Stable fractures of the ankle can be safely treated non-operatively. It is also gradually being recognised that the integrity of the ‘medial column’ is essential for the stability of the fracture. It is generally thought that bi- and tri-malleolar fractures are unstable, as are pronation external rotation injuries resulting in an isolated high fibular fracture (Weber type-C), where the deltoid ligament is damaged or the medial malleolus fractured. However, how best to identify unstable, isolated, trans-syndesmotic Weber type-B supination external rotation (SER) fractures of the lateral malleolus remains controversial.

We provide a rationale as to how to classify SER distal fibular fractures using weight-bearing radiographs, and how this can help guide the management of these common injuries.

Cite this article: Bone Joint J 2017;99-B:851–5.

Most posterior hindfoot procedures have been described with the patient positioned prone. This affords excellent access to posterior hindfoot structures but has several disadvantages for the management of the airway, the requirement for an endotracheal tube in all patients, difficulty with ventilation and an increased risk of pressure injuries, especially with regard to reduced ocular perfusion.

We describe use of the ‘recovery position’, which affords equivalent access to the posterior aspect of the ankle and hindfoot without the morbidity associated with the prone position. A laryngeal mask rather than endotracheal tube may be used in most patients. In this annotation we describe this technique, which offers a safe and simple alternative method of positioning patients for posterior hindfoot and ankle surgery.

Cite this article: Bone Joint J 2013;95-B:1317–19.

Introduction

Lisfranc joint injuries account for only 0.2% of all fractures but early diagnosis improves the chances of a better outcom]. Radiographic signs, such as diastasis (>2mm) of the 1–2 interspace, are subtle and. often missed, leading to a poorer outcome. We present a new radiographic sign, less likely to result in missed diagnoses. Null nypothesis: The intermetarsal angle remains unchanged in Lisfranc injuries.

Background: Morton’s Neuroma is most likely a mechanically induced degenerative neuropathy, presenting as forefoot pain.

Methods: The authors retrospectively reviewed clinical notes, imaging and histology from 71 consecutive patients (75 feet) treated operatively for Morton’s Neuroma between January 2006 and April 2009 and a control group of 20 patients (20 feet) undergoing MRI for other forefoot pathology. 7 feet were excluded from the surgical group due to recurrent disease or missing data.

Results: 84% of the surgical group were female. Mean age was 52. 97.4% of the surgical group presented with pain. 50% described pain in the plantar aspect of the forefoot and 85% reported that their pain was worse in shoes. Web space tenderness was positive in 95%, foot squeeze test 88%, plantar percussion 61% and toe tip sensation deficit 67%. Any two tests were positive in 92% of this group. In the control group any two tests were positive in only 39% – this difference was statistically significant (p< 0.0001 chi-squared test). MRI identified a neuroma in 97% of the surgical group (mean size 8mm) and 50% of the control group (mean size 6mm). 68% were in the 3rd web space; the remainder were in the 2nd web space. Histology confirmed neuroma in 99%.

Discussion: This cohort is larger than any other published series and is further strengthened by both the consistency of clinical testing and the independence of radiological and histological assessment.

Conclusion: We found that diagnosis of Morton’s neuroma was accurate. MRI correctly identified the neuromata in 97% and at least two clinical tests were present in 92%.

Introduction: The concept of minimally invasive total knee arthroplasty surgery evolved to reduce quadriceps muscle strength loss and improve clinical outcome following total knee replacement. We performed a systematic review of the published literature on Minimally Invasive Total Knee Arthroplasty (MITKA) and to analyse the reported surgical outcomes.

Material and Methods: A comprehensive search of databases using various combinations of the keywords: minimally invasive total knee arthroplasty, mini-incision total knee replacement and minimally invasive arthroplasty was performed. 28 studies published from January 2003 to June 2008 meeting the inclusion criteria were evaluated using the Coleman Methodology Score (CMS).

