Hallux valgus is a common condition often leading to significant symptoms. However, its correction has recently been suggested, to be a procedure of limited clinical value. Scarf osteotomy is one of the most commonly performed operations for hallux valgus correction. Although technically demanding, it is powerful in its capacity to correct the hallux valgus deformity and sufficiently robust with internal fixation to allow early weight bearing.

We prospectively collected data for consecutive scarf osteotomies between 2008 and 2011. Preoperative and 6 week postoperative assessment was made using radiographic measurements HVA (hallux-valgus angle) and IMA (inter metatarsal angle). We evaluated 130 scarf osteotomies. The mean HVA improved from 29.5 pre-operatively to 12.6 post correction. The mean IMA improved from 12.4 pre-operatively to 8.1 post correction. The AOFAS hallux scores improved from an average of 55 pre op to 79 post operation.

The results suggest that hallux valgus correction does have clinical value and that scarf osteotomy is a reproducible procedure, with a generally good to excellent results in the short term.

Purpose of the study

We report on the clinical, radiographic and functional outcomes after salvage arthrodesis for complex ankle and hindfoot problems the Portsmouth experience with the Ilizarov ring fixator.

We report on the clinical, radiographic and functional outcomes after salvage arthrodesis for complex ankle and hind-foot problems - the Portsmouth experience with the Ilizarov ring fixator.

11 patients underwent ankle and hind-foot (tibio-calcaneal) arthrodeses using an Ilizarov ring fixator between 2006 and 2010. The indications included failed fusion after primary arthrodesis, sepsis complicating internal fixation of fractures, talar avascular necrosis and failed total ankle arthroplasty (TAR).

All patients had undergone multiple previous surgeries, which had failed. There were 8 males and 3 females in this group. Average age of the patients was 58 (43 years – 77 years) Mean follow up was 36 months (7 – 60 months). Mean frame time was 24 weeks (15 – 36 weeks). BMP 2 (Inductos) was used in three cases. The procedure was combined with a proximal corticotomy and lengthening in 2 patients who had undergone a talectomy and tibio-calcaneal fusion. There were no major complications apart from minor pin site infections requiring oral antibiotics. There were no deep infections, thromo-embolic issues, CRPS, or functional problems on account of limb shortening. Patients were assessed clinically, radiologically and using functional outcome scores - EQ50 and AOFAS. Solid arthrodesis was achieved in all but one patient who was subsequently revised with a hind-foot nail. All patients were satisfied with their overall improvement in pain and function.

We conclude that this is an effective salvage technique for complex ankle and hind-foot problems in patients with impaired healing potential, insufficient bone stock and progressive deformity.

Introduction: Ankle diastasis injury occurs in up to 20% of ankle fractures. Various techniques have been used to treat syndesmosis injuries, but controversy remains and outcome is variable. In light of some recent cases of substandard syndesmosis fixations requiring revision, an audit of our results was undertaken.

Method: Study type: Retrospective audit of radiographs and patient records

Data collection: patients were selected using an orthopaedic database search for operations coded as distal tib/fib ORIF or ankle ORIF.

Study period: 12 months, July 2008 to July 2009 (currently data has been analyzed on the first 6 months only, the remaining 6 months will follow)

Audit questions to be answered: How is ankle diastasis injury being managed? Are we reducing syndesmosis correctly? Should there be a revision to local policy?

Audit standard: Syndesmoses should be adequately reduced and fixation techniques employed should be in accordance with recommendations in standard Orthopaedic reference texts (Rockwood & Green, AO fixation manual 3)

Results: 76 ankle ORIFs in July to December 2008 inclusive. Out of these, 16 had diastasis fixation (21%). 2 of the patients had a syndesmosis width over 6 mm indicating an inadequate reduction of the syndesmosis 1. Both of these required revision surgery. In total 70% of the post operative x-rays showed inadequate syndesmosis fixation or reduction.

Discussion: The single most predictive indicator of a favourable function is accurate reduction of the syndesmosis 2. Substandard fixations are associated with poor long term outcomes. This raises the potential for litigation and the requirement for education and policy change. We have produced policy guidelines for theatre and circulated the information to all surgeons. A further audit will be carried out to assess the effectiveness of this in 6 months time. (The data will be available from this re-audit for presentation at the conference.)

Medial malleolar stress fractures are uncommon even in the sporting population. They tend to occur almost exclusively in athletes involved in sports involving running and jumping. We believe that stress fractures of the medial malleolus may be the end stage of chronic anteromedial ankle impingement in elite running and jumping athletes. Anterior impingement spurs are thought to be caused by repetitive microtrauma at the limit of dorsiflexion causing subperiosteal haemorrhage and subsequent ossification. More specifically the lower surface of the anterior tibia and the anterior part of the medial malleolus undergo similar trauma during severe supination injuries. Repetitive trauma to the cartilage from the kicking action in soccer is also thought to play a part, the cartilage responding by the formation of scar tissue and subsequent calcification.

We present five cases of elite athletes (three AFLplayers, one sprinter and one A Grade cricketer) who presented to our establishment with vertical stress fractures of the medial malleolus over a three year period (2004–7). In each case preoperative imaging revealed an anteromedial bony spur on the tibia. All patients had the fractures internally fixed and at the same sitting had arthroscopic debridement of the impingement spur.

Average time to union was 10.2 weeks (6–16). At most recent review (average 18 months (8–37)) all fractures had united and all patients had resumed sporting activity. No patient had suffered a further fracture of the medial malleolus.

We believe this region of impingement causes premature abutment of the talus on the tibia in the supination-adduction motion that in severe trauma leads to the vertical fracture through the medial malleolus according to the Lauge-Hansen classification. We therefore feel it should be addressed at the time of fracture fixation to reduce the re-fracture rate.

Chronic exertional compartment syndrome of the foot is well recognised. There has been debate over the exact number and location of compartments. While the medial compartment has been consistently reported, the exact anatomy of the fasciotomy has been poorly documented in orthopaedic literature.

Over a four year period (2003–7) five patients (seven feet) with history and examination findings compatible with chronic exertional compartment syndrome affecting the medial compartment of the foot were treated in our unit. There were three female patients and two males, average age 23 (17–34).

Assessment was made using the Stryker compartment pressure monitor inserted into the compartment following exertion. The measurements were compatible with chronic exertional compartment syndrome according to the Pedowitz criteria. The patients then underwent complete surgical release of the medial compartment of the foot. This involved two small oblique incisions, over the proximal and distal ends of the muscle belly of abductor hallucis, the fascia on the superficial and deep surfaces was then released, thus releasing the distal end of the tarsal tunnel. Decompression was bilateral in one, sequential in one and unilateral in three. Three patients also had surgical treatment of chronic compartment syndrome elsewhere in their lower limbs. One patient underwent a simultaneous calcaneal osteotomy for a planovalgus foot.

Preoperative post exertional compartment pressure measurements were 67.8 (32–114) at 1 minute and 50.2 (28–97) at 5 minutes. At an average of 21 (9–57) months follow up all but one patient had significant relief of their symptoms.

We recommend that the surgical treatment of chronic exertional compartment syndrome affecting the medial compartment of the foot should involve full release of the fascia both superficial and deep to abductor hallucis. It is safe to perform this bilaterally and in association with other lower limb decompressions as required.