Biomechanical foot orthoses (or foot wedges) are commonly used in clinical practice. The aim of this study was to investigate the effect of foot wedges on plantar pressure during normal gait. Thirty normal adult subjects (11 men, 19 women; mean age = 25.2 years, range = 18–36 years) walked along a floor-mounted wooden walkway incorporating the Musgrave™ pressure plate under six testing conditions : (1) barefoot; (2) tubigrip stocking; (3) tubigrip stocking and medial forefoot wedge; (4) tubigrip stocking and lateral forefoot wedge; (5) tubigrip stocking and medial heel wedge; and (6) tubigrip stocking and lateral heel wedge. Pelite™ foot wedges were placed underfoot inside the tubigrip stocking. Recorded footprints were divided into four quadrants (anteromedial (AMQ), anterolateral (ALQ), posteromedial (PMQ), and posterolateral (PLQ)). Statistical analysis of quadrant plantar pressures, anterior-posterior plantar pressure ratios, medial-lateral plantar pressure ratios and mean centre of pressure to mid-axis distances was performed using the paired t-test. Forefoot wedges caused earlier forefoot loading (p< 0.05). They increased anterior-posterior plantar pressure distribution (p< 0.001): medial wedges increased AMQ plantar pressure (p< 0.001) and decreased PLQ plantar pressure (p< 0.01); lateral wedges increased ALQ plantar pressure (p< 0.001) and decreased PLQ plantar pressure (p< 0.01). Heel wedges delayed forefoot loading (p< 0.02). They decreased anterior-posterior plantar pressure distribution (p< 0.05): medial wedges decreased ALQ plantar pressure (p< 0.01); lateral wedges decreased ALQ plantar pressure (p< 0.01) and increased PLQ plantar pressure (p< 0.001). Foot wedges did not significantly affect medial-lateral plantar pressure distribution. We conclude that foot wedges do affect plantar pressure in those with normal feet and normal gait. Foot wedges affected anteroposterior plantar pressure distribution but did not affect mediolateral plantar pressure distribution

The Weil osteotomy has gained popularity for surgically treating patients with metatarsalgia, intractable plantar keratosis and/or metatarsophalangeal joint dislocation because of its simplicity and lack of complications. Different geometric configurations of the Weil osteotomy have been proposed to reduce plantar pressure. In a dynamic cadaver model, these different geometric configurations of the Weil osteotomy did not significantly alter plantar pressure. Metatarsal head resection was required to significantly reduce plantar pressure. The purpose of this study was to evaluate the effect of different geometric configurations of the Weil osteotomy on the plantar pressures in a dynamic cadaver model. Different geometric configurations of the Weil osteotomy have been proposed to decrease plantar pressure, but in a dynamic cadaver model, these modifications did not significantly alter plantar pressure. Metatarsal head resection was required to significantly reduce plantar pressure. The plantar translation of the metatarsal head occurring with a more oblique Weil osteotomy compared to a standard Weil osteotomy did not significantly increase plantar pressure in a dynamic cadaver model. The addition of a 4 mm slice resection did not significantly reduce pressure. Metatarsal head resection was required to significantly reduce pressure (p=0.02). Ten specimens (5 matched pairs of cadaver lower extremities) were tested. Each pair of specimens had an oblique Weil osteotomy performed on one side, and a standard (parallel) Weil osteotomy on the other. Then, a 4 mm slice resection, and metatarsal head resection were performed sequentially. The plantar pressures were measured with an F scan in-shoe sensor while cyclically loaded to 700 N at a frequency of 1 Hz in intact specimens, and after each intervention. The different geometric configurations of the Weil osteotomy did not significantly alter plantar pressure; metatarsal head resection was required to significantly reduce pressure. The Weil osteotomy reliably reduces dislocated metatarsophalangeal joints. The angle of the osteotomy does not affect plantar pressure. Further study in a dynamic model is required to identify other factors, which affect plantar pressure

