1. Twenty-three patients were treated by cross screwing for diastasis of the tibia and fibula in fractures at the ankle. 2. It is suggested that limitation of ankle dorsiflexion after this treatment was caused by the presence of a mechanical block to dorsiflexion by spur formation at the margins of tibia and talus. 3. An ordinary bone screw controlled the diastasis satisfactorily in twenty patients. 4. The screw did not interfere with movement at the inferior tibio-fibular joint because bone resorption about that part of the screw in the fibula allowed a small range of movement. 5. Discomfort from the screw was relieved by its removal

We reviewed, retrospectively, 13 patients who had undergone open anterograde autologous bone grafting of the talus for symptomatic osteochondral defects of the dome of the talus. The mean age of the seven men and six women was 38.4 years. The defects included the full thickness of articular cartilage, extended through the subchondral plate and were associated with subchondral cysts. Six patients (46%) were clinical failures requiring further surgery. Of the remaining seven, functional outcome results were obtained at a mean of 51.9 months after surgery. The mean outcome scores for the Musculoskeletal Outcomes Data Evaluation and Management System foot and ankle questionnaire and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale were 87.0 and 84.3, respectively. There was an overall 46.2% patient satisfaction rate. We believe that the technique of autologous bone grafting presented should be used with extreme caution, when considered as the primary treatment for the adult patient with a symptomatic advanced osteochondral defect of the talus

The databases of the Picture Archiving and Communication Systems of two hospitals were searched and all children who had a lateral radiograph of the ankle during their attendance at the emergency department were identified. In 227 radiographs, Bohler’s and Gissane’s angles were measured on two separate occasions and by two separate authors to allow calculation of inter- and intra-observer variation. Intraclass correlation coefficients were used to assess the reliability of the measurements. For Bohler’s angle the overall inter-observer reliability, the intraclass correlation coefficient was 0.90 and the intra-observer reliability 0.95, giving excellent agreement. This reliability was maintained across the age groups. For Gissane’s angle, inter- and intra-observer reliability was only fair or poor across most age groups. Further analysis of the Bohler’s angle showed a significant variation in the mean angle with age. Contrary to published opinion, the angle is not uniformly lower than that of adults but varies with age, peaking towards the end of the first decade before attaining adult values. The age-related radiologic changes presented here may help in the interpretation of injuries to the hindfoot in children

1. Thirteen cases of fracture of the lateral process of the talus seen over a period of thirteen months are reported. 2. The mechanism of the injury would appear to be inversion strain of the foot with dorsiflexion of the ankle. 3. The diagnosis would no doubt be made more often if the possibility of this fracture were kept in mind, and if radiographs of good quality were taken with the ankle at 0 degree and the leg rotated inwards 10 to 20 degrees. 4. With regard to treatment, early operation appears to give good results, a single large fragment being reduced accurately and small or comminuted fragments being removed

1. Eighty-five patients have been studied soon after a ligamentous injury at the foot or ankle. These patients were treated in one of three ways, and in fifty-six patients the results were evaluated six to fifteen months after injury. 2. It is concluded: a) that ligamentous injuries at the foot and ankle frequently produce a proprioceptive deficit affecting the muscles of the injured leg; b) that such a deficit is responsible for the symptom of "giving way" of the foot; and c) that the incidence of both the proprioceptive deficit and the symptom of "giving way" can substantially be reduced by treatment after injury with the coordination exercises described in this study. 3. The mechanism of production of the proprioceptive defect is discussed

The treatment of acquired flat foot secondary to dysfunction of the posterior tibial tendon (PTT) of stage II, as classified by Johnson and Strom, remains controversial. Joint sparing and soft-tissue reconstructive procedures give good early results, but few studies describe those in the medium-term. We studied prospectively the outcome of surgery in 51 patients with classical stage-II dysfunction of the PTT treated by a medial displacement calcaneal osteotomy and transfer of the tendon of flexor digitorum longus. We reviewed 44 patients with a mean follow-up of 51 months (38 to 62). The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot rating scale improved from 48.8 before operation to 88.5 at follow-up. The operation failed in two patients who later had a calcaneocuboid fusion. The outcome in 43 patients was rated as good to excellent for pain and function, and in 36 good to excellent for alignment. There were no poor results

