Introduction Fracture dislocation of the midtarsus with subsequent collapse of the longitudinal arch, dislocation of the forefoot and development of the rocker-bottom deformity is a significant complication of the neuropathic foot. Bony deformity and lack of protective sensation may lead to plantar ulceration, infection and amputation. Surgical reconstruction entails reduction of the dislocation and restoration of the alignment of the foot. Fixation of the arthrodesis may be challenging due to bony dissolution, fragmentation and osteoporosis which accompany the Charcot process. The purpose of the the current study is to describe the technique and review the clincial results of midtarsal arthrodesis with intamedullary axial screw fixation used to treat Charcot midfoot collapse. Methods A retrospective study of 12 patients undergoing surgical reconstruction and arthrodesis of Charot midfoot deformity was done. Long intramedullary screws were applied antegrade or retrograde to bridge the apex of the deformity after the area had been prepared for arthrodesis through bony resection or osteotomy. Axial screws are applied such that the head or shaft of the screw gained purchase in the intramedullary canal of two or more metatarsal bones. Compression of the arthrodesis bed was achieved by tightening the screws. Radiographic measurements were taken pre-operatively, immediately post-operatively and at the last follow-up to assess the amount of durability of the correction achieved. Results Patients were evaluated clincally and radiographically at an average of 35 month follow-up (5 to 144 months). Bony union was achieved in 83% of patients, at an average of 5.3 months. All patients returned to functional ambulatory status within seven months. The talar-first metatarsal angles in the anterior and lateral planes, talar declination angle and calcaneal-fifth metatarsal angle were all corrected to near normal values following the surgery and showed no significant collapse between immediate post-op and final follow-up. The amount of dorsal displacement of the medial column was reduced to normal values and showed no significant recurrence at final follow-up. There were no recurrent plantar ulcerations. Hardware failure occurred in one patient who was unable to comply with weight bearing restrictions and significant soft tissue complications were encountered. Conclusions Surgical correction of Charcot midfoot collapse with midfoot osteotomy and arthrodesis utilizing multiple large-diameter intramedullary axial screws which span the area of dissolution provides an adequate construct to achieve arthrodesis and maintain alignment and reduction of the deformity. In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits

The August 2014 Children’s orthopaedics Roundup. 360 . looks at: Conservative treatment still OK in paediatric clavicular fractures; Femoral anteversion not the usual suspect in patellar inversion; Shoulder dislocation best treated with an operation; Perthes’ disease results in poorer quality of adult life; Physiotherapy little benefit in supracondylar fractures; Congenital vertical talus addressed at the midtarsal joint; Single-sitting DDH surgery worth the effort; and cubitus valgus associated with simple elbow dislocation

Treatment of comminuted intraarticular calcaneal fractures remains controversial and challenging. Anatomic reduction with stable fixation has demonstrated better outcomes than nonoperative treatment of displaced intraarticular fractures involving the posterior facet and anterior calcaneocuboid joint (CCJ) articulating surface of the calcaneus. The aim of this study was to investigate the biomechanical performance of three different methods for fixation of comminuted intraarticular calcaneal fractures. Comminuted calcaneal fractures, including Sanders III-AB fracture of the posterior facet and Kinner II-B fracture of the CCJ articulating calcaneal surface, were simulated in 18 fresh-frozen human cadaveric lower legs by means of osteotomies. The ankle joint, medial soft tissues and midtarsal bones along with the ligaments were preserved. The specimens were randomized according to their bone mineral density to 3 groups for fixation with either (1) 2.7 mm variable-angle locking anterolateral calcaneal plate in combination with one 4.5 mm and one 6.5 mm cannulated screw (Group 1), (2) 2.7 mm variable-angle locking lateral calcaneal plate (Group 2), or (3) interlocking calcaneal nail with 3.5 mm screws in combination with 3 separate 4.0 mm cannulated screws (Group 3). All specimens were biomechanically tested until failure under axial loading with the foot in simulated midstance position. Each test commenced with an initial quasi-static compression ramp from 50 N to 200 N, followed by progressively increasing cyclic loading at 2Hz. Starting from 200 N, the peak load of each cycle increased at a rate of 0.2 N/cycle. Interfragmentary movements were captured by means of optical motion tracking. In addition, mediolateral X-rays were taken every 250 cycles with a triggered C-arm. Varus deformation between the tuber calcanei and lateral calcaneal fragments, plantar gapping between the anterior process and tuber fragments, displacement at the plantar aspect of the CCJ articular calcaneal surface, and Böhler angle were evaluated. Varus deformation of 10° was reached at significantly lower number of cycles in Group 2 compared to Group 1 and Group 3 (P ≤ 0.017). Both cycles to 10° plantar gapping and 2 mm displacement at the CCJ articular calcaneal surface revealed no significant differences between the groups (P ≥ 0.773). Böhler angle after 5000 cycles (1200 N peak load) had significantly bigger decrease in Group 2 compared to both other groups (P ≤ 0.020). From biomechanical perspective, treatment of comminuted intraarticular calcaneal fractures using variable-angle locked plate with additional longitudinal screws or interlocked nail in combination with separate transversal screws seems to provide superior stability as opposed to variable-angle locked plating only

