Lisfranc injuries were previously described as fracture-dislocations of the tarsometatarsal joints. With advancements in modern imaging, subtle Lisfranc injuries are now more frequently recognized, revealing that their true incidence is much higher than previously thought. Injury patterns can vary widely in severity and anatomy. Early diagnosis and treatment are essential to achieve good outcomes. The original classification systems were anatomy-based, and limited as tools for guiding treatment. The current review, using the best available evidence, instead introduces a stability-based classification system, with weightbearing radiographs and CT serving as key diagnostic tools. Stable injuries generally have good outcomes with nonoperative management, most reliably treated with immobilization and non-weightbearing for six weeks. Displaced or comminuted injuries require surgical intervention, with open reduction and internal fixation (ORIF) being the most common approach, with a consensus towards bridge plating. While ORIF generally achieves satisfactory results, its effectiveness can vary, particularly in high-energy injuries. Primary arthrodesis remains niche for the treatment of acute injuries, but may offer benefits such as lower rates of post-traumatic arthritis and hardware removal. Novel fixation techniques, including suture button fixation, aim to provide flexible stabilization, which theoretically could improve midfoot biomechanics and reduce complications. Early findings suggest promising functional outcomes, but further studies are required to validate this method compared with established techniques. Future research should focus on refining stability-based classification systems, validation of weightbearing CT, improving rehabilitation protocols, and optimizing surgical techniques for various injury patterns to ultimately enhance patient outcomes.

Cite this article: Bone Joint J 2024;106-B(12):1431–1442.

Introduction

Early clinical examination combined with MRI following a high ankle sprain allows accurate diagnosis of syndesmosis instability. However, patients often present late, and for chronic injuries clinical assessment is less reliable. Furthermore, in many centres MRI may be not be readily available. The aims of the current study were to define MRI characteristics associated with syndesmosis instability, and to determine whether MRI patterns differed according to time from injury.

Introduction

Osteoarthritis in the foot and ankle affects approximately 30,000 patients annually in the UK. Evidence has shown that excess weight exacerbates foot pain, with significant increases in joint forces. However, despite the current trend for Clinical Commissioning Groups to ration surgery for obese patients, studies have not yet determined the effect of weight loss in obese patients with foot and ankle arthritis.

The TL Hex (Orthofix) is a relatively new hexapod frame system that we have been using at our institution since August 2013 to treat acute fractures and correct tibial and femoral deformity. We report our initial experience of 48 completed treatments with this novel system in 46 patients and discuss illustrative cases.

For acute fracture, 30 patients (24 male, 7 female) required framing with a mean age of 43 years (range 19–80). One patient underwent bilateral framing. The tibia was involved in all cases. In two cases, the femur also required framing. Open fractures occurred in 13 cases (43.3%).

For elective limb reconstruction, 16 patients (14 male, two female) required framing with a mean age of 35 years (range 16–67). One patient underwent bilateral framing. The tibia was involved in all but one case, which affected the femur. Surgical indications included congenital deformity in four cases, malunion in eight cases, non-union in three cases and chronic infection in two cases.

For acute fractures, the mean frame time was 164 days (range 63–560) and all but one fracture achieved union. Complications included pin, wire or strut failure requiring adjustment (three patients) and pin site infection (six patients). Three patients are being considered for residual deformity correction or treatment of non-union.

In the elective limb reconstruction group, mean frame time was 220 days (range 140–462). All treatments successfully achieved deformity correction and bone union. Complications included two pin site infections. There was no evidence of recurrence of infection in the two osteomyelitis cases.

In conclusion, the TL Hex frame system appears to be a safe and reliable tool for limb reconstruction. We have observed acceptable frame times, low complication rates and almost 100% bony union.

Introduction

Injections are used to treat a wide variety of pathologies. Our aim was to evaluate the efficacy and safety of foot and ankle injections in our clinic.

The saphenous nerve is classically described as innervating skin of the medial foot extending to the first MTP joint and thus is at risk in surgery to the medial ankle and forefoot. However, it has previously been demonstrated by the senior author that the dorsomedial branch of the superficial peroneal nerve consistently supplies the dorsomedial forefoot, leading to debate as to whether the saphenous nerve should routinely be included in ankle blocks for forefoot surgery. We undertook a cadaveric study to assess the presence and variability of the saphenous nerve.

