Our aim was to evaluate the results of triple arthrodesis, performed without the use of supplementary bone graft. We carried out a retrospective review of 100 consecutive triple arthrodeses. All the operations had been performed by the senior author (TSS) using a standard technique. Only local bone graft from the excised joint surfaces had been used, thereby avoiding complications at the donor site. The mean age of the patients at surgery was 58 years (18 to 84). The mean time to union was 5.1 months (3 to 17). There were 75 good, 20 fair and five poor results. There were four cases of nonunion. Our study has shown that comparable rates of union are achieved without the need for supplementary bone graft from the iliac crest or other donor site

The feet of 13 spina bifida patients who had undergone triple arthrodesis in adolescence were reviewed at an average of 10 years after operation. Fifteen of 18 feet were considered satisfactory (83%); of the remaining three, two had recurrent planovalgus deformities and one a painful pseudarthrosis. Three feet had required revision of the triple arthrodesis, and there was one postoperative infection. No patient had lost ambulatory status as a result of foot problems and eight of the 10 patients who previously needed calipers were able to discard them or to use lighter ones

The results of triple arthrodesis performed in 80 feet and followed for an average of 13 years are reviewed. Although the majority of patients were very pleased, the results of objective assessment were less favourable. There was a high incidence of degenerative joint changes in the ankle and midfoot and also of pseudarthrosis, avascular necrosis of the talus and residual deformity. Pre-operative rigid equinovarus deformity produced the majority of the poor results. It is suggested that bony resection alone might not be the best means of correcting severe equinus

The results of 10 patients with severe rigid drop-foot corrected by the Lambrinudi triple arthrodesis were studied. The average amount of correction was 47 degrees, as evaluated from standing radiographs taken before and after operation. Radiological features of osteoarthritis and of flattening of the talus were common, but the feet were painless when reviewed at an average of 70 months later. A satisfactory range of movement was obtained at the ankle joint

A method of triple arthrodesis is described which involves inlay of the subtalar and midtarsal joints. It is applicable to the undeformed and valgus foot as is encountered in poliomyelitis, spasmodic flat foot, cerebral palsy and spina bifida. The operation was successful in controlling deformity and pain. The only significant complication was failure of fusion of the midtarsal joint which occurred in three of eighty-five feet (3-5%)

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

We present our experience with a medial approach for triple arthrodesis for correction of severe rigid hindfoot deformity in patients who were at risk for wound complications with a standard lateral approach. Between 1995 and 2002, we treated 17 patients with a rigid hindfoot valgus deformity, and for whom a triple arthrodesis was planned, using a single medial incision. The indication for surgery was pain refractory to shoe wear, orthotic and brace modifications. The severity of the hindfoot deformity itself was not sufficient an indication for this procedure, since during the same time period, 157 triple arthrodesis procedures were performed using a two incision technique, many of which were associated with severe hindfoot varus or valgus deformities. The medial incision was indicated specifically for patients who were at risk for wound complications following correction of the hindfoot valgus deformity due to stretching of the lateral skin. There were 15 patients with rheumatoid arthritis (RA), and two patients who had deformity of the hind-foot following a crush injury associated with scarring of the lateral skin over the sinus tarsi. In addition to standard weight bearing radiographs of the foot and ankle, non-invasive vascular studies were performed in 5/17 patients pre-operatively who on clinical examination were considered to have peripheral vascular disease. Immunosuppressant medication(s) were not discontinued prior to surgery for the patients with RA, and were renewed once wound healing occurred. The surgery was performed in a standard manner for each patient, with an extensile medial incision, the use of a laminar spreader to facilitate exposure and joint debridement, and removal of appropriate bone wedges to improve correction. Cannulated partially threaded 5.0 mm (for the talonavicular and calcaneocuboid joints) and 6.5 mm (for the subtalar joint) screws were used in each patient. All 17 patients were examined a mean of 4.5 years following surgery (range 2.5–8), and the examination focused on the success of arthrodesis, the presence of ankle arthritis, as well as hindfoot deformity. Other outcome parameters were not specifically examined since these patients had multiple additional lower limb deformities, as well as arthritides of the foot and ankle unrelated to the performance of the triple arthrodesis. The correction obtained was compared with preoperative radiographs. There were no wound healing complications in any patient. Arthrodesis was obtained in 16/17 patients. In one patient with RA, a non-union of the calcaneocuboid joint was noted radiographically, but had been present for 6 years, and was asymptomatic. There was no loss of correction, however hindfoot valgus was present in three patients, caused by arthritis of the ankle associated with valgus tibiotalar deformity. Two additional patients had since undergone a total ankle replacement for correction of arthritis not associated with deformity, and one had undergone an ankle arthrodesis 2 years following the triple arthrodesis for correction of severe arthritis as well as tibiotalar deformity. On the anteroposterior foot radiograph, the talus-first metatarsal angle improved from a mean of 26 degrees (range 15–45), to a mean of 5 degrees (range 0–15). The talocalcaneal angle was not measured, since reproducible preoperative measurements could not be obtained. The axial talocalcaneal angle was not measured. The medial approach to triple arthrodesis is a reliable procedure, and can be used with a predictable outcome in patients who are at risk for wound healing complications for correction of hindfoot valgus deformity

Background. Ankle and hindfoot fusion in the presence of large bony defects represents a challenging problem. Treatment options include acute shortening and fusion or void filling with metal cages or structural allograft, which both have historically low union rates. Impaction grafting is an alternative option. Methods. A 2 centre retrospective review of consecutive series of 32 patients undergoing hindfoot fusions with impaction bone grafting of morselised femoral head allograft to fill large bony void defects was performed. Union was assessed clinically and with either plain radiography or weightbearing CT scanning. Indications included failed total ankle replacement (24 patients), talar osteonecrosis (6 patients) and fracture non-union (2 patients). Mean depth of the defect was 29 ±10.7 mm and mean maximal cross-sectional area was 15.9 ±5.8 cm. 2. Tibiotalocalcaneal (TTC) arthrodesis was performed in 24 patients, ankle arthrodesis in 7 patients and triple arthrodesis in 1 patient. Results. Mean age was 57 years (19–76 years). Mean follow-up of 22.8 ±8.3 months. 22% were smokers. There were 4 tibiotalar non-unions (12.5%), two of which were symptomatic. 10 TTC arthrodesis patients united at the tibiotalar joint but not at the subtalar joint (31.3%), but only two of these were symptomatic. The combined symptomatic non-union rate was 12.5%. Mean time to union was 9.6 ±5.9 months. One subtalar non-union patient underwent re-operation at 78 months post-operatively after failure of metalwork. Two (13%) patients developed a stress fracture above the metalwork that healed with non-operative measures. There was no bone graft collapse with all patients maintaining bone length. Conclusion. Impaction of morselised femoral head allograft can be used to fill large bony voids around the ankle and hindfoot when undertaking arthrodesis, with rapid graft incorporation and no graft collapse despite early loading. This technique offers satisfactory union outcomes without the need for shortening or synthetic cages

