Fifth metatarsal fractures in sport are known to be associated with acceleration and cross cutting movements when running. It is also established that playing surface has an impact on the ground reaction forces through the foot, increasing the strain through the fifth metatarsal. But what impact does boot design have on these forces? Current thought is that boots that utilise a blade stud design resist sideways slipping of the planted foot more than boots with a rounded stud. This study aims to compare ground reaction forces through the fifth metatarsal in 2 two different designs of rugby boot to assess what impact stud design might have. The forces across the foot were measured using Tekscan in-shoe pressure plates in 24 rugby players. Each player was asked to complete an agility course to measure acceleration, cutting and cross-cutting in the two different designs of rugby boot, reproducing true playing conditions. The boots used were the Canterbury Phoenix Club 8 Stud boot and the Canterbury Speed Club Blade boot. The trial was conducted on an 4G artificial pitch at the Cardiff Arms Park rugby ground. Ethical approval was obtained from Bath University and a research grant was provided by British Orthopaedic Foot and Ankle Society. The blade boot had significantly higher contact pressures than the stud boot on the fifth metatarsal in the combined movements (17.909 ± 10.442 N/cm2 Blade Vs 16.888 ± 9.992 N/cm2 Boot; P < .0125; n= 864 steps in each boot group). The blade boot also produced higher pressure during cross-cutting (32.331 ± 13.568 N/cm2 Vs 27.651 ± 15.194 N/cm2 p < 0.007). Pressures were also higher in both acceleration and cutting, although not significantly so. These results will guide clinicians advising athletes in shoe design, especially those predisposed to or rehabilitating from a fifth metatarsal fracture

Background. The Plantaris Longus Tendon (PLT) may be implicated in Achilles (AT) tendinopathy. Different mechanical characteristics may be the cause. This study is designed to measure these. Methods. Six PLT and six AT were harvested from frozen cadavers (aged 65-88). Samples were stretched to failure using a Minimat 2000(tm) (Rheometric Scientific Inc.). Force and elongation were recorded. Calculated tangent stiffness, failure stress and strain were obtained. Averaged mechanical properties were compared using paired, one-tailed t-tests. Results. Mean stiffness was higher (p<0.001) in the PLT, measuring 5.71 N/mm (4.68-6.64), compared with 1.73 N/mm (1.40-2.22) in AT. Failure stress was also higher (p<0.01) in PLT: 1.42 N/mm. 2. (0.86-2.23) AT: 0.20 N/mm. 2. (0.16-0.25). Failure strain was less (p<0.05) in PLT: 14.1% (11.5-16.8) than AT: 21.8% (14.9-37.9). Conclusions. The PLT is stiffer, stronger than AT, demonstrating potential for relative movement under load. The stiffer PLT could tether AT and initiate an inflammatory response

Heel pain is very prevalent. Pain, especially after a period of rest, is the main symptom. Reduced ability to walk long distances and inability to participate in exercise and sport are other complaints. Plantar heel pain is most commonly caused by plantar fasciitis. Whilst only the recalcitrant cases reach secondary care, this can still be a significant workload. In the Royal Surrey County Hospital, Guildford, we see approximately 200 cases of recalcitrant heel pain each year. The vast majority of cases never come to hospital and are managed in primary care (1500/yr in podiatry alone). Effective primary treatments should reduce the number of long-term sufferers. Recalcitrant cases of plantar fasciitis often have atypical symptoms. Radiological imaging is extremely useful in clarifying the diagnosis. Ultrasound is our preferred modality. There is a spectrum of pathology that affects the plantar fascia, and this is less well classified than for the achilles tendon, where the distinction between insertional tendinopathy and tendinopathy of the main body of the tendon is helpful in guiding treatment. The evidence for many forms of treatment for plantar fasciitis is weak. Currently, the use of formal calf stretching programs is widely considered to be the best first-line treatment. There are additional benefits with stretches to the fascia itself. The mechanism by which these stretches help is not well established. Calf contracture is, however, associated with a variety of clinical problems in the foot and ankle. This is especially true for isolated gastrocnemius contracture. There is also laboratory evidence that increased plantar fascia strain is seen with increased calf muscle tension. Surgery to release a gastrocnemius contracture improves biomechanics and has been used in refractory cases of heel pain with good effect. Radial extracorporeal shock wave lithotripsy is the latest version of this non-invasive treatment. Results in our centre are encouraging. For selected cases of atypical plantar fasciopathy injection treatments are effective

