Aims. We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity. Patients and Methods. We prospectively studied 28 calcaneal malunion patients (the study group) who were managed by subtalar distraction arthrodesis using local calcaneal bone graft. The study group included 16 male and 12 female patients. The median age was 37.5 years (interquartile range (IQR) 29 to 43). The outcome of the study group was compared with a control group of ten patients previously managed by subtalar distraction arthrodesis using iliac bone graft. The control group included six male and four female patients. The median age was 41.5 years (IQR 36 to 44). Results. The mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly in the study and the control groups (p < 0.001). Fusion was achieved in 27 patients in the study group at a median time of 13 weeks (IQR 12 to 14), while all the patients in the control group achieved fusion at a mean time of 13.2 weeks (11 to 15). The mean talocalcaneal height and talar declination angle improved significantly in both the study and the control groups (p < 0.001). There was no significant difference between both groups concerning the preoperative or the postoperative clinical and radiological measurements. Donor site morbidity was reported in four out of ten patients in the control group. Conclusion. Local calcaneal bone graft can successfully be used to achieve subtalar distraction arthrodesis with appropriate correction of alignment and calcaneal malunion. We recommend using local instead of iliac bone graft as it gave comparable results and avoids the possibility of donor site morbidity. Cite this article: Bone Joint J 2019;101-B:596–602

We studied retrospectively the results in 24 patients (25 feet) who had been treated by subtalar arthrodesis with internal compression for post-traumatic arthritis from 1988 to 1992. Fifteen patients were men (16 feet) and nine (9 feet) were women. Their mean age was 43 years (22 to 68), and the average duration of follow-up was four years (2 to 6). A single compression screw was used in all feet and iliac-crest bone grafting in ten. Union was achieved in 24 of the 25 feet (96%). Based on a clinical scale the results were excellent in 10 feet, good in 7, fair in 6, and poor in 2 and on the Angus and Cowell score they were good in 19 feet, fair in 4, and poor in 2. The two poor results were due to nonunion in one patient and reflex sympathetic dystrophy in the other. One reoperation was performed for nonunion. Eighteen patients (18 feet) were satisfied with the results, four were satisfied with reservations, and three were dissatisfied. Progressive ankle and midfoot arthritis did not occur in the absence of pre-existing degenerative changes in these joints. We conclude that isolated subtalar arthrodesis with internal compression was effective treatment for post-traumatic subtalar arthritis. Iliac-crest bone grafting was not routinely required

Of 23 children (35 feet) with cerebral palsy who had undergone a Grice extra-articular subtalar arthrodesis for a valgus hindfoot between 1976 and 1981, we reviewed 17 (26 feet), at a mean of 20 years (17 years 3 months to 22 years 4 months) after operation. Seven were quadriplegic, eight spastic diplegic, and two hemiplegic. They were all able to walk at the time of operation. Thirteen patients (20 feet) were pleased with the Grice procedure, 13 had no pain and 15 (23 feet) were still able to walk. The clinical results were satisfactory for most feet. Radiography showed that the results had been maintained over time but 14 feet developed a mean ankle valgus of 11° (6 to 18) with a compensatory hindfoot varus in 12 feet. No deformity of the talus or arthritis of adjacent joints was noted. The Grice procedure gives good long-term results in children with cerebral palsy

A new technique is described for extra-articular subtalar arthrodesis; it combines the main elements of the Batchelor and the Grice procedures. Results were reviewed after a minimum of three years. Of the 25 feet treated 24 had solid fusion and had maintained the operative correction of the valgus deformity; the one non-union was due to deep infection

A technique of subtalar arthrodesis by means of metallic internal stabilisation and autogenous cancellous bone grafting is described. Of forty-eight feet with mobile pes planus treated by this method forty-five gained union after an average of seven and a half weeks in a below-knee weight-bearing plaster, and forty-three had satisfactory correction of the deformity

We have reviewed the long-term results of 22 patients (23 fusions) with fractures of the os calcis, who had subtalar arthrodesis with correction of the deformity between 1975 and 1991. The mean follow-up was nine years (5 to 20). All patients were evaluated according to a modified foot score. A radiological assessment was used in which linear and angular variables were measured including the fibulocalcaneal abutment, the height of the heel and fat pad, the angle of the arch and the lateral talocalcaneal and the lateral talar declination angles. The technique used restores the normal relationship between the hindfoot and midfoot and corrects the height of the heel. This leads to better biomechanical balance of the neighbouring joints and gives a favourable clinical outcome. The modified foot score showed a good or excellent result in 51% of the feet. Residual complaints were mostly due to problems with the soft tissues. Subjectively, an excellent or good score was achieved in 78% of the cases. After statistical analysis, except for the height of the heel and the degenerative changes in the calcaneocuboid joint, no significant difference was found in the measured variables between the operated and the contralateral side

The August 2023 Foot & Ankle Roundup. 360. looks at: Achilles tendon rupture: surgery or conservative treatment for the high-demand patient?; First ray amputation in diabetic patients; Survival of ankle arthroplasty in the UK; First metatarsophalangeal joint fusion and flat foot correction; Intra-articular corticosteroid injections with or without hyaluronic acid in the management of subtalar osteoarthritis; Factors associated with nonunion of post-traumatic subtalar arthrodesis; The Mayo Prosthetic Joint Infection Risk Score for total ankle arthroplasty

Background

Subtalar nonunion has a detrimental effect on patients' function, and pose a significant challenge for surgeons particularly in the setting of higher risk factors.

Talonavicular and subtalar joint fusion through a medial incision (modified triple arthrodesis) has become an increasingly popular technique for treating symptomatic flatfoot deformity caused by posterior tibial tendon dysfunction.

The purpose of this study was to look at its clinical and radiological mid- to long-term outcomes, including the rates of recurrent flatfoot deformity, nonunion and avascular necrosis of the dome of the talus.

A total of 84 patients (96 feet) with a symptomatic rigid flatfoot deformity caused by posterior tibial tendon dysfunction were treated using a modified triple arthrodesis. The mean age of the patients was 66 years (35 to 85) and the mean follow-up was 4.7 years (1 to 8.3). Both clinical and radiological outcomes were analysed retrospectively.

In 86 of the 95 feet (90.5%) for which radiographs were available, there was no loss of correction at final follow-up. In all, 14 feet (14.7%) needed secondary surgery, six for nonunion, two for avascular necrosis, five for progression of the flatfoot deformity and tibiotalar arthritis and one because of symptomatic overcorrection. The mean American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score) at final follow-up was 67 (between 16 and 100) and the mean visual analogue score for pain 2.4 points (between 0 and 10).

In conclusion, modified triple arthrodesis provides reliable correction of deformity and a good clinical outcome at mid- to long-term follow-up, with nonunion as the most frequent complication. Avascular necrosis of the talus is a rare but serious complication of this technique.

Cite this article: Bone Joint J 2015; 97-B:668–74.

Background. Open subtalar arthrodesis has been associated with a moderate rate of non-union, as high 16.3%, and high rates of infection and nerve injury. Performing this operation arthroscopically serves to limit the disruption to the soft tissue envelope, improve union rates and reduce infection. Our study describes our outcomes and experience of this operation. Method. Retrospective review of all patients who underwent an arthroscopic subtalar arthrodesis between 2023 and 2008. We excluded patients undergoing concurrent adjacent joint arthrodesis. The primary aim was to report on rates of union. Secondary outcomes included reporting on conversion to open procedure, duration of surgery, infection, and iatrogenic injury to surrounding structures. Results. 135 patients were included in the final analysis. 129 patients (95.5%) achieved union. The median time to fusion was 98 days. All cases were performed through sinus tarsi portals. 38 cases were performed with an additional posterolateral portal. Most cases (107/77%) were performed with 2 screws. 3 cases (2.2%) were converted to open procedures. The median tourniquet time was 86 minutes but available in only 88 (65%) cases. There were 4 (2.9%) superficial infections and no deep infections. 1 patient sustained an injury to FHL and there were no reported nerve injuries. Conclusions. At present this is the largest series of arthroscopic subtalar arthrodeses. We demonstrate that this operation can achieve high rates of union with low rates of infection with an equally low likelihood of needing to convert to an open procedure with modest operative times. In our experience the addition of a posterolateral portal does not appear to increase the incidence of nerve injury and aids in the visualisation of all 3 facets

Subtalar arthrodesis known as talocalcaneal fusion is an end-stage treatment for adult hind foot pathologies. The goal of the arthrodesis is to restrict the relative motion between bones of the subtalar joints, aiming to reduce pain and improve function for the patient. However, the change of the subtalar structures through the fusion is considered a disturbance to the joint biomechanics, which have been suggested to affect the biomechanics of the adjacent joints. However, no quantitative data are available to document this phenomenon. The purpose of the current study was to quantify the effects of subtalar arthrodesis on the laxity and stiffness of the talocrural joint in vitro using a robot-based joint testing system (RJTS) during anterioposterior (A/P) drawer test. Six fresh frozen ankle specimens were used in this study. The lateral tissues of the specimens were removed but the anterior and posterior talofibular ligaments and calcaneofibular ligament were kept intact. A/P drawer tests were performed on each of the specimens at neutral position, 5° and 10° of dorsiflexion, and 5?and 10?of plantarflexion using a robot-based joint testing system (RJTS), before and after subtalar arthrodesis. The RJTS enabled unconstrained A/P drawer testing at the prescribed ankle position while keeping the proximal/distal and lateral/medial forces, and varus/valgus and internal/external moments to be zero. This was achieved via a force-position hybrid control method with force and moment control, which has been shown to be more accurate than other existing force-position hybrid control methods. The target A/P force applied during the A/P drawer test was 100N in both anterior and posterior directions. The stiffness and laxity were calculated from the measured force and displacement data. The anterior and posterior stiffness of the talocrural joint were defined as the slope beyond 30% of the target A/P force, and the peak displacements quantified the laxity of the joint. Comparisons of laxity and stiffness between the intact and fusion ankle specimens were performed using Wilcoxon signed rank test (SPSS 19.0, IBM, USA) and a significance level of 0.05 was set. Subtalar arthrodesis did not lead to significant changes in the stiffness and laxity in both anterior and posterior directions (P>0.05). The mean anterior stiffness before arthrodesis was 9.54±1.17 N/mm and was 10.35±2.40 N/mm after arthrodesis. The mean anterior displacements before and after arthrodesis were 9.68±0.94 mm and 8.97±1.42 mm, respectively. Subtalar arthrodesis did not show significant effects on the A/P laxity and stiffness of the talocrural joint in both anterior and posterior directions. This may imply that the motion of the subtalar joints do not have significant effects on the A/P stability of the talocrural joint, which is the main joint of the ankle complex. This agrees with the anatomical roles of the subtalar joints which provide mainly the varus/valgus motions for the ankle complex. The current study provides a basis for further studies needed to evaluate the effects subtalar arthrodesis on the varus/valgus stability

Aims. The aim of this study was to report the results of three forms of reconstruction for patients with a ditsl tibial bone tumour: an intercalary resection and reconstruction, an osteoarticular reconstruction, and arthrodesis of the ankle. Methods. A total of 73 patients with a median age of 19 years (interquartile range (IQR) 14 to 36) were included in this retrospective, multicentre study. Results. Reconstructions included intercalary resection in 17 patients, osteoarticular reconstruction in 11, and ankle arthrodesis in 45. The median follow-up was 77 months (IQR 35 to 130). Local recurrence occurred in eight patients after a median of 14 months (IQR 9 to 36), without a correlation with adequacy of margins or reconstructive technique. Major complications included fracture of the graft in ten patients, nonunion of the proximal osteotomy in seven, and infection in five. In the osteoarticular group, three of 11 patients developed radiological evidence of severe osteoarthritis, but only one was symptomatic and required conversion to ankle arthrodesis. Functional evaluation showed higher values of the Musculoskeletal Tumour Society (MSTS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores in the intercalary group compared with the others. Conclusion. Preservation of the epiphysis in patients with a distal tibial bone tumour is a safe and effective form of limb-sparing treatment. It requires rigorous preoperative planning after accurate analysis of the imaging. When joint-sparing resection is not indicated, ankle arthrodesis, either isolated tibiotalar or combined tibiotalar and subtalar arthrodesis, should be preferred over osteoarticular reconstruction. Cite this article: Bone Joint J 2020;102-B(11):1567–1573

