Introduction. Medial column insufficiency in patients with painful acquired flatfoot can be difficult to appreciate. The reverse Coleman block test (as described and published by Mr E Wood in 2009) is used in this study to predict medial column instability. Methods. Patients who underwent a procedure for medial column insufficiency with use of the reverse Coleman block test pre-operatively were investigated. Weight bearing radiographs were used to determine the joints in the medial column contributing to the deformity and also to estimate the angle which the first ray must be depressed to re-establish hindfoot neutrality. The reverse Coleman block test corrects a mobile valgus heel to a neutral position by placing a block, of appropriate height, under the first metatarsal head. With the heel in neutral and the relative forefoot supination compensated the foot returns to a neutral anatomic position. Gender, age, complications and radiological outcomes were investigated. Results. Over the last three years 25 medial column procedures were performed for painful insufficiency on 17 females and five males by the senior author. Three patients underwent staged bilateral procedures. The average age was 62 years old. Three feet had been on operated on the medial column previously. The pre-operative weight bearing lateral radiographs showed instability in the medial column greater than 5° in 12 cases. With the reverse Coleman block test instability was seen in 25 cases and the deformity increased from an average of 7° (range 0° to 25°) to 14° (range 5° to 30°). Post-operative weight bearing radiographs, with fusion of the unstable joint, the average medial column alignment was 1° (range -10° to 10°). Three patients developed superficial infections requiring oral antibiotics for treatment. One patient had a non-requiring revision surgery. Discussion. The reverse Coleman block test revealed instability in 13 out of 27 cases not seen with simple weight bearing lateral radiographs. The test also on average doubled the size of any deformity seen. This aided pre-operative planning to predict the scale of deformity correction required. Conclusion. The reverse Coleman block test is a useful test to determine medial column insufficiency and assist with pre-operative planning

Introduction. Medial column insufficiency in patients with painful acquired flatfoot can be difficult to appreciate. The reverse Coleman block test is used in this study to predict medial column instability. Methods. Patients who underwent a procedure for medial column insufficiency with use of the reverse Coleman block test pre-operatively were investigated. Weight bearing radiographs were used to determine the joints in the medial column contributing to the deformity and also to estimate the angle which the first ray must be depressed to re-establish hindfoot neutrality. The reverse Coleman block test corrects a mobile valgus heel to a neutral position by placing a block, of appropriate height, under the first metatarsal head. With the heel in neutral and the relative forefoot supination compensated the foot returns to a neutral anatomic position. Gender, age, complications and radiological outcomes were investigated. Results. Over the last three years 25 medial column procedures were performed for painful insufficiency on 17 females and five males by the senior author. Three patients underwent staged bilateral procedures. The average age was 62 years old. Three feet had been on operated on the medial column previously. The pre-operative weight bearing lateral radiographs showed instability in the medial column greater than 5° in 12 cases. With the reverse Coleman block test instability was seen in 25 cases and the deformity increased from an average of 7° (range 0° to 25°) to 14° (range 5° to 30°). Post-operative weight bearing radiographs, with fusion of the unstable joint, the average medial column alignment was 1° (range −10° to 10°). Three patients developed superficial infections requiring oral antibiotics for treatment. One patient had a non-union requiring revision surgery. Discussion. The reverse Coleman block test revealed instability in 13 out of 27 cases not seen with simple weight bearing lateral radiographs. The test also on average doubled the size of any deformity seen. This aided pre-operative planning to predict the scale of deformity correction required. Conclusion. The reverse Coleman block test is a useful test to determine medial column insufficiency and assist with pre-operative planning

