Introduction. Charcot neuroarthropathy is a limb threatening condition and the optimal surgical strategy for limb salvage in gross foot deformity remains unclear. We present our experience of using fine wire frames to correct severe midfoot deformity, followed by internal beaming to maintain the correction. Materials and Methods. Nine patients underwent this treatment between 2020–2023. Initial deformity correction by Ilizarov or hexapod butt frame was followed by internal beaming with a mean follow up of 11 months. A retrospective analysis of radiographs and electronic records was performed. Meary's angle, calcaneal pitch, cuboid height, hindfoot midfoot angle and AP Meary's angle were compared throughout treatment. Complications, length of stay and the number of operations are also described. Results. Mean age was 53 years (range:40–59). Mean frame duration was 3.3 months before conversion to beaming. Prior frame-assisted deformity correction resulted in consistently improved radiological parameters. Varying degrees of subsequent collapse were universal, but 5 patients still regained mobility and a stable, plantargrade, ulcer-free foot. Complications were common, including hardware migration (N=6,66%), breakage (N=2,22%), loosening (N=3,33%), infection (N=4,44%), 1 amputation and an unscheduled reoperation rate of 55%. Mean cumulative length of stay was 42 days. Conclusions. Aggressive deformity correction and internal fixation for Charcot arthropathy requires strategic and individualised care plans. Complications are expected for each patient. Patients must understand this is a limb salvage scenario. This management strategy is resource heavy and requires timely interventions at each stage with a well-structured MDT delivering care. The departmental learning points are to be discussed

Purpose. Operative treatment of Lisfranc joint injuries typically includes reduction and stabilization of the medial and middle columns of the midfoot. Mobility of the lateral column is preserved where possible, such that indications for lateral column stabilization rely upon the surgeons assessment of instability. In this case series, the indication for lateral column stabilization was defined by the results of an intra-operative stress test. The purpose of this study was to determine whether an intra-operative fluoroscopic stress test of the lateral column was sufficient to determine the need for internal fixation of the lateral column in Lisfranc joint injuries. Method. 35 adult patients with Lisfranc injuries operated in our centre by a single surgeon from 2005–2009 were reviewed. All patients had unstable midfoot fracture dislocations, treated by reduction and internal fixation including an intra-operative stress examination to determine the need for lateral column fixation. Patients were contacted for clinical and radiographic review at a mean of 31 months post injury. Functional outcome was assessed using general and joint-specific outcome tools (AOFAS midfoot score and LEM). Radiographic review included analysis of joint displacement and arthritic changes in preoperative, postoperative, and most recent radiographs. Results. Pre-operative imaging demonstrated displacement of the lateral column in 25 / 35 patients. Nineteen of these 25 had a stable reduction of the lateral column following medial and middle column fixation, based upon an intra-operative stress examination. Only 6 patients had persistent instability; these were treated with lateral column stabilization. Reduction of the lateral column was maintained at final follow up in 100 percent of 35 patients. Lateral midfoot pain was present in 5/6 patients requiring lateral fixation, compared to 1/(19) patient who did not require lateral fixation. AOFAS midfoot scores (mean) were 80 15. in patients with no evidence of lateral column instability, 79 15. in patients with preoperative displacement but a negative stress examination, and 77 18 in patients requiring lateral fixation (p>0.05). Post-traumatic arthrosis was present in 3/10 patients with no evidence of lateral column instability, 4/19 patients with preoperative displacement but a negative stress examination, and 4/6 in patients requiring lateral fixation (p>0.05). Conclusion. The decision to stabilize the lateral column during surgery on Lisfranc injuries was aided by an intra-operative fluoroscopic stress examination. Based upon the stress examination, 19 / 25 patients who had a displaced lateral column at the time of presentation avoided lateral fixation. None of these 19 patients treated without lateral fixation lost reduction in the follow up period. A fluoroscopic intra operative stress test safely reduced the need for lateral column fixation in displaced Lisfranc joint injuries

