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Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 591 - 591
1 Oct 2010
Tryfonidis M Dermon A Kazakos K Lyras D Petrou C Stavrakis T Tilkeridis C
Full Access

Introduction: We present the long term results in 204 cases of Hallux Valgus deformity correction using a modified Mitchell’s osteotomy.

Methods: 168 patients (204 feet) that had Mitchell’s osteotomies between 1986 and 2001 were recalled for clinical and radiological evaluation. The patients had hallux valgus angles of up to 50o and intermetatarsal angles of up to 20o. They all had a modified procedure using two crossed Kirschner wires to fix the capital fragment into plantar displacement and angulation. Lateral soft tissue release was performed when deemed necessary during the procedure. Mild to moderate arthritis of the 1st metatarsophalangeal joint was not a contraindication. The AOFAS scores as well as any complications were recorded and the Xrays were used to measure hallux valgus and intermetatarsal angles. Mann-Whitney U test was used to analyze data.

Results: The mean follow up was 12.9 years. The mean AOFAS score improved from a preoperative of 49.6 to a postoperative of 87.9 points (p=0.004), due to improvement in the pain (14.2 Vs 37.6, p=0.001) and function (30.6 Vs 39.8, p=0.043) parameters. 57 cases (27.9%) had Hallux Valgus angles > 40o. Lateral soft tissue release was performed in only 16 of these cases with no significant difference in the postoperative Hallux Valgus angle compared to the ones not requiring soft tissue release (21.3o Vs 20.8o, p=0.08). There was a decrease in the pre-operative Vs post-operative incidence of lateral metatarsalgia and symptomatic callosities (18.33% Vs 11.8%, p=0.023). We had only one case of avascular necrosis.

Discussion/Conclusion: Mitchell’s osteotomy is a reliable technique with successful outcomes and minimal complications when performed with accurate surgical technique, stable fixation and lateral soft tissue release when appropriate. It may also be successfully performed for Hallux Valgus angles > 40o. We believe that it has still got a role in the treatment of Hallux Valgus.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 499 - 499
1 Oct 2010
Tryfonidis M Anjarwalla N Cole A
Full Access

A number of studies have looked at the incidence of cervical rib in various ethnic groups, but have a number of limitations. This is the first large scale study looking at the incidence in White British with direct comparison to the Asian population. A total of 1545 consecutive cervical spine radiographs performed for any reason were collected and reviewed. 5.9% of White British and 24.9% of Asian patients had evidence of cervical rib. This was statistically significant (p< 0.0001, χ2 test). Asians are 5 times more likely compared to White British to have cervical rib (OR=5.303, 95% CI=3.825–7.354). An analysis of male Vs female difference as well as incidence of the various subtypes of cervical rib will be presented. We reccomend that the results of this study should

be considered in the assessment of patients with symptoms of thoracic outlet syndrome,

taken into account during review of cervical spine radiographs and

included in anatomy textbooks in the future.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_II | Pages 365 - 365
1 May 2009
Tryfonidis M Jackson W Mansour R Ostlere S Teh J Cooke PH Sharp RJ
Full Access

Introduction: Acquired pes planus is caused by mechanical uncoupling of the bones of the tarsus due to failure of the osseoligamentous complex that maintains the medial longitudinal arch of the foot. The most common cause of acquired flat foot deformity in adults is posterior tibialis tendon dysfunction. A solitary previous case report has documented an alternative aetiology of acquired flat foot in adults due to isolated spring ligament rupture; in that case diagnosis was made intra-operatively.

Materials and Methods: We present 9 cases of acquired flat foot deformity that were caused by isolated spring ligament insufficiency, mainly presenting after an eversion injury of the ankle. We present the clinical sign of ability to single leg tiptoe, but with persistent forefoot abduction and heel valgus, that allows differentiation of this diagnosis from posterior tibialis tendon dysfunction. In addition we illustrate the radiological features of this condition which have not been previously described and allow confirmation of the diagnosis non-operatively.

Results: Six patients have been managed with orthotics and three underwent surgery; one patient who presented early had an isolated repair of the spring ligament complex and has done well. The remaining two patients required a calcaneal osteotomy and Flexor Digitorum Longus transfer as for a PTT reconstruction. In all these three patients the spring ligament was found to be completely ruptured during surgery.

Discussion: This type of injury may not be as rare as previously thought and demonstrates the importance of the spring ligament on its own in maintaining the medial longitudinal arch. Awareness of this condition could lead to earlier diagnosis and better prognosis with earlier treatment.

