The present study sought to assess the clinical and radiological results and long-term joint impact of different techniques of lateral ankle ligament reconstruction.

Introduction: The double-hindfoot arthrodesis (subtalar and midtarsal joints) is traditionally performed through a lateral surgical approach associated or not with a medial approach. The main goal of this procedure is to correct severe deformities of the hindfoot in varus or in valgus. In this study we report a series of 19 double-hin-foot arthrodeses through a single medial approach.

Methods and Materials: 19 double arthrodeses (subtalar and talonavicular joint) were performed on 16 patients, 8 males and 8 females with a mean age at surgery of 58.3 years (range 27–72). The indications were: 12 pes planovalgus and 7 cavus foot. 9 deformities were fixed (3 in valgus and 6 in varus).

The chosen surgical technique was always identical using a medial approach and performed by a single dedicated orthopaedic foot and ankle surgeon (JLB), followed by an osteotomy of the insertion of the Tibialis posterior muscle to the Navicular bone, distraction and avivement of the articular surface done without bone resection, reduction of the talus on the calcaneus, fixation of the talonavicular joint with titanium staples (Pareos®) and of the subtalar joint with two 6.5 mm canulated cancellous screws (Unima®). On five occasions (in 3 pes planovalgus and in 2 cavus foot) arthrodesis of the calcaneocuboid joint was carried out through a mini lateral approach due to painful arthritic lesions.

Results: The average follow up was 16.5 months (range 6–40). Consolidation was always achieved.

In the subgroup with pes planovalgus: the mean Kitaoka score increased from 44 to 75, the axis of the hind-foot decreased from 21° to 11° in valgus, Djian’s angle decreased from 142° to 134.4°, the slope of the calcaneus increased from 17° to 19.4°. Two failures of the associated medial ligament reparation have led to a secondary complementary arthrodesis of the talo-crural joint.

In the subgroup with cavus foot: the mean Kitaoka score increased from 16 to 67. The axis of the hindfoot decreased from 13° in varus to 0.6° in valgus. Djians’s angle increased from 117° to 127.4°, the slope of the calcaneus ranges from 21.3° to 21.5°.

Discussion: The double-hindfoot arthrodesis via a medial approach permits the fusion without developing nonunion (in comparison with 20% non-union of triple arthrodesis reported in the literature).

Double arthrodesis via a medial approach provide a significant correction of the fixed deformities without resorting to bone grafts. Not classically used in cavus foot, it has permitted the correction of the cavo varus deformity without complications of the surgical wound and by extending the approach, a double elevating osteotomy of the metatarsal bases was performed when necessary.

Introduction: Achilles tendon (AT) rupture is a common sports injury. However, about 10% to 25% of the complete AT ruptures are not diagnosed. The management of neglected or chronic AT ruptures is usually different from that of acute rupture as the tendon ends were retracted and atrophied with short fibrous distal stumps. In the current series, we reported the mid- to long-term outcome of 10 patients with neglected or chronic AT rupture managed by a modified Flexor Hallucis Longus (FHL) transfer.

Materials and Methods: Between April 2002 and December 2003, 10 patients (6 males, 4 females) were operated on for a neglected or chronic AT rupture with a FHL transfer. The age at surgery averaged 44.1 years (range, 27–70). Five patients presented with a neglected AT rupture, 3 with a chronic AT rupture associated with Achilles tendinosis and 2 with an AT re-rupture. The AT defect after fibrosis debridement averaged 7.4 cm (range, 2.5–10). Beside FHL transfer, we performed a transfer augmentation with the 2 remaining Achilles fibrosis flaps. If no residual fibrosis after debridement was found, a Bosworth augmentation was performed to strengthen the transfer.

Functional assessment was performed using Kitaoka score. Postoperative complications were analyzed. Delay of work and sports recovery was noticed. Isokinetic evaluation was performed using Con-Trex^® dynamometer.

Statistical analysis was performed using Student’s t-test and Wilcoxon test (level of significance, p < 0.05).