Introduction. Surgical approaches to the dorsum of the foot are common for management of midfoot fracture dislocations and arthritis. The anatomy can be difficult to identify and neurovascular injury can be a serious complication. Extensor hallucis brevis (EHB) is a consistent and easily identifiable structure encountered in these approaches. This study assesses the close relationship of the EHB musculotendinous junction to the neurovascular bundle for use as a reliable landmark. Method. The relationship of the medial branch of the deep peroneal nerve (DPN) in the dorsum of the foot to the EHB tendon was examined by dissection of ten adult cadaveric feet preserved in formalin. Using a dorsal approach, the anatomy of the DPN neurovascular bundle was studied relative to its neighbouring structures. Local institutional review board approval was obtained. Results. The neurovascular bundle runs parallel to the lateral border of extensor hallucis longus (EHL) over the dorsum of the midfoot. Lateral to the neurovascular bundle is the EHB muscle running obliquely towards the first metatarsal. The average length of transition of the musculotendinous junction is 11mm and the neurovascular bundle passes underneath this junction in nine out of ten cases, and through it in one specimen. This junction is directly over the 2. nd. tarsometatarsal joint. Discussion. Although a cadaveric study where tissue characteristics are different to those of living tissue, this study has shown that the neurovascular bundle with the medial branch of the deep peroneal nerve and corresponding artery can be identified by finding the musculotendinous junction of the EHB

The mid foot joints are usually the first to be affected in Charcot neuroarthropathy(CN). Reconstruction is technically demanding and fraught with complications. Fixation methods have evolved over time from cancellous screws, plates, bolts and a combination of these.

We present our experience of mid foot fusion in CN from a tertiary diabetic foot centre. In this series we undertook mid foot corrective fusion in 27 feet (25patients) and are presenting the results of those with a minimumof six months follow up. Twelve of these had concurrent hindfoot fusion. Eleven patients had type 1 diabetes, 12 had type 2 and 2 were non-diabetics. 23 patients were ASA grade3 and 2 were ASA 2. 21 feet had ulcers preoperatively and mean HbA1c was 8.2. 13 patients had diabetic retinopathy and 6 had nephropathy.

Average patient age was 59 (43 to 80) and our mean follow up was 35 months (7 to 67). One patient was lost to follow up and 2 patients died. 18 patients had plates, 3 had bolts and 6 had a combination. Complete follow up data was available for 26 feet in 24 patients. Satisfactory correction of deformity was achieved in all patients. The mean correction of calcaneal pitch was from 0.6 preoperatively to 10.6 degrees postoperatively, mean Meary angle from 22 to 9 degrees, talo- metatarsal angle on AP view from 33 to 13 degree. Bony union was achieved in 21 out of 26 feet and atleast one joint failed to fuse in 5. 19 out of 24 patients were able to mobilize fully or partially weight bearing. We had 6 patients with persisting and 3 withrecurrent ulceration. Seven repeat procedures were carried out which included 2 revision fixations. 4 out of 5 non-unions were seen where bolts were used alone or supplemented with plates.

With our technique and a strict protocol 100% limb salvage and 81% union was achieved. 80% patients were mobile and ulcer healing was achieved in 72%. Corrective mid foot fusion is an effective procedure in these complex casesbut require the input of a multidisciplinary team for perioperative care.

Aim. The aim of this paper is to analyse the cause of neuropathic diabetic foot ulcers and discuss their preventive measures. Methods. Review of patients with foot ulcers managed in our diabetic MDT clinics since Feb 2018 were analysed. Based on this observation and review of pertinent literature, following observations were made. Results. Forefoot. Progressive hindfoot equinus from contraction of gastroc-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus muscles and, progressive plantar flexed metatarsal heads secondary to claw toe deformity results in increased forefoot plantar pressures. In patients with insensate feet, this result in ulcer formation under the metatarsal heads from shear stress when walking. Callosity under the metatarsal heads is the earliest clinical sign. Most patients by this time have fixed tightness of the muscle groups as assessed by negative Silfverskiold test. Percutaneous tendo-Achilles lengthening (TAL) has shown to reduce the mid-forefoot plantar pressures by 32% and ulcer healing in 96% of patients within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. Proximal metatarsal osteotomies further reduce the forefoot pressures to near normality. Midfoot. Midfoot ulcers are secondary to rocker-bottom deformity a consequence of Charcot neuroarthropathy (CN). Hindfoot equinus as described and relative osteopenia from neurally mediated increased blood flow (neurovascular theory) and repeated micro-trauma (neurotraumatic theory) result in failure of medial column osseo-ligamentous structures. As the disease progress to the lateral column, the cuboid height drops resulting in a progressive rocker bottom deformity. The skin under this deformity gradually breaks down to ulceration. In the pre-ulcerative stages of midfoot CN, TAL has shown to stabilise the disease progression and in some patents’ regression of the disease process was noted. The lump can excised electively and the foot accommodated in surgical shoes. Hindfoot. These develop commonly at the pressure areas and bony exostosis in non-ambulatory patients. In ambulatory patients, the most common cause are factors that result in over lengthening of tendo-Achilles such as after TAL, spontaneous tears, or tongue-type fractures. Conclusions. Early identification of factors that result in plantar skin callosity and treating the deforming forces prevent progression to ulceration. Total contact cast without treatment of these deforming forces results in progression of these callosities to ulceration while in the cast or soon after completion of cast treatment

