Aims. Arthroplasty has become increasingly popular to treat end-stage ankle arthritis. Iatrogenic posterior neurovascular and tendinous injury have been described from saw cuts. However, it is hypothesized that posterior ankle structures could be damaged by inserting tibial guide pins too deeply and be a potential cause of residual hindfoot pain. Methods. The preparation steps for ankle arthroplasty were performed using the Infinity total ankle system in five right-sided cadaveric ankles. All tibial guide pins were intentionally inserted past the posterior tibial cortex for assessment. All posterior ankles were subsequently dissected, with the primary endpoint being the presence of direct contact between the structure and pin. Results. All pin locations confer a risk of damaging posterior ankle structures, with all posterior ankle structures except the flexor hallucis longus tendon being contacted by at least one pin. Centrally-aligned transcortical pins were more likely to contact posteromedial neurovascular structures. Conclusion. These findings support our hypothesis that tibial guide pins pose a considerable risk of contacting and potentially damaging posterior ankle structures during ankle arthroplasty. This study is the first of its kind to assess this risk in the Infinity total ankle system. Cite this article: Bone Jt Open 2021;2(7):503–508

Background. Despite the suggestion by Virchow in 1856 that thrombosis was the result of venous stasis, endothelial dysfunction and hypercoagulability there are some fundamental questions which remain to be answered. The published studies fail to provide specific details such as cast type and anatomical location of the thrombosis, but instead focus on the incidence of VTE and which chemical thromboprophylaxis is most effective. Previous studies of VTE in trauma patients have involved small numbers of patients and have not look at the risk medium to long term risk. Most importantly they have not looked at the site of the VTE. This makes interpretation of the link between cast and VTE even more complex. Methodology. We analysed 1479 consecutive trauma cast applications and the incidence of symptomatic VTE in the six months following the injury. The diagonosis, cast type and site of the VTE was recorded. Results. The overall incidence of DVT was 2.5% (2.2% distal and 0.3% proximal), 50% occured inthe first 3 weeks, the rest were between 6–13 weeks. The incidence of PE was 0.7%, there was 1 death due to PE. Achilles tendon injury was a statistically significant risk factor, there were no other conditions with a specific risk. There was no difference between above and below knee cast immobilisation. However all symptomatic DVTs occured in the casted leg. Discussion. This is the first study to look at long term VTE risk and the site of thrombosis, these findings have implications for VTE prophylaxis. It would appear that the risk of developing symptomatic VTE extends beyound the currently advised treatment period. It also suggests that venous stasis and endothelial damage are more important that hypercoagulability in the development of VTE after cast treatment for trauma. We recommend a programme of exercises within the cast to reduce this risk

Background. The use of a knotless TightRope for the stabilisation of a syndesmotic injury is a well-recognised mode of fixation. It has been described that the device can be inserted using a “closed” technique. This presents a risk of saphenous nerve entrapment and post-operative pain. Aim. We aimed to establish the actual risk of injury to the Saphenous Nerve using a “closed” technique for the insertion of a TightRope. Method. 20 TightRopes were inserted into Fresh Frozen Cadavers. This was done using the senior authors preferred technique of divergent tightropes with the distal implant directed slightly anterior to the fibula-tibia axis and the proximal implant slightly posterior in order to simulate the greatest risk to the nerve. This was done under image Intensifier guidance to simulate an intraoperative environment. The medial side of the distal tibia was then dissected to directly record and measure the relationship of the TightRope to the Saphenous Nerve. Measurements were taken using digital calipers from the centre of the button on the medial side of the TightRope to the centre of the nerve at the point of closest proximity. Results. 12 TightRopes were found to exit posterior to the nerve, 7 anterior and 1 penetrated through the centre of the nerve. The mean distance from the centre of the button to the nerve was 6.99mm (range 0.72–14.52mm, standard deviation 4.33mm). In 9 of the 20 TightRopes, the nerve was found to be less than 5mm away. Conclusion. Our findings demonstrated that the risks of damaging or indeed entrapping the Saphenous nerve were high, and therefore we would advocate an open incision on the medial side with judicious exploration to ensure there is no damage to the medial neurological structures

Despite advancements, revision rates following total ankle replacement (TAR) are high in comparison to other total joint replacements. This explant analysis study aimed to investigate whether there was appreciable metal particulate debris release from various contemporary TARs by describing patterns of material loss. Twenty-eight explanted TARs (9 designs: 3 fixed and 6 mobile bearing), revised for any reason, were studied. The articulating surfaces of the metal tibial and talar components as well as the polyethylene insert were assessed for damage features using light microscopy. Based on the results of the microscopic analysis, scanning electron microscopy with energy dispersive X-ray spectroscopy was performed to determine the composition of embedded debris identified, as well as non-contacting 3D profilometry. Pitting, indicative of material loss, was identified on the articulating surfaces of 54% of tibial components and 96% of talar components. Bearing constraint was not found to be a factor, with similar proportions of fixed and mobile bearing metal components showing pitting. More cobalt-chromium than titanium alloy tibial components exhibited pitting (63% versus 20%). Significantly higher average surface roughness (Sa) values were measured for pitted areas in comparison to unpitted areas of these metal components (p<0.05). Additionally, metallic embedded debris (cobalt-chromium likely due to pitting of the tibial and talar components or titanium likely from loss of their porous coatings) was identified in 18% of polyethylene inserts. The presence of hard 3. rd. body particles was also indicated by macroscopically visible sliding plane scratching, identified on 79% of talar components. This explant analysis study demonstrates that metal debris is released from the articulating surfaces and the coatings of various contemporary TARs, both fixed and mobile bearing. These findings suggest that metal debris release in TARs may be an under-recognised issue that should be considered in the study of painful or failed TAR moving forwards