Aims

The traditional transosseus flexor hallucis longus (FHL) tendon transfer for patients with Achilles tendinopathy requires two incisions to harvest a long tendon graft. The use of a bio-tenodesis screw enables a short graft to be used and is less invasive, but lacks supporting evidence about its biomechanical behaviour. We aimed, in this study, to compare the strength of the traditional transosseus tendon-to-tendon fixation with tendon-to-bone fixation using a tenodesis screw, in cyclical loading and ultimate load testing.

Aims

Anatomical atlases document classical safe corridors for the placement of transosseous fine wires through the calcaneum during circular frame external fixation. During this process, the posterior tibial neurovascular bundle (PTNVB) is placed at risk, though this has not been previously quantified. We describe a cadaveric study to investigate a safe technique for posterolateral to anteromedial fine wire insertion through the body of the calcaneum.

Charcot neuroarthropathy is a rare but serious complication of diabetes, causing progressive destruction of the bones and joints of the foot leading to deformity, altered biomechanics and an increased risk of ulceration.

Management is complicated by a lack of consensus on diagnostic criteria and an incomplete understanding of the pathogenesis. In this review, we consider recent insights into the development of Charcot neuroarthropathy.

It is likely to be dependent on several interrelated factors which may include a genetic pre-disposition in combination with diabetic neuropathy. This leads to decreased neuropeptides (nitric oxide and calcitonin gene-related peptide), which may affect the normal coupling of bone formation and resorption, and increased levels of Receptor activator of nuclear factor kappa-B ligand, potentiating osteoclastogenesis.

Repetitive unrecognized trauma due to neuropathy increases levels of pro-inflammatory cytokines (interleukin-1β, interleukin-6, tumour necrosis factor α) which could also contribute to increased bone resorption, in combination with a pre-inflammatory state, with increased autoimmune reactivity and a profile of monocytes primed to transform into osteoclasts - cluster of differentiation 14 (CD14).

Increased blood glucose and loss of circulating Receptor for Advanced Glycation End-Products (AGLEPs), leading to increased non-enzymatic glycation of collagen and accumulation of AGLEPs in the tissues of the foot, may also contribute to the pathological process.

An understanding of the relative contributions of each of these mechanisms and a final common pathway for the development of Charcot neuroarthropathy are still lacking.

Cite this article: S. E. Johnson-Lynn, A. W. McCaskie, A. P. Coll, A. H. N. Robinson. Neuroarthropathy in diabetes: pathogenesis of Charcot arthropathy. Bone Joint Res 2018;7:373–378. DOI: 10.1302/2046-3758.75.BJR-2017-0334.R1.

Aims

The purpose of this study was to compare the clinical and radiographic outcomes of total ankle arthroplasty (TAA) in patients with pre-operatively moderate and severe arthritic varus ankles to those achieved for patients with neutral ankles.

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration.

In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:1299–1311.

Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:874–83.

Objectives

The goals of this study were: 1) to determine if high-fat diet (HFD) feeding in female mice would negatively impact biomechanical and histologic consequences on the Achilles tendon and quadriceps muscle; and 2) to investigate whether exercise and branched-chain amino acid (BCAA) supplementation would affect these parameters or attenuate any negative consequences resulting from HFD consumption.

