Introduction Twenty-one feet in fifteen patients underwent osteotomies of the calcaneus and one or more metatarsals for symptomatic cavo-varus foot deformity.

Methods Seven (nine feet) were male, and eight (12 feet) were female. The etiology included hereditary motor sensory neuropathy (HMSN) (15 feet), post-polio syndrome (two feet) sacral cord lipomeningicoccle (two feet), parietal lobe porencephalic cyst (one foot) and idiopathic peripheral neuropaty (one foot). Presenting complaints were metatarsalgia (15 feet), ankle instability (five feet and ulceration beneath the second metatarsal head (one foot). Eleven feet were assessed using the Maryland Foot Rating Score (MFRS).

Results MFRS improved from 72.1 (average) pre-operatively to 89.9 (average) post-operatively (follow-up 70.9 months average). Eight feet were assessed using the AOFAS ankle-hindfoot and midfoot scores. The AOFAS ankle-hindfoot score improved from 46.3 (average) pre-operatively to 89.1 (average) post-operatively and the AOFAS midfoot score improved from 40.9 (average) pre-operatively to 88.8 (average) post-operatively (follow-up 20.8 months average). Two patients were lost to follow-up and were not included in the study. Ankle, hindfoot and midfoot motion was maintained or improved in 16 feet. Complications included delyed union in two and non-union in three of 66 metatarsal osteotomies. While three patients required an AFO (ankle-foot orthosis) for ambulation pre-operatively, all patientrs were brace free post-operatively and expressed willingness to undergo the same procedure again if it were necessary. Weight bearing radiographs were available for 17 feet. Radiographic analysis revealed a decrease in forefoot adduction (9.6° average) and a reduction in both hindfoot (9.1° average) and forefoot cavus (10.6°) leading to an overall 13% reduction in the height of the longitudinal arch.

Conclusions Lateral sliding elevating calcaneal ostetomy combined with doso-lateral closing wedge osteotomies of one or more metatarsal bases in the severe symptomatic cavovarus foot can provide a pain free, plantigrade foot with a lowered longitudinal arch and a stable ankle without sacrificing motion.

In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits.

Introduction Twelve patients with an osteochondral lesion of the talus were treated with excision of the lesions and local osteochondral autogenous grafting.

Methods The lesion was accessed through a replaceable bone block removed from the anterior tibial plafond. The graft was harvested from the medial or lateral talar articular facet on the same side of the lesion. The average age of the patients was 41 years and duration of symptoms was 90 months (average). There were six males and six females with the right talus involved in eight and the left in four patients. Graft sizes ranged from four to eight millimetres in diameter.

Results There was a significant improvement in the AOFAS score from 64.4 (average) pre-operatively to 90.8 (average post-operatively (p< 0.0001) at follow-up of 25.3 months (average). The AOFAS score was slightly higher in patients under 40 years of age and in those without pre-existing joint arthritis. All patients were very satisfied with the procedure. Arthroscopy performed in two patients at six and 12 months following surgery showed good graft incorporation. No complications occurred at the donor site or the site of the bone block removal on the distal tibia.

Conclusions The results showed that stage III and stage IV talar osteochondral lesions can be accessed successfully excising a tibial bone block and using local autogenous osteochondral graft harvested from the ipsilateral talar articular facet.

In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits.

Introduction Fracture dislocation of the midtarsus with subsequent collapse of the longitudinal arch, dislocation of the forefoot and development of the rocker-bottom deformity is a significant complication of the neuropathic foot. Bony deformity and lack of protective sensation may lead to plantar ulceration, infection and amputation. Surgical reconstruction entails reduction of the dislocation and restoration of the alignment of the foot. Fixation of the arthrodesis may be challenging due to bony dissolution, fragmentation and osteoporosis which accompany the Charcot process. The purpose of the the current study is to describe the technique and review the clincial results of midtarsal arthrodesis with intamedullary axial screw fixation used to treat Charcot midfoot collapse.