Results: The mean follow-up was 61 months (range, 40–73). Functional outcome was excellent with a significant improvement of the average Kitaoka score at latest follow-up (98/100 (range, 90–100)). Average delay of work and sports recovery was 5 months (range, 2–12) and 10 months (range, 6–18) respectively. All patients returned to a sports activity within minor limitations. No re-rupture has been described. No major complication was observed particularly on wound healing. All patients presented with a loss of active range of motion of the hallux interphallangeal joint without subsequent hyperextension. However, no patient presented with functional weakness of the hallux during athletic or daily life activities. Isokinetic testing at 30 deg/sec and 120 deg/sec revealed a significant average decrease of 28±11% and 36±4.1% respectively, in the plantar flexion peak torque of the involved ankle compared with the non-involved ankle.

Discussion: Although strength deficit persisted at latest follow-up, functional improvement was significant. Morbidity due to FHL harvesting was clinically in significant at latest follow-up. For patients with neglected or chronic Achilles tendon rupture with a rupture gap of at least 5 centimeters, surgical repair using FHL transfer with fibrous AT stumps reinforcement achieved excellent outcome at our latest follow-up.

Dynamization of fracture fixation is used clinically to improve the bone healing process. This study evaluated the effect of late dynamization on callus stiffness and size in a rat diaphyseal femoral osteotomy. The external unilateral fixator was dynamized by removal of the inner fixator bar, at three weeks (D3-group: n=8) or four weeks (D4-group: n=9) post-operation. Published data of a five week rigid (R-group: n=8) and flexible fixation group (F-group: n=8) were included for comparison. Preoperative and postoperative movements of the rats were measured using a motion detection system. After 5 weeks the rats were sacrificed and healing was evaluated by biomechanical and densitometric methods. By 34 days post-operation, rats from the four fixation groups had similar activity levels. There was no significant difference in flexural rigidity, callus volume or callus mineral density between the D3 and D4-groups. Both the D3-group and D4-group had significantly greater flexural rigidity (p< 0.01) and significantly lower callus total volume (p< 0.03) and callus bone volume (p< 0.03) compared to the F-group. There was no significant difference in flexural rigidity or callus mineral density between the dynamized groups compared to the R-group. However, the D3-group had less callus bone volume (p=0.06) compared to the R-group. The D4-group had significantly less callus bone volume (p=0.02) and less callus total volume (p=0.05) compared to the R-group. Late dynamization led to a stiffer callus with a smaller callus volume compared to continuously flexible fixation. The late dynamized groups had less callus volume than the continuously rigid group, but the stiffness and calcification and of the callus were similar. The late dynamized groups had undergone resorption processes, indicative of more advanced healing. Late dynamization enhanced fracture healing compared to the continuously rigid or flexible fixation.

Purpose of the study: The pathophysiology of reflex dystrophy or type I complex regional pain syndrome remains poorly understood, but the cost is considerable in terms of public health expenditures both for programmed and emergency orthopedic surgery. We present a historical cohort assessed to evaluate the usefulness of vitamin C for the prevention of reflex dystrophy in programmed foot and ankle surgery.

Material and methods: The study included two groups of patients treated in two successive periods: July 2002 to June 2003 and July 2003 to June 2004. All patients underwent foot and ankle surgery performed by the same senior surgeon. Diabetic feet were excluded. The first group (185 feet, 177 patients) was not given any particular preventive treatment. The second group (235 feet, 215 patients) was given one gram vitamin C for 45 days. The diagnosis of reflex dystrophy was retained on the basis of clinical and radiological arguments noted at follow-up visits with the operator. Several factors were studied: gender, age, type of disease condition, history of reflex dystrophy, psychological context, duration of tourniquet, cast immobilization.

Results: Reflex dystrophy occurred in 18 feet in group

1 (9.6%) and in 4 (1.7%) in group 2. The difference was significant. Presence of a history of dystrophy was significantly associated with development of dystrophy (RR=10.4). A psychological context appeared to increase the risk of dystrophy (RR 2.6) but did not reach significance. There was no statistical relationship with age, gender, duration of tourniquet, type of disease condition, or surgical procedure performed.

Discussion: Vitamin C has been found to be effective in the prevention of reflex dystrophy after wrist fractures. Data in the literature is scarce on dystrophy of the foot and ankle. Our study provided objective evidence of the usefulness of vitamin C for the prevention of reflex dystrophy in foot and ankle surgery patients, a complication frequently observed in our control group (9.6%). The psychological context and history of dystrophy increase the risk of dystrophy.

