Spasm or contracture of the gastrocnemius muscle is predominantly responsible for the equinus deformity of the foot in cerebral palsy. Its release is therefore logical in the treatment of all cases which do not respond to conservative measures. The authors have demonstrated, by the use of metal markers and radiographic control at operation, that adequate release cannot be achieved by severance of the calcaneal tendon alone, and that in order to ensure relaxation of the gastrocnemius muscle, the operation of choice is gastrocnemius recession by the method of Strayer, coupled with lengthening of the calcaneal tendon to deal with such degree of the deformity as may be attributable to shortening of the soleus. A survey of 100 limbs treated by this method revealed a recurrence rate of equinus of 9% and a degree of calcaneus deformity resulting in inadequate push-off in 3% of cases after an average follow-up period of six years

1. The results of thirty-nine operations for correction of drop-foot in thirty-three patients with leprosy are discussed. 2. The procedure used was circumtibial, subcutaneous, two-tailed, tendon-to-tendon transfer of the tibialis posterior to extensor hallucis longus and to extensor digitorum longus and peroneus tertius. The motor slips were inserted into the recipient tendons on the dorsum of the foot. 3. Analysis of the results showed some correlation between the angle of active dorsiflexion and the range ofactive movement ofthe ankle. The angle ofdorsiflexion seemed to determine the range of movement. 4. When contracture of the tendo calcaneus was present, simultaneous lengthening improved the angle of dorsiflexion more than the range of active movement. 5. The causes of failure were sepsis, failure of re-education and unrecognised tightness of the tendo calcaneus. 6. The advantages of the present procedure are mentioned

Over a period of one year we treated nine fractures of the sesamoid bones of the hallux, five of which were in the medial sesamoid. All patients had symptoms on exercise, but only one had a recent history of injury. The mean age of the patients was 27 years (17 to 45) and there were six men. The mean duration of symptoms was nine months (1.5 to 48). The diagnosis was based on clinical and radiological investigations. We describe a new surgical technique for percutaneous screw fixation for these fractures using a Barouk screw. All the patients were assessed before and after surgery using the American Orthopaedic Foot and Ankle Society Hallux Score (AOFAS). There was a statistically significant improvement in the mean score from 46.9 to 80.7 (p = 0.0003) after fixation of the fracture with a rapid resolution of symptoms. All patients returned to their previous level of activity by three months. We believe that this relatively simple technique is an excellent method of treatment in appropriately selected patients

In a retrospective study we compared the results of 31 Wilson and 31 Hohmann osteotomies of the first metatarsal in the treatment of hallux valgus. There were no differences between the two operations in terms of patient satisfaction, pain relief, appearance, footwear and walking ability. First metatarsal shortening was the same after both operations, and the degree of shortening was unrelated to either the clinical or the pedobarographic findings. Although the long-term radiographic changes after the Hohmann osteotomy were more worrying, the pedobarographic patterns tended to be worse after the Wilson osteotomy. There were no poor results and the numbers of feet with the same final grade were identical in each group. However, there was abnormal loading of the lateral metatarsal heads after both osteotomies when compared with the normal foot, and hallux-contact time during the stance phase was also significantly reduced after osteotomy

1. It has been shown in fifty normal feet that the perpendicular static plantar pressures rise by about 35 per cent between the ages of five years and maturity. 2. It is very likely that similar increases in plantar pressures occur between two and five years of age. 3. The plantar pressures in seventy-eight feet of children with spina bifida were with a few exceptions substantially higher than those of normal children of the same age. It is likely that this is so, at least in part, because the feet of children with spina bifida are smaller than normal. 4. This increase in perpendicular static pressure during growth must be relevant in the production of trophic foot ulceration. 5. The existence and importance of "flail deformity" as a factor producing areas of increased pressure and ulceration in anaesthetic feet is postulated

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

Spondylolisthesis without a defect in the neural arch, the "pseudo-spondylolisthesis" of Junghanns, usually affects the fourth lumbar vertebra. The essential lesion is an increase in the angle between tile inferior facets and the pedicles which allows subluxation at the inferior joints. The forward displacement averages less than one centimetre. It commonly produces a clinical picture of backache and sciatica, but may present with. a "drop foot," and in unusual instances compression of the cauda euluina may occur. Patients seen in the early stages without signs of nerve root compression are best treated by localised spinal fusion. Late fusion may afford no relief because of secondary changes in the spine, but these patients obtain some benefit from a corset. Laminectomy is indicated for severe symptoms in patients who show signs of nerve root compression; it should be followed by spinal fusion

Aims

The objective of this study was to compare early postoperative functional outcomes and time to hospital discharge between conventional jig-based total knee arthroplasty (TKA) and robotic-arm assisted TKA.

