Background:. Calcaneal osteotomy is an established technique in correcting hind foot deformity. Patients have traditionally received an open osteotomy through Atkins lateral approach. In order to reduce the rate of wound complications associated with the Atkins approach, a minimally invasive surgical (MIS) technique has been adopted since 2011. This uses a low-speed, high-torque burr to perform the same osteotomy under radiographic guidance. The results of the new MIS technique, including post-operative complication rates, are compared to the standard open approach. Methods:. The safety of the new MIS technique was investigated by conducting a case controlled study on all patients who underwent displacement calcaneal osteotomy at the Nuffield Orthopaedic Centre, Oxford from 2008 to 2014. The primary outcome measure was 30 day post-operative complication rate. Secondary outcome measures included operating time, duration of stay, fusion rates and amount of displacement achieved. Results:. 82 patients underwent calcaneal osteotomy as part of their corrective surgery; 50 patients in the Open approach group and 32 patients in MIS group. The average age at the time of surgery was 47.7 years (range 16–77) for the Open group and 48.5 (range 21–77) in the MIS group. A mean calcaneal displacement of 8.0mm (s.d. 1.32, 7 to 11 mm) and 8.33mm (s.d.1.53, 6 to 10 mm) was achieved through the MIS and open approaches respectively. There were significantly fewer wound complications in the MIS group (6.25%) compared to the Open group (28%, P=0.021) and the MIS group was associated with significantly lower rates of wound infection (3% versus 20%, P = 0.043). Three patients in the Open group experienced sural peripheral neuropathy. Conclusions:. MIS calcaneal osteotomy was found to be a safe technique. It was as effective as calcaneal osteotomy performed through an open lateral approach but was associated with significantly fewer wound complications and fewer nerve complications

Lateral approach open calcaneal osteotomy is the described gold standard procedure in the management of hindfoot deformity. With development of minimally invasive surgery, a MIS approach has been described, citing fewer wound complications and lower risk of sural nerve injury. This audit compares MIS to the traditional procedure. A retrospective review of all patients undergoing calcaneal osteotomy in Northumbria Trust in the past 5 years was performed. A total of 105 osteotomies were performed in 97 patients; 28 (13M:15F) in MIS group and 77 (40M:37F) had an open approach. The average age was 52.1 (range 16–83) for MIS and 51.5 (range 18–83) in the open group. All patients were followed up for development of wound complication, nerve injury and fusion rate. Wound complications were similar (10.7% in MIS group vs 10.3% in Open group) with no significant difference (p=0.48). Patients were treated for infection in 3(3.8%) cases in the open group and 2(7.1%) in the MIS group. This difference was not significant (p=0.43). 4 (14.3%) patients in the MIS group had evidence of sural nerve dysfunction post-operatively (managed expectantly), compared to 12(15.5%) patients in the open group (p=0.44). Of these, 2 went on to undergo neuroma exploration. There was no difference in nerve dysfunction in varus or valgus correction. Mean translation in the open group was measured as 7.3mm(SD=1.91;3 to 13mm) and 7.5mm(SD=1.25;5 to 10mm) in the MIS group. Translation was similar in varus or valgus correction. Non-union occurred in 2 patients in the MIS group and none in the open group (p= 0.06). MIS calcaneal osteotomy is a safe technique, that works as effectively as osteotomy performed through an open approach. There were lower rates of nerve injury, wound complication and infection, but this was not significantly different comparing groups. There was a higher risk of non-union in MIS technique

