Lower Limb


Atypical Femur Fractures

Atypical Femur FracturesAtypical femur fracture xray





Lateral femoral shaft




Stress fractures


Associated with long term bisphonate use




Black et al. NEJM 2020

- reduction of hip fracture risk v risk of atypical femur fracture

- 10 year period

- 196,000 women > 50, 277 atypical femur fractures

- differences dependent on race

- in white women, over 3 years prevented 149 hip fractures and caused 2 atypical femur fractures

- in asians, over 3 years prevented 91 hip fractures and caused 8 atypical femur fractures



Dell et al. Osteoporosis International 2018

- recommendations for drug holidays

- consider DEXA scan or other imaging every 3 - 5 years

- look for any focal or generalised lateral femoral cortical changes





Will typically have thigh pain for some times





Lateral femur

- tension side

- see thickening of the lateral cortex

- beaking

- most common in the subtrochanteric region, but can be in shaft


Atypical femur fracture xrayAtypical femur fracture



Atypical femur fracture CTAtypical femur fracture CT 2


Incomplete Fracture


Stress Fracture Lateral


Complete fracture


Femoral stress fracture





Koh et al. Bone Joint J 2017

- systematic review

- nonoperative treatment of complete fractures failed in 50%, and surgery achieved union in 97%

- complete fractures - IMN nonunion rate 12.9%, plate fixation nonunion rate 31%

- must discontinue bisphonates

- mean time to union 7 months post surgery



Nail aptypical 1Nail atypical 2


Femoral stress fractureFemoral Stress Fracture IMN




Refer to osteoporosis

- cease bisphosphonates

- treat with calcium and vitamin D

- consider teriparatide



Compression Stress Fractures


Medial femur

- rare

- usually unite



Stress Fracture Medial


Distal Femur Fractures

AO Classification




1. Supracondylar

2. Unicondylar

3. Intracondylar




Supracondylar / Extra-condylar


Distal Femoral FractureSupracondylar Femur Fracture Retrograde Nail0002


Distal femoral fractureDistal Femur Fracture Lateral




Unicondylar 1Unicondylar 2Unicondylar CTUnicondylar CT 2




Distal Femur Fracture Intercondylar  2Intercondylar fractureDistal Femur Fracture Intercondylar CT




Non operative Management





- cannot immobiise joint above

- need to keep knee stiff

- probably only indicated in the very fraile and elderly


Operative Management




1.  Retrograde nail

2.  Lateral Plate

3.  Dual plating

4.  Distal femoral replacement




Plate v Nail


Shin et al. KSSTA 2017 meta-analysis

- similar time to union / rates of nonunion / rates of reoperation



1.  Retrograde Nail


Supracondylar Femur Fracture Retrograde Nail0001Supracondylar Femur Fracture Retrograde Nail0001



Supracondylar Femur Fracture Retrograde Nail0003Supracondylar Femur Fracture Retrograde Nail0004Distal femoral nailDistal femoral nail



- distal 1/3 extra-articular femur fracture

- floating knee

- concomitant pelvic and acetabular fracture

- concomitant femoral neck fracture with femoral shaft fracture



- small incision

- good for floating knee



- probably contra-indicated for intra-articular fractures

- technically difficult to perfectly restore alignment

- does destroy some cartilage in the knee from entry point / risk chronic knee pain


Surgical Technique


Pietu and Ehlinger 2017 Orthopaedics and Traumatology

- free technique article on retrograde IMN



Vumedi video



Synthes retrograde nail technique guide



Set up

- patient supine

- put knee over radiolucent triangle / bundle of gowns

- allows entry to knee

- ensure xray imaging for AP and lateral of knee and AP of hip for proximal locking screw


Entry point

- medial parapatella approach

- entry above ACL origin

- slightly medial

- ensure central in AP and lateral of the distal fragment

- awl / 3.2 mm guide wire

- ream for enlarged end of retrograde nail


Pass guide wire

- consider blocking screws to aid reduction

- measure length


Ream & insert nail

- distal locking performed with jig

- proximal AP locking under xray control




Iannacone et al J Orthop Trauma 1994

- 41 distal femur fractures treated with retrograde nail

- 4 non unions requiring revision fixation

- 4 fatigue fractures of the IMN; changed to using minimum 12 and 13 mm rods



2.  Lateral Plate


Distal femur plateDistal Femur Plate 2


Distal Femur Fracture Medial ORIFSupracondylar Plate ORIFSupracondylar Plate Lateral



- easier to fix intracondylar extension

- can be done MIPO / minimally invasive plate osteosynthesis

- plates anatomically contoured so can restore mechanical axis


Surgical Technique


Vumedi video



Synthes LISS Plate surgical technique guide




- patient supine on radiolucent table with II

- place distal femur over radiolucent triangle / drapes

- reduces fracture



- incision over lateral distal femoral condyle

- longitudinal

- through skin and soft tissue

- divide ITB

- elevate vastus lateralis

- down to bone


Reduce intra-articular portion if required

- anterolateral arthrotomy

- can elevate patella to assess reduction

- compress with bone reducing forcep

- 6.5 mm cannulated screws

- anterior and posterior to plate

- ensure not in joint / above blumensaat's

- ensure not in PFJ (distal femur is trapezoidal)


MIPO plate technique

- percutaneously elevate muscle off femur with elevator

- insert appropriate length plate (4 cortical screws above) with targeter

- temporarily fix distal plate to distal fragment

- if place screws parallel to joint line, the plate will be in correct valgus

- temporarily fix proximal plate percutaneously with temporary fixation screws

- obtain an indirect reduction

- check aligment and plate position AP and lateral

- attach plate with screws



- longer plate better

- titanium plate

- reduce rigidity may be superior

- cortical non locking screws in proximal plate




Schutz et al Arch Orhop Traum Surg 2005

- 62 patients average age 52 years treated with LISS plate

- union achieved in 85% patients

- 6 required bone grafting, 3 required revision of components



3.  Dual plate


Complex distal femur 1Complex distal femur 2Complex distal femur


Complex distal femurFemur dual plate 1Complex distal femur 2



- highly comminuted fractures

- large medial gaps




Sain et al. Cereus 2019

- free article on dual plating





Bologna et al. J Orthop 2019

- increased union rates with double v single plate



4. Distal Femoral Replacement


Distal Femur Replacement 1Distal Femur Replacement 2Distal Femur Replacement 3Distal Femoral Replacement 4



- elderly osteoporotic patient

- unreconstructable distal femur

- multiple co-morbidities

- difficulty non weight bearing




Hart et al. J Arthroplasty 2017

- ORIF v distal femoral replacement in patients > 70 years old

- reoperation rate 10% in both groups

- 20% non union in ORIF

- at one year, 1/4 ORIF patients wheelchair bound, all DFR patients ambulatory









Yoon et al. Arch Orthop Trauma Surg 2021

- meta-analysis

- 166/2156 nonunion (5%)

- no difference nail v plate



Risk Factors


Rodriguez et al. Injury 2014

- nonunion assocatiated with obesity / open fracture / infection / stainless steel plates



Kiyono et al. J Orthop Surg Res 2019

- increased nonunion with medial fracture gap > 5 mm



Harvin et al. Injury 2017

- 96 patients

- more rigid plate screw constructs associated with nonunion

- avoid locking screws in the diaphysis



Rodriguez et al. Injury 2016

- 271 patients

- increased non union stainless steel plates c.f. titanium plates





1.  Cortical allograft / revision lateral plating +/- medial plating


Kanakeshar et al. Injury 2017

- cortical allograft strut with autograft and lateral plate



Holzman et al. CORR 2017

- addition of medial plate with autograft



2.  Distal Femoral Replacement


Retrograde Nail Nonunion0003Retrograde Nail Nonunion0004Retrograde Nail Nonunion0001Retrograde Nail Nonunion0002


Supracondylar Nonunion TKR0001Supracondylar Nonunion TKR0002


Femoral Shaft Fractures



Usually young patients

- 15 - 40


15% compound




High velocity injury



- pedestrian v car

- fall from height


Emergency Managment


EMST principles

- need for transfusion not uncommon

- hypotension from isolated closed femoral fracture unlikely



- ipsilateral NOF / pelvic fracture / acetabular fracture

- knee injury / ACL or other ligament injury

- floating knee / ipsilateral tibial fracture


Thorough neurovascular exam

- incidence vascular injury 1%


Thomas splint

- ring against ischium

- velcro around foot

- pneumatic traction

- can only be applied for 12 hours or so


Thomas SplintThomas Splint


Carbon traction splints

Femur carbon traction splint


Balanced Traction


Balanced traction


Compound wound


Compound femur


Betadine pack




Winquist Classification


Type 1                                                                                                                      

- minimal or no comminution                                                                                                                                            

Femoral Shaft Fracture No comminution                    


Type 2  

- < 50% comminution

Femur fracture


Type 3

- 50 - 100% comminution 

- inherently unstable

- needs distal locking

Femoral fracture


Type 4

- segmental comminution

- no contact or inherent stability


Associated injuries


Femoral Shaft Fracture with Neck Fracture


Up to 10% concurrence

- can be missed on plan film

- splints can obscure



- carefully review pelvic xrays

- order CT if required

- assess carefully using fluoroscopy during surgery




Byon et al. Injury 2018

- 87 knee ligament injuries in 429 femoral shaft fractures (20%)

- 20 PCL, 11 ACL, 16 MCL, 8 LCL and 32 multiligament knee injuries

- always assess knee after femoral stabilisation



Femoral Fracture + ACL Reconstruction


Floating Knee


Ipsilateral femur + tibial fracture


Floating Knee 1Floating Knee 2


Operative Management Issues


Surgical Timing


Early fixation < 24 hours

- indicated for isolated injuries

- reduce risk of pulmonary complications


Harvin et al. J Trauma Acute Care Surg 2012

- compared early stabilisation (<24 hrs) with delayed (>24 hrs)

- retrospective review of 1,376 patients

- early IMN associated with decreased pulmonary complications such as pneumonia / PE / ARDS

- decreased length hospital stay



Damage Control Orthopaedics



- severely injured polytrauma patients

- head / chest / abdominal / pelvic injuries

- patients have elevated cytokines (IL-6) in multitrauma

- avoid second hit of surgery during this period

- second hit may be associated with ARDS and multi-organ failure



- stabilise femoral fracture with simple external fixator

- allow return to ICU for warming / stabilisation

- delay definitive treatment until inflammatory state reduces

- approximately day 6




Pape et al J Orthop Trauma 2002

- retrospective study of polytrauma patients at risk of multi-organ failure

- patients treated with early IMN femur v DCO (early stabilisation femur external fixation with later IMN)

- significant reduction in incidence of multiorgan failure

- significant reduction ARDS (15% down to 9%)

- no increased rate of local complications (infection, non union)



Surgical Options


1. External fixation

2. IMN

3. Plate


1. External Fixation



- severely contaminated wound

- Damage Control Orthopaedics

- complex femoral fracture with vascular injury


AO Surgery Technique

- safe zone is lateral



Timing of conversion to IMN


Harwood et al J Orthop Trauma 2006

- two groups

- 81 patients treated with early IMN

- 111 patients treated with external fixation converted to IMN at mean of two weeks

- at time of surgery, pin sites excised, washed, and overdrilled

- no difference in deep infection rates between two groups



2. Antegrade Femoral Nail


Femoral Nail0001Femoral Nail


Reamed v Unreamed IMN


Nonunion rates


Canadian Orthopaedic Trauma Society (COTS) JBJS Am 2003

- multicentred randomised trial

- non union rates reamed v unreamed IMN

- 8 / 107 (7.5%) smaller unreamed femoral nail nonunion

- 2 / 121 (1.7%) larger reamed femoral nail nonunion



Li et al. Medicine 2016

- meta-analysis of 8 RCT and 1078 patients

- reamed nails had shorter times to union

- reamed nails had reduced rates of nonunion and reoperation

- no increased rates of ARDS, mortality or blood loss with reaming





Canadian Orthopaedic Trauma Society (COTS) J Orthop Trauma 2006

- multicentred randomised trial reamed v unreamed

- incidence ARDS in multiply injured patients

- 3/63 reamed v 2/46 unreamed developed ARDS

- very low incidence of ARDS in both groups

- not statistically significant



Trochanteric v Piriformis Entry Point


Kumar et al. Injury 2019

- systematic review of 9 studies

- trochanteric entry reduced OR time, fluoroscopy time, reduced abductor weakness, better functional outcome

- similar union rates



3. Femoral Plate



- associated proximal / distal femoral fracture

- vascular injury

- medulla too narrow for IMN

- paediatric population

- treatment of non union



- tension side / load bearing

- significant disruption to blood supply required

- plate will break early if union not achieved



- large fragment plate

- minimum 8 cortices each side of fracture

- need periord of NWB




Giessler et al Orthopedics 1995

- 71 femurs diaphyseal fractures

- 93% union at 16 weeks

- recommended bone grafting at same time



Difficult Scenarios


1. Floating Knee


Single incision at knee

- retrograde femoral nail

- tibial IMN if appropriate


High complication rates including non union / malunion, knee stiffness and hetertopic ossification






Floating Knee 1Floating Knee 2Floating Knee 3


2. NOF (Neck of Femur) + Femoral shaft fracture


Must pay attention first to meticulous NOF ORIF



1.  Pin and Plate NOF / Retrograde Nail

2.  Pin and Plate NOF / Plate femur

3.  Reconstruction Nail

- difficult to anatomically reduce NOF

- increased incidence NOF non union


Difficult scenario

- antegrade IMN in place before diagnosis of NOF fracture

- if undisplaced, can place screws anterior to nail

- if displaced must remove nail




Ostrum et al. CORR 2014

- 95 cases treated with proximal screws / sliding hip screws inserted first

- retrograde IMN second

- 98% union rate femoral neck

- 91% union rate femoral shaft



Vumedi video



3. Dislocated Hip + Femoral shaft fracture


1.  Simple dislocation

- may be able to reduce hip with proximal steinman pin

- then IMN femur / retrograde or antegrade

- or plate femur


2.  Dislocation with Pipkin fracture

- may need anterior approach to ORIF femoral head fracture

- may be best to plate / retrograde nail femur


3.  Dislocation with posterior acetabular fracture

- may need posterior approach to acetabulum

- consider plating femur / distal femoral or tibial steinman pin

- delayed ORIF posterior wall


4. Distal femoral condylar fracture + shaft fracture



1.  Screws anterior and posterior to retrograde nail

2.  Distal Locking plate


5. Bilateral Femur Fractures


Lane et al. Orthopedics 2015

- 72 patients

- high rate of complications

- mortality rate 6.9%

- increased risk of DVT and pulmonary complications



Stavlas et al. Injury 2009

- systematic review 197 patients

- treated with bilateral reamed IMN

- fat embolism 4.1%

- ARDS 14%

- PE 7%

- suggest damage control orthopaedics



6.  Segmental bone defects / critical bone defects



- temporary fixation with nail / plate / ext fix

- cement spacer

- delayed Masquelet technique / induced membrane technique at 6 - 8 weeks


Morwood et al. J Orthop Trauma 2019

- 65 femurs with critical bone loss

- increased union, time to weight bearing with IMN v plate

- fewer grafting procedures and reoperations with IMN



Trochanteric Entry Antegrade Femoral Nail Surgical Technique


Vumedi Video



Smith and Nephew Trigen TAN FAN




- GA, IV ABx, transexamic acid

- traction table

- patient legs adducted, torso adducted

- allows access to GT

- flex and abduct other hip for image intensifier / fluoroscopy access



- incision proximal to GT

- split abductors in line

- palpate tip of GT

- check entry point on AP xray view

- check entry point on lateral xray view (junction anterior 1/3 posterior 2/3)

- entry with awl or 3.2 mm guide wire

- ensure wire doesn't penetrate medial cortex

- use proximal reamer for thickened proximal portion of nail


Pass guide wire

- ball tipped

- femoral fractures difficult to reduce with traction

- use reduction tool to reduce in AP and lateral views to pass guidewire

- if having difficulty +++, can perform miniopen incision to pass guide wire

- measure guide wire to determine nail length


Note typical deformity of proximal fragment which needs to be corrected

- flexed by psoas

- abducted by G medius

- externally rotated


Femoral Shaft Fracture Standard Displacement Lateral



- tight fit best

- nails come in 8.5, 10, 11 and 12 mm

- need to ream 1 - 2 mm larger than nail


Pass nail

- attach to proximal locking jig

- ensure drill passes through jig into proximal nail holes

- insert nail

- visualise with flurosocopy at fracture site

- ensure nail doesn't get caught on one cortex

- excessive hammering in this position can cause fracture





- usually proximal locking first

- screw should purchase cortex of lesser trochanter


Femoral Nail Proximal Locking0001Femoral Nail Proximal Locking0002



- straighten out other leg / lower so can obtain lateral II

- perfect circle technique

- distal locking performed


Femoral Nail Distal Locking0001Femoral Nail Distal Locking0002




Arazi et al. J Trauma 2001

- 24 patients with comminuted femoral fractures allowed to weight bear in first 2 weeks

- all full weight bearing without aids by second month

- 100% union

- 2 slightly bent locking screws


Complications of Femoral Nail


Nerve Palsy


Kao et al. 1993 J Orthop Trauma

- 15% incidence pudenal nerve palsy

- usually transient

- related to longer traction times








> 100 may be prevalent in up to 40% of patients

Probably not relevant unless > 300

May be associated with anterior knee pain and/or hip pain




A.  Clinical

- difficult

- probably best to assess internal and external rotation of the hip

- when swelling goes down can assess internal and external rotation of the foot


B.  CT

- axial cuts of the femoral neck and the femoral condyles


Femoral Nail Malrotation CT 1Femoral Nail Malrotation CT 2




A.  Match cortices on the proximal and distal fragment


B. Both patellas pointing anterior

- match lesser trochanter position of  both hips




A.  Early

- remove distal locking screws but leave in wires

- correct rotation based upon CT measurement

- insert new distal locking screws at the predetermined angle from previous screws


B.  Late

- may need osteotomy


Vergano 2020 Summary article



Distal femoral breach



- insufficient curvature of femoral nail

- abnormal femoral curvature

- posterior starting point on the greater trochanter


Distal femoral breachDistal Breach ORIF


Non union


Femoral Non union




- uncommon

- 1 - 2% with reamed nails

- increased with unreamed nails



- not united (3/4 cortices) after 6 months

- no progressive union for 3 months



1.  Dynamisation / removal of distal locking screws

2.  Exchange nailing +/- bone graft

3.  Remove nail / plate + bone graft

4.  Augmentation with plating and bone grafting

5.  External Fixation


1.  Dynamisation



- stable fractures

- non comminuted / non segmental

- evidence of fracture gapping from over traction or bone resorption


Huang et al. Injury 2012

- 39 patients

- union rate 83% when dynamisation performed 10 - 24 weeks

- union rate 33% when dynamisation performed after 24 weeks



Vaughn et al. World J Orthop 2018

- systematic review of exchange nail v dynamisation

- union rate dynamisation 66%

- exchange nail union rate 85%

- dynamisation good for delayed union

- exhange nail best for nonunion



2.  Exchange nailing



- remove old nail

- ream up to larger size

- insert new larger nail


Swanson et al. J Orthop Trauma 2015

- 50 cases

- removal of nail, ream

- insertion of different manufacturer nail at least 2 mm bigger

- static locking

- early dynamisation if signs slow healing

- union in 100% at mean 7 months



Tsang et al. Injury 2015

- risk factors for failure of exchange nail

- infection

- cigarette smoking

- may require repeat procedure

- technique eventually successful in 91%



3.  Removal Nail / Plating / Bone Graft


Maimaitiyiming et al. Injury 2015

- 14 patients nonunion

- bone grafting and double plating

- union in 100% at mean of 5 months



4.  Augment nail with Plate + Bone Graft


Medlock et al. Strategies Traumatic Limb Reconstruction 2018

- systematic review of augmentive plating v exchange nailing

- union rate 99.8% with augmentive plating

- 74% with exchange nail



Infected Non union


Exchange Nail Bone Graft




1.  Open debridement

- antibiotic beads


2. Removal of nail

- ream and irrigate

- antibiotic nail / cover IMN with antibiotic cement

- IV antibiotics

- definitive nail / external fixator


Pradhan et al. Injury 2017

- infection nonunion femoral shaft 21 patients

- infection eliminated in 100%

- union in 16/21, others required further surgery to obtain union

- 2 broken nails due to noncompliance with weightbearing



Infected Femoral Nail 1Infected Femoral Nail2Infected Femoral Nail3Infected Femoral Nail4




No evidence increased risk if nail removed > 1 year

Hoffa fracture


Hoffa Fracture Xray


Coronal plane fracture of distal femoral condyle

- intra-articular

- often only attachment is posterior capsule








Usually a severe valgus trauma




1. Unicondylar


Lateral femoral condyle > medial femoral condyle


Hoffa Fracture Xray

2. Bicondylar




Aids surgical planning


Medial Hoffa CT 1Medial Hoffa CT 2Medial Hoffa CT 3Medial Hoffa CT 4




Excludes associated LCL / MCL injury


Hoffa Fracture MCL Avulsion MRI 1Hoffa Fracture MCL Avulsion MRI 2






Usually unstable and intra-articular

- needs ORIF

- can be associated with LCL injuries


Must preserve the posterior soft tissue for vascularity




Lateral Approach


May need combined approach


a. Lateral between ITB and LHB

- elevate ITB

- open joint capsule anterior to gastrocnemius, posterior to LCL

- preserve lateral meniscu inferiorly


b. Lateral parapatellar

- may be needed for reduction

- allows AP screws


Vumedi video



Medial approach


Medial Hoffa ORIF 1Medial hoffa ORIF 2


a.  Medial approach to knee

- semimebranosus inferior

- gastrocnemius posterior

- MCL anterior

- open posteriomedial capsule

- preserve medial meniscus inferiorly


b. Medial parapatellar

- allows direct reduction

- allows AP screws


Unicondylar Fixation


1.  AP screws


Hoffa Fracture ORIF APHoffa Fracture Lateral


2.  PA screws


Hoffa Fracture ORIF PA screws


3.  Combined


Hoffa fracture


4.  Consider buttress plate


Lu et al. J Int Med Research 2019



Bicondylar fixation


Lee et al. Case Report Ortho 2014

- lateral parapatellar approach with tibial tuberosity osteotomy





Trikha et al. J Orthop Surg 2017

- 32 cases

- all united

- no athrithris

- stiffness in 4

- recommend early and aggressive ROM



Onay et al. Injury 2018

- 13 patients

- OA developed in 50%

- AVN developed in 2/12



Foot And Ankle

Achilles Tendon

Achilles Tendon Rupture

AnatomyAchilles tendon anatomy


Gastrocnemius tendon 10-25 cm long

- soleus 3-10 cm

- inserts superior calcaneal tuberosity

- fibres spiral 90°

- fibres that lie medially in proximal portion become posterior distally

- allows elastic recoil & energy storage


Plantaris present in 90% population

- medial to T Achilles


Poor blood supply midportion

- mesotenal vessels

- fewest at 2-6 cm

- other blood supply from osseous insertion




Usually age > 40 years

- M:F = 12:1

- occasional sportsman

- 75% during sports




Calf contraction with forced dorsiflexion in setting of tendon degeneration


Combination of


1.  Repetitive microtrauma

2.  Hypovascularity

- occurs at watershed of vascular supply 

- an area of hypovascularity 5 cm proximal to tendon insertion



- corticosteroids - oral or injected

- anabolic steroids

- flouroquinolone / ciprofloxacin (especially elderly)

- gout

- hyperthyroidism

- tendinitis (10% ruptures have preexisting achilles tendon disorder)

- cavovarus OR planovalgus foot


Mechanical Overload

- footwear (low heel, inadequate shock absorption)

- sudden training increase

- cross training


Classification of Tendon Inflammation


1. Paratenonitis 

- inflammation of paratenon

- swelling, pain, crepitation, tenderness, warmth


2. Paratenonitis with tendinosis


3. Tendinosis 

- intratendinous degeneration due to atrophy

- aging, microtrauma, vascular compromise

- swelling absent

- +/- palpable nodule


Rupture Site


1.  Watershed area

- 5 cm proximal to insertion

- most common


2.  Insertion

- common with insertional tendonitis


3.  Musculotendinous juntion

- avulsion of medial or lateral head

- may present with chronic weakness


Medial Head Gastrocnemius RuptureMusculotendinous Gastrocnemius Rupture 2


NHx (if neglected)


Weakness / wasting

- difficulty with push off

- compromised running / jumping / stairs 

- can still walk with use of FHL / FDL / T posterior / Peroneals


Calf Wasting Left Leg




Sudden pain in calf

- with audible snap

- on unaccustomed exercise

- especially tennis / squash




MAJOR SIGNS (AAOS Clinical Practice Guidelines 2010)

Positive Thompson Test (90% sensitivity and specificity)

- patient prone

- squeezing calf doesn't produce plantarflexion of ankle


Thompson Sign Normal PreThompson Sign Normal Post 

Palpable gap (70% Sensitivity and Specificity)


Achilles Tendon Rupture 1Achilles Tendon Rupture 1


MINOR SIGNS (more difficult to elicit acutely) 

Weak PF

- unable to perform single heel raise 


Increased DF comparted to contralateral side


Chronic tear

- gap fills with scar tissue

- gap not palpable

- excessive DF compared with other side


TA rupture increased DF



Only indicated if associated bony tenderness 




Cheap, dynamic, fast

- operator dependant

- check reduction of tendon ends with plantarflexion


Acute Achilles Tendon Rupture UltrasoundAcute Achilles Tendon Rupture Reduced with Plantarflexion





- incomplete rupture 

- signs of degeneration

- clinical uncertainty (two major signs not present) 

- measurement of gap in chronic cases / preoperative planning for reconstruction


MRI TA rupture chronic


Operative v Non-operative Management




1.  Complications 

- infection & skin necrosis with operative

- ? re-rupture with non operative


2.  Function

- strength & patient return to activity / sports

- ? better function with non operative




Khan et al JBJS Am 2005

- 12 trials involving 800 patients

- operative treatment associated with lower RR (.27; CI .11 - .64) of rerupture

- higher risk of complications (RR 10.6; CI 4.82 – 23.2) 



Willits et al JBJS Am 2010 

- 144 patients randomised trial operative v non operative

- concept of accelerated functional rehabilitation in both groups

- 2 weeks NWB

- weight bear in aircast with 2 cm heel raise up to 8 weeks

- able to actively DF / PF below neutral

- no significant difference in rerupture rate or loss of motion / power at all time indices

- 13 complications in operative versus





- elderly, DM, PVD, smokers

- non athlete




Equinus front slab 

- need to do within 24 hours

- try to close gap before haematoma forms

- change to full cast at 1 week

- debatable if need long leg cast v short leg

- 2 weeks


Functional Rehabilition

- heel raise 2 cm and air cast

- FWB for further 6 weeks

- active ROM below neutral


Achilles Tendon Boot and heel raise





- rate unknown

- likely in order of 5%

- likely some minimal loss of plantarflexion strength


No risk of infection / wound breakdown




Achilles tendon ruptureAchilles tendon repairKrackow suture



- young, active

- athlete 





- ? delay for one week to allow swelling to reduce



- prone

- prep both feet to check tension


Posteromedial approach

- avoids sural nerve and short saphenous vein

- don’t place scar directly posteriorly / less scar discomfort

- full thickness skin to paratenon


Open paratenon and dissect off tendon

- want to repair at end of case on dorsum of tendon

- this reduces skin adhesions

- incise paratenon in the midline anteriorly / increases tissue available for closure


Tendon repair

- Bunnell Suture  / Krackow suture x 2 with high strength suture / fibre wire

- one in proximal and one in distal tendon ends

- tie via two knots with foot fully plantar flexed

- augment with circumferential 4.0 prolene to minimise bunching



- not usually needed acutely


Paratenon repair

- closure posteriorly to aid glide

- prevents adherence to scar

- use 3.0 vicryl


Careful skin closure

- LA with adrenalin

- front slab short leg


Post operative

- accelerated rehab as above

- jog at 3/12

- sports at 6/12






Swab, washout, primary closure


Infection post tendoachilles repair


Wound breakdown


Debride, manage infection

- vac dressing

- free muscle flap (usually gracilis) + SSG

- fasciocutanous flap (radial or lateral thigh) has better wear characteristics




Case 1


Previously non operative management / new onset severe pain with bump

- intrasubstance / incomplete tear


Tendoachilles Nonoperative ReruptureAchilles Tendon Rerupture0001Achilles Tendon Rerupture0002


Case 2


Acute pain 8 weeks post non operative management rupture

- ultrasound demonstrates scar tissue

- no reduction with plantarflexion


Achilles Tendon Scar TissueAchilles Tendon Scar Tissue No Reduction Plantarflexion


Reconstruction / Augmentation




Unable to primary repair / chronic setting




< 3cm 

- turndown


Achilles Tendon Turndown


3 - 5 cm 

- VY lengthening


Achilles Tendon VY Turndown


VY Advancement


> 5 cm 

- FHL / FDL / peroneal transfer

- free gracilis graft

- allograft


Chronic TA rupture reconstruction with graft


Large gaps

- turndown + FHL

- FHL is most accessible / directly medial to T achilles




VY advancement


Turndown / Bosworth technique


Harvest central third fascia

- from musculotendinus junction as far proximal as possible

- leave attached distally, detach proximally

- closure fascia above

- tubularise fascia with 2.0 ethibond

- drill hole through calcaneal tuberosity

- pass through calcaneum

- suture to itself


Can reinforce with plantaris / FHL / FDL / PB


Turndown and FHL Harvest


FDL / FHL transfer


Medial foot incision

- harvest tendon

- suture distal FDL stump to FHL


Medial calf incision

- pull tendon through

- through drill hole in calcaneum

- pass tendon through and suture to itself


FHL Transfer 2FHL Transfer 3


Peroneus brevis transfer


Lateral incision

- divide tendon


Standard Posteromedial calf incision

- pass through calcaneal drill hole


Augment with plantaris if needed


Free Gracilis tendon transfer

Achilles Tendonitis



Inflammation of achilles tendon; insertional or noninsertional




Tendonitis / Tendonosis / Rupture




Triceps surae

- medial and lateral gastrocnemius

- soleus

- surrounded by paratenon which allows gliding and supplies nutrition


Inserts middle 1/3 calcaneal tuberosity

- 2 x 2 cm area

- 90o rotation distally


Retrocalcaneal bursa (x2)

- proper is between tendon and calcaneum

- superficial is between tendon and skin




1.  Non-insertional form 


Younger / fitter / more active patients

- overuse and over training


Occurs in area of hypo-vascularity & fibre rotation

- 3-5 cm from insertion

- due to repetitive loading associated with jumping

- Angiofibrotic Dysplasia


Risk Factors


A.  Pronated foot 

- mid-foot pronation is coupled with IR force on tibia 

- opposite to the normal ER in knee extension

- forces are concentrated at the hypovascular area of TA producing high tensile stresses


B.  Heel cord tightness


C.  Changes in activity level 


2.  Insertional form 


Occurs at site of insertion

- more common in the overweight / middle aged / comorbidities

- have combination of tendonitis / retrocalcaneal bursitis / spur

- also occurs in athletes 30s - 40s


Risk factors


A. Poor women's shoe-wear


B. Bony protuberance of Os Calcis 

- Haglund's Deformity / Pump bump

- Patrick Haglund, 1928, Swedish orthopaedic surgeon

- prominence of posterosuperior & lateral calcaneus

- causes impingement & mechanical abrasion of T achilles at insertion


Pump Bump Clinical Photo


C. Retrocalcaneal Bursitis

- retrocalcaneal bursa lies between tendon & posterior surface of calcaneum

- normal lubricating structure

- may become inflamed


Ankle Retrocalcaneal Bursa


DDx insertional

- seronegative enteropathy

- gout

- corticosteroids

- oral fluoroquinolones

- hyperlipidaemia






- inflammation limited to paratenon



- tendon thickened

- focal areas of degeneration

- increased type 3 collagen

- may be partial tear


Clinical Features


Non Insertional



- pain 2-6 cm proximal to insertion

- usually worse in morning & post exercise

- may present with tendon rupture



- localised tenderness

- tendon may be palpably thickened

- pain with DF and PF

- DF may be limited





- pain at bone-tendon interface

- worse after exercise



- localised tenderness & thickening

- bony lump

- DF may be limited



Some younger patients may present only with pump bump / Haglund's

- no tendonitis

- just problems with foot wear




Haglund's Deformity

- may be calcification of bone-tendon interface with spur in insertional tendonitis

- can define with Pavlow lines / Fowler's angle


Achilles Insertional Tendonitis XrayTendoachilles insertional calcification



- lateral weight bearing x-ray

- draw parallel pitch lines

- defines Haglund's deformity to be removed (above second line)


Achilles Haglund's and Pavlov linesPavlov's Lines


Fowler's angle  


Normal < 70°

Abnormal > 80°


Fowler's Angle




Thickening of the tendon with some intra-substance degeneration


Tendoachilles Noninsertional Tendonitis Sagittal MRITendoachilles Noninsertional Tendonitis Axial MRI


Non-Insertional Management


Non-operative (ELMPOPI) 


1) Education 


2) Lifestyle modification - Rest 


3) Physiotherapy - Alfredson protocol 


- Eccentric exercise program originally devised by Curwi

- Duration extended and scientifically validated by Alfredson 

- 90% success rate if adhered to 


4) Orthotics - Heel cups ; raises ; medial arch supports 


5) Pharmacologics - NSAIDs


6) Injectables - Steroids contraindicated ; alternatives PRP , Autologous blood , sclerosing agents 

Limited evidence for any injectable currently

Gross et al FAI 2013 






- failure non operative > 12 months




Para-tenon resected

- tendon debrided

- tears in tendon repaired


Percutaneous vertical tenotomies

- may stimulate revascularisation


> 50% tendon degenerative

- may need augmentation





Rompe Am J Sports Med 2009

- RCT of eccentric v eccentric + ECSW

- improved results with combined treatment


Kearney 2012 Foot Ankle Int

- systematic review

- some evidence for eccentric loading and ECSW

- minimal evidence for surgery / case series only






As for non-insertional





- if fails to settle in one year

- high risk

- these patients have poor tendon and skin


Open / Arthroscopic Technique


Supine positioning


Sandbags & rolled towel under knee on operative side


Tilt bed away from operative side (increases ER)


Lateral approach

- preserve sural nerve (blunt dissection superficially)

- open plane between lateral achilles tendon & deep fascia

- usually need release portion of achilles tendon


Retrocalcaneal bursa excised


Osteotome resection Haglund's if present


Resection of bone spur if present


Tendon debrided 

- remove inflammed paratenon

- vertical tenotomies

- reattach tendon with anchors

- if tendon severely compromised, transfer required


Insertional Achilles Tendonitis Surgery

Ankle Arthrodesis



90% fusion rates


Lose70% sagittal plane ROM


Disadvantages of Arthrodesis 


Non union rates up to 12%

Decreased gait speed

Poor mobility over uneven surfaces

Need for shoe modification

Arthritic degeneration in STJ of up to 100%




Tibiotalar arthrodesis


1.  Intra-articular


A. Open

- gold standard

- especially significant deformity / mal-alignment

- screws from tibia into talus


B. Arthroscopic

- 8 Vs 14 weeks for fusion time

- minimal deformity only


2.  Extra-articular / Frame

- children

- sepsis

- osteopenia


Tibiotalocalcaneal (TTC)  Intramedullary Nail

- commonly needed in RA


Blair Fusion

- refer to talar fracture complications




1.  5° Valgus

- excess varus causes cavovarus


2.  Neutral Dorsiflexion

- if fused in plantar flexion develop genu recurvatum to put foot on floor


3.  5-10° ER


4.  Tibia anterior on talus

- preserves heel

- decreases lever arm = less energy required for toe-off


5.  Subtalar Joint 5°Valgus

- for TTC hindfoot fusion nails 


Surgical Techniques 


1. Intraarticular Technique 

Dual incision reciprocal flat-cut technique


Ankle Fusion APAnkle Fusion Lateral



- over distal fibular, curved forward over ST joint

- inter nervous plane between sural and superficial peroneal nerves

- full thickness down to bone


Superficial dissection

- subperiosteally expose distal fibula

- protect peroneal tendons posteriorly


Fibula osteotomy / excise distal fibula

- oblique cut ending 1.5 cm proximal to joint


Fibula Osteotomy Ankle FusionFibula Osteotomy and Reflected Posteriorly


Deep dissection

- expose talar neck anteriorly

- expose tibia posteriorly

- protect anterior tendons and NV bundles with retractors

- protect posterior peroneal tendons with retractors

- open the tibio-talar joint with lamina spreaders


Distal tibial cut

- oscillating saw

- perpendicular to tibial axis

- just above subchondral bone / 2-3 mm

- care not to take off medial malleolus

- if cut is too thick, will enter medial malleolus


Make a separate antero-medial incision

- medial to T anterior, protect saphenous nerve and vein

- use osteotome to complete tibial cut and protect medial malleolus

- denude medial malleolus of articular cartilage

- also clear medial talus

- note that the deltoid ligament carries the primary blood supply to the talus, and should be preserved


Talar dome cut

- place foot in desired position

- 5o valgus and neutral DF

- make a parallel cut to distal tibia

- again only 2-3 mm

- ensure two cuts appose


Stimulate bleeding bony surfaces

- drill holes in distal tibia and talar dome / sharp osteotome

- especially if sclerotic bone


Position foot

- ER 5 – 10o depending on other foot position

- with respect to patella

- hold with wires for 6.5 mm cannulated screws




Option 1

- medial tibia down to talus

- one into dome & one into neck / parallel


Option 2

- lateral talus up to medial tibia

- region sinus tarsus / lateral process

- parallel



- medial malleolar screw

- fibular to talus screw


Check II 


Options for fibular 

- discard 

- reattach to tibia and talus as onlay graft 

- morcellize with reamer and insert 



NWB 6/52 in cast

PWB in moon boot further 6/52

Double time if diabetic


2.  External Fixation


2 circular rings distal tibia

- 4 half pins


2 wires metatarsals

- connect to half ring


2 x wires calcaneum

- foot plate

- connect to half ring


Rods between and compress


3.  Tibiotalocalcaneal (TTC) Fusion 


Pantalar Fusion APPantalar Fusion Lateral



- prepare ankle arthrodesis site as per compression arthrodesis

- approach and prepare subtalar joint between peroneus brevis and tertius

- elevate EDB

- stabilize both joints with K wires placed to not interfere with nail insertion 


Insertion site

- line from 2nd toe through centre of heel pad

- line in coronal plane / junction anterior & middle 1/3 of heel pad

- should pass through anterior part of posterior facet of calcaneum

- posterior to lateral plantar artery and nerve

- screw fixation in calcaneum and talus (lateral to medial ; possible posterior to anterior calcaneal screw)  

- compression (distally locking and tapping on inserter or company specific jig) 

- 2 x proximal screws medial to lateral 





-NV Damage 

-Metalwork Breakage 



- Immediate - Infection ; compartment syndrome 

- Medium Term - Delayed or nonunion ; painful malunion 

- Long Term - Stiffness and Gait Changes ; Arthrosis in adjacent joints 




Arthrodesis nonunionArthrodesis nonunion lateral

Ankle Arthroplasty

Ankle OA Pre ArthroplastyAnkle Arthroplasty APAnkle Arthroplasty Lateral




First generation (late 70s early 80s) 



- 80-85% Good / excellent in  short term

- severe osteolysis, aseptic loosening 90% 



- cemented 

- highly constrained

- considerable bone resection

- subsequent revision technically challenging


Second Generation (mid 80s onwards) 



- semiconstrained

- uncemented

- mobile and fixed bearing options

- bone preserving 




1.  Older patient with low demand


2.  Other joints arthritic

- degenerative SJT / midtarsal joint

- contra-lateral AKJ AO 

- previous triple arthrodesis


Absolute Contraindication


Infection (Acute or Chronic) 

Neuroarthropathies i.e Charcot 


Poor soft tissue envelope

Severe malalignment or instability that cant be corrected intraoperatively 

Major AVN affecting >1/3 of talus 


Relative Contra-indication


Dx - Posttraumatic worse outcomes than RA which has worse outcomes OA  


Age - Younger (worse outcomes in < 50 years) 


Ankle OA Post ORIF Ankle OA Arthroplasty APAnkle Arthroplasty post ORIF lateral


Minor Malalignment (>10 degrees of varus or valgus as compromises ligament stability) 




Stiffness (preoperative ROM = Postoperative ROM) 


Minor AVN talus


Second Generation Implants





- cobalt chrome tibia and talus

- titanium porous coating

- talus single keel

- tibial component two rounded keels

- mobile bearing poly


Anderson et al JBJS Am 2004

- 51 STAR

- 12 revisions

- 5 year survival 70%


Depuy Agility



- fusion of the distal tibio-fibular syndesmosis to support tibial component

- titanium tibial component with cobalt chrome talar resurfacing

- uncemented

- modular poly inserts into tibial component


Knecht et al JBJS Am 2004

- 69 followed clinically with 90% reporting decreased pain and satisfactory outcome

- 11% revision rate

- 76% demonstrated peri-implant radiolucency

- 20% progressive subtalar OA and 15% progressive TNJ OA




Anterior approach

- protect SPN

- between T ant and NV bundle

- remove anterior osteophytes


Tibial cut

- distal alignment jig

- resect few mm above eroded bone

- neutral cut

- must not cut medial or lateral malleolus


Talar dome

- resurfaced

- 3-4 mm removed




Haddad et al JBJS Am 2011

- systemic review

- similar satisfaction rates and and ankle scores in arthroplasty and arthrodesis groups

- 5 and 10 year survival of arthroplasty 77%

- 7% revision rate in arthroplasty (loosening and subsidence)

- 9% revision rate in arthrodesis (non union)


Is ankle replacement cost effective compared with arthrodesis?






TAR LooseLoose TAR AP




Revision TAR APRevision TAR Lateral


Ankle Arthroscopy

IndicationAnkle Arthroscopy




Pain / Stiffness / Locking


- exclude OCD

Assess syndesmosis





Osseous lesions / Tibiotalar impingement spurs

Osteochondral defects

Anterolateral impingement lesions (soft tissue)

Loose bodies


Ankle Scope Loose BodyAnkle Scope Loose Body 2





Set up



- supine on table

- tourniquet



A.  Assistant provide traction

B.  Foot traction halter

C.  Skeletal distracter


Ankle Arthroscopy Traction



- standard knee scope or

- 2.7mm 30° scope

- small scope better for getting across joint line without chondral damage




Ankle distended first

- 20 ml syringe, normal saline

- anteromedial

- insert needle, move ankle

- if on bone and needle moves, on talus and need to redirect proximally

- if on bone and needle doesn't move, on tibia and need to redirect inferiorly

- insufflate with 15 mls to create anterior space



- usually want instrumentation on side of pathology

- exception is anterior spurs

- usually large osteophyte laterally so first portal insert medially


Ankle Scope Medial and Lateral PortalsAnkle Superficial Peroneal Nerve



- lateral to peroneus tertius

- can then transilluminate and avoid saphenous nerve on AM portal

- structure at risk is branches SPN

- Just proximal to joint line

- incision in skin only

- blunt dissect down to capsule

- insert blunt trochar

- aim anterior to joint to create space



- second portal

- medial to tibialis anterior

- structure at risk is G saphenous vein and saphenous nerve

- use transillumination to avoid

- insert and visualise needle

- skin incision, blunt dissection

- insert shaver, again anteriorly

- clear soft tisse until can visualise joint line

- beware anterior tendons and nerves




1.  Inspect anterior talus

- plantarflex foot

- look for chondral lesions


2.  Inspect distal tibia

- look for osteophytes


3.  Inspect gutters


A.  Medial


Ankle Arthroscopy Medial GutterAnkle Scope Medial GutterAnkle Scope Medial Gutter


B.  Lateral

- exclude meniscoid lesions


Ankle scope lateral gutterAnkle Scope Lateral Gutter


4.  Look across joint

- distract

- insert probe or shaver and use as level

- look at tibial plafond and syndesmosis


Ankle Arthroscopy Lateral GutterAnkle Scope Talar Dome


5.  Inspect syndesmosis

- probe and assess stability


Ankle scope syndesmosisAnkle scope syndesmosis 2


6.  Inspect posterior joint line


Ankle Scope Posteromedial CapsuleAnkle scope posterior capsule laterally


Posterior Ankle Arthroscopy


Posterior ankle arthroscopy



- just lateral to tendo achilles

- medial to fibular

- 1.2-1.5cm above tip of fibula

- sural nerve & vein anterior

- remember joint 1cm higher at back


Subtalar Arthroscopy


Subtalar arthroscopy




Nerve Injury




Anterolateral portal - SPN

Anteromedial portal - Saphenous

Posterolateral portal - Sural

Anterocentral - Deep Peroneal

Posteromedial - Posterior Tibial


Minimise by

1.  Marking of skin prior to arthroscopy

2.  Transillumination to visualise nerves

3.  Feel nerve 

4.  Use of blunt dissection


Mechanism injury

- penetration

- neural structures close to capsule

- anterior penetration by chondrotome may injure DPN

- traction device

- pins in talus and calcaneus may injure sural nerve




Compartment syndrome

- From extravasation of fluid into calf


Articular cartilage damage






Pseudoaneurysm AngiographyPseudoaneurysm MRI


Ankle Fractures

Ankle Fracture

AnatomyDislocated Ankle



- 90% load through plafond to talus

- 10% load through lateral talofibular articulation




A.  Lateral Ligament Complex


ATFL (Anterior Talo-Fibular Ligament) 

- tight in plantar flexion


CFL (Calcaneo-fibular ligament)

- slopes down & back

- tight in dorsiflexion


PTFL (Posterior Talofibular Ligament)

- scissors with Posterior Tibiofibular Ligament


B.  Medial Ligaments


Superficial Deltoid (SDL)

- origin medial tibia

- broad insertion talus / calcaneum / navicular

- resists hindfoot eversion


Deep Deltoid (DDL) 

- tibiotalar

- key to stability / primary stabiliser of ankle

- resists talus ER

- if divided get abnormal ER of talus in plantar flexion


C.  Syndesmosis


Interosseous Ligament

- between AITFL and PITFL (anterior inferior and posterior inferior tibio-fibular ligament)





- DF = 30°

- PF = 45°

- Rolls & slides to produce DF/PF



- deltoid ligament acts as a checkrein

- prevents ER of talus

- causes 5° IR talus



- talus wider anteriorly 2.5 mm

- fibula moves laterally & ER to accommodate


Ramsey 1976

- 1mm talus shift = Contact area decreased by 40%

- non-physiological study

- jammed wedges in intact ankle


Ankle Fracture Classification 


No system prognostic


1.  Weber ABC


A.  Fracture distal to syndesmosis

- stable / avulsion type fracture



Weber A


B.  Fracture at level of syndesmosis

- syndesmosis intact

- ORIF if medial structures not intact

- xray below demonstrates Weber B with rupture deltoid ligament

- ankle unstable


Ankle Weber B Fracture


C.  Fracture above level syndesmosis

- syndesmosis at risk / must assume is torn

- medial structures often torn


Ankle Weber C Fracture


2.  Lauge-Hansen 1950


Two part 


1.  Position of talus

- supination tenses lateral structures

- pronation tenses medial structures


2.  Direction of force

- rotation or translational injury


A. Supination-Adduction

Stage 1: Transverse fracture of lateral malleolus at or below the level of anterior talo-fibular ligament (Weber B) 

Stage 2: Vertical fracture of medial malleolus (often a marginal impaction at medial edge of plafond)


Ankle Fracture Supination Adduction


B.  Supination-External Rotation (Most common - up to 85% all injuries)

Stage 1: Rupture of AITFL

Stage 2: Short oblique fracture of the lateral malleolus (Weber B) (stable)

Stage 3: Rupture of PITFL / fracture of posterior malleolus of tibia

Stage 4: Transverse fracture of medial malleolus (unstable) 


Ankle Fracture Supination ER


C. Pronation-Abduction (Less than 5% of ankle fractures)

Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus

Stage 2: Rupture of the anterior and posterior inferior tibiotalofibular ligaments or bony avulsion

Stage 3: Proximal fibula fracture (often butterfly)


Ankle Pronation Abduction


D. Pronation-External Rotation

Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus

Stage 2: Rupture of the anterior inferior tibiotalofibular ligaments or bony avulsion

Stage 3: Spiral/Oblique fracture of the fibula above the level of the syndesmosis        

Stage 4: Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus


Ankle Fracture Pronation External Rotation


X-ray assessment


3 standard views


AP, lateral and mortise


Ankle AP XrayAnkle Mortise View





- foot internally rotated

- AP projection

- should be symmetrical clear space around talus


Ankle Mortise View


1.  Lateral talar shift / increased medial clear space

- medial clear space > superior clear space

- should be < 4mm

- indicates injury to medial structures

- instability


Ankle Fracture Increased Medial Clear SpaceAnkle Fracture Increased Medial Clear Space 2


2.  Tibia / fibular overlap < 1mm / syndesmotic injury


Ankle Fracture Syndesmosis WidenedAnkle Diastasis




Unimalleolar 70%

Bimalleolar 25%

Trimalleolar 7%

Open 2%







- protects skin medially

- conscious sedation in emergency department

- well moulded POP

- unstable ankles need monitoring for loss of reduction

- can need external fixation to maintain position


Ankle Fracture Severely Dislocated Dislocated Ankle Lateral



- operate when swelling reduced

- usually < 6 hours or 6 days

- higher risk with bimalleolar / 2 incision operations

- risk not being able to close wounds / infection


Long term results rely on

- reduction of talus under tibia

- mechanical stability

- degree of chondral damage


Medial ligament injury is the key to management


1.  Isolated Lateral Malleolar / Weber B Fracture


Ankle Fracture Isolated Weber BIsolated Fibula Fracture 3 mm displaced



- no medial fracture / no complete deep deltoid injury

- no increased medial clear space

- no instability on stress ER views

- no syndesmotic injury




85% have no medial injury

- by definition have no talar shift 


LM displacement not important if medial side not injured

- Biomechanical studies show Talus doesn't follow LM when axially loaded if medial ligament  intact 

- Doesn't lead to altered biomechanics


There is no external rotation of the distal fragment 

- its relationship to the talus is fixed

- the proximal fragment is internally rotated

- again, this does not alter the biomechanics


Diagnostic Dilemma / Is the deltoid ligament intact?




