Background. Outcome of Type II and III (Sander's CT classification) fracture of the calcaneum who underwent open reduction and internal fixation was assessed. Methods. Thirty-three type II and III fractures of the calcaneum (all unilateral) underwent open reduction and internal fixation using the ‘extensile lateral approach’. There were twelve Type II and twenty-one Type III fractures. Patients were followed up for a mean of 40.81 months (Range 28 to 62 months). Patients were assessed clinically by the Creighton Nebraska Health foundation score for assessment of fractures of the calcaneum. Radiologically assessment was done comparing the pre and post operativeBohler's and Gissane angles and measuring the calcaneal width on the axial xrays. Results. Nineteen patient were classified as excellent and 14 as good. There were no poor or fair results. The mean correction of Bohler's angle was 5.6 +/− 7.2 and the Gissane'sanglecorrected by 7.8 +/−5.8 °. Superficial skin necrosis was the most common complication encountered (3 patients). Two patients preferred removal of the implant after fracture union due to prominent hardware. Conclusion. Open reduction Type II and III intra – articular calcaneal fractures is associated with minimal complications and gives reproducible results, especially in young adults

The extended lateral approach offers a safe surgical approach in the fixation of calcaneal fractures. Lateral plating of the calcaneum could put structures on the medial side at risk. The aim was to identify structures at risk on the medial side of the calcaneum from wires, drills or screws passed from lateral to medial. Ten embalmed cadaveric feet were dissected. A standard extended lateral approach was performed. The DePuy perimeter plate was first applied and 2mm K-wires were drilled through each of the holes. The medial side was now examined to determine the structures at risk through each hole. The process was repeated with the Stryker plate. The calcaneum was divided into 6 zones, by two vertical lines, from the margins of the posterior facet and a transverse line along the axis of the bone through the highest point of the peroneal tubercle. The DePuy and the Stryker plates have 12 screw positions, 5 of which are common. With both systems, screw positions in zone 1 risk injury to the medial plantar nerve and zone 3 the lateral plantar nerve. A screw through zone 2 compromises the medial plantar in both. Screws through zone 4 risk the lateral plantar nerve with the DePuy plate. Screws through zone 5 of the DePuy plate risk the medial calcaneal nerve. Zone 5 of the Stryker plate and Zone 6 of both are safe. There is significant risk to medial structures from laterally placed wires, drills or screws. Subtalar screws have the highest risk and have to be carefully measured and placed. The Stryker plating system is relatively safer than the DePuy perimeter plate with three safe zones out of six

Objectives: To report the outcome and comparison of calcaneum fracture managements for intra-articular fractures. Methods: A prospective study of the patients with intra-articular calcaneum fractures in the foot& ankle unit of a busy trauma hospital. All the patients were followed up with the calcaneal fracture score. We compared the outcome of surgical management Sanders type 2 (Group A) and type 3 (group B) fractures with conservative treatment (group C) at 2 years and assessed the medium term outcomes of groups A and B. Group C were a consecutive series of patients recruited to the study later than A and B, hence the smaller number in that group. Results: 126 patients were included in our study. There were 70 in group A, 38 in group B, and 18 in group C. Mean follow-ups for the groups were A=6y, B=5.5y and C=2.34y. Mean two-year scores for the groups were A=68.13, B=63.78, and C=51.36, with statistically significant differences between groups A and C (P=0.0006), and between groups B and C (P=0.04), but no significant difference between groups A and B. At medium-term follow-up (> 5 years), the scores for group A and B were 77.06 and 63.66 respectively. There were 7 deep, 5 superficial infections and 32 metalwork removals in total. Conclusion: On comparing the medium term outcome to the two-year one, group A showed some improvement and group B stayed the same. In this series, there was a better outcome at two years with surgical treatment than conservative treatment

