Aims

The Chopart joint complex is a joint between the midfoot and hindfoot. The static and dynamic support system of the joint is critical for maintaining the medial longitudinal arch of the foot. Any dysfunction leads to progressive collapsing flatfoot deformity (PCFD). Often, the tibialis posterior is the primary cause; however, contrary views have also been expressed. The present investigation intends to explore the comprehensive anatomy of the support system of the Chopart joint complex to gain insight into the cause of PCFD.

Aims

Patients with a deformity of the hindfoot present a particular challenge when performing total knee arthroplasty (TKA). The literature contains little information about the relationship between TKA and hindfoot alignment. This systematic review aimed to determine from both clinical and radiological studies whether TKA would alter a preoperative hindfoot deformity and whether the outcome of TKA is affected by the presence of a postoperative hindfoot deformity.

Aims

Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis.

Talonavicular and subtalar joint fusion through a medial incision (modified triple arthrodesis) has become an increasingly popular technique for treating symptomatic flatfoot deformity caused by posterior tibial tendon dysfunction. The purpose of this study was to look at its clinical and radiological mid- to long-term outcomes, including the rates of recurrent flatfoot deformity, nonunion and avascular necrosis of the dome of the talus. A total of 84 patients (96 feet) with a symptomatic rigid flatfoot deformity caused by posterior tibial tendon dysfunction were treated using a modified triple arthrodesis. The mean age of the patients was 66 years (35 to 85) and the mean follow-up was 4.7 years (1 to 8.3). Both clinical and radiological outcomes were analysed retrospectively. In 86 of the 95 feet (90.5%) for which radiographs were available, there was no loss of correction at final follow-up. In all, 14 feet (14.7%) needed secondary surgery, six for nonunion, two for avascular necrosis, five for progression of the flatfoot deformity and tibiotalar arthritis and one because of symptomatic overcorrection. The mean American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score) at final follow-up was 67 (between 16 and 100) and the mean visual analogue score for pain 2.4 points (between 0 and 10). In conclusion, modified triple arthrodesis provides reliable correction of deformity and a good clinical outcome at mid- to long-term follow-up, with nonunion as the most frequent complication. Avascular necrosis of the talus is a rare but serious complication of this technique. Cite this article: Bone Joint J 2015; 97-B:668–74

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy is a well-recognised form of treatment for stage II posterior tibial tendon dysfunction. Although excellent short- and medium-term results have been reported, the long-term outcome is unknown. We reviewed the clinical outcome of 31 patients with a symptomatic flexible flat-foot deformity who underwent this procedure between 1994 and 1996. There were 21 women and ten men with a mean age of 54.3 years (42 to 70). The mean follow-up was 15.2 years (11.4 to 16.5). All scores improved significantly (p < 0.001). The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up. The mean pain component improved from 12.3 to 35.2 (20 to 40). The mean function score improved from 35.2 to 45.6 (30 to 50). The mean visual analogue score for pain improved from 7.3 to 1.3 (0 to 6). The mean Short Form-36 physical component score was 40.6 (. sd. 8.9), and this showed a significant correlation with the mean AOFAS score (r = 0.68, p = 0.005). A total of 27 patients (87%) were pain free and functioning well at the final follow-up. We believe that flexor digitorum longus transfer and calcaneal osteotomy provides long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction. Cite this article: Bone Joint J 2015;97-B:346–52

Moderate to severe hallux valgus is conventionally treated by proximal metatarsal osteotomy. Several recent studies have shown that the indications for distal metatarsal osteotomy with a distal soft-tissue procedure could be extended to include moderate to severe hallux valgus.

The purpose of this prospective randomised controlled trial was to compare the outcome of proximal and distal Chevron osteotomy in patients undergoing simultaneous bilateral correction of moderate to severe hallux valgus.

The original study cohort consisted of 50 female patients (100 feet). Of these, four (8 feet) were excluded for lack of adequate follow-up, leaving 46 female patients (92 feet) in the study. The mean age of the patients was 53.8 years (30.1 to 62.1) and the mean duration of follow-up 40.2 months (24.1 to 80.5). After randomisation, patients underwent a proximal Chevron osteotomy on one foot and a distal Chevron osteotomy on the other.

At follow-up, the American Orthopedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal interphalangeal (MTP-IP) score, patient satisfaction, post-operative complications, hallux valgus angle, first-second intermetatarsal angle, and tibial sesamoid position were similar in each group. Both procedures gave similar good clinical and radiological outcomes.

This study suggests that distal Chevron osteotomy with a distal soft-tissue procedure is as effective and reliable a means of correcting moderate to severe hallux valgus as proximal Chevron osteotomy with a distal soft-tissue procedure.

Cite this article: Bone Joint J 2015;97-B:202–7.