Lisfranc injury is named after Jacques Lisfranc, a field surgeon in Napoleon’s army. Based on Columnar classification of Lisfranc fracture dislocation, study of injury to medial column was carried out as they have the potential to be a severe cause of residual disability in the foot if not properly treated at the initial stage. Importance of Medial column is that it forms the highest point of longitudinal arch and may be injured in isolation or in association with lateral and middle column. Complex deforming forces may cause unusual pattern of medial column injuries at more than one level. There is renewed interest in this injury over past decade as modalities of treatment have changed over a period of time from conservative to fixation with K-wires to rigid fixation with screws to fixation with absorbable screws or combination of above. We present 21 cases of medial column injuries in Lis-franc fracture-dislocation. Age ranged from 18 to 65 yrs. All were male. Four fixed with compression screws,12 fixed with K-wires, 2 managed conservatively, 3 were neglected cases. Post-operatively POP back splint was given, K-wire removal at 8 weeks, screw removal after 12 weeks and partial weight bearing started at 8-12 weeks. Follow-up ranged from 3 months to 3 years. They were graded on basis of residual pain, foot shape, and movements. Best results were seen in cases where rigid intertarsal / intercolumnar stability was achieved by screw fixation. There was residual inter-cuneiform subluxation in 4 cases, which were fixed with K-wires, and this led to residual pain. Conservative/neglected cases had poor results. Intercolumnar / intertarsal instabilities should be primarily recognized and stabilized under compression. Stabilization should not only be within the 3 columns but also intercolumnar, thus maintaining the relative length of 3 columns and hence reconstitution of medial longitudinal arch

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

Progressive collapsing foot deformity (PCFD) is a complex foot deformity with varying degrees of hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. In its management, muscle and tendon balancing are important to address the deformity. Peroneus brevis is the primary evertor of the foot, and the strongest antagonist to the tibialis posterior. Moreover, peroneus longus is an important stabilizer of the medial column. To our knowledge, the role of peroneus brevis to peroneus longus tendon transfer in cases of PCFD has not been reported. This study evaluates patient reported outcomes including pain scores and any associated surgical complications for patients with PCFD undergoing isolated peroneus brevis to longus tendon transfer and gastrocnemius recession. Patients with symptomatic PCFD who had failed non-operative treatment, and underwent isolated soft tissue correction with peroneus brevis to longus tendon transfer and gastrocnemius recession were included. Procedures were performed by a single surgeon at a large University affiliated teaching hospital between January 1 2016 to March 31 2021. Patients younger than 18 years old, or undergoing surgical correction for PCFD which included osseous correction were excluded. Patient demographics, medical comorbidities, procedures performed, and pre and post-operative patient related outcomes were collected via medical chart review and using the appropriate questionnaires. Outcomes assessed included Visual Analogue Scale (VAS) for foot and ankle pain as well as sinus tarsi pain (0-10), patient reported outcomes on EQ-5D, and documented complications. Statistical analysis was utilized to report change in VAS and EQ-5D outcomes using a paired t-test. Statistical significance was noted with p<0.05. We analysed 43 feet in 39 adults who fulfilled the inclusion criteria. Mean age was 55.4 ± 14.5 years old. The patient reported outcome mean results and statistical analysis are shown in Table one below. Mean pre and post-operative foot and ankle VAS pain was 6.73, and 3.13 respectively with a mean difference of 3.6 (p<0.001, 95% CI 2.6, 4.6). Mean pre and post-operative sinus tarsi VAS pain was 6.03 and 3.88, respectively with a mean difference of 2.1 (p<0.001, 95% CI 0.9, 3.4). Mean pre and post-operative EQ-5D Pain scores were 2.19 and 1.83 respectively with a mean difference of 0.4 (p=0.008, 95% CI 0.1, 0.6). Mean follow up time was 18.8 ± 18.4 months. Peroneus brevis to longus tendon transfer and gastrocnemius recession in the management of symptomatic progressive collapsing foot deformity significantly improved sinus tarsi and overall foot and ankle pain. Most EQ-5D scores improved, but did not reach statistically significant values with the exception of the pain score. This may have been limited by our cohort size. To our knowledge, this is the first report in the literature describing clinical results in the form of patient reported outcomes following treatment with this combination of isolated soft tissue procedures for the treatment of PCFD. For any figures or tables, please contact the authors directly

Aims. Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures. Methods. The search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles involving patients with complex proximal humeral fractures treated using open reduction with locking-plate fixation, with or without augmentation, were considered. A meta-analysis of comparative studies comparing locking-plate fixation with cement augmentation or with bone-graft augmentation versus locking-plate fixation without augmentation was performed. Results. A total of 19 studies were included in the qualitative synthesis, and six comparative studies were included in the meta-analysis. Overall, 120 patients received locking-plate fixation with bone-graft augmentation, 179 patients received locking-plate fixation with cement augmentation, and 336 patients received locking-plate fixation without augmentation. No statistically relevant differences between the augmented and non-augmented cohorts were found in terms of the Disabilities of the Arm, Shoulder and Hand questionnaire score and Constant-Murley Score. The cement-augmented group had a significantly lower rate of complications compared to the non-augmented group. Conclusion. While locking-plate fixation with cement augmentation appears to produce a lower complication rate compared to locking-plate fixation alone, functional outcomes seem comparable between augmented and non-augmented techniques. Cite this article: Bone Joint J 2024;106-B(7):646–655