Objectives: To report the outcome and comparison of calcaneum fracture managements for intra-articular fractures. Methods: A prospective study of the patients with intra-articular calcaneum fractures in the foot& ankle unit of a busy trauma hospital. All the patients were followed up with the calcaneal fracture score. We compared the outcome of surgical management Sanders type-2 and type-3 fractures with conservative treatment at 2 years and then, the medium term (> 5 years) outcomes of type-2 and type-3 surgical groups were assessed. Conservative group was a consecutive series of patients recruited to the study later than surgical groups, hence the smaller number in that group. Results: 126 patients were included in our study. There were 70 in group type-2 and 38 in group type-3 with surgical management, while only 18 in the group with conservative management. The mean age for surgical type-2 = 46.2, type-3= 46.3 and conservative group = 51.7. Mean follow-ups for the groups were type-2=6y, type-3 =5.5y and conservative one =2.34y. Mean two-year scores for the surgical groups were type-2=68.13, type-3=63.78, while conservative one =51.36. There was a statistically significant differences in their score between type-2 surgical and conservative groups (P=0.0006), and between type-3 surgical and conservative ones (P=0.04), but no significant difference between type-2 and type-3 surgical groups. At medium-term follow-up, the scores for type-2 and type-3 surgical groups were 77.06 and 63.66 respectively, with significant increase in type-2 while type-3 remains similar comparing to two-year scores. There were 7 deep, 5 superficial infections and 32 metalwork removals in total. Conclusion: On comparing the medium term outcome to the two-year one, surgical type-2 group of patients showed some improvement, while type-3 stayed the same. In this series, contrary to published articles, there was a better outcome at two years with surgical treatment than conservative treatment

INTRODUCTION – Tuberosity fractures of the calcaneum are rare injuries. The traditional operative treatment involves open reduction and internal fixation with a tension band wire construct. We have developed a new technique of fixing these fractures with internal fixation using cannulated screws and a figure of eight wire. This paper describes the new technique outlining its advantages and compares the 2 methods of fixation biomechanically to determine their properties with respect to fracture fixation. METHOD – 20 sections of bovine bone were taken to act as an experimental model for the calcaneum. They were osteotomised to create the posterior process fracture model. 10 were fixed using a traditional tension band wire construct and 10 were fixed using the cannulated screw and wire construct. Each construct was subjected to biomechanical testing to identify the stiffness, energy to failure and load to failure. RESULTS – During loading the cannulated screw and wire constructs showed a significant increase in stiffness and energy to failure compared to the tension band wire constructs. CONCLUSION – The increased stability of the cannulated screw construct demonstrated by the testing offers biomechanical benefit over the traditional tension band wire construct. This, as well as the improved technical aspects of the cannulated screw fixation, may be beneficial for clinical use

Purpose of the study: Because of the difficulty of maintaining anatomic reconstruction, plate fixation is limited for complex fractures of the calcaneum. Implants with angular stability can broaden classical indications and improve outcome. Material and method: From February 2004 to February 2008 we treated 35 articular fractures of the calcaneum: 26 male, 6 female, 3 bilateral cases, mean age 41.46±15.99 years, age range 17–71, ≥ 3 displace fragments [Duparc IV:16; Duparc V: 16], preoperative CT [Sanders III: 22; IV: 13]. The surgical procedure was performed by one operator on days 4 to 7: lateral wide-L incision; articular and extra-articular reduction; lateral fixation using an AO-LCP. ®. plate with locking screws. Intra- and postoperative X-rays (Boehler angle, talo- and cubocalcaneal congruence), postoperative CT. Rehabilitation: mobilisation of the talocalcaneal joint on day 21; partial weight bearing after 2 months; complete weight bearing after 3 months. Radiological and clinical (Kitaoka) follow-up every 60 months. Results: Anatomic joint reduction was achieved and maintained by osteosynthesis (35/35). Late healing (smoking) (6/35). Healing: 2 months (21/35), 3 (14/35). Plate failure at 3 months without displacement (2/35). Anatomic joint reduction sustained ≥12 months (35/35). Gait without crutches after three months (35/35). Infection at 12 months (1/35). Mean follow-up (40 months, range 12–60). Discussion: The purpose of surgical treatment is to achieve anatomic reconstruction of all joint surfaces and restore calcaneal height, length, width and alignment until bone healing. Complex joint fractures with a high risk of loss of correction or secondary nonunion have limited the use of conventional reduction-osteo-synthesis methods in favour of first-line reconstruction-arthrodesis. These complex fractures require plates with multiple fixations to maintain stability. Optimal recover of function can be achieved if the anatomic reduction of the joint surface and extra-articular elements can be maintained stable from the start and sustained to healing, demonstrating the usefulness of reconstruction. No series has reported this innovating therapeutic concept. Conclusion: The reconstruction plate with locked screws enabled osteosynthesis of the most complex calcaneal joint fractures for which the discussion remains open concerning the role of osteosynthesis. The resistant fixation of all the fragments using screws with angular stability enabled stable reconstruction without loss of primary reduction, either secondarily or late, and allowed rapid rehabilitation. The long-term stability of the anatomic reconstruction guarantees good functional outcome which persists over time