Aims

The Chopart joint complex is a joint between the midfoot and hindfoot. The static and dynamic support system of the joint is critical for maintaining the medial longitudinal arch of the foot. Any dysfunction leads to progressive collapsing flatfoot deformity (PCFD). Often, the tibialis posterior is the primary cause; however, contrary views have also been expressed. The present investigation intends to explore the comprehensive anatomy of the support system of the Chopart joint complex to gain insight into the cause of PCFD.

For many surgeons amputation is the usual treatment in sarcoma of the foot. The aim of our study was to report the functional and oncologic results of treatment in 54 sarcomas of the foot to assess if conservative treatment was acceptable. We retrospectively reviewed the records of 54 patients with sarcomas of the foot, aged 6 to 50 (mean 17), 30 females and 26 males. At time of referral, 18 had a local recurrence of a previous inadequate treatment. There were 27 soft tissue sarcomas (STS: 10 synovial sarcomas, 6 rhadomyosarcomas, 1 liposarcomas and 10 others) and 27 bone tumours (16 Ewing's, 8 chondrosarcomas, 3 osteosarcomas). Toes tumours were excluded, 18 tumours involved the metatarsal, 12 the plantar soft tissues, 11 the calcaneum, 3 the talus, 2 the midtarsal bones. Surgery consisted in 19 resection without reconstruction, 21 resections with bone reconstruction, 9 partial amputations of the foot, and 6 trans tibial amputations. In 34 cases surgical margins were adequate (R0), in 13 patients resection was inadequate (9 R1 and 4 R2). In 7 cases the margins were not assessed. After a 5.5 years average follow-up (3m to 17y), 31 patients had no evidence of disease, 8 were in second remission, 4 had an evolutive disease and 11 were deceased. The mean MSTS score was 26/30 (31 cases). In conclusion, a conservative treatment is feasible in metatarsal bones with skin coverage by flap if necessary. In STS adequate margins are difficult to achieve with a high rate of local recurrence. In calcaneus and talus, a conservative treatment is possible in tumours limited to bone after good response to chemotherapy. In other cases conservative treatment is debatable because amputation gives excellent functional results

Introduction: In situ subtalar arthrodesis cannot restore anatomical shape of the hindfoot in severe flat foot deformities. Purpose of this paper is to evaluate the result of 250 feet consecutively operated by subtalar arthrodesis with distraction and insertion of a mini structural bone block (SAMBB). Material and Methods: 178 patients (250 feet), mean age 55+/−11 years affected by acquired adult flat foot with subtalar arthritis were evaluated clinically and radiographically and selected to receive SAMBB. Arthrodesis was performed through a 2.5 cm incision, with partial cartilage removal and insertion of a structural corticocancellous block (2 × 1cm), harvested from the proximal ipsilateral tibia, vertically positioned into the sinus tarsi. Associate procedures were Achilles tendon lengthening (124), SERI procedure (61), hind-foot deformity correction (32). Postoperatively plaster-cast without weight-bearing for 4 weeks followed by walking boot was advised. All patients were reviewed at a minimum follow-up of 5 years. Results: Before surgery the mean AOFAS score was 42+/−15, while it was 90+/−8 at follow-up (p< 0.005). Mean heel valgus deviation at rest was 15°+/−8° preoperatively and 6°+/−5° at follow-up (p< 0.005). Mean angulation of Meary’s line at talonavicular joint level was 160°+/−11° preoperatively and 174°+/−8 at follow-up. No complications were found. No or minimal arthritis progression was observed in the ipsilateral foot joints at follow up. Conclusions: SAMBB resulted in an adequate correction of the deformity, with restoration of the anatomical shape of the hind foot and correction of the relationship with the midtarsal joint with no need of hardware. Consequent reduced arthritis progression and excellent clinical result were obtained