Background: Calcaneal osteotomy is performed commonly as an adjunct to many corrective procedures of the abnormal hindfoot. Preservation of the hindfoot joints restores the normal biomechanics and can potentially delay arthritic changes in adjacent joints. Calcaneal osteotomy improves the weight bearing alignment of the foot by reducing varus or valgus deformity without impairing subtalar or mid-tarsal joint function. We are unaware of any studies documenting the complication rates associated with this procedure. Methods: 36 calcaneal osteotomies (medial and lateral displacement, and Dwyer) were performed on 35 patients between April 2005 and October 2007 by the senior surgeon. Data was collected retrospectively by review of casenotes and assessment of radiographs. Average age was 54 years (range 18 to 81) and mean time of follow-up was 22 months (6 to 36). Indications were varus OA deformity (40%), Posterior tibialis tendon deficiency (30%), Charcot-Marie-Tooth (12%) and pes cavus (17%). Results: All case notes and radiographs were available for analysis. Eight patients (22%) developed a complication. One patients (5%) had failed to fuse at 6 weeks following surgery. This patients developed a non-union and required re-fusion with bone grafting. Two patients (10%) had sural nerve damage, which persisted and required specialist pain team involvement. Two patients developed symptoms relating to prominent screws. A further two patients had wound breakdown and one had a superficial infection. In total, there were five further procedures (14%) – two directly related to problems with the calcaneal osteotomy. All osteotomies united within a translation distance of 10% in the sagittal plane. Discussion: Calcaneal osteotomy is a useful adjunct procedure for correcting anatomical malalignment of the hindfoot in several conditions, with an acceptable complication rate and a low re-operation rate

Introduction. Calcaneal osteotomy is often performed together with other procedures to correct hindfoot deformity. There are various methods of fixation ranging from staples, headed or headless screws or more recently stepped locking plates. It is not clear if one method is superior to the other. In this series we compare the outcome of various methods of fixation with particular attention to the need for subsequent hardware removal. Patients and Methods. A retrospective review of the records of a consecutive series of patients who had a calcaneal osteotomy performed in our unit within the last 5 years was undertaken. All patients had had their osteotomy through an extended lateral approach to their calcaneous. The subsequent fixation was performed using one of three methods; a lateral plate placed through the same incision; a ‘headless’; or a ‘headed’ screw through a separate stab incision inserted through the infero-posterior heel. Records were kept of subsequent symptoms from the hardware and need for metalwork removal as well as any complications. When screws were inserted the entry point in relation to the weight-bearing surface of the calcaneous was also recorded. Results. Sixty-three osteotomies were investigated of which 15 were fixed using a headed screw, 18 using a headless screw (acutrak TM) and the remaining 30 were fixed using a lateral plate. There was a 100% union rate regardless of method of fixation, no patient was investigated or subject to revision surgery for a suspected non-union. Overall 47% of the headed screws, 10% of the headless screws and 9% of the lateral plates were removed to address symptoms that were suspected to arise from the hardware. There was a 10% (3 from 30) rate of wound complication in the lateral plate cohort. In all these cases there was persisting discharge from the extended lateral wound that resolved with dressing and antibiotic therapy alone. Conclusions. Calcaneal osteotomies have a high union rate regardless of fixation method. Fixation using a headed screw is associated with a high rate of secondary screw removal and this is unrelated to the position of the screw in relation to the weight-bearing surface of the calcaneous. Hardware problems are less frequent in the ‘headless’ screw or the lateral plate groups; however in this series, the incidence of local wound complications was higher in the group fixed with a lateral plate

Introduction:. There are concerns with the use of the Shannon burr in calcaneal osteotomies entered from the lateral side, with the medial structures possibly at risk when performing the osteotomy of the medial calcaneal wall. Our aims with this study were to investigate the neurovascular relationships with the calcaneal osteotomy performed using a Shannon burr. Methods:. This study was performed at the anatomy department, University of Sussex, Brighton. There were 13 fresh frozen below knee cadaveric specimens obtained for this study. The osteotomy was performed using a Shannon burr using a minimally invasive technique. The neurovascular structures were then dissected out to analyse their relation and any damage. Results:. Laterally, there was no evidence of damage to any neurological structure in 11 feet. In two feet, a very small lateral calcaneal branch was transected. In both cases, this was a very proximal branch from the sural nerve. There were between one and five lateral calcaneal branches of the sural nerve, and a very proximal branch present in nine feet. The minimum distance from the burr to the sural nerve was 9mm. In all cases, the entry point was within 6mm of the closest lateral calcaneal branch. Medially, there was no evidence of damage to any neurovascular structure. Quadratus plantae was present in 12 of 13 feet acting as a barrier to the neurovascular structures, and was not breached by the burr, shielding the neurovascular structures from injury. There were one or two medial calcaneal nerve branches, which all crossed the osteotomy, but were not damaged. Conclusion:. The calcaneal osteotomy performed by a Shannon burr can cause possible damage to small branches of the sural nerve, but is protected by QP form causing damage to any medial structures