Introduction. Charcot Arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. The traditional surgical method of extensive surgical exposure, excision of bone, acute correction and internal fixation is not always appropriate in presence of active ulceration, deep infection and poor bone quality. Minimally invasive osteotomies and gradual correction of deformities with a circular frame are proving helpful in minimizing complications. We present our experience with the use of Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. Materials and Methods. Our indication for the treatment with TSF is recurrent or intractable ulceration with or without active bone infection or a history of infection in a deformed foot and/or ankle. There are 2 female and 8 male patients in this cohort. We used a long bone module for ankle and hindfoot deformities (3 patients) and a forefoot 6×6 butt frame (7 patients) for midfoot deformities. An osteotomy through midfoot was performed in all chronic stable midfoot deformity cases and a calcaneal osteotomy and gradual correction through ankle in when hindfoot and ankle deformities co-existed. Results. Our outcome measures are a complete healing of ulcer and infection without recurrence, clinically plantigrade foot and ability to wear regular shoes or diabetic footwear. We achieved this outcome in 9 out of 10 patients. Successful patients remain ulcer free at minimum 7 and maximum 14 years follow up. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. Conclusions. Our results confirm that Taylor Spatial Frame treatment is a good alternative to traditional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities

Introduction. Hindfoot surgery is assumed to be more painful than midfoot/forefoot procedures with the former often requiring an inpatient stay for pain relief. Poorly controlled pain is associated with adverse patient outcomes and consequently, peripheral nerve blocks (PNB) have become popular for their effective pain control. Aim. To investigate whether hindfoot procedures are more painful than forefoot/midfoot procedures by measuring pain scores, assessing effectiveness of PNBs and patient satisfaction in foot and ankle surgery. Method. In total 140 patients were prospectively studied. Inclusion criteria: Adults undergoing elective foot and ankle surgery. Exclusion criteria: Paediatric patients 16 years and under, those with alternate sources of pain, peripheral neuropathy or incomplete pain scores. Pain was measured via the Visual Analog Scale (VAS) at 3 intervals; immediately, 6 hours and at 24 hours post-operatively. A Johnson patient satisfaction assessment was conducted at 2 weeks. Statistical analysis was performed using SPSS v.18.0. Results. Forefoot/midfoot surgery vs. hindfoot surgery pain scores showed that there was no significant difference at any post-operative interval. PNB vs. no PNB pain scores showed that there was no significant difference at the first two intervals, except at 24 hours post-operatively, p = 0.024. Patients' who had a PNB experienced rebound pain at 24 hours. Overall 94% of patients were satisfied with their experience and anaesthetic. Conclusion. Hindfoot surgery is not more painful than forefoot/midfoot surgery when PNBs are used. Additionally, patients who have a PNB experience rebound pain at 24 hours post-operatively, a finding that requires further research

The Lisfranc fracture dislocation of the tarsometatarsal joint (TMTJ) is a complex injury with a reported incidence of 9.2 to 14/100,000 person-years. Lisfranc fixation involves dorsal bridge plating, transarticular screws, combination or primary arthrodesis. We aimed to identify predictors of poor patient reported outcome measures at long term follow up after operative intervention. 127 patients underwent Lisfranc fixation at our Level One Trauma Centre between November 2007 and July 2013. At mean follow-up of 10.7 years (8.0-13.9), 85 patients (66.92%) were successfully contacted. Epidemiological data including age, gender and mechanism of injury and fracture characteristics such as number of columns injured, direction of subluxation/dislocation and classification based on those proposed by Hardcastle and Lau were recorded. Descriptive analysis was performed to compare our primary outcomes (AOFAS and FFI scores). Univariate analysis and multivariate regression analysis was done adjusted for age and sex to compare the entirety of our data set. P<0.05 was considered significant. The primary outcomes were the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Foot Function Index (FFI). The number of columns involved in the injury best predicts functional outcomes (FFI, P <0.05, AOFAS, P<0.05) with more columns involved resulting in poorer outcomes. Functional outcomes were not significantly associated with any of the fixation groups (FFI, P = 0.21, AOFAS, P = 0.14). Injury type by Myerson classification systems (FFI, P = 0.17, AOFAS, P = 0.58) or open versus closed status (FFI, P = 0.29, AOFAS, P = 0.20) was also not significantly associated with any fixation group. We concluded that 10 years post-surgery, patients generally had a good functional outcome with minimal complications. Prognosis of functional outcomes is based on number of columns involved and injured. Sagittal plane disruption, mechanism and fracture type does not seem to make a difference in outcomes