Muller-Weiss disease is an uncommon condition with unclear etiology and no gold standard treatment. The question arises; which joints to fuse? Although no consensuses prevail, one must postulate fusion should include those affected. Consequently, to establish an algorithm for its surgical management we set out to study clinical and radiographic features with use of SPECT-CT and a literature review. 57 consecutive feet presenting with Muller-Weiss disease analysed; 15 men, 25 women, age 22–84. Condition bilateral in 17, left side 16, right in 7 patients. Specific history and examination by senior author. Radiographic series and SPECT-CT obtained with surgery performed on significantly symptomatic feet. Measurements of Meary-Tomeno angles, anteroposterior thickness of navicular at the midpoint of each naviculo-cuneiform, alongside the medial extrusion distance and percentage of compression in each case performed. Poor correlation between Meary's angle and 1) degree of compression at naviculo-cuneiform joints, 2) degree of extrusion 3) compression vs extrusion using R. 2. coefficient of determination (invalidating Maceira et al. classification). In unilateral cases, extrusion significantly greater on affected side 94.7% (P< 0.001 Fisher exact test). Degree of extrusion significantly greater in bilateral than unilateral cases (p=0.004 unpaired T test). Valgus hindfoot and Meary's negative most common pattern with no correlation between heel alignment and Meary's R. 2. = 0.003. SPECT-CT useful to determine subtalar involvement in ‘stage 2 disease.’. Following review of cases and published literature we propose the following classification for Muller-Weiss disease with treatment algorithm. 3 Stage delineation; Stage 1 (Normal hindfoot alignment); 1A. Talonavicular disease only - Isolated Talonavicular arthrodesis 1B. Talonavicular + Subtalar; double medial or triple arthrodesis. Stage 2. Talonavicular + Naviculocuneiform; 2A. Adequate bone stock - Talo-naviculo-cuneiform arthrodesis, 2B. Inadequate bone stock +- subtalar disease; Talo-naviculo-cuneiform arthrodesis with tricortical bone graft (Mayich). Stage 3; Asymmetric ankle varus. Pantalar arthrodesis Double/triple/TNC/TAR arthrodesis with hindfoot re-alignment

Introduction: Recent studies suggest that preservation of the calcaneocuboidal joint and a single medial approach may lead to equally good results as a conventional triple arthrodesis for painful malalignment or arthritis of the hindfoot. The theoretical advantage of a single medial approach for subtalar and talonavicular fusion is a lower risk for postoperative wound healing problems. The aim of our study was to assess the capability of the modified triple arthrodesis to correct hindfoot malalignment. Methods: We retrospectively measured radiological parameters in 36 consecutive feet in 34 patients who underwent a modified triple arthrodesis. All operations were done with a single medial incision using rigid internal fixation with screws. Radiological evaluation was done at a mean of 15 months (range 6 to 34) postoperatively. Results: The following angles showed a significant (p< 0.001) improvement: the talonavicular coverage from 23° (range,−51 to 51°) to 10° (range, −13 to 32°), the dorsoplantar talar-first metatarsal angle from 18° (range, −19 to 76°) to 9° (range, −11 to 28°), the lateral talo-calcaneal angle from 38° (range, 14 to 57°) to 28° (range, 12 to 44°), and the lateral talar-first metatarsal angle from −15° (range, −51 to 23°) to −4°(range, −18 to 22°). We encountered neither primary wound healing problems, nor bony nonunion. Conclusions: In our study all radiological parameters improved postoperatively. We therefore believe that this is a safe and effective technique in the management of hindfoot deformity with predictable outcome even in patients with severe malalignment

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

Ten patients with Charcot-Marie-Tooth disease have been reviewed at an average of 14 years after soft tissue procedures to correct foot deformities. No patient has so far required triple arthrodesis and the overall results as regards function, appearance and symptoms are satisfactory in all patients. It is concluded that soft tissue procedures can certainly postpone the need for triple arthrodesis and in many cases may obviate it altogether

Triple arthrodesis is the most effective treatment resource for restoring shape and stability to the hind-foot. It is used in order to achieve a plantigrade foot, aligned, stable and painless, in the treatment of various pathologies. However, it has the effect of changing the dynamic mobility of the foot and diminishes the adapting ability to uneven ground, influencing the outcome. Opinions differ on the necessity of internal fixation to maintain the proper alignment of the hind-foot and improve consolidation, influencing the results. The authors reviewed the patients who underwent triple arthrodesis between 01/01/1998 and 31/12/2008. Of a total of 46 patients 28 were reviewed, corresponding to 29 feet that underwent 36 interventions (7 recurrences). Patients were divided into two groups according to whether or not the placement of internal fixation. They were evaluated according to the AOFAS ankle and hindfoot score and correlated with the radiologic result. The most frequent indications for surgery were osteoarthrosis of the tarsus and sequelae of fractures of the calcaneus. In the group without fixation 68% had radiological signs of consolidation. 24% required revision for non consolidation. In the group with internal fixation there was 72.7% consolidation and 9.1% required revision surgery. Bone graft was more often used in internal fixation group (72.7% vs 40%). Group without fixation vs group with internal fixation:. AOFAS mean score: 74.5% vs 61.6%, patients without pain: 50% vs 20%; plantigrade foot with good alignment: 66.7% vs 40% without pain: 50% vs 20%; tibiotarsal arthritis: 48% vs 63.6%; Lisfranc arthrosis: 44% vs 63.6%. There is a higher rate of consolidation in the group setting. However, the functional outcome seems to be better in the group without fixation. Fixation seems to be associated with better consolidation. The functional outcome is related to a plantigrade and well aligned foot

Between 1997 and 2002, seven talipes equino varus deformities in six patients were treated using gradual distraction and correction with the Ilizarov external fixator. Three patients had poliomyelitis, four patients had neglected clubfeet and two patients had relapsed club-feet. The mean age of patients was 13.3 years (5 to 21) and the mean duration of fixator application was 3.25 months. When the plantigrade position was achieved the fixator was removed and a below-knee walking cast was applied. Four months after fixator removal, additional bony correction surgery (triple arthrodesis) was done in three patients. At the time of fixator removal, a plantigrade foot was achieved in all patients. The mean follow-up time from surgery was 26 months. Pin-tract sepsis in two patients was treated effectively with oral antibiotics. Other complications included meta-tarsophalangeal subluxation from flexor tendon contractures in one foot. There have been no recurrences of deformities. Compared to preoperative status, gait was subjectively improved in all patients. Correction of the deformity in the patients who had a triple arthrodesis of the foot was achieved with less bone loss than in patients who had undergone a primary triple arthrodesis. These results suggest that treatment with Ilizarov frames is effective in the management of neglected and relapsed clubfoot deformities

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

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

Surgical resection of the persistently painful talocalcaneal tarsal coalition has not been shown to reliably relieve symptoms in patients with coalitions that are large and have associated hindfoot valgus and subtalar arthrosis. It has been recommended that these patients undergo triple arthrodesis, a procedure that is known to lead to premature arthrosis of the ankle joint. To avoid additional stress on this important joint, treatment of this patient group using calcaneal lengthening osteotomy (CLO), with or without resection of the coalition, has been performed at our institution for the last 15 years. A retrospective review of all patients with talocalcaneal coalitions who had undergone CLO was performed. Clinical and radiographic records were reviewed. Demographic data, and pre- and post-operative pain and function were recorded. Pre- and post-operative radiographs and computed tomography (CT) scans were reviewed and measurements recorded. CT scans were used to calculate the degree of hindfoot valgus and the size of the coalition. Patients were invited to return for clinical examination and follow-up x-rays if two years had passed since their operation. They completed American foot and ankle hindfoot scores, VAS pain scores and were asked satisfaction questionnaires. Radiographic measurements were performed. There were 13 patients who underwent 19 CLOs. Of these 13 patients, eight patients with 13 CLO’s returned for clinical examination and radiographs. Five patients had nine CLO’s to correct deformity without resection of a large middle facet talocalcaneal coalition with severe hindfoot deformity. All patients had restoration of normal foot shape with improvement in comfort and function. One patient had improvement in comfort and function following bilateral simultaneous coalition resection of cartilaginous coalition and CLO to correct significant hindfoot deformity. Two patients had improvement in pain and function in a foot that had residual pain and deformity following prior talocalcaneal coalition resection. CLO, usually accompanied by a heel cord lengthening, is a useful operation both in the failed middle facet resection where there is persistent pain and deformity, and also in the very large coalition with associated deformity and/or arthrosis that is not appropriate for resection. It corrects the foot deformity, improves comfort and function, maintains motion in Chopart’s joints and therefore, unlike triple arthrodesis, avoids additional stresses in the ankle joint

