Aims. Arthroscopically controlled fracture reduction in combination with percutaneous screw fixation may be an alternative approach to open surgery to treat talar neck fractures. The purpose of this study was thus to present preliminary results on arthroscopically reduced talar neck fractures. Patients and Methods. A total of seven consecutive patients (four women and three men, mean age 39 years (19 to 61)) underwent attempted surgical treatment of a closed Hawkins type II talar neck fracture using arthroscopically assisted reduction and percutaneous screw fixation. Functional and radiological outcome were assessed using plain radiographs, as well as weight-bearing and non-weight-bearing CT scans as tolerated. Patient satisfaction and pain sensation were also recorded. Results. Primary reduction was obtained arthroscopically in all but one patient, for whom an interposed fracture fragment had to be removed through a small arthrotomy to permit anatomical reduction. The quality of arthroscopic reduction and restoration of the talar geometry was excellent in the remaining six patients. There were no signs of talar avascular necrosis or subtalar degeneration in any of the patients. In the whole series, the functional outcome was excellent in five patients but restricted ankle movement was observed in two patients. All patients had a reduction in subtalar movement. At final follow-up, all patients were satisfied and all but one patient were pain free. Conclusion. Arthroscopically assisted reduction and fixation of talar neck fractures was found to be a feasible treatment option and allowed early functional rehabilitation. Cite this article: Bone Joint J 2018;100-B:461–7

Background. Talar neck fractures occur infrequently and are associated with high complication rates. Anatomical restoration of articular congruity is important. Adequate exposure and stable internal fixation of these fractures are challenging. Aims. We investigate the use of an anterior extensile approach for exposure of these fractures and their fixation by screws introduced through the talo-navicular articulation. We also compare the quality and quantity of exposure of the talar neck obtained by this approach with the commonly described combined medial/lateral approaches. Materials and Methods. An anterior approach to the talus between the tibialis anterior and the extensor hallucis longus tendons protecting both the superficial and deep peroneal nerves was performed on 5 fresh frozen cadaveric ankles . The surface area of talar neck accessible was measured using an Immersion Digital Microscibe and analysed with Rhinoceros 3D graphics package. Standard antero-medial and antero –lateral approaches were also carried out on the same ankles, and similar measurements taken. Seven patients with talar neck fractures (4 Hawkins Type II and 3 Hawkins Type III) who underwent operative fixation using this approach with parallel cannulated screws through the talo-navicular joint were followed and the clinical radiological outcomes were recorded. Results. 3D mapping demonstrated that talar surface area visible by the anterior approach (mean 1200sqmm) is consistently superior to that visible by either the medial or lateral approaches in isolation or in combination (mean medial 350sqmm, mean lateral 600sqmm). Medial malleolar osteotomy does not offer any additional visualisation of the talar neck. 3D reconstruction of the area visualised by the three approaches confirms that the anterior approach provides superior access to the entirety of the talar neck. 5 male and 2 female patients (mean age -) were reviewed at a mean follow up period of 6 months. All had anatomical articular restoration, and no wound problems. None developed non or AVN. There were no symptoms referable to the talo-navicular joints which showed no evidence of any secondary changes on the radiographs. Discussion. The anterior extensile approach offers superior visualisation of the talar neck in comparison to other approaches for anatomical articular restoration. Surgical morbidity with this approach is low, and introduction of screws through the talo-navicular joint allows stable fixation of talar neck fractures along the axis of the bone. We argue that this approach is safe, adequate and has the potential to cause least vascular disruption

