From 1975 to 1990 we performed subtalar or triple arthrodesis on 54 patients; 48 of them were reviewed after a mean follow-up of 10 years (6 to 15). There were 17 subtalar fusions in 14 patients and 37 triple arthrodeses in 28 patients. We assessed tibiotalar ankle function using the criteria of Mazur which gives a points score of a maximum of 100. Radiological evidence of degenerative change was graded on a scale of 0 to 4. The mean Mazur score was 85 for the subtalar fusions and 78 for the triple arthrodeses. The radiological score showed no degenerative changes in 36 feet (24 triple and 12 subtalar arthrodeses) and an increase of one grade in 14 feet (10 triple and 4 subtalar), of two grades in three feet (all triple arthrodeses) and of three grades in one foot after a subtalar arthrodesis. We found no statistically significant difference in the radiological score in unilateral fusions between feet with subtalar and triple arthrodeses and the contralateral foot. In all four feet which showed an increase in degenerative changes of two or more grades, there was an abnormality of the tibiotalar joint before the fusion operation. Of the 14 feet which showed an increase of one grade, there was a similar increase on the contralateral side in nine. Our findings show that subtalar or triple arthrodesis has little adverse influence on the function of the tibiotalar joint, even after many years

The April 2024 Foot & Ankle Roundup. 360. looks at: Safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus; Bipolar allograft transplantation of the ankle; Identifying risk factors for osteonecrosis after talar fracture; Balancing act: immediate versus delayed weightbearing in ankle fracture recovery; Levelling the field: proximal supination osteotomy’s efficacy in severe and super-severe hallux valgus; Restoring balance: how adjusting the tibiotalar joint line influences movement after ankle surgery

Objectives. The objective of this study was to quantify the relative movement between the articular surfaces in the tibiotalar and subtalar joints during normal walking in asymptomatic individuals. Methods. 3D movement data of the ankle joint complex were acquired from 18 subjects using a biplanar fluoroscopic system and 3D-to-2D registration of bone models obtained from CT images. Surface relative velocity vectors (SRVVs) of the articular surfaces of the tibiotalar and subtalar joints were calculated. The relative movement of the articulating surfaces was quantified as the mean relative speed (RS) and synchronization index (SI. ENT. ) of the SRVVs. Results. SI. ENT. and mean RS data showed that the tibiotalar joint exhibited translational movement throughout the stance, with a mean SI. ENT. of 0.54 (. sd. 0.21). The mean RS of the tibiotalar joint during the 0% to 20% post heel-strike phase was 36.0 mm/s (. sd. 14.2), which was higher than for the rest of the stance period. The subtalar joint had a mean SI. ENT. value of 0.43 (. sd. 0.21) during the stance phase and exhibited a greater degree of rotational movement than the tibiotalar joint. The mean relative speeds of the subtalar joint in early (0% to 10%) and late (80% to 90%) stance were 23.9 mm/s (. sd. 11.3) and 25.1 mm/s (. sd 9.5). , respectively, which were significantly higher than the mean RS during mid-stance (10% to 80%). Conclusion. The tibiotalar and subtalar joints exhibited significant translational and rotational movement in the initial stance, whereas only the subtalar joint exhibited significant rotational movement during the late stance. The relative movement on the articular surfaces provided deeper insight into the interactions between articular surfaces, which are unobtainable using the joint coordinate system. Cite this article: C-B. Phan, D-P. Nguyen, K. M. Lee, S. Koo. Relative movement on the articular surfaces of the tibiotalar and subtalar joints during walking. Bone Joint Res 2018;7:501–507. DOI: 10.1302/2046-3758.78.BJR-2018-0014.R1