A.  Non tender / no bruising

- is intact

- non operative management


B.  Tender / bruising

- may be partially injury sprained / or completely ruptured and unstable

- inconclusive


Lateral BruisingMedial bruising




1.  Mortise view

- any increased clear space



2.  Stress views


Option A:  Gravity Stress View

- Patient lies injured side down, cross table xray

- see if medial clear space opens


Option B:  Valgus view

- lead gloves

- can be painful as patient has acute injury


Option C:  EUA


Results of Isolated Weber B Fibular Fracture


Results of surgical and non surgical management equally good

- Talus is stable if medial ligament is intact

- If  < 3mm fibula displacement, nil poor outcome


Non operative

- Kristensen and Hansen etal

- 95% good outcome non operatively

- no salvage operations required for post-traumatic arthritis



- 1-3% chance of serious infection

- more long term swelling




Cast in Internal Rotation to reduce the deformity


2.  Bi Malleolar Injury




A.  Medial Malleolus and Lateral Malleolus Fractured


Ankle Fracture Bimalleolar


B.  Deltoid tear + Lateral Malleolus Fractured


Ankle Fracture Weber B + Deltoid Ligament


If have talar shift, then by definition bi-malleolar injury

- must be an interruption to medial structures




Superior results with operative management

- able to obtain and maintain anatomical reduction

- 90% good results


Closed treatment

- for elderly or medically unfit

- acceptable reduction / ankle internally rotated

- 60% good results




1.  Weber B + Medial Malleolus fracture



- interfragmentary lag screw

- derotation 1/3 tubular plate


Medial malleolus (dependant on fragment size)

- 2 partially threaded lag screws

- 1 screw and one k wire



Screen syndesmosis

- should be stable with Weber B

- stress view (ER and dorsiflexion)

- cotton test (clamp on fibula and attempt to open syndesmosis under II)


Ankle Fracture Bimalleolar ORIFAnkle Fracture Bimalleolar ORIF


2.  Weber B + Deltoid Ligament


Ankle Weber B Deltoid Ligament InjuryAnkle Weber B Deltoid Ligament ORIF


A.  Manage Fibula as above

- ensure joint fully reduced


Ankle Fracture Fibula ORIF Increased Medial Clear Space


B.  Medial clear space remains open

- ensure fibular out to length and anatomical

- assess syndesmosis intact / reduce and fix

- if remains open, must be suspicious of OCD fragment or deltoid ligament blocking medial reduction

- may need to open medially


No evidence that repair of medial ligament improves results


3.  Tri-Malleolar Fracture


Posterior malleolus



- avulsion of PITFL


Ankle Fracture Small Posterior Malleolus Xray


Ankle instability results if

- > 1/3 articular surface (>30%)

- displacement of > 2mm 

- risk posterior subluxation of the tibio-talar joint



- these can be highly unstable and require external fixation


Trimalleolar UnstableTrimalleolar Unstable


Ankle External Fixator APAnkle External Fixator Lateral


Indications to ORIF posterior malleolus

- usually get anatomical reduction after plating of LM

- ORIF if > 30% and > 2mm displaced


 Ankle Fracture Large Posterior Malleolus XrayAnkle Fracture Large Posterior Malleolus CT


Surgical Options


1.  Posterolateral approach to fibula

- enable AP clamp to reduce and hold fracture

- anterolateral approach

- front to back screws


2.  Formal posterolateral approach

- patient lateral or prone

- PA screws or buttress plate


Posterior Malleolus LargePosterior tibial buttress plate


Ankle Fracture Trimalleolar ORIFAnkle Fracture Trimalleolar ORIF Lateral


4.  Syndesmosis Injury


Ankle Fracture Clear Syndesmotic Injury




Disruption of syndesmosis between level of fracture and plafond

- distal tibia and fibular not connected and stable




A.  Weber C fracture

- extremely high risk

- almost always safer to ORIF


Ankle Weber C Syndesmotic InjuryAnkle Weber C Syndesmotic Screw


B.  Weber B fracture + medial column injury

- occasionally syndesmotic injury

- check intraoperatively


C.  Maisonnerve injury

- high fibula fracture

- medial clear space opening / deltoid injury

- need diastasis screw


Ankle Fracture Maisonnerve InjuryAnkle Fracture Maisonnerve Proximal Fibula


D.  Isolated Injury


Ankle DiastasisORIF Diastasis


Intraoperative tests


Cotton test

Stress test




Reduction technique

- foot in neutral, clamp across medial and lateral malleolus

- don't reduce in plantarflexion as posterior talus is more narrow

- don't over reduce the joint

- check symmetrical joint space on mortise view


Diastasis Screw Fixation technique


1.  With other LM / MM fracture

- 1 or 2 screws

- 3 or 4 cortices

- 3.5 or 4.5 mm

- at level of epiphyseal scar


Ankle Fracture Diastasis Screw


2.  High Weber C fibula / Maisonnerve

- don't have to plate fibula

- ensure fibula out to length

- usually 2 screws

Post op


Need screw in for 8 - 10 weeks

- need to await ligament healing


- usually remove screw as will break


Ankle Broken Diastasis Screws


5.  Medial Malleolar Fractures


Medial Malleolus Fracture






- 20% risk of non union



- can usually manage in cast

- still small risk of non union




A.  Large fragment

- 2 x screws


Ankle Fracture Medial Malleolus 2 Screws


B.  Small fragment

- screw + K wire



Ankle Fracture Medial Malleolus TBW


C.  Plate

- vertical fractures


Medial Malleolus Plate


6.  Open Ankle Fractures




Compound Ankle FractureMedial compound wounds


Clean & Closeable wound

- wound usually medial

- washout / ORIF / close


Dirty wound / wounds need skin cover

- external fixation

- wound management

- ORIF later


7.  DM



- amputation (6% open, 40% closed)

- infection

- malunion / non union / delayed union


Increased in patient with neuropathy and PVD



- increase fixation

- double NWB times

- leave sutures in for twice as long


8.  Elderly / Osteoporotic



- bone very poor

- good fixation difficult


Ankle Fracture OsteoporoticAnkle Osteoporotic Fixation





- uncommon

- Improve for up to 9 yrs


Medial Malleolus Non union



- worse after ORIF 

- continues > 3/12


Fibula malunion 

- decreases tibiotalar contact by 30%

- correction <4 years = Good results


Infection 1-4%


Missed fractures

- plafond fractures

- chondral lesions (50%)

- anterior process calcaneum








Ankle OA Post ORIF

Complex Ankle Sprain



Simple sprain 

- injury to ATFL

- will almost always get better in 6-8/52


Complex sprain 

- associated injury

- suspect if patient slow to recover 

- diagnose most things on MRI





- clinical diagnosis 

- most will get better with appropriate physio



- if pain is present as well then consider other pathology

- isolated instability isn't usually painful




1.  Soft tissue

- lateral gutter fibrosis

- Bassett's ligament (thicknened AITFL)

- meniscoid / ferkel lesion


2.  Bony Injury

- OCD / loose body

- bone bruise

- fracture anterior calcaneum / lateral process / sustenaculum tali


3.  Tendon / ligament

- deltoid

- peroneal dislocation / tears

- high ankle sprain / syndesmotic injury

- sinus tarsi syndrome

- Achilles tendonitis




Soft Tissue


1.  Lateral gutter fibrosis


Ligament healing thicker than normal 

- associated scar tissue

- initial injury seemed to get better 

- ongoing pain and swelling over lateral ankle



- arthroscopy and debride

- most will get better


2. Bassett's Lesion




Primary injury to AITFL

- tear may produce laxity

- talar dome may extrude anteriorly in DF



- normally thin and above level of ankle joint

- may become thickened and scarred causing lateral ankle pain and swelling




Difficult to diagnose

- tender in syndesmosis & interosseous membrane

- positive squeeze test



- arthroscopy and debride

- most will get better


3.  Meniscoid Lesion




Scar tissue beginning in the lateral gutter

- extending across between tibia and talus

- looks like a meniscus



- arthroscopy and debride

- most get better


Bony Injury


1.  Fracture Anterior process of calcaneum




Avulsion of the origin of the bifurcate ligament

- often missed if x-ray is in the wrong plane


Calcaneum Anterior Process Fracture




Suspect if tender over anterior calcaneus

- CT or more plain films


Calcaneum Anterior Process Non Union



- non-op for 6/12 

- most will unite or get a painless fibrous nonunion


2.  Fracture Lateral Process




Eversion injury leading to lateral ankle pain

- tends to be larger than appears on plain x-ray

- often cause stiffness as involves STJ









- > 1cm

- displaced > 2mm


Small and comminuted 

- excise


3.  Fracture Sustenaculum Tali


Caused by impaction on medial malleolus as the talus internally rotates



- usually treat non-operatively


4.  Fractured Os peroneum 


Pain distally over the CCJ



- non-operative initially

- late excise 


5.  Bone bruise




Oedema in bone usually medial talar body and medial malleolus

- initial injury settles 

- get pain with resumption of activity








Usually settles in 6/12


5.  Osteochondral fracture



- occur as the talus is inverted within the mortise





- caused by shear stresses as the lateral talus abuts the lateral malleolus 

- tend to be smaller and generally do better



- caused with medial ridge impacting the roof

- more significant injury

- tends to be larger with underlying necrotic bone


6.  Loose Body


Tendon / Ligament


1.  Deltoid Tear



- severe injury / almost an ankle dislocation

- gross inversion of talus with distraction 

- complete tear of lateral structures and tear of deltoid

- medial pain with lateral sprain




Initially treat non-operatively

- may need debridement / repair


2.  High Ankle Sprain




Injury to AITFL

- point tenderness and swelling




Exclude diastasis


Treat non-operatively

- will take 12 weeks


Can benefit from late debridement


3.  Peroneal Dislocation




Occurs with inversion while plantar flexed (strong contraction of peroneals)

- more common in cavus type feet 

- usually not diagnosed at the time




Patient complaining of painful snapping or clicking on lateral ankle

- after ~ 1/12 get synovial lined pouch anterior to malleolus from chronic subluxation

- won't heal





- surgery with repair &/or deepening of groove

- repair and augment with periosteal flap or slip of Tendo achilles


4.  Peroneal Tear


Single or multiple longitudinal split

- associate with subluxation / dislocation

- associated with cavus feet


5.  Sinus Tarsi Syndrome


Lateral ankle pain

- injury to interosseous ligament

- residual synovitis




- excision of contents of sinus


6.  Achilles tendonitis


Insertional tendonitis

Retrocalcaneal bursitis

Haglund' s deformity





Deltoid Ligament




Incidence isolated deltoid ligament injury 2.5%




Strong fan-shaped structure 

- composed of a deep and superficial layer


Superficial layer 

- inserts as one continuous structure 

- navicular anteriorly, spring ligament (calcaneonavicular), sustentaculum, and calcaneum 

- measures 10 mm wide at its origin and 2 to 3 mm thick

- length varies from 20 to 30 mm


Deep layer

- inserts onto the nonarticular medial wall of the talus 

- most of the fibers concentrated on the posterior medial aspect of the talus




Isolated deltoid injuries are extremely rare 

- need proximal fibular xrays to exclude maisonneuve injury & / or syndesmotic injury

- treated in a cast or brace




Lateral Ligament Complex

Acute Injury



Partial or complete rupture of one or parts of lateral ligaments of ankle

- common ankle sprain




Lateral ligaments sprains are the most common ligamentous injuries of the human body

- account for approximately 15% of all athletic injuries

- it is estimated that there is one ankle inversion injury per day per 10,000 people


Most common young males

- average age 27

- M:F 2.5 : 1

- common injury in sport 

- basketball & soccer

- 10% emergency consults




Up to 20% to 40% of ankle sprains treated conservatively have some residual symptoms

- undertreatment is more common than overtreatment

- inadequate treatment can result in chronic ankle instability with recurrent sprains and early degenerative arthritis

- 10% of lateral ligament injuries will have subtalar instability also




Inversion injury

- jumping sports

- land plantarflexed and inverted




Peroneal muscle weakness

Pes Cavus

Tarsal Coalition




The ankle is a uniaxial joint that resembles a mortise and tenon


It is very stable when loaded in the neutral position

- bony contact and stability decrease with plantar flexion


1.  ATFL 


The most frequently injured ligament in the human body



- 15 to 20 mm long, 6 to 10 mm wide, and 2 mm thick on average



- arises anterior aspect fibula, 1 cm above tip, 2 cm long, attaches 8 mm above STJ



- primary restraint to anterior displacement, internal rotation, and inversion of the talus at all flexion angles

- in cadaveric studies, the ATFL always failed first


2.  CFL 


Cylindrical structure

- lies deep to the peroneal tendons

- 2.5 times stronger than the ATFL



- 20 to 30 mm long, 3 to 5 mm thick, and 4 to 8 mm wide



- arises tip fibular, 2 cm long

- subtends angle 130 degrees from fibula

- attaches 13 mm below STJ



- crosses two joints and acts as a subtalar joint stabilizer

- isolated CFL ruptures rare

- the ATFL and the CFL function together at all positions of ankle flexion to provide lateral ankle stability  


3.  PTFL 


The strongest of the lateral ligaments

- least often injured



- 30 mm long, 5 mm wide, and 5 to 8 mm thick



- medial surface of lateral malleolus to posterior lip talus


Ankle MRI PTFLMRI Ankle Intact PTFL




Most are mid-substance tears

- avulsion injuries occur in about 14%



- isolated ATFL tear is most common injury(60% to 70%)

- combined ATFL / CFL tear (20%)

- isolated CFL, PTFL, & subtalar ligament ruptures all very rare






Fingertip palpation of all structures 

- shown to be almost as accurate and more cost-effective than the tests available


Instability testing


Controversial & unreliable without anaesthesia in acute setting  (LA or GA)


1.  Anterior drawer 


Most important & best predictor ATFL

- 10° plantarflexion neutral rotation

- CFL plays no role


> 3mm is positive


Ankle Anterior Drawer


2.  Talar tilt 


CFL test / subtalar instability

- 10% of patients with lateral ligament instability also have subtalar instability


Patient seated / foot unsupported

- 10-20° PF

- stabilise tibia /  gentle inversion

- compare to other side


> 20o abnormal


Talar Tilt






Advisable with significant ankle injuries / unable to weight bear

- AP, Mortise & Lateral views

- +/- AP Foot


Look for OCD / Weber A fibula


High resolution CT & MRI


Exclude OCD if needed

Not required acutely

Define injury in chronic situation


Grading Acute Injury


Grade I 


Mild injury with minimal swelling and tenderness and slight or no functional loss

- ankle is stable 

- negative drawer and talar tilt tests


Considered to be a partial tear

- patient can perform normal activities but with pain


Grade II 


Moderate injury with diffuse swelling and tenderness

- moderate functional loss with difficulty with toe walking

- partial stability is lost 

- mildly positive anterior drawer  (ATFL complete tear) 

- negative talar tilt (CFL partial tear only)


Partial to possibly complete tear of the ATFL and a possible partial tear of the CFL

- patient cannot perform normal activities and can bear weight but with increased pain


Grade III 


Severe injury

- significant functional loss and marked tenderness, swelling, and pain

- lateral ankle stability is lost 

- positive drawer and talar tilt tests


Considered to signify a double ligament injury with complete rupture of the ATFL and CFL

- weight bearing is usually not tolerated


Acute Management


Grade I & II Injuries 


Mechanically stable 


Benefit from protection 

- stirrup-type brace or high boot

- until nonprotected weight bearing is relatively pain-free


Ankle Orthosis


During the protected period 

- non-weightbearing ROM exercises are performed


Progressing to proprioceptive & ultimately agility training

- shown to shorten the period of disability

- Grade I ankle sprain should be near full recovery at 1-2 weeks

- Grade II ankle sprain at 2-3 weeks (may take a lot longer)


Grade III Injuries


Mechanically unstable by definition


Previously thought to all require surgery but now shown to be successfully treated non-operatively


1.  Casting for 4-6 weeks 

- in slight dorsiflexion & eversion to approximate ligament ends

- then functional rehabilitation


2.  Functional Bracing

- removable brace

- progressive weightbearing

- ROM, proprioception & strengthening exercises

- success demonstrated with MRI studies






Kannus Meta-analysis


Functional treatment superior in

- time to return to work

- physical activity


- less wasting

- complications


No difference in

- instability 

- pain, swelling & stiffness

- re-injury





- figure 8 weave

- in neutral DF & slight ER

- shortens ATFL & helps proprioception



- peronei rehab is the key

- proprioception exercises


Return to Sport 

- successful performance of simple tests provide adequate guidelines

- ability to run, cut and jump 10 times on the single injured foot

- to stand on one foot with eyes closed for one minute 

- all without excessive pain

- athletes can return to sports when they are able to run and pivot without pain while the ankle is braced

- bracing or taping for sports is continued for 6 months after injury




Most return to work by 8/52

20% have pain that limits activity

20 - 40% will have recurrent sprains



Chronic Ankle Instability



Chronic instability due to rupture of one or more parts of the lateral ligament




Progressive injury

1. Anterolateral capsule


3. CFL




Can lead to ankle OA over time


Ankle OA Post Lateral Ligament Instability




Swelling over anterolateral ankle


Giving way with inversion

- occurs with activity & walking on uneven ground

- stiffness, locking, crepitation


Chronic pain is unusual with isolated chronic instability




Tender & swelling over involved ligaments

- anterior to lateral malleolus for ATFL 

- inferior to lateral malleolus for CFL


Limited dorsiflexion


Calf atrophy (especially peroneal)



- depends on ligaments involved


ATFL Instability


1.   Positive Anterior Drawer

- anterior subluxation on anterior drawer of talus on tibia

- ankle in 10° PF


Ankle Anterior Draw


2.  Increased inversion on varus stress with AJ in PF 


CFL Instability


1.  Increased inversion on varus stress with AJ in DF


2.  Positive Talar Tilt


Talar TIlt


ATFL & CFL instability


1.  Increased inversion on varus stress in all positions of AJ


2.  Positive Anterior Drawer and Talar Tilt


Stress Xrays


Plain xray usually normal

- look for OCD

- medial aspect of talus


1.  Talar Tilt 


Best to supervise personally, use lead gloves

- mortise view

- AJ 10o PF

- > 10° side to side difference


2.  Anterior Drawer


AJ 10° PF knee flexed

- side to side diff 3mm

- > 10mm on single film




Will demonstrate tears of ATFL / CFL


MRI Torn ATFL Axial VewAnkle MRI CFL





- tibiofibular synostosis

- stress fractures (calcaneum)

- intra-articular fracture / OCD

- lateral talar process



- syndesmosis strain



- peroneal tendonitis / subluxation / dislocation


Nerve / RSD


Sinus tarsi syndrome

- pain & tenderness over lateral opening sinus tarsi

- inversion injury

- tear of interosseous talocalcaneal ligament

- usually heals but can get synovitis


Mechanical Instability vs Functional Instability



- beyond physiologic range

- >10mm anterior drawer / >10° talar tilt



- ankle giving way during ADL's


Classification O'Donoghue


Grade 1


Partial Tear ATFL or CFL

- incomplete injury

- negative Anterior Draw clinically and on xray

- negative Talar Tilt clinically and on xray


Grade 2


Torn ATFL +/- partial CFL

- positive Anterior Draw clinically and on xray

- negative Talar Tilt clinically and on xray


Grade 3



- positive Anterior Draw clinically and on xray

- positive Talar Tilt clinically and on xray




Non-operative  (90%)


Rehabilitation programme

- strengthen of peronei

- proprioception (wobble board)


Shoe-wear modification with lateral flared heel


Operative Management




Instability with failure of non-operative treatment

Patient not willing to accept the discomfort 




1.  Anatomic repair / modified brostrom

2.  Advancement

3.  Augmentation of repairs


1.  Anatomic Repair / Modified Brostrom



- mid substance repair

- often attenuated 



- restore normal anatomy & mechanics

- no donor site morbidity or weakening


Gould Modification



- suturing extensor retinaculum over ATFL repair


Advantages of modification

- reinforces repair

- limits inversion

- correct STJ part of instability (present in 10%)


Inferior extensor retinaculum anatomy

- laterally arises from anterior surface calcaneum

- medially has 2 limbs - med malleolus & plantar aponeurosis




85% G/E without Gould modification

95% G/E with Gould modification


Poor outcome

1.  Generalised ligamentous laxity

2.  >10 yrs instability

3.  Previous operations

4.  Ankle osteoarthrosis


2.  Fibular advancement of ATFL / CFL




- confirm talar tilt / anterior draw


Longitudinal incision anterior to lateral malleolus

- protect branches of SPN

- expose tissue of ATFL / CFL

- can often feel them

- tissue is broad and diffuse


Lateral Ligament Repair IncisionLateral Ligament Repair Flap Incisions


Dissect out two flaps

- anterior incision between ATFL and CFL to talus

- begins at tip of fibula to talus

- superior flap is ATFL

- take off fibula as broad / thick flap

- inferior flap is CFL

- need to protect peroneals with inferior portion of dissection


First Transverse IncisionATFL FlapInferior CFL Flap


Inspect talar dome for OCD

- place retractor across talar dome

- ensure no loose bodies

- can remove anterior ankle osteophyte if necessary


Place foot in eversion and AJ neutral


Inferior AnchorAnterior Anchor


2 x 3.5 mm anchors in fibula

- ensure not in joint and not prominent

- 4 sutures through ATFL

- 2 through CFL

- 2 sutures either side of interval of ATFL and CFL so can close this


4 Sutures ATFL2 Sutures Inferior Flap2 Sutures to Close Interval


Make sure FROM & anterior drawer is negative at end


Extensor retinaculum is sutured over the site

- over ATFL

- over anterior aspect of fibula


Post op

- weight bear in moon boot for 6/52

- sport 3/12


Ankle Ligament Reconstruction APAnkle Lateral Ligament Reconstruction Lateral


3.  Augmented Repairs



- most use peroneus brevis (PB)



- poor tissue for anatomic repair

- long standing instability

- hypermobile STJ / ligamentous laxity

- previous surgery / revision


A. Chrisman & Snook


Reconstructs ATFL + CFL

- stabilizes the STJ

- preserves 1/2 PB

- most widely used non-anatomic reconstruction


Good results in 90%

- restricted inversion (100%) and dorsiflexion (20%)



- split PB in 2 leaving 1/2 attached to 5th MT base

- drill fibula transversely in AP direction

- drill calcaneus with small tunnel inferior to fibula

- thread tendon from fibula anterior to posterior & then into calcaneus 

- then back onto PB / PL or to PB anterior to fibula


B.  Evans


Tenodesis of PB

- divide proximally

- re-route through drill hole from anteroinferior tip to postero-superior

- pass PB through & suture to proximal end

- will also limit SJ motion


Baltopoulis et al. CORR 2004

- 27 patients, average AOFAS score 91

- 1/3 restricted hindfoot movement


C. Watson-Jones


Attempt to recreate ATFL with PB tenodesis

- detach PB tendon as proximally as possible

- drill hole through fibula transversely 1 inch from tip

- drill second hole through talar neck

- thread tendon through fibular posterior to anterior

- then through talus superior to inferior

- suture back to itself over LM

- limits STJ motion


D. Colville


Anatomic reconstruction CFL and ATFL

- 1/2 PB left attached distally

- through calcaneal tunnel

- to tip fibula tunnel to anterior fibula 8mm proximally

- to talar neck tunnel and back to anterior tibia

- idea is not to restrict STJ movement

Os Trigonum FHL Impingement

Posterior Ankle Impingement




Repetitive plantar flexion

- soccer players, ballet dancers




Os trigonum

FHL stenosing tenosynovitis

Soft tissue mass


Os Trigonum


Secondary centre of ossification of talus

- lateral to groove for FHL

- 2-7% of normal feet

- impinges against plafond with forced PF

- can cause FHL tenosynovitis


Os TrigonumOs TrigonumOs Trigonum




Pain with forced plantarflexion

Pain with resisted FHL





- synovitis over posterolateral process talus

- fluid in sheath about FHL


May also see

- posterior tibia bone oedema

- thickened posterior capsule

- os trigonum




Non Operative


US guided HCLA

- good results reported






1.  Lateral approach



- resection of os trigonum only


2.  Medial approach



- also release of FHL



- incision between medial malleolus and T achilles

- T post, FDL and neurovascular bundle anterior

- release FHL compartment, look for accessory muscle or nodule

- open capsule over os trigonum

- excise

- need to ensure don't damage posterior talus articular cartilage


Os Trigonum Skin MarkingOs Trigonum Skin IncisionOs Trigonum Superfical Dissection


Os Trigonum FHLOs Trigonum FHL Accessory MuscleOs Trigonum Capsule


Os Trigonum ExposedOs Trigonum ExcisedOs Trigonum Posterior Talus Cartilage


FHL Tenosynovitis




Pain behind medial malleolus

Pain with stressing FHL




No os trigonum


Arthroscopic release


FHL Arthroscopic Release 1FHL Arthroscopic Release 2


Subtalar Dislocation








- 80%

- calcaneum dislocated medially



- 20%

- higher energy injury


Subtalar Dislocation Xray 1Subtalar Dislocation Xray 2


Anterior / Posterior

- extremely rare




Tearing of strong interosseous ligament


Dislocation of

- talonavicular joint

- talo-calcaneal




Subtalar dislocationSubtalar dislocation 2


Conscious sedation

- flex knee to relax gastrocnemius

- increase deformity

- reduce calcaneum whilst holding talus


Blocks to reduction

- medially - talar head buttonholes through capsule / EDB

- laterally - tibialis posterior


Post reduction



- exclude intra-articular fragments

- ensure congruent reduction


CT post subtalar dislocationCT post subtalar dislocation 2




Main risk is restricted ROM

- very difficult to treat surgically

- usually stable after reduction

- don't immobilize for long or subtalar joint will stiffen


Risk of osteochondral injury and later OA




Syndesmotic Injuries



High ankle sprain





- often unrecognised or misdiagnosed as lateral ligament injuries

- seen in ice hockey


1-15% of ankle sprains involve the syndesmosis


Mechanism Injury


Hyperdorsiflexion and forced external rotation





- anterior inferior tibiofibular ligament (AITFL)

- posterior inferior tibiofibular ligament (PITFL)

- interosseous ligament (provides only 10% of strength)


Ankle MRI AITFL PITFLSyndesmosis MRI Normal




High Ankle Sprain Clinical


1.  Tenderness over the AITFL


2.  Positive squeeze test 

- pain at ankle with squeezing the tibia & fibula at mid-calf


3.  Painful ER

- probably most reliable test

- neutral ankle with knee flexed 90o

- hold tibia in neutral

- externally rotate foot




Usually is no evidence of syndesmotic widening


Ankle AP Xray Syndesmotic MeasurementsAnkle Mortice Xray Syndesmotic Measurements


3 reliable indicators of syndesmotic widening


1.  Clear space 

- between the medial border of the fibula and the lateral border of the posterior tibia (incisura fibularis)

- measured 1 cm above the plafond

- distance should be approximately 5 mm or less on both the AP and mortise views in the normal ankle 


2.  Overlap of the fibula and the anterior tibial tubercle

- greater than 6 mm on the AP views

- greater than 1 mm on the mortise view


3.  Stress films for syndesmotic instability

- application of an external rotation and abduction force

- anesthesia is often required because of the painful nature of this examination


Syndesmosis stress view




May see HO / MO interosseous ligament


Ankle Interosseous HO






CT Syndesmosis normal




Highly accurate

- see disruption of ligament

- bone contusions posteromedial talus and posteromedial tibia


High Ankle Sprain MRI 1High Ankle Sprain MRI 2


Syndesmosis Injury T1Syndesmosis injury T2




Inspect the syndesmosis under external rotation stress test

- see widening > 2mm between tibia and fibula

- can also visualise AITFL and PITFL

- often a tibial chondral injury




1.  Xray evidence of widening


Syndesmosis InjurySyndesmosis TightropeSyndesmosis Tightrope 2



- diastasis screw / tightrope


2.  Syndesmotic injury with no widening


Takes 6 - 12 weeks to resolve

- impossible to strap

- WBAT but no impact sports 6 weeks


3.  Chronic injury / pain


Ogilvie-Harris Arthroscopy 1994

- arthroscopic debridement of sydesmosis and chondral injuries in 19 patients

- good results reported

- elimination of external rotation test



Ankle Osteoarthritis

AetiologyAnkle OA




A. Ankle Fracture


- Weber A 4%
- Weber C 33%
- Displaced large posterior malleolar


Any OA develops in first 2 years



- articular damage at time of injury
- non anatomical reconstruction
- complications i.e. infection


B. Plafond Fracture


C. Talus Injury


Talar Dome OCD

Talus AVN

Talar neck malunion




Inflammatory OA








Ankle OA much lower than hip or knee




Thin cartilage 1 mm


Joint highly congruent


Tibio-talar contact stresses
- 1mm shift causes 40% decrease in contact area
- medial instability more important than lateral instability





- with weight bearing

- nightime


Stiff Ankle Joint




Ranges from

- anterior spurring

- severe OA


Ankle Xray Anterior Tibial OsteophyteAnkle OA Kissing Spurs


Ankle OA AP XrayAnkle OA Lateral Xray




Useful to define small anterior osteophytes

- may be causing pain with excessive dorsiflexion


Ankle CT Anterior Osteophyte




Ankle OA MRI


Ankle OA Coronal MRIAnkle OA Sagittal MRI




Non Operative


Solid Ankle Foot Cushion (SACH) + rocker bottom sole


HCLA / Hyaluronic acid Injections


Operative Options


1.  Arthroscopic debridement


Technique 1

- debride chondral lesions
- microfracture / abrasion


Ankle Scope Medial OA


Technique 2

- removing kissing osteophytes

- anterior tibial and talar neck osteophytes


Ankle Spurs with Anterior ImpingementAnkle Scope Anterior Tibial OsteophyteAnkle Scope Osteophyte Debridement


2. Articular distraction with external fixator



- apply for 4/12
- distracted 5 mm
- reasonable results reported
- up to 3 years improvement
- delays arthrodesis


3.  Ankle Arthrodesis


4.  Ankle Replacement



Calcaneal Fractures




3 facets


1.  Posterior facet (STJ)

2.  Middle facet (sustenaculum tali)

3.  Anterior facet (on distal medial aspect)


Anterior process 

- forms calcaneocuboid (CCJ) articulation


Thalamic portion 

- under lateral process talus




Posterior tuberosity 

- posterior process / T Achilles attachment


Medial tuberosity 

- ABDH, FDB, plantar fascia, ADM, Flex Acc


Lateral tuberosity

- ADM, long plantar ligament, Flex Acc




Usually fall from height

- heel in valgus


Lateral process talus strikes Crucial Angle Guisanne 

- primary fracture line

- calcaneus driven up against talus




Direct blow


Essex-Lopresti Classification


A.  Extra-Articular  (25%) 


Anterior Process fracture

Avulsion of Posterior Tuberosity

Medial & lateral Tuberosity

Sustentaculum Tali

Extra-articular body fractures


B.  Intra-Articular (75%) 



- 10% bilateral

- 10% associated with lumbar spine fracture


Primary Fracture Line of Palmer

- lateral process of talus driven into crucial angle

- starts at lateral wall near tarsal sinus at crucial angle (in coronal plane)

- passes obliquely across posterior facet

- position of line within the posterior facet variable

- may be medial towards S Tali, middle or lateral towards wall   

- exits at medial wall posterior to sustentaculum tali


Produces 2 main fragments


1.  Tuberosity / Lateral wall / Variable amount posterior facet

- usually comminuted

- usually displaces superiorly & laterally


2.  Sustentaculum / Anterior / Middle facet

- usually undisplaced



- based on appearance of secondary fracture line on lateral X-ray


1.  Tongue type (20%)

- secondary fracture line passes posteriorly along calcaneal body to exit laterally below T Ach          

- tuberosity fragment attached to articular fragment (thalamic fragment)


Calcaneal Fracture Tongue TypeCalcaneal Fracture Intra-articular


2.  Joint Depression (80%)

- secondary fracture line also exits posteriorly

- passes immediately behind the posterior facet of the subtalar joint              

- exits posterior to posterior facet & anterior to T Ach insertion

- creates thalamic portion containing posterior facet


Calcaneal Fracture Joint Depression


Fracture Anatomy


1. Sustenacular Fragment

- constant

- supero-medial 

- attached to talus by deltoid lig


2. Superolateral fragment

- thalamic fragment

- lateral fragment of posterior facet


3. Lateral wall fragment


4. Tuberosity fragment

- posterior heel






Lumbar spine

- log roll

- injury in 10%


Other heel

- 10% bilateral



- compartment syndrome



- loss heel height

- increased heel width

- varus heel


X-ray Views



- Bohler's angle

- crucial angle Guisane


Calcaneal Fracture Lateral


Harris axial views

- 45o axial of heel

- normally hindfoot 10o of valgus

- view varus malalignment & heel width


Calcaneal Fracture Harris Axial ViewCalcaneal Fracture Harris Axial View


Oblique view



Calcaneal Fracture Oblique Xray


Broden's view

- visualise posterior facet

- IR foot 45 degrees with ankle neutral initially

- plantar flex the foot 10° increments from 10° to 40

- alternatively angle beam cephalad in 10 degree increments

- replaced by CT

- useful intra-op to assess congruency of STJ


Xray Angles


1.  Bohler's angle  (20-40°)


Highest point on anterior process to highest point on posterior facet to highest point on tuberosity

- represents the height of the calcaneus

- angle of </=0° is associated with a poor outcome



- the posterior facet/ STJ  has collapsed

- proximal displacement of tuberosity


Calcaneum Normal Bohlers AngleCalcaneal Fracture Reduced Bohlers Angle


2.  Crucial Angle Guisane 120-140°

- lies inferior to lat process of the talus

- where the primary fracture line starts

- disrupted in joint depression fracture


Formed by 2 cortical struts

a) lateral border of posterior facet

b) anterior to beak of calcaneus


Thus see

- decrease in Bohlers angle

- increase in Gissanes angle 


CT scan


3 mm cuts

- foot flat on table

- transverse and coronal

- sagittal reconstruction


1. Axial

- parallel to bottom of foot

- information regarding CCJ & sustentaculum


Calcaneal Fracture Axial CT


2. Coronal plane

- perpendicular to posterior facet

- information regarding posterior facet and number of fragments +

- sustentaculum / heel shape / position peroneal & FHL tendons


Calcaneal Fracture Coronal CT


3.  Sagittal

- Bohlers angle / depression of posterior facet


Calcaneal Fracture Lateral CTCalcaneal Fracture Lateral CT


Sanders Coronal CT Classification



- calcaneum divided into 3 columns by 2 lines

- based on lateral, central & middle columns of posterior facet

- number of longitudinal fracture lines on coronal CT through post facet



- patient positioned supine in scanner with hips & knees flexed 45°


Type I 

- undisplaced, irrespective of number of parts

- cast


Type II 

- 2 parts of the posterior facet

- > 2mm displacement

- subgroups A,B,C based on primary fracture line

- more medial the fracture line (C), the more difficult to ORIF


Calcaneal Fracture Sanders 2


Type III 

- 3 part (AB, AC, BC)

- ORIF / fusion


Calcaneal Fracture Sanders 3 CT


Type IV 

- highly comminuted

- primary fusion




Wound necrosis


Superficial infection 17%


Sural nerve neuroma


Intra-articular hardware penetration


Compartment Syndrome 10%


Deep infection

- Debridement and removal of metalwork

- Free flap over Abx beads, IV ABx

- Late grafting and STJ OA






Non union


Heel pad problems




- may require arthrodesis




Calcaneal Malunion


Stephens and Sander's classification



- varus hindfoot locks Midfoot

- shortened foot / shortened lever arm

- peroneal impingement

- shoewear problems




1.  Lateral wall exostectomy and peroneal tenolysis


2.  Above + STJ arthrodesis


3.  Above + calcaneal osteotomy

- this may not allow the wound to be closed

- may need to do so gradually with frame





Management Extra-articular Fractures

1.  Anterior process


Part of complex sprain / easily missed

- non operative if small

- ORIF if large and displaced


2.  Tuberosity fractures


Need ORIF if displaced

- have T Achilles attached and can put skin under threat

- ORIF (usually closed reduction and screw)


Calcaneum Tuberosity Fracture


3.  Body fractures


Non operative treatment


4.  Sustentacular fractures


Sustenaculum Fracture CT 1Sustenaculum Fracture CT 2


ORIF if displaced

- medial approach with buttress plate




Management Intra-articular Fractures

Operative v Nonoperative Literature


1.  Buckley etal JBJS Am 2002


Prospective multi-centred RCT

- 309 displaced intra-articular fractures

- operative v non operative management

- 2 year follow up



- used patient orientated functional outcomes

- overall VAS and SF36 not significantly different between 2 groups


Improved Operative Outcome if

- not workers compensation

- women

- < 29

- bohler's angle 0 - 14 initially (not -56 to -1)

- light workload (not heavy manual worker)

- anatomical reduction < 2mm (CT of post facet)

- type 2 sanders (types 3 and 4 did not)



Any patient who required a subtalar arthrodesis to relieve pain was removed from the study.  

A non operatively treated patient was 5.5 x more likely to need this operation!



- 5% deep infection

- 17% superficial infection

- STJ arthrodesis: non operative 17%, operative 3%


2.  Sanders 1993


Heel shape restored in 98+%

- Type II - 85% reduction and 75% good results

- Type III - 60% reduction and 70% good results

- Type IV - no anatomical reduction and 10% good results



Sanders classification gives guide of prognosis

Once posterior facet is in more than 3 parts, good outcome decreases drastically


3.  Stulik etal JBJS Br 2006


287 displaced intra-articular fractures

- 1 year follow up

- Sanders 2, 3, 4


Any patient excluded from ORIF but amenable to OT

- DM / smokers / vascular insufficiency / compound wound / severe fracture blisters



- MUA & Gissane spike percutanous reduction

- additional K wires



- 16.5% excellent, 55.7% good

- 14.8% fair and 13% poor

- Sanders 2 > 4



- 1.7% deep infection

- 7% superficial infection

- nil amputation



There are intermediate options between ORIF and non operative

- with the ability to somewhat restore heel height and width

- in high risk patients who cannot have ORIF

- probably makes subsequent fusion easier


4.  Poeze et al JBJS Am 2008


Calcaneal volume load v outcome

- centres with higher volume load

- reduced rates of deep infection and subsequent subtalar arthrodesis


5.  Heller JBJS Am 2003


43 compound calcaneal fractures

- wound usually medial



- no infections in 7/7


Type II 

- 3/8 infection



- 3/12 infection



- 10 /13 infection 

- 6 /13 became deep osteomyelitis

- 3 required amputation



- very dangerous to ORIF anything other than Type I compound fracture

- a quarter to a third of type II and IIIA will get a deep infection

- absolutely not in any patient who will need a flap


6.  Folk et al JOT 1999


If patient had DM + PVD + smoker, wound problem rates > 90%


5. Rodger Atkins AOA 2000


Salvage arthrodesis very difficult

- always better to attempt reconstruction initially even if just to make arthrodesis easier

- alternative is Primary Arthrodesis


6.  Wei et al. Medicine 2017


Meta-analyis of operative v non operative for displaced intra-articular fractures

- 8 RCTs, 10 controlled trials, 1467 patients

- 4 studies used AFOS outcome measure, with no difference

- no significant difference in pain or shoe wearing

- operative group more likely to return to work

- complication rate of 26% in the operative group, significanlty higher









Pain free functional foot that can fit in a shoe




1.  Restore heel shape (height, length and width)

2.  Reduce joint surface




1. Non-operative


3. Primary STJ arthrodesis

4. Salvage / STJ arthrodesis




1.  Patient factors



- higher incidence infection

- try to get them to stop



- high risk of infection


Heavy manual workers 

- will find it difficult to return to work


Bilateral fractures

- do worse



- women do better



- younger do best


2.  Soft tissue envelope


Compound fractures

- wound medial

- operative for Type 1


3.  Fracture type


Bohler's angle

- if less than 0o initially, do poorly however managed



- prognostic (type I do well, type IV high rates fusion)

- lateral wall fragments easier to fix (2A)

- very medial fractures (2C) very difficult



- Bohler's angle

- Posterior facet / Sanders

- CCJ joint

- lateral wall fragment

- sustentaculum fragment

- tuberosity / heel in valgus


4.  Surgeons experience


Non Operative Management



- non displaced

- Bohler's > 20

- Sanders IV


- compound fracture Type 2 & 3 



- elevate +++


- NWB 6/52

- Then progressive WB




- peroneal impingement or subluxation

- calcaneocuboid arthritis

- malunion of hindfoot

- posterior tibial nerve entrapment

- difficulty with show wear





- healthy patient

- ? smoking

- Saunders II / III

- Bohler's < 20o

- displaced tongue type fractures



- severely comminuted sustentaculum tali

- type IV


Needs to be an individualised approach with risk stratification



- Bed rest, elevation, ice & compression till skin wrinkles evident

- between 1 week and 4 weeks



- clear fluid (some epidermis attached to dermis)

- bloody fluid (no epidermis attached to dermis)

- shown that there is some increased risk of wound problems if incision passes through blisters


1.  ORIF  


Calcaneal ORIFCalcaneal ORIF LateralCalcaneal ORIF Axial





- patient on side, blankets under foot

- operated foot up

- radiolucent table, II available

- GA, IV Abx, tourniquet



- extensile lateral approach

- behind posterior edge of fibula

- anterior to T Achilles

- sural nerve posteriorly in flap

- along borders of calcaneum (Abd H below)

- keep distal cut along inferior margin calcaneum

- angle up towards CCJ


Superficial dissection

- elevate full thickness flap with peroneal tendons

- down to bone

- divide CFL

- K wires to retract skin flap

- 2 in talus / 1 in fibula

- expose CCJ



- calcaneal artery

- branch of peroneal artery


Steinmann pin to tuberosity 

- through heel skin

- can elevate and pull out of varus


Hinge lateral wall fragment 

- opens on posterior / inferior periosteum

- gives access to subtalar joint

- if type 2C may need lateral wall osteotomy

- divide interosseous ligament 

- homan or lamina spreader to expose STJ



- Reduce medial fragments and work laterally


1. Restore posterior facet with screws

2. Restore calcaneum height and Bohler's by reducing tuberosity fragment

3. Pull out of varus

4.  Reduce posterior facet & lateral joint fragment onto sustentaculum fragment

- golden screw

- 3.5 mm screw

- aimed anteriorly, medially and slightly upwards

5.  Elevate anterior process fragment

6.  Locking contoured plate


Intra-operative II

- lateral

- Broden's view



- careful haemostasis

- closure over drain

- elevate +++ for one week


Post op

- NWB 12 weeks

- early ROM exercises once wound healed (2-4 weeks)


2.  Essex-Lopresti closed reduction and percutaneous pinning 



- tongue type fractures 

- joint depression fractures not suitable for ORIF

- compound fractures


A.  Technique 1 for IA Fractures



- patient prone with knee flexed


1st steinmann pin (if comminuted IA)

- from medial to lateral through body

- traction to restore height

- correct varus

- manually compress heel to reduce lateral wall displacement


2nd steinmann pin

- Posteromedial corner of posterior tuberosity

- aim towards sole and towards CCJ

- under thalamic portion, then lever pin dorsally

- aiming to correct Bohler's

- then aim towards CCJ and can even pass through


Incorporate 2 pins into plaster

- remove after 6 weeks


B.  Technique 2 Stulik et al JBJS Br 2006 for IA Fractures


Calcaneal Fracture Percutaneous Pinning


Transverse Steinmann as above

- disimpact fragments

- pull out of varus


Plantar stab incision

- posterior facet elevated with bone punch


Longitudinal Steinmann pins x 2

- elevate and hold thalamic portion


Transverse K wires under posterior facet



- 1.7% deep infection

- 7% superficial infection


C.  Technique 3 for IA fractures


Percutaneous screws + Ilizarov


D.  Technique 4 Stulik et al for tongue type


Reduce tongue with longitudinal Steinmann


Fix with 2 mm K wire / screws


Calcaneal Fracture Tongue TypeCalcaneum Fracture Tongue Type ORIF


3.  STJ Arthrodesis



- type IV Sanders

- late STJ OA



- ORIF with lateral plate

- 2 x 6.5 mm screws



- In setting on previous fracture very difficult

- Still have to restore anatomy

- restore heel height & width 

- may have skin problems if have very planovalgus foot

- may need lateral bone block

- need lateral wall ostectomy


Calcaneal Fracture OA FusionCalcaneal Fracture OA Post Fusion




Charcot Foot


Charcot Joint

Charcot Foot AP Charcot Foot Lateral




Neuropathic Arthropathy


Progressive destructive arthropathy 2° to neurological condition

- usually minimal to no trauma





- western world


Leprosy / syphilis

- third world



- polio

- paraplegia

- syringomyelia




Likely combination of :


1.  Neuro-traumatic theory

- cumulative trauma in insensate foot unrecognised

- results in progressive joint destruction


2.  Neurovascular theory

- neurally stimulated vascular reflex

- stimulates bone resorption


Newer theory: due to inflammatory cytokines

(TNF Alpha & IL-1) = stimulates osteoclast resorption  


Classification Temporal - Eichenholtz


Sidney N Eichenholtz, American surgeon, 1966


Stage 0


- added by Shibata et al 1990

- clinical signs (swelling/ erythema) precede XRay changes

- NWB during this period may prevent XRay changes


Stage 1 Dissolution



- acute inflammation (swollen, red, warm)

- DDx infection

- erythema reduces with elevation 10 minutes


Charcot FootCharcot Foot Elevated



- demineralisation of regional bone

- periarticular fragmentation

- joint dislocation

- hyperaemia precedes fragmentation by hours to weeks


Charcot Foot Stage 1 Fragmentation



- TCC remains gold standard

- WBAT ; no evidence that better outcomes with NWB

- applied weekly until clinical progression to stage II

- frequency of application may decrease as progress


Stage 2 Coalescence



- inflammation decreases / less swelling

- reduced temperature



- absorption of osseous debris

- organization and early healing of fracture fragments

- periosteal new bone formation


Charcot Foot Stage 2 Resolution



- TCC or transition to CROW (Charcot Resistant Orthotic Walker)i.e bivalved AFO

- may need to modify CROW a number of times before stage III




Stage 3 Reconstruction



- normal temperature

- swelling reduced

- clinically stable



- smoothing of edges

- sclerosis, osseous or fibrous ankylosis

- complete bone healing 

- resolution of osteopenia


Charcot Foot Stage 3 Consolidation



- accommodative shoes with custom moulded orthotic

- CROW or AFO if ongoing ankle instability



- 30% will relapse between stages

- 7% risk of BKA without ulcer

- 28% risk of BKA with ulceration


Classification Anatomical - Brodsky


James Brodsky; Orthopaedic F&A Surgeon; Dallas Tx ; 1993


Type 1 Midfoot (60%)

- metatarsocuneiform and naviculocuneiform

- collapse of the medial longitudinal arch with rocker bottom foot

- progress through Eichenholtz stages quicker

- may present stage III with bony prominences & DFU


Charcot Midfoot


Type 2 - Hindfoot (30%)

- any / all subtalar joint i.e TNJ; subtalar; calcaneocuboid

- more instability than type 1

- require longer periods immobilisation

- varus or valgus


Charcot Hindfoot


Type 3 (10%) 


- tibiotalar joint

- usually post ankle fracture

- most unstable pattern



- pathologic fracture calcaneal tubercle

- weak push-off and ulceration




DDx infection


- combination labelled WCC + Bone Scan if MRI CI






Stable plantigrade foot that is shoe-able or braceable


Few require operative surgery

- control with casts and braces


Indications For Surgery 


1.  Severe deformity unable to brace


2.  Marked instability (usually type II or IIIa)


3.  Ulcers

- common type 1

- aim to try and heal ulcer first

- may be caused by fixed bony deformity i.e. midfoot collapse


4.  Soft tissues at risk




Uncontrolled diabetes


Medically unwell

Stage 1 disease


Goals of Operative Management


Restore alignment & stability so brace &/or shoe can be worn

- prevent alternative which is amputation


Timing of Surgery


Operating in stage 1 or 2 remains very controversial


Correct deformity in resolution / consolidation stage III 

- after cast / brace, shoe failed


Acute Fractures



- is it charcot or non charcot?


