Hindfoot disorders are complex 3D deformities. Current literature has assessed their influence on the full leg alignment, but the superposition of the hindfoot on plain radiographs resulted in different measurement errors. Therefore, the aim of this study is to assess the hindfoot alignment on Weight-Bearing CT (WBCT) and its influence on the radiographic Hip-Knee-Ankle (HKA) angle. A retrospective analysis was performed on a study population of 109 patients (mean age of 53 years ± 14,49) with a varus or valgus hindfoot deformity. The hindfoot angle (HA) was measured on the WBCT while the HKA angle, and the anatomical tibia axis angle towards the vertical (TA. X. ) were analysed on the Full Leg radiographs. The mean HA in the valgus hindfoot group was 9,19°±7.94, in the varus hindfoot group −7,29°±6.09. The mean TA. X. was 3,32°±2.17 in the group with a valgus hindfoot and 1,89°±2.63 in the group with a varus hindfoot, which showed to be statistically different (p<0.05). The mean HKA Angle was −1,35°±2.73 in the valgus hindfoot group and 0,4°±2.89 in the varus hindfoot group, which showed to be statistically different (p<0.05). This study demonstrates a higher varus in both the HKA and TA. X. in valgus hindfoot and a higher tibia valgus in varus hindfoot. This contradicts the previous assumption that a varus hindfoot is associated with a varus knee or vice versa. In clinical practice, these findings contribute to a better understanding of deformity corrections of both the hindfoot and the knee

The relationship between hindfoot and forefoot kinematics is an important factor in the planning of ankle arthrodesis and ankle arthroplasty surgery. As more severe ankle deformities are corrected, improved techniques are required to assess and plan hindfoot to forefoot balancing. Gait analysis has previously been reported in patients with ankle arthritis without deformity. This group of patients have reduced intersegment motion in all measured angles. We have looked at a small group of patients with hindfoot deformity and ankle arthritis awaiting fusion or replacement. Using the Oxford Foot Model we have assessed lower limb kinematics with a focus on hindfoot to forefoot relationships. The results of our pilot study are in variance to previous studies in that we have shown that in the presence of hindfoot/ankle deformity, the forefoot range of motion increases. We feel that these data may impact on surgical planning

In 12 infants aged under 16 months with unilateral club foot we used MRI in association with multiplanar reconstruction to calculate the volume and principal axes of inertia of the bone and cartilaginous structures of the hindfoot.

The volume of these structures in the club foot is about 20% smaller than that in the normal foot. The reduction in volume of the ossification centre of the talus (40%) is greater than that of the calcaneus (20%). The long axes of both the ossification centre and the cartilaginous anlage of the calcaneus are identical in normal and club feet. The long axis of the osseous nucleus of the talus of normal and club feet is medially rotated relative to the cartilaginous anlage, but the angle is greater in club feet (10° v 14°). The cartilaginous structure of the calcaneus is significantly medially rotated in club feet (15°) relative to the bimalleolar axis. The cartilaginous anlage of the talus is medially rotated in both normal and club feet, but with a smaller angle for club feet (28° v 38°). This objective technique of measurement of the deformity may be of value preoperatively.

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.

Aims. Patients with a deformity of the hindfoot present a particular challenge when performing total knee arthroplasty (TKA). The literature contains little information about the relationship between TKA and hindfoot alignment. This systematic review aimed to determine from both clinical and radiological studies whether TKA would alter a preoperative hindfoot deformity and whether the outcome of TKA is affected by the presence of a postoperative hindfoot deformity. Methods. A systematic literature search was performed in the databases PubMed, EMBASE, Cochrane Library, and Web of Science. Search terms consisted of “total knee arthroplasty/replacement” combined with “hindfoot/ankle alignment”. Inclusion criteria were all English language studies analyzing the association between TKA and the alignment of the hindfoot, including the clinical or radiological outcomes. Exclusion criteria consisted of TKA performed with a concomitant extra-articular osteotomy and case reports or expert opinions. An assessment of quality was conducted using the modified Methodological Index for Non-Randomized Studies (MINORS). The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered in the PROSPERO database (CRD42019106980). Results. A total of 17 studies were found to be eligible for review. They included six prospective and ten retrospective studies, and one case-control study. The effects of TKA showed a clinical improvement in the hindfoot deformity in three studies, but did not if there was osteoarthritis (OA) of the ankle (one study) or a persistent deformity of the knee (one study). The radiological alignment of the hindfoot corrected in 11 studies, but did not in the presence of a rigid hindfoot varus deformity (in two studies). The effects of a hindfoot deformity on TKA included a clinical association with instability of the knee in one study, and a shift in the radiological weightbearing axis in two studies. The mean MINORS score was 9.4 out of 16 (7 to 12). Conclusion. TKA improves both the function and alignment of the hindfoot in patients with a preoperative deformity of the hindfoot. This may not apply if there is a persistent deformity of the knee, a rigid hindfoot varus deformity, or OA of the ankle. Moreover, a persistent deformity of the hindfoot may adversely affect the stability and longevity of a TKA. These findings should be interpreted with caution due to the moderate methodological quality of the studies which were included. Therefore, further prospective studies are needed in order to determine at which stage correction of a hindfoot deformity is required to optimize the outcome of a TKA. Cite this article: Bone Joint J 2021;103-B(1):87–97

Introduction

Hind foot Charcot deformity is a disastrous complication of diabetic neuropathy and can lead to instability, ulceration and major amputation. The treatment of these patients is controversial. Internal stabilization and/or external fixation have demonstrated variable results of limb salvage and some authorities thus advise patients to undergo elective major amputation. However, we report a series of 9 diabetic patients with severe hind foot deformity complicated by ulceration in 5/9, who underwent acute corrective internal fixation with successful correction of deformity, healing of ulceration in 4/5 patients and limb salvage in all cases.

