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°. Methods. A matched cohort of patients similar for demographics and components used but differing in preoperative coronal-plane tibiotalar valgus deformity ≥ 15° (valgus, n = 50; 52% male, mean age 65.8 years (SD 10.3), mean body mass index (BMI) 29.4 (SD 5.2)) or < 15° (control, n = 50; 58% male, mean age 65.6 years (SD 9.8), mean BMI 28.7 (SD 4.2)), underwent TAA by one surgeon. Preoperative and postoperative radiographs, Ankle Osteoarthritis Scale (AOS) pain and disability and 36-item Short Form Health Survey (SF-36) version 2 scores were collected prospectively. Ancillary procedures, secondary procedures, and complications were recorded. Results. At mean 5.1 years follow-up (SD 2.6) (valgus) and 6.6 years (SD 3.3) (controls), mean AOS scores decreased and SF-36 scores increased significantly in both groups. Improvements in scores were similar for both groups – AOS pain: valgus, mean 26.2 points (SD 24.2), controls, mean 22.3 points (SD 26.4); AOS disability: valgus, mean 41.2 points (SD 25.6); controls, mean 34.6 points (SD 24.3); and SF-36 PCS: valgus, mean 9.1 points (SD 14.1), controls, mean 7.4 points (SD 9.8). Valgus ankles underwent more ancillary procedures during TAA (40 (80%) vs 13 (26%)) and more secondary procedures postoperatively (18 (36%) vs 7 (14%)) than controls. Tibiotalar deformity improved significantly (p < 0.001) towards a normal weightbearing axis in valgus ankles. Three valgus and four control ankles required subsequent fusion, including two for deep infections (one in each group). Conclusion. Satisfactory mid-term results were achieved in patients with preoperative valgus malalignment ≥ 15°, but they required more adjunctive procedures during and after TAA. Valgus coronal-plane deformity ≥ 15° is not an absolute contraindication for TAA if associated deformities are addressed. Cite this article: Bone Joint J 2020;102-B(12):1689–1696

Background. Weightbearing computed tomography scans allow for better understanding of foot alignment in patients with Progressive Collapsing Foot Deformity. However, soft tissue integrity cannot be assessed via WBCT. As performing both WBCT and magnetic resonance imaging is not cost effective, we aimed to assess whether there is an association between specific WBCT and MRI findings. Methods. A cohort of 24 patients of various stages of PCFD (mean age 51±18 years) underwent WBCT scans and MRI. In addition to signs of sinus tarsi impingement, four three-dimensional measurements (talo-calcaneal overlap, talo-navicular coverage, Meary's angle axial/lateral) were obtained using a post processing software (DISIOR 2.1, Finland) on the WBCT datasets. Sinus tarsi obliteration, spring ligament complex and tibiospring ligament integrity, as well as tibialis posterior tendon degeneration were evaluated with MRI. Statistical analysis was performed for significant (P<0.05) correlation between findings. Results. None of the assessed 3D measurements correlated with spring ligament complex or tibiospring ligament tears. Age, body mass index, and TCO were associated with tibialis posterior tendon tears. 75% of patients with sinus tarsi impingement on WBCT also showed signs of sinus tarsi obliteration on MRI. Of the assessed parameters, only age and BMI were associated with sinus tarsi obliteration diagnosed on MRI, while the assessed WBCT based 3D measurements were, with the exception of MA axial, associated with sinus tarsi impingement. Conclusion. While WBCT reflects foot alignment and indicates signs of osseous impingement in PCFD patients, the association between WBCT based 3D measurements and ligament or tendon tears in MRI is limited. Partial or complete tears of the tibialis posterior tendon were only detectable in comparably older and overweight PCFD patients with an increased TCO. WBCT does not replace MRI in diagnostic value. Both imaging options add important information and may impact decision-making in the treatment of PCFD patients