It has been suggested that a supramalleolar osteotomy can return the load distribution in the ankle joint to normal. However, due to the lack of biomechanical data, this supposition remains empirical. The purpose of this biomechanical study was to determine the effect of simulated supramalleolar varus and valgus alignment on the tibiotalar joint pressure, in order to investigate its relationship to the development of osteoarthritis. We also wished to establish the rationale behind corrective osteotomy of the distal tibia. We studied 17 cadaveric lower legs and quantified the changes in pressure and force transfer across the tibiotalar joint for various degrees of varus and valgus deformity in the supramalleolar area. We assumed that a supramalleolar osteotomy which created a varus deformity of the ankle would result in medial overload of the tibiotalar joint. Similarly, we thought that creating a supramalleolar valgus deformity would cause a shift in contact towards the lateral side of the tibiotalar joint. The opposite was observed. The restricting role of the fibula was revealed by carrying out an osteotomy directly above the syndesmosis. In end-stage ankle osteoarthritis with either a valgus or varus deformity, the role of the fibula should be appreciated and its effect addressed where appropriate

Myriad protocols exist for isolated Weber B lateral malleolus fractures with a congruent tibiotalar joint on initial radiographs. Stress and weight-bearing radiographs, all at various timepoints, may be employed to identify those injuries that develop significant talar shift but consensus is elusive. This study outlines a safe and reproducible protocol for such injuries, utilising a removable orthosis, immediate weight bearing and standard supine radiographs. A retrospective analysis of a prospective trauma database was analysed to identify patients with an isolated Weber B ankle fracture with adequate presentation radiographs demonstrating a congruent mortise. Patient records and radiographs were evaluated a minimum of 5 years after initial presentation to determine ankle stability, complications, and the burden on outpatient services. Between 2014 and 2016, 657 patients were referred to the specialist trauma clinic from the emergency department. Of the 657, 52 patients had inadequate ED radiographs to determine ankle congruity. At the two-week assessment, 11 of the 52 demonstrated talar shift and required intervention. Therefore 646 patients demonstrated ankle congruity at two weeks after weight bearing. No patient demonstrated talar shift at the six-week assessment. Average number of follow up appointments was 2.4 with 3.5 radiographs. Our new treatment protocol advocates discharge after a single orthopaedic assessment after two weeks of weight bearing. This study supports immediate weight-bearing of Weber B ankle fractures with a congruent mortise in an orthosis. Follow up beyond two weeks is unnecessary and our protocol offers a safe means of significantly reducing the outpatient burden

To be able to assess the biomechanical and functional effects of ankle injury and disease it is necessary to characterise healthy ankle kinematics. Due to the anatomical complexity of the ankle, it is difficult to accurately measure the Tibiotalar and Subtalar joint angles using traditional marker-based motion capture techniques. Biplane Video X-ray (BVX) is an imaging technique that allows direct measurement of individual bones using high-speed, dynamic X-rays. The objective is to develop an in-vivo protocol for the hindfoot looking at the tibiotalar and subtalar joint during different activities of living. A bespoke raised walkway was manufactured to position the foot and ankle inside the field of view of the BVX system. Three healthy volunteers performed three gait and step-down trials while capturing Biplane Video X-Ray (125Hz, 1.25ms, 80kVp and 160 mA) and underwent MR imaging (Magnetom 3T Prisma, Siemens) which were manually segmented into 3D bone models (Simpleware Scan IP, Synopsis). Bone position and orientation for the Talus, Calcaneus and Tibia were calculated by manual matching of 3D Bone models to X-Rays (DSX Suite, C-Motion, Inc.). Kinematics were calculated using MATLAB (MathWorks, Inc. USA). Pilot results showed that for the subtalar joint there was greater range of motion (ROM) for Inversion and Dorsiflexion angles during stance phase of gait and reduced ROM for Internal Rotation compared with step down. For the tibiotalar joint, Gait had greater inversion and internal rotation ROM and reduced dorsiflexion ROM when compared with step down. The developed protocol successfully calculated the in-vivo kinematics of the tibiotalar and subtalar joints for different dynamic activities of daily living. These pilot results show the different kinematic profiles between two different activities of daily living. Future work will investigate translation kinematics of the two joints to fully characterise healthy kinematics

