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Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_13 | Pages 10 - 10
17 Jun 2024
Malhotra K Patel S Cullen N Welck M
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Background

The cavovarus foot is a complex 3-dimensional deformity. Although a multitude of techniques are described for its surgical management, few of these are evidence based or guided by classification systems. Surgical management involves realignment of the hindfoot and soft tissue balancing, followed by forefoot balancing. Our aim was to classify the pattern of residual forefoot deformities once the hindfoot is corrected, to guide forefoot correction.

Methods

We included 20 cavovarus feet from adult patients with Charcot-Marie-Tooth who underwent weightbearing CT (mean age 43.4 years, 14 males). Patients included had flexible deformities, with no previous surgery. Previous work established majority of rotational deformity in cavovarus feet occurs at the talonavicular joint, which is often reduced during surgery. Using specialised software (Bonelogic 2.1, Disior) a 3-dimensional, virtual model was created. Using data from normal feet as a guide, the talonavicular joint of the cavovarus feet was digitally reduced to a ‘normal’ position. Models of the corrected position were exported and geometrically analysed using Blender 3.6 to identify anatomical trends.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_13 | Pages 21 - 21
17 Jun 2024
Jamjoom B Malhotra K Patel S Cullen N Welck M Clough T
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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 cm2. Tibiotalocalcaneal (TTC) arthrodesis was performed in 24 patients, ankle arthrodesis in 7 patients and triple arthrodesis in 1 patient.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_12 | Pages 12 - 12
10 Jun 2024
Barnett J Rudran B Patel S Aston W Welck M Cullen N
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Background

Tenosynovial giant cell tumour (TGCT) is a benign proliferative disease affecting synovial membranes. There are two forms, localised and diffuse, which although histologically similar are managed differently. It is locally invasive and is treated in most cases by operative excision. The aim of this study was to assess outcomes from the largest single-centre experience to date in patients with this condition.

Methods

A retrospective analysis of 123 cases was performed in patients treated between 2003 and 2019 with TGCT of the foot and/or ankle. Data was collected on age at presentation, radiological pattern of disease, location of disease, treatment provided and recurrence rates. The minimum follow-up was 2 years with a mean of 7.7 years.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_11 | Pages 7 - 7
4 Jun 2024
Sangoi D Ranjit S Bernasconi A Cullen N Patel S Welck M Malhotra K
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Background

The complex deformities in cavovarus feet may be difficult to assess and understand. Weight-bearing CT (WBCT) is increasingly used to evaluate complex deformities. However, the bone axes may be difficult to calculate in the setting of severe deformity. Computer-assisted 3D-axis calculation is a novel approach that may allow for more accurate assessment of foot alignment / deformity. The aim of this study was to assess differences in measurements done manually on 2D slices of WBCT versus 3D computer models in normal and cavus feet.

Methods

We retrospectively analyzed WBCT scans from 16 normal and 16 cavus feet in patients with Charcot-Marie Tooth. Eight measurements were assessed: Talus-1st metatarsal angle (axial plane), Forefoot arch angle (coronal plane), and Meary's angle, calcaneal pitch, cuneiform to floor, cuneiform to skin, navicular to floor and navicular to skin distance (sagittal plane). 2D measurements were performed manually and 3D measurements were performed using specialised software (BoneLogic, DISIOR).


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_11 | Pages 18 - 18
4 Jun 2024
Najefi AA Alsafi M Katmeh R Zaveri AK Cullen N Patel S Malhotra K Welck M
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Introduction

Recurrence after surgical correction of hallux valgus may be related to coronal rotation of the first metatarsal. The scarf osteotomy is a commonly used procedure for correcting hallux valgus but has limited ability to correct rotation. Using weightbearing computed tomography (WBCT), we aimed to measure the coronal rotation of the first metatarsal before and after a scarf osteotomy, and correlate these to clinical outcome scores.

Methods

We retrospectively analyzed 16 feet (15 patients) who had a WBCT before and after scarf osteotomy for hallux valgus correction. On both scans, hallux valgus angle (HVA), intermetatarsal angle, and anteroposterior/lateral talus-first metatarsal angle were measured using digitally reconstructed radiographs. Metatarsal pronation (MPA), alpha angle, sesamoid rotation angle and sesamoid position was measured on standardized coronal CT slices. Preoperative and postoperative(12 months) clinical outcome scores(MOxFQ and VAS) were captured.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_10 | Pages 2 - 2
23 May 2024
Oswal C Patel S Malhotra K Sedki I Cullen N Welck M
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Introduction

Severe, multiplanar, fixed, pantalar deformities present a challenge to orthopaedic surgeons. Surgical options include limb salvage or amputation. This study compares outcomes of patients with such deformities undergoing limb preservation with either pantalar fusion (PTF) or talectomy and tibiocalcaneal fusion (TCF), versus below knee amputation (BKA).