Introduction and Aims: Non-union following triple arthrodesis has been significant, up to 23%. Iliac crest bone grafting and internal fixation has reduced this to 0–4%. Harvesting bone graft incurs significant donor site morbidity and may be unnecessary. We present the results of 100 triple arthrodeses performed with local graft, avoiding donor site complications. Method: Between January 1993 and July 2002 the senior author performed 112 triple arthrodeses. We performed a retrospective chart review, evaluating the incidence of union and the post-operative complications, with a minimum follow-up of six months. For this study, we excluded all (seven) revision fusions, and all (five) fusions using iliac crest or other donor site graft (e.g. calcaneus or tibia). One hundred fusions were performed using a standard technique with internal fixation and without supplementary bone graft. All patients were reviewed until fusion had occurred or non-union declared. Results: Ninety-six patients had one hundred triple arthrodeses, with an average age of 58 years. Fifty fusions were performed for posterior tibial tendon deficiency, 20 for rheumatoid arthritis, seven for osteoarthritis and 12 for post-traumatic osteoarthritis. The remaining 11 cases included: tarsal coalition, psoriatic arthritis and polio. There were 26 males and 74 females, with 37 fusions performed on the right foot and 73 on the left. The average time to union was 5.4 months (range 3–24) with three patients developing non-unions. Of the three patients diagnosed with a non-union, two had fair outcomes and elected to be treated non-operatively. The third non-union had a poor result, and achieved a successful outcome following revision. Overall, there were 74 good outcomes, 22 fair and four poor results. The complications following surgery included: nine wound infections, one DVT, one malunion and seven cases of prominent screws, requiring removal. The one patient with malunion was successfully revised at two years. Conclusion: The majority of authors advocate the use of iliac crest bone graft during triple arthrodesis. However, harvesting iliac crest graft has a significant short and long-term morbidity. This study indicates that comparable rates of union are achieved without the need for supplementary bone graft and thereby avoiding donor site morbidity

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

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. Methods. We retrospectively analyzed a consecutive series of 49 subtalar nonunions between October 2001 and July 2013. Patient records and radiographs were reviewed for specific patient demographics and comorbidities, subsequent treatments, revision fusion rate, use of bone graft, complications, and clinical outcome. Results. Forty-nine patients with a mean age of 49 years (range 23–80) were included. Sixteen (32%) were heavy smokers (>1 pack per day) and five (10%) had diabetes. Forty one (84%) of the nonunions were symptomatic and underwent a revision procedure at a mean of 16 months (range 2.8 to 57) from the time of the primary arthrodesis. Four of these patients required a triple arthrodesis at the time of revision. Bone graft was used in all cases, and in 25 cases (61%) additional adjuvant orthobiologics. Thirty-two (78%) of the patients achieved a solid arthrodesis at a mean of 3.4 months (range 1.4 to 7.6). Patients who were diabetic and smokers as a group had a 68% rate of union. Of the nine nonunions following a revision arthrodesis, five were in the setting of a prior ankle arthrodesis, three were complicated by a deep infection, and one had no obvious risk factors. Four of the repeat nonunions elected to not undergo an additional procedure, two had a successful third attempt at arthrodesis, one had an additional nonunion followed by a successful fourth attempt at arthrodesis, one had a successful tibiotalocalcaneal arthrodesis, and one ultimately required a below-knee amputation. Discussion. Management of subtalar nonunions pose a significant challenge with a low rate of arthrodesis at 78% fusion rate, but which can be achieved with rigid fixation and utilization of bone graft and orthobiologics

Hindfoot fusions are not new and can be a very valuable tool to address a variety of hindfoot problems. It is, however, not a procedure without significant issues. With the combination of a subtalar and talo-navicular fusion most of the ability to compensate for uneven terrain is lost, as is the ability to compensate for minor misalignments in the foot itself. It is therefore extremely important to be diligent in planning and execution of a triple arthrodesis. Deformities should be corrected, but not over-corrected. It is seldom that in situ fusions of deformities are indicated. Stable internal fixation is recommended to avoid loss of correction in the healing period. Indications, surgical approach and rationale for treatment will be discussed

The correction of a relapsed or neglected clubfoot by an external distractor is an alternative to a major operation which may involve triple arthrodesis and is often associated with skin problems. We report the use of the Ilizarov method to treat nine severely deformed feet, with satisfactory results in terms of function and appearance. The distractor enables treatment to be applied before maturity and avoids the shortening of the foot that results from wedge osteotomies. We discuss the indications, technique, complications and results of the method

Eleven patients were reviewed an average of 23 years after they had been treated by excision of a symptomatic calcaneonavicular bar in 16 of their feet. Of these feet 69% (11 feet) had a good or excellent result. Of the five failures, three feet had good results after subsequent triple arthrodesis, but two treated by repeated excision of the bar were still unsatisfactory. Beaking of the talus seen before operation correlated with poor results

We examined 16 feet, 33 to 133 months (mean 83) after simultaneous calcaneocuboid and talonavicular fusions performed for a variety of painful disorders of the hindfoot. Objectively, four feet were rated excellent, eight good, four fair and none poor. There was one asymptomatic nonunion of the talonavicular joint. Progressive degenerative arthritis of the ankle was seen in six patients and of the naviculocuneiform joint in seven. Biomechanically, simultaneous calcaneocuboid and talonavicular arthrodesis is better than an isolated talonavicular fusion and is a simple and effective alternative to triple arthrodesis

Introduction. Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, a review of literature suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomittant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes. Methods. Thirteen consecutively treated patients (eighteen feet) were retrospectively reviewed from the senior author's practice. Clinical examination, American Orthopaedic foot and Ankle Society (AOFAS) hindfoot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction. Results. All patients with resection and simultaneous flat foot reconstruction (calcaneal lengthening, medial cuneiform osteotomy) were satisfied and would have the same procedure again. Most patients were able to return to a higher level of sporting activity compared with preoperative ability. None of the patients had a fair or poor outcome as adjudged by their AOFAS scores. Conclusion. Our study shows that concomittant flatfoot reconstruction in patients with symptomatic middle facet tarsal coalition increased hindfoot motion, corrected malalignment and significantly improved pain. We believe that coalition resection and concomitant flatfoot reconstruction is better option than surgical resection alone or hindfoot fusion in this cohort of patients. Triple arthrodesis should be reserved as a salvage procedure

Posterior tibial tendon dysfunction is a well-recognised condition. It commonly occurs in middle aged overweight women. In contrast to most tendon pathology, the tendon is still often intact and the tendon is stretched rather than completely ruptured. The diagnosis can be made on clinical grounds. Clinical features include acquired flatfoot deformity, inability to perform a single heel raise, ‘too many toes’ sign and loss of inversion power with the foot in forced plantarflexion. Disease is staged into four stages, Stage II is the most common presentation. Treatment options for Stage I are non-operatively including rest and antiinflammatories. Surgical treatment for this is required if this fails or progresses to next stage. Treatment for Stage II disease is most commonly a tendon transfer using FDL tendon transfer and some bony procedure, most commonly calcaneal osteotomy. More recently move to sub-classify Stage II into sub-classification depending on severity of hindfoot valgus and presence of fixed forefoot varus. Other treatment options for Stage II include lateral column lengthening or medial column shortening procedures. Stage III disease is fixed deformity which is classically treated with triple arthrodesis. Stage IV deformity is fixed deformity with ankle valgus. Difficult condition to treat. This requires ankle and hindfoot fusion

