Aims. The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a percutaneous extra-articular reverse-L chevron (PERC) osteotomy. . Patients and Methods. A total of 38 patients underwent 45 procedures. There were 35 women and three men. The mean age of the patients was 48 years (17 to 69). An additional percutaneous Akin osteotomy was performed in 37 feet and percutaneous lateral capsular release was performed in 22 feet. Clinical and radiological assessments included the type of forefoot, range of movement, the American Orthopedic Foot and Ankle (AOFAS) score, a subjective rating and radiological parameters. . The mean follow-up was 59.1 months (45.9 to 75.2). No patients were lost to follow-up. Results. The mean AOFAS score increased from 62.5 (30 to 80) pre-operatively to 97.1 (75 to 100) post-operatively. A total of 37 patients (97%) were satisfied. At the last follow up there was a statistically significant decrease in the hallux valgus angle, the intermetatarsal angle and the proximal articular set angle. The range of movement of the first metatarsophalangeal joint improved significantly.. There was more improvement in the range of movement in patients who had fixation of the osteotomy of the proximal phalanx. Conclusion. Preliminary results of this percutaneous approach are promising. This technique is reliable and reproducible. Its main asset is that it maintains an excellent range of movement. Take home message: The PERC osteotomy procedure is an effective approach for surgical management of moderate hallux valgus which combines the benefits of percutaneous surgery with the versatility of the chevron osteotomy whilst maintaining excellent first MTPJ range of motion. Cite this article: Bone Joint J 2016;98-B:365–73

Introduction. The attachment of the plantar aponeurosis to the proximal phalanx of the toe, through the plantar plate (PP), forms the main flexor of the toe during gait by the reversed windlass mechanism. Disruption of the plantar plate is a common cause of pain, instability and toe deformity. Surgical techniques have recently been described to repair tears but long term results are awaited. This study aims to review the results of a technique designed to reconstruct and reinforce the failed plantar plate and restore the reversed windlass. Methods. Through a dorsal extra-articular approach the EDL tendon of the affected toe is used to restore the mechanical link between the proximal phalanx and the plantar aponeurosis on the plantar aspect of the joint. 42 PP reconstructions in 39 patients (36 female) aged 44–72 were undertaken, most frequently on the 2. nd. toe. 25 required correction of hallux valgus and four had undergone this previously. Follow up was 2–81 months. Results. Normal alignment and joint stability was obtained in 33 toes (81%). These patients reported no pain and were completely satisfied with the final result. Recurrence of the deformity with an unstable joint occurred in 8 toes, requiring revision surgery. Failure was more likely with pre-operative dislocation, lateral subluxation, or multiple toe involvement. Minor complications occurred in 5 patients. Conclusions. Repair or reconstruction of the plantar plate for lesser claw toe deformity is a logical option for correcting the deformity, and restoring toe function and the reversed windlass mechanism. The extra-articular approach may reduce the risk of joint stiffness, avoid scarring of the plantar tissues, and avoid toe elevation associated with metatarsal shortening. This approach is designed to reinforce the weakened plantar plate and may be a satisfactory alternative and more durable technique than direct plantar plate repair

In recent years the Weil osteotomy has become the dominant technique employed by most surgeons for distal metatarsal osteotomy. This is generally a reliable technique but problems with stiffness can frequently occur in the operated metatarso-phalangeal joints. We present our experience with a minimally invasive distal metatarsal extra-articular osteotomy technique. This technique utilises a high-speed burr via a tiny skin portal to perform a distal metatarsal extra-articular osteotomy under image intensifier guidance without the need for fixation. A consecutive series of 55 osteomies in 21 patients were included in the study. All osteotomies were performed for metatarsalgia/restoration of metatarsal cascade. The mean age was 49 (38-78), and 20/21 were female. The senior author performed all surgery. All patients were allowed to weight bear immediately in a postoperative shoe and then an ordinary shoe from 4-6 week post-operatively. Mean follow-up was 8 months (4-13) and patients were assessed clinically and scored using the AOFAS scoring system and a subjective outcome score. The mean AOFAS score improved significantly postoperatively. All patients were very satisfied/satisfied with the outcome. Two patients had minor superficial portal infections, which resolved with oral antibiotics. One patient reported irritating numbness and stiffness in toes (1st case performed). Most patients reported swelling persisting to 3-4 months. There was one symptomatic delayed at 4 months treated successfully with short air boot immobilisation. There were no mal unions. This series suggests that MIS distal metatarsal osteotomy results compare well with outcomes reported with modern open techniques such as the Weil. We now favour an MIS distal metatarsal osteotomy technique for most indications due to the minimal stiffness observed postoperatively as well as much reduced surgical time without the need for tourniquet

