Background: Ankle fractures are amongst the most common type of fractures. If surgery is not performed within 12 to 24 hours, ankle swelling is likely to develop and delay the operative fixation. This leads to increased hospital stay and occupancy. This prolonged stay has significant financial implication as well as frustration for both patients and health care workers. Aims: To formulate a pathway for the ankle fracture patients coming to the emergency department, outpatients and planned for operative intervention. To identify whether pre-operative hospital admissions of these patients are reduced with the implementation of the pathway. Methods: Our formulated ankle fracture fixation pathway was approved for use in December 2020. Data from ankle fracture patients admitted between January to June 2020 patients was retrospectively analysed. The duration from admission to the actual surgery was collected to review if some admissions could have been avoided and instead brought directly on the day of their surgery.
Results: Of the 23 patients included, 10 patients were appropriately discharged. 7 Patients were appropriately admitted and 6 patients were unnecessarily admitted. These 6 patients were admitted on presentation to ED. This cohort also met the safe discharge criteria and could have been discharged. Duration of unnecessary stay ranged from 1 to 11 days with potential savings of £6300. Conclusion: Pre-operative hospital admission has shown to be reduced using the proposed pathway with 74% of cases meeting the standards. It is a valuable tool and should be implemented to reduce further unnecessary hospital bed occupancy.

Introduction: A huge variety of operations have been described to correct Hallux Valgus deformity. In recent years, minimally invasive techniques have been developed. The most recent iteration, third-generation minimally invasive chevron akin (MICA) osteotomy has shown promising early results. This study presents three year follow up of a single surgeon case series.
Methods: 40 patients underwent 3rd generation MICA between 2017 and 2018. Patient reported outcome measures included Manchester-Oxford Foot Questionnaire (MOXFQ), American Orthopaedic Foot & Ankle Society (AOFAS) scores and Coughlin satisfaction rates. Radiographic parameters, complications and reoccurrence rates were also monitored throughout the follow up period. Results were compared with those published for the same patients at 12 months post-surgery.
Results: Median MOXFQ scores increased from 57.8 pre-operatively to 0.0 at 36 months. Median AOFAS improved from 49.0 to 100.0 at 36 months. Hallux Valgus Angles (HVA) improved from 34.6 degrees pre-operatively to 14.8 degrees at 36 months and the Intermetatarsal Angle (IMA) improved from 13.1 to 9.9 degrees. The complication rate at 36 months was 18.2% with 6 patients requiring akin screw removal due to soft tissue irritation. No patients required revision.
Discussion: Third-generation MICA is safe and produces sustained improvements in patient outcomes. Outcomes continued to subtly improve from those seen at 12 months post-surgery.

Background
This study evaluates preoperative education's impact on the length of hospital stay after foot and ankle surgery. Preoperative education encourages patients to play an active role in their rehabilitation after surgery.

Methods
All patients listed for an elective foot and ankle procedure were invited to attend foot school, which consisted of a multi-disciplinary team whose aim was to educate patients about their surgical procedures, rehabilitation and discharge goals. Not all patients attended foot school, as attendance to foot school was recommended but not mandatory for surgery. Data on all foot and ankle surgeries performed in 2019 were collected, and patients were divided into two groups based on their foot school attendance

Results
92% of the patients who attended foot school were discharged on the same day. 65% of patients who did not attend foot school returned home the same day. There was a statistically significant difference in the mean length of postoperative hospital stay between the two groups. Patients who attended foot school stayed at the hospital for a lesser duration than those who did not (Mean difference=8.55 hours, p-value= 0.004). Early discharges can also increase the turnover of patients for day case procedures and improve cost saving.

Conclusion
Our study demonstrates that preoperative education allows for a significantly shorter hospital stay, thereby facilitating early patient discharges. This improves patient turnover rate and also saves the hospital cost per procedure. Patients should, therefore, be encouraged to attend Foot school before their surgical procedure