Introduction. The goal of arthrodesis around the ankle or of triple (hind foot) arthrodesis is a painless, plantigrade, and stable foot. Stress fracture is a differential diagnosis for pain following an ankle/subtalar arthrodesis. Management of stress fractures following sound ankle/subtalar fusion is extremely difficult as the entire movement tends to occur at the fracture site, hence hampering healing. Methods and materials. 33 patients underwent ankle/subtalar arthrodesis at our institute from 2000-2008. The average age of the patients was 69 years and the male: female ratio was 2:1. The minimum follow-up was for one year. Although there were some variations in technique, all the arthrodesis were performed by removal of articular cartilage, bone grafting of any defects and rigid internal fixation. Results. 2/33 patients developed a stress fracture of the distal tibia following successful ankle/subtalar fusion. An angle of ankle/subtalar fusion showed an average of 0 degrees +/− 3 degrees in the sagital plane, except for the two cases that developed the stress fracture. The angles in these cases were 13 and 11 degrees. The stress fractures occurred proximal to the level of the previous arthrodesis internal fixation devices (arthrodesis nail/cancellous screws). Intramedullary and extramedullary devices were utilised to obtain union across the stress fracture sites, without success. Discussion. Equinus of more than 10 degrees following ankle/subtalar arthrodesis is a high risk factor for developing a stress fracture of the distal tibia following ankle/subtalar arthrodesis. Stress fracture following successful ankle/subtalar arthrodesis causes severe morbidity. They are extremely difficult to treat, hence are best avoided if possible

Traditional open approaches for subtalar arthrodesis have reported nonunion rates of 5–16% and significant incidence of infection and nerve injury. The rationale for arthroscopic arthrodesis is to limit dissection of the soft tissues in order to preserve blood supply for successful fusion, whilst minimising the risk of soft tissue complications. The aim of this study was to determine the outcomes of sinus tarsi portal subtalar arthrodesis. Case records of all patients undergoing isolated arthroscopic subtalar arthrodesis by two senior surgeons between 2004 and 2014 were examined. All patients were followed up until successful union or revision surgery. The primary outcome measure was successful clinical and radiographic union. Secondary outcome measures included occurrence of infection and nerve injury. Seventy-seven procedures were performed in 74 patients, with successful fusion in 75 (97.4%). One (1.3%) superficial wound infection and one (1.3%) transient sural nerve paraesthesia occurred. Fixation with a single screw provided sufficient stability for successful arthrodesis. To our knowledge this is the largest reported series of isolated arthroscopic subtalar arthrodeses to date, and the first series reporting results of the two portal sinus tarsi approach. This approach allows access for decortication of all three articular facets, and obviates the need for a posterolateral portal, features which may explain the high union rate and low incidence of sural nerve injury in our series

Aims: Numerous techniques for subtalar arthrodesis have been described, with intraarticular and extraarticular methods. The purpose of this paper is to show our results with subtalar arthrodesis with arthroscopic technique. Methods: We reviewed 30 subtalar fusions and followed 26 patients (20 females and 6 males, average age 56,3 years) for an average of 48 months. The preoperative diagnosis was primary arthrosis in 19 cases, arthrosis secondary to trauma in 7 cases and subtalar instability secondary to neuropathic conditions in 4 cases. Patients are placed in a prone position. All arthroscopic procedures were done with non-invasive distraction, thigh tourniquet. Two portals, one each side of Achilles tendon, 2,5-3,0 cm above the junction of posterosuperior surface of the calcaneus and the Achilles tendon. A 4,0 mm 30 degree oblique arthroscope and a rotatory 4mm burr were used. Fixation was done with dynamic cannulated screw from calcaneus into talus. Results: Fusion occurred in all cases. Using the American Orthopaedic Foot and Ankle Society (AOFAS) scored system the patients averaged is 92,7. Twenty four patients (92,3%) were satisfied and two are not satisfied (7,7). No Complications were reported. All patients wore normal shoes. Conclusions: Arthroscopic subtalar arthrodesis and open arthrodesis have similar results, with less morbidity in first one. It can be the chirurgical technique of choice for subtalar arthrodesis in all cases without hind-foot malalignment requiring correction

Introduction. AlloStem/Cellular Bone Allograft and autologous bone graft are accepted methods for managing hindfoot degenerative arthritis. The purpose was to evaluate outcomes of AlloStem and autograft in subtalar arthrodesis and compare overall fusion rates. Methods. This study was conducted in IRB compliance. Patients between 18–80 years who qualified for a subtalar fusion were randomized 1:1 to AlloStem or autologous graft. The AOFAS hindfoot ankle scale, FFI-R and SF-12 were collected pre-operatively, 6 weeks, 3 & 6 months, 1 and 2 year. Weight-bearing 3-view ankle X-rays were done at the same intervals. A CT scan was obtained at 6 months. Results. 140 patients were enrolled; 124 patients had surgery(60-AlloStem and 64-Control). Withdrawals included 14 voluntarily before surgery and 2 intra-operative failures. 19 were lost to follow-up. Mean age for AlloStem was 56.69(20.3–79.6) and Autograft was 54.60(20.74–80.07). 59 AlloStem patients completed their 6 month visit and 45 completed 2 years. AOFAS score improved: 40.02 at pre-op to 72.16(6 mo) to 79.51 at 1 year and 80.38 at 2 year. SF-12 improved 58.29 at pre-op to 65.67 at 6 month and 71.59 at 2 year. FFI-R improved 236.88 at pre-op to 203.53 at 6 month 149.93 at 2 year.60 Autograft patients completed their 6 month visit and 51 patients completed their 2 year. AOFAS score improved 42.89 at pre-op to 75.67 (6 mo) to 79.75 at 1 year and 78.62 at 2 year. Autograft SF-12 improved 60.55 at pre-op to 70.40 at 6 month and 75.26 at 2 year. Autograft FFI-R improved 217.16 at pre-op to 166.77 at 6 month and 145.43 at 2 year. AlloStem patients had a mean posterior fusion rate of 28.9% at 6 months whereas the Autograft had 46.3%(p=.049). Non-union rates were AlloStem(9/57)(15.7%) whereas Autograft was 3/60(5%). Conclusion. AlloStem trended to be inferior to Autologous graft

We have treated 14 patients (15 fractures) with nonunion of an intra-articular fracture of the body of the calcaneum. The mean follow-up was six years (2 to 8.5). A total of 14 fractures (93%) had initially been treated operatively with 12 (86%) having non-anatomical reductions. Four feet (27%) had concomitant osteomyelitis. Of the nonunions, 14 (93%) went on to eventual union after an average of two reconstructive procedures. All underwent bone grafting of the nonunion. The eventual outcome was a subtalar arthrodesis in ten (67%) cases, a triple arthrodesis in four (27%) and a nonunion in one (6%). Three patients had a wound dehiscence; all required a local rotation flap. The mean American Orthopaedic Foot and Ankle Society score at latest follow-up was 69, and the mean Visual analogue scale was 3. Of those who were initially employed, 82% (9 of 11) eventually returned to work. We present an algorithm for the treatment of calcaneal nonunion, and conclude that despite a relatively high rate of complication, this complex surgery has a high union rate and a good functional outcome

Between 2000 and 2004 we used subtalar arthrodesis to treat 44 patients for continued pain after intra-articular calcaneal fracture. All the fractures were due to laboral accidents. Average time to union was 3 month(2 to 4 months). Complications were minor in 12 patients and major in 10 patients. Lenght of follow-up was 23 months. Hindfoot scores (clinical rating system of the American Orthopaedic Foot and Ankle Society)improved from 35,11 to 67,22. The results were excelent in 7 patients, good in 24, fair in 7 and bad in 6 patients. Return to previous activities was possible in 26 pacients. We concludes that subtalar arthrodesis represents a rather effective treatment of the subtalar arthritis due to inta-articular calcaneal fractures. The majority of patients can have improvement with surgical reconstruction but pain relief is usually not complete

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle

Introduction. Postoperative pain following the 3 component ankle arthroplasty (AA) (Mobility™) is a recognised problem without any apparent cause. This study aimed to determine pattern of postoperative pain following Total Ankle Arthroplasty (TAA) and its management options. Materials and methods. In prospective observational study 167 patients who had (AA) and minimum follow-up of 24 months were included. FAOS ankle score, patients' satisfaction, SF36 and diagrammatic mapping of postoperative pain among other parameters were collected preoperatively and postoperatively at 3 months, 6 months and the annually. 20 Patients (12%) had moderate to severe postoperative ankle pain following the ankle arthroplasty. Results. Most of patients with mild pain and low AOFAS score during first year improved by the 2 year review. The pain was localised to the medial aspect of the ankle in 10 patients, lateral side in 8 patients, and both medial and lateral side in 1 patient and global in 1 patient with complex regional pain syndrome. 8 patients with medial or lateral pain needed a re-operation. 5 patients with medial pain were treated by complete release of deltoid ligament along with bony decompression of the medial compartment. None of the above implants were loose intra-operatively. 2 AA with lateral pain needed subtalar arthrodesis. 1 patient needed removal of metalwork from the calcaneum for relief of symptoms. A significant improvement of pain and AOFAS scores was observed in 3 out of the 5 patients who underwent medial compartment decompression and both patients who underwent subtalar arthrodesis. Conclusion. There are 10–13% of low AOFAS scores following Ankle Arthroplasty due to pain. In our series, the pain did not co-relate to implant loosening. Our treatment protocol of mapping of pain and re-do surgery could improve the long term outcome in a significant proportion of the patients

Grice-Green subtalar arthrodesis was initially reported to correct valgus hindfoot deformities in patients with poliomyelitis. Nowadays, the indications of the Grice-Green arthrodesis have been significally broadened. The aim of this study is to analyse the indications of treatment and evaluate the results of the Grice-Green arthrodesis in children. During the period 1986–2006, 17 children with valgus hindfoot deformities were treated in our department. In 12 of them the procedure was performed in both feet and in the rest (5 patients) unilaterally. The mean age at operation was 8.8 years. The most common group of patients suffered from cerebral palsy (10 patients), followed by the patients suffering from myelomeningocele (4 patients), 2 patients suffered from overcorrection following treatment of congenital equinovarus and one patient from Charcot Marie Tooth disease. In neine patients the operation was combined with Achilles tendon lengthening, capsulotomies, tendon transfers, tendonotomies, and Evans arthrodesis. In all operations bone graft from the tibia or the fibula was used. Postoperatively a balow knee non weightbearing cast was applied for 8 weeks followed by a weightbearing cast for 4 weeks. The results were avaluated according to Alman and Zimbies criteria. The mean follow up of the patients was 4.2 years. The results in 24 feet were considered excellent and in 5 cases satisfactory. In all cases subtalar arthrodesis was achieved. Grice-Green arthrodesis is a very useful operative technique for the correction of severe valgus hindfoot deformities in children. The results of the technique are usually good and the operation does not influence the normal growth of the foot. An accurate preoperative planning and a good surgical technique is neccesary for good results

Aims: The purpose of this paper is to show our results with subtalar arthrodesis. Methods: We reviewed 16 sub-talar fusions and followed 14 patients (12 females and 2 males, average age 56,3 years) for an average of 30 months. The preoperative diagnosis was primary arthrosis in 13 cases and secondary to trauma in 3 cases. All arthroscopic procedures were done with non-invasive distraction, thigh tourniquet, a rotatory 4mm burr and þxation with dynamic cannulated screw from the neck of the talus into the calcaneus. Results: Fusion occurred in all cases. Using the American Orthopaedic Foot and Ankle Society (AOFAS) scored system the patients averaged is 92,7. Thirteen patients (98,9) were satisþed and one is not satisþed (7,1). All patients wore normal shoes. Conclusions: Arthroscopic subtalar arthrodesis and open arthrodesis have similar results, with less morbidity in þrst one. It can be the chirurgical technique of choice in subtalar arthrosis without hindfoot malalignment

We treated 31 feet in 17 children with myelomeningocele by extra-articular subtalar arthrodesis. Two patients were lost to follow-up. In the rest, we assessed the correction of valgus deformity and the growth of the tarsal bones. At operation the mean age of the eight girls and nine boys was 6.3 years (3 to 9). At a mean follow-up period of 5.5 years (3 to 9) patients were evaluated clinically and radiologically. We assessed calcaneal growth by calculating the ratio of calcaneal and naviculo-metatarsal longitudinal length on the preoperative and follow-up lateral radiographs. Results of valgus correction were good in 19 feet. In eight they were unsatisfactory owing to progressive valgus of the ankle. Orthotic fitting was difficult and pressure sores over the medial malleolus often developed. Four of the patients underwent further correction by distal tibial osteotomy. The growth ratio was increased in 15 feet, remained the same in seven and decreased in five. Extra-articular subtalar arthrodesis produced satisfactory partial correction of a complex valgus deformity and stability of the hindfoot, and did not have a detrimental effect on the growth of the calcaneus

