The purpose of this study was to compare the results of proximal and distal chevron osteotomy in patients with moderate hallux valgus. We retrospectively reviewed 34 proximal chevron osteotomies without lateral release (PCO group) and 33 distal chevron osteotomies (DCO group) performed sequentially by a single surgeon. There were no differences between the groups with regard to age, length of follow-up, demographic or radiological parameters. The clinical results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and the radiological results were compared between the groups. At a mean follow-up of 14.6 months (14 to 32) there were no significant differences in the mean AOFAS scores between the DCO and PCO groups (93.9 (82 to 100) and 91.8 (77 to 100), respectively; p = 0.176). The mean hallux valgus angle, intermetatarsal angle and sesamoid position were the same in both groups. The metatarsal declination angle decreased significantly in the PCO group (p = 0.005) and the mean shortening of the first metatarsal was significantly greater in the DCO group (p < 0.001). We conclude that the clinical and radiological outcome after a DCO is comparable with that after a PCO; longer follow-up would be needed to assess the risk of avascular necrosis. Cite this article: Bone Joint J 2013;95-B:649–56

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

Severe hallux valgus deformity is conventionally treated with proximal metatarsal osteotomy. Distal metatarsal osteotomy with an associated soft-tissue procedure can also be used in moderate to severe deformity. We compared the clinical and radiological outcomes of proximal and distal chevron osteotomy in severe hallux valgus deformity with a soft-tissue release in both. A total of 110 consecutive female patients (110 feet) were included in a prospective randomised controlled study. A total of 56 patients underwent a proximal procedure and 54 a distal operation. The mean follow-up was 39 months (24 to 54) in the proximal group and 38 months (24 to 52) in the distal group. At follow-up the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal score, patient satisfaction level, and complications were similar in each group. Both methods showed significant post-operative improvement and high levels of patient satisfaction. Our results suggest that the distal chevron osteotomy with an associated distal soft-tissue procedure provides a satisfactory method for correcting severe hallux valgus deformity. Cite this article: Bone Joint J 2013;95-B:510–16

Aims. The mainstay of surgical correction of hallux valgus is first metatarsal osteotomy, either proximally or distally. We present a technique of combining a distal chevron osteotomy with a proximal opening wedge osteotomy, for the correction of moderate to severe hallux valgus. Patients and Methods. We reviewed 45 patients (49 feet) who had undergone double osteotomy. Outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) and the Short Form (SF) -36 Health Survey scores. Radiological measurements were undertaken to assess the correction. The mean age of the patients was 60.8 years (44.2 to 75.3). The mean follow-up was 35.4 months (24 to 51). Results. The mean AOFAS score improved from 54.7 to 92.3 (p < 0.001) and the mean SF-36 score from 59 to 86 (p < 0.001). The mean hallux valgus and intermetatarsal angles were improved from 41.6. o. to 12.8. o. (p < 0.001) and from 22.1. o. to 7.1. o. , respectively (p < 0.001). The mean distal metatarsal articular angle improved from 23. o. to 9.7. o. The mean sesamoid position, as described by Hardy and Clapham, improved from 6.8 to 3.5. The mean length of the first metatarsal was unchanged. The overall rate of complications was 4.1% (two patients). Conclusion. These results suggest that a double osteotomy of the first metatarsal is a reliable, safe technique which, when compared with other metatarsal osteotomies, provides strong angular correction and excellent outcomes with a low rate of complications. Cite this article: Bone Joint J 2016;98-B:1202–7

Van Nes rotationplasty may be used for patients with congenital proximal focal femoral deficiency (PFFD). The lower limb is rotated to use the ankle and foot as a functional knee joint within a prosthesis. A small series of cases was investigated to determine the long-term outcome. At a mean of 21.5 years (11 to 45) after their rotationplasty, a total of 12 prosthetic patients completed the Short-Form (SF)-36, Faces Pain Scale-Revised, Harris hip score, Oswestry back pain score and Prosthetic Evaluation Questionnaires, as did 12 age- and gender-matched normal control participants. A physical examination and gait analysis, computerised dynamic posturography (CDP), and timed ‘Up & Go’ testing was also completed. Wilcoxon Signed rank test was used to compare each PFFD patient with a matched control participant with false discovery rate of 5%. There were no differences between the groups in overall health and well-being on the SF-36. Significant differences were seen in gait parameters in the PFFD group. Using CDP, the PFFD group had reduced symmetry in stance, and reduced end point and maximum excursions. Patients who had undergone Van Nes rotationplasty had a high level of function and quality of life at long-term follow-up, but presented with significant differences in gait and posture compared with the control group. Cite this article: Bone Joint J 2013;95-B:192–8

Locked plates confer angular stability across fusion sites, and as such are more rigid than either screws or intramedullary nails. This gives the advantage of reducing motion to enhance union rates and potentially allowing early weight bearing. The Philos plate (Synthes) is a contoured locking plate designed to fix humeral fractures but which also fits the shape of the hindfoot and provides strong low profile fixation. Its successful use for tibiotalocalcaneal (TTC) arthrodesis has been reported.

