BOFAS Foot Print - Issue 1 - July 2024

Issue 1

Foot Print July 2024

Bulletin of the British Orthopaedic Foot and Ankle Society

The Bofas New Consultants’ Course – An Evolution And Revolution p8

Lisfranc Injuries: Technical Tips For Non-Rigid Fixation p18

Randomised Controlled Trials: p24

Foot Print

July 2024

Bulletin of the British Orthopaedic Foot and Ankle Society

CONTENTS 5 FROM THE PRESIDENT - MARK DAVIES Welcome to the inaugural edition of Foot Print.

8 THE BOFAS NEW CONSULTANTS’ COURSE – AN EVOLUTION AND REVOLUTION This November, the BOFAS Education Committee will run its fourth New Consultants Course, a highly successful addition to its world-renowned educational meetings.

7 FROM THE EDITOR - JITENDRA MANGWANI It is an honour to be the inaugural editor of this brand-new initiative of the British Orthopaedic Foot and Ankle Society.

23 ROUND TABLE MEETING The meeting generates considerable debate and reaches a consensus on many issues.

17 BUNIONS: A NATIONAL THINK TANK 18 LISFRANC INJURIES: TECHNICAL TIPS FOR NON-RIGID FIXATION Two alternative fixation methods of Lisfranc injuries using case examples.

24 RANDOMISED CONTROLLED TRIALS: The holy grail or just controlled chaos?

21 ANKLE ARTHRITIS ACADEMY The first meeting of its kind, dedicated solely to the management of ankle arthritis.

22 HOW TO LOOK LIKE A HERO WHEN REMOVING BROKEN SCREWS! This technique tip will harness the laws of physics to help you get the job done, specifically, using the magic of gears.

Foot Print is the Bulletin of the British Orthopaedic Foot and Ankle Society

Edited by Professor Jitendra Mangwani.

Associate Editors - Mr Graham Chuter, Miss Verity Currall. Assistant Editors Mr Munier Hossain, Mr Kailash Devalia

BOFAS

Company Registration Number: 01610419 Charity Number: 326114 General enquiries: administrator@bofas.org.uk

Disclaimer

28 THE EVOLUTION OF THE HUMAN FOOT During the course of human evolution, the foot of our ancestors has undergone gradual modification as we acquired erect posture and habitual bipedalism.

32 ALL ABOUT AFAP Membership group for Physios and AHPs interested in foot and ankle rehabilitation.

Open Box Media & Communications l Director Stuart.Walters@ob-mc.co.uk l Director Sam.Skiller@ob-mc.co.uk l Studio Manager Mark.Lamsdale@ob-mc.co.uk l Production Matt.Hood@ob-mc.co.uk l Advertising Sales Andrew.Hull@ob-mc.co.uk

12 DEVELOPMENT OF A VIRTUAL CADAVER TRIAL TOOL A simulation tool can help answer clinical questions about the ankle without the need for cadaveric testing.

13 BOFAS 2025 50 GOLDEN YEARS BOFAS 2025 will be held in Brighton 29th - 31st January.

34 1ST BOFAS MEMBERSHIP SURVEY The BOFAS Membership Survey was designed to capture relevant information on membership’s clinical practice, evaluate benefits offered to BOFAS members, challenges and barriers faced by the membership of the Society.

36 WHEN, HOW AND WHY TO USE THE ZADEK OSTEOTOMY When to consider and how to perform a Zadek Osteotomy.

Foot Print is produced on behalf of BOFAS by Open Box Media & Communications, Premier House, 13 St Pauls Square, Birmingham B3 1RB. T: 0121 200 7820.

For sales or design services, please discuss your requirements with a member of our team.

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The articles and advertisements in this publication are the responsibility of the contributor or advertiser concerned. The publishers and Open Box Media and Communications Ltd and their respective employees, officers and agents accept no liability whatsoever for the consequences of any inaccurate or misleading data, opinions or statement or of any action taken as a result of any article in this publication.

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Open Box Media & Communications are proud to be corporate sponsors of Heart Research UK (Midlands)

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Foot Print

July 2024

Bulletin of the British Orthopaedic Foot and Ankle Society

WELCOME BOFAS PRESIDENT, MARK DAVIES

Dear BOFAS members, friends and colleagues...

W

elcome to the inaugural edition of Foot Print. The Council of BOFAS has long felt that our growing membership, and the wider community of providers of foot and ankle care, would benefit from a regular bulletin keeping you up to speed with news. In our 50th anniversary year since the creation of the British Orthopaedic Foot Surgery Society in the dining room of a house in London, it seems appropriate to mark out our future with the launch of this publication.

Therefore, the content is governed by your valuable input and will be edited by the founding editor, Prof Jit Mangwani and his editorial team. If you have any bright ideas, articles, or events that you feel need to be communicated and reach out to a wider audience, please feel free to contribute.

The remit of this bulletin is not to make you aware of scientific papers but to inform you of hot topics, news, and events. This bulletin is for you.

The next BOFAS congress will be held in Brighton at the Hilton Doubletree conference centre between 29-31 January 2025. Here we will commence

our celebrations of our first 50 years as a society. Together with many helpful suggestions, I am putting together an exciting and stimulating programme of international speakers from Germany, Netherlands, Belgium, Spain, South Africa, and USA, complementing our UK Faculty. The themes of the meeting will be reflecting upon our past successes but also looking at the technological innovations that continue to advance foot and ankle care and keep us on our toes…!

“ T HE RE MI T OF T HIS B UL L E T IN IS NOT T O M A K E Y O U AWA R E O F S C I E N T I F I C PA P E R S B U T T O INF O R M YO U O F HOT TOPICS, NE WS, AND E VENTS. T H I S B U L L E T I N I S F O R Y O U .”

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Please make this meeting very much something to look forward to in those short days after Christmas and put the dates in your diary to visit the south coast of the UK for the best of the Winter sunshine and some warm hospitality! n

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Foot Print

Congratulations

In partnership with...

On behalf of the American Orthopaedic Foot and Ankle Society, I would like to congratulate you as editor and the British Orthopaedic Foot and Ankle Society on the initial issue of Foot Print. The AOFAS strongly applauds the spirit of collaboration this Bulletin seeks to foster between the societies representing the members of the global foot and ankle communities. We look forward to reading this inaugural issue and the many to follow.

Michael Aronow, MD, FAAOS, FACS President, American Orthopaedic Foot and Ankle Society

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On behalf of EFAS, I extend heartfelt congratulations for the successful launch of this journal.

As a foot and ankle surgeon and president of EFAS, I have observed the evolution and collaboration between BOFAS and EFAS, driven by the innovation and dedication of their leaders. The launch of Foot Print represents a notable milestone in this journey. Creative initiatives like Foot Print are the way forward. Creating a friendly and creative environment is the motto of both EFAS and BOFAS. This fosters a diverse and open academic debate that brings the foot and ankle community together.

I wish Foot Print every success in its endeavors.

Kristian Buedts, MD President EFAS

Congratulations from...

Congratulations to BOFAS on launching the new initiative, Foot Print! This effort is connecting the foot and ankle community globally, fostering collaboration and innovation. Best of luck!

Dr T V Raja President, Indian Foot and Ankle Society

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The British Indian Orthopaedic Society congratulates BOFAS for conceiving the idea and publishing Foot Print which will strengthen the evidence-based practice of the specialist and the non-specialist Foot & ankle surgeons around the world helping them improve patient outcomes and encourage research.

We very much look forward to sharing the first edition of Foot Print with the members of our society at BIOS. Sunil Garg President, British Indian Orthopaedic Society

On behalf of the BOA I congratulate Jit and the BOFAS team on the launch of this Bulletin. As a foot and ankle surgeon, it has been my pleasure to watch BOFFS and then BOFAS develop and flourish over the years down to the innovation and hard work of its leaders. The addition of Foot Print is the icing on the cake. The BOA has strong links to the specialists societies but clearly mine are stronger than most to BOFAS. I wish Foot Print well and hope it helps foster links internationally with other foot and ankle societies.

Simon Hodkinson President, British Orthopaedic Association

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July 2024

Foot Print

Bulletin of the British Orthopaedic Foot and Ankle Society

FROM THE EDITOR Committees Council Membership: President: Mark Davies President Elect: Robert Clayton Immediate Past President: Rick Brown Honorary Secretary: Jitendra Mangwani Treasurer: Hiro Tanaka Media & Comms Committee Chair: Karan Malhotra Education Committee Chair: Callum Clark Clinical Practice Committee Chair: Lyndon Mason Scientific Committee Chair: Dave Townshend Chief Operating Officer: Jo Millard Director: Paul Halliwell Trustee: Steve Hepple Trustee: Steve Bendall EFAS Representative: James Ritchie EDI Lead: Anna Chapman

Clinical Practice Committee Membership: Chair: Lyndon Mason Secretary: Nilesh Makwana Caldicott Guardian: Jitendra Mangwani Registry Lead: Ed Wood Data Protection Officer: Jo Millard Member: Tim Clough Member: Ben Hickey Member: Joel Humphrey Member: Shilpa Jha Member: Robbie Ray Co-opted: Andy Goldberg Co-opted: Karan Malhotra

Education Committee Membership: Chair: Callum Clark Secretary: Howard Davies Member: Maneesh Bhatia Member: Jim Carmichael Member: Graham Chuter Member: Verity Currall Member: Vivek Dhukaram Member: Rajesh Kakwani Member: Krishna Vemulapalli Member: Matthew Welck Overseas Comm: Tim Williams

It is a real privilege and honour to be the inaugural editor of this brand-new initiative of the British Orthopaedic Foot and Ankle Society.

A

s BOFAS heads towards its Golden Jubilee celebrations in 2025, it is very clear to me that the society is leading the way in delivering world class education and research in the field of foot and ankle surgery. The key ingredients to the success of BOFAS activities have been the perfect blend of its passionate leadership and active engagement of its membership.

The ethos of a Bulletin is very different to that of a Scientific Journal. The vision of the Foot Print is to create a global platform of communication amongst healthcare professionals delivering foot and ankle care to the patients worldwide. I am extremely grateful to the leadership of American Orthopaedic Foot Ankle Society, European Foot & Ankle Society, Canadian Foot and Ankle Society, Indian Foot and Ankle Society, Association of Foot Ankle Physiotherapists and British Indian Orthopaedic Society for supporting this endeavour and disseminating electronic copies of Foot Print to their membership. This will help us share experiences and knowledge across borders, foster links between societies and develop areas of collaboration in education and research.

I feel blessed to lead a team of self-motivated, inspirational individuals on the Foot Print editorial board who have worked very hard to put together great educational content for the first issue. This edition features a selection of articles including evolution of the human foot, novel techniques in foot ankle surgery, revolutionary educational courses, survey results and personal reflections of running a randomised controlled trial. I sincerely hope that you enjoy reading this edition of Foot Print and would welcome any feedback, suggestions for future articles via honorarysecretary@bofas.org.uk.

Finally, I’d like to thank Industry sponsors for supporting this initiative and hopefully helping to make it a global phenomenon in the field of foot and ankle surgery.