Introduction: Regional ankle blockade with targeted local anaesthetic for wide-awake forefoot surgery has been described but not widely used in the United Kingdom. This study investigates patient experience of wide-awake forefoot surgery with a regional anaesthetic protocol. Methods: Forty-six patients (19 male, 27 female) aged 28 to 90 (mean 64) were recruited. Regional anaesthesia was performed by a senior anaesthetist, under ultrasound guidance, following an established protocol. Patients were contacted post-operatively to assess levels of pain peri-operatively, satisfaction and overall experience. Results: Response rate was 87% leaving 41 cases for analysis. 95% of patients reported no pain during surgery, 76% of patients experienced no or mild pain post-operatively and 65% of patients experienced no or mild pain during administration of anaesthesia. 98% of patients reported they were very satisfied or satisfied with the wide-awake forefoot surgery process and 98% of patients reported they would undergo the same process again. Perceived positive benefits of wide-awake surgery by patients were improved safety, more patient involvement, increased reassurance and faster recovery. Conclusions: Patient experience of wide-awake forefoot surgery under regional anaesthesia is very positive. Although some patients find administration of the regional anaesthetic uncomfortable, this provides excellent analgesia peri- and post-operatively. Patients also described many perceived benefits.

Based on the work of Prof. Peter Fröhlich, Hungary 1999, we completely changed our treatment concepts for intra-articular calcaneal fractures to minimal-invasive surgery. Since 2007, we have operated more than 380 cases. We use these techniques for all types of fractures, including severe cases (Sanders 4). Patients were followed up to the end of 2015. A new study until 2020 is currently being conducted. We could show that the reduction results (Böhler angle before surgery 5.30 degrees after surgery 25.69 degrees) and the scores (e.g., AOFAS for isolated fracture and non-work accidents 83.22) are well comparable with international results. A major advantage for our concepts is that we see practically no contraindication for surgery. Patients with co-morbidities, older people, smokers, and cases with critical soft-tissue situations can be treated early and at low risk. The rate of complications requiring revision of 2.7% by the end of 2015 could be reduced in recent years. The decision for the reduction technique, the position and type of osteosynthesis must be determined preoperatively based on fracture analyses. A 3D reconstruction is indispensable. We divide fractures into tongue-type, depression-type, comminuted and atypical fractures. The first group can usually be reduced using a modified Westhues technique. In our experience, the use of a specialized extension tool is necessary for the other fractures. We work almost always only with stab incisions, sometimes sinus-tarsi approach. Stabilization is done with a standardized screw osteosynthesis, fixation-free after treatment. We are continuously working on improvements, innovations and standardisation.

PURPOSE:
To explore the effectiveness and operative methods to treat various mal-united calcaneal fractures with subtalar joint saving.
METHODS:
Between January 2011 and December 2019, 53 patients with mal-united calcaneal fractures were treated with subtalar joint saving by osteotomy and reconstruction. There were 33 males and 20 females with an average age of 42.4 years (range, 20-56 years). 36 were left feet and 17, right. The time from injury to reconstructive operation was 8 months to 6 years. 31 received operative treatment previously, and 22 were treated conservatively. According to Sanders classification, 10 were rated as type Ⅱ and 31 type Ⅲ, 12 type IV. All patients received standardized postoperative managements.
RESULTS:
All patients were followed up for more than 1 year. All the fractures were reunited in an average time of 13.2 weeks (range 9 to 22 weeks). The mean visual analogue scale (VAS) score was 2.13 (range 0 to 6) and the mean ankle and hindfoot scale of the American Orthopaedic Foot and Ankle Society (AOFAS) score was 72.21(range 50 to 94) 1 year after operation. The VAS score was 5.45 (range 2 to 8) and the AOFAS score was 46.32 (range 13 to 64) before. Comparing to preoperative data, statistically significant difference was found postoperatively (P<0.05).
CONCLUSION:
Results by osteotomy and reconstruction to realign articular surfaces of subtalar joint and restore calcaneus are acceptable. Functions and symptoms are improved significantly after operation. Subtalar joint saving operation can be a considerable option for treating mal-united calcaneal fractures.

Introduction: Average length of stay after an ankle replacement is 2 to 4 days. The aim of the study was to confirm the safety & cost-effectiveness of a new daycase ankle replacement pathway. Methods: A new day case pathway for ankle arthroplasty was set up in consultation with all stakeholders. Patients were given crutches before surgery. Post-operative pain relief was optimized, and patients were reviewed within 2-5 days. Results: 20 ankle replacements performed as day case over a two-year period from November 2017 were reviewed. No patients required readmission within the first 4 weeks. There were no complications related to day case surgery. All patients except one rated the experience as excellent or good. Conclusions: Average cost reduction was £880 per case when compared to 20 inpatient procedures from the previous years. With proper patient selection, education and multi-disciplinary protocols ankle arthroplasty can be safely carried out as daycase procedure.