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INTRODUCTIONIn this article we look at the aetiology of plantar fasciitis, the other common differentials for heel pain and the evidence available to support each of the major management options. We also review the literature and discuss the condition.METHODSA literature search was performed using PubMed and MEDLINE®. The following keywords were used, singly or in combination: ‘plantar fasciitis’, ‘plantar heel pain’, ‘heel spur’. To maximise the search, backward chaining of reference lists from retrieved papers was also undertaken.FINDINGSPlantar fasciitis is a common and often disabling condition. Because the natural history of plantar fasciitis is not understood, it is difficult to distinguish between those patients who recover spontaneously and those who respond to formal treatment. Surgical release of the plantar fascia is effective in the small proportion of patients who do not respond to conservative measures. New techniques such as endoscopic plantar release and extracorporeal shockwave therapy may have a role but the limited availability of equipment and skills means that most patients will continue to be treated by more traditional techniques.

Ann R Coll Surg Engl 2013; 95: 228-229We read with interest the review on plantar fasciitis (PF) by Cutts et al. While this was an excellent account of the pathology and management of the condition, it was disappointing that management using a gastrocnemius release was totally excluded, especially as the authors had recognised reduced ankle dorsiflexion and tightness of the Achilles tendon as risk factors for PF. In fact, a number of modern series reported in the literature have used this technique in preference to local surgery on the plantar fascia.Riddle et al found that individuals with ≤0º of dorsiflexion are 23 times more likely to get PF compared with the group of individuals who had >10º of ankle dorsiflexion. 1 Cheung et al showed a relationship between the PF and equinus. 2 Achilles tendon loading has twice the amount of straining effect on the plantar fascia than body weight. They conclud-ed that lengthening of the Achilles tendon may benefit PF. Patel and DiGiovanni found that 83% of 254 patients with PF had limited dorsiflexion and 57% of 254 had an isolated gastrocnemius contracture. 3 Maskill et al performed gastrocnemius recession on 25 patients with PF who had failed 6 months of conservative therapy. 4 The average visual analogue scale score improved from 8.1 to 1.9 at 19.5 months.We reported on proximal gastrocnemius lengthening on 21 heels with chronic PF. 5 At follow-up, 81% had reported total or significant pain relief following the surgery. Local surgery on the plantar fascia has a poorer outcome and longer recovery with problems associated with lateral column dysfunction and arch collapse. We believe that a gastrocnemius release is a simple way of treating a patient with PF who has failed to respond to conservative management and that it should be considered before plantar fascia release when surgical intervention is contemplated. References 1. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study.

Patients undergoing primary total hip arthroplasty (THA) have historically been over-transfused. In a district general hospital setting, the authors observed a significant downward trend in blood transfusion requirements in these patients over 6 years after a change in transfusion policy. The purpose of this study was to retrospectively analyze the change in transfusion practice and present the results of the restrictive transfusion policy. All patients undergoing primary THA between January 2003 and December 2008 were identified from hospital records. Pre- and postoperative hemoglobin levels, transfusion trigger hemoglobin, blood transfusion requirements, patient age and sex, 30-day mortality, and length of stay data were analyzed for all patients. A total of 1169 primary THAs were performed. Annual allogeneic blood transfusion requirements reduced progressively from 151 units in 2003 to 90 units in 2008 despite an increase in the number of patients undergoing THA. During this period, the proportion of patients transfused decreased from 35% to 17%. A reduction of mean transfusion trigger hemoglobin from 79 to 73 g/L was observed over the study period. No patient experienced any significant complications as a result of undertransfusion. The authors' institution has steadily restricted the use of blood transfusion in patients undergoing THA to those symptomatic of anemia. Increasing confidence among medical and nursing staff that reduced postoperative hemoglobin levels can be safely tolerated has resulted in a 55% reduction in blood transfusion in patients undergoing THA with no other change of practice.

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Category: Trauma; Ankle Introduction/Purpose: Truly isolated Weber B distal fibula fractures are stable injuries that usually recover well following non- operative treatment, however the concern over the possibility of a medial ligament injury, and ankle instability has traditionally lead to regular surveillance in the fracture clinics to exclude delayed talar shift developing. After recent studies suggesting this risk is low we introduced a new functional treatment protocol and present our early results. Methods: 141 consecutive patients presenting acutely with isolated Weber B fractures without talar shift during a 12 months period were included. ED notes and radiographs were reviewed. All patients were splinted in a removable boot, and allowed to fully weight bear up to their comfort levels. Patients without signs of a medial ligament injury were then discharged from follow-up with advice to wear the boot for 6 weeks, an information leaflet and exercise sheet and a helpline number in case of difficulties. If they wanted clinic review this was organised. If signs of a medial ligament injury were documented, or the medial findings were not clear the patient was reviewed with up to date radiographs in the fracture clinic at 4 weeks post-injury. If talar shift developed the patient was to be converted to operative treatment. Olerud and Molander scores were collected between 6 and 12 months post- injury. Results: There were 51 patients without signs of medial ligament injury and of these 23 were discharged according to protocol and 28 patients attended fracture clinic. 89 patients had signs of medial ligament injury or no documented medial findings and of these 65 attended fracture clinic. One discharged patient re-accessed care. Of 93 patients reviewed in the fracture clinic none developed delayed talar shift. One underwent delayed ORIF for ongoing fibula discomfort and the remainder continued with non- operative treatment. 99 (70%) patients provided outcome scores. The mean Olerud and Molander score at a minimum of 6 months follow-up was 87 and the median score was 100. No significant difference was found between treatment arms. The scores were comparable to those in the published literature. Conclusion: We conclude the risk of delayed talar shift is low and satisfactory outcomes can be safely achieved with our functional protocol. Additional tests/imaging to establish the integrity of the medial ligament may be unnecessary.