Conclusion: We propose that early diagnosis (with ultrasound confirmation) and management of this condition would offer a better prognosis and allow less interventional surgery.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_II | Pages 364 - 364
1 May 2009
Tryfonidis M Smith G Cooke P Sharp R
Full Access

Introduction: An ideal screw for subtalar fusion would be designed such that screw thread length in the distal bone would be maximised but without distal perforation, whilst having no threads across the fusion site that would inhibit compression.

Method: Radiographs and clinical assessment of 100 patients who had undergone subtalar fusion were analysed and correlated with the presence or absence of non-union.

In addition, using the characteristics of the inserted screw as a scaleable marker, it was calculated what would have been the optimum length of screw thread in order to maximise screw thread length in the target bone whilst preventing the screw threads being across the fusion site.

Results: There is no correlation between the presence of screw threads across the fusion site and non-union.

Currently available screws have thread lengths that are either too long (breaching the fusion site) or too short for ideal fixation and we propose a different thread length to those currently available.

However, even with current screws, we found no correlation between thread length, thread positioning across the fusion site and non-union.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_II | Pages 362 - 362
1 May 2009
Dermon A Tilkeridis C Liras D Tryfonidis M Kazakos K Hardouvelis C Petrou G
Full Access

Introduction: We present the long term results in 204 cases of Hallux Valgus deformity correction using a modified Mitchell’s osteotomy.

Methods: 168 patients (204 feet) that had Mitchell’s osteotomies between 1986 and 2001 were recalled for clinical and radiological evaluation. The patients had hallux valgus angles of up to 50o and intermetatarsal angles of up to 20o. They all had a modified procedure using two crossed Kirschner wires to fix the capital fragment into plantar displacement and angulation. Lateral soft tissue release was performed when deemed necessary during the procedure. Mild to moderate arthritis of the 1st metatarsophalangeal joint was not a contraindication. The AOFAS scores as well as any complications were recorded and the Xrays were used to measure hallux valgus and intermetatarsal angles. Mann-Whitney U test was used to analyze data.

Results: The mean follow up was 12.9 years. The mean AOFAS score improved from a preoperative of 49.6 to a postoperative of 87.9 points (p=0.004), due to improvement in the pain (14.2 Vs 37.6, p=0.001) and function (30.6 Vs 39.8, p=0.043) parameters. 57 cases (27.9%) had Hallux Valgus angles > 40o. Lateral soft tissue release was performed in only 16 of these cases with no significant difference in the postoperative Hallux Valgus angle compared to the ones not requiring soft tissue release (21.3o Vs 20.8o, p=0.08). There was a decrease in the pre-operative Vs post-operative incidence of lateral metatarsalgia and symptomatic callosities (18.33% Vs 11.8%, p=0.023). We had only one case of avascular necrosis.

Discussion/Conclusion: Mitchell’s osteotomy is a reliable technique with successful outcomes and minimal complications when performed with accurate surgical technique, stable fixation and lateral soft tissue release when appropriate. It may also be successfully performed for Hallux Valgus angles > 40o. We believe that it has still got a role in the treatment of Hallux Valgus.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 212 - 212
1 Jul 2008
Tryfonidis M Jass GK Charalambous CP Jacob S Stanley D
Full Access

A significant number of patients return with persistent symptoms following surgical release of the posterior interosseous nerve for radial tunnel syndrome. The aim of this study was to attempt to explain this fact in anatomical terms by defining the anatomy of the posterior interosseous nerve and its branches in relation to the supinator muscle and arcade of Frohse. Using standard dissection tools 20 preserved cadaveric upper limbs were dissected. The radial nerve and all its branches within the radial tunnel were exposed and a digital calliper was used to measure distances. The bifurcation of the radial nerve to posterior interosseous nerve and superficial sensory branch occurred at a median distance of 4.35mm proximal to the elbow joint-line. The bifurcation was proximal to the joint-line in 11 cases, at the level of the joint-line in one case and distal in eight cases. There was a range of 0–5 branches to the supinator originating proximal to the entry point of the posterior interosseous nerve under the arcade of Frohse at a median distance of 10.27mm (medial branches) or 11.11mm (lateral branches) distal to the elbow join-line. These branches either passed under the arcade of Frohse or entered through the proximal edge of the superficial belly of the supinator. In 10 limbs there was a variable number of branches to the supinator originating under its superficial belly and in five limbs multiple perforating posterior interosseous nerve branches within the muscle were identified. This variation in anatomy we believe may explain the persistence of symptoms following surgical release of the posterior interosseous nerve for radial tunnel syndrome and suggests that careful exploration of all the nerve branches during surgical decompression should be routinely performed.