Aims. The morphology of medial malleolar fracture is highly variable and difficult to characterize without 3D reconstruction. There is also no universally accepeted classification system. Thus, we aimed to characterize fracture patterns of the medial malleolus and propose a classification scheme based on 3D CT reconstruction. Methods. We retrospectively reviewed 537 consecutive cases of ankle fractures involving the medial malleolus treated in our institution. 3D fracture maps were produced by superimposing all the fracture lines onto a standard template. We sliced fracture fragments and the standard template based on selected sagittal and coronal planes to create 2D fracture maps, where angles α and β were measured. Angles α and β were defined as the acute angles formed by the fracture line and the horizontal line on the selected planes. Results. A total of 121 ankle fractures were included. We revealed several important fracture features, such as a high correlation between posterior collicular fractures and posteromedial fragments. Moreover, we generalized the fracture geometry into three recurrent patterns on the coronal view of 3D maps (transverse, vertical, and irregular) and five recurrent patterns on the lateral view (transverse, oblique, vertical, Y-shaped, and irregular). According to the fracture geometry on the coronal and lateral view of 3D maps, we subsequently categorized medial malleolar fractures into six types based on the recurrent patterns: anterior collicular fracture (27 type I, 22.3%), posterior collicular fracture (12 type II, 9.9%), concurrent fracture of anterior and posterior colliculus (16 type III, 13.2%), and supra-intercollicular groove fracture (66 type IV, 54.5%). Therewere three variants of type IV fractures: transverse (type IVa), vertical (type IVb), and comminuted fracture (type IVc). The angles α and β varied accordingly. Conclusion. Our findings yield insight into the characteristics and recurrent patterns of medial malleolar fractures. The proposed classification system is helpful in understanding injury mechanisms and guiding diagnosis, as well as surgical strategies. Cite this article: Bone Joint J 2021;103-B(5):931–938

Aims. Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot. Patients and Methods. We undertook a retrospective review of 285 consecutive patients presenting over an eight- year period with a fracture of the navicular. Five common patterns of injury were identified and classified according to the radiological features. Type 1 fractures are dorsal avulsion injuries related to the capsule of the talonavicular joint. Type 2 fractures are isolated avulsion injuries to the tuberosity of the navicular. Type 3 fractures are a variant of tarsometatarsal fracture/dislocations creating instability of the medial ray. Type 4 fractures involve the body of the navicular with no associated injury to the lateral column and type 5 fractures occur in conjunction with disruption of the midtarsal joint with crushing of the medial or lateral, or both, columns of the foot. Results. In order to test the reliability and reproducibility of this new classification, a cohort of 30 patients with a fracture of the navicular were classified by six independent assessors at two separate times, six months apart. Interobserver reliability and intraobserver reproducibility both had substantial agreement, with kappa values of 0.80 and 0.72, respectively. Conclusion. We propose a logical, all-inclusive, and mutually exclusive classification system for fractures of the navicular that gives associated injuries involving the lateral column due consideration. We have shown that this system is reliable and reproducible and have described the rationale for the subsequent treatment of each type. Cite this article: Bone Joint J 2018;100-B:176–82

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

Introduction. The current treatment for Freiberg's osteochondrosis centres around either: simple debridement or debridement osteotomy. The main principle of the osteotomy is to rotate normal articular cartilage into the affected area. We recommend the use of CT scanning to delineate the amount of available, unaffected cartilage available to rotate into the affected space. Methods. We retrospectively reviewed 32 CT scans of new Freiberg's diagnoses in Sheffield over a 10 year period using the PACS system. We identified the sagittal CT slice that displayed the widest portion of proximal articular margin of the proximal phalanx and measured the diseased segment of the corresponding metatarsal head as an arc (in degrees). This arc segment was divided by 360°. This gave a ratio of the affected arc in the sagittal plane. Results. 28 out of 32 cases involved the 2nd metatarsal with the remaining 4 involving the 3rd metatarsal head. Of 32 cases, 18 had fragmentation. Surgically, 20 had debridement only, 5 also had an osteotomy and 1 had a fusion. 6 of the 32 cases were managed non-operatively. 11 cases out of 32 had an arc ratio of < 0.3. Of these, only 3 had an osteotomy, 3 had no procedure and 5 had a simple debridement. Of those that had osteotomies (5/32), 3 of the 5 cases had an arc ratio of < 0.3 with the other 2 being 0.42 and 0.38. Discussion. We hypothesise that those cases with an arc ratio of less 0.3 would be amenable to a dorsal closing wedge osteotomy and those with a ratio of more than 0.4 would be better suited to a simple debridement. For those cases between 0.3–0.4, we feel either option is viable. Further work to prove or disprove outcomes related to our classification is required

