Purpose:. To describe a plating technique for the Lapidus procedure as an alternative to the traditional screw fixation technique. To look at the complications experienced during the Lapidus procedure and to find possible solutions to prevent these complications. Methods:. A retrospective study of 34 Lapidus procedures in 26 patients (8 bilateral) between 2006 and 2009 was performed. All were done with a plating technique and a primary bone graft. The indications were:. metatarsus primus varus. hypermobility. degenerative TMT joint. Results:. The average intermetatarsal angle pre-operatively was 17.1° and this was reduced to 6,4° post – operatively. The complications experienced were:. post –operative metal removal = 6. transfer metatarsalgia = 1. hallux varus = 1. screw breakage = 1. delayed union = 1. non-union = 1. Conclusion:. The plating technique for the Lapidus procedure gives stable fixation and the outcome compares well with other methods of fixation

Introduction: The Lapidus procedure is a fusion operation of the 1st tarso-metatarsal joint for the treatment of moderate to severe hallux valgus (HV) in association with first ray hypermobility. This procedure has been shown to produce excellent correction of the deformity but is associated with complications such as prolonged healing and non-union. This study aims to determine the effectiveness of the procedure in correcting the HV deformity; record patient satisfaction and the incidence of complications. Materials and Methods: Patients who underwent a Lapidus procedure at Glasgow Royal Infirmary between November 2001 and October 2006 were reviewed. Gender, age, previous surgery for HV, complications and outcome were investigated. Pre and post-operative HV and intermetatarsal (IM) angles were obtained from weight-bearing radiographs. Results: 24 Lapidus procedures were performed on 21 patients, all female. 3 underwent bilateral procedures. The average age was 50.9 years. 7 feet (29%) had been operated on previously for HV. The HV angle improved from a pre-operative mean value of 44.3° to 15° post-operatively (average reduction 29.4°). The IM angle improved from 13.4° to 8.1° (average reduction 5.2°). There were 7 (29%) non-unions. 10 patients (42%) had minor transient complications. 12 patients (57.14%) were happy with the outcome while 7 patients (33.33%) expressed dissatisfaction. 2 patients remain under review. Discussion: Excellent anatomical correction of the HV deformity can be achieved with the Lapidus procedure. It is, however, a technically challenging procedure and only just over half of the patients were satisfied with the results. In addition, we encountered higher non-union rates than previous studies. Conclusion: The Lapidus procedure is extremely effective in correcting severe HV deformities but patient satisfaction is low and the complication rate is significant. In our view, the role of this procedure in HV corrective surgery requires further evaluation

The purpose of this prospective study was to evaluate the functional outcome of patients who underwent the Lapidus procedure as a treatment for moderate to severe metatarsus primus varus and hallux valgus deformities. Inclusion criteria were failure of non-surgical management for moderate or severe deformity, inter-metatarsal angles of more than 14° and hallux valgus angles of more than 30°. Exclusion criteria were any previous hallux valgus procedures, insulin-dependent diabetics, previous ankle or subtalar fusions, peripheral vascular disease or peripheral neuropathy. Bilateral procedures had to be at least six months apart to be included. The AOFAS Hallux Metatarsophalangeal Interphalangeal Scale (HMIS), Visual Analogue Pain Scale (VAPS), Musculoskeletal Function Assessment Scale, clinical examination and weight-bearing radiographs were used for assessment. All patients were followed up for at least six months. Patients lost to follow-up in less than a year were excluded from the analysis. For a mean of 3.7 years (1 to 6.2), 126 feet in 110 patients were followed up, 105 of them (91 patients) for at least one year. At most recent follow-up, HMIS scores increased from 52 preoperatively to 87 (p < 0.0001). VAPS improved from 5.3 to 1.3 (p < 0.0001). The hallux valgus angle improved from 37° to 16° and the intermetatarsal angle improved from 18° to 8.2°. At 3.7 years, 88.5% of patients were very satisfied, 5% somewhat dissatisfied and 1.5% dissatisfied. With proper technique and attention to detail, the Lapidus procedure is an excellent alternative for moderate to severe metatarsus primus varus and hallux valgus deformities

