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					                          Patient Pathway                              Orthopaedics
                          Evidence Tables                 Subgroup:     Foot & Ankle
Author             Year   Study type        Population   Summary of Paper                                                                Comments

Gopal, S. and      2002   Clinical          UK           Paediatric Foot: Normal Feet Referred to an Orthopaedic Surgeon                 The authors present an overview of the
Templeton, P.             Expertise                                                                                                      postnatal development of the foot,
                                                         The paper describes:-                                                           together with a brief description of some
                                                         •   The developmental anatomy of the foot through the Infant, Toddler, Child    of the common variations that are
                                                             and Adolescent phases;                                                      misinterpreted as problems. Although
                                                         •   Perceived problems with the normal foot, differentiating conditions that    essentially advice directed at non-
                                                             require treatment from those that are acceptable variants of normal.        paediatric orthopaedic specialists, the
                                                                                                                                         paper will also be of considerable value
                                                         Main Statistical Points:-                                                       to GPs.
                                                         •   97% of children are flat-footed under the age of 18 months;                 The following conditions are addressed:
                                                         •   4% remain flat-footed at 10 years of age;                                   •    Flat Foot
                                                         •   Metatarsus varus resolves spontaneously in 85-90% of infants and children   •    In-toeing
                                                                                                                                         •    Femoral Torsion
                                                                                                                                         •    Tibial Torsion
                                                                                                                                         •    Metatarsus Varus
                                                                                                                                         •    Toe Walking
                                                                                                                                         •    Curly Toes
                                                                                                                                         •    Overriding Fifth Toes
                                                                                                                                         •    Accessory Navicular

Lothian Referral          Expert Opinion    UK           Advice for GPs on referral of foot and ankle problems.                          See Appendix 1
Belthur, M.V.J. et al.   2003   Retrospective   UK   Effectiveness of a Physiotherapy Specialist Clinic in Paediatric                   As a result of the initial assessment and
                                Study                Orthopaedics                                                                       management by the trained
                                                     Assessment of GP referral letters by consultant paediatric orthopaedic surgeon     physiotherapist only a small proportion
                                                     for suitability for inclusion in Physiotherapy specialist clinic.                  (7%) of non-urgent simple orthopaedic
                                                                                                                                        cases (41.6% of GP referrals) eventually
                                                     Measures of Effectiveness:-                                                        needed to be evaluated by the consultant.
                                                         •    Reduction in median waiting times for non-urgent, simple orthopaedic      93% of the cases seen in the
                                                              conditions from 72 weeks in May 1996 to 5 weeks in May 1999;              physiotherapy clinic were assessed and
                                                         •    Reduction in median waiting times for urgent and complex cases seen       appropriately managed by the
                                                              by consultant reduced from 17 weeks to 7.5 weeks;                         physiotherapist without direct consultant
                                                         •    High (90%) level of patient satisfaction with the service with some       intervention.
                                                              recommendations that more facilities should be available at the clinic;
                                                         •    Low number of re-referrals from GPs.                                      Since 71.6% of patients seen in the clinic
                                                                                                                                        were either normal or had variants of
                                                                                                                                        normal, the authors felt that educating
                                                                                                                                        GPs about the normal development of the
                                                                                                                                        musculoskeletal system in a child and
                                                                                                                                        devising a primary care referral protocol
                                                                                                                                        would reduce the demand for new
                                                                                                                                        paediatric orthopaedic referrals.
Kilmartin, T.   2002   Retrospective   UK    Podiatric Surgery in a Community Trust                                               The author provides a convincing case
                       Analysis                                                                                                   for the role of the podiatric surgeon in
                                             The author reviews 5553 referrals to podiatric surgery services provided by a        performing foot surgery under local
                                             community NHS trust in Nottingham over a period of 4 years in terms of:              anaesthetic and argues in favour of
                                             activity, surgical outcomes, complications and patient satisfaction.                 increasing the availability of podiatric
                                                                                                                                  surgery throughout the UK.
                                             Patient satisfaction with the service was high (93% of patients surveyed
                                             agreeing that they would opt for this route of treatment if they were required to    It is pointed out that in 1999 there were
                                             have another foot operation).                                                        only 64 podiatric surgeons working in the
                                                                                                                                  NHS in England and Wales of whom 24
                                             The author reports that 247 adverse events/complications arose including: 31         held consultant status: there were none in
                                             bacterial infections; 9 deep vein thromboses; 3 complex regional pain                Scotland, Northern Ireland or south-west
                                             syndromes; 53 adverse reactions to analgesia.                                        England (Society of Chiropodists and
                                                                                                                                  Podiatrists, 1999).
                                             The author concludes that podiatric surgery is both safe and effective and, in

