Introduction. Severe, multiplanar, fixed, pantalar deformities present a challenge to orthopaedic surgeons. Surgical options include limb salvage or amputation. This study compares outcomes of patients with such deformities undergoing limb preservation with either pantalar fusion (PTF) or talectomy and tibiocalcaneal fusion (TCF), versus below knee amputation (BKA). Methods. Fifty-one patients undergoing either PTF, TCF and BKA for failed management of severe pantalar deformity were evaluated retrospectively. Twenty-seven patients underwent PTF, 8 TCF and 16 BKA. Median age at surgery was 55.0 years (17 to 72 years) and median follow-up duration was 49.9 months (18.0 to 253.7 months). Patients with chronic regional pain syndrome, tumour, acute trauma or diabetic Charcot arthropathy were excluded. Clinical evaluation was undertaken using the MOxFQ, EQ-5D and Special Interest Group in Amputee Medicine score (SIGAM). Patients were also asked whether they were satisfied with their surgical outcome and whether they would have the same surgery again. Results. There was no statistically significant difference in patient reported outcomes, satisfaction, or complication profile between the groups. Twenty-two patients undergoing PTF (81.5%), 6 patients undergoing TCF (75%), and 15 patients undergoing BKA (93.8%) were satisfied overall (p=0.414). Similarly, there was no difference in the proportion of patients who would opt for the same procedure again (p=0.142): 23 in the PTF group (85.2%), 8 in the TCF group (100%), and 11 in the BKA group (68.8%). Seven patients undergoing PTF (25.9%), 2 patients undergoing TCF (25%) and 6 patients undergoing BKA (37.5%) had major complications (p=0.692). Conclusion. This study has shown that PTF, TCF and BKA can all provide an acceptable outcome in treatment of severe, degenerative deformities of the lower extremity. Therefore, surgical decisions must be based on individual patient considerations. This data may also be useful in counselling patients when considering limb salvage versus amputation for severe deformity

Aims. Limb salvage for diabetic foot infections often require multiple procedures. Some patients will eventually end up with below knee amputation (BKA) when all limb salvage attempts fail. We seek to study the patients’ ability to return to normal life, functional status, prosthesis usage and perspectives on multiple limb salvage procedures that culminated in BKA to review if they would undertake a similar path if their situation was repeated. Patients and Methods. A total of 41 patients who underwent BKA between July 2011 and June 2013 were reviewed. They were divided into primary and creeping (prior multiple salvage procedures) amputations. The Barthel’s Index (BI) and the Reintegration to Normal Living Index (RNLI) were used. A questionnaire was used to identify whether the patient would undergo the same multiple attempts at limb salvage again if faced with the same problem. Results. All patients had a good mean BI of 14.2 (3 to 20) and RNLI of 73.2 (31 to 100). There was no difference in prosthesis usage, BI and RNLI between both groups. We found that 16 (94.1%) out of 17 patients with creeping amputation would undergo the same multiple salvage procedures if given a similar option. Conversely, only 15 (62.5%) patients with primary amputation would do the same again while the other nine (37.5%) patients choose to do everything possible to save their leg if faced with a similar situation (p = 0.001). Conclusion. Most patients preferred to undergo multiple procedures to salvage the limb from diabetic foot infection even if it ultimately concluded with a BKA. All the patients had a moderately good functional outcome and ability to return to normal living after BKA. Cite this article: Bone Joint J 2017;99-B:1502–7