CT- scan as an management tool is being used extensively in managing calcaneal fractures. We set out to see if a CT-scan makes any difference to the management plan as obtained by looking at the plain radiograph. We also looked at the correlation with the actual management. Methodology: This was a retrospective study involving 24 patients with fracture of the calcaneum. These patients had both a plain radiograph and a CT- scan to help decide on management. The actual management that each of these patients had was documented. Three consultants who were blinded to the actual management and names of the subjects were independently asked to grade the radiographs, as operative or non-operative. They were then similarly, asked to decide on operation or no-operation based on blinded CT- scans. The data obtained from the three observers were compared to the actual management and were subjected to statistical analysis. Results: As the data was categorical and matched, the Mcnemars test was used to test the association between the management plan obtained from the radiographs and the management plan obtained from the CT scans, for each consultant. They were also compared with the actual management. The statistical analysis showed that there was no statistically significant association between the management decision obtained from the radiographs and the CT san, for all three observers. Radiograph and CT scan based management decisions also did not correlate with the actual management. Conclusion: The CT scan should only be done when a definite decision is made to operate on a patient, based on plain radiographs. Calcaneal fractures which are decided not to operate, based on X rays, should not have a CT scan as a routine as it provides no valuable additional information

Purpose: Dwyer osteotomy remains controversial as shown by the numerous series reported. Conclusions have varied and there is no real consensus. The cause of these divergent opinions is related to the variability of indications (association or not with active neurological disease) and surgical schools. Interpretation of outcome and comparisons are hindered. Material and methods: We reviewed 22 cases of Dwyer osteotomy of the calcaneum performed between 1972 and 2002. The lateral approach was used for closed osteotomy. Mean follow-up was ten years (1–30). Patients were aged 8 to 55 years. The objective and subjective rating system of Laaveg and Panseti (1980) was used. Indications were: neurological pes cavus (n=13) including five unilateral and four bilateral cases, pes equinovarus sequela of clubfoot (n=n=2), idiopathic varus of the hindfood with ankle instability (n=5), posttraumatic varus sequela of a compartment syndrome (n=2). Discussion: Dwyer osteotomy is rarely performed alone and is frequently associated with other interventions (tendon lengthening and transfer, forefoot procedure, toe procedure) making it difficult to interpret results. Our study was not designed to draw definitive conclusion but rather to compare our indications and results with earlier reports. Conclusion: Dwyer osteotomy performed with a rigorous technique appears to be an effective means for correcting constitutional varus. The site of the osteotomy and bone resection are particularly important. There are few complications. Bone healing is generally achieved. The procedure is an excellent solution for patients with associated ankle instability because it provides an easy and effective way to correct moderate varus. It is also a good solution for revision of clubfoot when aponeurotic and tendon release is also indicated. Results are insufficient for neurological pes cavus when there is residual or active tendon imbalance. It can however be a temporary solution in the young patient who will undergo arthrodesis later