Jit Mangwani - Editor - Foot Print

Media & Communications Committee Membership: Chair: Karan Malhotra Secretary: Togay Koç Member: May Labidi Co-opted: Charline Roslee

ASSOCIATE EDITORS

Foot Print

ASSISTANT EDITORS

Scientific Committee Membership: Chair: David Townshend Member: Toby Jennison Member: Sarah Johnson-Lynn Member: Dev Mahadevan Member: Madhu Tiruveedhula Member: Nijil Vasukutty Co-opted: James Ritchie

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Graham Chuter

Verity Currall

Munier Hossain

Kailash Devalia

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New Consultants Course

Foot Print

Issue 1

THE BOFAS NEW CONSULTANTS’ COURSE – AN EVOLUTION AND REVOLUTION This November, the BOFAS Education Committee will run its fourth New Consultants Course, a highly successful addition to its world-renowned educational meetings. Nearly 50 young UK Foot and Ankle Consultants have benefitted from this course since its inception in 2021, and with the 50th Anniversary of the Society around the corner, it is perhaps worth reflecting on how the course came into being and the ideas behind it.

Callum Clark Chairman of BOFAS Education Committee, Founder of Advanced Foot and Ankle Forum

T

he reality is that the course itself evolved organically from the Education Committee’s growing suite of courses. The pivotal moment came in 2011 with the creation of the BOFAS Principles of Foot and Ankle Surgery course, designed for Speciality Trainees in Trauma & Orthopaedics (ST3+). Prior to Principles, the society’s role in delivering education was limited to running sessions at the BOFAS and BOA annual conferences.

BOFAS was the only society to answer the call from the BOA to run a sub-speciality course directed specifically at pre-FRCS (Tr & Orth) exam trainees.

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Anna Chapman BOFAS Lead for Equality, Diversity, and Inclusion, Founder of New Consultants Course

The aim, therefore, was to provide a comprehensive experience of the Foot and Ankle curriculum. This was achieved by providing a core knowledge base with lectures and a hands-on practical experience with the clinical examination of patients. What set this course apart from others was the sheer number of patients to examine and interact with and the small group interaction with Consultant trainers.

In designing Principles, the Education Committee also laid down strict criteria so that the course would be repeatable but consistent in its content and mode of delivery. The format of the course was standardised, and a Course Director’s information pack and previous courses’ lectures were made accessible on a cloud server. This enabled consistency of message

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July 2024

Foot Print

Bulletin of the British Orthopaedic Foot and Ankle Society

“ N E A R LY 5 0 Y O U N G UK FOOT AND ANKLE C O N S U LTA N T S H AV E BENEFIT TED FROM THIS COURSE SINCE I T S I N C E P T I O N .”

Foot and Ankle teams across the UK. The Principles philosophy continues to expand with 42 courses and over 1000 surgeons educated around the world to date.

and provided a resource for faculty, so that new lectures did not need to be prepared each time. This proved essential in retaining faculty and to ensure volunteers returned to teach. The course was made deliberately informal and interactive, with a 2:1 ratio of delegates to faculty, and heavily weighted in favour of small-group learning (and away from didactic lectures).

Critically, there was also a commitment to modify courses continually based on meaningful delegate feedback.

The foundations were now laid for future course development, and these core principles have remained at the heart of the BOFAS Education Committee’s philosophy ever since. Principles itself expanded into the international forum with modified courses in India in 2017 and Africa in 2018. Care has been taken to modify the

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content of the courses to support the specific learning needs of the delegates, and international courses are now a regular occurrence in Low- and Middle-Income countries, supporting surgeons to develop a specialist interest in foot and ankle surgery.

The basic format of Principles was also adapted to create the BOFAS Allied Healthcare Professionals Principles Course. BOFAS worked in conjunction with the Association of Foot and Ankle Physiotherapists and AHPs (AFAP) to design and implement a unique course that caters to the educational needs of the growing number of advanced Allied Health Professionals with a declared specialist interest in the foot and ankle.

This group includes physiotherapists, clinical nurse specialists, podiatrists and orthotists, most of whom work within

The next piece of the jigsaw fell into place in 2016 when the Education Committee decided to fashion a course for a new audience—the “lost tribe” of post-CCT foot and ankle trainees—the Fellows.

Inspired by the excellent Round Table of Orthopaedics meetings, which had run since 2011, and adhering to the Education Committee’s evolving educational philosophy, the Advanced Foot and Ankle Forum (AFAF) was created, dispensing with the traditional faculty/delegate split and instead seating all 16 delegates and 10 faculty around a large table. In addition to the usual informality, small group break-out sessions and plenty of discussion time were built into the programme. Fellows were encouraged to challenge the faculty with yellow and red cards when it was found they were taking over the conversation with too much eminence! By this time, the Education Committee had gained experience in running cadaveric courses since its first Principles Course Cadaveric day in 2014, so a third day of cadaveric teaching was added to AFAF in 2018, and the format has remained the same with the eighth course just recently completed.

The educational content of AFAF predominantly focused on a three-year rolling programme of advanced clinical topics. However, after running the course for a year, it was observed that >>

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New Consultants Course

Foot Print

Issue 1

specialists, rather than the generality of surgery, or even just Orthopaedics. Topics specific to Foot and Ankle surgery can therefore be discussed, making the course appealing and high yield.

“ THE BASIC AIM OF THE COURSE IS TO HELP YOUNG SURGEONS WITH T H E D I F F I C U LT T R A N S I T I O N T O L I F E A S A C O N S U LTA N T O R T H O P A E D I C F O O T A N D A N K L E S U R G E O N .” the Fellows would bring up and enjoy discussing non-technical topics such as dealing with complications or setting up a new service in a Trust. This highlighted the need for a non-technical component to the course and so a “Life as a New Consultant” session was implemented on the second day of the 2017 course.

The session included faculty talks on How to set up an excellent Foot and Ankle Service and Life as a New Consultant and was followed by a 90-minute series of small group break-out sessions with faculty members including Clinic/ Theatre Planning, What is a Job Plan?

Complications and Complaints and The “Other” Sector. The session was repeatedly a big hit with delegates and faculty alike, and thus ultimately spawned the New Consultants Course.

Once again, one course had evolved from another, taking with it lessons

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learned since 2011 and the progressive educational philosophy of the BOFAS Education Committee. Like AFAF, the “Round table” format, break-out discussion sessions, and trademark informality were retained, but the emphasis in the New Consultants Course is very much on non-technical skills.

There is, of course, a clinical element, with a small group Complex Case discussion (exclusively for discussion of the delegates’ own cases) and a second day of cadaveric dissection.

The basic aim of the course is to help young surgeons with the difficult transition to life as a Consultant Orthopaedic Foot and Ankle surgeon.

There are other “New Consultant” courses on offer, but this new BOFAS course was revolutionary as it was bespoke—tailored to our specific interests and experiences as sub-

The ratio of delegates to faculty is nearly 1:1 and has remained so. Twelve short, punchy talks designed to start conversation are delivered by the faculty (based on their own experiences) on the topics of: 10 things I wish I’d known when I started as a Consultant, Practical Tips and Tricks for Life On Call, Life as a Trainer - Working with a Registrar, Managing your own Complications, Working expertly with your CD and managers, Dealing with complaints & litigation, Colleagues and Communication – expert advice, Introducing New Technologies, Research as a full-time surgeon: is it possible?, Setting yourself up on the BOFAS Registry, Quality Improvement and Tips & Tricks for working in the private sector. After each couple of lectures, discussion is encouraged, and the direction of the course is led by the delegates themselves. Faculty includes both experienced surgeons and those in the first few years of their practice, who can provide up-to-date support and insight for the delegates settling into their new posts. It is also an excellent opportunity to include younger BOFAS members on a course as faculty.

Day 2 of the New Consultants Course is a cadaveric day and from the outset pushed the boundaries on what BOFAS had offered thus far in the lab. Once again, the aim of the day is to learn from others’ experience, and the day starts with How I do it talks from the faculty on some of the less common procedures. Those which are ideal to practice in the cadaveric lab include the Lapidus procedure, lateral column lengthening, and the medial approach to a double hindfoot fusion.

Delegates are supported by the faculty,

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July 2024

but it would be true to say that every day is a school day, even for the faculty!

Whilst working, everyone enjoys the opportunity to pick up new tips and tricks, and chat through complex cases.

It is pivotal to the effective running of the New Consultants Course that the delegates feel at ease to talk frankly about their experiences and challenges amongst their peers and mentors.

Those present are therefore asked to abide by “Chatham House Rules.” The rule, which was first defined in 1927 and refined in 2002, states “When a meeting, or part thereof, is held under the Chatham House Rule, participants are free to use the information received, but neither the identity nor the affiliation of the speaker(s), nor that of any other participant, may be revealed.”

Quite apart from the educational content of the course, we recognise that over the two days, there is ample opportunity for young surgeons to network and form clinical support groups and, of course, friendships with peers and faculty. It is recommended that young surgeons attend the AFAF & New Consultant courses at least one year apart, and therefore a significant proportion of delegates from each AFAF course meet up again at the next New Consultants Course. This familiarity

Foot Print

Bulletin of the British Orthopaedic Foot and Ankle Society

and “reunion” of sorts help to establish a rapport, such that conversation more readily flows on the New Consultants Course. WhatsApp groups are established by the delegates on both courses, and this further helps to solidify the peer group, providing support at this challenging time in a surgeon’s career. These courses are therefore a great opportunity to meet colleagues from across the country and settle into the established UK Foot and Ankle network. The BOFAS-specific nature of the course makes it uniquely advantageous to us as a sub-specialty and Society. Increasingly, we are seeing a cohort of young surgeons, who have been supported by BOFAS through Principles, AFAF, and then the New Consultants Course.

More formally, mentorship is something which BOFAS and its Education Committee very strongly support, and such relationships are encouraged and reinforced at the New Consultants Course. The BOFAS Mentorship scheme is advertised and encouraged on the course, and we hope that those who have been mentored will one day become mentors themselves.

All BOFAS courses, but especially AFAF and the New Consultants Course, break down the barriers within the hierarchy, enabling delegates to interact with

faculty on an informal basis to network and learn from their experience. We open courses by welcoming the delegates to BOFAS and support them in feeling part of the Society from the outset. Courses such as these ensure that BOFAS and the Foot and Ankle surgery network in the UK are a welcoming and supportive place.

It is hoped that, in turn, we will attract the best and most talented individuals to our sub-specialty. This is essential for the future of the sub-specialty and must not be underestimated. We hope that the delegates will join as faculty in the future so that we can keep the tradition of supporting and welcoming our younger surgeons strong.

Of course, any analysis of the educational courses that BOFAS has developed and run over the last decade or so must reflect on two other pivotal factors. At the heart of all BOFAS courses is the presence and dedication of the Consultants, who give up their time to join as faculty. In an era of tightened budgets, multiple demands, and limited resources, the BOFAS membership has come out in force to teach our young surgeons and AHPs. Secondly, none of the above is possible without the support of industry, and we are very fortunate to have had the financial support of several medical device companies, enabling us to offer these courses at heavily subsidised rates and ensure that cost is not a barrier to top-quality education.

As BOFAS approaches its 50th year, we feel very optimistic about UK Foot and Ankle education in the next 50 years, with innovative new courses under development, VR and simulation projects, and most importantly, a sound educational philosophy guiding us.

BOFAS and the Education Committee extend their sincere gratitude to all of our members who have organized and participated in the BOFAS courses and to all the delegates for their enthusiasm. n Should you wish to get involved in teaching, please contact: education@bofas.org.uk All BOFAS Courses are advertised on the BOFAS website under the Meetings tab.

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Virtual Cadaver Trial Tool

Foot Print

Development of a Virtual Cadaver Trial Tool

Dr Elise Pegg

D

r Elise Pegg, Orthopaedic Research UK Early Career Fellow at the University of Bath, is developing a simulation tool which can help answer clinical questions about the ankle without the need for cadaveric testing. Dr Pegg, a Senior Lecturer in Mechanical Engineering, has created the model using finite element simulation tools which engineers would typically use for inanimate objects, but work just as well for the human body.