Results: AT A mean CMS of 60, most studies reporting on outcome of MITKA are of moderate scientific quality. Patients undergoing MITKA tend to have decreased post operative pain, rapid recovery of quadriceps function, reduced blood loss, improved range of motion (mostly reported as a short term gain) and shorter hospital stay in comparison to patients undergoing standard total knee arthroplasty. These benefits however need to be balanced against the incidence of increased tourniquet time and increased incidence of component malaligment in the MITKA group.

Conclusion: Evidence based knowledge regarding results of MITKA comes from prospective studies of moderate quality with short follow up periods. Multicenter studies with longer follow ups are needed to justify the long term advantages of MITKA over standard total knee arthroplasty.

Introduction: The optimal treatment of intra-articular calcaneal fractures remains controversial.

Material and Methods: Electronic databases were searched for randomised trials comparing interventions for treating patients with calcaneal fractures. Two reviewers independently assessed trial quality, using a 12-item scale, and extracted data. Where appropriate results were pooled.

Results: Six trials met the inclusion criteria. Two reports reported on the same group of patients at differing follow-up intervals. All six included trials had methodological flaws. Another two trials are ongoing. Four trials (134 patients) compared open reduction and internal fixation (ORIF) with non-operative management. Pooled results showed no difference in residual pain (24/40 versus 24/42; OR 0.90, 95% CI 0.34 to 2.36), but a lower proportion of the operative group was unable to return to the same work (11/45 vs 23/45; OR 0.30, 95% CI 0.13 to 0.71), and was unable to wear the same shoes as before (12/52 vs 24/54; OR 0.37, 95% CI 0.17 to 0.84). One large-scale study showed that the outcomes (SF-36, visual analogue scale (VAS), Bohler’s angle) after non-operative treatment were not different to those after ORIF. ORIF gave superior results for return to work, return to normal activities and ability to wear the same shoes. The subtalar fusion rate was reduced after ORIF. Excluding patients receiving Workers’ Compensation, the outcomes were significantly better in some groups of surgically treated patients. One trial (23 patients), evaluated impulse compression therapy. At one year there was a mean difference of 1.40 pain VAS units (95% CI 0.02 to 2.82) in favour of the treated group. The impulse compression group had greater subtalar movement at three months, and patients returned to work three months earlier.

Conclusions: The relatively poor quality of existing trials means that current evidence is only tentative. It remains unclear whether the possible advantages of surgery are worth its risks.

Introduction: The use of total ankle arthroplasty for the management of end stage arthritis of the ankle is gaining in popularity. We performed a review of the literature on Total Ankle Arthroplasty to assess the methodology of studies and to detect possible variation in the reported surgical outcomes.

Material and Methods: All relevant articles in peer-reviewed journals were retrieved except those not mentioning outcomes, case reports, review of literature and letters to editors. Studies reporting on implants presently used, with at least 20 subjects followed for a mean of at least two years were included. Two authors independently scored the quality of the studies using the Coleman Methodology Score (CMS). We collected data for type of study, patient numbers, length of follow-up, complications, outcome and prosthesis survival with revision or fusion as an endpoint. Where appropriate, pooling of data was performed.

Results: Twenty-one level IV studies, published from 2003 to 2008, reporting on 2167 ankle replacements followed for a mean of 5.6 years, were included. The CMS was 65 (SD 15), with substantial agreement between the two examiners. Inflammatory arthropathy was present in 31% of ankles. The intra-operative fracture rate was 10.5%. Superficial wound healing complication rate was 6.4%, and deep infections occurred in 1.2% of ankles. Patients’ satisfaction rate was 94%. The failure rate of the primary ankle prosthesis was 11.6% (Agility: 12.2% at 4 years, STAR: 11.7% at 4.6 years and Buechel-Pappas (BP): 12.8% at 7.3 years). Pooling the data the six-year survivorship for the Agility was 0.70 (CI 95%, 0.50–0.90), whereas the 10-year survivorship for the STAR was 0.79 (CI 95%, 0.56–1.00) and for the BP 0.87 (CI 95%, 0.69–1.00).