Background: While several studies in the last years tried to identify clinical limitations of patients suffering from end-stage ankle osteoarthritis (OA), very few attempted to assess foot and ankle function in a more objective biomechanical way, especially using dynamic pedobarography. The aim of the study was therefore to explore plantar pressure distribution characteristics in a large cohort of posttraumatic end-stage ankle OA. Method: 120 patients (female, 54; male, 66; 120 cases) suffering from posttraumatic end-stage ankle OA were included. The clinical examination consisted of assessment of the AOFAS hindfoot score, a pain score, the range of motion (ROM) for ankle dorsiflexion and plantar flexion, and the body mass index (BMI, kg/m2). Radiological parameters included the radiological tibiotalar alignment and the radiological ankle OA grading. Plantar pressure distribution parameters were assessed using dynamic pedobarography. Results: Intra-individual comparison between the affected and the opposite, asymptomatic ankle revealed significant differences for several parameters: maximum pressure force and contact area were decreased in the whole OA foot, such was maximum peak pressure in the hindfoot and toes area. No correlations could be found between clinical parameters, such as AOFAS hindfoot score, VAS for pain, and ROM, and the pedobarographic data. However, there was a positive correlation between dorsiflexion and the pedobarographic parameters for the hindfoot area. Conclusion: In conclusion, posttraumatic end-stage ankle OA leads to significant alterations in plantar pressure distribution. These might be interpreted as an attempt of the patient to reduce the load on the painful ankle. Other explanations might be bony deformity and ankle malalignment as a consequence of either the initial trauma or of the degenerative process itself, pain related disuse atrophy of surrounding muscles, and scarred soft tissue

Introduction. In rheumatoid arthritis, the forefoot is frequently affected. A variety of surgical procedures have been established in the treatment of rheumatic forefoot disorders. Postoperatively, patients are mobilized in specially designed footwear to reduce forefoot stress. Our study was conducted to investigate peak and mean plantar pressure occurring in two differently designed forefoot relief shoes by using the novel pedar ® system. Materials and Methods. Ten symptom-free volunteers were asked to walk on a treatmill, performing two trials at self-selected speed. The ”Barouk” (sole and heel supporting proximal fifty percent of the foot) and “Hannover” (Sole under whole foot, heel supporting proximal fifty percent of the foot) forefoot relief shoe (fior and gentz, Lueneburg, Germany) were compared. In a first trial, the shoe had to be used adequately, while in a second trial, the volunteers tried to put pressure on the forefoot, mimicking non-compliance. Peak and mean plantar pressure were obtained using the pedar® cable system (novel, Munich) and compared to the contralateral foot. Statistical t-test analysis was performed using SPSS 10. 0 for windows™. Results. When wearing the “Barouk” shoe with short sole, the forefoot was completely relieved in all trials. Non-compliant use of the shoe did not result in any forefoot stress. At the edge of the sole, peak pressure values were not higher than in conventional footwear. The shoework with complete sole reduced forefoot peak and mean pressure in contrast to normal gait by a mean of 34 percent. However, all volunteers were able to put stress on the forefoot when mimicking non-compliance, reaching peak values similar to normal gait. Conclusion. With regard to reconstructive forefoot surgery, the design of forefoot relief shoework affects the safety to non-compliance

Aims: To evaluate the effect of different geometric conþgurations of the Weil osteotomy on the plantar pressures in a dynamic in vitro cadaver model. Methods: Ten specimens consisting of 5 matched pairs of cadaver lower extremities were tested. Each pair of specimens had an oblique Weil osteotomy with 5 mm shift performed on one side, and a standard (parallel) Weil osteotomy with 5 mm shift on the other. Then, a 4 mm slice resection, and metatarsal head resection were performed sequentially on each specimen. The plantar pressures were measured while cyclically loaded to 700 N at a frequency of 1 Hz with a F scan in-shoe sensor in intact specimens, and after each intervention. Results: This is the þrst study to demonstrate that the plantar translation of the metatarsal head occurring with a more oblique Weil osteotomy compared to a standard (parallel) Weil osteotomy did not signiþcantly increase plantar pressure in a dynamic in vitro cadaver model. Furthermore, the addition of a 4 mm slice resection did not signiþcantly unload the metatarsal head. Metatarsal head resection was required to signiþcantly unload the metatarsal head (p=0.02). Conclusions: The different geometric conþgurations of the Weil osteotomy did not signiþcantly alter plantar pressures in a dynamic cadaver model. Metatarsal head resection was required to signiþcantly unload the metatarsal head. Future studies of the effect of metatarsal osteotomies on plantar pressure should include evaluation in a dynamic in vitrocadaver model to account for all factors, which determine the distribution of plantar pressure