One of the key challenges with such simulation techniques is that one model cannot represent an entire population. It is therefore critical to have a collection of patient-specific models which can then be used for what is called an ‘in silico trial’.

Ideally, there would be thousands of such models to get a reliable result but, practically, this is a challenge because one model takes several months to create, and the simulation takes several hours to solve. Currently, Dr Pegg (along with her postdoctoral researchers Dr Subrata Mondal and Dr Harriet Talbott) has created three models of the ankle, but they aim to create more.

Each model starts with a standard clinical CT scan of the joint. From this, the bony geometry is created using a process called segmentation. The CT scans have kindly been provided for the project by Prof Claire Brockett from the University of Sheffield.

As the attenuation of an X-ray is also dependent on the density of the bone, it is possible to map the material properties of the bone from the CT scan to the model.

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Senior Lecturer in Mechanical Engineering and Orthopaedic Research UK Early Career Fellow, University of Bath

This ensures that the model captures the spatially varying properties of bone specific to that patient.

Because soft tissues are not visible on a CT scan, it is necessary to approximate these from the anatomy. If an MRI scan were taken of the same patient in the same position, then the geometry of the soft tissues could be identified. However, as this is rarely done clinically, Dr Pegg decided to design the model using only the CT scan data.

This also has the benefit of reducing the complexity of the models so they will solve in a shorter period of time.

Ligaments are represented in the model by tension-only spring elements, which are based on Hooke’s law under tension and collapse under compression. Joint loads and muscle forces are included by applying a direct force to the bones.

So what are the Open Ankle Models useful for? They can answer clinical questions that would typically require a cadaver study, or potentially a clinical trial. The models can be run for free because the model and software are fully open-source, and they can be run as many times as desired.

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It enables clinicians to explore potentially high-risk ideas and look at the impact of many different parameters in a controlled manner, without needing to worry about high costs or harming a patient. The hope is that this will lead to increased innovation. Compared to cadaver tests, the model also has a higher reliability because there is no variability in the tissue properties with time or storage condition.

However, as the models have simplified reality and limitations, it is important for clinicians to only use it to answer appropriate questions. For example, ligament anatomy has been simplified to a simple spring equation and so could not assess ligament rupture or healing.

However, it could look at how ligament placement influences ankle stability. Also, there are only currently three models which is not sufficient for any proper trial.

Currently, the model cannot simulate injury or healing, but can highlight tissues at risk of injury. Dr Pegg is looking for collaborators to try out the models and see if it could help their research, as they haven’t yet been widely tested and still very much a work in process.

A critical part of the success of this project has been the multidisciplinary collaboration team and the support from Orthopaedic Research UK. The project has a steering group which includes two orthopaedic surgeons: Prof Jitendra Mangwani and Mr Aashish Gulati, as well as Prof Claire Brockett, an expert in biomechanics of the foot and ankle. The steering group have met every couple of months to keep the project on track. With projects such as this, which are led by engineers and aim to improve healthcare, it is so important that the clinical voice is heard, and it enables clinicians to be at the forefront of exciting new research possibilities. n If you are interested to try the Open Ankle Models then please contact Dr Pegg: e.c.pegg@bath.ac.uk.trainees

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Foot Print

July 2024

Bulletin of the British Orthopaedic Foot and Ankle Society

BOFAS 2025 - 50 Golden Years

BOFAS 2025 will be held in Brighton from 29th to 31st of January BOFAS 2025 Scientific Programme

Abstract Submissions Now Open

BOFAS 2025 - Venue

The following is an outline of the topics which will be included:

You can submit your abstracts here https://app.medall.org/ sign-in?requestedRoute=/ event-listings/bofasannual-scientific-meeting2025-brighton/abstracts.

Doubletree Hilton Metropole, Kings Rd, Brighton and Hove, Brighton BN1 2FU

This year abstracts will be submitted via MedAll. To submit abstracts you will have to create a MedAll account.

You will need to either sign in with your account, or create an account before you can access the page.

Accomodation

Day 1 - The Hindfoot • Mechanics of hindfoot deformity • Ankle replacements in patients with deformity / bone loss • Supramalleolar osteotomies • The use of patient specific instrumentation and custom prostheses • Revising total ankle replacements (talus preserving / sacrificing) • Converting ankle replacements to fusions and dealing with bone loss / infection • Dealing with talar tumours and AVN • Dealing with bone voids after trauma • Tips in complex hindfoot surgery

Day 2 • Case debates/Consultant Sessions/ Industry Workshops • Registrar/Fellow and AHP sessions • BOFAS 50 years

Day 3 • Minimally Invasive Surgery Instructional The provisional programme can be found here. Please note that this is subject to change at this time.

You can find more information about our BOFAS 2025 guest speakers here.

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Key Dates • Abstract Submission OPEN - 1st June 2024 • Abstract Submissions CLOSE - 6th September 2024 • Responses to applicants - 1st October 2024 • Early Bird registration ends - 30th October 2024

https://www.hilton.com/en/ hotels/bshmedi-doubletreebrighton-metropole/

VisitBrighton is the official accommodation booking provider for the BOFAS Annual Scientific Meeting - BOFAS at 50.

We are delighted to offer specially negotiated accommodation rates for attendees. We advise early booking to guarantee your preferred hotel.

To book at the discounted rates for the duration of the conference, please visit: https://rb.gy/ cod12k

Social Events Gala Dinner – Thursday 30th January 2025 @ 19:30 Brighton Corn Exchange, Royal Pavilion Gardens, Brighton and Hove, Brighton BN1 1EE Open to all attendees (booking required - additional cost shown in Registration rates document)

Past Presidents' Dinner – Wednesday 29th January 2025 @ 19:30 (By Invite only) Additional cost to guests who wish to attend - please contact events@bofas.org.uk for further information

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Critical Intervention Case Series

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A Novel Local Antibiotic Delivery / Prophylaxis System with PRF Matrix for Total Talus Replacement in Avascular Necrosis of the Talus

NHS Foundation Trust

Anand Pillai and Team at University Hospitals South Manchester, Wythenshawe

Anand Pillai, Consultant Orthopaedic and Trauma Surgeon

Avascular necrosis (AVN), otherwise known as osteonecrosis, aseptic necrosis and ischaemic bone necrosis, is a bone disease characterised by the interruption of subchondral blood supply, leading to ischaemic damage and subsequent tissue necrosis. 1 AVN typically affects the epiphysis of long bones of weight-bearing joints; common sites include the femoral head, knee and talus. 1 The talus is predisposed to AVN due to its unique structure, characteristic extraosseous arterial sources, and variable intraosseous blood supply.2 A 58 year old male was referred with right ankle pain which had worsened over the preceding 3 years. Prior to referral, the patient received multiple steroid injections into the ankle for symptomatic relief. He mentioned that he was experiencing similar pain in his left ankle and both of his hips. The patient's ankles were duly investigated with further MRls, the findings of which were consistent with avascular necrosis in both talar bodies, but more severe in the right talus (figure 1 and 2).

The patient was managed conservatively until his referral to the author following a CT scan of his ankle in July 2023 (figure 3), which revealed a threatened collapse of the talar body. The patient had no typical risk factors associated with AVN in his past medical or family history.

Fig. 1 Right Ankle MRI April 2021

Fig. 2 Left Ankle MRI April 2021

Fig. 3 Right Ankle CT July 2023

Different surgical options were discussed, including fusion of the ankle +/- subtalar joint, or a total talar replacement. A repeat MRI scan of the right ankle was performed to assess the subtalar joint for osteoarthritis; none was identified. The patient opted for the total talus replacement; therefore, a CT scan of the left ankle was performed to map out the 3D anatomy of his "normal" talus, which fortunately had not collapsed.

The custom total talus implant and spacer (figure 4) was designed and manufactured by Meshworks@, who have developed and adopted additive manufacturing techniques in order to produce custom made implants for the reconstruction of adult foot and ankle skeletal anatomy which has been compromised by deformity and/or bone loss.

Different size implants were manufactured, along with corresponding size and fixture congruence template tools (figure 7) to ensure the correct fit. Due to the large implant load, there was concern about the potential for infection to develop, and considerable thought was given as to how a high load of local, bioavailable prophylactic antibiotic, with a sustained period of release, might be administered. Other recognised forms of local antibiotic delivery - such as calcium carriers - could not be used in this case due to their unsuitability in articulating surfaces or joints, and the fact that post-operative white exudate

Fig. 4 Total Talus design algorithm

Continued overleaf

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July 2024

Bulletin of the British Orthopaedic Foot and Ankle Society

BUNIONS: A NATIONAL THINK TANK

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t’s time to get serious about bunions (hallux valgus). That was the message of the first National Bunions Think Tank, held in London on 21st June 2024, sponsored by medical research charity, Orthopaedic Research UK, in association with Rosetrees Trust. The Think Tank included many of the country’s leading foot health experts, including primary care physicians, podiatrists, physiotherapists, surgeons, academics and research funders, who came together to discuss ways to improve patient care and identify areas requiring further research.

The consensus in the room was that care of bunions, despite affecting over 10 million people in the UK alone, is underfunded and under-recognised as a serious, debilitating condition that impacts people’s personal, social and professional lives. There are also huge variations in the care provided to people with this condition, limited research on the most effective surgical and nonsurgical interventions, especially when it comes to measuring long-term outcomes, and inconsistent and often ineffective patient information. The discussions were informed by films of patients talking about their experiences of living and working with the condition, and access to treatment and recovery after surgery.

The Think Tank discussions focused on four core areas – how to improve patient pathways and make them uniform,

identifying the research required to improve knowledge, understanding of the most effective treatment options, improvements in the quality of patient information provided, and the case that needs to be made to policy makers and funders to take the condition more seriously. The event chair, Professor Jit Mangwani, Consultant Trauma and Orthopaedics at the University Hospitals of Leicester described the discussions as ‘very insightful, inspirational and thought provoking, with great ideas on how to improve pathways and outcomes for patients suffering with this condition.’

Outputs from the Think Tank included several workstreams focused on pathways, patient education, research and creation of a policy document. Please stay tuned for further developments. In the meantime, if you have any queries and/or suggestions, please get in touch via jitendra-mangwani-orthopaedics n

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Lisfranc Injuries

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Issue 1

LISFRANC INJURIES: TECHNICAL TIPS FOR NON-RIGID FIXATION This article describes two alternative fixation methods of Lisfranc injury. The focus is on the description of these two techniques using case examples.

Richard Freeman Consultant Trauma and Orthopaedic Surgeon, Maidstone and Tunbridge Wells NHS Trust

Suture Button Fixation – Richard Freeman (Co-author Richard Dimock - ST8 registrar in KSS) Rationale The principal advantage of suture button fixation is that it provides stable yet dynamic reduction and fixation of the diastasis through a percutaneous approach.

Whilst biomechanical studies have shown that suture buttons provide a less stiff fixation than screw fixation(1), with perhaps a slight relative increase in diastasis on initial loading(2), multiple case series have reported promising clinical and patient-reported outcomes(3).

