Purpose of the study: The purpose of this retrospective study was to evaluate the reliability of the sural flap with a distal pedicle for covering tissue loss of the posterior aspect of the heal and the malleolar region in diabetic patients.

Material and methods: We present a retrospective consecutive series with 28 month follow-up. Thirteen flaps in 13 patients (10 men, 3 women), mean age 64 years. A homolateral flap was used in all cases, covering on average 48 cm². Substance loss involved the hind foot in ten cases and the malleolar region in three. Three patients had recent bone trauma, four had chronic osteitis and six a pressure wound involving the heel. All patients had non-insulin dependent diabetes mellitus.

Results: The flap head in 24 days on average (range 18–45), the donor site in 15 days. Eleven patients were able to wear normal shoes. At last follow-up all patients were free of infectious recurrence. There was one flap necrosis, three necrotic borders (one skin graft), two cases of venous insufficiency, and ten cases of hypoesthesia of the lateral border of the foot.

Discussion: There have not been any reports in the literature of the neurocutaneous sural flap with a distal pedicle for diabetic patients. In our series, this flap was found to be a reproducible solution for covering substance loss of the heel and malleolar region in the diabetic.

Conclusion: This flap with a long pedicle does not require microvascular qualification. It is easy to perform, induces few functional sequelae. For diabetic patients, it is an alternative to amputation, without compromising future options since the vascular and muscle stock are preserved.

Purpose: A pre- and postoperative radiographic analysis of 50 total knee arthroplasties (TKA) was performed to determine the femorotibial correction angle and the tibial and femoral mechanical angles obtained as a function of the initial bony deformity. The preoperative angle beyond which correction was not achieved was determined.

Material and methods: This prospective single-centre study included 50 TKA (25 men and 25 women), mean age 69.1 years (range 53–83). Degenerative disease involved the right knee in 21 cases and the left knee in 29. A Wallaby I TKA (semi-restrained with preservation of the posterior cruciate ligament) was implanted in all cases. Three angles were calculated on the AP loaded knee: AFT (femorotibial angle), AFM (femoral mechanical angle), ATM (tibial mechanical angle). For each angle, statistic analysis was performed on four groups of patients: group I: overall population, group II: patients with normal axis (178°< AFT< 182°; 88°< AFM< 92°; 88)< ATM< 92°), group III: patients with varus (AFT> 182°; AFM> 92°; ATM> 92°), and group IV: patients with valus (AFT< 178°; AFM< 88°; ATM< 88°). Non-parametric tests (Spearman rank test and MacNemar symmetry test) were performed on SAS software for statistical analysis with p< 0.05 considered as significant.

Results: Pre- and postoperative AFT showed: significant improvement of the mean (> 3.44° in group I, > 6.87° in group III, and > 6.12° in group IV). There was no significant difference in group II. Pre- and postoperative AFM showed: constant but non-significant improvement in groups I and III (> 3°) and constant and significant improvement in groups III and IV (> 2.5°). Pre- and postoperative ATM showed: significant improvement in groups I and III (> 3°), constant but non-significant improvement in group IV (n=4). There was no group II. An ATM > 94° was the threshold angle beyond which correction was not obtained.

Discussion: Taken together, the results of this study confirm the reliability of the Wallaby I instrumentation for achieving a correct postoperative mechanical axis. These results are comparable with data in the literature (with or without preservation of the posterior cruciate ligament). However, the correction of the bony deformity obtained depended uniquely on the initial deformity of the tibia. Extreme deformity of the tibia should be corrected with osteotomy or with a more restrained prosthesis.

Purpose: The purpose of this work was to evaluate function of 256 total knee arthroplasties (TKA) (Wallaby) with preservation of the posterior cruciate ligament and to compare the femorotibial angle obtained postoperatively.

Material and methods: This prospective study included 256 consecutive TKA (cemented Wallaby 1) in 249 patients (mean age 68 years) with osteoarthritis (n=249) or rheumatoid polyarthritis (n=7). Pre- and postoperative clinical findings (HKS score, flexion, extension, laxity, walking distance, use of crutches) and AP full leg views with 20° loaded lateral views pre- and postoperatively (mechanical femoral, mechanical tibial, and femorotibial angles, tibial slope, patellar height, anterior tibial translation) were recorded.

Results: The 256 TKA were reviewed at a mean 3-year follow-up. Flexion amplitude was the evaluation criterion. Mean preoperative flexion was 109° (40–130°) with mean persistent flexion of 5° (0°–40°). Mean postoperative flexion was 98° (30–130°) with no persistent flexion. The mean preoperative femorotibial angle was 181.8° (160–201°) and was 180.4° (172–195°) postoperatively. The mean preperative mechanical femoral angle was 88° (82–96°) and 89.8° (80–96°) postoperatively. Mean mechanical tibial angle was 93° (85–104°) and 90.4° (84–86°) postoperatively.

Discussion: For certain authors, the only parameter predictive of postoperative flexion after gliding TKA with preservation of the posterior cruciate ligament is preoperative flexion. The statistical analysis of our series showed that correction of the femorotibial malalignement in the frontal plane was not correlated with postoperative knee function and precisely with postoperative flexion. Postoperative flexion was correlated with preoperative flexion. Our results on postoperative flexion of TKA related to preoperative flexion are in agreement with earlier analyses reported in the literature that do not find any absolute correlation with a neutral femorotibial angle in the frontal plane.

Conclusion: The quality of the functional outcome after total knee arthroplasty cannot be predicted solely on the correction of the initial deformity.

Purpose: Talonavicular arthritis, associated or not with rear foot deformity, is common in patients with rheumatoid arthritis. The work by Steinhauser and Gérard demonstrated the usefulness of talonavicular arthrodesis for the treatment of this rear foot disorder. The purpose of this study was to assess outcome after this surgical technique in patients with rheumatoid polyarthritis.

Material and methods: Between 1988 and 1998, 26 feet (24 men, 2 women, 17 right, 7 left) were operated by the same surgeon. Mean age of the patients at surgery was 51 years. Mean delay from disease onset to talonavicular arthrodesis was 13 years. Postoperative immobilisation lasted 45 days. Mean follow-up was five years (1–10).

Results: Patients were very satisfied or satisfied in 92.3% of the cases. Mean pre- and postoperative pain score was 8.14 and 1.77 respectively (p = 0.0001). Normal shoes could be worn by 37.5 and 66.7% of the patients pre- and postoperatively. Patient independence was significantly improved (p = 0.0001). The postoperative analysis of the plantar prints demonstrated pes planus and pes cavus. In 29.2 and 12.5%, the mean postoperative tibiocalcaneal angle was 0.78° with pes varus in eight cases (2°–10°). The mean Djean angle was 122.3° and 122.8° pre- and postoperatively (p = 0.24). Three talocrural joints (11.5%) that were intact preoperatively had degraded at last follow-up. The statistical analysis showed that clinical outcome was not affected by the postoperative aspect of the foot. There were three cases of tight non-union (11.5%) two of which were asymptomatic and two cases of infection (7.5%) requiring revision surgery. These complications led to two poor outcomes.

Discussion: The rate of non-union varies in published series from 3 to 37%. The rate observed in our series has led us to delay weight bearing. The residual varus found in eight feet, related to a shortened medial column, may warrant intertalonavicular grafting.

Conclusion: Talonavicular arthrodesis is a useful procedure despite a significant risk of complications.