so far. This edition captures the variety of modern foot and ankle practice, sharing insights from clinical experience, evolving management approaches, everyday learning, and medicolegal challenges.
As BOFAS continues to support excellence in foot and ankle care, sharing knowledge remains central to our collective endeavour. Each article offers a chance to learn, each shared experience can shape clinical practice, and each international contribution strengthens a wider community committed to improving patient care and outcomes. The international perspective offered by articles on diabetic foot care from colleagues around the world is especially welcome in this issue. Diabetic foot disease remains a major global health challenge, with significant effects on patients, families, and healthcare systems. While the clinical problems may be familiar, available resources, care pathways, cultural contexts, and practical challenges vary widely between countries and regions. This makes international exchange particularly valuable. Learning how colleagues approach prevention, early recognition, multidisciplinary management, limb preservation, and the wider challenges of diabetic foot disease can broaden our thinking and prompt us to consider whether established practices remain the most effective. Collaboration also means understanding context, recognising the strengths of different systems, and identifying lessons that can be thoughtfully adapted to our own practice. Foot Print aims to bring these perspectives together. With its international reach, Foot Print has become a forum for conversation, curiosity, and constructive exchange. Contributions from the UK and beyond help us recognise shared challenges, appreciate different solutions, and build connections across geographical and professional boundaries. They also remind us that meaningful progress is rarely achieved in isolation. I, on behalf of the editorial board, hope that this issue of the Foot Print encourages you to explore topics beyond your immediate interests, reflect on colleagues’ experiences in different settings, and consider how their insights might inform your own practice. Also, Puzzle Corner is back in this issue. Our purpose is shared: to learn together, improve practice, and deliver better care. Through openness, collaboration, and the thoughtful exchange of wisdom, we can help the knowledge in these pages reach further than the bulletin itself.
Jit Mangwani - Editor - Foot Print
Foot Print Associate EditorS
ASSISTANT EditorS
Scientific Committee Membership: Chair: Sarah Johnson-Lynn Secretary: Dev Mahadevan Member: Kailash Devalia Member: Toby Jennison Member: Adrian Kendall Co-Opted: James Ritchie
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Verity Currall
Munier Hossain
Kailash Devalia
Rajiv Limaye
Miguel Fernandez
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Elevated glycosylated haemoglobin (HbA1c)
Foot Print
Issue 5
Should elevated HbA1c delay diabetic foot surgery?
E
levated glycosylated haemoglobin (HbA1c) is regarded as a negative prognostic factor in the management of diabetic foot disease1-3. Consequently, elevated HbA1c may influence clinical decision making, and surgery is often delayed or deferred until glycaemic control has improved. The aetiology of diabetic foot ulceration (DFU) can be broadly classified as ischaemic, neuropathic, or neuroischaemic. Ischaemic ulcers typically occur distally, involving the toes or in the heel. In contrast, neuropathic ulcers are due to abnormal mechanical loading resulting in elevated plantar pressures. These commonly occur beneath the metatarsal heads or in the midfoot due to Charcot neuroarthropathy (CN). Neuropathy and ischaemia may coexist, resulting in a neuroischaemic ulcer. This distinction is clinically important because the underlying pathology determines the surgical strategy. In ischaemic DFU, treatment is principally directed towards restoration of perfusion and debridement of the infected or necrosed tissue with limited amputation of the toe or midfoot. These patients might need more than one operation if the infection is not adequately controlled or the vascularity of the tissues worsens. In contrast, surgical offloading is the fundamental principle when managing a neuropathic ulcer. These fundamentally different disease processes are frequently considered together when reporting outcomes. Consequently, an observed association between elevated HbA1c and an adverse
8
Madhu Tiruveedhula FRCSGlasg (Ortho) Consultant Orthopaedic Surgeon Basildon Hospital
Dr Gaurav Malhotra MBBS, DNB Gen Medicine, MRCP UK, PG Diploma Endocrine & Diabetes (London), CESR Endocrine Diabetes Consultant Diabetologist
surgical outcome may be due to other compounding factors such as male gender, smoking, body weight, body mass index, low vitamin D, peripheral arterial disease (PAD), ulcer duration and depth, osteomyelitis with elevated CRP or ESR4. The specific influence of elevated HbA1c on surgical outcomes in vascularly optimised patients with predominantly neuropathic DFU remains less clearly defined.
Pathophysiology of chronic hyperglycaemic state
Chronic hyperglycaemia impairs wound healing by reducing neutrophil recruitment and chemotaxis, resulting in ineffective pathogen clearance5. In addition, accumulation of advanced glycation end-products (AGEs) alters collagen cross-linking and impairs extracellular matrix turnover. The result is impaired progression from inflammation to proliferation and remodelling, allowing the DFU to stall in a chronic, non-healing state6. HbA1c changes slowly because it reflects average glycaemic exposure; meaningful reduction therefore requires weeks of sustained improvement rather than the days available before urgent or limb-threatening surgery.
“HbA1c cha nges slowly because it reflec ts av er age glyca emic e xp osure; me a ningf ul reduc tion t herefore requires weeks of susta ined improv ement.” www.bofas.org.uk
November 2026
Foot Print
Bulletin of the British Orthopaedic Foot and Ankle Society
complications, or subacutely for surgical offloading or reconstruction. Patients were divided according to their preoperative HbA1c levels into Group A (≤69 mmol/mol) and Group B (>69 mmol/mol). Forefoot: Outcomes were compared between 88 feet in Group A and 43 feet in Group B. Unfavourable outcomes occurred in 8/88 feet (9.1%) and 8/43 feet (18.6%), respectively (p=0.155). Amputation rates were 8.0% (7/88) in Group A and 18.6% (8/43) in Group B (p=0.085). Although both outcomes were approximately twice as frequent in Group B, neither difference reached statistical significance. Midfoot: Outcomes were compared between 45 feet in Group A and 37 feet in Group B. Amputation rates were Figure 1: Result of urgent surgical offloading for a transfer lesion in a patient with osteomyelitis and similar (13.3% vs 16.2%; chronic hyperglycaemia. p=0.761). Reoperation was more frequent in A higher value should provoke an MDT Initial analysis of patients undergoing Group A (42.2% vs 27.0%), although the discussion about whether to proceed urgent surgery demonstrated that HbA1c difference was not statistically significant or optimise diabetes first for each was not an independent risk factor (p=0.171). These findings suggest that, individual case, rather than postponing for adverse perioperative outcomes. once vascular status has been adequately automatically. Consequently, surgical indications were optimised, elevated HbA1c alone was extended to patients with neuropathic not significantly associated with adverse When surgery cannot be delayed, the foot complications irrespective of outcomes (Figure 1). priority is control of perioperative their HbA1c levels. This approach hyperglycaemia, with variable rate was agreed upon by the MDT, with Conclusion intravenous insulin infusion (VRIII) close postoperative monitoring and DFU is a manifestation of complicated used when indicated to maintain blood appropriate metabolic management by diabetes, reflecting established endglucose <10 mmol/L. the diabetes team. organ damage from neuropathy, ischaemia, or both. These complications Clinical Outcomes For the present study, age-matched develop over years of chronic Patients were identified from our patients undergoing surgery for hyperglycaemia and may persist despite clinical database of all patients who neuropathic or neuroischaemic forefoot subsequent glycaemic improvement; underwent surgery for neuropathic, ulcers or midfoot Charcot neuropathy therefore, HbA1c at surgery may not ischaemic or neuroischaemic diabetic were selected. Surgery was performed reflect the cumulative metabolic burden foot complications from 2019 onwards. either urgently for acute ulcer-related of diabetic foot disease. >>
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Foot Print
Elevated glycosylated haemoglobin (HbA1c)
Reducing HbA1c takes time and may not be achievable before urgent or timesensitive surgery. Delaying necessary intervention solely to achieve an arbitrary HbA1c threshold may therefore not improve outcomes. The priority should be optimisation of perioperative glycaemic control, with early involvement of the diabetic MDT to correct acute hyperglycaemia and minimise its adverse physiological effects7. HbA1c remains an important marker of chronic glycaemic exposure and perioperative risk but should be considered within the broader clinical context rather than used in isolation to defer necessary diabetic foot surgery. n References 1. Parylo J, Pond E, McQuail P, Budair B. The Impact of HbA1C on Postoperative Complications Following Orthopaedic
Surgeries to the Foot and Ankle: A Systematic Review. Foot Ankle Orthop. 2024 Dec 30;9(4). 2. Farooque U, Lohano AK, Hussain Rind S, Rind MS Sr, Karimi S, Jaan A, Yasmin F, Cheema O. Correlation of Hemoglobin A1c With Wagner Classification in Patients With Diabetic Foot. Cureus. 2020 Jul 15;12(7):e9199. 3. Shen JF, Jiang RM, Wang ZQ, Li M, Li J, Xie SY, Kang JJ. [Recurrence and influencing factors of diabetic foot ulcer in patients with type 2 diabetes mellitus]. Zhonghua Shao Shang Za Zhi. 2020 Oct 20;36(10):947-952. 4. Wukich DK, Johnson MJ, Raspovic KM. Limb Salvage in Severe Diabetic Foot Infection. Foot Ankle Clin. 2022 Sep;27(3):655-670.
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5. Dowey R, Iqbal A, Heller SR, Sabroe I, Prince LR. A Bittersweet Response to Infection in Diabetes; Targeting Neutrophils to Modify Inflammation and Improve Host Immunity. Front Immunol. 2021;12:678771. 6. Lin H, Yang Y, Wang X, Chung M, Zhang L, Cai S, Pan X, Pan Y. Targeting the AGEs-RAGE axis: pathogenic mechanisms and therapeutic interventions in diabetic wound healing. Front Med (Lausanne). 2025;12:1667620. 7. Ahmed S, Vainieri E, Manu C, Hester T, Kavarthapu V. Time critical Charcot foot reconstructions can be safely performed in the absence of optimal preoperative glycaemic control when delivered by MDT. Foot Ankle Surg. 2026 Apr;32(3):269-274.
