1. Occult fracture-subluxation of the midtarsal joint is described and illustrated by a typical case. 2. Comments are made on the mechanism of injury, diagnostic features and treatment

Injuries involving the midtarsal joint, which are frequently misdiagnosed, have been studied to clarify the mechanism, classification and treatment. The necessity for routine antero-posterior, lateral and oblique radiographs is emphasised. Seventy-one injuries have been classified according to the direction of the deforming force : medial, longitudinal compression, lateral, plantar and crush types are described. Included in the medial and lateral types is a hitherto undescribed tarsal rotation or " swivel" injury. The mechanism whereby longitudinal compression causes fractures of the body of the navicular is described, and two varieties having different prognoses are defined : one due to purely longitudinal compression and the other due to longitudinal compression with a medial component. The results of treatment have been assessed clinically and radiologically. Reduction, open if necessary, with internal fixation, is recommended for displaced fractures : primary arthrodesis is not indicated. For severe persistent symptoms from medial and longitudinal force injuries triple arthrodesis is recommended, and from lateral force injuries, calcaneo-cuboid arthrodesis

In this study we evaluated the results of midtarsal release and open reduction for the treatment of children with convex congenital foot (CCF) (vertical talus) and compared them with the published results of peritalar release. Between 1977 and 2009, a total of 22 children (31 feet) underwent this procedure. In 15 children (48%) the CCF was isolated and in the remainder it was not (seven with arthrogryposis, two with spinal dysraphism, one with a polymalformative syndrome and six with an undefined neurological disorder). Pre-operatively, the mean tibiotalar angle was 150.2° (106° to 175°) and the mean calcaneal pitch angle was -19.3° (-72° to 4°). The procedure included talonavicular and calcaneocuboid joint capsulotomies, lengthening of tendons of tibialis anterior and the extensors of the toes, allowing reduction of the midtarsal joints. Lengthening of the Achilles tendon was necessary in 23 feet (74%). The mean follow-up was 11 years (2 to 21). The results, as assessed by the Adelaar score, were good in 24 feet (77.4%), fair in six (19.3%) and poor in one foot (3.3%), with no difference between those with isolated CCF and those without. The mean American Orthopaedic Foot and Ankle Society midfoot score was 89.9 (54 to 100) and 77.8 (36 to 93) for those with isolated CCF and those without, respectively. At the final follow-up, the mean tibiotalar (120°; 90 to 152) and calcaneal pitch angles (4°; -13 to 22) had improved significantly (p < 0.0001). Dislocation of the talonavicular and calcaneocuboid joints was completely reduced in 22 (70.9%) and 29 (93.6%) of feet, respectively. Three children (five feet) underwent further surgery at a mean of 8.5 years post-operatively, three with pes planovalgus and two in whom the deformity had been undercorrected. No child developed avascular necrosis of the talus. Midtarsal joint release and open reduction is a satisfactory procedure, which may provide better results than peritalar release. Complications include the development of pes planovalgus and persistent dorsal subluxation of the talonavicular joint. Cite this article: Bone Joint J 2014;96-B:837–44

Aims. Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot. Patients and Methods. We undertook a retrospective review of 285 consecutive patients presenting over an eight- year period with a fracture of the navicular. Five common patterns of injury were identified and classified according to the radiological features. Type 1 fractures are dorsal avulsion injuries related to the capsule of the talonavicular joint. Type 2 fractures are isolated avulsion injuries to the tuberosity of the navicular. Type 3 fractures are a variant of tarsometatarsal fracture/dislocations creating instability of the medial ray. Type 4 fractures involve the body of the navicular with no associated injury to the lateral column and type 5 fractures occur in conjunction with disruption of the midtarsal joint with crushing of the medial or lateral, or both, columns of the foot. Results. In order to test the reliability and reproducibility of this new classification, a cohort of 30 patients with a fracture of the navicular were classified by six independent assessors at two separate times, six months apart. Interobserver reliability and intraobserver reproducibility both had substantial agreement, with kappa values of 0.80 and 0.72, respectively. Conclusion. We propose a logical, all-inclusive, and mutually exclusive classification system for fractures of the navicular that gives associated injuries involving the lateral column due consideration. We have shown that this system is reliable and reproducible and have described the rationale for the subsequent treatment of each type. Cite this article: Bone Joint J 2018;100-B:176–82

