Aims. Management of intra-articular calcaneal fractures remains a debated topic in orthopaedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures and those in whom surgery was highly likely to produce an equivocal functional outcome with potential post-operative complications. Methods. All patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and post-operative fracture geometry with Computed Tomography (CT) used for pre-operative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score. Results. Fifty-eight intra-articular calcaneal fractures (fifty-three patients including five bilateral, mean age = 46.91 years) were included. Forty-nine patients were injured as a result of a fall from a height (92.4%). Mean time from presentation to surgery was 3.23 days (range 0–21). Mean Maryland Foot score was found to be 77.6 (+/− 16.22) in forty-five patients. Five patients (9.4%) had wound complications; two superficial (3.7%) and three deep (5.6%). Conclusion. Intra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of post-operative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management

Aims. No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. Methods. Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler’s angle and calcaneal width, and posterior facet reduction. Results. Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001). Conclusion. The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286–293

Traditional open approaches for subtalar arthrodesis have reported nonunion rates of 5–16% and significant incidence of infection and nerve injury. The rationale for arthroscopic arthrodesis is to limit dissection of the soft tissues in order to preserve blood supply for successful fusion, whilst minimising the risk of soft tissue complications. The aim of this study was to determine the outcomes of sinus tarsi portal subtalar arthrodesis. Case records of all patients undergoing isolated arthroscopic subtalar arthrodesis by two senior surgeons between 2004 and 2014 were examined. All patients were followed up until successful union or revision surgery. The primary outcome measure was successful clinical and radiographic union. Secondary outcome measures included occurrence of infection and nerve injury. Seventy-seven procedures were performed in 74 patients, with successful fusion in 75 (97.4%). One (1.3%) superficial wound infection and one (1.3%) transient sural nerve paraesthesia occurred. Fixation with a single screw provided sufficient stability for successful arthrodesis. To our knowledge this is the largest reported series of isolated arthroscopic subtalar arthrodeses to date, and the first series reporting results of the two portal sinus tarsi approach. This approach allows access for decortication of all three articular facets, and obviates the need for a posterolateral portal, features which may explain the high union rate and low incidence of sural nerve injury in our series

Background. Weightbearing computed tomography scans allow for better understanding of foot alignment in patients with Progressive Collapsing Foot Deformity. However, soft tissue integrity cannot be assessed via WBCT. As performing both WBCT and magnetic resonance imaging is not cost effective, we aimed to assess whether there is an association between specific WBCT and MRI findings. Methods. A cohort of 24 patients of various stages of PCFD (mean age 51±18 years) underwent WBCT scans and MRI. In addition to signs of sinus tarsi impingement, four three-dimensional measurements (talo-calcaneal overlap, talo-navicular coverage, Meary's angle axial/lateral) were obtained using a post processing software (DISIOR 2.1, Finland) on the WBCT datasets. Sinus tarsi obliteration, spring ligament complex and tibiospring ligament integrity, as well as tibialis posterior tendon degeneration were evaluated with MRI. Statistical analysis was performed for significant (P<0.05) correlation between findings. Results. None of the assessed 3D measurements correlated with spring ligament complex or tibiospring ligament tears. Age, body mass index, and TCO were associated with tibialis posterior tendon tears. 75% of patients with sinus tarsi impingement on WBCT also showed signs of sinus tarsi obliteration on MRI. Of the assessed parameters, only age and BMI were associated with sinus tarsi obliteration diagnosed on MRI, while the assessed WBCT based 3D measurements were, with the exception of MA axial, associated with sinus tarsi impingement. Conclusion. While WBCT reflects foot alignment and indicates signs of osseous impingement in PCFD patients, the association between WBCT based 3D measurements and ligament or tendon tears in MRI is limited. Partial or complete tears of the tibialis posterior tendon were only detectable in comparably older and overweight PCFD patients with an increased TCO. WBCT does not replace MRI in diagnostic value. Both imaging options add important information and may impact decision-making in the treatment of PCFD patients

