Introduction: Tendon lengthening is an important cause of morbidity after Achilles tendon rupture. However, direct measurement of the tendon length is difficult. Ankle dorsiflexion has therefore been used as a surrogate measure, on the assumption that it is the Achilles tendon that limits this movement. The aim of this investigation was to assess the relationship between Achilles tendon length and ankle dorsiflexion. The primary research question was whether or not the Achilles tendon is the structure that limits ankle dorsiflexion. The secondary purpose was to quantify the relationship between Achilles tendon lengthening and dorsiflexion at the ankle joint. Methods: Five cadaveric specimens were dissected to expose the tendons and capsular tissue of the leg and hindfoot. Fixed bony reference points were used as markers for the measurements. In the first specimen, the Achilles tendon was intact and the other structures that may limit ankle dorsiflexion were sequentially divided. In the other specimens the Achilles tendon was lengthened by 1cm intervals and the effect upon ankle dorsiflexion movement was recorded. Results: Division of the other tendons and the capsular tissue around the ankle joint did not affect the range of ankle dorsiflexion. When the Achilles was divided the foot could be dorsiflexed until the talar neck impinged upon the anterior aspect of the distal tibia. There was a mean increase of 12 degrees of dorsiflexion for each centimetre increase in tendon length. Conclusion: The Achilles tendon is the anatomical structure that limits ankle dorsiflexion, even when the tendon is lengthened. There was a linear relationship between the length of the Achilles tendon and the range of ankle dorsiflexion in this cadaveric model. Ankle dorsiflexion would appear to be a clinically useful indicator of tendon length

Aims. This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years. Methods. We prospectively evaluated 89 patients who underwent transfibular TAA for end-stage osteoarthritis. Patients’ clinical and radiological examinations were collected pre- and postoperatively at six months and then annually for up to five years of follow-up. Three patients were lost at the final follow-up with a total of 86 patients at the final follow-up. Results. A total of 86 patients were evaluated at a mean follow-up of 65.4 months (60 to 90). At five-year follow-up, statistically significant improvements (p < 0.001) were found in the mean American Orthopaedic Foot & Ankle Society Ankle Hindfoot Score (from 33.8 (SD 14.3) to 86.1 (SD 8.8)), visual analogue scale for pain (from 8.5 (SD 1.7) to 1.5 (SD 1.2)), Short Form-12 Physical and Mental Component Scores (from 29.9 (SD 6.7) and 43.3 (SD 8.6) to 47.3 (SD 7.5) and 52.2 (SD 8.0), respectively), and mean ankle dorsiflexion and plantarflexion (from 6.2° (SD 5.5°) and 9.6° (SD 5.8°) to 23.9° (SD 7.7°) and 16.9° (SD 7.2°), respectively). Radiologically, the implants maintained neutral alignment without subsidence. Tibial or talar radiolucency was found in eight patients, but none of these patients was symptomatic. At five-year follow up, 97.7% of implants (95% confidence interval 91.2 to 99.4) were free from revision or removal with 84 implants at risk. We recorded two cases (2.3%) of failure for septic loosening. Conclusion. Transfibular TAA is safe and effective with a high survival rate at mid-term follow-up and satisfactory clinical and radiological results. Further studies are required to determine the long-term performance of these implants. Cite this article: Bone Joint J 2022;104-B(4):472–478

Aims. The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques. Methods. We conducted a comprehensive review of clinical trials comparing anteroposterior (A-P) screws, posteroanterior (P-A) screws, and plate fixation. Two investigators validated the data sourced from multiple databases (MEDLINE, EMBASE, and Web of Science). Following PRISMA guidelines, we carried out a network meta-analysis (NMA) using visual analogue scale and American Orthopaedic Foot and Ankle Score (AOFAS) as primary outcomes. Secondary outcomes included range of motion limitations, radiological outcomes, and complication rates. Results. The NMA encompassed 13 studies, consisting of four randomized trials and eight retrospective ones. According to the surface under the cumulative ranking curve-based ranking, the A-P screw was ranked highest for improvements in AOFAS and exhibited lowest in infection and peroneal nerve injury incidence. The P-A screws, on the other hand, excelled in terms of VAS score improvements. Conversely, posterior buttress plate fixation showed the least incidence of osteoarthritis grade progression, postoperative articular step-off ≥ 2 mm, nonunions, and loss of ankle dorsiflexion ≥ 5°, though it underperformed in most other clinical outcomes. Conclusion. The NMA suggests that open plating is more likely to provide better radiological outcomes, while screw fixation may have a greater potential for superior functional and pain results. Nevertheless, clinicians should still consider the fragment size and fracture pattern, weighing the advantages of rigid biomechanical fixation against the possibility of soft-tissue damage, to optimize treatment results. Cite this article: Bone Jt Open 2024;5(3):227–235

This study used the lunge test to measure the difference between ankle dorsiflexion with the knee flexed and extended in persons with and without foot and ankle pathology. This may help us devise a weight bearing test for GT. Rationale. There is little credible research comparing GT in people with and without foot and ankle pathology. There is no normative data for ankle dorsiflexion range measured using a Lunge test and prevalence of GT in the normal population. Methodology. 97 ankles with foot and ankle (FA) pathology and 89 ankles of healthy volunteers (HV) without FA pathology were recruited from the royal national orthopaedic hospital (RNOH). Degrees of ankle dorsiflexion range were measured using an inclinometer and a version of the lunge test with the knee flexed and extended. These findings were then compared between groups. Results. The difference between FA vs HV for knee flexed: Ankle dorsiflexion with the knee flexed was lower in the FA group (mean=27.56 degrees, SD=8.10) than the HV group (mean=29.95 degrees, SD=6.37) however, the mean difference (2.39 degrees) between the groups was not statistically significant (p=0.30 [CI 2.40–4.54]). The difference between FA vs HV for knee extended: Ankle dorsiflexion was lower in the FA group (mean=22.02 degrees, SD=8.27) than the HV group (mean = 26.25 degrees, SD=6.04) with the knee extended. The mean difference (4.23 degrees) between the groups was statistically significant (p=< 0.001 [CI 2.11–6.34]); Cohens d=0.58. The difference in ankle dorsiflexion between knee positions in FA vs HV: The difference in ankle dorsiflexion between knee positions was higher in the FA group (mean=5.62 degrees, SD=4.41) than the HV group (mean=3.62 degrees, SD=3.12). The mean difference (1.996 degrees) between the groups was statistically significant (p=0.001 [CI 0.88–3.11]); Cohens d=0.52. Conclusion. FA patients have significantly lower ranges of ankle dorsiflexion with the knee extended when compared to controls using the lunge test. The difference in ankle dorsiflexion between knee positions is significantly higher in FA patients when compared to controls; this may be attributable to GT. We aim to continue recruiting healthy controls, patients with FA pathology and patients with other musculoskeletal pathology to show the prevalence of GT in the general population. These findings could improve both conservative and surgical management of GT in associated musculoskeletal pathology