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www.bofas.org.uk
Negligence litigation
Foot Print
Issue 5
How to avoid trouble in negligence litigation
T
he average orthopaedic surgeon will be sued every seven years. Roughly one in 10 negligence claims in the NHS involves orthopaedic surgery. Some negligence is due to surgical error. However, other reasons to be sued include delayed or failed treatment, and incorrect decision making pre- or post-surgery. We are all aware of the issues around informed consent, particularly following the Montgomery v Lanarkshire ruling. A major contributing factor here can simply be the mismatch between patient expectation and what we as surgeons can realistically achieve, with the potential for us to fail to communicate realistic outcome possibilities, particularly in elective surgery. Career-defining catastrophic cases are thankfully very rare in orthopaedic surgery. However, low-value nuisance claims are common and are extremely stressful to go through. To succeed in making a claim, the pursuer and their legal representatives must be able to prove that there has been a breach in the duty of care, and then they must prove the breach in the duty of care led to actual quantifiable harm. The legal tests applied are the Bolam test (Hunter versus Hanley in Scotland), which requires the legal team to prove that the treating surgeon acted in a way that no ordinarily competent surgeon in that area of practice would have acted. However, to successfully defend a case, it is not sufficient simply to get another specialist along to say that what you did was okay. The second legal test is that your actions must stand up to logical scrutiny. In practice, this means that what you did must be supported by medical literature. This is known as the Bolitho test (Honisz in Scotland).
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Robert Clayton Immediate Past President, BOFAS When it comes to questions of informed consent, much has been written about the implications of the Montgomery v Lanarkshire ruling, but to distil it down to its simplest level, the treating clinician must show that they have considered patient's individual circumstances. This includes their age, comorbidities, employment, and hobbies. The surgeon must have tailored their advice to this profile and outlined the risks and benefits of different treatment modalities, including non-operative treatments that are available for this condition. This includes discussing what will happen if the condition is left untreated. Often simply going through this with your patient will help focus your mind on the advice you give. Everyone reading this article will know the importance of accurate documentation. Your contemporaneous
clinic letter or operation note will be your key line of defence. It will often appear to be the case that “if it is not written down, it did not happen”. You might be defending your actions many years after the event, and you will possibly have no direct recollection of the discussions or events. If the claim pertains to what was or was not said in a consultation, the patient is likely to clearly recall (even if not always accurately) what they believe was said, which will mean the court will place greater credibility on their account than yours – for the patient seeing you about their foot was probably a one-off experience, whereas for you the patient will be one of many that day, week, month and year. However, if what you said was written down at the time, that puts your narrative on a sound footing. Beware that a patient is allowed to record the consultation without asking you – but conversely you cannot record a consultation unless the patient agrees. An article like this in 2026 cannot pass without a word of caution about AI. Tools like Heidi have become popular in clinical practice. If using it, get consent from each patient. You will need to carefully proofread each Heidi-generated letter as you go along to check for errors or subtle changes in meaning. I personally view my clinic letter as such an essential piece of my communication and defence that I do not subcontract its drafting from my own mind to any other form of intelligence.
“ where a medic olega l cl aim seems a p os sibilit y, t he first a nd most imp orta nt st ep is to ensure t hat your patient is well look ed a f t er.” www.bofas.org.uk
November 2026
Foot Print
Bulletin of the British Orthopaedic Foot and Ankle Society
In situations where a medicolegal claim seems a possibility, the first and most important step is to ensure that your patient is well looked after. Careful explanation of a problem to a patient, paying detailed care and attention to their welfare, and taking time to ensure that all steps have been taken to rectify their condition will, in many cases, prevent a patient from feeling the need to consult with lawyers in the first place. It is also essential, particularly in private practice, to immediately notify your indemnity provider of any circumstances that you think might potentially lead to a claim. This protects your own interests and ensures that if the formal claim later arrives, your indemnity provider has then been primed to act on your behalf and will do so.
is a high chance it will not proceed, but you must obey the instructions of the court – do not book a holiday on those dates (but do book one for some time soon after). If you are going to court, it is worth getting some specialist training on witness familiarisation. Such courses cannot tell you what to say but can leave you feeling better prepared for the experience. You will feel as out of place in a courtroom as the advocate would feel in an operating theatre.
If you find yourself being sued, this will be a lengthy process. It will appear to be a stop-start ordeal that will at times appear to have gone away, but other times will appear to bounce back out of nowhere. This can be very stressful, and do not underestimate the impact this will have on you.
There are a few key things you must not do if a claim is proceeding against you. Firstly, do not change the medical records in any way. This will look dishonest; it will destroy your credibility and could potentially land you in front of the GMC. If there are inaccuracies in the records, do not change them, but you can add clearly dated separate notes or address these in your witness statement later.
While it will often not be appropriate to discuss the specifics of the case widely, it will be important for you to seek support of colleagues, friends, family, and not infrequently, specialist psychological support due to the toll this can take on you. In private practice, a claim will be directly against you and the care you provide. In the NHS, the claim is against your employer - your own role might only be a tiny part of the issue, which might relate to other clinicians, non-clinical staff, administrative systems, hospital procedures or organisational structural issues. Most cases will either be dropped or will settle out of court. One frustration may be that you never really get to find out what the outcome is, as such settlements are frequently bound by non-disclosure agreements. The chances of you having to appear in court are very low, but if you are cited, this will ramp up the stress levels. Even if you are summoned to court, there
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The whole process can often feel very personal. Behind every lawyer will be the expert opinion of a specialist in the field. In a small specialty like foot and ankle surgery, there is a high chance that you have either met or will know of the expert concerned in some capacity.
Second, do not be tempted to handle the case yourself, even if it looks simple. You are a surgeon, not a lawyer, and you do not know what you do not know about the process. Involve your legal team and support every step along the way so that you do not inadvertently do something that jeopardises your case or, even worse, leaves you exposed without appropriate cover. Third, do not write things down on social media, WhatsApp, or other email discussions: all of these can be disclosed in court, so if you do not want something read aloud, do not write it down anywhere. Fourth, do not make any emotional statements: simply provide a factual explanation and account of what you did and why. If you cannot remember something, then say so, if you are depending on your medical records, then state this.
Fifth, do not criticise colleagues and do not criticise expert witnesses. However, if an expert giving evidence against you does not have expertise in the field in question, then it is appropriate to point this out to your defence team. Do not discuss the situation with expert witnesses. Easy as it may be to say this, do not take it personally. The whole thing is not about you, even though it will often feel that way. Do remember that being sued is a common part of orthopaedic practice, but it need not define your career. Even some of the most respected surgeons with the very best reputations in our field have been successfully sued. Sometimes this will be common knowledge, other times it is not. Of course, a case in which you are being sued should provoke due reflection on your practice, but do not be forced to change your practice in a negative, reactive way. n
Declaration of interest: The author is a director of Resolve Medicolegal and of the Expert Witness Institute. References 1. Hunter vs Hanley ruling: https:// www.casemine.com/judgement/ uk/5a8ff8d660d03e7f57ece1f2 2. Honisz vs Lothian Health Board ruling: https://www.casemine.com/ commentary/uk/standard-of-care-inmedical-negligence%3A-insights-fromhonisz-v.-lothian-health-board/view 3. Montgomery vs Lanarkshire Health Board ruling: https://www.bailii.org/ uk/cases/UKSC/2015/11.html 4. Bolam vs Friern Hospital Management Committee ruling: https://www.scribd. com/document/503724215/Bolamv-Friern-Hospital-ManagementCommittee-1957-Wlr-582 5. Bolitho vs City and Hackney Health Authority ruling: https://publications. parliament.uk/pa/ld199798/ldjudgmt/ jd971113/boli01.htm
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Changes to foot and ankle forms
Foot Print
Issue 5
NJR and BOFAS update: changes to the foot and ankle forms A joint update from the National Joint Registry (NJR) and the British Orthopaedic Foot & Ankle Society (BOFAS)
T
Worked examples
he NJR is starting an audit to improve historical ankle replacement data. Alongside it, the NJR forms have had some changes over recent years that ankle arthroplasty surgeons need to know about.
• Primary: A patient with no previous implant has a primary TTR combined with a subtalar fusion. Record this on an A1 form, coded as “prosthetic replacement not classified elsewhere (e.g. hybrid)”, and ask your team to add the sticker from the TTR implant packet.
Ankle data audit
The NJR, in collaboration with BOFAS, is running an audit programme to go back and improve the quality of the ankle joint replacement data it holds. Better data means better ankle analysis, which supports our shared aims of improving outcomes and keeping patients safe.
Joel Humphrey CPC Chair
The NJR has checked the ankle procedures on the registry against Hospital Episode Statistics (HES) records, between 2010 and 2021. That check has flagged total ankle replacement procedures that there are missing from the registry. BOFAS has contacted, or will contact, surgeons who performed total ankle replacements, during the audit timeframe, along with NJR Trust leads. If you are contacted, please help the NJR resolve any flagged cases.
1. Total talus replacement (TTR): A1 and A2 forms
TTR doesn't have its own procedure category on the foot and ankle forms yet. The A1 and A2 forms will be updated to list it by name, and the NJR will send more details soon. Until then, record TTR as "prosthetic replacement not classified elsewhere (hybrid)" and use these rules:
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• Revision: A patient's talar component from a previous TAR has failed. The talar component is removed and a TTR is inserted, and the tibial component is kept. Record this on an A2 form, coded as “prosthetic replacement not classified elsewhere (eg hybrid)”, and ask the team to include the sticker for the TTR component used.
2. Reoperations other than revision (RO form)
Andy Goldberg OBE NJR Lead for CPC
• A1 form (primary): use it whenever a primary total talus is implanted. This applies whether the talus is done on its own articulating freely, as part of a total ankle replacement, or fixed to the talus or navicular. • A2 form (revision): use it whenever an existing talar prosthetic component (TAR or TTR) is removed so that a TTR can be inserted.
The RO form was introduced by the NJR in June 2023. It records operations around a joint replacement that don't involve the removal or exchange of any prosthetic components. Before it existed, these operations were often not recorded or were recorded on an A2 form. They should now go on the RO form. Complete an RO form for: • Closed or open reduction of a dislocation • Fixation of a periprosthetic fracture • Superficial or deep debridement, antibiotics and implant retention (DAIR) • Washout of a haematoma • Manipulation under anaesthesia (MUA)
www.bofas.org.uk
November 2026
• Soft tissue repair or procedure (ligament, capsule or tendon) • Excision of heterotopic bone or scar tissue • Adjacent joint surgery (eg deformity correction or fusion surgery for arthritis) • Excision of excess cement These additional procedures are important to be recorded, because without them we are unable to reliably inform patients how often they may need surgery after an ankle replacement.
