We studied in vivo the talonavicular alignment of club foot in infants using MRI. We examined 26 patients (36 feet) with congenital club foot. The mean age at examination was 9.0 months (4 to 12). All analyses used MRI of the earliest cartilaginous development of the tarsal bones in the transverse plane, rather than the ossific nucleus. The difference in the mean talar neck angle (44.0 ± 8.1°) in club foot was statistically significant (p < 0.001) when compared with that of the normal foot (30.8 ± 5.5°). The difference between the mean angles in the group treated by operation (47.9 ± 6.7°) and those treated conservatively (40.1 ± 7.5°) was also statistically significant. The anatomical relationship between the head of the talus and the navicular was divided into two patterns, based on the position of the mid-point of the navicular related to the long axis of the head. In the operative group, 18 feet were classified as having a medial shift of the navicular and none had a lateral shift. In the conservative group, 12 showed a medial shift of the navicular and six a lateral shift. All nine unaffected normal feet in which satisfactory MRI measurements were made showed a lateral shift of the navicular. Club feet had a larger talar neck angle and a more medially deviated navicular when compared with normal feet. This was more marked in the surgical group than in the conservative group

1. The mechanical qualities of the peritalar joint, the calcaneo-contact joint, and their interreaction with the hip joint in the standing weight-bearing foot are considered. 2. The most efficient ways of correcting the pronated foot have been indicated

We carried out a prospective study over a period of 12 months to measure the exposure to radiation of the hands of a dedicated foot and ankle surgeon. A thermoluminescent dosimeter ring (TLD) was used to measure the cumulative dose of radiation. Fluoroscopy was used in operations on the foot and ankle. The total screening time was 3028 s, with a mean time per procedure of 37.4 s (0.6 to 197). This correlated positively with the number of procedures performed (r = 0.92, p < 0.001), and with the dose of radiation in both the left (r = 0.85, p = 0.0005) and right TLDs (r = 0.59, p = 0.419). There was no significant difference in the dose of radiation between the two hands (t-test, p = 0.62). The total dose to the right TLD over the 12 months was 2.4 millisieverts. This is a simple and convenient method for evaluating the exposure of a single surgeon to radiation. The radiation detected was well below the annual dose limit set by the International Commission on Radiological Protection

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

Diagnostic and operative codes are routinely collected for every patient admitted to hospital in the English NHS. Data on post-operative complications following foot and ankle surgery have not previously been available in large numbers. Data on symptomatic venous thromboembolism events and mortality within 90 days were extracted for patients undergoing fixation of an ankle fracture, first metatarsal osteotomy, hindfoot fusions and total ankle replacement over a period of 42 months. For ankle fracture surgery (45 949 patients), the rates of deep-vein thrombosis (DVT), pulmonary embolism and mortality were 0.12%, 0.17% and 0.37%, respectively. For first metatarsal osteotomy (33 626 patients), DVT, pulmonary embolism and mortality rates were 0.01%, 0.02% and 0.04%, and for hindfoot fusions (7033 patients) the rates were 0.03%, 0.11% and 0.11%, respectively. The rate of pulmonary embolism in 1633 total ankle replacement patients was 0.06%, and there were no recorded DVTs and no deaths. Statistical analysis could only identify risk factors for venous thromboembolic events of increasing age and multiple comorbidities following fracture surgery. Venous thromboembolism following foot and ankle surgery is extremely rare, but this subset of fracture patients is at a higher risk. However, there is no evidence that thromboprophylaxis reduces this risk, and these national data suggest that prophylaxis is not required in most of these patients

We investigated the pathogenesis of soft-tissue contracture in club foot, using immunohistochemistry to study 41 biopsy specimens and 12 normal deltoid ligaments from cadavers. Five biopsy specimens were studied by electron microscopy (EM) to determine the presence of myofibroblasts. All 41 specimens of club foot stained positively for vimentin as against only one of the 12 control specimens. By contrast, there was no difference in staining for desmin or α-smooth muscle actin. EM showed some variability in the appearance of ligamentous cells. Most contained bundles of microfilaments in the cytoplasm and many had abundant pinocytotic vesicles, but no basal lamina or plasmalemmal attachment plaques. Cells of the medial ligamentous tissue in patients with club foot contain vimentin and others have myofibroblastic characteristics. Both features may contribute to recurrence after soft-tissue release