Foot pain and related problems are quite common in the community. It is reported that 24% of individuals older than 45 experienced foot pain. Also, it is stated that at least two thirds of individuals experiences moderate physical disability due to foot problems. In the absence of evaluation of risk factors such as limited ankle dorsiflexion in the early period of the diseases (Plantar fasciitis, Achilles Tendinopathy e.g.) and the lack of mobile systems with portable remote access, foot pain becomes refractory/chronic foot pain, secondary pathologies and ends with workload of 1., 2. and 3rd level healthcare services. In the literature, manuel and dijital methods have been used to analyze the ankle range of motion (ROM). These studies are generally based on placing protractors on the image and / or angle detection from inclination measurement by using the gyroscope sensor of the mobile device. Some of these applications are effective and they are designed to be suitable for measuring in a clinical setting by a physician or physiotherapist. To the best of our knowledge, there is no system developed to measure real-time ankle ROM remotely with collaboration of the patients. In this research, we proposed to develop an ankle ROM analyze system with smart phone application that can be used comfortably by subjects. We present a case of a 22-year-old male with a symptomatic pes planus. The mobile application, which was used for data collection, was designed and implemented for Android devices. Initially, before the mobile application home page is opened, a consent page was submitted to the acceptance of individual within the scope of Law (KVKK) data privacy. Then, the participant was asked to state his sociodemographic characteristics [age, gender, height, weight] and dominant side. No history of foot-ankle injury, trauma, and surgery was recorded. Activity pain of the foot was 6 according to visual anolog scale (VAS) in the mobile application. His ankle dorsiflexion was 15 ° by manuel goniometer. Besides, server was responsible for storing the collected data and ROM measurement. ROM was calculated by processing the foot video which was sent through the mobile application. During the processing phase, a segmentation model was used which was trained with image process and deep learning methods. With the developed system, we obtained the manual goniometric measurement result with 2 degrees deviation. As the application is calibrated, it is expected to approach the actual measurement of ROM. We can conclude that mobile app-goniometer result in dorsiflexion measurement is a novel promising evaluation method for ankle ROM. it will be easy and practical to detect and monitor risk factor of the diseases, decrease medical costs, provide health services in rural areas, and contribution to life quality and to reduce the workload on physicians and physiotherapist

Idiopathic Toe-walking (ITW) is a condition where children persistently walk on their toes in the absence of neurological or orthopaedic structural abnormalities. ITW affects 2% of children at the age of 5.5yr. This may eventually result in fixed ankle equinus. There is a paucity of long-term natural history studies in untreated ITW however persisting equinus contractures are implicated in common adult foot conditions. The Aim of this study is to show if the percentage of contact pressure through the hindfoot during standing and walking improve following surgical tendoachilles lengthening one year after surgery in children with ITW when compared to a normative cohort. 23 patients (46 feet) diagnosed with ITW between 2017-2022; were treated with open zone III Achilles lengthening. We reported patient demographics, clinical resolution, or revision. Passive dorsiflexion range and hindfoot pressure percentage when standing and walking were measured on a baropodometric walkway and compared pre-operatively and at 12-18months postoperatively. We compared this to data from a previously studied normative cohort. 87% of children had compete resolution of toe-walking. 3 had recurrence with 1 patient having a revision surgery. Mean pre-operative static heel pressure percentage was 15.7%, this improved to 54.7% (p<0.001). This neared normative average of 70.6%. Mean pre-operative dynamic heel pressure percentage was 5.5%, this improved to 44.6% (p<0.001). This neared the normative mean of 52.0%. Mean Passive dorsiflexion in extension and 90˚ knee flexion was −5.8˚ and 0.5˚ respectively. This improved on average by 17.4˚ and 14.5˚ to a new mean of 11.6˚ and 15.0˚ (p<0.001). Open Zone III Achilles lengthening for ITW has high resolution rates. Hindfoot contact pressures and passive ankle dorsiflexion show improvement at 1 year post operatively

Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects

The natural history of gait pattern change in children with spastic diplegia is a transition from toe walking to progressive hip and knee flexion with eventual crouch gait. This has been attributed to the adolescent growth spurt, progressive lever arm dysfunction, and iatrogenic weakening of the soleus with isolated tendo achilles lengthening (TAL). The relative contribution of TAL to the development of crouch gait is uncertain. The purpose of this study was to identify the frequency of crouch gait in spastic diplegic patients with and without history of prior TAL. Patients with spastic diplegia greater than 10 years of age with instrumented gait analysis were reviewed. Exclusion criteria included diagnosis other than cerebral palsy, prior dorsal root rhizotomy, or incomplete past surgical history. Patients were divided into three groups: Group 1, no prior orthopaedic surgical intervention; Group 2, prior orthopaedic surgery without TAL; Group 3, prior orthopaedic surgery with TAL. Instrumented gait analysis data was analysed. Gait data were analysed using a single randomised limb from each patient. One hundred and seventy-eight patients were identified: 39 in Group 1, 49 in Group 2, and 90 in Group 3. Mean time from TAL to gait analysis was 7.5 years (range 1.0–14.6 years). Mean age at TAL was 6.3 years (range 1.2–17.5 years). There was no significant difference in age, BMI, walking speed, or cadence between groups. Kinematic analysis showed no significant difference in mean stance phase maximum knee or ankle flexion between groups. There was no significant difference in frequency of increased mid stance knee flexion between groups (Group 1, 53.8%; Group 2 46.9%; Group 3, 43.3%, p=0.546). There was a trend towards increased frequency in excessive stance phase ankle dorsiflexion in Group 3 (60% Group 3 vs 46.2% Group 1, and 40% Group 2, p=0.071). Crouch gait (stance minimum hip flexion > 30, mid stance minimum knee flexion > 200, and stance maximum ankle dorsiflexion > 150) was seen with similar frequency in all groups (Group 1, 23.1%; Group 2, 18.4%; Group 3, 26.7%; p=0.544). There is a trend towards increased frequency of excessive stance phase ankle dorsiflexion in spastic diplegic patients with prior TAL. However, no significant difference in frequency of crouch gait between patients with and without history of TAL was identified. Crouch gait is part of the natural history of gait pattern change in spastic diplegic patients independent of prior surgical intervention

The purpose of the study was to document the outcome in adulthood of treatment for idiopathic toe walking. Twenty of 23 adults who had been previously treated for idiopathic toe walking from 1984 to 1990 were contacted. Three of the 20 subjects lived outside Auckland and four subjects declined to participate, giving a total of 13 subjects suitable for study. All but one of the subjects had had serial casts between the ages of 3.7 to 9.5 years. Six subjects had no further treatment while the other seven subjects went on to surgical lengthening of either TA or calf (average age 10.7 years). All participants underwent 3-D gait analysis and heel-rise test. Average follow-up was 10.8 years (range 5.4–15.6 years). Three patients still had signs of toe walking on visual observation of their gait. The maximum ankle dorsiflexion in stance averaged 90 on 3-D gait analysis (range 20 to 140). Eleven subjects showed maximum ankle dorsiflexion in stance greater than 2 standard deviations below normative values. Nine subjects had abnormal timing of maximal ankle dorsiflexion in stance with maximum ankle dorsiflexion prior to 50 percent of the gait cycle. Only two patients had ankle push off powers below normative values of 2 watts/kg. This is the first study to report on adults treated for idiopathic toe- walking as children. Most subjects showed restricted range and altered timing of ankle dor-siflexion in gait, however this was detectable visually in only three subjects

To evaluate the outcome of combined tibialis anterior tendon shortening (TATS) and calf muscle-tendon lengthening (CMTL) in spastic equinus. Prospectively collected data was analysed in 26 patients with hemiplegic (n=13) and diplegic (n=13) cerebral palsy (CP) (GMFCS level I or II, 14 males, 12 females, age range 10–35 years; mean 16.8 years). None had received botulinum toxin A injections or surgery in the preceding six and 12 months respectively. All patients had pre-operative 3D gait analysis and a further analysis at a mean of 17.1 months (± 5.6months) after surgery. None was lost to follow-up. Twenty-eight combined TATS and CMTL were undertaken and 19 nineteen patients had additional synchronous multilevel surgery. At follow-up 79% of patients had improved foot positioning at initial contact. Statistically significant improvements were seen in the Movement Analysis Profile for ankle dorsi-/plantarflexion (4.25, p=0.032), maximum ankle dorsiflexion during swing phase (11.68°, p<0.001), and Edinburgh Visual Gait Score (EVGS) (4.85, p=0.014). Diplegic patients had a greater improvement in the EVGS than hemiplegics (6.27 -vs- 2.21, p = 0.024). The originators of combined TATS and CMTL showed that it improved foot positioning during gait. The present study has independently confirmed favourable outcomes in a similar patient population and added additional outcome measures, the EVGS, foot positioning at initial contact, and maximum ankle dorsiflexion during swing phase. Study limitations include short term follow-up in a heterogeneous population and that 19 patients had additional surgery. However, distinguishing between the natural history of CP and interventions and isolating the effects of one intervention from others in multilevel surgery are well recognised difficulties in cohort studies in CP. TATS combined with CMTL is a recommended option for spastic equinus in ambulatory patients with CP