Aims. There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure. Patients and Methods. A total of 39 patients (12 women, 27 men; mean age 47 years (28 to 72)) with a distal tibial recurvatum deformity were treated with a flexion osteotomy, between 2010 and 2015. Nine patients (23%) subsequently required conversion to either a total ankle arthroplasty (seven) or an arthrodesis (two) after a mean of 21 months (9 to 36). A total of 30 patients (77%), with a mean follow-up of 30 months (24 to 76), remained for further evaluation. Functional outcome, sagittal ankle joint OA using a modified Kellgren and Lawrence Score, tibial lateral surface (TLS) angle, and talar offset ratio (TOR) were evaluated on pre- and postoperative weight-bearing radiographs. Results. Postoperatively, the mean score for pain, using a visual analogue scale, decreased significantly from 4.3 to 2.5 points and the mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly from 59 to 75 points (both p < 0.001). The mean TLS angle increased significantly by 6.6°; the mean TOR decreased significantly by 0.24 (p < 0.001). Radiological evaluation showed an improvement or no progression of sagittal ankle joint OA in 32 ankles (82%), while seven ankles (18%) showed further progression. Conclusion. A flexion osteotomy effectively improved the congruency of the ankle joint. In 30 patients (77%), the joint could be saved, whereas in nine patients (23%), the treatment delayed a joint-sacrificing procedure. Cite this article: Bone Joint J 2019;101-B:682–690

Correction of valgus deformity of the hindfoot using a medial approach for a triple fusion has only recently been described for patients with tight lateral soft tissues which would be compromised using the traditional lateral approach. We present a series of eight patients with fixed valgus deformity of the hindfoot who had correction by hindfoot fusion using this approach. In addition, we further extended the indications to allow concomitant ankle fusion. The medial approach allowed us to excise medial ulcers caused by the prominent medial bony structures, giving simultaneous correction of the deformity and successful internal fixation. We had no problems with primary wound healing and experienced no subsequent infection or wound breakdown. From a mean fixed valgus deformity of 58.8° (45° to 66°) pre-operatively, we achieved a mean post-operative valgus angulation of 13.6° (7° to 23°). All the feet were subsequently accommodated in shoes. The mean time to arthrodesis was 5.25 months (3 to 9). We therefore recommend the medial approach for the correction of severe fixed valgus hindfoot deformities

It has been suggested that a supramalleolar osteotomy can return the load distribution in the ankle joint to normal. However, due to the lack of biomechanical data, this supposition remains empirical. The purpose of this biomechanical study was to determine the effect of simulated supramalleolar varus and valgus alignment on the tibiotalar joint pressure, in order to investigate its relationship to the development of osteoarthritis. We also wished to establish the rationale behind corrective osteotomy of the distal tibia. We studied 17 cadaveric lower legs and quantified the changes in pressure and force transfer across the tibiotalar joint for various degrees of varus and valgus deformity in the supramalleolar area. We assumed that a supramalleolar osteotomy which created a varus deformity of the ankle would result in medial overload of the tibiotalar joint. Similarly, we thought that creating a supramalleolar valgus deformity would cause a shift in contact towards the lateral side of the tibiotalar joint. The opposite was observed. The restricting role of the fibula was revealed by carrying out an osteotomy directly above the syndesmosis. In end-stage ankle osteoarthritis with either a valgus or varus deformity, the role of the fibula should be appreciated and its effect addressed where appropriate