Technique The typical surgical technique involves percutaneously passing the suture button between the medial wall of the medial cuneiform and the lateral border of the base of the second metatarsal. Published variations include augmenting this with a second device in the same plane, or across to the intermediate cuneiform. In patients with poorer bone quality, or revision procedures(4), the use of a washer between the button and the medial cuneiform distributes the load and can prevent “blowin” of the medial wall of the medial cuneiform. Once the keystone is reduced, the whole arch is stabilised, including the first to fifth TMTJs, so only rarely is any additional fixation needed. No tourniquet is required and operative time can be significantly shorter than using conventional plate and screw fixation method.

Post-operative Management Non-weight bearing for six weeks, then increasing weight bearing as pain allows, with no planned metalwork removal. If patients have to weight bear, I add a washer to distribute forces at the medial cuneiform.

Case example: 62 yo man, road traffic accident

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Bulletin of the British Orthopaedic Foot and Ankle Society

Soft tissue Lisfranc reconstruction technique – Ed Gee Indications A purely ligamentous Lisfranc injury, with no fractures to the bases of the medial three metatarsal or cuneiforms (avulsion flakes are acceptable.

Commonly, a combination of some or all of the medial naviculo-cuneiform joints, the medial and lateral inter-cuneiform joints and the 1st and 2nd TMTJs are involved. If further joints are unstable, this technique may not be appropriate or at least should be combined with temporary screw or plate fixation to joints required to be mechanically rigid.

Ed Gee Consultant Trauma and Orthopaedics, Salford Royal NHS Foundation Trust

Intra-operative planning and preparation Perform a comprehensive EUA of the midfoot in flexion, extension, abduction, adduction, internal and external rotation. Draw a quick sketch of the foot onto the operating table and mark all unstable joints with an ‘X’ as you go. (Fig.1)

Figure 1: EUA of the right foot under rotation revealing instability of the 1st and 2nd TMTJ, Lisfranc space, medial intercuneiform space and the medial naviculo-cuneiform joint (left) and a drawing of foot bones with affected joints marked with X (right).

My preferred approach for this injury pattern would be a dual incision.

One medial incision along the plantar border of the 1st ray. The dorsal incision is between the 2nd and 3rd rays.

Once joints are anatomically reduced each joint should be stabilised with suture tape in a specific order.

Specialist equipment required 2mm FiberTape, 36” working length, 3mm x 8mm Biotenodesis disposables kit, Biceps Button, 4.75mm x 19.1mm Biocomposite Swivelock anchors (Arthrex equipments were used for the illustrated case).

Reconstruction of the Lisfranc ligament: Pass the 2mm K-wire across the Lisfranc joint from the plantar aspect of the medial cuneiform, exiting the centre of the lateral cortex of the 2nd metatarsal. Replace the K-wire with the 1.6mm guidewire with the looped end laterally out of the 2nd metatarsal base and the 1.6mm wire end in the medial cuneiform.

Drill over this with the 3.5mm cannulated drill from the Biotenodesis disposables until you reach (but do not breach) the lateral cortex of the medial cuneiform. Measure the depth of the drill hole to ensure the Swivelock anchor (19.1mm) will fit in the cuneiform and not breach the joint. If not the anchor may need trimming at the proximal end. Load the long FiberTape (2mm, 36” working length) onto the biceps button. Pull the FiberTape from lateral to medial through the 2nd metatarsal base and medial cuneiform until the button is seated on the lateral cortex of the 2nd metatarsal base. Remove the end eyelet and central Fiberwire of the Swivelock anchor. Tension the FiberTape hard by hand and insert the Swivelock anchor into the medial cuneiform as an interference screw. (Fig 2)

Figure 2: Biceps button seated on the lateral cortex of 2nd metatarsal base with FiberTape through 2nd metatarsal base and medial cuneiform, tensioned and Swivelock anchor inserted into medial cuneiform as interference screw.

Reconstruction of the inter-cuneiform ligaments: Pass a 2mm K-wire from lateral-to-medial, from the lateral border of the dorsal middle cuneiform to the plantar aspect of the medial border of the medial cuneiform. (Fig 3) Back the K-wire out laterally, following the tip of it with the passing wire from medial-to-lateral, and use this to pass >>

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Figure 3: 2mm K wire from dorsal lateral edge of middle cuneiform to plantar medial cuneiform.

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Lisfranc Injuries

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Figure 4: Fibertape is passed through the medial and middle cuneiforms, delivered dorsally then passed through the lateral cuneiform from dorsal to plantar. It is then delivered through the medial wound, tensioned and a 4.75mm biocomposite Swivelock anchor is inserted dorsally as an interference screw.

the free ends of the previous FiberTape Lisfranc ligament reconstruction back through the medial and middle cuneiforms, exiting onto the dorsum, on the lateral edge of the middle cuneiform.

To fix the wire, using an oblique X-ray, drive the 1.6mm guidewire into the centre of the lateral cuneiform, passing through the plantar cortex slightly. Drill over this with the 3.5mm cannulated drill until the far cortex is reached, measure the depth of the bone and trim the Swivelock anchor if required. Now exchange the guidewire for the much more bendy 8” suture passing wire and retrieve it through the medial wound by blunt dissecting under the cuneiforms. Use the loop to pass the FiberTape from dorsal to plantar through the lateral cuneiform, tension by hand and insert the Swivelock interference screw (without eyelet and central Fiberwire) dorsally into the lateral cuneiform to secure the tension and trim the FiberTape against the plantar cortex through the medial wound. (Fig.4)

Reconstruction of the 1st TMTJ: Instability of the 1st TMTJ should be identified at the start during the EUA, as a reconstruction of this joint requires a change in the previously described technique.

Once the Lisfranc ligament has been reconstructed the FiberTape can be cut at the medial cortex. A separate, second,

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Issue 1

Figure 5: A common construct of FiberTape and interference screws to stabilise the 1st and 2nd TMTJs, the Lisfranc space, the intercuneiform spaces and the medial naviculo-cuneiform joint.

long FiberTape is utilised to reconstruct the 1st TMTJ and intercuneiform joints.

The second FiberTape is either threaded through the original biceps button holes before application, wrapped around the base of the previous biceps button once it is seated or a second button can be used. A 2mm wire is passed transversely, across the base of the first and second metatarsals.

The 8’ suture passing wire is used to pass the FiberTape lateral-to-medial. Optionally a 3.5mm drill hole and interference screw can be used in the base of the 1st metatarsal but this isn’t necessary if the FiberTape is being locked elsewhere.

The medial free end of FiberTape must then be taken proximally across the 1st TMTJ to stabilise the joint fully. Using this FiberTape across the inter-cuneiform joints by pulling it through the previously described 2mm wire hole (instead of the Lisfranc joint FiberTape) and fixing it into the lateral cuneiform. (Fig.5)

Post-operative instructions Continue non-weight bearing until 8 weeks post-op. 8-10 weeks 50% partial weight bearing in the boot and arch support insole. 10-12 weeks full weight bearing in the boot and arch support insole. At 12 weeks the boot can be removed and the patient can fully weight-bear in supportive shoes, with the medial arch support insole to be used until 6 months after surgery. n

Ed Gee - Conflict of interest declaration: Paid work for Arthrex, Lavendar and Bone support.

References 1. Hopkins J, Nguyen K, Heyrani N, Shelton T, Kreulen C, GarciaNolen T, Christiansen BA, Giza E. InternalBrace has biomechanical properties comparable to suture button but less rigid than screw in ligamentous lisfranc model. Journal of Orthopaedics. 2020 Jan 1;17:7-12.

2. Marsland D, Belkoff SM, Solan MC. Biomechanical analysis of endobutton versus screw fixation after Lisfranc ligament complex sectioning. Foot and ankle surgery.

2013 Dec 1;19(4):267-72.

3. Lachance AD, Giro ME, Edelstein A, Lee W. Suture button fixation yields high levels of patient reported outcomes, return to sport, and stable fixation in isolated Lisfranc injuries: A systematic review. Journal of ISAKOS. 2023 Aug 21.

4. Lundeen G, Sara S. Technique tip: the use of a washer and suture endobutton in revision lisfranc fixation. Foot & ankle international.

2009 Jul;30(7):713-5.

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July 2024

ANKLE ARTHRITIS ACADEMY

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he inaugural Ankle Arthritis Academy was held on the Newcastle Gateshead Quayside on the 11th and 12th of June 2024. This was the first meeting of its kind, dedicated solely to the management of ankle arthritis and was attended by over 100 delegates.

The faculty of experienced surgeons from around the UK were joined by Dr Kris Buedts (Belgium, President of the European Foot and Ankle Society) and Dr Murray Penner (Canada).

The agenda for the first day included indications and technique tips for

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Bulletin of the British Orthopaedic Foot and Ankle Society

supra-malleolar osteotomy, discussion around the evidence and decision-making between ankle replacement and ankle arthrodesis, the role of ankle networks, techniques and management of complications in ankle arthrodesis, management of deformity and finished with a lively debate on mobile versus fixed bearing in arthroplasty.

The second day delved into more complex ankle arthritis management including juvenile idiopathic arthritis, investigation of the failed replacement, revision ankle replacement and prosthetic joint infection. Each session

was followed by case discussion with some fantastic challenging cases submitted by the delegates. The meeting received support from a variety of industry sponsors, for which the organisers are very grateful. Feedback was excellent and the organisers hope that Ankle Arthritis Academy will become a regular fixture in the foot and ankle education calendar. n

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Removing Broken Screws

Issue 1

How to look like a hero when removing broken screws!

B

roken/stripped screws... it is difficult to look good while taking them out. Often, the process of screw removal causes unwanted cortical intrusion / destruction and may require an armamentarium of instruments, but what choice do we have?

Well, in this technique tip, I will show you how to harness the laws of physics to help you get the job done, specifically, using the magic of gears.

Figure 1: Worm gear.

Karan Malhotra Consultant Orthopaedic Surgeon, Royal National Orthopaedic Hospital, Stanmore, Honorary Associate Professor, UCL, London

Disclaimers • This technique may not work in all situations and is dependent on the type of screw.

• Locking screws are more difficult to remove than cancellous screws.

Figure 2: Mechanism of screw removal.

• This technique is not possible for screws with threads that are too deep to reach or for screws locked into an overlying plate.

This simple technique utilises the concept of a worm gear (Figure 1). All you require is a drill with about the same core diameter as the screw to be removed. When the drill is run forward, it engages the threads of the screw and reverses it, causing the screw to back itself out (Figure 2).

To achieve this, direct the drill obliquely to the screw, at around 35 to 45 degrees, such that the drill bit engages with the screw threads at roughly 90 degrees (Figure 3a), the optimal angle for engagement (Figure 3b). This will require only a small cortical intrusion to gain access to the threads.

Have patience, start slowly, feel your way. Some trial and error is required to find the correct angle. However, once the screw starts backing out, keep it steady.

You can also watch the video for a more detailed explanation at: www.bofas.org.uk/Portals/0/Video%20Archive/BOFAS%202024/ KaranMalhotra-BOFAS-2024-Tips_Screws.mp4 Good luck! n

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Figure 3: Angle of drills compared to the threads of the screw.

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July 2024

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Bulletin of the British Orthopaedic Foot and Ankle Society

ROUND TABLE MEETING

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raditionally, foot and ankle meetings tend to adopt a format where a faculty lectures to delegates with limited time for discussion. A novel concept was conceived

by Mr Dishan Singh, Consultant Orthopaedic Surgeon at the Royal National Hospital, whilst he was president of BOFAS in 2010 with a view that 25 senior members of BOFAS and 2 to 3 invited international participants would meet in a hotel setting for 3 days to discuss selected topics with ample time for an informal discussion. This Round Table approach was thought to be conducive to a more effective learning experience.