Injuries involving the midtarsal joint, which are frequently misdiagnosed, have been studied to clarify the mechanism, classification and treatment. The necessity for routine antero-posterior, lateral and oblique radiographs is emphasised. Seventy-one injuries have been classified according to the direction of the deforming force : medial, longitudinal compression, lateral, plantar and crush types are described. Included in the medial and lateral types is a hitherto undescribed tarsal rotation or " swivel" injury. The mechanism whereby longitudinal compression causes fractures of the body of the navicular is described, and two varieties having different prognoses are defined : one due to purely longitudinal compression and the other due to longitudinal compression with a medial component. The results of treatment have been assessed clinically and radiologically. Reduction, open if necessary, with internal fixation, is recommended for displaced fractures : primary arthrodesis is not indicated. For severe persistent symptoms from medial and longitudinal force injuries triple arthrodesis is recommended, and from lateral force injuries, calcaneo-cuboid arthrodesis

1. Sixty feet operated upon either by triple or pantalar tarsal fusion for instability after poliomyelitis were re-examined ten to twenty-four years later. 2. After triple fusion with preservation of the ankle joint there was a striking absence of late osteoarthritis of the ankle, and only a low incidence of troublesome lateral instability of the ankle. The results were generally good provided the patient had reasonable power of extension of the knee. 3. Triple arthrodesis for completely flail foot in patients without active muscle control of the knee was often disappointing, so far as the limb as a whole was concerned, because of a persistent flexion deformity of the knee which usually necessitated the wearing of an appliance. 4. The results of pantalar arthrodesis for the flail foot were satisfactory. When this operation was performed (with the foot in slight equinus) in patients who lacked active extension of the knee it helped to stabilise the knee in walking by encouraging hyperextension

Aims

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

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

Introduction: Cavus deformity of the foot is defined as equinus (plantar flexion) of the forefoot in relation to the hind foot. In 1/2–3/4 of the children an underlying disease could be diagnosed, usually neuromuscular in origin. Pathomechanism. Gradual developing deformity caused by muscular imbalance, the intrinsic muscles of the foot being weaker as well as the foot dorsiflexors. Main deformities are: claw toes, flexion of the first metatarsal, heel varus and equinus. The deformities will become more rigid with increasing growth and/or progression of the underlying disease. Symptoms are: shoefitting problems, pain, callosities under the forefoot and lateral border, clumsiness during gait and running, tripping. Predominant ages are 8 – 12. Diagnosis: The primary goal is to establish or role out an underlying disease before adequate treatment can be applied. The examination should focus on detailed muscle function and joint mobility. Standardised standing X-ray examination and EMG is often needed for diagnosis and to evaluate muscles to be transferred. Treatment: Moulded insoles, shoe modifications and AFOs are symptomatic. Preventing progression is important. In flexible feet tendon transfers is often sufficient. In rigid deformities various osteotomies is helpful. In the older teenager and adults triple arthrodesis combined with tendon transfers is often needed. Summary: Cavus foot is a common cause for foot problem in the growing child. Neuromuscular dysfunction has to be diagnosed. Surgical procedures are often needed

Introduction: Recurrent clubfoot deformity continues to present a problem in pediatric orthopedic practice. Because of the complexity of feet deformation, the correction represents a significant challenge even for orthopedists having experience in work with the Ilizarov device. Materials and Methods: We apply the Ilizarov fixator consisting of a base from two rings on a shin, an anterior support on the foot – the half ring perpendicular to metatarsal bones and a posterior support from the extended half ring attached to the heel. Anterior and posterior supports are attached to the base by standard details of the Ilizarov apparatus and remain unconnected between them. Such a frame design allows independent and simultaneous correction of forefoot and hind-foot deformities. From 1999–2006, 9 patients aged 3–30, 13 feet with recurrent clubfoot were treated with this technique. Three patients were females and 6 were males. Closed correction was perform in 5 cases, mid-foot osteotomy 4 cases triple arthrodesis 4 cases. The average deformity was: forefoot (supination – 30° FFA – 30°) hind foot (supination 35° equinus 40°). Results: The correction commenced on fourth-seventh day after surgery. Corrections of deformity were achieved in all cases. The average correction period was 8 weeks. Fixation after complete correction was 6–8 weeks. Complications included pin-tract infection 16%, flexion contracture of toes – 87.5%, and severe pain during deformity correction 33%. On mean follow-up of 40 months all patients had good functional outcome. Conclusion: Our frame variant is easy to compose, requires only standard components and allows good correction of all foot deformities

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: Ankle Arthroplasty is an alternative to arthrodesis for patients with disabling ankle arthritis. It aims to remove pain and preserve joint motion. We aimed to review the outcome of all total ankle replacements carried out in our institution between 2002 and 2006. Materials and Methods: We retrospectively reviewed the results of all patients who underwent the Agility ankle replacement performed by a single surgeon. Case notes and radiographs were reviewed and outcome assessment included standardised questionnaires. Results: 30 arthroplasties were performed in 30 consecutive patient. 11 males, 19 females, Pre operative diagnosis was rheumatoid arthritis (16), primary osteoarthritis (12) and post-traumatic osteoarthritis (2) with a mean age of 61.8 yrs. 8 patients required an additional procedure at the time of arthroplasty : tendoachilles lengthening (6); Calcaneal osteotomy (2); triple arthrodesis (2); tip post reconstruction (1). Intra operative technical complications included: Fracture of medial malleolus (3); nerve injury (3); tendon injury (1). 8 patients had wound problems: Delayed healing > 3/52 (8); Superficial infection (2); Deep infection (2). 1 patient had delayed union of the syndesmosis (> 6 months) and 6 had non-union (> 12 months). After a mean follow up of 3.2 years 2 patients had died and 9 patients had required further surgery: Implant removal for infection (1); Talar revision for loosening (1); Re-fusion of the syndemosis (4); Removal of syndesmosis screws (3); Calcaneal osteotomy for valgus hindfoot (1). Discussion: We found a high rate of complications which may be related to the surgeons learning curve, although some are specific to the design of implant which requires a tibio-fibular fusion. Conclusion: The first 30 agility ankle replacements performed in our centre demonstrates several potential complications and shows that there is often a need for subsequent surgery. Short term survivorship of the implant is acceptable and long term review is required

Purpose: In paediatric patients, autografts are limited by the quantity of available bony tissue in donor regions, the need for a second incision, the longer surgical time, and donor site morbidity. Bone substitutes would be an advantage in many cases. Serum and platelet autologous growth factors favouring osteo-induction can be obtained readily. When used in conjunction with osteoconductive materials, they can favour bone growth. The purpose of this work was to evaluate the use of combined autologous growth factors (AGF) and hydroxyapatite (HA) in paediatric patients instead of autologous grafts. Material and methods: This prospective study was conducted in 14 children (16 grafts), nine boys and six girls, mean age 9.4 years. These children required bone grafting related to femoral osteotomy, osteomyelitis, benign cystic tumours, bone nonunion, triple arthrodesis with osteopenia, and insufficient autologous graft material. The AGF-HA combination with human thrombin was used in all cases. AGF was prepared after fractioning autologous blood according to the child’s blood volume, height and weight. A platelet ultraconcentrate was added to thrombin (500 IU) and HA (500 R) at the time of implantation. Mean preparation time was 20 minutes. An autologous graft was not used in any of the children. Results: There were no cases of superficial or deep infection after implantation. Bone healing as assessed clinically and radiologically was obtained in eleven weeks on average (range 8–16) except in two cases (11%). Discussion: The AGF-HA combination is a useful alternative to autologous bone grafting in children. It is a simple technique which accelerates bone healing and HA integration. There were no cases of rejection. Conclusion: 1) In children, this method is a valid alternative which avoids the need for bone harvesting and the corresponding morbidity. 2) Use of AGF-HA in combination does not transmit infection, does not lengthen surgery time, and is an interesting alternative to autologous or heterologous bone grafting