Decreased ankle dorsiflexion is common after injury and may result in patient complaints of stiffness and subsequent injury. The weight-bearing lunge test (WBLT) is a simple clinical measure of dorsiflexion. Previous study has defined a 2.0cm side-to-side discrepancy in WBLT as likely significant. With review of current literature, ankle stiffness is a concept largely undefined; we aim to relate patient complaints of stiffness to WBLT. This was a population-based inception cohort with longitudinal follow-up. Patients between ages 18–65 receiving surgical fixation for ankle fracture were screened. Pilon/plafond fractures, bilateral injuries, or polytrauma were excluded. At 6-weeks, 6-months, and 1-year WBLT was measured along with non-weight-bearing goniometry; and an Olerud-Molander ankle score completed. 155 patients were recruited (90 female, 65 male; mean age 42, range 20–67). 47% of injuries were unimalleolar, 17% bimalleolar, and 36% trimalleolar; 35% received syndesmotic fixation. 89% of patients reported feeling stiff at 6-weeks, 82% at 6-months, and 74% at 1-year. 98% of patients had ≥2.0cm discrepancy of WBLT at 6-weeks, 78% at 6-months, and 72% at 1-year. Different thresholds of WBLT (larger discrepancy or absolute negative measurement) had worse correlation with patient reported stiffness. Our population had high incidence of stiffness at 1-year. The proportion of patients complaining of stiffness after ankle fracture was similar to that measured with ≥2.0cm discrepancy of WBLT. This is the first study that we are aware of that relates the WBLT and the previously reported threshold of 2.0cm to stiffness. This measurement may give clinicians a better objective idea regarding patient perception of a “stiff” ankle. Reducing side to side discrepancy in range of motion should be considered in rehabilitation rather than total range of motion

Tenodesis effect and digital cascade of the foot were never described in the current literature. However, understanding of these effects are important in the diagnoses and managements of foot flexor tendon rupture and lesser toe deformities. We aim to investigate the presence of these effects in the foot with intact and cut tendons. Ten fresh frozen cadaveric specimens were used in our study. 2. nd. , 3. rd. and 4. th. toe metatarsophalangeal joint (MTPJ) and proximal interphalangeal joint (PIPJ) range of motion (ROM) at ankle resting position were measured. Same measurements were repeated with maximum ankle plantarflexion and dorsiflexion. 4. th. toe Flexor Digitorum Longus (FDL) was then identified over plantar aspect of metatarsal shaft and cut transversely. 2. nd. , 3. rd. and 4. th. toe MTPJ and PIPJ ROM at ankle resting position, maximum plantarflexion and dorsiflexion were then measured. Mean 4. th. toe MTPJ and PIPJ ROM at ankle dorsiflexion were 13.5 ° of dorsiflexion and 25 ° of plantarflexion respectively, compared with values at ankle plantarflexion which were 35 ° and 25 ° respectively. After 4. th. toe FDL was cut, mean 4. th. toe MTPJ and PIPJ ROM at ankle dorsiflexion were 14 ° and 24 ° respectively and at ankle plantarflexion the values were 34.5 ° and 25 ° respectively. At ankle resting position before 4. th. FDL was cut, mean 4. th. toe MTPJ and PIPJ ROM were 22 ° and 31 ° respectively, compared with the values after 4. th. FDL was cut, ie 22.5 ° and 30.5 ° respectively. Tenodesis effect of the foot was shown in our study. However unlike in hand, this effect was only present in MTPJ and was still present following cut FDL. Similarly, digital cascade was still present following cut FDL. The maintenance of tenodesis effect and digital cascade following cut flexor tendon is likely contributed by various soft tissue restraints and intrinsic muscle actions. These findings are important in both the diagnosis and management of foot flexor tendon rupture and help us to better understand the biomechanics of lesser toe deformities and the managements of these deformities

Introduction and Aims: We studied the outcome of single event multilevel surgery (SEMLS) for the correction of severe crouch gait in spastic diplegia, over a five-year period. It was unknown if gait correction post-SEMLS could be sustained at skeletal maturity. Method: This was a prospective cohort study, utilising validated outcome measures. Presenting symptoms were increasingly abnormal gait, anterior knee pain, patellar fractures and fatigue. SEMLS was based on pre-operative gait analysis: mean of seven procedures (range 5–10), including lengthening of contracted muscle-tendon units (particularly hamstrings and psoas), as well as rotational osteotomies and bony stabilisation procedures to correct lever arm dysfunction. Post-operatively subjects wore Ground Reaction Ankle Foot Orthoses (GRAFOs) and received a community-based rehabilitation program. Post-operative changes were evaluated at five years: technical outcome by 3D kinematics and functional outcome by mobility status. Outcomes were analysed with linear regression with robust standard errors. Results: Eleven children with spastic diplegic cerebral palsy fulfilled the criteria for ‘severe crouch gait’, defined as knee flexion > 30 degrees and ankle dorsiflexion > 15 degrees throughout stance. Ten of 11 subjects had previous Tendo Achilles lengthening. Mean age pre-operatively was 12 years one month (range 8–16) and at follow-up 17 years 10 months (range 16–21). All subjects regained pre-operative mobility levels with improved gait pattern, relief of knee pain and healing of patellar fractures. There was a significant decrease in dependence on assistive devices. Pre- versus five years post-operative kinematics showed clinically and statistically significant increases in knee extension and decreases in ankle dorsiflexion. Improvements were seen in knee extension initial contact (p< 0.001, 95% CI 15°, 31°); maximum knee extension (p< 0.001, 95% CI 16°, 37°), ankle dorsiflexion (p< 0.001, 95% CI 8°, 18°) and plantarflexion 3rd rocker in stance (p=0.03, 95% CI 1°, 17°); knee excursion (p=0.003, 95% CI –24°, −6°), and peak knee flexion timing (p=0.02, 95% CI 2%, 20%). Conclusion: Multilevel surgery for severe crouch gait in spastic diplegia results in consistently marked improvements in dynamic knee and ankle function, but not at the hip and pelvic levels. The results are durable in most patients, after five years and after reaching skeletal maturity

Introduction. The muscles of the leg collectively comprise the calf pump, however the action of each muscle group on calf pump function is not known. Patients with foot or ankle injury or surgery are often advised to perform foot and ankle movements to help prevent deep venous thrombosis. Our aim was to determine which foot and ankle movements were most effective in stimulating the calf pump. Method: Nine healthy participants were enrolled in this research and ethics approved prospective study. Participants with a previous history of peripheral vascular disease, varicose veins, deep venous thrombosis or previous foot and ankle surgery were excluded. Each participant followed a standardized protocol of foot and ankle movements, starting with foot in neutral position and the baseline and movement peak systolic velocity within the popliteal vein was measured during each movement. The movements tested were toe dorsiflexion, toe plantar flexion, ankle dorsiflexion, ankle plantar flexion. Results. The mean patient age was 34 years (range 28–58), the majority were female (n = 6). All movements resulted in statistically significant changes in peak systolic velocity (p = <0.05). In order of decreasing peak velocity the exercises which had greatest effect on calf pump function were: Ankle dorsiflexion (101cm/s), Ankle plantarflexion (84cm/s), Toe dorsiflexion (63cm/s), Toe plantarflexion (59cm/s). We have shown that all four exercises significantly increased calf pump function. The greatest effect was seen with ankle movements. Conclusion. Toe and ankle flexion and extension exercises significantly increase calf pump function and should be advised for all patients following foot or ankle injury and surgery as this may reduce venous stasis and risk of venous thromboembolism