Introduction: In situ subtalar arthrodesis cannot restore anatomical shape of the hindfoot in severe flat foot deformities. Purpose of this paper is to evaluate the result of 250 feet consecutively operated by subtalar arthrodesis with distraction and insertion of a mini structural bone block (SAMBB). Material and Methods: 178 patients (250 feet), mean age 55+/−11 years affected by acquired adult flat foot with subtalar arthritis were evaluated clinically and radiographically and selected to receive SAMBB. Arthrodesis was performed through a 2.5 cm incision, with partial cartilage removal and insertion of a structural corticocancellous block (2 × 1cm), harvested from the proximal ipsilateral tibia, vertically positioned into the sinus tarsi. Associate procedures were Achilles tendon lengthening (124), SERI procedure (61), hind-foot deformity correction (32). Postoperatively plaster-cast without weight-bearing for 4 weeks followed by walking boot was advised. All patients were reviewed at a minimum follow-up of 5 years. Results: Before surgery the mean AOFAS score was 42+/−15, while it was 90+/−8 at follow-up (p< 0.005). Mean heel valgus deviation at rest was 15°+/−8° preoperatively and 6°+/−5° at follow-up (p< 0.005). Mean angulation of Meary’s line at talonavicular joint level was 160°+/−11° preoperatively and 174°+/−8 at follow-up. No complications were found. No or minimal arthritis progression was observed in the ipsilateral foot joints at follow up. Conclusions: SAMBB resulted in an adequate correction of the deformity, with restoration of the anatomical shape of the hind foot and correction of the relationship with the midtarsal joint with no need of hardware. Consequent reduced arthritis progression and excellent clinical result were obtained

Distraction bone-block arthrodesis has been advocated for the treatment of the late sequelae of fracture of the os calcis. Between 1997 and 2003 we studied a consecutive series of 17 patients who had in situ arthrodesis for subtalar arthritis after fracture of the os calcis with marked loss of talocalcaneal height. None had undergone any previous attempts at reconstruction. We assessed the range of dorsiflexion and plantar flexion and measured the talocalcaneal height, talocalcaneal angle and talar declination angle on standing lateral radiographs, comparing them with the normal foot. The mean follow-up was for 78.7 months (48 to 94). The mean American Orthopaedic Foot and Ankle Society hindfoot score improved from 29.8 (13 to 48) to 77.8 (48 to 94) (Student’s t-test, p < 0.001). The mean loss of talocalcaneal height was 10.3 mm (2 to 17) and the mean talar declination angle was 6.7° (0° to 16°) which was 36% of the normal side. One patient suffered anterior ankle pain but none had anterior impingement. Two patients complained of difficulty in ascending slopes and stairs and four in descending. The mean ankle dorsiflexion on the arthrodesed side was 11.6° (0° to 24°) compared with 14.7° (0° to 24°) on the normal side, representing a reduction of 21.1%. The mean plantar flexion on the arthrodesed side was 35.5° (24° to 60°) compared with 44.6° (30° to 60°) on the normal side, a reduction of 20.4%. These results suggest that anterior impingement need not to be a significant problem after subtalar arthrodesis for fracture of the os calcis, even when the loss of talocalcaneal height is marked. We recommend in situ arthrodesis combined with lateral-wall ostectomy for all cases of subtalar arthritis following a fracture of the os calcis, without marked coronal deformity, regardless of the degree of talocalcaneal height loss

Aim: To analyse retrospectively patients after subtalar extra-articular arthrodesis in CP patients. Material and methods: The operation was designed to correct pronated valgus foot. Followed cohort involved 43 patients with 72 affected and operated feet. Subtalar arthrodesis was based on insertion of bicortical graft obtained from iliac wing in the corrected position of the foot. Immobilisation in POP cast continued for 6 weeks postoperatively. Patients were followed clinically and radiographically in standing position before the operation, and after that at regular intervals. Clinical examination involved estimation of heel valgus, foot-prints, videodocumentation. Lateral talo-calcaneal angle (TC) and calcaneal-bottom angle (CB) were measured on radiographs. Moreover qualitative-descriptive classification was used (good, fair, poor). Results: The median of preoperative TC angle was 44,5° at right foot and 48,0° at left foot. The median of postoperative angle changed to 29,5° at right foot and 29,0° at left foot. The difference in TC angles before and after operation was statistically significant. The median of preoperative CB angle was 7,5° at right foot and 7,0° at left foot. The median of postoperative CB angle was 10,5° at right foot and 7,5° at left foot. The difference in CB angles before and after operation was not statistically significant. Operation failed in two cases due to collapse or migration of the graft. Significant improvement in this study was found in 59 (82%) of cases. Discussion: Plenty of reports concerning the use of classical Grice-Green operation in different modifications were reported. This study is based on the use of bicortical cortico-cancellous graft, which provided good stability as well as a smooth incorporation to the neighbouring bones. The correction in TC angle dominated over change in CB angle. Conclusion: Subtalar extra-articular arthrodesis showed in mid-term follow up very good results

Background: Heel valgus and flattening of arch are common in rheumatoid arthritis (RA). The progression of hindfoot valgus deformity results in pain and debilitating disability, and causes the excessive stress on the ankle joint. Subtalar arthrodesis is often indicated in these cases to reduce the pain and to correct the talocalcaneal alignment. However, accurate correction is not easy without bone grafting, because bone defect often appears after correction. Bone grafting is necessary for accurate correction in these cases, but we have avoided it because of following reasons; donor site problem like insufficiency fractures of pelvis, supply limitation of autograft for possible multiple operations during long term disease progression of RA and the lack of bone graft substitutes, which possesses enough osteoconductivity. Now we have developed the interconnected porous calcium hydroxyapatite (IP-CHA) which possesses good osteoconductivity and achieves major incorporation with host bone much more rapid than the other porous calcium hydroxyapatite. So, we evaluated the usefulness of the packing with the newly developed IP-CHA in bone defect after correction of pes planovalgus deformity of RA patients. Methods: The best possible correction of talonavivular alignment and fixation is performed using one cubic hydroxyapatite block (1x1x1cm), staple and Kirschner wire. Then granular IP-CHA is implanted in bone defect existing mainly in talar body, gap of talonavicular joint and sinus tarsi. Six planovalgus feet were treated with subtalar arthrodesis in 4 female RA patients (3; triple arthrodesis, 3; subtalar and talonavicular arthrodesis). The average age was 56.8 years. Angle of internal arch (IA), tibiocalcaneal (TC) angle in modified Cobey’s method, talocalcaneal height (TCH) in standing position were assessed on the basis of the radiographies at just before operation and final follow-up (average 17.5 months, range 7 to 25 months). Results: Mean IA angle was 138.9 degrees pre-operatively and 132.4 at the last follow-up. Mean TC angle was 14.9 degrees pre-operatively and 7.2 at the last follow-up. No collapse or deformity of hydroxyapatite implanted in the bone defect was observed. Conclusion: Our original technique using IP-CHA was shown to prevent from initial sinking or loss of correction. This technique could make it quit easy to correct the malalignment of talocalcaneal joint with regaining of TCH in painful planovalgus deformity of RA patients

Arthrodesis of both the ankle and the hindfoot has been discussed in the literature since the early part of the last century. Techniques have been modified substantially since these early discussions, though complications remain a frustrating element in patient management. Early procedures relied on molded plaster casts to hold fixation in corrected positions. Successful outcomes were hampered by loss of reduction in these casts and subsequent malunions. In addition, motion within these casts lead to a high rate of nonunion between the opposed bony surfaces. The era of internal fixation allowed compression across arthrodesis sites, enhancing union but creating a host of technical errors leading to unsatisfying results. Malunion is also seen in post-traumatic situations. In particular, non-operative management of calcaneus fracture (or other hindfoot fractures) leads to not only arthritis of the involved joint surfaces, but malunion complicating successful fusion. Fusion in-situ leads to a high level of patient dissatisfaction, leading surgeons to challenging deformity correction while trying to achieve successful arthrodesis in compromised joints. This lecture will focus on two types of malunion, one iatrogenic, one acquired. Revision triple arthrodesis (iatrogenic) can range from simple to challenging. A variety of studies document patient dissatisfaction following correction via this technique, ranging from Graves and Mann (1993) where the highest dissatisfaction rate was in highest in valgus malunion, to Sangeorzan and Hansen (1993), who found a 9% failure rate, most with varus malunion. The precarious balance required to create a plantigrade foot via triple arthrodesis with pre-existing deformity leaves even the most skilled surgeon challenged. As such, this component of the lecture will focus on recognition and correction of malunion based on a structured algorithmic approach we first presented in 1997. This algorithm is based on recognition of the apex of the deformity, and creating osteotomies to achieve balance. We reviewed 28 patients who returned for follow-up examination who received treatment through this algorithm and found a statistically significant improvement in pre- and postoperative AOFAS ankle/hindfoot score, from an average of 31 points preoperatively to 59 postoperatively (p<0.01). All patients united, and all stated they would undergo the revision procedure again. Comparisons of pre- and postoperative shoe wear modification demonstrated a statistically significant improvement (p=0.01). Preoperatively, 20 patients required restrictive devices such as ankle foot orthoses and orthopaedic shoes. Postoperatively, only 1 patient required such a restrictive device. In fact, 17 patients required no modifications to their shoe wear at all. The second component to this lecture will assess acquired hindfoot deformity, from malunion created by calcaneus fractures. A 2005 JBJS study by Brauer, et.al. found operative management resulted in a lower rate of subtalar arthrodesis with a shorter time off work compared to non-operative management. Removing the expense of time off work still netted a $2800 savings for operative management over non-operative management. Sanders echoed these thoughts in a JBJS 2006 paper, suggesting patients with displaced intra-articular calcaneal fractures may benefit from acute operative treatment given the difficulty encountered in restoring the calcaneal height and the talo-calcaneal relationship in symptomatic calcaneal fracture malunion. Thus, with these challenges in mind, the goal of this component of the lecture is to introduce methods to achieve balance and union with calcaneus fracture malunion. Vertically oriented multiplanar calcaneal osteotomy may assist the surgeon in avoiding the higher non-union rate associated with bone-block arthrodesis procedures. In this vein, the challenges associated with bone block subtalar arthrodesis will be explored

1. A modification of the Grice extra-articular subtalar arthrodesis is described. 2. The results of this operation are presented

We describe a congenital deformity of the foot which is characterised by calcaneus at the ankle and valgus at the subtalar joint; spontaneous improvement does not occur and serial casting results in incomplete or impermanent correction of the deformities. Experience with five feet in four children indicates that release of the ligaments and tendons anterior and lateral to the ankle and lateral to the subtalar joint is the minimum surgery necessary; subtalar arthrodesis may be required in addition. The foot deformity described may occur as an isolated condition or in association with multiple congenital anomalies. The possibility of a neurological deficit should always be excluded

The Australian National Joint Replacement Registry is now one of the largest of its kind in the world with over 420,000 surgeries having been collected. Of these the majority are THR and TKR. Recently replacements of the shoulder, elbow, wrist and ankle (TAJR) have been included on the registry and we already have approxi-mately200 TAJR on the registry. It is anticipated that within 4 years we should be able to provide TAJR sur-vivorship data that will be world class. For this to occur it will mean that revision surgeries of any kind will need to be tracked which will not automatically occur unless an implant is changed or removed. As revision surgeries could involve conversion to an arthrodesis, gutter clearance, ligament stabilization, subtalar arthrodesis, treatment of malleolar fractures or realignment hindfoot procedures the AOA member must notify the registry of such events for the data set to be a true indication of the performance of any particular prosthesis. The aim of this presentation is to promote discussion on what secondary interventions the registry will need to be notified of and what processes will need to be established so the additional data can be verified by the registry

We reviewed 19 children with 24 congenital club feet at a mean of 11 years after one-stage posteromedial release at the age of five years or older (mean 6.8 years). Thirteen feet had undergone previous surgery. Nineteen feet were functionally excellent or good, three were fair and two had required subtalar arthrodesis. Radiographs showed good alignment of the tarsal bones, although mild adduction or varus deformity remained in several feet. Deformities of the bones were more common in feet which had had previous surgery

Tibiotalocalcaneal (TTC) arthrodesis using a retrograde nail is a common salvage procedure for a range of indications. Previous work has suggested subtalar joint preparation is unnecessary to achieve satisfactory results. We examine the incidence of symptomatic subtalar nonunion following tibiotalocalcaneal fusion in a series of patients, all of whom had full preparation of the subtalar joint, and consider the possible contributing factors. We performed a retrospective review of all patients who underwent TTC arthrodesis from 2004–2010. All fusions were performed by the same surgeon with full preparation of both tibiotalar and subtalar joints. 61 TTC arthrodeses were performed in 55 patients (mean age = 59 years) using an intramedullary retrograde nail. Mean follow-up was 18 months (6–48 months). Fifty-six ankles (92%) achieved satisfactory union. Five patients (8%) had symptomatic non-union: 4 patients of the subtalar joint - with 3 patients undergoing revision subtalar arthrodesis and 1 patient of the tibiotalar joint. Nine patients required removal of the calcaneal screw (16%) – all had evidence of isolated subtalar nonunion prior to metalwork failure. Eight of these patients achieved asymptomatic union following screw removal. Subtalar nonunion following TTC fusion has resulted in recent changes to nail design to increase stability across the subtalar joint. Our results demonstrate a favourable overall nonunion rate with isolated subtalar nonunion making up the majority of cases. We also observed a significant rate of distal screw loosening, also associated with subtalar nonunion prior to screw removal, the significance of which merits further investigation

