Introduction

Arthrodesis of the 1st metatarso-phalangeal joint (MTPJ) is a common procedure in forefoot surgery for hallux rigidus and severe hallux valgus. Debate persists on two issues - the best preparation method for the articular surfaces, and the optimal technique for operative stabilisation of the joint.

Introduction: Hallux varus deformity leads to a major esthetic and shoe wearing discomfort with a severe functional disability. Surgical procedures for correction must be adapted to the degenerative changings in the first MTP joint, to the joints stiffness and the IP joint claw.

Material and Methods: 80 patients have been operated on from 1981 to 2004

An enlarged debridment of the first MTP joint was mandatory before any reconstructive procedure.

The collateral lateral ligament reconstruction has been achieved with a synthetic suture (LigaproÒ or LigasticÒ of 1.5 mm diameter) according to flexible joint with no arthritis (regimen 1 (25 cases), youngpopulation (44 years) with an average varus of −12°).

The first MTP joint arthrodesis was performed for osteoarthritis combined with stiffness. (regimen 2 (40 cases), older (64 years) with an average varus of −16°.

Results: 15 patients were lost for FU.65 patients were clinically and radiologically reviewed with a medium FU of 10 years(2 to 25 years).

In series 1 (ligament reconstruction),24/25 patients were totally painless with an artificial device well tolerated. The joint motion, the gait and the shoe-wearing were normal in 24/25 of cases. The medium post-operative valgus was of 12°.

In series 2 (MTP arthrodesis), arthrodesis healed in 39 cases with an average time of 60 days. Valgus positionning was always restaured.Degenerative changings occured in the IP joint in 4 cases without any complain. Shoe- wearing was classical in all the cases.

Conclusions: The first MTP joint arthrodesis must be the referred procedure for hallux varus deformity according to OA and stiffness in the joint site.

Among the procedures for the first MTP joint preservation, enabled to restore valgus strength, the synthetic reconstruction of the collateral lateral ligament is a reliable and reproducible technique, without any damages for the active tendons nor for the joint function.

Purpose: The purpose of this work was to evaluate clinical and radiological results of surgical treatment of 80 calcaneum fractures involving the posterior talar process using 1/4 tubes used for triangulation fixation.

Material and methods: The series involved 73 patients (seven bilateral fractures), 56 men and 17 women, average age 39.6 years (15–67) who were treated between 1990 and 1999. Patients were victims of 34 home accidents (46.6%), 19 sports accidents (26%), 14 occupational accidents (19.2%), and six traffic accidents (8.2%). The Duparc classification was: type 2 (n=2) type 3 (n=17), type 4 (n=51), and type 5 (n=10). Junior surgeons performed most of the procedures who used seven ‘inverted-V’ assemblies and 73 triangular assemblies. Forty-two patients (47 fractures) were reviewed (58.8% of fractures) clinically and radiologically to assess stability of the fixation (Boehler angle and talocalcaneal angle) and search for osteoarthritis.

Results: Mean follow-up was six years (1.5–11.5). There were few complications: four late healing (5%), five reflex dystrophy (6.3%) and two infections (2.5%) (Met-S Staphylococcus aureus and Bacterium bovis corineus. Subjectively, 93.5% of patients were satisfied or very satisfied. At last follow-up, the Boehler angle was 27.5±6.7°. The subtalar space was normal or nearly normal in 46.8% and narrowed or destroyed (osteoarthritis) in 53.2%. The Kitaoka function score (AOFAS) was 73.2 points on average with 44.7% excellent or good results and 44.8% fair results. The SOFCOT score was very good, good, or rather good in 63.8% and fair in 10.3%; it was also noted that among the 25.5% poor results, three patients required secondary subtalar arthrodesis. 86% of the patients resumed their occupational activities and 63% of the patients practicing sports resumed their activities.

Conclusion: Osteosynthesis of calcaneum fractures using 1/4 tubes used in a triangular configuration provides stable fixation (little secondary loss of Boehler angle) with a satisfactory cutaneous impact (few cases of skin necrosis). The subjective outcome is very satisfactory. Objective outcome may appear disappointing but is generally related to the severity of the fracture (76% types 4 and 5) or type of fixation configuration.