Objective

The objective of this study was to evaluate the rotation and translation of each joint in the hindfoot and compare the load response in healthy feet with that in stage II posterior tibial tendon dysfunction (PTTD) flatfoot by analysing the reconstructive three-dimensional (3D) computed tomography (CT) image data during simulated weight-bearing.

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. Ankle fractures represent an increasing workload, particularly in the elderly female population. The posterior tibial tendon is exposed to injury during displaced medial malleolar fractures. Posterior tibial tendon dysfunction delays rehabilitation and results in significant morbidity and is most prevalent in women over 40. Objective. To ascertain whether posterior tibial tendon should be routinely explored in displaced medial malleolar fractures and consequently should post-operative rehabilitation of ankle fractures be modified. Intra-operative assessment of the tendon may help with this diagnosis and consequently alter post-operative rehabilitation. Method. We performed a prospective case series of 25 patients with displaced medial malleolar ankle fractures admitted to the Royal Victoria Hospital Belfast between August and November 2009. The admission notes were then checked for any previous injuries and the initial reduction was assessed radiologically. At the time of surgery the primary operator explored the posterior tibial tendon and assessed the tendon for damage using the following scale: nil, bruising, superficial, partial tear, complete tear. Results. The average age was 58. The majority of injuries were Weber B (20/25), bimalleolar (19/25), had an initial satisfactory reduction (19/25) and had the surgery performed by SPR/STR (22/25). The mechanism of injury was reported as mainly supination-external rotation (13/25). Eight patients were reported as having superficial damage and one with a partial rupture. Of note all patients included under the age of forty were reported as having no damage to posterior tibial tendon. Conclusion. This study does not support the routine exploration of the posterior tibial tendon in displaced medial malleolar fractures. However, the study would advocate an altered post-op regime for at risk groups for posterior tibial dysfunction

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

Posterior tibial tendon dysfunction is a well-recognised condition. It commonly occurs in middle aged overweight women. In contrast to most tendon pathology, the tendon is still often intact and the tendon is stretched rather than completely ruptured. The diagnosis can be made on clinical grounds. Clinical features include acquired flatfoot deformity, inability to perform a single heel raise, ‘too many toes’ sign and loss of inversion power with the foot in forced plantarflexion. Disease is staged into four stages, Stage II is the most common presentation. Treatment options for Stage I are non-operatively including rest and antiinflammatories. Surgical treatment for this is required if this fails or progresses to next stage. Treatment for Stage II disease is most commonly a tendon transfer using FDL tendon transfer and some bony procedure, most commonly calcaneal osteotomy. More recently move to sub-classify Stage II into sub-classification depending on severity of hindfoot valgus and presence of fixed forefoot varus. Other treatment options for Stage II include lateral column lengthening or medial column shortening procedures. Stage III disease is fixed deformity which is classically treated with triple arthrodesis. Stage IV deformity is fixed deformity with ankle valgus. Difficult condition to treat. This requires ankle and hindfoot fusion

Our aim was to evaluate the results of triple arthrodesis, performed without the use of supplementary bone graft. We carried out a retrospective review of 100 consecutive triple arthrodeses. All the operations had been performed by the senior author (TSS) using a standard technique. Only local bone graft from the excised joint surfaces had been used, thereby avoiding complications at the donor site.

The mean age of the patients at surgery was 58 years (18 to 84). The mean time to union was 5.1 months (3 to 17). There were 75 good, 20 fair and five poor results. There were four cases of nonunion.

Our study has shown that comparable rates of union are achieved without the need for supplementary bone graft from the iliac crest or other donor site.

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

Aims: To clarify correlation between magnetic resonance imaging (MRI) and pathology of pain in posterior aspect of the ankle in ballet dancers. Methods: Twenty feet of þfteen patients, who underwent surgery with the average age of 19.2 years, were retrospectively analyzed. They were diagnosed as ßexor hallucis longus (FHL) tendon injury or posterior ankle impingement (PAI) syndrome mainly based on physical signs. MRI þndings of FHL tendon were classiþed with the classiþcation of posterior tibial tendon dysfunction presented by Conti et al., and were compared with macroscopic changes of the tendon. FHL injuries were classiþed as follows; paratendinitis as grade-1, superþcial injury (< 1/2 thickness) as grade-2, and deep injury as grade-3. MRI þndings of PAI syndrome were also compared to surgical and histological þndings. Results: Correlation of FHL tendon injury with MRI þndings was presented on the table. There was a case with a ganglion cyst of FHL tendon presented on MRI. There were, however, two cases with ganglions on þbro-osseous tunnel MRI could not reveal. In four feet of three patients, bone marrow edema in os trigonum or posterior part of the talus was observed. Conclusion: MRI was useful to investigate the pathology of pain in posterior aspect of the ankle