Conclusion: Vitamin C is associated with a lower risk of reflex dystrophy in the postoperative period after foot and ankle surgery. We advocate preventive treatment with vitamin C.

Purpose of the study: The iliopsoas bursa lies immediately anteriorly to the hip joint capsule and in certain cases there exists a natural communication between a hip prosthesis and the iliopsoas bursa, enabling formation of an inguinal mass by distension of the bursa.

Material and methods: We report six cases of a pseudo-tumoral mass which developed in the femoral scarpa triangle revealing a complication of total hip arthroplasty. These six patients, aged 66–79 years had their prosthesis for 11.5 years on average (range 4–20 years). Three had a history of acetabular dysplasia. All complained of pain. Five patients presented a palpable mass in the inguinal region. Two patients underwent emergency surgery, one for suspected strangulation of a crural herniation and the second for septic inguinal adenopathy. In two patients the clinical presentation was related to the local effect of the mass: lower limb edema with recurrent phlebitis due to venous and lymphatic compression, and femoralgia due to compression of the femoral nerve. The underlying prosthetic complications were: aseptic loosening (n=4), polyethylene wear (n=2), infection (n=1). All patients underwent revision surgery to change the prosthesis. The cystic formation was drained without resection. Symptoms resolved after replacement surgery in all patients.

Discussion: Palpation of an inguinal mass with signs of local compression in a patient with a painful total hip arthroplasty is a sign of a prosthetic complication (infection, loosening, wear). The diagnostic work-up should include bacteriology and plain x-rays of the hip joint. Bone scintigraphy may be contributive. Arthrography can demonstrate presence of a communication. Computed tomography provides the best visualization of the mass and its relations with neighboring organs. A duplex-Doppler is needed in all cases to search for thromboembolic complications prior to surgery. We chose not to resect the cystic formation in our patients, preferring treatment of the intra-articular cause. The fact that the mass and local its effects resolved in all cases with no recurrence at last follow-up leads us to recommend this attitude for typical presentations.

Purpose of the study: Reconstruction of the anterior cruciate ligament (ACL) has become a common procedure. We compared two randomized series: intra-articular (Kenneth-Jones) versus intra- and extra-articular (MacInJones).

Material and methods: From January 1995 through March 1998, 73 knees were treated surgically for differential medial laxity measured at 7 to 12 mm on passive stress x-rays in 20° flexion. Group 1 (ACL reconstruction alone) included 34 patients (aged 27.1±7.5 years). Group 2 (ACL reconstruction plus extra-articular plasty) included 29 patients (aged 28.5±12 years). Function was scored 72% in group 1 and 68% in group 2 at mean seven years follow-up (102 and 93 months follow-up respectively). Anterior laxity was measured radiographically and with KT-1000 and the position of the tunnels was assessed according to Aglietti.

Results: According to the IKDC, functional outcome was 83.9±3.1 in group 1 and 83.3±3.6 in group 2. The overall IKDC classification was 0A, 57.8% B, 26.3% C, and 15.7% D for group 1 and 58% A, 52.9% B, 29.4% C, and 11.7% D for group 2. The pivot-shift test was negative in 61.1% of group 1 knees (27.7% grade 1 and 11.1% grade 2) and negative in 83.3% of group 2 knees (16.6% grade 1). In group 1, the radiological drawer showed 46.09% improvement in the differential laxity for the medial compartment and 41% for lateral compartment. In group 2 the corresponding improvements were 44.8% and 44.6%. There was no difference in tunnel position between the two groups.

Discussion: The two-year results of this series did not provide any evidence favoring a clear advantage of complementary lateral plasty. At seven years follow-up, the pivot-shift test appeared to favor associated lateral plasty (p=0.09), but with no significant difference in laxity for the two compartments.

Conclusion: Anterior laxity was only incompletely controlled by both reconstruction techniques. In this context of relatively limited laxity (7–12 mm initially), at seven years follow-up there was no certain advantage of complementary lateral extra-articular plasty in combination with ACL reconstruction.

