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. Methods. The study was conducted on 40 adult embalmed cadaveric lower limbs. Chopart joint complexes were dissected, and the structures supporting the joint inferiorly were observed and noted. Results. The articulating bones exhibit features like a cuboid shelf and navicular beak, which appear to offer inferior support to the joint. The expanse of the spring ligament complex is more medial than inferior, while the superomedial part is more extensive than the intermediate and inferoplantar parts. The spring ligament is reinforced by the tendons in the superomedial part (the main tendon of tibialis posterior), the inferomedial part (the plantar slip of tibialis posterior), and the master knot of Henry positioned just inferior to the gap between the inferomedial and inferoplantar bundles. Conclusion. This study highlights that the medial aspect of the talonavicular articulation has more extensive reinforcement in the form of superomedial part of spring ligament and tibialis posterior tendon. The findings are expected to prompt further research in weightbearing settings on the pathogenesis of flatfoot. Cite this article: Bone Jt Open 2024;5(4):335–342

The treatment of acquired flat foot secondary to dysfunction of the posterior tibial tendon (PTT) of stage II, as classified by Johnson and Strom, remains controversial. Joint sparing and soft-tissue reconstructive procedures give good early results, but few studies describe those in the medium-term.

We studied prospectively the outcome of surgery in 51 patients with classical stage-II dysfunction of the PTT treated by a medial displacement calcaneal osteotomy and transfer of the tendon of flexor digitorum longus. We reviewed 44 patients with a mean follow-up of 51 months (38 to 62). The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot rating scale improved from 48.8 before operation to 88.5 at follow-up. The operation failed in two patients who later had a calcaneocuboid fusion. The outcome in 43 patients was rated as good to excellent for pain and function, and in 36 good to excellent for alignment. There were no poor results.

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

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

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

Tendinopathy can commonly occur around the foot and ankle resulting in isolated rupture, debilitating pain and degenerative foot deformity. The pathophysiology and key cells involved are not fully understood. This is partly because the dense collagen matrix that surrounds relatively few resident cells limits the ability of previous techniques to identify and target those cells of interest. In this study, we apply novel single cell RNA sequencing (CITE-Seq) techniques to healthy and tendinopathic foot/ankle tendons. For the first time we have identified multiple sub-populations of cells in human tendons. These findings challenge the view that there is a single principal tendon cell type and open new avenues for further study. Healthy tendon samples were obtained from patients undergoing tendon transfer procedures; including tibialis posterior and FHL. Diseased tendon samples were obtained during debridement of intractable Achilles and peroneal tendinopathy, and during fusion of degenerative joints. Single cell RNA sequencing with surface proteomic analysis identified 10 sub-populations of human tendon derived cells. These included groups expressing genes associated with fibro-adipogenic progenitors (FAPs) as well as ITGA7+VCAM1- recently described in mouse muscle but, as yet, not human tendon. In addition we have identified previously unrecognised sub-classes of collagen type 1 associated tendon cells. Each sub-class expresses a different set of extra-cellular matrix genes suggesting they each play a unique role in maintaining the structural integrity of normal tendon. Diseased tendon harboured a greater proportion of macrophages and cytotoxic lymphocytes than healthy tendon. This inflammatory response is potentially driven by resident tendon fibroblasts which show increased expression of pro-inflammatory cytokines. Finally, identification of a previously unknown sub-population of cells found predominantly in tendinopathic tissue offers new insight into the underlying pathophysiology. Further work aims to identify novel proteins targets for possible therapeutic pathways

Acquired flatfoot deformity after injury is usually due to partial or complete tearing of the tendon of tibialis posterior, with secondary failure of the other structures which maintain the medial longitudinal arch. We describe a patient in whom the rupture of the plantar calcaneonavicular (spring) ligament resulted in a clinical picture similar to that of rupture of the tendon of tibialis posterior. Operative repair of the ligament and transfer of the tendon of flexor digitorum gave an excellent result at four years with the patient returning to full sporting activities

Introduction. Fixation of posterior malleolar fragments associated with ankle fractures aims to stabilise the syndesmosis and prevent posterior subluxation. Haraguchi described 3 types of posterior malleolar fractures, with type 2 being a medial extension injury, these fractures often involve medial and posterior fragments. We describe the techniques and outcomes for a double window posteromedial approach allowing optimal reduction and stabilisation. Methods. A retrospective review was performed at 2 units, Bristol Royal Infirmary and QE Hospitals Birmingham, between August 2014 and April 2016. Inclusion criteria were all patients having this posteromedial approach for closed ankle fracture fixation. Patients were assessed for complications and postoperative ankle function with the Olerud and Molander scoring system. Results. We identified 9 patients treated over an 18 months with average follow up 9 months (range 4–18 months). All had an ankle dislocation reduced on scene or in ED, with 5 having posterior subluxation of the talus on the original films. None were open injuries. All had fixation of a posteromedial malleolar fragment, with 7 requiring a further direct lateral incision. Olerud and Molander ankle function score averaged at 72 (range 60–85) at short term follow up. Discussion. Approaches to the posteromedial fragments have been previously described in 2 ways. One utilises a window just medial to the Achilles tendon taking the neurovascular bundle medially, while the other approaches between tibialis posterior and FDL taking the neurovascular bundle laterally. Neither delivers complete access to an injury that often has sagittal and coronal splits needing individual reduction and fixation. Our approach over the neurovascular bundle allows 2 safe corridors through a single incision facilitating fragment specific fixation of both the medial and posterior components of the injury. Early results suggest this to be a safe and reliable technique to reduce and stabilise complex posteromedial ankle fractures