1.  Likely Charcot



- fracture a week or 2 old / red & swollen

- peripheral neuropathy & displaced fracture

- mimimal trauma


Eichenholtz I

- treat non-operatively


2.  Non Charcot 


Truly acute fracture

- reasonable trauma

- patient has peripheral neuropathy / DM

- treat as per usual, but accept higher complication rate



- ORIF early before acute (dissolution) phase sets in

- if delayed be wary of ORIF as bone stock very poor

- need very strong and augmented ORIF

- must warn of risk of Charcot in acute fracture

- with peripheral neuropathy double period of immobilisation

- NWB 3/12 then further 3-4 month in TCC


Surgical procedures


1.  Midfoot ostectomy


Charcot Midfoot CollapseNeuropathic Ulcers from midfoot collapse


Midfoot most common site for neuropathic destruction

- mid foot collapse 

- apex of rocker-bottom common site for recurrent ulceration


Technique Ostectomy


1.  Attempt to heal ulcer first


- debridement +/- IV ABs if OM


2.  Remove bony prominence causing ulcer

- medial or lateral incision

- avoid areas of ulceration

- full thickness soft tissue dissection to expose exostosis

- remove with osteotome / saw

- smooth edges with rasp

- haemostasis

- closure over drain; compressive dressing

- postoperative TCC for 6/52


2.  Hindfoot Realignment & Arthrodesis



- hindfoot Charcot not amenable to bracing 

- severe deformity or instability following failed bracing

- amputation is only alternative


Amputation v Arthrodesis


May develop bilateral issues

- try to avoid bilateral amputations


Contraindications to Arthrodesis

1. Disease Factors

 - Active infection (consider staged)

 - Stage I Eichenholtz

 - Insufficient soft tissue coverage

 - Insufficient bone stock

2. Patient Factors

 - Uncontrolled DM or malnutrition

 - Nonreconstructable PVD 

 - Non-compliant  





- cast / TCC till Stage III

- optimise HBA1c and nutrition



- longitudinal incisions with full thickness flaps under no tension

- meticulous soft tissue handling

- resect bone to correct deformity

- strongest fixation device possible ; often augmented

- if using hindfoot nail ensure >200mm length

(risk of tibial stress fractures with shorter nail)

- often need percutaneous T Achilles lengthening

- alternative: fine wire fixation if active infection



- TCC - 3/12 NWB ; 1/12 PWB; 1/12 WBAT

- Lifelong AFO

- Periodic 6/12 follow-up



- Lowery FAI 2012 - 76% bony fusion; 22% fibrous ; 1.2% amputation

- fibrous union can still result in good function

Total Contact Cast

Total Contact Cast 1Total Contact Cast




TCC’s heal ulcers by reducing pressure

- 1/3 of load is taken by wall of cast & transmitted to the leg

- 45% reduction in forefoot pressure but not heel pressure


Works best if closely applied & moulded to leg




Protection from trauma


Reduce oedema

Reduce pressure over ulcers

Redistributes pressure over a greater weight bearing surface




1.  Superficial forefoot and midfoot plantar ulceration


Neuropathic Midfoot Ulcers


Deeper ulcers with exposed tendon & bone

- require surgical debridement to convert them to superficial ulcers prior to TCC


2.  Eichenholtz stage I or II neuroarthropathic fractures


3.  Post operative neuropathic foot surgery

- post-op immobilisation after ORIF of acute fractures

- after reconstruction of deformity




1.  Heel ulcers

- not effective

- heel ulcers typically have ischaemic component & osteomyelitis

- TCCs don’t reduce heel pressure


2.  Deep infection

- abscess, osteomyelitis, gangrene

- beware of ulcer with drainage


Treat infection with rest in bed / NWB / Antibiotics


If ulcer is deeper than wide

- surgically debride to open ulcer

- allow deeper layers to heal & convert to superficial ulcer


3.  Poor skin quality

- especially if on steroids or have stasis ulcers


4.  Severe arterial insufficiency (pre-gangrenous feet)

- ABI < 0.45

- Doppler toe pressure < 30mmHg

- TcPO2 < 30


5.  Poor patient compliance

- must attend follow up & follow cast precautians


TCC Application




TCC Toe PaddingTCC Padding Bony Prominences



- absorbent gauze on ulcer

- enclose the toes with gauze between toes to reduce moisture

- seamless stocking

- felt over bony prominences

- avoid overpadding the cast / increases shear forces

- well moulded POP / fibre glass


Post Application Protocol


First 6 weeks

- change weekly

- because oedema subsides quickly

- photos of ulcer at each change


Then 2 weekly

- until ulcer healed / Stage 2 Charcot


6 months / orthosis

- CROW (Charcot restraint orthotic walker)




Compartment Syndrome Foot



10% of calcaneus fractures 

40% of crush injuries




High index of suspicion / classic signs less reliable


Pain & pain with passive stretch remain the cardinal signs

- pallor, paresthesia, pulselessness, & paralysis occur later or sometimes not at all

- low threshold calcaneal compartment pressures & surgical exploration




Nerve supply sole of foot


1.  Medial calcaneal 

- posterior weight bearing surface


2.  Medial plantar

- medial 3 & 1/2 sensation

- AbdH, FHB, 1st lumbrical


3.  Lateral plantar

- lateral 1 & 1/2 


4 muscle layers of the foot


Layer 1 (3)

- 3 short muscles that cover the sole

- AbdDM, FDB, AbdH


Layer 2 (3)

- long tendons to the digits

- FDL, Flexor accessorius, FHL


Layer 3 (3)

- short muscles of the digits



Layer 4 (3)

- plantar / dorsal interossei and tendons

- P longus, T posterior & interossei


4 Compartments


Septae from the plantar fascia

- insert 1st and 5th metatarsals

- separate medial / calcaneal and lateral compartments


1. Medial 



2. Central / Calcaneal compartment

- superficial: FDB

- deep: ADDH / F accessorius


3. Lateral 



4. Interosseous 

- interossei


The calcaneal compartment communicateswith the deep post compartment of the leg through the medial retro-malleolar space




3 incision emergent decompression


Two dorsal longitudinal incisions

- medial aspect of the 2nd MT

- lateral aspect of the 4th MT 

- release interossei compartments


One 6-cm medial incision

- begins at the post margin of MM

- distally along the sole 

- open ABDH & 1st MT interval

- release medial / calcaneal / lateral compartments

- DPC or split-thickness skin grafting at 5 days


Non Treated Compartment Syndrome



- claw toes

- cavus

- FDL tethering


DDx / Posterior leg compartment syndrome / FDL involvement

- if the deformity decreases with PF of ankle

- FDL muscle & deep post compartment of leg are involved


Diabetic Foot


Diabetic Foot Pathophysiology 


1. Neuropathy

2. Arteriopathy

3. Immunopathy




Most important aetiologic factor in foot disease. Due to : 

- metabolic (glycosylation of nerves)

- ischaemic factors 


A.  Sensory Neuropathy



- loss of protective sensation - level of sensory loss allows damage to occur without being “painful”



- stocking i.e. affects longest fibers first



1) Semmes Weinstein 5.07 monofilament

- applies 10gm of force

- defines the presence & severity of neuropathy 

- tip pressed against skin until starts to bend; patient asked if they can feel it

- no standardized number of testing sites

- 90% of patients who are able to feel won’t ulcerate


2) 128 Hz Tuning Fork

- Less predictive of ulceration


B.  Autonomic Neuropathy


20 – 40% of Diabetics

- skin dry / scaly / Cracked  

- easier access for bacteria


C.  Motor Neuropathy


Loss of intrinsic muscle balance = claw & hammer toes

- Achilles tendon contraction = MT head pressure 

- Results in IPJ dorsal & MT head plantar ulcers




50% of diabetic foot ulcers (DFU) have arteriopathy 

- large and small vessel disease 


Vascular Foot


A.   Large Vessel Disease


Different disease pattern to non-DM population:

- younger onset

- more rapidly progressive

- above and below knee (non-DM below knee rare)

- typical location at or just distal to popliteal vessels

- more diffuse with longer occlusions       



- vascular claudication

- rest pain

- nonhealing or hindfoot ulcer


B.  Small Vessel Disease



- primarily responsible for retinopathy / nephropathy

- may contribute to delayed ulcer healing




Good BSL control improves healing  (less microbial growth;

no impaired chemotaxis)


Nutrition affects wound healing; predictive indices 

- total protein > 6 g/dl or 60 g/L

- albumin > 3.5 g/dL or 35 g/L

- lymphocyte count > 1500 /mm3

- transferrin < 200mg/dl


Diabetic Foot Complications

1)   Diabetic Foot Ulcers (DFU)

2)   Diabetic Foot Infections

3)   Charcot Arthropathy (refer to separate section)


1. Diabetic Foot Ulceration (DFU)


Rule of 50s -

50% DM admissions 

50% of all leg amputations

50% involve major level (BKA or AKA)

50% coexisting vascular disease

50% contralateral amputation 5 years

50% mortality 5 years (higher than breast and prostate ca)


85% of diabetic amputations involve DFU


2. Diabetic Foot Infection




1) Acute & Mild Infections

- usually monomicrobial

- commonly S Aureus, Strep

- Up to 30% of DFU hospitalized patients MRSA  


2) Chronic & Severe

- more likely polymicrobial

- G + Cocci (Staph; Group B Strep)

- G - (E Coli; Pseudomonas)

- Anaerobes –in ischaemic Limbs; Eg Bacteriodes Fragilis


Workup of Diabetic Foot 


Diabetic Foot History



- duration 

- episodes of infection

- mobility level 

- prior treatments (wound care; shoe-wear) 


Diabetic Control

- HbA1c

- end organ disease (vascular; cardiac; retinopathy; neuropathy; nephropathy)  





- shoes – fit, material, wear-pattern

- bony prominences / deformity

- ulcers

   size, depth, granulation tissue, deep structures, cellulitis

- toenails - ingrown, thickened (vascular/ fungal)



- pulses / capillary refill

- temperature (Charcot)



- anterior and lateral compartment mm power (for balancing transfers)  


Special Tests 

- Silfverskiold Test (need for TAL) 

Diabetic Amputations

Risk FactorsToe gangrene

- DM > 10 years

- chronic hyperglycaemia

- impaired vision or joint mobility

- lack education

- increasing age

- previous amputation



- blood flow

- soft tissue envelope

- deformities / Charcot collapse

- sensation

- contractures - Achilles tendon, knee, toe

- rehab goals


Selection of Level


Aim is to preserve foot

- BKA leads to contralateral BKA in 1/2 in 5 years


'Biologic Amputation Level'

- most distal functional amputation level with reasonable potential for wound healing




No tourniquet


Cover with IV Abs 10 days then oral until wound healing


2 stage procedure


No sharp corners on bone


Long plantar flap if available 

- otherwise fish mouth

- tensionless flap

- sutures 8/52

- non constrictive dressings


Delay Weight bearing and prosthesis






Try & leave base proximal phalanx


If complete toe amputation 

- proximal to metatarsal neck



- must stabilise sesamoids or they retract & expose base MT


2nd toe 

- avoid because get severe hallux valgus

- may need to fuse 1st MTPJ




Most useful for 1st or 5th ray

- central ray resection takes a long time to heal if wound left open

- avoid multiple ray amputations 

- often difficult to close wounds after ray amputation & may need to leave open rather than close under tension


Fifth ray 

- racquet for toe and then straight lateral

- preserve base of fifth (P brevis)


Transmetatarsal amputation 



- toe filler only, no shoe modification


A.  Lisfranc

- preserve base 5th MT

- leave PB attach


B.  Chopart

- reattach T Ant and T Post to neck of talus

- post op cast in dorsiflexion


Late equinovarus

- percutaneous TA lengthening

- 2 medial and one lateral

- in theory leaves more intact laterally

- +/- lateral transfer of Tibialis Anterior




Talectomy & calcaneotibial arthrodesis

- forward translation of the calcaneus

- similar flaps to Symes but longer

- Occasionally in children

- Poor in adults




Talectomy & vertical osteotomy of calcaneus 

- osteotomy thru midbody then forward rotation of calcaneum to appose tibial plafond

- good in kids, too long to unite / heal in elderly




Ankle disarticulation preserving heel pad




1.  Able to go to toilet in night without prosthesis

- can ambulate short distances if need


2.  Bulb makes the socket self suspending



- cosmetically poor because stump is very wide 

- many women unhappy with cosmesis


Partial Calcanectomy 



- for non-healing heel ulcers associated with vascular insufficiency 

- not so severe that wound won't heal



- ulcer excised & longitudinal incision proximal & distal

- T Achilles reflected

- all of posterior process of calcaneum excised

- this makes skin closure easy

- T Achilles can't be reattached & is left free

- patient must wear rigid AFO style partial foot prosthesis with cushion heel long term




Long posterior flap now standard

- previously always 6 inches from knee joint but trend now is to make as long as possible 

- avoid distal 1/3 as poor soft tissue coverage & padding


Posterior flap length is equal to diameter of limb at level of bone cut plus 1cm

- fibula is cut 1-2cm shorter

- don't perform tibiofibular synostosis 

- usually get painful non-union 

- gastrocnemius myodesis 


BKA AP XrayBKA Lateral Xray







Perfusion Estimation


1. ABI



- use doppler US & BP cuff

- systolic BP at ankle & arm

- ABI = Ankle / Brachial


Normal Range

.9 – 1.3


Measurement in DM

- may be falsely elevated due to calcification of media

- “trusted when low but not high”

- <.9 suggestive of PVD

- <.7 severe PVD


2. Transcutaneous O2 Measurement  (TcPO2)


Measured by electrode placed on warmed foot

- affected by oedema/ infection / neuropthy

- <25 mmHg = unlikely to heal


3. Toe Blood Pressure


Measured by plethysmography

- >30 mmHg = good wound healing potential

- Less sensitive / specific than TcPO2




 If foot pulses are absent / asymmetric


Osteomyelitis Imaging


1. X-Ray


- may not show changes in early stages (<14 days)

- later Stages - Triad– Osteolysis, periosteal reaction, bone destruction


2. MRI


Most sensitive imaging for diabetic foot infections



- bone oedema

- abscesses (Low Signal T1; Gad Ring enhancement)




Stable, shoe-able plantigrade foot


Multidisciplinary approach


Multidisciplinary foot clinics (MDFC) 1st established UK 1980s

- shown to significantly reduce rate of diabetic amputations

- involve:


Endocrinologist +/- diabetic nurse

- glycaemic control crucial



- non-surgical debridement

- orthoses


Orthotist / Plaster tech


Vascular surgeon

- referral if absent or asymmetrical pulses


Orthopaedic surgeon


- foot reconstruction; amputations


Infectious Disease Consultant

- infected / nonhealing ulcers


Diabetic Foot Care


Foot Hygiene

- daily wash with mild soap & warm water

- powder between toes & moisturiser to ankle

- plain cotton socks inside out (2 socks ↓shear)

- minimum tds inspection

- report immediately all blisters / ulcers & unilateral warmth / swelling (Charcot’s fractures)

- no walking barefoot


Shoes / Orthoses

- custom made orthoses and shoes reduce DFU recurrence 1

- shoes should be

wide/ deep/ round toe box

soft leather (hard materials irritate)


no/low heel









1.  Diabetic Foot Infections

(Therapeutic Guidelines; Version 15; 2015)


A.  Mild Cellulitis (+/- Ulcer)


Combination oral Abx

- Augmentin Duo Forte

OR Cephalexin PLUS Metronidazole 

OR Ciprofloxacin PLUS Clindamycin (Penicillin Allergy)

- offload ulcer (crutches, custom orthotics )


B.  Severe Cellulitis (+/- Ulcer)


IV Abs (Timentin or Pip-Taz; IV Cipro + Clind for Penicillin Allergy)

- Offload Ulcer


C.  Ulcer with Osteomyelitis



- probe-to-bone test (Positive predictive value .57; Negative Predictive Value .98) 2

- plain films (low sensitivity; particularly early stage)

- MRI (high sensitivity and specificity; with plain films Ix of choice)

- Tc Bone Scan + Labelled WCC (if MRI contraindicated)


Management OM

- consider debridement & intra-operative deep MCS (more accurate)



- broad spectrum initially / timentin or pip-taz

- adjust 2° to MCS

- ID consult


Diabetic Calcaneal Abscess



Diabetic Heel Abscess XrayDiabetic Heel Abscess MRIDiabetic Heel Abscess MRI 2


2. Neuropathic Ulcers


Diabetic Ulcer





1)Wagner Classification3


Most used classification for DFU in ortho literature


Grade 0      


Pressure area           

- Footwear Modification


Grade I      


Superficial Ulceration           

- local treatment, footwear modification


Grade II    


Deep Ulceration (probes to tendon / capsule)          

- TCC, footwear modification


Grade III   


Deep ulceration + secondary infection           

- debridement, antibiotics


Grade IV   


Partial foot gangrene

- Abx, amputation, hyperbaric O2


Stage V    


Whole foot Gangrene

- regional amputation, Abx


2) University of Texas4


Each wound has a grade and stage

- increasing stage, across all grades, more predictive of amputation & prolonged healing time

- UT better prognosticator than Wagner


Grade 1 Preulcerative

Grade 2 Superficial Wound

Grade 3 Deep wound penetrating to capsule or tendon

Grade 4 Deep penetrating to bone or joint


Stages A Clean

Stages B Nonischaemic Infected

Stages C Ischaemic Noninfected

Stages D Ischaemic Infected






1) Off-load 

TCC remains the gold standard

- other options: removable cast walkers; modified footwear


2) Increase healing rates

Hyperbaric O2 - short-term reduction ulcer size

Negative Pressure Wound Therapy (NPWT)

Biologic Therapy eg amniotic membrane (experimental)



1) Tendoachilles lengthening (TAL)

Aim to reduce forefoot pressures


Colen et al Plast Reconstr Surg 2013

- level 3 retrospective cohort

- 25% of patients with DFU & no TAL Vs 2% of DFU with TAL had recurrent ulcer


2) Gastrocnemius Recession

3) Toe Flexor Tenotomy


3.  Charcot Foot


See Charcot Foot


4.  Fractures in Neuropathic / Diabetic Feet




1.  Augment ankle ORIF

2.  Double time for sutures

3.  Double immobilisation period

- 12 weeks NWB

- 4-5 months in walking cast

4.  Brace for 1 year after surgery

- to prevent late Charcot arthropathy

- assume Charcot joint will develop



1- http://www.ncbi.nlm.nih.gov/pubmed/22336901

2- http://www.ncbi.nlm.nih.gov/pubmed/17259493

3-  http://www.ncbi.nlm.nih.gov/pubmed/7319435

4- http://www.ncbi.nlm.nih.gov/pubmed/8986890

Foot Fractures

Chopart Dislocation


Francois Chopart (1743–1795)

French surgeon who described Chopart amputation 




Traumatic dislocation of TNJ or CCJ




High velocity injury


- fall from height 


Crush Injury 




Urgent Reduction


Assess stability

- K wire

- +/- primary fusion if joints severely damage



Cuboid Fractures



1.  Capsular avulsions


2.  Body / Nutcracker fracture


Nutcracker fracture



- rare



- forced eversion / abduction of forefoot

- cuboid crushed between 4th and 5th MT and calaneum



- displaced cuboid fracture with subluxation of tarsus

- may interfere with peroneal tendons

- shortens lateral border of foot




Oblique xray

- foot 30o medial



- ORIF and bone graft

- rarely need bridging external fixation



March Fracture




Insufficiency fracture

- secondary to exceeding fatigue threshold

- usually of second or third MT shaft




Onset of new and very intense / strenuous physical activity

- i.e. new army recruits / dancers


Women with postmenopausal osteoporosis




Cavus feet




Pain after walking & then with walking

Swelling after activity




Tender swelling along MT shaft


Often visible dorsal swelling




Initially normal

- may need oblique xray to diagnose


Second Metatarsal Stress Fracture


Later shows callus around fine transverse / oblique fracture

- usually midshaft or distal

- usually incomplete

- often 2nd or 3rd MT longer than 1st


Bone Scan / MRI


Show increased activity prior to xray changes


Second MT Stress Fracture Bone Scan




Non operative



- rest for 4-6 / 52

- MT dome

- may need strapping / cast / moon boot 


95% union rate

- complete fracture rare




Rarely required


Dorsal approach / plate / bone graft


Metatarsal Fractures

Metatarsal Fractures


Indications for Surgery


1.  Displacement > 4 mm

2.  Angulation > 10o

3.  Intra-articular


Base of 5th Metatarsal




Zone 1

- avulsion fractures


Base of fifth MT FractureZone 1 base 5th displaced


Zone 2

- fracture at the metaphyseal-diaphyseal junction

- fracture closely akin to the injury described by Jones 


Fifth Metatarsal Undisplaced Avulsion Fracture5th Metatarsal Stress Fracture


Zone 3

- proximal diaphysis

- stress fracture of the proximal 1.5 cm of the shaft of the fifth metatarsal

- these fractures are not acute 

- always have prodromal symptoms or radiographic signs of repetitive stress injury


Base of 5th Metatarsal Fracture Zone 2Jones FractureJones Fracture 2


Zone 1



- tuberosity avulsion fracture

- usually extra-articular but may extend into cuboid-metatarsal joint



- Peroneus brevis contracture following inversion 




1.  Apophysis 

- smooth and longitudinal 

- appears F 9-11 M 11-14 

- can look displaced or fragmented

- fuses 2-3 yrs after appearance

- apophysis does not enter cuboid-MT joint


2.  Os peroneum


3.  Os Vesalium


Os Vesalium


Non Operative Management


WBAT in moonboot


Randomised trial

- cast v soft dressings

- better outcome without cast


Operative indications


Displaced intra-articular fracture > 30% of articular surface / > 2mm step

- rare 

- aim to restore integrity of the cuboid MT joint



- open / closed reduction with pinning/screws


Zone 2 



- transverse fracture of 5th MT shaft 1.5cm from base 

- at diaphysis / metaphysis junction

- goes into the 4th/5th MT joint



- adduction to forefoot


Non Operative


Undisplaced fracture

- NWB for 6-8/52

- xray healing occurs from medial to lateral

- lags behind clinical healing by weeks to months

- lack of clinical healing after 8-10/52 NWB is not unusual

- consider continued protection / cast immobilisation / surgery at that time


Quill OCNA 1995

- 1/3 went on to re-fracture

- argument for early surgery





- displaced / athlete / non union

- 50% either do not heal primarily or refracture



- IM screw / TBW / plate +/- bone graft


Zone 3



- diaphyseal stress fracture

- distal to 4/5 MT joint

- secondary to repetitive distraction force



- cortical hypertrophy, narrowing medullary canal & periosteal reaction

- prolonged immobilization often required

- may take 20/52







NWB initially


Competitive athlete 

- bone graft & IM screw +/- USS

- NWB 6/52


Lareau et al Foot Ankle Int 2016

- 25 NFL players with acute Jones fracture

- Jones specific screw with BMAC from iliac crest

- average RTP of 8.7 weeks

- 12% refracture requiring revision surgery


Jones Screw 2



Surgical technique

- shaft of 5th MT is not straight

- entry point is high and medial to get straight shot

- may need to sequential increase cannulated drill size

- Jones specific screws 4.5, 5.5, 6.0 with low profile heads


Neck of 5th / Shaft metatarsal fractures


Fifth Metatarsal Neck Fracture

Navicular fractures



1.  Dorsal lip fracture / Tuberosity fracture

- avulsion fractures

- most common

- beware avulsion T post


2.  Body fracture


3.  Stress Fractures


Body Fractures




A.  Transverse fracture in coronal plane

B.  Transverse from dorsolateral to plantarmedial

C.  Central or lateral comminution


Navicular fractureNavicular fracture 2


Displaced Navicular FractureDisplaced Navicular Fracture




ORIF if displaced

- aim to restore TNJ

- 70% satisfactory reduction





- lose some inversion / eversion as part of STJ




AVN 30%


Navicular AVNNavicular AVN


4. Stress fracture





No distinct trauma




Navicular Stress Fracture




Navicular Fracture CT




Can go on to displaced nonunion


Navicular Stress Fracture DisplacingNavicular Stress Fracture Nonunion




1.  Strict NWB in boot

- consider bone stimulator


2.  ORIF and graft

- if >50% of width of bone and failure of non-operative management


Case 1


Navicular Stress Fracture UnionNavicular ORIFNavicular ORIF Union


Case 2


Navicular Fracture APNavicular Fracture Lateral


Navicular Fracture CTNavicular Fracture CT2Navicular Fracture CT3


Navicular Fracture ORIFNavicular ORIF 1Navicular ORIF 2



Foot Tumours

Benign Bone Tumours

1. Giant cell tumour


Often present with a painful swollen area, lytic on X-ray

- calcaneus > talus

- rare in skeletally immature

- curettage and grafting

- local recurrence ~50 %

- may need to bone graft defects


2. Osteochondromas


Can occur in foot and ankle

- single or multiple

- simple excision at base

- malignant transformation very rare in foot


Subungal exostosis 

- under the toenail (esp 1st)


3. Osteoid osteoma


Especially in hindfoot

- difficult to diagnose on x-ray

- CT / MRI / bone scan

- excision / RF ablation (CT guided)


Osteoid Osteoma 2nd Toe Bone ScanOsteoid Osteoma 2nd Toe CTOsteoid Osteoma 2nd Toe MRI


4. UBC


Infrequent in foot

- calcaneum

- UBC can become symptomatic from stress fractures

- treat with curettage and BG


5. ABC


Originate in metaphyseal bone

- MT most common foot site (also calcaneus)

- treat with curettage and BG / excision


Foot Aneurysmal Bone CystFoot ABC MRIFoot ABC Excision and Autograft



Benign Soft Tissue Tumours

Assume all malignant until proven otherwise


1. Ganglion


Foot GanglionAnkle ganglion MRI


Mucoid degeneration of a joint capsule or tendon sheath

- may fluctuate in size or disappear

- firm subcutaneous nodule

- may be painful, especially if compressed

- often transilluminate



- observe

- multiple aspirations / cortisone injections

- surgical excision


Surgical excision

- need to find neck

- may arise from AKJ / STJ / T post tendon

- tie off neck or excise segment of capsule


Foot Ganglion 1Foot Ganglion 2Foot Ganglion Neck 1


Foot Ganglion Neck 2Foot Ganglion Neck 3


2. Plantar fibromatosis


Most common soft tissue tumour in the foot

- see other notes


3. Fibroma


Discrete nodule of well differentiated fibroblasts

- on sole or dorsum

- slow growing

- pain uncommon

- usually subcutaneous, firm, not attached to skin



- local excision if required

(recurrence rare)



- Fibrosarcoma

- Plantar fibromatosis


4. Giant cell tumour of the tendon sheath


Ankle Giant Cell TumourAnkle Giant Cell Tumour


Usually in tendon adjacent to ankle (can be anywhere)

- well defined firm nodule with an obvious capsule

- not always painful

- pain with direct pressure



- observe (may involute)

- surgical excision (recurrence rare)




Common around the ankle or midfoot

- may involve multiple bones

- usually in young adults



- may show bony erosions

- brown villonodular synovium



- excision include complete synovectomy

- recurrences common but not all symptomatic

- DXRT if severe


6. Lipoma


Most common on dorsum

- subcutaneous

- soft feeling / mobile / grape like

- painless unless compressed



- marginal excision

(local recurrence rare)


7. Neurilemmoma


Benign schwannoma

- well encapsulated solitary tumour

- originates from nerve sheath

- slow growing

- nerve fibres spread over its surface

- painful if compressed or causes compression



- hyperintense rim on T2



- separate nerve fascicles

- excise neurilemmoma

- marginal excision

- attempt to preserve normal nerve fibres


8. Neurofibroma


Singular or multiple

- extend along course of the nerve 

- 1/2 not associated with NF


Often local pain especially with compression

- may affect distal nerve function

- malignant change rare in solitary lesion (occurs with NF)



- target sign

- can be seen with neurilemmoma



- tumour arises from within the nerve

- excision usually cause further loss of function


9. Solitary Hemangioma


Present with episodes of dependent swelling

- often after local trauma

- diffuse edges / can be difficult to palpate


Diagnose on MRI

- hyper-intense on T2 FS



- only needs excision if limits function

- often incomplete - recur


10. Glomus tumour


Presents as painful toe, sensitive to cold

- pain with local pressure

- usually subungual



- may scallop adjacent bone on x-ray



- marginal excision for pain

Malignant Bone Tumours

1. Osteosarcoma


Second / Third decade, M>F

- calcaneal

- diagnosis often delayed

- treat with radical resection


2. Chondrosarcoma


Middle age or older

- slow growing

- malignant change of osteochondroma / enchondroma

- treat with wide / radical resection


3. Ewing's


Lytic expansile mass in a MT

- can be anywhere

- Treat with wide resection / chemo / DXRT


4. Metastatic Tumours



- <1% all bony metastases

- often lung

- often below the diaphragm (i.e. ovarian)


Malignant Soft Tissue Tumours



Most common malignant tumour

- malignant melanoma


Most common sarcoma

- synovial sarcoma 50%

- consider it for every foot lump

- most in dorsum and hindfoot


Foot and ankle considered single compartment

- Enneking staging

- unless tumour confined to singe ray


1. Synovial Sarcoma


Consider it for every foot lump


Diagnosis often delayed

- varied presentation

- slow growing firm fixed mass

- indolent course

- small latent mass with period of rapid growth

- rapidly growing mass

- painful (even before mass) or painless lump


Peak incidence 20-50


Spread via lymphatics (rare for sarcoma)



- soft tissue mass (+/- Ca++)



- aggressive on appearance



- size can predict outcome



- wide / radical excision +/- DXRT

- ? role of chemotherapy


2.  Malignant melanoma


Common in  the foot

- often in junctional naevi



- wide excision

- depth of lesion most important prognostically

- assess lymph nodes


3. Subungal melanoma


Less aggressive than other MM

- present with loss of the nail



- haematoma

- mark nail with knife

- return 2 weeks later

- if melanoma the pigment will be in same position and the mark on the nail will be distal



- toe amputation

- assess lymph nodes


4. Clear cell sarcoma


Highly malignant

- common in foot and ankle (43%)

- usually 2nd/3rd decade

- wide excision +/- chemotherapy


5. Epithelioid sarcoma


Innocuous nodule on the dorsum of the foot in young adults

- wide  / radical excision

- lymphatic & haematogenous spread


6. Hemangioendothelioma


Vascular tumor in bones or soft tissue

- any age

- multiple on same extremity

- wide excison +/- DXRT

- long follow up for all

- difficult to predict which will behave aggressively


7.  Acral Myxoinflammatory Fibroblastic Sarcoma


DDx ganglion, GCTTS, tenosynovitis

- low grade

- don't metastasise but can recur locally

- marginal excision


8.  Fibrosarcoma


Prognosis depends on histological grade

- wide / radical excision

- in childhood need less aggressive treatment





Plantar Fibromatosis



Fibrous proliferative lesion in plantar fascia




Male, white, middle age


May arise in isolation


Association Dupuytren's Diathesis

- aka Lederhosen disease




Proliferative Fibroblastic lesion

- May resemble fibrosarcoma histologically




Heavy strands of relatively acellular mature collagen


Enneking 3 Stages

- proliferative phase

- involutional (active) phase 

- final (residual) phase




Present with lump in foot


Often painless

- unlike Dupuytren's there is no inflammatory proliferative phase

- asymptomatic through growth




Tender subcutaneous nodule found in the medial half of the middle plantar fascia

- rarely causes contracture




Ganglion cyst

Neurofibroma / neurilemmoma

Fibrosarcoma / any of the other sarcomas


Rheumatoid nodule



Sweat gland carcinoma





- T1 - low SI

- T2 - low or medium SI




Non Operative


Observe if not symptomatic



- padded shoes and orthoses

- transfer weight away






1.  Relieve associated symptoms from local extension & invasion

- may invade NV structures

2.  Pain when weight bearing




May recur after excision

- usually after incomplete / simple excision

- can recur & become locally invasive

- doesn't metastasise or become locally destructive


Technique Wide resection



- prone

- tourniquet



- S shaped

- avoid 1st MT head

- avoid weight bearing arch

- minimise disruption of blood supply

- usual medial longitudinal incision interrupts most of the arterial supply to the skin beneath the longitudinal arch


Block resection of plantar fascia 

- 2 cm normal fascia proximal and distal

- entire width

- lateral plantar nerve is adherent to fascia on lateral side




Consider radiotherapy



Great Toe





- dancers

- athletes




Hyperdorsiflexion of the MTPJ




MT head dislocates plantar

- may buttonhole through capsule

- can prevent closed reduction


Blocks to Reduction


1.  Sesamoids

2.  Conjoint tendon

3.  Intersesamoid Ligament




Closed Reduction


Open Reduction


Dorsal Approach

- protect dorsal superficial nerve

- divide capsule medial to EHL

- may need to divide intersesamoid ligament

- may need to divide adductor hallucis




Hallux Rigidus



Painful restriction of dorsiflexion of the great toe 

- secondary to degenerative changes in MTPJ

- initially pain and synovitis

- osteophytes don't form medially or on plantar aspect




Two peaks

1.  Adolescence F > M

2.  Middle Age M > F




Often Idiopathic




- hyperextension injuries



- pronated foot

- abnormally long 1st MT

- pes planus

- DF 1st ray



- gout


- inflammatory arthropathy




Pain on walking

- especially slopes & rough ground

- pain may become continuous



- compression of dorsomedial cutaneous nerve




Shoe shows excessive lateral wear

- toe off on lateral border 

- patient avoids dorsiflexion



- hallux is usually straight

- MTPJ is enlarged



- synovial thickening

- palpable dorsomedial osteophyte & bunion 

- altered sensation dorsal toe / due to tethering of dorsomedial nerve by osteophytes



- DF restricted & painful N = 90°

- PF often reduced and painful N = 30°




Changes of osteoarthritis

- dorsomedial osteophyte

- joint space narrowing


Great Toe Dorsal OsteophyteHallux Rigidus Dorsal Osteophyte




Non Operative




Education & Reassurance



- initially stiff soled shoes

- rockerbottom sole

- high toe box







1.  Moberg Osteotomy



- young patient with mild OA & > 30° PF



- dorsal closing wedge osteotomy of P1 

- converts PF range into functional DF


2.   Cheilectomy


Mann 1988 JBJS



- removal of dorsal osteophytes

- increase painless DF range (average 20°)


Great Toe Cheilectomy



- for adults with minimal degenerative changes

- normal joint space in plantar half MTPJ



- recurrence of pain



- dorsal incision over MTPJ

- joint incised either side EHL

- synovectomy

- remove ~ 1/3 of dorsal MT head

- remove osteophytes from base of P1

- need DF of ~ 90°

- stiff shoe till ROS

- then flexible sole and ROM exercise


3.  Arthrodesis


Great Toe MTPJ OAGreat Toe MTPJ Fusion APGreat Toe MTPJ Fusion Lateral



- adults with significant degenerative changes



- lateral transfer metatarsalgia


- malposition

- limitation of footwear type

- non-union



- dorsomedial approach

- protect dorsal cutaneous nerve

- mobilise EHL laterally and open capsule

- divide collaterals

- free P1 of soft tissue attachments

- 15° valgus

- 15° DF relative to plantar surface / 20 - 25° relative to metatarsal shaft

- dorsal plate / crossed screws



- 30% develop asymptomatic OA IPJ


Hallux Rigidus Fusion 2 screws APHallux Rigidus Fusion 2 screws Lateral


4.  Interpositional Arthroplasty



- severe OA & moderate demand

- minimal bone resection



- imbricate dorsal & volar capsule into joint space


5.  Swanson Arthroplasty



- adults with low demands



- breakage

- silicon synovitis

- very difficult to salvage


6.  Keller's Procedure



- for elderly with low demands



- lose windlass mechanism

- transfer metatarsalgia

- cosmetically poor

- drifts into both DF & valgus / Cock Up deformity



Hallux Valgus


DefinitionHallux Valgus Severe



- medial prominence of head of 1st MT


Hallux Valgus

- medial deviation 1st MT

- lateral deviation of great toe




Metatarsal head

- has 2 grooves separating ridge (cristae)



- in each tendon of FHB

- sesamoids attach to P1

- no attachment to MT head

- sesamoid ligaments attach to sesamoids and plantar plate

- FHL passes plantar to the plate & between the sesamoids


Plantar plate

- formed by

- FHB / Abd. Hall / Add. Hall / Plantar aponeurosis /  capsule


Sesamoids and plantar plate stabilised

- abductor hallucis (medial)

- adductor hallucis & trans metatarsal ligament (lateral)

- insert into sesamoids & Base P1

- no muscles insert into head MT


Collateral ligaments

- from head of MT to base of P1

- insert into sesamoids




Great Toe provides stability to the medial aspect of the foot


Windlass mechanism of plantar aponeurosis

- plantar aponeurosis arises from tubercle of calcaneum

- medial slip inserts into base of proximal phalanx via sesamoids

- as body passes over foot, P1 forced into DF & slides over MT head

- plantar aponeurosis winds around MT head & plantarflexes the 1st MT

- creates arch


In hallux valgus, windlass is less effective

- results in transfer of weight to lateral aspect of foot

- especially second MT head


Blood Supply


3 main

- 1st dorsal and plantar metatarsal artery

- superficial branch of medial plantar artery




Medial plantar artery

- remains plantar to the MT until the level of the neck when it runs obliquely dorsally

- divides into the medial cervical branch, and the medial sesamoid branch




First plantar MT artery

- is formed by the deep plantar arch and a perforating branch from the DPA

- runs distally in the 1st MT space

- nutrient artery to neck (variable)

- cervico-sesamoid branch (constant)


Lateral Cervical branch

- enters plantar surface at base of neck

- supply major part of head

- care in not stripping under the neck to preserve the cervical branch



- small branch from DPA

- penetrates the dorso-lateral capsule near margin of  articular cartilage

- not big enough to provide sole supply

- can be sacrificed if needed




Great toe

- lateral deviation of the great toe  (HVA > 15o)

- medial deviation of the first metatarsal  (IMA > 9o)

- +/- subluxation of the first MTPJ

- hallux pronation

- prominent mediation eminence

- sesamoid rotation / uncovering


Lesser toes

- overriding of the second toe

- metatarsalgia

- lesser toe hammer & claw




Two ages of presentation


1.  Adolescent form

- usually bilateral


2.  Adult form ~ 50's

- strongly familial

- positive FHx in 2/3

- F > M

- F:M = 9:1 in those needing operations




Likely multifactorial


1.  Shoe Wearing



- more women are affected

- women's shoes are tight-toed

- unshod 2% vs 33% shod

- unshod toes separate on weight bearing

- in shoes, toes crowded & hallux abducted


2.  Hereditary

- usually strong FHx

- tend to present earlier

- AD with incomplete penetrance

- made worse by female's shoe wear


3.  Generalised Ligamentous Laxity

- splaying of forefoot

- excessive mobility of 1st TMT

- laxity of medial capsule of MTPJ


4.  Anatomical factors


Metatarsus Primus Varus

- associated with HV

- especially adolescent variety


Metatarsus Varus


1st MT

- long / short

- hyper pronated


2nd Toe amputation

- loss of lateral support for great toe



- rounded joint



- hypermobile

- medially slanted




Short achilles tendon


5.  Pathological Conditions


Rheumatoid arthritis

- leads to loss of capsular support

- RA best treated with fusion


Neurological conditions

- CP best treated with fusion




A.  Congruent MTP joint



- increased DMAA 

- Hallux valgus interphalangeus



- enlarged medial eminence (bunion)

- pressure against shoe

- painful bursa or cutaneous nerve



- MTP joint usually stable & won't sublux

- can’t do distal soft tissue release

- will sublux a congruent joint


B.  Incongruent MTPJ


Hallux Valgus Incongruent Joint, ex


Subluxed MTPJ

- usually progressive



- starts with lateral pressure on great toe

- tight high heels

- P1 moves laterally



- PI moves laterally & puts pressure on MT head

- moves it medially, thus increasing intermetatarsal angle

- attenuation of medial joint capsule

- sesamoid sling held in place by ADDH & transverse metatarsal ligament

- MT head moves further medially / varus deformity

- slides off sesamoids


Final deformity

- appearance of lateral migration of sesamoids

- however sesamoids maintain constant distance from second MT

- lateral sesamoid lies beside MT head in intermetatarsal space

- ADDH pronates the great toe

- medial extensor hood / capsule stretched

- EHL & FHL comes to lie lateral to MTPJ

- finally, lateral capsular structures become contracted & the deformity becomes fixed


C.  Medial Eminence

- MT head changes occur

- groove or medial sagittal sulcus develops at medial border of articular cartilage


D.  Bunion

- callosity of skin + bursa


E.  Lesser Toes

- MTP less stable & weight transferred to MT 2 & 3 -> callosities

- great toe may drift beneath 2nd toe

- alternatively, 2nd toe may subluxate laterally

- lateral toes become crowded

- often develop claw or hammer deformity

- increased weight bearing through middle MT heads may lead to metatarsalgia

- worse with clawing of lesser toes





- over medial eminence (75%)

- metatarsalgia under lesser toes

- degeneration of sesamoid joint

- dorsal aspect osteophytes / rigidus


Shoe problems

- wide foot

- difficulty fitting shoes


Secondary deformity of lesser toes

- especially hammer deformity of the second toe

- rubbing of the PIPJ on shoe


Cosmetic appearance




Hallux Valgus Clinical



- bunion

- HV

- clawing / hammer toes


Assess ROM ankle and STJ

- tight T Achilles


Look at wear patterns on foot

- callosities under 2/3 MT head



- tender bunion

- painful MTJP

- correctable / ROM correctable

- pain over sesamoids



- hypermobility

- > 9mm abnormal


Lesser toes

- deformity / correctable


Neurovascular examination


Weight Bearing AP X-ray


1.  Hallux Valgus Angle / MTPA

- metatarso-phalangeal angle

- normal < 15o


Hallux Valgus MTPA > 40


2.  Intermetatarsal angle/ IMA

- normal < 9o


Hallux Valgus Intermetatarsal Angle > 20 degrees


3.  Congruence

- place dots

- medial & lateral edges of the articular surfaces of the MT head & P1 base

- assess to see if line up / joint congruent


Hallux valgus Incongruent Joint


4. Interphalangeal angle

- normal is <10°

- identify hallux interphalangeus


5.  DMAA

- distal metatarsal articular angle

- normal < 6o


Hallux Valgus Increased DMAA


5.  Sesamoid subluxation

- amount of lateral sesamoid uncovered by MT

- medial sesamoid should not cross midline axis of MT


Hallux Valgus Lateral Sesamoid Uncovered




7.  Size of the medial eminence

- amount of MT head medial to the line along the medial border of the MT


8.  TMT Angle

- medial sloping


Hallux Valgus Medial Sloping TMTJ


Mann Classification  


1.  Congruent


2.  Incongruent


A.  Mild


MTPA < 30°

IMA < 15°

Lateral sesamoid < 50% uncovered


Hallux Valgus Mild


B. Moderate


MTPA 30 - 40°

IMTA 15 - 20o

Lateral sesamoid 50 - 75% uncovered


C. Severe


MTPA > 40°

IMTA > 20°

Lateral sesamoid > 75% uncovered


Hallux Valgus Severe Unilateral


3.  Degenerative


Hallux Valgus Severe Degenerative





Education regarding shoe wear

- extra wide / large toe box



- longitudinal arch support

- pre MT dome for metatarsalgia

- podiatry to attend to callosities


Toe spacers








1.  Continued pain and discomfort

2.  Difficulties with shoe wear

- split size shoe requirements 

- difficulty fitting shoes

- only 60% wear "fashionable" shoe post-op

3.  Deformity of lesser toes

4.  Skin problems

5.  Cosmetic appearance – relative indication




Poor peripheral arterial circulation

Current sepsis

Uncontrolled diabetes

Peripheral neuropathy (relative)




1. Correction of the hallux valgus and intermetarsal angles 

2. Creation of a congruent MTP joint

3. Sesamoid realignment

4. Removal of the medial eminence

5. Retention of functional range of motion of the MTPJ

6. Maintenance of normal weight bearing mechanics of foot


Surgical Options




1. DMAA  < 15°

- treat hallux interphalangeus

- Akin with exostectomy


2. DMAA > 15°

- Chevron with closing wedge





- Chevron

- DSTP (Distal Soft Tissue Procedure) +/- proximal osteotomy



- DSTP & proximal osteotomy

- Scarf



- DSTP & proximal osteotomy

- arthrodesis




Mild to Moderate / Low demand

- arthroplasty



- arthrodesis


Hypermobile TMTJ

- fusion (Lapidus) & DSTP


Surgical Procedures


1.  Chevron


Hallux Valgus ChevronGreat Toe Chevron



- incongruent joint

- HVA < 30o / IMA < 15o

- patient < 60 years




Avoid lateral release = AVN 40%


Approach to Hallux Valgus


Dorsomedial approach in internervous plane

- don't go directly medial as will get sensitive scar

- protect dorsal sensory nerve

- distally based "V" capsular flap

- expose MTP joint



- remove medial eminence with saw

- leave 1- 2 mm medial to medial sulcus

- otherwise risk hallux varus


60° osteotomy apex distal

- longer plantar limb to avoid sesamoids and inferior joint surface

- apex 1 cm from articular surface

- translate 5mm

- 1mm displacement corrects IM angle 1º

- can perform medial closing wedge to correct DMMA



- not always necessary

- sutures / k wire / screw



- imbricate capsule

- advance to tighten medially


Second toe releases as needed


Post op

- bandage / POP to maintain correction

- check wound at 1 week

- bunion boot / heel walk

- toe spacer

- 6/52


Hallux Valgus Toe Spacer




GE 75% if IMA >12° 

GE 95% if IMA <12°




AVN is rare

- ensure apex 8-10 mm from articular surface

- avoid DSTP


2.  Distal Soft Tissue Procedure


Hallux Valgus Pre DSTPHallux Valgus Post DSTP


Modified McBride

- release of tight lateral structures (ADDH, lateral capsule, transverse MT ligament)