Purpose: The purpose of this work was to evaluate clinical and radiological results of surgical treatment of 80 calcaneum fractures involving the posterior talar process using 1/4 tubes used for triangulation fixation. Material and methods: The series involved 73 patients (seven bilateral fractures), 56 men and 17 women, average age 39.6 years (15–67) who were treated between 1990 and 1999. Patients were victims of 34 home accidents (46.6%), 19 sports accidents (26%), 14 occupational accidents (19.2%), and six traffic accidents (8.2%). The Duparc classification was: type 2 (n=2) type 3 (n=17), type 4 (n=51), and type 5 (n=10). Junior surgeons performed most of the procedures who used seven ‘inverted-V’ assemblies and 73 triangular assemblies. Forty-two patients (47 fractures) were reviewed (58.8% of fractures) clinically and radiologically to assess stability of the fixation (Boehler angle and talocalcaneal angle) and search for osteoarthritis. Results: Mean follow-up was six years (1.5–11.5). There were few complications: four late healing (5%), five reflex dystrophy (6.3%) and two infections (2.5%) (Met-S Staphylococcus aureus and Bacterium bovis corineus. Subjectively, 93.5% of patients were satisfied or very satisfied. At last follow-up, the Boehler angle was 27.5±6.7°. The subtalar space was normal or nearly normal in 46.8% and narrowed or destroyed (osteoarthritis) in 53.2%. The Kitaoka function score (AOFAS) was 73.2 points on average with 44.7% excellent or good results and 44.8% fair results. The SOFCOT score was very good, good, or rather good in 63.8% and fair in 10.3%; it was also noted that among the 25.5% poor results, three patients required secondary subtalar arthrodesis. 86% of the patients resumed their occupational activities and 63% of the patients practicing sports resumed their activities. Conclusion: Osteosynthesis of calcaneum fractures using 1/4 tubes used in a triangular configuration provides stable fixation (little secondary loss of Boehler angle) with a satisfactory cutaneous impact (few cases of skin necrosis). The subjective outcome is very satisfactory. Objective outcome may appear disappointing but is generally related to the severity of the fracture (76% types 4 and 5) or type of fixation configuration

Purpose of the study: Treatment of calcaneal fractures is specific because of the fact that these fractures dis-organise the subtalar joint, requiring precise reduction. The clinical result is not always satisfactory considering the efforts made to obtain reduction and fixation. Functional treatment often gives acceptable clinical results, but leaves important anatomic and functional sequelae. We developed a technique for percutaneous balloon reduction and cementoplasty similar to the method used for vertebral fractures treated with the same material. Material and methods: We describe four cases of thalamic fractures treated surgically in a semi-emergency setting. The patients were four women, mean age 39 years (range 26–55). Fractures included vertical compression fractures of the thalamic surface in all cases. The operation was performed under radiographic control in the operative theatre and included a phase for percutaneous reduction and a phase for cemented fixation, allowing a minimal incision and control in two planes. Results: Operative time was 30 minutes and blood loss was negligible. Bone healing with maintenance of the subtalar reduction was achieved in all cases. The clinical result was remarkable, with sedation of the pain and oedema within hours and weight bearing within a few weeks. One patient developed a lateral submaleolar impingement which required infiltration at four months. All patients were totally pain free and had no radiographic evidence of osteoarthritis at two years. Discussion: Percutaneous reduction cemented fixation is a new method for the treatment of thalamic fractures of the calcaneum. We demonstrated the feasibility in a small series; the procedure was simple and allowed effective treatment compared with the classical methods. Conclusion: These excellent clinical results are encouraging for the development of the technique and incite us to propose this method as the first-line treatment for displaced thalamic fractures. We are working on the development of this concept

Background:

In 1931, Gaenslen reported treatment of haematogenous calcaneal osteomyelitis through an incision on the sole of the heel, without the use of antibiotics. We have modified his approach to allow shorter healing times and early mobilisation in a modern series of cases.