Background. The adult acquired flat foot is caused by a complete or partial tear of the tibialis posterior tendon. We present the results of flexor digitorum longus transfer and medializing calcaneal osteotomy for recontruction of the deformity. Material & Methods. Twenty-six patients (31 feet) with an average age of 58 years (36–75) were operated for an acquired flat foot deformity. The patients were seen before surgery, one year after surgery and an average of 85 months after surgery to assess the following parameters: AOFAS Score, VAS Score for pain (0–10). Foot x-rays in full weightbearing position (dorsoplantar and lateral) were done at every visit in order to assess the following parameters: tarsometatarsale angle on the dorsoplantar and lateral x-ray, talocalcaneal angle on the lateral x-ray, calcaneal pitch angle and medial cuneiforme height on the lateral x-ray. Results. The AOFAS hindfoot score improved from 46.4 to 89.5 (max.: 100) points 1 year postoperatively und decreased to 87.8 points at the last follow-up. VAS for pain decreased from 6.6 to 1.1 at the one year follow-up and increased to 1.5 at the last follow-up. All radiologic parameters improved and stayed without significant changes over time. Following complications were seen: one recurrence, two patients with irritation of the sural nerve, one patient with hypesthesia of the big toe. In six patients the screws had to be removed. Apart from that no other revision surgery had to be done. Conclusion. Flexor digitorum longus transfer together with medializing calcaneal osteotomy provides excellent results for the therapy of acquired flat foot deformity. The results did not change significantly over time

Background. Acquired flatfoot deformity goes ahead with a partial or complete rupture and thus insufficiency of the tibialis posterior tendon. We present the results of flexor digitorum longus transfer and medial displacement calcaneal osteotomy to reconstruct the acquired deformity. Material & Methods. Twenty two patients (24 feet) with an average age of 58 (36–75) years were operated on for acquired flexible flatfoot deformity. Two patients had a bilateral procedure. Patients were seen pre-and postoperatively in order to evaluate following parameters: AOFAS hindfoot score, visual analogue scale for pain (0–10), the tarsometatarsal angle on lateral and ap standing x-rays, the cuneiform heights and talocalcaneal angle on lateral standing x-rays and subjective postoperative satisfaction score (1-worst to 5-best). Average time of follow-up was 24.7 months (12–48). Results. The AOFAS hindfoot score could be increased from 46.4 to 89.5 points, the visual analogue scale for pain decreased from 6.6 to 1.1. The average satisfaction score was 4.5 points with one patient scoring 2 and another one scoring 3. All the other patients scored either 4 or 5. All radiological parameters could be improved. Following complications were seen: one recurrence, two patients with irritation of the sural nerve, one patient with hypesthesia of the big toe. The calcaneal screws had to be removed in 3 patients. Conclusion. Flexor digitorum longus transfer together with medial displacement calcaneal osteotomy gave satisfactory results for the treatment of acquired flatfoot deformity. All radiologic parameters were improved