Introduction:. All reported RA forefoot deformities in the literature so far have arisen from shoe wearing populations. Our aim in this study was to compare hallucal deformities seen in a shod to a non-shod population. Methods:. A case-control study was undertaken in two specialist foot and ankle units, one in India and one in the UK. All patients suffering from RA and attending for consideration of forefoot surgery from January 2007 to October 2013 were included in this study. Standardized anteroposterior weight bearing radiographs were obtained to measure the hallux valgus, inter-metatarsal and metatarsus primus varus angles. Results:. In the shod population, there was 1 hallux varus deformity, 10 without hallucal deformity and 90 feet with varying degrees of hallux valgus deformity. In contrast, in the unshod population, there were 19 hallux varus deformities and 6 hallux valgus deformities. There was great variability in the lesser toe deformity seen. In the shod population, it was most common to see dorsal subluxation or dislocation, with the 5. th. toe in a varus position. This was seen in 95% (n=96) of the shod population. In the unshod population, the most common lesser toe deformity seen was varus deviation or dislocation. This was present in 80% (n=20) of the unshod population. Conclusion:. Instability of the metatarsophalangeal joint in the rheumatoid foot predisposes it to significant deformity. External forces of shoe wear dictate the deformity, with hallux valgus being the most likely scenario in a shoe-wearing patient. In the non-shoe wearing population, intrinsic forces and weight bearing forces determine the deformity, with hallux varus being the most common presenting problem

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

We studied 11 patients with checkrein deformities of the hallux who underwent surgical treatment. Six had lengthening of the flexor hallucis longus tendon by Z-plasty in the midfoot, and five underwent release of adhesions and lengthening of the tendon by Z-plasty at the musculotendinous junction at the fracture site. All six patients who underwent Z-plasty at the midfoot showed complete correction of the deformity without recurrence. Of the five who had release of adhesions and Z-plasty of the tendon at the fracture site, two showed partial and one showed complete recurrence

Our study describes the clinical outcome of total ankle replacement (TAR) performed in patients with moderate to severe varus deformity. Between September 2004 and September 2007, 23 ankles with a varus deformity ≥ 10° and 22 with neutral alignment received a TAR. Following specific algorithms according to joint congruency, the varus ankles were managed by various additional procedures simultaneously with TAR. After a mean follow-up of 27 months (12 to 47), the varus ankles improved significantly in all clinical measures (p < 0.0001 for visual analogue scale and American Orthopaedic Foot and Ankle Society score, p = 0.001 for range of movement). No significant differences were found between the varus and neutral groups regarding the clinical (p = 0.766 for visual analogue scale, p = 0.502 for American Orthopaedic Foot and Ankle Society score, p = 0.773 for range of movement) and radiological outcome (p = 0.339 for heterotopic ossification, p = 0.544 for medial cortical reaction, p = 0.128 for posterior focal osteolysis). Failure of the TAR with conversion to an arthrodesis occurred in one case in each group. The clinical outcome of TAR performed in ankles with pre-operative varus alignment ≥ 10° is comparable with that of neutrally aligned ankles when appropriate additional procedures to correct the deformity are carried out simultaneously with TAR

Introduction. There is less literature reporting outcomes following total ankle replacement (TAR) in patients presenting with a coronal plane deformity preoperatively. This study compares clinical and patient reported outcomes at 1 year between TAR patients with and without coronal plane deformity. Methods. Patients from single centre prospective cohort (132) who underwent TAR between 2006 and 2010 were included. They were divided into 2 groups based on preoperative coronal plane deformity. Groups 1 and 2 had a coronal plane deformity of <10 and >10 respectively. Assessments included American Orthopaedic Foot and Ankle Score (AOFAS), Foot and Ankle Outcome Score (FAOS), SF-36 (Generic Health Measure) and complications recorded preoperatively and 3, 6 and 12 months postoperatively. Results. There were 102 ankles (77.2%) in group 1 and 30 ankles (22.7%) in group 2. There was no difference in age and BMI between groups (p > 0.05). AOFAS, FAOS and SF-36 scores showed improvement for both groups from pre-op to 1 year (p < 0.01) with no difference between groups (p > 0.05) at all assessment times; except for mental health scores (SF-36 component) which showed no significant improvement (p > 0.05) and no difference between groups (p > 0.05). There was no difference in patient satisfaction for overall outcomes, pain relief, improvement in ADL and recreational activities between groups at 1 year (p > 0.05). There was no incidence of DVT/PE in both groups. The incidence of peri-prosthetic fractures was 8 (7.8%) for group 1 and 2 (6.6%) in group 2. Discussion and Conclusion. These early results of total ankle replacement demonstrate that patients with >10 degrees coronal plane deformity had equivalent outcomes to patients with <10 degrees of coronal plane deformity. Our surgical techniques for correction of deformity are reliable to reduce the requirement of ankle fusion