The aim of this study was to evaluate the time of return to play of elite basketball and voleyball players (both grouped together as jumper) with Haglund deformity after surgical resection of the prominence in the postero-superolateral aspect of the calcaneum. Haglund deformity is a prominence in the postero superolateral aspect of the calcaneum, causing a painful bursitis, which may be difficult to treat by non-operative techniques. In this study, we evaluated the duration that is needed to reach a level that a player perform regularly in a competition. This study consists of players operated by the same surgeon with same technique from 2011 to 2019. Twenty eight feet of 22 patients underwent resection of Haglund deformity with lateral approach and the outcome was analysed using AOFAS Ankle-Hind Foot Scale for hindfoot and time to restart a full range regular training was reported. All players received one dose (5–6 cc) platelet rich fibrin to attachement site of Achilles tendon peroperatively just after decompression of prominence. The mean AOFAS score at the follow up was 90/100, at the end of first year and the majority of players returned to play at 4th to 8th month of follow-up. Only two players with deformity of three feet could start to perform after one year. We conclude that minimal invasive approach ostectomy is an effective treatment for players suffering from Haglund deformity and the results were from good to excellent. However, the player should be well informed that the recovery and returning to play can take a longer time than they expect

Introduction. The purpose of this study was to analyse the efficacy and complications associated with the use of Calcium Sulphate synthetic bone graft in a paediatric population. There are no published articles on the use in children. Materials & Methods. A retrospective review was undertaken of the notes, microbiology, and X-Rays of 17 cases (in 15 patients) of calcium sulphate use in paediatric patients. As well as patient demographic data, data collected included indication, use of additional agents (antibiotics), return to theatre, and wound complications. Major complications were also assessed for. Results. There were 17 cases, in 15 patients, in our case series where calcium sulphate synthetic bone graft was used. The average patient age was 12.0 years (range 5 years – 17 years). Indications for use included likely infection (12), possible infection (3), and 2 elective finger cases (enchondroma and osteotomy). The humerus was the most common target site (5), followed by the femur (4), tibia (3), calcaneum (2), finger (2) and metatarsal (1) also included. There were positive intra-operative microbiology samples for eleven cases (Staphylococcus aureus and Staphylococcus epidermidis). Antibiotics were used in all cases except the elective finger surgery, and choice ranged between vancomycin, gentamicin, or a combination of both. Two patients required return to theatre for management of ongoing deep infection, although one case was later deemed to be non-infective osteomyelitis. Seven patients had undergone debridements prior to the definitive one with calcium sulphate (5 without Calcium Sulphate, 2 with Calcium Sulphate). Three patients experienced wound issues in the form of discharge/leakage, all were managed with dressings and did not require return to theatre. Conclusions. Calcium Sulphate synthetic bone graft, with addition of antibiotics, is an efficacious treatment in the paediatric population and is not associated with any major complications. Wound discharge should be observed for, and patients/parents warned about this, but only as per the adult population

A medializing calcaneal osteotomy (MCO) is one of the key inframalleolar osteotomies to correct progressive collapsing foot deformity (PCFD). While many studies were able to determine the hind- and midfoot alignment after PCFD correction, the subtalar joint remained obscured by superposition on plain radiography. Therefore, we aimed to perform a 3D measurement assessment of the hind- and subtalar joint alignment pre- compared to post-operatively using weightbearing CT (WBCT) imaging. Fifteen patients with a mean age of 44,3 years (range 17-65yrs) were retrospectively analyzed in a pre-post study design. Inclusion criteria consisted of PCFD deformity correct by MCO and imaged by WBCT. Exclusion criteria were patients who had concomitant midfoot fusions or hindfoot coalitions. Image data were used to generate 3D models and compute the hindfoot - and talocalcaneal angle as well as distance maps. Pre-operative radiographic parameters of the hindfoot and subtalar joint alignment improved significantly relative to the post-operative position (HA, MA. Sa. , and MA. Co. ). The post-operative talus showed significant inversion, abduction, and dorsiflexion of the talus (2.79° ±1.72, 1.32° ±1.98, 2.11°±1.47) compared to the pre-operative position. The talus shifted significantly different from 0 in the posterior and superior direction (0.62mm ±0.52 and 0.35mm ±0.32). The distance between the talus and calcaneum at the sinus tarsi increased significantly (0.64mm ±0.44). This study found pre-dominantly changes in the sagittal, axial and coronal plane alignment of the subtalar joint, which corresponded to a decompression of the sinus tarsi. These findings demonstrate the amount of alternation in the subtalar joint alignment that can be expected after MCO. However, further studies are needed to determine at what stage a calcaneal lengthening osteotomy or corrective arthrodesis is indicated to obtain a higher degree of subtalar joint alignment correction