Charcot osteoarthropathy of the foot is a chronic and progressive disease of bone and joint associated with a risk of amputation. The main problems encountered in this process are osteopenia, fragmentation of the bones of the foot and ankle, joint subluxation or even dislocation, ulceration of the skin and the development of deep sepsis. We report our experience of a series of 20 patients with Charcot osteoarthropathy of the foot and ankle treated with an Ilizarov external fixator. The mean age of the group was 30 years (21 to 50). Diabetes mellitus was the underlying cause in 18 patients. Five had chronic ulcers involving the foot and ankle. Each patient had an open lengthening of the tendo Achillis with excision of all necrotic and loose bone from the ankle, subtalar and midtarsal joints when needed. The resulting defect was packed with corticocancellous bone graft harvested from the iliac crest and an Ilizarov external fixator was applied. Arthrodesis was achieved after a mean of 18 weeks (15 to 20), with healing of the skin ulcers. Pin track infection was not uncommon, but no frame had to be removed before the arthrodesis was sound. Every patient was able to resume wearing regular shoes after a mean of 26.5 weeks (20 to 45)

The August 2014 Children’s orthopaedics Roundup. 360 . looks at: Conservative treatment still OK in paediatric clavicular fractures; Femoral anteversion not the usual suspect in patellar inversion; Shoulder dislocation best treated with an operation; Perthes’ disease results in poorer quality of adult life; Physiotherapy little benefit in supracondylar fractures; Congenital vertical talus addressed at the midtarsal joint; Single-sitting DDH surgery worth the effort; and cubitus valgus associated with simple elbow dislocation

A method of triple arthrodesis is described which involves inlay of the subtalar and midtarsal joints. It is applicable to the undeformed and valgus foot as is encountered in poliomyelitis, spasmodic flat foot, cerebral palsy and spina bifida. The operation was successful in controlling deformity and pain. The only significant complication was failure of fusion of the midtarsal joint which occurred in three of eighty-five feet (3-5%)

1) Supination and pronation are the only material tarsal movements; other terms describe their hypothetical components only. 2) The subtalar and talo-navicular joints form a single joint functionally, which may be called the peritalar joint. 3) Peritalar movement comprises a wide range of supination and pronation of the foot about an axis which passes from the tuberosity of the calcaneum upwards, forwards and slightly medially to the neck of the talus. 4) Midtarsal movement comprises a narrow range of supination and pronation of the foot about an axis similar to that of peritalar movement. 5) Tile peritalar and midtarsal joints are thus oblique hinge joints

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

Aims

The Chopart joint complex is a joint between the midfoot and hindfoot. The static and dynamic support system of the joint is critical for maintaining the medial longitudinal arch of the foot. Any dysfunction leads to progressive collapsing flatfoot deformity (PCFD). Often, the tibialis posterior is the primary cause; however, contrary views have also been expressed. The present investigation intends to explore the comprehensive anatomy of the support system of the Chopart joint complex to gain insight into the cause of PCFD.

We report four cases of fracture of the cuboid treated by open reduction, bone grafting where necessary and internal fixation. We recommend this treatment where there is appreciable displacement of one or more of the articular surfaces. The preliminary results were better than those previously reported for conservative treatment or for later midtarsal fusion

Twenty-four patients who attended the Edinburgh Limb Fitting Centre with 26 healed amputations through the middle part of the foot have been traced. The results in patients with Chopart's ablation through the midtarsal joints and in those with amputation through or near the tarsometatarsal region, were surprisingly good. Three of the patients who also had a contralateral Syme's stump reported that the shortened foot was superior in almost all respcts

A retrospective study involving thirty-six patients with thirty-seven ankle fusions was undertaken to assess the rate of fusion, the subjective and objective results, the residual subtalar and midtarsal movement, and the functional disability. Fusion occurred in thirty-one ankles (84 per cent). Twenty-four patients were reviewed, on average 7.5 years after fusion, and eighteen had good or excellent results; only four had been unable to return to their previous employment. The conclusion is that fusion is still a good treatment for the painful post-traumatic arthritis ankle, the resulting functional disability being minimal

The results of 62 ankle arthrodeses, mostly performed for osteoarthritis, have been reviewed; of these, 39 were examined clinically and radiographically after an average follow-up period of seven years. Compression arthrodesis was associated with the highest incidence of complications, and an anterior sliding graft gave the most satisfactory results. Very few patients required modification of their footwear; most could walk independently with a slight limp and were able to return to their pre-operative work. However, after operation, the ability to run and to participate in vigorous sporting activities was limited. Complications included wound infection, non-union, and some change in midtarsal mobility, but excellent pain relief was reported by all patients