Purpose: Failed anterior cruciate ligament reconstruction as defined by recurrent pathologic laxity, is increasingly commonplace. We reviewed 77 patients who had undergone unsuccesful anterior cruciate ligament surgery to correct persisting instability, and who underwent revision surgery.

Material and Methods: During the first operative treatment, were used synthetic ligament in 18 cases, autograft in 54 cases, extra-articular plasty in 4 cases, allograft in 1 case and primary repair in 1 case. For revision, we used autograft in all cases according to differents anatomicals factors: 41 patellar tendons, 15 quadriceps tendons and 17 hamstring tendons. 46 patients had meniscectomy during one of the two surgeries ; 19 patients had cartilage lesions (grade 3 or 4).

For clinical evaluation, we used the IKDC score (1999), and laxity measurement with the KT-1000 arthrometer and stress X-rays.

The mean follow-up was 24 months.

Results The mean IKDC subjective score was 71,5 and 75% of knee were considered as normal or nearly normal. The surgery was successfull in objectively improving the stability in most of patients with a KT-1000 differential maxi-manual of 2 1,7 mm.

We found no statistical difference between the three groups of graft used for revision. The results are a trend toward less good results, when patients had a meniscec-tomy. Subjectively the result were worse in cases of cartilage lesion. In fact, no patient who had grade IV lesion returned to there previous level activity (pre-operative level activity). The worse results are in the group of failed synthetic ligaments.

Conclusion ACL revision surgery leads to poorer results than primary surgery.

There was no clinical difference for the revision, whether we used autograft of patellar tendon, quadriceps tendon or hamstring tendon with an adapted fixation device.

On the other hand, meniscal or cartilage lesion or the use of synthetic grafts are factors of poor clinical outcome.

Purpose: The posterior cruciate ligament (PCL) has two strands, an anterolateral strand (AL) and a posteromedial strand (PM). Its femoral insertion fans out over 3 cm and cannot be replaced by a unique transplant during surgical reconstruction. The purpose of this study was to define the anatomic centre of the femoral insertion of each stand in order to identify precise and reproducible landmarks for the bone tunnels (one for each strand) used to fix the transplants during reconstruction of the PCL.

Material and methods: A metallic landmark was placed on the centre of the femoral insertion of the two PCL strands in ten cadaver knees. The Metros software package was used to analyse the digitalised radiograms of each knee to determine the position of the strands on the medial condyle. Intra- and inter-observer variability was determined.

Results: The AL strand was situated 31.6 + 2.45% (47.2 + 6.02% for the PM strand) from the anterior border of the notch or 41.18 + 2.73% (54.46 + 5.07% for the PM) from the anterior border of the medial condyle relative to the Blumensaat line and 16.12 + 4.45% (33.68 + 7.2 for the PM) from the apex of the notch.

Discussion: Clinical and objective results of reconstruction depend on the ideal, basically femoral, position of the PCL insertions. Intraoperative identification of the ideal point for the femoral insertion can be improved with measurements made on cadaver knees. The values observed in the present study are reproducible. Presented in the form of percentages of length limiting the errors related to patient morphotype can be integrated into navigation systems.

Purpose: This prospective study focused on an interhospital collaboration for foot and ankle surgery. Collaboration was organised between the referring surgeon and four regional foot and ankle specialists. We evaluated concordance and discordance between expert opinions.

Material and methods: Patients for whom an opinion was requested were selected by the requesting surgeon based on problems involving diagnosis or therapeutic indications. Opinions were requested by email. Individual protocols were established for the clinical report and x-ray file of each type of condition. The final therapeutic decision was made by the requesting surgeon.

Results: Among the 450 patients seen for foot and ankle disorders, opinions were requested from experts for 30. The conditions involved: the forefoot (46%), the middle foot (16%), the hindfoot (7%) and the ankle (31%). Mean time for the response was eleven days (1–60). Experts responded to all requests (120 responses) but in four cases (3%) could not provide an opinion. The index of diagnostic agreement among the experts was 3.2/4. The index for therapeutic indications showed agreement at 2.6/4. Agreement between the therapy proposed to the patient and that proposed by the experts was 2.6/3.