Twenty-four patients with 26 symptomatic recurrences of deformity after previous hallux valgus procedures were included in this study. Exclusion criteria were hallux metatarsophalangeal joint fusion, Keller/Mayo procedures, insulin-dependent diabetes, previous ankle or subtalar fusions, peripheral vascular disease or peripheral neuropathy. An AAOS Foot and Ankle Outcomes Data Collection questionnaire, a Visual Analogue Pain Scale (VAPS), and the AOFAS Hallux Metatarsopha-langeal Interphalangeal Scale (HMIS) were administered preoperatively, at six months and then annually. Weight-bearing radiographs were taken preoperatively, at 6 weeks, 3 months, 6 months and 12 months. The mean follow-up was 21.6 months (6 to 36). At final follow-up, the mean HMIS scores increased from 47.5 to 87.8 and the mean VAPS improved from 6.2 to 1.3. The mean hallux valgus angle improved from 37° to 14° and the mean intermetatarsal angle improved from 18° to 7°. In 77%, patients were very satisfied, in 4% satisfied, and in 19% somewhat satisfied.There were no cases of hallux varus. Complications included three nonunions, all of which occurred in smokers, and two superficial wound infections. In appropriately selected patients, the Lapidus procedure is a reliable and effective alternative for failed hallux valgus surgery

Introduction: The modified Lapidus-arthrodesis with standard AO screw-fixation is well known for the treatment of severe metatarsus primus varus deformity respectively a hypermobile or an arthrotic first tarso-metatarsal joint. High rates of non-union and malunion (range 3 to 12%) due to improper or poor fixation despite the postoperative course of nonweightbearing were reported in literature. The immediate postoperative weightbearing protocol varies from 2 to 6 weeks of cast immobilization. To our knowledge, this prospective investigation comprises the largest cohort of patients undergoing the Lapidus-arthrodesis, fixed with the Lapidus-Orthner locking plate. Methods: 130 feet with an average patient’s age of 52 years (range 23 – 83 years), underwent the Lapidus fusion with the locking Orthner-plate. Indications were severe hallux valgus deformities respectively moderate hallux valgus deformities with a hypermobile first TMT 1- joint or an arthrotic first tarsometatarsal joint. The surgical technique was standardized, and the operations were performed by the inventor of the plate. All patients had a failed trial of nonoperative management (shoe-wear modification). The 130 feet were divided into 2 groups. Group I was without TMT 1 – compression screw (n= 60) and group II with an additional compression-screw (n=70). Average age of group I was 54-years. The average age of group II was 50-years. The American-Orthopaedic-Foot and Ankle Society (AOFAS) Forefoot-Score, Visual-analog-pain-scale and foot radiographs were assessed preoperatively and after a mean of 23 months for group I and 39 months for group II. All 130 feet were treated immediately postoperative with a postoperative Darco orthowedge ® shoe. Results: The average AOFAS score improved significantly from preoperative to follow up time-point in both groups. AOFAS pain-subscore significantly improved in both groups. The intermetatarsal-angle (IMA) of all 130 feet decreased significantly from 14° to 6° after surgery. At time of follow-up 9 % of non-unions were seen in group I whereas 0% were seen in group II with proximal compression screw, the difference is significant (p=0,024). The mean immobilisation with the Darco-Ortho® wedge shoe was 7,2 weeks (range 6 to 14 weeks) in group I and 6,3 weeks (range 5 to 12 weeks) in group II. Conclusion: The prospective mid-term results from this study show that the locking Lapidus-Orthner plate is a very good and promising technique for the Lapidus-arthrodesis. The modified technique with compression screw has shown none non-union, despite of immediate weight-bearing in a post-op shoe after surgery. The procedure significantly reduced pain, the hallux valgus and intermetatarsal angle and increased the patient’s ambulatory capacity and patient satisfaction