We have reviewed the results of 19 ankle arthrodeses in 18 patients by a new technique of posterior internal compression. Sixteen of the ankles fused at a mean time of 14 weeks and the other three after reoperation. Complications included one case each of infection, Sudeck's atrophy and non-fatal pulmonary embolism. Clinical assessment using Mazur's ankle score showed excellent or good results in nine ankles and three painfree ankles in patients who were wheelchair-bound for other reasons. The mean position of fusion was in 1.7 degrees equinus and 0.8 degrees varus, and the mean range of midtarsal movements was 15.8 degrees. Twelve patients showed radiographic signs of talonavicular or subtalar osteoarthritis

Patients with spina bifida cystica commonly have significant disability from a combination of valgus deformity of the ankle and subtalar joints with lateral tibial torsion and plano-abduction deformity of the foot. These deformities can be corrected by a single procedure which combines a supramalleolar tibial osteotomy with a lateral inlay triple fusion. This procedure was carried out on 20 feet in 15 patients and the results were reviewed after an average of three years (range 18 months to 7 years). In 75 per cent of feet the combination of deformities was fully corrected, ulcers and callosities were eliminated in 95 per cent, the use of calipers minimised in 95 per cent, and in all patients the problem of shoe-wrecking was reduced. Complications included recurrent valgus deformity, delayed union of the tibial osteotomy and failure of midtarsal fusion

We studied the development of ball-and-socket deformity of the ankle by arthrography and radiography in 14 ankles of ten patients with congenital longitudinal deficiency of the fibula accompanied by various anomalies. The mean follow-up was for 18 years 10 months. In three ankles in infants less than one year old the lateral and medial sides of the ankle were already slightly round. In another seven ankles the ball-and-socket appearance developed before the age of five years. This was thought to be due to osseous coalition which limits eversion and inversion. In another four ankles in children who were over the age of one year at the initial examination, the deformity was demonstrated by arthrography and radiography at their first examination. Ball-and-socket deformity accompanied by tarsal coalition is an acquired deformity secondary to limitation of movement of the subtalar and midtarsal joints. It has completely developed by about five years of age

Isolated dislocations of the navicular are rare injuries; we present our experience of six cases in which the navicular was dislocated without fracture. All patients had complex injuries, with considerable disruption of the midfoot. Five patients had open reduction and stabilisation with Kirschner wires. One developed subluxation and deformity of the midfoot because of inadequate stabilisation of the lateral column, and there was one patient with ischaemic necrosis. We believe that the navicular cannot dislocate in isolation because of the rigid bony supports around it; there has to be significant disruption of both longitudinal columns of the foot. Most commonly, an abduction/pronation injury causes a midtarsal dislocation, and on spontaneous reduction the navicular may dislocate medially. This mechanism is similar to a perilunate dislocation. Stabilisation of both medial and lateral columns of the foot may sometimes be essential for isolated dislocations. In spite of our low incidence of ischaemic necrosis, there is always a likelihood of this complication

1. Fifty-eight major injuries in the region of the talus were reviewed regarding treatment, incidence of complications and long-term results. 2. The prognosis for simple fractures of the head, neck or body was good, as was that for dislocations of the midtarsal and peritalar joints. 3. The prognosis for fracture-dislocations of the neck and body was better than has been frequently reported. It was related to the degree of initial trauma. A good result occurs only if accurate reduction is effected and maintained. Fixation with a Kirschner wire is a useful method of maintaining the reduction after unstable fracture-dislocations. 4. Avascular necrosis occurred only in the more severe injuries and its incidence was related to the degree of initial displacement. The late results were better than have been previously described. The condition is best treated conservatively by protection from weight-bearing until revascularisation is well advanced. 5. A case with an unusual pattern of fracture of the neck of the talus is described following a plantar-flexion inversion injury