Background. The cavovarus foot is a complex 3-dimensional deformity. Although a multitude of techniques are described for its surgical management, few of these are evidence based or guided by classification systems. Surgical management involves realignment of the hindfoot and soft tissue balancing, followed by forefoot balancing. Our aim was to classify the pattern of residual forefoot deformities once the hindfoot is corrected, to guide forefoot correction. Methods. We included 20 cavovarus feet from adult patients with Charcot-Marie-Tooth who underwent weightbearing CT (mean age 43.4 years, 14 males). Patients included had flexible deformities, with no previous surgery. Previous work established majority of rotational deformity in cavovarus feet occurs at the talonavicular joint, which is often reduced during surgery. Using specialised software (Bonelogic 2.1, Disior) a 3-dimensional, virtual model was created. Using data from normal feet as a guide, the talonavicular joint of the cavovarus feet was digitally reduced to a ‘normal’ position. Models of the corrected position were exported and geometrically analysed using Blender 3.6 to identify anatomical trends. Results. We identified 3 types of cavovarus forefoot morphotypes. Type 1 was seen in 13 cases (65%) and was defined as a foot where only the first metatarsal was relatively plantarflexed to the rest of the foot, with no significant residual adduction after talonavicular correction. Type 2 was seen in 4 cases (20%) and was defined as a foot where the second and first metatarsals were progressively plantarflexed, with no significant adduction. Type 3 was seen in 3 cases (15%) and was defined as a foot where the metatarsals were still adducted after talonavicular de-rotation. Conclusion. We classify 3 forefoot morphotypes in cavovarus feet. It is important to recognise and anticipate the residual forefoot deformities after hindfoot correction as different treatment strategies may be required for different morphotypes to achieve balanced correction

Introduction:. Prompted by the success of hip and knee arthroplasty, total ankle replacement (TAR) has become increasingly popular as a treatment for end stage arthritic complaints of the ankle. Glazebrook et al proposed a three grade classification of complications to assist prediction of early implant failure. We have compared the experience of a tertiary referral centre in the UK to Glazebrook's proposed system. Method:. A retrospective review of the Sheffield Foot and Ankle Unit TAR database was performed from 1995 to 2010. All complications were recorded and categorised using Glazebrook's proposed system. Glazebrook described eight main complications of increasing severity. Low grade complications; Post operative bone fracture, Intra-operative bone fracture and wound healing problems were very unlikely to lead to revision. Medium grade complications; technical error and subsidence, lead to failure < 50% of the time. High grade complications; deep infection, aseptic loosening and implant failure lead to revision > 50% of the time. Results:. 217 TAR were implanted in 198 patients with a minimum follow up of 30 months. The complication rate was 23% with a revision rate of 17%. All complications recorded in our study except intraoperative bone fracture and wound healing had a failure rate of at least 50%. Conclusion:. The proposed classification system of Glazebrook et al was the first step towards an international system of classifying TAR complications. Most complications associated with TAR have a significant impact on the lifespan of a TAR. Glazebrook et al's proposed three tier system did not reliably reflect our experience. We would categorise complications as either high or low risk for early failure of TAR