The 1st Round Table meeting was held in Padua, Italy in June 2011 and, thereafter, rapidly became a prominent highlight in the annual foot and ankle calendar. The meeting generates considerable debate,

Mr Dishan Singh Consultant Orthopaedic Surgeon at the Royal National Hospital (1995-2021)

but the group is able to reach a consensus on many issues. The proceedings of the meeting, the literature review, the personal experience, the discussions and the consensus views of all those who participate are collated in a booklet, with the skilful assistance of two scribes.

The theme for the recently held 11th Round Table, which was held in 2024 at Cambridge, England was “What, Why and Where.” The focus was on the strategies to not only treat a disorder, but also to identify and deal with its causes. The topics discussed were the adult acquired flat foot,

gastrocnemius tightness, stress fractures, hallux valgus and osteochondral lesions.

Orthosolutions have kindly provided financial and administrative support to the meeting since its inception. The meeting has received excellent feedback over the years and continues to appeal to BOFAS members for its format and choice of topics.

The consensus booklets for previous Round Table meetings can be found on the BOFAS website at https://www.bofas. org.uk/clinician/education/round-tableconsensus-booklets n

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Randomised Controlled Trials

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Issue 1

RANDOMISED CONTROLLED TRIALS:

THE HOLY GRAIL OR JUST CONTROLLED CHAOS?

More than one billion pounds of public funding is available for medical research in the UK(1).

Meanwhile, most orthopaedic articles start with a sentence like “the incidence is common and increasing” and end with a sentence like “randomised controlled trials are needed.”

The author explores these ideas using a large NIHR HTA-funded trial as a case study.

I

t was November 2011, and my wife had just given birth to our third son. As a clinical academic at University College London with an honorary role as a consultant foot and ankle surgeon at the Royal National Orthopaedic Hospital in Stanmore, UK, I was under immense pressure. The university valued grant money above all, and I needed to deliver. With the NHS offering over £1 billion in research funding, securing a mere 0.1% seemed feasible. Yet, despite the vast resources, trials in surgery, particularly in orthopaedics, were minimal. The situation was even more dire in foot and ankle surgery, with almost no trials.

Was the lack of trials due to a scarcity of applications, or was it a matter of inadequate training in grant writing among surgeons? I was on a mission to find out.

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Meeting the Funders and Defining the Research Question

Andrew Goldberg MD FRCS (Tr&Orth) Consultant Orthopaedic Foot & Ankle Surgeon, Visiting Professor in Trauma & Orthopaedics, Imperial College London, and Honorary Associate Professor, UCL Division of Surgery

My first tip is to meet with the funders.

Understand what they are looking for and demonstrate your enthusiasm. The advice I received was consistent: start with a burning question. But what was that question in my field?

I cajoled about twenty of my peers, and we concluded that determining the best surgical treatment for end-stage ankle arthritis was the most pressing issue. We submitted a brief outline to the National Institute for Healthcare Research (NIHR), only to be asked a simple question: “How common is ankle arthritis?” My initial response, “Well, it’s common and increasing,” was met with laughter. It became clear why orthopaedics lagged in research.

To address this, I spent the next few months conducting a study to determine

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July 2024

Bulletin of the British Orthopaedic Foot and Ankle Society

“RUNNING A L ARGE TRIAL IS A LOT OF WORK , REQUIRING REGUL AR OVERSIGHT COMMIT TEE M E E T I N G S A N D C O N S TA N T C O M M U N I C AT I O N W I T H E A C H S T U D Y S I T E ’ S P R I M A R Y I N V E S T I G AT O R S .” mass and collaborate rather than compete with colleagues. This approach may seem counterintuitive to the classic A-type personality of orthopaedic surgeons, but it is essential for success in securing funding and conducting impactful research.

Lesson 2: Realistic Recruitment Estimates

the incidence of ankle arthritis, which we published in a peer-reviewed journal by the end of 2012. With solid data in hand, we had an answer to the funders’ first question. But so much more was needed. It became evident that applying for a large grant is a full-time job requiring skilled experts in trial methodology, statistics, health economics, and surgeons capable of recruiting participants.

Forming the TARVA Study Group Over the next year, we assembled the TARVA study group, focusing on the proposed study “Total Ankle Replacement Versus Arthrodesis” (TARVA)(2). Surgeons from 17 NHS Trusts attended regular meetings to develop the protocol—all before securing funding. Fast forward another year, adding some serendipity in that the NIHR wanted to fund surgical trials, coupled with our attendance at various

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NIHR events and familiarisation with the funding team, and we suddenly became credible applicants. Out of 300 applications, we were successful. Was it because we made such a compelling case, or because there had never been a randomised controlled trial (RCT) in our field? Probably both.

Challenges and Lessons Learned Fast forward 10 years and more than £2million of NIHR funding, the initial study is now complete, and we are well into long-term follow-up. What lessons have we learned?

Lesson 1: Collaboration Over Competition The first lesson is that you are not competing against your colleagues in your specialty, but against experts from other fields such as virology, oncology, rheumatology, and diabetology. In this scenario, it is crucial to gain critical

The second lesson is that you should never take surgeons’ estimates of how many cases they handle at face value.

Initially, we based our recruitment predictions on data from our recruiting surgeons, only to find that the actual numbers were much lower. This discrepancy matters because, as the chief investigator, you are responsible for delivering results and overseeing the expenditure of significant public funds. In the end, we managed the overestimates by applying for an extension, securing additional funding, and developing a compelling case for why we needed more time. We even managed to persuade Hollywood Actor, Sylvester McCoy to help us develop a recruitment video.

The Day-to-Day Reality of Running a Large Trial Running a large trial is a lot of work, requiring regular oversight committee meetings and constant communication with each study site’s Primary Investigators. You need to work with a clinical trials group, whose expertise you cannot underestimate. Nonetheless, the rewards are substantial. Winning the prestigious Roger Mann Award in 2022, a recognition rarely given to studies outside the US, was a testament to the team’s hard work and dedication. >>

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Randomised Controlled Trials

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“ R E F L E C T I N G O N T H I S J O U R N E Y, I R E A L I S E T H E I M M E N S E VA L U E O F P E R S E V E R A N C E , C O L L A B O R AT I O N , AND CONTINUOUS LE ARNING. THE T R I A L S A N D T R I B U L AT I O N S O F RU NNIN G A C L INI C A L T R I A L E X T E ND FA R BE YOND T HE OPE R AT ING RO OM.” Study Findings and Statistical Insights Our study compared the clinical and cost-effectiveness of ankle replacement versus ankle fusion for treating end-stage osteoarthritis (OA) in patients aged 50 to 85(3).

We found that both treatments led to significant improvements in clinical scores and quality of life, exceeding four times the minimal important difference of the measures. While ankle replacement showed a slight edge over ankle fusion, we have yet to prove that 5 additional points are meaningful between groups, when the patients have already improved by 50 points.

Lesson 3: Understanding Statistics This brings me to my third lesson: spend a lot of time with your statistician and truly understand how statistics work. I would have used a novel model to ask patients whether an additional 5 points is meaningful to them. This approach has not been widely explored and highlights the need for more research in understanding outcome measures in surgery.

Human Nature and Research Interpretation We also found that a fixed-bearing ankle replacement seemed to outperform ankle fusion, unlike mobile-bearing ankle replacements(4).

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However, this was a post-hoc analysis, and there are many reasons for this outcome, too complex to explain here. The key point is that human nature influences how research is interpreted. Those who believe ankle replacements are superior will cite our study extensively, while critics will focus on methodological flaws. This bias underscores the challenge of persuading sceptics, even with an RCT.

Is the RCT the Holy Grail?

So, is the RCT the holy grail? While even an RCT may not convince all naysayers, it remains the highest quality evidence available. At the end of the day, your best argument must be the quality of the evidence, and a Level I RCT is the gold standard in research.

Reflections and Future Directions Reflecting on this journey, I realise the immense value of perseverance, collaboration, and continuous learning. The trials and tribulations of running a clinical trial extend far beyond the operating room.

They encompass grant writing, data collection, patient recruitment, and a deep understanding of statistical analyses. Each step is fraught with challenges, but each challenge is an opportunity to advance medical knowledge and improve patient outcomes.

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Looking ahead, the future of orthopaedic research lies in embracing innovation and interdisciplinary collaboration. The TARVA study has set a precedent, but there is still much work to be done. The evolving landscape of medical research demands adaptability and a willingness to explore new methodologies and technologies.

Conclusion: A Call to Action In conclusion, the journey of running a clinical trial is certainly controlled chaos, requiring meticulous planning, relentless effort, and the courage to venture into uncharted territories. However, surrounded by the right colleagues, collaboration, and camaraderie, and in the pursuit of scientific truth, the voyage is worthwhile.

You can watch the TARVA video of Sylvester McCoy and find out more details on the study at http://www.anklearthritis.co.uk n

References 1. UKRI – UK Research and Innovation 2. Goldberg AJ, Zaidi R, Thomson C, Doré CJ, Skene SS, Cro S, Round J, Molloy A, Davies M, Karski M, Kim L, Cooke P; TARVA study group. Total ankle replacement versus arthrodesis (TARVA): protocol for a multicentre randomised controlled trial. BMJ Open. 2016 Sep 6;6(9): e012716.

3. Goldberg AJ, Chowdhury K, Bordea E, Blackstone J, Brooking D, Deane EL, et al. Total ankle replacement versus ankle arthrodesis for patients aged 50 85 years with end-stage ankle osteoarthritis: the TARVA RCT. Health Technol Assess 2023;27(5).

4. Andrew J. Goldberg, Kashfia Chowdhury, Ekaterina Bordea, et al; TARVA Study Group. Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial.

Ann Intern Med.2022;175:16481657. [Epub 15 November 2022]. doi:10.7326/M22-2058.

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The Evolution of the Human Foot

Issue 1

THE EVOLUTION OF THE HUMAN FOOT Prof Lyndon Mason Foot and Ankle Lead, Liverpool University Hospitals NHS Foundation Trust

Karan Malhotra Consultant Orthopaedic Surgeon, Royal National Orthopaedic Hospital, Stanmore, Honorary Associate Professor, UCL, London

Dr Kris D'Aout Senior Lecturer, Institute of Life Course and Medical Sciences, University of Liverpool

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Evolution is the change in the heritable characteristics of biological populations over successive generations.

This depends on the development through selection of inherited variations, an increase in the individual's ability to compete, survive, and reproduce. The evolution of the foot, being the only mechanical contact with the environment, must have been the subject of strong selective pressures.

D

uring the course of human evolution, the foot of our ancestors has undergone gradual modification as we acquired erect posture and habitual bipedalism(1).

This has resulted in a structure which exhibits uniquely well-developed abilities to act as a shock absorber and a rigid lever during the different phases of gait.

In the early 20th century, the concept of human evolution as the origin of orthopaedic ailments was one of intrigue and curiosity. The transformation of the human foot from an arboreal primate foot to that of bipedalism has resulted in many alterations. Firstly, a sacrifice of the grasping ability of the foot in exchange for a more lever like structure, important for propulsion. Secondly, a change in the calcaneal elevation to allow more torque conversion in the hindfoot(2).

Thirdly, the development of the medial longitudinal arch.

Theories of a modern bipedal human foot evolved from an arboreal primate were later supported by the discovery of fossil intermediates including the Olduvai (OH) 8, those from eastern Africa and the Laetoli footprints(3). However,

these concepts have been challenged in recent years following the emergence of early hominin foot fossils; Ardipithecus ramidus and the Australopithecus species of africanus, afarensis and sediba(4, 5).