The objective of this study is to determine if surgical lengthening of the hamstrings and gastrocnemius/Achilles complex, affect muscle tone in patients with cerebral palsy. The question is if the dynamic component of muscle length changes after orthopedic surgery. A retrospective study was performed on ambulatory children with cerebral palsy who underwent either hamstring lengthening or gastrocnemius/Achilles tendon lengthening. A total of 135 consecutive patients with an average age of 13 years were included in the study. A single random side was selected for children with bilateral surgery and the affected limp was analyzed for those undergoing unilateral surgery. The popliteal angle was performed with a quick and slow stretch, as well as, the ankle dorsiflexion, and measured with a goniometer. The difference between initial grab with fast stretch, and end of range (EOR) with slow stretch was used as a measure of spasticity. The Bohanon modification of the Ashworth score was also assessed. 18° popliteal angle improvement in end of range and 32° improvement in quick stretch in the hamstrings group were notice postoperatively, with change in slow stretch, quick stretch and Δml (comparison between quick and slow stretch) being significant at p< .0001. In the triceps surae group, 14° ankle dorsiflexion improvement in end of range, and 18° improvement in quick stretch were noticed postoperatively, with change in slow stretch, quick stretch and Δml at p< .0001, p< .0001, and p< .0180 respectively. Asworth scale was reduced by at least one grade in 89% of subjects in the hamstring group and 78% of subjects in the triceps surae group of the children with preoperative Asworth 3 and above. We concluded that significant decreases in spasticity were observed following tendon lengthening in children with cerebral palsy and that the orthopedic surgery can affect both static and dynamic components of muscle tightness in these children

We studied the results of multi-level surgical intervention for children with cerebral palsy. Thirty patients, aged 7–16 years, with spastic diplegia (n=20), or spastic hemiplegia (n=10) were studied prospectively by gait analysis. Multilevel surgery included a combination of psoas lengthening, medial hamstring lengthening, rectus femoris transfer and gastrocnemius lengthening +/− foot surgery or femoral derotation osteotomies. Gait analyses were carried out pre-op and at 6 and 24 months post-op. Children with spastic diplegia increased their walking velocity by an average of 20% at two years (p< 0.05). Mean stride length increased from 89cm pre-op to 102cm at two years (p< 0.05) with similar improvements in both groups of children. Maximum knee extension in stance improved from an average 17.5 degrees flexion pre-operatively to an average 5 degrees flexion postoperatively (p< 0.05). Peak knee flexion in swing was maintained and the timing improved. Peak ankle dorsiflexion in stance was unchanged following surgery but the timing of peak ankle dorsiflexion was normalised to late stance (from 24% of cycle pre-operatively to 48% of cycle post-operatively (norm = 48%). Average maximum hip extension in stance did not change. The mean anterior pelvic tilt did not change post-operatively. However, a number of children with spastic diplegia had increased anterior pelvic tilt post-operatively. These results are similar to those reported internationally, with most improvement seen distally at the knee and ankle and less improvement at the hip. Increased anterior pelvic tilt was seen as a consequence of hamstring lengthening in some more involved patients

Introduction and Aims: Pivotal to most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of Botulinum A toxin (BTX-A) in defunctioning the triceps surae muscle complex as an alternative to tenotomy was investigated. Method: Newborns, infants and children referred for suspected clubfoot deformity to the authors’ institution from September 1, 2000 to September 17, 2003 were reviewed consecutively for inclusion in this prospective study. Patients underwent manipulation and castings (above knee casts) emulating Ponseti’s principles until hindfoot stall was encountered. In order to defunction the triceps surae muscle complex, BTX-A at 10 IU per kilogram was injected into this muscle complex. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: Group I (< 30 days old) and Group II (> 30 days and < 8 month old). Results: Fifty-one patients with 73 feet met the criteria for inclusion in the study with 29 patients in Group I and 22 in Group II. Mean age of Group I was 16 months (2.5–33 months) and average follow-up was nine months post-BTX-A injection (1 week-27 months post-injection). Mean age of Group II was 23.5 months (3.8–44.6 months) and average follow-up was 15 months post BTX-A injection (1 week–27 months post-injection). Ankle dorsiflexion in knee flexion and extension remained above 20/15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. All but one patient (one foot) who reached the point of hindfoot stall during the protocol of manipulations and castings had successful defunctioning of the triceps surae complex using a single BTX-A injection. This one patient out of 51 (1.9% of patients and 1.3% of feet) did not respond to the protocol. Of the 50 patients who responded to the protocol, nine patients lost some degree of dorsiflexion due to non-compliance with boots and bars, with fitting problems accounting for two cases. All these patients have corrected with either a return to manipulations and casting alone (one patient), or a combination of repeated BTX-A injection and further manipulations and castings (eight patients). Conclusion: These results are comparable to those reported in the literature using Ponseti’s method or the physical therapy method and were achieved without the need of tenotomy or more frequent manipulations. The use of BTX-A as an adjunctive therapy in the non-invasive approach of manipulation and casting in idiopathic clubfoot is an effective and safe alternative and one that may be preferable to parents

We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed. The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal. We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head

Aims

There is a lack of high-quality research investigating outcomes of Ponseti-treated idiopathic clubfeet and correlation with relapse. This study assessed clinical and quality of life (QoL) outcomes using a standardized core outcome set (COS), comparing children with and without relapse.

Ambulating children with bilateral spastic cerebral palsy (BSCP) demonstrate atypical posture and gait due to abnormal muscle and skeletal growth when compared to typically–developing (TD) children. Normal postural alignment in standing facilitates many of the tasks of daily living because it allows a stable base of support without requiring significant muscular effort. Similarly, increasing gait abnormality is associated with poorer functional capacity. Our aims were to compare the standing posture of TD children and children with BSCP using the Standing Profile Score and identify if any abnormality in standing is correlated with abnormality in walking in children with BSCP using the Gait Profile Score index. We retrospectively compared 44 typically-developing children to 74 age-matched children with BSCP (GMFCS I & II). We performed 3D Gait Analysis during long-standing (10seconds) and in gait after application of 16 retro-reflective markers on anatomical landmarks of the lower limb and pelvis. Analysis of all kinematics was performed for movements in the sagittal, coronal and axial planes. The Gait Profile score (GPS) is a validated index of overall gait pathology. The Standing Profile Score (SPS) was developed using the same calculations for GPS but during static trials. A significant correlation was observed between the Standing Profile Score (SPS) and Gait Profile Score (GPS) in children with BSCP (p<0.001). Significant differences were exhibited in GPS between the two groups, across all parameters, except the pelvic obliquity (p<0.05). A significant positive correlation existed for hip rotation in both groups, however the correlations observed at hip flexion and ankle dorsiflexion were significantly greater in the BSCP group compare to the TD group (p<0.01). We have shown that posture during gait (GPS) is predictable from standing posture (SPS) in patients with BSCP. This biomechanical relationship can aid surgical decision-making

The December 2022 Foot & Ankle Roundup³⁶⁰ looks at: Evans calcaneal osteotomy and multiplanar correction in flat foot deformity; Inflammatory biomarkers in tibialis posterior tendon dysfunction; Takedown of ankle fusions and conversion to total ankle arthroplasty; Surgical incision closure with three different materials; Absorbable sutures are not inferior to nonabsorbable sutures for tendo Achilles repair; Zadek’s osteotomy is a reliable technique for treating Haglund’s syndrome; How to best assess patient limitations after acute Achilles tendon injury; Advances in the management of infected nonunion of the foot and ankle.

