Aims. Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions. Methods. We retrospectively analyzed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between January 2007 and December 2019 in our unit. Patient demographic details, comorbidities, weightbearing status, and postoperative complications were noted. Metalwork breakage, nonunion, deformity recurrence, concurrent midfoot reconstruction, and the measurements related to intramedullary nail were also recorded. Results. There were 70 patients with mean follow-up of 54 months (SD 26). Overall, 51 patients (72%) and 52 patients (74%) were fully weightbearing at one year postoperatively and at final follow-up, respectively. The overall hindfoot union rate was 83% (58/70 patients). Age, BMI, glycated haemoglobin, and prior revascularization did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the nonunited group (0.90 (SD 0.06) and 0.86 (SD 0.09), respectively; p = 0.034). In those with a supplementary hindfoot compression screw, there was a 95% union rate (19/20 patients), compared to 78% in those without screws (39/50 patients; p = 0.038). All patients with a miss-a-nail hindfoot compression screw went on to union. Hindfoot metalwork failure was seen in 13 patients (19%). An intact medial malleolus was found more frequently in those with intact metalwork ((77% (44/57 patients) vs 54% (7/13 patients); p = 0.022) and in those with union ((76% (44/58 patients) vs 50% (6/12 patients); p = 0.018). Broken metalwork occurred more frequently in patients with nonunions (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001) and midfoot deformity recurrence (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001). Conclusion. Rates of hindfoot union and intact metalwork were noted in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail and supplementary hindfoot screws. An intact medial malleolus is protective against nonunion and hindfoot metalwork failure. Cite this article: Bone Joint J 2022;104-B(6):703–708

Medial Displacement Osteotomy (MDO) of the os calcis is used to correct the hind foot valgus in a flat foot deformity. Screw fixation is commonly used although contemporary locking plate systems are now available. This study tested the hypothesis that a 10mm MDO would support a higher load to failure with a locked step plate than with a single cannulated screw. Materials and Methods. Eight pairs of embalmed cadaveric limbs harvested 10cm below the knee joint were axially loaded using a mechanical testing rig. Two pairs served as non-operated controls loaded to 4500N. The remaining limbs in pairs underwent a 10mm MDO of the os calcis and were stabilised with a locked step plate or a 7mm cannulated compression screw. One pair was loaded to 1600N (twice body weight) as a pilot study and the remaining 5 pairs were loaded to failure up to 4500N. The force-displacement curve and maximum force were correlated with observations of the mechanism of failure. Results. In one pair of control limbs, failure occurred with fractures through both os calcis bones, whilst the other pair did not undergo mechanical failure to 4500N. In the pilot osteotomy, the plate did not fail whilst loss of fixation with the screw was observed below 1600N. For the remaining five pairs, the median (with 95% Confidence Intervals) of the maximum force under load to failure were 1778.81N (1099.39 – 2311.66) and 826.13N (287.52 – 1606.67) for the plate and screw respectively (Wilcoxon Signed Rank test p=0.043). In those with screw fixation loaded to 4500N, the tuberosity fragment consistently failed by rotation and angulation into varus. Conclusion. In this model of load to failure with a medial displacement os calcis osteotomy, a locked step plate supported a significantly higher maximum force than a single large cannulated screw

Background. Whereas arthroscopic arthrodesis of the ankle is commonplace and of the subtalar joint is established, reports of arthroscopic talo-navicular fusion are a rarity. Aim. To review a case series to establish if arthroscopic talo-navicular arthrodesis is a feasible surgical option. Methods. Arthroscopic decortication of the talo-navicular joint is performed via x1-2 sinus tarsi portals and x1-2 accessory talo-navicular portals using a standard arthroscope and a 4.5 barrel burr. Internal fixation is by a 5mm screw from the navicular tuberosity and x2 headless compression screws introduced under image intensification from the dorsal navicular to the talar head. Between 2004 and 2017 a consecutive series of 164 patients underwent arthroscopic hindfoot arthrodeses of which 72 involved the talo-navicular joint. Only 13 procedures were of that joint alone in unsullied feet. The medical records of these 13 patients were reviewed to assess radiological fusion, complications and improvement of pre-operative state. Results. All Talo-navicular joints were successfully decorticated. All united radiologically by a mean 4.4 months (range 3–8). There were no major complications. All patients reported improvement to their pre-operative symptoms but one patient developed lateral column pain requiring fusion. Conclusions. Arthroscopic Talo-navicular arthrodesis is technically feasible with good rates of union. Complications were rare, making the technique attractive when encountering a poor soft tissue envelope. The surgery cannot be used if bone grafting is required. Long term discomfort can arise from adjacent joints. Accurate alignment is critical

A consecutive series of 23 patients (25 ankles) with osteoarthritis of the ankle and severe varus or valgus deformity were treated by open arthrodesis using compression screws. Primary union was achieved in 24 ankles one required further surgery to obtain a solid fusion. The high level of satisfaction in this group of patients reinforces the view that open arthrodesis, as opposed to ankle replacement or arthroscopic arthrodesis, continues to be the treatment of choice when there is severe varus or valgus deformity associated with the arthritis