29 feet were dissected from a level 10 cm above the medial malleolus, and distally to the termination of the saphenous nerve. In 24 specimens (83%), a saphenous nerve was present at the ankle joint. In 5 specimens the nerve terminated at the level of the ankle joint, and in 19 specimens the nerve extended to supply the skin distal to the ankle. At the ankle, the mean distance of the nerve from the tibialis anterior tendon and saphenous vein was 14mm and 3mm respectively. The mean distance reached in the foot was 5.1cm. 28% of specimens had a saphenous nerve that reached the first metatarsal and no specimens had a nerve that reached the great toe.

The current study shows that the course of the saphenous nerve is highly variable, and when present usually terminates within 5cm of the ankle. The saphenous nerve is at risk in anteromedial arthroscopy portal placement, and should be included in local anaesthetic ankle blocks in forefoot surgery, as a significant proportion of nerves supply the medial forefoot.

Aims

Cauda equina syndrome (CES) is a rare condition which requires urgent treatment to reduce the risk of long term neurological morbidity. Most authors recommend surgical decompression within 24–48 hours of the onset of symptoms, which may not be possible if there are delays in referral to hospital, performance of diagnostic imaging or poor access to a spine surgeon. We present a snap shot of referrals of patients with suspected cauda equina syndrome to the Orthopaedic department in a district general hospital including the diagnoses, management and outcome.

The saphenous nerve is classically described as innervating skin of the medial foot to the first MTP joint and thus is at risk in surgery to the medial ankle and foot. However, it has previously been demonstrated that the dorsomedial branch of the superficial peroneal nerve consistently supplies the dorsomedial forefoot, and therefore previous descriptions of the saphenous nerve maybe erroneous.

We undertook a cadaveric study to assess the presence and variability of this nerve.

21 cadaveric feet were dissected from a level 5 cm above the medial malleolus, and distally to the termination of the saphenous nerve. In 16 specimens (76%), a saphenous nerve was present, of which 14 were anterior to the saphenous vein. Two of 16 nerves terminated above the medial malleolus. Therefore, only 14 of 21 specimens (66%) had a saphenous nerve present at the level of the medial malleolus. In seven of these 14 specimens (50%), the nerve terminally branched before the level of the tip of the malleolus. The mean distance reached in the foot was 46mm. Only two nerves reached the forefoot, at 97mm and 110 mm from the ankle joint respectively. At the ankle, the mean distance of the nerve from the tibialis anterior tendon was 9mm, and the saphenous vein 1.2mm.

We describe the use of a dental tool for the removal of excess cement during unicompartmental knee arthroplasty (UKA).

Retained excess cement following UKA is a well recognised complication. It may result in pain, impingement, loose body symptoms, vascular problems and damage to the prosthesis or structures within the lateral compartment. Symptomatic patients require additional surgery to manage such complications. The removal of excess cement becomes technically difficult during cementation of the prosthesis because there is limited surgical exposure. Consequently, the incidence of retained excess cement associated with minimally invasive knee arthroplasty ranges from 8 to 21%.

The senior author uses a ‘flat plastic’ dental instrument that is ideally shaped for use in UKA. The tool has blunt ends aligned at 90 degrees to each other which are perfectly angled to allow the rapid removal of excess cement from the femoral component and tibial tray during prosthesis insertion. It can be manoeuvred easily to break off excess bits of cement and also to retrieve them by sweeping around the prostheses from back to side. It is also used to assess alignment of the tibial tray medially and posteriorly to feel for over or under hang.

The ‘flat plastic’ dental tool helps to avoid retained excess cement and its associated complications in UKA, and is applicable in other minimally invasive arthroplasty procedures.

Introduction: The success of cemented total hip replacements (THR) has been well documented. However, few studies have shown how patients who have had a primary THR function compare with the general population.