Introduction. Second ray problems are common, especially chronic MTP joint dislocation, and intractable metatarsalgia caused by a relatively long second ray we describe a new extra-articular technique that allows considerable shortening. Patients. We retrospectively reviewed 19 patients who underwent this type of osteotomy between 2006 and 2008. Mean age at operation was 62 years (43-78). All patients were. The indications for the operation were either MTP joint dislocation, or metatarsalgia caused by a relatively long metatarsal. This in turn was usually due to length lost on the first ray. Functional outcome was evaluated using the Manchester-Oxford foot and ankle score (MOXF), which is a validated outcome measure, the score being from zero to 64. A low numerical score indicates a good outcome. It assesses three main domains, walking, pain and social interaction. Range of motion, patient satisfaction and complication rates were also recorded. All patients had AP and lateral weight bearing radiographs. Results. At an average follow up of 20 months (5 -42) the mean total MOXF score was 17 (SD16). The metric scores for pain was15, walking 20 and social 15. Radiographically all patients showed sound bone. The majority of patients (16 of 19) reported that they are either ‘better’ or ‘much better’ following surgery, in terms of pain, function and quality of life. No patient developed transfer or recurrent metatarsalgia. No significant MTP joint stiffness was seen, and none of our patients developed osteonecrosis of the metatarsal head. Conclusion. Our new technique allows a planned, controlled shortening of the metatarsal with a stable fixation. The ‘long oblique’ osteotomy heals well, and is extra-articular. This avoids the joint stiffness which can follow the Weil osteotomy. We believe this technique makes a useful contribution to the surgical treatment of metatarsalgia and chronic MTP joint sublu

Introduction:. The surgical treatment of intractable metatarsalgia has been traditionally been an intra-articular Weil's type of metatarsal osteotomy. In such cases, we adopted the option of performing a minimally invasive distal metaphyseal metatarsal ostetomy (DMMO) to decompress the affected ray. The meta-tarsophalangeal joint was not jeopardised. We present our outcomes of Minimally Invasive Surgery for metatarsalgia performed at our teaching hospital. Material and methods:. This is a multi-surgeon consecutive series of all the thirty patients who underwent DMMO. The sex ratio was M: F- 13:17. Average age of patients was 60 yrs. More than one metatarsal osteotomy was done in all cases. The aim was to try and decompress the affected rays but at the same time, restore the metatarsal parabola. It was performed under image-intensifier guidance, using burrs inserted via stab incisions. Patients were encouraged to walk on operated foot straight after the operation; the rationale being that the metatarsal length sets automatically upon weight bearing on the foot. Outcome was measured with Manchester-Oxford Foot Questionnaire's (MOXFQ's) and visual analogue pain score (VAS). Minimum follow up was for six months. Results:. The average MOXFQ score was 26. Average improvement in the visual analogue pain score was 3.5. VAS deteriorated in three patients' whose pain got worse after surgery. Among these three, two had a further procedure on their toes. All of the patients experience prolonged forefoot swelling for at least 3 months. Discussion:. The most common complication after intra-articular ostetomy of the metatarsal head is stiffness of the metatarsophalangeal joint. We believe that using minimally invasive surgery with an extra-articular osteotomy, reduces the soft tissue injury to the joint, and therefore the amount of post-operative stiffness. In our cohort of patients, DMMO is associated with good patient satisfaction and low complication rates in the vast majority of cases

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

Aims

Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°.

Aims

This paper documents the epidemiology of adults (aged more than 18 years) with a calcaneal fracture who have been admitted to hospital in England since 2000. Secondary aims were to document whether publication of the United Kingdom Heel Fracture Trial (UK HeFT) influenced the proportion of patients admitted to hospital with a calcaneal fracture who underwent surgical treatment, and to determine whether there has been any recent change in the surgical technique used for these injuries.