Phylogenetic, ontogenetic and advancing technology are producing a plethora of new ideas and concepts regarding the aetiology and functional deficits of foot and ankle disease. In this paper, we are going to explore these ideas in the forefoot, midfoot and hindfoot evolution.

The Forefoot The most striking difference in the forefoot structure between humans and apes is in the structure and function of the first ray. Norman Lake published writings on the foot in 1935, where he described the development of hallux valgus as the “tendency of the great toe to return to its primitive position”(6). However, it is generally recognised that the primitive hallux is short and abducted. This is seen in non-human primates but also in early hominins. Even modern humans, when habitually unshod, have a slightly fanshaped toebox(7). Nevertheless, Morton agreed with Lake and believed that dorsal hypermobility of the first metatarsal

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Bulletin of the British Orthopaedic Foot and Ankle Society

Figure 1: Comparative skeletal anatomy of Chimpanzee (pan troglodytes), Humans and the theoretical common ancestor as described by Morton in 1935.

segment was responsible for the widest array of foot deformity(8). (Figure 1) Regardless, hypermobility as a factor in hallux valgus development has increasing evidence with movements in other planes also playing major roles(9). It is undeniable that the medialisation of the first metatarsal in hallux valgus deformity is a direct consequence of proximal failure or congenital deformity. (Figure 2)

“DURING THE COURSE OF HUMAN E VOLUTION, THE FOOT OF OUR ANCESTORS HAS UNDERGONE G R A D U A L M O D I F I C AT I O N A S W E ACQUIRED ERECT POSTURE A N D H A B I T U A L B I P E D A L I S M .”

The Midfoot - Medial Arch

Figure 2: Comparative WB CT 3D reconstruction between hallux valgus and non hallux valgus individuals showing first ray instability.

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Lapidus wrote that one of the main morphologies of the human foot was its ability to absorb bending stresses so that it can be used as a functional lever(10). Due to the ankle plantarflexion in the propulsive phase of gait, the medial column endures significant shearing forces. Wang et al. modelled a non-human ape foot and compared this to a human foot in bipedal gait; they illustrated a significant increase in joint force across the medial column in humans(11). One of the main adaptations of the human foot is the relative plantarflexed position of the

talonavicular joint , thus preventing bending moments at this joint as the apex of the medial arch(12).

The Hindfoot The human hindfoot is unique in its ability to function as an effective torque converter. Kidd argues that as the degree of bipedality increased at the expense of quadrupedality or arboreality, there was a greater need for torque conversion at the rearfoot. In comparison to arboreal primates, humans have an elevated subtalar joint axis from the transverse plane(13). Unique to humans is the enlargement of the calcaneal tuberosity >>

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Foot Print

The Evolution of the Human Foot

Issue 1

and the development of the talus lateral tubercle. The calcaneal pitch is clearly increased in comparison to the very flat primate calcaneum. This increase in calcaneal pitch profoundly increases the subtalar torque.

Secondly, analysis of the gait between humans and chimpanzees shows the main difference being the way in which the heel leaves the ground(14).

Humans have a more consistent and progressive heel elevation as the foot advances to the propulsive phase, compared to the gradual two stage heel lift in chimpanzees, combined with significant midfoot dorsiflexion.

Interestingly, both DeSilva and Gill, and Bates et al. found independently that in non-pathological human feet, a midtarsal break (i.e. a two stage heel lift) was present in a subgroup of individuals, although these individuals had significantly flatter feet(15, 16).

References

Conclusion

5. Haile-Selassie Y, Saylor BZ, Deino A, Levin NE, Alene M, Latimer BM. A new hominid foot from Ethiopia shows multiple Pliocene bipedal adaptations.

Nature. 2012;483:565-9.

Our knowledge of the path of evolutionary change of the foot is developing. Regarding the midfoot and hindfoot, this is more complex due to the complex interactions of the changes in bony architecture, tendon insertions and ligamentous supports. When comparing humans to other primates, it is at times difficult to distinguish clearly between primitive features which are ancestral and specialized features, which are derived in their own adaptations and therefore we need to be mindful in our conclusions. The knowledge of the evolutionary origins of the foot gives much better understanding in the functional normalities we possess and take for granted.

Although there may be small differences in foot anatomy between populations, there are likely larger variations at an ontogenetic level (i.e. plasticity) due to footwear habits with some authors reporting characteristics adapted to individuals surroundings(17). External influences are likely to drive any further foot changes in the future. n

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1. Laitman JT. Evolution of the human foot: a multidisciplinary overview. Foot Ankle.

1983;3:301-4.

2. Kidd R. Evolution of the rearfoot. A model of adaptation with evidence from the fossil record.

J Am Podiatr Med Assoc.

1999;89:2-17.

3. Day MH, Wickens EH. Laetoli Pliocene hominid footprints and bipedalism.

Nature. 1980;286:385-7.

4. Lovejoy CO, Latimer B, Suwa G, Asfaw B, White TD. Combining prehension and propulsion: the foot of Ardipithecus ramidus.

Science. 2009;326:72-e8.

“ THE KNOWLEDGE OF THE E VOLUTIONARY ORIGINS OF THE FOOT GIVES MUCH BE T TER U N D E R S TA N D I N G I N THE FUNCTIONAL NORMALITIES WE P O S S E S S A N D TA K E F O R G R A N T E D .”

6. Lake NC. The Foot. London: Bailliere, Tindall and Cox; 1935.

7. Zipfel B, Berger LR. Shod versus unshod: the emergence of forefoot pathology in modern humans?

Foot. 2007;17:205-13.

8. Morton DJ. The Human Foot: Its Evolution, Physiology, and Functional Disorders. New York: Columbia University Press; 1935.

9. Singh D, Biz C, Corradin M, Favero L. Comparison of dorsal and dorsomedial displacement in evaluation of first ray hypermobility in feet with and without hallux valgus. Foot Ankle Surg.

2016;22:120-4.

10. Lapidus PW. Kinesiology and mechanical anatomy of the tarsal joints. Clin Orthop Relat Res. 1963;30:20-36.

11. Wang W, Abboud RJ, Gunther MM, Crompton RH. Analysis of joint force and torque for the human

and non-human ape foot during bipedal walking with implications for the evolution of the foot. J Anat.

2014;225:152-66.

12. Elftman H, Manter J. The Evolution of the Human Foot, with Especial Reference to the Joints. J Anat.

1935;70:56-67.

13. Hicks JH. The mechanics of the foot.

I. The joints. J Anat. 1953;87:345-57.

14. Holowka NB, O'Neill MC, Thompson NE, Demes B. Chimpanzee and human midfoot motion during bipedal walking and the evolution of the longitudinal arch of the foot.

J Hum Evol. 2017;104:23-31.

15. DeSilva JM, Gill SV. Brief communication: a midtarsal (midfoot) break in the human foot. Am J Phys Anthropol.

2013;151:495-9.

16. Bates KT, Collins D, Savage R, McClymont J, Webster E, Pataky TC, et al. The evolution of compliance in the human lateral mid-foot. Proc Biol Sci. 2013;280:20131818.

17. Stewart SF. Human gait and the human foot: an ethnological study of flatfoot. II. Clin Orthop Relat Res. 1970;70:124-32.

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This is why we decided to sponsor the Ministry of Health supported Barry University Medical Mission Trip 2-10 March 2024 led by Dr Shanika Hill, in the island nation of The Bahamas.

We wanted to learn from the challenges facing care providers in a country with complex environmental, socio-economic and health challenges. Moreover, we wanted to reflect on how we could make our business model and products more accessible, relevant and fit-for-purpose to both care givers, and those being cared for, in such global locations.

When we think of The Bahamas we may not fully appreciate the many challenges that this island nation faces… With 30 inhabited islands, a population of over 400,000 and only 4 podiatrists in the entire country (all of whom are based on New Providence Island) the first practical challenge is ‘how do some people even get to see a podiatrist’? Internal flights are expensive, often disrupted during the hurricane season, which historically

has decimated many parts of The Bahamas.

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There is a growing reliance on fast / fried food, high sugar and starch diets, and with sedentary lifestyles leading to growing obesity, there is a growing and alarming rise of cardiovascular disease, diabetes and prediabetic cases. In 2019 the Bahamas Steps Report estimated that around 11.5 % of the population was living with diabetes and around 6.8 % with pre-diabetes. The Bahamas now also exceeds the regional prevalence (The Americas) for overweight and obesity prevalence (71.1 % versus 62.4 %).

Over the course of 6 days, over 50 students and staff from Barry University Podiatric Medical School in Florida, together with volunteers and DARCO employees from the

Scan here to watch our video of our shared experiences

USA and UK offices (observing / documenting the programme) treated over 1200 patients across 11 clinic locations on 2 islands. For the first time in the 3-year history of the programme a surgical day was offered providing minimally-invasive surgery for those patients most in need. DARCO donated over 850 foot and ankle devices, including our brand new Body Armor® Stirrup Walker, which were used during the clinics and for follow-up treatments.

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The Association of Foot & Ankle Physiotherapists

Foot Print

ALL ABOUT AFAP

Membership group for Physiotherapists and AHPs interested in foot and ankle rehabilitation.

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he Association of Foot & Ankle Physiotherapists & AHPs (AFAP) is a charity providing educational opportunities for physiotherapists and other Allied Health Professionals (AHPs) with a special interest in musculoskeletal foot and ankle problems to learn, connect and share information, thereby improving patient care.

We currently have 846 members across physiotherapy, podiatry, and clinical nurse specialists, based all over the UK. We are a group that brings together all the AHPs you need to rehabilitate your patients and facilitate the best outcomes from your interventions. In sharing knowledge across professions, we hope to continually improve the rehabilitation of foot and ankle patients to improve outcomes and ultimately help patients lead fulfilling lives.

The Association of Foot & Ankle Physiotherapists (AFAP) was launched in October 2012 by four like-minded physiotherapists who had the good fortune to meet at a Foot & Ankle conference earlier that year. They wanted to provide a forum in which AHPs could access support and information regarding evidence-informed practice for foot and ankle patients across all areas of healthcare, and so the group was formed!

Jodie Breach National Physiotherapy Lead, Nuffield Health, Chair - AFAP Our charitable aims are to increase learning, research and skillsharing opportunities within the musculoskeletal field of foot and ankle for physiotherapists and AHPs, thereby leading to an improvement in patient care and outcomes.

Issue 1

across the foot and ankle specialty to further add to the evidence base and our knowledge of rehabilitation in the area.

We were working towards achieving this pre-COVID but had to put things on pause in 2020. Since then, as events have returned, we have been building up our reserves again. Hopefully, in the relatively near future, we will be able to award bursaries for F&A related activities such as the following: • Postgraduate education (MSc, MRes, MPhil and PhD) • Travel to conferences (particularly if presenting or representing AFAP) • Costs towards research posters • Research or relevant projects • Travelling fellowships We have a very collaborative working relationship with BOFAS on several educational events. BOFAS subsidise an AHP Principles Day every year for our members which is one of the highlights of our calendar. It is a phenomenal opportunity to learn as a full MDT with live patients. We also support the organisation of the AHP Day at the annual BOFAS conference and love seeing other AHPs as well as our consultant colleagues. The opportunity we have in improving the management of our F&A patients through true collaborative working and understanding each other’s professions is endless.