Background. Research on midfoot injuries have primarily concentrated on the central column and the Lisfranc ligament without amassing evidence on lateral column injuries. Lateral column injuries have historically been treated with Kirschner wire fixation when encountered. Objective. Our aim in this study was to analyse lateral column injuries to the midfoot, their method of treatment and the radiological lateral column outcomes. Our nul hypothesis being that fixation is required to obtain and maintain lateral column alignment. Methods. Data was retrospectively collected from four centres on surgically treated midfoot fracture dislocations between 2011 and 2021. Radiographs were analysed using departmental PACS. All statistics was performed using SPSS 26. Results. A total of 235 cases were diagnosed as having a lateral column injury out of the 409 cases included. On cross tabulation, there was a significant association with having a central column injury (234/235, p<.001) and 70% of cases (166/235) also had an additional medial column injury. Of the 235 lateral column injuries, data was available regarding fixation radiographic alignment on 222 cases. There were 44 cases which underwent Kirschner wire fixation, 23 plate fixations and 3 screw fixations. Lateral column alignment loss was seen in 2.84% (4/141) of those which didn't undergo fixation, 13.64% (6/44) which underwent K wires, and 0 % in those fixed by screws or K wires. Conclusion. Lateral column injury occurs in over half of midfoot fractures in this study. It rarely occurs alone and is most commonly related to three column injuries. Nevertheless, following stabilisation of the central column, additional fixation of injuries to the lateral column do not appear beneficial. The use of a bridge plate to fix the central column appears protective and purely ligamentous injury was a higher risk than an injury that included the bone

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. Comminuted mid-foot fractures are uncommon. Maintenance of the length and alignment of the medial column, with restoration of articular surface congruity, is associated with improved outcomes. Conventional surgery has utilised open or closed reduction with K-wire fixation, percutaneous techniques, ORIF, external fixation or a combination of these methods. In 2003 temporary bridge plating of the medial column was described to reconstruct and stabilise the medial column. The added advantage of locking plates is the use of angle-stable fixation. We present our experience with temporary locking plates in complex mid-foot fractures. Materials and methods. Prospective audit database of 12 patients over a 6 year period (2003-2009). 5 males 7 females mean age 41.9. Mechanism of injury: 11 high-energy injuries (6 falls from height, 5 RTCs), 1 low energy injury. Fracture type: All involved the medial column - 12 fracture dislocations of the medial column. 4 concomitant injuries to the lateral column. All underwent ORIF, realignment, and stabilisation with locking plates across the mid-foot. Results. Median length of time to plate removal: 3 months (range 2-6). Prior to removal of the metalwork, there was no loss of reduction, no infections, and no implant breakage. 10 out of 12 required plate removal at 3 months. Long-term follow-up (Mean 12.4 months, range 4-32): 11 have minimal symptoms of swelling or discomfort from the midfoot which does not restrict their ADLs, whilst 1 patient developed post-traumatic arthritis with medial arch collapse. No secondary procedures following plate removal. The two patients with the plate in-situ were asymptomatic with regards to the metalwork at final follow-up. Conclusion. Locking plates provide adequate stabilisation following open reduction and internal fixation of complex and unstable midfoot fracture dislocations. However, the majority will require removal of the metalwork. Following removal of the metalwork, satisfactory length and alignment, and stability of the midfoot, is maintained