Introduction. Anatomic reduction of talar body fractures is critical in restoring congruency to the talocrural joint. Previous studies have indicated a maximum of 25% talar body exposure without malleolar osteotomy. The aim of this study was to investigate the percentage talar body exposure when using the lateral transligamentous approach. Methods. The lateral transligamentous approach to the talus was undertaken in 10 fresh frozen cadaveric specimens by surgeons inexperienced in the approach, following demonstration of the technique. An incision was made on the anterolateral aspect of the ankle augmented by the removal of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) from their fibular insertions. A bone lever was then placed behind the lateral aspect of the talus and levered forward with the foot in equinus and inversion. The talus was disarticulated and high resolution images were taken of the talar dome surface. The images were overlain with a reproducible nine-grid division. Accessibility to each zone within the grid with a perpendicular surgical blade was documented. ImageJ software was used to calculate the surface area exposed with each approach. Results. The mean percentage area of talar dome available through the transligamentous approach was 77.3 % (95% confidence interval 73.3, 81.3). In all specimens the complete lateral talar process was accessible, along with the lateral and dorsomedial aspect of the talar neck. This approach gives complete access to Zones 1,2, 3,5 & 6 with partial access to Zones 4,8 & 9. Conclusion. The lateral transligamentous approach to the talus provides significantly greater access to the talar dome as compared to standard approaches. The residual surface area that is inaccessible with this approach is predominantly within Zone 4 and Zone 7, the posteromedial corner

Aims

The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

Metatarsus primus varus deformity correction is one of the main objectives in hallux valgus surgery. A ‘syndesmosis’ procedure may be used to correct hallux valgus. An osteotomy is not involved. The aim is to realign the first metatarsal using soft tissues and a cerclage wire around the necks of the first and second metatarsals. We have retrospectively assessed 27 patients (54 feet) using the American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographs and measurements of the plantar pressures after bilateral syndesmosis procedures. There were 26 women. The mean age of the patients was 46 years (18 to 70) and the mean follow-up was 26.4 months (24 to 33.4). Matched-pair comparisons of the AOFAS scores, the radiological parameters and the plantar pressure measurements were conducted pre- and post-operatively, with the mean of the left and right feet. The mean AOFAS score improved from 62.8 to 94.4 points (p < 0.001). Significant differences were found on all radiological parameters (p < 0.001). The mean hallux valgus and first intermetatarsal angles were reduced from 33.2° (24.3° to 49.8°) to 19.1° (10.1° to 45.3°) (p < 0.001) and from 15.0° (10.2° to 18.6°) to 7.2° (4.2° to 11.4°) (p < 0.001) respectively. The mean medial sesamoid position changed from 6.3(4.5 to 7) to 3.6 (2 to 7) (p < 0.001) according to the Hardy’s scale (0 to 7). The mean maximum force and the force–time integral under the hallux region were significantly increased by 71.1% (p = 0.001), (20.57 (0.08 to 58.3) to 35.20 (6.63 to 67.48)) and 73.4% (p = 0.014), (4.44 (0.00 to 22.74) to 7.70 (1.28 to 19.23)) respectively. The occurrence of the maximum force under the hallux region was delayed by 11% (p = 0.02), (87.3% stance (36.3% to 100%) to 96.8% stance (93.0% to 100%)). The force data reflected the restoration of the function of the hallux. Three patients suffered a stress fracture of the neck of the second metatarsal. The short-term results of this surgical procedure for the treatment of hallux valgus are satisfactory. Cite this article: Bone Joint J 2014;96-B:502–7

Introduction. Diabetes is increasing on a global scale. By 2030, 10% of the global population, ½ billon people, are predicted to have diabetes. Potentially there will be a corresponding increase in number of patients referred for surgery. Traditional surgical management of these patients is challenging. Presented is a case series utilizing Minimally Invasive Surgical Techniques of percutaneous metatarsal neck osteotomies, metatarsal head debridement, mid-foot closing-wedge osteotomies and hind-foot arthrodesis, for the surgical management of diabetic foot pathology. The potential socio-economic benefits analysis with regards to reduction in out-patient and theatre time, patient length of stay and time to healing are also postulated. Methods. Minimally Invasive Surgical Techniques of metatarsal neck osteotomy, metatarsal head debridement, closing wedge osteotomy, mid-fusion and hind-foot arthrodesis nailing are described. Procedures are preformed as day cases with fluoroscopic guidance. Low speed, high torque burrs and wedges, create the osteotomies, which can be held with percutaneous fixation. Comparative cost analysis of conservative treatment, including clinic visits, out-patient debridement, dressings, intravenous and oral antibiotics, versus Minimally Invasive Surgical Techniques is presented. Results. Six patients had metatarsal osteotomies for mechanical ulceration. Five reported good outcome. One patient required revision to forefoot arthroplasty due to mal-union. Five patients had debridement of metatarsal heads, which healed on average at six to eight weeks. Eight patients had mid-foot arthrodesis. Two infected cases required removal of metalwork. Three patients had hind-foot arthrodesis for arthritis following ankle fracture with degeneration and deformity. Patients had good short and early medium term outcomes, with no reports of below-knee amputation. This technique is reproducible once the initial learning curve is mastered. Comparative cost analysis, suggests significant financial savings by reducing inpatient admissions, clinic visits and theatre time. Conclusion. Minimally Invasive Surgical Techniques may provide an alternative surgical management for diabetic patient with foot and ankle pathology