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Osteochondral lesions of the talus (OLT) are a common cause of disability and chronic ankle pain. Many operative treatment strategies have been introduced; however, they have their own disadvantages. Recently lesion repair using autologous cartilage chip has emerged therefore we investigated the efficacy of particulated autologous cartilage transplantation (PACT) in OLT.

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Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm². However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus.

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The aim of this study was to capture 12-month outcomes from a representative multicentre cohort of patients undergoing total ankle arthroplasty (TAA), describe the pattern of patient-reported outcome measures (PROMs) at 12 months, and identify predictors of these outcome measures.

Introduction:. There are concerns with the use of the Shannon burr in calcaneal osteotomies entered from the lateral side, with the medial structures possibly at risk when performing the osteotomy of the medial calcaneal wall. Our aims with this study were to investigate the neurovascular relationships with the calcaneal osteotomy performed using a Shannon burr. Methods:. This study was performed at the anatomy department, University of Sussex, Brighton. There were 13 fresh frozen below knee cadaveric specimens obtained for this study. The osteotomy was performed using a Shannon burr using a minimally invasive technique. The neurovascular structures were then dissected out to analyse their relation and any damage. Results:. Laterally, there was no evidence of damage to any neurological structure in 11 feet. In two feet, a very small lateral calcaneal branch was transected. In both cases, this was a very proximal branch from the sural nerve. There were between one and five lateral calcaneal branches of the sural nerve, and a very proximal branch present in nine feet. The minimum distance from the burr to the sural nerve was 9mm. In all cases, the entry point was within 6mm of the closest lateral calcaneal branch. Medially, there was no evidence of damage to any neurovascular structure. Quadratus plantae was present in 12 of 13 feet acting as a barrier to the neurovascular structures, and was not breached by the burr, shielding the neurovascular structures from injury. There were one or two medial calcaneal nerve branches, which all crossed the osteotomy, but were not damaged. Conclusion:. The calcaneal osteotomy performed by a Shannon burr can cause possible damage to small branches of the sural nerve, but is protected by QP form causing damage to any medial structures

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The rationale for exacting restoration of skeletal anatomy after unstable ankle fracture is to improve outcomes by reducing complications from malunion; however, current definitions of malunion lack confirmatory clinical evidence.

Objectives. The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits. Methods. A PubMed search about the management of acute Achilles tendon rupture was performed. The search was open for original manuscripts and review papers limited to publication from January 2006 to July 2017. A total of 489 papers were identified initially and finally 323 articles were suitable for this review. Results. The treatments of acute Achilles tendon rupture include operative and nonoperative treatments. Operative treatments mainly consist of open repair, percutaneous repair, mini-open repair, and augmentative repair. Traditional open repair has lower re-rupture rates with higher risks of complications. Percutaneous repair and mini-open repair show similar re-rupture rates but lower overall complication rates when compared with open repair. Percutaneous repair requires vigilance against nerve damage. Functional rehabilitation combining protected weight-bearing and early controlled motion can effectively reduce re-rupture rates with satisfactory outcomes. Biological adjuncts help accelerating tendon healing by adhering rupture ends or releasing highly complex pools of signalling factors. Conclusion. The optimum treatment for complete rupture remains controversial. Both mini-open repair and functional protocols are attractive alternatives, while biotherapy is a potential future development. Cite this article: X. Yang, H. Meng, Q. Quan, J. Peng, S. Lu, A. Wang. Management of acute Achilles tendon ruptures: A review. Bone Joint Res 2018;7:561–569. DOI: 10.1302/2046-3758.710.BJR-2018-0004.R2

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

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The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes.