Objectives. The surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function. Methods. Follow-up was attempted in all United Kingdom military casualties sustaining hindfoot fractures. All respondents underwent short-form (SF)-12 scoring; those retaining their limb also completed the American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) outcomes questionnaire. A multivariate regression analysis identified injury features associated with poor functional recovery. Results. In 12 years of conflict, 114 patients sustained 134 fractures. Follow-up consisted of 90 fractures (90/134, 67%), at a median of five years (interquartile range (IQR) 52 to 80 months). The median Short-Form 12 physical component score (PCS) of 62 individuals retaining their limb was 45 (IQR 36 to 53), significantly lower than the median of 51 (IQR 46 to 54) in patients who underwent delayed amputation after attempted reconstruction (p = 0.0351). Regression analysis identified three variables associated with a poor F&A score: negative Bohler’s angle on initial radiograph; coexisting talus and calcaneus fracture; and tibial plafond fracture in addition to a hindfoot fracture. The presence of two out of three variables was associated with a significantly lower PCS compared with amputees (medians 29, IQR 27 to 43 vs 51, IQR 46 to 54; p < 0.0001). Conclusions. At five years, patients with reconstructed hindfoot fractures have inferior outcomes to those who have delayed amputation. It is possible to identify injuries which will go on to have particularly poor outcomes. Cite this article: P. M. Bennett, T. Stevenson, I. D. Sargeant, A. Mountain, J. G. Penn-Barwell. Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years. Bone Joint Res 2018;7:131–138. DOI: 10.1302/2046-3758.72.BJR-2017-0217.R2

Background. Disability and slow return to sport and work after tendon rupture are major challenges. Platelet Rich Plasma (PRP) is an autologous supraphysiological concentration of platelets from whole blood that has demonstrated positive cellular and physiological effects on healing in laboratory conditions but evidence from adequately powered robust clinical trials is lacking. We aimed to determine the clinical efficacy of PRP for treatment of acute Achilles tendon rupture. Methods. In a placebo-controlled, participant- and assessor-blinded, trial at 19 NHS hospitals we randomly assigned 230 adults starting acute Achilles rupture non-surgical management to PRP injection or dry-needle insertion (placebo) to the rupture gap under local anaesthetic. Patients with confounding or contraindicated concurrent medical conditions were excluded. The primary outcome was muscle-tendon function, assessed by the limb symmetry index (LSI, uninjured limb/injured limb × 100, higher scores better) of the work (Joules) performed during the heel-rise endurance test at 24 weeks. Secondary outcomes were: Achilles Tendon Rupture Score (ATRS, 0–100, higher scores better), quality of life (SF-12), pain, and goal attainment. Trial registration: ISRCTN54992179. Results. Participants were aged mean 46 years and 57 (25%) were female. 103/114 (90%) of the PRP group and all (n=116) in the placebo group received allocated treatment. At 24 weeks, mean LSI was 34.4 for the PRP group and 38.8 for placebo (adjusted mean difference −4.4 95% CI −11.2 to 2.5, n=201) and ATRS was mean 65.2 PRP vs 65.8 (adjusted mean difference −0.6, 95% CI −4.9 to 3.7, n=224). There were no differences between groups in the other secondary outcomes. Conclusion. We found no evidence of PRP efficacy for improving muscle-tendon function or patient-reported recovery after acute Achilles tendon rupture. Our findings challenge the increasing global use of PRP for acute tendon injury and indicate that robust evaluations are required in other applications

Introduction. Charcot neuroarthropathy (CN) of foot and ankle presents significant challenges to the orthopaedic foot and ankle surgeon. Current treatment focuses on conservative management during the acute CN phase with offloading followed by deformity correction during the chronic phase. However, the deformity can progress in some feet despite optimal offloading resulting ulceration, infection, and limb loss. Our aim was to assess outcomes of primary surgical management with early reconstruction. Methods. Between December 2011 and December 2019, 25 patients underwent operative intervention at our specialist diabetic foot unit for CN with progressive deformity and or instability despite advanced offloading. All had peripheral neuropathy, and the majority due to diabetes. Twenty-six feet were operated on in total - 14 during Eichenholtz stage 1 and 12 during stage 2. Fourteen of these were performed as single stage procedures, whereas 12 as two-stage reconstructions. These included isolated hindfoot reconstructions in seven, midfoot in four and combined in 14 feet. Mean age at the time of operation was 54. Preoperative ulceration was evident in 14 patients. Results. Mean follow up was 45 months (Range 12–98). There was 100% limb salvage. One-year ambulation outcomes demonstrate FWB in bespoke footwear for 17 patients and in an ankle foot orthosis (AFO), Charcot restraint orthopaedic walker (CROW) or bivalve cast for seven. All preoperative ulceration had healed. Union was achieved in 18/21 hindfoot reconstructions and 7/18 midfoot reconstructions. There were nine episodes of return to theatre, of which five were within the first 12 months. There was one episode of new ulceration. Conclusion. Surgical management of acute CN (Eichenholtz one and two) of the foot provides functional limb salvage. In particular, hindfoot reconstruction shows good rates of bony union. It should be considered in ‘foot at risk’ presentations of acute CN foot

