Background

The decision to attempt limb salvage vs to amputate in a significant traumatic limb injury is based on patient´s best predicted outcome. When amputation cannot be avoided the aim is to provide a pain free limb whilst preserving the soft tissue and limb length.

The Cobb Stainsby forefoot arthroplasty for claw and hammer toes combines excision arthroplasty (Stainsby) with extensor tendon transfer to the metatarsal head (Cobb). We present a retrospective, three surgeon case series of 218 toes in 128 patients over four years. Clinical notes were reviewed for all patients and 77 could be contacted for a telephone survey. Follow up ranged from 12–82 months.

All patients presented with pain and shoe wear problems from dislocated metatarsophalangeal joints either from arthritis, hallux valgus, Freiberg's disease or neurological disorders. Ipsilateral foot procedures were performed simultaneously in 24 (30%) patients. Seventy-two patients (94%) were satisfied, 72 (94%) reported pain relief, 55 (71%) were happy with toe control, 61 (79%) were pleased with cosmesis, 59 (77%) returned to normal footwear and 56 (73%) reported unlimited daily activities. Minor complications occurred in 17 (13%) and 3 (2%) developed complex regional pain syndrome. Four (5%) developed recurrent clawing.

The Stainsby procedure permits relocation of the plantar plate under the metatarsal head for cushioned weight-bearing but can create a floppy, unsightly toe. By combining this with the Cobb procedure, our case series demonstrates improved outcomes from either procedure alone with benefits over alternatives such as the Weil's osteotomy.

Oxford Level 4 evidence – retrospective case series.

Lisfranc fracture dislocations of the midfoot are uncommon but serious injuries, associated with posttraumatic arthrosis, progressive deformity, and persistent pain. Management of the acute injury aims to restore anatomic tarsometatarsal alignment in order to minimise these complications. Reduction and stabilisation can be performed using image-guided percutaneous reduction and screw stabilisation (aiming to minimise the risk of wound infection) or through open plating techniques (in order to visualise anatomic reduction, and to avoid chondral damage from transarticular screws). This retrospective study compares percutaneous and open treatment in terms of radiographic reduction and incidence of early complications.

Case records and postoperative radiographs of all patients undergoing reduction and stabilisation of unstable tarsometatarsal joint injuries between 2011 and 2014 in our institution were reviewed. Dorsoplantar, oblique and lateral radiographs were assessed for accuracy of reduction, with malreduction being defined as greater than 2mm tarsometatarsal malalignment in any view. The primary outcome measure was postoperative radiographic alignment. Secondary outcome measures included the incidence of infection and other intra- or early postoperative complications.

During the study period, 32 unstable midfoot injuries were treated, of which 19 underwent percutaneous reduction and screw stabilisation and 13 underwent open reduction and internal fixation. Of the percutaneous group, no wound infections were reported, and there were four (21.1%) malreduced injuries. Of the open group, two infections (15.4%) were observed, and no cases of malreduction.

In conclusion, our study shows a strong trend towards increased risk of malreduction when percutaneous techniques are used to treat midfoot injuries, and an increased risk of infection when open surgery is used. Whilst conclusions are limited by the retrospective data collection, this study demonstrates the relative risks to consider when selecting a surgical approach.

Background: It is taught that ruptures of the Achilles tendon occur at the musculotendinous junction and indeed ultrasound reports will often confirm this. This study investigates the orthopaedic surgeon’s understanding of the clinical significance and location of the musculotendinous junction.

Materials and Methods: A survey of orthopaedic surgeons at a regional orthopaedic meeting. Two transverse lines were drawn on a photograph of a lower limb identifying the musculotendinous junction, and marking the highest level at which they would consider a surgical repair. They were asked about their understanding of the term “musculotendinous junction”.

Results: Twenty two delegates of various degrees of seniority responded.

Surgeons estimate of musculotendinous junction level: 10.1 cm

Conclusions: There is confusion regarding the exact location and nature of the Achilles musculotendinous junction amongst orthopaedic surgeons. Particular care is advised when interpreting ultrasound reports. An Achilles surgical zone has been identified (0–10 cm from the calcaneal insertion) within which the majority of surgeons would consider surgical intervention for rupture.