Introduction: Arthrodesis has been recommended for the treatment of end-stage osteoarthritis of the ankle joint, especially as the results of prosthetic ankle replacement are not comparable with those achieved with total hip or knee replacement. In vitro studies revealed that ankle arthrodesis restricts kinematics more than total ankle replacement in terms of range of motion as well as movment transfer. However, little is known about in vivo gait patterns in patients with arthrodesis of the ankle joint. Aim of this retropective study was to determine plantar pressure distribution in patients who underwent ankle arthrodesis with a standardized screw fixation technique in a single surgeon population. Methods: 21 patients (7 male/14 female) who underwent isolated unilateral ankle arthrodesis with 3 crossed 7,3 mm AO screws (Synthes Gmbh, Austria) in a standardized technique by a single surgeon between October 2000 and January 2008 have been included in this study. At a mean follow-up of 25 months (range 12 – 75) pedobarograhy (Novel GmbH., Munich), clinical evaluation using the AOFAS hindfoot score and weight-bearing x-rays of the foot were performed. Results: Pedobarographic assessment revealed no statistically significant difference between the operated foot and the contralateral foot eighter in terms of peak pressure, maximum force, contact area and contact time or the gait line parameters velocity of center of pressure, lateral-medial force indices or lateral-medial area indices. The average AOFAS score was 80,5 (range 46 – 92) and mean tibioplantar angle determined on the lateral standing radiograph was 91° (82° – 100°). Non-union didn’t occur in any patient. Discussion: The results of the present study indicate that ankle arthrodesis restores plantar pressure distribution patterns to those of healthy feet. Therefore, the functional outcome of ankle arthrodesis seems to be good as long as the fusion is in fixed in an appropriate position

Patients with diabetes mellitus may develop plantar flexion contractures (equinus) which may increase forefoot pressure during walking. In order to determine the relationship between equinus and forefoot pressure, we measured forefoot pressure during walking in 27 adult diabetics with a mean age of 66.3 years (. sd. 7.4) and a mean duration of the condition of 13.4 years (. sd. 12.6) using an Emed mat. Maximum dorsiflexion of the ankle was determined using a custom device which an examiner used to apply a dorsiflexing torque of 10 Nm (. sd. 1) for five seconds. Simple linear regression showed that the relationship between equinus and peak forefoot pressure was significant (p < 0.0471), but that only a small portion of the variance was accounted for (R. 2. = 0.149). This indicates that equinus has only a limited role in causing high forefoot pressure. Our findings suggest caution in undertaking of tendon-lengthening procedures to reduce peak forefoot plantar pressures in diabetic subjects until clearer indications are established

Static and dynamic measurements of foot pressure have been carried out on three groups of subjects: diabetic patients with neuropathy (with and without a history of ulceration), diabetic patients with no neuropathy, and normal subjects as controls. In many cases both techniques of measurement detected areas of abnormally high pressure under the foot, but in some cases a particularly high-pressure spot was detected on only one of the tests and sometimes both methods were needed to reveal all the areas of the foot which might be considered to be at risk. The dynamic measurements tended to show multiple areas of high pressure better than the static measurements. Our results indicate the importance of making both types of measurement when seeking to devise suitable means of protecting the foot from ulceration.