Introduction. Crossover and claw toe deformity has traditionally been a very difficult condition to manage surgically, with high recurrence rates. Multiple methods have been used to treat this condition. Plantar plate “repair” has recently been advocated, with sutures used to repair an assumed tear. Based on clinical experience and anatomical studies (Deland et al. 1995), we believe the main pathology is a distal migration of the plantar plate complex resulting in exposure of the metatarsal to the thin posterior synovial attachment of the plate. The downward forces on the metatarsal head results in herniation of the head inferiorly. Accordingly we have developed a technique using full cuff release of the plantar plate complex that includes complete release of the collateral ligaments, repositioning the plantar plate anatomically and reinforcing the hernial defect with a synthetic mesh graft. Methods. 12 cases of severe crossover toe deformity have undergone plantar plate reconstruction using synthetic mesh graft in addition to other bony procedures (e.g. Weil's osteotomy, PIPJ fusion) since 2015 operated upon by the lead author. We collated data regarding patient satisfaction using Coughlin's Score (Coughlin 1991). We have also evaluated the sustainability of correction and any complications. Results. All patients reported “excellent” outcomes using Coughlin's score, with no cases of recurrence of any significance or complications, and a mean time to follow up of 180 days (range 23–23). Conclusions. Our understanding of the pathology of this condition is somewhat different from the conventional wisdom. Our technique of using a synthetic mesh graft to reconstruct the plantar plate complex shows promising results in terms of safety and decreased recurrence rate compared to traditional techniques. Further long term prospective results are required to confirm this pilot data

Proximal osteotomies for forefoot deformity in patients with rheumatoid arthritis have hitherto not been described. We evaluated combination joint-preserving surgery involving three different proximal osteotomies for such deformities. A total of 30 patients (39 feet) with a mean age of 55.6 years (45 to 67) underwent combined first tarsometatarsal fusion and distal realignment, shortening oblique osteotomies of the bases of the second to fourth metatarsals and a fifth-ray osteotomy. The mean follow-up was 36 months (24 to 68). The mean foot function index scores for pain, disability and activity subscales were 18, 23, and 16 respectively. The mean Japanese Society for Surgery of the Foot score improved significantly from 52.2 (41 to 68) to 89.6 (78 to 97). Post-operatively, 14 patients had forefoot stiffness, but had no disability. Most patients reported highly satisfactory walking ability. Residual deformity and callosities were absent. The mean hallux valgus and intermetatarsal angles decreased from 47.0° (20° to 67°) to 9.0° (2° to 23°) and from 14.1° (9° to 20°) to 4.6° (1° to 10°), respectively. Four patients had further surgery including removal of hardware in three and a fifth-ray osteotomy in one. With good peri-operative medical management of rheumatoid arthritis, surgical repositioning of the metatarsophalangeal joint by metatarsal shortening and consequent relaxing of surrounding soft tissues can be successful. In early to intermediate stages of the disease, it can be performed in preference to joint-sacrificing procedures