A recognised treatment for severe sub-talar arthritis is joint fusion. This can be performed using a well established open technique or achieved through an arthroscopic approach. The aim of this retrospective study was to investigate the results of arthroscopic sub-talar arthrodesis performed by a single surgeon in our institution. 13 arthroscopic sub-talar joint fusions were performed over a 2 year period in patients presenting with isolated arthritis of the joint in question. All arthrodeses were carried out using two posterolateral portals and one posteromedial portal and fixed with two single 7 mm partially threaded cancellous screws. Outcome measures included the American Foot and Ankle (AFOS) score, time to union and post-operative complications. No patients were lost to follow-up. 12 out of 13 arthrodeses went onto clinical and radiological fusion. The AFOS score improved from36 (range 32–50) pre-operatively to 75 (range 65–80) at final follow up. Complications included 1 non-union, 1 DVT and 1 superficial wound infection. 3 patients have had metalwork removed secondary to screw irritation. The results of subtalar arthrodesis performed using an arthroscopic technique is comparable with an open approach and provides high patient satisfaction

Purpose of the study: When treating flatfoot, the objective of subtalar arthrodesis is to reestablish appropriate relations between the talus and the calcaeum by implanting a spacer. The purpose of this study was to evaluate the use of an expansion screw placed in the tarsal sinus and to assess the outcome. Material and methods: Thirty patients with reducible symptomatic flatfoot participated in the study. There were 28 men and 2 women. Surgery was proposed because of pain-related functional disability and failure of orthopedic treatment. Mean age at surgery was 21 years. The Djian-Annonier angle was 134°. The patients were reviewed retrospectively. The Kitaoka function score was noted. Results: Mean follow-up was four years. None of the patients wore orthopedic shoes. Degenerative joint remodeling was not observed. The overall outcome was: very good (n=20), good (n=4), fair (n=2), poor (n=4). Discussion: Arthrorisis using a spacer positioned in the tarsal sinus is a technically simple procedure enabling significant podoscopic correction of flatfoot which persists. Conclusion: This simple technique enables satisfactory anatomic and functional results

1. The history of open operations on fractures of the calcaneum is reviewed. 2. A report is given of the results of treatment of comminuted and depressed fractures of the calcaneum by primary arthrodesis by a modified Gallie procedure. 3. Of twenty-nine patients, twenty-seven returned to full employment within an average of 6·4 months. Twenty-five of these returned to their previous jobs. 4. Poor tendo calcaneus function and lateral sub-malleolar pain were found to be closely allied; both complaints were absent in the usually successful case and occurred only where there had been some complication. 5. It is contended that subtalar arthrodesis is a successful method of treatment for this fracture, but that the operation should be performed soon after the injury in order that the deformity may be corrected

Background. Subtalar fusion is traditionally an open procedure with potentially significant complications but there is little published on arthroscopic subtalar arthrodesis. Methods. We present the first UK series of 33 arthroscopic subtalar fusions in 32 patients, with a variety of pathologies. Results. There were 14 males and 18 females operated on between March 2004 and February 2009. Patients with previous hindfoot fusions were excluded as were patients who underwent combined arthroscopic hindfoot fusions. All patients had surgery by the senior author and followed an identical post-operative management plan. No patients were lost to follow-up. Successful outcome was taken as clinical and radiological evidence of fusion. We report a 100% union rate with 75.8% [25/33] union by 12 weeks, 97% [32/33] by 16 weeks with a single outlier achieving fusion at 22 weeks. There were no wound breakdowns, deep infections, neuromas or thrombotic events. Two patients required removal of metalwork. One patient developed mild CRPS and a further patient became symptomatic from concomitant calaneo-cuboid and talo-navicular joint arthrosis. Discussion. Previous authors have reported variable complication rates and significant rates of delayed and non-unions following open subtalar fusion. This technique respects the soft tissue envelope and therefore is less traumatic to the hindfoot. Our early results suggest that isolated arthroscopic subtalar fusion is a safe and reliable technique, even in patients with deformity, with an excellent union rate and minimal complications

After severe poliomyelitis, which is still relatively common in some developing countries, lateral rotation deformity of the tibia may occur. We have reviewed 51 patients treated by O'Donoghue's rotation osteotomy of the tibia. An average lateral rotation deformity of 57 degrees was fully corrected in all the patients, and in 38 of them the graft obtained during the osteotomy was used for a simultaneous Grice-Green subtalar arthrodesis in one or both feet. All the osteotomies united in an average of 11 weeks, some with relatively minor and unintentional posterior angulation. There was no posterior angulation when the length of the step cut osteotomy was 4.5 cm or more. O'Donoghue's osteotomy is a simple and safe operation, being particularly advantageous if a Grice-Green procedure is also required

Objective: to study the surgical applicability and clinical results of the Vira. ®. system in treatment for severe fractures of the calcaneus. Material and Method: 50 acute intraarticular fractures of the calcaneus treated with the Vira. ®. system over a two-year period were analyzed in 42 patients. The mean age was 41 years. Eight were bilateral fractures and 47 were closed fractures. According to the Sanders classification, most of the fractures were type IV, followed by type III AB, and the inferior cortical was broken in 42 cases. All the patients were evaluated, in a prospective manner, using the AOFAS scale, plain radiographs and CT scan studies. Results: the average AOFAS score 12 months after surgery was 76.6 points (SD: 13.9). In 26% cases the results were very good, in 62% good, and in 12% mild and poor. The Böhler angle improvement after surgery was significant (p=0.05) though clinically irrelevant. Subtalar arthrodesis was achieved in all but two cases. The post-surgical complications were: 4 disorders of the plantar support, 4 cases of osteolysis at the tip of the screws, and 3 soft tissue problems. Conclusions: The Vira system is a validated option for the surgical treatment of severe fractures of the calcaneus, yielding good clinical and radiological results with a surgical procedure that is only minimally aggressive and has a low rate of complications

Persistent pain is a common cause of disability in patients after fractures of the calcaneum. Amongst the possible causes for post traumatic pain is the development of degenerative osteoarthritis of the posterior facet of the subtalar joint. However there are many other causes of post-traumatic hindfoot pain which require consideration prior to treatment. Knowledge of the patho-anatomy of calcaneal fractures is required to reach an accurate diagnosis. Significant symptoms and disability may be treated by arthrodesis of the subtalar joint. Post-traumatic arthritis in the non-operatively treated calcaneal fracture is however usually associated with deformity of the hindfoot, disordered hindfoot biomechanics, lateral wall fibular impingement and fibular tendon dysfunction. Fractures treated by primary open reduction and fixation should be well aligned but despite anatomic reduction may also develop posterior facet arthritis. Symptoms may also be caused by prominence or impingement of the implant, particularly of locked perimeter plates on the lateral wall. Patients therefore require careful assessment prior to surgery and any operative measures have to address these key features in order to produce a satisfactory clinical result. This lecture will address the potential problems of this type of surgery and key features in the clinical assessment and imaging of these patients. Subtalar arthrodesis in the presence of deformity is technically complex and requires careful planning in order to correct the deformity and to produce a well aligned hindfoot to allow corrected biomechanics without impingement and the fitment of suitable footwear. The surgical techniques and different types of surgery required to adequately manage the posterior facet and deformity will be covered and will include arthroscopically assisted in-situ fusion, the safe approaches for open surgery and techniques to reconstruct the lateral wall, fibular tendon function and osteotomies required to restore calcaneal height and alignment

Aims

Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

We describe the surgical technique and results of arthroscopic subtalar release in 17 patients (17 feet) with painful subtalar stiffness following an intra-articular calcaneal fracture of Sanders’ type II or III. The mean duration from injury to arthroscopic release was 11.3 months (6.4 to 36) and the mean follow-up after release was 16.8 months (12 to 25). The patient was positioned laterally and three arthroscopic portals were placed anterolaterally, centrally and posterolaterally. The sinus tarsi and lateral gutter were debrided of fibrous tissue and the posterior talocalcaneal facet was released. In all, six patients were very satisfied, eight were satisfied and three were dissatisfied with their results. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from a mean of 49.4 points (35 to 66) pre-operatively to a mean of 79.6 points (51 to 95). All patients reported improvement in movement of the subtalar joint. No complications occurred following operation, but two patients subsequently required subtalar arthrodesis for continuing pain. In the majority of patients a functional improvement in hindfoot function was obtained following arthroscopic release of the subtalar joint for stiffness and pain secondary to Sanders type II and III fractures of the calcaneum

Introduction and Objectives: Our aim was to study the clinical and work-related results of minimally invasive athrodesis in the treatment of severe calcaneus fractures. Materials and Methods: A total of 50 fractures (42 patients) with intraarticular calcaneus fractures were treated by means of a minimally invasive primary arthrodesis using the VIRA. ®. (Biomet, Valencia, Spain) system with a minimum follow-up of 12 months and a mean follow-up of 21 months. Mean age was 41 years of age. Eight procedures were bilateral and 3 open. According to Sanders classification 74% were type IV. We performed a prospective study with clinical and radiographic assessment (AOFAS scale) 12 months after surgery. Results: The mean AOFAS score was 76.6 points (SD: 13.97): 26% were very good, 62% good and 12% fair to poor. There was no statistical variation of AOFAS in Sanders type of fracture, whether or not the lesion was bilateral and whether or not there was an associated lesion. We found an association (p=0.06) between the AOFAS score and the previous health status of the patient. Böhler’s angle improved slightly, although significantly (p=0.05), and there was seen to be correspondence with the postoperative AOFAS scale. Subtalar arthrodesis was achieved in 48 cases (96%) at 3 months. Discussion and Conclusions: Primary arthrodesis using minimally invasive systems is a valid option for the surgical treatment of severe fractures of the calcaneus. It provides good clinical and radiological outcomes with minimally aggressive surgery and a low complication rate

Hind foot arthrodesis through traditional lateral approach in patient with severe valgus deformity carries a significant risk of wound breakdowns, infection and the risk of sural nerve damage. It is also difficult to fully correct a severe valgus deformity through the lateral approach. To overcome some these problems a medial approach has been recommended. Few authors have reported good results in a small series of cases. We present a retrospective review of 18 consecutive patients with valgus hind foot deformity who underwent hind foot arthrodesis via a medial approach. There were 10 male and 8 female with an average age of 55 years (range 28–75years). The indications included osteoarthritis in 13; post traumatic OA in 3 and rheumatoid arthritis in 2. The mean pre-op subtalar valgus angle was 32o (range 12 – 49) and mean post op valgus angle was 17 (range 10 – 25). All the wounds healed primarily and there were no incidence of wound breakdown or infection. None of the patients developed neuro-vascular complications. The average time for fusion was 5.6 months (range 3–9). Two patients needed further surgical intervention, one for FHL tethering at the fusion site and one for non-union of subtalar joint in a chronic smoker. The medial approach not only allows a safe and fantastic access to subtalar joint making correction of valgus deformity easier but is also extendable to include talo- navicular and naviculo-cunieform fusion and FDL transfer as additional procedures through the same approach as and when indicated. In conclusion we recommend the medial approach for performing subtalar arthrodesis in valgus hind foot deformities

Purpose: Fusion of subtalar arthrodesis is achieved in 94% of cases. There is a significant superficial cutaneous and neurological risk. Since 1985, we have performed partial arthrodesis using curettage-filling of the tarsal sinus via a minimally invasive approach. We wanted to know whether this technique decreases morbidity while preserving maximal rate of fusion. Material and methods: We reviewed 52 patients (55 arthrodeses) operated on by the same surgeon. Immediate weight-bearing was allowed in all patients with a walking boot cast worn for ten weeks. We studied speed of fusion, the hindfoot axis, the development of complications, and the functional outcome (Kitaoka score). Results: Fusion was not achieved in one case at ten weeks. Cutaneous necrosis occurred on one patient who had required a wide approach for other procedures. There was one superficial infection and one reflex dystrophy. Defective residual alignment was observed in six feet where the deformation could not be reduced preoperatively. The mean function score was 39/100 preoperatively and 86/94 postoperatively. Conclusion: This technique provides excellent results with minimal morbidity but can only be proposed if the misalignment can be reduced preoperatively