Methods

Fifty-one patients undergoing either PTF, TCF and BKA for failed management of severe pantalar deformity were evaluated retrospectively. Twenty-seven patients underwent PTF, 8 TCF and 16 BKA. Median age at surgery was 55.0 years (17 to 72 years) and median follow-up duration was 49.9 months (18.0 to 253.7 months). Patients with chronic regional pain syndrome, tumour, acute trauma or diabetic Charcot arthropathy were excluded. Clinical evaluation was undertaken using the MOxFQ, EQ-5D and Special Interest Group in Amputee Medicine score (SIGAM). Patients were also asked whether they were satisfied with their surgical outcome and whether they would have the same surgery again.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_9 | Pages 20 - 20
16 May 2024
Bernasconi A Cooper L Lyle S Patel S Cullen N Singh D Welck M
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Introduction

Pes cavovarus is a foot deformity that can be idiopathic (I-PC) or acquired secondary to other pathology. Charcot-Marie-Tooth disease (CMT) is the most common adult cause for acquired pes cavovarus deformity (CMT-PC). The foot morphology of these distinct patient groups has not been previously investigated. The aim of this study was to assess if morphological differences exist between CMT-PC, I-PC and normal feet (controls) using weightbearing computed tomography (WBCT).

Methods

A retrospective analysis of WBCT scans performed between May 2013 and June 2017 was undertaken. WBCT scans from 17 CMT-PC, 17 I-PC and 17 healthy normally-aligned control feet (age-, side-, sex- and body mass index-matched) identified from a prospectively collected database, were analysed. Eight 2-dimensional (2D) and three 3-dimensional (3D) measurements were undertaken for each foot and mean values in the three groups were compared using one-way ANOVA with the Bonferroni correction.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_14 | Pages 22 - 22
1 Dec 2015
Chambers S Goldberg A Cullen N Singh D
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This study used the lunge test to measure the difference between ankle dorsiflexion with the knee flexed and extended in persons with and without foot and ankle pathology. This may help us devise a weight bearing test for GT.

Rationale

There is little credible research comparing GT in people with and without foot and ankle pathology. There is no normative data for ankle dorsiflexion range measured using a Lunge test and prevalence of GT in the normal population.

Methodology

97 ankles with foot and ankle (FA) pathology and 89 ankles of healthy volunteers (HV) without FA pathology were recruited from the royal national orthopaedic hospital (RNOH). Degrees of ankle dorsiflexion range were measured using an inclinometer and a version of the lunge test with the knee flexed and extended. These findings were then compared between groups.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_17 | Pages 31 - 31
1 Nov 2014
Swann A Goldberg A Cullen N Singh D
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Introduction:

Wound healing and poor bone healing are complications seen in patients who smoke and some surgeons prefer not to operate on smokers. However, self reporting of smoking by patients may be biased. This study compares self-reporting of smoking habits and cotinine levels in the urine of our patients.

Method:

77 patients admitted for an osteotomy or arthrodesis procedure between September 2013 and May 2014 agreed to participate in this study. A questionnaire was completed and a urine sample was obtained and tested for cotinine, a metabolite of nicotine, by 2 techniques: a dipstick, the COT One Step Cotinine Test, yielding a positive result when the cotinine in the urine exceeds 200 ng/mL and the Concateno laboratory assay test, providing a mean value to give a qualitative reading whereby the cut off for non-smokers is 500ng/ml.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_21 | Pages 40 - 40
1 Apr 2013
Ferrero A Cullen N Singh D
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Introduction

Bone Marrow Oedema Syndrome (BMOS) is an unusual and poorly understood condition. It commonly affects the hips and knees and is reported to have a tendency to recur. The foot and ankle are less frequently involved but nevertheless patients can be severely impaired. Only case reports of BMOS of the foot and ankle have been published.