Posterior cruciate ligament deficiency (PCLD) leads to structural and proprioceptive impairments of the knee, affecting the performance of daily activities including obstacle-crossing. Therefore, identifying the biomechanical deficits and/or strategies during this motor task would be helpful for rehabilitative and clinical management of such patients. A safe and successful obstacle-crossing requires stability of the body and sufficient foot clearance of the swing limb. Patients with PCLD may face demands different from normal when negotiating obstacles of different heights. The objective of this study was thus to identify the biomechanical deviations/strategies of the lower limbs in unilateral PCLD during obstacle-crossing using motion analysis techniques. Twelve patients with unilateral PCLD and twelve healthy controls participated in the current study with informed written consent. They were asked to walk and cross obstacles of heights of 10%, 20% and 30% of their leg lengths at self-selected speeds. The PCLD group was asked to cross the obstacles with each of the affected and unaffected limb as the leading limb, denoted as PCLD-A and PCLD-U, respectively. The kinematic and kinetic data were measured with a 7-camera motion analysis system (Vicon, Oxford Metrics, U.K.) and two force plates (AMTI, U.S.A.). The angles of the stance and swing limbs (crossing angles) and the moments of the stance limbs (crossing moments) for each joint in the sagittal plane when the leading limb was above the obstacle were calculated for statistical analysis. A 3 by 2, 2-way mixed-model analysis of variance with one between-subject factor (PCLD-A vs. Control, and PCLD-U vs. Control) and one within-subject factor (obstacle height) was performed (α=0.05). Paired t-test was used to compare the variables between PCLD-A and PCLD-U (α=0.05). SAS version 9.2 was used for all statistical analysis. When the leading toe was above the obstacle, the PCLD group showed significantly greater hip flexion in the swing limb but decreased dorsiflexion in the stance limb, both in PCLD-A and PCLD-U (P<0.05). Greater knee flexion and greater ankle dorsiflexion were found in the leading limb in PCLD-A (P<0.05). Meanwhile, the PCLD group showed significantly decreased ankle plantarflexor but increased knee extensor crossing moments in the stance limb compared with the Control (P<0.05). None of the calculated variables were found to be significantly different between PCLD-A and PCLD-U (P>0.05). When crossing the obstacle, patients with PCLD reduced ankle plantarflexor moments that were mainly produced by the gastrocnemius. This may help reduce the posterior instability of the affected knee. Greater knee extensor crossing moments may also help reduce the posterior instability of the standing knee when the leading toe was above the obstacle. The changed joint kinetics as a result of PCLD were not only seen on the affected side but also on the unaffected side during obstacle-crossing. This symmetrical pattern may be necessary in performing functional activities that may require either the affected side or the unaffected side leading. These results suggest that rehabilitative intervention, including muscular strengthening, on both affected and unaffected sides are necessary in patients with unilateral PCLD

1. Twenty-three patients were treated by cross screwing for diastasis of the tibia and fibula in fractures at the ankle. 2. It is suggested that limitation of ankle dorsiflexion after this treatment was caused by the presence of a mechanical block to dorsiflexion by spur formation at the margins of tibia and talus. 3. An ordinary bone screw controlled the diastasis satisfactorily in twenty patients. 4. The screw did not interfere with movement at the inferior tibio-fibular joint because bone resorption about that part of the screw in the fibula allowed a small range of movement. 5. Discomfort from the screw was relieved by its removal

The August 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Antibiotic prophylaxis and infection rates in paediatric supracondylar humerus fractures; Clinical consensus recommendations for the non-surgical treatment of children with Perthes’ disease in the UK; Health-related quality of life in idiopathic toe walkers: a multicentre prospective cross-sectional study; Children with spinal dysraphism: a systematic review of reported outcomes; No delay in age of crawling, standing, or walking with Pavlik harness treatment: a prospective cohort study; No value found with routine early postoperative radiographs after implant removal in paediatric patients; What do we know about the natural history of spastic hip dysplasia and pain in total-involvement cerebral palsy?; Evaluating the efficacy and safety of preoperative gallows traction for hip open reduction in infants

To study the association between hip and ankle biomechanics during gait and moderate knee osteoarthritis (OA). Gait analysis was performed on a group of forty-four patients clinically diagnosed with moderate knee OA, and on a group of sixty asymptomatic subjects. Three-dimensional net joint angles and net joint reaction moments at the hip, knee and ankle joints were calculated. Peak values were extracted from the gait waveform patterns and compared between the two subject groups with Student’s t-tests. The peak hip extension moment, the peak hip adduction moment, the peak hip internal and external rotation moments, and the peak ankle dorsiflexion and plantarflexion moments were all reduced in the knee osteoarthritis population compared to the asymptomatic population. Differences in knee joint loading patterns with moderate knee osteoarthritis have been previously reported, but these data suggest that changes in the mechanical environment of all lower extremity joints are associated with early stages of knee osteoarthritis. Other studies have associated reduced peak hip adduction moments with reduced likelihood of OA progression. These data provide a rationale for hip abductor muscle strengthening as a means to lower knee joint loading

Background. Lack of ankle dorsiflexion secondary to a tight gastrocnemius-soleus complex is believed to be a contributing factor in forefoot pain particularly metatarsalgia. It is believed that by lengthening the gastroc-soleus complex weight is distributed more evenly over the foot reducing symptoms. However lengthening any tendon, especially using a percutaneous method carries risks of over-lengthening. In the summer of 2008 we started to see some patients who complained of significant weakness in their Achilles tendons following the 3 cut percutaneous tenotomy procedure. Method. All patients who underwent a percutaneous tendo-achilles release performed between June 2007 and October 2008 were identified through the clinical coding department and theatre log books. Their clinical notes were reviewed until discharge. Patients who were diabetic or had a foot deformity secondary to neurological complications were excluded. Results. 40 percutaneous tendo-achilles releases were performed in 38 patients, with an average age of 51 (male:female ratio 5:33). 37 were performed in combination with forefoot procedure. 36 were mobilized full weight bearing in a heel weight bearing shoe post operatively, of which 8 developed symptomatic over lengthening of the Achilles tendon at a mean of 7 months (2-15) post-operatively. Of these 7 required surgical treatment in the form of Achilles shortening. Conclusion. We no longer perform percutaneous Achilles tendon lengthening in neurologically normal patients, due to our concern regarding the risk of over lengthening. We now prefer to perform an open gastrocnemius lengthening

Injuries to the ankle are common in children. We investigated whether decreased dorsiflexion predisposes to such fractures and sprains. Passive dorsiflexion in children with ankle injuries was compared with that in a control group of patients with a normal ankle. The uninjured side was examined to determine flexibility in those patients with ankle injuries. In 82, the mean dorsiflexion was 5.7° with the knee extended and 11.2° with the knee flexed. In 85 controls, the mean dorsiflexion was 12.8° with the knee extended and 21.5° with the knee flexed (p < 0.001, Student’s t-test). There was a strong association between decreased ankle dorsiflexion and injury in children. A flexible triceps surae appeared to absorb energy and protect the bone and ligaments, while stiffness predisposed to injury. We suggest that children with tight calf muscles should undergo a regimen of stretching exercises to improve their flexibility