In 2010, we published results of Ponseti versus primary posteromedial release (PMR) for congenital talipes equinovarus (CTEV) in 51 prospective patients. This study reports outcomes at a median of 15 years from original treatment. We followed 51 patients at a median of 15 years (range 13–17 years) following treatment of CTEV with either Ponseti method (25 patients; 38 feet) or PMR (26 patients; 42 feet). Thirty-eight patientsd were contacted and 33 participated in clinical review (65%), comprising patient reported outcomes, clinical examination, 3-D gait analysis and plantar pressures. Sixteen of 38 Ponseti treated feet (42%) and 20 of 42 PMR treated feet (48%) had undergone further surgery. The PMR treated feet were more likely to have osteotomies and intra- articular surgeries (16 vs 5 feet, p<0.05). Of the 33 patients reviewed with multimodal assessment, the Ponseti group demonstrated better scores on the Dimeglio (5.8 vs 7.0, p<0.05), the Disease Specific Instrument (80 vs 65.6, p<0.05), the Functional Disability Inventory (1.1 vs 5.0, p<0.05) and the AAOS Foot & Ankle Questionnaire (52.2 vs. 46.6, p < 0.05), as well as improved total sagittal ankle range of motion in gait, ankle plantarflexion range at toe off and calf power generation. The primary PMR group displayed higher lateral midfoot and forefoot pressures. Whilst numbers of repeat surgical interventions following Ponseti treatment and primary PMR were similar, the PMR treated feet had greater numbers of osteotomies and intra-articular surgeries. Outcomes were improved at a median of 15 years for functional data for the Ponseti method versus PMR, with advantages seen in the Ponseti group over several domains. This study provides the most comprehensive evaluation of outcomes close to skeletal maturity in prospective cohorts, reinforcing the Ponseti Method as the initial treatment of choice for idiopathic clubfeet

Introduction. Continuous compression implants (CCIs) are small memory alloy bone staples that can provide continuous compression across a fracture site, which change shape due to temperature changes. Reviews of CCIs in orthopaedics have documented their use in mainly foot and ankle surgery, with very limited descriptions in trauma. They could be beneficial in the management of complex or open injuries due to their low profile and quick insertion time. The aim of this case series were to clarify the use of CCIs in modern day limb reconstruction practice. Materials & Methods. This was a single centred study looking retrospectively at prospective data for patients who were treated for an acute fracture or non-union with a CCI between September 2019 and May 2023. Primary outcome was to determine the function and indication of the CCI as judged retrospectively and secondary outcomes investigated unplanned returns to theatre for infection or CCI failure. Results. Sixty patients were eligible with a mean age of 44.2 (range 8–89). Fifty-one patients were treated for acute fractures, nine for non-unions; and almost half (27 patients) had open injuries. There were seven different sites for treatment with a CCI, the most common being tibia (25 patients) and humerus (14 patients). Of the 122 CCIs used, 80 were used as adjuncts for fixation in 48 patients. Their indication as an adjunct fell into three distrinct categories – reduction of fracture (39 CCIs), fixation of key fragments (38 CCIs) and compression (3 CCIs). Of these 48 patients, 4 patients had a frame fixation, 19 had a nail fixation, 24 patients had a plate fixation. Forty-two CCIs were used in isolation as definitive fixation, all were for midfoot dislocations expect an open iliac wing fixation from a machete attack and an isolated paediatric medial malleolus fixation. Two patients returned to theatre for infection and two due to CCI failure. Conclusions. This series has demonstrated the versality of CCIs across multiple sites of the body and for a large variety of injuries. It has identified, when not used in isolation, three main indications to support traditional orthopaedic fixations. Given the unpredictability in limb reconstruction surgery, the diversity and potential of CCIs could form part of the staple diet in the modern-day practice