We describe the surgical technique and results of arthroscopic subtalar release in 17 patients (17 feet) with painful subtalar stiffness following an intra-articular calcaneal fracture of Sanders’ type II or III. The mean duration from injury to arthroscopic release was 11.3 months (6.4 to 36) and the mean follow-up after release was 16.8 months (12 to 25). The patient was positioned laterally and three arthroscopic portals were placed anterolaterally, centrally and posterolaterally. The sinus tarsi and lateral gutter were debrided of fibrous tissue and the posterior talocalcaneal facet was released. In all, six patients were very satisfied, eight were satisfied and three were dissatisfied with their results. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from a mean of 49.4 points (35 to 66) pre-operatively to a mean of 79.6 points (51 to 95). All patients reported improvement in movement of the subtalar joint. No complications occurred following operation, but two patients subsequently required subtalar arthrodesis for continuing pain. In the majority of patients a functional improvement in hindfoot function was obtained following arthroscopic release of the subtalar joint for stiffness and pain secondary to Sanders type II and III fractures of the calcaneum

The results are presented of 47 compression arthrodeses of the ankle performed for osteoarthritis in 44 patients. In 26 cases the transverse anterior incision of Charnley had been used and in 21 cases medial and lateral incisions with division of the malleoli. Complications included infection (19%), non-union (14.9%) and malposition requiring a further procedure (8.5%). Three patients (6.4%) eventually had an amputation. Clinical assessment using a standard grading method showed that the functional result was not related to the angle of plantar flexion of the ankle, but was related to the varus/valgus position of the heel, the neutral position being associated with the best results. The anterior approach was more reliable in avoiding varus or valgus of the heel

Aims

This study aimed to explore whether intraoperative nerve monitoring can identify risk factors and reduce the incidence of nerve injury in patients with high-riding developmental dysplasia.

After obtaining informed consent, 80 patients were randomised to undergo a navigated or conventional total knee replacement. All received a cemented, unconstrained, cruciate-retaining implant with a rotating platform. Full-length standing and lateral radiographs and CT scans of the hip, knee and ankle joint were carried out five to seven days after operation. No notable differences were found between computer-assisted navigation and conventional implantation techniques as regards the rotational alignment of the femoral or tibial components. Although the deviation from the transepicondylar axis was relatively low, there was a considerable range of deviation for the tibial rotational alignment. There was no statistically significant difference regarding the occurrence pattern of outliers in mechanical malalignment but the number of outliers was reduced in the navigated group

We treated 20 children (40 limbs) with diplegic cerebral palsy who could walk by multilevel soft tissue operative procedures including conversion of the biarticular semitendinosus and gastrocnemius to monoarticular muscles. The mean age at surgery was 11.5 years (5.6 to 17.0). All patients underwent clinical and radiological examination and three-dimensional instrumented gait analysis before and at a mean of 3.1 years (2.0 to 4.5) after surgery. The passive range of movement at the ankle, knee and hip showed improvement at follow-up. Kinematic parameters indicated a reduced pelvic range of movement and improvement of extension of the knee in single stance after operation (p < 0.0001). However, postoperative back-kneeing was detected in five of the 40 limbs. The kinetic studies showed that the power of the hamstrings and plantar flexors of the ankle was maintained while the maximum knee extensor moment during stance was reduced. The elimination of knee flexor activity of semitendinosus and gastrocnemius combined with transfer of distal rectus femoris led to an improvement in gait as confirmed by gait analysis