Talonavicular and subtalar joint fusion through a medial incision (modified triple arthrodesis) has become an increasingly popular technique for treating symptomatic flatfoot deformity caused by posterior tibial tendon dysfunction. The purpose of this study was to look at its clinical and radiological mid- to long-term outcomes, including the rates of recurrent flatfoot deformity, nonunion and avascular necrosis of the dome of the talus. A total of 84 patients (96 feet) with a symptomatic rigid flatfoot deformity caused by posterior tibial tendon dysfunction were treated using a modified triple arthrodesis. The mean age of the patients was 66 years (35 to 85) and the mean follow-up was 4.7 years (1 to 8.3). Both clinical and radiological outcomes were analysed retrospectively. In 86 of the 95 feet (90.5%) for which radiographs were available, there was no loss of correction at final follow-up. In all, 14 feet (14.7%) needed secondary surgery, six for nonunion, two for avascular necrosis, five for progression of the flatfoot deformity and tibiotalar arthritis and one because of symptomatic overcorrection. The mean American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score) at final follow-up was 67 (between 16 and 100) and the mean visual analogue score for pain 2.4 points (between 0 and 10). In conclusion, modified triple arthrodesis provides reliable correction of deformity and a good clinical outcome at mid- to long-term follow-up, with nonunion as the most frequent complication. Avascular necrosis of the talus is a rare but serious complication of this technique. Cite this article: Bone Joint J 2015; 97-B:668–74

Rocker bottom deformity may occur during the conservative treatment of idiopathic congenital clubfoot. Between 1975 and 1996, we treated 715 patients (1120 clubfeet) conservatively. A total of 23 patients (36 feet; 3.2%) developed a rocker bottom deformity. It is these patients that we have studied. The pathoanatomy of the rocker bottom deformity is characterised by a plantar convexity appearing between three and six months of age with the hindfoot equinus position remaining constant. The convexity initially involves the medial column, radiologically identified by the talo-first metatarsal angle and secondly by the lateral column, revealed radiologically as the calcaneo-fifth metatarsal angle. The apex of the deformity is usually at the midtrasal with a dorsal calcaneocuboid subluxation. Ideal management of clubfoot deformity should avoid this complication, with adequate manipulation and splinting and early Achilles’ percutaneous tenotomy if plantar convexity occurs. Adequate soft-tissue release provides satisfactory correction for rocker bottom deformity. However, this deformity requires more extensive and complex procedures than the standard surgical treatment of clubfoot. The need for lateral radiographs to ensure that the rocker bottom deformity is recognised early, is demonstrated

Charcot neuro-osteoarthropathy (CN) of the midfoot presents a major reconstructive challenge for the foot and ankle surgeon. The Synthes 6 mm Midfoot Fusion Bolt is both designed and recommended for patients who have a deformity of the medial column of the foot due to CN. We present the results from the first nine patients (ten feet) on which we attempted to perform fusion of the medial column using this bolt. Six feet had concurrent hindfoot fusion using a retrograde nail. Satisfactory correction of deformity of the medial column was achieved in all patients. The mean correction of calcaneal pitch was from 6° (-15° to +18°) pre-operatively to 16° (7° to 23°) post-operatively; the mean Meary angle from 26° (3° to 46°) to 1° (1° to 2°); and the mean talometatarsal angle on dorsoplantar radiographs from 27° (1° to 48°) to 1° (1° to 3°). . However, in all but two feet, at least one joint failed to fuse. The bolt migrated in six feet, all of which showed progressive radiographic osteolysis, which was considered to indicate loosening. Four of these feet have undergone a revision procedure, with good radiological evidence of fusion. The medial column bolt provided satisfactory correction of the deformity but failed to provide adequate fixation for fusion in CN deformities in the foot. In its present form, we cannot recommend the routine use of this bolt. Cite this article: Bone Joint J 2015; 97-B:809–13

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

The relationship between hindfoot and forefoot kinematics is an important factor in the planning of ankle arthrodesis and ankle arthroplasty surgery. As more severe ankle deformities are corrected, improved techniques are required to assess and plan hindfoot to forefoot balancing. Gait analysis has previously been reported in patients with ankle arthritis without deformity. This group of patients have reduced intersegment motion in all measured angles. We have looked at a small group of patients with hindfoot deformity and ankle arthritis awaiting fusion or replacement. Using the Oxford Foot Model we have assessed lower limb kinematics with a focus on hindfoot to forefoot relationships. The results of our pilot study are in variance to previous studies in that we have shown that in the presence of hindfoot/ankle deformity, the forefoot range of motion increases. We feel that these data may impact on surgical planning