A subjective, objective and radiographic study of 21 patients with comminuted calcaneal fractures showing severe involvement of the subtalar joint is reported. The average follow-up was 14.6 years (range 8 to 29 years). Only patients with unilateral closed fractures and no associated injuries to either lower limb were admitted to the study. All were treated by early active mobilisation of the ankle, and the subtalar and the midtarsal joints. Seventy-six per cent of the patients achieved a good result with minor symptoms which did not interfere with their occupation or leisure requirements. Although two-thirds of the patients reached a point of maximal recovery at two to three years, 24% continued to improve for six years. None of the patients experienced any deterioration after this time. Neither the degree of clinical stiffness nor the degeneration of the subtalar joint, assessed radiographically, correlated with the severity of symptoms or functional disability. The role of the soft tissues in the aetiology of residual symptoms is discussed

Aims

Patients with a deformity of the hindfoot present a particular challenge when performing total knee arthroplasty (TKA). The literature contains little information about the relationship between TKA and hindfoot alignment. This systematic review aimed to determine from both clinical and radiological studies whether TKA would alter a preoperative hindfoot deformity and whether the outcome of TKA is affected by the presence of a postoperative hindfoot deformity.

Aims

To assess the effect of age on clinical outcome and revision rates in patients who underwent total ankle arthroplasty (TAA) for end-stage ankle osteoarthritis (OA).

Aims

This study reports the outcomes of a technique of soft-tissue coverage and Chopart amputation for severe crush injuries of the forefoot.

Aims

There is increasing evidence that flexible flatfoot (FF) can lead to symptoms and impairment in health-related quality of life. As such we undertook an observational study investigating the aetiology of this condition, to help inform management. The hypothesis was that as well as increased body mass index (BMI) and increased flexibility of the lower limb, an absent anterior subtalar articulation would be associated with a flatter foot posture.

Aims

The purpose of this study was to analyse the biomechanics of walking, through the ground reaction forces (GRF) measured, after first metatarsal osteotomy or metatarsophalangeal joint (MTP) arthrodesis.

The results of further soft-tissue release of 79 feet in 60 children with recurrent idiopathic congenital talipes equinovarus were evaluated. The mean age of the children at the time of re-operation was 5.8 years (15 months to 14.5 years). Soft-tissue release was performed in all 79 feet and combined with distal calcaneal excision in 52 feet. The mean follow-up was 12 years (4 to 32). At the latest follow-up the result was excellent or good in 61 feet (77%) according to the Ghanem and Seringe scoring system. The results was considered as fair in 14 feet (18%), all of whom had functional problems and eight had anatomical abnormalities. Four feet (5%) were graded as poor on both functional and anatomical grounds.

The results were independent of the age at which revision was undertaken.

We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently.

Between 2000 and 2006 we performed salvage tibiotalar arthrodesis in 17 diabetic patients (17 ankles) with grossly unstable ankles caused by bimalleolar fractures complicated by Charcot neuro-arthropathy. There were ten women and seven men with a mean age of 61.6 years (57 to 69). A crossed-screw technique was used. Two screws were used in eight patients and three screws in nine. Additional graft from the malleoli was used in all patients. The mean follow-up was 26 months (12 to 48) and the mean time to union was 5.8 months (4 to 8). A stable ankle was achieved in 14 patients (82.4%), nine of whom had bony fusion and five had a stiff fibrous union. The results were significantly better in underweight patients, in those in whom surgery had been performed three to six months after the onset of acute Charcot arthropathy, in those who had received anti-resorptive medication during the acute stage, in those without extensive peripheral neuropathy, and in those with adequate peripheral oxygen saturation (> 95%). The arthrodesis failed because of avascular necrosis of the talus in only three patients (17.6%), who developed grossly unstable, ulcerated hindfeet, and required below-knee amputation.

Our goal was to evaluate the use of Ponseti’s method, with minor adaptations, in the treatment of idiopathic clubfeet presenting in children between five and ten years of age. A retrospective review was performed in 36 children (55 feet) with a mean age of 7.4 years (5 to 10), supplemented by digital images and video recordings of gait. There were 19 males and 17 females. The mean follow-up was 31.5 months (24 to 40). The mean number of casts was 9.5 (6 to 11), and all children required surgery, including a percutaneous tenotomy or open tendo Achillis lengthening (49%), posterior release (34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue release combined with an osteotomy (2%). The mean dorsiflexion of the ankle was 9° (0° to 15°). Forefoot alignment was neutral in 28 feet (51%) or adducted (< 10°) in 20 feet (36%), > 10° in seven feet (13%). Hindfoot alignment was neutral or mild valgus in 26 feet (47%), mild varus (< 10°) in 19 feet (35%), and varus (> 10°) in ten feet (18%). Heel–toe gait was present in 38 feet (86%), and 12 (28%) exhibited weight-bearing on the lateral border (out of a total of 44 feet with gait videos available for analysis). Overt relapse was identified in nine feet (16%, six children). The parents of 27 children (75%) were completely satisfied.