Metatarsus primus varus deformity correction is one of the main objectives in hallux valgus surgery. A ‘syndesmosis’ procedure may be used to correct hallux valgus. An osteotomy is not involved. The aim is to realign the first metatarsal using soft tissues and a cerclage wire around the necks of the first and second metatarsals. We have retrospectively assessed 27 patients (54 feet) using the American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographs and measurements of the plantar pressures after bilateral syndesmosis procedures. There were 26 women. The mean age of the patients was 46 years (18 to 70) and the mean follow-up was 26.4 months (24 to 33.4). Matched-pair comparisons of the AOFAS scores, the radiological parameters and the plantar pressure measurements were conducted pre- and post-operatively, with the mean of the left and right feet. The mean AOFAS score improved from 62.8 to 94.4 points (p < 0.001). Significant differences were found on all radiological parameters (p < 0.001). The mean hallux valgus and first intermetatarsal angles were reduced from 33.2° (24.3° to 49.8°) to 19.1° (10.1° to 45.3°) (p < 0.001) and from 15.0° (10.2° to 18.6°) to 7.2° (4.2° to 11.4°) (p < 0.001) respectively. The mean medial sesamoid position changed from 6.3(4.5 to 7) to 3.6 (2 to 7) (p < 0.001) according to the Hardy’s scale (0 to 7). The mean maximum force and the force–time integral under the hallux region were significantly increased by 71.1% (p = 0.001), (20.57 (0.08 to 58.3) to 35.20 (6.63 to 67.48)) and 73.4% (p = 0.014), (4.44 (0.00 to 22.74) to 7.70 (1.28 to 19.23)) respectively. The occurrence of the maximum force under the hallux region was delayed by 11% (p = 0.02), (87.3% stance (36.3% to 100%) to 96.8% stance (93.0% to 100%)). The force data reflected the restoration of the function of the hallux. Three patients suffered a stress fracture of the neck of the second metatarsal. The short-term results of this surgical procedure for the treatment of hallux valgus are satisfactory. Cite this article: Bone Joint J 2014;96-B:502–7

Purpose: The purpose of this study is to describe the pedobarographic (plantar pressure) profiles of normal children across all ages, with specific focus on young children (< 6 years) and explore age-related changes in foot pressure patterns.

Method: The Tekscan HR Mat^™ system and Research Foot Module were used in a protocol involving a dynamic test of 146 normal children (age range 1.6–14.9 yrs). Using previously described methods1, relative force and timing data were obtained across five foot segments (heel, lateral midfoot, medial midfoot, lateral forefoot, and medial forefoot). An exploratory approach using analysis of variance (ANOVA) techniques followed by Scheffe post-hoc tests were conducted to determine if there were any age-related differences in foot pressure profiles in children across a priori pedobarograph variables: % of stance at initiation at the heel; % of stance at initiation at the medial midfoot; maximum % force at the heel; and maximum % force at the medial midfoot.

Results: Differences in foot force and timing profiles were distinguished across three age groups: 1) Group 1: 5 years. Data shows that with increasing age, force at the heel increases (Group 1: 61.4, Group 2: 66.9, Group 3: 71.9; p-value=0.019). Data also shows that force at the medial midfoot decreases with increasing age (Group 1: 17.7, Group 2: 8.8, Group 3: 4.7; p-value=0.0). Younger children also demonstrate early initiation of force at the medial midfoot compared to older children (Group 1: 5.9, Group 2: 33.5, Group 3: 44.8; p-value=0.0). In children > 5 years, there are no changes in foot forces or timing of forces.

Conclusion: This is the first study to provide a comprehensive description of the pedobarographic profiles of a large sample of normal children across all ages, with specific focus on the young child. Quantifying foot pressure of children will have relevance to clinical decision making.