Progressive collapsing foot deformity (PCFD) is a complex foot deformity with varying degrees of hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. In its management, muscle and tendon balancing are important to address the deformity. Peroneus brevis is the primary evertor of the foot, and the strongest antagonist to the tibialis posterior. Moreover, peroneus longus is an important stabilizer of the medial column. To our knowledge, the role of peroneus brevis to peroneus longus tendon transfer in cases of PCFD has not been reported. This study evaluates patient reported outcomes including pain scores and any associated surgical complications for patients with PCFD undergoing isolated peroneus brevis to longus tendon transfer and gastrocnemius recession. Patients with symptomatic PCFD who had failed non-operative treatment, and underwent isolated soft tissue correction with peroneus brevis to longus tendon transfer and gastrocnemius recession were included. Procedures were performed by a single surgeon at a large University affiliated teaching hospital between January 1 2016 to March 31 2021. Patients younger than 18 years old, or undergoing surgical correction for PCFD which included osseous correction were excluded. Patient demographics, medical comorbidities, procedures performed, and pre and post-operative patient related outcomes were collected via medical chart review and using the appropriate questionnaires. Outcomes assessed included Visual Analogue Scale (VAS) for foot and ankle pain as well as sinus tarsi pain (0-10), patient reported outcomes on EQ-5D, and documented complications. Statistical analysis was utilized to report change in VAS and EQ-5D outcomes using a paired t-test. Statistical significance was noted with p<0.05. We analysed 43 feet in 39 adults who fulfilled the inclusion criteria. Mean age was 55.4 ± 14.5 years old. The patient reported outcome mean results and statistical analysis are shown in Table one below. Mean pre and post-operative foot and ankle VAS pain was 6.73, and 3.13 respectively with a mean difference of 3.6 (p<0.001, 95% CI 2.6, 4.6). Mean pre and post-operative sinus tarsi VAS pain was 6.03 and 3.88, respectively with a mean difference of 2.1 (p<0.001, 95% CI 0.9, 3.4). Mean pre and post-operative EQ-5D Pain scores were 2.19 and 1.83 respectively with a mean difference of 0.4 (p=0.008, 95% CI 0.1, 0.6). Mean follow up time was 18.8 ± 18.4 months. Peroneus brevis to longus tendon transfer and gastrocnemius recession in the management of symptomatic progressive collapsing foot deformity significantly improved sinus tarsi and overall foot and ankle pain. Most EQ-5D scores improved, but did not reach statistically significant values with the exception of the pain score. This may have been limited by our cohort size. To our knowledge, this is the first report in the literature describing clinical results in the form of patient reported outcomes following treatment with this combination of isolated soft tissue procedures for the treatment of PCFD. For any figures or tables, please contact the authors directly

The December 2024 Trauma Roundup. 360. looks at: Percutaneous lumbopelvic fixation is effective in the management of unstable transverse sacral fractures; A systematic review on autologous matrix-induced chondrogenesis (AMIC) for chondral knee defects; Stable clinical and radiological outcomes at medium and over five-year follow-up of calcaneus fracture open reduction internal fixation using a sinus tarsi approach; Right or left? It might make a difference; Suprapatellar versus infrapatellar tibial nailing – is there a difference in anterior knee pain and function?; Can patients safely weightbear following ankle fracture fixation?; Anterior-to-posterior or a plate fixation for posterior malleous fractures?; Audio distraction for traction pin insertion: a prospective randomized controlled study; Is intramedullary nailing of femoral diaphyseal fractures in the lateral decubitus position as safe and effective as on a traction table?