Background. Many approaches to management of medial malleolar fractures are described in the literature however, their morphology is under investigated. The aim of this study was to analyse the morphology of medial malleolar fractures to identify any association with medial malleolar fracture non-union or malunion. Methods. Patients who had undergone surgical fixation of their MMF were identified from 2012 to 2022, using electronic patient records in a single centre. Analysis of their preoperative, intraoperative, and postoperative radiographs was performed to determine their morphology and prevalence of non-union and malunion. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology. Results. A total of 650 patients were identified across a 10-year period which could be included in the study. The overall non-union rate for our cohort was 18.77% (122/650). The overall malunion rate was 6.92% (45/650). There was no significant difference in union rates across the Herscovici classification groups. Herscovici type A fractures were significantly more frequently malreduced at time of surgery as compared to other fracture types (p=.003). Medial wall blowout combined with Hercovici type B fractures showed a significant increase in malunion rate. There is a higher rate of bone union in patients who have been anatomically reduced. Conclusion. The morphology of medial malleolar fractures does have an impact of the radiological outcome following surgical management. Medial wall blowout fractures were most prevalent in adduction-type injuries; however, it should not be ruled out in rotational injuries with medial wall blowouts combined with and Herscovici type B fractures showing a significant increase in malunions. Herscovici type A fractures had significantly higher malreductions however the clinical implications of mal reducing small avulsions is unknown

Background. The only existing classification of Müller-Weiss Disease (MWD), based solely on Méary's angle, serves neither as guide for prognosis nor treatment. This accounts for lack of gold standard in its management. Methods. Navicular compression, medial extrusion, Kite's angle and metatarsal lengths were measured on all radiographs of 95 feet with MWD. Joints involved, presence and location of navicular fracture were recorded. Results. We identified three distinct groups. Group 1 comprises 11 “early-onset” MWD feet, aged 9 to 29 years. These had the greatest compression and medial extrusion, and lowest Kite's angles. All except 1 were index minus and had a lateral navicular fracture. None has required surgery to date. Only 1 has moderate talonavicular joint (TNJ) degeneration. Group 2 comprises 23 “Müller-Weissoid” feet with radiologically normal navicular in their fifties and developing MWD, on average, 4.5 years later. These had the lowest compression and extrusion, and highest Kite's angles. None had complete fracture. All had TNJ arthritis, with early changes at lateral naviculocuneiform joint (NCJ) in 43%. Group 3 “late-onset” MWD, presenting in the sixth decade, is subdivided into 3 sub-groups. Only TNJ is involved in group 3A (16). Group 3B denotes affection of TNJ more than NCJ (20). In group 3C “reverse Müller-Weiss disease”, which affects NCJ more than TNJ (25), second metatarsal overlength is highest of all groups. No difference in age, compression, extrusion and Kite's angle exists among the 3 subgroups. No fracture occurred in group 3A compared to 65% and 32% in groups 3B and 3C, respectively. Conclusions. With a need to compare like-for-like pathology, the proposed classification provides a common platform for reporting outcomes of different treatment modalities, operative or nonoperative. We theorize pathogenetic pathways in the different groups and propose systematic surgical approaches for each category

Introduction. Tibial Pilon fractures are potentially limb threatening, yet standards of care are lacking from BOFAS and the BOA. The mantra of “span, scan, plan” describes staged management with external fixation to allow soft tissue resuscitation, followed by a planning CT-scan. Our aim was to evaluate how Tibial Pilon fractures are acutely managed. Methods. ENFORCE was a multi-centre retrospective observational study of the acute management of partial and complete articular Tibial Pilon fractures over a three-year period. Mechanism, imaging, fracture classification, time to fracture reduction and cast, and soft tissue damage control details were determined. Results. 656 patients (670 fractures) across 27 centres were reported. AO fracture classifications were: partial articular (n=294) and complete articular (n=376). Initial diagnostic imaging mobilities were: plain radiographs (n=602) and CT-scan (n=54), with all but 38 cases having a planning CT-scan. 526 fractures had a cast applied in the Emergency Department (91 before radiological diagnosis), with the times taken to obtain post cast imaging being: mean 2.7 hours, median 2.3 hours, range 28 mins – 14 hours). 35% (102/294) of partial articular and 57% (216/376) of complete articular (length unstable) fractures had an external fixator applied, all of which underwent a planning CT-scan. Definitive management consisted of: open reduction internal fixation (n=495), fine wire frame (n=86), spanning external fixator (n=25), intramedullary nail (n=25), other (n=18). Conclusion. The management of Tibial Pilon fractures is variable, with prolonged delays in obtaining post cast reduction radiographs, and just over half of length unstable complete articular fractures being managed with the gold standard “span, scan, plan” staged soft tissue resuscitation. A BOFAS endorsed BOAST (British Orthopaedic Association Standard for Trauma) for Tibial Pilon fractures is suggested for standardisation of the acute management of these potentially limb threatening injuries, together with setting them apart from more straightforward ankle fractures