We carried out 123 consecutive total ankle replacements in 111 patients with a mean follow-up of four years (2 to 8). Patients with a hindfoot deformity of up to 10° (group A, 91 ankles) were compared with those with a deformity of 11° to 30° (group B, 32 ankles). There were 18 failures (14.6%), with no significant difference in survival between groups A and B. The clinical outcome as measured by the post-operative American Orthopaedic Foot and Ankle Surgeons score was significantly better in group B (p = 0.036). There was no difference between the groups regarding the post-operative range of movement and complications. Correction of the hindfoot deformity was achieved to within 5° of neutral in 27 ankles (84%) of group B patients. However, gross instability was the most common mode of failure in group B. This was not adequately corrected by reconstruction of the lateral ligament. Total ankle replacement can safely be performed in patients with a hindfoot deformity of up to 30°. The importance of adequate correction of alignment and instability is highlighted

Varus ankle osteoarthritis (OA) is typically associated with peritalar instability, which may result in altered subtalar joint position. This study aimed to determine the extent to which total ankle replacement (TAR) in varus ankle OA can restore the subtalar position alignment using 3-dimensional semi-automated measurements on WBCT. Fourteen patients (15 ankles, mean age 61) who underwent TAR for varus ankle OA were retrospectively analyzed using semi- automated measurements of the hindfoot based on pre-and postoperative weightbearing WBCT (WBCT) imaging. Eight 3-dimensional angular measurements were obtained to quantify the ankle and subtalar joint alignment. Twenty healthy individuals were served as a control groups and were used for reliability assessments. All ankle and hindfoot angles improved between preoperative and a minimum of 1 year (mean 2.1 years) postoperative and were statistically significant in 6 out of 8 angles (P<0.05). Values The post-op angles were in a similar range to as those of healthy controls were achieved in all measurements and did not demonstrated statistical difference (P>0.05). Our findings indicate that talus repositioning after TAR within the ankle mortise improves restores the subtalar position joint alignment within normal values. These data inform foot and ankle surgeons on the amount of correction at the level of the subtalar joint that can be expected after TAR. This may contribute to improved biomechanics of the hindfoot complex. However, future studies are required to implement these findings in surgical algorithms for TAR in prescence of hindfoot deformity

Several emerging reports suggest an important involvement of the hindfoot alignment in the outcome of knee osteotomy. At present, studies lack a comprehensive overview. Therefore, we aimed to systematically review all biomechanical and clinical studies investigating the role of the hindfoot alignment in the setting of osteotomies around the knee. A systematic literature search was conducted on multiple databases combining “knee osteotomy” and “hindfoot/ankle alignment” search terms. Articles were screened and included according to the PRISMA guidelines. A quality assessment was conducted using the Quality Appraisal for Cadaveric Studies (QUACS) - and modified methodologic index for non-randomized studies (MINORS) scales. Three cadaveric, fourteen retrospective cohort and two case-control studies were eligible for review. Biomechanical hindfoot characteristics were positively affected (n=4), except in rigid subtalar joint (n=1) or talar tilt (n=1) deformity. Patient symptoms and/or radiographic alignment at the level of the hindfoot did also improve after knee osteotomy (n=13), except in case of a small pre-operative lateral distal tibia- and hip knee ankle (HKA) angulation or in case of a large HKA correction (>14.5°). Additionally, a pre-existent hindfoot deformity (>15.9°) was associated with undercorrection of lower limb alignment following knee osteotomy. The mean QUACS score was 61.3% (range: 46–69%) and mean MINORS score was 9.2 out of 16 (range 6–12) for non-comparative and 16.5 out of 24 (range 15–18) for comparative studies. Osteotomies performed to correct knee deformity have also an impact on biomechanical and clinical outcomes of the hindfoot. In general, these are reported to be beneficial, but several parameters were identified that are associated with newly onset – or deterioration of hindfoot symptoms following knee osteotomy. Further prospective studies are warranted to assess how diagnostic and therapeutic algorithms based on the identified criteria could be implemented to optimize the overall outcome of knee osteotomy. Remark: Aline Van Oevelen and Arne Burssens contributed equally to this work

Lateral approach open calcaneal osteotomy is the described gold standard procedure in the management of hindfoot deformity. With development of minimally invasive surgery, a MIS approach has been described, citing fewer wound complications and lower risk of sural nerve injury. This audit compares MIS to the traditional procedure. A retrospective review of all patients undergoing calcaneal osteotomy in Northumbria Trust in the past 5 years was performed. A total of 105 osteotomies were performed in 97 patients; 28 (13M:15F) in MIS group and 77 (40M:37F) had an open approach. The average age was 52.1 (range 16–83) for MIS and 51.5 (range 18–83) in the open group. All patients were followed up for development of wound complication, nerve injury and fusion rate. Wound complications were similar (10.7% in MIS group vs 10.3% in Open group) with no significant difference (p=0.48). Patients were treated for infection in 3(3.8%) cases in the open group and 2(7.1%) in the MIS group. This difference was not significant (p=0.43). 4 (14.3%) patients in the MIS group had evidence of sural nerve dysfunction post-operatively (managed expectantly), compared to 12(15.5%) patients in the open group (p=0.44). Of these, 2 went on to undergo neuroma exploration. There was no difference in nerve dysfunction in varus or valgus correction. Mean translation in the open group was measured as 7.3mm(SD=1.91;3 to 13mm) and 7.5mm(SD=1.25;5 to 10mm) in the MIS group. Translation was similar in varus or valgus correction. Non-union occurred in 2 patients in the MIS group and none in the open group (p= 0.06). MIS calcaneal osteotomy is a safe technique, that works as effectively as osteotomy performed through an open approach. There were lower rates of nerve injury, wound complication and infection, but this was not significantly different comparing groups. There was a higher risk of non-union in MIS technique