A plantigrade foot was achieved in 46 feet (84%) without an extensive soft-tissue release or bony procedure, although under-correction was common, and longer-term follow-up will be required to assess the outcome.

Cite this article: Bone Joint J 2013;95-B:1721–5.

We present two children with massive defects of the tibia and an associated active infection who were treated by medial transport of the fibula using the Ilizarov device. The first child had chronic discharging osteomyelitis which affected the whole tibial shaft. The second had sustained bilateral grade-IIIB open tibial fractures in a motor-car accident. The first child was followed up for three years and the second for two years. Both achieved solid union between the proximal and distal stumps of the tibia and the fibula, with hypertrophy of the fibula. The first child had a normal range of movement at the knee, ankle and foot but there was shortening of 1.5 cm. The second had persistent anterior angulation at the proximal tibiofibular junction and the ankle was stiff in equinus.

Rocker bottom deformity may occur during the conservative treatment of idiopathic congenital clubfoot. Between 1975 and 1996, we treated 715 patients (1120 clubfeet) conservatively. A total of 23 patients (36 feet; 3.2%) developed a rocker bottom deformity. It is these patients that we have studied. The pathoanatomy of the rocker bottom deformity is characterised by a plantar convexity appearing between three and six months of age with the hindfoot equinus position remaining constant. The convexity initially involves the medial column, radiologically identified by the talo-first metatarsal angle and secondly by the lateral column, revealed radiologically as the calcaneo-fifth metatarsal angle. The apex of the deformity is usually at the midtrasal with a dorsal calcaneocuboid subluxation. Ideal management of clubfoot deformity should avoid this complication, with adequate manipulation and splinting and early Achilles’ percutaneous tenotomy if plantar convexity occurs.

Adequate soft-tissue release provides satisfactory correction for rocker bottom deformity. However, this deformity requires more extensive and complex procedures than the standard surgical treatment of clubfoot. The need for lateral radiographs to ensure that the rocker bottom deformity is recognised early, is demonstrated.

There are few data available regarding the association between hallux valgus and pain or functional limitation. We determined the prevalence of hallux valgus in a rural Korean population aged between 40 and 69 years, and its association with pain and function. A total of 563 subjects was examined using the foot health status questionnaire, the Short Form-36 questionnaire and weight-bearing anteroposterior radiographs.

Hallux valgus was present in 364 subjects (64.7%). It did not significantly correlate with age and was more common in women. Of the 364 subjects, 48 (13.2%) had moderate or greater deformity, defined as a hallux valgus angle > 25°. This was significantly associated with pain, worse function and worse foot health. The putative risk factors associated with painful hallux valgus were female gender, low educational attainment and the presence of pain in the knee.

A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients.

We report the clinical and radiological outcome of total ankle replacement performed in conjunction with hindfoot fusion or in isolation. Between May 2003 and June 2008, 60 ankles were treated with total ankle replacement with either subtalar or triple fusion, and the results were compared with a control group of 288 ankles treated with total ankle replacement alone.

After the mean follow-up of 39.5 months (12 to 73), the ankles with hindfoot fusion showed significant improvement in the mean visual analogue score for pain (p < 0.001), the mean American Orthopaedic Foot and Ankle Society score (p < 0.001), and the mean of a modified version of this score (p < 0.001). The mean visual analogue pain score (p = 0.304) and mean modified American Orthopaedic Foot and Ankle Society score (p = 0.119) were not significantly different between the hindfoot fusion and the control groups. However, the hindfoot fusion group had a significantly lower mean range of movement (p = 0.009) and a higher rate of posterior focal osteolysis (p = 0.04). Both groups showed various complications (p = 0.131) and failure occurring at a similar rate (p = 0.685).

Subtalar or triple fusion is feasible and has minimal adverse effects on ankles treated with total ankle replacement up to midterm follow-up. The clinical outcome of total ankle replacement when combined with hindfoot fusion is comparable to that of ankle replacement alone. Thus, hindfoot fusion should be performed in conjunction with total ankle replacement when indicated.