Introduction. Freiberg's infarction poses a challenge to foot and ankle surgeons. Several surgical and non surgical treatment methods are described. We performed a dorsal closing wedge osteotomy, debridement and microfracture of the metatarsal head. Dorsal closing wedge osteotomy helps in bringing the smooth plantar articular surface of the metatarsal head to articulate with the phalangeal articular cartilage whilst offloading the damaged dorsal articular cartilage. Debridement and Microfracture of the metatarsal head helps in regeneration of the damaged cartilaage via subchondral stem cells. Materials and Methods. Total of 15 patients (12F, 3M) underwent the above surgery between year 2002 and 2008. Mean age was 35yrs (range14-60). All of them had an extraarticular dorsal closing wedge osteotomy fixed with a single screw along with debridement of the joint and mocrofracture of the damaged cartilage. Post operatively heel weight bearing was allowed with a special shoe for 6 weeks. Serial radiological assessments were done to assess healing of the osteotomy and reshaping of metatarsal head. Patients had a mean follow up of 2.5 yrs (Range 1-6). All patients were assessed using subjective patient satisfaction scores (scale 0-10) and AOFAS scores. Results. 2nd metatarsal was involved in 14 and 3rd in one patient. All the osteotomies healed at a mean period of 10 weeks (range6-18). The mean patient satisfaction score was 8 (range5-10). The mean pre and post operative AOFAS scores were 54 and 82. One patient developed post operative haematoma which resolved spontaneously. No other complications noted. Conclusions. A combination of dorsal closing wedge osteotomy, debridement and microfracture is a simple, reproducible and effective method of treating Freiberg's disease with no major complications

Introduction:. Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe a purely arthroscopic technique for excising talocalcaneal coalitions. We present a retrospective two-surgeon case series of the first eight patients (nine feet). Methods:. Subtalar arthroscopy is performed from two standard sinus tarsi portals with the patient in a saggy lateral position. Coalitions are resected with a barrel burr after soft tissue clearance with arthroscopic shavers. Early postoperative mobilisation and non-steroidal anti-inflammatory drugs prevent recurrence of coalition. Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 to 5.5 years. Results:. Pain and SAFAS scores improved in 7 patients. Subtalar movements were improved in all feet and were sustained to final follow-up. All patients achieved early good function and returned to sports and demanding jobs. One patient's pain recurred requiring subsequent fusions. One posterior tibial nerve was damaged. Both of these patients had coalitions extending across more than one quarter of the posterior facet. Conclusion:. Minimal destruction of bone and soft tissues with an arthroscopic technique allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from both open and arthroscopic excision of tarsal coalitions. Patient selection and preoperative planning are crucial to avoid relapse and complication. If significant degenerative changes are present at surgery or resections are too extensive onto the posterior facet early recurrence of pain may occur. This series from two independent surgeons supports the feasibility and effectiveness of this technique

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To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle.

MIS (minimally invasive surgery) aims to improve cosmesis and facilitate early recovery by using a small skin incision with minimal soft tissue disruption. When using MIS in the forefoot, there is concern about neurovascular and tendon damage and cutaneous burns. The aim of this anatomical study was to identify the structures at risk with the proposed MIS techniques and to determine the frequency of iatrogenic injury. Materials and Methods. 10 paired normal cadaver feet were used. All procedures were performed using a mini C-arm in a cadaveric lab by 2 surgeons: 1 consultant who has attended a cadaveric MIS course but does not perform MIS in his regular practice (8 feet), and 1 registrar who was supervised by the same consultant (2 feet). In each foot, the surgeon performed a lateral release, a MICA (minimally invasive chevron and Akin) procedure for the correction of hallux valgus, and a minimally invasive DMO (distal metatarsal extra-articular osteotomy) procedure. Each foot was then dissected and photographed to identify any neurovascular or tendon injury. Results. The dorsal medial cutaneous and the plantar interdigital nerves were intact in all specimens. There was no obvious damage to the arterial plexus supplying the first metatarsal head. No flexor or extensor tendon injuries were identified. There is a significant learning curve to performing the osteotomy cuts in the desired plane. In the DMO, the dissection also revealed some intact soft tissue at the osteotomy site indicating that the metatarsal heads were not truly floating. Discussion. Although there has been concern regarding neurovascular and tendon injury, our findings indicate minimal risk, which is consistent with reports in the literature. This study also reflects the learning curve. Conclusion. We suggest that training on cadaveric specimens may be advantageous, particularly, with regard to the plane of the osteotomy

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A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

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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.

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In the context of tendon degenerative disorders, the need for innovative conservative treatments that can improve the intrinsic healing potential of tendon tissue is progressively increasing. In this study, the role of pulsed electromagnetic fields (PEMFs) in improving the tendon healing process was evaluated in a rat model of collagenase-induced Achilles tendinopathy.

We have recently described an extended lateral approach to the hindfoot for the operative treatment of displaced intra-articular fractures of the calcaneum. It has the advantage of avoiding damage to the sural nerve and preserving blood supply to allow prompt healing. We dissected 15 formalin-preserved cadavers, taking photographs to show the structures of the posterolateral aspect of the hindfoot and ankle. We describe a superficial and a deep triangle: the deep triangle contains a constant posterior peroneal artery which supplies the skin of the posterolateral heel. An approach designed to expose the sural nerve will divide this important artery and cause ischaemia of the posterior skin. The extended lateral approach elevates the sural nerve in a thick flap and preserves the blood supply of the skin. We have reviewed 150 consecutive patients after the use of this approach to study the indications for operation, the quality of wound healing, any damage to the sural nerve and other complications. We recommend the careful use of this approach. Our understanding of its anatomical basis has allowed us to widen the indications for its use