The aim of this study is to present guidelines for treatment of acquired adult flat foot (AAFF) and review the results of a series of patients consecutively treated. 180 patients (215 feet), mean age 54? 12 years affected by AAFF were evaluated clinically, radiographically and by MRI to chose the adequate surgical strategy. Tibialis posterior dysfunctions grade 1 were treated by tenolysis and tendon repair (48 cases), grade 2 by removal of degenerated tissue and tendon augmentation (41 cases), grade 3 by flexor digitorum longus tendon transfer (23 cases); in these cases subtalar pronation without arthritis was corrected by addictional procedures consisting of either calcaneal osteotomy (66 cases), subtalar athroereisis (25 cases) or Evans procedure (21 cases) in case of severe midfoot abduction. Subtalar arthrodesis (82 cases) or triple arthrodesis (21 cases) were performed in case of subtalar arthritis isolated or associated with midtarsal arthritis respectively. Postoperatively plastercast without weight-bearing for 4 weeks followed by walking boot for 4 weeks was advised. All patients were followed up to 5 years. Before surgery the mean AOFAS score was 48+\−11, while it was 89+\−10 at follow-up (p< 0.005). Mean heel valgus deviation at rest was 15°+\−5° preoperatively and 8°+\−4° at follow-up (p< 0.005). Mean angulation of Meary’s line at talonavicular joint level was 165°+\−12° preoperatively and 175°+\6 at follow-up. Surgical strategy in AAFF should include adequate treatment of tibialis posterior disfunction and osteotomies for correction of the skeletal deformities if joints are arthritis free; arthrodesis should be considered in case of severe joint degeneration

The foot and ankle are very commonly affected in various paralytic conditions. Paralysis of different muscles acting on the foot results in characteristic gait aberrations. The gait abnormalities are a result of one or more of the consequences of paralysis including: loss of function, muscle imbalance, deformity and instability of joints. The aims of treatment of the paralysed foot and ankle are to: make the foot plantigrade, restore active dorsiflexion during the swing phase of gait (if this is not possible then prevent the foot from ‘dropping’ into plantar flexion during swing), ensure that the ankle and subtalar joints are stable throughout the stance phase of gait, facilitate a powerful push-off at the terminal part of the stance phase (if this is not possible, at least prevent a calcaneal hitch in terminal stance). The specific aims of treatment in each patient depend on the pattern and the severity of paralysis that is present and hence the aims are likely to vary. In order to determine what treatment options are available in a particular patient, it is imperative that a careful clinical assessment of the foot is done. Based on the clinical assessment, these questions need to be answered before planning treatment: What are the muscles that are paralysed What is the power of each muscle that is functioning? Is there muscle imbalance at the ankle, subtalar or midtarsal joints that has either already produced a deformity or has the potential to produce a deformity in future? Are there any muscles of grade V power that can be spared for a tendon transfer without producing a fresh imbalance or instability. To facilitate responses to these questions, the muscle power of each muscle can be charted on a template that facilitates graphic representation of the muscle balance around the axes of the ankle and subtalar joints. This assessment clarifies whether a tendon transfer is a feasible option. If a tendon transfer is considered feasible, then the following questions also need to be answered: Is there a fixed, static deformity that needs to be corrected prior to a tendon transfer? If a tendon transfer was performed, would the child be capable of comprehending and cooperating with the post-operative muscle re-education programme?. The decision-making process will be outlined and the use of the template in choosing the tendon transfer and deciding the site of anchorage of the transferred tendon will be explained. With suitable examples the choice of tendon transfers in different patterns of paralysis would be illustrated

