The April 2023 Foot & Ankle Roundup³⁶⁰ looks at: Outcomes following a two-stage revision total ankle arthroplasty for periprosthetic joint infection; Temporary bridge plate fixation and joint motion after an unstable Lisfranc injury; Outcomes of fusion in type II os naviculare; Total ankle arthroplasty versus arthrodesis for end-stage ankle osteoarthritis; Normal saline for plantar fasciitis: placebo or therapeutic?; Distraction arthroplasty for ankle osteoarthritis: does it work?; Let there be movement: ankle arthroplasty after previous fusion; Morbidity and mortality after diabetic Charcot foot arthropathy.

Purpose. To establish the early outcome, satisfaction and complications of sinus tarsi implants in the management of symptomatic flexible flatfeet for a paediatric population. Methods and results. We included all patients aged 18 years or less who were treated for flexible flatfeet with a sinus tarsi implant between January 2010 and June 2012. We excluded patients who had a history of clubfeet or tarsal coalition. 34 patients had 59 implants. The mean age at surgery was 13.7 yrs (9–17 yrs), with mean follow-up of 22 months (range 10–35). Mean AOFAS improved from 65.7 to 87.9 (p<0.001), with an improvement in AOFAS pain scores (p=0.0001). Radiographic correction occurred in all feet, with average improvement of the anteroposterior talar-second metatarsal angle of 16 degrees, and the lateral talar-first metatarsal angle of 9 degrees. Implant placement satisfaction rate was 86%, with 81% claiming that they would have the procedure again. Complications included peroneal spasm (8%), extrusion (7%), revision (5%), and removal (5%). Peroneal spasm was recalcitrant in 3 of the 5 cases, and those with spasm had a higher average forefoot abduction measurement (35 degrees) than the remaining treated cases (25 degrees). Conclusion. In paediatric patients with flexible flatfeet, utilisation of the sinus tarsi implant has good short-term outcome, with our failure and revision rates comparable to other published studies in the adult population. We introduce the concept of isolated subtalar hyperlaxity which appeared to be a distinct etiological factor. A learning curve in assessing implant size was noted. Overcorrection and implant migration were the indications for revision surgery. Severe forefoot abduction appears to have a poorer outcome, and may be associated with peroneal spasm. Level of evidence: IV

Objective

The objective of this study was to evaluate the rotation and translation of each joint in the hindfoot and compare the load response in healthy feet with that in stage II posterior tibial tendon dysfunction (PTTD) flatfoot by analysing the reconstructive three-dimensional (3D) computed tomography (CT) image data during simulated weight-bearing.

Peroneal spastic flatfeet without coalition or other known etiologies in adolescence remain a challenge to manage. We present eight such cases with radiological and surgical evidence of bony abnormalities in the subtalar region just anterior to the posterior facet. All patients had presented as tertiary referrals with recalcitrant pain and had undergone a trial of orthotics and physiotherapy. Diagnostic workup included a clinical and radiographic evaluation. Clinical examination consisted of gait examination, foot alignment, range of motion, torsional profile of the lower limbs and marking of symptomatic foci. All patients had standing weightbearing AP and lateral projections of the foot and ankle. CT and/or MRI scans of the foot were performed in axial coronal and saggital planes. Coalitions and other intraarticular known pathologies were ruled out. All patients had bilateral flatfeet but unilateral peroneal spasm. All patients had an accessory talar facet in front of the posterior subtalar facet. This caused lateral impingement between the facet and the calcaneum, confirmed by bone edema around the sinus tarsi. All patients had stiff subtalar joints with very limited movement under anaesthesia, indicating peroneal muscle contracture. Patients were treated with a combination of facet excision, peroneal lengthening and calcaneal lengthening to correct the flatfoot and prevent lateral impingement. We propose a mechanism of subtalar impingement between the anterior extra-articular part of the talar lateral process and the Gissane angle and believe that resection of the accessory facet without addressing the the primary driving force for impingement, which is the structural malalignment in flatfeet, would only give partial relief of symptoms. This impingement appears to occur with growth spurts in adolescents, in patients with known flatfeet

Painful peroneal spastic flatfeet without coalition or other known etiologies in adolescence, remains a difficult condition to treat. We present eight such cases with radiological and surgical evidence of bony abnormalities in the lateral subtalar region just anterior to the posterior facet. All patients had presented as tertiary referrals with recalcitrant pain and had undergone a trial of orthotics and physiotherapy. Diagnostic workup included a clinical and radiographic evaluation. Clinical examination consisted of gait examination, foot alignment, range of motion, torsional profile of the lower limbs and marking of symptomatic foci. All patients had standing weightbearing anteroposterior and lateral projections of the foot and ankle, CT and/or MRI scans of the foot. Coalitions and other known intra-articular pathologies like subtalar arthritis were ruled out. All patients had bilateral flatfeet but unilateral peroneal spasm. All patients had an accessory anterolateral talar facet (ATF) which was arising as an anterior and distal extension of the lateral process of the talus. This caused lateral impingement between the facet and the calcaneum, confirmed by bone edema around the sinus tarsi and marked at the apex of the angle of Gissane on MRI scans. All patients had stiff subtalar joints with very limited movement under anaesthesia, indicating peroneal muscle contracture. Patients were treated with a combination of facet excision, fractional peroneal and gastrosoleus lengthening and calcaneal lengthening to correct the flatfoot and prevent lateral impingement

We conducted a retrospective analysis of all elective Paediatric Orthopaedics referrals during the period 1998–1999 made by general practitioners to one of the two Paediatric Orthopaedic consultants in a moderate sized district general hospital serving a population of approximately 300, 000 with a delivery rate of approximately 3000 live births per year. This study was taken with a view to assess the spectrum of elective Paediatric Orthopaedic referral quality of work generated and to find out the final outcome and hence try to improve resource utilisation. We found out that majority of cases (85%) needed simple assurances or supportive measures, a task that can be easily shared by a trained clinical assistant along with the consultant and routine clinical cases are not adequately covered in Paediatric Orthopaedics courses for trainees. During 1999, a total of 120 new elective Paediatric Orthopaedic referrals from GPs were seen in 600 bedded district general hospital by one of the Paediatric Orthopaedics consultants out of the 2 in the hospital. Case notes were analysed for age of patient, sex, joint affected, reason for referral, diagnosis made and the outcome following consultation. The outcome was measured in the form of whether the patient had an operation, was referred to Physiotherapy, orthotics, kept under observation (include masterly inactivity), referred to other subspecialty or reassured and discharged. Mean age of presentation was 7. 8 years and there was near equal presentation of boys and girls. Maximum cases were referred for knee problems 32 (26. 67%), hip 28 (23. 33%), foot 18 (15%), general 18(15%). Majority of patients referred need simple assurance to parents and majority of patients seen in Clinics need no operation (85%), indicating that Orthopaedic Surgeons need to spend more time on reassuring parents than on operation, a task that can be easily shared by a trained Clinical Assistant. In majority of Paediatric Orthopaedic training courses, main emphasis is on complex conditions like Perthes’ disease. CDH or slipped capital epiphysis whereas these conditions constitute a minor part of clinical situations. Other common conditions like Inteoing gait, anterior Knee pain, Osteochondritis, flatfeet and other common problems including the normal variants should also be included in the courses so trainees can deal after these clinical problem in a better way in Outpatients