Aim. We report the results of Cobb I procedure and Rose calcaneal osteotomy for stage II posterior tibial dysfunction in a consecutive series of thirty patients. Methods. These patients were reviewed prospectively after average of 30 months (range: 12-92 months). An experienced independent, biomechanics specialist carried out the ultrasound examination to assess dynamic function of the posterior tibial tendon at final follow-up. Results. Twenty-eight patients were available for final follow-up. Two patients died of unrelated causes. Mean age was 60 years (range: 40-81 years). Average AOFAS score improved from 53.6 pre-operatively to 89.8 at final follow-up. Twenty-five (89%) patients were able to perform single heel raise. Six (22%) were using some form of orthotics at final follow-up. All calcaneal osteotomies united. On ultrasound examination, the posterior tibial tendon was intact in all patients and it was found to be mobile in twenty-six (93%) patients. There was one superficial wound infection and two prominent screws were removed. Three patients had subtalar joint arthritis. The surgical intervention improved the quality of life in all but two patients and only two patients were not satisfied with the surgery. Conclusion. These results suggest that a combination of Cobb I procedure and Rose Calcaneal osteotomy is a safe, effective, reliable and attractive option for the treatment of stage II posterior tibial tendon dysfunction, which provides dynamic function of posterior tibial tendon without sacrificing the primary function of long flexor tendons in foot and ankle

Introduction:. The dorsal closing wedge calcaneal osteotomy has been described for the treatment of insertional pathology of the tendo-achilles. The aim of this study was to evaluate the efficacy of the technique using outcome measures. Method:. This was a prospective case series. Patients were included if they had tendo-achilles insertional pathology (calcific tendonitis, bursitis or Haglund's deformity). A short extended lateral approach was used and a 1 cm dorsally based closing wedge osteotomy of the calcaneus performed. Fixation was with 2 staples. Patients were scored pre-operatively and at 6 and 12 months post-operatively using the VISA-A and AOFAS ankle-hindfoot scores. Results were analysed with the paired student t-test. Results:. Twenty five feet in 23 patients were enrolled in the study February 2011 – May 2013. 22 patients underwent the osteotomy (9 males and 14 females). Average age was 47.2 years (range 19–62 years). 12 feet have been followed up for 1 year, 6 for 6 months, 5 less than 6 months. Average VISA-A improvement was 27.87 points (−13–71) at 6 months p=0.001 and 38 (−13–81) at 12 months p=0.001. Average AOFAS improvement was 11 points (−8–31) at 6 months p=0.005 and 11 (−18–42) at 12 months p=0.04. 82.3% of patients would have the procedure again. Complications included minor wound problems (3), sural nerve symptoms (1) and plantar fasciitis (3). All complications have resolved. Conclusion:. The results of this study show that the use of the Zadek osteotomy of the calcaneus can provide consistent symptomatic relief from insertional Achilles pathology by altering the biomechanics of the tendon without disrupting the bursa. There is a small risk of minor complications, which should be included in the consent process

An adult acquired flatfoot deformity (AAFD) is a complex 3D deformity. Surgical correction consists of a medial calcaneal osteotomy (MCO) but shows limitations due to the current 2D assessment. Therefore, the aim is to determine the influence of an MCO on the longitudinal foot arch assessed by 2D and 3D weightbearing CT (WBCT). Seventeen patients with a mean age of 44,5 years (range 18–66 yrs) were retrospectively included. MCO was indicated in a stage II AAFD (N=15) and a post-traumatic valgus deformity (N=2). Pre- and post-operative imaging was obtained from a WBCT. The height of the longitudinal foot arch was measured as the distance from the navicular tuberositas to the floor (Navicular Height, NH) on 2D CT images (NH. 2D. ) and computed on 3D CT data (NH. 3D. ). Additionally, 3D assessment could compute the degree of exorotation (α) of the navicular bone towards the vertical axis. The mean pre-operative NH. 2D. and NH. 3D. were respectively 29.57mm ± 7.59 and 28.34mm ± 6.51. These showed to be statistically different from the mean post-operative NH. 2D. and NH. 3D. , respectively 31.62mm ± 6.69 and 31.67mm ± 6.47 (p < 0,001). A statistical difference was also found when comparing the mean degree of exorotation in pre- and post-operative, respectively: α. pre. =14.08° ± 4,92 and the α. post. =19,88° ± 3.50 (p < 0,001). This study demonstrates a significant correction of the longitudinal foot arch after a MCO. The novelty is attributed to the accurate degree of rotation assessment using WBCT. This information could be assistive to optimise a pre-operative planning