Background: Lapidus (first metatarsocuneiform joint) arthrodesis is an established procedure for the management of hallux valgus. This study investigated the utility of fixation with a medial locking plate with adjunct compression screw versus fixation with two crossed screws. Methods: Eight pairs of fresh-frozen human specimens were used in a matched paired test. Bone mineral density (BMD) was measured with peripheral quantitative computed tomography (pQCT). Fixation with two 4-mm-diameter crossed screws was compared versus a medial locking plate (X-Locking Plate 2.4/2.7; Synthes, Solothurn, Switzerland) with adjunct 4-mm-diameter compression screw. The specimens tested in a four-point bending test. Parameters obtained were initial stiffness; plantar joint-line gapping after one cycle, 100 and 1000 cycles; and number of cycles to failure. Failure was defined as ≥ 3 mm plantar gapping displacement. Results: The groups did not differ significantly with regard to BMD (p = 0.866) and initial stiffness (p = 0.889). The plate-and-screw construct showed significantly less movement during testing, and significantly (p = 0.001) more cycles to failure than did the crossed-screw construct. There was a significant correlation (crossed-screw construct: p = 0.014; plate-and-screw construct: p = 0.010) between BMD and the number of cycles to failure. Conclusions: Under cyclic loading conditions, the construct using a medial locking plate with adjunct compression screw was superior to the construct using two crossed screws. Clinical Relevance: The medial locking-plate technique described holds promise for shortening the time off weight-bearing and for reducing the risk of non-union

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. Results. Mean HVA was 28.6±10.1 degrees preoperatively and 12.1±7.7 degrees postoperatively. Mean IMA was 13.7±3.8 degrees preoperatively and 7.5±3.0 degrees postoperatively. Before and after surgery, there were no significant differences in MPA (11.4±7.7 and 11.4±9.9 degrees, respectively; p = 0.75) or alpha angle (10.9±8.0 and 10.7±13.1 degrees, respectively; p = 0.83). There were significant improvements in SRA (26.4±10.2 and 15.7±10.2 degrees, respectively; p = 0.03) and sesamoid position (1.4±1.0 and 0.6±0.6, respectively; p = 0.04) after a scarf osteotomy. There were significant improvements in all outcome scores after surgery. Poorer outcome scores correlated with greater postoperative MPA and alpha angles (r= 0.76 (p = 0.02) and 0.67 (p = 0.03), respectively). Conclusion. A scarf osteotomy does not correct first metatarsal coronal rotation, and worse outcomes are linked to greater metatarsal rotation. Rotation of the metatarsal needs to be measured and considered when planning hallux valgus surgery. Further work is needed to compare postoperative outcomes with rotational osteotomies and modified Lapidus procedures when addressing rotation

Introduction. Metatarsus adductus (MA) increases the risk of recurrence following surgery for hallux valgus (HV). The goal of this study was to analyze patients with severe MA and identify clinical/surgical factors that are associated with a lower rate of recurrent deformity. Methods. 587 patients underwent correction of HV deformity. The rate of recurrence of HV was 15% (63 out of 414 patients) in patients without MA (MA angle < 20°) and 29.6% (50 out of 173 patients) in patients with MA. 19 patients with severe MA (>31°) were identified; 8 of 19 had associated tarsometatarsal arthritis, and two patients had a skew foot deformity. Ten patients had severe valgus lesser toe deformities. Clinical information collected included associated diagnoses, the presence of arthritis of the tarsometatarsal joints, the presence and degree of lesser toe valgus deformities and surgical procedures performed. Radiographic recurrence was defined as a postoperative HVA > 20°. Results. 9/19 patients were treated with a modified Lapidus procedure and 10 patients underwent a distal first metatarsal osteotomy. Of the 9 patients who were treated with a modified Lapidus procedure, 6 patients underwent simultaneous realignment lesser metatarsal osteotomy or arthrodesis of the 2. nd. /3. rd. TMT joints. 1/9 of these patients had radiographic recurrence of deformity. Of the 10 patients who underwent a distal first metatarsal osteotomy without realignment proximal osteotomy or arthrodesis, 5 had recurrence of deformity. Of the 11 patients with severe valgus lesser toe deformity, those who were treated with simultaneous additional distal lesser metatarsal osteotomies, did not have recurrence of hallux valgus. Conclusion. The use of a modified Lapidus procedure led to a lower rate of HV deformity recurrence in comparison to isolated distal first metatarsal osteotomies. Treatment of lesser toe deformity with distal osteotomy should be included as part of the treatment algorithm

