Purpose

Coronal plane malalignment at the level of the tibiotalar joint is not uncommon in advanced ankle joint arthritis. It has been stated that preoperative varus or valgus deformity beyond 15 degrees is a relative contraindication and deformity beyond 20 degrees is an absolute contraindication to ankle joint replacement. There is limited evidence in the current literature to support these figures. The current study is a prospective clinical and radiographic comparative study between patients who underwent total ankle arthroplasty with coronal plane varus tibiotalar deformities greater than 10 degrees and patients with neutral alignment, less than 10 degrees of deformity.

Total ankle arthroplasty is used as a treatment for end stage arthritis of the ankle.

Surgical techniques highlight risk of injury to anterior neurovascular structures. No literature highlights injury risk to the posterior neurovascular structures in ankle replacement surgery. Current literature consists of cadaveric study in relation posterior ankle arthroscopy.

A retrospective review was done of ankle MRI's, performed by the senior author in his practice. Studies were included in the study where there was no pathology of the posterior ankle present. Axial, coronal and sagital T1 weighted films were reviewed and measurements of the posterior neurovascular structures and tendons were made in relation to the posterior tibia and medial malleolus in relation to planned tibial and talar cutting planes.

A total of seventy-eight MRI's were included in the study (ages ranged from 22 to 78 years). There were 40 females and 38 males. At the level of the tibial cut the tibial nerve and artery were between two to six millimeters from the posterior surface of the tibia. The flexor hallucis longus (FHL) is located in the midline between the medial malleolus and fibula, closely related to the posterior tibial surface. The flexor digitorum longus (FDL) tendon is located in the posterior medial corner of the ankle. There is a window approx ten millimeters wide between where the neurovascular structures lie between the FDL and FHL tendons. At the level of the talus cut the tibial nerve and artery were between five to 11 mm from the posterior body of the talus.

A similar window is present at this level where the neurovascular structures lie between the FDL and FHL tendons.

The neurovascular structures of the ankle are potentially at risk during the tibial and talar bone resection. They are most at risk with the transverse cut of the tibia. This may be decreased by preventing direct pressure over these structures during bone resection.

Introduction: Lesser toe problems and metatarsalgia are common complaints in patients presenting with foot problems. Associated toe deformities include mallet toes, hammer toes, claw toes. The patient may complain of pain over the proximal interphalangeal joint from shoe ware, diffuse or localized pain under the metatarsal heads, or swelling and irritation of the metatarsophalangeal joint. Most patients can be treated with shoe ware modification, NSAID medication, tapping of toes, orthotics, or steroid injections. Surgical treatment includes flexor to extensor transfers, PIP excision arthroplasty, plantar condylectomy and metatarsal osteotomy.

Indications and Complications: The osteotomy is performed when there instability of the MTP joint, reduction of MTP joint subluxation or dislocation, relatively long ray with transfer metatarsalgia. Complications include avascular necrosis, joint stiffness, transfer metatarsalgia to subsequent toes, and plantar flexion of the metatarsal.

Surgical Technique: The Weil osteotomy is performed through a dorsal incision, performing a dorsal capsulotomy of the MTP joint and plantar flexing the proximal phalanx to expose the metatarsal head. The osteotomy is started in dorsal aspect of the metatarsal head and is made along the shaft keeping parallel to the floor. Key points are to make a long osteotomy cut to allow broad surface area for healing, avoid lowering the head by performing the cut parallel to the floor. The head will naturally displace proximally, most authors recommending 5–10mm of shortening.

Fixation: The osteotomy is fixed using a twist off screw. Factors that influence fixation include angle of screw insertion, size of the screw and the number of screws. Fixation in relatively porotic bone is improved when using two screws.

Introduction Unstable distal clavicle fractures have a high rate of non and delayed union, with many authors recommending surgical fixation. There are several techniques described in the literature reporting good results. We report the outcome of eighteen patients undergoing temporary fixation with a coracoclavicular screw, reinforced with Mersilene tape and Ethibond sutures.

Methods Eighteen patients were treated by a single surgeon between October 1999 and March 2003. All patients were male with an average age of 35 years. The indication for surgery was an unstable Type II fracture of the distal third clavicle. Fixation was achieved with a 6.5 mm cancellous screw through the clavicle into the coracoid process, reinforced by Mersilene tape and number 5 Ethibond sutures around the coracoid process. The arm was immobilized for two to four weeks after surgery. Each patient had the screw removed at about 11 weeks from surgery.

Results Eighteen patients achieved osseous union with painless range of motion. Union time ranged between six to 11 weeks. One patient developed a superficial skin infection, which settled with oral antibiotics, the scar required revision at time of screw removal. Two patients had screw breakage after union, which did not affect their outcome. There was no cases of screw penetration.

Conclusions This method of screw fixation is a relatively safe and easy technique of open reduction and internal fixation of the unstable distal third of clavicle. The outcome of this procedure is predictable with minimal complications.

Introduction The results of open reduction and internal fixation of displaced intra-articular calcaneal fractures has been shown to be superior to closed management. We report our early experience with the AO locking calcaneal plate for these injuries in particular looking for wound complications.

Methods Between December 2001 and March 2003 a total of 28 patients with 29 displaced intra-articular calcaneal fractures were treated by two surgeons. The average delay from injury to time of surgery was 11 days. A standard “L” shape lateral approach was used with the patient in a lateral decubitus position. Reduction was temporarily held with K wires before the locking plate was applied, with the bending tools used for in-situ plate moulding. Wounds were closed over a drain using Allgower-Donati sutures after haemostasis. Stitches were removed at two weeks when the wounds had healed.

Results Of the 29 fractures treated there was only two minor wound problems. In one patient this occurred after using the larger plate and consisted of slight necrosis at the inferior corner of the wound, which healed non-operatively. There have been two patients requiring removal of their plates between 10 and 15 months after surgery. They both complained of lateral pain, which may have been due to the plate being bulkier than other currently used plates. After removal both patients had immediate relief from their symptoms. The AO locking plate offers advantages over the standard plate. These include the option for locking screws as well as 2.7 mm and 3.5 mm screws, increased strength, and the ability to mould the plate in-situ using the bending irons in the screw holes. This in-situ moulding allows better contouring of the plate. On one occasion even this plate was too large and required trimming to fit the bone. We have not experienced an increase in wound problems due to bulkier plate.

Conclusions Our early experience with the AO Locking plate has been positive, with minimal complications. We would recommend the use of this plate for fixation of displaced intra-articular calcaneal fractures, and suggest the need for a smaller plate to be designed.