Introduction. The incidence of deep venous thrombosis (DVT) in patients with lower limb cast immobilization occurs in up to 20% of patients. This may result from altered calf pump function causing venous stasis. Our aim was to determine the effects of below knee cast on calf pump function. Method. Nine healthy participants were enrolled in this research and ethics approved prospective study. Four foot and ankle movements (toe dorsiflexion, toe plantar flexion, ankle dorsiflexion, ankle plantar flexion) and weight bearing were performed pre and post application of a below knee cast. Baseline and peak systolic velocity within the popliteal vein was measured during each movement. Participants with peripheral vascular disease, varicose veins, deep venous thrombosis or previous foot and ankle surgery were excluded. Results. The mean patient age was 34 years (range 28–58), the majority were female (n = 6). With cast in situ all movements resulted in a statistically significant increase in peak systolic velocity (p = <0.05). There was no significant difference in peak systolic velocity at the popliteal vein pre or post cast application. Discussion. This is the first study to examine the effect of a lower limb cast on calf muscle pump function. Despite cast immobilisation, toe and ankle flexion and extension movements significantly increase peak systolic velocity measured at the popliteal vein. Conclusion. Toe and ankle flexion and extension exercises significantly increase calf pump function in patients with below knee cast immobilization. We recommend that all patients treated in below knee cast immobilisation are advised to perform regular toe and ankle exercises to reduce venous stasis and risk of deep venous thromboembolism

Introduction. Anterior ankle arthroscopy currently provides the best chance of restricting local anatomy damage during ankle surgery. The anterior working area (AWA) of the ankle is restricted by the Dorsalis Pedis Artery (DPA) and the extensor muscle tendons when the procedure is conducted both in dorsiflexion and plantarflexion. During surgery, iatrogenic damage to the DPA can lead to the formation of a pseudoaneurysm, which can be difficult to identify intraoperatively. Our study investigates whether dorsiflexion or plantarflexion provides variability in the movement of the DPA to determine the positions at which anterior ankle arthroscopy provides the greatest anterior working area (AWA) without causing vascular damage. The current study expects the distance of the DPA from the inferior border of the medial malleolus (IBMM) (ankle joint) to be greater on ankle dorsiflexion than in ankle plantarflexion. Materials and Methods. Twelve cadaver ankles embalmed with a mixture of phenol and glycerol, allowing greater motion, were dissected to access the DPA. The ankles, while in a distracted position (in accordance with common surgical practice), were forced into dorsiflexion from a plantarflexion position at 5° intervals. The distance between the IBMM and the DPA was measured at the 5° intervals. Results. The mean amount of ankle flexion achieved was 24.58° (Range = 20–35). All twelve ankles showed positive range of movement (ROM) anteriorly from the IBMM with a mean ROM of 3.58mm (SE = 0.29mm) dorsiflexion. Discussion and Conclusion. Anterior movement of the Dorsalis Pedis Artery during dorsiflexion puts it at a lower risk of iatrogenic damage in a dorsiflexed position compared to plantarflexion. The increased AWA allows the surgeon more manoeuvrable space, possibly allowing the use of larger diameter surgical instruments

We report on the first clinical cases of the Arthrex Ankle Syndesmosis TightRope (winner of 2003 BOA Technological Achievement Award and 2004 Cutlers' Prize), which has recently been licensed for use where classically a syndesmosis screw would be used. Twelve patients with Weber C ankle fractures treated with Arthrex TightRope syndesmosis fixation have a minimum of six months follow-up. The syndesmosis was fixed with the ankle in plantarflexion to aid reduction. Patient demographics, including fracture classification and mode of injury were obtained. Parameters measured at follow-up included ankle range of motion, maintenance of reduction and fibular length, and AOFAS ankle outcome score. The patient cohort showed a typical bimodal distribution of age. Age over 65 years was associated with a poorer outcome. Five patients had ankle fracture-dislocations, which was a factor for a poorer outcome. Nine patients had fibular plate fixation in addition to syndesmosis fixation, whilst three patients with Maisonneuve injuries had syndesmosis fixation only. There were no major complications, loss of reduction, wound problems, implant loosening or osteolysis. Ankle dorsiflexion was not restricted and mean total ankle range of motion was comparable to the uninjured side. No patient required secondary surgery for any reason, including hardware removal. Arthrex TightRope fixation is a simple, safe and effective method of ankle syndesmosis fixation, which allows physiological micromotion. Fixation in plantarflexion provides optimum syndesmosis compression for reduction, and does not compromise ankle range of motion. The Arthrex Ankle Syndesmosis TightRope may become the treatment of choice in Weber C ankle fractures

Background: The treatment of congenital vertical talus has traditionally consisted of manipulation and application of casts followed by extensive soft-tissue releases. However, this treatment is often followed by severe stiffness of the foot and other complications. The purpose of this study was to evaluate a new method of manipulation and cast immobilization, based on principles used by Dobbs et al in patients with idiopathic congenital vertical talus, but applied in teratologic congenital vertical talus. Methods: Five consecutive cases of teratologic congenital vertical talus deformity were prospectively followed at a minimum of nine months post treatment with serial casting and limited surgery consisting of percutaneous Achilles tenotomy, fractional lengthening of the anterior tibial tendon, and percutaneous pin fixation of the talonavicular joint. The principles of manipulation and application of the plaster casts were similar to those used by Ponseti to correct a clubfoot deformity, but the forces were applied in the opposite direction. Clinical and radiographic assessments were carried out at the initial, immediate postoperative and the latest follow-up. Results: Initial correction was obtained both clinically and radiographically in all five feet. A mean of eight casts was required for correction. At the final evaluation, the mean ankle dorsiflexion was 20° and the mean plantar flexion was 31°. Radiographically, dorsal subluxation of the navicular recurred in one patient, but was functionally insignificant as the patient was a non-ambulator and required treatment for seating purposes only. At the time of the latest follow-up, there was a significant improvement in all of the measured radiographic parameters compared with the pretreatment values. Conclusions: Serial manipulation and cast immobilization followed by talonavicular pin fixation and percutaneous tenotomy of the Achilles tendon provides excellent results, in terms of the clinical appearance of the foot, and deformity correction, in patients with teratologic congenital vertical talus

Congenital convex pes valgus (congenital vertical talus) is a rare condition. We reviewed ten feet in seven patients who had had surgical correction. All had been operated on by the senior author (JF) and the same surgical technique was used throughout, incorporating transfer of the tibialis anterior to the neck of the talus. The mean age at surgery was 31 months and the mean follow-up was nine years (6 to 14). All patients completed a questionnaire and had clinical, radiological and photographic evaluation performed by an independent examiner. None had required further surgery. All but one were satisfied with the result, and had no functional limitations. They all wore normal shoes. The mean ankle dorsiflexion was 17° and plantar flexion 21°. The mean arc of subtalar motion was 27°. All radiological parameters measured were within the normal range, although irregularity of the talonavicular joint was common. No avascular necrosis of the body of the talus was seen. We conclude that the medium-term results of this procedure are very satisfactory

We treated 37 infants with 53 idiopathic club feet by posterolateral release alone at a mean age of 2.4 months. They were reviewed after a mean follow-up of 10 years 7 months. Both function and appearance were studied. Seventeen feet had required further surgery, at an average of four years after posterolateral release. In all cases hindfoot equinus had been well corrected; the mean ankle dorsiflexion at review was 15 degrees. Most feet showed subtalar joint movement of between 50% and 75% of normal. Four feet showed poor results: one had a stiff subtalar joint, two feet in one child showed fixed forefoot varus, and one foot had required a Dillwyn-Evans operation at 5.5 years. The overall reoperation rate of 32% at ten years suggests that a radical release operation is not necessary in all patients. Of 59 patients who had only a simple posterolateral release 27 (46%) have satisfactory results

We have studied the relationship between movements of the foot and ankle and venous blood flow from the lower limb using colourflow Duplex ultrasound to determine the optimum type of exercise for promoting venous return. Studies of both active and passive movements were carried out on 40 limbs in 20 subjects (18 men; 2 women), with a median age of 27 years (20 to 54). We assessed ankle dorsiflexion and plantar flexion, subtalar inversion and eversion, and a combination of all movements. There was no difference in venous flow when comparing opposite limbs in a single subject (p > 0.5), but active exercises produced higher peak and mean velocities of blood flow than passive ones. The active combined movement produced the highest velocities with an increase of 38% in mean and of 58% in peak flow velocities, which were significantly greater than the peak and mean flow rates produced by passive movements. The active combined exercise would therefore be the most effective in eliminating stasis and could contribute to the prevention of deep-vein thrombosis