Introduction: A Rose calcaneal osteotomy and Cobb procedure for treatment of acquired pes planus is gaining in popularity as a result of the advantages of anatomical reconstruction and reduced graft site morbidity. Although, its ability to provide long term dynamic function and effect on patient’s symptoms remains to be seen. Materials and Methods: Twenty-two patients with stage two and three Posterior tibialis tendon dysfunction underwent surgical reconstruction with a Cobb procedure and Rose calcaneal osteotomy between 2003 and 2008. The average age was 59 years (range: 20–80 years). There were 18 females and four males. Results: We evaluated the dynamic function of the Tibialis posterior muscle tendon function by ultra-sonograms postoperatively at mean follow-up time of 36 months. Eighty three per cent of patients achieved a single heel raise. Seventy-three percent of the patients showed an intact and mobile tibialis posterior tendon on supination and pronation movements. There was no difference in the satisfaction of patients with a tenodesis or non tenodesis. Conclusion: Our results suggest that Cobb procedure does provide dynamic Tibialis posterior function in majority of patients

Introduction. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (CO) is a well-recognised surgical treatment for stage II posterior tibial tendon dysfunction (PTTD). Whilst excellent results are quoted for short and medium term follow-up, the long-term outcome of this procedure is unknown. Materials and Methods. We reviewed the clinical outcome of patients with a symptomatic flexible flatfoot deformity undergoing this procedure at a mean follow up of 15.3 +/−0.7 years (range 14.4–16.5). We identified 48 patients who underwent surgery by the senior author between 1994 and 1996. We were able to contact 30 patients of whom 20 were available for clinical review. 10 patients participated via telephone interview, and also completed postal questionnaires. Results. All scores improved significantly from preoperative to latest follow-up. The mean AOFAS score improved from 48.4 presurgery to 90.0+/−13.6 (range 54–100) postsurgery. The pain component improved from a mean of 12.3 to 35.0+/−8.1 (range 20–40). Function score improved from 35.8 to 45.5+/−6.1 (range 30–50). Visual analogue score improved from 7.3 to 1.3+/−2.2 (range 0–6). Seven patients had only fair objective alignment, however six of those were totally satisfied and one satisfied with minor reservations, and all said they would have the surgery again. The mean SF36 physical component score was 39.8+/−8.4 and this showed significant correlation with the AOFAS score (r = 0.61, p = 0.009). Five patients developed further pain unresponsive to analgesia and orthotics and underwent further surgery in the form of calcaneocubuoid fusion, talonavicular fusion or triple fusion at a mean of 5.5+/−4.7 years (range 0.7–11.8) following initial surgery. 25(83%) patients were pain free and functioning well at an average of 15.3 years following surgery. Conclusion. We believe that FDL transfer and CO provides long-term pain relief and satisfactory function in the treatment of Stage II PTTD

Background. The treatment of chronic calcaneal osteomyelitis is a challenging and increasing problem because of the high prevalence of diabetes mellitus and operative fixation of heel fractures. In 1931, Gaenslen reported treatment of hematogenous calcaneal osteomyelitis by surgical excision through a midline, sagittal plantar incision. We have refined this approach to allow successful healing and early mobilization in a modern series of complex patients with hematogenous, diabetic, and postsurgical osteomyelitis. Methods. Twenty-eight patients (mean age 54.6 years, range 20–94) with Cierny-Mader stage IIIB chronic osteomyelitis were treated with sagittal incision and calcaneal osteotomy, excision of infected bone, and wound closure. All patients received antibiotics for at least 6 weeks, and bone defects were filled with an antibiotic carrier in 20 patients. Patients were followed for a mean of 31 months (SD 25.4). Primary outcome measures were recurrence of calcaneal osteomyelitis and below-knee amputation. Secondary outcome measures included 30-day postoperative mortality and complications, duration of postoperative inpatient stay, footwear adaptions, mobility, and use of walking aids. Results. All 28 patients had failed previous medical and surgical treatment. Eighteen patients (64%) had significant comorbidities. The commonest causes of infection were diabetes ± ulceration (11 patients), fracture-related infection (4 patients), pressure ulceration, hematogenous spread, and penetrating soft tissue trauma. The overall recurrence rate of calcaneal osteomyelitis was 18% (5 patients) over the follow-up period, of which 2 patients (7%) required a below-knee amputation. Eighteen patients (64%) had a foot that comfortably fitted into a normal shoe with a custom insole. A further 6 patients (21%) required a custom-made shoe, and only 3 patients required a custom-made boot. Conclusion. Our results show that a repurposed Gaenslen calcanectomy is simple, safe, and effective in treating this difficult condition in a patient group with significant local and systemic comorbidities