Applications of weightbearing computed tomography (WBCT) imaging in the foot and ankle have emerged over the past decade. However, the potential diagnostic benefits are scattered across the literature, and a concise overview is currently lacking. Therefore, we aimed to systematically review all reported diagnostic applications per anatomical region in the foot and ankle. A systematic literature search was performed in the electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science. Search terms consisted of “weightbearing/standing CT and ankle, hind-, mid- or forefoot”. English language studies analyzing the diagnostic applications of WBCT were included. Studies were excluded if they simulated weightbearing CT, described normal subjects, included cadaveric samples or samples were case reports. The modified Methodological Index for Non-Randomized Studies (MINORS) was applied for quality assessment. The added value was defined as the review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered in the Prospero database (CRD42019106980). A total of 48 studies (prospective N=8, retrospective N=36, cohort study N=1, diagnostic N=2, prognostic comparative study N=1) were found to be eligible for review. The following diagnostic applications were identified per anatomical area in the foot: ankle (osteoarthritis N=5, ligament injury N=6); hindfoot (deformity N=9); midfoot (Lisfranc injury N=2, flatfoot deformity N=13, osteoarthritis N=1); forefoot (hallux valgus N=12). The identified studies contained diagnostic applications that could not be used on plain radiographs. The mean MINORS equaled 10.1 on a total of 16 (range: 8 to 12). Diagnostic applications of weightbearing CT imaging are most frequently studied in hindfoot deformity, but other area's areas are on the rise. Post-processing of images was identified as the main added value compared to WBRX. However, the findings should be interpreted with caution as the average quality score was moderate. Therefore, future prospective studies are warranted to consolidate the role of WBCT in diagnostic and therapeutic algorithms

Aims. To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population. Methods. In all, 73 children with idiopathic club foot were included: 31 children treated with the Ponseti method (mean age 8.3 years; 24 male; 20 bilaterally affected, 13 left and 18 right sides analyzed), and 42 treated with primary surgical correction (mean age 11.6 years; 28 male; 23 bilaterally affected, 18 left and 24 right sides analyzed). Foot function data was collected during walking gait and included Oxford Foot Model kinematics (Foot Profile Score and the range of movement and average position of each part of the foot) and plantar pressure (peak pressure in five areas of the foot). Oxford Ankle Foot Questionnaire, Disease Specific Index for club foot, Paediatric Quality of Life Inventory 4.0 were also collected. The gait data were compared between the two club foot groups and compared to control data. The gait data were also correlated with the data extracted from the questionnaires. Results. Our findings suggest that symptomatic children with club foot deformity present with similar degrees of gait deviations and perceived disability regardless of whether they had previously been treated with the Ponseti Method or surgery. The presence of sagittal and coronal plane hindfoot deformity and coronal plane forefoot deformity were associated with higher levels of perceived disability, regardless of their initial treatment. Conclusion. This is the first paper to compare outcomes between Ponseti and surgery in a symptomatic older club foot population seeking further treatment. It is also the first paper to correlate foot function during gait and perceived disability to establish a link between deformity and subjective outcomes. Cite this article: Bone Joint Open 2020;1-7:384–391

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

Introduction. Charcot Arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. The traditional surgical method of extensive surgical exposure, excision of bone, acute correction and internal fixation is not always appropriate in presence of active ulceration, deep infection and poor bone quality. Minimally invasive osteotomies and gradual correction of deformities with a circular frame are proving helpful in minimizing complications. We present our experience with the use of Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. Materials and Methods. Our indication for the treatment with TSF is recurrent or intractable ulceration with or without active bone infection or a history of infection in a deformed foot and/or ankle. There are 2 female and 8 male patients in this cohort. We used a long bone module for ankle and hindfoot deformities (3 patients) and a forefoot 6×6 butt frame (7 patients) for midfoot deformities. An osteotomy through midfoot was performed in all chronic stable midfoot deformity cases and a calcaneal osteotomy and gradual correction through ankle in when hindfoot and ankle deformities co-existed. Results. Our outcome measures are a complete healing of ulcer and infection without recurrence, clinically plantigrade foot and ability to wear regular shoes or diabetic footwear. We achieved this outcome in 9 out of 10 patients. Successful patients remain ulcer free at minimum 7 and maximum 14 years follow up. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. Conclusions. Our results confirm that Taylor Spatial Frame treatment is a good alternative to traditional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities

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

The relationship between hindfoot deformity and forefoot pressure was assessed in 28 rheumatoid patients who had undergone forefoot reconstruction four years previously. Patients with valgus hindfoot deformities tended to have high forefoot pressures whereas those with a normal hindfoot recorded normal pressures on the dynamic pedobarograph. All patients with residual forefoot pain recorded abnormal forefoot pressures. We believe that orthotic control of hindfoot deformities should be considered for those patients who require forefoot surgery as a combination of surgical and orthotic management may offer the best chance of success

Introduction: Total ankle replacement is proving a reliable procedure for ankle arthrosis. Some authors have recommended that significant hindfoot deformity should be a contraindication. This study aims to provide guidance on the management of this difficult problem. Methods: 170 consecutive total ankle replacements were performed in 147 patients, aged 32–83 (mean 65) between 1999 and 2006 by a single surgeon. All surviving patients (5 deaths) were followed up prospectively on an annual basis, for a mean of 3 years (1–8 years). Comparison was made between Group A (45 ankles with a hindfoot deformity of > 10° varus or valgus) and Group B (the remaining 120 ankles). Results: There was no statistical difference between the 2 groups for age, sex or indication for surgery (osteoarthritis in 81%). Group A comprised 8 valgus and 36 varus ankles. 23/36 varus ankles had a deformity of > 20°. 6 revisions (13%) were performed in Group A (5 of these related to instability – all preoperatively varus of > 20 degrees). 10 revisions (8%) were performed in Group B (2 related to instability). 6 ankles underwent intra-operative deltoid release and 6 had pre or post-operative calcaneal osteotomy. Only one of these required revision for instability. 4 ankles underwent post-operative lateral ligament reconstruction. These ankles all failed due to instability. The mean postoperative American Foot and Ankle Society score in Group A was 85, compared to 78 in Group B. Discussion: Our study reveals that patients with significant hindfoot deformity may benefit from total ankle replacement. However, the risk of revision due to instability and need for further surgery is higher, especially with a varus deformity of > 20°. Almost a quarter of these ankles required revision. Potential solutions may be to correct the deformity with additional calcaneal osteotomy or medial release, whereas lateral ligament reconstruction alone is inadequate

