Fifth metatarsal fractures in sport are known to be associated with acceleration and cross cutting movements when running. It is also established that playing surface has an impact on the ground reaction forces through the foot, increasing the strain through the fifth metatarsal. But what impact does boot design have on these forces? Current thought is that boots that utilise a blade stud design resist sideways slipping of the planted foot more than boots with a rounded stud. This study aims to compare ground reaction forces through the fifth metatarsal in 2 two different designs of rugby boot to assess what impact stud design might have. The forces across the foot were measured using Tekscan in-shoe pressure plates in 24 rugby players. Each player was asked to complete an agility course to measure acceleration, cutting and cross-cutting in the two different designs of rugby boot, reproducing true playing conditions. The boots used were the Canterbury Phoenix Club 8 Stud boot and the Canterbury Speed Club Blade boot. The trial was conducted on an 4G artificial pitch at the Cardiff Arms Park rugby ground. Ethical approval was obtained from Bath University and a research grant was provided by British Orthopaedic Foot and Ankle Society. The blade boot had significantly higher contact pressures than the stud boot on the fifth metatarsal in the combined movements (17.909 ± 10.442 N/cm2 Blade Vs 16.888 ± 9.992 N/cm2 Boot; P < .0125; n= 864 steps in each boot group). The blade boot also produced higher pressure during cross-cutting (32.331 ± 13.568 N/cm2 Vs 27.651 ± 15.194 N/cm2 p < 0.007). Pressures were also higher in both acceleration and cutting, although not significantly so. These results will guide clinicians advising athletes in shoe design, especially those predisposed to or rehabilitating from a fifth metatarsal fracture.

Background

The Plantaris Longus Tendon (PLT) may be implicated in Achilles (AT) tendinopathy. Different mechanical characteristics may be the cause. This study is designed to measure these.

Introduction. Syndesmosis injuries are significant injuries and require anatomical reduction. However, stabilisation of these injuries with syndesmosis screws carries specific complications and many surgeons advocate a second operation to remove the screw. Primary Tightrope suture fixation has been shown to be an effective treatment for syndesmotic injuries and avoids the need for a second operation. Materials and Methods. A retrospective audit identified patients who were treated for syndesmosis injuries over a two year period. Theatre and clinic costs were obtained to compare the cost of syndesmosis fixation using diastasis screws with the estimated cost of primary syndesmosis fixation using a Tightrope suture. Results. 79 patients received diastasis screw fixation of syndesmosis injuries between January 2007 and January 2009. The mean number of follow up clinic appointments was 3.7 following initial surgery, and 2.2 following diastasis screw removal. Allowing for device, theatre time and clinic appointment costs, and an estimated average of 4 follow up appointments following Tightrope syndesmosis fixation, primary fixation with this device could a saving of 34 theatre slots, 68 outpatient clinic appointments, and £12,138 per year at our hospital. Discussion. Biomechanical studies have demonstrated a reduction in normal tibiotalar external rotation with the presence of a diastasis screw, and there are several published reports of complications when these screws are retained. The Tightrope suture provides reduction of the syndesmosis whilst allowing normal physiological movement at the distal tibiofibular joint and negates the need for a second operation to remove the implant. In addition there may be improvements in foot and ankle scores and a faster return to work when these devices are used compared with traditional screw fixation. Conclusion. In addition to the patient benefits, our audit suggests that there may be significant financial benefits associated with primary syndesmosis fixation with Tightrope sutures

TMTJ fusion is performed for arthritis or painful deformity. K-wire and trans-articular screws are usually used to stabilize the joints. We present our experience with LP for TMTJ fusion in first 100 joints. Patients and methods. 100 TMTJ in 74 patients were fused and stabilised with LP between January 2007 and December 2010. The indication was Lisfranc arthritis and hallux valgus. Iliac crest bone autograft was used in 64 joints. Auto graft was used in 22/53 first TMT fusions. All patients post-operatively had below knee plaster immobilization and protected weight bearing walking for first 6 weeks. Clinical and radiological surveillance continued until bone. AOFAS midfoot scale was used as outcome measure. Results. There were 18 male and 56 female patients with average age of 51 (14 -68). AOFAS midfoot scale improved 42% for pain, 30% for function and 53% for alignment. Average AOFAS overall score improved from 30 pre-op to 67 post op. 95 joints had clinical and radiological fusion. 1 patient needed removal of metalwork and 3 had delayed wound healing and 4 had radiological non- . All non- s were in 1st TMTJ where bone graft failed and were revised. None of the lesser ray TMTJ had non- . Average satisfaction score was 7 out of 10. 86% said they would recommend it to a friend and 91% would have it again. Discussion. Biomechanical studies has shown plates are not as strong or stiff as trans-articular screw fixation however they are easy to use, have more flexibility and act as a buttress for autograft. Our results show that dorsal locking plate has satisfactory clinical out come with or without bone graft for lesser rays. 1st TMT fusion without bone graft has higher fusion rate compare to 3 failures in 22 1st TMTJ with bone graft. This is due to multiple factors including LP being not strong enough to sustain the stresses until creeping substitution through the bone graft. Conclusion. Locking plates provide satisfactory stability without complications for lesser ray with or without bone graft. Fusion for 1st TMTJ with auto bone graft has high failure of 13%

Aims

The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes.

We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed.

The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal.

We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.