Background: Total hip arthroplasty (THR) is a commonly performed procedure to treat displaced fractures of the femoral neck, either as a primary procedure, or as a secondary procedure after failed healing of internal fixation. Dislocation of the prosthesis remains as a problem, and controversies still exist regarding the optimal surgical approach and its influence on stability of the THR. The main issue is whether to use an anterolateral or a posterolateral surgical approach. Repair of the posterior soft tissue structures when performing a posterolateral approach has been proposed to increase the stability. Other factors such as age, gender, indication for surgery (primary, secondary), caput size and the experience of the surgeon may also influence the stability, but are not well documented.

Material and Methods: Between January 1 1999, and December 31 2005, 532 consecutive THR’s in 523 patients were performed at our institution as a primary, or a secondary, procedure after fracture of the femoral neck. The patients have been followed with a prospective 6 week questionnaire, and after that via the clinics journal database. Finally, thanks to the Swedish personal identification number, a search has been done in a national registry by the Swedish National Board of Health and Welfare. For all patients, all dislocations and related reoperations until December 31 2006, or death, were registered and analyzed. Logistic regression analyse was performed in order to evaluate factors associated with prosthetic dislocation. Age, gender, indication for surgery, the surgeon’s experience, caput size and surgical approach were tested as independent variables in the model.

Results: Dislocation of the THR occurred in 27 patients. In the multivariate regression analyze the posterolateral surgical approach performed without posterior repair was associated with a significant higher risk of dislocation compared with the anterolateral approach (OR 4.7, 95% CI 1.1–19.6). The 28 mm caput size was associated with a significant lower risk of dislocation compared with the 22 mm (OR 0.3, 95% CI 0.1–0.99). There was a strong, but not significant, trend of higher risk for dislocation with a posterolateral approach performed with posterior repair compared with the anterolateral approach (OR 3.3, 95% CI 0.9–11.4). Age, gender, indication for surgery or the experience of the surgeon did not affect the risk for dislocation.

Interpretations: We recommend the anterolateral surgical approach and 28 mm caput size for THR after femoral neck fracture.

Introduction: Recurrent clubfoot deformity continues to present a problem in pediatric orthopedic practice. Because of the complexity of feet deformation, the correction represents a significant challenge even for orthopedists having experience in work with the Ilizarov device.

Materials and Methods: We apply the Ilizarov fixator consisting of a base from two rings on a shin, an anterior support on the foot – the half ring perpendicular to metatarsal bones and a posterior support from the extended half ring attached to the heel. Anterior and posterior supports are attached to the base by standard details of the Ilizarov apparatus and remain unconnected between them. Such a frame design allows independent and simultaneous correction of forefoot and hind-foot deformities. From 1999–2006, 9 patients aged 3–30, 13 feet with recurrent clubfoot were treated with this technique. Three patients were females and 6 were males. Closed correction was perform in 5 cases, mid-foot osteotomy 4 cases triple arthrodesis 4 cases. The average deformity was: forefoot (supination – 30° FFA – 30°) hind foot (supination 35° equinus 40°).

Results: The correction commenced on fourth-seventh day after surgery. Corrections of deformity were achieved in all cases. The average correction period was 8 weeks. Fixation after complete correction was 6–8 weeks. Complications included pin-tract infection 16%, flexion contracture of toes – 87.5%, and severe pain during deformity correction 33%. On mean follow-up of 40 months all patients had good functional outcome.

Conclusion: Our frame variant is easy to compose, requires only standard components and allows good correction of all foot deformities.