Lisfranc injuries account for 0.2% of all fractures and have been linked to poorer functional outcomes, in particular resulting in post-traumatic arthritis, midfoot collapse and chronic pain. This study assesses the longitudinal functional outcomes in patients with low and high energy Lisfranc injuries treated both operatively and non-operatively. Patients above 16 years with Lisfranc injuries from January 2008 and December 2017 were identified through the Victorian Orthopaedic Trauma Outcomes (VOTOR) registry. Follow-up performed at 6, 12 and 24 months through telephone interviews with response rate of 86.1%, 84.2% and 76.2% respectively. Longitudinal functional outcome data using Global Outcome Assessment, EQ-5D-5L, numerical pain scale, Short-Form 12, the WHO Disability Assessment Schedule and return to work status were collected. Univariate analysis was performed and variables showing a significant difference between groups (p < 0.25) were analysed with multivariable mixed effects regression model. 745 patients included in this retrospective cohort study. At 24 months, both the operative and non-operative groups demonstrated similar functional outcomes trending towards an improvement. Mixed effect regression models for the EQ items for mobility (OR 1.80, CI 0.91 – 3.57), self-care (OR 1.95, 95% CI 1.09-3.49), usual activities (OR 1.10, 95% CI 0.99-1.03), pain (OR 1.07, 95% CI 0.61-1.89), anxiety (OR 1.29, 95% CI 0.72-2.34) and pain scale (OR 1.07, 95% CI 0.51 – 2.22) and return to work (OR 1.28, 95% CI 0.56-2.91) between groups were very similar and not statistically significantly different. We concluded that there was no statistically significant difference between operative and non-operative patients with low and high energy Lisfranc injuries. Current clinical practices in Lisfranc injury management are appropriate and not inadvertently causing any further harm to patients. Future research comparing fracture patterns, fixation types and corresponding functional outcomes can help determine gold standard Lisfranc injury management

Aim. The aim of this work was to evaluate, via foot and ankle TC scans, the outcomes of the use of a bone substitute (CERAMENT|™G) and the growth of native bone in the treatment of osteomyelitis (OM) of the diabetic foot. Method. In nine patients from July 2014 to December 2016 we used a Calcium Sulphate Hemihydrate + Hydroxyapatite + Gentamicin Sulfate (CSH + HA + GS) compound to fill resected bone voids following surgical intervention in OM diabetic foot cases. Of these nine patients, three were female and six were male and their ages were between 49 and 72 years. Four patients had hindfoot involvement and underwent partial calcanectomy. Two patients presented a rocker-bottom Charcot foot pattern III according to Sanders and Frykberg's classification and were treated with esostectomy of the symptomatic bony prominence of the midfoot. One patient presented OM of the 3°, 4° and 5° metatarsal bones. One patient underwent partial resection of the midfoot and hindfoot with arthrodesis stabilised by an internal-external hybrid fixator. One patient with a Charcot foot pattern IV-V underwent partial talectomy and calcanectomy with arthrodesis stabilised by an internal-external hybrid fixator. In all these patients - after removal of the infected bone - we applied 10 to 20 ml CSH + HA + GS filling the residual spaces with the aim of stabilising the remaining bone fragments. The uniqueness of this product is that it induces native bone growth, while the synthetic bone disappears and antibiotic is released into the surrounding tissues. In March 2018, the above nine patients underwent foot and ankle TC scans to evaluate bone growth. Results. The first four patients showed new bone formation in the calcaneus. Two patients with previous midfoot destruction showed chaotic but stable bone formation. The patient with metatarsal OM showed partial bone healing with residual pseudoarthrosis. Both the two patients who underwent arthrodesis with hybrid fixators showed a plantigrade and stable foot even though a heel wound is still present in one of the patients. All patients except this one are now wearing suitable shoes as post-operative wounds have healed. The patient still with the heel wound is walking with an aircast brace. Conclusion. The TC scans have shown new bone formation sufficient to stabilise the foot and allow ambulation. In particular, very good results come from the filling of the calcaneus, probably due to the anatomy of the bone itself