The aim of this study is to present guidelines for treatment of acquired adult flat foot (AAFF) and review the results of a series of patients consecutively treated. 180 patients (215 feet), mean age 54? 12 years affected by AAFF were evaluated clinically, radiographically and by MRI to chose the adequate surgical strategy. Tibialis posterior dysfunctions grade 1 were treated by tenolysis and tendon repair (48 cases), grade 2 by removal of degenerated tissue and tendon augmentation (41 cases), grade 3 by flexor digitorum longus tendon transfer (23 cases); in these cases subtalar pronation without arthritis was corrected by addictional procedures consisting of either calcaneal osteotomy (66 cases), subtalar athroereisis (25 cases) or Evans procedure (21 cases) in case of severe midfoot abduction. Subtalar arthrodesis (82 cases) or triple arthrodesis (21 cases) were performed in case of subtalar arthritis isolated or associated with midtarsal arthritis respectively. Postoperatively plastercast without weight-bearing for 4 weeks followed by walking boot for 4 weeks was advised. All patients were followed up to 5 years. Before surgery the mean AOFAS score was 48+\−11, while it was 89+\−10 at follow-up (p< 0.005). Mean heel valgus deviation at rest was 15°+\−5° preoperatively and 8°+\−4° at follow-up (p< 0.005). Mean angulation of Meary’s line at talonavicular joint level was 165°+\−12° preoperatively and 175°+\6 at follow-up. Surgical strategy in AAFF should include adequate treatment of tibialis posterior disfunction and osteotomies for correction of the skeletal deformities if joints are arthritis free; arthrodesis should be considered in case of severe joint degeneration

Purpose: We assess the results of the surgical treatment of intra-articular fractures of the calcaneus using the Ilizarov external fixator. Materials and Methods: During the period of January 2004 to June 2009 we treated 72 intra-articular calcaneus fractures in 68 patients, 51 male and 17 female with a mean age of 34 (range 18–56). The mean follow –up period was 2 years and 10 months (range 3 months to 4 years). All patients received preoperative CT-scan to facilitate classification and pre-operative planning. Of the 72 fractures, 37 (51.4%) were Sanders type II, 30 (41.6%) were type III and 5 (7%) were type IV. The Ilizarov fixator used consisted of 2 rings positioned above the ankle joint and a foot plate. 1.5 and 1.8 mm wires were used, as well as 1.8 mm wires with an olive for the reduction of displaced fragments. Under image intensification and distraction the fracture was reduced and the articular surface was restored as close as possible. Results: The clinical outcome was excellent in 29 patients (40.4%), good in 32 (44.4%), moderate in 7 (9.7%) and poor in 4 (5.5%). As far as the complications are concerned, we had 17 cases of pin track infection treated with the removal of the pins, ankle joint stiffness in 12 patients treated with physiotherapy, 2 patients developed reflex sympathetic algodystrophy, 2 malunion, 8 developed post-traumatic osteoarthritis and 1 of them underwent subtalar arthrodesis. Conclusion: The use of the Ilizarov external fixator for the treatment of intra-articular calcanear fractures has proved itself to be an alternative method to O.R.I.F with similarly good results. Given the fact that the learning curve is relatively steep, it has proven, from our experience, to be a safe and valuable tool for the treatment of these challenging fractures

We have assessed the long-term results after operative and non-operative treatment of undisplaced and displaced calcaneal fractures. At a mean of 6.5 years, we reviewed 70 patients with a calcaneal fracture who were divided into four groups: group 1, 18 patients with undisplaced fractures and a normal Böhler’s angle (BA) who had been treated non-operatively; group 2, 23 with intra-articular fractures and a BA < 10° who had been treated non-operatively; group 3, 13 with intra-articular fractures and a BA > 10° who had been treated surgically; and group 4, 16 with intra-articular fractures and a BA < 10° who had been treated surgically. The results were assessed by a clinical score considering pain, return to work, return to physical activity, change in shoe-wear and the requirement for subtalar arthrodesis. Patients with undisplaced calcaneal fractures had a good outcome. Those with displaced fractures treated surgically who presented at follow-up with a BA > 10° had a satisfactory functional outcome and those with displaced fractures who had non-operative treatment had a poor outcome. The poorest outcome was consistently seen in patients who were treated operatively without restoration of BA. Open reduction and internal fixation of intra-articular calcaneal fractures can only be expected to benefit those patients in whom nearly anatomical reconstruction is obtained

Arthroscopy of the ankle and subtalar joints are established techniques in foot and ankle surgery. Arthroscopic ankle arthrodesis is well described and is useful in patients with a poor soft tissue envelope. Subtalar fusion is traditionally an open procedure with potentially significant complications but there is little published on arthroscopic subtalar arthrodesis. 22 patients, made up of 9 males and13 females were operated on from March 2004 to present day with 12 to 36 months follow up. Indications for surgery included primary osteoarthritis and degeneration secondary to previous calcaneal fracture, tibialis posterior insufficiency, neurological conditions and previous ankle fusion. 8 Patients had a concurrent arthroscopic ankle fusion and 4 patients also had a talonavicular fusion. All patients had surgery by the senior author and followed the same postoperative course. Patients were protected in plaster for 12 weeks with gradual increase to fully weightbearing at 6 weeks and x-rays taken at 6 and 12 weeks. Successful outcome was taken as clinical and radiological evidence of fusion. 21 patients (95.5%) achieved fusion by 12 weeks. There has been 1 nonunion but there have been no wound breakdowns, deep infections or other serious complications. Previous authors have reported variable complication rates and significant rates of delayed and non-unions following open subtalar fusion. These early results suggest that arthroscopic subtalar fusion is a safe and reliable method with a high success rate and a low complication rate. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon

Introduction and purpose: The VIRA system allows reconstruction of the fractured bone and its arthrodesis with the talar bone eliminating all movement of the subtalar joint by means of a minimally invasive approach. The aim is to restore the shape of the foot and prevent joint degenerative changes in the long term without the complications and sequelae of open surgery. Material and methods: Between November 2004 and June 2006, 30 intraarticular calcaneal fractures in 25 patients were treated surgically by means of the Vira System. Using Sanders’ classification 6 cases were classified as type II, 13 as type III and 11 as type IV. Five patients had open fractures. There was a mean period of 8.7 days between the accident and surgery. Seven cases had associated lesions and fractures in other locations. Only 2 cases required iliac crest grafts in the operated area. Results: All patients except 10 have returned to their usual occupations. Eight cases evolved favorably but have had a short follow-up. Two cases experienced a delayed healing of the subtalar arthrodesis and had to be reoperated; they required an autologous graft. The mean period of temporary disability in patients discharged from hospital was 163.7 days. Clinical assessment using the AOFAS scale reached a mean value of 76.6 points. No surgical or post-surgical complications were seen in the group studied. Conclusions: The VIRA System seems capable of achieving its purpose in the first series of patients operated. It allows a quick recovery both postoperatively and in the subsequent evolution without any associated complications. It accelerates the patients’ return to work by decreasing convalescence and minimizing sequelae

Aim: To report the clinical and radiological results of patients undergoing hindfoot fusion using an intramedullary nail. Methods: Retrospective review of notes of patients undergoing combined ankle and subtalar arthrodesis using retrograde intramedullary nailing. The procedure is performed mainly for the treatment of complex hindfoot deformities or following failed total ankle arthroplasty. Outcome was assessed by notes review, clinical examination and telephone questionnaire. Results: Between 1995 and 2001 56 arthrodeses in 52 patients have been performed. The average follow up is 3 years. Approach to the joints was via an anterolateral incision unless previous surgery dictated otherwise. All cases utilised an ACE¨ humeral nail which was locked proximally and distally. Most procedures utilised bone graft from the þbula, proximal tibia, iliac crest or allograft femoral head. Mean tourniquet time was 114 mins. Post-operative management generally consisted of 3 months plaster immobilisation. Post-operative complications included deep infection, amputation, stress fracture, non-union & prominent metalwork. At review 90% of patients were satisþed and approximately 90% felt the pain level & function of their foot had improved. Average postoperative AOFAS hindfoot score was 65. Conclusion: Hindfoot fusion by intramedullary nailing is an effective technique in complex cases of deformity and in many cases is the only alternative to amputation. Patient satisfaction appears to be high but the procedure is demanding and the complication rate can be signiþcant

Purpose: Comparison of functional, anatomical and roenthgenological outcomes of subtalar arthrodesis technique: Ilizarov apparatus- EF and internal fixation IF. Materials and Methods: 41 patients (31 men, 10 women) , average age of 38.8 years (12–71) with 44 symptomatic feet underwent procedures for painful arthrodeses. In 28 (30 feet) we performed subtalar arthrodeses by lateral approach, rigid internal fixation with screws. 13(14 feet) others underwent minimal invasive intervention and compression arthrodesis using Ilizarov frame. Nonweightbearing for 4–6 weeks. Removal – 8–10 weeks after the procedure. Evaluation: subjective complaints, physical examination, postoperative radiographs. Patient suspected to have union problems underwent a CT. Results:. In IF union rate 90% (25 patients). Complications: Three re-arthrodeses for nonunion, entrapment of sural nerve – 2 patients, postoperative infection – 2 patients, postoperative infection – 2 patients. In one case intravenous antibiotic resolved the problem, another one needed surgical debridement. The IF overall results were excellent in 79%, good in 12%, fair in 9%. In group EF – solid bone fusion was obtained in all patients. Pin tract infection treated in four, in one case with reinsertion of KW. Conclusions:. Ilizarov external frame is superior for fusion. Disadvantages: Pin tract infection and rare sensory disturbances. Older arthritic patients have fewer complications. Period for bone fusion was shorter in EF group

From 1975 to 1990 we performed subtalar or triple arthrodesis on 54 patients; 48 of them were reviewed after a mean follow-up of 10 years (6 to 15). There were 17 subtalar fusions in 14 patients and 37 triple arthrodeses in 28 patients. We assessed tibiotalar ankle function using the criteria of Mazur which gives a points score of a maximum of 100. Radiological evidence of degenerative change was graded on a scale of 0 to 4. The mean Mazur score was 85 for the subtalar fusions and 78 for the triple arthrodeses. The radiological score showed no degenerative changes in 36 feet (24 triple and 12 subtalar arthrodeses) and an increase of one grade in 14 feet (10 triple and 4 subtalar), of two grades in three feet (all triple arthrodeses) and of three grades in one foot after a subtalar arthrodesis. We found no statistically significant difference in the radiological score in unilateral fusions between feet with subtalar and triple arthrodeses and the contralateral foot. In all four feet which showed an increase in degenerative changes of two or more grades, there was an abnormality of the tibiotalar joint before the fusion operation. Of the 14 feet which showed an increase of one grade, there was a similar increase on the contralateral side in nine. Our findings show that subtalar or triple arthrodesis has little adverse influence on the function of the tibiotalar joint, even after many years

Isolated arthrodesis of the subtalar joint has the advantage that it preserves some motion at the midfoot. In cadaveric studies, movement at the Talonavicular joint is reduced by up to 74% and at the Calcaneocuboid joint by up to 44%. This allows some midfoot flexibility, which would not occur with a triple arthrodesis. There are several methods of performing a subtalar arthrodesis, broadly divided into extra or intra articular techniques, using structural or cancellous bone graft and a variety of fixation methods. Earlier studies on primary arthrodesis have shown rate of non union from 0 – 6%. More recently, larger studies have reported higher rates of non union from 14 – 17%. We present the results of 95 subtalar fusions performed with a standard technique, using one screw from the calcaneum to the talar dome, with 100% follow up. Between 1993 and 2003 the senior author performed 105 subtalar arthrodeses. We performed a retrospective chart review. All patients with a primary subtalar fusion were included. All cases had been refractory to conservative therapy. The senior author reviewed all patients until fusion had occurred or a diagnosis of nonunion was established. Fusion was diagnosed when the patient were pain free while fully weight bearing, with a clinically rigid subtalar joint and radiographs showing trabeculae crossing the arthrodesis. A CT scan was performed in all cases where nonunion was suspected, and the patient complained of persistent pain. A total of ninety five subtalar arthrodeses were performed in ninety two patients. All were reviewed with clinical and radiological examination, until union had occurred or nonunion diagnosed. The average time to union was 5.0 months, range 3 – 12 months. The outcomes, graded using the method of Angus and Cowell, were 21 Fair, 7 Poor and 67 Good results

Introduction and purpose: Posttraumatic compartmental syndromes of the deep posterior compartment of the leg are usually given an incorrect diagnosis. There can be an involvement of the three muscles of the posterior compartment (albeit to different degrees) and muscle necrosis can cause a retraction that flexes the hallux and other toes as well as varus hindfoot and various degrees of equinus and cavus, hindering gait. We revised patients operated on who had had previous tibia and fibular fractures which had led to subsequent foot deformities. Materials and methods: Seven patients were operated on in 5 years. The whole of the fibrous scar tissue was removed from the involved muscle and tendon and a medial capsule release was performed. A subtalar arthrodesis was carried out, laterally displacing the calcaneus under the talus, to correct the varus hindfoot. In addition a transplant of the FHL was made to the base of first phalanx as well as a transplant of the EHL to the base of the first metatarsal/tibialis anterior and a tenodesis of the distal end to EHB. The small toes were treated by means of a replacement of the extensor longus by the extensor brevis and an intrinsicoplasty of every toe. Results: Using the AOFAS ankle and hindfoot scales, the mean postop score was e 90.8 points (range: 62–100), for hallux and small toes it was 90.2 points (range: 67–100). 5 patients (71.4 %) were considered to have obtained excellent results, 1 good and 1 poor. As regards complications, there was one instance of varus recurrence and one case of late consolidation. Conclusions: Repair after a compartmental syndrome can be successfully carried out to achieve a plantigrade foot that allows ambulation