- medial exostectomy (just medial to sagittal sulcus)

- medial capsular plication


(Modification: no longer excise sesamoid)



- mild HV with incongruent joint

- severe HV when combined with proximal osteotomy




1.  Dorsomedial approach

- protect nerve

- V shaped capsulotomy

- remove medial prominence


2.  Incision first web space

- protect branches of DPN

- insert lamina spreader

- release ADD hallucis at P1

- cut capsule between sesamoid and MT

- divide transverse MT ligament



92% good results




Nerve injury

- plantar cutaneous nerve


Hallux varus

- from releasing lateral FHB from sesamoid


3.  Proximal Osteotomy + DSTP



- severe HV

- correct IMA with osteotomy

- correct HVA with DSTP



- in combination with DSTP

- GE 90 %



- crescentertic

- opening wedge (lengthens)

- closing wedge (shortens)


Opening wedge

- extend medial incision

- incomplete ostetomy with saw at base MT

- use bone from bunionectomy to fill gap

- fixation with small plate


4.  Scarf



- moderate HV

- see separate technique

- technically challenging but good results


5.  Akin



- congruent joint

- DMAA < 15o

- hallux interphalangeus > 10o

- residual HV after other procedures



- medial closing wedge osteotomy of P1

- combine with cheilectomy


6.  Keller Procedure



- resection 1/3 of proximal phalanx

- should use pin to stop cock up deformity & to stiffen joint



- housebound / non ambulator

- elderly

- salvage

- marginal circulation - DM / PVD

- hallux rigidus if cheilectomy or arthrodesis contra-indicated



- instability / cock up deformity

- transfer metatarsalgia (in young)



- 80% good results


7.  Arthrodesis



- hallux valgus with arthritis

- severe hallux valgus

- neuromuscular disease i.e. cerebral palsy

- RA

- salvage procedure for failed procedures



- 15º valgus

- DF 10º relative to plantar aspect of foot

- DF 30° relative to ray



- dorsomedial approach

- release EHB / mobilise EHL / release collaterals

- Coughlin male and female reamers

- secure with cross screws or plate


Hallux Valgus Arthrodesis


8. Lapidus Procedure


Hallux Valgus SevereHallux Valgus Proximal Osteotomy and Lapidus



- TMTJ hypermobility

- fusion TMTJ



- difficult to achieve union

- difficult to get position correct


Joint multiplanar

- malrotation poorly tolerated

- shortens medial column

- can get metatarsalgia



- slight plantar flexion and lateral deviation


Lapidus APLapidus Lateral


Complications of Surgery


Transfer Metatarsalgia



- incorrect surgery

- poorly performed surgery

- high risk groups i.e. adolescent


Nerve injury

- dorsal and plantar cutaneous nerve


Cock up Toe



- post Keller’s




Arthrodesis MP joint

- shorten if don't use graft

- fusion rate 95% (BG) vs 70% (no BG)


Hallux Varus



- excessive medial resection

- resection of fibular sesamoid

- excessive lateral release or medial plication



- not always painful

- cosmetically unacceptable

- difficulties with shoe wear

- cockup deformity

- with time stiffens in extension & medial deviation



- soft, well fitting shoe

- arthrodesis

- soft tissue reconstruction


EHL Reconstruction           

- lateral two thirds of the tendon removed from its insertion

- detached distally, passed under transverse ligament

- inserted into proximal phalanx




Rarely seen in Chevron

- due to disruption of volar blood supply


Great Toe AVN Post Chevron



- arthrodesis / excise avascular fragment and shorten toe

Scarf Osteotomy



A.  Longitudinal Cut

- plantar proximal / dorsal distally

- ends up being parallel to sole

- leave strong plantar portion of head to prevent dorsiflexion

- mark centre of head

- distally to a point 2mm prox and 3mm above the centre of the head


B.  Transverse cuts

- plantar proximal / dorsal distal

- angle of 45o with the long cut

- directed slightly proximal (10-15o) to aid displacement




A. Transverse plane

- Primary direction of displacement

- can be up to ¾ of the surface as the strong lateral strut is preserved

- lateral rotation should be avoided as it increases the DMAA

- medial rotation can be used (to improve DMAA) but limits the amount of lateral displacement


B. Frontal plane

-  Lowering of the 1st MT head is achieved via the obliquity of the transverse cut

-  It will act to relieve metatarsalgia


C. Sagittal plane

- Lengthening can be done but tends to increase soft tissue tension and lead to stiffness

- shortening can be readily achieved by

- increasing the obliquity of the transverse cuts (max shortening 3mm)

- resecting ends of prox  / distal fragments (doesn’t elevate head as II to sole)




Cannulated screws over K wires


A. Distal

- start lateral where the bone is string and allows medial resection

- aim obliquely into the MT head

- screw to end 2mm prox to cartilage


B. Proximal

- important to respect the lateral part of the fragment to avoid fracture

- aim transverse from dorso-medial to plantar-lateral


The corner is then taken off the proximal fragment 

- rounded with rongeurs where bunion has been sliced off



Ingrown Toe Nail





Improper nail trimming

Tight shoes & socks

Poor hygiene

Repetitive trauma to distal toe

Curved nail bed in elderly




1.  Inflammation

- painful irritation about embedded nail plate in lateral groove


2.  Infection

- overt infection with granuloma & discharge 

- starts as serous discharge then purulent


3.  Granulation

- stage 1 & 2 + chronic changes

- hypertrophy of lateral wall

- growth of epithelium over chronic granulation tissue 




Stage 1 

- non-operative


Stage 2 

- oral ABx then non-operative

- if fails partial nail avulsion


Stage 3 

- often requires partial nail matrix ablation


Non Operative

- warm saline soaks x2 /day

- pledget under nail corner

- cleaning of lateral groove

- nail will grow 2 mm /month

- aim for nail plate that protrudes distal to hyponychium




1.  Wedge resection



- remove lateral part of nail

- partial ablation of nail matrix

- debulk tissue in lateral fold


Post op

- non adherent dressings 48/24 then warm soaks

- open toe box shoe 10/7

- 3-4 weeks before normal shoes again



- recurrence spicules nail plate 

- 5%


2.  Zadek's



- removal of nail plate 

- removal of entire germinal nail matrix proximal to lunule


3.  Terminal Symes procedure



- amputation of the distal half of the distal phalanx

- good for dystrophic and mycotic nails

- toe end appears bulbous




Juvenile Hallux Valgus



More common in girls

High incidence of positive family history (75%)


Can be associated with mild CP




Juvenile Hallux Valgus


Congruent joint

- 50% compared with 9% in adult HV


Metatarsus primus varus

- increased IM angle

- often the primary deformity


Epiphyses usually still open


Oblique first TMTJ Angle


Ligamentous Laxity


Difference from Adult HV


Less severe

- no arthrosis

- sesamoid subluxation & pronation less common than in adult

- medial eminence not as prominent

- HVA not as big a contributor




Ligamentous laxity


T Achilles tightness


TMTJ hypermobility


Neurological examination




Normal Angles

- HV < 15o

- IMA < 9o

- DMAA < 10o


Often DMAA increased






Delay any surgery until

- adolescence

- physis closed (but not CI if open)


Well fitting shoes


Flexible flat foot may benefit from medial arch support





- reduce DMAA

- reduce IMA


Congruent joint 

- less likely to progress (therefore treat conservatively)

- requires extra-articular realignment




1.  Double or triple osteotomies


A.  Akin / proximal phalangeal osteotomy

- corrects interphalangeal angle


B.  Chevron biplanar distal metatarsal osteotomy

- adjust DMAA by adding closing wedge osteotomy


C.  Proximal metatarsal osteotomy

- further corrects IMA


2.  Hypermobile TMTJ common

- Lapidus procedure


Hallux Valgus Lapidus Procedure


3.  1st Cuneiform Opening Wedge Osteotomy

- severe IM angle with open 1st metatarsal epiphysis

- marked M-C joint obliquity with high IM angle

- opening wedge (iliac crest graft)




20% recurrence rate

- failure to correct IMA


Hallux varus 

- split extensor hallucis longus transfer



- rare even in combined distal procedure







Fungal infection of the nail




Toenail affected 4x more common than fingernail

Prevalence has increased x 4 in last 2 decades




Dermatophytes most common cause


99% T rubrum & T mentagrophytes

- destroy nail by chemical or enzymatic process





- keratin of hyponychium is infected by the dermatophyte



- involves nail bed & nail plate

- initially invades ventral plate which arises from nail bed

- intermediate plate has soft keratin & can become involved

- dorsal nail plate rarely involved




Usually cosmetic problem only

- may become painful




Microscopy of nail scrapings & culture studies

-> hyphae

- can culture if necessary






Debride & remove part or all of nail


Topical agents less effective than systemic because don't target matrix


Oral antifungals 

- griseofulvin & ketoconazole (need up to 1 year of treatment)

- terbinafine (Lamasil) & itraconazole (Sporanox) 

- more effective with shorter treatment (3-6m)

- remain in the nail for 6 months





Terminal Syme amputation





3 Sesamoids may be present in great toe

- 2 almost always present on plantar aspect of MTPJ

- 1 may be present on plantar aspect of IPJ


MTPJ sesamoids most important

- embedded in FHB tendons

- held together by intersesamoid ligament & plantar plate

- each side of crista / inter-sesamoid ridge

- articulate with plantar facets of 1st MT


Tibial usually larger than fibula


Tibial more impacted in weight bearing than fibula

- higher incidence traumatic injury to tibial




- Adductor hallucis

- Abductor hallucis

- Plantar plate

- Intersesamoid Ligament

- Plantar aponeurosis



- Proximal to MT head in stance

- Pulled under MT head with DF / toe off



- between 7-10 years

- often multiple centers 

- may result in bipartite / tripartite appearance



- fibular rare

- tibial bipartite in ~ 10% 

- bilateral in ~ 25% of these

- congenital absence - one or both


Bipartite Sesamoid


Blood Supply


Type A 50% medial plantar artery and plantar arch

Type B 25% plantar arch

Type C 25% medial plantar artery


Increased risk of AVN if only single vessel into sesamoid

- which is seen in Type C more commonly than B



- absorb weight bearing pressure

- reduce friction

- protect tendons

- act as fulcrum to inc mechanical force of FHB

- Sesamoids and Collats provide medial / lateral stability of 1st MTPJ




Do not always present with symptoms directly referable to sesamoids

- generalized pain around Hallux

- pain after sudden pop or snap after running


Pain as hallux extends in terminal part of stance phase


Neuralgic symptoms or numbness if digital nerve compressed 




Local tenderness

Decreased strength on PF

Pain on passive DF

Loss of active & passive DF


Cavus foot

- plantar flexed 1st ray 

- excess axial load on sesamoid




Standard lateral not very useful

- AP, medial oblique, lat oblique, axial


Bone scan 


Projection important to differentiate sesamoids from MTPJ

- may be obscured by AP scan

- PA or oblique with Collimation useful for DDx

- caution with increased uptake in ~25% of asymptomatic patients

- marked difference to contralateral side significant




Useful for Osteomyelitis




Useful for post-traumatic changes 

- compared with contralateral side




1.  Fracture


Difficult to differentiate from symptomatic multipartite sesamoid

- especially if fracture through bipartite 

- comparison X-ray with contralateral foot 

- MRI & bone scan with pin hole collimation useful


 Fractured SesamoidSesamoid Fracture CT


Non operative management

- initial treatment

- orthosis / dancer's pad / cast / MT bar

- especially stress fracture



- excision of most comminuted fragment or entire sesamoid

- preferred over bone graft in most cases

- consider graft for athletes


2.  Osteochondritis



- osteonecrosis with regeneration & calcification may be present

- may be enlarged / deformed / sclerotic with mottling / fragmentation


3.  Infection


Rare except diabetic neuropathy

- Pseudomonas relatively common 


4.  Sesamoiditis


Repetitive trauma especially teens / young adults

- Inflammation & bursal thickening may be present


5.  Osteoarthritis


May be in conjunction with MTPJ OA / RA / Gout




Stiff soled or rocker bottom shoe + MT pad



- may decreases pain

- Don't remove both

- leads to clawing of hallux


6.  Intractable Plantar Keratoses


Usually caused by

- sesamoid with plantar located osseous prominence

- plantarflexed first metatarsus / cavus




Intractable lesions

- sesamoid shaving or resection

- avoid shaving if 1st MT is plantarflexed

- consider basilar dorsiflexion osteotomy


7.  Nerve Impingement


Impingement of medial branch plantar digital nerve on medial sesamoid






1.  Never excise both 

- high incidence of Hallux Valgus or Cock Up deformity

2.  Never make incision directly over sesamoid

3.  Always repair adductor if excising lateral sesamoid


Produce mechanical defect in FHB unit

- can excise up to 2/3 of either without disturbing ligamentous attachments

- may relieve pain without disrupting FHB mechanism




Tibial sesamoid excision

- 3cm plantar medial incision

- Medial branch plantar digital nerve identified & retracted

- Locate sesamoid by palpation

- Flex hallux 20-30o & retract FHL

- Incise inter-sesamoid ligament & pull sesamoid medial

- Shell out from capsule & plantar plate with knife

- Imbricate capsule


Tibial sesamoid shaving

- Plantar medial approach

- Excise plantar 1/2 with microsagittal saw

- Smooth with rongeur





- either dorsal or plantar approach

- dorsal demanding due to depth

- plantar - NV bundle & FHL to negotiate  


Dorsal incision 

- from 2-3 cm proximal to web space

- Identify & protect branch SPN

- Interval between Adductor Hallucis & joint capsule opened

- Tendon of Add Hallucis reflected from lateral sesamoid

- Grasp sesamoid & divide inter-sesamoid ligament

- Release proximal & distal & excise

- repair adductor

- Close skin 


Plantar incision

- Flex hallux

- 4cm incision between MT 1 & 2

- Retract NV bundle either lateral or medial

- Locate FHL & open pulley over it

- Flex hallux to relax FHL & retract medially

- Divide inter-sesamoid ligament

- Excise proximally & distally

- Reattach cuff of FHB

- Consider oblique wire across MTPJ




Cock up toe

Hallux valgus or varus

Nerve injury

Fat pad disruption

Painful plantar scar if plantar incision

Turf Toe



Hyper-dorsiflexion injury to 1st MTP joint




Grade 1 - Mild sprain



- minimal swelling / ecchymosis



- return to play immediately



Grade 2 Partial tear plantar plate



- tender / swelling / ecchymosis



- return to sport 1-2 weeks

- taping toe to prevent hyper-extension

- stiff soled shoes


Grade 3 complete tear plantar plate



- marked pain / swelling / ecchymosis / marked decrease ROM

- +/- sesamoid fracture / disruption of FHB



- return to sport 3-6 weeks

- surgical removal of loose bodies



- see proximal displacement of sesamoids

- require operative repair of plantar plate


Lesser Toes




Painful prominence of lateral eminence of 5th metatarsal head 


Coughlin Classification 


Type I deformity 

- prominent lateral condyle 5th metatarsal head

- lateral condylectomy


Type II deformity 

- lateral bowing of 5th metatarsal

- chevron osteotomy


Bunionette Type 2


Type III deformity 

- increased 4-5 IMA > 10° (N ~5°) 

- straight but laterally deviated 5th metatarsal

- midshaft osteotomy / Scarf


Type IV 

- combination (especially RA)


Clinical Features


Often leads to overlying corns & calluses

- lateral keratosis / plantar keratosis / combined






4-5th IMA is normally 5°

5th MTPJ angle is 10°






Pressure relief by padding

Shoe stretching

Changing to wider softer shoes

Broad-toed shoes & insole

Callus paring




Procedure depends on the underlying deformity

- true proximal osteotomies avoided due to blood supply 

- remember problems with Jones fracture


1. Lateral Condylectomy



- Type I deformity

- enlarged lateral metatarsal head

- no increase in IMA


2. Coughlin Proximal Osteotomy



- type II deformity / lateral bowing of 5th metatarsal



- medial displacement

- midshaft oblique osteotomy


3. Chevron Osteotomy



- Type III lesion 


4. Metatarsal Head Resection



- can get transfer pain





Claw / Hammer / Mallet / Curly





- DIP flexed

- MTP / PIPJ neutral



- PIP flexion

- DIPJ neutral / extended


Simple - MTP not involved

Complex - MTP hyper-extended



- PIPJ and DIPJ flexed

- MTPJ hyperextended


Curly toe 

- PIP and DIP flexion


Great toe 

- only have hammer 

- no mallet


Claw toe v hammer toe 


1. Claw toes frequently are caused by neuromuscular diseases

- often a similar deformity is present in all toes

- in hammer toe deformity only one or two toes are involved


2. Claw toes always have extension deformity at the MTPJ

- in hammer toe deformity extension of metatarsophalangeal joint may or may not be present


3. Claw toes often have a flexion deformity at the distal interphalangeal joint

- this usually does not occur in hammer toes





- divides 3 slips over P1

- middle - P2

- sides - P3

- thus no insertion to P1

- but main action is to extend P1 at MCPJ  

- only extends IPJ if P1 neutral or flexed



- arises upper and lateral surface of calcaneum

- has four tendons

- one inserts into base P1 great toe - EHB

- other 3 into lateral side of EDL tendon toes 2 - 4



- inserts P3

- flexes DIP



- inserts P2

- flexes PIP 



- dorsal to transverse ligament

- insert P1 (mostly) and extensor hood

- mainly MTPJ flexor



- plantar to transverse ligament

- insert extensor hood only

- mainly allow IPJ extension with MTPJ flexion




Shoe Wear

- main cause is ill-fitting shoes


Hallux valgus



- compartment syndrome

- fracture

- tendon or ligament injury



- long 2nd ray with buckling of toe

- irregularly shaped P2 with deviation of P3

- long 4th toe with curling under 3rd toe



- Polio


- MD


Inflammatory arthritis

- RA



- Syndactyly



Insensate Foot

- DM

- Hansen's disease


Claw Toe



Hyperextension of MTPJ and PIPJ / DIPJ flexion

- usually all toes affected 


Claw Toes




1.  Complex hammer

- hammer toe with MTPJ extension

- hammer usually affects second toe


2.  Curly toe

- normal MTPJ

- flexed PIPJ and DIPJ




Cavus foot 

Compartment syndrome

Diabetic neuropathy

Rheumatoid arthritis




Imbalance between intrinsics and extrinsics

- intrinsic weak (MCPJ flexion and IPJ extension)

- extrinsics strong



- extension strong

- flexion weak



- extension weak

- flexion strong


P1 subluxes dorsally

- it pushes the MT head plantar-ward 

- leading to metatarsalgia


Cavus foot 

- claw occurs not only due to intrinsic weakness but because of plantar flexed MT's 

- lead to dorsiflexion at MTPJ's 

- results in flexion of IPJ's as seen above

- If claw flexible may correct if reduce MT's




Pain & callosities under MT heads (metatarsalgia)





- cavus

- coleman block



- characteristic deformity



- dorsum PIPJ

- bleow MTPJ


Mobile or fixed of MTPJ / PIPJ crucial



- claw disappears with ankle PF 

- returns with DF ankle (tight long flexors)


Cavus foot

- when DF to correct MT claw actually improves (tight plantar fascia) 






Extra width and depth toe box shoe 

MT dome




Significant deformity of the hindfoot ± a cavus foot should be addressed first if symptomatic


Surgical Algorithm


1.  Flexible Deformity PIPJ / MCPJ


Girdlestone Taylor FETT 

- divide FDL in two and suture dorsally over P1

- +/- Extensor tenotomy & Dorsal MTPJ capsulotomy


2.  Fixed PIPJ Deformity / Flexible MCPJ


A.  Du Vries Excisional Arthroplasty PIPJ

- resection of head & neck of P1 

- stabilise with K wire

- aiming for fibrous union

- ROM 15o


B.  Extensor tenotomy + PIPJ Fusion


+/- Dorsal MTP capsulotomy MP joint


3.  Fixed PIPJ / MCPJ 


PIPJ arthrodesis + Extensor tendon tenotomy 

+ dorsal MTPJ capsulotomy

+ MT neck osteotomy


4.  Great toe involved


Jones procedure

- arthrodesis of IPJ

- EHL to MT neck 


Metatarsal options


Persistent MTPJ DF main cause of failure



1. Excision of MT head (Keller's)(RA)

2. Distal metatarsal oblique osteotomy (Weil)

3. Hibbs (if from cavovarus)




1.  FETT Technique / Modified Girdlestone Taylor


A.  Release FDL distally / divide into two

- 2 plantar incisions P2 and P3

- transverse incision plantar aspect P3

- divide FDL, protect NV bundles

- transverse incision plantar aspect P2

- harvest FDL and split in two

- can do single longitudinal plantar incision


B. Pass FDL over plantar aspect P1

- dorsal incision over P1

- place clamp each side of hood

- don't trap digital nerve

- bring tendon through incision slot in extensor tendon over P1 on each side 

- if over P2 will not work

- toe placed in approximately 20 degrees of plantar flexion at the MTP joint

- suture to each other & ED

- if varus or valgus take whole FDL either side


2.  PIPJ fusion 



- important to shorten the toe



- Ellipse of skin excised over dorsum PIPJ

- Extensor tendon taken in the ellipse

- release the collaterals so that P1 subluxes into operative field 

- elevate volar plate off P1

- bone cutters to resect P1 condyles

- resect base P2

- retrograde K wire out through P2 and P3 first

- back through P1, rest against subchondral bone

- bend wire over and tape



- check blood supply at end of case

- if problematic

- release dressings / warm / increase BP

- can use antispasmodic

- will usually reperfuse over 5 minutes

- keep patient asleep in meantime

- need to have ischaemia as part of consent


3.  Weil Osteotomy 



- Dorsal metatarsal exposed

- web space incisions if doing multiple toes

- homan retractors each side of MT

- saw enters at edge of articular surface dorsally

- Blade angled as low / horizontal as possible

- When osteotomy complete the MT head slides back

- Needs to slide back at least 5mm

- Then fix with screw from dorsal to distal plantar

- Amputate leading edge of proximal fragment

- if have valgus or varus deformity then can correct for this


Weil Ostetomy PIPJ FusionWeil Osteotomy PIPJ Fusion Lateral



Curly Toe



Under-riding toe

- toe lies beneath adjacent toe

- congenital deformity




Due to tight FDL & FDB

- capsule initially normal

- becomes constricted with time




Usually 3rd toe

- flexed, ER, medially deviated


Deformity accentuated when standing


Ankle dorsiflexion

- increases deformity


May present with

- cosmetic concerns

- callus & blister formation






Most don't require treatment

- most non symptomatic

- 25% improve spontaneously




If symptoms judged sufficient

- wait till > 4 years old




Flexible deformity 4 - 12 year old

- flexor tenotomy thru plantar skin

- just divide FDL


Fixed deformity > 12 years old

- resection / arthrodesis of IPJ


Case scenario

- 2 year old with curly toes

- nil other abnormality

- vast majority will improve

- give stretches for parents to do

- only if continual problem, do FDL release



Hammer Toe



Flexion deformity PIPJ with

- MTPJ normal / simple

- MTPJ hyper-extended / complex

- DIPJ any position

- P1 may become subluxed or dislocated






Long second toe / MT

Hallux valgus

Tight shoes




Hammer Toe Clinical Photo



- dorsum of PIPJ

- beneath second MT head


Rigid v flexible

Correctable / Non correctable






Extra depth or padded shoe, low heel





- need to ensure enough room for corrected toe / shorten toe

- may need to treat HV as well

- may need to release flexor tendons if tight


1.  Flexible Deformity


Girdlestone-Taylor FETT


2.  Fixed PIPJ


A. DuVries Arthroplasty


B. Extensor tendon tenotomy + PIPJ fusion


C. Partial Proximal Phalangectomy

- leaves toe floppy

- poor cosmesis

- only as salvage


3.  Fixed PIPJ and Subluxed MTPJ


Extensor Tendon Tenotomy + PIPJ fusion

+ Dorsal MTPJ capsulotomy

+ MT osteotomy


PIPJ Fusion Weil OsteotomyPIPJ Fusion Weil Osteotomy Lateral




Mallet Toe



Flexion deformity of DIPJ 




Usually in 2nd toe

- Long second MT

- Constrictive footwear




Pain over

- tip of toe

- over dorsum of DIP joint


May be corn on tip of toe 


Fixed or flexible






Shoes with roomy toe box




Surgical Algorithm


1.  Flexible


Percutaneous FDL tenotomy


2.  Fixed


A.  Excision arthroplasty of DIPJ  ± FDL release


B.  Arthrodesis 


C.  Terminal Symes amputation


3.  2nd MTPJ Dislocation


Reducible dislocation 

- Hammer toe repair


Reducible but unstable 

- FETTS + Hammer toe repair



- E/O MT head + FETT + Hammer toe repair



Fifth Toe

Over-riding Fifth Toe




5th toe adducted & overrides 4th toe

- extended, adducted & laterally rotated at MTPJ




Toe arises more dorsally than it should


Contracture of EDL tendon

Contracted dorsal skin & dorsal MTPJ capsule




Usually congenital deformity

- toe usually hypoplastic


Clinical Features


Cosmetic deformity

Problems with footwear

Usually bilateral

Usually needs surgery (compared with underriding or curly)


Non-operative Management


Strapping & taping ineffective

Broad toe box


Operative Management


Mild / Moderate - Butler procedure 

- racquet shaped incision dorsally

- dorsal limb over extensor tendon

- circumferential limb must preserve NV bundle

- EDL and dorsal capsule divided

- toe swung back into position and sutured


Severe - Lapidus procedure 

- EDL transfer to AbDM

- curvilinear incision

- cut EDL over mid MT proximally leaving attached distally

- capsule release MTPJ

- tendon transferred medial, plantar and laterally around P1

- sutured to abductor digit minimi


Underriding fifth toe


Opposite deformity of above


Thompson excisional arthroplasty

- Z incision laterally over P1

- proximal phalanx resection and capsule imbrication

- K wire


Cock Up Deformity 



- of MTP 

- realign at MTPJ & IPJ

- usually hammer toe deformity as well


Surgical Algorithm


Mild to moderate 

- extensor tenotomy & fixed hammer toe repair



- Ruiz-Mora procedure

- resection arthroplasty of proximal phalanx

- elliptical plantar incision with proximal phalyngectomy



- end up with floppy toe 

- syndactylisation may be salvage

- but swapping one deformity for another




Keratotic Deformities




- accumulation of keratotic layers of epidermis

- thickened epithelium elevates prominence causing further pressure


Hard Corn


Due to extrinsic pressure from footwear

- most common on lateral aspect of 5th toe

- over head of proximal phalanx


Soft Corns

- on the condyle of proximal phalanx between the toes

- due to pressure between adjacent bony prominences

- DDx fungal infection

- soft due to moisture

- commonest is medial aspect 5th toe

- also common at base of web space overlying 4th proximal phalanx lateral condyle




Combination of Extrinsic or Intrinsic pressure



- shoewear increasing compression 



- underlying prominent condyle of P1




See on plain film with marker over corn


Non-operative Management


Usually not successful long term

- education re shoewear / wide shoe with extra depth toebox

- lambs wool dressing or foam pads

- trim hyperkeratosis


Operative Management


Isolated small keratosis over 5th PIPJ

- treat with condylar resection of 5th PIPJ alone


Keratosis over 5th PIPJ & base 4th web

- treat with resection of 5th condyle & lateral proximal phalangeal condyle of 4th toe


Intractable Plantar Keratoses


1.  Resection Arthroplasty of Mann and DuVries 1973



- 85-90% patient satisfaction



- dorsal Incision over MTP

- retract EDL

- divide transverse MT ligament

- severe collaterals and deliver head

- remove 2-3mm of distal MT head

- remove the plantar lip so approximately 50% of head has been excised


2.  Giannestra Shortening Oblique MT Osteotomy


Best when long MT

- aim to shorten 5-6mm

- fix with screw


3.  Dorsal Closing Wedge Osteotomy


Aim for dorsal wedge of 2-3mm

- fix with cross K-wires

- must pop for 6/52






Lis Franc

HistoryLis Franc

Jacques LisFranc De St-Martin (1790 - 1847)

General Surgeon in Napoleonic army




High energy


1.  Twisting / Abduction injury of forefoot

- original description is fall from horse with foot caught in stirrups



2.  Axial Loading


A Extrinsic axial compression applied to heel

B Extreme ankle equinus with axial loading of body weight


3.  Direct Crushing

- to dorsum of mid-foot

- greatest risk of compartment syndromes and open fractures




A: Quenu & Kuss; Modified by Hardcastle (JBJS 1982)


1. Homolateral 

- all 5 metatarsals displaced in same direction

- most common


Homolateral Lis FrancLis Franc Homolateral


2.  Isolated 

- only 1st MT injured / displaced


Lis Franc


3.  Divergent 

- 1st MT displaces medially

- other 4 MT displace laterally

- least common


B: Myerson


A: Total incongruity (medial or lateral)

B: Partial incongruity

  B1: Medial

  B2: Lateral (most common)

C: Divergent displacement

  C1: Partial

  C2: Total




Bony Stability


1-3 MT articulate with cuneiforms

4 & 5 articulate with cuboid


Bases of MT wider dorsally than plantar

- form 1/2 of Roman arch 


Metatarsal Base Roman ArchFoot CT


2nd MT is keystone of transverse MT arch

- medial cuneiform is recessed proximally

- mortise provided for base of second


Ligamentous stability


Lis Franc ligament

- plantar structure

- 1 cm long x 0.5 cm diameter

- base 2nd MT to medial cuneiform

- avulsion as 'fleck fracture'


Note: no intermetatarsal ligament from 1st MT to 2nd


Mobility (Sagittal)


Medial Column (1st MT) - 3.5 mm

Middle Column (2/ 3) - .6mm

Lateral Column (4/5) - 13mm




Swelling and pain

- out of proportion

- must suspect Lis Franc


Brusing plantar aspect foot

- indicative of Lis Franc Ligament rupture


Signs compartment syndrome




Fleck sign

- avulsion of LF from base of 2nd MT

- can be only sign of isolated Lis Franc Injury


Lis Franc Fleck SignLis Franc Fleck Sign


Diastasis between 1st & 2nd MT

- may need to perform bilateral weight bearing stress view


Lis Franc Diastasis


AP / Assess medial column

- medial border 1st MT should line up medial border medial cuneiform

- medial border of 2nd MT should line up with medial border middle cuneiform


 Lis Franc Medial Column ViewFoot Medial Column Normal


Internal Oblique 30o / Assess lateral column

- medial border 3rd MT line up with medial border lateral cuneiform

- medial border of 4th MT line up with medial border cuboid


Lis Franc Lateral ColumnLis Franc Lateral Column Disruption


CT scan


Confirm displacement of MT from respective joints


Lis Franc Displaced TMT Joints CT0001Lis Franc Displaced TMT Joints CT0002


Identify fleck sign


Lis Franc CT Fleck SignLis Franc CT Fleck Sign and Diastasis


Identify dorsal displacement of metatarsals


Lis Franc CT Dorsal Displacement MTLis Franc Dorsal Displacement


Compression fractures / nutcracker of cuboid


Cuboid Fracture Lis Franc




Confirm oedema or tear of Lis Franc ligament

Bone brusining tarsometatarsal ligaments

Subluxation of ligaments



Curtis stress views

Hindfoot stabilised & forefoot pronated/ abducted




Residual pain & stiffness with non-anatomical reduction

- 2° OA

- progressive planovalgus




Non Operative


Sprains with no displacement

- 6/52 in NWB SLPOP

- close serial follow up

- strapping/ medial arch support 6/12






Any displacement


Closed Technique



- isolated Lis Franc with diastasis

- early diagnosis and treatment



- longitudinal traction

- reduction first intermetatarsal joint

- percutaneous fixation screws

- from medial cuneiform to 2nd metatarsal


Lis Franc Isolated Injury FixationLis Franc Medial Column ORIF


Open Technique



- wait for swelling to reduce

- may take 2 - 3 weeks



- reduced and stabilise all MTJ that are injured


First incision

- dorsal

- between 1st and 2nd MT

- lateral to EHL

- protect branches of SPN

- dorsalis pedis and DPN are in this intermetatarsal space

- very difficult to identify



- clean out joint

- reduce first and second metatarsal to cuneiforms

- check AP reduction


Provisional fixation

- K wire 1st MT to medial cuneiform

- K wire 2nd MT to intermediate cuneiform

- K wire medial cuneiform to base 2nd MT

- +/- K wire medial to intermediate cuneiform if unstable

- insert 4.0 mm cannulated screws


Lis Franc Post ORIF


2nd incision between 3rd and 4th MT if required

- reduce 3rd and 4th MTPJ

- K wire / screw 3rd MT to lateral cuneiform

- Fix 4th and 5th to cuboid with K wires

- 5th K wire usually inserted percutaneously

- check with oblique view

- may use screw / k wire to 3rd MTPJ


Post op


Strict NWB for 8/52

- Lis Franc ligament takes time to heal


Removal of K wires at six weeks


Screw removal

- no sooner than 4/12

- broken screws rarely bothersome




Compartment Syndrome


Open fracture

- closed reduction and hold with external fixator


Midfoot Arthritis

- can develop later

- require midfoot fusion

- some surgeons advocate primary fusion if joint surfaces very damaged / comminuted


DDx Metatarsalgia



Pain in the forefoot in the region of the MT heads


3 groups


1.  Localised


Morton's neuroma


Stress fracture

Infection / tumour

Plantar Keratosis

Plantar Wart


2.  Systemic disease




3.  Altered forefoot biomechanics / Transfer Metatarsalgia

- irregular Distribution of MT load


A  1st ray insufficiency syndrome

- splayed forefoot

- 1st ray unloaded


Metatarsalgia Splayed Foot


B.  Short 1st MT 

- > 2 cm back from 2nd MT

- varus 1st MT

- 1st ray unloaded


Metatarsalgia Short 1st Metatarsal


C.  Hyper-extended MTPJ with claw toe


D.  Iatrogenic

- bunion surgery

- excision of metatarsal head


E.  Lax soft tissues

- Lis franc injury


F.  Flatfoot

- supination, elevation of 1st metatarsal





Crushing osteochondritis of metatarsal head






Usually 2nd metatarsal (80%)

- occasionally third

- can occur in any


Age 10-15 years

- peak 15 year old girls

- F:M = 3:1

- occurs during the growth spurt at puberty


Bilateral in 6%




Trauma / repetitive stress

- interrupts blood supply to epiphysis

- fragmentation and AVN


2nd MT prone to stress fracture & AVN

- long MT

- fixed base

- thin shaft




Ischaemic necrosis of epiphysis


Commonly have synovitis as well




Tender enlarged MT head

- pain on dorsiflexion

- limited dorsiflexion due to synovitis or degenerative change




MTPJ synovitis / arthritis / synovial cyst

Interdigital neuroma

Stress fracture




Enlarged flattened MT head

- widened joint space

- osteolysis & collapse in late stages


Leads to MTPJ OA




Friebergs MRIFriebergs MRI


Classification Smillie 


Stage I 


Subchondral fissure in epiphysis


Xray normal

Bone scan / MRI positive


Stage II 


Collapse of dorsal central portion of MT head



- slight widening of joint space

- sclerosis of epiphysis


Stage III 


Friebergs Stage III



- progressive flattening of the head / osteolysis / collapse


Stage IV 



- fragmentation of epiphysis

- multiple loose bodies


Stage V 


Friebergs Stage V



- advanced degenerative arthrosis

- joint space narrowing

- hypertrophy of MT head

- osteophyte formation 











Limit activities 6/52

Metatarsal bar / preMT dome to unload MT head

Avoid high heels

Consider POP / moonboot to reduce symptoms






Synovectomy & joint debridement / removal of loose bodies



- stage II / III disease


Osteophyte removal / Cheilectomy


Closing wedge extension osteotomy



- dorsiflexion osteotomy

- most affected portion MT head is dorsal

- redirects plantar articular surface


Excision of MT head 



- severe disease



- not a great operation 

- associated with hallux valgus and transfer metatarsalgia

Morton's Neuroma



Benign enlargement of the common digital branch

- usually 3rd webspace


Mortons Neuroma Common Site




Found at level of or just distal to MT heads

- deep to the deep transverse MT ligament




Classically women between 40 and 60




Can be traumatic but usually degenerative




Demyelination of nerve fibres with fibrosis




Pain with weight bearing

- worse with wearing tight shoes

- in the ball of foot

- may be shooting type pain


Numbness / tingling in the affected toes




Mulder sign

- palpate webspace with fingers superiorly and inferiorly

- with other hand compress metatarsal heads together

- either palpate the lump or feel a click


Mulders Sign




Usually normal

- can have splaying of MT heads




Aid in confirming the diagnosis




Non operative


Wide toe box

Metatarsal Pads

HCLA - Temporary relief

Sclerosing injections / phenol

- can solve problem





- resection (dorsal or plantar)

- decompression


Resection Technique


Dorsal incision

- beginning at webspace edge

- separate MT with lamina spreader / retractor

- divide deep MT ligament / can preserve especially in athletes

- identify common digital nerve proximally

- identify neuroma / place forceps under

- resect proximal to neuroma

- resect distal to bifurcation

- send to pathology to confirm


Mortons Neuroma IncisionMortons Neuroma 1Mortons Neuroma 2


Mortons NeuromaMortons Neuroma




Patient will have numbness

Painful stump neuroma (revise via plantar approach)

Hammer toe (inadvertant lumbrical resection)

Pain secondary to instability / division intermetatarsal ligament

Plantar Warts



Human papilloma virus


Occur in any part of sole


Clinical Features


Do not project above level of skin

- because of pressure of weight bearing

- seldom more than 1cm in diameter

- skin surrounding wart thickened and raised

- edge clearly demarcated from surrounding skin


Severe localised pain on walking


Local tenderness on pressure




Plantar callosities

- warts occur anywhere

- callosities occur over points of pressure

- warts have clearly defined edge with possible cleft between it and skin

- callosities blend with surrounding skin

- warts have punctate bleeding






Cauterisation / freezing / Paring




Curettage and cauterisation of base

- (care taken with digital nerves etc)



Accessory Medial Cuneiform

Accessory Medial Cuneiform0001Accessory Medial Cuneiform0002Accessory Medial Cuneiform0003


Accessory Navicular



1 - 2 %




Medial Aspect of foot

- proximal to navicular

- part of T posterior tendon


Usually will fuse with navicular (50%)




1.  Probably not a cause of flat foot

- excising accessory navicular / rerouting / reattaching tibialis posterior

- will not help pes planus


2.  Pain

- may fracture

- may cause insertional tendonitis




Type 1


Small ossicle proximal to insertion


Type 2



- may fracture with injury


Accessory Navicular Fractured SynchondrosisAccessory Navicular



- treat in cast 6/52

- excise if symptomatic


Type 3


Large cornuate navicular

- likely that the accessory has fused


Accessory Navicular Cornuate


Bone Scan


Acessory Navicular Bone Scan


Identifies if accessory navicular cause of symptoms




Show oedema about a symptomatic accessory navicular




T Posterior tendonitis

Navicular stress fracture




Non operative



Moon Boot




Kidner Procedure

- medial incision dorsally over navicular

- enucleate accessory navicular from tendon

- may need to take away navicular prominence

- reattach tendon if necessary through drill holes


Brailsford Disease



Adult form

- 45 year old females

- more severe than Kohler's




Intense pain +/- oedema & inflammation

- often pronounced limp

- marked flat foot with prominant navicular




Navicular narrowed

- lateral part dense, sclerotic & thin

- occasional fracture line

- degenerative TNJ

- due to wedge shape concentrating forces dorsally

- fracture collapses




Often necessary

- to graft navicular & restore anatomy


Gait cycle



- from point of initial contact of one foot with the ground

- until that foot hits the ground again


Two parts


1.  Swing phase

- foot not in contact with ground

- 40% walking gait


2.  Stance phase

- heel strike to toe off

- 60% of walking gait

- 3 rocker phases


Rocker Phases


1st rocker phase / Heel Strike


Ankle plantar flexes 

The foot is lowered onto the ground under the control of the eccentrically acting tibialis anterior

Foot pronates with flattening of medial arch, and hind foot in valgus to allow show absorption


Lose with

- heel pain

- fixed equinus

- true or apparent LLD


2nd rocker phase / Stance Phase


Progressive  dorsiflexion of the ankle allows the tibia and the centre of gravity to progress over the foot

- modulated by the eccentrically acting triceps surae

- maximal pronation


3rd rocker phase / Toe Off


The foot rotates over the MT heads

Foot moves into supination, heel into varus

Tibialis posterior locks Midfoot so foot can act as a rigid lever

Concentric contraction of the triceps surae and FHL provides pushoff 



- painful forefoot (Hallux valgus / rigidus)

- loss of PF (NM, stiff hindfoot, ruptured TA)




Walking ground reaction force 1.5 X body weight

Running ground reaction force 3 X body weight


Running has floating phase

- neither foot touching ground


Heel Pain DDx


- Sever's disease

- Tarsal Coalition






- calcaneal fracture

- stress fracture

- lateral talar process fracture



- soft tissue

- calcaneal osteomyelitis



- osteoid Osteoma

- osteochondroma

- bone Cyst

- ewing's Tumour

- metastasis



- plantar fasciitis

- tibialis posterior tendonitis

- peroneal tendonitis

- achilles tendonitis

- retrocalcaneal bursitis

- fat pad atrophy

- tarsal tunnel syndrome

- RA / seronegative arthropathy



Sinus Tarsi Syndrome



Osseous canal between talus and calcaneum

- interosseous talo-calcaneal ligament

- cervical ligament

- joint capsule

- nerve endings / arterial anastomoses


Sinus Tarsi




Flat foot / overpronation

Inversion / sprain





- compression / pinching injury

- develop scarring of ligament and capsule

- predisposes to further pinching




Pain at lateral aspect ankle

- below lateral malleolus


May get pain when running on outside of foot / track work


Pain on uneven ground




Tenderness sinus tarsi

- soft indentation below and anterior to LM


Pain with eversion / inversion STJ





- relieves pain




Display fluid in sinus tarsi

May detect excess scar tissue




Non operative Management


Usually very effective






Subtalar joint manipulation

Correction of over pronation / orthotics


Orthotics to stabilise STJ




Lee et al Arthroscopy 2008

- 33 cases of subtalar arthroscopic debridement

- 88% good or excellent

- 12% fair



- partial tear interosseous ligament 88%

- synovitis in 55%

- partial tear cervical ligament 33%

- arthrofibrosis 24%

- soft tissue impingement 21%



Tarsal Tunnel Syndrome



Entrapment neuropathy of posterior tibial nerve within the tibial tunnel




Taral Tunnel


Flexor Retinaculum 

- medial malleolus to posterior calcaneum


Tarsal tunnel

- roof is flexor retinaculum

- tibia anteriorly

- talus and calcaneum laterally



- T. Post


- Posterior tibial artery, tibial nerve



Tibial nerve

- 3 terminal branches

- medial and lateral plantar

- medial calcaneal

- usually divide within tunnel




Specific cause identified in 60% cases



- 40% cases

- most common



- scarring after sprain

- bony prominence 2° calcaneal fracture



- RA

- tenosynovitis



- tumours

- ganglion of tendon sheath

- lipoma

- neurilemmoma (Schwannoma) 
- varicose veins

- medial talo-calcaneal bar


Accessory muscles





Diffuse pain plantar aspect

- burning, tingling or numbness

- 1/3 have proximal radiation to leg


Aggravated by activity




Tenderness over Tarsal Tunnel


Positive Tinel's sign    


Palpate for thickening or swelling (cyst, ganglion etc)


Usually no sensory loss or weakness 


May see wasting of abductor hallucis




At best 90% accurate

- Prolonged sensory conduction time in 75%

- Prolonged motor latency in 50%

- conduction velocity of CPN done to exclude peripheral neuropathy




MRI positive in 85% 

- FHL synovitis, dilated veins, mass, fracture, scar, etc

- 25% have contralateral MR findings with no symptoms




At least 2 of

- Hx of tingling & burning

- positive tinels

- positive NCS





- plantar fasciitis

- fracture

- tenosynovitis



- peripheral neuritis

- diabetic neuropathy

- leprosy

- neurilemmoma

- neuroma

- spinal compression






Of little benefit

- try NSAIDs




Surgical release by division of Flexor Retinaculum



- 10 cm proximal to medial malleolus

- curved distally to TNJ



- flexor retinaculum

- proximal investing fascia

- individual tendon sheaths / tibialis posteror in separate sheath

- abductor hallucis fascia


Follow and release both plantar nerves

- protect medial calcaneal branch

- runs off lateral plantar


Post op

- NWB for 3/52




75% success if no underlying causes

Pantalar Fusion

Pantalar Fusion APPantalar Fusion Lateral




Rheumatoid arthritis


Pantalar OA


Combined ankle and subtalar joint osteoarthritis


Talar AVN


Talus AVN




Severe Deformity

- acquired flat foot

- neurological conditions


Severe Valgus APSevere Valgus Lateral


Surgical Technique


1. Prepare joint surfaces



- curved incision

- posterior border fibular

- curved anteriorly along peroneal tendons

- towards 4th MT


Exposure AKJ

- excise distal fibular


Exposure subtalar joint

- elevate peroneals and EDB

- divide TC interosseous ligament


Prepare arthrodesis

- decorticate / remove cartilaginous surfaces

- drill holes

- correct deformity

- ankle joint: 5o valgus, plantigrade, ER 10o

- subtalar joint:  5o valgus


2.  Hindfoot nail


Pantalar Fusion Talus AVN APPantalar Fusion Talus AVN Lateral


Insertion point

- in line with 2nd metatarsal

- junction of posterior 2/3 and anterior 1/3 heel

- should pass through anterior aspect posterior subtalar joint


Insert nail

- distal locking screws calcaneum using jig

- insert bone graft

- compress

- proximal locking


Smith and Nephew Hindfoot Fusion Nail Surgical Technique PDF



Smith & Nephew Hindfoot nail


Synthes Hindfoot Arthrodesis Nail Surgical Technique PDF



Synthes HIndfoot Nail

Peroneal Tendons




Anterior displacement of peroneal tendons out of peroneal groove




Most common in young adults


Acute injury often missed 






3 % neonates

- resolves spontaneously




Occurs following sporting activities

- snow skiing

- football

- gymnastics


Forced DF and inversion




Fibro-osseous tunnel

- retro-malleolar groove

- lined by fibrocartilage



- fibula 







Peroneus longus

- posterolateral to PB


Superior Peroneal Retinaculum

- 2 bands

- fibula to lateral T Achilles

- fibula to posterolateral calcaneum


Inferior peroneal retinaculum

- lateral wall calcaneum below sinus tarsi

- no role in stability




1.  Traumatic


Violent contraction of Peroneal muscles 


Forced dorsiflexion and inversion

- injury to superior peroneal retinaculum


May be predisposition

- laxity of retinaculum

- shallow groove


Patient may also have tears


2.  Subluxation within sheath


Raikin JBJS Am 2009

- described intrasheath subluxation

- superior retinaculum intact

- patients still having painful snapping

- demonstrated by US

- half had peroneal tendons switching positions

- these patients had a convex groove

- these where treated with groove deepening and retinaculum reefing

- other half had a tear in PB through which PL could sublux





- sudden pain behind lateral malleolus

- snap may be heard

- unable to continue with activities



- painful snapping of lateral ankle with activity




Tenderness & swelling behind LM

- pain or dislocation reproduced by active eversion & DF


Peroneal Tendon Dislocation 1Peroneal Dislocation 2




Usually normal


May be avulsed fragment of cortical bone lateral to LM

- fleck sign




Defines anatomy & relationships of tendons

- may detect anatomical variants




Very good at demonstrating subluxation




Detects tendinous & ligamentous injuries




Opinion divided regarding acute injuries

- non-operative management v surgical repair


Most treat chronic injuries surgically




Acute injuries

- cast in plantarflexion for 6/52





- acute injury in athletes

- chronic injuries


Acute Repair




1.  Superior retinaculum stripped

- reattach to fibula via trans-osseous sutures / anchors


2.  Retinaculum torn

- primary repair


3.  Bony avulsion

- fragment reattached with sutures, wires or screws




1.  Groove Deepening

- if necessary

- elevate cortical flap / decancellation / cortical recession


2.  Address tears in tendons


3.  Address superior peroneal retinaculum


A.  Direct repair / Advancement of superior peroneal retinaculum if able


B.  Reconstruction of SPR if attenuated

- periosteal flap from fibula

- slip of T Achilles left attached distally

- free plantaris / palmaris graft


C.  Rerouting under CFL

- substitution of CFL for peroneal retinaculum

- tendons transposed into inframalleolar tunnel

- division & repair CFL or fibular bone block with CFL


4.  +/- lateral ligament repair if needed


Surgical Technique



- chronic subluxation / anterior dislocation

- normal groove

- retinaculum stretched and not attached to normal insertion anterior fibula

- repair and tightened with suture anchors


Anterior Peroneal DislocationAnterior Peroneal DislocationAnterior stripping of SPR