Introduction Plantar foot pressure measurements using pressure distribution instruments is a standard tool for diagnostic and therapeutic interventions. Foot pressure studies have measured pressure distributions in patients with various conditions such as rheumatoid arthritis, diabetes and obesity . Pressure studies in metatarsalgia and Hallux rigidus, to our knowledge, has not been reported previously. Our aim was to measure plantar foot pressures in normal individuals and to compare them with variations in patients with metatarsalgia and Hallux rigidus. This data may enable us to identify areas of abnormal pressure distributions and thus plan foot-orthosis or surgical intervention. Materials and Methods This was a case control study. We measured the plantar foot pressures in different parts of the foot in normal subjects of various ages and then compared this with foot pressures of patients with metatarsalgia and hallux rigidus. For measurement and statistical analysis, the plantar contact of the foot was divided into six anatomical divisions. The foot pressures were measured under the hallux, head of first metatarsal, over heads of second, third and fourth metatarsals, the fifth metatarsal, midfoot and hindfoot. This was measured using the FSCAN insole pedobarograph system (Tekscan, Inc, Boston, MA). Results The foot pressures were measured in Kilopascals(Kpa). Independent T-tests was used to compare mean pressure distributions in the six anatomical divisions. Comparing normal with metatarsalgia, the mean pressures through the 5th metatarsal head 217(t=−2.32,p< 0.05) and midfoot 94(t=−3.17, p< 0.05), were significantly higher when compared to pressures in normal subjects. In patients with hallux rigidus, the mean pressures through the hallux 314 (t=−3.62, p< 0.01) and mid-foot 140 (t=-5.11, p< 0.01), were significantly higher, as compared to pressures in normal subjects. Discussion Metatarsalgia is a condition that presents with pain under the region of the 2nd to 4th metatarsal heads. Hence, the normal response of the body would be to avoid putting increased pressure through this region, thus causing increased pressures to be transmitted through other parts of the foot. The foot pressures through the hallux and midfoot were higher in patients with hallux rigidus (compared to normal). This results in pressure imbalances and thus may contribute to pain, deformity and abnormal gait. Our study, confirms this, the mean plantar foot pressures were higher under the 5th metatarsal head and the midsole as compared to normal subjects. This could be explained by the tendency to walk on the outer aspect of the sole to avoid the painful area. Thus, any foot orthosis or surgery should aim to redistribute these forces. Conclusion We have demonstrated increased pressures transmitted through the outer aspect of the sole of the foot, in patients suffering from metatarsalgia. The pressures through the Hallux and midfoot were higher in oatients with hallux rigidus. This information can be used further to plan any foot-orthosis or surgery to distribute pressures more evenly across the sole of the foot

Aims: Better understanding of the influence of body mass to plantar peak pressure as a main biomechanical risk factor for ulcerations in the diabetic foot. To predict the effect of weight change on peak pressure. Methods: In-shoe peak pressure measurement (PEDAR, Novel) are performed in 5 patients with diabetic neuropathy and 5 controls: all wearing the same kind of ready made shoes with ready made standard fitting insoles of cork. Each subject is measured in 3 modes of weight simulation: normal weight, 20 kg weight increase (waistcoat with weight pieces) and 20 kg weight release by a movable overhead suspension covering a 6m walkway. Pace is selected individually after some pre-test walking to be comfortable in all 3 weight modes. For data analysis the plantar area of the foot is divided into 6 regions, particularly metatarsal region and heel. Results: No significant difference between diabetics and controls is found. In the most threatened regions (metatarsals and heel) peak pressure increases and decreases linearly with weight: A simulated weight change ± 20 kg increases/ decreases metatarsal peak pressure by ± 6.4 N/cm2. The corresponding figure for the heel region is ± 2.6 N/cm2. Conclusions: Weight increase or weight loss in the individual patient has at least in the metatarsal and heel region a significant effect to the plantar peak pressure. The linear relationship allows for a simple method of predicting the effect of weight change to peak pressure

Aim. To describe a 2-stage treatment pathway for managing neuropathic forefoot ulcers and the safety and efficacy of percutaneous tendo-Achilles lengthening (TAL) in out-patient clinics. Methods. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressure. Plantar flexed metatarsal heads secondary to progressive claw toe deformity and hindfoot equinus from changes within the gastrocnemius-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus, secondary to motor neuropathy results in progressive increase in forefoot plantar pressures. Consecutive patients, who presented to our Diabetic Foot clinic since February 2019 with forefoot ulcers or recurrent forefoot callosity were treated with TAL in the first instance, and in patients with recurrent or non-healing ulcers, by proximal dorsal closing wedge osteotomy; a 2-stage treatment pathway. Patients were followed up at 3, 6, and 12 months to assess ulcer healing and recurrence. Results. One hundred and twelve patients (146 feet) underwent TAL by 3 consultants in the out-patient clinics. Of these, 96 feet were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 feet (96%), the ulcers healed 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. In 12 feet (10%), the ulcer failed to heal or recurred, the MRI scan in these patients showed plantar flexed metatarsals secondary to progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy. In patients with osteomyelitis, the intramedullary canal was curetted and filled with local antibiotic eluting agents such as Cerament G. ®. The osteotomy site was stabilised with a percutaneous 1.6mm k-wire. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after out-patient percutaneous TAL alone. TAL is a safe and effective initial out-patient procedure with improved patient outcomes