A medializing calcaneal osteotomy (MCO) is one of the key inframalleolar osteotomies to correct progressive collapsing foot deformity (PCFD). While many studies were able to determine the hind- and midfoot alignment after PCFD correction, the subtalar joint remained obscured by superposition on plain radiography. Therefore, we aimed to perform a 3D measurement assessment of the hind- and subtalar joint alignment pre- compared to post-operatively using weightbearing CT (WBCT) imaging. Fifteen patients with a mean age of 44,3 years (range 17-65yrs) were retrospectively analyzed in a pre-post study design. Inclusion criteria consisted of PCFD deformity correct by MCO and imaged by WBCT. Exclusion criteria were patients who had concomitant midfoot fusions or hindfoot coalitions. Image data were used to generate 3D models and compute the hindfoot - and talocalcaneal angle as well as distance maps. Pre-operative radiographic parameters of the hindfoot and subtalar joint alignment improved significantly relative to the post-operative position (HA, MA. Sa. , and MA. Co. ). The post-operative talus showed significant inversion, abduction, and dorsiflexion of the talus (2.79° ±1.72, 1.32° ±1.98, 2.11°±1.47) compared to the pre-operative position. The talus shifted significantly different from 0 in the posterior and superior direction (0.62mm ±0.52 and 0.35mm ±0.32). The distance between the talus and calcaneum at the sinus tarsi increased significantly (0.64mm ±0.44). This study found pre-dominantly changes in the sagittal, axial and coronal plane alignment of the subtalar joint, which corresponded to a decompression of the sinus tarsi. These findings demonstrate the amount of alternation in the subtalar joint alignment that can be expected after MCO. However, further studies are needed to determine at what stage a calcaneal lengthening osteotomy or corrective arthrodesis is indicated to obtain a higher degree of subtalar joint alignment correction

Purpose. To establish the early outcome, satisfaction and complications of sinus tarsi implants in the management of symptomatic flexible flatfeet for a paediatric population. Methods and results. We included all patients aged 18 years or less who were treated for flexible flatfeet with a sinus tarsi implant between January 2010 and June 2012. We excluded patients who had a history of clubfeet or tarsal coalition. 34 patients had 59 implants. The mean age at surgery was 13.7 yrs (9–17 yrs), with mean follow-up of 22 months (range 10–35). Mean AOFAS improved from 65.7 to 87.9 (p<0.001), with an improvement in AOFAS pain scores (p=0.0001). Radiographic correction occurred in all feet, with average improvement of the anteroposterior talar-second metatarsal angle of 16 degrees, and the lateral talar-first metatarsal angle of 9 degrees. Implant placement satisfaction rate was 86%, with 81% claiming that they would have the procedure again. Complications included peroneal spasm (8%), extrusion (7%), revision (5%), and removal (5%). Peroneal spasm was recalcitrant in 3 of the 5 cases, and those with spasm had a higher average forefoot abduction measurement (35 degrees) than the remaining treated cases (25 degrees). Conclusion. In paediatric patients with flexible flatfeet, utilisation of the sinus tarsi implant has good short-term outcome, with our failure and revision rates comparable to other published studies in the adult population. We introduce the concept of isolated subtalar hyperlaxity which appeared to be a distinct etiological factor. A learning curve in assessing implant size was noted. Overcorrection and implant migration were the indications for revision surgery. Severe forefoot abduction appears to have a poorer outcome, and may be associated with peroneal spasm. Level of evidence: IV

Background. Whereas arthroscopic arthrodesis of the ankle is commonplace and of the subtalar joint is established, reports of arthroscopic talo-navicular fusion are a rarity. Aim. To review a case series to establish if arthroscopic talo-navicular arthrodesis is a feasible surgical option. Methods. Arthroscopic decortication of the talo-navicular joint is performed via x1-2 sinus tarsi portals and x1-2 accessory talo-navicular portals using a standard arthroscope and a 4.5 barrel burr. Internal fixation is by a 5mm screw from the navicular tuberosity and x2 headless compression screws introduced under image intensification from the dorsal navicular to the talar head. Between 2004 and 2017 a consecutive series of 164 patients underwent arthroscopic hindfoot arthrodeses of which 72 involved the talo-navicular joint. Only 13 procedures were of that joint alone in unsullied feet. The medical records of these 13 patients were reviewed to assess radiological fusion, complications and improvement of pre-operative state. Results. All Talo-navicular joints were successfully decorticated. All united radiologically by a mean 4.4 months (range 3–8). There were no major complications. All patients reported improvement to their pre-operative symptoms but one patient developed lateral column pain requiring fusion. Conclusions. Arthroscopic Talo-navicular arthrodesis is technically feasible with good rates of union. Complications were rare, making the technique attractive when encountering a poor soft tissue envelope. The surgery cannot be used if bone grafting is required. Long term discomfort can arise from adjacent joints. Accurate alignment is critical