Background: While several studies in the last years tried to identify clinical limitations of patients suffering from end-stage ankle osteoarthritis (OA), very few attempted to assess foot and ankle function in a more objective biomechanical way, especially using dynamic pedobarography. The aim of the study was therefore to explore plantar pressure distribution characteristics in a large cohort of posttraumatic end-stage ankle OA. Method: 120 patients (female, 54; male, 66; 120 cases) suffering from posttraumatic end-stage ankle OA were included. The clinical examination consisted of assessment of the AOFAS hindfoot score, a pain score, the range of motion (ROM) for ankle dorsiflexion and plantar flexion, and the body mass index (BMI, kg/m2). Radiological parameters included the radiological tibiotalar alignment and the radiological ankle OA grading. Plantar pressure distribution parameters were assessed using dynamic pedobarography. Results: Intra-individual comparison between the affected and the opposite, asymptomatic ankle revealed significant differences for several parameters: maximum pressure force and contact area were decreased in the whole OA foot, such was maximum peak pressure in the hindfoot and toes area. No correlations could be found between clinical parameters, such as AOFAS hindfoot score, VAS for pain, and ROM, and the pedobarographic data. However, there was a positive correlation between dorsiflexion and the pedobarographic parameters for the hindfoot area. Conclusion: In conclusion, posttraumatic end-stage ankle OA leads to significant alterations in plantar pressure distribution. These might be interpreted as an attempt of the patient to reduce the load on the painful ankle. Other explanations might be bony deformity and ankle malalignment as a consequence of either the initial trauma or of the degenerative process itself, pain related disuse atrophy of surrounding muscles, and scarred soft tissue

Introduction: Gastrocnemius contracture, as demonstrated by Silfverskiold’s test, is increasingly recognised as an underlying cause of painful disorders of the foot and ankle. Elevated pressure beneath the forefoot and symptoms in the hindfoot and ankle are produced as a result of the biomechanical imbalance. Adaptive shortening of the gastrocnemius can be treated by a supervised stretching program. Night splintage and serial casting are other useful non-operative treatments. Refractory cases may be considered for surgical release of the gastrocnemius. Materials and Methods: The purpose of this study was to follow-up all those patients who were treated with a medial proximal gastrocnemius release with a minimum follow-up of six months. Results: Eighty procedures were performed in sixty-five patients. There was one post operative infection. One patient has diminished sensation in the distribution of a branch of the saphenous nerve. There was an improvement in ankle dorsiflexion with the knee extended in all patients. Those patients with heel pain felt their symptoms had improved in the majority of cases. Discussion: Release of the gastrocnemius aponeurosis at the gastrosoleus junction may be performed open or endoscopically. Both techniques place the sural nerve at risk of injury. Proximal release of the gastrocnemius is an alternative technique. Proponents of this method release both the medial and lateral heads through a single transverse skin incision over the popliteal fossa. It has been postulated that release of the medial head alone is sufficient to overcome the muscle contracture. Advantages of this approach include a smaller skin incision and a surgical field more distant from neurovascular structures. Conclusion: The proximal medial gatrocnemius release is a safe, well tolerated, and effective procedure for those patients who fail an appropriate stretching program. In selected patients it can be preformed under local anaesthetic and light sedation

Screw fixation of the injured syndesmosis restores stability, but may reduce ankle motion. We wished to determine whether functional and radiographic results are improved by removal of syndesmosis screws. In addition, we studied whether large fragment screws have an advantage compared to small fragment screws. We hypothesised that retained intact syndesmosis screws are detrimental to ankle function. One hundred and seven adults with ankle fractures requiring syndesmosis screw fixation between 2001 and 2005 were retrospectively studied. Indications for syndesmosis fixation were a positive intraoperative external rotation stress test or inadequate lateral column buttress. Weight bearing was encouraged six weeks postoperatively. Syndesmosis screws were only removed for tenderness, prominence or ankle dorsiflexion < 0.05. The LEM score for patients with intact screws was 70 ± 26 compared with 85 ± 20 for broken, loosened or removed screws (p=0.05). The OM score for patients with intact screws was 48 ± 36 compared with 63 ± 27 for broken, loosened or removed screws (p=0.12). There was no difference in outcome comparing broken, loosened, and removed screws. The tibiofibular clear space for intact screws was 3.3 ± 1.3 compared with 4.1 ± 1.7 for removed, broken or loosened screws (p=0.02). There was no difference in outcome comparing large and small fragment screws. Patients with broken, loosened or removed syndesmosis screws have better functional outcome compared to intact screws. The syndesmosis allows fibular rotation, shortening and translation during gait; the presence of an intact syndesmosis screw may restrict this motion. There was no disadvantage to leaving broken or loosened screws in-situ

Myoneural blockade is a well-established means of reducing tone in spastic muscles, thereby delaying or avoiding the need for operative intervention. The recent interest in botulinum A toxin has tended to obscure the fact that other agents such as alcohol have been used for many years to achieve a similar effect. Eighty-two children between the ages of 2 and 16 years with cerebral palsy underwent myoneural blocks using 45% ethanol for dynamic contracture of the hamstrings and/or gastrocnemius. The injections were performed under a light general anaesthetic, using a nerve stimulator to localise the myoneural junction. A total of 153 muscle groups were injected. Hamstring tightness improved as a result of ethanol injection, the popliteal angle reducing from a mean of 73° (range 40° – 90°) to 43° (range 10° – 70°). Gastrocnemius tightness also improved, the ankle dorsiflexion with knee extended improving from a mean of −7° to +3°. The maximal effect was achieved in a mean of 12 weeks and was maintained for a further 12 weeks before starting to deteriorate. The time from injection to the next intervention ranged from 13 weeks to over 2 years. There were no complications or adverse effects. The effect of any one therapy in cerebral palsy is difficult to establish, given that there are often several different modalities of treatment operating concurrently. However, the results from this series indicate that myoneural blockade with ethanol is a useful and safe adjunct to other therapies in the child with lower limb spasticity

Aim of study: To assess ankle dorsiflexion of operated pedes equinovari congenitales in both clinical examination and gait analysis. Introduction: Mac Kay subtalar release corrects mostly perfectly deformed feet. Operated feet show however stiffness not only in subtalar but as well as in ankle joint. The range of motion in ankle joint was not yet studied systematically at all. Gait analysis offers the possibility to follow the motion in ankle joint dynamically. Material: Thirty six consecutively operated feet were examined by clinical as well as by gait analysis examination. All were operated by Mac Kay procedure at least one year before examination (range 1–7 years). Feet were examined in lying and stance positions. Gait analysis was based on use of Oxford foot model (8 cameras motion capture system). Results: Dorsiflexion/plantiflexion of the foot estimated by clinical examination was compared with maximum dorsiflexion in phase of mid-stance (second rocker)/maximum plantiflexion in pre-swing phase (third rocker). Differences individually for each patients in dorsiflexion/plantiflexion were calculated. Mean of difference between dorsiflexion in clinical examination and dorsiflexion in gait analysis x = 14.3°. Mean of diference between plantiflexion in clinical examination and plantiflexion in gait analysis x= 5,4°. Using T-paired test these differences were found statistically significant (p=0,01). Normal maximum dorsiflexion of the children’ foot in gait analysis is about 20°. From this point 14 operated feet out from 36 did not fulfill this criterion. On the other hand only 4 operated feet showed in gait analysis dorsiflexion less than 10°. Discussion: Dorsiflexion of the foot is important for smooth gait. The diference between dates from clinical examination and dates from gait lab can be explained by weight - bearing force pushing the foot into dorsiflexion during second rocker or by secondary adaptive intrinsic bending of the foot. Conclusion: Operated feet showed moderate/severe stiffnes of ankle joint. Despite of it, the gait cycle was not significantly impaired