3) New M forms for megaprosthesis procedures
A new set of M forms for megaprosthesis procedures launched in January 2026. A megaprosthesis is a
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Foot Print
Bulletin of the British Orthopaedic Foot and Ankle Society
specialised implant that replaces a joint along with a large segment of bone. It is usually used after tumour resection or major bone loss from trauma or infection. Foot and ankle surgeons will rarely need these forms, but should know they exist: • M1: primary megaprosthesis in a native joint • M2: revision of an existing megaprosthesis to another megaprosthesis • MS: revision of a conventional joint replacement to a megaprosthesis Which form to use depends on the patient's implant history and the operation performed. Most custom-made implants can be routinely captured on an A1 or A2 form, rather than an M form. If you are not sure please do contact the NJR.
Summary: what to do now • Respond to any NJR audit contact about ankle procedures from 2010 to 2021. • Record TTR as "prosthetic replacement not classified elsewhere (hybrid)": use A1 for a primary implant and A2 when an existing talar component is removed. • Submit an RO form for every reoperation on a patient who has had a TAR, and where a prosthetic component is not removed during the case. • Use the M forms for megaprosthesis cases, but not for custom-made implants.
Questions?
If you're unsure how to code a particular case, contact the NJR directly on 0800 0150167. BOFAS will send out more communication once the NJR confirms the form updates and audit outcome. n
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Foot Print
Puzzle Corner
puzzle corner
Issue 5
Compiled by Dr Elise Pegg, School of Engineering, Newcastle University
Wordsearch Can you find all fourteen words related to the foot and ankle listed below, in the grid?
• PROSTHESIS
• CAST
• SCALPEL
• DRILL
• STAPLE
• FRACTURE
• TALUS
• GRAFT
• TENDON
• IMPLANT
• TOURNIQUET
• PHYSIOTHERAPY
• ULTRASOUND
Crossword
1 2
• CARTILAGE
3
Across 2. Break from fur crate restoration (8) 4. Foot's part in brief dialogue with America (5)
4
5
9. Treatment misrepresented as hippy theory (13) 10. Set places with plate for starter and knife (7)
6 7
12. Daughter brought in particular saw for part of joint (6) 13. Diagnostic technique upset dour sultan (10)
8
14. House pet seen with son trapped in shed (4)
9
Down 10
1. Reversing a long way in sports car is hard work (5)
11 12
3. Fresh garlic tea that lets joints move freely (9) 5. Fastener is essential (6) 6. Artificial part of expert’s argument (10)
13
7. Start of major scheme in Italy needs graft (7) 14
8. Device that prevents pouring out of claret (10) 11. School, boring one (5)
Worddsearch and crossword solutions can be found on page 28 Note: Wordsearch and Crossword created with TheTeachersCorner.net. Cryptic crossword clues written using Copilot or from cryptics.georgeho.org.
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www.bofas.org.uk
Foot Print
November 2026
Bulletin of the British Orthopaedic Foot and Ankle Society
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Foot Print
Finite element modelling
Issue 5
Finite element modelling of foot and ankle mechanics
Hengshuo Zhang
Simin Li
Daniel T.P. Fong
Jitenda Mangwani
Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Loughborough University
Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Loughborough University
National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University
Consultant Orthopaedic Foot and Ankle Surgeon, University Hospitals of Leicester
F
inite element analysis (FEA) allows researchers to explore how load passes through bones, ligaments and implants, including responses that are difficult to measure directly. Foot and insole models can connect external loading with stresses and strains inside the foot1. We applied this approach to hindfoot fusion, Lapidus fixation and sole stiffness. Each model starts with CT-based reconstruction of the anatomy. Bones are assembled with representations of soft tissues and, where relevant, implants
or a sole (Figure 1). Controlled loading allows different designs to be compared using the same anatomy. Where relevant, the models incorporated anatomical soft tissues and walking inputs.
Hindfoot fusion fixation
Tibiotalocalcaneal arthrodesis fuses the ankle and subtalar joints. To examine how fixation affects load transfer, we compared an intramedullary nail with a lateral locking plate (Figure 2). Static axial loads from one to three times body weight were applied using the same anatomy, material assumptions and support conditions2.
The nail produced lower maximum absolute displacement on the prepared fusion surfaces across the simulated loads. The plate produced lower peak screw stress and shared implant loading more broadly. These findings reveal a trade-off between movement of the prepared surfaces and the distribution of implant loading. They do not establish a clinically superior construct: the analysis used one anatomy and simplified loading, without modelling healing, torsion or fatigue. The displacement measure also describes absolute surface movement, rather than relative micromotion across the fusion interface.
Figure 1: CT-based reconstruction and assembly of the foot–ankle model, including anatomical soft tissues and ground contact.
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November 2026
Foot Print
Bulletin of the British Orthopaedic Foot and Ankle Society
Figure 2: Virtual hindfoot fusion constructs: intramedullary nail (left) and lateral locking plate (right).
surface and the response of internal anatomical structures. Firm and soft 9-mm soles were compared under the same gait inputs. Keeping sole thickness and walking inputs consistent provided a controlled basis for examining the role of sole stiffness. The two sole conditions were assessed within the same modelling framework, connecting the footwear comparison with the anatomy and loading conditions represented in the foot model.
Lapidus fixation during walking For the Lapidus procedure, which fuses the first tarsometatarsal joint, we examined how fixation influences load transfer during walking. This application focused on the mechanical behaviour of the fusion construct and the distribution of loading between the implants and surrounding bone.
We compared three-screw and plateand-screw constructs using a CT-derived model that included anatomical ligaments, plantar fascia and encapsulating soft tissue. Both fixation approaches were examined within the same anatomical framework, providing a consistent basis for comparing construct mechanics. Including the surrounding structures allowed the fixation site to be considered as part of the wider foot model.
Motion capture and force-plate measurements supplied the walking inputs. The analysis assessed implant stress, local bone stress and first-metatarsal movement. These measures describe complementary aspects of fixation: loading carried by the hardware, loading within the adjacent bone and movement of the first metatarsal. Examining these measures together provides a framework for investigating how different fixation designs transmit load through the fusion region during walking.
Sole stiffness and internal tissue loading
Footwear provides another application for finite element modelling, with sole stiffness linking footwear design to the mechanical loading of the foot. We used the model to investigate this relationship by considering both loading at the plantar
“Finit e element a n a lysis (FE A) a l lows rese a rchers to e xplore how loa d pas ses through bones, liga ments a nd impl a nts, including resp onses that a re difficult to me asure direc t ly.” Produced by
During propulsion, the analysis assessed forefoot plantar pressure, metatarsal stress and plantar Lisfranc ligament strain. These outputs address different components of the foot–sole interaction: contact loading beneath the forefoot, stress within the metatarsal bones and deformation of the plantar ligament. Assessing them together allows footwear design to be examined through both plantar contact mechanics and internal tissue loading. n
Declaration of interest: Co-Author Jitenda Mangwani is the Editor of BOFAS bulletin Foot Print. References 1. Cheung JT-M, Zhang M. A 3-dimensional finite element model of the human foot and ankle for insole design. Arch Phys Med Rehabil. 2005;86(2):353–358. doi:10.1016/j. apmr.2004.03.031. 2. Zhang H, Mangwani J, Wei F, Song Q, Ling SKK, Fong DTP, Li S. Comparison of the mechanical performance of intramedullary nail and locking plate in tibiotalocalcaneal arthrodesis: a finite element analysis. Bone Joint Res. 2025;14(11):1033–1044. doi:10.1302/2046-3758.1411.BJR2025-0035.R1.
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GIRFT academic fellowship
Foot Print
Issue 5
From Surgical Training to National Data My journey through the GIRFT academic fellowshiP
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s orthopaedic trainees, much of our development focuses on the individual patient in front of us: the consultation, radiograph, operative plan, technical execution and outcome. However, my academic fellowship with Getting It Right First Time (GIRFT), an NHS England programme, has taught me to look beyond individual cases and consider how care is delivered across healthcare systems. GIRFT aims to reduce unwarranted variation through national data, clinical insight and benchmarking. The fellowship has given me the opportunity to step outside conventional surgical training and explore how large national datasets can help us understand variation and outcomes within foot and ankle surgery. My work has focused on the variation in the management of ankle arthritis and surgical outcomes. Compared with hip and knee arthroplasty, ankle replacement remains a relatively low-volume, specialised procedure, making it particularly important to understand who receives surgery, where treatment is delivered, how practice varies between providers and whether experience influences outcomes. A central question has therefore been: does volume matter? I have explored whether annual surgeon and trust case volumes are associated with outcomes following primary ankle replacement and ankle fusion. These questions have potential implications for service configuration, training, patient counselling and future standards of care.
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Working with national data has required me to develop skills beyond those traditionally emphasised in surgical training, including understanding clinical coding, interrogating large datasets, interpreting statistical models and translating findings into clinically meaningful conclusions. Importantly, I have learnt that data rarely provides simple answers and must be interpreted alongside clinical context and an understanding of its limitations. The fellowship has also changed how I view variation. Variation does not necessarily represent poor care; it may appropriately reflect patient choice, case complexity or local expertise. The challenge is identifying unwarranted variation - differences that cannot be explained by patient need or evidence-based decision-making. GIRFT’s combination of national data and clinical leadership provides an opportunity to explore these differences constructively. This perspective is particularly relevant to ankle arthritis, where decisions between arthrodesis, ankle replacement, non-operative treatment and revision surgery are complex. However, when national data identifies differences in access, procedure volume or outcomes,
Rebecca Martin ST7 Trauma and Orthopaedic Registrar GIRFT academic fellow we should ask whether every patient is receiving the right treatment, in the right setting, at the right time; and how could a network model of care benefit decision making and care pathways. In a relatively small specialty performing technically demanding, often low-volume procedures, national data can inform these discussions around training, referral pathways, specialist networks and centralisation. The GIRFT fellowship has ultimately changed how I think as a clinician. Technical excellence and individualised decision-making remain fundamental, but high-quality care also requires us to understand the wider system. I would like to thank BOFAS, ORUK and Northumbria Healthcare NHS Foundation Trust for their support which has allowed me to complete this ongoing work. As I continue my career in foot and ankle surgery, I hope to carry this perspective forward: using data to question variation, collaborate across centres and improve outcomes. GIRFT has shown me that “getting it right first time” is not simply a national programme, but a mindset one that encourages us to understand our practice, learn from variation and continually improve the care we provide. n
“ Work ing with n ation a l data has required me to de v elop sk ills be yond t hose t r a dition a lly emphasised in surgica l t r aining.” www.bofas.org.uk
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Foot Print
Engineered to Twist
Issue 5
SPONSORED FEATURE
P roduced in partnership with O rtho S ol u t i o n s ® G ro u p
Engineered to Twist Helical Plate Design and the Volition® Ankle Fracture Plating System
Helical plates wrap around a bone instead of lying on one face of it, giving torsional control and safer screw corridors. The Volition® Ankle Fracture Plating System brings this principle to the ankle in a pre-manufactured, anatomically twisted form, designed around how ankle fractures actually happen.