Thirteen patients suffering from rheumatoid arthritis had 19 stress fractures of the tibia or fibula. These patients characteristically presented with sudden, severe, unexplained pain with localised tenderness just below the knee or above the ankle. In seven patients examination of the adjacent joint indicated a flare-up of disease activity or a pyogenic arthritis. In six patients the diagnosis was delayed by the late appearance of callus in minute fractures. All patients had rheumatoid deformities of the ipsilateral lower limb: valgus deformities of the knee and subtalar joints occurred most frequently. All patients had osteoporosis; all except two had received steroid treatment and five had abnormalities of calcium metabolism. We suggest that deformities of the knee and ankle predispose patients with rheumatoid arthritis and osteoporosis to stress fractures of the tibia and fibula

The contributions made by metatarsus primus varus, medial subluxation of the navicular, and angulation of the neck of the talus to the residual deformity in treated club feet were assessed from radiographs. Their relation to the appearance of the feet, to the age of the patient, to the results of operations, and to the age at the time of the first operation were investigated. Lateral rotation of the ankle and flattening of the talus were also studied. Medial subluxation of the navicular was found to be the most important factor influencing both the appearance of the feet and the lateral rotation of the ankle. Relocation of the talonavicular joint correlated with the success of operative treatment; and the timing of the primary operation determined the degree of relocation which could be achieved. Metatarsus primus varus and angulation of the talus were of little importance. Increased emphasis is given to the need for early relocation of the talonavicular joint

Among 449 patients with leprosy, 40 had clinical and radiographic evidence of neuroarthropathy in 50 feet. These changes were classified into four types according to the joints first involved by major lesions: ankle (25 feet), midtarsal (15 feet), tarsometatarsal (7 feet) and subtalar (3 feet). The progression of joint destruction was different in each type, but despite the severe destructive changes seen in radiographs, the patients had relatively few complaints. The muscles innervated by the peroneal nerve were severely paralysed in ankle and midtarsal types and it seems that, over a long term, repeated trauma and/or abnormal stress may lead to these types of neuroarthropathy. Neuropathy was less severe in the tarsometatarsal type of joint degeneration; the pathogenesis in this type seemed to be mainly direct trauma to the forefoot

1. Two boys complaining of pain in the ankle were shown to have centres of separate ossification for the medial malleoli. These were present bilaterally, but discomfort was unilateral. 2. In one, followed for fifteen months, the extra centre became wholly incorporated into the normal lower tibial epiphysis. 3. in a series of 100 children between the ages of six and twelve, without any known disease or injury of the ankles, radiographs showed that 20 per cent had a separate medial malleolar centre on one side. In 13 per cent this finding was present bilaterally. In one child a separate lateral malleolar centre was also found. 4. The significance of this finding is discussed, and it is considered to be a normal variant. 5. Occasionally one of these centres may remain unfused into adult life. Attention is drawn to the possible implications of this persistence

One hundred cases of Lambrinudi's arthrodesis are reviewed. The shortest follow-up was one year. and the longest twenty-seven years. Thirty-seven per cent were successful. Nineteen per cent were failures; many of these were associated with faulty technique, and one method of operation which gives good results is described. Success is likely if there is a balance of power between the dorsiflexors and plantarflexors of the ankle, especially if there is some fixed equinus before operation. Success is less likely when the operation is done for a flail foot. In such circumstances arthrodesis of the ankle may have to be considered subsequently for instability of the lateral ligament, recurrence of dropfoot, or arthritis which may develop in the more active patients. Age in itself is no bar to success, but pseudarthrosis is more likely to occur in patients over the age of twenty

The late results of treatment of calcaneal fractures in 17 children (19 fractures) were reviewed at a mean of 16.8 years after injury. With the exception of one patient, all fractures had been treated conservatively. At follow-up there were few complaints. All but two patients had full or slightly reduced mobility of the subtalar joint and unrestricted foot function, including the ability to walk comfortably on uneven surfaces. Minor radiological abnormalities of the hindfoot were common; there were two cases of post-traumatic osteoarthritis. Clinical scoring of the ankle and hindfoot using the American Orthopaedic Foot and Ankle Society rating system averaged 96.2 points. The results suggest that up to 16.8 years after injury almost all children achieve excellent long-term functional results with conservative treatment of fractures of the os calcis. Open management may only be appropriate for adolescents with severe displacements