Patients with a hindfoot deformity impose a particular challenge when performing a total knee arthroplasty (TKA). This could be attributed to the lack of insights concerning the outcome towards the hindfoot alignment. Our objective was to perform a systematic review of the literature to investigate the influence of TKA on hindfoot alignment and vice-versa. In accordance with the Methodological Index For Non-Randomized Studies (MINORS) statement standards, we performed a systematic review. Electronic databases Pubmed, EMBASE, Web of Science, Google Scholar and Cochrane Library were searched to identify capable studies studying the influence between TKA and hindfoot malalignment. We indentified four prospective cohort studies, seven retrospective cohort studies and one case-control study. All twelve articles addressed the influence of TKA on hindfoot alignment. Seven out of nine studies which noticed an improvement of hindfoot alignment after TKA, found a significant improvement (p<0.05). Aditionally three of these studies reported a significant improvement only in valgus hindfeet (p<0.05). On the topic of hindfoot alignment influencing TKA, we identified two studies. These studies reported an impact of hindfoot alignment on the weightbearing and described that 87% of hindfeet remained in valgus alignment after TKA. Available data suggests that alignment in valgus hindfeet can improve after TKA, though long term results are not present. Contrary to last, improvement of hindfoot alignment is not expected in varus hindfeet. Furthermore hindfoot alignment deformity may cause a reduction of the long term survival of the knee prosthesis and therefore should be taken in to account

We reported the outcomes of patients with Charcot neuropathy who underwent hind foot deformity correction using retrograde intramedullary nail arthrodesis. Twenty one feet in 20 patients, aged 45 to 83 years, with a mean BMI of 32.7 and a median ASA score of 3, were included in this study. All patients presented with severe hindfoot deformities and 15 had recurrent ulceration. All patients were treated with hindfoot corrective fusion and seven patients also underwent simultaneous mid foot fusion using a bolt or locking plate. After a mean follow up of 26 months, none of the cases required any form of amputation. Eighty percent of patients with ulceration achieved healing and all but one patient returned to independent ambulation. One nail fracture and three mid foot metal work failure resulted in fixation failure requiring revision surgery. Distal locking screw displacement occurred only with standard screws but not with hydroxyapatite-coated screws. The AAOS-FAO score improved from 50.7 to 65.2 (p=0.015). The EQ-5D-5L improved from 0.63 to 0.67 (p=0.012) and the SF-36 PCS from 25.2 to 29.8 (p=0.003). Single stage deformity correction with intramedullary hindfoot arthrodesis nail is a viable treatment option for severe Charcot hindfoot deformity with ulceration and instability

Introduction We report a modified technique using peroneus brevis for reconstruction of the anterior talofibular and calcaneo-fibular ligaments in the ankle for chronic instability. Method The surgery was carried out using a double drill-hole in the distal fibula with either a complete or partial tendon graft. An examination under anaesthetic with ankle arthroscopy has been utilised to confirm the clinical diagnosis and assess the articular surfaces. In appropriate cases a translational os calcis osteotomy is added to correct varus hindfoot deformity. Forty-five procedures were carried out over a 10-year period. The patients were retrospectively assessed with a case note review, and an updated clinical evaluation. The assessment focussed on pain, stability and impact on daily living. Results Our results compare favourably with existing techniques for lateral ligament reconstruction, with most patients being satisfied with the improvement in pain relief and stability. These will be discussed in detail. Complications included superficial wound infections and sensory neurological symptoms. There were two failures following surgery both of which were associated with a high body mass index and joint laxity. Conclusion This procedure provides anatomical reconstruction, is technically undemanding and gives adequate pain relief, stability and return to sporting activity. With careful patient selection, including treatment of intra-articular pathology and hindfoot deformity, it is a useful alternative to the methods currently available

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

Aims: Hindfoot deformity in varus position is an aetiology of chronic ankle instability without laxity. In this condition, a Dwyer osteotomy has to be performed. Methods: Between 1992 and 2000, 15 patients have been operated on, with this technique. The mean varus deformity was of 5û (3û to 10û).13 patients had sporting activities, 8 of them in competition. Instability during sporting activity were present in 60% of cases. Associated lesions were reported in 6 cases. A Dwyer procedure using a 1/3 tube plate þxed with two screws were performed in all cases. Associated procedures were performed at the same time as such as a lateral ligamentoplasty or a þrst metatarsal osteotomy. All patients were reviewed clinically and radiologically using AOFAS score. Results: The mean follow-up was of 3.5 years (1 to 9 years). The only one complication reported was a skin necrosis, treated by a cutaneous ßap in a patient operated on with Dwyer and ligamentoplasty in the same procedure. No ankle instability was reported. Mild pain was reported in 10 patients and 50% of them only for sporting activities.11 patients returned to sporting activity and 33% of them at the same level. The mean Kita-oka score was of 92 (85 to 100). The patients were satisþed and very satisþed in 80 of cases. Conclusions: Dwyer lateral closing wedge calcaneal osteotomy is successful for the treatment of chronic ankle instability without laxity and with varus hindfoot deformity. When laxity is associated with varus deformity an operative procedure in two steps is necessary to avoid wound complication. Dwyer osteotomy has to be performed þrst