Background. Open subtalar arthrodesis has been associated with a moderate rate of non-union, as high 16.3%, and high rates of infection and nerve injury. Performing this operation arthroscopically serves to limit the disruption to the soft tissue envelope, improve union rates and reduce infection. Our study describes our outcomes and experience of this operation. Method. Retrospective review of all patients who underwent an arthroscopic subtalar arthrodesis between 2023 and 2008. We excluded patients undergoing concurrent adjacent joint arthrodesis. The primary aim was to report on rates of union. Secondary outcomes included reporting on conversion to open procedure, duration of surgery, infection, and iatrogenic injury to surrounding structures. Results. 135 patients were included in the final analysis. 129 patients (95.5%) achieved union. The median time to fusion was 98 days. All cases were performed through sinus tarsi portals. 38 cases were performed with an additional posterolateral portal. Most cases (107/77%) were performed with 2 screws. 3 cases (2.2%) were converted to open procedures. The median tourniquet time was 86 minutes but available in only 88 (65%) cases. There were 4 (2.9%) superficial infections and no deep infections. 1 patient sustained an injury to FHL and there were no reported nerve injuries. Conclusions. At present this is the largest series of arthroscopic subtalar arthrodeses. We demonstrate that this operation can achieve high rates of union with low rates of infection with an equally low likelihood of needing to convert to an open procedure with modest operative times. In our experience the addition of a posterolateral portal does not appear to increase the incidence of nerve injury and aids in the visualisation of all 3 facets

Background. Optimal management of displaced intra-articular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiological outcomes of minimally invasive surgery (MIS) versus non-operative treatment in displaced intra-articular calcaneal fracture up to 2-years. Methods. All displaced intra-articular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma centre were considered for inclusion. The decision to treat was made by a multidisciplinary meeting. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction & internal fixation. Non-operative protocol involved symptomatic management with no attempt at closed reduction. All fractures were classified, and the MOXFQ/EQ-5D-5L scores were used to assess foot and ankle and general health-related quality of life outcomes respectively. Results. 101 patients were recruited at a level 1 major trauma centre, between August 2014 and January 2019. Our propensity score matched 44 patients in the surgical cohort to 44 patients in the non-surgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (p<0.05) however the patients in the surgical cohort had a significantly higher EQ-5D-5L Index score (p<0.05). There was also a higher return to work (91% vs 72%, p<0.05) and physical activity rate (46 vs. 35%, p<0.05) in the surgical cohort despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. 14% of patients in the non-operative cohort subsequently underwent arthrodesis compared to none of the patients in the surgical cohort. Conclusion. In this study, we found operative treatments were associated with low rates of surgical complication at 2-years and long term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared to nonoperative treatment

Background. Surgical management of calcaneus fractures is demanding and has a high risk of wound complications. Traditionally these fractures are managed with splinting until swelling has subsided. We describe a novel protocol for the management of displaced intra-articular calcaneus fractures utilising a temporizing external fixator and staged conversion to plate fixation through a sinus tarsi approach. The goal of this technique is to allow for earlier treatment with open reduction and internal fixation, minimise the amount of manipulation required at the time of definitive fixation and reduce the wound complication rate seen with the extensile approach. Methods. The records of patients with displaced calcaneus fractures from 2010–2014 were retrospectively reviewed. A total of 10 patients with 12 calcaneus fractures were treated with this protocol. All patients underwent ankle-spanning medial external fixation within 48 hours of injury. Patients underwent conversion to open plate fixation through a sinus tarsi approach when skin turgor had returned to normal. Time to surgery, infection rate, wound complications, radiographic alignment, and time to radiographic union were recorded. Results. The average Bohler's angle improved from 13.2 (range −2 to 34) degrees preoperatively to 34.3 (range 26 to 42) degrees postoperatively. The average time from external fixation to conversion to internal fixation was 4.8 (range 3 to 7) days. There were no immediate post-surgical complications. The average time to weight bearing was 8.5 weeks. The average time to radiographic union was 9.5 (range 8 to 12) weeks. There were no infections or wound complications at the time of last follow-up. Conclusions. Early temporizing external fixation for the acute management of displaced calcaneus fractures is a safe and effective method to reduce and stabilise the foot and may decrease the time to definitive fixation. In our series there were no complications related to the use of the external fixator. Level of Evidence. IV Retrospective case series