The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia. This study supports selective ultrasound screening of hips in infants with CTEV

1. Deformities of the foot in children with myelomeningocele are described and classified. The results of a policy of operative correction of deformity in 148 patients all of whom had had at least one operation on the foot between 1947 and 1965 are described. 2. In 241 feet in which there were deformities 433 operations were performed, including tenotomies, soft-tissue divisions, tendon transfers and bony procedures. At the time of review successful correction of deformity had been obtained in 81 per cent with a plantigrade foot that could bear weight safely, and with a distribution of muscle activity that required minimal external support and presented the least liability to recurrent deformity. 3. The management of individual deformities is described and the causes of failure are analysed and discussed

We hypothesised that adjuvant intermittent pneumatic compression (IPC) beneath a plaster cast would reduce the risk of deep-vein thrombosis (DVT) during post-operative immobilisation of the lower limb. Of 87 patients with acute tendo Achillis (TA) rupture, 26 were prospectively randomised post-operatively after open TA repair. The treatment group (n = 14) received two weeks of IPC of the foot for at least six hours daily under a plaster cast. The control group (n = 12) had no additional treatment. At two weeks post-operatively all patients received an orthosis until follow-up at six weeks. At two and six weeks the incidence of DVT was assessed using colour duplex sonography by two ultrasonographers blinded to the treatment. Two patients withdrew from the study due to inability to tolerate IPC treatment. An interim analysis demonstrated a high incidence of DVT in both the IPC group (9 of 12, 75%) and the controls (6 of 12, 50%) (p = 0.18). No significant differences in incidence were detected at two (p = 0.33) or six weeks (p = 0.08) post-operatively. Malfunction of the IPC leading to a second plaster cast was found to correlate with an increased DVT risk at two weeks (φ = 0.71; p = 0.019), leading to a premature abandonment of the study. We cannot recommend adjuvant treatment with foot IPC under a plaster cast for outpatient DVT prevention during post-operative immobilisation, owing to a high incidence of DVT related to malfunctioning of this type of IPC application. Cite this article: Bone Joint J 2013;95-B:1227–31

1. A simple model embracing both the hind and forefoot is described. 2. From this model the expected results of various methods of correcting the pronated foot can be deduced, and these were confirmed by human experiment. 3. It is indicated that a permanent correction requires a biological modification of foot posture achieved by mechanical means

Compression foot pumps are widely used for the prevention of postoperative venous thrombosis. We tested the efficiency of the pump in ten healthy subjects; the velocity of venous blood flow in the common femoral vein was measured in the horizontal, Trendelenberg (foot-up) and reverse-Trendelenberg (foot-down) positions. Application of the foot pump produced an increase in the venous velocity in all subjects. The mean increase in the horizontal position was 27.2% and in the Trendelenberg position 15.4%. In the reverse-Trendelenberg position, the foot pump produced a mean increase of 102.8%. The efficiency of the compression foot pump in increasing venous return is improved by adopting the reverse-Trendelenberg position. This may increase its thromboprophylactic effect

1. There seem to be two distinct methods of destruction of the foot, once pain sensibility has been lost: the first is a slow erosion and shortening associated with perforating ulcers under the distal weight-bearing end of the foot. The second is a proximal disintegration of the tarsus in which mechanical forces often determine onset and progress of the condition. 2. Once the tarsus begins to disintegrate it is difficult to halt the rapid destruction of the foot. 3. It is possible to detect early stages of this condition in time to take preventive measures. Routine palpation of anaesthetic feet will reveal patches of warmth localised to bones and joints which are in a condition of strain. Radiographs of such feet and a study of posture and gait may define early changes which point to one of several possible patterns of disintegration which may follow. 4. These patterns are described and discussed and suggestions made for preventive and corrective measures

The exceptionally high prevalence of diastrophic dysplasia in Finland has enabled us to analyse the foot deformities of 102 patients at their first orthopaedic evaluation and classify 204 feet into five categories. The most common finding (43%) was a foot with tarsal valgus deformity and metatarsus adductus; 37% showed either equinovarus adductus (29%) or equinus (8%) deformities. At the first examination 13% showed metatarsus adductus deformity alone, and 7% were clinically normal. The expression 'club foot', generally used for the foot deformity in diastrophic dysplasia is a misnomer. There is a wide spectrum of deformities, some of them specific for the condition