Discussion: We analysed the advantages for the patient, the responsibility of the requesting and responding surgeon, and the problems related to remuneration of this type of counselling. Compared with other technologies, email was found to be simple, reliable, and low-cost with good quality images. This work showed that there was concordance between the opinions and that electronic expertise counselling is certainly very useful for foot disorders. Requests addressed to several experts increases precision and provides complementary information for difficult cases. It is important that the different participants know each other.

Conclusion: This work is the first step towards the development of a care network for foot and ankle disease enabling graduated patient management.

Purpose: Constitutional factors responsible for hallux falgus and hallux rigidus remain unclear. The purpose of this work was to compare the radiological feature of the forefoot in three populations with “normal” feet, hallux rigidis, and hallux valgus.

Material and methods: One standard protocol was used within the same unit to obtain dorsoplantar AP views of the foot in the standing position in all subjects. Fifty “normal” feet, with no apparent deformation, callosity, or pain, were selected among the orthopaedic unit personnel; mean age of the 25 subjects was 30.3±9.6 years, and 44% were women. The 30 patients with hallux rigidus were operated on at a mean age of 57.4±10.7 years, and 48.4% were women. The 50 patients with hallux valgus were operated on at a mean age of 50.8±12.8 year and 92% were women.

All radiograms were digitalised (Vidar VXR-12 plus) and analysed by four observers using the FootLog software which provides semiautomatic measurements. The following parameters were recorded: distance between the lateral sesamoid and the second metatarsal (LS-M2), the M1P1 angle (for the diaphyseal and mechanical axes of M1), the diaphyseal and mechanical distal metatarsal articular angle (DMAA) of M1, Meschan’s angle (M1–M2–M5), the distance between a line perpendicular to the axis of the foot drawn through the centre of the lateral sesamoid and the centre of the head of M4 (MS4–M4) (a corrective factor was introduced for the MS4–M4 distance to account for the displacement of the lateral sesamoid in hallux valgus), the M1 index = d1-D2 (length of the head of M1/MS4 – length of the head of M2/MS4), maestro 1 = d2–d3, maestro 2 = d3–d4, maestro 3 = d4–d5. The measured parameters were recorded automatically on an Excel data sheet and statistical analysis was performed with SPSS 9.0.

Results and discussion: Intra- and inter-observer reproducibility of measurements and morphological classifications were excellent. The LS/M2 distance was comparable in the three populations, proving that the lateral sesamoid is relatively fixed compared with the M2 and enabling its use as reference for the MS4 line. The Meschan angle did not discriminate between the three populations, likewise for the mean M1/M2 index, the M1P1, M1M2, and DMAA angles which were different in the three populations; there were 2° to 3° variations for the mechanical or shaft axis. The morphotype analysis demonstrated objective evidence of morphological differences of the forefoot in the three populations. The hallux rigidus group showed a predominance of the index plus and plus-minus with long M23 lateral patterns, while the hallux valgus group exhibited a predominance of M4M5 hypoplasia.

Discussion: Morphotypic definition of the metatarsals is an interesting approach providing a measurable way of interpreting forefoot disorders and guide surgical correction. These results should be confirmed with measures in larger series, which can be accomplished with FootLog software. It would also be useful to combine radiological studies with baropodometric studies.

Purpose: Since 1996, our multidisciplinary medicosurgical team has decided to propose orthopaedic treatment for diabetic perforating ulcers with osteitis, cellulitis, or necrosis (“cooling down” the acute infected ulcers before programmed surgery) rather than conservative treatment with prolonged antibiotic therapy. We present here a prospective study of 44 cases of diabetic perforating ulcers.

Material and methods: Thirty-two diabetic patients underwent surgery: 77% males, mean age 65.2±8.6 year (range 43–86 years), 87% type 2 diabetes, 52% with a history of perforating ulcers, 45% with minor amputations, and 14% with history of vascular surgery. The lesions—perforating ulcer with osteitis (n=34), vascular necrosis of the toes (n=2), “acute feet” with cellulitis (n=8)—had progressed over 13.2±15.1 weeks. The preoperative work-up included: bacteriology samples 89%; standard x-rays of the foot 100% (osteitis 84%); duplex Doppler of the lower limb arteries 77% (tibial arteriopathy 87%); double bone scintigraphy 34% (osteitis 93%); TcPO2 (40±14mmHg); arteriography 27%; vascular surgery consultation 18%. Before surgery, 77% of the patients were hospitalised in an endocrinology unit (13±3 days) and 88% were on an antibiotic regimen for 26±18 days (50% i.v.).