Background. Traditionally, the extended lateral approach (ELA) was the favoured approch for calcaneal fractures, but has been reported to have high incidence of wound complications. There has been a move amongst surgeons in the United Kingdom towards the sinus tarsi approach (STA) due to its minimally invasive nature, attempting to reduce such complications. Aims. To evaluate outcomes of ELA and STA for all consecutive calcaneal fracture fixation in our institution over a 10yr period. Method. Retrospective cohort study of all calcaneal fractures surgically treated with either approach between January 2008 and January 2018. Anatomic restoration was assessed radiologically by the change in Gissane's and Bohler's angles and calcaneal width. Post-operative complications including metalwork removal were recorded. Results. 35 calcaneal fractures were managed surgically via either approach during this period (21 STA and 14 ELA). There was a statistically significant improvement in the radiological makers when the post-operative films were compared to pre-operative ones. When the post-operative films from the 2 groups were compared against each other, there was no significant difference (p< 0.05) in any of the radiological markers. In the ELA group, 2 patients (14.3%) developed deep infections requiring metalwork removal and 1 had delayed wound healing (7.1%). No deep infections occurred with the STA; 1 patient (4.8%) had a superficial infection, treated with antibiotics. Of patients who had metalwork in situ for more than 1 year, 37.5% of the STA group required removal due to pain compared to only 16.7% with ELA. Conclusions. We have moved from ELA to STA. Our results have shown no difference in restoration of calcaneal anatomy but with a decrease in post-operative wound complications including infection. However, we have shown an increase in metalware removal in the STA group and it is important to ascertain the cause and significance of this

We describe the surgical technique and results of arthroscopic subtalar release in 17 patients (17 feet) with painful subtalar stiffness following an intra-articular calcaneal fracture of Sanders’ type II or III. The mean duration from injury to arthroscopic release was 11.3 months (6.4 to 36) and the mean follow-up after release was 16.8 months (12 to 25). The patient was positioned laterally and three arthroscopic portals were placed anterolaterally, centrally and posterolaterally. The sinus tarsi and lateral gutter were debrided of fibrous tissue and the posterior talocalcaneal facet was released. In all, six patients were very satisfied, eight were satisfied and three were dissatisfied with their results. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from a mean of 49.4 points (35 to 66) pre-operatively to a mean of 79.6 points (51 to 95). All patients reported improvement in movement of the subtalar joint. No complications occurred following operation, but two patients subsequently required subtalar arthrodesis for continuing pain. In the majority of patients a functional improvement in hindfoot function was obtained following arthroscopic release of the subtalar joint for stiffness and pain secondary to Sanders type II and III fractures of the calcaneum

We report a single surgeon series of 33 arthroscopic subtalar fusions performed through a 2-portal sinus tarsi approach on 32 patients between March 2004 and February 2009. Background pathologies included primary arthrosis, post-traumatic arthritis, planovalgus foot, rheumatoid disease, sinus tarsi syndrome and CTEV. 97% [32/33] of fusions as assessed by both clinical and radiological means were achieved within 16 weeks [76% [25/33] within 12 weeks] with only a single outlier which had fused by 22 weeks. There were no deep infections, thrombotic events or neuromas. Five patients suffered complications of which four were successfully treated with a satisfactory outcome. One patient developed persistent pain and was eventually referred to another centre for further management. In our experience arthroscopic subtalar fusion surgery has been demonstrated to give excellent outcomes with minimal complications. Furthermore, it is a technique allowing surgery even in patients with significant hindfoot deformity. It is a suitable operation even for patients with a compromised soft tissue envelope which would normally preclude an open procedure

The thalamus is the part of the calcaneus that supports the posterior articular facet and continues forward, becoming thinner towards the groove of the sinus tarsi. The main displacements after fracture depend on 1) a primary fracture line dividing the bone into anterior and posterior fragments, and 2) a semilunar fragment in the thalamic region. In the operation advised the sinus tarsi is exposed and the semilunar fragment is reduced by rotation in the opposite direction and is fixed to the medial fragment (the sustenaculum tali not being displaced) by a transverse Kirschner wire. The two main fragments are fixed by an antero-posterior wire. Plaster is applied and is retained for twelve weeks. Weight-bearing is not permitted for the first four weeks. There were no major complications in fifty-eight operations. The anatomical results were good: restoration of the tuber-joint angle by reduction of the semilunar fragment was maintained. The functional results were very satisfactory: permanent disability was slight or mild