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

Introduction:. The purpose of this study was to elucidate the specific radiographic effects that the Cotton osteotomy confers when used in combination with other reconstructive procedures in the management of the flexible flat foot deformity. Methods:. Between 2002–2013, 198 Cotton osteotomies were retrospectively identified following IRB approval. 131 were excluded on the basis of ipsilateral mid/hindfoot arthrodesis, inadequate radiographs or being less than 18yrs old at time of surgery. Parameters including the articular surface angles of the hindfoot/forefoot, Meary's angle and a newly defined Medial Arch Sag Angle (MASA) were recorded. A matched group of patients who did not undergo a Cotton osteotomy but who underwent similar hindfoot reconstructive procedures served as historic controls. Results:. 67 Cotton osteotomies in 59 patients with a mean age of 45 years (range, 18–80) were evaluated. Concomitant procedures included combinations of tibialis posterior tendon (PTT) reconstruction, Evans lateral column lengthening, medial displacement calcaneal osteotomy (MDCO). In all patients who underwent a Cotton osteotomy, there were statistically significant improvements in the articular surface angles along the medial side of the foot (p < 0.05). Improvement in arch height was also found to be statistically significant (p < 0.05). In comparison to matched controls, the Cotton osteotomy did not improve Meary's angle but provided an additional 11.21° of MASA correction (p < 0.05) when used in in conjunction with the Evans procedure and PTT reconstruction. A similar trend was seen with MDCO and PTT reconstruction. Discussion:. This study confirms the Cotton osteotomy is a powerful surgical adjunct in flatfoot reconstruction and quantifies the additional 11.21° of MASA correction it provides when the Cotton osteotomy is added to a calcaneal osteotomy and PTT reconstruction. This has relevance as an alternative for selection of a medial column stabilization procedure, which is joint sparing

Introduction:. Peroneal muscle weakness is a common pathology in foot and ankle surgery. Polio, charcot marie tooth disease and spina bifida are associated with varying degrees of peroneal muscle paralysis. Tibialis Posterior, an antagonist of the peroneal muscles, becomes pathologically dominant, causing foot adduction and contributes to cavus foot posture. Refunctioning the peroneus muscles would enhance stability in toe off and resist the deforming force of tibialis posterior. This study determines the feasibility of a novel tendon transfer between peroneus longus and gastrocnemius, thus enabling gastrocnemius to power a paralysed peroneus tendon. Method:. 12 human disarticulated lower limbs were dissected to determine the safety and practicality of a tendon transfer between peroneus longus and gastrocnemius at the junction of the middle and distal thirds of the fibula. The following measurements were made and anatomical relationships quantified at the proposed site of the tendon transfer: The distance of the sural nerve to the palpable posterior border of the fibula; the angular relationship of the peroneus longus tendon to gastrocnemius and the achilles tendon; the surgical field for the proposed tendon transfer was explored to determine the presence of hazards which would prevent the tendon transfer. Results:. The mean angle between the tendons of peroneus longus and gastrocnemius/achilles tendon was 3°. The sural nerve lies on average 30 mm posterior to the palpable posterior border of the fibula. There were no significant intervening structures to prevent the proposed tendon transfer. Conclusion:. The line of action of peroneus longus and gastrocnemius are as near parallel as to be functionally collinear. The action of gastrocnemius may be harnessed to effectively power a paralysed peroneus longus tendon, without significant loss of force owing to revectoring of forces. The surgical approach to effect such a tendon transfer is both safe and practical