Our aim was to prospectively evaluate the use of the Philos plate in hindfoot arthrodesis Twenty-one hindfoot arthrodeses were performed using the Philos plate between Oct 2008 and Jan 2010. Patients were followed up for a minimum of 1 year and had preoperative and 6 monthly AOFAS hindfoot scores and serial radiographs until union. Overall there were 15 ankle fusions, 5 tibiotalocalcaneal fusions and 1 subtalar fusion. At 6 months there were 13 unions and 9 non-unions (4 ankle, 5 TTC) giving a non-union rate of 38% overall and 25% for ankle fusions in isolation. Mean AOFAS scores at 6 months were 74/100 for the union group and 47 for non-unions (chi squared p < 0.001). No patient in the non-union group went on to fuse within a year without further surgery. Both groups had similar case mixes including osteoarthritis, AVN of the talus and failed arthroplasty. They also had similar co-morbidities, rates of smokers and bone grafting.

Our conclusion is that the high non-union rates are probably due to the lack of compression conferred across the join by the Philos plate as there is no compression hole and we did not supplement the fixation with a lag screw. We recommend using locked plates for hindfoot arthrodesis only with additional compression.

Introduction

Lesser toe proximal interphalangeal joint arthrodesis is a common forefoot procedure for correction of claw toe deformities. The most common method of fixation is with k-wires. Although this is a very cost-effective method of fixation, well-known disadvantages include pin site infection, non union, wire migration and the inconvenience to the patients of percutaneous wires for up to six weeks. For these reasons, intramedullary devices for joint fixation without crossing the distal IP joint have been developed. Many different designs are currently available. The Smart Toe prosthesis which has appeared as a type I and II, is one such implant. In two recent studies using type I, the use of this implant is advocated. We wish to present our experience with the use of the Smart Toe II.

Introduction. Tibial nerve anatomy has not been studied profoundly in comparison to Tarsal Tunnel Syndrome (TTS). Assuming symptoms are caused by an anatomical variant or mechanical cause regarding the tibial nerve, it is essential to investigate the anatomy of this structure taking in consideration that surgical and conservative treatments have shown poor results. Methods. 40 lower-leg specimens were obtained. Dissection started 20 centimeters proximal to the Dellon-McKinnon (DM) line towards the medial aspect of the naviculo-cuneiform joint distally. Anteriorly, dissection began at the tibio-talar medial gutter until the medial aspect of the Achilles tendon posteriorly. The plantar aspect extended from medial to lateral within the parameters previously described, ending at the level of the second metatarsal. Results. The flexor retinaculum had a denser consistency in 22.5% of the cases and the average length was 51.9 mm. The flexor retinaculum as an independent structure was found absent and 77.2% of cases as undistinguished extension of the crural fascia. The lateral plantar nerver (LPN) and abductor digiti minimi (ADM) nerve shared same origin in 80% of cases, 34.5% bifurcated proximal to the DM line, 31.2% distally and 34.3% at the same level. The medial calcaneal nerve (MCN) emerged proximal to the DM line in 100% of specimens. The medial plantar nerve (MPN) has its origin proximal to the DM line in 95% of cases. Conclusion. The flexor retinaculum is an extension of the crural fascia and not an independent structure. The LPN and ADM have the same origin in most cases and this presents as an important finding that must be studied in detail for clinical correlations between the motor and sensatory affections of the ADM and LPN respectively. Finally, the branches of the MCN and MPN are the most constant in their distribution and proximal origin in relation to the Dellon-McKinnon line