Aims

The pathogenesis of intraneural ganglion cysts is controversial. Recent reports in the literature described medial plantar intraneural ganglion cysts (mIGC) with articular branches to subtalar joints. The aim of the current study was to provide further support for the principles underlying the articular theory, and to explain the successes and failures of treatment of mICGs.

We describe the radiographic measurement of the angle of tilt of the patella and relate it to malalignment of the extensor mechanism. The tilt angle is defined as the angle subtended by a line joining the medial and lateral edges of the patella and the horizontal. The radiograph (Merchant type) is taken with the foot pointing up, the lower edge of the film parallel to the ground, and the knee at 30 degrees flexion. The mean tilt angle of a group of patients with signs and symptoms suggesting patellofemoral malalignment was 12 degrees (+/- 6 degrees); in a similar group of control subjects it was 2 degrees (+/- 2 degrees) (p < 0.01). Tilting of 5 degrees was taken to be the limit of normal. For the detection of patellar malalignment, the tilt angle was almost as specific as the congruence angle (92% v 99%) but more sensitive (85% v 25%) and more accurate (89% v 62%)

Injury to the dorsomedial cutaneous nerve in the foot may occur after operations for hallux valgus. Pressure neuropathy before operation is also described but remains largely unexplored. We have investigated the incidence of sensory deficit in the great toe before operating for hallux valgus and examined to what extent any deficit was related to the degree of angulation of the joint. Forty-three patients with a total of 61 great toes with hallux valgus presenting for consideration of surgical correction had their sensation tested in pre-designated zones using a five-filament set of Semmes-Weinstein monofilaments. These allowed good inter-observer reliability with an intra-class correlation coefficient of 0.84. Sensory symptoms were noted by only 21% of the patients, a measurable reduction in sensation by one monofilament grade or more was found in an additional 44%. No relationship was found between the degree of sensory loss and the degree of angulation. Patients with symptomatic hallux valgus may have sensory loss in the toe without being aware of it. Normal subjective sensation does not reliably predict normal sensory function. Given the potentially high rates of nerve damage following operations for hallux valgus, we recommend objective sensory testing as part of routine assessment before surgery

Sixty patients each of whom had a fracture of the lower limb a minimum of five years (median 11 years) previously were studied by photoplethysmography, foot volumetry, popliteal venous reflux and arterial Doppler measurements. The non-fractured limb was used as a control. Postphlebitic symptoms were present in 51% and signs in 49% of fractured limbs compared with 4% and 24% respectively in the control limbs. The incidence was greater in patients who had fractured 15 years or more previously than in those who had fractured 5 to 15 years previously. Eleven limbs had clinically disabling postphlebitic symptoms including venous ulceration. The postphlebitic syndrome following lower limb fractures in young patients is more common than generally appreciated and develops after a prolonged latent interval. A prospective randomised study using prophylactic anticoagulation for lower limb shaft fractures may be justified

To study the effect of ligament injuries and surgical repair we investigated the three-dimensional kinematics of the ankle joint complex and the talocrural and the subtalar joints in seven fresh-frozen lower legs before and after sectioning and reconstruction of the ligaments. A foot movement simulator produced controlled torque in one plane of movement while allowing unconstrained movement in the remainder. After testing the intact joint the measurements were repeated after simulation of ligament injuries by cutting the anterior talofibular and calcaneofibular ligaments. The tests were repeated after the Evans, Watson-Jones and Chrisman-Snook tenodeses. The range of movement (ROM) was measured using two goniometer systems which determined the relative movement between the tibia and talus (talocrural ROM) and between the talus and calcaneus (subtalar ROM). Ligament lesions led to increased inversion and internal rotation, predominantly in the talocrural joint. The reconstruction procedures reduced the movement in the ankle joint complex by reducing subtalar movement to a non-physiological level but did not correct the instability of the talocrural joint