Introduction. Longstanding complex muliplanar foot deformities represent a significant challenge. The traditional surgical techniques involve excessive dissection and excision of large bony wedges or modifications of the triple fusion to correct the deformity. The majority of the reports in the literature present collective data on different deformity patterns and also mix paediatric and adult patients, even with multiple correction techniques. The aim of this study was to evaluate the clinical, radiological and functional outcomes of the gradual correction of a single common deformity pattern of equino-cavo-varus using a single correction technique of the V-osteotomy and the Ilizarov frame. Material and methods. We present prospectively collected data on 40 feet in 35 adult patients with stiff longstanding equino-cavo-varus deformity. All patients had a V-osteotomy and gradual correction using an Ilizarov frame, with a mean follow-up of 20 months. We collected the American Orthopaedic Foot and Ankle Scocity score (AOFAS), the Foot and Ankle Disability Index (FADI) and a Visual Analogue Pain score (VAS) for all ptients preoperatively and between 1 and 2 years following frame removal. Results. In 33 patients (38 feet) a stable plantigrade foot was achieved with significant improvement in the gait and the foot alignment. The mean equinus, heel varus and metatarsus adductus improved significantly as measured on x-rays. The mean AOFAS score improved from 38.2 to 73.2, the mean FADI improved from 51.1 to 70.6 and the mean VAS improved from 4.5 to 0.5. Pin-site infection was encountered in 7 feet, premature consolidation in 2 feet and undercorrection in 4 feet. In 2 patients the correction had to be stopped. Conclusion. The results of this report on a single deformity pattern of equino-cavo-varus support the use of this technique for the management of these challenging cases, as a safe, versatile and powerful tool with predictable outcome

Introduction. Traditional treatment of idiopathic flatfoot in the adult population include calcaneal neck lengthening or fusions. These surgical methods result in abnormal function with significant complication rates. Our prospective study aimed to quantify the functional and radiological outcome of a new technique for spring ligament reconstruction using a hamstring graft, calcaneal osteotomy and medial head of gastrocnemius recession if appropriate. Methods. 22 feet were identified from the senior authors flatfoot reconstructions over a 3 year period (Jan 2013 to Dec 2015). 9 feet underwent a spring ligament reconstruction. The control group were 13 feet treated with standard tibialis posterior reconstruction surgery. Follow up ranged from 8 to 49 months. Functional assessment comprised VAS heath and pain scales, EQ-5D and MOXFQ scores. Radiographic analysis was performed for standardised parameters. Results. Each group contained two bilateral procedures. The spring ligament patients had a mean age of 43, BMI of 29 and a male to female ratio of 4;1 There were no statistical differences between groups starting point functional scores or pre-operative radiological deformity. Post-operatively there was a statistically significant improvement of all domains and overall MOXFQ, EQ5d and VAS in the spring ligament patients. There was a statistically significant improvement in all radiological parameters with all patients being returned to normal. Functional scores were not significantly better than the control group [MOXFQ components, Control vs spring ligament group, Pain: 42 vs 45 (p=0.71), Walking: 50 vs 56 (p=0.43), Social: 35 vs 39 (p=0.72), EQ-5D: 0.64 vs 0.70 (p=0.72)]. Spring ligament reconstruction produced statistically better deformity correction for 4 of 5 measured radiological parameters (p< 0.05). Conclusion. Our new method of spring ligament reconstruction restores normal anatomy. In comparison to traditional procedures our method provides equivalent functional results and improved deformity correction

In distal fibular resection without reconstruction, the stabilising effect of the lateral malleolus is lost. Thus, the ankle may collapse into valgus and may be unstable in varus. Here, we describe a child who underwent successful staged surgical correction of a severe neglected valgus deformity after excision of the distal fibula for a Ewing’s sarcoma