Introduction. We aimed to retrospectively identify risk factors for delayed / non-union for first metatarsophalangeal joint fusion. Methods. Case notes and radiograph analysis was performed for operations between April 2014 and April 2016 with at least 3 months post-operative follow up. Union was defined as bridging bone across the fusion site on AP and lateral radiographic views with no movement or pain at the MTPJ on examination. If union was not certain, CT scans were performed. All patients operations were performed/supervised by one of three consultant foot surgeons. Surgery was performed through a dorsal approach using the Anchorage compression plate. Blinded pre-operative AP radiographs were analysed for the presence of a severe hallux valgus angle equal or above 40 degrees. Measurement intra-observer reliability was acceptable (95%CI:1.6–2.3 degrees). Smoking and medical conditions associated with non-union underwent univariate analysis for significance. Results. 73 patients, 9 male, 64 female with a mean age of 61 years (range, 29 to 81) comprised the patient group. Mean follow up time was 13 months for both union vs non-union groups (range 3 to 24 months). 7 patients were identified as non / delayed union (9.6%). All smokers healed (n = 17), age, diabetes, COPD and rheumatoid arthritis did not show significant associations with non-union. Pre-operative hypothyroidism (relative risk 6.9, p = 0.05) and severe hallux valgus (relative risk 9.9, p = 0.002) were significantly associated with non / delayed union. Conclusion. Although overall bone mineral density is unaffected, studies have demonstrated abnormal bone remodelling in patients with hypothyroidism which may account for this unexpected finding. A dorsally placed locking plate with a dorsal to plantar placed compression screw is at a biomechanical disadvantage to resist lateral force when trying to hold a corrected severe hallux valgus. These patient groups may benefit from supplementary fixation techniques

Introduction. We describe our experience with a minimally invasive Chevron and Akin (MICA) technique for hallux valgus correction. This technique adheres to the same principles as open surgical correction but is performed using a specialized high-speed cutting burr under image intensifier guidance via tiny skin portals. Methods. All patients undergoing minimally invasive hallux valgus correction between November 2009 and April 2010 were included in this study and were subject to prospective clinical and radiological review. Patients were scored using the Kitaoka score as well as radiological review and patient satisfaction survey. Surgery was performed under general anaesthetic and included distal soft tissue release, Chevron and Akin osteotomies, with the same indications as for open surgery. All osteotomies were internally fixed with cannulated compression screws. Results. 83 operations were performed on 70 patients (2 male 65 female, mean age 54 years (27-78)). The pre-operative mean HVA was 34° and IMA 14°. Post-operative mean HVA was 9° and IMA 9.5°. Kitaoka score improved significantly at 3-12 months follow-up. There were no delayed or non- s and no osteonecrosis. Six M1 osteotomies moved during the postoperative period (3 feet (2 patients) required further surgery + 3 incomplete corrections without need for further surgery) and the fixation technique was successfully modified to avoid this problem. Mild transfer metatarsalgia was observed in 4 patients. There were 2 superficial wound infections. Cutaneous nerve injuries were noted in 3 feet but none painful. No recurrent deformities observed to date. Overall, 65% patients very satisfied, 29% satisfied, 6% unsatisfied. Discussion. This study suggests that good results can be obtained in forefoot surgery with the MICA technique. We believe this technique may offer advantages for some patients in terms of reduced morbidity and cosmesis. A randomized study is in progress to compare open and minimally invasive techniques

We studied retrospectively the results in 24 patients (25 feet) who had been treated by subtalar arthrodesis with internal compression for post-traumatic arthritis from 1988 to 1992. Fifteen patients were men (16 feet) and nine (9 feet) were women. Their mean age was 43 years (22 to 68), and the average duration of follow-up was four years (2 to 6). A single compression screw was used in all feet and iliac-crest bone grafting in ten. Union was achieved in 24 of the 25 feet (96%). Based on a clinical scale the results were excellent in 10 feet, good in 7, fair in 6, and poor in 2 and on the Angus and Cowell score they were good in 19 feet, fair in 4, and poor in 2. The two poor results were due to nonunion in one patient and reflex sympathetic dystrophy in the other. One reoperation was performed for nonunion. Eighteen patients (18 feet) were satisfied with the results, four were satisfied with reservations, and three were dissatisfied. Progressive ankle and midfoot arthritis did not occur in the absence of pre-existing degenerative changes in these joints. We conclude that isolated subtalar arthrodesis with internal compression was effective treatment for post-traumatic subtalar arthritis. Iliac-crest bone grafting was not routinely required

Aims

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

Aims

The morphology of medial malleolar fracture is highly variable and difficult to characterize without 3D reconstruction. There is also no universally accepeted classification system. Thus, we aimed to characterize fracture patterns of the medial malleolus and propose a classification scheme based on 3D CT reconstruction.

Aims

We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity.

Aims

Arthroscopically controlled fracture reduction in combination with percutaneous screw fixation may be an alternative approach to open surgery to treat talar neck fractures. The purpose of this study was thus to present preliminary results on arthroscopically reduced talar neck fractures.

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.

We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently.

We describe a retrospective review of the clinical and radiological parameters of 32 feet in 30 patients (10 men and 20 women) who underwent correction for malalignment of the hindfoot with a modified double arthrodesis through a medial approach. The mean follow-up was 21 months (13 to 37). Fusion was achieved in all feet at a mean of 13 weeks (6 to 30). Apart from the calcaneal pitch angle, all angular measurements improved significantly after surgery. Primary wound healing occurred without complications.

The isolated medial approach to the subtalar and talonavicular joints allows good visualisation which facilitated the reduction and positioning of the joints. It was also associated with fewer problems with wound healing than the standard lateral approach.

Salvage of a failed total ankle replacement is technically challenging and although a revision procedure may be desirable, a large amount of bone loss or infection may preclude this. Arthrodesis can be difficult to achieve and is usually associated with considerable shortening of the limb.

We describe a technique for restoring talar height using an allograft from the femoral head compressed by an intramedullary nail. Three patients with aseptic loosening were treated successfully by this method with excellent symptomatic relief at a mean follow-up of 32 months (13 to 50).