Aims. Tibial plateau fractures (TPFs) are complex injuries around the knee caused by high- or low-energy trauma. In the present study, we aimed to define the distribution and frequency of TPF lines using a 3D mapping technique and analyze the rationalization of divisions employed by frequently used classifications. Methods. In total, 759 adult patients with 766 affected knees were retrospectively reviewed. The TPF fragments on CT were multiplanar reconstructed, and virtually reduced to match a 3D model of the proximal tibia. 3D heat mapping was subsequently created by graphically superimposing all fracture lines onto a tibia template. Results. The cohort included 405 (53.4%) cases with left knee injuries, 347 (45.7%) cases with right knee injuries, and seven (0.9%) cases with bilateral injuries. On mapping, the hot zones of the fracture lines were mainly concentrated around the anterior cruciate ligament insertion, posterior cruciate ligament insertion, and the inner part of the lateral condyle that extended to the junctional zone between Gerdy’s tubercle and the tibial tubercle. Moreover, the cold zones were scattered in the posteromedial fragment, superior tibiofibular syndesmosis, Gerdy’s tubercle, and tibial tubercle. TPFs with different Orthopaedic Trauma Association/AO Foundation (OTA/AO) subtypes showed peculiar characteristics. Conclusion. TPFs occurred more frequently in the lateral and intermedial column than in the medial column. Fracture lines of tibial plateau occur frequently in the transition zone with marked changes in cortical thickness. According to 3D mapping, the four-column and nine-segment classification had a high degree of matching as compared to the frequently used classifications. Cite this article: Bone Joint Res 2020;9(6):258–267

Introduction. Locking plates can provide greater stability than conventional plates; however, reports revealed that fractures had a high incidence of failure without medial column support; the mechanical support of medial column could play a significant role in humeral fractures. Recent studies have demonstrated the importance of intramedullary strut in proximal humeral fracture fixation, the relationship to mechanical stability and supporting position of the strut remain unclear. The purpose of this study was to evaluate the influence of position of the intramedullary strut on the stability of proximal humeral fractures using a locking plate. Materials and methods. Ten humeral sawbone (Synbone) and locked plates (Synthes, cloverleaf plate), with and without augmented intramedullary strut (five in each group) for proximal humerus fractures, were tested using material testing machine to validate the finite element model. A 10 mm osteotomy was performed at surgical neck and a strut graft (10 cm in length) was inserted into the fracture region to lift the head superiorly. Each specimen was statically tested at a rate of 5 mm/min until failure. To build the finite element (FE) model, 64-slices CT images were converted to create a 3D solid model. The material properties of screws and plates were modeled as isotropic and linear elastic, with an elastic modulus of 110 GPa, (Poisson's ratio, n=0.3). The Young's moduli of cortical and cancellous bones were 17 GPa and 500 MPa (n=0.4), respectively. Three alter shifting toward far cortex by 1, 2, and 3 mm in humeral canal were installed in the simulating model. Results and discussion. The test result showed stiffness for only locked plate was 149.2±21.3 N/mm; and the plating combined with an intramedullary strut was 336.5±50.4 N/mm. On average, the stiffness was increased by 2.2 times in the augmented fixation relative to the only locking plate fixation. The finite element analytical results showed stiffness of 162 N/mm for fixation without strut, and 372 N/mm for those with strut augmentation. The stiffness between experiment and FE analysis agreed in 8.6% for the only locking plate case; and agreed in 10.5% for the case fixed with intramedullary strut. FE analysis showed the stability of construct increased 7%, 11% and 20% as the strut shift by 1, 2, and 3 mm, respectively. Gardner (2007) reported the importance of mechanical support at the medial region for maintenance of reduction when proximal humerus fracture treated with locking plates. Conclusion. The intramedullary strut may provide superior stability than the only locking plate fixation. The FE model provides a useful implement to find the optimal configuration of plate fixation. Acknowledgements. All authors thank the funding support from National Science Council (NSC 102-2628-B-650-001) and E-Da Hospital (EDPJ1020027)