Purpose of the study: Computed tomography is recommended for the preoperative work-up of joint fractures as it allows an optimisation of the access as a function of the injury. During the operation, 2D radiographic or fluoroscopic controls are still widely used. After one year’s experience, we evaluated the potential pertinence of using 3D reconstructions intraoperatively with a mobile isocentric fluoroscope (iso-C-3D). Material and methods: All operations for which the amplifier was used were collected prospectively. The type of fixation as well as the details of the installation and measures taken intraoperatively were noted. Results: At one year, intraoperative 3D reconstructions were made during 48 operations in 47 patients: fracture of the calcaneum (n=13), thoracolumbar spin (n=12), acetabulum (n=11), tibial condyles (n=9), odontoid (n=2), pelvis (n=1). The installation was habitual for the calcaneum and odontoid fractures. For the other localizations, use of a carbon plateau table facilitated good quality imaging for spinal and tibial condyle fractures; a carbon orthopaedic table was useful for acetabulum and pelvis fractures. With the intraoperative 3D reconstruction the surgeon was able to check the freedom of the canal after reduction and fixation. For the calcaneum fractures, reduction of the thalamic fragment was revised in one patient; in another, an intra-articular screw was replaced. One intra-articular screw stabilizing the posterior wall was also changed during an acetabulum fixation. Discussion: During our first year of use, 3D reconstruction intraoperatively has allowed us to avoid three early reoperations (for two calcaneums and one acetabulum). Classical 2D imaging of these two localizations is difficult to interpret because of the spherical form of the hip joint and, for the calcaneum, the difficulty in obtaining quality retrotibial images. Quality images requires specific installation, limiting interference with metallic supports. Conclusion: The results we have obtained in our first year of use of the ISO-C-3D amplifier has led us to generalise its use for percutaneous fixation procedures involving the acetabulum and the calcaneum

Interventional MRI provides a novel non-invasive method of in-vivo weight-bearing analysis of the talo-calcaneal joint. Six healthy males (mean 28.8 years) underwent static right foot weight bearing MRI imaging at 0o, 15o inversion, and eversion. Using known radiological markers the motion of the talus and calcaneum were analysed. The calcaneum externally rotates, plantar-flexes and angulates into varus. The talus shows greater plantarflexion with similar varus angulation, with variable axial rotation. Relative talo-calcaneal motion thus involves, 6o relative talar internal rotation, 3.2o flexion and no motion in the frontal plane. Concurrently the talus moves laterally on the calcaneum, by 6.5mm, with variable translations in other planes. The calcaneum plantar-flexes, undergoes valgus angulation, and shows variable rotation in the axial plane. The talus plantar-flexes less, externally rotates, and shifts into varus. Relative motion in the axial and saggital plane reverses rotations seen during inversion. The 8o of relative valgus talo-calcaneal angulation is achieved through considerable varus angulation of the talus, in a direction opposite to the input motion. This phenomenon has not been previously reported. From coronal MRI data, comparative talo-calcaneal motion in inversion is prevented by high bony congruity, whereas during eversion, the taut posterior tibio-talar ligament appears to prevent talar valgus angulation. We have demonstrated that Interventional MRI scanning is a valuable tool in analysing the weight-bearing motion of the talo-calcaneal joint, whilst approaching the diagnostic accuracy of stereophotogammetry. We have also demonstrated consistent unexpected talar motion in the frontal plane. Talo-calcaneal motion is highly complex involving simultaneous rotation and translation, and hence calculations of instantaneous axes of rotation cannot effectively describe talo-calca-neal motion. We would suggest that relating individual and relative motion of the talus / calcaneum better describes subtalar kinematics