Introduction. Treatment pathways of 5. th. metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management. Primary objective. To investigate the reliability of assessment of subtypes of 5. th. metatarsal fractures by different observers. Methods. Patients were identified from our prospectively collected database. We included all patient referred to our virtual fracture clinic with a suspected or confirmed 5. th. metatarsal fracture. Plain AP radiographs were reviewed by two observers, who were initially trained on the 5. th. metatarsal classification identification. Zones were defined as Zone 1.1, 1.2, 1.3, 2, 3, diaphyseal shaft (DS), distal metaphysis (DM) and head. An inter-observer reliability analysis using Cohen's Kappa coefficient was carried out, and degree of observer agreement described using Landis & Koch's description. All data was analysed using IBM SPSS v.27. Results. 878 patients were identified. The two observers had moderate agreement when identifying fractures in all zones, apart from metatarsal head fractures, which scored substantial agreement (K=.614). Zones 1.1 (K=.582), 2 (K=.536), 3 (K=.601) and DS (K=.544) all tended towards but did not achieve substantial agreement. Whilst DS fractures achieved moderate agreement, there was an apparent difficulty with distal DS, resulting in a lot of cross over with DM (DS 210 vs 109; DM 76 vs 161). Slight agreement with the next highest adjacent zone was found when injuries were thought to be in zones 1.2, 1.3 and 2 (K=0.17, 0.115 and 0.152 respectively). Conclusions. Reliability of sub-categorising 5. th. metatarsal fractures using standardised instructions conveys moderate to substantial agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow up during a virtual clinic review, defining fractures of zones 1–3 needs careful consideration

Aims. To describe outcome reporting variation and trends in non-pharmacological randomized clinical trials (RCTs) of distal tibia and/or ankle fractures. Methods. Five electronic databases and three clinical trial registries were searched (January 2000 to February 2022). Trials including patients with distal tibia and/or ankle fractures without concomitant injuries were included. One reviewer conducted all searches, screened titles and abstracts, assessed eligibility, and completed data extraction; a random 10% subset were independently assessed and extracted by a second reviewer at each stage. All extracted outcomes were mapped to a modified version of the International Classification of Functioning, Disability and Health framework. The quality of outcome reporting (reproducibility) was assessed. Results. Overall, 105 trials (n = 16 to 669 participants) from 27 countries were included. Trials compared surgical interventions (n = 62), post-surgical management options (n = 17), rehabilitative interventions (n = 14), surgical versus non-surgical interventions (n = 6), and pre-surgical management strategies (n = 5). In total, 888 outcome assessments were reported across seven domains: 263 assessed body structure or function (85.7% of trials), 136 activities (68.6% of trials), 34 participation (23.8% of trials), 159 health-related quality of life (61.9% of trials), 247 processes of care (80% of trials), 21 patient experiences (15.2% of trials), and 28 economic impact (8.6% of trials). From these, 337 discrete outcomes were described. Outcome reporting was inconsistent across trials. The quality of reporting varied widely (reproducibility ranged 4.8% patient experience to 100% complications). Conclusion. Substantial heterogeneity in outcome selection, assessment methods, and reporting quality were described. Despite the large number of outcomes, few are reported across multiple trials. Most outcomes are clinically focused, with little attention to the long-term consequences important to patients. Poor reporting quality reduces confidence in data quality, inhibiting data synthesis by which to inform care decisions. Outcome reporting guidance and standardization, which captures the outcomes that matter to multiple stakeholders, are urgently required. Cite this article: Bone Jt Open 2022;3(10):832–840

