We analyzed the radiographic results of patients treated surgically for flatfoot deformity and who underwent medial cuneiform opening wedge osteotomy as part of the operative procedure. The aim of this study was to confirm the utility of the cuneiform osteotomy as part of the correction of hindfoot and ankle deformity. All patients requiring operative management of flatfoot deformity between January 2002 and December 2007 were prospectively entered in a database. We selected all patients who underwent medial cuneiform opening wedge osteotomy. We measured standardized and validated radiographic parameters on pre and post-operative weight bearing radiographs of the foot. All radiographs were assessed using the digital imaging software package (Siemens). The following measurements were used: lateral talus-1st metatarsal angle; medial cuneiform to floor distance (mm), talar declination angle, calcaneal-talar angle, calcaneal pitch angle, 1st metatarsal declination angle, talonavicular coverage angle, and anteroposterior talus-1st metatarsal angle. Other variables including concomitant surgical procedures, healing of the osteotomy, malunion, and adjacent joint arthritis were also noted. There were 86 patients with a mean age of 36 years (range 9–80). 15 patients had bilateral surgery. The aetiology of the deformity was flexible flat-foot in 48, rupture of the posterior tibial tendon in 41, rigid flatfoot deformity with a fixed forefoot supination deformity in 7, and fixed forefoot varus with metatarsus elevatus in 5. In addition to an opening wedge medial cuneiform osteotomy, a lateral column lengthening calcaneus osteotomy was performed in 80, a gastrocnemius recession in 76, a supramalleolar osteotomy in 2, a triple arthrodesis in 4, a subtalar arthroerisis in 13, excision of an accessory navicular in 6, a tendon transfer in 15 and medial-slide calcaneal osteotomy in 8 patients. The mean lateral talus-1st metatarsal angle improved from 23° to 1°; the mean medial cuneiform to floor distance improved from 20mm to 34mm; the mean talar declination angle improved from 39° to 27°; the mean calcaneal-talar angle improved from 64° to 55°; the calcaneal pitch angle improved from 14° to 23°; the mean 1st metatarsal declination angle improved from 17° to 26°; the mean talonavicular coverage angle improved from 45° to 18°; and the mean anteroposterior talus-1st metatarsal angle improved from 19° to 0° Radiographical analysis confirms that the medial cuneiform opening wedge osteotomy is a reliable and valuable surgical tool in the correction of the forefoot which is associated with flatfoot deformity and that arthrodesis of the 1st metatarsocuneiform joint may not be required to obtain correction of the elevated 1st metatarsal

Introduction

The aetiology of hallux valgus is almost certainly multifactoral. The biomechanics of the first ray is a common factor to most. There is very little literature examining the anatomy of the proximal metatarsal articular surface and its relationship to hallux valgus deformity.

Being commonly missed in the clinical practice, Lisfranc injuries can lead to arthritis and long-term complications. There are controversial opinions about the contribution of the main stabilizers of the joint. Moreover, the role of the ligament that connects the medial cuneiform (MC) and the third metatarsal (MT3) is not well investigated. The aim of this study was to investigate the influence of different Lisfranc ligament injuries on CT findings under two specified loads. Sixteen fresh-frozen human cadaveric lower limbs were embedded in PMMA at mid-shaft of the tibia and placed in a weight-bearing radiolucent frame for CT scanning. All intact specimens were initially scanned under 7.5 kg and 70 kg loads in neutral foot position. A dorsal approach was then used for sequential ligaments cutting: first – the dorsal and the (Lisfranc) interosseous ligaments; second – the plantar ligament between the MC and MT3; third – the plantar Lisfranc ligament between the MC and the MT2. All feet were rescanned after each cutting step under the two loads. The average distances between MT1 and MT2 in the intact feet under 7.5 kg and 70 kg loads were 0.77 mm and 0.82 mm, whereas between MC and MT2 they were 0.61 mm and 0.80 mm, without any signs of misalignment or dorsal displacement of MT2. A slight increase in the distances MT1-MT2 (0.89 mm; 0.97 mm) and MC-MT2 (0.97 mm; 1.13 mm) was observed after the first disruption of the dorsal and the interosseous ligaments under 7.5 kg and 70 kg loads. A further increase in MT1-MT2 and MC-MT2 distances was registered after the second disruption of the ligament between MC and MT3. The largest distances MT1-MT2 (1.5 mm; 1.95 mm) and MC-MT2 (1.74 mm; 2.35 mm) were measured after the final plantar Lisfranc ligament cut under the two loads. In contrast to the previous two the previous two cuts, misalignment and dorsal displacement of 1.25 mm were seen at this final disrupted stage. The minimal pathological increase in the distances MT1-MT2 and MC-MT2 is an important indicator for ligamentous Lisfranc injury. Dorsal displacement and misalignment of the second metatarsal in the CT scans identify severe ligamentous Lisfranc injury. The plantar Lisfranc ligament between the medial cuneiform and the second metatarsal seems to be the strongest stabilizer of the Lisfranc joint. Partial lesion of the Lisfranc ligaments requires high clinical suspicion as it can be easily missed