Purpose: The purpose of this study was to investigate the results of the surgical treatment of intra-articular calcaneum fractures according to the Ilizarov method or in combination with mini open reduction. Materials and Methods: In the period 1996–2003, 17 patients with 19 calcaneal fractures (14 men and 3 women) were surgically treated by the Ilizarov method. 2 patients had calcaneum fractures on both sides. 15 fractures were caused by fall, whereas 4 of them by car accident. Fractures were classified according to the Saunders CT classification: 12 fractures were type II, 5 type III and 2 type IV. The device consisted of two rings applied at the distal tibia and a foot plate. The closed reduction of the calcaneum fracture was achieved with the use of a 1,8 mm pin in the posterior side of the calcaneum body, which improved the Bohler angle, along with the Gissane angle. In cases where necessary a short approach to the posterior subtalar joint was implemented for the reduction of the articular surface. The patients were encouraged to partially load their foot from the 1st postoperative day. Results: Results were evaluated according to the Maryland Foot Score. 7 fractures gave excellent results, 10 gave very good results, 1 fracture good result and 1 poor result. Conclusion: Traditional methods of open reduction and internal fixation of calcaneum fractures are usually a contraindication in cases of severe fractures and severe soft tissue damage. According to several authors the use of pins in the reduction of fractures is comparable to the open reduction. From this study the Ilizarov method was found to be particularly safe and can be used in cases associated with severe soft tissue damage offering a quick surgical treatment

Background. The current ‘gold standard’ method for enabling weightbearing during non-invasive lower limb immobilisation is to use a Patella Tendon-Bearing (PTB) or Sarmiento cast. The Beagle Böhler Walker™ is a non-invasive frame that fits onto a standard below knee plaster cast. It is designed to achieve a reduction in force across the foot and ankle. Our objective was to measure loading forces through the foot to examine how different types of casts affect load distribution. We aimed to determine whether the Beagle Böhler Walker™ is as effective or better, at reducing load distribution during full weightbearing. Methods. We applied force sensors to the 1st and 5th metatarsal heads and the plantar surface of the calcaneum of 14 healthy volunteers. Force measurements were taken without a cast applied and then with a Sarmiento Cast, a below knee cast, and a below knee cast with Böhler Walker™ fitted. Results. Compared to a standard below knee cast, the Böhler Walker™ reduced the mean peak force through the first metatarsal head by 58.9% (p < .0001); 73.1% through the fifth metatarsal head (p < .0001); and by 32.2% (p < .0001) through the calcaneum. The Sarmiento cast demonstrated a mean percentage reduction in peak force of 8.6% (P = .39) and 4.4% (P = .87) through the 1st and 5th metatarsal heads respectively, but increased the mean peak force by 5.9% (P = .54) through the calcaneum. Conclusions. Using a Böhler Walker™ frame applied to a below knee cast significantly reduces loadbearing through the foot compared to a Sarmiento cast or a standard below knee cast. Implications. This could mean early weightbearing is safer and better tolerated in patients with a wide variety of foot and ankle pathologies, which can in turn improve quality of life and reduce the incidence of immobility dependent morbidity