Orthopaedic surgery (without tourniquet, anaesthesia block, mean duration 53±24 min) involved: partial resection of a toe 23%; amputation of a ray 36% (first ray one, second ray five, third ray one, fourth ray two, fifth ray six); transmetatarsal amputation 32%; resection of the metatarsal heads 4%; calcanectomy (n=1); below knee amputation (n=1); and systematic and multiple samples for bacteriology (deep soft tissue and bone tissue) and for pathology.

Results: Mean hospital stay in the surgery unit was 4±1 days, followed by 18±10 days in the endocrinology unit with antibiotics (oral for 88%) for 34±22 days, 91% of the lesions healed within 33±18 days; four required repeated procedures (two transmetatarsal amputations, one amputation of the first ray, one lower limb amputation); three lesions relapsed.

The peroperative bacteriology samples of the deep soft tissue and bone tissue demonstrated, in comparison with the preoperative samples, that antibiotics had sterilised only 14% of the lesions; with discordant comparison in 40%, partial concordance in 24%, and total concordance in 24%. For the diagnosis of osteitis (confirmed by histology of peroperative bone samples), the x-ray interpretations were largely confirmed (79% exact diagnosis, 87% sensitivity, false positives 12%), as were the bone scintigrams with labelled polymorphonuclears (exact diagnosis 93%, sensitivity 93%, false positives 7%).

Conclusion: This prospective study demonstrated the advantages of programmed surgery over emergency surgery, including for “acute feet”: limited resection, primary suture, rapid wound healing, short antibiotic treatment. It raises some questions concerning the validity of non-surgical bacteriological samples for perforating ulcers, even when performed under rigorous conditions (unique strain isolated from 76% of the samples) and on the possibility of antibiotic pressure on bacterial selection.

Purpose: We analysed knee prostheses preserving the posterior cruciate ligament (or both cruciates) performed after tibial osteotomy. We determined outcome as a function of any tibial callus deformation created by the tibial osteotomy.

Material and methods: This retrospective study included a consecutive series of 56 knee prostheses with preservation of the posterior cruciate ligament (n=43) or both cruciate ligaments (n=13). The patients had undergone prior tibial osteotomy for valgisation (n=47) or varisation (n=9). Seven groups were defined as a function of the preoperative tibial angle prior to TKA. The angle were measured with telegonometry. Minimum follow-up was one year, mean follow-up 4.1±2.8 years.

Results: The tibial tuberosity was raised in 15 cases. If there was major valgus or rotation deformation, tibial osteotomy was associated with the prothesis (n=9). At last follow-up, the mean IKSg, IKSf and HSS scores were 81.5, 77.6, and 82.3 respectively. The mean femorotibial angle was 177.4±4.2°. The mean tibial angle was 87.8±3° and the mean femoral angle was 89.8±2°. Preoperative tibial deformation was not influenced by clinical results. In case of preoperative tibial deformation situated between 5° valgus and 5° varus, operation time, blood loss, and femoraotibial axis at last follow-up were not significantly different. To correct for tibial valgus greater than 7°, tibial osteotomy was associated with prosthesis implantation during the same operative time in six out of thirteen cases. For preoperative tibial varus greater than 5°, the femorotibial axis was less well corrected.

Discussion: These clinical results were comparable to those reported in other series with preservation or not of the posterior cruciate ligament. Correction of the femorotibial angle was less satisfactory than in certain series, but the deformation and the surgical history were among the most marked in the literature. Preservation of the posterior cruciate ligament (or both cruciates) appears to have increased the technical difficulties for upper tibia exposure and position of the tibia implant. For tibial callus with valgus greater than 7°, the prostheses cannot be expected to provide a solution alone and osteotomy should be associated. For tibial callus with 5° or more varus, the indication for associated tibial osteotomy merits discussion.