Materials and Methods: We prospectively collected data on 193 patients (83 males, 109 females, 1 missing) who had a primary cemented THR (Exeter stem). 25 patients had bilateral hip replacements. Patients were evaluated using the Oxford Hip Score and Short Form-36 Health Survey (SF-36) questionnaire pre operatively and at 3 months and 1, 3, 4 and 5 years follow up. SF-36 questionnaires were also completed by 8117 people from the general population, recruited from 12 General Practices in the local city. The two groups (age and sex matched) were then compared for quality of life and function.

Results: The mean age of patients in the THR group was 54 years (range 21 – 93 years). The underlying diagnosis was primary osteoarthritis in 159 patients, secondary osteoarthritis in 20 and rheumatoid arthritis in 6 patients. Post operative complications included deep vein thrombosis (2.7%), infection (1.8%) and dislocation (2.7%). There was a significant improvement in the mean Oxford Hip score post operatively in patients following THR and this trend was maintained at 5 years. Apart from physical function, for all other aspects of the SF-36 there were no significant differences between patients following THR at 5 years and that of the general population.

Conclusion: Cemented total hip arthroplasty significantly improves quality of life and can restore it to that of the general population.

Purpose: To assess the outcome of patients with an infected TKA who developed complex wounds requiring surgical intervention in our institution.

Methods: The computerised local database was searched for patients recorded as having complex knee wounds associated with an infected TKA. Fifteen patients operated on between 1997 and 2007 were retrospectively reviewed. Data including the limb salvage rate, type of soft tissue surgery performed, local wound complications, and re-implantation rate were recorded. Average follow up was 3.2 years. Three patients had died at the time of review.

Results: Eleven out of 15 patients had been referred to our centre from other hospitals with an infected TKA. Fourteen patients were treated with two stage revision surgery. The remaining patient had direct exchange of the infected implant. Mean age at the time of surgery to address the soft tissue defect was 69.6 years.

Nine patients required a medial gastrocnemius flap. Three patients received fasciocutaneous flaps (one bipedicle); one patient was managed with a tissue expander pre-operatively; one with a split skin graft, and one patient required perforating skin incisions in order to close the wound. 60% of patients developed local wound complications and 27% required further soft tissue procedures.

The overall limb salvage rate was 73.3% (four patients required an above knee amputation for persistent infection). Five patients had successful re-implantation surgery. Four patients had arthrodesis surgery with successful eradication of infection. Two patients developed chronic infection.

Conclusions: Intensive specialist input from plastic and orthopaedic surgeons is required with such difficult cases. Contrary to recent literature, the risk of failure may be higher than previously thought. Patients should be fully counselled pre-operatively about the risks of such procedures.

Cementless total hip replacements (THR) have a theoretical advantage over cemented designs in that bone lysis and probably aseptic loosening are less common complications. NICE guidelines suggest that prosthesis should have an aseptic loosening rate of < 10% at 10 years. Long-term follow-up of the Joint Replacement Instrumentation (JRI) Hydroxyapatite coated (HAC) Furlong system is gradually emerging following its first clinical application in 1985.

A retrospective study was performed to identify all patients having undergone a primary JRI HAC THR under a single Consultant at Barnsley Foundation Hospital NHS Trust between 1985 and 1995. This identified 124 joints in 106 patients (52% males). All living patients were sent a modified Oxford Hip Score questionnaire; case notes were also reviewed to identify any revision surgeries.

Median age at operation was 54.0 years. 17 patients (16%) had died at the time of this study. Median follow-up was 13.7 years (range 9.4–18.5 years). For 30 patients (24.2%) it was impossible to gather data on the survival of the hip.

Mean survival of all hips followed up was 16.2 years. Twenty-four hips (19.4%) required revision surgery; the median time to this surgery was 10.2 years, mean 8.2 years. Reasons included aseptic loosening of the stem in one patient at 12.7 years, aseptic loosening of the cup in 7 patients (range 10.2–17.4 years), worn polythene insert in 4 patients, infective loosening in 3 patients and recurrent dislocations in 2 patients. The remainder of revisions were for unknown reasons.

The Oxford Hip Score postal questionnaire was returned by 79% of patients. Mean score was 12.6/45 but 88% of patients reported overall satisfaction with the hip.

In summary, there were no revision surgeries at ten-year follow-up for aseptic loosening.