A medializing calcaneal osteotomy (MCO) is one of the key inframalleolar osteotomies to correct progressive collapsing foot deformity (PCFD). While many studies were able to determine the hind- and midfoot alignment after PCFD correction, the subtalar joint remained obscured by superposition on plain radiography. Therefore, we aimed to perform a 3D measurement assessment of the hind- and subtalar joint alignment pre- compared to post-operatively using weightbearing CT (WBCT) imaging. Fifteen patients with a mean age of 44,3 years (range 17-65yrs) were retrospectively analyzed in a pre-post study design. Inclusion criteria consisted of PCFD deformity correct by MCO and imaged by WBCT. Exclusion criteria were patients who had concomitant midfoot fusions or hindfoot coalitions. Image data were used to generate 3D models and compute the hindfoot - and talocalcaneal angle as well as distance maps. Pre-operative radiographic parameters of the hindfoot and subtalar joint alignment improved significantly relative to the post-operative position (HA, MA. Sa. , and MA. Co. ). The post-operative talus showed significant inversion, abduction, and dorsiflexion of the talus (2.79° ±1.72, 1.32° ±1.98, 2.11°±1.47) compared to the pre-operative position. The talus shifted significantly different from 0 in the posterior and superior direction (0.62mm ±0.52 and 0.35mm ±0.32). The distance between the talus and calcaneum at the sinus tarsi increased significantly (0.64mm ±0.44). This study found pre-dominantly changes in the sagittal, axial and coronal plane alignment of the subtalar joint, which corresponded to a decompression of the sinus tarsi. These findings demonstrate the amount of alternation in the subtalar joint alignment that can be expected after MCO. However, further studies are needed to determine at what stage a calcaneal lengthening osteotomy or corrective arthrodesis is indicated to obtain a higher degree of subtalar joint alignment correction

Introduction. Charcot Arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. The traditional surgical method of extensive surgical exposure, excision of bone, acute correction and internal fixation is not always appropriate in presence of active ulceration, deep infection and poor bone quality. Minimally invasive osteotomies and gradual correction of deformities with a circular frame are proving helpful in minimizing complications. We present our experience with the use of Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. Materials and Methods. Our indication for the treatment with TSF is recurrent or intractable ulceration with or without active bone infection or a history of infection in a deformed foot and/or ankle. There are 2 female and 8 male patients in this cohort. We used a long bone module for ankle and hindfoot deformities (3 patients) and a forefoot 6×6 butt frame (7 patients) for midfoot deformities. An osteotomy through midfoot was performed in all chronic stable midfoot deformity cases and a calcaneal osteotomy and gradual correction through ankle in when hindfoot and ankle deformities co-existed. Results. Our outcome measures are a complete healing of ulcer and infection without recurrence, clinically plantigrade foot and ability to wear regular shoes or diabetic footwear. We achieved this outcome in 9 out of 10 patients. Successful patients remain ulcer free at minimum 7 and maximum 14 years follow up. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. Conclusions. Our results confirm that Taylor Spatial Frame treatment is a good alternative to traditional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities

The June 2015 Foot & Ankle Roundup. 360 . looks at: Syndesmosis and outcomes in ankle fracture; Ankle arthrodesis or arthroplasty: a complications-based analysis; Crosslinked polyethylene and ankle arthroplasty; Reducing screw removal in calcaneal osteotomies; Revisiting infection control policies; Chevron osteotomy: proximal or distal?; Ankle distraction for osteoarthritis

Introduction:. The purpose of this study was to elucidate the specific radiographic effects that the Cotton osteotomy confers when used in combination with other reconstructive procedures in the management of the flexible flat foot deformity. Methods:. Between 2002–2013, 198 Cotton osteotomies were retrospectively identified following IRB approval. 131 were excluded on the basis of ipsilateral mid/hindfoot arthrodesis, inadequate radiographs or being less than 18yrs old at time of surgery. Parameters including the articular surface angles of the hindfoot/forefoot, Meary's angle and a newly defined Medial Arch Sag Angle (MASA) were recorded. A matched group of patients who did not undergo a Cotton osteotomy but who underwent similar hindfoot reconstructive procedures served as historic controls. Results:. 67 Cotton osteotomies in 59 patients with a mean age of 45 years (range, 18–80) were evaluated. Concomitant procedures included combinations of tibialis posterior tendon (PTT) reconstruction, Evans lateral column lengthening, medial displacement calcaneal osteotomy (MDCO). In all patients who underwent a Cotton osteotomy, there were statistically significant improvements in the articular surface angles along the medial side of the foot (p < 0.05). Improvement in arch height was also found to be statistically significant (p < 0.05). In comparison to matched controls, the Cotton osteotomy did not improve Meary's angle but provided an additional 11.21° of MASA correction (p < 0.05) when used in in conjunction with the Evans procedure and PTT reconstruction. A similar trend was seen with MDCO and PTT reconstruction. Discussion:. This study confirms the Cotton osteotomy is a powerful surgical adjunct in flatfoot reconstruction and quantifies the additional 11.21° of MASA correction it provides when the Cotton osteotomy is added to a calcaneal osteotomy and PTT reconstruction. This has relevance as an alternative for selection of a medial column stabilization procedure, which is joint sparing

Chronic postoperative pain (CPP) can occur in elective mid/hindfoot and ankle surgery patients. Multimodal pain management has been reported to reduce postoperative pain and opioid use, which may prevent the development of CPP. However, few studies have examined the impact of multimodal pain management strategies on CPP following complex elective mid/hindfoot and ankle surgery. The purpose of this study was to 1) evaluate current pain management strategies and 2) determine current definitions, incidence, and prevalence of CPP after elective mid/hindfoot and ankle surgery. Three databases (MEDLINE, Embase and Cochrane Library) were manually and electronically searched for English language studies published between 1990 and July 2017. For the first aim, we included comparative studies of adults undergoing elective mid/hindfoot and ankle surgery that investigated pre-, peri- or postoperative pain management. For the second aim, we included observational studies examining CPP definition, incidence, and prevalence. Two reviewers independently screened titles and abstracts, followed by full texts. Conflicts were resolved through discussion with a third reviewer. Reviewers also independently assessed the quality of studies meeting inclusion criteria using the Joanna Briggs Institute Critical Appraisal Checklist. For the first aim, 1159 studies were identified by the primary search, and seven high quality randomized controlled trials were included. Ankle arthroplasty or fusion and calcaneal osteotomy were the most common procedures performed. The heterogeneity of study interventions, though all regional anesthesia techniques, precluded meta-analysis. Most investigated continuous popliteal, sciatic and/or femoral nerve blockade. Participants were typically followed up to 48 hours postoperatively to examine postoperative pain levels and morphine consumption in hospital. Interventions effective at reducing postoperative pain and/or morphine consumption included inserting popliteal catheters using ultrasound instead of nerve stimulation guidance, perineural dexamethasone, and adding continuous femoral blockade to continuous popliteal blockade. Using more than one analgesic was generally more effective than using a single agent. Only two studies examined longer term pain management. One found no difference in pain levels and opioid consumption at two weeks with perineural or systemic dexamethasone use. The other found that pain with activity was significantly reduced at six months postoperatively with the addition of a femoral catheter infusion to a popliteal catheter infusion. For the second aim, only two studies of the 747 identified were selected. One prospective observational study defined CPP as moderate-to-severe pain at one year after foot and ankle surgery, and reported 21% and 43% of patients as meeting their definition at rest and with activity, respectively. The other study was a systematic review that reported 23–60% of patients experienced residual pain after total ankle arthroplasty. There is no standardized definition of CPP in this population, and incidence and prevalence are rarely reported and vary largely based on definition. Although regional anesthesia may be effective at reducing in-hospital pain and opioid consumption, evidence is very limited regarding longer-term pain management and associated outcomes following elective mid/hindfoot and ankle surgery