“ O U R C H A R I TA B L E A I M S A R E T O

INCRE ASE LE ARNING, RESE ARCH

A ND SKILL-SH A RING OPP ORT UNITIES.”

AFAP gained official charitable status in February 2014 (Registered Charity Number 1155774). We are self-funded through educational courses, events and donations. The AFAP charity aims to help support and bring together physios and AHPs who have a special interest or expertise within the area of foot and ankle to improve the quality of care and is therefore run for the benefit of the public.

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This is achieved by: • Providing a forum for physios and other AHPs with a special interest in F&A problems to network and share knowledge • Disseminating research and promoting evidence-based practice amongst its members and in the wider medical and allied health community • Providing a database of F&A care pathways, outcome measures, guidelines and protocols • Organising and disseminating information about upcoming F&A educational events such as courses and conferences

Our goal is to be able to offer bursaries to members to support learning activities

AFAP membership is free to all MSK Physiotherapists, MSK Podiatrists, Nurse Specialists or any other Allied Health Professionals interested in sharing their knowledge or improving their skills within MSK foot and ankle specialty.

We want to facilitate collaborative working as this is in the best interests of our patients and improves our learning opportunities. If your team members are not yet a member of our group, we would love to welcome them, and they can gain membership via our website https://www.afap.org.uk/home/join n

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July 2024

Foot Print

Bulletin of the British Orthopaedic Foot and Ankle Society

CLINICAL TRIALS AND THE DEVELOPMENT OF CLINICAL ACADEMIC CAREERS IN ALLIED HEALTH PROFESSIONS Recent years have seen a rapid growth in clinical trial activity in foot and ankle orthopaedics in the UK.

Prof Rebecca Kearney Physiotherapist, Professor and Director of Bristol Trials Centre, University of Bristol

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upport from the National Institute for Health and Care Research (NIHR) and Versus Arthritis has been integral to ensuring that Allied Health Professionals are joining the multidisciplinary research effort. Prof Rebecca Kearney (Physiotherapist, Professor and Director of Bristol Trials Centre, University of Bristol) and Dr David Keene (Associate Professor, University of Exeter and Clinical Specialist Physiotherapist, Royal United Hospitals Bath NHS Foundation Trust) have collaborated extensively with BOFAS and AFAP members to successfully deliver several RCTs / large scale prognostic studies in the field: • Achilles tendon - PATH-2 (PRP in rupture), ATM (PRP for tendinopathy), UKSTAR (boot vs cast rupture) • Ankle fracture - AIR (boot vs cast), WAX (early weight bearing), AFTER (rehabilitation), AIM (close contact casting vs surgery) • Ankle sprain – SPRAINED (prognostic tool) Instrumental for Prof Kearney and Dr Keene’s research development has been the training support for clinical academic careers in under-represented health professions, including nursing and AHPs. NIHR support is tailored to all levels of experience, including the NIHR Fellowships Programme (open to all health professions) and the Integrated Clinical and Practitioner Academic Programme (for nurses and AHPs specifically). The ICA Programme has several levels of support depending on career stage: • Internship Scheme • Pre-doctoral Clinical and Practitioner Academic Fellowship (PCAF) Scheme

Dr David Keene Associate Professor, University of Exeter and Clinical Specialist Physiotherapist, Royal United Hospitals Bath NHS Foundation Trust

“ I N S T R U M E N TA L F O R PROF KE ARNE Y AND DR KEENE’S RESE ARCH DE VELOPMENT HAS BEEN THE TR AINING SUPPORT FOR CLINICAL ACADEMIC CAREERS IN UNDERR E P R E S E N T E D H E A LT H

• Doctoral Clinical and Practitioner Academic Fellowship (DCAF) Scheme

PROFESSIONS, INCLUDING

• Advanced Clinical and Practitioner Academic Fellowship (ACAF) Scheme n

N U R S I N G A N D A H P S .”

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Foot Print

1st BOFAS Membership Survey

Issue 1

1st BOFAS Membership Survey

B

OFAS is approaching its 50th year in 2025. This means that the Society is officially middle aged. Middle age is described as a time when you appreciate, who you are, where you have come from and should have a clear direction of travel for your future.

This BOFAS Membership Survey was designed to capture relevant information on membership’s clinical practice, evaluate benefits offered to BOFAS members, challenges and barriers faced by the membership of the Society. This article features key findings of the survey, conducted between February to April 2024, which will help shape the strategy and future direction of the society’s activities with direct input from its membership.

Respondents In total, there were 277 respondents. 79.9% were practising consultant orthopaedic surgeons, 9.4% were podiatrists practising surgery (PPS) , 4.3% were orthopaedic trainees and 2.9% were allied health professionals (AHP). 84.8% of respondents were BOFAS members. In total 217 full BOFAS members responded out of 524 full members at the time of survey (41.4%).

277 respondents

Practice of Respondents

BOFAS Membership Benefits

12% had a purely elective practice and 20% had a practice which was 80% or more elective. Conversely, 2% report no elective foot and ankle practice.

86.8% of members responding would be likely or extremely likely to recommend BOFAS to colleagues. 3.8% felt they would not be very likely to recommend BOFAS.

On average participants spent: • 15% of their workload on diabetic foot care.

• 50% of their trauma workload on foot and ankle trauma • 88% of their elective workload on foot and ankle surgery

3.8% respondents who would not recommend BOFAS, suggested that there was nothing that BOFAS offered which was above and beyond what is available online for free, or that BOFAS did not provide as many guidelines as they would expect.

205 out of 221 Orthopaedic Consultants who responded had at least some exposure to trauma in their practice (92.8%).

92% felt that the price of membership (currently £150/year for full members) reflected good to excellent value for money.

8% felt it is marginal/poor value for money.

193 out of 221 Orthopaedic Consultants who responded had at least some exposure to diabetic foot care in their practice (87.3%).

52% had a mixed NHS and Private practice, whilst 37.9% had a purely NHS practice and 5% had a purely private practice.

MDT Working 71% of respondents had a timetabled local foot and ankle MDT. This varied from weekly to once every 2 months. 79.8% attended regional MDTs / network meetings.

• 39.3% had a physiotherapist working in their team • 27.1% had a specialist foot and ankle nurse in the team • 43.0% had a non-surgical podiatrist in the team • 18.4% had a podiatrist practising surgery in the team 67.5% were not involved with podiatrists practising surgery (PPS), 3.3% are involved in teaching podiatrists and 22.7% work in a trust which employs podiatrists who practise surgery.

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Members felt that the most useful benefits offered by BOFAS are the annual meeting, followed closely by the online webinar offerings with approximately two-thirds of members rating these as excellent or very good. The BOFAS Hyperbook was also highly rated, but 28.5% of members were either not aware of, or had no experience with this resource. Over 36% had no experience with the BOFAS Registry and over 42% of members were not aware about the find a surgeon feature on the website. Over half the members responding did not have knowledge or experience of the research and travelling fellowship grants that BOFAS offers.

Overall, members felt that the most important reason for being a member of BOFAS was to help stay current with information on foot and ankle surgery.

Other key reasons highlighted included networking and building professional relationships, and to attend BOFAS meetings and events. Approximately 67% of members felt that BOFAS membership fulfilled their expectations with regards to the aforementioned reasons, and about 25% felt that BOFAS exceeded their expectations.

BOFAS Website 91% felt the website was good to excellent.

60% felt the website was fine in its current state, whilst 40% felt it could be modernised.

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July 2024

Education Resources outside of BOFAS Outside of BOFAS, the most common source for obtaining professional information was journals (87.5%), other conferences (61%), textbooks (54.5%), other websites (47%), and NHS / NICE guidance (44%).

Workplace Challenges The most common areas of future concern for respondents included: NHS financial shortages (85.6%), increasing demand for foot and ankle surgery (62%), and expansion of scope of non-medically trained health-workers (43%). Other key areas of concern shared by less than a third of the respondents were increasing costs of implants / technology, and restrictions imposed by private health insurers.

BOFAS - International Involvement Although two-thirds of members were not aware of the overseas courses that BOFAS currently organises, over 55% of all members expressed a strong interest in teaching on overseas courses. 42% would be happy to mentor and link with overseas surgeons and 35% expressed a strong interest in working overseas in a BOFAS foot and ankle service.

32% would be happy to host a fellow from East, Central or Southern Africa. There was very little interest in a compulsory additional subscription fee to support overseas training.

BOFAS Annual Meeting 56.3% of the respondents attend every BOFAS meeting, 32% BOFAS 2 out of 3 years, and 13% once every 3 years.

Reasons cited for not attending more frequently included location of meetings, cost of the meeting, timing of meeting and lack of ability for all surgeons from a unit to attend together.

Themes suggested for changes to future annual meetings included: variety of topics, avoiding clashes of interesting sessions, increased number of debates, discussion and cases, and increasing the variety of speakers.

Views of Non-members Out of the 42 respondents who were not current members of BOFAS, 4 were Orthopaedic Consultants, 6 were Orthopaedic Trainees, 6 were AHPs, 1 was a podiatrist and 25 were podiatrists practising surgery.

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Foot Print

Bulletin of the British Orthopaedic Foot and Ankle Society

The most common reasons cited for people not being a member of BOFAS included a lack of interest in membership benefits, or that the respondents’ needs are met by other organisations. 48% of non-member respondents felt they were likely to join BOFAS in the future.

Majority of the podiatrist non-members responding felt that they would be more likely to join BOFAS if there was an effort made to acknowledge their role, work with them in a multidisciplinary setting, and offer them access to the educational resources available to orthopaedic surgeons.

Other Suggestions Recurring suggestions for BOFAS in general included: addressing the situation with podiatrists practising surgery, increasing the accessibility for members to be involved in the society, encouraging networking and research, and taking a leading role in developing guidelines / policy.

Equity, Diversity and Inclusion 84.8% of respondents were male, 11.6% female, 0.4% transgender with the rest preferring not to say.

52% were White British / Irish. The second most common ethnic group was Asian / Asian British Indian with 17.0%. A further 11.7% were White (European or Other). 4.3% were Asian from the subcontinent, 2.2% were Chinese and 3.2% were other Asian. 0.7% were Black (Caribbean or African), 2% defined as Other and 4% preferred not to say.

Age Demographics

No respondents were under the age of 30 years. 9% were between 30 and 39, 36.2% were between 40 and 49, 41.8% were between 50 and 59, 11.9% were between 60 and 69, and 1.1% were above 70.

A very small minority (0.7%) suggested that the BOFAS membership did not match their preferred demographic, and that they did not feel supported / included.

Future Direction for BOFAS 78.9% of respondents felt that the key priority for BOFAS should be to teach foot and ankle surgery to the next generation of orthopaedic surgeons. Over 50% felt that it was important for BOFAS to provide more sets of current guidelines for practising foot and ankle surgery and representing foot and ankle surgeons with British Orthopaedic Association, the National Joint Registry and National Institute of Care and Excellence. Over a third of respondents also felt that it was important for BOFAS to help strengthen clinical networks, improve the BOFAS Registry and have an increased number of working groups specialising on certain aspects of foot and ankle surgery.

The findings of this survey have helped the Society understand the current practice of its members, what they perceive BOFAS does well, and which benefits they most appreciate.