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

Aims. The aims of this study is to report the clinical and radiological outcomes after pre-, central-, and postaxial polydactyly resection in children from a tertiary referral centre. Methods. All children who underwent resection of a supernumerary toe between 2001 and 2013 were prospectively enrolled and invited for a single re-assessment. Clinical parameters and several dedicated outcome scores (visual analogue scale (VAS), Paediatric Outcomes Data Collection Instrument (PODCI), Activities Scale for Kids (ASK), and American Orthopaedic Foot and Ankle Society Score (AOFAS)) were obtained, as were radiographs of the operated and non-operated feet along with pedobarographs. Results. In all, 39 children (52 feet) with a mean follow-up of 7.2 years (3.1 to 13.0) were included in the study. Resection of a duplicated great toe was performed in ten children, central polydactyly in four, and postaxial polydactyly in 26. The mean postoperative VAS (0.7; 0 to 7), ASK (93.7; 64.2 to 100), and AOFAS range (85.9 to 89.0) indicated excellent outcomes among this cohort and the PODCI global functioning scale (95.7; 75.5 to 100) was satisfactory. No significant differences were found regarding outcomes of pre- versus postaxial patients, nor radiological toe alignment between the operated and non-operated sides. Minor complications were observed in six children (15%). There were seven surgical revisions (18%), six of whom were in preaxial patients. In both groups, below the operation area, a reduced mean and maximum force was observed. Changes in the hindfoot region were detected based on the prolonged contact time and reduced force in the preaxial group. Conclusion. Excellent mid-term results can be expected after foot polydactyly resection in childhood. However, parents and those who care for these children need to be counselled regarding the higher risk of subsequent revision surgery in the preaxial patients. Also, within the study period, the plantar pressure distribution below the operated part of the foot did not return to completely normal. Cite this article: Bone Joint J 2021;103-B(2):415–420

Aims. To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population. Methods. In all, 73 children with idiopathic club foot were included: 31 children treated with the Ponseti method (mean age 8.3 years; 24 male; 20 bilaterally affected, 13 left and 18 right sides analyzed), and 42 treated with primary surgical correction (mean age 11.6 years; 28 male; 23 bilaterally affected, 18 left and 24 right sides analyzed). Foot function data was collected during walking gait and included Oxford Foot Model kinematics (Foot Profile Score and the range of movement and average position of each part of the foot) and plantar pressure (peak pressure in five areas of the foot). Oxford Ankle Foot Questionnaire, Disease Specific Index for club foot, Paediatric Quality of Life Inventory 4.0 were also collected. The gait data were compared between the two club foot groups and compared to control data. The gait data were also correlated with the data extracted from the questionnaires. Results. Our findings suggest that symptomatic children with club foot deformity present with similar degrees of gait deviations and perceived disability regardless of whether they had previously been treated with the Ponseti Method or surgery. The presence of sagittal and coronal plane hindfoot deformity and coronal plane forefoot deformity were associated with higher levels of perceived disability, regardless of their initial treatment. Conclusion. This is the first paper to compare outcomes between Ponseti and surgery in a symptomatic older club foot population seeking further treatment. It is also the first paper to correlate foot function during gait and perceived disability to establish a link between deformity and subjective outcomes. Cite this article: Bone Joint Open 2020;1-7:384–391

