We dissected 12 fresh-frozen leg specimens to identify the insertional footprint of each fascicle of the Achilles tendon on the calcaneum in relation to their corresponding muscles. A further ten embalmed specimens were examined to confirm an observation on the retrocalcaneal bursa. The superficial part of the insertion of the Achilles tendon is represented by fascicles from the medial head of the gastrocnemius muscle, which is inserted over the entire width of the inferior facet of the calcaneal tuberosity. In three specimens this insertion was in continuity with the plantar fascia in the form of periosteum. The deep part of the insertion of the Achilles tendon is made of fascicles from the soleus tendon, which insert on the medial aspect of the middle facet of the calcaneal tuberosity, while the fascicles of the lateral head of the gastrocnemius tendon insert on the lateral aspect of the middle facet of the calcaneal tuberosity. A bicameral retrocalcaneal bursa was present in 15 of the 22 examined specimens.

This new observation and description of the insertional footprint of the Achilles tendon and the retrocalcaneal bursa may allow a better understanding of the function of each muscular part of the gastrosoleus complex. This may have clinical relevance in the treatment of Achilles tendinopathies.

Cite this article: Bone Joint J 2014; 96-B:1344–8

Introduction: Closure with interrupted mattress sutures is useful where careful skin apposition is required following hindfoot surgery. However, suture removal around the hindfoot can be awkward and painful. Modification with an additional loop creates a “traction loop suture”. We hypothesise this technique makes removal easier and reduced tension placed on sutures during their removal reduces pain.

Materials: 17 patients undergoing elective hindfoot surgery were included. Nylon suture was used for all wound closures. Suturing and removal techniques were standardised. Ethical approval and patient consent was obtained.

Methods: Half of each wound length was sutured normally and the other with traction loop sutures (both interrupted mattress type). Follow-up was at 2 and 6 weeks. Comparison of time taken for suture removal and associated wound complications were noted for both. Pain scores during suture removal were recorded using a screen to “blind” the patient and a visual analogue pain score (VAPS) was obtained. Statistical analysis calculated p-values at the 5% significance level and 95% confidence intervals (CI).

Results: Traction loop sutures were 20% faster to remove than normal interrupted sutures (mean difference 19.3 seconds, CI 5.39 to 33.1 seconds, p-value 0.004). Traction loop sutures were also 20% less painful during removal (mean difference 1.05 on VAPS, CI 0.021 to 2.085, p-value 0.027. At 2 weeks, 1 normally sutured wound suffered complications. At 6 weeks, no complications were noted in either group.

Discussion: Traction loop sutures provide a statistically significant method of reducing pain and time during suture removal. The study method could be applied to comparisons of other skin closures where removal is required. The technique is novel and requires minimal change in suturing.

Conclusion: Pain levels and time taken for removal of interrupted mattress sutures are significantly reduced using the traction loop suture technique in hindfoot surgery. The study is continuing.

Introduction: Standard arthrodesis of the first metatarsophalageal joint (MTPJ) is often carried out for degenerative disease in the presence of a hallux valgus without a first metatarsal corrective osteotomy. Despite this there is an improvement in the intermetatarsal angle (IMA) as well as the position of the tibial sesamoid. We attempt to quantify the amount of correction in this study.

Method: A cohort of 30 (35 feet) consecutive patients (10 males, 20 females) treated from May 2006 to May 2007 were reviewed. The mean age was 61.6 years (39 to 78 years). All patients underwent a standard primary fusion of the first MTPJ with a low profile plate and compression screw. There was no attempt to free the sesamoids, perform a lateral release or medial reefing of the medial capsule. We measured the hallux valgus angle (HVA), IMA as well as the position of the tibial sesamoid pre and postoperatively using a digital radiology imaging system.

Result: The mean improvement in IMA was 3.38° (p< 0.001) with a mean correction of 2.5° (p=0.02), 6.5° (p=0.02) and 5.8° (p=0.06) in the mild, moderate and severe groups respectively. A greater correction is expected with a more severe initial IMA (r=0.688). A similar trend is seen with the severity of the initial HVA (r=0.640). The tibial sesamoid position also tends to improve by one station (spearman correlation 0.861) post operatively.

Conclusion: There is an improvement in the IMA when the first MTPJ is fused. This improvement is proportional to the severity of the initial HVA and IMA. There is also an improvement in the resting position of the tibial sesamoid. We conclude that with a mobile first metatarsal medial cuneiform joint, the IMA corrects spontaneously when the first MTPJ is arthrodesed negating the need for a separate corrective osteotomy of the first metatarsal.

Introduction: Mal-united ankle fractures are uncommon. When they occur they produce symptoms of pain, joint effusion, limitation of dorsiflexion and are likely to lead to ankle arthritis. In such cases it has been shown that, even many months after the original fixation, correction of the ankle alignment can improve the final outcome.

Method: From May 2004 to April 2006, seven patients with a mal-united fibular fracture aged 25–62 years (average 44yrs, male: female ratio 5:2) were treated in the Foot and Ankle unit at the Royal Liverpool University Hospital. All the patients were referred with persistent pain. The range of time delay between injury and secondary surgical intervention was 3 to 16 months (average 6 months). All the patients were assessed using clinical examination, functional scoring using the AOFAS Ankle-Hindfoot score and plain radiographs. They were followed for an average of 11 months (range 6–24 months) after the surgery.

Surgical procedure: The surgical procedure involves a transverse fibular osteotomy made just above the ankle joint and below the tibio-fibular syndesmosis. The osteotomy is then distracted and internally rotated to gain the fibular length and to correct talar tilt using an image intensifier. A tri-cortical iliac bone graft and a lateral fibular plate are applied to maintain the reduction. We do not use a syndesmotic screw.

Results: We managed to regain the fibular length and reconstruct ankle mortise in all the cases. All patients showed radiological evidence of bony union on follow-up. The average time to bony union was 8 weeks. Talar shift was corrected in all patients and all had good hind foot alignment. Average AOFAS score was 82 (pain: 31.43 function: 40.57 and alignment: 10).

Conclusion: We present our early experience with fibular osteotomy aiming to correct ankle joint mal-alignment following fibular fractures. We believe this is a technique with reproducible results in our short term follow-up. It shows satisfactory functional outcome improving pain and function especially in younger patients.