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nkle fracture plates have changed little in decades: a straight or gently contoured plate is laid on one cortical surface, and the fracture is reduced to fit it. Yet the ankle is not a straight structure, and most of the injuries we fix are rotational.
Small errors matter. Fibular malreduction of a few millimetres or degrees alters tibiotalar contact pressures1, and CT studies report syndesmotic malreduction in a substantial proportion of ankles that looked acceptable on fluoroscopy2. The posterior malleolus, now recognised as a primary rotational stabiliser, is most commonly fractured by a rotating, loaded talus in the Type 2 patterns of
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reported twisted plates in 1992 across humeral, tibial and radial fractures, describing a 90° twisted plate as 49% stronger in bending and 132% stronger in torsion than its flat equivalent5,6. Fernández Dell'Oca introduced true helical implants in 2002, primarily to route plates around neurovascular structures and to allow minimally invasive insertion7.
Professor Lyndon Mason Consultant Foot and Ankle Surgeon, Liverpool University Hospitals NHS Foundation Trust Honorary Associate Clinical Professor, University of Liverpool the Mason and Molloy classification3,4. Helical plating, in which the implant follows a three-dimensional path around the bone, has matured in the humerus and femur5. This article sets out the evidence behind the principle and shows how the Volition® Ankle Fracture Plating System translates it into fixation built for the twisted anatomy and rotational injuries of the ankle.
What is a helical plate?
The terms are often used loosely, so definitions help. A twisted plate is a flat plate subjected to axial torsion; a helix is a three-dimensional curve that rotates around an axis while advancing along it. On this framework, a twisted plate is a helix of zero radius, and a straight plate is a helix of infinite pitch5. Kumar first
In practice, plates contoured in theatre combine twist and helix, and the result varies by surgeon5. Pre-manufactured anatomical plates can deliver a defined geometry without intraoperative bending, a distinction that proves important below.
Biomechanical rationale
The argument starts with beam theory. A tubular bone's resistance to bending and torsion scales with the fourth power of its outer radius, through the second moment of area and the polar moment of inertia8:
Where ‘I’ is the second moment of area (resistance to bending), ‘J’ is the polar moment of inertia (resistance to torsion), ‘D’ is the outer diameter of the bone and ‘d’ is the inner (medullary canal) diameter. The equation states that a tube’s stiffness depends overwhelmingly on how far its material sits from the centre, because diameter is raised to the fourth power. Small increases in diameter give large gains in stiffness. Make a tube 10% wider and it becomes about 46% stiffer in bending and torsion, because 1.14 ≈ 1.46. Double the diameter and it becomes sixteen times stiffer.
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Foot Print
November 2026
Figure 1: Top Axial (A) and coronal (B) renders of the distal tibia with a helical plate (Volition 2B) passing from the medial surface proximally to the posteromedial surface distally. The screws lie in two divergent planes, spreading fixation around the circumference of the bone (C). Bottom Axial (A) and medial (B) renders of the distal tibia with a straight medial plate. All screws lie in a single plane (C), so the plate adds stiffness mainly about one bending axis
What does this mean for plating? A straight plate on one surface adds stiffness on one side of the bone only, so the construct behaves like an off-centre beam. A plate that wraps around the bone places fixation on several sides and further from the centre. The construct then behaves more like a wider tube, which resists bending and twisting more efficiently. (Figure 1)
Ankle injuries are mainly rotational, so that torsional advantage is the one that matters most. Although this is an idealised model, as real bones are not perfect circles and a plate is not part of the bone, it does explain the principle of the advantage of a helical plate. The experimental work broadly supports this. Sezek et al. combined finite element modelling with sheep tibiae and found helical compression plates gave greater torsional resistance and better fracturegap control than straight plates in transverse and oblique fractures9. Krishna et al. showed hemi-helical plates held oblique and spiral (torsional) fracture patterns better, with higher screw pull-out resistance attributed to divergent screw angles10. Lenz et al. added a helical plate to a lateral locking plate in a femoral gap model: axial stiffness rose 86% (contact) and 436% (gap), torsional stiffness 29%, and lateral plate surface strain fell from 0.3% to below 0.1%11. Pereira et al. found a
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Plate (custom-bent) vs straight
Torsional and shear movement
Cycles to failure
Authors' verdict
90° helical14
Higher (torsion at 6,000 cycles 30.7° vs 18.4°)
No difference
Not a true alternative
45° helical15
No difference; lower axial and varus/valgus displacement
No difference
Valid alternative
medial helical plate significantly increased the stiffness of a lateral distal femoral plate construct with a medial defect, from 181 to 253 N/mm on average12. Clinically, Perren and colleagues described a helical plate rescuing a femoral defect after repeated plate failures, adding leverage without exposing the fracture biology [13]. Divergent screw trajectories, inherent to a helix, are a further advantage in short metaphyseal fragments.
Getting the twist right: Lessons built into the Volition Plating System®
Not every helical plate performs equally, and the long-bone literature shows why design matters5. Paired cadaveric humeri tested under cyclic internal rotation give the clearest comparison. Both research groups attributed the poorer 90° result largely to heavy bending of a straight plate in theatre, which can weaken the implant14,15. The Volition® Ankle Fracture Plating System was designed around these lessons. Each plate is manufactured with its twist already built in, so no Figure 2: 2A and 2B Volition® Ankle Plates illustrating protection of danger zones (posterior tibial tendon and incisura in red)
intraoperative bending is needed (Figure 2). The degree of twist is matched to the measured anatomy of each region, derived from CT fracture mapping rather than a generic bone shape and contoured to avoid areas which might cause injury to tendon and joints.
Anatomical and neurovascular advantages
The most consistent clinical benefit of helical plating is protecting structures, not stiffness. In a 10-year cohort of 62 humeral shaft fractures, there were no iatrogenic radial nerve lesions with helical PHILOS™ plates against two with straight plates, though the difference was not significant16. Helical plates also produced less axillary nerve elongation during minimally invasive insertion17. In the distal femur, helical designs allow medial plating while avoiding the medial neurovascular bundle5. The common principle is that a helix lets the plate follow a safe corridor as the bone's neighbours change along its length. That is precisely the problem at the ankle.
Why the ankle?
Three features of the ankle favour a helical approach. • The anatomy is twisted. Over a few centimetres, the fibula moves from a lateral position on the shaft to sit posterolateral to the tibia at the syndesmosis. With a straight lateral plate there will be compromise. When placed anteriorly on the distal fibula, it directs proximal syndesmotic screws centrally and can miss the tibia. Placed posteriorly, it overlies the posterior plafond on lateral fluoroscopy. Cadaveric and CT work show a posterolateral-to-anteromedial trajectory best replicates syndesmotic orientation and lies within safe >>
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Engineered to Twist
Foot Print
tendon posteromedially. A plate that changes orientation along its length can stay on safe bone throughout.
The Volition® Ankle Fracture Plating System: Helical principles in practice
Figure 3: Syndesmosis safe zone due to helical Volition lateral fibular plate location on proximal fibular
drilling zones; deviation increases malreduction and neurovascular risk18,19. (Figure 3) • The injuries are rotational. Most ankle fractures arise from external rotation, and the posterior malleolus restrains both posterior translation and horizontalplane rotation4. Type 2 posterior malleolar fractures are rotational pilon injuries3. Fixation should resist torsion, the very load in which helical geometry performs best9,10. (Figure 4) • The soft-tissue envelope is thin and crowded. Within a short segment, lie the superficial peroneal nerve anteriorly, with the perforating branch of the peroneal artery passing through the interosseous membrane about 3 cm above the joint, and the tibialis posterior
The Anatomical Lateral Fibula Plate The Volition® Anatomical Lateral Fibular Plate twists from distal-anterior to proximal-posterior, resolving each compromise of a straight plate:
4. Ligament repair. Suture and fixation holes at the average AITFL footprint allow Wagstaffe fragment fixation or direct ligament repair, reflecting Fisher et al.'s finding that Wagstaffe fragments usually carry only the proximal part of the footprint20.
1. Distal anterior seating. The distal plate sits on the anterior tibiofibular ligament tubercle, so its screws do not overlap the posterior plafond on the lateral view. Posterior malleolar reduction can then be judged after fibular fixation, which helps in delayed or supine cases.
The posterior malleolus On the tibia, the helix is applied fragment by fragment. The Volition® Type 2A plate rotates as it descends, staying between the fibular incisura and the tibialis posterior tendon (figure 2). The Volition® Type 2B plate is the most overtly helical Plate within the Volition® Ankle Fracture System: it sits on the posteromedial fragment and wraps around the posterior tibia. Seating it generates the lateralising and anterior force needed to reduce the deep fragment, consistent with the medial-side-first sequence21.
2. Proximal posterior seating. Syndesmotic or pro-tibial screws pass posterolateral to anteromedial (figure 3), 1.5 to 3 cm above the plafond, without freehand angulation. Because the trajectory suits the plate, these screws can be locked, which is useful in osteoporotic bone.
Its path keeps the plate outside the tibialis posterior sheath. This matters: Posterior Tibialis tendon entrapment occurs in about 22% of posterior malleolar fractures and in over 40% when the fracture line enters the sheath22. These plates suit the medial posteromedial approach.
3. Access to the anterior incisura. An incision of 1 cm anterior to the usual lateral line allows direct inspection of syndesmotic reduction, rather than reliance on fluoroscopy2.