Background. Ankle and hindfoot fusion in the presence of large bony defects represents a challenging problem. Treatment options include acute shortening and fusion or void filling with metal cages or structural allograft, which both have historically low union rates. Impaction grafting is an alternative option. Methods. A 2 centre retrospective review of consecutive series of 32 patients undergoing hindfoot fusions with impaction bone grafting of morselised femoral head allograft to fill large bony void defects was performed. Union was assessed clinically and with either plain radiography or weightbearing CT scanning. Indications included failed total ankle replacement (24 patients), talar osteonecrosis (6 patients) and fracture non-union (2 patients). Mean depth of the defect was 29 ±10.7 mm and mean maximal cross-sectional area was 15.9 ±5.8 cm. 2. Tibiotalocalcaneal (TTC) arthrodesis was performed in 24 patients, ankle arthrodesis in 7 patients and triple arthrodesis in 1 patient. Results. Mean age was 57 years (19–76 years). Mean follow-up of 22.8 ±8.3 months. 22% were smokers. There were 4 tibiotalar non-unions (12.5%), two of which were symptomatic. 10 TTC arthrodesis patients united at the tibiotalar joint but not at the subtalar joint (31.3%), but only two of these were symptomatic. The combined symptomatic non-union rate was 12.5%. Mean time to union was 9.6 ±5.9 months. One subtalar non-union patient underwent re-operation at 78 months post-operatively after failure of metalwork. Two (13%) patients developed a stress fracture above the metalwork that healed with non-operative measures. There was no bone graft collapse with all patients maintaining bone length. Conclusion. Impaction of morselised femoral head allograft can be used to fill large bony voids around the ankle and hindfoot when undertaking arthrodesis, with rapid graft incorporation and no graft collapse despite early loading. This technique offers satisfactory union outcomes without the need for shortening or synthetic cages

Purpose. The goal of Total Ankle Arthroplasty (TAA) is to relieve pain and restore healthy function of the intact ankle. Restoring intact ankle kinematics is an important step in restoring normal function to the joint. Previous robotic laxity testing and functional activity simulation showed the intact and implanted motion of the tibia relative to the calcaneus is similar. However there is limited data on the tibiotalar joint in either the intact or implanted state. This current study compares modern anatomically designed TAA to intact tibiotalar motion. Method. A robotic testing system including a 6 DOF load cell (AMTI, Waltham, MA) was used to evaluate a simulated functional activity before and after implantation of a modern anatomically designed TAA (Figure 1). An experienced foot and ankle surgeon performed TAA on five fresh-frozen cadaveric specimens. The specimen tibia and fibula were potted and affixed to the robot arm (KUKA Robotics Inc., Augsburg, Germany) while the calcaneus was secured to a fixed pedestal (Figure 1). Passive reflective motion capture arrays were fixed to the tibia and talus and a portable coordinate measuring machine (Hexagon Metrology Group, Stockholm, Sweden) established the location of the markers relative to anatomical landmarks palpated on the tibia. A four camera motion capture system (The Motion Monitor, Innovative Sports Training, Chicago, IL) recorded the movement of the tibia and talus. The tibia was rotated from 30 degrees plantar flexion to 15 degrees dorsiflexion to simulate motions during the stance phase of gait. At each flexion angle the robot found the orientation which zeroed all forces and torques except compressive force, which was either 44N or 200N. Results. Preliminary data indicates the tibiotalar motion of the TAA is similar to the intact ankle. The pattern and magnitude of tibiotalar translations and rotations are similar between the intact and implanted states for both 44N and 200N compressive loads (Figure 2). The most variation occurs with internal-external rotation. Increased translation especially in the anterior-posterior directions was observed in plantarflexion while the mediolateral translation remained relatively centered moving less than a millimeter. The intact talus with respect to the calcaneus had less than 3 degrees of rotation over the whole arc of ankle flexion (Figure 3). The angular motion of the implanted talus was similar in pattern to the intact talus, however there were offsets in all three angular directions which changed depending on the loading (Figure 3). This indicates that most of the motion that occurs between the intact tibial calcaneal complex occurs in the tibiotalar joint. Conclusion. Although more investigation is required, this study adds to the limited available tibiotalar kinematic data. This current study suggests the anatomical TAA design allows the tibiotalar joint to behave in similar way to the intact tibiotalar joint. Restoring intact kinematics is an important step in restoring normal function to the joint. For figures/tables, please contact authors directly.