Normal GrooveNormal GrooveSuture Anchors


Sutures PassedSutures Passed 2Repair 1



Tendonitis / Tendonopathy



Lateral compartment of leg

- run through retromalleolar groove

- pass superior and inferior to peroneal tubercle

- covered by inferior peroneal retinaculum


Peroneus longus

- origin lateral condyle of tibia and head fibula

- tendon PL superficial and inferior to brevis in retromalleolar groove

- runs in cuboid groove 

- insert plantar surface base of 1st MT and lateral aspect medial cuneiform

- everts the foot / plantar flexes the first ray / plantar flexes the ankle

- stabilises the medial arch in stance


Os peroneum

- sesamoid in PL

- level CCJ / articulates with cuboid

- 20% population


Os Peronei


Peroneus brevis

- origin middle third fibula and intermuscular septum

- inserts tuberosity base 5th

- abducts and everts the foot / plantar flexes the ankle


Nerve supply






- inflammation of tenosynovium



- degenerative change in tendon

-  can lead to tears






Prolonged or repetitive activity

- usually after period activity

- runners and ballets dancers


Cavovarus hind foot



- acute injury

- chronic tendonitis

- dislocation / subluxation




Chronic lateral ankle instability

Peroneal tendon subluxation

Cavovarus hindfoot


Peroneal Tendon Tears




P. brevis torn more frequently than longus




Sobel & Mizel 1993


Zone 1 

- behind lateral malleolus

- brevis more commonly injured 


Zone 2 

- distal to tip of fibula 

- longus only 

- cuboid tunnel acts as a fulcrum

- can get inflammation & swelling

- loss of excursion as brevis & longus skirt around pulley




Acute or chronic lateral ankle pain




Tenderness / swelling along tendons


Peroneal Tendon Swelling



- passive inversion and PF

- active eversion




Lateral instability

Fracture fibula / 5th MT / cuboid / Calcaneal

OCD talus

Loose body ankle

OA ankle

Sinus tarsi syndrome

Tarsal coalition




10 tendons about ankle

- axial views most usefull

- T1 displays anatomy

- T2 STIR shows tears 

- beware magic angle (fibres orientated 55 degrees to scan)



- tendon thickening / tendonopathy

- fluid about tendons / tendonitis

- tears


Peroneal TendonitisPeroneal Tendonitis MRIPeroneal Tendonitis MRI 2




Non Operative



Modification activities

Lateral heel wedge if hindfoot varus

Moon boot / SL walking cast




1.  Tenosynovitis


Open debridement and tenosynovectomy

- incision posterior to fibula and to base 5th MT

- sural nerve halfway between peroneals and T Achilles

- open peroneal tendon sheath

- debride synovitis


Peroneals Intra-operatively


Must also treat any

- inflamed os peroneum

- varus heel

- tears


2.  Tears


A.  <50% 

- excise &  repair tears by tubularisation

- incision 1 cm posterior to fibular

- from 5 cm above to base of 5th metatarsal

- immobilise with foot PF and everted to rest in POP

- after 2 weeks in moonboot for progressive mobilisation


B.  > 50%


One tendon torn

- tenodesis to other tendon


Both tendons torn

1.  2 stage reconstruction


2.  Tendon transfer FDL to PB / plantaris to PL


Pes Cavus

Calcaneo Cavus



Pure Cavus Deformity characterised by 

- dorsiflexion of Calcaneus 

- plantarflexion of Forefoot




Weakness of Tendoachilles


Usually neuromuscular

- Polio (Most common worldwide) 

- Spina bifida

- CP (can be due to overcorrection of T Ach)

- Spinocerebellar Degen (Friedreich's Ataxia)


- Spinal dysraphism


Compartment Syndrome Deep Posterior 




Imbalance of tendoachilles and dorsiflexors

- dorsiflexion of calcaneus

- moves insertions of T Achilles anterior

- further weakens the lever arm


Forefoot becomes flexed because of

- gravity 

- action of muscles during gait

- result is elevated longitudinal arch 




Difficulty walking 

Obvious deformity 

Shoe fitting & wear problems 

Painful callosities




Elevated longitudinal arch 


Prominent heel with abundant callus on plantar aspect 

- called pistol grip deformity 


Heel usually in neutral


Usually claw toes 




Lateral xray

- calcaneal pitch > 30o

- Meary's angle > 30o




Exclude dysraphism






Modification of shoe wear & orthoses required 

- cannot control deformity alone

- doesn't work




Age 0 - 5


Best avoided


Tendon transfer

- T Ant to T Achilles


Age 5-12


Grice arthrodesis STJ 

- extra-articular

- stabilise STJ


Transfer muscles

- must be > Grade 5 power



- Tibialis anterior

- Tibialis posterior

- peroneals


Age >12


As Above


Triple arthrodesis



Cavo Varus




A fixed equinus deformity of the forefoot in relation to the hindfoot 

- resulting in an abnormally high arch that fails to flatten with weight bearing

- deformity may be forefoot, hindfoot or combination


Foot CavusFoot Cavovarus




2/3 have neurological disorder

1/3 have CMT








Muscle imbalance of intrinsics and extrinsics


1. Neuromuscular


A. Central 

- Friedreich's Ataxia (absent ankle jerks & balance)

- Cerebral Palsy

- Hydrocephalus


B. Spinal cord

- Spinal Dysraphism / spina bifida

- Diastematomyelia /Syringomyelia

- Spinal Cord tumours

- CMT Type 2 (degeneration of spinal axons)


C. Anterior horn cell

- Polio (imbalance between anterior and posterior m)



D. Peripheral nerves (+roots)

- CMT type 1 (demyelinating peripheral neuropathy)

- Polyneuritis


E. Muscle Disease

- Muscular Dystrophy


2. Congenital


Congenital cavus foot

Residual clubfoot



3. Traumatic


Compartment Syndrome

Malunion of fractured foot


4. Degenerative


OA / RA of hindfoot


5. Idiopathic




Inherited disorder of nerves

- most common inherited neurological disorder

- heterogenous group

- characterised by weak muscles and abnormal sensation

- positive FHx



- most common 80%

- demyelinating disorder

- peripheral nerve roots



- glove and stocking parasthesia

- nil reflexes

- claw toes, cavus feet, stork legs

- loss of intrinsics in hand

- abnormal NCS



- second most common 20%

- primary axonal neuropathy

- degeneration of spinal axons



- normal DTR


CMT 3 / 4 / X 




Rang Tripod concept

- heel / MTPJ 1st / MTPJ 5th 

- all must touch ground

- if 1st MTPJ plantaflexed

- heel must move into varus


Imbalance is the key to understanding

- PL creates cavus and equinus

- TP creates varus


A.  PL > T Ant 

- equinus forefoot

- plantar flexed first ray

- cavus foot


B.  T Post > PB 

- varus


C.  Weak Intrinsics & EDL < FDL

- clawing




A.  Cavus foot


PF 1st ray initially 

- weak T Ant

- EHL & EDL act to DF ankle

- this increases windlass mechanism 


Contracture of plantar fascia 

- fixed Cavus

- fixed navicular-cuneiform & 1st CMTJ

- holds MT plantar flexed


B.  Varus heel 




1.  Overpowering T Post & long toe flexors

- T post may be primary deforming force


2.  Supination of forefoot due to PF 1st ray

- then need varus heel to place lateral column on floor with PF ray

- may be primary deformity


C.  Clawing of toes  


Weak intrinsics 

- unopposed flexors and extensors

- hyper-extended MCPJ +/- dorsal subluxation MTPJ's

- claw toes


D.  Ankle Instability


Weak P Brevis

- Loss of dynamic restraint


Varus heel increases inversion moment on ankle 




1.  Bilateral Cavovarus


Central Pathology

- Spinal Cord Tumour / Dysraphism

- CNS 


2.  Unilateral Cavovarus 


Peripheral or Local Pathology

- Polio

- clubfoot

- Incomplete spinal cord or Cauda equina trauma

- Deep posterior Compartment Syndrome

- Compartment Syndrome of Foot


3.  CalcaneoCavus


Hindfoot Cavus 2° DF of calcaneus only


The apex is the differential

- Midfoot Cavus has apex in tarsus

- Forefoot Cavus from PF of 1st Ray (form seen in CMT)




1. Flexible cavus / Flexible 1st MT

- plantarflexion corrects with pressure on 1st MT


Cavus FootCavus Foot Flexible First Metatarsal


2. Fixed 1st MT equinus / hindfoot mobile varus

- hindfoot corrects with Coleman block test


3. Fixed lesser MT's equinus / fixed hindfoot varus


4. Bony changes




Family history


Is it progressing?




Lateral ankle sprain 

- secondary to hindfoot varus


Ulcerations due to clawing


Foot numbness


Difficulty shoewear





- aetiology

- define deformity / correctability

- motor drive to deformity





- dysmorphism

- stork legs

- shoes

- parents



- cavus foot / plantar flexed first ray

- claw toes



- varus heel

- signs spinal dysraphism




High stepping gait

- weak T Achilles

- drop foot


Back knee gait

- fixed equinus


Heel walk 

Toe walk



Coleman Block  / Lateral Block Test 



- block under lateral foot

- first ray touches the ground



- eliminate forefoot deformity

- if hindfoot corrects with this test the hindfoot is flexible

- forefoot surgery should be sufficient to correct hind foot





- Claw toes - ? correctable

- Plantar keratoses from uncovering MTPJ

- Dorsal toe corns from claw toes


Plantarflexed 1st MTPJ 

- ? correctable


Motor examination

- T Post / T Ant /  PB & PL

- Ankle DF & STJ Eversion weak 



- is T Achilles tight ?



- abdominal reflexes

- LL neurology

- CMT 1 abnormal sensation and absent reflexes




Lateral x-ray

- sinus tarsi easily seen

- PF 1st ray


Meary's angle

- talo - 1st metatarsal angle 

- normal 0o

- increased in cavus > 30o


Calcaneal Pitch

- normally 20o or less

- > 30o abnormal

- will demonstrate hindfoot DF

- demonstrates calcaneovarus


Pes CavusCalcaneal Pitch


MRI spine


Exclude spinal dysraphism




Can help diagnose CMT


Neurology review



Non Operative





- preMT dome


Claw toes

- wide deep toe box


Foot drop



Insensate foot

- custom orthosis



- lateral heel wedge

- AFO (flexible)

- medial iron with lateral T strap


Ankle Orthoses




Pes Cavus Post Op




Difficulty with Footwear


Lateral instability 




Need to ensure is not progressing

- otherwise surgery will not work

- i.e. does patient need spinal surgery first for dysraphism




Soft tissue surgery

- for dynamic / flexible deformity


Bony surgery

- for static / fixed deformity




Stage 1 / Flexible 1st MT PF


Shoe modification


Stage 2 / Fixed 1st MT + Flexible Hindfoot


Steindler release (plantar fascia release)

Jones / 1st MT osteotomy

Lesser toes as necessary

T post transfer if weak dorsiflexion

PL to PB transfer if weak eversion


Stage 3 / Fixed 1st MT / Fixed Hindfoot


Above +

Lateral Shift Calcaneal Osteotomy

T Achilles lengthening


Stage 4 / STJ and other bony deformities


Triple arthrodesis

Tarsal / MT osteotomy




Soft tissue


1.  Steindler Release / Plantar fascia release


Best < 8 years

- for cavus



- medial incision extending 1.5 inches anterior to calcaneal tuberosity



- separate above and below fascia

- divide plantar fascia & Long Plantar ligament at calcaneum

- excise 1 cm of fascia

- NV lie between 1st & 2nd layers

- if stay on periosteum will avoid damage to NV

- lateral plantar nerve is at lateral edge of fascia


2.  Tibialis Posterior transfer



- weak dorsiflexion



- through interosseous membrane to lateral cuneiform


3.  P Longus to Brevis transfer 


Removal of 1st ray PF & increase eversion


4.  First Toe / Jones Procedure



- great toe clawed

- MTP hyperextended and IP flexion




A.  Leave EDB to P1 intact

- will drive extension toes


B.  Harvest distal EHL

- pass through drill hole neck MT

- suture to itself


C.  Fusion of IPJ

- K wire


5.  Hibbs 


EDL transfer

- plug into middle cuneiform 

- act as DF instead of weak T Anterior


6.  Lesser Claw Toes 


A.  Girdlestone FETT if flexible

B.  Extensor Tenotomy / PIPJ fusion / MTPJ dorsal capsulotomy / Weil's osteotomy if fixed




1st MT osteotomy 



- dorsal closing wedge osteotomy

- extension osteotomy



- incomplete correction of first ray

- mature patient with closed physis



- dorsal closing wedge osteotomy

- base of MT

- leave plantar surface intact

- 3-4 mm wedge

- close osteotomy, fixation with K wires

- +/- 2nd and 3rd




Soft Tissue


1.  Tendo achilles lengthening



- unable to reach plantigrade



- percutaneous

- 2 medial and one lateral to take out of varus


2. Lateral Ligament reconstruction 


If complain of ankle instability




1.  Dwyer lateral closing wedge Calcaneal osteotomy 



- correct fixed hindfoot varus 



- shortens foot further


2.  Calcaneal Lateral Shift Osteotomy


Lateral approach

- curve just behind peroneals

- homann in front of tenoachilles

- homann under calcaneum


Oblique osteotomy 

- 45o

- behind posterior facet

- osteotome

- open with lamina spreader

- split periosteum medially with osteotome

- this avoids damage to medial structures

- transfer laterally 1 cm

- may need to lengthen T Achilles


Fix with screw or lateral staple


3.  Midtarsal Osteotomy / V shaped



- fixed, difficult cases


Cole Osteotomy

- use ilizarov


4.  Triple Arthrodesis


For salvage of rigid deformity


Planovalgus Foot

Aquired Adult Flatfoot Deformity



Acquired Adult Flatfoot Deformity (AAFD)

- collapse of medial longitudinal arch

- secondary to ligament / tendon / joint or bony pathology




1. Congenital


Flexible / Physiological


Ligamentous Laxity (DIAL HOME)



- Congenital Vertical Talus 

- Tarsal Coalition


2.  Acquired


Tibialis Posterior Dysfunction


RA Flat Foot



- Charcot Foot

- spinal dysraphism

- CP

- polio




Midfoot OA / Lis Franc injury


Midfoot OA Planovalgus


Subtalar joint OA (calcaneal fracture)

Ankle OA


Ankle OA Valgus Tilt



- isolated spring ligament rupture (rare)

- iatrogenic / traumatic plantar fascia rupture (rare)


Compensory to Rotational & Coronal plane deformities

- tibial torsion

- genu valgum

- ankle equinus 2° tight TA


Biomechanics of FlatFoot


Normal Gait / 3 phase rocker


1.  Heel Strike 


Tibia IR 


Hindfoot Everts

- unlocks TNJ & CCJ 

- forefoot pronates


Allows shock absorption by hind/mid/forefoot


2.  Stance 

- WB axis passes through ASIS to patella to middle of foot


3.  Toe Off


T Posterior "locks" the midfoot (i.e. the transverse tarsal joints)

- T Anterior inverts the hindfoot

- T Achilles plantar flexes the calcaneum

- Tibia externally rotates


Flatfoot Gait


The above components are exaggerated

- More stress on ligament structures


WB axis shifts medially, causing

- increased femoral anteversion

- internal knee rotation

- increased Q angle


T Achilles becomes evertor


Increased pronation

- may cause Hallux Valgus


Specific Conditions


Lisfranc Joint OA


Acquired Adult Flatfoot




1.  Post injury


Degenerative arthritis develops after fracture dislocation

- Acute injury often missed

- Adequate acute treatment may not prevent occurrence


2.  Idiopathic 

- not related to trauma


3.  Charcot




Degenerative changes invariably involve second MT/ 2nd Cuneiform joint

- may involve 1st & 3rd joints

- rarely involves 4th & 5th joints


Midfoot AP Secondary to Missed Lis Franc




Moulded arch support / UCBL initially if correctable

Lateral Single Upright caliper with Medial T strap if not




Realignment of Lisfranc joint with arthrodesis


Rheumatoid Flat Foot


50% will get flat foot

- subtalar OA

- spring ligament attenuation

- tibialis post dysfunction

- progressive valgus deformity at hindfoot 


OA of Ankle Joint


Usually post traumatic

- valgus tilt of Talus leads to pronation of Talus & Calcaneus


Flatfoot def corrected when AJ realigned


Charcot Flat Foot


90% changes in hind and midfoot

- repetitive microtrauma in presence of neuropathy leads to microfracture

- 2° to Sensory & Autonomic Neuropathy


Progressive subluxation / collapse


Usually associated with Diabetes

- may be marked collapse

- develop bony prominence on medial sole

- may cause ulceration


Plantar Fascia Rupture


Traumatic or spontaneous

- pain at calcaneal origin

- palpable gap

- often 2° excess HCLA



- arch support

- longitudinal arch will slightly flatten, but rupture should heal


Spring Ligament Rupture



- ? Repair

- probably in reality treat as for PTTD



Flexible Flat Foot



Complain of pain with prolonged standing


Complain feet tire easily




Adult Flatfoot Clinical Valgus Hindfoot Clinical


Overall alignment


Heel raises


Flexibility of Flat foot / STJ


T Achilles tightness




Planovalgus Lateral XrayPlanovalgus Foot Meary's Angle


Meary's angle

- Talus - first MT angle

- lateral weight bearing view



- 0o normal

- mild - 15o

- severe  - 30o


Non Operative


Medial arch support

Medial heel raise






- failure non operative measures

- inability to wear shoes




1.  Evans anterior calcaneal osteotomy



- lateral column lengthening



- incision tip of fibula to base of 4th MT

- elevate EDB anteriorly

- peroneal tendons anteriorly

- sural nerve posteriorly

- identify CCJ joint but do not open capsule

- insert Homan retractor and identify interval between middle and anterior facet

- osteotomy between the two, 1.5 cm from CCJ

- insert lamina spreader, assess arch at this point

- insert tri-cortical iliac crest bone graft (slightly trapezoidal) with bone tamp

- 1cm opening wedge

- stabilise with plate or screws


Evans Osteotomy + MT Osteotomy + FDL transferEvans Osteotomy + MT Osteotomy + FDL transfer Oblique


2.  Medial reefing / repair spring ligament / FDL Transfer

- incision at inferior aspect head of talus

- above tibialis posterior tendon

- excise segment of spring ligament approximately 6mm

- reapproximate ligament with non absorbable sutures


3.  Medial Cuneiform Plantarflexing Osteotomy



- Restore weight bearing tripod




Dorsal osteotomy mid-substance cuneiform

- lever open with osteotome

- 4 - 7 mm tri-cortical graft

- fixation with 2 x screw


Post operative

- back slab

- wound check at 1 week

- sutures out at 2 weeks unless DM or RA

- SL POP for 6/52 NWB

- then WBAT in boot 6/52


4.  +/- T Achilles lengthening

- if unable to passively DF ankle past 10o with knee extended


Post op

- POP for 6/52 (mould into arch)

- arch support / UCBL for 6/12


Tibialis Posterior Dysfunction





- inflammatory

- degenerative



- traumatic

- spur




F > 40


Associations 60% of cases  

- hypertension

- diabetes

- obese

- trauma 

- prior surgery

- steroids





- flat foot also secondary to synovitis TNJ and STJ


Hypermobile flat foot


Seronegative disorders

- Ankylosing spondylitis / psoriasis / reiter's


Anatomy Tibialis Posterior



- posterior tibia, fibula and inter-osseous membrane

- acute angle around medial malleolus

- flexor retinaculum holds TP in groove 

- no mesotenon

- relative hypo-vascular zone 1-2cm distal to medial malleolus



- navicular tuberosity

- plantar cuneiforms

- 2,3,4 MT

- sustentaculum tali



- 2cm only


Nerve Supply

- tibial nerve (L4/5, S1)




1.  Runs medial to axis STJ

- inverts STJ & adducts forefoot


2.  Runs posterior to axis AKJ

- plantar flexor


3.  Maintains longitudinal arch


4.  Locks the midtarsal joints

- allows T Achilles to perform heel raise

- otherwise T Achilles acts at TNJ


Opposed mainly by peroneus brevis




Avascular zone 

- behind medial malleolus

- paratenon is supplied by blood vessels from a mesotenon on its post aspect

- tendon is composed of fibrocartilage where it changes direction around the med malleolus 


Tendon Changes


Starts with varying combination


1. Paratendinitis

- fluid in sheath 

- synovial proliferation


2. Tendinosis 

- tendon degeneration 

- tendon enlarged

- longitudinal splits develop 

- becomes yellowish 


Tibialis Posterior Tendinosis


3. Elongation of tendon


4. Rupture


5. Deformity 

- loss TP function leads to acquired Planovalgus

- initial deformity is collapse of medial longitudinal arch




1. Medial arch collapses

2. STJ everts

3. Valgus heel

4. Foot abducts at TNJ

5. Achilles tendon acts as evertor when heel in valgus

6. Calcaneus impinges on fibular causing lateral AJ pain

7. Attenuation of TNJ capsule, spring ligament and deltoid ligament




Pain medially at first

- swelling


Lateral pain with impingement of fibula


Foot shape changes / progressive deformity


Difficulty wearing shoes




Any sign of RA



- flattened medial arch

- valgus heel


Too many toes sign

- abducted forefoot

- > 2.5 toes

- more than on other side when in symmetrical posture


Single Heel Raise

- unable to heel raise

- need T Post to invert STJ & lock hind foot rigid so T Achilles can pull up Calcaneus


Sit over edge





- tender medial

- is tendon thickened

- may be tender laterally



- fixed or flexible



- fixed or flexible


T Achilles

- silverskiold



1.  T Post with foot inverted in equinus

2.  Foot equinus and everted

- ask patient to invert the foot


NV examination




Lateral weight bearing



- reduced talo-metatarsal angle (Meary's angle  0-10°)

- medial cuneiform to floor distanced reduced (N= 2.5cm)

- talus plantar flexed





AP weight bearing of foot and ankle


Early - abduction of forefoot with navicular lateral to talus


Late - ankle OA / TNJ OA




Enlarged T Post - tendinosis


Thickned Tibialis Posterior


Torn T Post - half size of FDL


Johnson Classification


Stage 1 

- T Post tendonitis 

- no deformity


Stage 2 

- T Post rupture

- unable SHR

- foot remains flexible


IIA - minimal forefoot abuction

IIB - forefoot abducted throught THJ / > 30% uncovered


Stage 3 

- fixed deformity of STJ (may have STJ OA)


Stage 4 

- valgus angulation of talus & OA of ankle joint




Surgical Algorithm


Stage 1 Tendonitis




Walking cast / NSAIDS

- 6/52



- 3/12

- worn inside the shoe

- ends under malleoli

- controls the heel (which must be flexible)

- supports the arch


Operative / Synovectomy and debridement

(+/- FDL transfer and calcaneal osteotomy +/- T Achilles lengthening)


Stage 2  Tendon Rupture


Non Operative





2A - FDL transfer & calcaneal osteotomy +/- T Achilles lengthening

2B - + Lateral column lenthening to correct abduction


Stage 3 Rigid valgus hindfoot


Non Operative


Rigid AFO

Caliper: Outside iron with inside T strap




Triple arthrodesis


Stage 4 / Abnormal AKJ



- valgus angulation of talus

- deltoid ligament gone 

- early degeneration of ankle joint

- degenerative changes in subtalar & midtarsal joints 

- valgus angulation of talus


Non Operative

- double metal uprights with PTB



- pan talar fusion 




Tibialis Posterior Synovectomy and Debridement



- supine on table

- foot falls into ER

- tourniquet



- tip of medial malleolus to navicular

- open tendon sheath

- often fluid and synovitis




Repair any fissures


Inspect insertion

- if partially avulsed

- FDL transfer


Close tendon sheath


S/L cast for 3/52



- 75% good results


Calcaneal Osteotomy / Medial Calcaneal slide



- shifts calcaneum medially

- reduces valgus thrust on hindfoot

- pull of gastoc/soleus is medial to STJ



- stage 1 or 2

- in combination with FDL transfer



- perform osteotomy first, then tension FDL


Set up

- sandbag under ipsilateral hip

- table rolled over to expose lateral heel

- then unroll bed to expose medially


Calcaneal Sliding Osteotomy LateralCalcaneal Sliding Osteotomy Harris Axial



- lateral incision

- in line with peroneal tendons

- need to protect sural nerve posteriorly



- protect peroneals

- protect T Achilles

- behind posterior facet STJ

- transverse osteotomy at 45o to plane of foot

- complete with osteotome to protect medial structures

- use osteotome to gently break up periosteum

- use lamina spreader to break up final adhesions

- translate 10mm medially



- K wire lateral to T Achilles, towards CCJ

- check II, 6.5 mm partially threaded cannulated screw


Lateral column lengthening



- midfoot abduction



- anterior calcaneal ostetomy

- insertion bone graft wedge

- stabilisation plate or screws


FDL transfer 



- FDL easily found by reflecting abductor hallucis



- foot should be supple with no fixed deformity 

- stage 1 / 2



- along entire length T posterior

- 10 cm proximal to medial malleolus

- to metatarsal cuneiform joint


Superficial dissection

- expose T posterior in sheath

- may be ruptured, avulsed, deficient, fissured


Deep dissection

- abductor hallucis reflected plantarward

- find fat / Knot of Henry

- release Master Knot of Henry 

- crossover of FDL & FHL 

- FDL plantar to FHL

- suture together and release proximal FDL 



- open to visualise

- 4.5mm drill hole through navicular

- Reinsert FDL into underside of navicular

- plantar to dorsal

- pulled tight with ankle in equinus & forefoot in varus 

- close TNJ capsule

- No need to attach proximal T Post to FDL


Repair spring ligament


Closure abductor fascia


Post op

- 6/52 in equinus and inversion NWB

- x-ray to check osteotomy has healed

- 4/52 weight bearing in removable cast with ROM exercises

- may need physio


Triple Arthrodesis



- fixed hindfoot deformity with lateral joint pain



- realign hindfoot

- plantigrade surface

- maintain integrity of adjacent jts

- avoid neuromas




1.  Fuse TNJ first 

- this should passively align STJ

- need medial approach to reduce TNJ


2.  Fuse STJ 

- slight valgus not neutral or varus

- lateral approach

- may need large lateral bone wedge

- may have issues with lateral skin closure



Plantar Fasciitis



Pain at attachment of thickened central part of plantar aponeurosis to Medial Calcaneal Tuberosity


Anatomy Plantar Fascia



- medial calcaneal tuberosity



- 5 bands superfical & deep layers



- insert transverse MT ligament & skin



- flexor sheath, volar plate & periosteum of P1



- when toes passively DF in toe off

- inelastic

- stabilises and elevates arch of foot

- windlass mechanism


Fat Pad 

- absorbs 20-25% of force at heel strike

- U-shaped, fat arranged in fibro-elastic septa




Usually middle-aged male

- age 40-70 years

- M:F = 2:1

- usually unilateral


Predisposing factors

- obesity

- certain occupations i.e. Policeman's heel

- athletes and repetitive stress




Usually idiopathic


May be associated condition especially if bilateral

- Reiter's Disease

- Ankylosing Spondylitis (enesopathy)

- Gout


Pronated feet / cavus feet / planus feet


Tight tendoachilles




1.  Degenerative change fat pad most common finding 

- decreased ability to cushion heel


2.  Injury to windlass mechanism with micro trauma


3.  Nerve entrapment


4.  Heel spur present in 50% with heel pain

- spur is in origin FDB (short flexors) not plantar fascia


Shmokler 1000 patients

- 13.2% incidence heel spurs

- 5.2% of which had heel pain



- 45 patients 52 painful heels

- 75% painful heels with spur

- 65% opposite heel had spur


Foot Calcaneal Spur




Degeneration 80% 


Repetitive stress at attachment

- leads to microscopic tears & cystic degeneration

- maybe periosteal reaction & spur formation


Entrapment 20%


Nerve Entrapment Syndrome

- lateral plantar nerve / Baxter's nerve

- mixed motor and sensory

- motor to abductor digiti minimi

- runs superior to plantar fascia

- may be compressed by spur or fascia

- difficult to diagnose




Pain at inferomedial aspect of heel

- worse when first rising from bed

- worse with prolonged standing or extreme exercise




Local tenderness at inferomedial aspect of Calcaneal tuberosity


Pain aggravated by passive dorsiflexion of toes


Tinel's sign


Cavus / Planus


Tight T Achilles




Maybe calcaneal spur (50%)

- exclude tumour & infection


Bone Scan


Can be useful in atypical presentations




Plantar fasciitis MRIPlantar Fasciitis MRI


Inflammation of the plantar fascia at its insertion

May show compression of 1st branch of lateral plantar nerve




Inferior heel

- calcaneal stress fracture

- fat pad atrophy

- calcaneal apophysitis

- nerve compression / tarsal tunnel


Posterior heel

- Achilles tendonitis

- retrocalcaneal bursitis





80-95% settle with non-operative management

- in 6-12/12






Acute cases respond better to HCLA

Chronic better to orthoses


Soft Heel Cup with Instep



- T Achilles stretches

- Plantar fascia stretches

- can rolling



- well padded running shoes

- viscous heel cushions + longitudinal arch support

- Soft Heel Cup with Instep


Night splint 

- hold in 15o DF

- very effective

- maintain night-time stretch






Aqil et al. CORR 2013

- meta-analysis of RCTs

- safe and effective treatment

- effects evidence at 12 weeks, last up to 12 months


High energy ECSW v low energy ECSW

- evidence for both


Cast immobilisation 

- keeps plantar fascia under constant stretch and minimises microtrauma

- patient should undergo this treatment before consideration for surgery

- very effective treatment





- ? US guided

- max 2 (plantar fascia can rupture)




Acosta-Olivo et al. J Am Podiatr Assoc 2016

- RCT of cortisone v PRP

- equally efficacious

- no between group difference




Ahmed et al Foot Ankle Int 2016

- RCT of saline v Botox

- significant improvement in botox group





- must have minimum 12 months non-operative treatment

- 5% of patients

- results of surgery variable





- 129 patients

- 43% complete improvement

- 38% some improvement

- none worse off


Open Release of Plantar Fascia


Set up

- tourniquet

- prone / lateral / supine



- medial longitudinal incision

- this is often vertical in line with posterior border medial malleolus

- protect medial calcaneal branch 



- divide ABHB fascia

- reflect this superiorly

- identify plantar fascia origin from tuberosity

- FDB is above plantar fascia

- insert homan retractors above and below

- lateral plantar nerve deep to abductor, above FDB laterally




Resect medial rectangle of plantar fascia

- divide 3/4 of fascia

- don't release in full unless very old and decrepit

- take 6 deep by 2 mm thick rectangle


+/- neurolysis


+/- Resect spur

- reflect FDB

- remove with osteotome / nibbler


B.  Endoscopic release


Ogilvie-Harris Arthroscopy 2000

- 53 patients with 65 feet

- complete resolution of pain in 89%

- 71% returned to unrestricted sport




Cochrane Review 2012

- no evidence for laser or ultrasound

- limited evidence for dorsiflexion night splints

- limited evidence topical corticosteroid

- some evidence for injected CS

- equivocal for ECSW

Rheumatoid Foot




1.  Painful Bunion / Hallux valgus


Rheumatoid Forefoot Hallux Valgus


2.  Metatarsalgia / MTPJ dislocation


Rheumatoid Foot


3.  Claw toes


Claw Toes




Earliest manifestation is synovitis of MTPJ 

- capsular destruction 


Dorsal subluxation MTPJ

- claw toes develop (MTPJ hyperextended, PIPJ flexed)


Plantar fat pad displaced distally

- MT heads exposed to plantar skin

- corns develop over PIPJ & under MT heads




Non-operative Management


Shoe-wear modification


Extra-depth shoe / low heel / roomy toe-box

Custom-made arch support

Pre-MT dome for metatarsalgia

Heel cup to prevent heel valgus

STJ - single lateral upright with medial T strap

AKJ - double upright with square ferrule


Operative Management




Continuing pain

Increasing deformity

Footwear modification failure




Poor wound healing



Recurrence of deformity


Timing in multiple joint surgery


Forefoot often first

- eliminates pedal sepsis


Hallux Valgus / Rigidus



- arthrodesis

- arthroplasty

- Keller's procedure




Rheumatoid Forefoot Fowlers MTPJ Fusion


Procedure of choice

- provides forefoot power & buttresses lesser toes



- involvement of IPJ 

- need to have mobile IPJ to put tip of toe onto the ground

- consider arthroplasty



- non-union

- malposition

- stress transfer to IPJ


Silicone Arthroplasty / Double-Stemmed Swanson



- low-demand patient

- IPJ of hallux affected



- breakage

- silicone synovitis


Keller's Procedure



- in low demand patient where bony union expected to be difficult

- salvage procedure



- cock up deformity

- transfer metatarsalgia

- loss of power

- recurrence





- synovectomy

- Weil's osteotomy

- Fowler's procedure





- early disease / synovitis



- 3 incision

- one over first MT

- 2 between 2/3 and 4/5

- incise extensor hood


Weil's Osteotomy



- enlocated MTPJ

- i.e. in conjuction with treatment of claw toe



- transverse osteotomy

- MT head moved proximally

- secured with screw


Fowler's operation 





- dislocation MTPJ



- cascading excision of II - V MT heads 

- 2nd 3 mm longer than 1st or 3rd

- 3rd 3mm longer than 4th

- 4th 3 mm longer than 5th 




Single dorsal transverse skin excision just proximal to toe webs 

- can be performed via transverse plantar ellipse

- with severe dislocation may be easier to approach through plantar aspect 

- MT heads subcutaneous & NV bundle usually subluxed dorsally


Extensor tenotomy


MT heads excised in gentle curve

- dorsal distal to plantar proximal

- contoured on plantar surface to give rounded surface

- very little length removed from 5th MT 

- must not leave bony fragments in weight bearing pad


Second incision on plantar surface 

- proximal to MT heads

- ellipse of skin only excised 

- closed to pull skin of forefoot under MT ends


Claw toes


EPL lengthening / EDB tenotomy / PIPJ fusion



General Concepts



Disorder of immune system 

- antigen-antibody complexes

- stimulate release of proteolytic enzymes

- leading to vasculitis, synovitis and cartilage destruction




Articular Effects

- synovitis

- ligamentous and capsular laxity

- cartilage destruction

- osseous erosion



- rheumatoid nodules

- digital ischaemia

- skin ulceration

- poor wound healing



- mononeuritis multiplex




90% will have foot problems




Most commonly involves forefoot

- 10x more common than hindfoot


1.  Hallux Valgus

2.  Dorsal Subluxation MTPJ

3.  Clawing of toes










A.  STJ / Planovalgus (50%)

- destruction of soft tissues especially STJ capsule and interosseous ligament

- + Destruction of TNJ 

- leads to Planovalgus foot

- May be initiated or exacerbated by rupture of Tibialis Posterior (common)

- hindfoot valgus leads to T Achilles contracture


B.  Ankle

- Rarely affected (10%)

- Destroyed Ankle rarely occurs in isolation

- i.e. typically would have pan-talar arthritis




Multiple Joint Surgery Timing


1.  Forefoot OT

- great symptomatic relief

- minimal patient stress

- eliminates pedal sepsis

- wound problems common & occur before prostheses implanted


2.  THR 

- easier to rehabilitate following THR with deformed knees

- allows correction of proximal limb contractures & lordosis


3.  TKR


4.  Hindfoot OT

- usually for planovalgus




Vascular assessment

- ABI > 0.7

- ankle pressure > 90 mmHg


Examine for neuropathy



- stop MTX

- ? stop steroids


Infection prevention

- clean skin meticulously prior to surgery

- repeat in OT

- prophylactic ABx for 72hrs


C spine x-ray


Post operatively


Leave sutures in for 3/52 due to delayed healing on steroids

- elevate feet for 2-3/7 post-op

- change dressing that evening if large drainage or oedema




Midfoot / Hindfoot



A.  Lis Franc Joints OA


May cause flat foot

Treat with midfoot fusion


Rheumatoid Foot APRheumatoid Midfoot OA




May be affected in isolation early

- may cause passively correctable valgus foot

- UCBL insert


Talonavicular Arthrodesis



- erosion confined to this joint

- correct valgus deformity



- dorsomedial incision

- protect saphenous nerve and vein



- will lose 80% STJ motion


Rheumatoid TNJ Fusion LateralRheumatoid TNJ Fusion AP




A.  Tendo Achilles Insertional Tendonitis


Ankle Synovitis


Rheumatoid involvement of bursa at T Achilles insertion

- nodules may develop within the tendon

- can weaken attachment & precipitate rupture



- excision of nodules

- may need tendon augmentation / reconstruction


B.  Retrocalcaneal Bursitis



- heel lift initially

- may need debridement and excision of posterosuperior calcaneal prominence


C.  Tibialis Posterior Tendonitis /  Rupture


Synovitis of sheaths of T post & Peroneal tendons common

- treat with tenosynovectomy


Rupture of TP with flatfoot

- FDL transfer in Stage 2 

- triple arthrodesis in Stage 3

- pan talar arthrodesis in Stage 4


D.  Planovalgus





- tibialis posterior rupture

- synovitis and rupture of the talocalcaneal interosseous ligament

- tight T Achilles



- subtalar joint valgus angulation

- talar head drops into plantarflexion

- navicular subluxes laterally

- get planovalgus foot with forefoot abduction


Non Operative



- double upright with square ferrule




Triple Arthrodesis



- fixed painful hindfoot

- TNJ and STJ OA

- AKJ preserved




Total Ankle Replacement


Attractive concept

- reduces loading across other joints

- results similar to OA


Ankle Arthrodesis


Treatment of choice


Complicated by

- prolonged period to union  - 6/12

- non-union in 10%




DefinitionTalus OCD MRI Coronal


Fracture talus through articular cartilage into subchondral bone

- 2° force transmitted from distal tibia


Osteochondritis dissecans v osteochondral fracture




6% ankle sprains

Average age = 25 

M > F




1.  Anterolateral 50% 


Talus OCD Anterolateral FragmentTalus OCD Anterolateral 2


2.  Posteromedial 50% 


Talus OCD MedialAnkle OCD Medial




30% associated with other injuries

- medial and lateral malleolar fractures

- ankle sprains


A.  Traumatic / anterolateral


2° to inversion injuries

- will usually heal


B.  Atraumatic / posteromedial


2/3 caused by trauma

- 1/3 no history trauma 

- are chronic and won't heal 


Non-traumatic causes

- ? AVN 

- 20% bilateral (can be asymptomatic)

- some patients have multiple joints with OCD

- can have family history of talus OCD




Start as acute intra-articular fracture


Bony fragment may

- revascularise & unite

- undergo AVN & not unite


Overlying cartilage may degenerate


Cyst may develop under fragment


Berndt & Harty Xray Classification


Stage 1 

- subchondral compression fracture


Stage 2 

- partially attached osteochondral fragment / flap


Stage 3 

- fragment detached in-situ / not displaced


Talus OCD Medial Type 3


Stage 4 

- detached displaced fragment


Talus OCD Medial Type IV




Determine stability of fragment

- stable lesion has intact overlying cartilage

- unstable lesion has fluid at fragment-crater interface


Stage 1

- stable

- no detachment, no synovial fluid


Stage 2

- partially detached, some synovial fluid


Talus OCD Type 2


Stage 3

- completely detached, not displaced


Talus OCD Anterolateral MRI0001Talus OCD Anterolateral MRI0002


Talus OCDTalus OCD


Stage 4

- displaced




Lateral ankle sprain from inversion injury


Chronic symptoms after ankle sprain settled

- activity-related pain, stiffness & swelling

- crepitus, instability & locking (true locking rare)


Symptoms of lateral ligament instability




Tenderness around ankle joint


Pain with dorsiflexion / eversion


Decreased ROM, especially dorsiflexion




Test for ligament instability




Chronic ligament instability

Lateral gutter ST impingement

Calcaneal fracture

Lateral process fracture

Tarsal coalition

Sinus tarsi syndrome




Non Operative


Higher success with acute injury

- POP & NWB 6/52

- progressive to weight bearing over 3 - 4 months


Tol et al Foot Ankle Int 2000

- meta-analysis

- 14 studies with 201 patients

- 45% success rate




1.  Percutaneous Drilling



- Type 1, 2


Ankle OCD ArthroscopyAnkle OCD Percutaneous Drilling 1Ankle OCD Percutaneous Drilling 2


2.  ORIF



- acute

- large type 2 , 3

- in situ but unstable and not healing




A.   Lateral lesion

- approached through anterolateral approach

- ± Fibular osteotomy if large 


B.  Medial lesion

- approached through anteromedial approach

- ± medial malleolar osteotomy


Medial Malleolar Osteotomy



- partially displace

- debride base

- insert bone graft as paste

- fix with bioabsorbably headless compression screws


3.  Excision / curettage / abrasion / microfracture



- small lesion

- fragment detached with chondral lesion




Tol Meta-analysis

- 88% success stage 3 and higher

- less if no curettage or dilling

- can do so arthroscopically


Ankle Scope OCD Grade 4Ankle Scope OCD Abrasion


Talus Chondral LesionTalus OCD Bleeding


4.  Allograft



- large lesions

- > 1cm diameter and > 5mm thick


Post operative

- PTB brace 1 year




Gross Foot Ankle Int 2001

- 3/9 resorbed


4.  Osteochondral autograft / mosaicoplasty



- stage 4 lesion


Donor Site

- taken from knee NWB surface

- allograft



- fresh frozen talus

- 6.5 mm chisel used to take 10 mm plug

- medial malleolar osteotomy

- 6.5 mm drill into OCD site with drill guide, over drill 4 mm

- dilator

- insert plug, countersink 1 - 2 mm


Medial Malleolar Osteotomy


Talus MosaicplastyTalus Mosaicplasty 1Talus Mosaicplasty 2




Management Algorithm


Stage 1


Restricted activity / watch to see if heals


Stage 2 



- SL POP for 6/52 

- Successful in 90%



1.  ORIF

2.  Removal of necrotic fragment & drill base 


Stage 3 


Surgery probably indicated as very unstable



Stage 4 



- acute ORIF if possible (i.e fragment is replaceable)

- chronic may have to discard fragment 

- manage chondral defect / abrasion

Talar Body Fracture



Body Fracture

- fracture line exits inferior surface behind lateral process

- into posterior facet

- intra-articular body fracture


Neck Fracture

- fracture line exits inferior surface anterior to lateral process

- in front of sinus tarsi

- extra-articular neck fracture




1.  Shear

2.  Crush

3.  Posterior Process

4.  Lateral Process

5.  Talus Head


1.  Shear


Boyd & Knight classification

- coronal or sagittal 

- horizontal




13-20% of all talus fractures




Involves both AJ and posterior facet STJ


CT Talar Dome FractureCT Talar Dome Fracture 2




A.  50% develop post-traumatic arthritis


B.  25-100% AVN

- Usually patchy and so avoid collapse









- either medial or lateral approach

- may need medial or lateral malleolar osteotomy


Talar Dome ORIF APTalar Dome ORIF Lateral


Talar Dome ORIF APTalar Dome ORIF LateralTalar Dome ORIF Non Union




Talus Body Nonunion CTTalus Body Nonunion CT2Talus Body Nonunion MRI


Talus Body Nonunion ORIF 1Talus Body Nonunion ORIF 2


2.  Crush


High energy

- associated injuries common

- prognosis as above



- as above 


3.  Posterior Process Fractures




Composed of Posterolateral & Posteromedial tubercles

- separated by sulcus for FHL

- lateral larger than medial 


PL tubercle

- size variable

- Superior surface non articular, attaches PTFL

- Inferior surface in continuity with posteror articular surface of Talus


PM tubercle

- also varies in size

- deep & superficial Deltoid ligaments attach


Os Trigonum

- accessory bone seen in association with PL tubercle of talus

~ 50% of feet

- may be unilateral or bilateral

- may be fused to talus or calcaneus 

- relationship to PL tuberosity varies from complete separation to fusion


Os TrigonumTalus Posterior Tubercle Synchondrosis




A.  Forced PF 

- impingement especially ballet / soccer


B.  Excess DF 

- increased tension on PTFL with avulsion




Tender posteriorly

Crepitus with PF

Pain with motion of Hallux in groove




Lateral process fracture

Fracture of fused os trigonum

Disruption of synchondrosis of os to talar body






Talus Posterior Process Fracture


Bone Scan / CT useful in Dx


Talus Posterior Process Fracture CT




Same for medial & lateral

- conservative initially


Persistent symptoms >6/12 

- excision of fragement

- posteromedial or posterolateral approach

- Persistent problems from non-union not uncommon 


4.  Lateral Process Fractures


Talus Lateral Process FractureTalus Lateral Process Fracture CT


Eponymous name


Snowboarder's fracture




Wedge shaped prominence

- most lateral aspect of talar body

- point of attachment of lateral talocalcaneal, cervical, bifurcate & ATFL

- fracture involves talofibular and STJ




Acute dorsiflexion & inversion of foot

- most are avulsion fracture




Identical to lateral ankle sprain




Best seen on mortise view


Lateral Process Fracture




Depends on size and displacement


1.  Large and non displaced

- non operative


2.  Large and displaced



3.  Comminuted

- non operative

- excise if problematic 


5.  Talus Head Fractures


Talar Head FractureTalar Head Fracture CT




< 10% of all talus fractures

- rare

- often missed




Disability via involvement articular surface 

- late TNJ arthritis

- associated with subluxation / dislocation of transverse tarsal joints




1. Compression fracture

- impaction injuries with force through navicular to compress head

- hyperdorsiflexion

- may also produce compression fracture of navicular


2. Shear fracture

- secondary to inversion injury

- causes midtarsal adduction with navicular tearing off portion head





- cast NWB



- ORIF via medial approach

- if extremely comminuted consider TNJ arthrodesis


Talar Neck Complications



Largely related to degree of displacement




Hawkins Type I

- 0% to 13% 


Talus AVN Hawkins 1


Hawkins Type II 

- 20% to 50% 

- usually only patchy and not a problem (rarely collapses)

- usually unites 


Hawkins Type III / IV

- 90% to 100% 

- often a problem


 Talus AVN Post ORIF


Talus AVN 1Talus AVN 2


Hawkins Sign 1970


Means talus is vascularised

- makes diagnosis of AVN unlikely


AP view

- at 6 - 8 weeks see disuse atrophy of bones

- due to NWB

- thin rim of radiolucency under cartilage of talar dome

- subchondral atrophy




Best method to diagnose AVN






Talus ACN CT 1Talus AVN CT 2




Usually posterolateral corner

- furtherest from medial blood supply


Collapse occurrs despite years of NWB

- NWB does not prevent collapse 


Creeping substitution can take up to 36 months

Collapse in most is well tolerated

Hawkins advocates weightbearing once united as re-ossification takes years


Management Limited collapse with OA


Arthrodesis of the affected joint


Management Complete collapse



- have a dead talus

- very difficult to obtain tibio-talar-calcaneal fusion


1.  Blair fusion / tibio-talar arthrodesis / sliding anterior tibial graft


Ankle Blair Fusion APAnkle Blair Fusion Lateral



- maintains length


Anterior approach between EDL and EHL

- excise avascular body

- use saw to take 5 x 2.5 cm graft anterior tibia

- slide graft from distal tibia

- insert into notch in residual viable talar neck and head

- foot in 0o DF, 5o valgus, 10o ER

- single screw x graft into tibia

- additional tibio-talar scrws

- Pack cancellous bone grafts around the fusion site.