The aim of this study is to evaluate the sites of occurrence, risk factors, efficacy of immobilisation, response to intravenous biphosphonates and local or remote recurrence over the following years.

Methods

A retrospective review of 25 adult patients who have been diagnosed with BMOS have been followed-up for an average of 5.8 years (range: 2–11). Six patients have not been traced.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 7 - 7
1 Jan 2013
Zaidi R Abbassian A Cro S Guha A Hasan K Cullen N Singh D Goldberg A
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Background

The focus on evidence-based medicine has led to calls for increased levels of evidence in surgical journals. The purpose of the present study was to review the levels of evidence in articles published in the foot and ankle literature and to assess changes in the level of evidence over a decade.

Methods

All articles from the years 2000 and 2010 in Foot and Ankle International, Foot and Ankle Surgery, and all foot and ankle articles from JBJS A and JBJS B were analysed. Animal, cadaveric, basic science, editorials, surveys, letters to Editor and correspondence were excluded. Articles were ranked by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 6 - 6
1 Sep 2012
Monda M Cullen N Singh D Goldberg A
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Introduction

The Z or “scarf” osteotomy was first described by Meyer in 1926 and then by Burutaran in 1976. It was later popularised by Weil in the USA and Barouk in Europe in the 1990's and is now an accepted technique that forms part of a surgeons' armamentarium. The theory of Diffusion of Innovations was described by Rogers in 1962 to explain how novel ideas are accepted into practice across different industries, including medicine. It has never previously been used to study the adoption of ideas in foot and ankle surgery.

Methods

This paper uses publication volume as a surrogate marker for adoption, as described previously by the authors. Briefly, a systematic review of the literature was carried out. MESH headings included ‘Hallux Valgus’, and ‘osteotomy’ or ‘SCARF’ or ‘Z osteotomy’ or ‘bunionectomy’. 2818 publications were identified and the abstracts were reviewed excluding 2699 publications for non-relevance. The data was analysed by year of publication, country of origin, as well as for level of evidence.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 60 - 60
1 Sep 2012
Abbassian A Zaidi R Guha A Cullen N Singh D
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Introduction

Calcaneal osteotomy is often performed together with other procedures to correct hindfoot deformity. There are various methods of fixation ranging from staples, headed or headless screws or more recently stepped locking plates. It is not clear if one method is superior to the other. In this series we compare the outcome of various methods of fixation with particular attention to the need for subsequent hardware removal.

Patients and Methods

A retrospective review of the records of a consecutive series of patients who had a calcaneal osteotomy performed in our unit within the last 5 years was undertaken. All patients had had their osteotomy through an extended lateral approach to their calcaneous. The subsequent fixation was performed using one of three methods; a lateral plate placed through the same incision; a ‘headless’; or a ‘headed’ screw through a separate stab incision inserted through the infero-posterior heel. Records were kept of subsequent symptoms from the hardware and need for metalwork removal as well as any complications. When screws were inserted the entry point in relation to the weight-bearing surface of the calcaneous was also recorded.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 37 - 37
1 Sep 2012
Guha A Zaidi S Abbassian A Cullen N Singh D
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Single stage total talectomy with tibio-calcaneal arthrodesis in adult patients has been rarely reported in the literature. In patients with severe rigid, unbraceable equinovarus deformities, talectomy can offer excellent correction.

We performed single stage total talectomy with tibiocalcaneal arthrodesis on 11 feet in 10 patients (6F; 5M) of average age 67 years (range 54–77 years). 6 patients had neuropathic deformity, 2 had failed fusion procedures and 2 had severe Rheumatoid hindfoot disease. The fusion was undertaken using a hindfoot nail and screws in 5 patients, plate and screws in 4 patients, a hindfoot nail in 1 and cancellous screws in 1 patient. All patients followed the standard post operative protocol and were reviewed at 2, 6 and 12 weeks and thereafter every 4 weekly till union. All patients were mobilised strictly non weight bearing for the first 6 weeks and thereafter, touch weight bearing was allowed with the leg in a protective cast. Full weight bearing was allowed once the fusion had consolidated.

Fusion was achieved in 7 feet (64%) at an average time of 17 weeks. In 4 patients, non-union persisted but they were pain free at latest review and would not consider further surgery. Average duration of follow-up was 20 months (range 6–24 months). All patients had stiff hindfeet with a jog of movement at the tibio navicular articulation. All patients had a stable, plantigrade, braceable foot and were community ambulators. All patients were satisfied with the outcome.