Purpose of the study: The aim of this study was to evaluate the results of the repeated soft tissue release for recurrent postoperative idiopathic congenital talipes equinovarus. There is no real consensus on the appropriate therapeutic option. Materials and Methods: Fifty two patients (74 feet) underwent revision surgery performed by our senior surgeon between 1974 and 2001. One, two or three soft tissue release procedures were performed on 59, 12 and 3 feet respectively. Mean age at the time of the revision surgery was 5.7 years (range 15m-14y). Triple deformity (varus, equinus, adductus) was found in 46 feet, while 28 feet had one dominant deformity. The operation consisted of complete release of the soft tissues in 26 feet and partial release in 48. Subtalar release was indicated in 21 feet. Lichtblau osteotomy was performed in 48 feet. The clinical and radiological outcome was assessed using the Ghanem and Seringe scores recorded before surgery and at last follow-up. Results: Mean follow-up was 11 years (range 4–30). Complications included overcorrection in valgus (n=6) and recurrence (n=8). The anatomic correction was highly significant. Dorsoplantar X-rays show the improvements in the mean talocalcaneal divergence (18–21°), the mean talus-first metatarsal angle (reduced from 28° to 4°), and the calcaneus-fifth metatarsal angle (reduced from 20° to 2°). The average of tibiocalcaneal angle in lateral view increased from 1° to 10° and the average of calcaneal incidence from 6° to 9°. At last follow-up, outcome was considered as ‘excellent’ in 29% and ‘good’ in 42% of the cases. We had ‘fair’ results in 14 feet (19%) because of poor functional results in one third and anatomical defects in two-thirds of them. The outcome was considered ‘poor’ in seven feet (10%), which was due to significant anatomical defects. Triple arthrodesis was needed in seven feet after skeletal maturity. Discussion and Conclusion. Repeated soft tissue release provides an effective means for correcting anatomical anomalies caused by recurrent postoperative talipes equinovarus. The mid-term results are however affected by functional limitations characterised by decreased range of motion and joint pain, particularly in ankle joint. Excessive subtalar release raises the risk of valgus overcorrection. A splint worn at night may be helpful for preventing the recurrence

The records of 82 patients (129 feet) with resistant clubfoot deformity treated surgically by means of different releases were retrospectively reviewed. There are many treatment regimes for clubfoot. Some authors recommend manipulation with minimal multi-stage surgery, whereas others recommend neonatal corrective surgery. However, objective comparison of different treatment programs is not easy because different criteria are used to evaluate the results. Teratologic or neuromuscular clubfeet were not included in this revision. Between 1982 and 1998, 82 patients (27 girls, 55 boys) with 129 clubfeet underwent surgical treatment. All feet were initially treated with a serial long-leg cast for a minimum of four months. Mean age at the time of first surgery was 5.5 months (range 3.5 to 24). Minimum follow-up was two years. Primary posterior release was performed on 105 feet. Subsequent medial release was performed on 16 feet, posteromedial release on three, and a subtalar (Cincinnati) release on three. Primary isolated posteromedial release was performed on 14 feet, and two of these required a subsequent subtalar (Cincinnati) release. Primary isolated medial release was performed on seven feet. Primary isolated lateral release was performed on one foot and primary isolated subtalar (Cincinnati) release was performed on two feet. Subsequent derotative tibial osteotomy was performed in seven cases, wedge tarsectomy on four feet, triple arthrodesis on five, and calcaneocuboid fusion on one foot. Residual varus was present in seven feet. Calcaneal gait caused by overlengthening of the Achilles tendon occurred in one foot, and residual equinus in two feet. Residual valgus heel was observed in three feet. The surgeon must assess each foot and plan the surgery accordingly. A total release is not required for every foot

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

Introduction: The mini C-arm is a compact, user-friendly device with the advantage of reducing exposure to ionising radiation compared to the conventional C-arm. Optimising radiation exposure is not only desirable, but also a legal requirement and protocols should be in place to achieve this. The purpose of this paper is to review our use of the mini C-arm for elective foot surgery and to suggest guidelines for optimising its use. Materials and Methods: Between 2004 and 2006, all elective foot surgery requiring intraoperative imaging were performed using the mini C-arm unit. Procedures performed included ankle, midfoot and hindfoot arthrodeses and joint injections or aspirations. Screening times and radiation doses were recorded for each procedure. Results: Following an initial learning curve, the screening times stabilised around the median value for the individual procedures. For a subtalar or triple arthrodesis this was less than 60 seconds, for ankle arthrodesis, less than 90 seconds and for hindfoot arthrodesis using a nail, less than 100 seconds. Other single joint arthrodeses had a screening time under 30 seconds and injections or aspirations, under 12 seconds. Discussion: As screening time is the main variable that can be controlled by the surgeon, assuming that all other precautions are followed, screening time can be used as a useful audit tool to measure optimum use of the mini C-arm. A protocol is presented which includes completion of an audit form for every operation where the mini C-arm is used. The above times can be used as a guide to enable hospital trusts to formulate their own protocols to regulate radiation exposure. Conclusion: The mini C-arm is well suited for foot and ankle surgery. Having a protocol in place and periodic audit is essential to optimise its use. Apart from being good clinical practice, this is now a legal requirement. Results: In males CA was significantly larger in all regions of the foot than in females. There were no significant between sex differences in PP, CT and PTI. FTI was significantly greater in males than females for most regions in the foot. IPP was earlier in females. MaxF was also significantly higher in males in all the regions except the 2nd toe. MeanF was also higher in males. Conclusion: There were no PP differences; however the plantar surface area of the male foot was larger than females

Deltoid ligament insufficiency has been shown to decrease tibiotalar contact area and increase peak pressures within the lateral ankle mortise. Sectioning of the deltoid ligament has been shown to decrease tibiotalar contact area by 43%. This detrimental effect may create an arthritic ankle joint if left unresolved. Reconstructive efforts thus far have been less than satisfactory. Pankovich and Shivaram described the deltoid ligament as having superficial and deep components based on insertion sites. The superficial layer originates from the anterior colliculus of the medial malleolus and inserts on the navicular, calcaneus and talus. The deep layer originates from the intercollicular groove and posterior colliculus and inserts on the talus. Boss and Hintermann noted that the most consistent and strongest bands of the deltoid were the tibiocalcaneal and posterior deep tibiotalar ligaments. Chronic deltoid ligament insufficiency may be seen in several disorders including trauma and sports injuries, posterior tibial tendon disorders, prior triple arthrodesis with valgus malunion, or total ankle arthroplasty with improper component positioning or pre-existing ligament laxity. The reconstruction of the deltoid ligament in these settings may be critical to the prevention of tibiotalar arthrosis or failure of ankle prostheses from edge loading and polyethylene wear. The reconstructive technique we describe, under low torque, was able to restore eversion and external rotation stability to the talus, which was statistically similar to the native deltoid ligament. In addition, though we maximally tension this graft to give the most secure repair possible, we did not note any increased stiffness in the ankle joint through our measurement techniques. This unusual, positive secondary effect is different from that noted in studies of lateral ligament reconstruction, where ligament tensioning by all methods attempts to reproduce the native tension and not exceed it. All medial ankle ligament repairs of substance involve some type of tendon-weave (whether autograft or allograft) to achieve reconstruction. Our technique develops its strength not only from the anatomic orientation of the reconstructed ligament, but the strength of the components chosen to fix the tendon graft to the bone. The use of Endobuttons allows the entire graft to sit within the tunnels, without the potential violation of the graft ends achieved through techniques utilizing interference screw fixation. Tensioning the graft proximally through the tibia against a rigid distal construct allows greater tension to be placed on the graft at the deltoid ligament site itself than techniques which employ distal tensioning while holding the ankle into inversion. Finally, the use of a looped graft proximally secured with a post that may be moved even further proximally at the surgeon's discretion creates superior tension to achieve medial column rigidity in grossly unstable situations. Thus, given the critical importance of the deltoid ligament and the relative paucity of repair/reconstruction options available, we believe this novel approach will assist the clinician in anatomically reconstructing this challenging condition. Deltoid ligament reconstruction technique using semitendinosis allograft, with superimposed line drawing demonstrating orientation of looped graft