Introduction. Charcot neuroarthropathy is a debilitating condition that frequently leads to skeletal instability, and has an increased risk of ulceration leading to infection and amputation. However, surgical reconstruction may offer limb salvage and restauration of an ulcer-free, plantigrade stable foot for functional weight-bearing. We report on our case series according to a prospective protocol and analyse factors leading to a favourable outcome. Methods. We report a prospective follow-up of 62 patients undergoing Charcot reconstruction, May 2014- Jan 2022, by two surgeons. Peripheral vascular disease was routinely assessed using Duplex scan and major arterial disease was treated before reconstruction. Utilising 3D modelling, pre-operative planning and standardised osteotomies, we performed anatomical correction with radiological evidence. Definitive fixation was undertaken with internal fixation to stabilise the hindfoot. Multivariant analysis was performed to assess risk factors for failure (P>0.05 statistical significance). Results. 59 feet were included, 3 patients did not progress to definitive surgery and 3 patients had bilateral surgery. 62.7% patients were male with an average age of 56, 88.13% had Type 2 diabetes, 56% were hypertensive, 14% were on dialysis. Twenty (54.1%) single stage reconstructions had pre-operative ulceration, 3 pts had ischaemic heart disease and 36 pts had evidence of peripheral arterial disease. 81% of patients achieved normalisation of the 3 out of 4 anatomical angles (P<0.05). Two patients (3.1%) required metalwork removal for infection and limb salvage, 11 (18.6%) had delayed wound healing. Survivorship was 97% at 3yrs, and 94% at 6yrs, however if pre-existing vascular disease was present, it was 94% at 3yrs 85.3% at 6yrs. All patients were mobile at a 3 years mean follow up. Conclusion. Careful patient selection, multidisciplinary team and anatomic reconstruction led to predictable outcomes and functional limb salvage. Pre-operative vascular compromise led to a slight reduction in survivorship, but no major amputation

Introduction. Tibial Pilon fractures are potentially limb threatening, yet standards of care are lacking from BOFAS and the BOA. The mantra of “span, scan, plan” describes staged management with external fixation to allow soft tissue resuscitation, followed by a planning CT-scan. Our aim was to evaluate how Tibial Pilon fractures are acutely managed. Methods. ENFORCE was a multi-centre retrospective observational study of the acute management of partial and complete articular Tibial Pilon fractures over a three-year period. Mechanism, imaging, fracture classification, time to fracture reduction and cast, and soft tissue damage control details were determined. Results. 656 patients (670 fractures) across 27 centres were reported. AO fracture classifications were: partial articular (n=294) and complete articular (n=376). Initial diagnostic imaging mobilities were: plain radiographs (n=602) and CT-scan (n=54), with all but 38 cases having a planning CT-scan. 526 fractures had a cast applied in the Emergency Department (91 before radiological diagnosis), with the times taken to obtain post cast imaging being: mean 2.7 hours, median 2.3 hours, range 28 mins – 14 hours). 35% (102/294) of partial articular and 57% (216/376) of complete articular (length unstable) fractures had an external fixator applied, all of which underwent a planning CT-scan. Definitive management consisted of: open reduction internal fixation (n=495), fine wire frame (n=86), spanning external fixator (n=25), intramedullary nail (n=25), other (n=18). Conclusion. The management of Tibial Pilon fractures is variable, with prolonged delays in obtaining post cast reduction radiographs, and just over half of length unstable complete articular fractures being managed with the gold standard “span, scan, plan” staged soft tissue resuscitation. A BOFAS endorsed BOAST (British Orthopaedic Association Standard for Trauma) for Tibial Pilon fractures is suggested for standardisation of the acute management of these potentially limb threatening injuries, together with setting them apart from more straightforward ankle fractures