Total talectomy with tibiocalcaneal arthrodesis is a useful procedure to correct severe rigid equinovarus deformities in adults. The tibionavicular articulation forms a pseudarthrosis and retains a jog of movement. Retention of the head of the talus with talotibial arthrodesis is unnecessary. We recommend this procedure as a salvage option in this difficult problem.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 150 - 150
1 Sep 2012
Gordon D Zicker R Cullen N Singh D Monda M
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Introduction

Debate remains which surgical technique should be used for ankle arthrodesis. Several open approaches have been described, as well as the arthroscopic method, using a variety of fixation devices.

Both arthroscopic and open procedures have good results with union rates of 93–95%, 3% malunion rate and patient satisfaction of 70–90%, although some report complication rates as high as 40%.

Aims

To identify union, complication and patient satisfaction rates with open ankle fusions (using the plane between EHL and tibialis anterior).


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXII | Pages 71 - 71
1 May 2012
Molvik H Smitham P Cullen N Singh D Goldberg A
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Introduction

Following recommendations in the NHS Plan, all Trusts in the UK now send copies of correspondence to patients as standard practice. It is not clear whether patients wish to receive such correspondence, nor whether this practices an additional workload on the NHS as patients seek clarification on the medical terminology used in their letters.

Methods

We surveyed 90 consecutive patients in three Consultant Foot & Ankle surgeons' new outpatient clinics at our institution. Sixty patients received a copy of the letter sent to their GP (standard practice) and 30 patients received a letter in plain English addressed to the patient and a copy was sent to the GP (new practice). Patients were sent a cover letter explaining the study a copy of their clinic note and also a questionnaire that asked details about their preferred methods of communication. In addition qualitative interviews with 4 GP Partners were carried out to harbour their opinions.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXII | Pages 78 - 78
1 May 2012
Smitham P Molvik H Smith K Attard J Cullen N Singh D Goldberg A
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Introduction

There are approximately 1.2 million patients using orthotics in the UK costing the NHS in excess of £100 million per annum. Despite this, there is little data available to determine efficacy and patient compliance. There have been a few reports on patient satisfaction, which indicate that between 13-50% of patients are dissatisfied with their orthotics. Our aim was to evaluate patient reported satisfaction with orthotics prescribed and to investigate the reasons behind patient dissatisfaction.

Methods

Seventy consecutive patients receiving foot orthoses at the Royal National Orthopaedic Hospital were retrospectively asked to complete a questionnaire and to bring their shoes and orthotics to research clinic. The inside width of the shoes and corresponding width of the orthotic were measured. A semi-structured interview was carried out on 10 patients, including those that were satisfied or unsatisfied, using qualitative research methods to identify issues that are important to patients.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 478 - 479
1 Nov 2011
Attard J Singh D Cullen N Gemmell E Cooper D Smith K
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Background: Non-operative treatment for plantar fasciitis varies widely and includes the use of night ankle-foot orthoses (AFO’s). Some studies have shown that this is more effective in the initial management of plantar fasciitis than anti-inflammatory therapy. During sleep the foot and ankle tend to assume a plantarflexed position, which results in tightness of the calf muscle group, accounting for the stiffness and pain experienced by patients as they take their first weight bearing steps in the morning. However, when the foot and ankle are kept in a dorsiflexed stretched position at night, stress relaxation occurs and the plantar fascia relaxes.

Aim: Compliance with night AFO’s that dorsiflex the foot/ankle has always been a problem. This study compares the effectiveness of a posterior AFO, which dorsiflexes the foot, with an anterior AFO, which maintains the foot in plantigrade, asking whether it is absolutely necessary to dorsiflex the foot and ankle during the night to avoid early morning pain and stiffness, or whether it is it sufficient just to maintain the foot in plantigrade.

Methods: 18 participants were recruited on a voluntary basis and at random from among those patients referred to the Orthotics department with plantar fasciitis to be provided with a night orthosis. The inclusion criterion was that the diagnosis was purely plantar fasciitis with no secondary diagnosis, symptoms or complications. Each participant was given a questionnaire to fill in; this evaluated how satisfied the participants were with the orthosis with regards to comfort, ease of use and appearance, and whether the pain in the foot was reduced and at what stage was it reduced. The two types of AFO’s used in this study were:

A posterior AFO that holds the foot in dorsiflexion. The amount of dorsiflexion could be adjusted.