Introduction Nineteen consecutive patients underwent flexor hallucis longus (FHL) tendon transfer and medial displacement calcaneal osteotomy for the treatment of Stage 2 posterior tibial tendon dysfunction. Methods The FHL tendon was utilized for transfer because it approximates the strength of the posterior tibiais muscle and is stronger than the peroneus brevis muscle. Seventeen patients returned for follow-up examination (average 18 months). Results The AOFAS hindfoot score improved from 62/100 to 84/100. The subjective portion of the AOFAS hindfoot score improved from 31/60 to 49/60. Weight bearing pre-operative and post-operative radiographs revealed no statistically significant improvement for the medial longitudinal arch in measurements of lateral talo-first metatarsal angle, calcaneal pitch, vertical distance from the floor to the medial cuneiform or talo-navicular coverage angle. Three feet had a normal medial longitudinal arch and six feet had a longitudinal arch similar to the opposite side following the procedure. Patient satisfaction was high: 10 patients satisfied without reservations, six patients satisfied with minor reservations and one dissatisfied. No patient complained of donor defecit from the harvested FHL tendon. Conculsions Despite the inability of the procedure to improve the height of the medial longitudinal arch, FHL transfer combined with medial diplacement calcaneal osteotomy yielded good to excellent clinical results and a high patient satisfaction rate. In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits

Introduction: Total ankle replacement is proving a reliable procedure for ankle arthrosis. Some authors have recommended that significant hindfoot deformity should be a contraindication. This study aims to provide guidance on the management of this difficult problem. Methods: 170 consecutive total ankle replacements were performed in 147 patients, aged 32–83 (mean 65) between 1999 and 2006 by a single surgeon. All surviving patients (5 deaths) were followed up prospectively on an annual basis, for a mean of 3 years (1–8 years). Comparison was made between Group A (45 ankles with a hindfoot deformity of > 10° varus or valgus) and Group B (the remaining 120 ankles). Results: There was no statistical difference between the 2 groups for age, sex or indication for surgery (osteoarthritis in 81%). Group A comprised 8 valgus and 36 varus ankles. 23/36 varus ankles had a deformity of > 20°. 6 revisions (13%) were performed in Group A (5 of these related to instability – all preoperatively varus of > 20 degrees). 10 revisions (8%) were performed in Group B (2 related to instability). 6 ankles underwent intra-operative deltoid release and 6 had pre or post-operative calcaneal osteotomy. Only one of these required revision for instability. 4 ankles underwent post-operative lateral ligament reconstruction. These ankles all failed due to instability. The mean postoperative American Foot and Ankle Society score in Group A was 85, compared to 78 in Group B. Discussion: Our study reveals that patients with significant hindfoot deformity may benefit from total ankle replacement. However, the risk of revision due to instability and need for further surgery is higher, especially with a varus deformity of > 20°. Almost a quarter of these ankles required revision. Potential solutions may be to correct the deformity with additional calcaneal osteotomy or medial release, whereas lateral ligament reconstruction alone is inadequate