We report on the first clinical cases of the Arthrex Ankle Syndesmosis TightRope (winner of 2003 BOA Technological Achievement Award and 2004 Cutlers' Prize), which has recently been licensed for use where classically a syndesmosis screw would be used.

Twelve patients with Weber C ankle fractures treated with Arthrex TightRope syndesmosis fixation have a minimum of six months follow-up. The syndesmosis was fixed with the ankle in plantarflexion to aid reduction. Patient demographics, including fracture classification and mode of injury were obtained. Parameters measured at follow-up included ankle range of motion, maintenance of reduction and fibular length, and AOFAS ankle outcome score.

The patient cohort showed a typical bimodal distribution of age. Age over 65 years was associated with a poorer outcome. Five patients had ankle fracture-dislocations, which was a factor for a poorer outcome. Nine patients had fibular plate fixation in addition to syndesmosis fixation, whilst three patients with Maisonneuve injuries had syndesmosis fixation only. There were no major complications, loss of reduction, wound problems, implant loosening or osteolysis. Ankle dorsiflexion was not restricted and mean total ankle range of motion was comparable to the uninjured side. No patient required secondary surgery for any reason, including hardware removal.

Arthrex TightRope fixation is a simple, safe and effective method of ankle syndesmosis fixation, which allows physiological micromotion. Fixation in plantarflexion provides optimum syndesmosis compression for reduction, and does not compromise ankle range of motion. The Arthrex Ankle Syndesmosis TightRope may become the treatment of choice in Weber C ankle fractures.

Introduction: The goals of TKR are restoration of the mechanical axis, joint line and Q –angle. Reproduction of the offset of the extensor mechanism during arthroplasty is less well understood. The lever arm of the extensor mechanism is primarily affected by femoral component position, patella tracking and overall patellar thickness. Changing this lever arm alters quadriceps muscle and patellofemoral joint reaction force. Some TKR designs purposefully aim to increase this offset in order to reduce PFJ contact pressures. Overstuffing the PFJ will however adversely affect outcome.

The aims of this study were to measure and compare the pre and postoperative quadriceps lever arm and its effect on function in a consecutive series of patients undergoing TKR.

Methods: Fifty consecutive patients who had an LCS TKR without patellar resurfacing by a single surgeon were reviewed. Patient demographics were recorded. We measured the pre and post-operative quadriceps lever arm using comparable lateral radiographs and digital imaging software. Functional outcome in these patients was determined using the American Knee Society Score pre and 6-months post-operatively. Patients were specifically questioned regarding the presence or absence of anterior knee pain

Results: Quadriceps lever arm was on average 6 mm greater post-operatively than pre-op but this difference was not significant [t-test]. The functional outcome in these patients was independent of any change in quadriceps lever arm.

Conclusions Reproduction of normal biomechanics is essential in order to optimise outcome from TKR.

Using the LCS system, there is a small but insignificant increase in the quadriceps moment arm. We have not found that this has any bearing on functional outcome in these patients.

Recurrent dislocation of peroneal tendons is an uncommon presentation following ankle injuries. It usually follows an inversion injury to the ankle, most commonly seen in skiing, however it has also been described in many other sporting activities. X rays appear normal, and patients usually get treated as ankle sprain. The diagnosis, usually delayed is a clinical one, patients usually describe ankle instability and sudden painful snapping or popping of the subluxating peroneal tendons. This makes it difficult for them to participate in any sporting activities and is a source of continous discomfort while walking. Examination may show tender peroneal tendons and demonstration of subluxing tendons is facilitated by eversion against resistance or manually by thumb pressure. The common pathology is tear of the peroneal retinaculum and striping of periosteum from the anterior attachment to the lateral maleolus.

We describe 11 cases of recurrent dislocation of peroneal tendons from February 1999 to October 2004. They all suffered trauma related dislocation of peroneal tendons, causing recurrent peroneal tendon dislocation. All procedures were performed by a single consultant. Procedure involves soft tissue anatomic reconstruction of the peroneal retinaculum. There were 9 males and 2 females, mean age was 30.1 years (range 15 to 58 years). All patients were treated initially with rest followed by period of physiotherapy to no benefit. All complained of ankle instability with pain associated with tendon dislocation even while walking. The mean duration from time of injury to surgery was 10 months (range 2 to 45 months). We performed clinical assessment, ankle scoring, SF 36 version2 scoring and assessed patient satisfaction with the procedure.

At the latest follow up of 6 months to 6 years all patients were extremely satisfied with the procedure. There was no recurrence of dislocation. All patients were back to their normal daily activities and sports within 6 months of surgery. One patient complained of occasional mild pain over the tendon. One patient reported mild paraesthesiae in distribution of sural nerve, which recovered over 3 months. On clinical assessment the tendon was stable in all patients with full ROM and strength in the affected ankle when compared to normal side. The mean ankle score increased from 62 pre-op (range 22 to 89) to 96 post-operative (range 90 to 100). Mean SF 36 scores increased from PCS of 41 and MCS of 53 pre-op to a PCS of 57 and MCS of 60 post-op.

In the past procedures have been described for treatment of recurrent dislocation of peroneal tendons. We report the results of a procedure previously described and published by the senior author ( ‘The Foot’: 2003 ). This is an anatomic procedure for repair of torn peroneal retinaculum and double breasting of redundant periosteum. Our latest follow up of 6 months to 6 years shows excellent results with no recurrence and no limitation of ankle movement or sporting activities.