An anterior AFO that keeps the ankle and foot in plantigrade, with no adjustment to the amount of dorsiflexion.

Results: 67% of the participants confirmed that morning pain and stiffness was less after wearing the AFO; this included 78% of those that wore the anterior AFO and 56% of those that used the posterior orthosis. 56% of all participants reported that the orthoses were uncomfortable and disrupted sleep. The most uncomfortable was the posterior AFO (89%), as opposed to the anterior one (22%). Both types of orthoses were reported to be relatively easy to don and doff (89% anterior AFO and 78% posterior AFO). On a scale of 1 to 10, the participants were asked to grade the pain before starting the orthosis treatment regime, after 6 weeks of wearing the AFO and again 6 weeks later. On average, the anterior AFO reduced the pain from 7 to 2.1, while the posterior orthosis only reduced the pain from 8.1 to 6.7.

Conclusion: In general, plantar fasciitis night AFO’s are poorly tolerated orthoses, however, their use can be justified in that the pain levels are reduced. The anterior AFO seems to be more effective in achieving this, without dorsiflexing the foot/ankle beyond plantigrade. Thus, one could argue that there is no need to dorsiflex to achieve the goal. However, further investigation is necessary with a larger patient cohort.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_II | Pages 368 - 368
1 May 2009
Patten L Singh D Cullen N Wiggins S
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In the belief that many of the barriers that patients face when deciding upon an ankle or hindfoot fusion procedure stem from inadequate information about the procedure and its outcomes, the novel concept of a “Fusion forum” has been developed: a nurse-led informal group meeting to facilitate patients’ understanding and perception of fusion procedures. The aims were to provide more in-depth information than it is possible to deliver during the limited time of an initial doctor-patient consultation, to get the patient to meet and question a guest (an expatient who has previously had a fusion procedure) and to allow patients time to reflect upon their choices.

The value of the fusion forum has been evaluated by a questionnaire which was completed by the first 48 patients who attended the forum. 96% (46/48) of respondents felt that the quality of information that they were given was excellent or good. No respondent thought that the information was unsatisfactory. Patients were asked how valuable they had found meeting the guest. Four patients did not respond to this question. All of the respondents thought that meeting another patient who had already undergone the procedure was excellent or good

The mechanics of setting up a foot and ankle fusion forum is discussed, along with the lessons learnt from the first cohort of patients. This process has been found to greatly increase patient understanding of arthrodesis. It has been found during the consent process in pre-admission clinic that patients demonstrate a more in-depth understanding of the operative procedure, a more comprehensive knowledge of what the whole process involves, as well as the relative risks and benefits and the expected time of recovery.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 228 - 228
1 Jul 2008
Cullen N Robinson A Chayya N Kes J
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Introduction: The Distal metatarsal articular angle (DMAA) is a radiographic measure of orientation of the first metatarsal articular surface, it is frequently used in the management of hallux valgus. There is a great deal of conflict regarding accuracy, reproducibility and validity of the DMAA within the literature. This study aims to test the validity of the measurement of the DMAA from standard radiographs, to explore the trigonometric relationship of first metatarsal rotation and the DMAA and to assess inter-observer reliability.

Materials/Methods: 34 seperate dry cadaveric first metatarsal bones were mounted onto a customized light-box/protractor allowing controlled incremental changes in rotation and inclination. A series of 39 digital photographs were taken of each metatarsal in 5 degree increments of rotation between 30 degrees supination and 30 degrees pronation and 10, 20 and 30 degrees of inclination. Three reviewers performed blinded DMAA measurements from each image; the data was collated for statistical analysis.

Results: The data was analysed using a mixed effects linear model comparing the DMAA with rotation of the first metatarsal. A strong statistically significant trend of increasing score with increasing pronation is observed, the relationship of which is approximately linear. There is a strong effect of inclination, but the strength of this varies with rotation this is amplified at higher inclinations. Inter-observor error was noted in line with other studies, the linear relationship is maintained.

Discussion: This study has shown that the distal metatarsal articular angle varies significantly, in an almost linear pattern, with axial rotation of the first metatarsal. Inclination of the first metatarsal is also shown to affect the magnitude of the angle.

This study does not refute the distal metatarsal articular angle as an entity, but does confirm the inaccuracy of extrapolating the DMAA from plain AP radiographs.