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

We report the outcomes of 20 patients (12 men, 8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction of deformities of the ankle and hindfoot using retrograde intramedullary nail arthrodesis. The mean age of the patients was 62.6 years (46 to 83); their mean BMI was 32.7 (15 to 47) and their median American Society of Anaesthetists score was 3 (2 to 4). All presented with severe deformities and 15 had chronic ulceration. All were treated with reconstructive surgery and seven underwent simultaneous midfoot fusion using a bolt, locking plate or a combination of both. At a mean follow-up of 26 months (8 to 54), limb salvage was achieved in all patients and 12 patients (80%) with ulceration achieved healing and all but one patient regained independent mobilisation. There was failure of fixation with a broken nail requiring revision surgery in one patient. Migration of distal locking screws occurred only when standard screws had been used but not with hydroxyapatite-coated screws. The mean American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22 to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7 to 44.2), (p = 0.003) and the mean Euroqol EQ‑5D‑5L score improved from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012). Single-stage correction of deformity using an intramedullary hindfoot arthrodesis nail is a good form of treatment for patients with severe Charcot hindfoot deformity, ulceration and instability provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2015;97-B:76–82

The development of lateral tibial torsion in the paralysed lower limb is well documented, but its pathogenesis is poorly understood. This paper attempts to provide an explanation for its development when it is associated with a varus or equinovarus deformity of the hindfoot. Correction of the lateral tibial torsion by supramalleolar derotation tibial osteotomy and reorientation of the ankle mortise appear to unlock the talus from the laterally rotated position, correcting a mobile hindfoot varus deformity and altering soft-tissue tensions about the ankle so that the correction achieved is maintained. In the presence of a fixed hindfoot deformity, supramalleolar derotation tibial osteotomy is useful as a first-stage procedure before corrective osteotomies of the foot. The operation described is technically simple and carries a low morbidity. Twenty supramalleolar derotation tibial osteotomies in 18 patients have been performed with satisfactory results and few complications

Background. A calcaneal medial osteotomy (CMO) is a surgical procedure frequently performed to correct a valgus alignment of the hindfoot. However currently little is known on its accurate influence on hindfoot alignment (HA). Aim. To assess the influence of a CMO on HA in both 2D and 3D measurements using weightbearing CT (WBCT). Methods. Twelve patients with a mean age of 49,4 years (range 18–67yrs) were prospectively included. Indications for surgical correction by a CMO with a solitary translation of the calcaneus consisted of an adult acquired flat foot stage II (N=10) and a talocalcaneal coalition (N=2). Fixation of the osteotomy was performed either using a step plate or double screw. A WBCT was obtained pre- and post-operative. HA was assessed by an angle between the anatomical tibia axis and the axis connecting the inferior calcaneus point and the middle of the talus in the coronal plane (HA. 2D. ) using Curvebeam® software. The tibia in the HA was separately assessed by the anatomical tibia axis (TA. X 2D. ). The same method was translated in 3D using 3-Matic® software with a Cartesian coordinate system originating in the inferior point of the calcaneus (HA. 3D. and TA. x 3D. ). Results. Both the mean pre-op HA. 2D. =12.8°± 4.5 and HA. 3D. =21.1°± 8.4 of valgus improved significantly post-operatively to a HA. 2D. =4.2°±4.5 and a HA. 3D. =11,9°± 6.1 (P < 0.001). Additionally, the mean pre-op TA. X 2D. = 4°± 2.6 and TA. X 3D. = 7,2 °± 3.2 showed a significant improvement to a TA. X 2D. = 3.1°± 2.7 and a TA. X 3D. = 6.1 °± 3.4 post-operatively (P < 0.05). The inter-rater reliability of the 2D measurement method with a mean ICC. HA2D. =0.74 and a mean ICC. TA2D. = 0.77 showed to be lower when compared to the 3D measurement method with a mean ICC. HA3D. =0.94 and a mean ICC. TA3D. =0.89. Conclusion. This study shows an effective correction of the valgus position from the calcaneus measured both in 2D and 3D when using a surgical CMO. The novelty is the marked influence on the tibia, which could now be accurately assessed using a weightbearing CT and additional 3D measurements. This resulted in 10% of the achieved HA correction, when analyzed both in 2D and 3D. This information could be of use when performing a pre-operative planning of a hindfoot deformity

Aims

Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions.

Background. There have been multiple techniques described to determine hindfoot alignment radiographically. The 2-dimensional nature of radiographs fails to take into account the contribution of the remainder of the foot to overall alignment. A new radiographic technique has been published in which the hindfoot alignment is calculated using the Ground Reaction Force Calcanea Offset. This technique accounts for the individual forefoot contribution to alignment, but is still limited by it´s 2-dimensional nature. The purpose of this study was to compare the hindfoot moment arm (HMA) described by Saltzman and the hindfoot alignment angle (HAA) described by Williamson, with a technique determining the ground reaction force calcaneal offset (GRF-CT) using 3-dimensional weight bearing CT Scans. Methods. The HMA, HAA, and GRF-CT 3-D weight bearing CT scans were measured by three different investigators. Each of these measurements were calculated twice on separate occasions by each investigator to determine the intra- and inter-observer reliability. Results. 104 patients underwent weight bearing hindfoot alignment radiographs and 3-dimensional weight bearing CT scans including 33 patients with varus and 71 patients with valgus hindfoot deformities. There was excellent intra- and inter-observer reliability with all three measurement techniques (P< 0.01), however the GRF-CT showed the best intra- and inter-observer reliability with the lowest standard deviation (P< 001). Conclusions. The GRF-CT technique is more reliable than traditional radiographic techniques for measuring the hindfoot alignment. While the intra- and inter-observer reliability is good for all three techniques, the GRF-CT technique resulted in the best intra- and inter-observer reliability with the lowest standard deviation. This technique provides the most accurate hindfoot alignment as it takes into account the effect of forefoot on overall alignment, preventing inaccuracies of projection and foot orientation in contrast to traditional radiographic techniques, which may be valuable in surgical decision making

The June 2024 Foot & Ankle Roundup³⁶⁰ looks at: First MTPJ fusion in young versus old patients; Minimally invasive calcaneum Zadek osteotomy and the effect of sequential burr passes; Comparison between Achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional Achilles tendinopathy; Revision ankle arthroplasty – is it worthwhile?; Tibiotalocalcaneal arthrodesis or below-knee amputation – salvage or sacrifice?; Fusion or replacement for hallux rigidus?.