- Apply a long leg cast with the knee flexed 30o



- 4 united, 3 pseudos

- 5 good, 1 fair, 1 poor


2.  Pantalar fusion with IM nail


3.  Ilizarov Tibio-calcaneal Fusion 


Disadvantage talus excision

- makes leg short

- 3cm short on average



- frame tibio-calcaneal fusion

- Ilizarov proximal corticotomy and lengthening






More of a problem than AVN in Type II 

- may be up to 40%

- most common with non operative or single incision operations




Varus secondary to medial comminution

- creates cavus foot with supination

- walk on lateral border of foot / walk with IR foot

- predispose to premature OA




1.  Talus osteotomy

2.  Medial column lengthening with tri-cortical graft

3.  Lateral column shortening




Subtalar joint arthritis

- most common complication

- rarely requires fusion


Non operative






- moulded AFO






Delayed Union 



- > 6 months

- incidence is 10%

- very common





- >12 months

- rare

Talar Neck Fracture



Second most common  hindfoot after calcaneal fractures




Aviators Astragalus


Fall from height

- hyper-dorsiflexion injury

- neck of talus strikes the anterior tibia




More than half surface covered by articular cartilage

- medial articular wall straight

- lateral articular wall curves posteriorly

- meet at posterior tubercle


Neck of talus

- medially 10 - 44o from axis of body

- plantar 5 - 50o


No muscle or tendon attachments



- deep deltoid medially


- FHL tendon in groove posteriorly

- head supported by spring ligament (CN ligament)



- posterior / middle / anterior

- correspond to calcaneal facets

- sinus tarsi between posterior and middle


Blood Supply


3/5 talus covered by articular cartilage

- blood can only enter through 2/5


1.  Posterior tibial / artery of tarsal canal

- main supply to body

- branches to deltoid ligament

- enters talar neck and supplies most of body


2.  Anterior tibial / Dorsalis pedis

- supplies head and neck


3.  Peroneal / artery of tarsal sinus

- supplies head and neck head and neck




1. With dorsiflexion body of talus locks in mortice 

- talar neck fractures on the tibia


2. Remainder of foot displaces medially thru STJ 

- disrupt inter-osseous and lateral / posterior ligaments 

- dislocation of subtalar and tibiotalar joint


3. Body of talus is forced out postero-medially

- intact deltoid ligament

- comes to lie posterior to medial malleolus & anterior to  tendoachilles

- often associated medial +/- lateral malleolus fracture


Hawkins Classification


1.  Undisplaced neck of talus fracture


Fracture of neck between posterior and medial facet

- precluded by any displacement of 1 - 2 mm

- may need CT to confirm

- means only one blood supply is disrupted


AVN 0%


2.  Displaced neck of talus fracture


Most common

- subluxed posteriorly or medially

- blood supply through neck and in canal disrupted

- blood supply through medial body usually maintained


AVN 16%


Talar Neck Fracture


3.  Subluxed subtalar and/or tibiotalar joint


Body extruded postero-medially

- head maintains relationship with navicular

- 25 % open 

- all three blood supplies are disrupted


Talus Fracture Type 3


AVN 39%


4.  Type 3 + subluxed talonavicular fracture


Dislocation of head and neck

- poor outcome

- significance is that blood supply to head may also be disrupted


AVN 55%


Hawkins 4 Talar Neck FractureHawkins 4 Talar Neck Fracture AP




Osteoarthritis is the most common complication


Jordan et al. J Foot & Ankle Surgery 2017


- OA

- subtalar OA

- malunion

- nonunion


Classification I II III IV
AVN 0% 16% 39% 55%
OA 25% 41% 54% 72%
Subtalar OA 0% 54% 46% 45%




Open wounds


Compound Talus


Skin under threat (Type III / IV)


NV compromise

- fragment can compress circulation




Canale view

- evaluates talar neck

- foot 15o pronated

- beam angled 75o to foot

- look for medial shortening / varus










Only for true type 1 injuries




Frequent review to prevent loss of position



Operative Management




Anatomic reduction

- rotation / length / angulation of talar neck


Any displacement of 2mm

- increases contact stresses of STJ

- leads to premature STJ OA


Closed Reduction



- fracture dislocations

- dislocated subtalar or tibio-talar joint

- must reduce initially

- return for delayed definitive fixation when soft tissues allow



- calcaneal pin for axial traction

- can place pin into talus from posterolateral incision to manipulate talus

- may need to use external fixator if very unstable


Timing of Surgery


Does early reduction prevent AVN?


Vallier et al JBJS Am 2004

- 102 patients

- no evidence that surgical delay increased AVN

- AVN associated with neck comminution / high energy injuries / open fractures

- recommend is reasonable to wait for swelling to subside



Halvorson et al J Foot & Ankle Surg 2013

- no evidence that delay in surgery associated with AVN



Surgical Technique


1.  Closed Type 2 - 4



- supine on radiolucent table

- tourniquet

- fluoroscopy


Important points

- consider medial and lateral femoral distractor

- dual incision technique

- consider medial malleolus osteotomy if talar dome fractures


Anteromedial incision

- just medial to tibialis anterior tendon 

- begin at talonavicular

- can extend to medial malleolus

- no stripping of dorsal neck

- preserve deep deltoid for blood supply

- can curve incision up and around medial malleolus for osteotomy


Anterolateral incision

- lateral to EDL

- mobilise EDB

- > 7 cm skin bridge

- expose lateral talar neck

- allows assessment of reduction

- lateral screw prevents compression into varus and loss of medial length



- only accept anatomical reduction

- avoid varus and shortening of the medial neck


Medial column

- typically screws

- headless compression screws


Lateral column

- typically screws

- can consider mini fragment plates if very comminuted

- custom talar neck anatomical plates with locking options exist


Talus ORIF APTalus ORIF LateralTalus ORIF


2.  Devitalised Type 3 / 4 with compound wound


Managment is controversial


1.  Reasonable to clean / replace / ORIF

- if become's infected remove 

- Abx spacer

- apply frame

- fuse late once infection cleared +/- lengthening


Compound Talus ORIF 1Compound Talus ORIF 2Compound Talus ORIF


Talus ORIF APTalus ORIF Lateral


2.  Can discard primarily & close wound

- fusion once soft tissues healed

- acute shortening and fusion with frame with proximal corticotomy and lengthening








Varus malunion

Reduced ROM


Poor function

Subtalar OA



Avascular necrosis




Largely related to degree of displacement


Hawkins Type II

- can be patchy and not a problem


Hawkins Type III / IV

- more likely to involve the entire talus and collapse

Talus AVN Hawkins 1Talus AVN Post ORIF


Talus AVN 1Talus AVN 2


Hawkins Sign


Means talus is vascularised

- makes diagnosis of AVN unlikely


AP view

- at 6 - 8 weeks see disuse atrophy of bones

- due to NWB

- thin rim of radiolucency under cartilage of talar dome

- subchondral atrophy








Talus ACN CT 1Talus AVN CT 2




Usually posterolateral corner

- furtherest from medial blood supply


Collapse occurrs despite years of NWB

- NWB does not prevent collapse 


Creeping substitution can take up to 36 months

Collapse in most is well tolerated

Hawkins advocates weightbearing once united as re-ossification takes years


Management Limited collapse with OA


Arthrodesis of the affected joint


Management Complete collapse



- have a dead talus

- very difficult to obtain tibio-talar-calcaneal fusion


1.  Blair fusion / tibio-talar arthrodesis / sliding anterior tibial graft


Ankle Blair Fusion APAnkle Blair Fusion Lateral



- maintains length


Anterior approach between EDL and EHL

- excise avascular body

- use saw to take 5 x 2.5 cm graft anterior tibia

- slide graft from distal tibia

- insert into notch in residual viable talar neck and head

- foot in 0o DF, 5o valgus, 10o ER

- single screw x graft into tibia

- additional tibio-talar scrws

- Pack cancellous bone grafts around the fusion site.

- Apply a long leg cast with the knee flexed 30o



- 4 united, 3 pseudos

- 5 good, 1 fair, 1 poor


2.  Pantalar fusion with IM nail


3.  Ilizarov Tibio-calcaneal Fusion 


Disadvantage talus excision

- makes leg short

- 3cm short on average



- frame tibio-calcaneal fusion

- Ilizarov proximal corticotomy and lengthening






More of a problem than AVN in Type II 

- may be up to 40%

- most common with non operative or single incision operations




Varus secondary to medial comminution

- creates cavus foot with supination

- walk on lateral border of foot / walk with IR foot

- predispose to premature OA




1.  Talus osteotomy

2.  Medial column lengthening with tri-cortical graft

3.  Lateral column shortening




Subtalar joint arthritis

- most common complication

- rarely requires fusion


Non operative






- moulded AFO






Delayed Union 



- > 6 months

- incidence is 10%

- very common





- >12 months

- rare

Triple Arthodesis



Able to achieve relatively high level of function after STJ fusion

- previously believed that isolated STJ fusion should not be performed

- believed that triple arthrodesis was operation of choice for hindfoot

- STJ fusion has superior result with less stress on AJ


Average loss of DF 30% / PF 10%


Position of hindfoot determines flexibility of transverse tarsal (CCJ & TNJ) joints

- imperative that fusion be positioned in ~ 5o valgus 

- permits TTJ mobility

- if varus TTJ locked & patient tends to walk on lateral aspect of foot 


Indications for STJ arthrodesis


 Subtalar Arthritis


Post traumatic / calcaneal fracture




Primary OA




Talar Coalition CN 1Calcaneonavicular coalition subtalar OA MRI


Tibialis posterior dysfunction


Neuromuscular disorders

- instability

- CMT / polio / nerve injury


Indication for Triple Arthrodesis


Valgus deformity



Triple Arthrodesis


Technique STJ Fusion


Subtalar ArthrodesisSubtalar Arthrodesis 2





- patient supine

- roll under hip to expose lateral aspect foot

- tourniquet, IV Abx, radiolucent table, II available




Direct lateral approach -  Tip of fibula toward base of 4th MT 

- internervous plane between SPN and sural nerve


Superficial dissection

- peroneal tendons lifted dorsally

- elevate EBD

- fatty tissue over sinus tarsi

- expose STJ / CCJ / sinus tarsi


Deep dissection

- remove TC interosseous ligament

- clear out sinus tarsi

- diathermy artery of tarsal sinus

- insert lamina spreader to expose posterior facet

- need to expose medial facet medially



- curette / osteotomes / burr

- simply remove cartilage if no deformity

- otherwise remove bone to correct deformity

- recreate 2 flat surfaces that come together in 5o valgus

- drill holes to stimulate bleeding +/- bone graft

- if previous calcaneal fracture, decompress lateral wall  

(5 - 10mm removed) 


Reduction technique in valgus foot



- talus internally rotated on calcaneum

- navicular abducted on talus



- need T Achilles lengthening

(assess at end) 

- need to perform TNJ and CCJ fusion

- likely need to have open reduced TNJ / CCJ before STJ reduction

- may need lateral bone block

- often deficient skin laterally



- reducing calcaneum back under talus difficult

- calcaneum also abducted like navicular

- lamina spreader between lateral process talus and anterior aspect of calcaneum

- open it up

- calcaneum internally rotates / talus externally rotates

- screw like motion

- need to have all joints opened and exposed for this to occur

- need care to ensure don't place foot into varus




Insert K wires for 6.5 mm/ 8.0 mm cannulated screw


- One or two from inferior calcaneum via stab incisions into body and neck of talus


Check position of K wires on II before screw insertion


Bone graft

- local usually sufficient 


- if large correction take from proximal lateral or medial tibia  


TNJ fusion


Arthrodesis CCJ TNJ



- isolated TNJ OA (lose 80% subtalar joint motion)

- as part of triple arthrodesis


Midfoot Approach



- medial to T anterior, anterior to T posterior

- talar neck to naviculo-cuneiform joint

- protect saphenous nerve and vein

- Tibialis posterior guide to navicular



- can sometimes only expose 2/3 of joint medially

- may need to utilize the lateral approach for full exposure

- inserting lamina spreader aids exposure to debride

- reduce forefoot onto navicular by adducting /plantar flexing and pronating it

- must not leave in varus

- provisionally fix with K wires



- 2 x 4.0 mm cannulated screws

- from navicular into talus

- parallel or triangular 

- may need to make notch in medial cuneiform 


CCJ fusion



- exposed through continuation of lateral approach 



- 2 x screws

- must hug lateral border

- alternatively can use specific plates


T Achilles lengthening



- tight T Achilles

- if don't will have to take a lot of bone to get foot plantigrade



A.  Formal Z lengthen

B.  Hoke lengthening

- want to lengthen laterally more than medially

- 2 incisions halfway laterally

- 1 half incision medially between them

- stretch out the T Achilles



Back-slab for 2/52 

Wound inspection at 10 - 14/7

NWB in full cast for 4/52 

WBAT in walking cast for a further 6/52

6/52 radiologic assessment until union 

(pain-free WB with evidence radiologic union) 




Bilateral Hip AVN Xray




Non-traumatic or traumatic condition of femoral head with bone death




20 - 50 yo (average 38)

- M: F 4:1




70-80% with AVN will progress within 1 year







- > 4000 ml / week



- > 20mg / day

- often bilateral



- incidence of hypercoagulability

- alcohol probably related to most idiopathic



- displaced subcapital

- dislocation


Gout, Gaucher's

Rheumatoid, radiation

Infection, increased lipids, inflamm (arteritis)

Pancreatitis, pregnancy

SLE, Sickle cell, smoking

CRF, chemotherapy, Caisson




Fat Embolism Theory


Alteration in lipid metabolism

- fat emboli have been demonstrated in subchondral arterioles in femoral head in patients on steroids

- steroids increases fat stores in liver, bm, blood


Lipocyte hypertrophy theory


Increased bone marrow fat stores & lipocyte hypertrophy 

- increased bone marrow pressure

- leads to decreased blood flow

- lipid lowering drugs shown to improve femoral head blood flow

- may represent a compartment syndrome

- Gaucher, leukaemia


Accumulative stress theory


Kenzora & Glimcher

- suggests AVN multifactorial

- accumulative insult

- eg alcohol, steroids, illness


Multiple hit theory


Either have cumulative dose response reaching threshold for AVN eg many different insults 


Susceptible individual exposed to aetiological factor

- attempts to explain why small ETOH or steroids causes AVN in some but not others


Vascular & Non Vascular Theories


1. Vascular 


A. Inside vessel


Fat Emboli in Alcohol & Steroids


?Nitrogen in Caisson Disease

Sickle Cell = Venous occlusion

Hyperlipidaemia of other causes


B. Vessel Wall


Traumatic disruption - 26 % of subcapital fractures


Arteriopathy & haemorrhage


C. Outside vessel via intraosseous pressure


Fat cell hypertrophy 

- steroids / alcohol 

- "Starling" effect

- increased intraosseous hypertension in fixed space


Oedematous marrow

- Gaucher cells / leukaemia / DXRT / gout / CRF


2.   Non Vascular


Chemotherapy / Radiotherapy  

- osteocyte death




Cumulative Risk

- dose x time cortisol ? 2000mg



- incidence 3-25%

- onset ~ 6/12 - 3 years

- usually bilateral & multiple sites



- steroids cause osteoblastic stem cells to become fat cells 



- MOA uncertain

- ? 2° to both intraosseous HTN & altered fat metabolism with fat emboli

- often affects other sites


Caisson Disease

- 2° N2 in blood vessels & extravascular

- compressed air workers ~ 20%

- divers ~ 5% in army

- humeral head > femoral




Starts in Anterior / Superior / Lateral head 

- wedge shaped area



- regions of bone reabsorption

- fibrous regions on microscopy


Crescent Sign 

- subchondral collapse of the necrotic segment

- separation of subchondral plate from necrotic cancellous bone



- accumulated stress fracture

- 2° OA results

- NHx is progression to collapse in >90%


Dead bone is resorbed prior to new bone formation  

- resorption begins just after vascular invasion

- resorption continues until majority of necrotic haversian bone is removed, but almost none of interlamellar bone removed

- only once this has occurred do osteoblasts begin forming new haversian bone


It is at the revascularisation phase when the head is at its most susceptible




1. Necrosis


2. Inflammation / Revascularisation / Resorption


3. Repair - osteoblasts, new bone on dead trabeculae 


4. Remodelling


Four Causes Sclerosis


1.  Relative osteopenia in surrounding bone

2.  Marrow saponification

3.  Microfracture

4.  New bone apposition


Classification Ficat 1985


Stage 0 


"Silent contralateral hip" 

- preclinical - non painful

- X-ray normal

- MRI = double Line positive on T2

- cold scan


Stage I 


Clinically painful

- normal X-ray 

- increased uptake on scan

- MRI positive


Hip AVN MRI Anterior headHip AVN MRI T1


Stage II


Diffuse porosis with

- sclerosis 

- cystic areas of reabsorption


HipAVN Type 2Hip AVN Type 2 APHip AVN Type 2 Lateral



- Crescenteric sign / subchondral fracture


Stage III


Collapse / Flattening

- sequestrum

- preserved joint space

- typically anterolateral head


Hip AVN Type 3


Stage IV


OA superimposed on a deformed head


Hip AVN Type IIIHip AVN Type 3Hip AVN Type IV




1.  Divided extent of head involved

- most important prognosticator


A = Mild <15%

B = Moderate 15-30% 

C = Severe >30%


2.  Stages


Stage 1: normal xray

Stage 2: sclerosis

Stage 3: crescent sign / subchondral collapse

Stage 4: flattening of femoral head

Stage 5 & 6: OA


Kerboul Combined Necrotic Angle 


JBJS B 1974


Guide to outcome 

- AP + Lat Necrotic Wedge Angle 

- > 200° = Poor




Limited place

- can eiagnose early collapse & flattening

- 1/3 of Grade II upgraded to grade III by CT




Te Scan


Sensitivity 80%

- non-specific

- most useful to investigate if head vascular after subcapital fracture




Sensitivity 100% in one series

- may take up to 7 days to show 


Low T1 / High T2


T2 Double Line Sign


Hip AVN MRI T2 Double Line Sign


Two lines virtually diagnostic of AVN

- outer line / low signal intensity

- inner line / hihg signal intensity / hypervascular granulation tissue


DDx Transient osteoporosis of the Hip



- third trimester pregnancy



- oedema into metaphysis or neck

- suspect AVN if collapse 


Natural History AVN


Asymptomatic Hip


Mont et al JBJS Am 2010

- systemic review of asymptomatic hips

- 59% progressed to symptoms or collapse

- small medial lesions progressed to collapse < 10%

- sickle cell high risk, SLE low risk


Hernigou JBJS Am 2006

- 91% asymptomatic sickle cell AVN became symptomatic

- 77% collapse


Management Summary


Stage 0


Natural history mixed

- depends on size of lesion and diagnosis

- treat if becomes asymptomatic

- may benefit from bisphosphonates


Stage 1 / Normal X-ray, abnormal MRI


Forage: 80% G/E



Stage 2 / Abnormal X-ray with cysts and sclerosis


A:  As for Stage I


B:  Vascularized fibula graft: 80% 


Stage 3 / Collapse / Crescent sign


A:  Forage: 20% G/E


B:  Osteotomy:  80% G/E (CAN < 200o)


C:  Trapdoor and BG 80%


D:  Vascularised fibula graft: 80% G/E


E:  Limited Femoral Head Resurfacing


Stage 4


A:  Conventional THR


B:  Resurfacing 


C:  Arthrodesis 

- only if unilateral (<50%)


Non operative Management






Hyperbaric oxygen





- inhibit osteoclast absorption

- limit head collapse




Lai et al JBJS Am 2005

- RCT of aledronate v control in non traumatic AVN

- 2/29 in treatment group collapsed, 1 had THR

- 19/25 in control group collapsed, 16 had THR




Extracorporeal shock wave therapy




Wang et al JBJS Am 2005

- RCT of ECSW v forage & bone graft

- 80% improvement and 10% unchanged in ECSW

- 29% improved and 36% unchanged in surgical group


Hyperbaric Oxygen




Camporesi J Arthroplasty 2010

- RCT of stage II AVN treated with hyperbaric O2 or air

- all HBO patients were pain free and non required THR

- 7/9 HBO showed radiographic healing


Operative Management




Femoral head preserving / pre-collapse

- forage

- vascularised bone graft

- non vascularised bone graft


Salvage / post collapse

- osteotomy

- limited resurfacing / femoral resurfacing



Femoral Head Preserving


Forage / Core Decompression




Ficat / Arlet

- initially used for diagnosis of HTN

- then used as treatment

- noticed pain relief of & cessation of progress



- decompress intraosseous hypertension

- promotion of vascular ingrowth

- promotion creeping substitution




Provides good pain relief

Does it prevent collapse / alter NHx?

Related to stage and size of lesion




Hip Forage Intraoperative


Take 6-8 mm core 

- insert guide wire under II

- ensure entry above LT

- 5mm from subchondral bone

- use DHS triple reamer

- NWB 6/52


Results Pain Relief


Stulberg Clin Orthop 1991

- prospective randomised study

- forage vs nonoperative management

- forage 70% success Ficat stage I to III in Harris Hip scores

- nonoperative success 20% Stage I / 0% Stage II / 10% stage III


Results NHx


Steinberg J Arthroplasty 1998

- patients post core decompression

- < 15% head involvement stage IA & IIA / only 20% needed THR

- > 15% head involvement stage IB & IIB / 40% needed THR


Khoo et al JBJS Br 1995

- RCT non operative v core decompression

- excellent pain relief in decompression group

- 80% developed femoral head collapse in both groups


Vascularised Cortical Bone Grafts



- core decompression and removal necrotic bone

- support of subchondral bone with vascularised fibular graft

- revascularisation

- callous formation / osteoinduction



- approach between TFL and G med

- reamer inserted

- packed with cancellous bone

- fibula segment harvested with peroneal artery and vein

- stabilised with K wire

- anastomosed to LCF

- abutting subchondral bone




Scully et al JBJS Am 1998

- stage III 

- 81% 4 year survival vascularised fibula graft

- 21% 4 year survival core decompression


Berend et al JBJS Am 2003

- stage III disease

- failure with THR as end point

- 64.5% 5 year survival


Non vascularised bone graft 




1.  Cortical strut graft


2.  Lightbulb procedure

- head neck junction

- cancellous bone graft


3.  Cartilage trapdoor 

- evacuate necrotic bone

- pack with cancellous bone




Wang Int Orthop 2010

- trapdoor technique

- excellent or good results in 90 - 100% stage IIA or IIB








Aim is to prevent collapse 

- move the avascular segment away from weightbearing area 

- also decompress intraosseous HTN

- must have sufficient intact femoral head to weight bear upon




Stage III 

CNA <200°

Young patient 

Not on steroids




Stage III with total head involvement

Stage IV





CT / MRI  / XR to decide osteotomy direction



- anterolateral AVN 

- undergoes a valgus flexion intertrochanteric osteotomy




Ha et al JBJS Am 2011

- 113 hips followed up for 4 years

- secondary collapse in 24%, THR required in 12%

- age > 40, stage III, CNA > 2000 and BMI > 24 poor prognostic factors


Limited Resurfacing Arthroplasty




Restores spericity to femoral head

- limits FAI which may cause progression to OA

- need to have limited acetabular damage at time of surgery




Mont et al J Arthroplasty 2001

- 30 patients treated after intra-operative inspection acetabulum

- all stage III or IV

- 90% 7 year survival






Femoral resurfacing only

- again need good acetabular cartilage

- not as predictable pain relief




Hungerford et al JBJS Am 1998

- 30 patients stage III or IV

- 61% G/E at 10 years

- remainder needed conversion to THR

- suggested good intermediate option in young patient






? Failure rate higher than in age matched OA patients

- also worse if caused by ethanol / steroids




Ortiguera et al J Arthroplasty 1999

- age matched AVN and OA

- 178 patients in each group

- follow up 17 years

- no difference patients over 50

- < 50 significant increased risk aseptic loosening


Australian Joint Registry 

- 7 years

- THR Revision rate 5% (4% OA)

- resurfacing 6% (4% OA)



Acetabular Fractures




Unusual anatomic convergence of ilium, pubis and ischium

- covered entirely by hyaline cartilage

- except at acetabular fossa, which is the site of attachment of the ligamentum teres

- deepened by peripheral fibrocartilage labrum


2 column theory (Letournel and Judet)


Anterior Column 

- superior pubic ramus

- anterior acetabular wall, anterior dome

- anterior iliac spines and anterior ilium


Acetabulum Anterior ColumnPelvis Anterior Column


Posterior Column 

- ischium

- posterior acetabular wall, posterior dome

- posterior ilium


Acetabulum Posterior ColumnCT Pelvis Posterior Column


Quadrangular Plate


CT Quadrangular Plate




Axial load applied through femur

- type of fracture depends on position of femur at time of injury

- IR - posterior column

- ER - anterior column




Resuscitation EMST


Detailed neurological exam

- sciatic nerve damaged in 20% cases with posterior wall or column injury 

- usually peroneal division


Careful soft tissue evaluation

- closed degloving injury

- 'Morel-Lavallee' lesion

- the serosanginous fluid collection can be culture positive in up to 30%


X-ray / 5 standard views


AP / Six X-ray Landmarks


Acetabulum Anterior and Posterior WallsAcetabulum Ilioischial Iliopectineal LinesAcetabulum Roof and Teardrop


1.  Iliopectineal line 

- along pelvic brim to pubic symphysis

- anterior column


2.  Ilioischial Line 

- pelvic brim to ischial tuberosity

- posterior column

- formed by posterior 4/5 of quadrilateral surface ilium


3.  The Teardrop 

- lateral: subchondral bone condensation at anterior margin of cotyloid fossa 

- medial:  anterior flat part of quadrilateral surface of iliac bone


4.  Roof of acetabulum


5.  Anterior rim of acetabulum

- semilunar


6.  Post rim of acetabulum


Judet views  / 45o obliques


Internal Oblique / Obturator Oblique

- affected side rotated forward

- anterior column + posterior wall


Judet ViewJudet View Acetabular FractureAcetabular Fracture Judet View


External Oblique / Iliac Oblique

- unaffected side rotated forward

- posterior column + anterior wall


Inlet view / Outlet view


Indicated for pelvic fractures usually


Pelvic Fracture Inlet ViewPelvic Fracture Outlet View






1-2 mm sections


CT reconstruction

- remove head to view acetabulum

- beware volume averaging

- used to guide surgery


Acetabular Fracture CT Reconstruction




Loose bodies

Femoral head fractures

Subtle subluxation

Articular steps

Roof arc measurement


Letournel Classification


5 Elementary

5 Complex


Elementary / One primary fracture line


1.  Posterior Wall

- often associated with posterior dislocation

- may be in one or many pieces

- may have marginal impaction fracture


Acetabular Fracture Posterior WallAcetabulum Posterior Wall Fracture


2.  Posterior Column

- whole posterior column separated in one piece

- fracture greater sciatic notch

- through inferior acetabulum

- into obturator foramen

- through inferior pubic rami


Posterior Column Fracture 1Posterior Column Fracture Xray 2Posterior Column Fracture Xray 3


Acetabular Fracture Posterior ColumnAcetabular Fracture Posterior Column 2


3.  Anterior Wall


Acetabular Fracture Anterior Wall


4.  Anterior Column

- from ilium above ASIS

- through inferior acetabulum  

- across obturator foramen

- out through inferior rami


Acetabular Fracture Anterior WallAcetabular Fracture Anterior Column


5.  Transverse

- from greater sciatic notch to AIIS

- obturator foramen not fractured


Pelvic Fracture TransverseAcetabular Fracture Transverse CT1Acetabular Fracture Transverse


High - above acetabulum 

Low - through acetabulum


Complex / More than one primary fracture line


1.  Posterior column & posterior wall


2.  Transverse & posterior wall


3.  T-shaped

- transverse through acetabulum

- inferior fracture line to obturator foramen


4.  Anterior & posterior hemi-transverse


5.  Both column

- Y Shaped transverse above acetabulum


Acetabular Fracture Both Columns 1Acetabular Fracture 2 Column


Acetabular Fracture 3D CT Anterior ColumnAcetabular Fracture 3D CT Posterior Column


Determinants of outcome


1.  Fracture displacement

- < 2mm articular step


Acetabular Fracture DisplacedAcetabular Fracture Undisplaced


2.  Fracture location


Early onset of arthritis and poor clinical results correlate with 

- displacement present at the time of union within the weight bearing dome

- any roof arc measurement less than 45°

- a broken CT subchondral ring


A.  Matta roof arc measurements


Describe location of fracture lines in relation to roof of acetabulum

- integrity of acetabular roof

- must be no hip subluxation


3 roof arc measurements

- AP, 2 Judet's views

- vertical line to centre of head

- line to where fracture enters joint

- the larger the arc, the further the fracture from the roof

- 10o - fracture in roof

- 900 - low fracture


Weight bearing dome is intact if angle > 45o on all 3 views


B.  CT subchondral arc

- 10 mm below subchondral bone of roof

- similar to xray roof arc measurements


Acetabular Fractures CT Subchondral arc 1Acetabular Fracture CT Subchondral Arc 2


3.  Stability / Concentric reduction



- incongruency between the head and the roof

- poor clinical results are obtained in more than 50% of fractures in which the head is subluxed  

- may also have an element of dynamic instability, with certain posterior wall fractures


Acetabular Fractur Non concentric 1Acetabular Fracture Non Concentric 2


Any subluxation on CT demonstrates clinical instability

- fractures affecting 40% or more of the posterior wall are usually associated with instability

- fractures less than 40% should be screened for stability under II


4.  Other factors


Direct cartilage injury at time of impact

Neurological injury

AVN of head


Acute management





Neurovascular assessment

Investigations - exclude Pipkin, NOF

Emergent reduction / skeletal stabilisation

Assess stability

Re-evaluate sciatic nerve


Insertion Femoral Steinman Pin



- displaced acetabular fracture


Femoral Steinman Pin APFemoral Steinman Pin Lateral



- above blummenstaat's line

- in metaphyseal bone

- minimum 10 pounds weight, may need more

- assess post operative reduction


Acetabular Fracture Pre Steinman PinAcetabular Fracture Post Steinman Pin


Goals of Management


1.  Restore Articular Congruency

2.  Reduce & Maintain Hip in Acetabulum


Non operative Management


Radiographic factors


1.  Articular step < 2mm

2.  Weight bearing roof intact

- Matta Roof > 45o

- CT subchondral roof 10 mm

3.  Congruent reduction

4.  Stable < 40% posterior wall fracture




Tornetta JBJS Br 1999

- 38 hips with above criteria for 2.7 years

- good or excellent outcome in 91%

- poor outcome related to other injuries


Patient factors



Osteoporotic bone

Pre-existing arthritis


The elderly patient can have a THR as salvage if required down the track


Operative Management




1.  Incongruent reduction

2.  Non intact weight bearing dome

3.  Articular step > 2mm 

4.  Retained fragment

5.  > 40% posterior wall or instability


Surgical factors


1.  Surgeon experience

- steep learning curve


Letournel & Judet Fractures of the Acetabulum 1993

- initial rate non anatomical reduction 32%

- 4 years later 10%


2.  Surgical timing


Letournel & Judet

- anatomical reduction in only 50% operated after 21 days

- if operate too early, bleeding +++


3.  Fracture complexity


Matta  JBJS Am 1996

- 262 patients

- 96% elemental fractures anatomically reduced

- 64% complex






1.  Anatomic reduction

2.  Provisional fixation with lag screws 

3.  Buttressing with curved reconstruction plates 




1.  Posterior / Kocher-Langenbeck approach

- posterior column / wall


2.  Ilioinguinal approach

- anterior column / wall


3.  Extended iliofemoral approach

- Smith-Petersen extended over iliac crest

- for transverse / both column fractures


4.  Triradiate approach

- Kocher-Langenbeck with anterior extension from GT to ASIS

- wide exposure for both column fractures

- high incidence HO


Triradiate approach Both Column Fracture


Preferred option is to perform

- ilioinguinal for anterior column / wall

- posterior / Kocher Langenbeck for posterior column / wall

- do both 1 week apart for combined fractures




Posterior Column & Wall Fracture


Acetabulum Posterior Wall Plating 1Acetabulum Posterior Wall Plating 2Acetabulum Posterior Wall Plating 3



- IDC, radiolucent table, IV Abx

- lateral position but patient rolled excessively over

- patient 45o up from table, exposes posterior

- top leg hip flexed, knee flexed

- bottom leg extended

- blankets under top leg

- lateral support in front of top knee to prevent too much hip flexion

- prevents excessive tension on sciatic nerve


Standard posterior approach

- divide fascia lata

- find and protect sciatic nerve at all times

- do so by keeping hip extended and knee flexed

- expose short external rotators, divide 1cm from insertion to preserve blood supply

- usually must divide some of G. max

- elevate G medius from ilium

- steinmann pin in ilium for exposure

- expose ischial tuberosity by elevating biceps femoris, again protecting sciatic nerve at all time

- steinmann pin in ischium


Reduction can be aided but applying femoral distracter

- between ilial and ischial pins


Expose fracture

- posterior wall fracture, elevate and clean callous

- capsule usually partially avulsed

- ensure no femoral head fractures or loose fragments

- posterior column fracture often up in ilium, can put a plate across it



- often indirect

- buttress plate from Ischial Tuberosity to Ilium

- contour or use pre-contoured

- screws at plate extremities

- often 2 parallel plates if wall and column fracture


II to ensure screws not in acetabulum


Anterior Column & Wall Fracture


Acetabulum ORIF 2 Column APAcetabulum ORIF 2 Column Judet 1Acetabular ORIF 2 Column Judet 2



- radiolucent table

- IDC to decompress bladder

- IV Abx

- sandbag under operative side for some elevation

- need to prep and drape pelvis so can virtually access both ASIS 

- often need to get  across pubis


Ilioinguinal approach


Curvilinear incision from above pubis to ASIS

- identify and protect LFCN / below ASIS

- divide external oblique 1 cm above inguinal ligament

- identify and protect spermatic cord / round ligament

- divide posterior wall / internal oblique and transversus


3 windows (medial / middle / lateral)

- find external iliac artery and vein with peanuts / place sling

- find psoas and femoral nerve / place sling

- find iliopectineal fascia between vessels and psoas and divide with scissors


Medial window medial to vessels

- superior pubic rami

- may have to release some of rectus


Beware corona mortis

- anomolous vascular connection

- 10 - 15% patients

- between external iliac / epigastric artery

- to obturator artery


Middle window between psoas and vessels

- exposes quadrilateral plate


Lateral window lateral to psoas

- elevate iliacus off crest to expose fracture in iliac wing

- exposes around to SIJ




1.  Reduce quadrilateral plate

- small T plate / will sit under pelvic reconstruction plate

- separate recon plate


ORIF Quadrilateral Plate


2.  Plate iliac crest fracture

- long 13 hole plate from pubis

- along superior pubic ramus up onto inner table of ilium

- indirect acetabular reduction




Judet and Letournel 1980 417 Fractures

- 73% perfect reduction with 84% very good results

- imperfect reduction 55% good results

- infection 5.6% / heterotopic bone 18%

- poor results related to > 3 weeks


Matta 1996 258 Fractures

- anatomical reduction 71% with 76% excellent to good results

- poor results related to injuries to femoral head / age / post-operative complications

- AVN 3%




Heterotopic Ossification

- ilioinguinal 1%

- Kocher-Langenbeck 7%

- extended Iliofemoral 12%


Failure of fixation


Acetabular Fracture Failed ORIF 1Acetabular Fracture Failed ORIF 2


Very problematic

- often need revision to THR

- pelvic discontinuity must be addressed


Acetabular Fracture Failed ORIF CT 1Acetabular Fracture Failed ORIF CT 2THR Post Acetabular Fracture



- rate very high

- prevent with mechanical and chemical prophylaxis


Sciatic nerve injury 2% 

- especially with posterior approach


AVN 2%

- higher with posterior dislocations and Pipkin fractures



- occur in 2-5%

- increased in the presence of Morel-Lavallee lesion



- the most common complication

- anatomic reduction - 10%, usually after 10 years

- imperfect reduction - 45%, usually before 10 years 2,6


Hip OA post Acetabular FractureHip OA post Acetabular Fracture


Bladder and spermatic cord injury


Hernia formation


Vascular injury


External iliac vein

- control distally with vessiloop

- suture with 5.0 / 6.0 prolene on noncutting needle







IndicationsHip Fusion


Young adult 

- 16 - 30 years old

- monoarticular disease

- heavy demand 


Exhausted options of osteotomy

- risk of THA failure  / multiple revision surgeries considered too high


Aims of arthrodesis


Maximise bony contact

Minimise shortening

Provide rigid internal fixation

Compress the fusion site

Facilitate future conversion to THR





- difficulties in obtaining arthrodesis without femoral bone stock


Poor bone stock due other causes


Bilateral hip disease

- need ROM in other hip 90o

- in order to compensate in gait


Polyarticular disease eg Rheumatoid arthritis

- likely to develop hip / knee / back OA


Degenerative disc disease

- lumbar spine ROM important to compensate in gait and ability to sit in chair


Stiff ipsilateral knee or contralateral hip 




Good pain relief


No activity restriction

- most patients employed

- can return to normal jobs, even heavy labour

- most able to walk > 1 mile


Long term solution c.f. THA




Functionally inferior to THA


Increased stress on other joints


1.  Lumbar spine 

- 50% back pain

- most common reason for converting to THR


2.  Ipsilateral knee 

- 50% knee pain and instability

- increase rotation demanded in knee due to arthrodesis


3.  Contralateral hip

- has to compensate with increased ROM

- may predispose to OA

- will certainly worsen any underlying arthritis


Difficulties with certain activities



Supine sex


Sitting erect in chair

Difficulty putting on shoes


Gait abnormalities


Increased energy requirements

- increased oxygen consumption

- gait 50% less efficient


Increased lumbar lordosis to compensate 

- decreases stride length

- shortened stance phase

- contralateral hip has increased mobility compared to normal






To retain option of conversion to THR 

- don't use pelvic osteotomy

- preserve abductors




1.  Intra-articular

- most common

- allows disease to be addressed

- better correction of deformity

- difficult in paediatrics due to large amount of cartilage present


2.  Extra-articular


3.  Combined

- usually use combination 




Sagittal / 25° flexion

- <20° flexion - difficult to sit

- >25° flexion - difficult to walk due to LLD


Coronal / 5° adduction

- never abduction: can't walk, fall over even with 5° abduction

- too much adduction: LLD


Rotation / 15° ER 


< 2 cm LLD




Pseudarthrosis - 10% 



Methods to Increase Union


1.  Inter-trochanteric / subtrochanteric osteotomy 

- can increase union rate by decreasing lever arm of abductors

- come back 6/52 later and fix intertrochanteric fracture


2.  Vascularised bony extra-articular method

- iliac crest with Tensor Fascia Lata still attached

- the graft is inserted into trough in the anterior joint




1.  Lateral cobra plate

- detach GT

- pelvis to femur

- nil pelvis osteotomy


Hip Fusion Cobra Plate


2.  DHS

- Sunderland method


Hip Fusion APHip Fusion Lateral 2


3.  Anterior plating

- Smith Peterson approach


4.  Double plating

- anterior and lateral plate


Sunderland Method


Intra-articular approach /  2 hole DHS




Radiolucent table with II

- supine


Smith Peterson approach

- leave abductors intact

- dislocate hip anteriorly

- between sartorius and TFL

- between G medius and Rectus Femoris

- take off reflected head


Remove cartilage from head & acetabulum

- cup arthroplasty instruments useful

- approximate raw surfaces

- pack cancellous autograft

- position hip & hold with guide-wires temporarily

- place one guide wire central in head


Check position of hip

- need to be able to do intra-operative Thomas test

- FFD 25o / Add 5o / ER 15o


Fix with 150° DHS

- through joint into thick supra-acetabular area of ilium

- supplement with additional screws as necessary

- +/- Sub-Trochanteric Osteotomy


Spica at 2/52 for final position 

- NWB until xray union union


Schneider Technique 


Previously very popular technique

- don't use now as THR conversion not possible 


Characterised by pelvic osteotomy

- increases surface area for fusion

- pelvic osteotomy compromises future THR conversion


Femoral head compressed into osteotomised pelvis

- Lateral Cobra plate fixed to pelvis




Lack of head technique

- for post AVN or failed THR

- using a lateral Cobra plate & inserting the neck into the acetabulum


Lateral approach with GT osteotomy

- reflect abductors cephalad

- denude acetabular cartilage

- apply lateral cobra plate

- fix the GT to the arthrodesis with screws and place graft at the site

- +/- anterior plate


Britian Technique 


Extra-articular arthrodesis

- ischio-femoral arthrodesis

- oblique subtrochanteric osteotomy

- place tibial cortical graft from inferior femur to osteotomy in ischium

- medialize femur on graft

- spica


Results of Arthrodesis


Sponseller JBJS 1984 (classic report)


53 patients at 20 years post fusion

- average age 14 years

- back pain 60% / similar incidence back pain to general POP

- ipsilateral knee pain 40%

- contralateral hip 20%

- pain was unrelated to length of arthrodesis

- high functional abilities / played sport

- knee laxity of MCL was common 2° to hip excesssive adduction in fusion

- 15% conversion to THR (for back or knee pain)


TKR with fused Hip


Technically difficult

- have knee over edge of bed

- only way to get high flexion of knee for insertion tibial prosthesis


Poor results

- poor ROM


Best to revise arthrodesis first

- not if abductors not functioning


Conversion to THR



- back pain main indication

- ipsilateral knee pain

- contralateral hip pain 




1. Abductors 

- adequate function related to good outcome

- test by palpation preoperatively


2. Reason for fusion ?infection


3. Bony loss at acetabulum & femur


4. LLD

- average 2cm


5. Skin


6.  Higher failure than 1° THR




Good relief of LBP

- less so hip and knee

- most patients happy

- hip scores change little (owing to good results from arthrodesis)


LL equality achieved


Improved ROM


Gait poor for a couple of years

- related to abductor function

- intensive physio required



- 80% 10 year

- increased risk of infection





Femoro-acetabular impingement syndrome (FAIS)

- Labral tears

- Pincer impingment

- CAM resection

- Removal of loose / foreign bodies


Hip Scope Loose BodyHip Scope Loose Body RetrievalHip Loose Body


Synovial biopsy / subtotal synovectomy / synovial chondromatosis





Lateral decubitus

II and traction


Hip Arthroscopy Set up





- both longitudinal & lateral in direction with vector parallel to femoral neck

- force required to distract femoral head varies considerably 

- range from 25 lb to 200 lb in unanesthetised adult volunteers

- majority performed with 50 lb (225 N) or less 

- important to limit periods of distraction with higher forces



1.  GA & skeletal muscle relaxation

2.  Negative intra-articular pressure

- released via joint capsule puncture with spinal needle + saline

- reduces force for distraction by 1/2

- "vacuum effect"





- viewing portal



- working portal



- working portal


Portal Placement


Hip Arthroscopy DistractionHip Arthroscopy InsufflationHip Arthroscopy Trochar InsertionHip Arthroscopy Cannular


Anterolateral portal / viewing portal


Anterolateral Portal 1Anterolateral Portal 2Anterolateral Portal 3


Insertion point

- 2 cm anterior to GT

- superior aspect of GT


Inserted under fluoroscopic guidance

- spinal needle directed medially & superiorly at 45° in each plane

- aim towards sourcil but under labrum

- joint distraction increases space in joint

- joint distended with normal saline

- guide wire inserted / blunt trochar / cannula



- LFCN - may result in partial or complete neuropraxia


Hip Arthroscopy Anterolateral InstrumentationHip Scope Air Arthrogram


Anterior portal / working portal


Anterior Portal 1Anterior Portal 2Hip Scope Nerves at Risk


Intersection of perpendicular lines

- superior aspect of GT and inferiorly from ASIS


Inserted under direct vision

- guide wire / trochar / cannula



- femoral NV bundle is 3 to 4 cm medial to insertion site 

- if placed inferior to neck ascending branch of lateral femoral circumflex artery is at risk


Hip Scope Anterior PortalHip Scope Anterior Portal 1Hip Scope Anterior Portal 2


Posterolateral Portal


Insertion point

- 2 cm posterior to GT

- level with superior border GT



- insert drainage portal

- improves visualisation



- sciatic nerve especially if foot ER during insertion


Posterior PortalHip Scope Nerves at Risk 2




Central compartment

- femoral head in acetabulum

- examine chondral surfaces

- examine labrum / debride / repair


Hip Arthroscopy Central Compartment



- head neck junction

- hip flexed, traction removed

- capsulotomy often required

- removal of CAM lesions


Hip Arthroscopy Peripheral Compartment






LFCN - anterolateral portal

Pudendal - traction

Sciatic - from traction / posterolateral portal


Pressure necrosis


Foot, scrotum, or perineum 




Scuffing of articular surfaces 






Femoral Head Fractures



5-15% of posterior dislocations




Posterior hip dislocation


Pipkin Classification


Type I - head fracture below fovea



- non operative



- excise fragment if small

- ORIF fragment if large (can contribute to instability)


Pipkin Fracture Type 1


Type II - head fracture above fovea



- rare, usually unstable



- excise if small

- ORIF if large


Type III - Type I/II with NOF fracture



- very high incidence of AVN



- ORIF young patient

- hemiarthroplasty / THR older patient


Pipkin Fracture Type 3


Type IV - Type I/II/III associated with acetabular fracture


Pipkin 4 Fracture


Non operative management




Type 1

- < 2mm displacement

- stable hip

- congruent joint


Type 2

- rarely anatomic

- usually unstable


Surgical Management


Choice of Approach


Fragment usually anteromedial


Type 1 and II

- anterior or anterolateral approach

- Smith Petersen / Watson Jones

- careful capsulotomy to preserve blood supply

- deep branch MCFA runs along superior femoral neck


Pipkin Open 1Pipkin Open 2Pipkin Open 3Pipkin ORIF


Type III

- anterolateral approach / Watson Jones

- ORIF NOF + fix/excise Pipkin fracture in young patient

- very high incidence AVN

- THR > 60


Type IV


A.  Associated with posterior dislocation / non operative acetabular fracture


Posterior approach

- this can make it difficult to access fragment

- need IR +++

- can attempt posterior to anterior screw fixation


Anterior approach

- if stable and no acetabular fracture requring ORIF

- involves making anterior capsulotomy

- patient already has posterior capsular defect


B.  Associated with posterior acetabular wall fracture that needs ORIF (>40%)

- posterior approach


C.  Associated with anterior acetabular fracture

- ilioinguinal with SP extension


Anterior Approaches


Many options

- Hardinge

- Watson Jones

- Smith Peterson 

- Ganz osteotomy


Any of these are blood supply preserving if perform safe capsulotomy

- avoid capsulotomy along superior neck

- Z capsulotomy

- capsulotomy along anterior acetabular rim superior to inferior

- along inferior femoral neck

- down medial femur


Ganz trochanteric flip osteotomy

- trochanteric slide

- gluteus medius and sastus lateralis attached / digastric

- osteotomy with saw posterior to anterior

- leave short external rotators attached to preserve deep branch MCFA

- slide GT fragment anteriorly

- capsulotomy as above

- allows access to anterior aspect femoral head

- dislocate femoral head anteriorly / surgical dislocation


Smith-Petersen approach

- good approach if only Pipkin fracture needs fixation

- higher risk of HO




Sciatic nerve injury 4%

- traumatic

- iatrogenic


Infection 3%


Recurrent instability

- large femoral head fracture excised

- posterior wall fracture

- rarely due to labral tear





- increased with anterior approach






Giannoudis et al Injury 2009

- systematic review

- Pipkin I: excision gave better results than fixation

- Pipkin II: ORIF
- AVN 11% / OA 20% / HO 17%

- no difference between trochanteric flip / anterior or posterior approach


Chen et al Int Orthop 2010

- RCT of excision v non operative for Pipkin 1 in fracture dislocation

- better outcomes in excision


Femoral Osteotomy





Prevention OA i.e SUFE / Perthes / DDH


Non union

Coxa Vara






Most OA is secondary to pre-existing disease 

- predisposes to articular cartilage failure

- failure of cartilage can be halted by decrease in load

- osteotomy corrects the underlying deformity


Pain relief achieved by


1.  Mechanical 

- decrease in unit load 


2.  Biological 

- decrease intra-osseous pressure




1.  Dysplasia 45%

2.  Perthes   20%

3.  SUFE 10%




< 25 - 30 years


Natural History


OA by age 50 in

- 50% with DDH / Perthes

- 20% with SUFE




1.  Correct deformity

2.  Increase congruency / decrease unit load

3.  Decrease JRF


Types of Osteotomy



- varus / valgus

- flexion / extension

- combination



- before OA begins

- age < 25 years

- Biological plasticity remains

- at-risk hip / painful hip ~ Ganz

- i.e. difficult to justify in the non painful hip



- before end stage OA occurs

- age < 50 years

- pathogenesis secondary to malalignment

- moderate OA where congruence increased by osteotomy




ROM important


1.  Flexion / extension arc

- >/= 90° to consider osteotomy


2.  Abduction / adduction arc 

- correction should not exceed arc


Flexion / adduction contractures common

- correct with valgus / extension osteotomy




AP pelvis


True lateral (Faux Profile) 