Objective. To assess the usefulness of radiographs alone to evaluate acute midfoot/forefoot injuries. We believe that foot injuries are often under-estimated and that CT scans should be routinely obtained to aid in their management and avoid additional morbidity for patients. Materials & Methods. In 26 months, 255 patients had foot injuries requiring X-Rays. Of these patients, 94 (37%) had primary radiographs indicating midfoot or forefoot fractures, and 28 had subsequent CT scans. Radiographs were retrospectively re-evaluated with respect to fracture location, type, mechanism of injury and then compared with CT results. Results. Of 255 patients, 213 (84%) had one or more fractures in their foot. A total of 397 fractures were seen with 105 patients having Os Calcis (41%) fractures. 94 patients (37%) had midfoot/forefoot fractures which included the 28 patients with subsequent CT scans. 56 patients (22%) had no injury. Of those patients with midfoot/forefoot injuries, 61 fractures were seen on plain radiographs and an additional 74 were identified on CT scanning. The major mechanism of injury in these patients was Road Traffic Accident (26 patients [28%]). Commonly missed individual fractures on plain radiography were Metatarsal (29), Cuboid (12) and Cuneiform fractures (11). Nine of the 29 (31%) metatarsal bone fractures involved missed fracture-dislocations of the Lisfranc joint. Other new fractures included Talus (4), Navicular (3), Os Calcis (2) and Tibia (2). 48 required operative fixation, including 20 patients that underwent CT scanning. We found that the sensitivity of radiographs in detection of midfoot fractures was low at 44%, and only 50% in forefoot injuries. Conclusion. In patients with high energy foot injury, and those with suspected complex injury, the sensitivity of radiography is only moderate at best. We suggest that CT scanning as the primary imaging modality would lead to a decrease in their morbidity

Introduction. Recurrence in CTEV is not uncommon and as the child becomes older the foot in question is often stiffer and less amenable to the more traditional serial casting Ponseti method. Treatment of these recurrent CTEV feet with external fixators has been previously documented. We aim to present the Sheffield technique of an external circular frame with adjunctive hindfoot and midfoot osteotomies to correct relapsed CTEV and their associated Roye (outcome) scores. Materials and Methods. Retrospective analysis of patient records from 1999 to 2019 were performed for those undergoing frame correction of CTEV. Patients were included if there was adjunctive foot osteotomies in the setting of CTEV frame correction and willingness to partake in retrospective Roye outcome scoring. The Roye score was sent out in the mail to parents asking for scoring of the current level of symptoms. Results. 160 patients were contacted for Roye score evaluation. We successfully collected outcome data for 46 feet in 39 patients. 27 (69%) patients had idiopathic CTEV. Average age at fixator application 12.6 years (range 7–18). Mean length of follow up 10.6 years (1 – 20). 76% of patients were either very (22%) or somewhat (54%) satisfied with the status of their foot. The largest negative score was 61% of parents found difficulty in finding shoes to fit their child's feet after treatment. 39% of patients had significant persistent pain associated with their feet but 67% were not at all (26%) or only somewhat (41%) limited in their walking ability. Conclusions. We have demonstrated short to mid term follow up for relapsed CTEV treated via external fixation. The Roye score has demonstrated a large proportion of patients are overall satisfied with their outcome with the most common complaints being difficulties in finding shoes to fit and persistent pain on strenuous activity

Flexible flat foot is considered one of the commonest normal variants in children's orthopaedic practice. The weightbearing foot is usually regarded as flexible on the basis of results from clinical and radiographic examination as well as measured foot-ground pressure pattern. Our aim was to compare the pedobarographic and radiographic findings of normal arched and symptomatic flexible flat feet and investigate if there were sensitive markers that could be used in selecting patients for surgical correction. We retrospectively collected data from eighteen patients (ten to sixteen year old). Our control group consisted of ten patients (twenty feet) with normal arched feet and the study group of eight patients (fifteen feet) with symptomatic flat feet who were awaiting surgical correction. The mean and standard deviations of three radiographic markers (Calcaneal pitch, Naviculocuboid overlap and lateral Talo-1st metatarsal angle) in addition to foot pressures measured at the hindfoot, medial/lateral/total midfoot (MMF, LMF, TMF), forefoot and the percentage of weight going through the MMF over the TMF (medial midfoot ratio (MMFR) during the mid-stance gait phase are reported. In addition, the sensitivity, specificity, positive predictive value and negative predictive value of the pedobarographic parameters were estimated. There was a significant difference in the Naviculocuboid overlap (P<0.001 T test) and Calcaneal pitch (P<0.05 T test) between both groups. The flat feet group had significantly higher MMF, LMF, TMF and MMFR (P < 0.001 Mann-Whitney). LMF had the highest sensitivity and negative predictive value (94%) whereas MMF, TMF and MMFR had the highest specificity and positive predictive value (100%). Compared to our control group, patients with symptomatic flexible flat feet had significantly higher pressures distributed in the midfoot, in particular in the medial midfoot. Pedobarography appears to be a sensitive and specific tool that can be used, in conjunction with clinical and radiographic findings, in diagnosing flat feet. Our study suggests that pedobarography could be used to measure the degree of deformity before and after surgical intervention