Management of ankle arthritis in young patients is challenging. Although ankle arthrodesis gives consistent pain relief, it leads to loss of function and adjacent joint arthritis. Ankle joint distraction (AJD) has been shown to give good outcomes in adults with osteoarthritis or post-traumatic arthritis. The efficacy in children or young adults and those with juvenile idiopathic arthritis is less well evidenced. Clinical notes and radiographs of all patients (n=6) managed with AJD in one tertiary referral centre were retrospectively reviewed. Radiographs were taken pre-surgery, intra-operatively, 1 month following frame removal and at the last follow up, tibiotalar joint space was assessed using ImageJ software. Measurements were taken at the medial, middle and lateral talar dome using frame components as reference. Radiographic data for patients with a good clinical outcome was compared with those who did not. At time of surgery mean age was 16.1 years (12 – 25 years). Mean follow up was 3.4 years (1.5 – 5.9 years). Indications were juvenile idiopathic arthritis (4) post-traumatic (1) and post-infective arthritis (1). Three patients at last follow up had a good clinical outcome. Two patients required revision to arthrodesis (1.3 and 2.4 years following distraction). One patient had spontaneous fusion. One patient required oral antibiotics for pin site infection. Inter-observer reliability was 95%. Mean joint space was 1.17mm (SD = 0.87mm) pre-operatively which increased to 6.72mm (SD = 2.23mm) at the time of distraction and 2.09mm (SD = 1.14mm) at the time of removal. At one-year follow up, mean joint space was 1.96mm (SD = 1.97mm). Outcomes following AJD in this population are variable although significant benefits were demonstrated for 50% of the patients in this series. Radiographic joint space preoperatively did not appear to be associated with need for arthrodesis. Further research in larger groups of young patients is required

Background. Procedural sedation (PS) requires two suitably qualified clinicians and a dedicated monitored bed space. We present the results of intra-articular haematoma blocks (IAHB), using local anaesthetic, for the manipulation of closed ankle fracture dislocations and compared resource use with PS. Methods. Patients received intra-articular ankle haematoma blocks for displaced ankle fractures requiring manipulation between October 2020 to April 2021. The technique used 10ml of 1% lignocaine injected anteromedially into the tibiotalar joint. Pain scores (VAS), time from first x-ray to reduction, and acceptability of reduction were recorded. A comparison was made by retrospective analysis of patients who had undergone PS for manipulation of an ankle fracture over the six month period March – August 2020. Results. During the periods assessed, 25 patients received an IAHB and 28 received PS for ankle fractures requiring manipulation (mean age 57.8yr vs 55.1yr). Time from first x-ray to manipulation was 65.9 min (IAHB) vs 82.9 min (PS) (p = 0.087). In the IAHB group mean pain scores pre, during and post manipulation were 6.1, 4.7 and 2.0 respectively (‘pre’ to ‘during’ p < 0.05; ‘pre’ to ‘post’ p < 0.01). In the IAHB group, 23 (92%) had a satisfactory reduction without need of PS or general anaesthetic. In the PS group 23 (82%) had a satisfactory reduction. There was no significant difference in the number of unsatisfactory first attempt reductions between the groups. There were no cases of deep infection post operatively in either group. Conclusion. Intra-articular haematoma block of the ankle appears to be an efficacious, safe and inexpensive means of providing analgesia for manipulation of displaced ankle fractures. Advantages of this method include avoiding the risks of procedural sedation, removing the requirement of designated clinical space and need for qualified clinicians to give sedation, and the ability to re-manipulate under the same block

Aims. The aim of this study was to present a series of patients with aseptic failure of a total ankle arthroplasty (TAA) who were treated with fusion of the hindfoot using a nail. Patients and Methods. A total of 23 TAAs, in 22 patients, were revised for aseptic loosening and balloon osteolysis to a hindfoot fusion by a single surgeon (NH) between January 2012 and August 2014. The procedure was carried out without bone graft using the Phoenix, Biomet Hindfoot Arthrodesis Nail. Preoperative investigations included full blood count, CRP and ESR, and radiological investigations including plain radiographs and CT scans. Postoperative plain radiographs were assessed for fusion. When there was any doubt, CT scans were performed. Results. The mean follow-up was 13.9 months (4.3 to 37.2). Union occurred at the tibiotalar joint in 22 ankles (95.6%) with one partial union. Union occurred at the subtalar joint in 20 ankles (87%) of cases with two nonunions. The nail broke in one patient with a subtalar nonunion and revision was undertaken. The only other noted complication was one patient who suffered a stress fracture at the proximal aspect of the nail, which was satisfactorily treated conservatively. Conclusion. This study represents the largest group of patients reported to have undergone revision TAA to fusion of the hindfoot with good results. Cite this article: Bone Joint J 2018;100-B:475–9