We report a single surgeon series of 33 arthroscopic subtalar fusions performed through a 2-portal sinus tarsi approach on 32 patients between March 2004 and February 2009. Background pathologies included primary arthrosis, post-traumatic arthritis, planovalgus foot, rheumatoid disease, sinus tarsi syndrome and CTEV. 97% [32/33] of fusions as assessed by both clinical and radiological means were achieved within 16 weeks [76% [25/33] within 12 weeks] with only a single outlier which had fused by 22 weeks. There were no deep infections, thrombotic events or neuromas. Five patients suffered complications of which four were successfully treated with a satisfactory outcome. One patient developed persistent pain and was eventually referred to another centre for further management. In our experience arthroscopic subtalar fusion surgery has been demonstrated to give excellent outcomes with minimal complications. Furthermore, it is a technique allowing surgery even in patients with significant hindfoot deformity. It is a suitable operation even for patients with a compromised soft tissue envelope which would normally preclude an open procedure

When total ankle arthroplasty (TAA) is performed, although tibial osteotomy is instructed to be perpendicular to long axis of tibia, there is no established index for the talar bone corrective osteotomy. Then, we have been deciding the correction angle at the plan for adjustment of the loading axis through whole lower extremities. We studied 17 TAA cases with rheumatoid arthritis (RA). X-ray picture of hip to calcaneus view (hip joint to tip of the calcaneus) defined to show more approximated loading axis has been referred for the preoperative planning. Furthermore, the data of correction angle has been reflected to pre-designed custom-made surgical guide. If soft tissue balance was not acceptable, malleolar sliding osteotomy was added. The distance between the centre of ankle joint and the axis (preD) was measured (mm) preoperatively, and the distance between the centre of prosthesis and the axis (postD) was measured postoperatively. Next, the tilting angle between tibial and talar components (defined as the index of prosthesis edge loading) were measured with X-rays during standing. Tibio Calcaneal (TC) angle was also measured pre and postoperatively. TC angle was significantly improved from 8.3±6.0° to 3.5±3.6° postoperatively (P=0.028). PreD was 12.9±9.6mm, and that was significantly improved to 4.8±6.3mm (postD) (P=0.006). Within 17 cases, 8 cases showed 0–1mm of postD, 4 cases showed 1–5mm of postD, remaining 5 cases concomitant subtalar fusion with severe valgus and varus hindfoot deformity showed over 8mm of postD. All of the 12 cases showing within 5mm of postD indicated within 13mm of preD. The tilting angle between components was 0.17±0.37° postoperatively. Taken together, pre-designed corrective talar osteotomy based on preoperative planning using hip to calcaneus view was useful to adjust the mechanical axis for replaced ankle joint in RA cases. Furthermore, after surgery, the hip to calcaneus view was useful to evaluate post-operative mechanical axis of whole lower extremities

The diagnosis of Osteochondral Chondral Lesion of the talar dome is ever more regularly made. Though algorithms of management have emerged by recognising the position, size and the most reliable treatment options, the problem of the failed or relapsed case has only been considered in limited publications. When considering the failed case a variety of possibilities have to be considered. The characteristics of the patient have to be considered. The nature of the original presentation and the history of the present as opposed to the past compliant are worth noting. Patients who have no history of trauma do seem to have a different natural history and response to treatment. The young and the old may well respond differently. Factors preventing recovery from surgery such as ongoing instability of the ankle or hindfoot deformity creating on going abnormal pressures on the joint surface should be looked for. The possibility that the surgery undertreated or missed the full nature of the lesion has to be considered. The possibility of an untreated further pathology should be reviewed. The severity of the original lesion and it's likely response to treatment should be considered. Larger cystic lesions would be more likely to have a poorer outcome. Ultimately if there are persistent symptoms and evidence of ongoing unresolved pathology on the joint surface alternative techniques to resurface the joint should be considered

Background: Open Tibiotalocalcaneal fusion has been shown to be an effective treatment for arthritis and complex foot deformities, but with a high complication rate. We are reporting the results of the first 14 feet undergoing arthroscopic tibiotalocalcaneal arthrodesis. Methods: Retrospective review identified 13 patients who had 14 combined ankle and subtalar arthrodeses performed arthroscopically, with no bone grafting. The procedure was performed for the treatment of combined ankle and subtalar arthritis or hindfoot deformity. The majority had fixation using 6.5mm ASNIS screws (Stryker (Kalamazoo, Michigan, USA)) introduced percutaneously, although in one case a hindfoot nail was used. Outcome was assessed by a combination of chart review, clinical examination and questionnaire. Follow up averaged 16 (6 to 33) months. Results: At follow up average patient satisfaction was 9.7/10. Average time to fusion was 12 (10–20) weeks. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 67 (41–83). Nine patients had no complications. Postoperative complications were pulmonary embolus, non-union, late stress fracture and infection. Conclusion: Arthroscopic hindfoot arthrodesis is an effective technique, and allows treatment in patients whose soft tissues would not tolerate an open procedure, where often the only alternative is amputation. Patient satisfaction is high, with a short inpatient stay, but the procedure itself is demanding