Introduction: Distraction bone block arthrodesis has been advocated in the literature to treat the late sequelae of os calcis fracture with loss of heel height including the prevention of anterior impingement. We have studied a consecutive series of subjects who have had in situ arthrodesis for subtalar arthrosis as a consequence of os calcis fracture with marked loss of talocalcaneal height paying particular attention to range of movement and anterior impingement. Materials and Methods: Between 1997 and 2003 31 consecutive subjects underwent subtalar arthrodesis. Five subjects who had undergone ORIF, two non-unions and three subjects with bilateral injuries were excluded. Two subjects who had marked coronal displacement that required additional surgery at the time of arthrodesis were also excluded. Two subjects were lost to follow up leaving 17 for assessment. AOFAS hind foot scores improved from 29.8 (range 13–48) preoperatively to 77.8 (range 48–94) postoperatively. Mean loss of talocalcaneal height was 10.3mm and the mean talar declination angle was 6.7 degrees which was 35% of the normal side. One subject suffered anterior ankle pain but none had anterior impingement. Two subjects complained of difficulty ascending slopes and stairs and four of difficulty descending. Mean ankle dorsiflexion was 11.6 degrees (range 0–24) compared to 14.7 degrees on the normal side: A reduction of 21.1%. Mean plantarflexion was 35.5 degrees (range 24–60) compared to 44.6 degrees on the normal side: A reduction of 20.4%. Discussion: Our results suggest that anterior impingement is not a significant problem in os calcis fracture, even when loss of talocalcaneal height is marked. We recommend ISA combined with lateral wall ostectomy for all cases of subtalar arthrosis as a result of os calcis fracture, without marked coronal deformity, regardless of the degree of talocalcaneal height loss

Aims: Consideration of gravity of talar neck fractures and evaluation of their treatment results. Methods: From 1992 to 2001 were admitted to our department 26 patients, suffering from talar neck fractures. We were able to reexam 22 patients (17 males and 5 females), with mean age 34,14y. (16 to 64y.). Fourteen pt. (63,6%) were car accident victims. In the rest of them fracture occurred after fall from height more than 3m. There were 8 (36.3%) multi-injured patients. Preoperative diagnostic approach included simple x-rays and CT scan and Hawkins classiþcation was used. All patients underwent surgical treatment. Operative technique included open reduction and internal þxation using screws and/or K-Ws. Postoperatively patients were evaluated with radiological and clinical criteria according to Iowa Ankle Evaluation score. Results: Mean follow up was 58 months (from 12 months to 9 years). Results were excellent in 10 (45,4%), good in 6 (27.2%), fair in 4 (18.1%) and poor in 2 (11%) patients. Two cases developed avascular necrosis (1 type D and 1 type C) followed by body collapse and treated with ankle arthrodesis. Furthermore 1 patient underwent ankle and 6 patients subtalar arthrodesis because of arthritis caused from concomitant fractures. Conclusions: Treatment of talar neck fractures is a challenge because of high rate of complications, because of talusñ shape and vascular anatomy. Anatomic reduction and rigid internal þxation, in combination with immobilization and no weight bearing until restoration of talusñ architecture is achieved, are essential requirements for good result

Aim. To report the clinical and radiological results of patients undergoing hindfoot fusion using an intramedullary nail. Methods. Retrospective review of notes and radiographs of the patients of 2 surgeons who perform combined ankle and subtalar arthrodesis using retrograde intramedullary nailing with an ACE® humeral nail. The procedure is performed mainly for the treatment of combined ankle and subtalar arthritis or complex hindfoot deformities. Outcome was assessed by a combination of notes review, clinical examination and telephone questionnaire. Results. Between 1995 and 2001 54 arthrodeses in 51 patients have been performed. The average follow up is 3 years. Approach to the joints was via a vertical anterolateral incision unless previous surgery dictated otherwise. All cases utilised an ACE® humeral nail which was locked proximally and distally. Most procedures utilised bone graft from the fibula, proximal tibia, iliac crest or allograft femoral head. Mean tourniquet time was 122 mins. Intra operative complications included one fractured tibia and one fractured medial malleolus. Postoperative management generally consisted of 3 months plaster immobilisation. Only 3 cases were immobilised significantly longer than this. Postoperative complications included deep infection, amputation, stress fracture, non-union & prominent metalwork. At review almost 78% of patients were satisfied with the results of surgery and approximately 80% felt the pain level & function of their foot had improved. Average postoperative AOFAS hindfoot score was 73. Conclusion. Hindfoot fusion by intramedullary nailing is an effective technique in complex cases of deformity and in many cases is the only alternative to amputation. Patient satisfaction appears to be high but the procedure is demanding and the complication rate can be significant

This edition of the Cochrane Corner looks at the three reviews that were published in the second half of 2023: surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures; cryotherapy following total knee arthroplasty; and physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents.

The purpose of the study was to perform an independent assessment of the results of open reduction and internal fixation (ORIF) on a selected group of displaced intra-articular calcaneal fractures from two centres. It still remains controversial whether to manage intraarticular calcaneal fractures conservatively or operatively with few long-term results. The identification of patients who may benefit from the procedure is still undecided. Fifty fractures in 46 patients with a defined significant displacement of an intra-articular fracture of the calcaneum underwent ORIF by one of the two senior authors. Mean age at operation was 46 years and mean follow-up was 44 months. 88% of the injuries were due to a fall from a height. 30% of the patients had contralateral foot/ankle injuries, and 20% of the patients developed a superficial wound infection. The infection rate was significantly higher in patients whose surgery was delayed more than 14 days. All patients were independently reviewed after a minimum two-year follow-up. A clinical, radiographic and subjective assessment of the outcome was made. The results were correlated to the original fracture type. The mean Atkins score was 88 (out of 100). Bilateral injuries fared worse. Heel pain at follow-up correlated with a poor score. Atkins scores over 90 occurred in 77% of Saunders Type II, 50% in Type III, and 43% in Type IV fractures. 94% returned to work at a mean of 10 months post-injury. Three patients have undergone a subtalar arthrodesis – two for persistent pain and one for a significant malunion. One patient required a flap but there have been no cases of chronic osteomyelitis. In patients with significantly displaced fractures, ORIF is a worthwhile procedure with 90% of patients satisfied and 94% returning to work. Gross articular comminution does not preclude a good/excellent result if hindfoot alignment is restored. ORIF after fourteen days should be avoided due to the high risk of infection

The purpose of the study was to perform an independent assessment of the results of open reduction and internal fixation (ORIF) on a selected group of displaced intra-articular calcaneal fractures from two centres. It still remains controversial whether to manage intraarticular calcaneal fractures conservatively or operatively with few long-term results. The identification of patients who may benefit from the procedure is still undecided. Fifty fractures in 46 patients with a defined significant displacement of an intra-articular fracture of the calcaneum underwent ORIF by one of the two senior authors. Mean age at operation was 46 years and mean follow-up was 44 months. 88% of the injuries were due to a fall from a height. 30% of the patients had contralateral foot/ankle injuries, and 20% of the patients developed a superficial wound infection. The infection rate was significantly higher in patients whose surgery was delayed more than 14 days. All patients were independently reviewed after a minimum two-year follow-up. A clinical, radiographic and subjective assessment of the outcome was made. The results were correlated to the original fracture type. The mean Atkins score was 88 (out of 100). Bilateral injuries fared worse. Heel pain at follow-up correlated with a poor score. Atkins scores over 90 occurred in 77% of Saunders Type II, 50% in Type III, and 43% in Type IV fractures. 94% returned to work at a mean of 10 months post-injury. Three patients have undergone a subtalar arthrodesis – two for persistent pain and one for a significant malunion. One patient required a flap but there have been no cases of chronic osteomyelitis. In patients with significantly displaced fractures, ORIF is a worthwhile procedure with 90% of patients satisfied and 94% returning to work. Gross articular comminution does not preclude a good/excellent result if hindfoot alignment is restored. ORIF after fourteen days should be avoided due to the high risk of infection

Purpose: The vast majority of forefoot infectious in neuropathy patients are plantar ulcers in diabetics. When conservative treatment is unsuccessful, radical treatment may be indicated, but correct choice of the amputation level is essential. The purpose of this work was to evaluate outcome after tibiocalcaneal arthrodesis achieved with an Ilizarof fixator. Material and methods: The procedure was performed in nine patients between 1991 and 2002. Male gender predominated (seven men). Mean age was 65 years. Eight patients had diabetes and seven of them had complicated mal perforant. Two patients had bilateral involvement so a total of eleven arthrodeses were performed. The procedure began with de-articulation of the Chopard space and talectomy. After high section of the lateral maleolus, the tibia was cut flush with the joint. The calcaneal cut was vertical passing just behind the tarsal sinus. After verticalising the calcaneum, the two cut surfaces were joined. Arthrodesis was maintained with a circular Ilizarof fixator using two rings on the tibia and one on the calcaneum. Results: At mean 20 months, we reviewed ten arthrodeses. Good results were obtained for seven and failure was observed in three (necrosis = 2 and severe suppuration = 1). All these problems resolved and fusion was achieved at five months on average. The type of diabetes, renal failure, duration of the infection, presence of severe contralateral lesions, and type of germ involved appeared to affect outcome. Discussion: Alternatives to the Pirogoff procedure include Chopard amputation, with or without subtalar arthrodesis, and Syme amputation. The technique used in this cohort offers several advantages. The circular external fixator avoids the classic cross screwing in an infectious setting. The mechanical properties of the Ilizarof fixator favour healing and bone fusion. Finally, vericalisation of the calcaneum produces a longer stump so excessively anterior cicatrisation, which can be bothersome for the orthesis, is avoided. Conclusion: This surgical technique provides a radical treatment for proximal osteoarticular infections of the forefoot, often observed in diabetics. Indications are exceptional and should be reserved for lesions which are inaccessible to transmetatarsal amputation. The arthrodesis cannot be achieved without healthy talar stock. The procedure produces a long stable stump which is painless and easy to fit

Introduction: There is a controversy regarding conservative or surgical treatment of calcaneal fracture. We report our experience in surgical treatment of calcaneal fractures. Materials and Methods: Between March 1998 and May 2004, 30 patients with 32 calcaneal fractures were treated surgically in our departments. Twenty four fractures were caused after a fall from height, 4 fractures were consequence of a road accident, 2 fractures after a blast injury and one after a football injury. There were 4 females and 26 males. Two cases were bi-lateral fractures. Age range 20–66 (mean 33). Follow-up time 7 to 72 months (mean 24 months). The fractures were classified according to Sanders classification: there were 22 patients with Sanders III, 8 patients with Sanders IV and one patient with Sanders II. All patients were operated with the same procedure and the same surgeon. The surgical procedure was delayed from 10 to 14 days post trauma, until swelling subsided. Open Reduction Internal Fixation was performed using lateral approach, “L” shape with subperiosteal dissection of lateral wall, and using a calcaneal reconstruction plate. Results: The functional outcome was evaluated according to Rowe Score. The clinical results were excellent in 3 patients (10%), good in 22 patients (70%), fair in 4 patients (14%) and poor in 2 patients (6%). The Boehler angle was reconstructed in 29 of 32 calcaneus. 3 patients returned to their previous level of activity, 9 patients returned to work, 14 patients mentioned some pain in the site of the operation. Two patients were treated successfully with oral antibiotics for superficial wound infection. Six patients suffered from peripheral nerve damage. One patient experienced subtalar pain, and underwent a subtalar arthrodesis, furthermore the patient developed Complex Regional Pain Syndrome (CRPS), finally he underwent below knee amputation (BKA). One patient had a flap necrosis and underwent sural flap coverage with excellent results. All the patients were recognized in a process to be recognized as disabled by the social security. Conclusion: Our results were good in majority of patients according to the known classification systems. However, the recovery period from calcaneal fractures is long and the majority of patients do not achieve their previous functional level. The secondary gain might bias the results