Most of the controversy surrounding management of the adult acquired flatfoot deformity revolves around the correction of Stage 2 deformity. Stage 1 deformity, uncommonly corrected surgically, involves tenosynovitis with preservation of tendon length and absence of structural deformity. Attempts at tenosynovectomy in light of structural deformity leads to operative failure, found in 10% of Teasdall and Johnson's 1992 patient population. Thus, with tenosynovectomy rarely becoming an operative situation, Stage 2 deformity becomes the mainstay of operative treatment of the adult flatfoot. Stage 2 deformity patients present with swelling medially, the inability to do a single heel raise, with a passively correctable subtalar joint. The tendon is functionally torn. In recent years, authors have subdivided Stage 2 deformity even further into A and B subcategories, where A involves less than 50% uncovering of the talonavicular joint, and B patients more than 50%. Recently, Anderson has added a C subtype, which may be applied to either A and B patients, in patients who have forefoot varus. Thus, Stage 2 patients suffer from pain that begins medially and progresses to the subfibular region over time. Most important, recognition of the continued sub classification in Stage 2 disease echoes the fact that this disorder is on a continuum, challenging the surgeon to recognize subtleties that, if unrecognized, lead to a poor patient outcome. The mainstay of treatment in Stage 2 disease is the medial slide calcaneal osteotomy, which realigns the hindfoot axis reducing valgus, improves the medial arch, protects the FDL tendon transfer, and allows the Achilles tendon to become a strong inverter. Over shift of the calcaneus can compromise the outcome, as will a lack of recognition of the congenital subtleties such that a valgus hindfoot can have a varus orientation to the calcaneus, both leading to lateral overload. A pure medial slide of a calcaneus that has a varus orientation does not correct deformity, rather, it creates it. Thus, an axial calcaneal view must be studied carefully, for a varus orientation may be corrected via a closing wedge osteotomy commensurate with the medial shift of the tuberosity. As noted above, the flexor digitorum longus tendon transfer is the staple procedure to replace the damaged posterior tibial tendon. This transfer balances the eversion power of the peroneal tendons, works in phase with the former posterior tibial tendon in the stance phase of gait, and replaces a painful diseased posterior tibial tendon. However, over tensioning the transfer results in a tenodesis rather than a functional tendon transfer, the relative weakness of the FDL tendon (30% as strong as the PTT) creates difficulty with heel raise, and inappropriate transfer to distal tarsal bones may compromise the result by limiting torque from the transferred tendon. Preservation of the posterior tibial tendon in combination with the transferred FDL tendon remains a consideration without answer, though Rosenfeld (2005) suggests a substantial improvement in strength through PTT preservation. Failure of the above protocol for treating Stage 2 disease most often revolves around the insufficient corrective power of the tandem procedures in longstanding ruptures. According to Guyton (2001), only 50% of patients report a perception in deformity improvement following FDL/calcaneal osteotomy procedures, and only 4% report a significant improvement in pre-existing deformity. Sangeorzan (2001) found such patients could not achieve a painless plantigrade foot due to acquired ligament laxity (primarily the Spring Ligament). Sangeorzan applied Evans' pediatric procedure to adults without confirming the pathomechanics of correction. Some speculate the windlass effect on the plantar fascia creates correction (refuted by Horton, 1998, finding the plantar fascia is loosened by a lateral column lengthening), others believe tightening the peroneus longus through lateral column lengthening increases first ray plantarflexion, restoring the medial arch. Controversy also remains in answering Cooper's (1997) claim that lengthening through the calcaneus creates static increase in pressure about the calcaneocuboid joint (1.4mPa total) that may lead to an arthritic joint long term. Painful lateral overload following lateral column lengthening remains difficult problem to both prevent and correct. This last point leads to some focusing their efforts on restoration of the medial column. This group focuses on the “C” type deformity noted by Anderson, those with forefoot varus. It is known that the medial column is supported by the navicular, the cuneiforms, and the first, second, and third metatarsals. While a Cotton (opening wedge medial cuneiform) osteotomy, a first tarsometatarsal joint arthrodesis, or a metatarsal osteotomy has value, the surgeon must note that this only corrects the first ray. Complete correction of the medial column is best achieved through naviculocuneiform joint arthrodesis. Standing radiographs commonly reveal collapse at that level; however, surgeons are reticent to perform such fusions in light of the higher nonunion rate