The purpose of this study was to evaluate the clinical results of a newly designed prosthesis to replace the body of the talus in patients with aseptic necrosis. Between 1999 and 2006, 22 tali in 22 patients were replaced with a ceramic prosthesis. A total of eight patients were treated with the first-generation prosthesis, incorporating a peg to fix into the retained neck and head of the talus, and the remaining 14 were treated with the second-generation prosthesis, which does not have the peg. The clinical results were assessed by the American Orthopaedic Foot and Ankle Society ankle/hindfoot scale. The mean follow-up was 98 months (18 to 174). The clinical results of the first-generation prostheses were excellent in three patients, good in one, fair in three and poor in one. There were, however, radiological signs of loosening, prompting a change in design. The clinical results of the second-generation prostheses were excellent in three patients, good in five, fair in four and poor in two, with more favourable radiological appearances. Revision was required using a total talar implant in four patients, two in each group. Although the second-generation prosthesis produced better results, we cannot recommend the use of a talar body prosthesis. We now recommend the use of a total talar implant in these patients

MTPJ instability is very common yet there is no consensus of best surgical technique to repair it. The current techniques range from extensive release, K-wire fixation or plantar plate repair, which requires release of remaining intact plantar plate and all collaterals. Such varieties reflect a controversy regarding its aetiology. The aim of this study was to assess how much each structure contributes towards the stability of MTPJ and describing a simple technique designed by the senior author that can anatomically reconstruct all contributing structures to the pathology. Eleven cadaveric toes in two groups (five in group 1 and six in group 2) were included. Dorsal displacement (drawer test) was used to measure instability in an intact MTPJ followed by two different series of sequential sectioning of each part of collateral ligament (PCL and ACL) and part or complete plantar plate. Group 1 result showed that after incising PCL dorsal displacement was 0.51mm, PCL+ACL was 0.8mm and PCL+ACL+50% plantar plate was 2.39mm. Group 2 results showed that after incising 50% plantar plate dorsal displacement was 0.48mm, after full plantar plate 0.62mm, plantar plate +PCL was 0.74mm and plantar plate +PCL+ACL was 1.06mm. To produce significant instability, both collaterals on one side with combination of 50% plantar plate tear was needed. An isolated 50% tear of plantar plate caused less displacement of MTPJ compared to isolated collaterals. PCL contributed more towards the stability of MTPJ when the plantar plate was intact. Whereas, ACL contributed more stability when plantar plate was sectioned. The current practice of releasing the collaterals to gain access for repairing plantar plate by indirect method should be re-evaluated. A new technique of proximal tenotomy of extensor digitorum brevis tendon looped around the transverse ligament and attached to the neck of metatarsal reconstructs both structures (plantar plate and collaterals)