Open Tibiotalocalcaneal fusion has been shown to be an effective treatment for arthritis and complex foot deformities, but with a high complication rate. We are reporting the results of the first 14 feet undergoing arthroscopic tibiotalocalcaneal arthrodesis. Methods: Retrospective review identified 13 patients who had 14 combined ankle and subtalar arthrodeses performed arthroscopically, with no bone grafting. The procedure was performed for the treatment of combined ankle and subtalar arthritis or hindfoot deformity. The majority had fixation using 6.5 mm ASNIS screws (Stryker (Kalamazoo, Michigan, USA)) introduced percutaneously, although in one case a hindfoot nail was used. Outcome was assessed by a combination of chart review, clinical examination and questionnaire. Follow up averaged 16 (6 to 33) months. Results: At follow up average patient satisfaction was 9.7/10. Average time to fusion was 12 (10–20) weeks. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 67 (41–83). 9 patients had no complications. Postoperative complications were pulmonary embolus, non-union, late stress fracture and infection. Conclusion: Arthroscopic hindfoot arthrodesis is an effective technique, and allows treatment in patients whose soft tissues would not tolerate an open procedure, where often the only alternative is amputation. Patient satisfaction is high, with a short inpatient stay, but the procedure itself is demanding

We reviewed 24 feet in 15 patients who had undergone talectomy for recurrent equinovarus deformity; 21 were associated with arthrogryposis multiplex congenita, two with myelomeningocele and one with idiopathic congenital talipes equinovarus. The mean follow-up was 20 years. Good results were achieved in eight feet (33%) in which further surgery was not needed and walking was painless; a fair result was obtained in ten feet (42%) in which further surgery for recurrence of a hindfoot deformity had been necessary but walking was painless; the remaining six feet (25%) were poor, with pain on walking. All patients wore normal shoes and could walk independently, except one who was wheelchair-bound because of other joint problems. Recurrent deformity, the development of tibiocalcaneal arthritis and spontaneous fusion of the tibia to the calcaneum were all seen in these patients

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

Background. Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems including combined arthritis of the ankle and subtalar joints, complex hindfoot deformities and failed total ankle arthroplasty. The aim of this study was to report the elective results of combined subtalar and ankle arthrodesis using one design of dynamic retrograde intramedullary compression nail-the T2 Ankle Arthrodesis Nail(Stryker). Methods. Retrospective review identified 53 consecutive patients who had 55 tibiotalocalcaneal arthrodesis procedures by two surgeons(ITS and NJT) using T2 Ankle nail fixation. 3 patients died of unrelated causes before follow up was complete which left 50 patients(52 nails); the largest consecutive series in the use of this device. Mean follow up was 23.5(3–72) months with the average age of patients being 61(range 22–89) years. An 84% response was achieved to a function and patient satisfaction questionnaire. Main indications for treatment were combined ankle and subtalar arthritis(63%-33/52) or complex hindfoot deformities(23%-12/52). Outcome was assessed by a combination of Clinical notes review, clinical examination, and telephone questionnaire. Results. 46 patients(83.6%) achieved union at a mean time of 3.7 months.8 patients required an allograft(femoral head) bone block procedure. 4 patients(10%) subjectively thought that the procedure was of no benefit or had a poor result whilst 35(83%) had a good or excellent result. The mean visual analog scale(VAS) score for preoperative functional pain was 7.1 compared to the mean post operative(VAS) score of 1.9(p< 0.001). Complications consisted of 2 amputations, 2 deep infections and 5 removals of broken or painful screws. The use of preoperative functional aids and orthotics dropped from 32% to 18% and 22% to 18% respectively. Conclusion. This device and technique is a safe and effective treatment of hindfoot arthrosis and deformity giving reliable compression and subsequent fusion with excellent results in terms of patient satisfaction and pain relief

Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems including combined arthritis of the ankle and subtalar joints, complex hindfoot deformities and failed total ankle arthroplasty. The aim of this study was to report the elective results of combined subtalar and ankle arthrodesis using one design of dynamic retrograde intramedullary compression nail-the T2 Ankle Arthrodesis Nail(Stryker). Retrospective review identified 53 consecutive patients who had 55 tibiotalocalcaneal arthrodesis procedures by two surgeons(ITS and NJT) using T2 Ankle nail fixation. 3 patients died of unrelated causes before follow up was complete which left 50 patients(52 nails); the largest consecutive series in the use of this device. Mean follow up was 23.5(3-72) months with the average age of patients being 61(range 22-89) years. An 84% response was achieved to a function and patient satisfaction questionnaire. Main indications for treatment were combined ankle and subtalar arthritis(63%-33/52) or complex hindfoot deformities(23%-12/52). Outcome was assessed by a combination of Clinical notes review, clinical examination, and telephone questionnaire. 46 patients(83.6%) achieved union at a mean time of 3.7 months. 8 patients required an allograft(femoral head) bone block procedure. 4 patients(10%) subjectively thought that the procedure was of no benefit or had a poor result whilst 35(83%) had a good or excellent result. The mean visual analog scale(VAS) score for preoperative functional pain was 7.1 compared to the mean post operative (VAS) score of 1.9(p<0.001). Complications consisted of 2 amputations, 2 deep infections and 5 removals of broken or painful screws. The use of preoperative functional aids and orthotics dropped from 32% to 18% and 22% to 18% respectively. This device and technique is a safe and effective treatment of hindfoot arthrosis and deformity giving reliable compression and subsequent fusion with excellent results in terms of patient satisfaction and pain relief