Background. Corrective fusion of a deformed / unstable Charcot neuroarthropathy (CN)of the midfoot and hindfoot is performed with the aim to prevent ulcers and maintain patient mobility. Methods. Between October 2007 and July 2018, 103 CN mid and hind foot corrections in 95 patients were performed. There were 34 hind-foot, 38 mid-foot and 31 combined hind and mid-foot surgeries. 83 feet had single stage corrections, whereas 20 required a staged operation. Results. Ninety-five patients were prospectively followed up. The mean patient age in our study was 57 years (21 – 85). Twenty-seven patients had type1 diabetes, 64 patients had type 2 and 4 patients had a neuropathy secondary to other conditions. Forty patients (42%) were offered a below knee amputation prior to attending our foot clinic. At a mean follow up of 56 months (12 – 140) we achieved 100% limb salvage with a 75% full bone fusion rate. There were 17 mortalities within our cohort at a mean period of 3 years. Ninety-seven percent (n=92) patients were mobilizing post-operatively in orthotic footwear. Fifty-two feet had pre-operative ulcers. Post-operatively 17 feet (16 patients) had persistent ulceration. Eight patients had ulcer resolution following further surgery and alteration of footwear, one patient has been listed for a below knee amputation for unstable non-union, whilst the remaining 7 patients have stable ulcers which are managed with dressings. Of the 26 feet (25 patients) with non-unions, 6 patients had revision fixation procedures whilst 8 patients required minor surgical procedures. The remaining 11 patients are stable non-unions who are asymptomatic and weight bearing. Other complications included a deep infection rate of 8% (n=7). Conclusion. We demonstrated a 100% limb salvage rate and an 83% success rate in ulcer resolution. We recommend this be done with the support of the multi-disciplinary team

Aims. In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method. Methods. We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months’ follow-up. Results. We identified 23 feet in 22 patients with a mean age of 56.7 years (33 to 70). The mean postoperative follow-up period was 44.7 months (14 to 99). Limb salvage was achieved in all patients. At one-year follow-up, all ulcers have healed and independent full weightbearing mobilization was achieved in all but one patient. Seven patients developed new mechanical skin breakdown; all went on to heal following further interventions. Fusion of the hindfoot was achieved in 15 of 18 feet (83.3%). Midfoot fusion was achieved in nine of 15 patients (60%) and six had stable and painless fibrous nonunion. Hardware failure occurred in five feet, all with broken dorsomedial locking plate. Six patients required further surgery, two underwent revision surgery for infected nonunion, two for removal of metalwork and exostectomy, and two for dynamization of the hindfoot nail. Conclusion. Two-stage reconstruction of the infected and deformed Charcot foot using internal fixation and following the principle of ‘long-segment, rigid and durable internal fixation, with optimal bone opposition and local antibiotic elusion’ is a good form of treatment provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2021;103-B(10):1611–1618

Aim. This retrospective case series reports the reoperation, major amputation, survival rates and mobility status in diabetic patients who underwent a trans-metatarsal amputation (TMA) managed within a multi-disciplinary diabetic foot care service. Methods and patients. Forty-one consecutive patients (37 men, 4 women) underwent a TMA between January 2008 to December 2017. They were retrospectively reviewed. The mean age at the time of surgery was 63 years (range 39 – 92). Results. Eighty-eight per cent (36/41) of the patients were followed-up. Four (11%) of the 36 patients required reoperation, including three major amputations (8%). All the patients requiring a reoperation were vasculopaths. The four-year patient survival rate following a TMA was 69% (25/36). Ninety-six per cent (21/22) of the surviving patients not requiring revision to a major amputation were fully mobile in bespoke orthoses, of whom a third required a stick. Conclusion. This study shows that transmetatarsal amputation in patients with diabetes, managed in a multi-disciplinary diabetic foot care service, is effective for limb salvage