Abstract. The aim is to describe the safety and efficacy of TAL in out-patient clinics when managing diabetic forefoot ulcers. Patients and Methods. Consecutive patients, who underwent TAL and had minimum 12m follow-up were analysed. Forceful dorsiflexion of ankle was avoided and patients were encouraged to walk in Total contact cast for 6-weeks and further 4-weeks in walking boot. Results. 142 feet in 126 patients underwent this procedure and 86 feet had minimum follow-up of 12m. None had wound related problems. Complete transection of the tendon was noted in 3 patients and one-patient developed callosity under the heel. Ulcers healed in 82 feet (96%) within 10 weeks however in 12 feet (10%), the ulcer recurred or failed to heal. MRI showed plantar flexed metatarsals with joint subluxation. The ulcer in this subgroup healed following proximal dorsal closing wedge osteotomy. Conclusion. Tightness of gastroc-soleus-Achilles complex and subluxed MTP joint from soft tissue changes due to motor neuropathy result in increased forefoot plantar pressures. A 2-stage approach as described result in long-term healing of forefoot ulcers, and in 96% of patients, the ulcer healed following TAL alone. TAL is a safe and effective out-patient procedure with improved patient satisfaction outcomes

Aim. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressures. Progressive hindfoot equinus from contraction of gastrocnemius-soleus-tendo-Achilles complex and progressive plantar flexed metatarsal heads secondary to claw toe deformity results callus at the metatarsal heads which break down to ulceration. The aim is to describe 2-stage treatment pathway for managing these ulcers. Methods. Consecutive patients, who presented with forefoot ulcers since February 2019 were treated with a 2-stage treatment pathway. The first stage of this is an out-patient tendo-Achilles lengthening (TAL). The second stage is surgical proximal dorsal closing wedge metatarsal osteotomy for patients with persistent or recurrent ulcers. Patients were followed for a minimum of 12 months. Results. 112 patients (146 feet) underwent TAL by 3 consultants. Of these, 96 patients were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 patients (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with 1. st. metatarsal and 5. th. metatarsal head ulcers respectively. In 12 patients (10%), the ulcer failed to heal or recurred. MRI scan in these patients showed plantar flexed metatarsals from progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy of the metatarsal/s, with no recurrence at a minimum 12months of follow-up. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after the first stage out-patient percutaneous TAL

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

Biomedical imaging is essential in the diagnosis of musculoskeletal pathologies and postoperative evaluations. In this context, Cone-Beam technology-based Computed Tomography (CBCT) can make important contributions in orthopaedics. CBCT relies on divergent cone X-rays on the whole field of view and a rotating source-detector element to generate three-dimensional (3D) volumes. For the lower limb, they can allow acquisitions under real loading conditions, taking the name Weight-Bearing CBCT (WB-CBCT). Assessments at the foot, ankle, knee, and at the upper limb, can benefit from it in situations where loading is critical to understanding the interactions between anatomical structures. The present study reports 4 recent applications using WB-CBCT in an orthopaedic centre. Patient scans by WB-CBCT were collected for examinations of the lower limb in monopodal standing position. An initial volumetric reconstruction is obtained, and the DICOM file is segmented to obtain 3D bone models. A reference frame is then established on each bone model by virtual landmark palpation or principal component analysis. Based on the variance of the model point cloud, this analysis automatically calculates longitudinal, vertical and mid-lateral axes. Using the defined references, absolute or relative orientations of the bones can be calculated in 3D. In 19 diabetic patients, 3D reconstructed bone models of the foot under load were combined with plantar pressure measurement. Significant correlations were found between bone orientations, heights above the ground, and pressure values, revealing anatomic areas potentially prone to ulceration. In 4 patients enrolled for total ankle arthroplasty, preoperative 3D reconstructions were used for prosthetic design customization, allowing prosthesis-bone mismatch to be minimized. 20 knees with femoral ligament reconstruction were acquired with WB-CBCT and standard CT (in unloading). Bone reconstructions were used to assess congruency angle and patellar tilt and TT-TG. The values obtained show differences between loading and unloading, questioning what has been observed so far. Twenty flat feet were scanned before and after Grice surgery. WB-CBCT allowed characterization of the deformity and bone realignment after surgery, demonstrating the complexity and multi-planarity of the pathology. These applications show how a more complete and realistic 3D geometric characterization of the of lower limb bones is now possible in loading using WB-CBCT. This allows for more accurate diagnoses, surgical planning, and postoperative evaluations, even by automatisms. Other applications are in progress