Introduction: The double-hindfoot arthrodesis (subtalar and midtarsal joints) is traditionally performed through a lateral surgical approach associated or not with a medial approach. The main goal of this procedure is to correct severe deformities of the hindfoot in varus or in valgus. In this study we report a series of 19 double-hin-foot arthrodeses through a single medial approach. Methods and Materials: 19 double arthrodeses (subtalar and talonavicular joint) were performed on 16 patients, 8 males and 8 females with a mean age at surgery of 58.3 years (range 27–72). The indications were: 12 pes planovalgus and 7 cavus foot. 9 deformities were fixed (3 in valgus and 6 in varus). The chosen surgical technique was always identical using a medial approach and performed by a single dedicated orthopaedic foot and ankle surgeon (JLB), followed by an osteotomy of the insertion of the Tibialis posterior muscle to the Navicular bone, distraction and avivement of the articular surface done without bone resection, reduction of the talus on the calcaneus, fixation of the talonavicular joint with titanium staples (Pareos®) and of the subtalar joint with two 6.5 mm canulated cancellous screws (Unima®). On five occasions (in 3 pes planovalgus and in 2 cavus foot) arthrodesis of the calcaneocuboid joint was carried out through a mini lateral approach due to painful arthritic lesions. Results: The average follow up was 16.5 months (range 6–40). Consolidation was always achieved. In the subgroup with pes planovalgus: the mean Kitaoka score increased from 44 to 75, the axis of the hind-foot decreased from 21° to 11° in valgus, Djian’s angle decreased from 142° to 134.4°, the slope of the calcaneus increased from 17° to 19.4°. Two failures of the associated medial ligament reparation have led to a secondary complementary arthrodesis of the talo-crural joint. In the subgroup with cavus foot: the mean Kitaoka score increased from 16 to 67. The axis of the hindfoot decreased from 13° in varus to 0.6° in valgus. Djians’s angle increased from 117° to 127.4°, the slope of the calcaneus ranges from 21.3° to 21.5°. Discussion: The double-hindfoot arthrodesis via a medial approach permits the fusion without developing nonunion (in comparison with 20% non-union of triple arthrodesis reported in the literature). Double arthrodesis via a medial approach provide a significant correction of the fixed deformities without resorting to bone grafts. Not classically used in cavus foot, it has permitted the correction of the cavo varus deformity without complications of the surgical wound and by extending the approach, a double elevating osteotomy of the metatarsal bases was performed when necessary

We analyzed the radiographic results of patients treated surgically for flatfoot deformity and who underwent medial cuneiform opening wedge osteotomy as part of the operative procedure. The aim of this study was to confirm the utility of the cuneiform osteotomy as part of the correction of hindfoot and ankle deformity. All patients requiring operative management of flatfoot deformity between January 2002 and December 2007 were prospectively entered in a database. We selected all patients who underwent medial cuneiform opening wedge osteotomy. We measured standardized and validated radiographic parameters on pre and post-operative weight bearing radiographs of the foot. All radiographs were assessed using the digital imaging software package (Siemens). The following measurements were used: lateral talus-1st metatarsal angle; medial cuneiform to floor distance (mm), talar declination angle, calcaneal-talar angle, calcaneal pitch angle, 1st metatarsal declination angle, talonavicular coverage angle, and anteroposterior talus-1st metatarsal angle. Other variables including concomitant surgical procedures, healing of the osteotomy, malunion, and adjacent joint arthritis were also noted. There were 86 patients with a mean age of 36 years (range 9–80). 15 patients had bilateral surgery. The aetiology of the deformity was flexible flat-foot in 48, rupture of the posterior tibial tendon in 41, rigid flatfoot deformity with a fixed forefoot supination deformity in 7, and fixed forefoot varus with metatarsus elevatus in 5. In addition to an opening wedge medial cuneiform osteotomy, a lateral column lengthening calcaneus osteotomy was performed in 80, a gastrocnemius recession in 76, a supramalleolar osteotomy in 2, a triple arthrodesis in 4, a subtalar arthroerisis in 13, excision of an accessory navicular in 6, a tendon transfer in 15 and medial-slide calcaneal osteotomy in 8 patients. The mean lateral talus-1st metatarsal angle improved from 23° to 1°; the mean medial cuneiform to floor distance improved from 20mm to 34mm; the mean talar declination angle improved from 39° to 27°; the mean calcaneal-talar angle improved from 64° to 55°; the calcaneal pitch angle improved from 14° to 23°; the mean 1st metatarsal declination angle improved from 17° to 26°; the mean talonavicular coverage angle improved from 45° to 18°; and the mean anteroposterior talus-1st metatarsal angle improved from 19° to 0° Radiographical analysis confirms that the medial cuneiform opening wedge osteotomy is a reliable and valuable surgical tool in the correction of the forefoot which is associated with flatfoot deformity and that arthrodesis of the 1st metatarsocuneiform joint may not be required to obtain correction of the elevated 1st metatarsal

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

The purpose of this study was to review the total ankle arthroplasties performed in consecutive series of 78 ankles and to determine the short-term results in cases with over 12 months follow-up. Preoperative diagnoses were post-traumatic osteoarthritis in 40 ankles (51.3%), primary osteoarthritis in 32 ankles (41.0%), and systemic arthritis in six ankles (7.7%). HINTEGRA. ®. (Newdeal SA, Lyon, France) total ankle system was used in all cases. Fifty-five total ankle arthroplasties including four revision cases, followed up for over 12 months (range, 13~49 months) were included in this study. Ankles were divided into three groups according to the coronal plane deformity in preoperative standing ankle AP radiograph; Varus (≥10°; 20 ankles (39.2%)), neutral (< 10° varus or valgus; 25 ankles (49%)), and valgus (≥10° valgus; 6 ankles (11.8%)). Various additional surgeries were performed simultaneously with the arthroplasty to correct the deformities; deltoid ligament release (25 cases), posterior tibialis tendon lengthening (2 cases), peroneus longus tendon transfer to brevis (5 cases), lateral ankle reconstruction with modified Broström procedure (4 cases), lateral closed-wedge calcaneal osteotomy (3 cases), percutaneous heel cord lengthening (19 cases), and gastrocnemius recession (1 case). In one patient with severe valgus deformity, staged total ankle arthroplasty was conducted after primary triple arthrodesis. Preoperative and postoperative visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, range of motion (ROM), as well as patient’s satisfaction and willingness to receive the operation again were evaluated The results were compared among the three groups. Serial radiographs were reviewed for any radiological changes. AOFAS score has improved from 54.3 ± 11.4 pre-operatively to 79.2 ± 11.4 at last follow-up. VAS has decreased from 6.8 ± 1.6 to 3.2 ± 1.6. Mean improvement in ROM was 15.6 ± 16.2 degrees. Forty-eight cases (873%) were satisfied with excellent or good results and 49 cases (89.1 %) were willing to receive the operation again. No significant differences in the postoperative VAS (p=0.14), AOFAS score (p=0.79), and ROM (p=0.06) were found among the three groups. Hetero-topic ossifications were observed in 12 cases (23.5%) and periosteal reactions proximal to medial malleolus occurred in four cases (7.8%). Perioperative complications include one intraoperative medial malleolus fracture which was successfully managed with two cannulated-screws, and one medial malleolar stress fracture at six weeks after surgery which has healed spontaneously. One case with osteolysis around tibial screws was managed with bone graft. One case with deep fungal infection was converted to arthrodesis after infection control. Four ankles had to be revised including three cases of polyethylene bearing change due to dislocation, and one case of tibial component and bearing change due to loosening. The patient with revised tibial component was converted to arthrodesis due to recurred loosening. The Kaplan-Meier cumulative survival rate was 90.9% at 12 months and 87.8% at 49 months postoperatively. The short term clinical results of HINTEGRA ankles showed favorable results. No significant differences were observed among different groups of coronal plane deformities when adequate additional surgeries were performed simultaneously. Long term follow-up study is required