Background. Charcot neuroarthropathy is a destructive disease characterized by progressive bony fragmentation as a result of the isolated or accumulative trauma in patients with decreased sensation that manifests as dislocation, periarticular fractures and instability. Although amputation can be a reasonable cost economic solution, many patients are willing to avoid that if possible. We explored here one of the salvage procedures. Methods. 23 patients with infected ulcerated unstable Charcot neuroarthropathy of the ankle were treated between 2012 and 2017. The mean age was 63.5 ±7.9 years; 16 males and 7 females. Aggressive open debridement of ulcers and joint surfaces, with talectomy in some cases, were performed followed by external fixation with an Ilizarov frame. The primary outcome was a stable plantigrade infection free foot and ankle that allows weight bearing in accommodative foot wear. Results. Limb salvage was achieved in 91.3% of cases at the end of a mean follow up time of 25 months (range: 19–32). Fifteen (71.4%) solid bony unions were evident clinically and radiographically, while 6 (28.5%) patients developed stable painless pseudoarthrosis. Two patients had below knee amputations due to uncontrolled infection. Conclusion. Aggressive debridement and arthrodesis with ring external fixation can be used successfully to salvage severely infected Charcot arthropathy of the ankle. Pin tract infection, delayed wound healing and stress fracture may complicate the procedure but can be easily managed. Amputation may be the last resort in uncontrolled infection

Aims. Hindfoot arthrodesis with retrograde intramedullary nailing has been described as a surgical strategy to reconstruct deformities of the ankle and hindfoot in patients with Charcot arthropathy. This study presents case series of Charcot arthropathy patients treated with two different retrograde intramedullary straight compression nails in order to reconstruct the hindfoot and assess the results over a mid-term follow-up. Patients and Methods. We performed a retrospective analysis of 18 consecutive patients and 19 operated feet with Charcot arthropathy who underwent a hindfoot arthrodesis using a retrograde intramedullary compression nail. Patients were ten men and eight women with a mean age of 63.43 years (38.5 to 79.8). We report the rate of limb salvage, complications requiring additional surgery, and fusion rate in both groups. The mean duration of follow-up was 46.36 months (37 to 70). Results. The limb salvage rate was 16 of 19 limbs. Three patients had to undergo below-knee amputation due to persistent infection followed by osteomyelitis resistant to parenteral antibiotic therapy and repeated debridement. Complications including infection, hardware removal, nonunion, and persistent ulcers requiring further intervention were also observed. Postoperative functional scores revealed significant improvement compared with preoperative scores on American Orthopaedic Foot and Ankle Society (AOFAS) – Hindfoot scale, Foot Function Index (FFI), visual analogue scale (VAS), and Foot and Ankle Outcome Score (FAOS). Conclusion. The use of retrograde intramedullary compression nail results in good rates of limb salvage when used for hindfoot reconstruction in patients with Charcot arthropathy. Cite this article: Bone Joint J 2018;100-B:190–6

Aims. To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or tendon transfer. Methods. A total of 21 eligible patients (mean age 34.0 years (standard deviation (SD) 11.2); mean follow-up period 31.8 months (SD 7.7), and 12 healthy controls (mean age, 26.8 years (SD 5.9) were included. For patients, clinical evaluation of the donor ankle was performed preoperatively and postoperatively. Square hop test, ankle strength assessment, and MRI of distal calf were assessed bilaterally in the final follow-up. The morphological symmetry of peroneal tendons bilaterally was evaluated by MRI in healthy controls. Results. Among the patients, the mean pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Karlsson-Peterson score were 98.7 (SD 2.5; p = 0.480) and 98.5 (SD 2.4; p = 0.480), and 98.3 (SD 2.4; p = 0.162) and 97.9 (SD 2.5; p = 0.162), respectively. There was no significant difference between square hop test bilaterally (p = 0.109) and plantar flexion peak force bilaterally (p = 0.371). The harvested limb had significantly less eversion peak force compared to the contralateral limb (p < 0.001). Evidence of probable tendon regeneration was observed in all the patients by MRI and the total bilateral peroneal tendon index (mean ratio of harvested side cross-sectional area of peroneal tendon compared with the contralateral side) was 82.9% (SD 17.4). In 12 healthy controls, peroneal tendons (mean 99.4% (SD 4.3) were found to be morphologically symmetrical between the two sides. Conclusion. The current study showed satisfactory clinical foot and ankle outcomes after full-thickness PLT harvesting and indicated the regenerative potential of PLT after its removal. Level of Evidence: Level IV, therapeutic retrospective case series. Cite this article: Bone Joint J 2020;102-B(2):205–211

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.