Purpose: Chronic ankle instability is generally related to lateral laxity of the tibiotalar joint. Stress x-rays may however be negative. Varus of the hindfoot is another possibility. In such cases, it would be logical to propose Dwyer valgus osteotomy of the calcaneum. The objective of this work was to review patients who underwent Dwyer osteotomy from 1992 to 2000.

Material and methods: The series included fifteen patients, nine men and six women, who complained of chronic ankle instability with no evidence of laxity. All presented a varus hindfoot (mean 5°, range 3–10°). Thirteen patients practiced sports, including eight at the competition level. Sixty percent had experienced instability accidents during sports activities. Associated lesions were fissures of the fibular tendons (n=2), osteochondral lesion of the talar dome (n=1), Haglund disease (n=1) and stage II pes cavus (n=2). Lateral closed Dwyer osteotomy was performed in all cases, generally with fixed with two screws in a 2-hole 1/3 plate. Associated procedures were: lateral ligamentoplasty (n=1), osteotomy to raise M1 (n=2), regularisation of an osteochondral lesion of the talar dome (n=1), Zadek osteotomy (n=1) and anterior arthrolysis (n=1). The same surgeon reviewed the patients clinically and radiologically, independent of the operator.

Results: Mean follow-up was 3.5 years (range 1–9, SD 2.5). There were no complications except one case of cutaneous necrosis in the patient who had simultaneous osteotomy and ligamentoplasty. Instability resolved in all patients. Ten patients experienced minor episodic pain (50% during sports activities). Eleven patients (70%) resumed their sports activities within eight months (3–36) and 33% at their former level. The mean Kitaoka score was 92 (85–100) and 80% of the patients were satisfied or very satisfied.

Conclusion: Dwyer osteotomy provides quite satisfactory results for patients with chronic ankle instability without evidence of laxity and hindfoot varus. When a complementary ligamentoplasty appears to be necessary, it is preferable to wait for a second operation in order to avoid the risk of cutaneous necrosis.

Purpose: As suggested by MacCraw in 1979, the digitorum brevis extensor island flap provides an excellent local cover for small sized tissue losses of the foot and ankle. Despite its advantages, this alternative is not widely used. We report our experience in 11 cases.

Material and methods: Eleven patients underwent reconstruction procedures using the digitorum brevis extensor island flap. There were nine men and two women, mean age 45 years (36–58). The reconstruction was required for post-traumatic infection sequelae of the ankle for four cases, resection of local malignant lesions of the dorsal foot in three, metatasophalangeal involvement of the great toe (septic arthritis and deep electric burn) for two, and finally fistulised chronic osteitis of the base of the fifth metatarus for one patient with insulin-dependent diabetes mellitus. For eight patients, the flap was harvested from the anteior tibial pedicle and for three, the retrograde flow was fed by the pedious artery to treat metatasophalangeal lesions of the great toe and the base of the fifth metatarsus.

Results: Healing was achieved in all cases with definitive cure of the infectious problem. Subjectively, all patients had a good functional and cosmetic outcome when the flap was harvested on a proximal pedicle. For the single patient with a distal pediculated flap, there as a moderate problem with toe flexion due to adherences. None of the patients developed secondary trophicity problems.

Discussion: The digitorum brevis extensor island flap is a reliable reconstruction option to be discussed as an alternative for distant or free flaps. The pedious muscle flap is easy to harvest and is close to the recipient site limiting functional sequelae. Depending on the pivot point, the pedicle is positioned proximally or distally, the rotation arc being sufficient to reach the ankle or the foot. In addition, this is the only simple local flap, particularly for covering metatasophalangeal joints.

Conclusion: This very useful method merits reconsideration in comparison with other technical solutions for the treatment of small-sized skin loss (20 cm2) or for cure of local infectious lesions of the ankle, the foot and the forefoot.