Introduction

Crossover and claw toe deformity has traditionally been a very difficult condition to manage surgically, with high recurrence rates. Multiple methods have been used to treat this condition. Plantar plate “repair” has recently been advocated, with sutures used to repair an assumed tear. Based on clinical experience and anatomical studies (Deland et al. 1995), we believe the main pathology is a distal migration of the plantar plate complex resulting in exposure of the metatarsal to the thin posterior synovial attachment of the plate. The downward forces on the metatarsal head results in herniation of the head inferiorly. Accordingly we have developed a technique using full cuff release of the plantar plate complex that includes complete release of the collateral ligaments, repositioning the plantar plate anatomically and reinforcing the hernial defect with a synthetic mesh graft.

Introduction: Traditionally flexion deformities in Proximal Interphalangeal joints of lesser toes like hammer toes and curly toes are treated with fusing the PIP joint with a single Large Kwire. We describe a new technique of fusing PIP joints using two 1.1mm K wires.

The advantages of this technique over single K wire are:

Less post operative complications like pain and pin tract infection.

Aim: To compare the clinical and radiological outcomes in two pin fusions with standard single pin fusions described by Coughlin. To prove that this is a technically and biomechanical better procedure.

Materials and Methods: Two pin technique was used for 36 PIP joint fusions in 25 patients with a mean age of 58 years (range–42 to 87 years) and female preponderance. Results were analysed using foot function scale, AOFAS (American Orthopaedic Foot and Ankle Society) lesser metatarsophalageal-Interphalageal scale. Post operative complications were documented.

Technique: Dorsal skin incision was used to approach the PIP joint. Articular surfaces were prepared and two 1.1mm K wires were inserted from the tip of the toe and joint fixed in 15 – 20 degrees of flexion which is optimal functional position of PIP joint. Patients were mobilised non weight bearing for 6 weeks when K wires were removed and weight bearing started.

Results: The results were analysed at 3–6 months post operatively. The foot function scores and objective parameters of AOFAS scores are slightly better in two pin fusions compared with single pin fusions.

Objective parameters of AOFAS scale like adduction/ abduction, flexion, rotational deformities are significantly less with two wire fusions compared with single wire procedures (Coughlin et al). Radiological analysis of the foot showed that 97% had bony union compared 81% with single pin, and only 3% had fibrous union compared to 19% with single wire. Both the procedures didn’t have any non-unions. Only one patient had superficial wound infection, and surprisingly none had pin tract infection.

Conclusion: Two pin PIP Joint fusion is relatively easy procedure with many technical advantages over single pin technique. The clinical and radiological outcomes are good. Results of the biomechanical studies should be available soon.

Introduction: Achilles tendinopathy is a source of significant pain and disability. While many patients respond to non-operative treatment, a proportion will require operative treatment. Both open decompression and percutaneous longitudinal tenotomy have been described. We describe a new technique and present the results of percutaneous circumferential decompression of the tendon, dividing adhesions between the paratenon and the tendon.

Methods: We followed up 10 patients for a mean of 10 months (5–19) post operatively. They were scored pre and post operatively using the tegner activity score, the puddu score and an analogue pain score. The functional result was also assessed with the SF12 questionnaire.

Results: All patients reported significant improvements in pain (p=0.007), tegner (p=0.007) and puddu (p=0.005) scores. They would all undergo the procedure again. The SF12 scores were not significantly different from a normal population.

Discussion: We believe that this technique addresses the underlying pathology, giving excellent results without the potential complications of an open decompression.

Hallux valgus is a common condition and surgical correction has remained a challenge. Scarf osteotomy with Akin procedure is well accepted method. Akin procedure gives spurious correction of the distal alignment of big toe. This study was performed to see alternative way to get best correction without additional phalangeal procedure. Senior author used innovative Y-V medial capsulorraphy with standard Scarf osteotomy. This technique allows reduction of MP joint along with correction of pronation deformity and reduction of sesamoids.

