For Matthew Solan & James Davis at St John & St Elizabeth Hospital and OneWelbeck

For Martin Klinke at London Bridge, Cromwell Hospital, Chiswick Outpatients, New Victoria Hospital & One Welbeck

How has foot and ankle care changed since LFAC began?

It is 21 years since the London Foot and Ankle Centre brought together bona-fide specialists aiming to raise the bar for patients with complaints affecting the complex mechanism that is the human foot.

For generations, orthopaedic surgery had paid little attention to the very foundation of the human skeleton. Better knowledge of anatomy, pathophysiology and improved imaging techniques now allow more accurate diagnoses. Conditions have been classified and sub-classified and new treatments evolved.

Ninety percent of the diagnosis is in the history. The LFAC team have excellent listening skills. We also carefully examine the patient, bucking the trend of “just get an MRI”. MRI is not always the wisest choice. Plain radiographs are invaluable and the 21st century version – the Standing CT scan – gives us 3D pictures with the patient standing up that look like CT images, at a fraction of the radiation exposure. Imaging is only useful with first rate radiologists to help interpret, report, and sometimes intervene with injections.

At LFAC the patient’s history, physical findings and radiological tests are combined with decades of experience to reach a diagnosis. After this the real Expert (the patient, who of course best understands their own symptoms, activities, and work/leisure pursuits) can choose from the whole range of available treatment options.

Non-surgical treatments remain the most common and important ways in which we are able to help patients with foot and ankle pathology – whether from an injury or of insidious onset.
Surgical treatment is the “last resort” option at LFAC. A wise person once noted:

“It takes 10 years to learn HOW to operate.
It takes another 10 years to learn WHEN to operate.
And another 10 years to learn when NOT to operate”

The LFAC team are experienced enough to have completed these life-lessons!

The team at the London Foot and Ankle Centre remain at the forefront of modern care. By keeping abreast of the latest developments, we advise and offer help for all conditions, whether surgical treatment is needed or (more commonly) not, based upon the best clinical evidence.

How has care changed since LFAC began?

a. Fractures of the ankle – In the 1980’s every broken ankle “needed fixing”. In 2003 when LFAC was born changes were afoot. The pendulum has truly swung and now the most common fractures can usually be managed non-surgically. Only if the whole ankle is demonstrably unstable is surgery required. Standing X-rays, or better still Standing CT scan images, allow proper assessment of borderline cases. If surgery is required, then secure fixation of all fragments allows early walking and a speedy recovery. LFAC surgeons published the landmark paper in the Bone and Joint Journal (the most read article of 2018) popularising this approach (Ref 1).

b. Heel Pain – “Policeman’s Heel” (plantar fasciitis) always gets better by itself, doesn’t it? Well, it usually DOES – without any clever treatments. And yet many patients seen elsewhere are offered invasive therapies BEFORE the simple treatments are in place. At LFAC patients are not “over-treated” but given information and simple strategies which are remarkably effective.
Therapy is only escalated once the basics are exhausted. At that stage the treatment is tailored to the individual patient (Ref 2a,bc).

c. Ankle Arthritis. “Nothing can be done” was the message in the twentieth century. In the 2000’s ankle fusion gained traction and is now performed arthroscopically. Ankle joint replacement has evolved since then. Once a hit and miss operation this procedure has advantages for carefully selected ankle arthritis sufferers. Others are better served with a fusion. LFAC surgeons participated in the internationally acclaimed Randomised Controlled Trial of Fusion versus arthroplasty (TARVA study), run across UK centres. Work has begun on the 5-year follow-up of these patients.

d. Achilles tendon rupture. In 2003, 90% of tendon ruptures were repaired surgically. Now that figure is closer to 10%. A better understanding of the healing process improved Orthopaedic boots and refined physio regimens, mean that most patients recover well without an operation. Expert non-surgical care gives excellent function.

e. Treatments with no evidence – really?
LFAC surgeons participated in the PATH-2 study investigating whether Platelet Rich Plasma (PRP) injected into a healing tendon brought benefits. The results showed no improvement in structure or function. This is just one of many high-quality studies that have proved that PRP has not (yet) any evidence to justify its use. The LFAC team have not therefore adopted an enthusiastic (sometimes indiscriminate) approach to “biological adjuncts to healing”. PRP is not just expensive but, until there is proper evidence of its efficacy, its use is misplaced, bordering on immoral.

These are just a few examples of conditions where LFAC has led the field and shaped modern practice of Foot and Ankle care, with an evidence-based approach, over the last 21 years.

Mark Davies is leaving the team to enjoy a hard-earned retirement after a glittering career. The Centre he established is second to none, and the rest of the Team continue to offer first-rate care to the patients who need our expertise.

1a. Posterior malleolus fractures: worth fixing.
Solan MC, Sakellariou A.
Bone Joint J. 2017 Nov;99-B(11):1413-1419. doi: 10.1302/0301-620X.99B11.BJJ-2017-1072.

1b. Syndesmosis Stabilisation: Screws Versus Flexible Fixation Foot Ankle Clin 2017 Mar;22(1):35-63.doi: 10.1016/j.fcl.2016.09.004.
Matthew C Solan 1, Mark S Davies 2, Anthony Sakellariou 3

2a. Duration of Symptoms Prior to Intense Therapeutic Ultrasound for Plantar Fasciopathy is a Major Determinant of Treatment Outcome.
Tsikopoulos K, Solan M.
J Foot Ankle Surg. 2022 Sep-Oct;61(5):1136. doi: 10.1053/j.jfas.2020.02.005. Epub 2020 Apr 10.

2b. Cadaveric experiments to evaluate pressure wave generated by radial shockwave treatment of plantar fasciitis.
Cirovic S, Gould DH, Park DH, Solan MC.
Foot Ankle Surg. 2017 Dec;23(4):285-289. doi: 10.1016/j.fas.2016.08.006. Epub 2016 Aug 26.

2c. Finite element modelling of radial shock wave therapy for chronic plantar fasciitis.
Alkhamaali ZK, Crocombe AD, Solan MC, Cirovic S.
Comput Methods Biomech Biomed Engin. 2016;19(10):1069-78. doi: 10.1080/10255842.2015.1096348.

3. Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial.
TARVA Study Group
Ann Intern Med. 2022 Dec;175(12):1648-1657. doi: 10.7326/M22-2058. Epub 2022 Nov 15.

4. The treatment of a rupture of the Achilles tendon using a dedicated management programme.
Hutchison AM, Topliss C, Beard D, Evans RM, Williams P.
Bone Joint J. 2015 Apr;97-B(4):510-5. doi: 10.1302/0301-620X.97B4.35314.

5. Platelet-rich plasma injection for acute Achilles tendon rupture : two-year follow-up of the PATH-2 trial.
PATH-2 Trial group
Bone Joint J. 2022 Nov;104-B(11):1256-1265. doi: 10.1302/0301-620X.104B11.BJJ-2022-0653.R1.


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