The information gathered on ethnicity and diversity has helped the Society in being more inclusive. In addition, BOFAS can reflect on the valuable views of the associated parties who are not yet members. Finally, we better understand the workplace challenges perceived by our membership who have given guidance for the future direction of BOFAS. BOFAS would like to thank everyone who completed the survey. n This survey was constructed, analysed and written by the following members of the BOFAS council: Rick Brown - Immediate past president Mark Davies - President Robert Clayton - President Elect Jitendra Mangwani - Honorary Secretary Anna Chapman - Equality, Diversity and Inclusion Lead Karan Malhotra - Media and Communications Director

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Zadek Osteotomy

Issue 1

When, How and Why to use the Zadek Osteotomy Don’t forget the Biomechanics in Haglund Syndrome!

H

How to perform a Zadek Osteotomy

aglund’s syndrome, first described in 1928 by a Swedish surgeon(1), includes insertional Achilles tendinopathy, retrocalcaneal bursitis and a posterosuperior bony prominence – a painful retrocalcaneal swelling caused by irritation of the Achilles tendon against the posterosuperior angle of the calcaneus(2).

The Zadek procedure, originally described in 1939(3), is a dorsal closing wedge osteotomy of the calcaneus.

Following more comprehensive studies of Haglund’s syndrome and Achilles insertional tendinopathy, combined with recent clinical evaluations(4-6) and technical updates using MIS(9,10), the Zadek osteotomy is becoming a popular procedure to manage Haglund syndrome.

When to consider a Zadek Osteotomy Calcaneal length may underlie impingement between the greater tuberosity and the Achilles tendon at the insertion. Tourné et al. recently described the X/Y ratio(9), measured on a lateral

The Zadek procedure is a cuneiform closing wedge osteotomy of the calcaneus with a dorsal and posterior base, the apex of which should be anterior to the plantar calcaneal tuberosity. This reduces the calcaneal pitch and advances its posterosuperior corner to reduce pressure on the anterior aspect of the distal Achilles tendon.

Yves Tourné Orthopaedic Foot and Ankle Surgeon, Past President, EFAS

weightbearing ankle view, where X is calcaneal length and Y is greater tuberosity length (Fig. 1). This ratio is easy to measure and is reproducible, with a cut-off value of 2.5. If the ratio is under 2.5, the pain is strongly related to a painful impingement at the insertion of the Achilles tendon.

The pitch angle of Ruch for the cavus foot is also correlated with the occurrence of the Haglund’s syndromes (4,5,9,10), when over 20° (Fig. 1).

Figure 1: X-rays on a lateral WB view to assess the X/Y ratio of Tourné and the pitch angle of Ruch.

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A preoperative MRI is mandatory to check the condition of the distal Achilles tendon.

When over 30% of the Achilles insertion is damaged on axial slices, an FHL transfer is recommended in order to bring additional blood supply provided by the FHL belly to the distal Achilles tendon.

1. Open Procedure(4) Position is lateral, or prone if an FHL transfer is indicated for additional insertional Achilles augmentation. The surgical approach is L-shaped, posterior and then inferior to the lateral malleolus. This allows subperiosteal access to the lateral aspect of the calcaneus and Achilles insertion, without any subcutaneous dissection.

Initially, the bursa in the triangle of Kager is resected. The Achilles tendon itself is not debrided, and neither is the posterior superior part of the calcaneus, to avoid additional damage. The dorsal and plantar borders of the calcaneal tuberosity, the distal insertion of the calcaneofibular ligament (CFL) anteriorly and the Achilles insertion posteriorly are identified, delineating a safe zone for the osteotomy (Fig.2).

Figure 2: The landmarks of the safe zone to perform the closing wedge osteotomy.

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Foot Print

July 2024

Figure 3a: Evaluation of the wedge before removal.

The anterior cut of the osteotomy is made 4.5 cm from the posterior border of the calcaneus backwards at a perpendicular angle to the plantar calcaneus cortex, behind the CFL footprint, without breaching the plantar cortex. The second (posterior) cut is anterior to the Achilles tendon, oblique and intersecting the first cut at its plantar extremity. The apex of the osteotomy is anterior to the plantar calcaneal tuberosity. A bony wedge of 7-10mm is removed while conserving a plantar hinge (Fig. 3a,b).

Dorsiflexing the ankle closes the osteotomy, which is temporarily held with a K-wire (Fig.4). Definitive fixation is achieved using a six-hole plate or two 6 or 7mm cancellous or double-threaded screws.

Bulletin of the British Orthopaedic Foot and Ankle Society

Figure 3b: The wedge removed, with plantar cortex intact, before dorsiflexing the ankle to close the osteotomy.

Postoperatively, the patient is managed non-weight-bearing in a cast for four weeks, followed full weightbearing in a boot for two weeks. At six weeks, mobilisation of the ankle is started, with isometric contraction of the gastrosoleus complex, cycling, swimming, and neuro-muscular rehabilitation.

Subsequently, a gradual return to full sporting activities is encouraged.

2. Minimally Invasive Technique (MIS) (7,8) Position is supine, with a bolster placed under the thigh to elevate the foot, and a sandbag under the ipsilateral buttock.

This allows the surgeon to visualize the heel and ensure that the burr is always perpendicular to it, as well as enabling easy lateral x-rays.

To guide the osteotomy, two 2mm guidewires can be inserted from inferiorly to mark the boundaries of the osteotomy, or it can be drawn on the skin: anterior to the Achilles tendon and posterior to the subtalar joint, with an anterior hinge approximately 5–10 mm dorsal to the plantar cortex of the calcaneus (Fig.5).

Figure 4: Provisional fixation.

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Through a small lateral skin incision, the osteotomy is performed using a 3/20 mm cutting burr, with a maximum torque of 6000 rpm. Two bicortical osteotomies are created, starting with an anterior based osteotomy, followed by a posterior osteotomy (both lateral then medial), with care to leave a plantar hinge. Next, a 3 mm wedge burr is used to remove a 5–10 mm dorsally based wedge.

As standard for MIS, saline is run onto the burr for cooling and to flush out bone paste.

The burr must be also removed regularly to clean the debris. The osteotomy is then closed by dorsiflexing the foot and ankle and secured with one or two 6 or 7 mm partially threaded or headless cannulated screws in a posteroinferior to anterosuperior direction across the osteotomy.

Why Does This Osteotomy Work in Haglund syndrome?

Unlike calcaneoplasty, the Zadek osteotomy profoundly changes the shape of the calcaneus (Fig. 7): • The closing wedge osteotomy geometrically changes both X and Y and hence the ratio, leading to a calcaneus anteroposterior shortening.

The mean X/Y ratio increases from <2.5 preoperatively to >2.5 post-operatively.

• As the apex of the osteotomy is anterior to the plantar calcaneal tubercle, it elevates the tuberosity and so reduces the verticalisation of the calcaneus. In addition, the mean pitch-angle changes from >20° preoperatively to <20° post operatively.

• Reduction of the overall length of the calcaneus (X/Y ratio >2.5), combined with an elevation of the insertion of the Achilles tendon, will reduce the lever arm for the Achilles tendon(4,5,7,8). This works like a Strayer or proximal medial gastrocnemius release, which explains the improvement in dorsiflexion and improvement in functional scores postoperatively(2,6). >>

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Foot Print

Zadek Osteotomy

Issue 1

a1 > a2 Figure 6: Effects of the Zadek osteotomy on calcaneus shape.

Figure 5: Landmarks for the MIS Zadek.

Conclusion The Zadek osteotomy is a reliable and effective procedure to be considered in the treatment of Haglund syndrome when the X/Y ratio is <2.5 and/or the pitch angle of Ruch >20°. The results at mid and long term follow up are superior to those with an isolated calcaneoplasty(11,12). The MIS technique is promising but needs further studies with long term follow-up. n

References 1. Haglund. Beitrag zur klinil der Achillesscehne. Z Orthop Chir.

1927;(49):49–58.

2. Zheng W, Du J, Liang J, et al. Zadek osteotomy for the treatment of Haglund’s Syndrome. Research Square; 2020. DOI: 10.21203/rs.3.rs-37115/v1. n.d.

3. Zadek I. An operation for the cure of achillobursitis. Am J Surg - AMER J SURG 1939;43:542–6. https://doi.org/10.1016/ S0002-9610(39)90877-9.

4. Y. Tourné, A.L. Baray, R. Barthélémy, T. Karhao, P. Moroney, The Zadek calcaneal osteotomy in Haglund’s syndrome of the heel: Clinical results and a radiographic analysis to explain its efficacy, Foot Ankle Surg, https:// doi.org/10.1016/j.fas.2021.02.001 n.d.

9. Tourné Y, Baray A-L, Barthélémy R, Moroney P. Contribution of a new radiologic calcaneal measurement to the treatment decision tree in Haglund syndrome. Orthop Traumatol Surg Res OTSR 2018;104:1215–9 https://doi. org/10.1016/j.otsr.2018.08.014.

5. López-Capdevila L, Santamaria Fumas A, Dominguez Sevilla A, Rios Ruh JM, Pich Aguilera E, Boo Gustems N, et al. Osteotomía calcánea con cuña de sustracción dorsal como tratamiento quirúrgico en la tendinopatía insercional de Aquiles. Rev Esp Cir Ortopédica Traumatol 2019. https:// doi.org/10.1016/j.recot.2019.09.004.

10. Ruch JA. Haglund’s disease. J Am Podiatry Assoc 1974;64:1000–3, doi: http:// dx.doi. org/10.7547/87507315-64-12-1000. n.d.

6. Y. Tourné Y., Francony, F., Barthélémy R., Karhao T., P. Moroney P. The Zadek calcaneal osteotomy in Haglund’s syndrome of the heel: its effects on the dorsiflexion of the ankle and correlations to clinical and functional scores. Foot and Ankle Surgery 2022, 28, 789–794.

12. Lehto MU, Järvinen M, Suominen P. Chronic Achilles peritendinitis and retrocalcanear bursitis. Long-term followup of surgically treated cases. Knee Surg Sports Traumatol Arthrosc Off J ESSKA 1994;2:182–5. https://doi.org/10.1007/ BF01467923. with long term follow-up.

7. Nordio A, Chan JJ, Guzman JZ, Hasija R, Vulcano E. Percutaneous Zadek osteotomy for the treatment of insertional Achilles tendinopathy. Foot Ankle Surg 2019. https://doi. org/10.1016/j.fas.2019.10.011.

Figure 7: The different biomechanical effects of the Zadek osteotomy explained by its geometrical modifications of the shape of the calcaneum.

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8. Syed TA, Perera A. A Proposed Staging Classification for Minimally Invasive Management of Haglund’s Syndrome with Percutaneous and Endoscopic Surgery. Foot Ankle Clin 2016;21:641–64. https://doi.org/10.1016/j. fcl.2016.04.004.

11. Schneider W, Niehus W, Knahr K. Haglund’s syndrome: disappointing results following surgery -- a clinical and radiographic analysis. Foot Ankle Int 2000;21:26–30. https://doi. org/10.1177/107110070002100105.

Image credits Figure 1 and 7: Y. Tourné Y., Francony, F., Barthélémy R., Karhao T., P. Moroney P. The Zadek calcaneal osteotomy in Haglund’s syndrome of the heel: its effects on the dorsiflexion of the ankle and correlations to clinical and functional scores. Foot and Ankle Surgery 2022, 28, 789–794.

Figure 2, 3a, 3b, 4 and 6: Y. Tourné, A.L. Baray, R. Barthélémy, T. Karhao, P. Moroney, The Zadek calcaneal osteotomy in Haglund’s syndrome of the heel: Clinical results and a radiographic analysis to explain its efficacy, Foot Ankle Surg, https://doi.org/10.1016/j.fas.2021.02.001.

Figure 5: Courtesy of Eduardo Rabat.

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