We reviewed all patients with a clinically infected foot ulcer attending a specialised neuropathic foot clinic. Neuropathy was confirmed by the inability to feel a 5.07 Semmes-Weinstein hair, areflexia and impaired vibration sense, as measured by a biothesiometer. Of 40 patients who attended the clinic over a two-year period, six with ischaemic ulcers were excluded. The remaining 34 had plain radiographs of the foot followed by a . 99m. Tc-MDP bone scan. If the latter was positive, an . 111. In-labelled WBC scan was performed with planar and/or tomographic dual-isotope studies where appropriate. Bone and WBC scans were performed in 31 patients. In ten, isotope imaging showed infection localised to the soft tissues only and conservative treatment was successful in them all. Eighteen patients were treated surgically with excision of the involved bone, which was sent for culture and histological examination. Dual-isotope scans had a sensitivity of 93% and a specificity of 83%. . 99m. Tc-MDP bone scans with the appropriate . 111. In-labelled WBC scans can reliably determine the site and extent of osteomyelitis in the neuropathic diabetic foot

We report a prospective study of the causes and treatment of 26 long-standing neuropathic ulcers of the foot in 21 patients. The most important causal factor, well illustrated by pressure studies, was the presence of a dynamic or static deformity leading to local areas of peak pressure on insensitive skin. All but one of the 26 ulcers had healed after an average of 10 weeks of treatment in a light, skin-tight plaster cast, with the prohibition of weight-bearing. Recurrent ulceration was prevented in all but one foot by early operation to correct the causative deformity; this was performed after the ulcer had healed and before allowing weight-bearing on the limb. Pressure studies after operation confirmed that pressure points had been relieved

We analysed the clinical and radiological outcomes of a new surgical technique for the treatment of heterozygote post-axial metatarsal-type foot synpolydactyly with HOX-D13 genetic mutations with a mean follow-up of 30.9 months (24 to 42). A total of 57 feet in 36 patients (mean age 6.8 years (2 to 16)) were treated with this new technique, which transfers the distal part of the duplicated fourth metatarsal to the proximal part of the fifth metatarsal. Clinical and radiological assessments were undertaken pre- and post-operatively and any complications were recorded. Final outcomes were evaluated according to the methods described by Phelps and Grogan. Forefoot width was reduced and the lengths of the all reconstructed toes were maintained after surgery. Union was achieved for all the metatarsal osteotomies without any angular deformities. Outcomes at the final assessment were excellent in 51 feet (89%) and good in six (11%). This newly described surgical technique provides for painless, comfortable shoe-wearing after a single, easy-to-perform operation with good clinical, radiological and functional outcomes. Cite this article: Bone Joint J 2013;95-B:929–34

1. Tarsal coalition often presents with the clinical picture of a peroneal spastic flat foot, but may present with a painful varus foot and spasm of the tibial muscles. 2. Three cases of tibialis spastic varus foot are described with a calcaneo-navicular bar as the associated anomaly. 3. Complete excision of the bar with interposition of the origin of the extensor digitorum brevis muscle appears to be a satisfactory method of treatment when carried out at a sufficiently early age

The precise localisation of osteoarthritic changes is crucial for selective surgical treatment. Single photon-emission CT-CT (SPECT-CT) combines both morphological and biological information. We hypothesised that SPECT-CT increased the intra- and interobserver reliability to localise increased uptake compared with traditional evaluation of CT and bone scanning together. We evaluated 20 consecutive patients with pain of uncertain origin in the foot and ankle by radiography and SPECT-CT, available as fused SPECT-CT, and by separate bone scanning and CT. Five observers assessed the presence or absence of arthritis. The images were blinded and randomly ordered. They were evaluated twice at an interval of six weeks. Kappa and multirater kappa values were calculated. The mean intraobserver reliability for SPECT-CT was excellent (κ = 0.86; 95% CI 0.81 to 0.88) and significantly higher than that for CT and bone scanning together. SPECT-CT had significantly higher interobserver agreement, especially when evaluating the naviculocuneiform and tarsometatarsal joints. SPECT-CT is useful in localising active arthritis especially in areas where the number and configuration of joints are complex