Aim: To improve our technique of subtalar fusion for the correction of flexible abducto-valgus foot deformities during single event multilevel surgery in children with cerebral palsy, specifically, to decrease operating time, avoid donor site morbidity, improve fusion rates and prevent loss of correction. Methods and Results: The modifications are:. Preparation of the sinus tarsi using hemispherical reamers. Grafting the sinus with a press fit, cortico-cancellous iliac crest allograft, cut with a circular “cookie cutter”. Placing an 8mm titanium cannulated screw parallel to the talo-navicular and calcaneo-cuboid joints. All patients had a preoperative instrumented gait analysis, video recordings of foot position, AP and lateral weight bearing radiographs. Patients were encouraged to weight bear as tolerated in a cast at three weeks. Six weeks postoperatively the casts were replaced with ankle-foot orthoses. Gait laboratory reviews were conducted at 3, 6, 9, 12 and 24 months postoperatively with radiological evaluation of the subtalar fusion at 6, 12 and 24 months postoperatively. Between January 2001 and December 2004, 58 children, mean age 9 years and 4 months underwent bilateral subtalar fusions with the modified technique during multilevel surgery. Fifty-eight patients were reviewed 12 months postoperatively and 54 at 24 months postoperatively. Deformity correction was uniformly satisfactory. All patients had complete graft incorporation on plane radiographs. No patient required a revision procedure. Six patients subsequently had first metatarso-phalangeal joint fusions for symptomatic hallux valgus. Conclusion: The reliability of extra-articular fusion of the subtalar joint improved dramatically using screw fixation and iliac crest graft as described by Dennyson and Fulford. This can be further improved by the use of hemispherical reamers to the sinus tarsi and cannulated screws for fixation of the talus to the os calcis. Allograft is a reliable substitute for autograft and is acceptable to most patients and families

This paper introduces a relatively new treatment of pes planus. Over three years we have treated 21 patients with idiopathic or acquired pes planus by inserting a cylindrical polyethylene prosthesis in the subtalar sinus tarsi to limit subtalar movements. After a two to four-week period in postoperative surgical plaster, patients become fully weight-bearing, with immediate correction of alignment of the pes planus. The polyethylene has excellent wear properties and we have encountered no wear or particular reactions. We have had no bone resorption or infections, and few and minor complications. Correction of the deformity is maintained even after removal of the prosthesis. The advantages of immediate correction of the deformity and early full weight-bearing make this simple and effective procedure an attractive alternative to conservative treatment, osteotomy and subtalar fusion in selected cases

Painful peroneal spastic flatfeet without coalition or other known etiologies in adolescence, remains a difficult condition to treat. We present eight such cases with radiological and surgical evidence of bony abnormalities in the lateral subtalar region just anterior to the posterior facet. All patients had presented as tertiary referrals with recalcitrant pain and had undergone a trial of orthotics and physiotherapy. Diagnostic workup included a clinical and radiographic evaluation. Clinical examination consisted of gait examination, foot alignment, range of motion, torsional profile of the lower limbs and marking of symptomatic foci. All patients had standing weightbearing anteroposterior and lateral projections of the foot and ankle, CT and/or MRI scans of the foot. Coalitions and other known intra-articular pathologies like subtalar arthritis were ruled out. All patients had bilateral flatfeet but unilateral peroneal spasm. All patients had an accessory anterolateral talar facet (ATF) which was arising as an anterior and distal extension of the lateral process of the talus. This caused lateral impingement between the facet and the calcaneum, confirmed by bone edema around the sinus tarsi and marked at the apex of the angle of Gissane on MRI scans. All patients had stiff subtalar joints with very limited movement under anaesthesia, indicating peroneal muscle contracture. Patients were treated with a combination of facet excision, fractional peroneal and gastrosoleus lengthening and calcaneal lengthening to correct the flatfoot and prevent lateral impingement