Purpose: The purpose of this work was to evaluate clinical and radiological results of surgical treatment of 80 calcaneum fractures involving the posterior talar process using 1/4 tubes used for triangulation fixation. Material and methods: The series involved 73 patients (seven bilateral fractures), 56 men and 17 women, average age 39.6 years (15–67) who were treated between 1990 and 1999. Patients were victims of 34 home accidents (46.6%), 19 sports accidents (26%), 14 occupational accidents (19.2%), and six traffic accidents (8.2%). The Duparc classification was: type 2 (n=2) type 3 (n=17), type 4 (n=51), and type 5 (n=10). Junior surgeons performed most of the procedures who used seven ‘inverted-V’ assemblies and 73 triangular assemblies. Forty-two patients (47 fractures) were reviewed (58.8% of fractures) clinically and radiologically to assess stability of the fixation (Boehler angle and talocalcaneal angle) and search for osteoarthritis. Results: Mean follow-up was six years (1.5–11.5). There were few complications: four late healing (5%), five reflex dystrophy (6.3%) and two infections (2.5%) (Met-S Staphylococcus aureus and Bacterium bovis corineus. Subjectively, 93.5% of patients were satisfied or very satisfied. At last follow-up, the Boehler angle was 27.5±6.7°. The subtalar space was normal or nearly normal in 46.8% and narrowed or destroyed (osteoarthritis) in 53.2%. The Kitaoka function score (AOFAS) was 73.2 points on average with 44.7% excellent or good results and 44.8% fair results. The SOFCOT score was very good, good, or rather good in 63.8% and fair in 10.3%; it was also noted that among the 25.5% poor results, three patients required secondary subtalar arthrodesis. 86% of the patients resumed their occupational activities and 63% of the patients practicing sports resumed their activities. Conclusion: Osteosynthesis of calcaneum fractures using 1/4 tubes used in a triangular configuration provides stable fixation (little secondary loss of Boehler angle) with a satisfactory cutaneous impact (few cases of skin necrosis). The subjective outcome is very satisfactory. Objective outcome may appear disappointing but is generally related to the severity of the fracture (76% types 4 and 5) or type of fixation configuration

We present the treatment protocol of congenital clubfoot in different age groups that has been widely used in Bulovka Orthopedic Clinic since 1984. Conservative treatment begins immediately after delivery and corrects all presented deformities on the principle of subtalar derotation of the calcaneus. The correction is applied and an above-knee cast is changed every 48 hours. After five corrections and changes of casts, the casting and correction is then repeated weekly. After achieving reduction of deformities, the cast is changed at intervals of two to three weeks. Cast immobilisation should be continued for two to three months for postural clubfoot, and six to seven months for congenital clubfoot. After retention in the cast, a polypropylene above-knee splint is applied up to the age of two to three years. In addition, passive stretching exercise and stimulation of the lateral part of the foot should be provided in order to achieve muscle balance between the evertors and invertors. Surgical treatment: When conservative treatment is unsatisfactory, the goal of operative treatment is to reduce all deformities in a one-step procedure. Posterior capsulotomy at the age of three to six months is indicated when the forefoot has been corrected by conservative treatment but the hindfoot remains fixed in the equinus and mild varus, or at the age of six to 12 months for residual hindfoot equinus. Complete subtalar release according to McKay is required at the age of over six months to three years. Post-operative treatment is the same as for the abovementioned conservative treatment. Treatment between the age of three and seven: The choice of surgical procedure must be individual according to the deformity, but surgical correction of severe deformity principally includes extensive subtalar release, and lateral column shortening by cuboid enucleation. Treatment between the age of seven and ten: Individual procedures (Ilizarov method; Dwyer osteotomy of the calcaneus, or osteotomy of the mid-tarsal bones) are chosen to treat deformities. These procedures are usually combined with soft tissue release, but not with complete subtalar release. Treatment after the age of ten (skeletal maturity of the foot): The same methods as in the previous group are used. When severe or unsatisfactory results after previous surgical treatment are obvious, a triple subtalar arthrodesis is the appropriate salvage method of correction. Treatment of residual deformities: For treatment of dynamic deformities due to muscle imbalance after the age of four, a temporary lateral transfer of the whole tendon of the anterior tibial muscle is performed. For the same age group, forefoot adduction and supination are corrected with a ball and socket osteotomy of the base of metatarsals I-V. This therapeutic concept was applied to 397 operated feet. 60% of the cases were primary surgical corrections, and 40% were repeated surgical corrections. 95% of primary surgical procedures and 75% of secondary surgical procedures were classified as satisfactory, indicating that the foot was sufficiently mobile, with plantigrade weight bearing

Purpose: The purpose of this study was to: 1) analyse sequelae after fracture of the lateral process of the talus (deformed callus or nonunion) in six patients included five who were operated, the impact on the talocrural and subtalar joint, and treatments that can be proposed and expected results; 2) emphasise the fact that this lesion is not often recognised in its initial stage, leading to late diagnosis despite the better results obtained with early treatment. Material and methods: Six patients were seen at consultation at the sequelar stage. There were six men, mean age 40 year (20–60); three were high-level athletes. The injury was cause by fall from a high level, two accidents leading to multiple injuries with an unanalysable mechanism, and ankle “sprain” in one patient. Delay to therapeutic management was four months to ten years (mean two years). Pain and joint stiffeness involving the talocrural joints and/or subtalar joints were the predominant signs. The deformed calluses involved the subtalar joint in five cases with one case of nonunion. Five of the patients had been treated surgically: four resections, one screw fixation of the nonunion, and one patient desired surgery. In all the operated cases, pain had disappeared almost entirely but the amplitude of the joints was not totally recovered. Discussion: Two aspects are particularly important. first fractures of the lateral process of the talus must be considered globally. Frequency has been estimated at 1% of all ankle trauma, certainly an underestimation since these fractures often go unrecognised in the early stages and are too often confused with ankle sprains. Incidence is also increasing with the practise of snow boarding where this injury occurs in 15% of all ankle traumas. The injury results from distraction via the talocalaneal ligaments in an inversion trauma or by compression during dorsiflexion and pronation. Clinical diagnosis is difficult and plain x-rays poorly visualise the lesion, irrespective of the anatomic type (MacCrory classification). CT scan is required to obtain an exact analysis of the fracture and its displacement, necessary for correct treatment: simple immobilisation if there is no displacement or resection of the fragment or osteosynthesis depending on the size of the fragment. Secondly, the pathology of this injury is important to recall: deformed callus or nonunion. The volume of the lesion and its site explain the observed impact, but in all cases, the injury involves the talocruaral joint (painful impingement of the fibular ligament) and talar disorganisation (pain, stiffness or osteoarthritis at the later stages). Depending on the case, treatment consists in excision of the deformed callus, fixation of the nonunion and, for cases seen late, subtalar arthrodesis. An improvment in pain can be achieved but there is almost always loss of joint amplitude. Conclusion: Whatever treatment is used, the results at the sequelar stage are never excellent. Only early diagnosis with a rigorous clinical examination and adapted imaging (CT scan) can lead to coherent early treatment which provides the best result

Aims

This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years.

Purpose: Fracture of the lateral process of the talus is exceptional. Diagnosis may be missed in 50% of patients, the fracture often being confused with severe ankle sprain. Through the seventies, less than 60 cases were reported in the literature. We report a retrospective study of seven cases treated surgically between 1990 and 2001. Material and methods: We examined the different mechanisms leading to fracture of the lateral process of the talus and propose a therapeutic algorithm. All patients were seen at follow-up consultations. We used the AOFAS hindfoot evaluation scale, radiographs (anteroposterior view of the ankle and 3/4 lateral view of the foot, Broden views). Outcome was scored excellent, fair, or poor. Mean patient age was 33 years (20–51). Mean follow-up was six years (1–12). The patients incurred the fracture during a snowboard accident (n=1), motocycle accidents (n=3), defenestration (n=1), and mountain climbing accidents (n=2). Fractures resulted from forced eversion in one patient and high-energy trauma in six. Fracture classification according to Hawkins was type 1 (n=4, type 2 (n=3), and type 3 (n=1). Time from the accident to diagnosis was less than 15 days except in one patient where the diagnosis was made ten months after the trauma. Associated lesions were subtalar dislocation (n=2), talar neck fracture (n=1), medial malleolar fracture (n=1), and open fracture of the first cuneiform (n=1). The procedure consisted in fixation of the fragments without resection in four cases, resection of small fragments and fixation of large fragments in two, and osteotomy of a deformed callus of the lateral process of the talus in one. Weight bearing was not allowed four six weeks except in one patient with subtalar dislocation whose calcaneotalar pin was withdrawn at eight weeks. Results: Complications were one case of superficial infection which resolved with antibiotic treatment and two cases of subtalar osteoarthritis at more than ten years. The overall score was 85 on average. The outcome was excellent in six cases and poor in one. Discussion: A review of the literature shows that fracture of the lateral process of the talus occurs in 1% of all ankle lesions. Five mechanisms have been described. The two most frequent are ankle inversion in dorsiflexion and high-energy trauma. The three other mechanisms are eversion, direct trauma and stress fracture. The consequences of inadequate treatment include: late healing, non-union, deformed callus (one case in our series), avascular necrosis, subtalar instability, and joint incongruency with risk of subtalar and/or talofibular osteoarthrosis. The appropriate treatment depends on the time of diagnosis, the size and nature of the fracture and the degree of displacement. The therapeutic algorithm used in Geneva is as follows: orthopaedic treatment (plaster resting boot for six weeks followed by physiotherapy) associated with close surveillance in the event of a fracture measuring less than 5 mm which is generally extra- articular. If the patient considers this treatment is insufficient, removal of the fragment can be proposed. For fractures measuring more than 1 cm, which are generally intra-articular, surgical treatment is needed if the fragment is displaced more than 2 mm. In the event of late diagnosis, it may be necessary to remove the fragment or perform subtalar arthrodesis, or as needed resection of a deformed callus. If the diagnosis is established early and appropriate treatment given, the results have been excellent at six years

We report the results of a retrospective review of patients that underwent distal tibial deformity correction with transphyseal or supramalleolar osteotomy with or without tibial lengthening. The aims of the procedures performed were to obtain equal leg length, restore the alignment of the ankle joint and tibio—fibular relationship. Supramalleolar osteotomy enables deformity correction, can be combined with lengthening and is appropriate where the tibio—fibular relationship is normal. When the tibio—fibular relationship is abnormal, as is often the case with bone dysplasias, differential tibio—fibular lengthening can be performed. If physeal arrest has occurred, for example after sepsis, deformity correction can be achieved with a transphyseal osteotomy allowing correction and ensuring epiphysiodesis. When the fibular length is excessive, transphyseal osteotomy can be combined with a fibular shortening. Our review encompassed 12 patients over a period of 10 years with 5 having deformity after previous meningococcal septicaemia, 4 with fibular hemimelia, 2 with a history of previous trauma and 1 with deformity occurring after a compartment syndrome as a consequence of snake bite. Seven transphyseal osteotomies were performed in 5 patients (2 bilateral), 4 with deformity secondary to meningococcal septicaemia and 1 with deformity secondary to previous trauma. After 1 transphyseal osteotomy there was recurrent distal tibial deformity (14%) which occurred within 1 year requiring a later supramalleolar dome osteotomy. Of the other 6 transphyseal osteotomies all healed with no residual leg—length inequality or deformity. Seven patients underwent supramalleolar osteotomies with all healing and recurrent deformity occurring in 1 patient (14%). Future lengthening is required in 2 patients and 1 patient will undergo a subtalar joint arthrodesis for a painful valgus hindfoot. Distal tibial deformity correction is challenging but our results show that providing the stated principles are adhered to, successful management with an acceptable recurrent deformity rate is possible

Background Tibiotalocalcaneal (TTC) arthrodesis is a salvage procedure for patients with severe disease of the ankle and subtalar joints. Method We report a series of 26 consecutive patients (26 feet) operated on by a single surgeon, in a single centre, over a 4-year period, with average follow up of 26 months (range 6–50). Mean age of the patients was 57 years (range 28–72). Subjects included 17 male and 9 females. Previously the patients had undergone between 0 to 6 operations, which were unsuccessful. All these patients had combined ankle and subtalar joint arthrodesis by an intramedullary nail device. Indications for surgery were pain except the Charcot joints. Only five patients did not have severe deformity pre-operatively. Aetiology included post-traumatic osteoarthritis, rheumatoid arthritis, psoriatic arthropathy, avascular necrosis, Charcot Marie Tooth disease, primary osteoarthritis, failed ankle replacement and alcohol-and diabetic-induced Charcot neuroarthropathy. Patients were assessed radiologically and by American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, SF-12 and by patient satisfaction scores. Results Clinically and radiologically, 15 cases have solid union. Six patients have signs of radiological non-union/ delayed union but are clinically asymptomatic with no progressive deformity. Two patients required amputation (one non-union and one infected non-union). One patient is awaiting further surgery for infected non-union. Two patients have died of unrelated causes ~2 years post-surgery. Most patients (79%) are very satisfied with the procedure and 83% would undergo the procedure again. Conclusion These results suggest that salvage is possible in the majority of cases with combined ankle and subtalar joint arthrosis and severe deformity

Tibiotalocalcaneal (TTC) fusion is indicated in rheumatoid patients with combined ankle and subtalar disease, particularly when severe deformity is present. In theory, if bone stock is good, a staged subtalar/triple arthrodesis followed by total ankle replacement (TAR) can be used. This is so rarely the case that the author has no experience of this. TTC fusion is also useful in rheumatoid patients with previous joint sepsis, to salvage a failed TAR and to salvage a non-united ankle fusion. It allows early weight bearing, which is valuable in those patients who have multiple joint, particularly upper limb, involvement. In our study, 18 patients underwent 21 TTC fusions from August 1988 to September 2002. The average age was 48 years (range 23–90). Nine patients had undergone previous hindfoot procedures, five were smokers, one was diabetic and one had chronic renal failure. Surgery was performed under GA with tourniquet. Patients were reviewed using a modified American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and with regard to their personal satisfaction. Follow up was 18–57 months. Post-operatively, the oldest patient died due to fulminant sepsis. Seven patients had superficial wound infections but none required re-operation. Fusion was achieved in 18 limbs. Average time to radiological union was 36 weeks (range 9–68), two patients required nail dynamisation. In six cases it was necessary to remove irritating locking screws, either the posterior screw for heel rubbing, or the medial tibial screws for stress riser symptoms. One patient required complete nail removal. There were no amputations. Fourteen patients were very satisfied, two reasonably so and one not. The average AOFAS pain score (max 40) improved from 11 to 32, and the average AOFAS functional score (max 28) from 4 to 21. We feel that despite the relatively high complication rate, this technically challenging procedure is a very useful salvage option in these very disabled patients

Aims

The purpose of this study was to determine the functional outcome and implant survivorship of mobile-bearing total ankle arthroplasty (TAA) performed by a single surgeon.