Intoduction: Ankle arthrodesis is the most commonly used procedure for the painful stiff ankle. A unilateral ankle arthrodesis results in good function, provided the subtalar and midtarsal joints are normal and provide a compensatory mechanism. The disadvantages of arthrodesis include the need for prolonged immobilisation and a pseudoarthrosis rate up to 10%. Superiority of arthroplasty over artrodesis has been provided by Kofoed and Stirrup (1994). In a series of 26 patients 13 patients with 14 arthrodesis were compared with 13 patients with 14 arthroplasties with follow-up of 84 months, arthroplasty gave better pain relief, better function and a lower infection rate. Results: We hahe implanted 36 STAR total ankle prosthesis on patients with mean follow-up of 22 (6–60) months. The mean age of patients was 47 (20–78) years at operation. The Indication for operation was Rheumatoid Arthritis in 23 patients and Post traumatic arthrosis in 13 patients. The mean Kofoed score before operation was 40 (12–73) points and at follow-up study it was 81 (44–98) points, P< 0.001. Result was excellent in 14 patients, good in 15 patients, fair in 2 patients and poor in 5 patients. The mean motion in the ankle at follow-up study was 30 (10–50) degrees. At follow-up study the mean valgus in the x-rays was 0.5 (0–7) degrees and Varus 1.8 (0–8) degrees. Radiolucent lines were obtained on 4 patients around the tibial component at the follow-up study. There was no difference in the results between rheumatoid patients and post-traumatic patients. Conclusions: Third generation ankle arthroplasty has moved from experimental procedure to that of worthwhile and durable solution

Introduction: The double-hindfoot arthrodesis (subtalar and midtarsal joints) is traditionally performed through a lateral surgical approach associated or not with a medial approach. The main goal of this procedure is to correct severe deformities of the hindfoot in varus or in valgus. In this study we report a series of 19 double-hin-foot arthrodeses through a single medial approach. Methods and Materials: 19 double arthrodeses (subtalar and talonavicular joint) were performed on 16 patients, 8 males and 8 females with a mean age at surgery of 58.3 years (range 27–72). The indications were: 12 pes planovalgus and 7 cavus foot. 9 deformities were fixed (3 in valgus and 6 in varus). The chosen surgical technique was always identical using a medial approach and performed by a single dedicated orthopaedic foot and ankle surgeon (JLB), followed by an osteotomy of the insertion of the Tibialis posterior muscle to the Navicular bone, distraction and avivement of the articular surface done without bone resection, reduction of the talus on the calcaneus, fixation of the talonavicular joint with titanium staples (Pareos®) and of the subtalar joint with two 6.5 mm canulated cancellous screws (Unima®). On five occasions (in 3 pes planovalgus and in 2 cavus foot) arthrodesis of the calcaneocuboid joint was carried out through a mini lateral approach due to painful arthritic lesions. Results: The average follow up was 16.5 months (range 6–40). Consolidation was always achieved. In the subgroup with pes planovalgus: the mean Kitaoka score increased from 44 to 75, the axis of the hind-foot decreased from 21° to 11° in valgus, Djian’s angle decreased from 142° to 134.4°, the slope of the calcaneus increased from 17° to 19.4°. Two failures of the associated medial ligament reparation have led to a secondary complementary arthrodesis of the talo-crural joint. In the subgroup with cavus foot: the mean Kitaoka score increased from 16 to 67. The axis of the hindfoot decreased from 13° in varus to 0.6° in valgus. Djians’s angle increased from 117° to 127.4°, the slope of the calcaneus ranges from 21.3° to 21.5°. Discussion: The double-hindfoot arthrodesis via a medial approach permits the fusion without developing nonunion (in comparison with 20% non-union of triple arthrodesis reported in the literature). Double arthrodesis via a medial approach provide a significant correction of the fixed deformities without resorting to bone grafts. Not classically used in cavus foot, it has permitted the correction of the cavo varus deformity without complications of the surgical wound and by extending the approach, a double elevating osteotomy of the metatarsal bases was performed when necessary