Background:. The Chevron osteotomy is straightforward, requires less dissection and allows earlier rehabilitation than some other osteotomies. However it is generally perceived as unsuitable for severe deformities even though a 2012 meta-analysis and an earlier RCT failed to show any advantage of the scarf over the chevron. We aim to assess the correctability of severe HV comparing the correction, the clinical outcomes and complications of the Chevron osteotomy with other techniques employed in a consecutive series. Methodology:. We reviewed a series of 92 cases of severe hallux valgus (IMA >17° regardless of the HVA). The follow-up period varied from 1 to 4 years. Pre-operative x-rays and final post-operative weight-bearing x-rays were performed. Outcome scores (MOXFQ and AOFAS), IMA, HVA and foot width were collected. Complications were monitored. Results:. There were 97 cases of severe hallux valgus performed during the study period, 55 were treated with a large-shift modified Chevron osteotomy, 42 with a number of other techniques that included Ludloff, Basal or Scarf osteotomy and also fusion in the form of a Lapidus or 1. st. MTP. The average pre-operative measurements were IMA of 19.1°, HVA of 40°, osseous forefoot width of 93.2 mm and the forefoot: hindfoot ratio was 3.11. Post-operatively the measurements were IMA of 9.2 and HVA of 9.76, the osseous forefoot width was 82.8 mm and the forefoot: hindfoot ratio was 2.57. Radiological outcomes for the Chevrons were similar to the alternative techniques though the rate of recovery was better. There is an increase in the rate of screw removal after a large shift Chevron osteotomy, reasons for this are discussed. Conclusion:. The Chevron osteotomy is successful in the management of severe hallux valgus. It has the advantage of being a stable osteotomy that permits immediate weight-bearing and movement of the MTP joint

The aetiology of hallux valgus is well published and largely debated. Hypermobility at the TMTJ was initially described by Morton, but it was not till Lapidus that its association with hallux valgus was hypothesized. However, little has been published on the anatomy of the tarsometatarsal joint. Our aim was to determine whether there was an anatomical basis for the coronal hypermobility in hallux valgus. Method. Anatomical dissection was completed on 42 feet from 23 bodies. Presence of hallux valgus was noted (displacement of sesamoids). Measurements and photographs were taken of the first tarsometatarsal joint and all differences noted. Observations. The TMTJ articular morphology is variable. There were 3 separate subtypes identified of the metatarsal articular surface. Results. The articular subtypes identified were called called A, B and C. Type A, was uni-facet with a single flat articular surface, Type B was bi-facet with two distinct flat articular surfaces, and Type C was tri-facet, with the presence of a lateral eminence on inferolateral surface of metatarsal. Type A was found exclusively in bodies with Hallux Valgus and Type C exclusively in bodies without Hallux Valgus. Type B was found in both groups. Type C was more common in males and type B was more common in females. The third facet was much more common in men. Another anomaly was found; measurements taken from the lowest to highest point of joint surface (mm) revealed a significantly flatter joint surface in bodies with hallux valgus. Conclusion. Coronal plane motion in varus is a consistent feature of hallux valgus. The lateral eminence acts as a sliding dovetail joint and prevents coronal plane motion and rotation. We believe we have identified a joint type that is protective of the development of hallux valgus

Introduction: TMTJ fusion is performed for arthritis or painful deformity. First TMTJ fusion may be performed for Hallux valgus deformity. K-wire and trans-articular screws are usually used to stabilize the joints. We present our audit of experience with LP for TMTJ fusion. Patients and Methods: 33 TMTJ in 19 patients were fused and stabilised using LP between January and September 2008. The procedure was performed for Lisfranc arthritis in 13 and Lapidus procedure in 6. Two out of 6 were revisions after failed fusion using transarticular screws. Iliac crest bone autograft was used in 26 joints in 12 patients. All patients post-operatively had below knee plaster immobilization and protected weight bearing walking for first 6 weeks. Clinical and radiological surveillance continued until bone union. AOFAS mid-foot scale was also used as an outcome measure. Results: There were 7 male and 12 female patients with average age of 51 (14–68). AOFAS midfoot scale showed 42% improvement in pain, 30% improvement in function and 53% improvement in alignment. Average total AOFAS score improved from 30 preoperative to 67 postoperative. All except 1 joint in one patient had clinical and radiological fusion of their joints. 1 patient needed removal of metalwork and 4 had delayed wound healing. Average satisfaction score was 7/10. 86% Patients would recommend it to a friend and 91% would have it again. Discussion: Locking plates have been recently introduced for ankle and foot surgery. Biomechanical studies have shown plates are not as strong or stiff as trans-articular screw fixation however they are easy to use, have more flexibility for realignment and can act as a buttress for bone graft. In our review all patients except one had bone union without loss of alignment. Conclusion: TMTJ fusion improves pain and function. Locking plates provide satisfactory stability for TMTJ fusion