Introduction. Medial calcaneal displacement osteotomy with an FDL tendon transfer is a common method of correcting pes planus deformity secondary to grade II tibialis posterior dysfunction. There is currently no evidence that calcaneal displacement alters the centre of pressure in the foot from a medial to a more central position as the normal shape is reconstituted. Materials and Methods. We prospectively evaluated 12 patients undergoing flatfoot reconstruction. Each patient had a preoperative AOFAS hindfoot score, pedobariographs and antero-posterior and lateral radiographs. This was repeated 6 months following surgery. Results. An angle (α) between the central axis of the foot (calcaneum to 2nd metatarsal head) and the centre of pressure (COP) was calculated for each patient both pre and post operatively and analysed using the Shapiro Wilk and the Students t test. Pressures directly under the 1st and 5th metatarsal heads and the calcaneum were also recorded and the pre and post operative differences analysed. The mean change in α angle is 6.1° (p < 0.01). The mean increase in pressure on the 1st metatarsal head is 460kPa (p = 0.08). The pressure changes on the 5th metatarsal head and the calcaneum are not statistically significant. The mean AOFAS score increases from 39.2 preoperatively to 82.8 postoperatively (p = 0.0019). The Meary angle improves from a mean of 12.7° to 5.7° (p = 0.027) and the calcaneal pitch improves from15.1° to 18.2° (p = 0.12). Conclusion. The medial displacement calcaneal osteotomy is able to significantly lateralise the centre of pressure in the foot and also increases the pressure under the 1st metatarsal head to more closely represent the parameters of the normal foot. The shape of the foot as judged radiographically and the clinical outcomes (AOFAS) are also improved

Aims

Arthroplasty has become increasingly popular to treat end-stage ankle arthritis. Iatrogenic posterior neurovascular and tendinous injury have been described from saw cuts. However, it is hypothesized that posterior ankle structures could be damaged by inserting tibial guide pins too deeply and be a potential cause of residual hindfoot pain.

Introduction. Major ankle and hindfoot surgery has traditionally been performed as an inpatient. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to contemplate performing major ankle and hindfoot operations as a day-case. This could have a significant impact on length of stay for these major cases, saving resources and in keeping with government policy. In this study, we prospectively audited the outcome of the first cohort of patients undergoing major ankle and hindfoot surgery as a day-case against a series of standards. Methods. Twenty four consecutive patients who underwent ankle or hindfoot surgery between August 2009 and April 2010 were considered for day surgery. Seven patients were deemed not suitable due to co-existing medical conditions or insufficient help at home. This left 17 patients who had ankle or hindfoot surgery as a day case. All patients received an ultrasound-guided regional nerve block and spinal or general anaesthesia. The data was collected on patient demographics, diagnosis, and type of surgical procedure. Patients received the standard follow-up regimen for a particular procedure. Patient satisfaction was assessed using a standard questionnaire which included self-monitoring of post-operative pain at 6, 24 and 48 hrs. In addition, any adverse outcomes were recorded. Results. The average age was 48 (range 23-67) years. There were 7 males and 10 females. The surgical procedures included arthroscopic ankle fusion (5), subtalar fusion (5), talonavicular fusion (1) midfoot fusion with calcaneal osteotomy (1), tibialis posterior reconstruction (3) tendo-achilles reconstruction (1) and arthroscopy and lateral ligament reconstruction (1). 93% patients reported that they were given enough information and advice about their operation as a day case. No patients reported severe pain at 6 hrs. One patient had severe pain at 24 hrs post-op. Four patients (23%) had significant pain at 48 hrs and required strong analgesia. Thirteen (77%) patients stated that they would recommend having this surgery as a day-case if they were having it again whereas four (23%) would prefer staying in overnight. The average length of stay for the patients deemed unsuitable for day surgery was 3.8 (range 1-6) days. Conclusions. Our initial results of performing major ankle and hindfoot procedures as day surgery are encouraging but pain control at 48 hrs still remains an unsolved issue and further optimisation is needed

Aims

To assess the effect of age on clinical outcome and revision rates in patients who underwent total ankle arthroplasty (TAA) for end-stage ankle osteoarthritis (OA).

Aims

There has been an evolution recently in the management of unstable fractures of the ankle with a trend towards direct fixation of a posterior malleolar fragment. Within these fractures, Haraguchi type 2 fractures extend medially and often cannot be fixed using a standard posterolateral approach. Our aim was to describe the posteromedial approach to address these fractures and to assess its efficacy and safety.

Aims

The traditional transosseus flexor hallucis longus (FHL) tendon transfer for patients with Achilles tendinopathy requires two incisions to harvest a long tendon graft. The use of a bio-tenodesis screw enables a short graft to be used and is less invasive, but lacks supporting evidence about its biomechanical behaviour. We aimed, in this study, to compare the strength of the traditional transosseus tendon-to-tendon fixation with tendon-to-bone fixation using a tenodesis screw, in cyclical loading and ultimate load testing.

Aims

Anatomical atlases document classical safe corridors for the placement of transosseous fine wires through the calcaneum during circular frame external fixation. During this process, the posterior tibial neurovascular bundle (PTNVB) is placed at risk, though this has not been previously quantified. We describe a cadaveric study to investigate a safe technique for posterolateral to anteromedial fine wire insertion through the body of the calcaneum.

Aims

Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot.

Aims

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?