Objectives. Cartiva synthetic cartilage implant (SCI) is licenced for use in management of symptomatic hallux rigidus in several countries including the UK. As for now, there are no independent comparative series for treatment of hallux rigidus utilising polyvinyl alcohol implants. Study design and methods. Patients at a single centre with symptomatic hallux rigidus who underwent Cartiva SCI implant procedure were identified. First metatarsophalangeal joint arthritis was radiographically graded according to the Hattrup and Johnson (HJ) classification. Pre-operative and post-operative patient-reported outcomes were evaluated using the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale and the Manchester-Oxford Foot Questionnaire (MOXFQ). Results. 66 patients (19M, 47F) (43R and 23L) were followed up for an average of 14 months (min=2, max=36). 17 patients suffered from HJ2/moderate arthritis and 49 patients with grade HJ3/severe arthritis. Post-operative mean FAAM scores showed statistically significant improvement (p< 0.0001). Patients reported a 40% increase in functionality during activities of daily living. All 3 MOXFQ Domain scores improved significantly (p< 0.02). The Index score improved by 28 points (p< 0.0001). There was no correlation between length of follow up or age and PROMs (r=0.129). No statistical difference was demonstrated between sexes. However clinically, males and older patients exhibit better outcomes. There was a 89.4% patient satisfaction with the use of Cartiva. Conclusions. Our study shows excellent results with statistically significant improvements in functional outcomes, and promising short-term follow-up with low early revision rates. Pain in particular was significantly reduced. One third of patients developed post-operative stiffness requiring a manipulation under anaesthesia. Patient selection is key. Additional imaging may be required to assess sesamoid osteoarthritis. At 3 years the implant has demonstrated to be safe and efficacious in the management of hallux rigidus. Durability and survivability of the implant will continue to be studied in this cohort

Introduction. This is a multi-centre, prospective, observational study of 503 INFINITY fixed bearing total ankle arthroplasties. We report the minimum two-year results of this prosthesis which was introduced to the UK Market in 2014 and is now the most used ankle arthroplasty in the National Joint Registry of England and Wales. Methods. Patients were recruited from 11 centres in the United Kingdom between June 2016 and November 2019. Demographic, radiographic, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Foot Ankle Questionnaire and Euroquol 5D-5L) were collected preoperatively, at 6 months, 1 year and 2 years and 5 years. The average age was 67.8 (range 23.9 to 88.5) and average BMI 29.3 (18.9 to 48.0). The COFAS grading system was used to stratify deformity. There were 261 (51.9%) COFAS Type 1, 122 (24.2%) COFAS Type 2, 31 (6.2%) COFAS 3 and 89 (17.7%) COFAS type 4. 38 patients (7.6%) presented with inflammatory arthritis. 99 (19.7%) implantations utilised patient specific instrumentation. Complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts and/or subsidence. Results. The mean follow up was 34.2 months (range 24–64). 15 patients have died, 8 withdrawn and 3 lost to follow up. 8 implants (1.6%) have been revised. According to the Glazebrook classification there were low grade complications in 6.6%, medium grade in 1.4% and high grade in 1.6%. There have been an additional 13 non revision re-operations (2.6%) at the latest follow up. There was a significant (p < 0.01) improvement across all functional outcome scores at a minimum of 2yr follow up. Discussion and conclusion. This large cohort has shown a low early revision rate and high functional outcomes with a low-profile fixed bearing prosthesis