In this paper, we critically appraise the recent publication of the United Kingdom Heel Fracture Trial, which concluded that when patients with an absolute indication for surgery were excluded, there was no advantage of surgical over non-surgical treatment in the management of calcaneal fractures.

We believe that selection bias in that study did not permit the authors to reach a firm conclusion that surgery was not justified for most intra-articular calcaneal fractures.

Cite this article: Bone Joint J 2015;97-B:880–2.

Aims

The purposes of this study were to clarify first, the incidence of peroneal tendon dislocation in patients with a fracture of the talus and second the factors associated with peroneal tendon dislocation.

The Bologna–Oxford (BOX) total ankle replacement (TAR) was developed with the aim of achieving satisfactory pain-free movement of the ankle. To date, only one single multicentre study has reported its clinical results. The aim of this study was to conduct an independent review of its mid-term results.

We retrospectively reviewed a total of 60 prospectively followed patients in whom 62 BOX TARs had been implanted between 2004 and 2008. We used the American Orthopedic Foot and Ankle Society (AOFAS) score to assess the clinical results. Standardised radiographs taken at the time of final follow-up were analysed by two observers. The overall survival was 91.9% at a mean follow-up of 42.5 months (24 to 71). The mean AOFAS score had improved from 35.1 points (sd 16.6; 4 to 73) pre-operatively to 78.0 (sd 10.7; 57 to 100) at final follow-up (p < 0.01). Tibial radiolucencies < 2 mm in width were seen around 16 TARs. Talar radiolucencies < 2 mm were seen around four TARs. A total of 47 patients (78.3%) were very satisfied or satisfied with the outcome. Five patients required revision for functional limitation or continuing pain.

Objectives

To review the systemic impact of smoking on bone healing as evidenced within the orthopaedic literature.

The extended lateral L-shaped approach for the treatment of displaced intra-articular fractures of the calcaneum may be complicated by wound infection, haematoma, dehiscence and injury to the sural nerve. In an effort to reduce the risk of problems with wound healing a technique was developed that combined open reduction and fixation of the joint fragments and of the anterior process with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and compared to a similar group of 26 patients managed by the extended approach and lateral plating. The operation was significantly shorter (p < 0.001) in the first group, but more minor secondary procedures and removal of heel screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. The accuracy and maintenance of reduction, and ultimate function were equivalent.

A total of 38 relapsed congenital clubfeet (16 stiff, 22 partially correctable) underwent revision of soft-tissue surgery, with or without a bony procedure, and transfer of the tendon of tibialis anterior at a mean age of 4.8 years (2.0 to 10.1). The tendon was transferred to the third cuneiform in five cases, to the base of the third metatarsal in ten and to the base of the fourth in 23. The patients were reviewed at a mean follow-up of 24.8 years (10.8 to 35.6). A total of 11 feet were regarded as failures (one a tendon failure, five with a subtalar fusion due to over-correction, and five with a triple arthrodesis due to under-correction or relapse).

In the remaining feet the clinical outcome was excellent or good in 20 and fair or poor in seven. The mean Laaveg-Ponseti score was 81.6 of 100 points (52 to 92). Stiffness was mild in four feet and moderate or severe in 23.

Comparison between the post-operative and follow-up radiographs showed statistically significant variations of the talo-first metatarsal angle towards abduction. Variations of the talocalcaneal angles and of the overlap ratio were not significant.

Extensive surgery for relapsed clubfoot has a high rate of poor long-term results. The addition of transfer of the tendon of tibialis anterior can restore balance and may provide some improvement of forefoot adduction. However, it has a considerable complication rate, including failure of transfer, over-correction, and weakening of dorsiflexion. The procedure should be reserved for those limited cases in which muscle imbalance is a causative or contributing factor.

The December 2014 Trauma Roundup³⁶⁰ looks at: infection and temporising external fixation; Vitamin C in distal radial fractures; DRAFFT: Cheap and cheerful Kirschner wires win out; femoral neck fractures not as stable as they might be; displaced sacral fractures give high morbidity and mortality; sanders and calcaneal fractures: a 20-year experience; bleeding and pelvic fractures; optimising timing for acetabular fractures; and tibial plateau fractures.

The April 2014 Foot & Ankle Roundup³⁶⁰ looks at: Hawkins fractures revisited; arthrodesis compared with ankle replacement in osteoarthritis; mobile bearing ankle replacement successful in the longer-term; osteolysis is an increasing worry in ankle replacement; ankle synostosis post-fracture is not important; radiofrequency ablation for plantar fasciitis; and the right approach for tibiotalocalcaneal fusion.

We describe the results of arthrodesis for the treatment of recurrent acute neuropathic bone disease in 24 feet and of chronic disease with deformity in 91 feet, undertaken between January 1984 and December 2003. All were due to leprosy.

Correction of the deformity was achieved in 80 of 106 feet (76%) and fusion in 97 of 110 feet (88%). In the 24 feet in which recurrent neuropathic bone disease was the reason for surgery, 17 (71%) obtained stability while in seven (29%) symptoms recurred postoperatively. Complications were experienced following 58 of the 110 operations (53%). In patients presenting primarily with deformity with a minimum follow-up of two years (79 feet), there was a reduced frequency of ulceration in 40 (51%). Normal footwear could be worn by 32 patients (40%) after surgery, while 40 (51%) required a moulded insole. Arthrodesis of the ankle in the neuropathic foot due to leprosy has a good overall rate of success although the rate of complications is high.

In this study we evaluated the results of midtarsal release and open reduction for the treatment of children with convex congenital foot (CCF) (vertical talus) and compared them with the published results of peritalar release. Between 1977 and 2009, a total of 22 children (31 feet) underwent this procedure. In 15 children (48%) the CCF was isolated and in the remainder it was not (seven with arthrogryposis, two with spinal dysraphism, one with a polymalformative syndrome and six with an undefined neurological disorder).

Pre-operatively, the mean tibiotalar angle was 150.2° (106° to 175°) and the mean calcaneal pitch angle was -19.3° (-72° to 4°). The procedure included talonavicular and calcaneocuboid joint capsulotomies, lengthening of tendons of tibialis anterior and the extensors of the toes, allowing reduction of the midtarsal joints. Lengthening of the Achilles tendon was necessary in 23 feet (74%).

The mean follow-up was 11 years (2 to 21). The results, as assessed by the Adelaar score, were good in 24 feet (77.4%), fair in six (19.3%) and poor in one foot (3.3%), with no difference between those with isolated CCF and those without. The mean American Orthopaedic Foot and Ankle Society midfoot score was 89.9 (54 to 100) and 77.8 (36 to 93) for those with isolated CCF and those without, respectively. At the final follow-up, the mean tibiotalar (120°; 90 to 152) and calcaneal pitch angles (4°; -13 to 22) had improved significantly (p < 0.0001). Dislocation of the talonavicular and calcaneocuboid joints was completely reduced in 22 (70.9%) and 29 (93.6%) of feet, respectively. Three children (five feet) underwent further surgery at a mean of 8.5 years post-operatively, three with pes planovalgus and two in whom the deformity had been undercorrected. No child developed avascular necrosis of the talus.

Midtarsal joint release and open reduction is a satisfactory procedure, which may provide better results than peritalar release. Complications include the development of pes planovalgus and persistent dorsal subluxation of the talonavicular joint.

Cite this article: Bone Joint J 2014;96-B:837–44.

A high rate of complications is associated with open reduction and internal fixation of Sanders type 4 fractures of the calcaneum. We assessed the long-term outcome of 83 Sanders type 4 comminuted intra-articular fractures of the calcaneum in 64 patients who underwent non-operative treatment between 1999 and 2005. Each fracture was treated by closed reduction and immobilisation in a long leg cast. Patients were reviewed every three months in the first year, and every six months thereafter. At each visit, the involved ankles were assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) criteria. The degree of fracture healing and the presence of osteoarthritis were assessed.

At a mean follow-up of 51 months (24 to 70) the mean AOFAS score was 72 (52 to 92). Osteoarthritis was scored radiologically using Graves’ classification and was evident in the subtalar joints of 75 ankles (90%) on x-ray and in all ankles on CT scans, of which 20 were grade 0 or 1, 39 grade 2, and 24 grade 3.

A non-operative approach to treating these fractures may be simpler, less expensive, easier to administer with fewer complications, and may be better tolerated than surgery, by many patients.

Endoprosthetic replacement of the distal tibia and ankle joint for a primary bone tumour is a rarely attempted and technically challenging procedure. We report the outcome of six patients treated between 1981 and 2007. There were four males and two females, with a mean age of 43.5 years (15 to 75), and a mean follow-up of 9.6 years (1 to 27). No patient developed a local recurrence or metastasis. Two of the six went on to have a below-knee amputation for persistent infection after a mean 16 months (1 to 31). The four patients who retained their endoprosthesis had a mean musculoskeletal tumour society score of 70% and a mean Toronto extremity salvage score of 71%. All were pain free and able to perform most activities of daily living in comfort.

A custom-made endoprosthetic replacement of the distal tibia and ankle joint is a viable treatment option for carefully selected patients with a primary bone tumour. Patients should, however, be informed of the risk of infection and the potential need for amputation if this cannot be controlled.

Correction of valgus deformity of the hindfoot using a medial approach for a triple fusion has only recently been described for patients with tight lateral soft tissues which would be compromised using the traditional lateral approach. We present a series of eight patients with fixed valgus deformity of the hindfoot who had correction by hindfoot fusion using this approach.

In addition, we further extended the indications to allow concomitant ankle fusion. The medial approach allowed us to excise medial ulcers caused by the prominent medial bony structures, giving simultaneous correction of the deformity and successful internal fixation.

We had no problems with primary wound healing and experienced no subsequent infection or wound breakdown. From a mean fixed valgus deformity of 58.8° (45° to 66°) pre-operatively, we achieved a mean post-operative valgus angulation of 13.6° (7° to 23°). All the feet were subsequently accommodated in shoes. The mean time to arthrodesis was 5.25 months (3 to 9).

We therefore recommend the medial approach for the correction of severe fixed valgus hindfoot deformities.

This study compares the initial outcomes of minimally invasive techniques for single-event multi-level surgery with conventional single-event multi-level surgery. The minimally invasive techniques included derotation osteotomies using closed corticotomy and fixation with titanium elastic nails and percutaneous lengthening of muscles where possible. A prospective cohort study of two matched groups was undertaken. Ten children with diplegic cerebral palsy with a mean age of ten years six months (7.11 to 13.9) had multi-level minimally invasive surgery and were matched for ambulatory level and compared with ten children with a mean age of 11 years four months (7.9 to 14.4) who had conventional single-event multi-level surgery. Gait kinematics, the Gillette Gait Index, isometric muscle strength and gross motor function were assessed before and 12 months after operation.

The minimally invasive group had significantly reduced operation time and blood loss with a significantly improved time to mobilisation. There were no complications intra-operatively or during hospitalisation in either group. There was significant improvement in gait kinematics and the Gillette Gait Index in both groups with no difference between them. There was a trend to improved muscle strength in the multi-level group. There was no significant difference in gross motor function between the groups.

We consider that minimally invasive single-event multi-level surgery can be achieved safely and effectively with significant advantages over conventional techniques in children with diplegic cerebral palsy.