The standard treatment of arthrosis of the ankle joint is arthrodesis while new prosthesis leed to good clinical results. Currently there is much controversial discussion, and knowledge of the fundamentals of biomechanics is becoming ever more important. Ten macroscopically and roentgenographically normal foot specimens were tested comparing tibio-talar arthodesis vs. nativ situation on a kinematic gait simulator. The stance- phase of normal walking gait was simulated from heel-contact to toe-off. Ground reaction forces were simulated by a tilting angle- and force-controlled translation stage upon which a pressure measuring platform was mounted. Force was applied to the tendons of the foot flexor and extensor muscle groups by cables attached to an additional set of six force-controlled hydraulic cylinders. Tibial rotation was produced by an electrical servo motor. The change after arthrodesis was a varying degree of relocation of average force and maximum pressure from the lateral onto the medial column of the foot; the increase force on talonavicular joint and decrease on calcaneocuboid joint is statistically significant. The average force increased from native 66.7N to 80.8N upon arthrodesis in the talonavicular joint and decreased in the calcaneocuboid joint from 71.9N to 58.5N. Peak pressure increased from 3728kPa to 4552kPa in talonavicular joint and decreased in calcaneocuboid joint from 3809kPa to 3627kPa. After arthrodesis, we measured inconsistent changes in Chopart joint. On some feet, the changes in stress were slight, but on majority, relocation of force and peak pressure was significant. The result was a change in the function of Chopart joint with increased extension load on talonavicular joint at time of highest joint load during push-off. These in vitro observations explain the clinical observations that have followed ankle arthrodesis. For one, there are reports on tibiotalar arthrodesis patients who are largely mobile and free of complaints, which correlates with the observation that not all preparations indicate a clear relocation of force and intraarticular peak pressure onto the talonavicular joint. In these cases, the ability of strong muscular plantar flexion could explain a good functional result. In contrast, and in addition to subtalar joint degeneration, arthroses in the talonavicular joint have been frequently observed following tibiotalar arthrodeses. The relocation of both force and intraarticular peak pressure onto the medial column of the foot in the majority of preparations explain the degeneration on the extensor side of the joint with osteophyte formation impressively

Severe femoral head deformities due to Perthes' disease are characterized by limitation of ROM, pain, and early degeneration, eventually becoming intolerable already in early adulthood. Morphological adaptation of the acetabulum is substantial and complex intra- and extraarticular impingement sometimes combined with instability are the underlying pathologies. Improvement is difficult to achieve with classic femoral and acetabular osteotomies. Since 15 years we have executed a head size reduction. With an experience of more than 50 cases no AVN of the femoral head was recorded. In two hips fracture of the medial column of the neck has been successfully treated with subsequent screw fixation. The clinical mid-term results are characterized by substantial increase of hip motion and pain reduction. Surgical goal is to obtain a smaller head, well contained in the acetabulum. It should become as spherical as possible and the gliding surface should be covered with best available cartilage. Together, it has to be accomplished under careful consideration of the blood supply to the femoral head. In the majority of cases acetabular reorientation is necessary to optimize joint stability. Femoral head segment resections without guidance is difficult. Therefore, 3D-simulation for cut direction and segment size including the implementation of the resultant osteotomy configuration was developed using individually manufactured cutting jigs. First experience in five such cases have revealed good results. The forthcoming steps are the improvement of computer algorithm and automation. Goal is that with first cut decision the other cuts are automatically determined resulting in optimal head size and sphericity

The April 2023 Foot & Ankle Roundup³⁶⁰ looks at: Outcomes following a two-stage revision total ankle arthroplasty for periprosthetic joint infection; Temporary bridge plate fixation and joint motion after an unstable Lisfranc injury; Outcomes of fusion in type II os naviculare; Total ankle arthroplasty versus arthrodesis for end-stage ankle osteoarthritis; Normal saline for plantar fasciitis: placebo or therapeutic?; Distraction arthroplasty for ankle osteoarthritis: does it work?; Let there be movement: ankle arthroplasty after previous fusion; Morbidity and mortality after diabetic Charcot foot arthropathy.