Aims. The Cartiva synthetic cartilage implant (SCI) entered mainstream use in the management of first metatarsophalangeal joint (MTPJ) arthritis following the positive results of large trials in 2016. Limited information is available on the longer-term outcomes of this implant within the literature, particularly when independent from the originator. This single-centre cohort study investigates the efficacy of the Cartiva SCI at up to five years. Methods. First MTPJ arthritis was radiologically graded according to the Hattrup and Johnson (HJ) classification. Preoperative and sequential postoperative patient-reported outcome measures (PROMs) were evaluated using the Manchester-Oxford Foot Questionnaire (MOXFQ), and the activities of daily living (ADL) sub-section of the Foot and Ankle Ability Measure (FAAM). Results. Patients were followed up for a mean of 66 months (SD 7.1). Of an initial 66 cases, 16 did not return PROM questionnaires. A total of six failures were noted, with survival of 82%. Overall, significant improvement in both objective scores (MOXFQ and FAAM ADL) was maintained versus preoperatively: 18.2 versus 58.0 (p > 0.001) and 86.2 versus 41.1 (p > 0.001), respectively. The improvement was noted to be less pronounced in males. Subjective scores had deteriorated since early follow-up, with an interval decrease in patient satisfaction from 89% to 68%. Furthermore, a subset of cases demonstrated clinically important interval deterioration in objective scores. However, no specific patient factors were found to be associated with outcomes following analysis. Conclusion. This study represents the longest-term independent follow-up in the literature. It shows reassuring mid-term efficacy of the Cartiva SCI with better-than-expected survival. However, deterioration in scores for a subset of patients and lower satisfaction may predict ongoing failure in this group of patients. Additionally, males were noted to have a lower degree of improvement in scores than females. As such, ongoing observation of the SCI to assess durability and survivability, and identify predictive factors, is key to improving patient selection. Cite this article: Bone Jt Open 2024;5(9):799–805

Background. Hallux rigidus is a common condition characterised by first metatarsophalangeal joint (MTPJ) degeneration, pain and limited range of motion (ROM). The gold standard surgical treatment is arthrodesis, providing good pain relief but sacrifices ROM. Recently the Cartiva synthetic cartilage implant (SCI) has been utilised as an interpositional arthroplasty, aiming to reduce pain whilst preserving range of motion. Current evidence for Cartiva SCI is largely based on a single cohort with mixed outcomes. We sought to evaluate the clinical outcomes of Cartiva SCI compared to arthrodesis undertaken in our centre. Methods. Retrospective review of patients undergoing Cartiva SCI or arthrodesis for treating hallux rigidus was conducted. Preoperative arthritis was radiographically graded using the Vanore classification. Patient reported outcomes (PROMs) were assessed using EuroQol 5-dimension score (EQ-5D-5L) and Manchester-Oxford Foot Questionnaire (MOXFQ). Results. Between 2017 and 2020 there were 33 cases (17 Cartiva, 16 arthrodesis, mean age 59.0±9.9 years) with a mean follow up of 2.3 years. For the first MTPJ arthrodesis cohort, the MOXFQ domain scores were: Index 3.9±5.8, Walking/Standing 5.1±7.6, Pain 3.2±5.0, and Social Interaction 2.6±4.0. EQ-5D-5L Index score was 0.828±0.270 and the EQ-VAS was 72.5±23.3. For the Cartiva cohort, the MOXFQ domain scores were: Index 7.7±6.0, Walking/Standing 8.9±7.9, Pain 7.1±5.0, and Social Interaction 6.4±5.4. EQ-5D-5L Index score was 0.631±0.234 and the EQ-VAS was 74.8±20.8. There was no statistically significant difference between any MOXFQ domain or EQ-5D-5L scores. However, a negative trend in MOXFQ domains was identified for the Cartiva group, as well as a reoperation rate of 23.5%. Conclusions. The Cartiva SCI demonstrated no advantage over arthrodesis in PROMs, despite the presumed benefit of preserved ROM. A significant reoperation rate was also observed. Surgeons should be cautious in the use of this novel implant

Aims. The hypothesis of this study was that bone peg fixation in the treatment of osteochondral lesions of the talus would show satisfactory clinical and radiological results, without complications. Methods. Between September 2014 and July 2017, 25 patients with symptomatic osteochondritis of the talus and an osteochondral fragment, who were treated using bone peg fixation, were analyzed retrospectively. All were available for complete follow-up at a mean 22 of months (12 to 35). There were 15 males and ten females with a mean age of 19.6 years (11 to 34). The clinical results were evaluated using a visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score preoperatively and at the final follow-up. The radiological results were evaluated using classification described by Hepple et al based on the MRI findings, the location of the lesion, the size of the osteochondral fragment, and the postoperative healing of the lesion. Results. The mean VAS and AOFAS score improved significantly from 6.3 (4 to 8) and 70.6 (44 to 78) preoperatively to 1.6 (0 to 5) and 91.1 (77 to 100) at the final follow-up, respectively (p < 0.001). The classification on MRI was stage 2a in nine patients, stage 3 in 14, and stage 4 in two. The lesion was located on the posteromedial aspect of the dome of the talus in 19 patients, the anterolateral aspect in five, and the centrolateral aspect in one. The mean size of the fragment was 11.2 mm (5 to 20) horizontally, 10.4 mm (7 to 18) vertically, and 5.2 mm (3 to 10) deep, respectively. The postoperative healing state was good in 19 patients and fair in six. Conclusion. Bone peg fixation for osteochondral lesions of the talus showed satisfactory clinical and radiographic results, without complications. This technique could be a good form of treatment for patients with this condition who have an osteochondral fragment. Cite this article: Bone Joint J 2020;102-B(10):1349–1353