Introduction. The current treatment for Freiberg's osteochondrosis centres around either: simple debridement or debridement osteotomy. The main principle of the osteotomy is to rotate normal articular cartilage into the affected area. We recommend the use of CT scanning to delineate the amount of available, unaffected cartilage available to rotate into the affected space. Methods. We retrospectively reviewed 32 CT scans of new Freiberg's diagnoses in Sheffield over a 10 year period using the PACS system. We identified the sagittal CT slice that displayed the widest portion of proximal articular margin of the proximal phalanx and measured the diseased segment of the corresponding metatarsal head as an arc (in degrees). This arc segment was divided by 360°. This gave a ratio of the affected arc in the sagittal plane. Results. 28 out of 32 cases involved the 2nd metatarsal with the remaining 4 involving the 3rd metatarsal head. Of 32 cases, 18 had fragmentation. Surgically, 20 had debridement only, 5 also had an osteotomy and 1 had a fusion. 6 of the 32 cases were managed non-operatively. 11 cases out of 32 had an arc ratio of < 0.3. Of these, only 3 had an osteotomy, 3 had no procedure and 5 had a simple debridement. Of those that had osteotomies (5/32), 3 of the 5 cases had an arc ratio of < 0.3 with the other 2 being 0.42 and 0.38. Discussion. We hypothesise that those cases with an arc ratio of less 0.3 would be amenable to a dorsal closing wedge osteotomy and those with a ratio of more than 0.4 would be better suited to a simple debridement. For those cases between 0.3–0.4, we feel either option is viable. Further work to prove or disprove outcomes related to our classification is required

Aim. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressures. Progressive hindfoot equinus from contraction of gastrocnemius-soleus-tendo-Achilles complex and progressive plantar flexed metatarsal heads secondary to claw toe deformity results callus at the metatarsal heads which break down to ulceration. The aim is to describe 2-stage treatment pathway for managing these ulcers. Methods. Consecutive patients, who presented with forefoot ulcers since February 2019 were treated with a 2-stage treatment pathway. The first stage of this is an out-patient tendo-Achilles lengthening (TAL). The second stage is surgical proximal dorsal closing wedge metatarsal osteotomy for patients with persistent or recurrent ulcers. Patients were followed for a minimum of 12 months. Results. 112 patients (146 feet) underwent TAL by 3 consultants. Of these, 96 patients were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 patients (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with 1. st. metatarsal and 5. th. metatarsal head ulcers respectively. In 12 patients (10%), the ulcer failed to heal or recurred. MRI scan in these patients showed plantar flexed metatarsals from progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy of the metatarsal/s, with no recurrence at a minimum 12months of follow-up. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after the first stage out-patient percutaneous TAL

Background. The use of a knotless TightRope for the stabilisation of a syndesmotic injury is a well-recognised mode of fixation. It has been described that the device can be inserted using a “closed” technique. This presents a risk of saphenous nerve entrapment and post-operative pain. Aim. We aimed to establish the actual risk of injury to the Saphenous Nerve using a “closed” technique for the insertion of a TightRope. Method. 20 TightRopes were inserted into Fresh Frozen Cadavers. This was done using the senior authors preferred technique of divergent tightropes with the distal implant directed slightly anterior to the fibula-tibia axis and the proximal implant slightly posterior in order to simulate the greatest risk to the nerve. This was done under image Intensifier guidance to simulate an intraoperative environment. The medial side of the distal tibia was then dissected to directly record and measure the relationship of the TightRope to the Saphenous Nerve. Measurements were taken using digital calipers from the centre of the button on the medial side of the TightRope to the centre of the nerve at the point of closest proximity. Results. 12 TightRopes were found to exit posterior to the nerve, 7 anterior and 1 penetrated through the centre of the nerve. The mean distance from the centre of the button to the nerve was 6.99mm (range 0.72–14.52mm, standard deviation 4.33mm). In 9 of the 20 TightRopes, the nerve was found to be less than 5mm away. Conclusion. Our findings demonstrated that the risks of damaging or indeed entrapping the Saphenous nerve were high, and therefore we would advocate an open incision on the medial side with judicious exploration to ensure there is no damage to the medial neurological structures

Introduction. The treatment of posterior malleolar fractures is developing. Mason and Molloy (Foot Ankle Int. 2017 Nov;38(11):1229-1235) identified only 49% of posterior malleolar rotational pilon type fractures had syndesmotic instabilities. This was against general thinking that fixation of such a fragment would stabilize the syndesmosis. Methods. We examined 10 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University in a solution of formaldehyde. The lower limbs were carefully dissected to identify the ligamentous structures on the posterior aspect of the ankle. To compare the size to the rotational pilon posterior malleolar fracture (Mason and Molloy 2A and B) we gathered information from our posterior malleolar fracture database. 3D CT imaging was analysed using our department PACS system. Results. The PITFL insertion on the posterior aspect of the tibia is very large. The average size of insertion was 54.9×47.1mm across the posterior aspect of the tibia. Medially the PITFL blends into the sheath of tibialis posterior and laterally into the peroneal tendon sheath. 78 posterior lateral and 35 posterior medial fragments were measured. On average, the lateral to medial size of the posteromalleolar fragment was 24.5mm in the posterolateral fragment, and 43mm if there is a posteromedial fragment present also. The average distal to proximal size of the posterolateral fragment was 24.5mm and 18.5mm for the posteromedial fragment. Conclusion. The PITFL insertion on the tibia is broad. In comparison to the average size of the posterior malleolar fragments, the PITFL insertion is significantly bigger. Therefore, for a posterior malleolar fracture to cause posterior syndesmotic instability, a ligamentous injury will also have to occur. This explains the finding by Mason and Molloy that only 49% of type 2 injuries had a syndesmotic injury on testing