Conclusions: Studies reporting on total ankle arthroplasty are of overall moderate quality. Survivorship analysis revealed superior results for mobile-bearing implants. Patients’ satisfaction rate was high.

Foot osteomyelitis is a common problem for which management is variable and few guidelines exist.

To present our treatment protocol and the results in 36 patients (20 men, 16 women, mean age: 49.5 years) with osteomyelitis distal to the ankle, followed up for 17.6 months (range: 3–64).

Bone infection involved toes (n=4), lesser metatarsals (n=11), hallux (n=3), midfoot (n=4), calcaneus (n=9), whereas 4 cases presented as generalised osteomyelitis. Postoperative infection was the cause in 10 cases. Eleven patients were classified as host-type A, 14 as B and 11 as C. A draining sinus was present in 28 cases. The treatment protocol included surgical debridement, the bead-pouch technique for local antibiotic administration and closure primarily (n=27), or by secondary healing (n=5), skin graft (n=2), local fasciocutaneous (n=1), or free vascularised muscle flap (n=1). Systemic antibiotics according to cultures were administered for 5–7 days. Generalized Charcot osteomyelitis was an indication for amputation.

Mean hospital stay was 13.8 days (range 1–34) and 2.7 (range 1–7) surgical procedures per patient were recorded. Infection control was achieved in 26 cases (72.2%), whereas amputations were performed in 10 cases (27.8%). Below-knee amputation was undertaken in 4 host-type C patients with Charcot osteomyelitis of the foot. Ray amputations were performed in 4 diabetic feet. Six amputees were classified as host-C and 3 as host-B. One host-type A patient with recurrent post-traumatic toe osteomyelitis, underwent a distal phalanx amputation as definitive solution. Amputation rates were 55% among host-C, 22% among host-B and 9% among host-A patients (p< 0.001).

Diffuse foot osteomyelitis in systemically compromised patients resulted in high amputation rates. Better results were obtained in non-compromised hosts and focal osteomyelitis.

Distal tibia and ankle sepsis can threaten the viability of the limb. We present the management protocol and results in 37 patients with chronic infection of the distal tibia and ankle, followed up for a mean of 4 years.

The mean age was 45.6 years. Host type A were 21 patients, type B were 9, and type C were 7 patients. Treatment included radical debridement, multiple cultures sampling and local antibiotic application. Twenty seven patients required bone stabilisation, whereas 3 host C patients were amputated. Soft tissue coverage included 5 free muscle flaps, 3 soleus flaps and 5 pedicle fasciocutaneous local flaps. Bone defects of a mean of 6.3 cm (3–13cm) in 20 cases were treated with distraction histogenesis (13 cases) or the free fibula vascularised graft (7 cases).

Mean hospitalisation time was 26.2 days (host-A: 19.6 vs. host B/C: 32.2, p=0.036). Host-A patients required 2.3 operative procedures whereas host-B/C 3.9 (p=0.01). Union occurred in 26/27 (96%) of cases requiring fixation (one ankle arthrodesis revision/host-B patient). External fixation frames were kept in situ for a mean of 31.7 weeks (12–85). Mean leg length discrepancy was 0.6 cm. Ankle arthrodesis was performed in 7 patients (5% among host-A patients vs. 38% among B/C). Independent ambulation was achieved in (35/37) 95%. All patients were satisfied with the result. Bacteriology revealed Staph. aureus in 71%, whereas 38% were polymicrobial (7% in host-A vs. 88% in B/C patients, p< 0.001). Infection recurrence occurred in 5.4% (none in host-A vs. 13% in B/C patients, p=0.03), whereas the overall complication rate was 43% (24% in host-A vs. 75% in B/C patients, p=0.02).

Functional limb salvage without leg length discrepancy was possible in 92% of cases. Systemically compromised patients required longer hospitalisation, more operative procedures, had frequently polymicrobial infections and more complications.

Introduction: Management strategies and results in 30 cases of foot osteomyelitis are presented.