We assessed peripheral nerve function during and after lower-limb lengthening by callotasis in 14 patients with short stature, using motor conduction studies. Four patients with short stature of varying aetiology showed unilateral and one showed bilateral weakness of foot dorsiflexion. Both clinical and electrophysiological abnormalities consistent with involvement of the peroneal nerve were observed early after starting tibial callotasis. There was some progressive electro-physiological improvement despite continued bone distraction, but two patients with Turner’s syndrome had incomplete recovery. A greater percentage increase in tibial length did not correspond to a higher rate of peroneal nerve palsy. The function of the posterior leg muscles and the conduction velocity of the posterior tibial nerve were normal throughout the monitoring period. The F-wave response showed a longer latency at the end of the bone distraction than in basal conditions; this is probably related to the slowing of conduction throughout the entire length of the nerve

1. Forty-eight cases of causalgia are reviewed and the clinical features are briefly described. 2. Multiple nerve injuries are common and the pain is often associated with all the injured nerves. In the upper limb there was always an incomplete lesion of the lower trunk or medial cord of the brachial plexus, or of the median nerve. In the lower limb there was always an incomplete lesion of the medial popliteal division of the sciatic, the medial popliteal, or the posterior tibial nerve. These nerves carry most of the sympathetic fibres to the hand and foot. With two exceptions all the nerve lesions were at or above the level of the knee or elbow. 3. Sympathectomy gives marked relief of pain in most cases of causalgia. Prompt treatment is essential to prevent the crippling deformities which follow prolonged voluntary immobilisation of the painful limb. The results of preganglionic are superior to those of postganglionic sympathectomy. 4. The possible pain pathways are discussed, and an explanation is offered for the successful results of sympathectomy in the treatment of causalgia

1. A series of cases of Morton's metatarsalgia is reported in which twenty-seven selected patients have had thirty-five operations on the sole of the foot. 2. At operation, degeneration of the plantar digital artery to the cleft between the third and fourth toes has now been found to precede the fibrous thickening of the nerve described by Betts in 1940. Similar changes rarely occur in neighbouring clefts. 3. Local resection of the nerve almost always gives complete relief from pain, and the plantar scar gives rise to no trouble. 4. Histological findings show that the nerve lesion is ischaemic in nature. 5. Acute pain arising as a new event in cases of the deformity of "anterior flat foot" may prove to be due to this condition. 6. Morton's metatarsalgia is a distinct clinical and pathological entity which can best be described as a plantar digital neuritis

We studied perioperative pain and postoperative neurological changes after surgery for hallux valgus in 50 patients operated on under local ankle block. Patients were randomised to have the pneumatic tourniquet either at calf level or just above the ankle. The cuffs were inflated to 100 mmHg above systolic blood pressure. One patient was withdrawn from the study after randomisation. Areas of pain, paraesthesia and numbness were marked by patients on a diagram of the foot before operation and at six and ten weeks after operation. Both positions of the tourniquet gave an excellent bloodless field. The proximal tourniquet gave significantly greater discomfort (p < 0.01) during the operation, after 10, 20 and 30 minutes. Application of the cuff at the ankle gave no relative increase in areas of numbness and paraesthesia at six and ten weeks. An ankle tourniquet gives less discomfort with no increase in the incidence of nerve injury

We reviewed 20 patients with spina bifida who had had surgical management of tibial torsion. Eight had had bilateral procedures and 12 a unilateral procedure, giving a total of 28 limbs for analysis. We performed closed osteoclasis on seven limbs and tibial osteotomy on 21. In the closed osteoclasis group six limbs (85%) had a good result after an average follow-up of nine years (2 to 22). All limbs developed postoperative anteromedial bowing of the tibia which later remodelled. In the tibial osteotomy group 19 (90%) had a good result. The average follow-up was nine years (2 to 28). Complications occurred in seven limbs (33%). We recommend closed osteoclasis of the tibia for the young patient with spina bifida in whom walking is impeded by excessive internal tibial torsion, and supramalleolar tibial osteotomy in the older patient with excessive external tibial torsion and a planovalgus foot

Since 1986, we have treated displaced intra-articular fractures of the calcaneum by open reduction through a lateral approach, stable internal fixation and bone grafting. We assessed the results at a mean follow-up of 2.92 years in 44 patients, comparing them with those for 19 patients treated non-operatively. Clinical assessment used the scoring system of Crosby and Fitzgibbons (1990) and radiological measurements were made from lateral, axial and internal oblique views. The articular congruity of the subtalar joint and any arthritic changes were also assessed. We found significantly better results in the operated group with respect to pain, activity, range of movement, return to work and swelling of the hind foot. Radiologically, the operated group showed significantly better scores for articular congruity and arthritic changes. We conclude that the operative treatment of displaced intra-articular fractures of the calcaneum gives better medium-term results than conservative management