Background. Lisfranc fracture dislocations are uncommon injuries, which frequently require surgical intervention. Currently, there is varying evidence on the diagnostic utility of plain radiographs (XR) and CT in identifying Lisfranc injuries and concomitant fractures. Our aim was to identify the utility of XR as compared to CT, with the nul hypothesis that there was no difference in fracture identification. Methods. A retrospective assessment of patients who had sustained a Lisfranc injury between 2013 and 2022 across two trauma centres within the United Kingdom who underwent surgery. Pre-operative XR and CT images were reviewed independently by 2 reviewers to identify the presence of associated fractures. Results. A total of 175 patients were included. Our assessment identified that XR images significantly under-diagnosed all metatarsal and midfoot fractures. The largest discrepancies between XR and CT in their rates of detection were in fractures of the cuboid (5.7% vs 28%, p<0.001), medial cuneiform (20% vs 51%, p=0.008), lateral cuneiform (4% vs 36%, p=0.113), second metatarsal (57% vs 82%, p<0.001), third metatarsal (37% vs 61%, p<0.001) and fourth metatarsal (26% vs 43%, p<0.001). As compared to CT, the sensitivity of XR was low. The lowest sensitivity for identification however was lateral foot injuries, specifically fractures of the lateral cuneiform (sensitivity 7.94%, specificity 97.3%), cuboid (sensitivity 18.37%, specificity 99.21%), fourth (sensitivity 46.7%, specificity 89.80%) and fifth metatarsal (sensitivity 45.00%, specificity 96.10%). Conclusion. From our analysis, we can determine that XR significantly under-diagnoses associated injuries in patient sustaining an unstable Lisfranc injury, with lateral foot injuries being the worst identified. We advised the use of CT imaging in all cases for appropriate surgical planning

Introduction. The exact action of the Peroneus Longus muscle on the foot is not fully understood. It is involved in a number of pathological processes like tendonitis, tenosynovitis, chronic rupture and neurological conditions. It is described as having a consistent insertion to the base of the first metatarsal, but there have also been reports of significant variations and additional slips. Our aim was to further clarify the anatomy of the main insertion of the Peroneus Longus tendon and to describe the site and frequency of other variable insertion slips. Methods and Materials. The course of the distal peroneus longus tendon and its variable insertion was dissected in 12 embalmed, cadaveric specimens. The surface area of the main insertion footprint and angle of insertion was measured using an Immersion Digital Microscribe and 3D mapping software. The site and frequency of the other insertion slips is also presented. Results. There was a consistent, main insertion to the infero-lateral aspect of the first metatarsal in all specimens. The only additional slip was to the medial cuneiform. This did not increase the total footprint. Discussion. The main footprint of the Peroneus Longus tendon is on the first metatarsal. There was an additional slip to the medial cuneiform in 33% of our specimens. Although we are unsure about the significance of this additional slip, we hope it will lead to a better understanding of the mechanism of action of this muscle and its role both in the normal and pathological foot

The exact action of the Peroneus Longus muscle on the foot is not fully understood. It is involved in a number of pathological processes like tendonitis, tenosynovitis, chronic rupture and neurological conditions. It is described as having a consistent insertion to the base of the first metatarsal, but there have also been reports of significant variations and additional slips. Our aim was to further clarify the anatomy of the main insertion of the Peroneus Longus tendon and to describe the site and frequency of other variable insertion slips. The course of the distal peroneus longus tendon and its variable insertion was dissected in 20 embalmed, cadaveric specimens. The surface area of the main insertion footprint was measured using an Immersion Digital Microscibe and 3D mapping software. The site and frequency of the other variable insertion slips is presented. There was a consistent, main insertion to the infero-lateral aspect of the first metatarsal in all specimens. The surface area of this insertion was found to be proportional to the length of the foot. The insertion in males was found to be significantly larger than females. The most frequent additional slip was to the medial cuneiform. Other less frequent insertion slips were present to the lesser metatarsals. The main footprint of the Peroneus Longus tendon is on the first metatarsal. There appears to an additional slip to the medial cuneiform frequently. Although we are unsure about the significance of these additional slips, we hope it will lead to a better understanding of the mechanism of action of this muscle and its role both in the normal and pathological foot