Introduction. Traditional treatment of idiopathic flatfoot in the adult population include calcaneal neck lengthening or fusions. These surgical methods result in abnormal function with significant complication rates. Our prospective study aimed to quantify the functional and radiological outcome of a new technique for spring ligament reconstruction using a hamstring graft, calcaneal osteotomy and medial head of gastrocnemius recession if appropriate. Methods. 22 feet were identified from the senior authors flatfoot reconstructions over a 3 year period (Jan 2013 to Dec 2015). 9 feet underwent a spring ligament reconstruction. The control group were 13 feet treated with standard tibialis posterior reconstruction surgery. Follow up ranged from 8 to 49 months. Functional assessment comprised VAS heath and pain scales, EQ-5D and MOXFQ scores. Radiographic analysis was performed for standardised parameters. Results. Each group contained two bilateral procedures. The spring ligament patients had a mean age of 43, BMI of 29 and a male to female ratio of 4;1 There were no statistical differences between groups starting point functional scores or pre-operative radiological deformity. Post-operatively there was a statistically significant improvement of all domains and overall MOXFQ, EQ5d and VAS in the spring ligament patients. There was a statistically significant improvement in all radiological parameters with all patients being returned to normal. Functional scores were not significantly better than the control group [MOXFQ components, Control vs spring ligament group, Pain: 42 vs 45 (p=0.71), Walking: 50 vs 56 (p=0.43), Social: 35 vs 39 (p=0.72), EQ-5D: 0.64 vs 0.70 (p=0.72)]. Spring ligament reconstruction produced statistically better deformity correction for 4 of 5 measured radiological parameters (p< 0.05). Conclusion. Our new method of spring ligament reconstruction restores normal anatomy. In comparison to traditional procedures our method provides equivalent functional results and improved deformity correction

Background. The Weil osteotomy is successful in the management of metatarsalgia and toe deformity. The aim is to achieve controlled shortening whilst avoiding plantarflexion. Recognised complications of the Weil osteotomy include a ‘floating toe’ in up to 20% or more of cases. Aim. Can modification of the Weil osteotomy avoid the metatarsal head plantarflexion and subsequent dorsal subluxation of the interosseous muscle that is implicated in the development of a ‘floating toe’. Methodology. The 2nd, 3rd and 4th rays were dissected out en bloc with all tendons attached from 6 pairs of fresh frozen cadavers. The ray was fixed to a board and the tendons physiologically balanced via low-friction pulleys and light weights. This model is highly sensitive to alterations in moment arm of the tendons. Once the MTP joint was balanced these weights were not altered. After standard release of the dorsal capsule a Maceira or ‘triple-cut’ osteotomy was performed. This osteotomy was developed in order to permit shortening without plantar flexion of the metatarsal head. The osteotomy was performed using a image intensifier in order to maintain uniformity of the osteotomy cut. The neck was shortened by removing a 2mm slice of bone made with parallel cuts. The ray was photographed and x-rayed pre and post ‘surgery’ and the relationships of the interosseous tendon andcentre of rotation of the metatarsal head, tendon balance and toe posture were recorded. Results. The Maceira osteotomy can avoid plantarflexion of the metatarsal head The line of pull of the interosseous tendon can maintains it's normal relationship with the centre of rotation of the metatarsal head. None of the toes developed dorsiflexion. In fact, plantarflexion at the MTP joint could be seen. PIP ‘fusion’ resulted in dorsiflexion at the MTP joint in some toes

Aims

To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or tendon transfer.

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There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure.

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We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity.

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The purposes of this study were to clarify first, the incidence of peroneal tendon dislocation in patients with a fracture of the talus and second the factors associated with peroneal tendon dislocation.

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Various radiological parameters are used to evaluate a flatfoot deformity and their measurements may differ. The aims of this study were to answer the following questions: 1) Which of the 11 parameters have the best inter- and intraobserver reliability in a standardized radiological setting? 2) Are pre- and postoperative assessments equally reliable? 3) What are the identifiable sources of variation?

Aims

A failed total ankle arthroplasty (TAA) is often associated with much bone loss. As an alternative to arthrodesis, the surgeon may consider a custom-made talar component to compensate for the bone loss. Our aim in this study was to assess the functional and radiological outcome after the use of such a component at mid- to long-term follow-up.

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The aim of this prospective study was to evaluate the intermediate-term outcomes after revision anatomical ankle ligament reconstruction augmented with suture tape for a failed modified Broström procedure.

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The surgical management of ankle arthritis with tibiotalar arthrodesis is known to alter gait, as compared with normal ankles. The purpose of this study was to assess post-operative gait function with gait before arthrodesis.

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To examine the mid-term outcome and cost utility of the BioPro metallic hemiarthroplasty for the treatment of hallux rigidius.

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This retrospective cohort study compared the results of vascularised and non-vascularised anterior sliding tibial grafts for the treatment of osteoarthritis (OA)of the ankle secondary to osteonecrosis of the talus.