Background. Benefits of day case foot and ankle surgery includes reduced hospital stay, associated cost savings for the hospital, high patient satisfaction and quicker recovery with no increase in complication rates. In 2007, we set up the preoperative foot and ankle group. Patients were seen three weeks before surgery by a specialist nurse, physiotherapist and a preoperative evaluation is done. The therapist explains the patient's weightbearing status and advices on how to carry this out. Our aim was to reduce inpatient hospital stay and increase our day case procedures. Methods. We evaluated length of stay and physiotherapy intervention for all our patients during the first three months of 2007 to 2011. Mean length of stay was calculated and Mann-Whitney U test was performed using median. Results. Mean length of stay for combined forefoot and midfoot group reduced by 1.92 days and median reduction was statistically significant(p< 0.01). For forefoot surgery alone, the mean length reduced by 2.14 and median reduction was significant(p< 0.001) and for midfoot surgery alone, the mean stay reduced by 1.34 days and median was significant (p< 0.001). Hind foot patient's mean length of stay reduced by 6.78 days and the median was significant (p< 0.001). But for the ankle group the mean length of stay did reduce but the median was not statistically significant (p=0.225). Day case surgery increased by 43.5% for forefoot, 23.2% for midfoot and 14% for ankle surgeries but not for hindfoot. Conclusions. The overall results show that the preoperative foot and ankle group has resulted in reduction of inpatient stay and increase in daycase surgery performed. A pre-operative group is a highly efficient method of enhancing patient care and improving length of stay at the hospital for the patient. The cost saving for the hospital is around £35,400 per annum

Aim. Since July 2013 our group has been using an antibiotic bone substitute, composed of calcium sulphate, hydroxyapatite and gentamicin sulphate (CSH + HA + GS), in the treatment of osteomyelitis (OM) in diabetic foot. The aim of this work was to evaluate the mid-term efficacy of this treatment regime on outcomes. A favourable outcome in diabetic foot includes no recurrence of OM, healed soft tissues and the ability to weight-bear. Method. To date we have used the CSH + HA + GS bone substitute in 24 diabetic patients with OM. In this study we reviewed patients treated from July 2013 to December 2014, in which we used CSH + HA + GS to treat OM of the forefoot, midfoot and hind foot, and evaluated how many patients are able to walk and fully weight-bear at present. We identified 11 pts treated during this time period; 1 with bilateral 1. St. metatarsal-head OM due to plantar ulcers, 5 with midfoot OM secondary to Charcot deformities and ulcers, 5 with hind foot OM due to pressure ulcers or Charcot deformity. We continuously monitored the patients for recurrence of OM, ulcers and soft tissue inflammation in our outpatient department. Results. Of the 11 patients, two died during follow up (both patients had calcaneal ulcers; one died in the 1. st. month and one in the 2. nd. month after treatment, both due to cardiovascular disease). For the remaining nine patients, we had an average of 25 (17–33) months follow-up. One patient did not heal, presenting with a persistent mid-foot lesion in a Charcot foot. Another patient with bilateral forefoot ulcers had a plantar ulcer recurrence under the left 1. st. metatarsal foot, 19 months after bone substitute application and primary healing. This patient is still weight-bearing on the right foot, as are the remaining 6 patients. In 7 patients (1 with bilateral forefoot, 4 with mid-foot and 3 with hind foot OM) no recurrence of OM or ulcers was observed. Conclusions. This study suggests that a CSH + HA + GS bone substitute can be used to treat diabetic foot OM. Our mid-term results show good clinical outcomes in terms of ulcer healing, no recurrence of OM and weight-bearing