Abstract. Skeletal kinematics are traditionally measured by motion analysis methods such as optical motion capture (OMC). While easy to carry out and clinically relevant for certain applications, it is not suitable for analysing the ankle joint due to its anatomical complexity. A greater understanding of the function of healthy ankle joints could lead to an improvement in the success of ankle-replacement surgeries. Biplane video X-ray (BVX) is a technique that allows direct measurement of individual bones using highspeed, dynamic X-Rays. Objective. To develop a protocol to quantify in-vivo foot and ankle kinematics using a bespoke High-speed Dynamic Biplane X-ray system combined with OMC. Methods. Two healthy volunteers performed five level walks and step-down trials while simultaneous capturing BVX and synchronised OMC. participants undertook MR imaging (Magnetom 3T Prisma, Siemens) which was manually segmented into 3D bone models (Simpleware Scan IP, Synopsis). Bone position and orientation for the Talus, Tibia and Calcaneus were calculated by manual matching of 3D Bone models to X-Rays (DSX Suite, C-Motion, Inc.). OMC markers were tracked (QTM, Qualisys) and processed using Visual 3D (C-motion, Inc.). Results. Initial results for level walking showed that OMC overestimated the rotational range of motion (ROM) in all three planes for the tibiotalar joint compared with BVX (Sagittal: OMC 30°/BVX 20°, Frontal: OMC 16°/BVX 15° and Transverse: OMC 20°/BVX 17°). For the subtalar joint, OMC (22°) over-estimated sagittal ROM compared with BVX (14°) and underestimated the ROM in the other planes (Frontal: OMC 8°/BVX 15° and Transverse: OMC 18°/BVX 20°). Conclusions. The results highlight the discrepancy between OMC and BVX methods. However, the BVX results are consistent with previous literature. The protocol developed here will form the foundation of future patient-based studies to investigate in-vivo ankle kinematics. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

A 16-year-old professional female ballet student sustained a plantar flexion-inversion injury to her left ankle while dancing. Clinical examination and MRI suggested subluxation of the tibiotalar joint. However, accurate diagnosis was hampered by a transient palsy of the common peroneal nerve. It was subsequently established that she had also sustained a dislocation of her calcaneocuboid joint, a rare injury, which was successfully stabilised by using a hamstring graft. The presentation and management of this rare condition are discussed