- lateral of pelvis with patient turned 25° to xray beam     

- to assess anterior uncovering

- VCA angle


Maximum Abduction / Adduction AP 


Von Rosen

- maximum abduction & IR








Examine nature of joint surface





Osteotomy Options





Flexion / Internal Rotation

Neck Lengthening


Varus Osteotomy / Pauwels Type I





- improve coverage

- rarely done alone

- only if little or no acetabular dysplasia

- CE > 15 - 20o



- improve coverage



- if medial head involved (unusual)


Coxa Valga > 135°

- lateral subluxation of head

- signs of lateral overload i.e. eccentric sourcil

- adduction contracture



- spherical head 

- increased congruity in max abduction

- minimum 15o abduction



- lateral head osteophyte



- subtrochanteric osteotomy

- medial shaft displacement 10 - 15 mm

- 120o Synthes locking plate with offset


Valgus Intertrochanteric / Pauwels Type II




1.  AVN

- to unload anterolateral head

- usually valgus flexion


2.  Subcapital fracture nonunion


3.  Severe medial OA with medial osteophytes

- capital drop osteophyte

- inferomedial femoral head osteophyte

- acts as fulcrum against acetabular osteophyte

- widens the superolateral joint surface


4.  Coxa vara

- congenital / developmental

- fibrous dysplasia


5.  Protrusio in young patient


6.  Fixed abduction contracture




90° flexion & 15° adduction




Calculate osteotomy

- mostly would be aiming for neck shaft angle 145 - 150o


Example coxa vara

- current neck shaft angle i.e. 110o

- desired neck shaft angle i.e. 145o

- require a 25correction



- use a 145o plate and screw

- place screw in centre of femoral neck and head

- thus when fixate the plate on femoral shaft, will have obtained desired correction



- mark proximal and distal femur with drill holes

- allows maintenance of current rotation / correction if required



- use 2 K wires

- usually performed at level of lesser trochanter

- insert distal wire parallel

- insert second wire at desired angle

- check with II / angle measurement devices

- may wish to insert distal steinman pin to control distal fragment

- anterior and posterior homan retractors

- osteotomy with saw


Close osteotomy

- apply plate

- use compression device Synthes


Extension Intertrochanteric Osteotomy




In association with correction in coronal plane

Anterior uncovering of femoral head in DDH

FFD / flexion contracture



- improved anterior covering of head

- eliminates FFD


Flexion / Internal Rotation Intertrochanteric Osteotomy




Severe SUFE 




Imhauser Technique




Femoroacetabular Impingement

DefinitionHip CAM CT 1


Aberrant morphology involving the proximal femur and acetabulum

- usually between the femoral neck and the acetabular rim

- during terminal motion of the hip


Can cause pain secondary to labral and chondral lesions

- may lead to early OA




Childhood conditions

- Perthes




Post trauma

- prior femoral neck fracture


Acetabular retroversion

- posteriorly orientated acetabular opening

- relative prominence of anterior rim

- crossing of anterior and posterior walls on the AP pelvis radiograph


Previous periacetabular osteotomy



- profunda (deep socket)

- breva

- magna

- vara




Many are idiopathic

- very common in sports

- i.e. soccer, hockey

- perhaps there is an abnormality that develops at the proximal femoral epiphysis






Mixed - CAM and Pincer


Cam impingement 


Between head and acetabulum 


Abnormal femoral head morphology

- often with flexion

- damage to anterior labrum and shearing of cartilage (carpet lesions)


Usually young men


Hip CT Anterior Cam Lesion


Pincer impingement 


Between neck and acetabulum


Due to overcoverage of femoral head

- profunda, protrusio

- acetabular retroversion / relative anterior rim overcoverage


Damage to anterior labrum




Young active males

- CAM impingement


Middle aged athletic women

- pincer impingement




Groin pain

- with rest

- with activity


Pain with flexion


Clicking from labral tear




Typically limited ROM


AP impingement 

- IR / flexion /  adduction

- most common


Posteroinferior impingement

- full extension and external rotation




True AP

- coccyx and symphysis pubis within 1-2cm of each other 

- for assesment of retroversion / crossover sign

- bony prominence junction anterolateral head and neck

- ossification of labrum

- acetabular spurs


AP Pelvis


Lateral / Dunn view

- shows CAM


CT reconstruction


Very good for bony morphology of the CAM


Case 1


CAM Lesion CT


Case 2


Hip Cam CT SagittalHip CT Cam 3DHip Cam CT 3D 2HIp Cam CT 3D 3


Case 3: Subspine Impingement


Subspine Impingement 1Subspine impingement 2




Labral lesions


Hip MRI Labral Tear CoronalHip CAM Anterior Labral Degenerative TearHip MRI Labral Lesion


Femoral head morphology / Alpha angle


T1 axial MRI

- circle drawn on circumference of femoral head

- line from centre to where head extends beyond circle

- line drawn to centre of femoral neck at its narrowest

- angle > 55o may be indicative of CAM


Hip MRI Anterior CAMHip CAM Alpha Angle


Beta angle


Distance between pathological head-neck junction and acetabular rim

- hip in 90o flexion




Non Operative


Activity modification


Core strengthening



- pain < 1 year

- OA


Hip Arthroscopy Anterior PortalHip Pincer Impingement

Hip Cam LesionHip Arthroscopy Chondral Damage







Open femoral head arthoplasty with surgical dislocation - now rearely done


Hip arthroscopy


Open femoral head arthoplasty


A.  Surgical dislocation of femoral head


Ganz Osteotomy

- preservation of blood supply

- deep branch of medial circumflex artery most important

- runs posterior to obturator externus

- emerges at superior border of quadratus femoris

- over short external rotators

- then retinacular vessels up anterosuperior neck



- must preserve short external rotators

- trochanteric osteotomy

- greater trochanter slid anteriorly

- has abductors and vas lateralis attached

- capsule divided in lazy S

- preserving capsule over anterosuperior neck 

- reflected subperiosteally off neck (like banana skin)

- dividing lig teres and dislocating hip


B.  Femoral head osteoplasty

- allow flexion of 120o

- rotation of 40o


3.  Acetabular debridement 

- debridement acetabular chondral flaps

- osteotomy of the acetabular rim (up to 1cm)

- reattachment / debridement of labral lesions





- debridement / repair of labral tears

- femoral head osteoplasty





- patient supine

- foot IR full initially, leg extended

- traction applied


Hip Arthroscopy Portal Insertion II




Proximal anterolateral viewing portal (PALA)

- hip distracted

- under II vision

- guide wire in place

- dilators, insert cannula


Mid Anterior working portal

- triangulate, using II

- anterior labral and CAM resection


Posterior working portal

- accessory for labrum and rim

- rarely used

- can be used to remove loose bodies


Distal anterolateral Working Portal (DALA)

- between midanterior and PALA
- useful for labral repair


Labral Repair


Assess for Labral Tears


Hip Arthroscopy Degenerative Labral Tear From CAM lesionHip scope normal acetabular Labrum

Hip Arthroscopy Carpet Lesion


Labral resection

- with long resector

- rarely performed now

- if labrum irreparable or ossified


Hip Arthroscopy Initial ViewHip Arthroscopy Post Labral Resection


Acetabular rim resection / Acetabuloplasty

- if necessary

- long burr

- difficult to know extent of resection required

- check on II


CAM resection

- flex hip, ER

- T capsulotomy to expose CAM lesion

- performed with long thin scapel

- burr resection of CAM lesion

- again, under II guidance

- put hip through range to ensure adequate debridement

- T capsulotomy exposes CAM well

- isolated reports of hip dislocation


Hip Arthroscopy Labral and Rim ResectionHip Arthroscopy CAM Lesion ExposedHip Arthroscopy CAM resection


FAI Cam Resection 1FAI Cam Resection 2FAI Cam Resection 3




RCT Surgery v Nonoperative


Griffin Lancet 2018

- 348 patients randomized to surgery v personalized hip therapy

- 1 year follow up, significant improvements in hip arthroscopy group


Labrum Repair v Debridement


Larson et al Arthroscopy 2009

- retrospective comparison of labral debridement v fixation in CAM / Pincer

- significantly improved hip scores in repair group

- 67% G/E in debridement

- 90% G/E in fixation


Athletes with CAM


Singh et al Arthroscopy 2010

- 27 Australian Rules Playes

- treatment of chondral lesions / labral lesions / majority with CAM lesions

- high level of satisfaction and 26/27 returned to high level sport




Byrd et al Arthroscopy 2009

- 10 year follow up

- 80% good results if no OA

- 7/8 with OA had THR at mean of 6 years

Hip Dislocation

IncidencePosterior Hip Dislocation


Young men


Posterior / Anterior 9:1




High velocity injury

- head direction at impact decides direction of dislocation


Anterior Dislocation 


Externally rotated & abducted leg

- flexion = inferior dislocation

- extension = pubic dislocation


Posterior Dislocation


Axial compression of adducted leg

- more flexion causes pure dislocation without fracture




Inherently stable joint

- large head on smaller neck

- allows deep seating of femoral head

- acetabulum deepened by labrum

- capsule reinforced by ilio/pubo/ischio femoral ligaments


40% femoral head in contact with articular cartilage

10% in contact with labrum


Blood supply


Majority by deep branch of Medial Circumflex Femoral Artery

- minimal by medial epiphyseal artery via ligamentum teres

- little to non via LCFA



- arises medial aspect of profunda

- along posterior intertrochanteric crest extracapsular / back of femoral neck

- passes between iliopsoas and pectineus medially

- runs along inferior border of obturator externus, above adductor brevis

- deep to quadratus femoris

- emerges between quadratus and inferior gemellus

- runs over conjoint tendon (2 gemelli and obturator internus)

- then penetrates capsule between conjoint and piriformis

- runs along superior aspect of neck to femoral head


Transverse branch (to ischium) and ascending branch (to trochanteric fossa0

- arise anterior to quadratus


Must protect this deep branch MCFA in a posterior approach


With dislocation and capsular tears

- some ascending cervical branches stretched/kinked

- emergent reduction can improve blood flow to femoral head


Associated Injuries


50-95% have other injury


Acetabular fracture


Femoral head fracture / Pipkin fracture


Sciatic nerve 10% / posterior dislocation


Patella fracture




Femoral artery injury - anterior dislocation


Femoral shaft fracture

- reduce head via steinman pin in proximal fragment

- then IMN femur






1. Medial / Central

- really medial displacement with acetabular fracture


2. Anterior 

- pubic / obturator / perineal


3. Posterior


Posterior Hip Dislocation Lateral




Capsule & Ligamentum teres torn


Labral tears & muscular injuries also occur


Y / iliofemoral ligament often intact with posterior dislocation

- blocks reduction

- bony fragments also block reduction


Clinical Features / Xray


Posterior dislocation

- leg shortened, flexed, adducted & internally rotated 

- head small on xray


Posterior Hip Dislocation


Anterior dislocation 

- leg short and externally rotated

- head larger on xray


Check NV status / sciatic nerve


Hip fracture dislocation






Assess & manage life threatening injuries

- EMST / ATLS principles




1. Emergent reduction

- closed +/- open

- reduce risk AVN 



- < 6 hours 10%

- 20% - 50% if >24 hours


2.  Assess stability


Posterior wall fracture > 40%

- need ORIF for stability


Hip Dislocation Posterior Wall FractureHip Dislocation Posterior Wall Fracture


Posterior wall fracture < 40%

- can be unstable

- EUA after reduction to assess stability

- should be able to flex to 90o and some IR without instability


3. Screen for retained fragments


Compulsory CT

- xray will not detect fragments < 2mm


Hip Dislocation Loose Body


Remove / ORIF depending on size of fragment and location / Pipkin type


4. Reconstruct acetabulum if unstable or incongruent


Closed Reduction Posterior Dislocation




Full muscle paralysis on radiolucent table 

- supine

- assistant places downward pressure on ASIS

- operator up on bed grasping leg

- flex hip to 90o, flex knee to 90o



- ER head around acetabulum / axial traction or

- IR head around acetabulum / axial traction


Post reduction

- check concentric reduction on II

- check stability in flexion


Unstable reduction

- skeletal traction / femoral steinman pin


Post op


NV examination when patient awake

- ensure sciatic nerve working

- ensure hasn't become entrapped with reduction




Closed Reduction Anterior Dislocation



- as above

- traction in line with femur flexed

- internal rotation maneuver


Irreducible Dislocations



- 2-15%




1.  Capsule / Labrum / Ligamentum teres

2.  Muscle interposition

- anterior usually rectus / psoas

- posterior usually piriformis / G maximus

3. Bone fragment

4.  Muscle tone

- patient requires relaxant




Open reduction


Non-concentric Reduction


Esssential to obtain X-ray and CT after reduction



- head - teardrop distance must equal contralateral side



- only with CT can < 2mm fragments be seen


Pipkin Infrafoveal CT



- may be needed to see labral tears blocking reduction


Open reduction




1.  Irreducible dislocation


2.  Non-concentric reduction

- loose bodies / interposed tissue


3.  Post operative sciatic nerve palsy


4.  Unstable posterior acetabular fracture


5.  Associated NOF fracture


6.  ORIF Pipkin fracture




Usually from direction of dislocation

- preserve intact capsule

- preserve remaining blood supply

- i.e. with posterior dislocation the posterior capsule will be torn

- provides entry into joint


Posterior Approach


Aim to preserve intact anterior capsule and blood supply

- beware sciatic nerve

- divide piriformis and conjoint tendon away from insertion to preserve deep branch MCFA

- may need to extend posterior capsular rent

- allows direct visualisation of blocks to reduction

- blocks include G. max, piriformis, capsule, bony fragments

- may need to excise ligamentum teres

- explore acetabulum for loose bodies

- close capsule afterwards

- may need to excise L Teres


Other issues


Posterior acetabular fracture

- ORIF if > 40% or unstable


Pipkin fracture

- manage as per Femoral Head Fractures


Subcapital fracture

- Watson Jones / Smith Peterson approach

- supplementary lateral approach to insert fixation


Post Operative


NWB for 6/52


Bone scan re vascularity 



- °AVN = FWB

- AVN = consider bisphosphonates


Yue et al J Orthop Trauma 2001

- 5/54 low blood flow on early SPECT

- no correlation with AVN






Related to

- time to reduction <12/24

- velocity of injury

- open reduction vs closed (x4)

- direction (anterior < posterior)



- < 6/24 = 2-10%

- > 12/24 = 52%



- posterior 17%

- anterior 2%


Tends to be localised

- revascularisation occurs on reduction

- damage to lateral & medial epiphyseal artery

- metaphyseal blood supply remains

- occurs in first 18 months





- 15 - 20 %




- instability

- incongruous reduction

- cartilage damage at time of dislocation


Philippon et al Arthroscopy 2009

- hip arthroscopy post traumatic dislocation in 14 athletes

- all had chondral defects, 11 had loose fragments

- all patients had labral tears


Sciatic Nerve Palsy 


Posterior dislocation

- 8 - 19%

- more common after fracture / dislocation



- usually partial CPN

- usually resolves


Only explore if onset after MUA


Else observe


Instability < 1%


Myostitis Ossificans



- usually little functional problem

Hip Fractures

Intertrochanteric Fractures

DefinitionHip Intertrochanteric Fracture Type 3


Fracture which extends between the trochanters of the proximal femur

- lower limit is inferior border of lesser tuberosity




Extra capsular / well vascularized


The key to stability is the posteromedial cortex





- 90% > 65

- peak at 80 years


F:M 2:1


NHx 1st year

- 1/3 die

- 1/3 worse function

- 1/3 same function


Mechanism of injury


Low energy injuries in osteoporotic patient

- direct = blow to GT

- indirect = torque force secondary to fall





- shortened

- externally rotated

- groin pain with leg movement




Judicious use of medications

- avoid confusing / sedating


Poor vision

- adapt home environment

- avoid slippery rugs etc


Adapt bathrooms for safety / stability


Hip pads


Dx Occult Hip Fractures




Hip pain

Normal Xray




CT scan

- easily obtained in emergency departments


Bone Scan

- 100% sensitive at 72 hours



- sensitive within 24 hours

- more expensive and difficult to obtain




Lubovsky et al Injury 2005

- compared CT and MRI

- MRI more accurate

- 4/6 CT inaccurate


Evans Classification 


Two main types

- Type 1 Intertrochanteric

- Type 2 Reverse Oblique



- depends on medial cortical reduction



- collapse into varus or shaft medialises

- comminuted PM cortex

- reverse oblique

- subtrochanteric extension


Type 1 Intertrochanteric


1.  2 part undisplaced & stable


Hip Intertrochanteric Fracture Type 3


2.  2 part displaced, but stable on reduction


Hip Displaced Intertrochanteric Fracture


3.  3 part with posterolateral support (GT fracture)


4. 3 part without posteromedial support (LT fracture)


Hip Intertrochanteric fracture Type 4


5. 4 part without posterolateral or medial support (combination 3 and 4)


Four Part Inter trochanteric fracture


Type II Reverse Oblique Type



Inherently unstable

- 2° tendency of femoral shaft fragment to shift medially


Modified Boyd Classification


Type I   21%

- nondisplaced & stable 


Type II   36%

- stable, but displaced fractures

- stable construct with pin and plate


Type III   28%

- unstable with pin and plate

- large posteromedial comminution 


Type IV  15%

- intertrochanteric with subtrochanteric component


Isolated GT Fracture


Isolated Greater Trochanter Fracture




Non operative




Little place for non operative treatment


Immobilization = Severe morbidity

- bed sores

- chest infection

- non-union




Unit for surgery


Incomplete fractures


Alam et al JBJS Br 2005

- 5 partial intertrochanteric fractures treated non operatively, 3 operatively

- no refractures

- similar length of hosptial stay




Medical Workup


1.  Improve any reversible medical disease


Otherwise surgery in first 24 hours


Consider Cause of fall

- exclude medical cause

- TIA / UTI / MI / Arrythmia



- electrolyte imbalance / anaemia

- pneumonia / UTI

- arrythmias


2.  Patient on anticoagulation

- operate if on plavix

- on warfarin, wait or use FFP to reduce INR < 1.6




Zuckerman et al JBJS Am 1995

- delay > 2 days increases mortality within the first postoperative year




Obtain stable anatomical reduction and allow early mobilisation




Sliding Hip Screw and Plate

Intramedullary Hip Screw

Calcar Replacing Prosthesis


Post operative


Mobilise +++


DVT prophylaxis

- chemical and mechanical




Foster et al J Orthop Trauma 1990

- higher morbidity if albumin< 3 (70%) than > 3 (17%)


Prevent secondary fractures

- vitamin D + calcium to all patients

- bisphosphonates if tolerated


Sliding hip screw and Plate


Hip Pin and Plate APHip Pin and Plate Lateral




Plate is a lateral tension band whilst the sliding screw allows controlled fracture impaction



1.  No lateral buttress 

2.  Reverse oblique fracture

3.  Subtrochanteric extension




Set up

- traction table with anatomic reduction

- traction, adduction, IR

- other leg: hip and knee flexed with hip abducted to allow II

- lateral approach to femur


Guide wire

- centred in femoral head in 2 planes 

- tip-apex distance < 25 mm


Tip - apex distance

- from tip of screw to apex femoral head

- accumulative on AP and lateral

- strong predictor of cut out

- < 25 mm, virtually zero

- > 25 mm, increases cut out


Measure angle

- wire in centre of neck / centre of head

- usually 130o prosthesis

- often only 135o available / need to be lower in neck

- being in the centre of the head is most important


Ream to within 5 mm of end of wire

- tap

- insert screw / tip apex distance < 25 mm

- attach plate


Options for improving stability


A.  Valgus Osteotomy for unstable Fractures



- reduces shear force

- increases compression

- stronger construct



- 135° plate placed in at 120°

- valgises proximal fragment 

- medializes shaft

- +/- lateral wedge removed / Sarmiento Valgus Osteotomy


Cochrane Database Sytemic Review 2009

- no evidence for improved outcome

- higher blood loss


B.  Trochanteric stabilisation plate



- buttresses the GT and prevents lateral displacement


Madsen et al J Orthop Trauma 1998

- compared first generation Gamma nail / CHS and DSH/TSP in unstable fractures

- DHS/ TSP had lowest rate of varus malunion / lag screw cutout / excessive lag screw sliding with medialisation

- CHS still had lowest rate of reoperation


Intra-medullary Hip Screw


Hip Intertrochanteri Fracture IMNHip Intertrochanteric IMN Lateral


Mechanical Advantages

- load sharing rather than load bearing

- decreases lever arm

- supports medial cortex

- less distance for collapse


Theoretical Surgical Advantages

- smaller incision / mini invasive

- reduced blood loss

- shorter surgical times



- reverse oblique

- unstable fracture / loss of lateral buttress / loss posteromedial support

- intertrochanteric extension

- pathological fractures




First generation Gamma Nail (Stryker) had 5% distal femoral fracture rate


Reasons for distal fracture

- fit and fill caused increased distal stresses (higher fracture with 16 mm diameter nail)

- no anterior bow

- poor distal locking technique (missed holes caused fractures)

- 2 distal screws


Second Generation intra-medullary hip screws


IMHS / Gamma Nail

- trochanteric entry

- decreased distal diameter

- shorter length (180 mm v 200mm)

- only 4o valgus offset

- 125 - 130o angle

- one distal screw with jig


Hip Reverse Obliquity Fracture IMN




Second Generation IMN v Sliding hip screws

- several prospective randomised studies

- very similar rates of complications

- similar cut out, blood loss, time of operation

- slight risk femoral fracture IMN

- learning curve for IMN (25 cases)


Cochrance database review 2008

- no evidence of superiority of IMN over sliding hip screw

- increased complications with nail


3.  Calcar replacing prosthesis



- salvage of failure of fixation

- severe comminution

- RA



- high cost

- higher morbidity / mortality

- high risk of dislocation




1.  Screw Cut Out 6%


Hip Pin and Plate Screw Cut outIntertrochanteric NOF Screw Cut out



- poor screw position

- 150° screw

- high tip apex distance



- 95o DCS

- THR / calcar replacing prosthesis


THR Issues


A.  Cemented femoral component

- cement will come out screw holes

- Option 1:  leave screws in laterally, and strip medially to insert small screws

- Option 2:  use uncemented stem


B.  Length of femoral stem

- should bypass distal screw hole by 2 cortical diameters


C.  Calcar

- normal stem usually sufficient if LT healed back on


THR Post Pin and PlateIntertrochanteric NOF Calcar Replacing THR


Barrel Impingement / Excessive Lateral sliding / Shaft medialisation




1.  Long screw

2.  Collapse with insufficent lateral buttress

3.  Reverse obliquity fracture


Intertrochanteric Fracture Barrel Impingement




1.  Fracture united

- remove screw


2.  Fracture non union

- revise fixation in young patient



Lateral Slide Off Proximal Fragment


Femoral medialisation


Due to

- insufficient lateral cortex

- reverse obliquity fracture


Use 95° plate


Non Union


Uncommon / 1%

- exclude infection



- continued pain (case 1)

- hardware failure (case 2)


Case 1


NOF Intertrochanteric Non unionNOF Intertrochanteric Nonunion CT


Case 2


Hip Broken Intertan NailHip Broken Intertan Non Union salvage




A. Closing lateral wedge valgising osteotomy + graft

- success 90% / indicated in younger patients

B.  95 degree DCS Plate

C.  Revision IMN



Infection 2-5%


Intertrochanteric Infected NonunionIntertrochanteric Infected Nonunion Spacer





- posterior sag of femur in unstable fracture

- get malrotation if use excessive IR to "reduce" fracture on II


Periprosthetic fracture


Usually fracture at tip of plate

- remove distal screws and insert retrograde nail


Stress Fractures

Femoral Neck Stress Fractures




Athletes with increase activity / distance

Women with eating disorders /  amenorrhea




Compression / inferior neck

- < 50% protective weight bear

- > 50% emergent ORIF


Tension side / superior neck

- emergent ORIF


Hip stress fractureFemoral Neck Stress Fracture


Hip Stress Fracture Axial CTHip Stress Fracture Coronal CT


Hip Stress FractureHIp Stress FractureHip Stress Fracture 3



Subcapital Fractures


DefinitionGarden 3 Displaced Subcapital


Fracture distal to articular surface & proximal to intertrochanteric region




On average 4 years younger than intertrochanteric fracture


One year mortality as high as 36%


Only 1/3 will return to pre-fracture living environment


Mechanism of Injury


Direct or Indirect


1.  Direct blow GT 


2.  Posterior cortex impingement on rim

- 2° to ER

- acts as a fulcrum


3.  Bending torque > threshold 

- major trauma in young


4.  Violent muscle contraction


5. Cyclical loading / Insufficiency fracture








Poor mobility / vision


Blood Supply


Medial and lateral circumflex femoral arteries

- extracapsular anastomosis at base of neck

- retinacular / ascending cervical branches

- intra-capsular branches


Majority via MCFA

- almost none to head via LCFA

- small amount via medial epiphyseal via ligamentum teres



- medial aspect of profunda

- along posterior intertrochanteric crest extracapsular

- between iliopsoas laterally and pectineus medially

- runs along inferior border of obturator externus, deep to quadratus femoris

- emerges at superior aspect quadratus femoris

- runs anterior to conjoint tendon then penetrates capsule

- runs along superior aspect of neck



- arises lateral aspect of profunda

- transverse branch runs under sartorius and rectus over vas lateralis to supply proximal femur


Garden's Classification


Type I 


Incomplete valgus impacted fracture


Subcapital NOF Garden 1 CTSubcapital NOF Garden 1 Xray


Type II 


Complete fracture, undisplaced


Type III 


Displaced with capsule intact 

- trabeculae don't line up with acetabulum


Subcapital NOF Garden 3


Type IV 



- trabeculae line up with acetabulum


Subcapital Fracture Garden 4


Eliasson Acta Orthop Scanda 1988

- best to divide into displaced / undisplaced

- based on work showing poor interobserver reliablity with Garden's


Pauwel's Classification


Relates vertical shear vector

- more vertical the fracture

- increased risk of non union


Type I:    < 30° from horizontal

Type II:   30 - 50° from horizontal

Type III:  > 50° from horizontal 


Subcapital Fracture Pauwels Type III


Problem 2° to parallax error






Undisplaced < 10%

Displaced 20 - 33% (variable, not complete)


Non union


Undisplaced 5%

Displaced up to 33%


This complication is more likely to need surgery


Clinical presentation




Short & ER leg




Medical Workup


1.  Improve any reversible medical disease


Otherwise surgery in first 24 hours


Consider Cause of fall

- exclude medical cause

- TIA / UTI / MI / Arrythmia



- electrolyte imbalance / anaemia

- pneumonia / UTI

- arrythmias


2.  Patient on anticoagulation

- operate if on plavix

- on warfarin, wait or use FFP to reduce INR < 1.6






Displaced v undisplaced

Age of patient


Undisplaced Subcapital


Cannulated screws

DHS + derotation screw


Displaced Subcapital Algorithm


1.  Expected life > Prothesis Survival



- anatomical reduction / closed or open

- compressive screws / DHS + derotation screw


2.  Expected life < Prothesis Survival


Hemiarthroplasty < 5 years survival

THR 5-15 years survival


Rogmark et al JBJS Am 2002

- multicenter RCT patients > 70 years with displaced fracture

- ORIF 43% failure

- hemiarthroplasty 6% failure


Displaced Arthroplasty



Patient > 70


Gjertsen et al JBJS Am 2010

- 4335 patients > 70 with displaced subcapital fractures

- minimum 1 year follow up

- 1 year mortality same in each group / 25%

- 22% reoperation in ORIF v 3% in hemiarthroplasty

- more pain / higher dissatisfaction / lower quality life in ORIF group





- unipolar monoblock

- unipolar modular

- bipolar




Burgers et al Int Orthopaedics 2012

- THR v hemiarthroplasty

- 8 trials involving nearly 1000 patients

- THR 4% revision v HA 7% revision

- THR 9% dislocation v HA 3%

- THR 94 WOMAC v 78 HA


Hopley BMJ 2010

- THR may lead to lower reoperation rates and better functional outcomes compared with HA in older patients

- heterogeneity across the available trials preclude definitive statements


Ingull Int Orthop 2013

- RCT of cemented unipolar v bipolar HA

- 4 year follow-up in 120 patients aged 80 or more

- better EQ-5D in bipolar

- no difference in revision rates / acetabular erosion / HHS


Li et al PLoS One 2013

- meta-analysis of cemented v uncemented HA in elderly

- cemented better hip function, less postoperative pain, fewer intra-operative complications but longer surgical time

- no difference in revision rate


Australian Joint Registry 2010 Revision Rates


1.  > 85 

- unipolar monoblock 3.4% 7 years

- unipolar modular 2.1% 5 years

- bipolar 2.9% 7 year


2.  75-84

- unipolar monoblock 8.5% 9 years

- unipolar modular 5.5% 7 years

- bipolar 3.5% 7 years


3.  < 75 

- unipolar monoblock 17.5% 7 year

- unipolar modular 13.4% 7 year

- bipolar 6% 7 year revision rate









- non modular - Austin Moore / Thompsons /

- modular







- minimises fracture risk

- reduced risk thigh pain

- slightly increased cardiac risk with cement


Australian Joint Registry

- revision rates lower for cemented than uncemented

- for all types of hemiarthroplasty for NOF fractures




Posterior approach

- increased short term morbidity

- may increase dislocation risk



- take off anterior 1/3 abductor tendons


Prosthesis Options


Austin Moore

- press fit non modular unipolar

- only 2 sizes of stem

- small patients can fracture femur

- larger patients the stem can be loose

- AJR: 7.8% 9 year revision rate


Hip Austin Moore



- cemented non modular prosthesis

- no offset options

- AJR: 5.1% 7 year revision rate


Thompsons Hemiarthroplasty


Modular Unipolar

- based on standard THR concepts

- trial and insert femoral component / cemented or uncemented

- can use standard or high offset

- opportunity to adjust neck length

- attach head


Modular Hemiarthroplasty




Hip Bipolar



- metal femoral head articulates with polyethylene socket

- reduces motion at acetabular / metal interface

- in theory reduces acetabular cartilage wear / degeneration / pain



- less dislocation compared with THR

- less acetabular wear / protrusio compared with unipolar

- less pain compared with unipolar

- more motion

- lower revision rates compared with unipolar (AJR)



- high cost (close to some THR)

- may need open reduction in dislocation if femoral head disassociates from socket

- loss of motion interface / becomes unipolar)







- similar to THR in long term


Hemiarthoplasty dislocatedBipolar Dislocation


GT Fracture


Hip Hemiarthroplasty GT Fracture




Hip Hemiarthroplasty LLD




Groin pain from acetabular cartilage erosion

- most common complication


Severe acetabular wear


Bipolar Acetabular Destruction 1Bipolar Acetabular Destruction 2


Bipolar Acetabular Destruction Revision 1Bipolar Acetabular Destruction Revision 2






Acetabular disease (RA, Paget's, OA)

Young, active, mobile patient




1.  Dislocation


Increased early dislocation rate

Long term dislocation rate similar to hemiarthroplasty


Keating et al Health Technol Assess 2005

- randomised study of bipolar v THR

- 2.7% dislocation rate v 4.3%


2. Revision / Survivorship


Good long term survival


Lee et al JBJS Am 1998

- 94% 10 year survival


3. Function


Parker et al Cochrane Database Review

- THA has better functional outcome


Bekerom et al JBJS Br 2010

- RCT of hemiarthroplasty v THR in over 70

- 252 patients 5 year follow up

- no difference in Harris Hip scores, revision rate

- increased early and late dislocation in THR

- did not recommend THR in over 70

Displaced ORIF



< 60 with good bone stock and preserved joint space




Union rates increased with anatomical reduction



- closed reduction

- open reduction / if closed reduction fails



- no varus

- < 15o valgus

- < 10o AP plane


Assessment of reduction


1.  Femoral neck shaft angle


2.  Garden alignment index

- angle of compression trabeculae to femoral shaft on AP should be 160o

- angle of compression trabeculae to femoral shaft on lateral should be 180o


3.  Lowell's alignment theory

- head neck junction should make a smooth S / reverse S on all views


4.  Restoration of Shentons line


Closed Reduction


Set up


Traction table / radiolucent table


Leadbetter Maneuver



- flexion / adduction / traction / IR 

- circumduction / abduction

- reduction Check in extension

- "Foot in Palm Test"

- if sufficiently reduced will sit without ER




Cannulated screws / DHS + derotation screw


Aminian JOT 2007

- biomechanical study of strength of fixation of vertical fractures

- locking plate > dynamic condylar screw > dynamic hip screw / 3 cannulated screws





- decrease intracapsular pressure

- in animal models increases blood flow



- open capsulotomy via Smith Peterson

- percutaneous needle drainage of hematoma


Open Reduction


Set up


Radiolucent table

- floppy lateral with sandbag under affected hip


Technique Watson Jones approach


Lateral incision

- divide fascia lata

- interval between G medius and TFL

- can take some of G medius off to aid exposure

- flexing hip 20-30o helps exposure

- take reflected head of rectus femoris off anterior capsule


"T" ant capsulotomy / Z shaped

- avoid dissecting superior aspect of femoral neck where major artery of MCFA runs

- vertical limb down anterior edge acetabulum / preserve labrum

- horizontal limb along inferior aspect of femoral neck


Steinman pin in femoral head

- allows manipulation and reduction

- may need second steinman pin in femur

- obtain anatomical reduction under direct vision


Separate lateral approach

- split ITB and vastus lateralis

- fixation of reduction


Check reduction on II

- ensure no varus on AP

- obtain lateral by adducting and IR hip / ensure good reduction on lateral


Ensure 2 guide wires centrally in femoral head

- 2 hole DHS + derotation screw (strongest)

- 3 or 4 cannulated screws


Open subcapital ORIF


Technique Smith Petersen


Smith Petersen Approach 1Smith Petersen Approach 2Smith Petersen Approach ORIF




Unstable fracture

- augment with a plate on inferior neck


Displaced Subcapital Inferior PlateDisplaced ORIF Lateral






Rogmark et al JBJS Am 2002

- multicenter RCT patients > 70 years with displaced fracture

- ORIF 43% failure

- hemiarthroplasty 6% failure




Jain et al JBJS Am 2002

- retrospective review of displaced fractures in 29 patients < 60

- significant reduction in AVN if fixed within 12 hours






Subcapital NOF AVN




Undisplaced <10%

Displaced  20-33% 


Risk factors



Injury velocity

Delay in Reduction

Non-anatomical Reduction




Whole head or small wedge 

- most common anterosuperiorlateral



- existing med and lateral epiphyseal blood vessels

- metaphyseal BV crossing fracture

- reduced by mal-reduction / non union


Only 30% with AVN will need re operation


Management Options


Older patient

- arthroplasty


Younger patient

- forage / vascularized fibula graft / non vascularised bone graft

- osteotomy








Risk Factors


Intial displacement

Non anatomical reduction


No compression across fracture

Vascularity - can unite if avascular


Failed Subcapital ORIFSubcapital ORIF Lateral


Subcapital Nonunion 1Subcapital Nonunion 2




Older patient

- arthroplasty


Young patient

- valgus osteotomy


Subcapital NOF Non UnionSubcapital NOF Nonunion CTTHR post Subcapital Nonunion


Valgus osteotomy



- patient must have at least 15o adduction



- aim to reduce the angle of the neck fracture to between 20 - 30o from horizontal

- this places it perpendicular to the forces acting across the hip

- measure angle of fracture from horizontal (usually 40 - 50o up to 70o)

- difference is angle of correction (20 - 30o)



- insert guide wire in centre of head / for screw

- place K wire superiorly in same plane as this wire at level of LT

- second K wire below at angle of required osteotomy

- resect bone piece

- apply appropriately angle device

- ensure straight line down femur in AP and lateral if need subsequent THR

Undisplaced Management



Garden 1 / 2





- ~ 15% displacement rate with non operative management

- increased risk of non union

- reduced hospital in patient stays




Cannulated screws

DHS + derotation screw


3 cannulated screws


Hip Cannulated Screws



- lateral on traction table

- adequate reduction / no varus

- small incision

- 1 x inferior screw, 2 x superior screws

- ensure inferior screw entry is above LT to prevent fracture

- ensure threads cross fracture site entirely to obtain compression

- need correct screw length so screw head can compress against cortex


DHS and derotation screw


Subcapital Fracture DHS Derotation Screw




Parker et al Acta Orthop Scand 1998 69

- meta-analysis of 25 randomised trials

- no superiority of pin and plate over 3 cannulated screws

- less blood loss with cannulated screws





Subtrochanteric Fractures



Fracture below lesser trochanter / proximal 5 cm femur


 Subtrochanteric Fracture Long SpiralSubtrochanteri Fracture




Young patients / high velocity injuries

Old patients / osteoporosis


Fixation techniques




A. 95o Dynamic Condylar Screw / DCS plate



- revision

- very short proximal fragment


Pai J Orthop Trauma 1996

- 16 cases without no bone graft

- union in 15/16


B. Locking plates


Burkes JOT 2012

- 18 pertrochanteric fractures treated with Synthes locking plate

- catastrophic failure in 7 (37%)

- poor Harris Hip Scores in remainder

- postulated that construct too stiff


Forward JOT 2012

- biomechanical comparison of subtrochanteric fixation

- IMN strongest

- 90 degree condylar and locking plate similar strengths




Cephalomedullary nails / screws into femoral head

- reconstruction nail

- IMHS / Gamma Nail / Intertan



- load sharing


Subtrochanteric Intertan NailSubtrochanteric Femur Fracture Gamma NailReconstruction NailReconstruction Nail Spiral Blade




Lee et al J Trauma 2007

- RCT of DCS v recon nail in 66 young patients with comminuted subtrochanteric fractures

- no significant difference in union rates


Rahme et al J Orthop Surg 2007

- RCT 58 patients

- revision rate 28% in plate group v 0% in IMN


Technique IMN




Varus position associated with non union


Shukla Injury 2007

- case series of subtrochanteric fractures treated with IMN

- all nonunion occured with varus > 10 degrees




Subtrochanteric FractureSubtrochanteric Lateral


Usual with short proximal fragments

- proximal fragment abducted, ER and flexed

- difficult to obtain trochanteric entry and straight shot down femur

- tendency for guide wire to go medial

- difficult to avoid fixing proximal fragment in varus


Reduce proximal fragment first

- avoid lateral entry on trochanter

- avoid varus

- allows accurate passing of guide wire


Reduction techniques



- ball tipped spikes / steinman pin to proximal fragment

- reduce varus



- percutaneous clamp / temporary reduction of fracture

- cerclage wiring - involve soft tissue stripping / may block femoral head screws


Cerclage wires

- can hold reduction


Afsari JBJS Am 2010

- cerclage reduction of displaced subtrochanteric fractures

- 43/44 fracture united

- good outcomes, if soft tissue dissection minimized


 Subtrochanteric Varus APSubtrochanteric Femur Varus Lateral




Varus Malunion



- trendelenberg gait


- increases risk non union



May need to open reduce fracture before nailing


Subtrochanteric Fracture Malreduced0001Subtrochanteric Fracture Malreduced0002


Non union


Subtrochanteric Fracture Nonunion




Non antomical reduction (varus / flexion / persistent displacement)

Excessive soft tissue stripping

Infection - must exclude with blood tests






Failure Hardware / Broken nail

- use guide wires with hook at tip

- catch distal end of nail and retrieve


Management Options


A. 95 degree condylar plate

- reduction of malunion / takedown non union

- bone graft


Subtrochanteric NonunionDCS 95 degree


B.  Exchange nailing

- need to be able to obtain reduction


Subtrochanteric non union Broken IntertanSubtrochanteric Nonunion Revision Nail


C.  THR / calcar replacing


Calcar Replacing Prosthesis


Screw Cutout


Recon Nail Cut outRecon Nail Cutout LateralRecon Nail Cutout Salvage

Pelvic Fractures



Pelvis Anatomy


Pelvis is a true ring

- any anterior fracture must have a posterior injury as well

- integrity of the posterior sacroiliac complex is key


Bony Anatomy


2 innominate bones + sacrum

Symphysis pubis < 5mm

SI joint 2-4 mm


Soft Tissue Anatomy


Suspension bridge like complex of post ligaments


1.  Posterior sacroiliac ligaments 

- are strongest in body

- maintain sacrum in position in pelvis


2.  Anterior sacroiliac ligaments

- flat and strong 

- resist ER and shearing forces

- they do not have the strength of posterior ligaments


3.  Iliolumbar ligaments 

- iliac crest to transverse process of L5


4.  Sacrospinous ligaments

- transversely from lateral edge of sacrum to ischial spine

- resist ER of pelvis


5.  Sacrotuberous ligaments 

- from sacroiliac complex posterior to sacrospinous ligament

- pass down to ischial tuberosity

- resist vertical shear


Sacrospinous and Sacrotuberous are complementary 

- running at 90o to each other 

- adapted to the major forces acting upon the pelvis


Injury Patterns






Vertical shear


Young and Burgess Classification


APC / Anterior Posterior Compression


APC 1 - 1-2 cm diastasis, minimal SIJ diastasis anteriorly


Pelvic Fracture APC 2


APC 2 - ST/SS + anterior SIJ disrupted


Pelvis APC 2Pelvic Fracture APC 2


APC 3 - complete SIJ disruption, nil vertical displacement


LC / Lateral Compression


LC1 - pubic rami + sacral compression same side


Pelvic Lateral Compression Fracture LC1


LC2 - pubic rami + iliac wing fracture


Pelvic Fracture LC2


LC3 - pubic rami + contralateral open book


Vertical Shear


Through SIJ or sometimes iliac wing / sacrum


Vertical Shear Sacral Fracture


CM / combined mechanism


Tile Classification


Type A: Stable (posterior arch intact)


A1: Avulsion injury
A2: Iliac-wing or anterior-arch fracture due to a direct blow
A3: Transverse sacrococcygeal fracture


Type B: Partially stable (incomplete disruption of posterior arch)


B1:  Open-book injury (external rotation)
B2:  Lateral-compression injury (internal rotation)
B2-1: Ipsilateral anterior and posterior injuries
B2-2: Contralateral (bucket-handle) injuries
B3:  Bilateral


Type C: Unstable (complete disruption of posterior arch)


C1: Unilateral
C1-1: Iliac fracture
C1-2: Sacroiliac fracture-dislocation
C1-3: Sacral fracture
C2: Bilateral, with one side type B, one side type C
C3: Bilateral


Open book injuries



- external rotation force

- no vertical displacement




Stage I - symphysis open < 2.5cm

Stage II - symphysis open > 2.5cm

Stage III - >2.5cm with peroneal wound


Is continuum with increasing external rotation force

- < 2.5cm posterior SIJ ligaments intact (like pregnancy)

- as progresses further the anterior SIJ ligaments rupture

- eventually posterior complex can be incompetent and have vertically unstable pelvis

- essentially have hemi-pelvectomy


Lateral compression



- IR force applied to ileum or more commonly to greater trochanter

- as pelvis is compressed risk of pelvic viscera injury especially bladder is great

- with increasing IR posterior structures may yield

- usually anterior sacroiliac crush is so stable that reduction is difficult



- ipsilateral

- superior and inferior rami fractured or

- superior ramus fracture with symphysis disrupted or

- locked symphysis



- bucket Handle

- contra-lateral ER / open book

- usually direct blow to pelvis

- fractured pelvis rotates like a bucket handle

- leads to LLD

- to reduce LLD need rotatory moment rather than traction






2 Types

- APC 1 & 2

- lateral compression injury




Instability in the vertical plane

- no integrity of posterior ligamentous complex

- disruption of sacrospinous / sacrotuberous and posterior SI ligaments


Radiographic signs of instability

- SIJ > 5mm in any plane

- posterior fracture displacement

- avulsion 5th lumbar transverse process

- avulsion ischial spine (SS ligament)

- avulsion lateral border sacrum (ST ligament)


Sacrospinous Ligament Avulsion




Inlet view

- 40o caudal

- shows AP displacement of sacrum c.f. pelvis

- anterior and posterior sacral borders

- enables insertion of SI screws


Pelvis Inlet viewPelvis Inlet


Outlet view

- 40o cephalad

- vertical displacement of sacrum relative to ilium

- to check reduction of vertical shear in OT

- enables insertion of SI screws


Pelvis Outlet ViewPelvis Outlet


CT scan


Better defines posterior injury



Management Acute

EMST / ATLS PrinciplesPelvic Fracture APC


Usually polytrauma

- 10% mortality



1. Volume replacement

2. Reduce pelvic ring

3. Stop exsanguination

- external stabilisation / surgery / embolisation


Associated Local Injuries


Arterial bleeders

- internal pudendal most common

- iliolumbar / SGA / IGA / lateral sacral / internal iliac


Retroperitoneal veins / bone bleeding

- 85% of bleeding


Compound injury

- urethra, vagina, rectum, peroneum

- need diverting colostomy prior to any anterior approach

- retrograde urethrogram for blood at meatus +/- retropubic catheter

- triple antibiotics (penicillin / gentamicin / metronidazole)


Pelvic Fracture Retrograde Urethrogram Normal


Neurological Damage

- L5/S1 most common

- L2 - S4 possible


Depends on location of sacral fracture and displacement

1.  Lateral to foramen - 6%

2.  Through foramen - 28%

3.  Medial to foramen - 57%


Sacral Fracture Transforaminal


Morel - Lavalle Lesion

- skin degloving

- high risk of contamination

- don't place incisions through this region

- needs debridement prior to definitive surgery


Intra-abdominal bleeding

- 32%


Management of bleeding / Liverpool Protocol / NSW Institute of Trauma



- external fracture stabilisation

- embolisation

- surgical control





- good for small arterial bleeders

- not haemodynamically compromised patient with massive bleeding

- unable to embolise large vessels and patient will die whilst attempting technique


Direct surgical control 

- rarely indicated and seldom successful

- main indications for open surgery are the open pelvic fracture and

- massive vessel injury leading to a patient in extremis from hypovolaemic shock


If patient is in extremis 

- i.e. BP < 60mmHg with no response to fluid management

- thoracic and abdominal bleeding ruled out

- blood loss is retroperitoneal

- need immediate laparotomy and cross clamping of aorta to buy time / allow haemostasis and vessel repair