Tarsometatarsal arthritis must be evaluated in conjunction with naviculocuneiform joint arthritis, as the two generally coexist. Primary osteoarthritis or systemic arthritis generally leads to uncomplicated non-deformity correction through arthrodesis. Challenges in correction become more pronounced following Lisfranc injury, where deformity and ligament instability introduce malalignment that mandates osteotomies to correct deformity. Diagnosis hinges on both CT scan data and selective diagnostic injections under fluoroscopy. The surgeon must simultaneously consider minimising bone resection to lessen the impact of metatarsal shortening. In addition, the three columns of the foot must be respected with reference to midfoot arthrodesis rules, introducing challenges in operative reconstruction as the lateral column mandates preserved flexibility. In addition, collapse at the midfoot often leads to a rigid pes planovalgus deformity, and the surgeon must consider when it is appropriate to add a medial slide calcaneal osteotomy and gastrocnemius recession. Finally, naviculocuneiform joint arthrodesis, if required, introduces significant technical challenges in both alignment and fixation that will be addressed

Introduction. Taylor Spatial Frame (TSF) has been designed to treat complex tibial, foot and ankle deformities using computer software. We have performed various osteotomies in combination with different soft tissue procedures, with the use of TSF. Material and Methods. A retrospective study of 20 consecutive patients operated by, senior author SSM, from 2004 onwards who underwent surgical correction of tibia, ankle, midfoot and hind foot including lateral column lengthening, calcaneal and midfoot osteotomies. Demographic details, diagnosis, procedures (including previous operations), length of follow-up, outcome and complications were recorded. Of the 20 patients, 13 were men and 7 women. The mean age was 39 years (range 18 to 70). 5 patients had TSF for malunion or non-union of ankle fractures, malunion of tibia (5), congenital talipes equino-varus(3), acute fracture of ankle (2), one patient each for spina bifida, Poliomyelitis, Charcot-Marie-Tooth disease, equino-varus due to periventricular leuco-encephalopathy and avascular necrosis of the talus. Bilateral TSF for torsional malalignment of tibia (1). Results. Follow up 6 to 54 months (mean 19.4). Patient based foot and ankle outcome criteria were used. Of the 20 patients, 16 had no pain and satisfactory range of movement and function at the last follow up. Post-operative complications included pin site infection(2) and frame hardware malfunction (2)patients, residual deformity requiring surgical correction at 22 months, (1) delayed union, neuropathic pain in (1), residual equinus deformity requiring Botox injections(1) and osteomyelitis requiring debridement(1). Conclusion. We present this series of complex congenital and acquired conditions of the foot and ankle treated with corrective osteotomies and Taylor Spatial Frame with good results

Background. Lateral column lengthening combining bony and soft tissue procedures has been described for symptom relief and deformity correction in the planovalgus foot. There are relatively few reports on its outcomes in childhood. We present our medium term outcomes using this technique in children. Methods. Twenty-five symptomatic mobile planovalgus feet in fifteen patients were operated upon between 2005 and 2008. The mean age at surgery was 12 years 6 months. Ten patients had idiopathic pes planovalgus, two had overcorrected congenital talipes equinovarus, and one had skewfoot deformity. The surgery included one or more bony elements - lengthening calcaneal osteotomy, heel shift, medial cuneiform osteotomy - iliac crest tricortical bone graft harvest and one or more soft tissue procedures - peroneus brevis/peroneus longus transfer, plantar fascia release and tibialis posterior advancement. The extent of surgery was decided per-operatively in an a la carte fashion. The Visual Analogue Score for Foot and Ankle (VAS FA) and American Foot and Ankle Association (AOFAS) ankle-hindfoot and midfoot scores were measured. Clinical findings and complications were recorded. Results. Twenty feet in twelve patients were available for follow up at a mean post-operative interval of 4 years 6 months. The mean VAS FA, AOFAS ankle-hindfoot and midfoot scores were 82 ± 17, 87 ± 14 and 80 ± 10 respectively. In all patients the medial arch was restored. One patient required bilateral lateral column shortening and medial cuneiform osteotomy to address overcorrection and supination, one had bilateral calcaneal screw removal and one had a subsequent heel shift. Conclusions. A la carte lateral column lengthening combining bony and soft tissue procedures for the symptomatic planovalgus foot is a powerful technique. We have shown satisfactory functional medium term outcomes with this surgery, and believe it can be used in childhood for symptomatic planovalgus foot deformity correction