V-Lock® variable-angle technology lets the surgeon choose each screw's trajectory, to raft subchondral bone and avoid the incisura and tendon groove, with a thread design that limits cross-threading. Variable-angle locking maintains clinically acceptable interface strength within a controlled angular range23,24. All plates are low-profile (1.3 to 1.8 mm) anodised titanium with countersunk screw heads, to reduce soft-tissue irritation.
Figure 4: Axial (A) and 3D rendering CT of a 2B ankle fracture, with axial coloured fracture fragments and intended fixation (arrows). Post operative weightbearing radiograph showing helical plate fixation using the Volition® lateral fibular, 2A and 2B plates controlling the rotational fracture pattern
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Issue 5
Independent clinical data is now emerging. A non-designer comparative study of 22 matched pairs reported significantly better activity and pain subscale scores with Volition® fragmentspecific fixation than with traditional fixation25.
Looking ahead
Much of the helical plating evidence comes from the long bones, and larger
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November 2026
ankle-specific studies remain warranted. Cadaveric cyclic testing of fibular and posterior malleolar plate geometries and CT-based reduction outcomes are the natural next steps. Due to the increase in strength that a helical plate provides, the plate can be thinner and reduce hardware related prominence and irritation.
Conclusion
Helical plates offer torsional control, circumferential load sharing and the ability to keep implants and screws in safe corridors. The ankle combines twisted anatomy, rotational injury and a crowded soft-tissue envelope, so it is well suited to the principle. The Volition® Ankle Fracture Plating System applies this principle via its pre-manufactured, anatomically matched plates. The primary aim of this system is to provide accurate fibular and posterior malleolar reduction, safe syndesmotic fixation and fewer compromises in theatre. n For surgical technique guides, booklets and training, visit orthosol.com or contact sales@orthosol.com. Declaration of interest: This is a paid feature sponsored by OrthoSolutions® Group. The author designed the Volition® plating system and is a paid consultant to OrthoSolutions® Group, which manufactures it.
References 1. Thordarson DB, Motamed S, Hedman T, Ebramzadeh E, Bakshian S. The effect of fibular malreduction on contact pressures in an ankle fracture malunion model. J Bone Joint Surg Am. 1997;79(12):1809-15. 2. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006;27(10):788-92. 3. Mason LW, Marlow WJ, Widnall J, Molloy AP. Pathoanatomy and associated injuries of posterior malleolus fracture of the ankle. Foot Ankle Int. 2017;38(11):1229-35. 4. Lambert LA, Falconer L, Mason L. Ankle stability in ankle fracture. J Clin Orthop Trauma. 2020;11(3):375-9.
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5. Kraus M, Gueorguiev B, Pastor T, et al. Evolving fracture management: the role of helical plating in orthopaedic trauma surgery – a narrative review. Eur J Trauma Emerg Surg. 2025;51(1):203. 6. Kumar K. Fixation of fractures by twisted plates – a new concept of osteosynthesis. Int Orthop. 1992;16:265-7. 7.
Fernández Dell'Oca AA. The principle of helical implants. Unusual ideas worth considering. Injury. 2002;33(Suppl 1):SA1-27.
8. Young WC, Budynas RG. Roark's Formulas for Stress and Strain. 8th ed. New York: McGraw-Hill; 2011. 9. Sezek S, Aksakal B, Gürger M, Malkoç M, Say Y. Biomechanical comparison of straight and helical compression plates for fixation of transverse and oblique bone fractures: modeling and experiments. Biomed Mater Eng. 2016;27(2-3):197-209. 10. Krishna KR, Sridhar I, Ghista DN. Analysis of the helical plate for bone fracture fixation. Injury. 2008;39(12):1421-36. 11. Lenz M, Varga P, Mischler D, et al. Helical plating – a novel technique to increase stiffness in defect fractures. Eur Cell Mater. 2021;42:110-21. 12. Pereira S, Bidolegui F, Garabano G, et al. Does the type of medial plate fixation matter for supplemental fixation of distal femur fractures managed with a lateral pre-contoured locked plate? A biomechanical study. Eur J Orthop Surg Traumatol. 2024;34:605-12. 13. Perren SM, Regazzoni P, Fernández AA. Biomechanical and biological aspects of defect treatment in fractures using helical plates. Acta Chir Orthop Traumatol Cech. 2014;81(4):267-71.
16. Da Silva T, Rummel F, Knop C, Merkle T. Comparing iatrogenic radial nerve lesions in humeral shaft fractures treated with helical or straight PHILOS plates: a 10-year retrospective cohort study of 62 cases. Arch Orthop Trauma Surg. 2020;140(12):1931-7. 17. Dauwe J, Grechenig P, Unterfrauner I, et al. Axillary nerve elongation in humeral fracture plating: a cadaveric study for comparison between straight and helical Philos plates. J Orthop. 2020;19:233-6. 18. Kennedy JG, Soffe KE, Dalla Vedova P, et al. Evaluation of the syndesmotic screw in low Weber C ankle fractures. J Orthop Trauma. 2000;14(5):359-66. 19. Baumbach SF, Synek A, Spindler FT, et al. Safe drilling zones for anteriorly, central, and posteriorly angulated syndesmotic stabilization devices. Knee Surg Sports Traumatol Arthrosc. 2023;31(6):2199-207. 20. Fisher A, Bond A, Philpott MDG, et al. The anatomy of the anterior inferior tibiofibular ligament and its relationship with the Wagstaffe fracture. Foot Ankle Surg. 2021;27(3):291-5. 21. Mason LW, Kaye A, Widnall J, Redfern J, Molloy A. Posterior malleolar ankle fractures: an effort at improving outcomes. JBJS Open Access. 2019;4(2):e0058. 22. Syziu A, Aamir J, Mason LW. Posterior tibialis tendon entrapment as a complication of posterior malleolar fractures in complex ankle fractures. Bone Jt Open. 2024;5(3):252-9. 23. Tidwell JE, Roush EP, Ondeck CL, et al. The biomechanical cost of variable angle locking screws. Injury. 2016;47(8):1624-30.
14. Pastor T, Zderic I, van Knegsel KP, et al. Biomechanical analysis of helical versus straight plating of proximal third humeral shaft fractures. Arch Orthop Trauma Surg. 2023;143:4983-91.
24. Hébert-Davies J, Laflamme GY, Rouleau D, et al. A biomechanical study comparing polyaxial locking screw mechanisms. Injury. 2013;44(10):1358-62.
15. Pastor T, Zderic I, Beeres FJP, et al. 45° helical plates are a valid alternative to straight plates for treatment of proximal humeral shaft fractures. J Orthop Res. 2025;43:473-82.
25. Amarasena DK, et al. Does fragmentspecific fixation provide better functional outcomes following trimalleolar ankle fractures? Foot Ankle Spec. 2026;19(2):219-24
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The Portfolio Pathway
Foot Print
Issue 5
Understanding the Portfolio Pathway for entry onto the T&O Specialist Register
Anna Chapman MMedEd, FRCS (Tr&Orth) Consultant Trauma and Orthopaedic Surgeon (Foot and Ankle) University Hosptials, Coventry and Warwickshire Chair, BOFAS Education Committee Portfolio Pathway Lead for the T&O Specialist Advisory Committee
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wo main pathways for entry onto the GMC Specialist Register exist in the UK. The most familiar route is through a competency-based T&O Training Programme with appointment at ST3 via National Selection. Trainees are subject to the Annual Review Competency Process (ARCPs). At the end of the 6-year programme, after successful final portfolio review by an ARCP panel and a Specialist Advisory Committee (SAC) Liaison member, a Certificate of Completion of Training (CCT) is awarded. This is a formal recommendation to the GMC for entry onto the Specialist Register in T&O. The other route is via the Portfolio Pathway. Again, this is a competency-based process, under the jurisdiction of the GMC, where applicants must demonstrate, through evidence, that they have the knowledge, skills and experience required of UK specialist in T&O. Eligible applicants can submit evidence from the previous 6-year
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period to demonstrate competencies in T&O. These are an operative logbook, structured references, work-based assessments and evidence from all the GMC domains, including research, quality improvement, education and others. Foresight of an intention to complete this process is invaluable for the applicant as it aids in the recording and collection of relevant evidence. Applicants must also be prepared for the cost of the process which currently sits just under £2000. The purpose of this article is to provide a helpful narrative and to familiarise the reader with the process of the PP. It will highlight the key elements of a successful application to support colleagues who choose this route.
What is the T&O Specialist Advisory Committee (SAC)? Each surgical speciality has an SAC made up of consultant surgeons of that specialty who have a strong personal commitment to the National Health Service (NHS). Members are appointed via an application process and have demonstrated interests in education and may include present or past Training Programme Directors. The have responsibility for supporting the ARCP process as Liasion Members for a training programme as above. The SAC is responsible for curriculum updates, training and competency requirements. For more information on applying to oin the SAC, please visit: https://www. jcst.org/committees/specialty-advisorycommittees-sacs/ The SAC plays a vital role into the PP process in that they provide overall assessment of each PP application
and work with the GMC to review the evidence and determine if the applicant is suitable for entry on to the Specialist Register. Two individual SAC members will review each portfolio individually to check and evaluate the evidence and make a recommendation to the GMC.
Why choose the Portfolio Pathway?
There are a variety of reasons as to why a surgeon may consider the Portfolio Pathway route. Applicants are often International Medical Graduates but can also include surgeons who have trained in T&O outside a recognised UK Training Programme or those UK graduates who have trained in T&O outside of the UK and wish to return. There are also occasional instances where a trainee has been unable to complete a UK training programme successfully in time due to personal circumstances. It can be that they are a capable surgeon with the relevant experience and skills, but for example, have not completed the exam in time due to personal issues or neurodiversity. The Portfolio Pathway option can be an alternative route in these, often, complex situations.
What is required?
There is a misconception that the Portfolio Pathway may be an “easier” option to CCT compared with the standard UK Training Programme. This couldn’t be further from the truth in terms of the level of organisation required from the applicant, both in terms of organisation of appropriate training posts to cover all surgical specialities required for eligibility for the FRCS (Tr&Orth) and eventual entry onto the Specialist Register. A successful PP application requires a proactive
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November 2026
approach to data collection and familiarity with the process and specific requirement, as well as a clear and organised presentation of the evidence.