Aims

Despite the increasing numbers of ankle arthroplasties, there are limited studies on their survival and comparisons between different implants. The primary aim of this study was to determine the failure rates of primary ankle arthroplasties commonly used in the UK.

Aims

Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England.

Aims

Treatment for delayed wound healing resulting from peripheral vascular diseases and diabetic foot ulcers remains a challenge. A novel surgical technique named ‘tibial cortex transverse transport’ (TTT) has been developed for treating peripheral ischaemia, with encouraging clinical effects. However, its underlying mechanisms remain unclear. In the present study, we explored the potential biological mechanisms of TTT surgery using various techniques in a rat TTT animal model.

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.

Aims. The surgical management of ankle arthritis with tibiotalar arthrodesis is known to alter gait, as compared with normal ankles. The purpose of this study was to assess post-operative gait function with gait before arthrodesis. Patients and Methods. We prospectively studied 20 patients who underwent three-dimensional gait analysis before and after tibiotalar arthrodesis. Cadence, step length, walking velocity and total support time were assessed. Kinetic parameters, including the moment and power of the ankle in the sagittal plane and hip power were also recorded. Results. Significant improvement was recorded across numerous parameters compared with pre-operative measurements. Temporal-spatial data demonstrated a significant increase in step length (p = 0.003) and velocity (p = < 0.001). Total support time decreased for the unaffected limb (p = 0.01). Kinematic results demonstrated that in the affected limb, total sagittal range of movement did not change significantly (p = 0.1259). However, the arc of movement had a near congruent shift with mean maximal dorsiflexion increasing from 5° (-17° to 16°) to 12° (5° to 18°) (p < 0.001) and mean maximal plantarflexion decreasing from 6.8° (6° to 21°) to 0.9° (-9° to 8°) (p = 0.003). Mean hip joint range of movement increased by 6° (-7° to 24°; p = 0.003). Kinetic results demonstrated no statistically significant change in ankle power (p = 0.1292). However, there was an increase in ankle moment (p = 0.04) and hip power (p = 0.01) in the surgically treated extremity. Sagittal plane range of movement was not reduced after tibiotalar fusion. Conclusion. Although following tibiotalar arthrodesis the gait demonstrated never matched the gait shown in unaffected ankles, compared with the pre-operative analysis there was improvement in numerous temporal-spatial, kinematic, and kinetic measures. Cite this article: Bone Joint J 2016;98-B:1369–75

We hypothesised that a minimally invasive peroneus brevis tendon transfer would be effective for the management of a chronic rupture of the Achilles tendon. In 17 patients (three women, 14 men) who underwent minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum, at a mean follow-up of 4.6 years (2 to 7) the modified Achilles tendon total rupture score (ATRS) was recorded and the maximum circumference of the calf of the operated and contralateral limbs was measured. The strength of isometric plantar flexion of the gastrocsoleus complex and of eversion of the ankle were measured bilaterally. Functional outcomes were classified according to the four-point Boyden scale. . At the latest review, the mean maximum circumference of the calf of the operated limb was not significantly different from the pre-operative mean value, (41.4 cm, 32 to 50 vs 40.6 cm, 33 to 46; p = 0.45), and not significantly less than that of the contralateral limb (43.1 cm, 35 to 52; p = 0.16). The mean peak torque (244.6 N, 125 to 367) and the strength of eversion of the operated ankle (149.1 N, 65 to 240) were significantly lower (p < 0.01) than those of the contralateral limb (mean peak torque 289, 145 to 419; strength of eversion: 175.2, 71 to 280). The mean ATRS significantly improved from 58 pre-operatively (35 to 68) to 91 (75 to 97; 95% confidence interval 85.3 to 93.2) at the time of final review. Of 13 patients who practised sport at the time of injury, ten still undertook recreational activities. . This procedure may be safely performed, is minimally invasive, and allows most patients to return to pre-injury sport and daily activities. Cite this article: Bone Joint J 2015;97-B:353–7