We report the use of a modified Y-V medial capsular repair in association with Scarf osteotomy for Hallux valgux in 45 patients (55 feet) aged 18 to 76 years (mean 43 years) between October 2004 and December 2005. Clinical follow up was both subjective and objective. Patients were asked about rating of their satisfaction and objective assessment was done in form of AOFAS score. Using this technique none of the patients required an additional proximal phalangeal osteotomy with metatarsal osteotomy. At six months follow up American Orthopaedic Foot and Ankle Society score improved from 46 to 87. Intermetatarsal (IM) angle and the hallux valgus (HV) angle improved from 16° to 9° and from 31° to 16° respectively (p< 0.05). At final follow up 8 patients were very satisfied, 12 were satisfied while 5 were not satisfied.

Of the 55 procedures 51 did not develop any complications. Two had superficial infections, treated successfully with oral antibiotics only. Two patients had recurrence, one was treated with Akin and second patient declined surgery as she was not bothered with it.

We recommend the use of this modified ‘Y-V’ medial capsular repair to reduce the need for an additional procedure to augment the correction achieved during Scarf osteotomy for hallux valgus. This reduces hallux valgus angle and maintains it.

The authors report the use of a modified ‘Y-V’ medial capsular repair in association with Scarf osteotomy for Hallux valgus in 55 patients (62 feet) aged 18 to 61 years (mean 43 years) between July 2004 and July 2005. All patients were followed up for minimum 6 months by questionnaire, physical examination (American Orthopaedic Foot and Ankle Society score) and comparison of preoperative and post operative x rays.

Using this technique none of the patients required an additional proximal phalangeal osteotomy (Akin Oste-otomy). At six months follow up American Orthopaedic Foot and Ankle Society score improved from 46 to 87. Intermetatarsal (IM) angle and the hallux valgus (HV) angle improved from 16 degree to 9 degree and from 31 degree to 16 degrees respectively (p less than 0.05).

Of the sixty two procedures 59 did not develop any complications. Two had superficial infections which required oral antibiotics only. One partial loss of correction of hallux valgus occurred for which the patient refused a second operation. Seven cases had some residual pronation deformity of the big toe identified by the patients who felt the deformity was ‘about 50%’ compared to before the operation.

Akins osteotomy achieves an apparent correction of hallux valgus without addressing subluxation of meta-tarso-phalangeal joint. Our technique reduces the meta-tarso-phalangeal joint and corrects the hallux valgus angle anatomically.

We recommend the use of this modified ‘Y-V’ medial capsular repair to correct the hallux valgus angle and reduce the need for an additional procedure to augment the correction achieved during Scarf osteotomy for hallux valgus.

We wish to report the use of a modified ‘Y-V’ medial capsular repair in association with Chevron osteotomy fixed rigidly with Barouk screw for Hallux valgus in 45 patients (52 feet) aged 16 to 70 years (mean 47 years) between July 2004 and September 2005. All patients were retrospectively reviewed by questionnaire, physical examination (American Orthopaedic Foot and Ankle Society score) and comparison of preoperative and post operative x rays.

Using this technique none of the patients required additional immobilization apart from wool and crepe bandage following surgery. All osteotomies healed without any problem. There was no deep infection reported in this series. There were two superficial infection treated with oral antibiotics. There is no recurrence of deformity so far. At an average of six months follow up American Orthopaedic Foot and Ankle Society score improved significantly. Intermetatarsal (IM) angle and the hallux valgus (HV) angles were also improved considerably.

Stabilization of Chevron osteotomy with k wires, plaster of Paris is well known but these techniques have problems of infection and stiffness. Osteotomies carried out without any stabilization has high recurrence rate. Fixation of osteotomy with Barouk screw is a very simple procedure, which not only gives stability and compression to osteotomy but also reduces need for any plaster immobilization thus speed up rehabilitation. This also gives extra confidence to surgeon to allow patient for early weight bearing and mobilization.

We also recommend the use of modified ‘Y-V’ medial capsular repair to correct the hallux valgus angle and reduce the meta tarso-phalangeal joint leading to reduction in possibility of recurrence.