Introduction

Orthopaedic and trauma surgeons not infrequently encounter the hallucal interphalangeal joint sesamoid (HIPJS) in irreducible traumatic dislocations. However, patients with the classic triad of plantar keratoma beneath a hyperextended interphalangeal (IP) joint associated with stiffness of the first metatarsophalangeal joint tend to present to podiatrists rather than orthopaedic surgeons.

Background

This study analyzes position of the peroneal tendons and status of the superior peroneal retinaculum (SPR) whenever a lateral malleolar bony flake fracture occurs.

Introduction:

Although dislocation of the peroneal tendons (PT's) in association with calcaneal fractures has been described over 25 years ago, it frequently passes unrecognised by radiologists and orthopaedic surgeons. This retrospective study aims to determine the prevalence of PT dislocation in association with calcaneal fractures at a single institution and describe systematic steps to avoid missed diagnosis at each stage of management.

Severe hallux valgus deformity is conventionally treated with proximal metatarsal osteotomy. Distal metatarsal osteotomy with an associated soft-tissue procedure can also be used in moderate to severe deformity. We compared the clinical and radiological outcomes of proximal and distal chevron osteotomy in severe hallux valgus deformity with a soft-tissue release in both. A total of 110 consecutive female patients (110 feet) were included in a prospective randomised controlled study. A total of 56 patients underwent a proximal procedure and 54 a distal operation. The mean follow-up was 39 months (24 to 54) in the proximal group and 38 months (24 to 52) in the distal group. At follow-up the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal score, patient satisfaction level, and complications were similar in each group. Both methods showed significant post-operative improvement and high levels of patient satisfaction. Our results suggest that the distal chevron osteotomy with an associated distal soft-tissue procedure provides a satisfactory method for correcting severe hallux valgus deformity.

Cite this article: Bone Joint J 2013;95-B:510–16.

In distal fibular resection without reconstruction, the stabilising effect of the lateral malleolus is lost. Thus, the ankle may collapse into valgus and may be unstable in varus. Here, we describe a child who underwent successful staged surgical correction of a severe neglected valgus deformity after excision of the distal fibula for a Ewing’s sarcoma.

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.

Percutaneous fluoroscopically asseisted iliosacral screw insertion has become one of the most popular methods of stabilisation of the posterior aspect of the vertically unstable pelvis. Screw malpositioning rates range from 0 to 10%. Screw misplacement can cause injury to the iliac and gluteal vessels, L4 to s1 nerve roots and sympathetic chain.

We performed two radiographic studies on dry human bones to seek safe radiographic landmarks for insertion of iliosacral screws.

Part 1: Two parallel linear densities are always present on lateral plain radiographs of the lumbosacral spine and pelvis. Using wire markers on pelvic bones, we accurtely define the origins of these “pelvic lines”. Steel wires of different lengths were placed along the iliopectineal and arcuate lines of the pelvis. The shorter wire stopped at the anterior limit of the sacroiliac joint. The longer wire extended further along the entire course of the medial border of the ilium to the iliac crest posteriorly. We demonstrate that each “pelvic line” represents the sharp bony ridge that forms the anterosuperior limit for insertion of the iliosacral screws.

Part 2: In a second experiment on dry pelvis, we inserted balloons filled with radio-opaque contrast medium into the spinal canal of the sacrum and exiting through the anterior and posterior sacral foramina on either side. Plain lateral radiographs and CT scan with reformatted images were obtained. We present a previously undescribed radiological sign on plain lateral radiographs of the lumbosacral spine. The inferior and posterior boundaries of the “acorn sign” are delineated. Together, the “pelvic lines” and “acorn sign” provide accurate landmarks for the safe insertion of iliosacral screws. Iliosacral screws should be contained within this “acorn sign” to avoid injury to the nerve roots and below the “pelvic lines” to safeguard the iliac vessels and lumbosacral trunk.

Percutaneous fluoroscopically assisted iliosacral screw insertion has become one of the most popular methods of stabilisation of the posterior aspect of the vertically unstable pelvis. Screw malpositioning rates range from 0 to 10 per cent. Screw malplacement can cause injury to the iliac and gluteal vessels, L4 to S1 nerve roots and sympathetic chain.

We performed two radiographic studies on dry human bones to seek safe radiographic landmarks for insertion of iliosacral screws.

Part 1. Two parallel linear densities are always present on lateral plain radiographs of the lumbosacral spine and pelvis. Using wire markers on pelvic bones, we accurately define the origin of these pelvic lines. Steel wires of different lengths were placed along the iliopectineal and arcuate lines of the pelvis. The shorter wire stopped at the anterior limit of the sacro-iliac joint. The longer wire extended further along the entire course of the medial border of the ilium to the iliac crest posteriorly. We demonstrate that each ‘ pelvic line ‘ represents the sharp bony ridge that forms the anterosuperior limit for insertion of iliosacral screws.

Part 2. In a second experimenton dry pelvis, we inserted balloons filled with radio-opaque contrast medium into the spinal canal of the sacrum and exiting through the anterior and posterior sacral foramina on either side. Plain lateral radiographs and CT scan with reformatted images were obtained. We present a previously undescribed radiological sign on plain lateral radiographs of the lumbosacral spine. The inferior and posterior boundaries of the acorn sign are delineated.

Seventy-four mobile bearing total knee arthroplasties (LCS) without patellar resurfacing were analysed in 54 patients who were followed for a minimum of one year. We examined the congruence angle on Merchant’s view, the component rotation to the epicondylar line of the femur on computed tomography(CT), the femorotibial angle on weight-bearing anteroposterior radiograph to assess the contributing factors for the patellofemoral malalignment. The statistical analysis was performed by ANOVA test, student t test, and chi sguare test.

The patellofemoral pain was noted in 17 knees(23%). The incidence of patellofemoral pain was significantly increased in the knee when its congruence angle was more than 16 degrees (p=0.034). But the pain did not correlate with the status of the articular cartilage of the patella on operation. The average congrunce angle was 4¢ªdegrees preoperatively and 24.2 degrees postoperatively. The congruence angle in 29 knees with lateral release was significantly lower than that in 45 knees without lateral release (p=0.037). All femoral components were internally rotated on CT scan with average of 6.7 degrees. More significant increase of the congruence angle was observed in 42 knees with femoral or tibial component rotation than in 15 knees with normal or minimal rotation of both components(p=0.017). Pre-operative congruence angle and postoperative femorotibial angle also affected the patellofemoral alignment, which increased postoperative congruence angle respectively.

Based on our findings, it seems that the excessive internal rotation of one component and excessive valgus of the femorotibial angle should be avoided to prevent the patellofemoral maltracking. We believe that “no thumb test” should be done carefully and the lateral release performed without hesitation if patellar tracking is a concern.

A Salter innominate osteotomy is used to treat acetabular dysplasia, but reports of its effects on the position of the femoral head are few and conflicting. Lateral shift would increase the resultant forces acting on the joint and be detrimental. We studied 15 Salter innominate osteotomies and demonstrated that a correctly performed osteotomy does not significantly alter the distance from the centre of the femoral head to the midline of the body. Stereophotogrammetry was used in three patients to delineate the axis of rotation of the distal acetabular fragment and determine the locus of movement of the centre of the femoral head about it. Our results explain why the Salter osteotomy does not lateralise the femoral head.