                                             •   Provides greater patient access and shorter waiting lists;
                                             •   Reduces pressure on orthopaedic waiting lists;
                                             •   Provides a “one stop shop” approach to treatment based on the enhanced
                                                 quality and range of care delivered by clinicians specifically trained in both
                                                 the conservative and surgical management of foot disorders;
                                             •   Reduces the cost of providing day case foot surgery usually under local
Fouts, D.       1998   Clinical        USA   Ankle Injuries: Current Recommendations for Diagnosis and Treatment                  The paper includes lateral and medial
                       Expertise                                                                                                  annotated images of the ankle and
                                             The author expresses the opinion that most ankle injuries are strains and sprains    describes the essentials of the physical
                                             that are amenable to treatment by the family physician and emphasises the need       examination.
                                             for an understanding of ankle anatomy and function and the common
                                             mechanisms of injury in correctly diagnosing ankle injuries.

                                             Starting with a review of ankle anatomy and pathophysiology, the article goes
                                             on to identify the three most common ankle injuries as:-

                                                  •    Lateral ligament injuries
                                                  •    Syndesmosis injuries
                                                  •    Medial ankle injuries

                                             The author recommends the use of the Ottawa Ankle Rules to facilitate the
                                             evaluation process and emphasises the importance of taking the history and
                                             performing the physical examination within the first hour after the injury.
Appendix 1

Lothian Referral Guidelines
Musculoskeletal Service

Foot and Ankle

The Foot and Ankle team consists of a multi-professional group.

All GP referral letters to the Foot and Ankle service are initially screened by the lead clinician and
patients are triaged to the appropriate clinician. If it is apparent from the letter that patients require an
operation then they will be seen by the orthopaedic surgeon. If it is a case where conservative measures
are appropriate then they will see the podiatrist or orthotist. The specialist orthopaedic nurse is involved
with the pre-assessment of patients and the post-operative management of patients. Generally the
surgeons, podiatrist, orthotists and nurse are working in the same location and so there is close
communication between the disciplines and potential for inter-disciplinary referral.

Who to refer
Urgent referral
     Non-traumatic conditions such as:

Routine referral
     Patients with foot and Ankle pain or deformity requiring specialist orthopaedic care, consideration
     for operative procedures or specialist investigation. Examples of suitable conditions suitable for
     referral are listed below.

Forefoot problems
     Hallux Valgus
     Hallux rigidus
     Problems with small toes
     Metatarsalgia (pain in the ball of the foot)
        Morton’s neuroma
        Freiberg’s infraction
        March fracture
        MTP joint synovitis

Hindfoot problems
     Plantar fasciitis
     Achilles tendonitis
     Ankle ligament problems/instability
     Ankle joint problems
     Retrocalacaneal bursitis
     Tibialis posterior dysfunction

Midfoot problems
     Midfoot arthritis
Appendix 1 continued

Whole foot problems
    Pes cavus (high arched foot)
    Pes plannus (flat foot)

Other/Miscellaneous conditions
     Plantar fibromatosis
     Tarsal tunnel syndrome

Who not to refer
The following conditions are best seen by the podiatrists in the community service.
Toenail problems such as
     Ingrowing toenails
     Fungal nails
     General podiatry
     Treatment of skins conditions (corns and callous)

There is an open access service and patients do not necessarily require a GP referral, patients can refer

Children under 16 should be referred to the Royal Hospital for Sick Children Edinburgh where there is a
paediatric orthopaedic service.

Patient information booklets
      Morton’s Neuroma
      Plantar Heel Pain (plantar fasciitis)
      Operations for Bunions (Mitchell’s Osteotomy)

Useful websites
      Department of Orthopaedic surgery website