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

Anterior cruciate ligament (ACL) injuries are among the most common and debilitating knee injuries in professional athletes with an incidence in females up to eight-times higher than their male counterparts. ACL injuries can be career-threatening and are associated with increased risk of developing knee osteoarthritis in future life. The increased risk of ACL injury in females has been attributed to various anatomical, developmental, neuromuscular, and hormonal factors. Anatomical and hormonal factors have been identified and investigated as significant contributors including osseous anatomy, ligament laxity, and hamstring muscular recruitment. Postural stability and impact absorption are associated with the stabilizing effort and stress on the ACL during sport activity, increasing the risk of noncontact pivot injury. Female patients have smaller diameter hamstring autografts than males, which may predispose to increased risk of re-rupture following ACL reconstruction and to an increased risk of chondral and meniscal injuries. The addition of an extra-articular tenodesis can reduce the risk of failure; therefore, it should routinely be considered in young elite athletes. Prevention programs target key aspects of training including plyometrics, strengthening, balance, endurance and stability, and neuromuscular training, reducing the risk of ACL injuries in female athletes by up to 90%. Sex disparities in access to training facilities may also play an important role in the risk of ACL injuries between males and females. Similarly, football boots, pitches quality, and football size and weight should be considered and tailored around females’ characteristics. Finally, high levels of personal and sport-related stress have been shown to increase the risk of ACL injury which may be related to alterations in attention and coordination, together with increased muscular tension, and compromise the return to sport after ACL injury. Further investigations are still necessary to better understand and address the risk factors involved in ACL injuries in female athletes.

Cite this article: Bone Jt Open 2024;5(2):94–100.

The August 2023 Foot & Ankle Roundup³⁶⁰ looks at: Achilles tendon rupture: surgery or conservative treatment for the high-demand patient?; First ray amputation in diabetic patients; Survival of ankle arthroplasty in the UK; First metatarsophalangeal joint fusion and flat foot correction; Intra-articular corticosteroid injections with or without hyaluronic acid in the management of subtalar osteoarthritis; Factors associated with nonunion of post-traumatic subtalar arthrodesis; The Mayo Prosthetic Joint Infection Risk Score for total ankle arthroplasty.

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

The August 2024 Foot & Ankle Roundup³⁶⁰ looks at: ESWT versus surgery for fifth metatarsal stress fractures; Minimally invasive surgery versus open fusion for hallux rigidus; Diabetes and infection risk in total ankle arthroplasty; Is proximal medial gastrocnemius recession useful for managing chronic plantar fasciitis?; Fuse the great toe in the young!; Conservative surgery for diabetic foot osteomyelitis; Mental health and outcome following foot and ankle surgery.

Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

Aims

Periacetabular osteotomy (PAO) is widely recognized as a demanding surgical procedure for acetabular reorientation. Reports about the learning curve have primarily focused on complication rates during the initial learning phase. Therefore, our aim was to assess the PAO learning curve from an analytical perspective by determining the number of PAOs required for the duration of surgery to plateau and the accuracy to improve.

Common peroneal nerve (CPN) palsy has been reported to be the most frequent lower extremity palsy characterized by a supinated equinovarus foot deformity and foot drop. Dynamic tendon transposition represents the gold standard for surgical restoration of dorsiflexion of a permanently paralyzed foot. Between 1998 and 2005, we operated on 16 patients with traumatic complete CPN palsy. An osseous tunnel is drilled from anterior tibialis tendon (ATT) bony insertion through the cuneiform bones in the direction of the third cuneiform, through which the ATT is extracted and then pulled proximally under the extensor retinaculum. New ATT origin on the third cuneiform is therefore created. A double tendon transfer is then performed with a direct tendon-to-tendon suture at the distal third of the leg between the rerouted ATT and the posterior tibialis tendon (PTT) (transposed anteriorly through interosseous membrane) and between the flexor digitorum longus tendon (FDL), similarly transposed and sutured side-to-side with the extensor digitorum longus and extensor hallucis longus tendons. This second transfer strengthens ankle dorsiflexion and reanimates toe extension. All 16 patients were reviewed at a minimum followup of 24 months. Results were assessed using the Stanmore system questionnaire and were classified as excellent in eight, good in five, fair in two, and poor in one. In all cases, transosseous rerouting of the ATT provided a sufficient tendon length, which permitted tendon-to-tendon suturing between the ATT and PTT to be performed proximal to the extensor retinaculum eliminating tendon length-related problems. The new origin of the ATT at the third cuneiform was confirmed to be the optimal traction line to achieve maximum dorsiflexion with minimal imbalance in accompanying pronation and supination. Double tendon transfer also avoids not only drop of the toes, but also allows some extension of the hallucis. Postoperative static and dynamic baropodometric evaluations also were performed showing an overall satisfying progression of gait characterized by the absence of external overload in toe plantar flexion and by reduction of foot contact time with the ground with improvement of heel contact and pushoff phase with evidence of a longer step. The novelty of our proposed technique is that of moving the insertion of the recipient tendon (ATT) toward the donor transferred tendon (PTT) and not the contrary, providing an appropriate direction of pull with adequate length and fixation. For treatment of complete CPN palsy, transosseous rerouting to the third cuneiform of the ATT and dual transfer of the PTT and FDL tendons is a reliable method to restore balanced foot and toe dorsiflexion producing a normal gait without the need for orthoses

Summary: The Ponseti technique with an initial percutaneous Achilles tenotomy fully corrected 19 arthrogrypotic clubfeet. At 30 months follow-up, 74% were plantigrade, all were braceable, none had surgery. Introduction: Surgical releases for arthrogrypotic clubfeet have high recurrence rates, requiring further surgery, resulting in short, stiff, painful feet. Hypothesis: a modified Ponseti technique could achieve plantigrade, braceable feet, without surgery during infancy or early childhood. Methods: Ten patients with 19 arthrogrypotic clubfeet, mean age 16.2 months (range, 3–40), underwent an initial percutaneous Achilles tenotomy (PAT), followed by weekly Ponseti style castings. A second PAT was performed prior to the last 3 week cast, except if the ankle dorsiflexed at least 20°. Correction was maintained by continuous ankle-foot orthoses (AFOs) bracing. Results: Mean follow-up was 30.6 months (range, 5–60), age 47 months (range, 11–86.5). Mean number of casts was 7.3 (range, 4–13), 10 feet required a second PAT. Initial Dimeglio/Bensahel (D/B) score was 16 (range, 12–18), and 5 (range, 2–9) at follow-up. Similarly, Catterall/Pirani (C/P) scores improved from 4.8 (range, 1.6–6.0) to 0.9 (range, 0–2.0). Mean ankle dorsiflexion improved from −45° (range, −30° to −75°) to 5° (range, −20° to 35°) at follow-up. Five feet (26%) developed an average equinus of 13° (range, 5° to 20°). All feet were braceable, none had surgery, and no patient’s ambulatory ability was compromised by foot shape. Five patients (10 feet) had more than 2 years follow-up (range, 39–59.5, average 49.7 months), with an average dorsiflexion of 6.5°, average D/B and C/P scores were 4.8 and 0.8, respectively. Discussion and Conclusion: Arthrogrypotic clubfeet were corrected without extensive surgery during infancy or early childhood. The initial PAT was crucial for unlocking the calcaneus from the posterior tibia, allowing for correction with Ponseti casting. Correction was maintained with AFOs at the final follow-up of 30 months. Although limited surgery may be required as the children age, plantigrade, braceable feet were achieved effectively in these patients with arthrogryposis, creating a stable platform for weightbearing

Aims

To identify the minimum set of outcomes that should be collected in clinical practice and reported in research related to the care of children with idiopathic congenital talipes equinovarus (CTEV).