Key tips for a successful Portfolio Pathway Application Be remarkably familiar with the Speciality Specific Guidance (SSG) and Curriculum
The SSG is essentially the list of evidence needed for the PP application (Table 1). These documents need to be reviewed in detail, and successful applicants report tips such as having it all printed out to review regularly and reference and tick off relevant requirements as well as having a robust way of filing the evidence for future upload. An incomplete portfolio is unlikely to be successful; there is minimal room for deviation from the requirements.
Bulletin of the British Orthopaedic Foot and Ankle Society
All the required information needs to be collected, uploaded and be mapped to the domains. All pieces of evidence are reviewed by the GMC and the SAC Team and gaps will be found.
Collect evidence prospectively
For anyone undertaking T&O training outside of a training programme, whether they know or don’t know if they wish to apply, it is highly advisable to collect evidence of competency from the very start of middle-grade level. There are tools to assist with this such as the British Orthopaedic Association (BOA) T&O Portfolio Pathway Progress (TOPP) Tracker (Table 1). eLogbook and ISCP are available for all trainees and evidence can be collected in the same way as for trainees in a training programme. Requirements for Level 4 Procedure Based Assessments and Critical
Case Based Discussions are the same for both pathways, so completion of workplacebased assessments should be actively encouraged and supported by trainers.
Ensure evidence is mapped effectively with the required domains Demonstrating competence as a surgeon extends beyond the logbook, and as with training programmes and appraisal, the GMC requires evidence of competency in all 4 Domains of Good Medical Practice and in the Generic Professional Capabilities Framework (GPCs).
Organise evidence in a clear and concise manner
This is crucial. The amount of evidence uploaded for an application is weighty at around 1000 pages. 2 members of the SAC will review this portfolio of evidence which can take anywhere from 3-6 hours to review. Clear presentation of evidence >>
Table 1. T&O 2026 Curriculum Update and T&O Portfolio Pathway Resources Resource
Detail
Link/Location
2026 T&O Curriculum Update
Comprehensive JTO article covering the 2026 T&O Curriculum changes.
https://www.boa.ac.uk/resource/trauma-andorthopaedic-curriculum-update.html Kerin, C. and Bose, D. Trauma and Orthopaedic Curriculum Update. JTO, Volume 14, Issue 3, September 2026 The ISCP link to the 2026 T&O Curriculum Document can be found in Table 2
T&O Curriculum
GMC Links to T&O Curriculum Can also be accessed through ISCP
https://www.gmc-uk.org/education/ standards-guidance-and-curricula/curricula/ trauma-and-orthopaedic-surgery-curriculum
T&O Speciality Specific Guidance (SSG)
GMC guidance on specific requirements for Portfolio Application in T&O
https://www.gmc-uk.org/registration-andlicensing/join-our-registers/registrationapplications/specialty-specific-guidance
Specialist, Associate Specialist and Speciality (SAS) Surgeons and Locally Employed Doctor (LED) T&O Network: STONe
A BOA supported network organisation to meet the professional development needs of our SAS and LED colleagues at both an organisational and individual level.
https://www.boa.ac.uk/careers-in-t-o/ surgeon-careers/specialty-and-associatespecialists/sas-led-network.html
BOA T&O Portfolio Pathway Progress Tracker (TOPP) and Specialist Grade Competency Matrix
BOA has two freely available tools to help arrange evidence in preparation for the PP and keep track of progress.
https://www.boa.ac.uk/careers-in-t-o/ surgeon-careers/specialty-and-associatespecialists/topp-tracker-request-form.html
British Indian Orthopaedic Society Portfolio Pathway Mentorship Program
1:1 personalised guidance for Portfolio Pathway applicants in Trauma and Orthopaedics to improve their chance of getting on the Specialist Register
https://britishindianorthopaedicsociety.org. uk/education/bios-portfolio-pathway-cesrmentorship-program/
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Foot Print
The Portfolio Pathway
Table 2. The 2026 T&O Curriculum Changes Specifically Related to F&A Surgery The following table highlights the specific 2026 T&O Curriculum updates directly affecting Foot & Ankle surgeons and trainees – a full summary document of the changes can be found at: https://www.iscp.ac.uk/media/1541/summary-statement-tov3-clean-24jun2026.pdf Category
Indicative Numbers
Level 4 PBAs
PBA Scope
Curriculum Requirement / Update
Key Details & Flexibility
20 Osteotomies
Up to 10 arthrodesis (fusion) procedures may be counted towards the required index target of 20 osteotomies.
10 External Fixators
Index number increased from 5 to 10 (and required Level 4 PBAs increased to 3) to reflect temporary stabilization before MTC transfer.
Osteotomy & Arthrodesis PBAs
Achieved via EITHER: • 3 x Level 4 PBAs for Osteotomy, OR • A combination of 2 x Osteotomy + 1 x Arthrodesis OR 1 x Osteotomy and 2x Arthrodesis.
Ankle Fracture PBA Update
Updated from 'Weber B Ankle Fracture' to 'Ankle Fracture PBA' (covering all ankle fractures) to align with unselected trauma take management.
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supports a straightforward review process which increases the chance of a smooth portfolio review and successful application.
Find a colleague who has had a recent successful application Be aware in your region of colleagues who have had a recent successful application to encourage networking, advice & support.
Whichever route our trainees choose to pursue, as trainers, we have a duty to support the process and our future workforce. It is hoped that with better familiarity and understanding of the PP pathway, sound advice and signposting can be given to our colleagues who navigate this route.
2026 T&O Curriculum Update
Finally, Table 2 summarises the 2026 T&O Curriculum changes that specifically affect Foot and Ankle Surgeons. Full details of all 2026 Curriculum changes can be found here: https://www.iscp. ac.uk/media/1541/summary-statementtov3-clean-24jun2026.pdf n
puzzle CORNER Solutions
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New guidelines
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New guidelines summary Diabetic Foot Problems: Prevention and Management NICE guideline. Reviewed July 2025. www.nice.org.uk/guidance/ng19 No changes from previous guidance (2019). Plan to update the guideline to add consideration for topical oxygen therapy as an adjunctive treatment for diabetic foot ulcers.
Diagnosis and Management of Arterial Injuries Associated with Musculoskeletal Trauma BOA Standard. Revised June 2026. https://www.boa.ac.uk/asset/7E8D1CA3 %2D7448%2D47C7%2D84980C6D3E7E9 6B0/?_gl=1*sdjkwi*_up*MQ..*_ga*MTA4N zQzNDM2NC4xNzg3NTExNTM1*_ga_GZ M76H2EF6*czE3ODc1MTE1MzUkbzEkZz AkdDE3ODc1MTE1MzUkajYwJGwwJGgw
Outpatient and On-call Services for People with Fractures or Musculoskeletal injury New BOA Standard. February 2026. https://www.boa.ac.uk/resource/ boast-outpatient-and-on-callservices-for-people-with-fractures-ormusculoskeletal-injury.html Background and justification: This document describes the key steps in the organisation of care for those with a musculoskeletal injury that does not necessitate immediate admission or emergency hospital management. Standards for Practice: 1. All relevant stakeholders should be involved in the development, governance, and surveillance of the standards described below.
Background and Justification: Accurate diagnosis and emergency surgical repair of arterial injuries associated with extremity musculoskeletal trauma is crucial for an optimum outcome. These are time critical emergencies with no safe ischaemic time; emphasis should, therefore, be on immediate revascularisation.
2. All hospitals providing acute care must have an outpatient pathway for patients with musculoskeletal injury presenting from the community or Emergency Department (ED). This pathway should be accessible to all clinicians providing point of contact care for these patients.
Changes to Standards for Practice:
3. Patients must have their case reviewed by a named consultant within 24 hours of first presentation. This can be performed in person or virtually in a trauma meeting. The outcome of this review should be documented and a copy sent to the patient and GP.
10. Revascularisation is an emergency procedure and should be commenced within one hour of arrival to hospital. 13. Arterial repair or interposition grafts should be used for revascularisation. Bypass grafts should only be considered in blast or ballistic injury, or where anatomic 17. Post-operative single antiplatelet therapy should be considered, after an appropriate bleeding risk assessment. 18. Out-patient follow-up should be provided by the surgical team performing revascularisation.
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4. All relevant imaging considered during a trauma meeting and outpatient clinic must be documented and included as part of the patient record. 5. A definitive treatment plan should be documented for all patients within 72 hours of first presentation and copied to the patient and their GP.
6. There must be a system that signposts patients to orthopaedic advice and/or review for concerns related to their presenting injury at any point in the pathway. 7. Information in an accessible format and language should be available and include instructions for casts, splints, slings, and appliances. 8. Appropriately staffed plaster room and radiology facilities must be available during all fracture clinics. 9. A documented risk assessment for venous thromboembolism (VTE) should be conducted for all patients with a lower limb injury. (NICE NG89) 10. Initial and subsequent weightbearing and mobilisation status must be documented for all injuries as set out in the weightbearing instruction BOASt. All patients >60 years should be considered for unrestricted weightbearing as a default. 12. Patients who require operative intervention, including those at home or in another treating facility, should have a documented admission plan. 12. All orthopaedic units providing acute care should have a dedicated trauma co-ordinator, AHP, or administrative staff member in an equivalent role. 13. Direct referrals to physiotherapy, occupational therapy, orthotics, and plaster room services should be available at all points of the pathway. 14. When transfer of care is required due to the nature of the injury, secondary condition, or geography, then the details of the referral should be documented and a copy sent to the patient and GP. 15. Fracture liaison and falls prevention services should be fully integrated
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into fracture clinics, allowing screening and onward referral of appropriate patients.
