Aims. Anatomical atlases document classical safe corridors for the placement of transosseous fine wires through the calcaneum during circular frame external fixation. During this process, the posterior tibial neurovascular bundle (PTNVB) is placed at risk, though this has not been previously quantified. We describe a cadaveric study to investigate a safe technique for posterolateral to anteromedial fine wire insertion through the body of the calcaneum. Materials and Methods. A total of 20 embalmed cadaveric lower limbs were divided into two groups. Wires were inserted using two possible insertion points and at varying angles. In Group A, wires were inserted one-third along a line between the point of the heel and the tip of the lateral malleolus while in Group B, wires were inserted halfway along this line. Standard dissection techniques identified the structures at risk and the distance of wires from neurovascular structures was measured. The results from 19 limbs were subject to analysis. Results. In Group A, no wires pierced the PTNVB. Wires were inserted a median 22.3 mm (range 4.7 to 39.6) from the PTNVB; two wires (4%) passed within 5 mm. In Group B, 24 (46%) wires passed within 5 mm of the PTNVB, with 11 wires piercing it. The median distance of wires from the PTNVB was 5.5 mm (range 0 to 30). A Mann–Whitney U test showed that this was significantly closer than in Group A (Hodges–Lehmann shift, 14.06 mm; 95% confidence interval (CI) 10.52 to 16.88; p < 0.0001). In Group B, with an increased angle of insertion there was greater risk to the PTNVB (r. s.  = -0.80; p < 0.01). Conclusion. Insertion of wires using an entry point one-third along a line from the point of the heel to the tip of the lateral malleolus (Group A) appears to be the safer technique. An insertion angle of up to 30° to the coronal plane can be used without significant risk to the PTNVB. Insertion of wires halfway along a line from the point of the heel to the tip of the lateral malleolus (Group B) carried a significantly higher risk of injury to neurovascular structures and, if necessary, an angle of insertion parallel to the coronal plane should be used. Cite this article: Bone Joint J 2018;100-B:1054–9

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

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

Aims

The aim of this prospective study was to evaluate the intermediate-term outcomes after revision anatomical ankle ligament reconstruction augmented with suture tape for a failed modified Broström procedure.