Aims

When a total ankle arthroplasty (TAA) fails, it can be converted to a fusion or a revision arthroplasty. Despite the increasing numbers of TAAs being undertaken, there is little information in the literature about the management of patients undergoing fusion following a failed TAA. The primary aim of this study was to analyze the survival of fusions following a failed TAA using a large dataset from the National Joint Registry (NJR).

Aims. The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations. Patients and Methods. A total of 108 patients were treated for a Lisfranc fracture dislocation over a period of nine years. Of these, 38 underwent transarticular screw fixation, 45 dorsal bridge plating, and 25 a combination technique. Injuries were assessed preoperatively according to the Myerson classification system. The outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) score, the validated Manchester Oxford Foot Questionnaire (MOXFQ) functional tool, and the radiological Wilppula classification of anatomical reduction. Results. Significantly better functional outcomes were seen in the bridge plate group. These patients had a mean AOFAS score of 82.5 points, compared with 71.0 for the screw group and 63.3 for the combination group (p < 0.001). Similarly, the mean Manchester Oxford Foot Questionnaire score was 25.6 points in the bridge plate group, 38.1 in the screw group, and 45.5 in the combination group (p < 0.001). Functional outcome was dependent on the quality of reduction (p < 0.001). A trend was noted which indicated that plate fixation is associated with a better anatomical reduction (p = 0.06). Myerson types A and C2 significantly predicted a poorer functional outcome, suggesting that total incongruity in either a homolateral or divergent pattern leads to worse outcomes. The greater the number of columns fixed the worse the outcome (p < 0.001). Conclusion. Patients treated with dorsal bridge plating have better functional and radiological outcomes than those treated with transarticular screws or a combination technique. Cite this article: Bone Joint J 2018;100-B:468–74

Aims

This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures.

Background. There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. In our previous multicenter study (Powell, BOFAS 2016) we showed that the Olerud-Molander Ankle Score (OMAS) was 79 for unimalleolar fractures and 65 for bi malleolar fractures, however it dropped significantly to 54 in trimalleolar fractures. In creating a treatment guiding classification, we report our results in a system change in management of posterior malleolar fractures in our unit. Method. All fractures were classified according to Mason and Molloy classification (BOFAS 2015, FAI 2017) based on CT scans obtained pre-operatively. This dictated the treatment algorithm. Type 1 fractures underwent syndesmotic fixation. Type 2A fractures underwent ORIF through a posterolateral incision, and type 2B and 3 fractures underwent ORIF through a posteromedial incision. The patient remained NWB for 6 weeks postoperative. Data was collected from December 2014 to July 2017. Results. Patient related outcome measures were obtained in 50 patients with at least 6 month follow up (mean 18 months). According to Mason and Molloy classification there were 17 type 1, 12 type 2A, 10 type 2B and 11 type 3. The mean OMAS for type 1 was 75.9 (Range 30–100, SD 18.4), type 2A 75.0 (range 35–100, SD 21.3), type 2B 74.0 (range 55–100, SD 13.7) and type 3 70.5 (Range 35–100, SD 17.1). An increase in OMAS of 4 is clinically significant. Conclusion. We have been able demonstrate an improvement in OMAS for all posterior malleolar fractures with the treatment algorithm applied using the Mason and Molloy classification. Compared to our previous study we have successfully increased our OMAS scores to what would be expected from unimalleolar fractures. Mason and Molloy type 3 fractures have marginally poorer outcomes, which correlates with a more significant injury, however this does not reach statistical significance