1. The amount of orthopaedic surgery which is possible in patients with leprosy is immense. It is likely to decline with improved medical care as deformity rarely begins after the start of medical treatment. In spite of prolonged chemotherapy, skin smears often remain positive for more than five years and lifelong treatment may be necessary. 2. In Hong Kong the disease affects mainly those in the best working years of their lives and at an age when they should be best able to understand the benefits that treatment confers. Education of the public must be one of the main points of disease control. This education should extend to enable patients with anaesthetic extremities to learn the limitations that the disease places upon their activities. Thus they will be less liable to injure themselves and better able to prevent minor injuries from becoming serious. Ulceration only occurs in areas lacking protective sensation but, although bilateral anaesthesia is common, bilateral ulceration is not often seen. 3. In patients with diminished sensation or with paralysed muscle groups there is usually enlargement of the nerves but this may be difficult to detect. 4. Clawing of the fingers is best treated by standard surgical procedures but opposition transplant in the combined median and ulnar nerve paralysis of leprosy is less satisfactory. Any transplant must prevent hyperextension at the metacarpo-phalangeal joint and this is best done by providing a double insertion for the transplant. If the soft tissues between the first and second metacarpals are contracted it is better to perform osteotomy of the base of the first metacarpal bone rather than to perform the standard operation of soft-tissue release and skin grafting. 5. The value of tibialis posterior transplantation in drop-foot has been confirmed. 6. The problem of fitting an artificial limb to an anaesthetic stump has not been solved. It was often found that ulcers of the stump occurred even with well-fitting sockets and cooperative patients. If amputation above the foot is necessary it is usually wiser to try a through-knee amputation. 7. Return of power or sensation after the start of medical treatment is unusual but it is also unusual for these symptoms to be noted for the first time when the patient is taking sulphones. It would be worth while investigating the effects of decompression of the median nerve at the level of the wrist by dividing the carpal ligament in those patients developing symptoms and signs of impaired median nerve function. Nerve decompression should also be performed in patients showing tender, swollen nerves in acute lepromatous reactions where steroid therapy fails to bring improved function within six hours. 8. It is essential that surgical methods of limiting disability such as incision, decapsulation or transposition of nerves, which have received favourable comment in the past, should be repeated in a controlled series. Series, so far, have lacked reference to the natural history of the condition under medical treatment alone and have often lacked adequate follow-up. 9. Acute lepromatous reactions in the foot often subside with little bone destruction if the patient is rested in bed with the foot immobilised in plaster. If deformity occurs it may be corrected by triple arthrodesis or pantalar arthrodesis. Shortening of the limb may be necessary to prevent stretching the posterior tibial artery. The use of staples at operation greatly eases the task of maintaining the position. Surgery is not always contra-indicated in the presence of long-standing ulceration

Purpose: Necrosis of the navicular bone, described by Müller then Weiss in 1927, is an uncommon finding, unlike talonavicular degeneration which is a rather frequent complication of talipes planovalgus. Between 1985 and 2000, we cared for 25 patients with this condition. The purpose of this retrospective analysis was to describe the clinical and radiological presentation and attempt to reconstruct its natural history with the aim of determining therapeutic indications. Material and methods: We analysed 25 cases of navicular bone necrosis observed in 14 women and 3 men (eight bilateral cases). Mean age of the patients was 39 years (range 16–59). The diagnosis of necrosis was established on the basis of structural alterations (densification, bone defects) and in the more advanced cases, flattening and “expulsion” of the navicular bone. We looked for clinical signs and described the radiological aspect of the necrotic zone. A computed tomography was available in 14 cases and magnetic resonance imaging in the five most recent cases. Results: Pain was the major sign in all cases. One-third of the cases occurred in a foot with prior planovalgus. History taking revealed elements suggestive of an aetiology in three cases: probable Köhler-Mouchet disease in a 16-year-old boy, sickle cell disease in a 35-year-old man, and prolonged walking with signs suggesting stress fracture in a 40-year-old woman. In the other 19 cases (11 women and 1 man, 7 bilateral cases), necrosis was considered idiopathic. Radiologically, we used the Ficat classification (described for hips): stage 0 with normal x-ray and strong uptake on scintigram (n=1), stage 1 with a normally shaped navicular bone but condensation or bone defect, stage 2 with modification of the shape of the bone without signs of degeneration, stage 3 where changes in the shape of the bone are associated with narrowing of the talonavicular then cuneonavicular space. Computed tomography included frontal and horizontal slices as well as lateral reconstructions indispensable to assess the posterior part of the interarticular spaces. Treatment was surgical in 12 cases and medical in 13. Well tolerated forms were treated with plantar ortheses with regular surveillance. Surgical procedures included triple arthrodesis (early in our experience), mediotarsal arthrodesis (n=2), talonavicular arthrodesis (n=7) and talocuneate arthrodesis with replacement of the scaphoid by an iliac graft (n=2). The natural course of necrosis was studied in the cases without surgery. The first sign was medial mediotarsal pain. At this stage scin-tigraphy or MRI was required for positive diagnosis. At stage 0 condensation of the navicular bone, confirmed by computed tomography, preceded bone flattening then expulsion upwardly and medially, sometimes with fragmentation and onset of talonavicular degeneration. Cuneonavicular degeneration appeared to occur later (except in one case). Long-term results of surgery were good with pain relief and renewed activity. Discussion: The clinical presentation initially described as Müller-Weiss disease or scaphoiditis, which concerns a bilateral condition generally occurring after trauma and sometimes with a favouring factor (alcoholism, osteoporosis), appears somewhat different from our description. Mechanical factors predominated in our patients and the aetiologies were quite similar to those observed in Kienböck syndrome. Excessive pressure on the navicular bone, which leads to avascular necrosis, flattening, and expulsion, is undoubtedly the essential cause of this condition. It is well tolerated in some individuals and can lead to spontaneous fusion. In this situation, treatment can be limited to surveillance or orthopaedic care. If the functional impact is important, surgical treatment can be proposed, generally limited to talonavicular arthrodesis. If the navicular bone is sclerosed and flat, the remaining fragment can be replaced by an iliac graft to achieve talocuneate fusion. Conclusion: Necrosis of the navicular bone appears to be less uncommon than in the classical description, particularly in black women aged 25–50 years. A more precise study of favouring anatomic factors (length of the medial ray, size of the talar neck, depression of the medial arch) could provide further information concerning the aetiology which appears to be similar to that of Kienböck disease