Osteoporosis Risk Assessment NICE guideline. 29 July 2026. www.nice.org.uk/guidance/ng259 Assess fragility fracture risk in all people aged 50 and over and women who have experienced menopause with either of the following risk factors: • a previous fragility fracture
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Foot Print
Bulletin of the British Orthopaedic Foot and Ankle Society
aged under 65 who have experienced • current or frequent use of systemic menopause with any of the following glucocorticoids (for example, 5 mg or risk factors: more prednisolone daily or equivalent for over 3 months, or intermittent use of • history of 2 or more falls in the last year higher doses) unless this is a replacement dose for adrenal insufficiency • history of hip fracture in a first-degree relative (particularly if the first-degree Consider assessing fragility fracture relative was aged under 80 at the time of risk in: hip fracture) • all men aged 75 and over
• low body mass index (<18.5 kg/m2)
• all women aged 65 and over
• current smoker
• all people aged 50 to 74 and women
• alcohol intake of 14 units/week n
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Diabetes epidemic in Asia
Foot Print
Diabetes epidemic in Asia (especially India) An emerging explosion of unrecognised Charcot feet
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sia is the epicentre of the world’s diabetes population. The IDF Diabetes Atlas (11th edition, 2025) estimates that, of 589 million adults worldwide living with diabetes in 2025, India accounts for nearly 90 million, placing it second only to China (about 138 million). These two countries alone account for about 40% of the world’s diabetes population. South Asians demonstrate considerable metabolic susceptibility, with insulin resistance and central adiposity frequently occurring at relatively lower body mass indices. The ICMR-INDIAB study, published in The Lancet Diabetes & Endocrinology in 2023, surveyed The Indian Council of Medical Research (ICMR). This national study reported a weighted diabetes prevalence of 11.4% and a prediabetes prevalence of 15.3%. The epidemic is no longer restricted to urban populations; diabetes is increasingly affecting rural communities and regions undergoing socioeconomic transition.
Figure 1
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and severe peripheral neuropathy. Though this should not be extrapolated to all people with diabetes, it illustrates the substantial burden among high-risk individuals and an emerging explosion of Charcot neuroarthropathy. Better epidemiological surveillance, early diagnosis, specialist access and coordinated diabetic foot care on a large scale is needed.
With IFAS spearheading the spread of knowledge of diabetic foot ulcer management and Charcot foot, the management is My Presidential slowly but steadily improving. theme for the Indian The International Working Foot and Ankle Dr Rajesh Simon Group on the Diabetic Foot Society (IFAS) in MBBS, MS (Ortho) emphasises regular foot 2023 was “Save Vice President & President Elect: assessment, neuropathy Charcot from the Asian Federation of Foot and Ankle Surgeons screening, vascular Catastrophe” and evaluation, appropriate I also wrote an Past President: Indian Foot and Ankle Society footwear and risk-based editorial in the follow-up. However, due to Journal of Foot and Indian-specific challenges (e.g. barefoot Ankle Surgery (Asia-Pacific) the same year walking, unsuitable footwear, limited entitled “India Becoming an Emerging public awareness, delayed presentation Diabetic Capital Burdened with an and insufficient access to specialised Explosion of Unrecognized Charcot Feet”. diabetic-foot clinics), we regularly see These highlighted the likely magnitude severe destruction with infection on of this under-recognised problem and presentation involving multiple regions emphasised the relationship between of the foot. the expanding diabetes population, inadequate awareness, delayed diagnosis To illustrate: a 60 year old shopkeeper, and limited access to multidisciplinary with diabetes for 15 years, developed diabetic foot services. swelling around his left ankle a year previously and a wound four months Although reliable nationwide estimates of later. He was dressed in local clinics Charcot prevalence remain unavailable, until the ankle collapsed and he a South Indian tertiary-centre study presented with wound involving the identified Charcot arthropathy in 9.8% of lateral aspect, extending to the plantar patients older than 50 with type 2 diabetes
Figure 2
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Foot Print
Bulletin of the British Orthopaedic Foot and Ankle Society
References • IDF Diabetes Atlas, 11th edition (2025) • Anjana RM, et al; Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: phase I results of the Indian Council of Medical ResearchINdia DIABetes (ICMR-INDIAB) study. Diabetologia. 2011 Dec;54(12):3022-7 • Salini D et al Prevalence of Charcot Arthropathy in Type 2 Diabetes Patients aged over 50 Years with Severe Peripheral Neuropathy: A Retrospective Study in a Tertiary Care South Indian Hospital. Indian J Endocrinol Metab. 2018 Jan-Feb;22(1):107-111
Figure 3
side and a varus hindfoot (Figure 1). Clinical and radiological examination (Figure 2) was suggestive of hind foot Charcot with complete dislocation at the subtalar region, along with osteomyelitis and high blood glucose levels. With an MDT approach, his blood glucose level was controlled and, after a satisfactory vascular assessment, we undertook staged surgical management.
Figure 4
We used an antibiotic impregnated TENS nail to provide hindfoot stability. (Figures 3-4) With this stability and good glycaemic control, the infection subsided and the wounds healed completely in eight weeks (Figure 5). In the second stage, the nail was removed and a super construct of the hindfoot was performed. Two years post surgery, he continues his normal life walking on his own feet (Figure 6).
• Simon R, Kavarthapu V. India Becoming an Emerging Diabetic Capital Burdened with an Explosion of Unrecognized Charcot FeetJ Foot Ankle Surg AsiaPacific 2023; 10(S1):S1-S2 • Patel AS et al. Reconstruction of the 'Foot at Risk' during Acute Charcot NeuroarthropathyJ Foot Ankle Surg Asia-Pacific 2023;10(S1):S15-S20 • Simon R, Jose DP et al: Surgical Technique for managing Infected Unstable Charcot Hind foot using an Antibiotic Cementimpregnated Titanium Elastic Nail System: A novel staged approach. J Foot Ankle Surg Asia-Pacific 2025 13, S1, 25–30 • Government of India. The Diabetic Foot: Prevention and Management in India (2016) • IWGDF Charcot Guideline 2023
The message is clear: preventing the complications of diabetic foot ulcers and Charcot feet begins with recognising the disease early and ensuring that every highrisk foot receives timely, appropriate care. However in case of complications or late presentation, salvage can be achieved.
Figure 5
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For the future, with more literature from around the world, we need to formulate reasonable guidelines and consensus in surgical management. n
Figure 6
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Bridging the gap in diabetic foot care
Foot Print
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Bridging the gap in diabetic foot care The UK India Diabetic Foot Foundation
I
ndia is often described as the diabetes capital of the world, with over 100 million people living with diabetes. Diabetic foot disease is among its most devastating consequences, yet access to multidisciplinary diabetic foot care remains limited, particularly outside major cities. Many patients present late with deep infection or advanced Charcot neuroarthropathy, and amputation is too often seen as the only option. Complex limb salvage, including Charcot foot reconstruction, has been largely unavailable.
How It Began
In 2020, Mr Krishnam Raju Uppalapati, a philanthropist in India, recognised this gap. He saw that patients had little access to a diabetic foot MDT and that advanced surgical procedures, including Charcot foot reconstruction, were not available to them. In 2021, he and his wife, Mrs Shyamala Uppalapati, discussed this with me. Together we established the UK India Diabetic Foot Foundation (UKIDFF), a registered charity, with support from clinicians in the diabetic foot unit at King’s College Hospital.
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Free remote MDT advice
Our first initiative was an app-based service allowing doctors in India to seek free expert opinion on any diabetic foot condition. A large panel of experts from the UK and India contributes, including surgeons, diabetologists, vascular specialists, podiatrists and others as required. Diabetic Foot Society of India (DFSI) has actively partnered with this programme.
Venu Kavarthapu Consultant Orthopaedic Surgeon, Mike Edmonds Foot Unit, King’s College Hospital, London
UKIDFF was launched with four objectives: • To provide free remote MDT advice to any doctor in India on any diabetic foot presentation • To deliver free MDT treatment through mega health camps • To provide training and support to doctors wishing to treat diabetic foot patients • To raise awareness of diabetic foot problems and their treatment
To date, 261 cases have been referred, predominantly for surgical advice. Most involved diabetic foot infections, and 95 were Charcot feet, the majority of which had been considered for amputation. The service has become a lifeline for isolated clinicians managing complex patients, and for patients who would otherwise have no access to such expertise.
The Annual Mega Health Camps
Advice alone cannot treat patients who have no access to care. In 2024, we therefore launched the UKIDFF Annual Mega Health Camps in South India, under my leadership. They are organised with great dedication by members of Mrs Uppalapati’s family. The camps deliver
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Foot Print
Charcot Pre-op
free, comprehensive MDT diabetic foot care at high volume through a structured, efficient, patient-centred, one-day model. The first camp involved 23 clinicians providing MDT care to 2,000 diabetic patients, including 47 bedside minor procedures and a further 11 procedures on admission. Activity has grown each year. The most recent camp, in January 2026, was supported by 50 doctors, 50 nurses and numerous volunteers. Some 2,500 patients received comprehensive evaluation and immediate treatment. Of these, 120 underwent bedside minor procedures, 16 were subsequently admitted for procedures, and 130 were provided with therapeutic footwear. The key to this scale is a high-throughput care pathway: registration, risk stratification, vascular and neurological assessment, wound care, offloading and footwear provision, with surgical and medical review throughout, without compromising quality.
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Charcot Post-op
From advice to surgery
The remote advice service exposed a further problem: recommendations for limb-saving surgery (e.g. Charcot foot deformity correction or reconstruction for diabetic foot osteomyelitis) often could not be acted upon because local expertise was lacking. To address this, in 2024 we partnered with clinicians at a hospital chain in Hyderabad, South India, to start a complex diabetic foot surgery programme, including Charcot foot reconstruction. I visit the hospital three times a year to operate, assisted by selected senior foot and ankle surgeons and podiatric surgeons from India. The specific fixation devices and injectable local antibiotic eluting material essential for such reconstruction were introduced in India. This gives the local population access to previously unavailable treatment, while training local surgeons in these techniques. Forty-two Charcot foot reconstructions have been performed since the programme began, with good outcomes reported so far.
Training the next generation
The health camps are also a powerful training platform. Indian surgeons and other diabetic foot clinicians work side by side with UKtrained colleagues, learning MDT working, decisionmaking in complex presentations, limb-salvage surgical techniques and the principles of offloading. Many go on to establish or
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strengthen diabetic foot services in their own hospitals. Visiting UK colleagues gain exposure to a breadth and severity of pathology rarely seen in the UK.