Metatarsus adductus (MA) is associated with a medially facing distal facet of the medial cuneiform (with a normal first metatarsal) and varus/adducted deformities of the metaphysis of the lesser metatarsals. A number of patients with severe symptomatic metatarsus adductus do not improve with time. A number of surgical techniques have been described but the series are small and use radiological rather functional outcomes. It is clear however that the failure and complication rate with these procedures is high. A combined medial cuneiform and lesser metatarsal basal closing wedge osteotomy has potential advantages over more commonly used procedures (including the combined cuneiform-calcaneal) osteotomy, by correcting at the level of deformity. We reviewed a consecutive series of 15 cases (11 severe idiopathic metatarsus adductus, 4 with history of clubfoot) (all Bleck’s grade severe) treated with combined cuneiform-metatarsal osteotomies. Patients were followed up for a mean of 30 months using child-, parent and clinician-based outcome measures as well as radiological assessment. Outcomes are also compared to currently used and historical procedures. Bleck’s grade improved to 65% normal 35% mild post op; Radiographic improvements (all p< 0.001); 1stray angle 30°→62°, 1stMT-Talar angle 43°→9°, 2ndMT-Talar angle 41°→8°, 2ndMT-Calcaneal angle 48°→14°, 5thMT-Calcaneal angle improved from 13°→3°. Mean postop scores; Chesney - 14 (12–15); Utukari – 13 (10–18); Laaweg – 93 (81–100); Vitale – 13 (10–14). None of the radiographic scores correlated with the clinical scores. All children gained improved levels of activity. Our findings indicate that this technique can be used effectively in children > 4 years and is a safe alternative to historical procedures, with excellent radiographic/ clinical outcomes, and a low complication rate

Injuries to the tarsometatarsal joint complex are uncommonly recognised. Many treatment modalities have been advocated. In recent years anatomic reduction and temporary rigid fixation with trans -articular screws has become popular. This is a study conducted over a period of at least two years. It reviews the management and subsequent outcome of a series of consecutive patients with an average age of 40.1 who suffered tarsometatarsal injury, or Lisfranc fracture. Anatomic or near anatomic reduction was achieved using temporary bridging plate fixation of the TMT joints and occasionally also with second metatarsal base medial cuneiform screw fixation. Two years post surgery a good or excellent functional result was generally achieved; however midfoot stiffness was a common problem

Introduction: Tarsometatarsal joint (TMTJ) arthrodesis is traditionally performed through a dorsal approach and is associated with higher incidence of cutaneous nerve damage, prominent metalware and high non-union rates. It is postulated that applying fixation to the plantar (tension) side, rather than the dorsal (compression) side would create a more stable construct with higher union rates. A suitable surgical approach has not previously been described. The aim of this study is to define a plantar surgical approach to the TMTJ’s. Methods: We dissected 10 cadaveric feet, identifying nerves, vessels, muscles and their innervation on the plantar aspect of the 1st and 2nd TMTJ’s. Results: We found that in all specimens a plane of dissection could be created between the two terminal divisions of the medial plantar nerve between flexor digitorum brevis and abductor hallucis. Although exposure of the 1st TMTJ was relatively easy, access to the 2nd TMTJ was difficult due to its location at the apex of the transverse metatarsal arch and the overlying peroneus longus insertion. We found that the peroneus longus tendon had a variable insertion not only at the base of the 1st metatarsal but also at the medial cuneiform and the base of the 2nd metatarsal. Discussion: This is a new surgical approach, following an internervous dissection plane. The feasibility of making an incision over the convex side of the rocker bottom deformity and the biomechanical advantage of a plantarly applied fixation device may make this an attractive surgical approach