Introduction: Tarsometatarsal joint (TMTJ) fusion is performed for arthritis or painful deformity. First TMTJ fusion may be performed as a part of corrective surgery for hallux valgus deformity. K-wires and trans-articular screws are often used to stabilize the joints. We present our experience with the use of locking plates (LP) for TMTJ fusion. Patients and Methods: Thirty-three TMTJ’s in 19 patients were fused and stabilised with LP’s between January and September 2008. The procedure was performed for Lisfranc arthritis in 13 patients and Lapidus procedures in six. Two out of 6 were revisions after failed fusion using transarticular screws. Iliac crest bone autograft was used in 26 joints in 12 patients. All patients post-operatively had below knee plaster immobilization and protected weight bearing walking for first 6 weeks. Clinical and radiological surveillance continued until bone union. AOFAS midfoot scale was used as outcome measure. Results: There were 7 male and 12 female patients with average age of 51 (14–68). The American orthopaedic foot and ankle surgery society (AOFAS) midfoot score showed a 42% improvement in pain, 30% improvement in function and 53% improvement in alignment. The average AOFAS overall score improved from 30 preoperativley to 67 postoperativley. All except one joint in one patient had clinically and radiologically fused joints. One patient underwent removal of the metalwork and four had delayed wound healing. The average satisfaction score was 7 out of 10. 86% said of patients said that they would recommend the surgery to a friend, and 91% would undergo the surgery again. Discussion: Locking plates have been recently introduced for ankle and foot surgery. Biomechanical studies have shown that the plates are not as strong or stiff as trans-articular screw fixation, however, they are easy to use, have more flexibility for realignment and can act as a buttress for bone graft. In our series all, except one, patients achieved bony union without loss of alignment. Conclusion: Locking plates provide satisfactory stability for TMTJ fusion, without complications

Background: Since 2003 we have offered correction of bilateral hallux valgus to suitable patients as a daycase but there is nothing in the literature to support this as safe practice. Two published series support unilateral hallux valgus surgery as a daycase. We prospectively evaluated 30 bilateral daycase patients assessing complications and overall satisfaction rating. Methods: The study group comprised 15 bilateral Scarf osteotomies, 9 bilateral Chevron osteotomies, 4 unilateral Scarf plus unilateral Chevron osteotomies, 1 bilateral 1st MTP joint fusion and 1 bilateral Lapidus procedure. All surgery was performed as a daycase under GA and ankle block. All patients were evaluated clinically and radiologically pre & post-operatively and had AOFAS scores measured. 21 patients were telephoned on the 3rd post-operative day to document their pain scores (0–10) and all patients responded to a patient satisfaction questionnaire at their discharge around 4.5 months. Results: 18 of the 21 patients interviewed on day 3 had mild pain (0–4) as their maximum pain score. 3 reported problems (2 of pain and 1 of poor mobility). There was one unilateral superficial wound infection which required oral antibiotics. No other patients required to call or attend their GP nor attend A& E. The mean overall patient satisfation rating (0–10) was 8.8 (median 9). If having similar repeat surgery 4 of the 30 patients (13%) would prefer an overnight stay. The reasons given by these 4 patients were: pain (1), poor mobility (1), a desire to be looked after by the nursing staff (2). Conclusions: Bilateral hallux valgus surgery can be performed safely as a daycase and with acceptable levels of patient satisfaction. It does not appear to result in an increased complication rate. To our knowledge this has not been previously documented in the literature