Introduction: Ankle inversion injuries are common, with an incidence of 1 per day per 10,000 of the population. Chronic instability is a frequent sequela, and has been estimated to occur after approximately 10 to 20% patients, regardless of the type of initial treatment. Magnetic Resonance Imaging (MRI) has become a routine diagnostic tool in investigating knee injuries, but little has been published concerning ankle injuries and ankle instability.

Aim: To compare the efficacy of conventional magnetic resonance (MR) imaging and stress radiography in the detection of lateral collateral ligament abnormalities in patients with chronic ankle instability.

Materials and Methods: All patients presenting to the senior author’s OPD with clinical impression of ankle instability were investigated prospectively using MRI and stress x-rays (Telos). These films were officially reported and then, these reports were subsequently reviewed post-anatomical reconstruction.

Results: Over a two-year period, 18 patients underwent anatomical reconstruction using the modified Brostrom technique. MRI identified a tear of the anterior talofibular (AFT) ligament in 12 (66%) patients, and the calcaneofibular (CF) ligament was torn in 9 (50%) patients. Stress radiography identified instability of 14 of the 18 (77%) patients. Stress radiography identified instability of 14 of the 18 (77%) patients. Surgical exploration revealed either attenuation or rupture of either the AFT and/or CF ligaments in all 18 patients. MRI demonstrated concomitant injuries to the ankle and subtalar joints, including peroneal tenosynovitis (76%), anterolateral impingement syndrome (66%) and attenuated peroneal retinaculum (55%).

Conclusion: Ankle instability may be more reliably demonstrated using stress x-rays than MRI: however, lowfield MRI is a very useful diagnostic tool in the study of concomitant ankle injuries and we would suggest that both modalities be considered, especially if surgical intervention is anticipated.

Hypotheses: The modified Brostrom procedure is an anatomic reconstruction of the lateral ankle ligaments. The aim of this retrospective study was to determine the clinical outcome after surgical repair of the lateral ankle ligaments using suture anchors as part of the modified Brostrom procedure in the treatment of chronic anterolateral ankle instability.

Methods: All patients were evaluated postoperatively by physical examinations and stress radiographs using Telos® equipment. Additional postoperative assessment consisted of a questionnaire, inversion and eversion isokinetic strength measurements and Sachs hop test to assess ankle confidence.

Results: Over a 3 year period, 27 young, athletic patients (mean age at operation 22 years) underwent anatomical reconstruction by the senior author. At a mean follow-up of 14 months (range 3–36 months), 25 (91%) reported a good or excellent functional outcome as assessed by the Karlsson and Peterson ankle function scoring scale. Twenty-five patients had no evidence of instability on physical examination or on stress radiographs. One patient required revision. One patient developed a superficial wound infection, which responded to oral antibiotics. Twenty five patients were able to jump 97% of the hop distance of the non operated ankle.

Conclusions: Reconstruction of the lateral ankle ligaments using the modified Brostrom procedure with suture anchors results in a good or excellent outcome in the majority of patients engaged in physically demanding sports.

Open reduction and internal fixation is the treatment of choice for patients with displaced fractures of the lateral and medial malleoli. Ideally, operative treatment restores sufficient stability to allow full mobility at the ankle joint. However, because of the necessity to protect the ankle from weight-bearing and other forces, we routinely immobilise the ankle in a below-knee cast because of our concerns about patient compliance. We carried out a prospective study to assess patient compliance with instructions on non-weight bearing following ORIF of ankle fractures.

All 30 patients at our hospital who were treated for an ankle fracture over a 14 month period were included in our study. 22 of these underwent ORIF. A below knee cast was applied in all cases, and patients were instructed not to put any weight on the injured limb. A pressure sensitive film (Fuji Prescale Film, Sensor Products Inc., NJ, USA) was incorporated into the cast beneath the heel pad. Patients were informed that this was being done to measure the pressure within the cast, for the purposes of a trial. The cast was changed (including the pressure sensitive film) at two-week intervals over a six week period, providing three separate measurements of pressure on the heel. The sole of the cast was also examined, to complement the findings on the pressure film. At each visit, the patients level of pain was assessed using a visual analogue score, and the wound (if present) was examined.

There was a remarkable variation in the amount of weight bearing performed by the patients in this study, but several trends could be observed. In most cases, patient compliance was greatest in the first four weeks following cast application, but patients tended to put significant weight on the limb in the 4–6 week period. Female patients tended to comply better than males. Patients with a history of alcohol or drug abuse complied poorly. Compliance was lower in those individuals with lower pain scores. Of interest, the degree of weight bearing did not significantly affect the radiological or clinical outcome at the 6-week mark in any case. We conclude that patient compliance with non-weight bearing is generally poor, although the effect of this poor compliance on the long-term outcome requires further study.

Flat foot due to rupture of the tibialis posterior tendon has not previously been described in children. We present three young patients who developed unilateral pes planus after old undiagnosed lacerations of the tendon. Transfer of the flexor hallucis longus to the distal stump of the tibialis posterior tendon achieved good results in all three cases.

We performed basal chevron metatarsal osteotomy on 32 feet (31 patients) for painful hallux valgus associated with an increased intermetatarsal 1/2 angle (> 12 degrees). Pedobarographic and radiological examinations were done preoperatively and at a minimum of six months postoperatively. The average hallux valgus angle was improved from 40.9 degrees to 19.2 degrees and the intermetatarsal 1/2 angle from 16.5 degrees to 6.8 degrees. The mean angle of declination of the first metatarsal was decreased by 1.4 degrees. The pedobarographs showed a significant reduction in areas sustaining pressure > 5 kg/cm2, an increased total foot contact area and a higher percentage forefoot contact area on heel raise. There was a high level of patient satisfaction with relief of symptoms and improved appearance of the foot.