Methods A retrospective study of 12 patients undergoing surgical reconstruction and arthrodesis of Charot midfoot deformity was done. Long intramedullary screws were applied antegrade or retrograde to bridge the apex of the deformity after the area had been prepared for arthrodesis through bony resection or osteotomy. Axial screws are applied such that the head or shaft of the screw gained purchase in the intramedullary canal of two or more metatarsal bones. Compression of the arthrodesis bed was achieved by tightening the screws. Radiographic measurements were taken pre-operatively, immediately post-operatively and at the last follow-up to assess the amount of durability of the correction achieved.

Results Patients were evaluated clincally and radiographically at an average of 35 month follow-up (5 to 144 months). Bony union was achieved in 83% of patients, at an average of 5.3 months. All patients returned to functional ambulatory status within seven months. The talar-first metatarsal angles in the anterior and lateral planes, talar declination angle and calcaneal-fifth metatarsal angle were all corrected to near normal values following the surgery and showed no significant collapse between immediate post-op and final follow-up. The amount of dorsal displacement of the medial column was reduced to normal values and showed no significant recurrence at final follow-up. There were no recurrent plantar ulcerations. Hardware failure occurred in one patient who was unable to comply with weight bearing restrictions and significant soft tissue complications were encountered.

Conclusions Surgical correction of Charcot midfoot collapse with midfoot osteotomy and arthrodesis utilizing multiple large-diameter intramedullary axial screws which span the area of dissolution provides an adequate construct to achieve arthrodesis and maintain alignment and reduction of the deformity.

In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits.

Introduction Nineteen consecutive patients underwent flexor hallucis longus (FHL) tendon transfer and medial displacement calcaneal osteotomy for the treatment of Stage 2 posterior tibial tendon dysfunction.

Methods The FHL tendon was utilized for transfer because it approximates the strength of the posterior tibiais muscle and is stronger than the peroneus brevis muscle. Seventeen patients returned for follow-up examination (average 18 months).

Results The AOFAS hindfoot score improved from 62/100 to 84/100. The subjective portion of the AOFAS hindfoot score improved from 31/60 to 49/60. Weight bearing pre-operative and post-operative radiographs revealed no statistically significant improvement for the medial longitudinal arch in measurements of lateral talo-first metatarsal angle, calcaneal pitch, vertical distance from the floor to the medial cuneiform or talo-navicular coverage angle. Three feet had a normal medial longitudinal arch and six feet had a longitudinal arch similar to the opposite side following the procedure. Patient satisfaction was high: 10 patients satisfied without reservations, six patients satisfied with minor reservations and one dissatisfied. No patient complained of donor defecit from the harvested FHL tendon.

Conculsions Despite the inability of the procedure to improve the height of the medial longitudinal arch, FHL transfer combined with medial diplacement calcaneal osteotomy yielded good to excellent clinical results and a high patient satisfaction rate.

In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits.

Twelve patients with an osteochondral lesion of the talus were treated with local osteochondral autogenous grafting. The graft was harvested locally from the medial or lateral talar articular facet. The procedure was combined with an osteotomy of the anterior tibial plafond modifying the technique of Flick and Gould. The average age of the patients was 41 years (range 19 to 68) with an average duration of symptoms of 90 months (range 3 – 240 months). There were six males and six females with the right talus involved in eight and the left in four patients.

Results showed an improvement in the AOFAS score from an average of 69 pre-operatively to 90.2 post-operatively, at an average follow up of 15 months (range 6 to 31 months). The results tended to improve with time and was higher for patients under 40 years of age and in those without pre-existing joint arthritis. All patients were very satisfied with the procedure. Arthroscopy performed in two patients at six and 12 months following surgery showed good graft incorporation. No complications were seen from the donor site or from the osteotomy site on the distal tibia. Our results show that stage III and IV talar lesions can be treated successfully using local autogenous osteochondral graft from the medial or lateral talar articular facet.