Background: Interventional MRI provides a novel non-invasive method of in-vivo weight-bearing analysis of the subtalar joint. Preceding in-vivo experimentation with stereophotogammetry of volunteers embedded with tantalum beads has produced valuable data on relative talo-calcaneal motion (Lundberg et al. 1989). However the independent motion of each bone remains unanswered. Materials and Methods: Six healthy males (mean 28.8 years), with no previous foot pathology, underwent static right foot weight bearing MRI imaging at 0°, 15° inversion, and 15° eversion. Using identifiable radiological markers the absolute and relative rotational and translational motion of the talus and calcaneum were analysed. Results and Discussion:Inversion: The calcaneum externally rotates, plantar-flexes and angulates into varus. The talus shows greater plantar-flexion with similar varus angulation, with variable axial rotation. Relative talo-calcaneal motion thus involves, 6° relative talar internal rotation, 3.2° flexion and no motion in the frontal plane. Concurrently the talus moves laterally on the calcaneum, by 6.5mm, with variable translations in other planes. This results in posterior facet gapping and riding up of the talus at its posterolateral prominence. Eversion: The calcaneum plantar-flexes, undergoes valgus angulation, and shows variable rotation in the axial plane. The talus plantar-flexes less, externally rotates, and shifts into varus. Relative motion in the axial plane reverses rotations seen during inversion (2.5° talar external rotation). The 8° of relative valgus talo-calcaneal angulation is achieved consistently through considerable varus angulation of the talus, in a direction opposite to the input motion. This phenomenon has not been previously reported. From coronal MRI data, comparative talo-calcaneal motion in inversion is prevented by high bony congruity, whereas during eversion, the taut posterior tibio-talar ligament prevents talar valgus angulation. Conclusion: We have demonstrated that Interventional MRI scanning is a valuable tool to analysing the weight bearing motion of the talo-calcaneal joint, whilst approaching the diagnostic accuracy of stereophoto-gammetry. We have also demonstrated consistent unexpected talar motion in the frontal plane. Talo-calcaneal motion is highly complex involving simultaneous rotation and translation, and hence calculations of instantaneous axes of rotation cannot effectively describe talo-calcaneal motion. We would suggest that relating individual and relative motion of the talus / calcaneum better describes subtalar kinematics

Haemangioendothelioma of bone is a rare intermediate grade malignancy. Because of its rareness there is a lack of information in the literature about the well established treatment strategies depending on series with large numbers. The outcome of wide resection with postoperative external irradiation would be presented. 4 patients (2 females, 2 males) with a mean age of 40.5 (26–52) with solitary haemangioendothelioma of bone admitted with local pain on the affected bone and limited restriction of function. Anatomical sites were scapula, calcaneum, midshaft of radius and metaphysodiaphyseal region of femur. Plain X-ray, CT, MRI, Tc 99 tecnetium wholebody bone scan investigations were applied. All lesions were hot on bone scan and lytic irregular permeative lesions T1 hypo, T2 hyper with gadolinium enhancement were present. Open biopsy resulted with the diagnosis of intermediate haemangioendothelioma of bone. Wide resection of tubular bones and intercalary lyophilised allograft recostruction with IM rod and cerclage wire and total calcaneum resection and allograft replacement with talar arthrodesis, total scapulectomy subsequent autoclaved bone reimplantation were the surgical procedures applied. Mean follow-up was 96 months (40–132). Three patients except scapula case received 50 Gy external irradiation. No patient developed local recurrence in the follow up. Regarding complications calcaneum patient developed skin necrosis after the irradiation which led to removal of the allograft but eventually healed. Scapula patient had late infection treated by antibiotics. All patients had satisfactory function. Intercalary allografts united in 6 months time. Calcaneum patient developed multiple small lung metastasis 1 year after the operation and treated by adriamycin based chemotherapy and interpherone. The lung lesions showed slight regression but the patient is alive since 112 months with no further relapse. Wide excision with subsequent irradiation and wide excision of total scapula resulted with no local recurrence in our small group of patients with this rare malignancy. Irradiation provided relatively less soft tissue sacrification and a sufficient local tumour control without risking the patient to an impending amputation in the occurence of local recurrence