Introduction: Functional Foot Orthoses (FFO’s) have been shown to improve one element of balance, postural sway, when prescribed for patients with ankle injuries. Little is known, however, about the effect of these devices on ankle stability/proprioception, or the changes which might occur as the patient becomes habituated to using the device. We studied these effects from the time of initial application of the FFO through to regular usage at six weeks.

Methods: Patients with musculoskeletal conditions affecting the lower limb that required custom made FFO’s were evaluated. A standardised protocol, using the Biodex stability system (a balance platform), to assess several stability indices was performed. Patients were assessed before fitting the orthosis, at the time of fitting and six weeks later. The American Orthopaedic Foot and ankle Society (AOFAS) score was also used to evaluate the progress of these patients.

Results: There were 13 male and seven female patients, aged 10 to 64 years. Patients had a range of orthopaedic conditions and all been assessed by orthopaedic specialist and podiatrist as having correctable foot biomechanics. In 6 patients, proprioception deteriorated on initial application of FFO’s. However, all patients exhibited improved over-all stability by a mean of 2.5 points (Normal range 0.82–3.35) at 6 weeks evaluation. The mean AOFAS on presentation was 72 and the final mean score was 97, both of which were clinically and statistically significant (t test, p< 0.05). Eighteen patients had complete resolution of symptoms of pain and instability.

Conclusions: FFO’s alter foot biomechanics, and in doing so appear also to improve balance and proprioception. Proprioception deteriorated in 30% of cases on initial application of orthotics, but pain and instability improved in more than 90% of patients on extended use of foot orthotics, with this improvement becoming manifest by 6 weeks after starting use of the device.

Introduction: Distraction bone block arthrodesis has been advocated in the literature to treat the late sequelae of os calcis fracture with loss of heel height including the prevention of anterior impingement. We have studied a consecutive series of subjects who have had in situ arthrodesis for subtalar arthrosis as a consequence of os calcis fracture with marked loss of talocalcaneal height paying particular attention to range of movement and anterior impingement.

Materials and Methods: Between 1997 and 2003 31 consecutive subjects underwent subtalar arthrodesis. Five subjects who had undergone ORIF, two non-unions and three subjects with bilateral injuries were excluded. Two subjects who had marked coronal displacement that required additional surgery at the time of arthrodesis were also excluded. Two subjects were lost to follow up leaving 17 for assessment. AOFAS hind foot scores improved from 29.8 (range 13–48) preoperatively to 77.8 (range 48–94) postoperatively. Mean loss of talocalcaneal height was 10.3mm and the mean talar declination angle was 6.7 degrees which was 35% of the normal side. One subject suffered anterior ankle pain but none had anterior impingement. Two subjects complained of difficulty ascending slopes and stairs and four of difficulty descending. Mean ankle dorsiflexion was 11.6 degrees (range 0–24) compared to 14.7 degrees on the normal side: A reduction of 21.1%. Mean plantarflexion was 35.5 degrees (range 24–60) compared to 44.6 degrees on the normal side: A reduction of 20.4%.

Discussion: Our results suggest that anterior impingement is not a significant problem in os calcis fracture, even when loss of talocalcaneal height is marked. We recommend ISA combined with lateral wall ostectomy for all cases of subtalar arthrosis as a result of os calcis fracture, without marked coronal deformity, regardless of the degree of talocalcaneal height loss.

Introduction: Arthroscopy to debride osteochondral lesions (OCL) of the talus is an accepted procedure with a good outcome in 70–80% of subjects. The minority of subjects that do not do well present a problem. Further arthroscopy and debridement procedures have been assumed to yield poor results and this has been used as justification for cartilage transplantation. The evidence for this is lacking.

Methods: In our unit the routine procedure for OCL is arthroscopic debridement. If this fails a further arthroscopic debridement is performed. We identified all subjects who had had a repeat procedure for failed arthroscopic debridement of an OCL by the senior author and reviewed them clinically. The outcome was scored using the AOFAS hind foot and ankle scoring system.

Results: Between 1993 and 2002 808 ankle arthroscopies were performed of which 215 were to treat OCLs. Of these 12 had repeat arthroscopies because of a poor outcome. AOFAS scores improved from a mean of 34.8 to 80.5 at a mean follow up of 5.9 years (range 18 months – 11 years). One subject had already undergone a cartilage transplantation procedure because of a poor outcome. The other 11 subjects scored themselves as fair or good and had returned to previous levels of activity, including two professional sportsmen. It was clear by 6 months in all subjects that their symptoms were significantly improved following the second procedure.