Purpose: Tibiotalar arthrodesis is a classical procedure for the treatment of painful deformation-destruction of the tibiotalar joint. The purpose of this retrospective study was to determine prognostic factors and tolerance to tibiotalar arthrodesis observed in 68 procedures performed with two different techniques (47 surgical fusions (Group 1), and 21 arthroscopic fusions (Group 2)). Material and methods: Between 1985 and 1999, 68 patients, mean age 51 years (22–88) underwent 55 arthrodesis procedures (47 post-traumatic, 2 paralytic, 6 rheumatoid polyarthritis, 4 sequelae of septic arthritis). All patients had major functional impairment. The tibiotalar joint was stiff in all cases and mean motion was 20 ± 15°. The subtalar facet was nearly normal in 33 cases, altered in six and had already fused in nine. The mediotarsal facet was altered in 12 cases, six had already had a double arthrodesis, and was normal in 50. On the preoperative Méary view, there was a normal axis in 13 patients, valgus in 28 and varus in 24. According to the Duquennoy radiographic criteria, there was subtalar involvement in 32 cases and mediotarsal involvement in 19. Tibiotalar arthrodeses procedures were performed arthroscopically after 1993 for cases with little axial deformation. Open surgery was used for all other cases (43 Méary technique). A plaster cast was used in all cases. All patients were reviewed using the Duguennoy score and two radiographic views: lateral weight-bearing view for the sagittal plane position (tibiopedious angle) and the Méary view for the frontal plane. Results: At a mean follow-up of four years, fusion rate was 82% (group 1 83%, group 2 81%). Mean delay to fusion was 3.2 ± 1 month irrespective of the causal disease or surgical technique. Functional outcome was very good in 28%, good in 34.5%, fair in 34.5% and poor in 3% and did not depend on the surgical technique. The subtalar was painful with zero motion in 18 cases (26.5%), generally associated with residual equine. The mediotarsal was stiff in 17 cases and very painful in four. In the frontal plane, 16 ankles were correctly axed, 27 were in valgus (mean 5.6°) and 20 in varus (mean 7.6°) with no difference between the two groups. In the sagittal plane, four ankles were in talus, nine in neutral position, and 49 had a residual equine, including 32 > 5°. In most cases, fair or poor outcome was related to subtalar pain. More than 50% of the patients with equine fusion greater than 5° had subtalar pain. Conclusion: For the same deformity, arthroscopic arthrodesis can shorten hospital stay and improve the rate and degree of trophic disorders. Arthroscopic tibiotalar arthrodesis is an elegant technique that we use for centred ankles or for patients with risk factors, particularly skin conditions. The rate of fusion with the arthroscopic approach is not however better than with open surgery. Precise clinical and radiological assessment of the subtalar facet as well as the position of the fusion in the sagittal plane at 90° without equine deviation are important prognostic factors observed in this series

Aims. Involvement of the posterior malleolus in fractures of the ankle probably adversely affects the functional outcome and may be associated with the development of post-traumatic osteoarthritis. Anatomical reduction is a predictor of a successful outcome. The purpose of this study was to describe the technique and short-term outcome of patients with trimalleolar fractures, who were treated surgically using a posterolateral approach in our hospital between 2010 and 2014. Patients and Methods. The study involved 52 patients. Their mean age was 49 years (22 to 79). There were 41 (79%) AO 44B-type and 11 (21%) 44C-type fractures. The mean size of the posterior fragment was 27% (10% to 52%) of the tibiotalar joint surface. Results. Reduction was anatomical in all patients with a residual step in the articular surface of ≤ 1 mm. In nine of the C-type fractures (82%), the syndesmosis was stable after fixation of the posterior fragment and a syndesmosis screw was not required. Apart from one superficial wound infection, there were no wound healing problems. At a mean radiological follow-up of 34 weeks (seven to 131), one patient with a 44C-type fracture had widening of the syndesmosis which required further surgery. Conclusion. We conclude that the posterolateral surgical approach to the ankle gives adequate access to the posterior malleolus, allowing its anatomical reduction and stable fixation: it has few complications. Take home message: Fixation of the posterior malleolus in trimalleolar fractures can be easily done via the posterolateral approach whereby anatomical reduction and stable fixation can be reached due to adequate visualisation of the fracture. Cite this article: Bone Joint J 2016;98-B:812–17