Introduction: This document is our report on the prospective follow-up of 38 patients operated between May 1998 and May 2005. If the technique in itself hardly poses any difficulty, our experience of talo-crural and sub-talar arthroscopy has proved to be a major asset. Materials and method: This involved 38 patients (23 men and 16 women) mean age 55y who received a double or triple talar arthrodesis by means of retrograde nailing. 4 patients had a septic history, and 7 an anterior sub-talar arthrodesis. In 19 cases, sub-talar refreshing was carried out in accordance with our arthroscopic principles. Whenever possible, the same procedure was followed at the talo-crural stage, despite an anterior or anterolateral approach (cartilaginous refreshing as regards the geometry of the surfaces, and careful refreshing of the splints and trans-osseous perforations). In one case, the technique was purely bifocal arthroscopy, 26 patients had bone grafts (25 autografts, 1 allograft). Indications therefore were 7 failed talar arthroplasties, 6 ankle pseudarthrodesis with side-effects in the sub-talar joint, 5 primitive bifocal arthosis, 5 complex traumatisms in the hinde foot, 4 neurological varus equinus feet, 3 side-effects of talar laxity, 1 diabetic osteo-arthropathy and one pseudarthrosis of the leg with subjacent talo-crural arthrosis. The average follow-up is of 38 months (12–90). Results: Complete weight bearing has always been possible, except for a paraplegic patient. 2 non-fusions (one at each level) are noted in two patients who were succesfully treated with a change of method. All of the other set within an average period of 2.6 months. We note one resolvent aseptic discharge in a looking screw, one algodystrophy, one sepsis of the iliac site, and one of a locking screw. The patients were evaluated by the AFCP, SFMCP talar score, whose average value rose from 20.7 to 66/100. 19 patients were very satisfied, 15 satisfied, 2 disappointed and 2 dissatisfied. Discussion: This osteosynthesis, very reliable biomechanically, enabled a number of delicate situations to be recovered, using a graft, however, in 68%of cases. Applying the principle of endoscopic refreshing resulted in a fusion rate of 97.5%. In our experience, a septic history doesn’t contra-indicate nailing. Conclusion: This technique, often reserced for difficulty cases, has proved to be extremely reliable, with an excellent fusion rate

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

The results of further soft-tissue release of 79 feet in 60 children with recurrent idiopathic congenital talipes equinovarus were evaluated. The mean age of the children at the time of re-operation was 5.8 years (15 months to 14.5 years). Soft-tissue release was performed in all 79 feet and combined with distal calcaneal excision in 52 feet. The mean follow-up was 12 years (4 to 32). At the latest follow-up the result was excellent or good in 61 feet (77%) according to the Ghanem and Seringe scoring system. The results was considered as fair in 14 feet (18%), all of whom had functional problems and eight had anatomical abnormalities. Four feet (5%) were graded as poor on both functional and anatomical grounds.

The results were independent of the age at which revision was undertaken.

Aims

The purpose of this study was to evaluate the long-term outcome of adolescents with cerebral palsy who have undergone single-event multilevel surgery for a flexed-knee gait, followed into young adulthood using 3D motion analysis.

We describe a retrospective review of the clinical and radiological parameters of 32 feet in 30 patients (10 men and 20 women) who underwent correction for malalignment of the hindfoot with a modified double arthrodesis through a medial approach. The mean follow-up was 21 months (13 to 37). Fusion was achieved in all feet at a mean of 13 weeks (6 to 30). Apart from the calcaneal pitch angle, all angular measurements improved significantly after surgery. Primary wound healing occurred without complications.

The isolated medial approach to the subtalar and talonavicular joints allows good visualisation which facilitated the reduction and positioning of the joints. It was also associated with fewer problems with wound healing than the standard lateral approach.

Aims

A flexed knee gait is common in patients with bilateral spastic cerebral palsy and occurs with increased age. There is a risk for the recurrence of a flexed knee gait when treated in childhood, and the aim of this study was to investigate whether multilevel procedures might also be undertaken in adulthood.

We report the outcome of 28 patients with spina bifida who between 1989 and 2006 underwent 43 lower extremity deformity corrections using the Ilizarov technique. The indications were a flexion deformity of the knee in 13 limbs, tibial rotational deformity in 11 and foot deformity in 19. The mean age at operation was 12.3 years (5.2 to 20.6). Patients had a mean of 1.6 previous operations (0 to 5) on the affected limb. The mean duration of treatment with a frame was 9.4 weeks (3 to 26) and the mean follow-up was 4.4 years (1 to 9). There were 12 problems (27.9%), five obstacles (11.6%) and 13 complications (30.2%) in the 43 procedures. Further operations were needed in seven patients. Three knees had significant recurrence of deformity. Two tibiae required further surgery for recurrence. All feet were plantigrade and braceable.

We conclude that the Ilizarov technique offers a refreshing approach to the complex lower-limb deformity in spina bifida.

The incidence of periprosthetic fractures of the ankle is increasing. However, little is known about the outcome of treatment and their management remains controversial. The aim of this study was to assess the impact of periprosthetic fractures on the functional and radiological outcome of patients with a total ankle arthroplasty (TAA).

A total of 505 TAAs (488 patients) who underwent TAA were retrospectively evaluated for periprosthetic ankle fracture: these were then classified according to a recent classification which is orientated towards treatment. The outcome was evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score and a visual analogue scale for pain, and radiologically.

A total of 21 patients with a periprosthetic fracture of the ankle were identified. There were 13 women and eight men. The mean age of the patients was 63 years (48 to 74). Thus, the incidence of fracture was 4.17%.

There were 11 intra-operative and ten post-operative fractures, of which eight were stress fractures and two were traumatic. The prosthesis was stable in all patients. Five stress fractures were treated conservatively and the remaining three were treated operatively.

A total of 17 patients (81%) were examined clinically and radiologically at a mean follow-up of 53.5 months (12 to 112). The mean AOFAS score at follow-up was 79.5 (21 to 100). The mean AOFAS score in those with an intra-operative fracture was 87.6 (80 to 100) and for those with a stress fracture, which were mainly because of varus malpositioning, was 67.3 (21 to 93). Periprosthetic fractures of the ankle do not necessarily adversely affect the clinical outcome, provided that a treatment algorithm is implemented with the help of a new classification system.

Cite this article: Bone Joint J 2015;97-B:950–6.

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy is a well-recognised form of treatment for stage II posterior tibial tendon dysfunction. Although excellent short- and medium-term results have been reported, the long-term outcome is unknown. We reviewed the clinical outcome of 31 patients with a symptomatic flexible flat-foot deformity who underwent this procedure between 1994 and 1996. There were 21 women and ten men with a mean age of 54.3 years (42 to 70). The mean follow-up was 15.2 years (11.4 to 16.5). All scores improved significantly (p < 0.001). The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up. The mean pain component improved from 12.3 to 35.2 (20 to 40). The mean function score improved from 35.2 to 45.6 (30 to 50). The mean visual analogue score for pain improved from 7.3 to 1.3 (0 to 6). The mean Short Form-36 physical component score was 40.6 (sd 8.9), and this showed a significant correlation with the mean AOFAS score (r = 0.68, p = 0.005). A total of 27 patients (87%) were pain free and functioning well at the final follow-up. We believe that flexor digitorum longus transfer and calcaneal osteotomy provides long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

Cite this article: Bone Joint J 2015;97-B:346–52.

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.

The Ponseti method of treating club foot has been shown to be effective in children up to two years of age. However, it is not known whether it is successful in older children. We retrospectively reviewed 17 children (24 feet) with congenital idiopathic club foot who presented after walking age and had undergone no previous treatment. All were treated by the method described by Ponseti, with minor modifications. The mean age at presentation was 3.9 years (1.2 to 9.0) and the mean follow-up was for 3.1 years (2.1 to 5.6). The mean time of immobilisation in a cast was 3.9 months (1.5 to 6.0).

A painless plantigrade foot was obtained in 16 feet without the need for extensive soft-tissue release and/or bony procedures. Four patients (7 feet) had recurrent equinus which required a second tenotomy. Failure was observed in five patients (8 feet) who required a posterior release for full correction of the equinus deformity.

We conclude that the Ponseti method is a safe, effective and low-cost treatment for neglected idiopathic club foot presenting after walking age.

A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients.

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.

Subluxation of the hip is common in patients with intermediate spinal muscular atrophy. This retrospective study aimed to investigate the influence of surgery on pain and function, as well as the natural history of subluxed hips which were treated conservatively. Thirty patients were assessed clinically and radiologically. Of the nine who underwent surgery only one reported satisfaction and four had recurrent subluxation. Of the 21 patients who had no surgery, 18 had subluxation at the latest follow-up, but only one reported pain in the hip. We conclude that surgery for subluxation of the hip in these patients is not justified.