Introduction: A retrospective evaluation of early results of arthroereisis. Material and Methods: Eight feet in five patients with pathological flexible planovalgus deformity that had failed non-operative management were treated with subtalar arthroereisis using the Kalix prosthesis. Diagnosis include oblique talus (2), vertical talus (1), diplegia secondary to head injury (1) and type I neurofibromatosis (1). The average age of patients was 6.4 years (range 4–12), and average follow-up was 9.9 months(range 4–20). Outcome was assessed using clinical assessment of the foot axis and functional improvement and radiographic measurements of change in the talocalcaneal angle and talonavicular sag. Results: Arthroereisis was never performed in isolation, additional procedure included achilles tendon lengthening (2), gastrocnemius recession (6), talonavivular and spring ligament plication (5) and split tibialis anterior tendon transfer (1). All patients had improvement of foot function and restoration of foot axis to a position parallel to the axis of progression. Restoration and maintenance of the talocalcaneal angle was excellent in all cases with preoperative average of 42 degrees (range 20–70), improved to a postoperative average of 23 (range, 0 – 40). Talonavicular sag improved from preoperative average of 16.5 degrees (range 0–32), to post operative average of 26 degrees (range 18–35). Complications include persistent first ray extension which required a Lapidus procedure (1), Ongoing minor discomfort (1). No patients or parents were dissatisfied. Discussion: The preliminary report supports the use of this technique in selected cases. Sizing of the implant and intraoperative assessment of correction of deformity and balanced surgery are critical to success. It is a simple and rapid procedure with advantages over alternatives such as Osteotomy and fusion. Long term results need further evaluation

Background. Thrombosis is a rare complication for the single orthopaedic surgeon. The objective for this study was to determine the incidence of thromboembolism after orthopaedic surgery at Söder Hospital.

Methods. All patients operated on during 1997–2000 (n= 25284) were given a short questionnaire regarding postoperative complications. The patients were asked to return the form at 6 weeks. About 50% of the forms were returned spontaneously. A research nurse contacted the rest of the patients. The questionnaires were compared with patient’s charts. An orthopaedic surgeon judged if the complication was related to surgery.

Results. 99.5% of the surveys were returned. 0.78% deep vein thrombosis (DVT) and 0.20% pulmonary emboli (PE) were radiographically diagnosed. DVT mean age was 59.6 and PE 74.7 years. Median DVT detection time was 18.0 and PE 20.6 days. DVT and PE incidence was higher in lower extremity compared to upper extremity surgery. DVT incidence in Achilles tendon ruptures (9.5%), knee replacement (5.8%), pelvic fractures (4.8%) was high.

Conclusions. Thromboembolism incidence in orthopaedic surgery was low. However, some surgical procedures had a high DVT incidence. The results of this study imply the need for adjusting thromboprophylaxis according to the surgical procedure.

Background: Prophylaxis against thromboembolic complications has become routine after major trauma and major orthopaedic surgery. In contrast, it remains an issue for debate whether prophylaxis after minor surgery and immobilization is necessary, even though these treatments are well-known risk factors for deep vein thrombosis (DVT).

Objectives: The objective of this study was to evaluate the efficacy of Dalteparin (5,000 U given subcutaneously once daily for six weeks) during lower limb immobilization after surgical treatment of Achilles tendon rupture.

Methods: After surgery, 105 consecutive patients were randomized to a placebo-controlled double-blind study to evaluate the efficacy of given thromboprophylaxis. DVT screening using validated color duplex sonography was performed three weeks and six weeks after surgery, and all DVTs were confirmed with phlebography.

Results: Primary endpoint analysis was available for 91 patients. DVT was diagnosed in 16/47 patients (34%) in the Dalteparin group and in 16/44 patients (36%) in the placebo group. These figures are not significantly different (p=0.8). Proximal DVT was diagnosed in one patient (2%) in the Dalteparin group and in three patients (6%) in the placebo group (p=0.6). No pulmonary emboli or major bleeding occurred in either of the groups.

Conclusions: DVT is common after surgical treatment of Achilles tendon rupture and therefore effective thromboprophylaxis is desirable. Thromboprophylaxis with Dalteparin however, does not affect the incidence of DVT during the immobilization after Achilles tendon rupture surgery. Long-term effects of immobilization, such as the risk for post-thrombotic syndrome, need to be investigated further.

The December 2013 Foot & Ankle Roundup³⁶⁰ looks at: Maisonneuve fractures in the long term; Not all gastrocnemius lengthening equal; Those pesky os fibulare; First tarsometatarsal arthrosis; Juvenile osteochondral lesions; Calcanei and infections; Clinical outcomes of Weber B ankle fractures; and rheumatologists have no impact on ankle rheumatoid arthritis.