Introduction. Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, a review of literature suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomittant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes. Methods. Thirteen consecutively treated patients (eighteen feet) were retrospectively reviewed from the senior author's practice. Clinical examination, American Orthopaedic foot and Ankle Society (AOFAS) hindfoot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction. Results. All patients with resection and simultaneous flat foot reconstruction (calcaneal lengthening, medial cuneiform osteotomy) were satisfied and would have the same procedure again. Most patients were able to return to a higher level of sporting activity compared with preoperative ability. None of the patients had a fair or poor outcome as adjudged by their AOFAS scores. Conclusion. Our study shows that concomittant flatfoot reconstruction in patients with symptomatic middle facet tarsal coalition increased hindfoot motion, corrected malalignment and significantly improved pain. We believe that coalition resection and concomitant flatfoot reconstruction is better option than surgical resection alone or hindfoot fusion in this cohort of patients. Triple arthrodesis should be reserved as a salvage procedure

Aims

The Chopart joint complex is a joint between the midfoot and hindfoot. The static and dynamic support system of the joint is critical for maintaining the medial longitudinal arch of the foot. Any dysfunction leads to progressive collapsing flatfoot deformity (PCFD). Often, the tibialis posterior is the primary cause; however, contrary views have also been expressed. The present investigation intends to explore the comprehensive anatomy of the support system of the Chopart joint complex to gain insight into the cause of PCFD.

Aim. Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, recent evidence suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomitant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes. Method. We identified eleven children (13 feet) who had resections of middle facet tarsal coalitions with or without complex foot reconstruction (calcaneal lengthening, medial cuneiform osteotomy) for concurrent severe planovalgus between 2003 and 2011. Clinical examination, American Orthopaedic Foot and Ankle Society (AOFAS) hind-foot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction. Results. Isolated coalition resection provided short to intermediate term pain relief for three children that had this as a solitary procedure. Calcaneal lengthening osteotomy performed as an additional procedure in patients with very severe and stiff planovalgus provided excellent correction and symptomatic pain relief in all six patients (Mean AOFAS: 91). Two patients had insertion of sinus tarsi implants in addition to resection also had satisfactory hind foot function (Mean AOFAS: 87.3) post operatively. Conclusion. This study shows that calcaneal lengthening osteotomy in addition to coalition resection in patients with severe rigid flat feet provides excellent pain relief and function. Rigid flat feet should be considered as a significant contributor to the pain complex in this cohort of patients

Introduction. The operative management for Distal Tibialis Anterior Tendinopathy (DTAT) without rupture has not previously been described. We present 15 cases. Method. of 39 patients diagnosed clinically and radiographically with DTAT, we reviewed the 13 patients who underwent surgery for failure of non-operative management. Assessment included pre and post-operative AOFAS midfoot scoring, clinical examination and post-operative VAS pain scoring. Results. Twelve women (13 feet) and one man (two feet) underwent surgery. Mean age at surgery was 59 years (42 to 76 years). The mean duration of symptoms prior to surgery was one year (5 to 25 months). The mean pre-operative AOFAS score was 50 (23 to 75). Pre-operative MRI showed tendinosis in six tendons and tendinosis with longitudinal split tears in nine tendons. Five of the 14 cases showed some associated degenerative changes of the midfoot. Six tendons were simply debrided and the insertion reinforced with a suture anchor. Nine tendons were augmented with an Extensor Hallucis Longus (EHL) transfer into the medial cuneiform. The mean improvement in AOFAS score was 35 (4 to 57), with mean post-operative pain VAS of 1 (0 to 6.7) at a mean follow-up of 24 months (three to 65). Two patients underwent concomitant procedures on the same foot. Four of the nine treated with EHL transfer have some symptomatic hallux interphalangeal joint extensor lag. In seven cases the patient was completely satisfied. Five were satisfied with minor reservations. Of the three that were dissatisfied, two underwent subsequent surgery improving their symptoms. The third, though pain-free, was troubled by her toe catching when walking barefoot. No patients regret having had the surgery. Conclusion. Debridement and repair of DTAT, with EHL augmentation for greater than 50% tendon involvement, provides a high level of patient satisfaction if non-operative management fails