BOFAS and UKIDFF
BOFAS members are warmly welcome to join us at the annual health camps, which offer a unique opportunity to teach, learn and make a real difference. Further information on UKIDFF, including the app, is available at ukidff.com Every limb saved is a person who can continue to walk, work and support their family. We invite you to be part of this journey. n References 1. International Working Group on the Diabetic Foot (IWGDF). IWGDF Guidelines on the prevention and management of diabetes-related foot disease. Published online 2023. Available from: https://iwgdfguidelines.org/ 2. Schaper NC, van Netten JJ, Apelqvist J, et al. Practical Guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3657. 3. Kavarthapu V. Diabetic foot complications: managing the global burden through specialized multidisciplinary care and international collaboration. The Foot. 2020;42:101650. 4. Simon R, Kavarthapu V. India Becoming an Emerging Diabetic Capital Burdened with an Explosion of Unrecognized Charcot Feet. J Foot Ankle Surg Asia-Pacific 2023; 10 (S1):S1-S2.
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Tackle big challenges, leave tiny footprints!
Foot Print
Tackle big challenges, leave tiny footprints!
M
inimally invasive surgery (MIS) has rapidly transformed the landscape of foot and ankle surgery in recent years. Although the drive toward minimally invasive intervention is not new, advances in instrumentation and surgical techniques have opened exciting new frontiers, particularly in the treatment of complex bony deformities. Early advances in minimally invasive foot and ankle surgery included softtissue procedures such as endoscopic gastrocnemius recession, percutaneous repair of acute Achilles tendon ruptures, and arthroscopic procedures such as ankle arthrodesis. However, one of the most significant developments has been the ability to perform precise bone-cutting procedures using specialized burrs instead of traditional oscillating saw blades (Fig 1). Traditionally, procedures involving ostectomies, osteotomies or realignment required incisions large enough to accommodate a saw blade, provide adequate visualization, and introduction of wound retractors to protect surrounding soft tissues. Often this meant not only a large skin incision and exposure but extensive dissection, deeper tissue mobilization, and periosteal elevation. Figure 1
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Prof. Vinod K. Panchbhavi, MD, FACS, FAOA, FABOS Professor, University of Texas Medical Branch Now when we use the specialized burrs instead of the saw blades, we can do these procedures with far less exposure or dissection, the skin incision itself may be only slightly larger than the diameter of the instrument, often less than 0.5 cm! (Fig 2).
Issue 5
expose the bone. With MIS techniques, the same bony prominence can often be addressed through a tiny incision (Fig 3,4). Similarly, wedge resections for correction of midfoot deformities can be performed with considerably less softtissue exposure (Fig 5). These advantages are especially relevant when treating patients with diabetes, who frequently have multiple comorbidities, compromised soft tissues, and challenges with wound healing. Minimizing surgical exposure may help reduce woundrelated complications and preserve the surrounding soft-tissue envelope— important considerations in this vulnerable patient population. The benefits extend beyond the size of the incision. Comparative studies increasingly support potential advantages of MIS techniques, including reduced postoperative pain and faster recovery in appropriately selected procedures.
These burrs feature specialized cutting surfaces and are distinct from conventional drills. When used with appropriate high-torque, low-speed equipment and proper technique, they allow surgeons to perform osteotomies, wedge resections, and exostectomy through remarkably small incisions while minimizing soft-tissue disruption.
The difference doesn’t rest there! There are several comparison studies now out there that support logical derivatives such as faster recovery and less postoperative pain with MIS interventions. The thing I like most about MIS interventions – comes at the end of the procedure, the wound closure or lack thereof, compared to the prolonged time and effort with open exposures often just a ‘Steri-Strip’ does the work! n
Consider a plantar exostectomy from the lateral aspect of the foot. An open approach may require an incision several centimeters long to accommodate the saw and safely
Declaration of interest: The author is a Co-Editor of the book 'Minimally Invasive Diabetic Foot Surgery'.
Figure 2
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Figures 3, 4 and 5
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Evidence corner
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Evidence corner Newly published research June - October 2026 Systematic reviews
Rigney, B., Storme, J., Condell, R., Coveney, E. I. & Kearns, S. R. (2026). Weightbearing after ankle fracture fixation; a systematic review and meta-analysis of randomised controlled trials, a modern perspective. Journal of Foot & Ankle Surgery, https://dx.doi.org/10.1016/j. fas.2026.06.017 Mankar, S., Kawalkar, A., Sakhare, R. & Zaidi, R. (2026). Functional outcomes of displaced intra-articular calcaneal fractures: a randomized superiority trial of essexlopresti versus 3-point distraction technique by forgon and zadravecz. Foot & Ankle Specialist, 19386400261456921. https:// dx.doi.org/10.1177/19386400261456921 Assi, A., Hamyeh, A., Mohanna, R., Boutros, M., Boueri, W. & Sebaaly, A. (2026). Plateletrich plasma vs. placebo injections in achilles tendinopathy: a systematic review and meta-analysis of randomized controlled trials. Journal of Foot & Ankle Surgery, 65(4), 139.e1-139.e5. https://dx.doi.org/10.1053/j. jfas.2026.04.005 Oesman, I., Kohar, K. & Sanjaya, I. S. (2026). Placental-derived injectable products for chronic plantar fasciitis: a systematic review and meta-analysis. Journal of Foot & Ankle Surgery, https://dx.doi.org/10.1053/j. jfas.2026.09.006 Tan, A. K. S., Lee, D. M. X., Mai, A. S., Toh, R. X., Li, Z. X., Mohamed Buhary, K. S. & Tay, K. S. (2026). Comparative effectiveness of surgical interventions for recalcitrant plantar fasciitis: a systematic review and network meta-analysis. Journal of Foot & Ankle Surgery, https://dx.doi.org/10.1053/j. jfas.2026.08.008
systematic review of anatomical corridors, nomenclature and surgical exposure. Journal of Foot & Ankle Surgery, https://dx.doi. org/10.1016/j.fas.2026.06.010 Encinas, R., Hall Kiriluk, S., DePaolo, S., Jackson, J. B., Shaath, M. K. & Gonzalez, T. (2026). Clinical outcomes and complications of surgical and conservative treatment for jones fractures: a systematic review. Journal of the American Academy of Orthopaedic Surgeons, https://dx.doi.org/10.5435/ JAAOS-D-25-01516 Yates, Z., Perry, F. & Kachooei, A. R. (2026). The effect of postoperative weightbearing protocols on total cost and complications following ankle fracture orif: a systematic review. Journal of Foot & Ankle Surgery, 65(5), 173.e1-173.e8. https://dx.doi. org/10.1053/j.jfas.2026.06.001
Clinical trials
Shepherd, J., Mason, L., Houchen-Wolloff, L., Malhotra, K., Mangwani, J., UK-FATE Collaborative, Carter, G. (2026). Infection following foot and ankle surgery : a subanalysis of data captured from the uk foot and ankle thromboembolism (fate) audit. Bone & Joint Journal, 108-B(6), 781-786. https://dx.doi.org/10.1302/0301620X.108B6.BJJ-2025-1345.R1 Purdie, S. D., Glazebrook, H. M., Dissanayake, R., Burgesson, B. N., Morash, J. G. & Glazebrook, M. A. (2026). To walk or not? a prospective, randomised controlled trial to evaluate the effect of weightbearing on patient outcomes following first metatarsophalangeal joint fusion. Foot & Ankle International, 10711007261481828. https://dx.doi. org/10.1177/10711007261481828
Lim, B., Lim, G. & Kon, C. (2026). Does an adjunct moberg osteotomy improve outcomes in patients undergoing cheilectomy for hallux rigidus? a systematic review. Journal of Foot & Ankle Surgery, https://dx.doi.org/10.1053/j. jfas.2026.08.015
Dyke, W. B., Owusu Ansah, K., Zaidi, Z., Smith, A., Strong, R., Whittingslow, D., Lalli, T. (2026). Dorsiflexion angles following first mtp arthrodesis in adult pes planus: a retrospective radiographic cohort study. Journal of Foot & Ankle Surgery, https:// dx.doi.org/10.1053/j.jfas.2026.10.004
Fernandez-Rojas, E., Osorio-Torres, W., AriasAlvarez, G., Bastias, G. F., Herrera-Perez, M., Fletcher, L. & Vila-Rico, J. (2026). Defining the posteromedial approach to the ankle: a
George-Johnson, D., Ward, J., Cloake, T. & Millington, A. (2026). Intramedullary nailing versus internal plate fixation in the repair of open, distal tibial fractures with articular
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Compiled by Pip Divall Clinical Librarian Service Manager, University Hospitals of Leicester involvement - a retrospective analysis. Journal of Foot & Ankle Surgery, https:// dx.doi.org/10.1053/j.jfas.2026.09.009 Huang, R., Ye, Y., Xiong, J. & Li, Z. (2026). A retrospective comparative study of arthroscopic versus open tibiotalocalcaneal arthrodesis using a straight retrograde intramedullary nail. Journal of Foot & Ankle Surgery, https://dx.doi.org/10.1053/j. jfas.2026.09.007 Karimi, S., Bakhsh, D., Luo, L., Mutch, J., Gagnon, J. & Gdalevitch, M. (2026). Longacting narcotic multimodal anesthesia versus standard of care anesthesia for hallux valgus patients undergoing a percutaneous distal metatarsal osteotomy: a multi-center randomized controlled trial. Journal of Foot & Ankle Surgery, https:// dx.doi.org/10.1053/j.jfas.2026.07.023 Afifi, A. A., Hewaidy, A. I. F., El Shazly, O. A., Farouk, A., Elaslaby, A. A. M., Gamal, M. A. & El Mowafi, M. A. (2026). Endoscopic versus open flexor hallucis longus tendon transfer for reconstruction of chronic achilles tendon rupture: a prospective randomized pilot trial. Journal of Foot & Ankle Surgery, https://dx.doi.org/10.1016/j. fas.2026.05.015 Vardar, F. S., Temel, M. H., Guler, M. A., Gulec, M. G. & Ata, E. (2026). Ultrasoundguided tibial nerve block vs. local corticosteroid injection in recalcitrant plantar fasciitis treatment: a single blind randomized controlled study. Journal of Foot & Ankle Surgery, 65(4), 125. e1-125.e5. https://dx.doi.org/10.1053/j. jfas.2026.02.008 Mansur, N. S. B., Fayed, A., Chinelati, R., Carvalho, K., Jasper, R., Casas, E. J. H., de Cesar Netto, C. (2026). Bio-integrative screws versus metallic screws for calcaneus osteotomies: a non-inferiority randomized clinical trial. Journal of Foot & Ankle Surgery, 65(4), 119.e1-119.e9. https:// dx.doi.org/10.1053/j.jfas.2026.02.001 n
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