Purpose of the study: The communicating branch of the lateral plantar nerve is an anastomotic branch between the medial and lateral plantar nerves. Morton’s pseudoneuroma is usually described as resulting from the combination of one of the divisions of the medial plantar nerve and the communicating branch of the lateral plantar nerve. Surgical treatment of Morton’s pseudoneuroma can fail, leading to recurrent neuroma, or digital hypoesthesia. We performed an anatomic dissection study to search for the anatomic basis for an improved surgical technique.

Material and methods: The study included 35 feet of embalmed cadavers. A standard protocol was used for dissection. We studied the communicating branch, its frequency and size, and measured its attachment on the 3rd and 4th plantar common digital nerves. All other nerve ramifications were noted.

Results: None of the 35 dissected feet presented a macroscopic Morton pseudoneuroma. The communicating branch was present in 77% of the specimens with frequent anatomic variations concerning the size, ramifications, orientation and distance from the intermetatarsal ligament. A fine plantar cutaneous branch was often found under the intermetatarsal ligament. The bifurcation of the 2^nd and 3^rd nerves was occasions not far from the junction of the communicating branch on the 3^rd nerve, raising the risk of injury to the 2^nd nerve during surgical excision of a Morton pseudoneuroma.

Discussion: The communicating branch appears to play a role in recurrence after excision of the Morton pseudoneuroma by preventing the retraction of the 3^rd digital nerve in the muscle zone if it is not sectioned. However, wide resection of the proximal part of the 3^rd nerve and the communicating branch could lead to digital hypoesthesis if the 2^nd digital nerve is injured. The proximity of the bifurcations of the 2^nd and 3^rd nerves and of the 3^rd nerve with the communicating branch could explain this type of complication.

Conclusion: We advocate resection of the pseudoneuroma under visual control in order to carefully resect the communicating branch without injuring the adjacent nerve branches.

Purpose of the study: The aim of this study was to analyze the mechanical function of the ankle after implantation of a total ankle arthroplasty. Gait analysis included kinematic and dynamic parameters of the lower limbs before and after prosthesis implantation in comparison with ankle fusion.

Material and methods: This prospective non-randomized study included three cohorts of patients. The first cohort included 12 patients presenting osteoarthritic lesions of the ankle requiring total ankle arthroplasty; these 12 patients were reviewed six months postoperatively and for six of them twelve months postoperatively. The second cohort was composed of 12 patients reviewed twelve months after tibiotalar arthrodesis. The third cohort was composed of 12 healthy volunteers who participated in the same study protocol. The gait analysis was conducted with the Motion Analysis optoelectronic system. Parameters recorded were: self-selected speed, fastest speed, stride rate, step length, stride symmetry and length, symmetry of floor contact, and symmetry of toe lift-off. In addition, patients participated in specific tests to step over an obstacle and go up and down stairs.

Results: Gail was slower an asymmetrical in patients with ankle fusion. Fusion enabled good recovery of gait speed but at the cost of imbalanced weight-bearing times and asymmetrical toe lift-off. Total ankle arthrodesis provided little improvement in gait speed but enabled progressive and persistent recovery of symmetrical gait.

Discussion: It is well established that an ankle prosthesis improved joint force and motion in comparison with the osteoarthritic ankle. Fusion provides good clinical and kinetic results but at the const of compensation by the joints above and below the ankle. Few studies have examined gait symmetry which in our opinion would be a good criterion for evaluating the quality of gait.

Conclusion: The raw data obtained in this study demonstrate that patients with an osteoarthritic or fused ankle can recover gait speed but that they retain a limp. Total ankle arthroplasty enables a more balanced fluid and symmetrical gait which is much more comfortable for the patient.

We evaluated the safety and efficacy of a multimodal approach for prophylaxis of thromboembolism after THA, which includes preoperative autologous blood donation; hypotensive epidural anesthesia; intravenous administration of heparin during surgery, before femoral preparation when the thrombogenesis is maximally activated; expeditious surgery, minimizing femoral vein occlusion and blood loss; pneumatic compression; and early mobilization after surgery. 1946 consecutive, non-selected patients (2016 THAs) who received multimodal thromboembolic prophylaxis were followed prospectively for 3 months. Only patients with history of thrombocytopenia (platelet count < 100.000) or adverse reaction to heparin were excluded. The average age was 65 years (14 to 93), ASA classification was 1 in 14%, 2 in 48%, 3 in 37% and 4 in 1% of patients. There was a history of DVT in 86 patients and PE in 35. After surgery, the patients also received pharmacologic prophylaxis for 6 weeks (aspirin 83%; warfarin 17%). The incidence of asymptomatic DVT assessed by ultrasound in the first 198 consecutive patients was 7.1% (14 of 198). The incidence of clinical DVT in the subsequent 1748 patients was 1.8% (32 of 1748). Symptomatic PE occurred in 0.56% (11 of 1946), none of them fatal. The rate of PE in patients receiving aspirin was 0.49% (8 of 1615) and warfarin 0.9% (3 of 331). There was 1 PE among 95 patients with a prior history of PE or DVT (1%). One morbidly obese patient died of a cardiac arrhythmia confirmed by autopsy. There was only one major bleeding complication: one patient with a history of coagulopathy developed hematuria requiring a bladder flush and five units of blood, with an uneventful recovery. No patients developed epidural hematoma following administration of intraoperative heparin. A multimodal approach to prevent thromboembolic disease, showed results that compare favorably with the literature, and with our historic control of 2592 THRs without intraoperative heparin (PE rate of 1%; 0.04% fatal). This multimodal approach appears safe and efficacious as thromboembolic prophylaxis. Our low rate of PE does not support routine anticoagulation prophylaxis with drugs with a significant risk of bleeding.

Purpose: Although hamstring retraction is a frequent complication of spastic hypertoniq, very few series have been reported in adults. The purpose of this study was to evaluate results of therapeutic modalities proposed: distal hamstring tenotomy and use of an external fixator in case of permanent knee flexion.

Material and methods: This retrospective series included 37 cerebral palsy patients, 59 with permanent knee flexion. Mean flexion was 69° (20–130°). Mean motion was 61° (10–100°). Deformation of the supra and infra joints was present in 82%. There were 22 patients with bilateral permanent knee flexion. Simple tenotomy of the sartorius, the semitendinous and the gracilis with lengthenings of the semimembranous and biceps. Disinsertion of the gastrocnemius and section of posterior aponeurosis were associated as needed. Postoperative immobilization was achieved with a Zimmer cast in case of moderate flexion and with an external femorotibial fixator in case of major deformation. Postoperative rehabilitation exercises performed several times daily were initiated in all patients.

Results: At mean follow-up of 641 days, residual flexion was 6° (0–40°) and mean joint motion was 111°. All knees were stable. Three dehiscent wounds required surgical repair. The function objective, established pre-operatively, was achieved or exceeded.

Discussion: When postoperative immobilization is necessary, external fixation limits cutaneous risks and facilitates rehabilitation. It appears to be better than successive cases. Unlike other authors, we did not find section of the posterior cruciate ligament to be necessary.

Conclusion: Distal hamstring tenotomy associated with postoperative immobilization with an external fixator is a reliable and effective technique for the treatment of permanent knee flexion in cerebral palsy adults.