Introduction. Calcaneal osteotomy is often performed together with other procedures to correct hindfoot deformity. There are various methods of fixation ranging from staples, headed or headless screws or more recently stepped locking plates. It is not clear if one method is superior to the other. In this series we compare the outcome of various methods of fixation with particular attention to the need for subsequent hardware removal. Patients and Methods. A retrospective review of the records of a consecutive series of patients who had a calcaneal osteotomy performed in our unit within the last 5 years was undertaken. All patients had had their osteotomy through an extended lateral approach to their calcaneous. The subsequent fixation was performed using one of three methods; a lateral plate placed through the same incision; a ‘headless’; or a ‘headed’ screw through a separate stab incision inserted through the infero-posterior heel. Records were kept of subsequent symptoms from the hardware and need for metalwork removal as well as any complications. When screws were inserted the entry point in relation to the weight-bearing surface of the calcaneous was also recorded. Results. Sixty-three osteotomies were investigated of which 15 were fixed using a headed screw, 18 using a headless screw (acutrak TM) and the remaining 30 were fixed using a lateral plate. There was a 100% union rate regardless of method of fixation, no patient was investigated or subject to revision surgery for a suspected non-union. Overall 47% of the headed screws, 10% of the headless screws and 9% of the lateral plates were removed to address symptoms that were suspected to arise from the hardware. There was a 10% (3 from 30) rate of wound complication in the lateral plate cohort. In all these cases there was persisting discharge from the extended lateral wound that resolved with dressing and antibiotic therapy alone. Conclusions. Calcaneal osteotomies have a high union rate regardless of fixation method. Fixation using a headed screw is associated with a high rate of secondary screw removal and this is unrelated to the position of the screw in relation to the weight-bearing surface of the calcaneous. Hardware problems are less frequent in the ‘headless’ screw or the lateral plate groups; however in this series, the incidence of local wound complications was higher in the group fixed with a lateral plate

Simultaneous arthrodesis of the ankle and subtalar joints is an established treatment option for combined ankle and subtalar arthritis or complex hindfoot deformities. The use of a curved intra medullary nail has potential advantages in terms of stability, hindfoot alignment and avoidance of the lateral neurovascular bundle. We devised a comparative description of the results of hindfoot fusion using a curved locking nail before and after the introduction of anatomically specific modifications to the device through a retrospective review of notes and radiographs of patients undergoing simultaneous ankle and subtalar fusion by retrograde intramedullary nailing using an ACE¯ (Humeral Nail. Patients undergoing the same procedure using the Tibiotalocalcaneal [TTC] Nail System [DePuy] were recruited and studied prospectively. The outcome was assessed by a combination of notes review, clinical examination and telephone questionnaire. Between 1996 and 2004, 71 arthrodeses in 67 patients have been performed. The average follow up is 27 months [3-73] and mean age 58 years. Fifty-two arthrodeses utilised the ACE humeral nail and nineteen used the newer TTC nail. Both nailing systems are locked proximally and distally and provide a short radius laterally directed distal curve. Mean time to union is 4.3 months [3-10]. Average AOFAS hindfoot score post-operatively is 65, with a mean improvement of 40 points from the pre-operative score in the TTC nail group. Post-operative complications included deep infection, amputation and a non-union rate of 10% overall. In the humeral nail group, four symptomatic stress reactions [8%] and three fractures of the tibia [6%] occurred at the tip of the nail. No stress-riser effect has to date been seen in the TTC nail group. Prominent metalwork removal has also been significantly reduced in the TTC nail group. Our results show hindfoot fusion using a curved intramedullary nail to be an effective technique in complex cases of hindfoot arthritis and deformity. Anatomically specific alterations to the nail have resulted in a significant reduction in certain complications. Alternate proximal locking options in the TTC nail have reduced prominent metalwork and, more significantly, the incidence of stress reactions and fractures appears to have been eliminated

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.

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

Aim: To evaluate the results of management of Char-cot foot and ankle deformities by the use of the Ilizarov apparatus. Material-Method: This is a retrospective study of 11 cases (9 patients) aged from 39 to 60 years old (mean 44 years), all suffering from Charcot foot neuroarthropathy. All cases showed established midfoot breakdown. In four cases hindfoot deformity coexisted. Three feet were ulcerated. In six cases the Iizarov frame was applied using complex hinges and closed compression fusions were performed, utilizing the bent wire technique. In five cases the correction of the deformities was performed acutely with the use of percutaneous cannulated screws. In the later cases the Ilizarov frame neutralized the former osteosynthesis method. The Ilizarov device remained attached for 8 weeks, regardless the presence of other osteosynthesis hardware. The Maryland Foot score (MFS) was utilized for objective assessment by the physician and the SF-36 questionaire for subjective assessment by the patient. Results: A statistically significant improvement in MFS and SF-36 score was recorded. In all cases the aim for a stable and painless extremity was achieved. All patients returned to their previous activities and kept using normal shoe wear. Conclusions: A lot of references are found in the literature describing failure in the treatment of Charcot foot deformity with the use of internal fixation. This is justified by the poor bone quality and decreased bone density of the diabetic and alcoholic patients. The use of tensioned wires in multiple levels provides adequate fixation in cases where a frame is used solely and safe neutralization where a frame is combined with internal fixation

This paper evaluates the ability to predict the need for a tenotomy prior to beginning the Ponseti method. The purpose of this study was to determine how one might predict the need for tenotomy at the initiation of the Ponseti treatment for clubfeet. Fifty clubfeet in thirty-five patients were treated with serial casting. The feet were prospectively rated according to two different scoring systems (Pirani, et. al. and Dimeglio, et. al.). The decision to perform a tenotomy was made when the foot could not be easily dorsiflexed 15 degrees prior to application of the final cast. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required a significantly greater number of casts (p< 0.05). Of 27 feet with an initial Pirani score 5.0, 85.2% required a tenotomy and 14.8% did not. 94.7% of the Dimeglio Type III feet required tenotomies. At the time of the initial evaluation there was a significant difference between those that did and did not require a tenotomy for multiple components of the Pirani hind-foot score. Following removal of the last cast there was no significant difference between those that did and did not have a tenotomy. In conclusion, children with clubfeet who have an initial score of 5.0 by the Pirani system or are rated as Type III feet by the Dimeglio system are very likely to need a tenotomy. Those that needed a tenotomy were more severely deformed with regard to all components of the hindfoot deformity, not just equinus. At the end of treatment feet were equally well corrected whether or not they needed a tenotomy

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

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

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