Introduction:. The purpose of this study was to elucidate the specific radiographic effects that the Cotton osteotomy confers when used in combination with other reconstructive procedures in the management of the flexible flat foot deformity. Methods:. Between 2002–2013, 198 Cotton osteotomies were retrospectively identified following IRB approval. 131 were excluded on the basis of ipsilateral mid/hindfoot arthrodesis, inadequate radiographs or being less than 18yrs old at time of surgery. Parameters including the articular surface angles of the hindfoot/forefoot, Meary's angle and a newly defined Medial Arch Sag Angle (MASA) were recorded. A matched group of patients who did not undergo a Cotton osteotomy but who underwent similar hindfoot reconstructive procedures served as historic controls. Results:. 67 Cotton osteotomies in 59 patients with a mean age of 45 years (range, 18–80) were evaluated. Concomitant procedures included combinations of tibialis posterior tendon (PTT) reconstruction, Evans lateral column lengthening, medial displacement calcaneal osteotomy (MDCO). In all patients who underwent a Cotton osteotomy, there were statistically significant improvements in the articular surface angles along the medial side of the foot (p < 0.05). Improvement in arch height was also found to be statistically significant (p < 0.05). In comparison to matched controls, the Cotton osteotomy did not improve Meary's angle but provided an additional 11.21° of MASA correction (p < 0.05) when used in in conjunction with the Evans procedure and PTT reconstruction. A similar trend was seen with MDCO and PTT reconstruction. Discussion:. This study confirms the Cotton osteotomy is a powerful surgical adjunct in flatfoot reconstruction and quantifies the additional 11.21° of MASA correction it provides when the Cotton osteotomy is added to a calcaneal osteotomy and PTT reconstruction. This has relevance as an alternative for selection of a medial column stabilization procedure, which is joint sparing

A discussion of the essential deformity in calcaneo-valgus feet develops a theme originally put forward in 1961 on the relapsed club foot (Evans 1961). Whereas in the normal foot the medial and lateral columns are about equal in length, in talipes equino-varus the lateral column is longer and in calcaneo-valgus shorter than the medial column. The suggestion is that in the treatment of both deformities the length of the columns be made equal. A method is described of treating calcaneo-valgus deformity by inserting cortical bone grafts taken from the tibia to elongate the anterior end of the calcaneus

Purpose. Locking plates are widely used in clinical practice for the surgical treatment of complex proximal humerus fractures, especially in osteoporotic bone. The aim of this study is to assess the biomechanical influence of the infero-medial locking screws on maintaining reduction of the fragments in a proximal humerus fracture. Materials & Methods. A standard 3-part proximal humerus fracture was created in fourth generation humerus saw bones. Each specimen was anatomically reduced and secured with a PHILOS locking plate. Eleven of the specimens had infero-medial locking screws inserted, and 11 specimens did not. Each humerus sawbone underwent cyclical loading at 532N, as previous studies showed this was the maximum force at the glenohumeral joint. The absolute inter-fragmentary motion was recorded using an infra-red motion analysis device. Each specimen was then loaded to failure. Results. The fixation of a 3-part proximal humerus fracture with the insertion of the infero-medial locking screws had significantly less inter-fragmentary motion at 250, 500, 750 and 1000 cycles, when compared to a similar fracture pattern without this strategically placed screw (P< 0.001). In both groups at each 250 cycle increment there was a significant increase in the overall fracture fragment movement (P< 0.01). The load to failure in the group with the infero-medial screws was also significantly more (P< 0.001). The median load of 1159N was required for construct failure compared to 1452N in the group without the inferomedial screws. Conclusion. This study supports the importance of anatomical reduction and adequate support of the medial column on maintaining fracture reduction of proximal humerus fractures. The key placement of the infero-medial locking screws is of significant importance in creating a solid construct for proximal humerus fracture healing. This may reduce implant complications such as screw perforations or the possible loss of reduction of fracture fragments

Posterior tibial tendon dysfunction is a well-recognised condition. It commonly occurs in middle aged overweight women. In contrast to most tendon pathology, the tendon is still often intact and the tendon is stretched rather than completely ruptured. The diagnosis can be made on clinical grounds. Clinical features include acquired flatfoot deformity, inability to perform a single heel raise, ‘too many toes’ sign and loss of inversion power with the foot in forced plantarflexion. Disease is staged into four stages, Stage II is the most common presentation. Treatment options for Stage I are non-operatively including rest and antiinflammatories. Surgical treatment for this is required if this fails or progresses to next stage. Treatment for Stage II disease is most commonly a tendon transfer using FDL tendon transfer and some bony procedure, most commonly calcaneal osteotomy. More recently move to sub-classify Stage II into sub-classification depending on severity of hindfoot valgus and presence of fixed forefoot varus. Other treatment options for Stage II include lateral column lengthening or medial column shortening procedures. Stage III disease is fixed deformity which is classically treated with triple arthrodesis. Stage IV deformity is fixed deformity with ankle valgus. Difficult condition to treat. This requires ankle and hindfoot fusion