We report an audit of 208 patients with a mean age of 39 years (16 to 65) attending the Orthopaedic Assessment Unit at the Wellington Hospital between January 2006 and December 2007 with an injury of the tendo Achillis requiring immobilisation in a cast. Information on assessment of venous thromboembolism (VTE) risk, prophylactic measures and VTE events for all patients was obtained from the medical records. A VTE risk factor was documented in the records of three (1%) patients. One of the 208 patients received aspirin prophylaxis; none received low molecular weight heparin. In all, 13 patients (6.3%, 95% confidence interval 3.4 to 10.5) developed symptomatic VTE during immobilisation in a cast, including six with a distal deep-vein thrombosis (DVT), four with a proximal DVT, and three with a confirmed pulmonary embolus. This incidence of symptomatic VTE is similar to that reported following elective hip replacement.

We propose that consideration is given to VTE prophylaxis during prolonged immobilisation of the lower limbs in a cast, to ensure that the same level of protection is provided as for patients undergoing elective hip replacement.

It has been suggested that a supramalleolar osteotomy can return the load distribution in the ankle joint to normal. However, due to the lack of biomechanical data, this supposition remains empirical. The purpose of this biomechanical study was to determine the effect of simulated supramalleolar varus and valgus alignment on the tibiotalar joint pressure, in order to investigate its relationship to the development of osteoarthritis. We also wished to establish the rationale behind corrective osteotomy of the distal tibia.

We studied 17 cadaveric lower legs and quantified the changes in pressure and force transfer across the tibiotalar joint for various degrees of varus and valgus deformity in the supramalleolar area. We assumed that a supramalleolar osteotomy which created a varus deformity of the ankle would result in medial overload of the tibiotalar joint. Similarly, we thought that creating a supramalleolar valgus deformity would cause a shift in contact towards the lateral side of the tibiotalar joint. The opposite was observed. The restricting role of the fibula was revealed by carrying out an osteotomy directly above the syndesmosis. In end-stage ankle osteoarthritis with either a valgus or varus deformity, the role of the fibula should be appreciated and its effect addressed where appropriate.

Proximal osteotomies for forefoot deformity in patients with rheumatoid arthritis have hitherto not been described. We evaluated combination joint-preserving surgery involving three different proximal osteotomies for such deformities. A total of 30 patients (39 feet) with a mean age of 55.6 years (45 to 67) underwent combined first tarsometatarsal fusion and distal realignment, shortening oblique osteotomies of the bases of the second to fourth metatarsals and a fifth-ray osteotomy.

The mean follow-up was 36 months (24 to 68). The mean foot function index scores for pain, disability and activity subscales were 18, 23, and 16 respectively. The mean Japanese Society for Surgery of the Foot score improved significantly from 52.2 (41 to 68) to 89.6 (78 to 97). Post-operatively, 14 patients had forefoot stiffness, but had no disability. Most patients reported highly satisfactory walking ability. Residual deformity and callosities were absent. The mean hallux valgus and intermetatarsal angles decreased from 47.0° (20° to 67°) to 9.0° (2° to 23°) and from 14.1° (9° to 20°) to 4.6° (1° to 10°), respectively. Four patients had further surgery including removal of hardware in three and a fifth-ray osteotomy in one.

With good peri-operative medical management of rheumatoid arthritis, surgical repositioning of the metatarsophalangeal joint by metatarsal shortening and consequent relaxing of surrounding soft tissues can be successful. In early to intermediate stages of the disease, it can be performed in preference to joint-sacrificing procedures.

We describe the medium-term results of a prospective study of 200 total ankle replacements at a single-centre using the Scandinavian Total Ankle Replacement. A total of 24 ankles (12%) have been revised, 20 by fusion and four by further replacement and 27 patients (33 ankles) have died. All the surviving patients were seen at a minimum of five years after operation. The five-year survival was 93.3% (95% confidence interval (CI) 89.8 to 96.8) and the ten-year survival 80.3% (95% CI 71.0 to 89.6).

Anterior subluxation of the talus, often seen on the lateral radiograph in osteoarthritic ankles, was corrected and, in most instances, the anatomical alignment was restored by total ankle replacement. The orientation of the tibial component, as seen on the lateral radiograph, also affects the position of the talus and if not correct can hold the talus in an abnormal anterior position. Subtalar arthritis may continue to progress after total ankle replacement. Our results are similar to those published previously.

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