Patients-Methods: From 1/2003 – 1/2006, 30 patients (15 men, 15 women, mean age 47.7 years, range 1.5–82) presenting with foot osteomyelitis were treated. Mean hospital stay was 12.6 days (range 1–45) and 1.3 hospital admissions were recorded (range 1–4). The follow-up period averaged 15.7 months (range 3–56). Bone infection involved the toes in 3 cases, the metatarsals in 9, the head of the hallux in 2, the midfoot in 3, the calcaneus in 9, whereas 3 cases presented as generalized charcot’s osteomyelitis. Eleven patients were classified as host-type A, 10 as B and 9 as C. Nine patients were diabetic, one rheumatoid, four had vascular insufficiency, two had insensate feet. An open calacaneal fracture was the cause in two cases, whereas ORIF of a closed calacaneal fracture in one, ORIF of metatarsal fractures in one and hallux valgus corrective surgery in two. One paediatric patient with calcaneal osteomyelitis developed subtalar arthritis. A draining sinus/wound was present in 24 cases. Each patient underwent an average of 2.3 surgical procedures (range 1–7). The treatment protocol included surgical debridement, use of the bead-pouch technique for local antibiotic administration and closure primarily (n=23), or by secondary healing (n=3), skin graft (n=2), local fasciocutaneous (n=1), or free vascularized muscle flap (n=1). Systemic antibiotics according to cultures were administered for 5–7 days. Amputation was undertaken if salvaging or reconstructive procedures could not be undertaken.

Results: Infection control (salvageable cases) was achieved in 23 cases (76.7%), whereas amputations were performed in 7 cases (23.3%). Four amputees were classified as host C (57.1%), whereas a significantly lower rate of patients successfully treated (21.7%) were host-C (p=0.0008). A below knee amputation was undertaken in two host-type C patients with generalized osteomyelitis of the foot. One 1st ray and two 1st and 2nd ray amputations were performed for not salvageable diabetic feet infections. Finally in 3 cases of posttraumatic chronic toe osteomyelitis in host-type A patients, a distal phalanx amputation was the definite solution. One patient developed a septic TKR in the contralateral leg and one diabetic patient developed osteomyelitis at a different location in the earlier affected foot.

Conclusions: The treatment strategy of radical debridement, local antibiotic delivery by the bead-pouch technique and use of flaps if needed, successfully treated salvageable feet. Amputation was the solution in neglected cases and in immunocompromised patients.

Purpose: Methods: Evaluation of the results of arthroscopic ankle arthrodesis, performed in 49 consecutive patients (52 ankles), with disabling ankle arthritis, between 08/1998 and 12/2004. Thirty ankles had no significant deformity (group A), whereas 22 ankles had a varus or valgus deformity greater than 10° (mean 21.7°, max 45°) (group B). Mean age in groups A and B was 49.7 and 57.5 years respectively (p=0.15). The primary diagnosis in groups A and B was post-traumatic arthritis in 66% and 27% and idiopathic osteoarthritis in 17% and 59%, respectively. Average hospital stay was 3.63 and 3.68 days in groups A and B respectively (p=0.96). Postoperative treatment included ankle immobilization for 3 months. Progressive weight-bearing was initiated at two weeks. Mean follow-up was 14.9 months (range 6–60).

Results: No infections or neurovascular problems occurred. Fusion occurred in 29/30 cases in group A at an average time of 11.52±5.2 weeks and in 21/22 patients at 11.67±2.3 weeks in group B (p=0.89). Not planned surgical procedures were required in eight cases (15.4%). Symptomatic arthritis from the adjacent joints developed in three cases during the follow-up period. The arthrodesis position angle measured in the sagittal plane from the lateral post-operative plane film averaged 105°±3° and 103°±6° in groups A and B respectively (p=0.27). The outcome in groups A and B was graded as very good in 73% and 72.7%, fair in 23% and 22.7% and poor in one case in each group, respectively (p=0.26).

Conclusions: The arthroscopic technique offers a high fusion rate, decreased time to fusion, short hospital stay and absence of limb-threatening complications. Deformity correction can be attempted with equally good results.