Purpose: We reviewed retrospectively 40 ligamentoplasties of the anterior cruciate ligament in patients who had undergone several prior reconstructions (1 to 6). The initial operation had used a synthetic ligament in 13 cases, patellar tendon in 23 and divers implants in four.

Material and methods: Forty patients, 12 women and 28 men, with recurrent ligament tears where reoperated by the same surgeon. Mean age was 28.5 years (16–51). Mean follow-up after the last operation was 27 months. All patients were reviewed (history, physical examinatin and KT 1000); 20 of them responded to a self-administered questionnaire using the IKDC chart later after the clinical review, and 23 of the 40 had radiographs to measure laxity. Arthroscopic reconstruction was used in 33 cases. A surgical procedure was necessary on a peripheral ligament in six cases and osteotomy for tibial valgisation in one. Reconstruction was achieved with the quadriceps tendon in 11 cases, the patellar tendon in 18, the hamstrings in eight and Mac in Jones in three. The IKDC score was used for clinical assessment with manual arthrometric measurement of laxity. Radiographs were obtained to measure the anterior drawer of the medial and lateral compartments of both knees for right-left and pre-postoperative comparisons.

Results: The initial handicap was marked (IKDC: 18 D, 21 C, 1 B). Reconstruction was good or very good in 72.5% of the knees (IKCD: 2 A, 27 B, 10 C, 1 D). Self-evaluation revealed 25% painful knees for intense activities. Laxity was improved with a mean differential gain of 5.35 mm of the maximal pre- and postoperative KT 100 (7.24 versus 1.89). Among the 24 knees with radiographic assessment, the mean differential preoperative was 9.14 mm preoperatively and 4.69 mm at last follow-up giving a gain of 4.45 mm. One athlete was able to resume sports activities at the same or higher level and others at a lower level.

Discussion, conclusion: This study confirms that the results obtained after revision repair are less satisfactory than after primary repair. This homogeneous (one operator) and large series with a sufficient follow-up can be compared with the rare published series. Each ligament reconstruction is specific and warrants a specific surgical approach adapted to each individual case.

Purpose: The growing use of foot surgery includes many innovating techniques which require adequate evaluation. To facilitate evaluation, the Association Française de Chirurgie du Pied (AFCP) elaborated a computer program for acquisition of clinical and radiological data on foot surgery. The data collected were centralised and analysed to assess surgical procedures.

Material and methods: Clinically. Signs of forefoot disorders were reviewed and classed by surgeons with extensive experience in forefoot surgery. Signs were classed by topic then formulated for the computer display to facilitate input during consultations. A system of profiles was designed to limit the data input filed and shorten input time. The program includes an automatic calculation of the Kitaoka forefoot score.

Radiologically: The system includes a tool for analysing radiographs using a vectorial drawing software integrated in the database. This system uses remarkable landmarks chosen by clicking on the radiographs: angles and lengths for preoperative planning are calculated automatically. These values are automatically integrated into the database and can be retrieved for file studies.

Operation report: Procedures performed on the forefoot are presented in picture form with clinical data. A profiles system is used to choose the items for input and reduce entry time.

Printout: Printouts can be made to include in the patient’s files.

Exploitation: Data can be exported for processing with another programme. This function was tested with a dissertation written on Weil osteotomies.

Conclusion: This freely distributed software is a first step toward a computer evaluation system for foot surgery. Our hope is that sufficient data can be collected to validate the reliability of our surgical techniques.

Purpose: There are three main causes of failure after valgisation osteotomy of the tibia requiring repeated osteotomies: insufficient valgus, excessive valgus, or loss of the valisation correction after a variable delay. The purpose of this study was to evaluate outcome after repeated oseotomies performed in relatively young patients or too active to propose arthroplasty. The technical problems were different for each aetiology.