Background. Venous Thrombo-Embolism is a recognized complication of lower limb immobilization. In the neuropathic patient total contact casting (TCC) is used in the management of acute charcot neuroathropathy and/or to off-load neuropathic ulcers, frequently for long time periods. To our knowledge there is no literature stating the prevalence of VTE in patients undergoing TCC. We perceive that neuropathic patients with active charcot have other risk factors for VTE which would predispose them to this condition and would mandate the use of prophylaxis. We report a retrospective case series assessing the prevalence of VTE in the patients being treated with TCCs. Methods. Patients undergoing TCC between 2006 and 2018 were identified using plaster room records. These patients subsequently had clinical letters and radiological reports assessed for details around the TCC episode, past medical history and any VTE events. Results. There were 143 TCC episodes in 104 patients. Average age at cast application was 55 years. Time in cast averaged 45 days (range 5 days – 8 months, median 35 days). 3 out of 4 patients had neuropathy as a consequence of diabetes. One TCC related VTE (0.7% of casting episodes) was documented. This was a proximal DVT confirmed on USS 9 days following cast removal. No patient received VTE prophylaxis while in TCC. Conclusion. Despite these complex patients having a multitude of co-morbidities the prevalence of VTE in the TCC setting remains similar to that of the general population. This may be due to the fact that TCCs permit weight bearing. This case series suggests that, while all patients should be individually VTE risk assessed as for any lower limb immobilization, chemical thromboprophylaxis is not routinely indicated in the context of TCCs

Background. Masses are not uncommon in the foot and ankle. Most of these masses are benign, often leading clinicians to underestimate their potential for malignancy. Methods. We conducted a retrospective review of our clinical records, on patients with histologically confirmed musculoskeletal tumours of the foot and ankle, treated in a single nstitution between 2010 and 2019. The maximum diameter of each lesion was determined through MRI or Ultrasound analysis in centimeters. To develop a scoring system we compared the risk of malignancy with five criteria: site (proximal or distal to the first TMTJ), gender, age, composition and the diameter as observed. Results. Our study included 496 patients, of whom 39 (7.9%) were identified as having malignancies. The incidence of malignancy demonstrated an increased propensity among male patients, patients over 50 years of age and lesions located proximal to the TMTJ. A ROC Analysis determined that lesions measuring over 2.85 cm had an increased risk of malignancy, with a PPV of 31.1%, a NPV of 94.2%, a Sensitivity of 0.82, and a Specificity of 0.62. These identified patterns of risk were employed to formulate a scoring system, aimed at facilitating informed clinical judgment in the referral of patients to regional tumor services. Conclusion. The new OxFAT scoring system highlights the importance of lesion size, site, age and gender of the patient in determining the risk of malignancy in lump in the foot and ankle. We propose this new scoring system to aid health care professionals in managing these patients. Based on our results any patient with a foot or ankle mass of less than 2.85cm, an OxFAT score < 4/7 and no malignant or sinister features on MRI or USS can be managed locally with excision biopsy. All other patients should be referred urgently to a Regional Tumour Service

Aims

This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures.

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

The first metatarsal pronation deformity of hallux valgus feet is widely recognized. However, its assessment relies mostly on 3D standing CT scans. Two radiological signs, the first metatarsal round head (RH) and inferior tuberosity position (ITP), have been described, but are seldom used to aid in diagnosis. This study was undertaken to determine the reliability and validity of these two signs for a more convenient and affordable preoperative assessment and postoperative comparison.

Aims

This cross-sectional study aimed to investigate the in vivo ankle kinetic alterations in patients with concomitant chronic ankle instability (CAI) and osteochondral lesion of the talus (OLT), which may offer opportunities for clinician intervention in treatment and rehabilitation.

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Aims

To describe outcome reporting variation and trends in non-pharmacological randomized clinical trials (RCTs) of distal tibia and/or ankle fractures.