Conclusions: This is the first series specifically assessing subjects who have had repeat arthroscopic debridement of OCLs of the talus. Our results disprove the assumption that repeat arthroscopic debridement yield poor results. It provides benchmark results at medium term follow up for cartilage transplantation to be compared to.

Distraction bone-block arthrodesis has been advocated for the treatment of the late sequelae of fracture of the os calcis. Between 1997 and 2003 we studied a consecutive series of 17 patients who had in situ arthrodesis for subtalar arthritis after fracture of the os calcis with marked loss of talocalcaneal height. None had undergone any previous attempts at reconstruction. We assessed the range of dorsiflexion and plantar flexion and measured the talocalcaneal height, talocalcaneal angle and talar declination angle on standing lateral radiographs, comparing them with the normal foot. The mean follow-up was for 78.7 months (48 to 94).

The mean American Orthopaedic Foot and Ankle Society hindfoot score improved from 29.8 (13 to 48) to 77.8 (48 to 94) (Student’s t-test, p < 0.001). The mean loss of talocalcaneal height was 10.3 mm (2 to 17) and the mean talar declination angle was 6.7° (0° to 16°) which was 36% of the normal side. One patient suffered anterior ankle pain but none had anterior impingement. Two patients complained of difficulty in ascending slopes and stairs and four in descending. The mean ankle dorsiflexion on the arthrodesed side was 11.6° (0° to 24°) compared with 14.7° (0° to 24°) on the normal side, representing a reduction of 21.1%. The mean plantar flexion on the arthrodesed side was 35.5° (24° to 60°) compared with 44.6° (30° to 60°) on the normal side, a reduction of 20.4%.

These results suggest that anterior impingement need not to be a significant problem after subtalar arthrodesis for fracture of the os calcis, even when the loss of talocalcaneal height is marked. We recommend in situ arthrodesis combined with lateral-wall ostectomy for all cases of subtalar arthritis following a fracture of the os calcis, without marked coronal deformity, regardless of the degree of talocalcaneal height loss.

Aims: To assess the failure rate at 5 years of the Elite Plus (DePuy) femoral stem and identify reasons for early failure. Particular attention was paid to the quality of the cement mantle.

Methods: A cohort of the first 241 primary THR performed in 234 patients were identified. Each patient completed the Oxford Hip Score (OHS), and had AP and lateral radiographs. The cement mantle was graded by Mulroy’s modification of Barrack’s system using all AP and lateral radiographs.

Results: At follow up 39 patients (42 hips) had died, 14 were lost to follow up and 35 (36 hips) too unwell/ unwilling to take part leaving149 hips in 146 patients available for independent assessment. The mean follow up was 60.2 months (range 48.3–75.8 months). Five hips (3.4%), have been revised, 1 after traumatic dislocation, 1 for deep infection and 3 for aseptic loosening. In a further 11 (7.4%) patients there was radiological evidence of progressive femoral loosening, although only 2 of the 7 available for review were symptomatic. The median OHS was 20 (range 12–51). All those revised or radiologically loose had defective cement mantles (C2). A cement mantle less than 1 mm thick was associated with early failure (p< 0.03).

Conclusions: The revision rate at 5 years is 3.4%. Loosening is related to suboptimal cement mantles in particular mantle thickness of less than 1 mm. We have documented the invisible cohort of those who have loosened radiologically but are asymptomatic. Regular surveillance of this cohort is mandatory to allow comparison with longer-term results of other prostheses.

In children with obstetric brachial plexus palsy (OBPP) who develop an internal rotation deformity of the shoulder, release of subscapularis improves the range of external rotation of the shoulder and the strength of supination of the forearm. We studied the strength of supination in 35 healthy adult volunteers at 45° of both internal and external rotation.

The mean and maximum torques were greater in external than internal rotation by 8.7% and 7.5%, respectively. This was highly significant (p < 0.0001).

The increased strength of supination in external rotation is probably because the maximum power of biceps, particularly the long head, may be exerted in this position. In children the difference may be even greater due to anatomical differences causing the dramatic increases in the strength of supination after surgery for OBPP.

In adults our findings suggest that the supination exercises which are undertaken after injury or surgery to the forearm or wrist should be performed in external rotation.