Tarsal fractures are rare in children. Clinical and radiographic evaluation of these injuries can be difficult. We present a retrospective study documenting all tarsal fractures presenting to an inner-city children’s hospital in the UK over a fifteen year period. Of 70 case notes retrieved from the hospital database, 7 patients were excluded due to inadequate data. This resulted in 69 tarsal injuries in 63 patients being included. Mean age at presentation was 9.3 years (2.5 – 13.9). 80% were male. 72% were calcaneal fractures, 12% cuboid, 9% navicular, 4% talus and 2% medial cuneiform. The main method of diagnosis was plain x-rays. Cause of injury was predominantly fall from height, crush or road traffic accident. 25% had another associated lower extremity injury. Three patients had bilateral tarsal injuries. Only 3% had upper limb injuries and there were no injuries with spinal involvement. Calcaneal fractures were treated with a short leg cast for a mean time of 4.1 weeks (2–6). Mean time to recovery was 5.7 weeks (2–20). Mean time to discharge from clinic was 7 weeks (2–40). There were two patients with open fractures requiring surgical debridement. One patient with a talar fracture had percutaneous fixation. Only one patient re-presented with pain following discharge. X-rays showed healing avascular necrosis of the proximal talus. Tarsal fractures are rare, usually benign and most require simple immobilisation for only a short period of time. Surgical intervention is only occasionally required in complex injuries. Complications and long term problems are rare, even following open injuries

Background: The results of operative management for distal tibialis anterior tendinopathy (DTAT) without rupture have not previously been described in the orthopaedic literature. We present the results of 15 operative procedures. Method: Of 40 patients diagnosed clinically and radiographically with DTAT, we reviewed the 13 patients who underwent surgery for failure of non-operative management. Assessment included pre and postoperative AOFAS midfoot scores, clinical examination and postoperative VAS pain scoring. Results: Twelve women (13 feet) and one man (2 feet) underwent surgery. The mean age at surgery was 59 years. The mean duration of symptoms prior to surgery was 1 year. The mean pre-operative AOFAS score was 53. Preoperative MRI showed tendinosis with longitudinal split tears in 10 tendons and tendinosis alone in two tendons. Seven of the 15 cases showed some associated degenerative changes of the midfoot. Six tendons were simply debrided and the insertion reinforced with a suture anchor. Nine tendons were augmented with an Extensor Hallucis Longus (EHL) transfer into the medial cuneiform. All patients improved postoperatively, with a mean improvement in AOFAS score of 32 and the mean postoperative pain VAS of 1.0 out of 10, at a mean follow-up of 24 months. Three patients underwent concomitant procedures on the same foot. Four of the nine treated with EHL transfer have some symptomatic hallux interphalangeal joint extensor lag. In seven cases the patient was completely satisfied. Five were satisfied with minor reservations. Of the three that were dissatisfied, two underwent subsequent surgery improving their symptoms. The third, though pain free, was troubled by her toe-catching when walking barefoot. No patient regretted having had the surgery. Conclusion: Debridement and repair of DTAT, with EHL augmentation for greater than 50% tendon involvement, provides a high level of patient satisfaction if non-operative management fails

Introduction Nineteen consecutive patients underwent flexor hallucis longus (FHL) tendon transfer and medial displacement calcaneal osteotomy for the treatment of Stage 2 posterior tibial tendon dysfunction. Methods The FHL tendon was utilized for transfer because it approximates the strength of the posterior tibiais muscle and is stronger than the peroneus brevis muscle. Seventeen patients returned for follow-up examination (average 18 months). Results The AOFAS hindfoot score improved from 62/100 to 84/100. The subjective portion of the AOFAS hindfoot score improved from 31/60 to 49/60. Weight bearing pre-operative and post-operative radiographs revealed no statistically significant improvement for the medial longitudinal arch in measurements of lateral talo-first metatarsal angle, calcaneal pitch, vertical distance from the floor to the medial cuneiform or talo-navicular coverage angle. Three feet had a normal medial longitudinal arch and six feet had a longitudinal arch similar to the opposite side following the procedure. Patient satisfaction was high: 10 patients satisfied without reservations, six patients satisfied with minor reservations and one dissatisfied. No patient complained of donor defecit from the harvested FHL tendon. Conculsions Despite the inability of the procedure to improve the height of the medial longitudinal arch, FHL transfer combined with medial diplacement calcaneal osteotomy yielded good to excellent clinical results and a high patient satisfaction rate. In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits

Introduction: Standard arthrodesis of the first metatarsophalageal joint (MTPJ) is often carried out for degenerative disease in the presence of a hallux valgus without a first metatarsal corrective osteotomy. Despite this there is an improvement in the intermetatarsal angle (IMA) as well as the position of the tibial sesamoid. We attempt to quantify the amount of correction in this study. Method: A cohort of 30 (35 feet) consecutive patients (10 males, 20 females) treated from May 2006 to May 2007 were reviewed. The mean age was 61.6 years (39 to 78 years). All patients underwent a standard primary fusion of the first MTPJ with a low profile plate and compression screw. There was no attempt to free the sesamoids, perform a lateral release or medial reefing of the medial capsule. We measured the hallux valgus angle (HVA), IMA as well as the position of the tibial sesamoid pre and postoperatively using a digital radiology imaging system. Result: The mean improvement in IMA was 3.38° (p< 0.001) with a mean correction of 2.5° (p=0.02), 6.5° (p=0.02) and 5.8° (p=0.06) in the mild, moderate and severe groups respectively. A greater correction is expected with a more severe initial IMA (r=0.688). A similar trend is seen with the severity of the initial HVA (r=0.640). The tibial sesamoid position also tends to improve by one station (spearman correlation 0.861) post operatively. Conclusion: There is an improvement in the IMA when the first MTPJ is fused. This improvement is proportional to the severity of the initial HVA and IMA. There is also an improvement in the resting position of the tibial sesamoid. We conclude that with a mobile first metatarsal medial cuneiform joint, the IMA corrects spontaneously when the first MTPJ is arthrodesed negating the need for a separate corrective osteotomy of the first metatarsal

Introduction: The unique architecture of the tarsometa-tarsal joints gives rise to a complex articulation between the midfoot and forefoot. The Lisfranc injury has a classic pattern leaving its telltale signs in an arch pattern starting at the medial cuneiform, continuing through the second, third and fourth tarsometatarsal regions and finally may end as a fracture of the cuboid. However, various other patterns and classifications of Lisfranc fracture dislocation have been recorded in medical literature. Aim: To highlight the hitherto undescribed arch patterns of Lisfranc injuries. Methodology: 8 patients with atypical Lisfranc injuries were studied prospectively. Arch patterns: In 2 patients the arch started at the medial aspect of the ankle with injury to the medial malleolus or the deltoid ligament, passed through the tarsometatarsal region and ended at the cuboid. In one patient the arch started at the tarsometatarsal joints and ended at the lateral malleolus and in another patient the lateral end point resulted in tear of the calcaneofibular ligament. One patient had the medial starting point at the Lisfranc ligament but the arch of injuries went through the forefoot fracturing the midshaft of the 2nd, 3rd and 4th metatarsal shafts without injuring the tarsometatarsal region, thus forming an arch pattern much more distal than usual. Six of the 8 patients had operative management. On follow up, in terms of activities of daily living, 75% had excellent function of the foot. It is not the aim of this paper to highlight the management of these injuries. Conclusion: In the process of listing the telltale signs of a Lisfranc injury it is mandatory to bear in mind that the arch of injuries may extend to as proximal as the ankle joint or as distal as the forefoot and this will enable us to define the entire spectrum of the Lisfranc injury, however atypical it may be

Introduction: Adult acquired flat foot deformity is recognised as a spectrum of pathology related to tibialis posterior dysfunction (TPD) and plantar ligament insufficiency. Cobb has described a method of reconstruction in pure Johnson and Strom type II TPD using a split Tibialis Anterior musculo-tendinous graft. Methods: We describe a prospective study of 32 patients treated by the Cobb technique and a medial displacement translational os calcis osteotomy for Johnson and Strom type II TPD. There were 28 females and four males (age range 44–66, average 54) each with unilateral disease. The average follow up was 5.1 years, range 3 to 7.2 years. Each patient had failed conservative management and the staging was confirmed clinically and radiologically (ultrasound scanning and MRI). The surgery was performed as described by Cobb but with a bone tunnel in the navicular rather than the medial cuneiform. Postoperative immobilisation in plaster was for eight weeks followed by orthotics and physiotherapy. Results: All the os calcis osteotomies healed uneventfully. 29 of the 32 patients were able to perform a single heel rise test (none prior to surgery) at twelve months follow-up. These patients had grade 5 power of the tibialis posterior tendon. The others had grade 4 power and were also happy with the result. The mean American orthopaedic foot and ankle society (AOFAS) hindfoot score was 82. There was one superficial wound infection successfully treated by antibiotics and a temporary dysaesthesia in the medial plantar nerve in another. Discussion: This prospective study confirms that the Cobb technique is an excellent method of treating pure Johnson and Strom type II TPD after failed conservative management. The procedure is performed with a medial displacement os calcis osteotomy but in selected cases may be combined with spring ligament repair and lateral column lengthening. An updated classification will be presented designed to facilitate the decision making process in this difficult condition