Traditional screw fixation of the syndesmosis can be prone to malreduction. Suture button fixation however, has recently shown potential in securing the fibula back into the incisura even with intentional malreduction. Yet, if there is sufficient motion to aid reduction, the question arises of whether or not this construct is stable enough to maintain reduction under loaded conditions. To date, there have been no studies assessing the optimal biomechanical tension of these constructs. The purpose of this study was to assess optimal tensioning of suture button fixation and its ability to maintain reduction under loaded conditions using a novel stress CT model. Ten cadaveric lower limbs disarticulated at the knee were used. The limbs were placed in a modified external fixator frame that allows for the application of sustained torsional (5 Nm), axial (500 N) and combined torsional/axial (5Nm/500N) loads. Baseline CT scans of the intact ankle under unloaded and loaded conditions were obtaining. The syndesmosis and the deltoid ligament complex were then sectioned. The limbs were then randomised to receive a suture button construct tightened at 4 kg force (loose), 8 kg (standard), or 12 kg (maximal) of tension and CT scans under loaded and unloaded conditions were again obtained. Eight previously described measurements were taken from axial slices 10 mm above the tibiotalar joint to assess the joint morphology under the intact and repair states, and the three loading conditions: a measure of posterolateral translation (a, b), medial/lateral translation (c, g), a measure of anterior-posterior translation (f), a ratio of anterior-posterior translation (d/e), an angle (Angle 1) created by a line parallel to the incisura and the axis of the fibula, and an angle (Angle 2) created between the medial surfaces of two malleoli. These measurements have all been previously described. Each measurement was taken at baseline and compared with the three loading scenarios. A repeated measures ANOVA with a Bonferroni correction for multiple comparisons was used to test for significance. Significant lateral (g, maximum 5.26 mm), posterior (f, maximum 6.42 mm), and external rotation (angle 2, maximum 11.71°) was noted with the 4 kg repair when compared to the intact, loaded state. Significant posterior translation was also seen with the both the 8 kg and 12 kg repairs, however the incidence and magnitude was less than with the 4 kg repair. Significant overcompression (g, 1.69 mm) was noted with the 12 kg repair. Suture button constructs must be appropriately tensioned to maintain reduction and re-approximate the degree of physiological motion at the distal tibiofibular joint. If inserted too loosely, these constructs allow for supraphysiologic motion which may have negative implications on ligament healing. These constructs also demonstrate overcompression of the syndesmosis when inserted at maximal tension however the clinical effect of this remains to be determined

The February 2023 Foot & Ankle Roundup³⁶⁰ looks at: Joint inflammatory response in ankle and pilon fractures; Tibiotalocalcaneal fusion with a custom cage; Topical application of tranexamic acid can reduce blood loss in calcaneal fractures; Risk factors for failure of total ankle arthroplasty; Pain catastrophizing: the same as pain forecasting?.

Between 1999 and 2005, 23 failed total ankle replacements were converted to arthrodeses. Three surgical techniques were used: tibiotalar arthrodesis with screw fixation, tibiotalocalcaneal arthrodesis with screw fixation, and tibiotalocalcaneal arthrodesis with an intramedullary nail. As experience was gained, the benefits and problems became apparent. Successful bony union was seen in 17 of the 23 ankles. The complication rate was higher in ankles where the loosening had caused extensive destruction of the body of the talus, usually in rheumatoid arthritis. In this situation we recommend tibiotalocalcaneal arthrodesis with an intramedullary nail. This technique can also be used when there is severe arthritic change in the subtalar joint. Arthrodesis of the tibiotalar joint alone using compression screws was generally possible in osteoarthritis because the destruction of the body of the talus was less extensive. Tibiotalocalcaneal arthrodesis fusion with compression screws has not been successful in our experience

Tibiotalocalcaneal (TTC) arthrodesis using a retrograde nail is a common salvage procedure for a range of indications. Previous work has suggested subtalar joint preparation is unnecessary to achieve satisfactory results. We examine the incidence of symptomatic subtalar nonunion following tibiotalocalcaneal fusion in a series of patients, all of whom had full preparation of the subtalar joint, and consider the possible contributing factors. We performed a retrospective review of all patients who underwent TTC arthrodesis from 2004–2010. All fusions were performed by the same surgeon with full preparation of both tibiotalar and subtalar joints. 61 TTC arthrodeses were performed in 55 patients (mean age = 59 years) using an intramedullary retrograde nail. Mean follow-up was 18 months (6–48 months). Fifty-six ankles (92%) achieved satisfactory union. Five patients (8%) had symptomatic non-union: 4 patients of the subtalar joint - with 3 patients undergoing revision subtalar arthrodesis and 1 patient of the tibiotalar joint. Nine patients required removal of the calcaneal screw (16%) – all had evidence of isolated subtalar nonunion prior to metalwork failure. Eight of these patients achieved asymptomatic union following screw removal. Subtalar nonunion following TTC fusion has resulted in recent changes to nail design to increase stability across the subtalar joint. Our results demonstrate a favourable overall nonunion rate with isolated subtalar nonunion making up the majority of cases. We also observed a significant rate of distal screw loosening, also associated with subtalar nonunion prior to screw removal, the significance of which merits further investigation