Aims

Identifying predictors of compartment syndrome in the foot after a fracture of the calcaneus may lead to earlier diagnosis and treatment. The aim of our study was to identify any such predictors.

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.

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration.

In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:1299–1311.

The last decade has seen a considerable increase in the use of in total ankle arthroplasty (TAA) to treat patients with end-stage arthritis of the ankle. However, the longevity of the implants is still far from that of total knee and hip arthroplasties.

The aim of this review is to outline a diagnostic and treatment algorithm for the painful TAA to be used when considering revision surgery.

Cite this article: Bone Joint J 2017;99-B:5–11.

Pigmented villonodular synovitis (PVNS) is a rare benign disease of the synovium of joints and tendon sheaths, which may be locally aggressive. We present 18 patients with diffuse-type PVNS of the foot and ankle followed for a mean of 5.1 years (2 to 11.8). There were seven men and 11 women, with a mean age of 42 years (18 to 73). A total of 13 patients underwent open or arthroscopic synovectomy, without post-operative radiotherapy. One had surgery at the referring unit before presentation with residual tibiotalar PVNS. The four patients who were managed non-operatively remain symptomatically controlled and under clinical and radiological surveillance. At final follow-up the mean Musculoskeletal Tumour Society score was 93.8% (95% confidence interval (CI) 85 to 100), the mean Toronto Extremity Salvage Score was 92 (95% CI 82 to 100) and the mean American Academy of Orthopaedic Surgeons foot and ankle score was 89 (95% CI 79 to 100). The lesion in the patient with residual PVNS resolved radiologically without further intervention six years after surgery. Targeted synovectomy without adjuvant radiotherapy can result in excellent outcomes, without recurrence. Asymptomatic patients can be successfully managed non-operatively. This is the first series to report clinical outcome scores for patients with diffuse-type PVNS of the foot and ankle.

Cite this article: Bone Joint J 2013;95-B:384–90.

There are few reports of the surgical treatment for late stage Freiburg’s disease with flattening of the metatarsal head and osteoarthritis. We describe the results of the surgical treatment of ten consecutive patients with advanced stage Freiburg’s disease (Smillie’s stage V), using a technique that has not been published previously.

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.

Severe hallux valgus deformity is conventionally treated with proximal metatarsal osteotomy. Distal metatarsal osteotomy with an associated soft-tissue procedure can also be used in moderate to severe deformity. We compared the clinical and radiological outcomes of proximal and distal chevron osteotomy in severe hallux valgus deformity with a soft-tissue release in both. A total of 110 consecutive female patients (110 feet) were included in a prospective randomised controlled study. A total of 56 patients underwent a proximal procedure and 54 a distal operation. The mean follow-up was 39 months (24 to 54) in the proximal group and 38 months (24 to 52) in the distal group. At follow-up the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal score, patient satisfaction level, and complications were similar in each group. Both methods showed significant post-operative improvement and high levels of patient satisfaction. Our results suggest that the distal chevron osteotomy with an associated distal soft-tissue procedure provides a satisfactory method for correcting severe hallux valgus deformity.

Cite this article: Bone Joint J 2013;95-B:510–16.

We describe the surgical technique and results of arthroscopic subtalar release in 17 patients (17 feet) with painful subtalar stiffness following an intra-articular calcaneal fracture of Sanders’ type II or III. The mean duration from injury to arthroscopic release was 11.3 months (6.4 to 36) and the mean follow-up after release was 16.8 months (12 to 25). The patient was positioned laterally and three arthroscopic portals were placed anterolaterally, centrally and posterolaterally. The sinus tarsi and lateral gutter were debrided of fibrous tissue and the posterior talocalcaneal facet was released. In all, six patients were very satisfied, eight were satisfied and three were dissatisfied with their results. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from a mean of 49.4 points (35 to 66) pre-operatively to a mean of 79.6 points (51 to 95). All patients reported improvement in movement of the subtalar joint. No complications occurred following operation, but two patients subsequently required subtalar arthrodesis for continuing pain.

In the majority of patients a functional improvement in hindfoot function was obtained following arthroscopic release of the subtalar joint for stiffness and pain secondary to Sanders type II and III fractures of the calcaneum.