Material and methods: The series included 47 knees operated on between 1974 and 1998 after a first osteotomy performed at a mean age of 46 years. Mean delay between the two operations was five years (1 to 12). A medial closure osteotomy had been performed at the first operation in 34 cases and a lateral opening osteotomy in 13. For the 19 knees with valgus, the second osteotomy was a medial closure in 14 and a lateral opening in five. A repeat valgisation was performed in 28 cases, 18 by lateral closure, one by medial opening and nine by curviplanar osteotomy. The IKS score was determined to assess function. The femoraotibial axes (HKA angle) were determined on full stance views. The Ahl-back osteoarthritis grading was used. For 17 patients who had undergone operations in other institutions, exact measurements were not always available concerning the preoperative status and the initial correction.

Results: The overall IKS score for function improved in 87% of the cases with a mean follow-up of five years. The IKS knee score improved from 73 to 89 points and the IKS function score from 65 to 81 points. For the 19 over-corrections, the mean HKA angle was changed from 190° to 184°. For the 28 under-corrections, the mean HKA angle was changed from 173° to 182°. The tibial tilt remained unchanged at 7° as did lateral gapping at 3°. Delay to consolidation was a mean 96 days.

Discussion: Revision osteotomies performed for correction defects should be distinguished. For these procedures, it would be logical to expect a good result if a 3 to 5 degree valgus is achieved. Revisions after a long period (33 cases) are different; required for wear, these cases correspond to progressive loss of the initial osteotomy effect. These patients are often candidates for prosthesis if seen after 70 years. Good results can however be obtained with a second osteotomy irrespective of the initial technique. We prefer reoperating with medial opening after initial lateral closure.

Purpose: Plantar pressure sores can lead to metatarsalgia depending on the patient’s activity level and age and on the status of the muscle-tendon system and the morphology of the forefoot. In 1995, Tanaka and Maestro attempted to quantify the relative lengths of the metatarsals. The purpose of this work was to check the results reported by Maestro and to try to define a morphotype classification of the metatarsals.

Material and methods: We analysed two series of normal feet: no apparent deformation, no callosity, no pain, no history of trauma or surgery. Fifty “normal” feet were selected among the personnel of the orthopaedics unit. Mean age of the 25 subjects was 30.3 ± 9.6 years, 44% were women. This series was compared with 34 “normal” feet reported by Maestro (age 55.2 ± 17.2 years, 62% women) used to define criteria for geometric progression (1995). A standing dorso-plantar radiograph was obtained with the same protocol for all patients. All radiographs were digitalized with a Vidar VXR-12 plus, then analysed by two observers with the semi-automatic FootLog measurements. The following measurements were recorded: SM4-M4 (distance between the line passing through the centre of the lateral sesmoid and perpendicular to the foot axis and the centre of the M4 head), M1 = d1 – d2 (length of the M1/SM4 head – length of the M2/SM4 head), Maestro criteria 1 = d2 – d3, Maestro 2 = d3 – d4, and Maestro 3 = d4 – d5.

Results: An SM4 line passing through the mid third of the M4 head (+2mm proximally / centre M4 head / −4 mm distally) as normal. The notion of row 2 geometric progression was conserved by tolerating 20% variation (Maestro 1 ± 1 mm, Maestro 2 ± 1mm, Maestro 3 ± 2 mm). Feet were classed in four metatarsal morphology types with subgroups: normal feet (line SM4 passing through the mid third of the M4 head – geometric progression) – long M23 (SM4 line centred on the mid third of M4 – but alteration of the geometric progression) with four subgroups (long M2, long M3, long M2-3, long M23 long 2) – M4M5 hypoplasia (distal SM4 line / at mid third of M4) with four subgroups (by geometric progression: long M2, long M23, long M23 long M2) – others (long M1: M1 > 3.3 mm causing distalization of SM4).

Discussion, conclusion: FootLog enables rapid radiographic measurements with excellent precision and intraobserver (variations from 0.1 to 0.2 mm and 0.1 to 0.5°) and interobserver (variations from 0.1 to 0.5 mm and 0.1 to 1°) reproducibility. In the two series of clinically “normal” feet, the measured parameters were strictly comparable. Radiologically, 31% were “normal”, and the others (30% long M23 – 37% M4M5 hypoplasia – 2% others) could be considered as predisposed to potential forefoot disorders. Finally only 48% of the subjects had the same morphotype for both feet. This study adds further precision to earlier qualitative evaluations of the forefoot architecture.