Management with angiography services available


1.  Small allquots fluid (100-200 mls) to maintain SBP 80 -90 mm Hg +

stabilise pelvis with non invasive device


2.  Abdominal fast scan


A.  Negative

- immediate interventional angiography

- if becomes stable, ICU, manage pelvic fracture

- if unstable, repeat fast scan

- if positive, OT

- if negative, repeat angiogram


B.  Positive

- laparotomy

- external fixation

- remain unstable, immediate interventional angiogram


Mx without angiography services available


1.  Manage initially as above


2.  Abdominal fast scan


A.  Negative or unknown

- if SBP < 70 mm Hg

- OT for surgical control of bleeding and pelvic packing

- await retrieval for interventional angiography


B.  Positive

- OT for laparotomy and external fixation

- await retrieval for interventional angiography if continues unstable


Provisional Stabilisation


Pelvic binder

- simple, easy to use

- adequately reduces pelvic space


C clamp


Enables posterior control

- contra-indicated in iliac wing fracture

- in sacral comminution can over compress


Entry point of steinmann pins

- intersection of 2 lines

- line parallel with femur

- line back from ASIS



- too anterior, perforate ilium, organ damage

- too posterior, enter greater sciatic notch with nerve and vessel damage


External Fixation


Decreases pelvic volume

- indicated in open book and unstable pelvis

- rarely required for lateral compression fractures

- simple 4 or 6 pin frame in iliac crest

- pins at 45o to each other

- rarely definitive as has nursing issues






Dalal et al J Trauma 1989

- review of 345 patients with relation to mortality

- brain injury compounded by shock major cause in LC

- shock, sepsis and ARDS in APC due to major abdominal trauma


Open fractures


Dente et al Am J Surg 2005

- 44 open pelvic fractures

- mortality 45% at average day 17

- concurrent intra-abdominal injury 89% mortality

- vertical shear fractures universally fatal

- pelvic sepsis 60% mortality


Angiogram / Embolisation


Miller et al J Trauma 2003

- 28 patients hemodynamically unstable pelvic fractures

- classified as non responders if BP < 90 after 2 units blood

- 26 had angiography, 73% had an arterial bleeder embolised

- recommended angio as first line treatment in non responders


Pelvic Packing


Cothren et al J Trauma 2007

- 28 patients hemodynamically unstable from pelvic fractures

- had external fixation and pelvic packing

- no deaths from acute bleeding


Fast scan


Fuchholtz et al J Trauma 2004

- 31 patients with unstable pelvic fractures and free fluid on FAST

- all but 1 had intra-abdominal pathology requiring surgery

- FAST negative in 49 patients, 3 of whom went on to require laparotomy




Management Definitive

APC compression




Non Operative

- < 2.5 cm displacement

- indicates SS and ST intact

- nil posterior opening




1.  > 2.5 cm

- single anterior plate through Pfannelstiel incision


2.  Posterior SIJ disruption

- reduction and posterior stabilisation

- usually with SI screws

- if comminuted may need posterior plating

- anterior plate


Pelvic APC ORIF 1Pelvic APC ORIF 2Pelvis APC ORIF 3


Pfannenstiel approach / Plating Pubic Symphysis




Set up

- supine on radiolucent table

- IDC to decompress bladder


Incision 2cm above pubis

- through fat and fascia

- avoid detaching rectus

- usually part torn off already


Reduction techniques

- during the reduction care must be taken to avoid trapping bladder or urethra in the symphysis when closing the clamp


A.  Assistant may apply pressure over each iliac crest or an external fixator can be applied

B.  Large pointed reduction clamp can be placed onto each pubic tubercle or through holes drilled in the bone

C.  Expose the medial obturator foramen and application of pelvic reduction forceps thru the medial aspect of the foramen


Superiorly applied plate

- pelvic reconstruction plate


Pelvis Pubic Symphysis Plate 1Pelvis Pubic Symphysis Plate 2Pelvis Pubic Symphysis Plate 3


Iliosacral Screws




Posterior sacral comminution / foraminal fracture

- may be better with anterior / posterior plating



Radiolucent table with II

- 45o cephalad and caudal

- inlet and outlet view


Must reduce joint / fracture initially

- reduce vertically with traction on limb / outlet view

- reduce AP usually via compression / inlet view


Guide wire insertion


Anatomic safe zone

- between S1 foramen and sup ala on outlet view (outlet view)

- between neural canal and anterior body  (inlet view)


Pelvis Sacroiliac Screws InletPelvis Sacroiliac Outlet


Insert 6.5 mm cannulated screw with compression




S1 nerve root inferiorly

Vessels and ureter anteriorly

Cauda equina posteriorly

L5 nerve root superiorly


Post operative


Check screw position with CT

NWB 6/52




S1 nerve root injury

SI osteoarthritis


Failure of fixation




Routt et al J Orthop Trauma 1997

- 177 patients treated with percutaneous SI screws

- open reduction required if unable to obtain closed reduction < 1cm widening

- inadequate II due to obesity or abdominal contrast in 18 patients

- 5 misplaced screws due to surgeon error with 1 transient L5 neuropraxia

- fixation failure in 7 patients usually due to head injury / non compliance / delayed union

- non union in 2 patients


Sacro-iliac Plating


A.  Anterior


Pelvic Anterior Sacroiliac Plate 1Pelvis Anterior Sacroiliac Plate 2Pelvis Anterior Sacroiliac Plate 3



- combination with anterior approaches

- anterior plating of pubic symphysis

- anterior approach acetabulum required



- use lateral window of ilioinguinal or stoppa approach

- L5 nerve root at risk


B.  Posterior



- comminuted posterior sacral injury



- patient prone

- vertical incision 1 cm lateral to PSIS

- from crest to sciatic notch

- incise and reflect G maximus

- apply transverse plate

- soft tissue can be a problem


Lateral Compression Fracture


Indications for ORIF


LLD  2.5 cm


Significant internal rotation

- risk of impingement

- especially young female / interfere with birth passage


Lateral Compression ORIF




External rotation external fixation


Vertically Unstable Fractures






Femoral steiman pin + 20lb weight to reduce vertical displacement

External fixation to pelvis




Anterior plate


Posterior stabilisation

- posterior SI screws / anterior or posterior plate




Griffin et al J Orthop Trauma 2006

- retrospective review of 62 patients treated with SI screws

- 4 failures in patients with vertical sacral fractures

- recommended plate fixation in this group


Non Ring Pelvic Fractures

Psoas Avulsion


Psoas Avulsion


Ileum Fracture


Ileum Fracture


ASIS Avulsion




AIIS Avulsion


Rectus femoris


Ischial Tuberosity avulsion



- see article on hamstring avulsion





Proximal Hamstring Tear

EpidemiologyProximal Hamstring Tear


Adolescent apophyseal avulsion

- treat non operatively

- unless displaced > 2 cm



- soft tissue avulsion




Usually associated with sporting activities

- skiing

- water skiing


Violent contraction

- knee extended

- hip flexing




Biceps / Semimembranosus / Semitendinosus all attach here





Unble to run


Chronic tears

- may have some neuralgia symptoms




Large haematoma / bruise

Palpable defect

Distal retraction of muscle into thigh with contraction


Proximal Hamstring Rupture Bruise




May see bony avulsion




Proximal Hamstring Avulsion MRI CoronalProximal Hamstring Avulsion MRI Axial


Proximal Hamstring TearProximal Hamstring Tear




Non operative




Harris et al Int J Sports Med 2011

- systematic review

- better subjective outcome / return to sport / hamstring strength with repair c.f. non operative

- better outcomes with acute (< 4 weeks) than chronic repair




Surgical Technique




Patient prone

- knee flexed over sterile gowns



- longitudinal incision centred on ischial tuberosity

- starting at gluteal crease

- allows identification of sciatic nerve distally

- can do a horizontal incision in the gluteal crease if injury very recent, minimal retraction


Superficial dissection

- divide fascia in line with incision

- preserve posterior femoral cutaneous nerve

- identify and elevate inferior edge of gluteus maximus


Deep dissection

- identify and preserve sciatic nerve (lateral to hamstring)


Hamstring Repair Sciatic NerveHamstring Repair Sciatic Nerve 2


Identify proximal hamstring tendon


Proximal Hamstring TendonProximal Hamstring Tendon


Exposure ischial tuberosity

- use osteotomes to create bleeding if needed

- 2 - 3 5 mm metal anchors, double loaded

- whipstich on one side, then use other suture to slide knot


Ischial tuberosityPost suture repair



Proximal Hamstring Rupture Post Op


Post op

- splint with knee flexed

- prevent hip flexion

- crutches


Proximal Hamstring Brace




Residual weakness (60 - 90% other side)



Chronic > 4 weeks



- patient complains they cannot run


More difficult

- careful dissection of sciatic nerve from adhesions

- release hamstring tendon


Augment options

- autologous ITB

- allograft




Release hamstring

- identify nerve, and use vessiloops

- avoid denervating the muscle, must preserve the nerve branches

- identify the ischial tuberosity

- see if hamstring will reach, sometimes will, but cannot repair under tension


Sciatic Nerve ReleaseChronic Hamstring Tear 1Chronic Hamstring Tear 2Chronic Hamstring Tear 3


Prepare allograft

- tendo achilles

- 9 x 20 mm bone block

- drill to 10 x 25 mm tunnel using ACL instruments

- ensure that beath pin does not advance

- secure with 7 x 20 mm screw, bone typically very strong


Drill hole ischial tuberositySecure allograft bone plug with screwSecure allograft bone plug with screw 2


Pulvetaft weave tendon through muscle stump

- through the strongest, thickest part of the stump

- high strength suture tendon to tendon

- can pass again

- tension leg, must be able to reach full extension

- brace for 6 weeks, no sport for 6 months


Hamstring Allograft ReconstructionHamstring Allograft ReconstructionPost Proximal Hamstring Reconstruction




Sarimo et al Am J Sports Med 2008 36

- 41 patients

- 5 chronic requiring achilles allograft

- 96% would have it done again, 80% return to sport

- no difference in strength between acute and chronic


Cohen Am J Sports Med 2012

- 52 patients

- 40 acute, 12 chronic

- 98% satisfied

- minimal difference in outcome between acute and chronic


Murray KSSTA 2009

- achilles allograft recon of chronic (6 months) rupture

- good outcome

Snapping Hip



Most common

- fascia lata on greater trochanter

- iliopsoas on lesser trochanter


1.  Intra-articular structures

- labrum

- ligamentum Teres

- loose bodies

- synovial chondromatosis

- osteochondoma


2.  Extra-articular structures

- fascia lata on greater trochanter (common) 

- iliopsoas on lesser trochanter / iliopectineal eminence 

- long head biceps femoris over ischial tuberosity

- iliofemoral ligament over femoral head


Iliotibial Band over GT




Usually painless

Can often be produced voluntarily




Hip flexion and internal rotation causes readily palpable snapping sensation

- tight iliotibial band subluxates over the greater trochanter




Majority of patients no treatment required

- rest

- iliotibial band stretching exercises

- NSAIDS +/- local corticosteroid injections



- rare persistent cases 

- elliptical resection of the iliotibial band over the greater trochanter + greater trochanteric bursectomy 


Iliopsoas Tendon



- snapping sensation felt in the groin as the hip is extended from a flexed position

- palpated as the supine patient extends the hip from a position of flexion / abduction & external rotation




Non operative as above



- resistant cases

- psoas lengthening

- resection prominence of lesser trochanter

- psoas division (can be done arthroscopically)




Sportsman's Hernia



Groin pain in athletes

- secondary to tear in external oblique fascia




Sports with aggressive adduction

- hockey / soccer




Tears in external oblique fascia

- tend to be central

- around spermatic cord and ilioinguinal nerve

- pain may be from nerve entrapment




Adductor Longus Tear

Osteitis Pubis


Symphysis Pubitis


Hip pathology




Adductor longus tears

- get better with time

- rarely need surgery

- pain stays below goin


Sports Hernia

- may have nerve / ilioinguinal symptoms

- above groin

- often get worse




Adductor longus tears

- tender over tendon

- pain / weakness on resisted adduction


Sports hernia

- tender over inguinal ring

- may have palpable dilatation of external inguinal ring

- pain with resisted sit up

- pain with resisted leg flexion


Dynamic ultrasound


May be useful in very experienced hands




Can be difficult to see

Is often a clinical diagnosis




Non Operative



Exclude other diagnosis




Hernia repair



- expose external oblique fascia

- identify and protect spermatic cord

- identify tears / pathology

- release ilioinguinal nerve

- repair primarily or with gortex mesh


Ilioinguinal nerve

- some surgeons cut the nerve

- risk neuroma

- suprapubic numbness only


Can combine with adductor tenotomy






THR Australian Joint Registry


2009 / Revision Rates 8 year


Prosthesis Type All Diagnosis 7 year


Unipolar Monoblock 6.8%

Unipolar Modular 6.8%

Bipolar Hemi 4.2%


Cemented THR 3.8%

Cementless THR 4.4%

Hybrid THR 3.9%


Total Resurfacing 5.4%

Thrust Plate 3.0%


Revision for OA 8 year


Conventional THR  4.0%

Total Resurfacing   5.3%


Partial Hip Replacement

Cemented better than cementless in all categories




1.  > 85 

- unipolar monoblock 3.4% 7 years

- unipolar modular 2.1% 5 years

- bipolar 2.9% 7 year


2.  75-84

- unipolar monoblock 8.5% 9 years

- unipolar modular 5.5% 7 years

- bipolar 3.5% 7 years


3.  < 75 

- unipolar monoblock 17.5% 7 year

- unipolar modular 13.4% 7 year

- bipolar 6% 7 year revision rate


Primary Conventional THR


By Age


< 55   4.9%

55-64  4.6%

65-74  3.6%

>75     3.7%


By Gender


Female  3.8%

Male     4.3%


By Fixation


Cemented    3.9%

Cementless  4.4%

Hybrid         3.4%


By Age & Fixation


< 55      hybrid (4.6) < cementless (4.8)

55-64     hybrid (3.6) < cementless (4.7)  < cemented (6.1)

65-74     hybrid (3.2) < cemented (3.8) < cementless (3.9)

> 75      cemented (3.1) < Hybrid (3.3) < cementless (4.2)


By Diagnosis


AVN 5.1%

DDH 3.5%

NOF  5.2%

OA    4.0%

RA    5.4%


By Bearing Surface


Ceramic / Ceramic  3.9%

Metal / Poly             3.2%

Ceramic / Poly         4.1%

Metal / Metal           7.7% (Head sizes > 28mm)


By Head Size


Ceramic / Ceramic

</= 28          4.6%

> 28              3.5%


Metal / Poly

>/= 28          3.9%

> 28              3.0%


By Cemented THR


MS30/Low Profile cup     1.0%

Exeter/Exeter                3.2%

Exeter / Contemporary   6.6%

Spectron / Reflection      6.9%


By Cementless THR


Securefit Plus / Trident  2.8%

Mallory Head                5.5%

Synergy/Reflection        3.8%

ABGII/ABGII                 5.6%


By Hybrid THR


Definition / Vitalock        1.5

Exeter/Vitalock              3.6%

Spectron/Reflection        5.4%


Identified as higher than expected


Corail / ASR 


Hip Resurfacing


13 300 procedures


Best outcome

- male < 65 with OA

- able to get > 50 mm head size

- 3.9% 9 year


Revision rate


Cumulative revision rate

- 7.2% 9 years for OA


Birmingham Resurfacing

- 6.2% 9 year


Reasons for revision

- fracture 36%

- loosening 33%

- metal sensitivity 7%


Revision by diagnosis 7 years

- OA 5.8%

- DDH 14%

- AVN 6%


Revision by prosthesis

- BHR 96.5% 5 year


Revision by age 7 years

- < 55     5.6%

- 55 - 64  5.8%

- > 65     7.3%


Revision by sex 7 years

- male 4.5%

- female 9.3%


Revision by head size 7 years

- < 44mm:    13.8%

- 45 - 49mm: 8.8%

- 50 - 54mm: 3.7%

- > 55mm:     2.2%






Femoral only 21.5%

Acetabular only 37.1%

Combined         35.8%




Loosening 45.7%

Dislocation           14.8%

Lysis                    10.1%

Fracture                9.2%

Infection               9.1%

Wear Acetabulum   3.3%

Pain                      2.1%


Re-revision Rate


Minor (head, liner)   19.4% 5 year

Major Partial            14.1% 5 year

Major Total               8.2%   3 year

THR Complications

DVT Prevention


ANZ Working Party on the Management and Prevention of Venous Thromboembolism 2007




Top 6 conditions associated with DVT

- stroke


- multi trauma


- hip fracture

- spinal cord injury


Not one of the 12 doctors was an orthopaedic surgeon




Heparin / LMWH / fondaparinux

- confirmed effectiveness



- not recommended

- at best weak effect in some people



- a role in some high risk surgical patient

- requires monitoring




Inconclusive in many areas


Recommend 28 - 35 days in

- hip fracture



Epidural Catheter


No anticoagulant within 12 hours of inserting / 6 hours of withdrawing epidural catheter


Mechanical compression


Graduated compression / intermittent pneumatic compression / foot pumps have all been shown to work


Recommended to combine with chemoprophylaxis


Use unless contra-indicated

- severe peripheral arterial disease or neuropathy


Specific Recommendations


THR / Hip Fracture


Enoxaparin 40 mg / day commencing 6 - 8 hours post op for 28 - 35 days 


TKR / Multi-trauma / Prior VTE / Cancer


Enoxaparin 40 mg / day commencing 6 - 8 hours post op

Post op for 5 - 10 days


Major Surgery (any surgery > 45 minutes)


Enoxaparin 20 mg / day commencing 6 - 8 hours post op for 5 - 10 days


High risk patients


Oestrogen therapy



Strong FHx VTE


Contraindications to chemoprophylaxis


Active bleeding

High risk bleeding

- hemophilia

- platelets < 50

- history GI bleeding

Severe hepatic disease (INR < 1.3)

Allergic to heparin

High risk of falls

Palliative Management





IncidenceTHR Dislocation


2-3% of cases 

- doubles with infrequent operator

- second most common reason for revision after loosening


Australian Joint Registry

- dislocation accounts for 14.8% of revisions




Posterior dislocation

- hip flexed, adducted, IR

- 80%

- usually getting out of chair


Anterior dislocation

- hip extended, adducted, ER


THR Anterior Dislocation




Early < 6/ 52

- majority of single dislocations

- usually excessive hip position by patient

- before adequate muscle control & soft tissue healing

- after six weeks strong pseudocapsule forms about hip

- adds to stability +++


Chance of recurrence 40%


Late > 6 weeks

- represents majority of recurrent dislocations

- sually due to increase in ROM & activity

- manifests unrecognised impingement / malposition


Chance of recurrence 60%




Surgeon factors

- experience

- approach

- component position

- component design

- soft tissue balance

- impingment


Patient factors

- soft tissue

- cognitive disorders

- NM disorders

- NOF fracture

- revision


Surgeon Factors


1.  Surgeon Experience

- < 30 THR per year

- 2 x dislocation rate


2.  Approach


A.  Increased with posterior approach

- common in early papers

- reduced with short ER repair / use of large heads / component position

- now equivalent rates to anterolateral


B.  Transtrochanteric

- increased with trochanteric non union x6


3.  Component position


Dislocated THR Open Acetabulum


A.  Acetabular safe zones

- abduction 40 +/- 10o

- anteversion 15 - 30o


B.  Excessive femoral anteversion

- especially when combined with excessive acetabular anteversion

- predisposes to anterior dislocation


C.  Ranawat concept of combined anteversion

- acetabular + femoral anterversion

- 25 - 35o for men

- 35 - 45o for women


D.  May wish to increase anteversion in posterior approach and reduce it in the anterior approach


4.  Component design


A.  Increased head size


THR Big Head Dislocation


Increased size increases head-neck ratio

- reduces impingement / increases arc of motion


Increased jump distance

- seated deeper in acetabulum

- decreases jump distance

- greater translation before dislocation


B.  Liner profile

- posteriorly elevated profiles

- i.e. neutral liners v 10o elevated rim liners

- theoretically more stable

- reduces dislocation rates early, but not late

- can cause impingement in extension and ER

- this may lead to dislocation and increased wear

- can put hood in variety of positions

- usually postero-superior


5.  Soft tissue tension


A.  Restore LLD and offset

- reduced offset associated with increased dislocation

- reduces ST tension

- increases risk of impingement


B.  Dislocations reduced with careful capsular and soft tissue repair

- reduces dislocation rate in posterior approach


6.  Impingement

- when two non articular surfaces come into contact during joint ROM

- decrease by increasing head neck ratio

- may be liner / osteophyte / excessive capsule

- always put hip through ROM

- ensure in full extension and ER, no posterior impingment

- ensure in flexion 90o and IR, no anterior impingment


Patient Factors


1.  Soft tissue function

- previous hip surgery 

- revision THR

- weak abductors


2.  Cognitive disorders

- dementia / delerium

- alcoholism


3.  NM disorders


4.  Women


5.  Post THR for Neck of Femur fracture

- no stabilising capsular hypertrophy / fibrosis seen in OA


6.  Revision

- dislocation rates higher in revision setting




Pre-operative education

- avoid dislocation in first 6 weeks



- restore offset and leg length




Posterior approach

- careful short ER repair


Trochanteric osteotomy

- large flat surface

- strong repair

- protected WB /52


Component positioning


A. Extrapelvic Landmarks

- careful patient positioning

- patient stable

- ASIS perpendicular to floor

- use guides on acetabular insertion jigs


B.  Intrapelvic Landmarks

- transverse acetabular ligament

- anterior and posterior acetabular walls if no osteophytes


Component design

- liner lip posterosuperior


Prevent impingement

- remove wall osteophytes

- restore offset

- anterior capsule can cause impingement

- avoid excess cement


Large head neck ratio


Trial reduction

- flex to 90o, IR 45o, adduct 20o

- full extension, ER 45o

- ensure stability

- restore offset

- check LLD


Post operative

- avoid extremes of position

- abduction pillow

- knee immobiliser in confused patients / limits hip flexion

- post-op education

- no driving, high chairs, low cars 6 weeks

- no crossing legs ever





- MUA 

- re-educated

- mobilise as tolerated




1st episode 

- treat with reduction



- treat with abduction brace 

- 20° flexion / Abudction / ER

- for 6/52



- revision


X-ray evaluation


A.  Component malposition


1.  Acetabular Abduction


Easy to assess on AP


THR Acetabulum Closed < 45 degreesTHR Acetabulum open > 45 degreesTHR Dislocation Abducted Acetabular Component


2.  Acetabular Anteversion


Much more difficult to assess

- compare ellipse of acetabulum on AP pelvis and AP hip



- AP pelvis the beam is centred over the pelvis

- AP hip the beam is centred over the hip


If cup anteverted

- looks flat on AP pelvis

- looks elliptical on AP hip


If cup retroverted

- looks elliptical on AP pelvis

- looks flat on AP hip


THR AP Pelvis Elliptical CUpTHR AP Hip Straight Cup


B.  Other


Eccentric liner wear

- draw lines on paper, compare each side

- thickness not equal both sides with wear


THR Poly Wear




Insufficient offset


Surgical Revision


Need to decide cause of problem

- preoperative and intraoperative

- malposition / impingement / soft tissue

- have options available to address each problem




1.  Impingement 

- removal of osteophytes or cement

- exchange components to improve head neck ratio

- may need to adjust component malposition


2.  Malposition 

- assess stem + cup on CT



- change for Augmented polyethylene lining (if uncemented cup)

- revise component positioning

- larger head technology


3.  Incorrect tissue tension 

- longer neck / correct offset


4.  Worn liner

- exchange liner


5. Abductor insufficiency 

- trochanteric advancement

- increase femoral offset (modular head, lateralised liner)




1.  Constrained cups


THR Constrained CUp



- an acetabular component that uses a mechanism to restrain the femoral head within the cup

- can be implanted denovo or cemented into well fixed cup

- usually has a metal locking ring



- deficient soft tissues

- paralysed abductors

- GT non union



A.  Cup and monopolar liner with locking ring

B.  Bipolar constrained liner with locking ring




A. A constrained cup may still dislocate

- usually require surgery to relocate / require revision


THR Dislocation Constrained Liner 1THR Dislocation Constrained Liner 2


B. Inhibit ROM and transmit significant forces, which may contribute to early loosening


2.  Failure or Unreliable patients 



- bipolar hemiarthroplasty

- girdlestones



Heterotopic Ossification

DefinitionHO Brooker 4


Extraskeletal bone formation in periarticular tissues 

- HA crystals within osteoid matrix


Different to calcification 

- osteoid matrix laid down




1.  Myositis Ossificans

- post traumatic


2.  Heterotopic Ossification / associated with TJR


3.  Neoplastic Ossification




Occurs 50-70% THR's

- significant in 20%

- clinically significant in 1%


More common in men x 2


Risk factors



- previous hip / other hip HO

- incidence is 80%



- hypertrophic OA

- active Ankylosing Spondylitis

- hyperostosis


- active Paget's 

- fracture (acetabular trauma, pre or intra operative)




- posterior approach < Hardinge < transtrochanteric




Similar cascade to fracture healing

- unknown trigger

- undifferentiated mesenchymal cells differentiate in osteoblasts

- occurs within first few days

- produce osteoid

- mineralised to bone (mature lamellar bone)


Two Precursor cells about the Hip / Friedenstein


1.  Determined Osteogenic Progenitor Cells

- from bone marrow

- develop into osteoblasts with inflammation


2.  Inducible Osteogenic Progenitor Cells

- need BMP to develop into osteoblasts


Brooker Classification


Only Type IV interferes with function


Type I:  Isolated islands of bone


Heterotropic Bone Brooker 1


Type II:  Bony spurs from pelves and proximal femur, gap > 1 cm


Heterotropic Bone Brooker 2


Type III:  Gap < 1 cm


Heterotropic Bone Brooker 3


Type IV:  Apparent ankylosis


Heterotropic Bone Brooker 4


Clinical Features


Usually none

- pain usually as it matures

- decreased ROM

- dislocation 2° impingement (rare due to loss of ROM)

- nerve irritation

- trochanteric bursitis

- hip can appear red, swollen and tender




New bone in peri prosthetic soft tissues

- visible by 3-6/52

- extent determined by 3/12


Maturation continues for 12-18/12 


Bone Scan


Increased uptake = continued activity

- remain increased for 12/12




Rise in serum alkaline phosphatase post surgery

- associated with HO




1.  Prevention 


Identify at patients risk preoperatively

- Ankylosing Spondylitis / Pagets / Previous HO / DISH


A.  Surgical Technique


Gentle handling of tissues

- avoid muscle stripping

- lavage tissues

- drain wound




Indomethacin 50 mg bd for 1 week

- significant reduction in risk of HO

- 7 days as effective as 14 days

- as effective as postoperative radiation


Risk of GIT side-effects ~ 20%

- interaction with anticoagulants

- double risk of significant bleeding with DVT prophylaxis




Knelles JBJS 1997

- 685 Primary THR

- 50mg bd Indocid for 1 week

- as effective as 1 x 7 Gy Post-op




For very high risk patients

- previous HO / indocid contraindicated because of PUD

- post surgical excision of HO



- 700 Rad / 7 Gy < day 5

- 800 Rad 6h pre-op prevents HO


Side effects

1.  Delay incorporation of bone graft / union of trochanter

2.  May delay porous ingrowth with uncemented components

3.  Can make patient nauseous

4.  Nil evidence wound problems (shielded, low dose)

5.  Risk of malignancy - nil evidence at this low dose


D. Biphosphonates


Delay calcification and delay Xray appearance of bone 

- doesn't prevent osteoid formation

- calcification occurs once drug stopped

- no longer used


2.  Surgical Excision




Significant symptoms / reduced ROM & > Brooker III

- revision of prosthesis




Usually 12-18 / 12 post-operatively

- mature appearance on XR

- cold Bone Scan

- serum ALP normal




Radiotherapy post oeratively as high risk 




Usually increased ROM

- unreliable effect on pain

- bone often reforms




THR HO Brooker 4THR HO Brooker 4 Poster ExcisionTHR Post HO Excision Dislocation









Infected THR

Risk factors




Advanced age

Immunosuppression - steroids / Rheumatoid / DM

Malnutrition - Lymphocyte count / Transferrin / Albumin

Vascular disease


Poor skin i.e. psoriasis

Previous infection in joint

Infection elsewhere - i.e. UTi

Prolonged hospital admission

Revision surgery


Operative Factors



- preoperative wash

- preoperative shave

- admission day of surgery to clean ward

- groin, nasal, axilla swabs clear

- clear urine (MCS preop)

- no skin breaks


Operative Period

- laminar flow

- minimal theatre traffic

- IV Abx on induction

- shields

- alcoholic prep

- prep drapes

- short procedure duration

- care of soft tissues

- ABx cement

- wound closure / drains / hemostasis


Postoperative Period

- wound haematoma & drainage

- skin necrosis

- post operative ABx

- management remote infections i.e. UTI

- care with dental procedures




Current rate 0.27 - 2 % 


Increased risk with high-risk patients (2%)

- immuno-compromised

- recurrent bacteraemia

- revision > 2%

- RA




S. epidermis most common with S. aureus second

- together make up two thirds of all infections


MRSA increasing in prevalence

Also vancomycin resistant S. aureus



- streptococcus

- S. capitus

- pseudomonas

- coliforms

- anaerobes

- mixed 1/4




Usually worsening hip pain

- often minimal constitutional symptoms




Progressive / rapid lysis / bone loss

May be normal appearing xray


Infected THR progressive bone loss and lysis




For full details, please see Investigation of Pain in THR Complications section




Fluid collection about hip




CRP > 10 and ESR > 30 very suspicious


Bone scan


Reveal increased uptake about both components

- blood flow, blood pool and delayed uptake phases

- more than 12/12 post implantation


Specificity increased by WC scan




Under II control

- off antibiotics

- confirm infection


THR Aspiration




1.  Prosthesis in bone

- difficult for antibiotics to access

- poor blood supply

- similar to osteomyelitis


2.  Glycocalyx 


Bacteria have two forms

A.  Planktonic form 

- individual free floating cells

B.  Sessile form 

- exist within biofilm of glycocalyx

- 500x more resistant than planktonic form


Glycocalyx is a slime layer of polysaccharides produced by bacteria 

- protective barrier against antimicrobial and host defences

- helps bacteria to exist and survive on synthetic substances

- biofilm requires minimum time to form

- infection can be irradicated by Abx while still in planktonic phase but not once form biofilm


3.  Prosthesis Surface Properties


CO-Cr more susceptible to infection than titanium

- may be related to faster osseointegration by titanium


Polished surfaces less susceptible

- smaller surface area for bacteria to adhere

- shorter distance for host cell to travel


Classification Gustilo 1993


1.  Early post-operative

- < 1/12

- febrile patient

- red swollen discharging wound


2.  Late post-operative

- indolent (low virulent)

- > 1/12



- well patient

- healed wound

- worsening of pain

- never pain-free interval


3.  Acute haematogenous

- antecedent bacteraemia

- can occur several years after surgery



- well patient

- previously well functioning hip

- UTi or other source of infection

- hip now very painful


4. Positive intra-operative culture

- presumptive diagnosis aseptic loosening

- intra-operative m/c/s comes back positive (2 out of 5)

- treat with 6 weeks Abx -> success rate 90% 






Eradicate infection

Relieve pain

Restore function




1.  ABx suppression

2.  Debridement and prosthesis retention

3.  One stage revision

4.  Two stage revision

5.  Three stage revision

6.  Resection arthroplasty


1. Antibiotic Suppression




1.  Gustillo Type 4 

- 90% success


2.  Elderly and frail




Known sensitive organism

Stable prosthesis

Tolerable oral Abx





- 50% retention of prosthesis at 3 years 


2. Debridement with Retention THR





- symptoms < 4/52



- well fixed prosthesis



- known sensitive organism



- Cierny A / B / C




No Abx until

- swab and tissue for M/C/S

- or after positive blood culture




Excision of all necrotic and infected tissue

- ensure implant well fixed

- exchange liner (if uncemented)

- wash +++

- monofilament nylon sutures

- drain


IV Abx 6/52


Vanco / genta initially until swabs available

- ID consult




1.  Early post-op infection in cemented well fixed THR

- success = 75% 


2.  Early post- op infection in uncemented 

- worse results

- due to lack of cement obstruction

- required 2 stage revision if no bone ingrowth


3.  Acute haematogenous

- only 50% success 

- often immunocompromised


4.  Chronic late

- poor results 

- window of opportunity lost


3. One-Stage Revision


Infected THR Pre One stage revisionInfected THR Post One Stage Revision





- remove prosthesis, debride and replace at single sitting

- lower success rate than two stage

- usually indicated in older, more frail patient

- meticulous debridement critical

- treat infection like cancer





- late onset



- healthy host



- sensitive organisms (gm+)



- no sinuses / good wound

- adequate bone stock




Debridement all necrotic and infected tissue

- removal of implants and all cement

- aided by extended trochanteric osteotomy

- wash +++

- re-drape, new instruments


Reimplant cemented polished femur and all poly cup

- must use ABx PMMA

- already has tobramycin in it

- add powder form vancomycin 

- 2-3 gram in each packet of cement

- each vanco vial is 0.5g

- femur and acetabulum


Can implant poly liner from uncemented acetabulum only

- more ABx cement can be impregnated

- large head for stability


Post operative

- IV Ab's 6/52


Antibiotics must be

- thermostable (excludes tetracycline & chloramphenicol)

- powder form (not genta)

- low allergenic potential

- elute from the cement

- effective against the infecting organism

- Palacos better as higher surface porosity




80% long term survival


4. Two-Stage Revision


Gold Standard




Chronic late

Acute haematogenous




Improved success rate compared with single stage

- success 90% with ABx cement

- 2 opportunities for debridement




1.  2 procedures required

- difficult for patient between stages


2.  Revision surgery more difficult

- scar formation 

- shortening

- distortion of anatomy


3.  Increased cost / Longer time


First stage


Complete debridement

- removal all implants and cement

- meticulous debridement necrotic an infected soft tissue

- insert spacer


A.  Ball of ABx Cement


Infected THR Cement Ball



- leeches ABx

- maintain space for revison hip



- very uncomfortable

- o mobility benefit to patient

- can cause bony erosion


B.  Abx cement in mould


Infected THR Cement Spacer Fracture



- poor function

- fractures / breaks

- painful

- difficult to mobilise

- can cause further bone loss


C.  Company produced cement spacer



- metal spine

- can dislocate / cause bone loss / cause femur fracture


Infected THR Prostalac SpacerInfected THR Dislocated ProstalacProstalac Femur Fracture


D.  All poly liner and cemented stem


Infected THR Kiwi Hip Spacer


Concept of the "kiwi" hip

- +++ Abx cement

- cheap polished femur loosely cemented in

- uncemented poly liner to increase cement load in acetabulum



- stable construct

- patient can mobilise

- no rush to revise



- cost


E.  Antibiotic Coated Nail


Infected THR NailAntibiotic Coated Nail


Second Stage



- Abx minimum 6/52

- at least 2 - 4 weeks off ABx

- consider hip aspiration

- normal CRP / ESR

- intra-operative FFS at time of surgery


5. Three stage Revision


A.  Remove implants - 4-6/52 Abx

B.  Bone graft defects - 3-12/12

C.  Revise components when graft incorporated


6. Resection Arthroplasty (Girdlestone)


Described in 1928 for TB


Infected THR GIrdlestones



- medically unfit for further revision surgery

- refusal for further revision surgery

- sepsis control / virulent bug

- unrevisable due to bone loss

- unlikely to become mobile




Effective control of infection (95%)




Poor function

- pain

- limp

- require walking aid

- 5cm average LLD

- increased energy expenditure 250%


Leaves pateint with nearly useless pseudoarthrosis

- weight bearing almost impossible

- severe shortening

- consider only as last resort


Post operative

- used to recommend 6/52 traction

- makes no difference


7. Amputation



- hip disarticulation




Life-threatening infection

Severe loss of ST & bone stock

Vascular injury




Performed in 0.1%




Intra-operative Fracture

THR Acetabular Fracture




Increased incidence with press-fit component

- especially if under ream




Don't under-ream >1mm


In osteopenic bone 

- line to line reaming

- i.e. ream to outer diameter of cup


This also avoids leaving gaps at floor 

- very common if under-ream by 2mm


Management Intra-operatively


Intra-operative undisplaced fracture + Stable cup

- 2-4 screws through cup

- TWB 2-3 months


Intraoperative displaced fracture

- remove cup

- plate posterior column if factured

- screw fixation anterior column

- additional screws in cup

- +/- antiprotrusio ring                    

- TWB 2-3 months


THR Fractured AcetabulumTHR Fractured Acetabulum 2THR Fractured Acetabulum 3


Diagnosis Post operatively


Can be difficult to diagnose & image

- if unexplained groin pain post-op & press-fit cup 

- look for fracture with multiple oblique views etc

- CT

- may see callous formation


THR Intraoperative Acetabular Fracture


Post-operative early


1. Non or minimally displaced

- recognised immediate post-op

- TWB 3 months


2. Displaced fracture unstable

- ORIF & revise cup


Post-operative late


Peterson & Lewallen JBJS Aug 1996


Type 1

- cup clinically & radiologically stable

- no treatment


Type 2

- cup unstable

- revise as above


THR Femoral Fracture


THR Femoral Intraoperative FractureUncement Femur Intraoperative Fracture




Increased incidence with press-fit components

- act like splitting wedge


Fracture may occur during


1. Dislocation

2. Reaming or broaching

3. Impaction of component

4. R/O cement or old components 




During dislocation


Beware in elderly, osteoporotic patient and in revision

- adequate exposure

- only 1 person manipulate femur


If difficult dislocation

- complete ST release

- removal of acetabular osteophytes

- ankylosed joint or protrusio, division of neck in situ & piecemeal removal of femoral head


During femoral preparation


Pre-op templating of component size

- use of reamers before broaching to remove endosteal bone

- gentle broaching with pause if failing to advance

- sufficient broaching for easy prosthesis insertion


Avoid creation of stress risers i.e. cracks, defects, windows


If cracks or defects created

- bypass with implant by 2-3 cortical diameters distally

- minimise cement extravasation as prevents healing of defect

- use cerclage wires to prevent propogation of fracture


During component insertion

- gentle impaction with pause if failing to advance

- uncemented components often 1 - 2 mm proud of equivalent sized broach




Vertical split not beyond LT

- cerclage wire


Vertical split beyond LT 

- cerclage wires

- longer stem


Perforation of shaft

- bypass defect

- fixate with plate





Investigation of Pain









Thigh pain in uncemented

- micro motion at distal end of stem

- modulus mismatch


Stress fracture / insufficiency fracture

- pubic rami, sacral


Intra-operative fracture


Prosthesis failure


Subtle instability




Muscular tendonitis

- irritation of Psoas

- stretching of Adductors

- vas lateralis herniation


Trochanteric bursitis / tear G medius


Non-union of Trochanteric Osteotomy


THR GT Nonunion




Lumbar / Knee / Pelvic / Abdominal pathology




Nature of Pain


°Pain-free interval  

- indolent infection

- pathology elsewhere (pain same as pre-op)

- poor implant fixation

- impingement


Pain-free interval 

- loosening

- infection

- implant failure


Mechanical pain 

- loosening


Start up pain

- pain with initial movement

- recedes as implant settles

- loosening symptoms


Rest pain / night pain 

- infection

- tumour




Buttock / groin pain 

- cetabular pathology


Thigh / knee pain 

- Femoral pathology


Pain over GT suggests

- trochanteric bursitis / tear G medius

- Non-union of trochanteric osteotomy


Pain in other locations 

- spinal stenosis 

- knee OA 


Radiating below knee

- radiculopathy




Drainage postoperative suggests +++ infection if > 1/12 post-op

History of bacteraemia suggests infection

Prolonged in hospital ABx treatment




Pain with ROM 

- loosening - extremes of motion

- infection - pain throughout motion

- implant failure


Tenderness over GT



- induration, erythema & drainage


Spine, knee & vascular  exam


Groin for inguinal hernia






1. May be normal in face of pathology

- serial comparison very important


2. Difficult to differentiate infection v loosening on XR




Infected THR Endosteal ScallopingInfected THR Periosteal New Bone


1. Radiolucent lines

2. Focal Osteolysis with Endosteal scalloping

3. Periosteal new bone 

- almost pathognomonic

- usually at junction meta / diaphysis on medial side

- only seen in 1-2%




Easier to identify loosening in femur than acetabulum

- femur 90% accuracy

- acetabulum 65% accuracy


Lucent lines don't necessarily represent problem

- may be present in well-fixed prosthesis (retrieval studies)

- due to remodelling




Little value

- increased in 15%

- raised only if sepsis +++




> 30 mm = 80% sensitivy & specificity for infection



- takes 6 - 12 / 12 to normalise post OT

- very non specific, increased in RA and remote pathology

- can be raised in aseptic loosening




> 10 mg/l = 90% sensitiviy & specificity

- rarely increased with loosening


More predicable response post OT

- peak 2/7 (~400)

- normal after 3 /52


In the absence of other causes of elevation


If CRP is negative can be confident is no infection

- negative predictive value 99%


If CRP is positive is still a 20% chance that is no infection

- positive predictive value 75%


IF both ESR > 30 and CRP >10, 84% probability of sepsis


Te99 Scan


Bone scan may show increased uptake from

- infection

- loosening

- HO

- Paget's

- stress fracture

- large uncemented stem (modulus mismatch)

- tumors




- pathology unlikely if negative



- very sensitive

- poor specificty

- doesn't differentiate cause


Lieberman et al JBJS Br  1993

- no benefit of NMBS over x-ray in diagnosis of infection or loosening


Residual activity 



- majority return to normal by 1 year

- 20% remain hot at portions of stem / GT / LT past 1 year



- can remain hot for 2 years 

- can remain hot at distal stem for many years


Infected prosthesis


All phases increased & usually diffuse in 3 phases

- highly suggestive of infection

- can get focal uptake similar to loosening but rarer


Loose prosthesis

- localised increased uptake on delayed phase only

- motion of prosthesis causes increased bone turnover due to bone resorption 

- increased uptake @ GT & LT alone may be normal post op change

- well advanced loosening can show diffuse uptake as for an infected hip


THR Bone Scan NormalTHR Hot Cup Quiscent Femur


Stress sites 

- will see localised area of uptake on scan

- corresponds with cortical thickening on plain XRs


Insufficiency fracture

- occur in osteopaenic patients

- pubic rami fractures may cause groin pain

- sacral fractures may cause posterior hip pain


Indium 111 Labelled WC Scan 


Uncertain role 

- expensive, difficult 

- have to harvest WC


More specific for infection

- especially when combine with bone scan

- sensitivity 92%

- range specificity 75 - 100%




THR Aspiration



- no Abx >4 weeks

- II control & with contrast / confirm in joint

- no LA (bacteriostatic)

- aspirate hip joint x 3 specimens

- if only 1 specimen positive then repeat


If dry, inject normal saline & aspirate 

- controversial


> 65% PMN infection likely

> 1600 white cells microlitre




Harris & Barrack JBJS 1996

- 2% positive rate if aspirate all hips

- therefore be selective


Lachiewicz et al JBJS Am 1996

- hip pain and elevate ESR

- 92% sensitivity & 97% specificity




Crawford et al JBJS 1998

- 95-100% sensitivity

- ff good results from LA expect same from THR

- demonstrates that the pain is from the hip


Intra-Operative Frozen Section


PMN Cell Count 

- 40x power, count white cells in that field

- average over 10 fields


Mirra 1976 > 5phpf

- 84% sens, 96% spec


Lonner 1996 > 10phpf

- 84% sens, 99% spec


Intra Operative gram stain & m/c/s


Gold Standard

- 10% false positive

- Gram stain sensitivity < 20%, but very specific


All revisions no antibiotics for 4 weeks prior


Surgical Opinion


Sensitivity 70%

Specificity 85%






Xray N / Scan N / ESR & CRP N

- not infected

- explore extrinsic causes


Xray Loose / ESR & CRP raised 

- infected

- 2 stage revision with intra-operative M/C/S


Xray normal / Hot scan / Raised ESR & CRP 

- infected

- 2 stage revision

- intra operative FFS to confirm


Xray / Scan / ESR / CRP all equivocal 





Leg Length Discrepancy



Most common reason for litigation against orthopaedic surgeons in THR

Usually from lengthening


Complications of LLD


1.  Nerve palsy


Sciatic nerve - tolerate average 4.4cm lengthening


Common peroneal nerve - tolerate average 2.7 cm lengthening


Lengthen by up to 15-20% of the resting nerve length

- but in reality is unknown and multifactorial


2.  Lower back pain / scoliosis


THR LLDTHR LLD with secondary scoliosis


3.  Abnormal gait


2 - 4 cm discrepancy

- significant increase in oxygen consumption

- also risk of falls


Assessment of LLD






Functional LLD

- blocks


Apparent LLD

- umbilicus to medial malleolus


True LLD

- ASIS to medial malleolus


Apparent shortening

- FFD & adduction hip


Apparent lengthening

- abduction contracture 

- scoliosis, fixed pelvic tilt




Very important

- must mention LLD


X-ray Assessment


AP pelvis 

- both femurs IR 15o

- compensate for anteversion




THR Template LLDTHR Leg Length Ischial LineCentre of Rotation Ranawat Method


1.  Establish Centre of rotation


Acetabular Templating

A.  Ilioischial line / Inter-tear drop line / Superior edge acetabulum

B.  Ranawat

- intersection of ilioishial and shenton's

- 5 mm laterally

- 1/5 pelvis up and 1/5 pelvis in

C.  Rule of thumb

- 2 cm horizontal and 4 cm vertical from teardrop


2.  Calculate LLD

- draw line LT / ischial tuberosity / inferior teardrop

- up to centre of femoral head / centre of rotation

- beware adducted hip on x-ray / false shortening


LLD with hip adduction


3.  Femoral Templating


A.  Size implant

B.  Determine offset

C.  Determine femoral osteotomy from lesser trochanter to restore LLD




1.  Leg to leg comparison


Careful patient positioning

- ASIS perpendicular to floor and patient stable

- ability to palpate both knees and feet

- small pillow to prevent adduction of superior leg

- feel LLD before surgery in this position

- upper femur often feels 1 cm short even if no LLD due to adduction

- aim to reduce LLD to normal after reduction of THR at end of case


2.  Intra-operative measurement



- proximal pin in superoacetabular region

- distally diathermy mark in vas lateralis

- calliper measures horizontal distance (LLD) and vertical distance (offset)

- must place leg in similar position each time to measure leg distance


3.  Tests


Shuck test

- distract femoral head from acetabulum

- should be only few mm of shuck with correct tension


Drop Kick Test

- with thigh extended, knee should remain flexed

- if tension too tight, knee will extend



- if hip tension too tight, ROM especially IR / ER / extension is limited




Transient Perception of LLD

- 14% patients

- usually passes

- may have had LLD before which has been adjusted

- will then feel that leg is longer / which is true



- may get back pain



- abductor weakness

- even dislocation




Delay using shoe lift for 6/12

- allows perceived LLD to resolve


Rarely revision surgery is required

- persistent neurological pain

- beware instability





Nerve Injury



Primary THR 1%

Revision THR 3%

DDH  5%


Sciatic nerve 90% of nerve palsy



- femoral nerve


- ulna / radial nerve from positioning







- exposure / sciatic and superior gluteal nerve

- drill reamer / obturator nerve

- spike of cement / obturator nerve



- diathermy

- cement / obturator nerve





- cerclage wires

- anterior acetabular retractors / femoral nerve

- posterior femoral retractors / sciatic nerve



- post op sciatic nerve palsy


Strap / Pillow (COPN)



- LLD > 4cm

- dislocation


Prognosis Nerve injury


Femoral > COPN  > Sciatic

- most have some residual loss

- 80% incomplete recovery over 18 month period

- none after this


Good prognostic signs

- retention of motor function

- recovery of motor function initial few days


Document neurological status prior to indexed procedure


Poor prognostic signs

- nil recovery by 7 months

- causalgia

- elderly

- poor medical condition

- DM, alcoholism

- spinal stenosis (double crush)

- smoking, steroids


Superior Gluteal Nerve



- L4/5 S1

- sciatic notch above piriformis

- runs between G. medius and minimus

- supplies G. medius and minimus & TFL



- anterior / SP approach injure branches to TFL

- lateral / Hardinge approach respect safe zone in G. medius 3-5 cm proximal to GT


Obturator Nerve



- L2-4 posterior division

- along sacral alar

- emerge obturator foramen

- sensation to medial thigh

- adductor muscles



- screws / cement / reamers / retractors

- antero-inferior quadrant of acetabulum


Sciatic Nerve



- most frequently injured nerve

- 1.5%




L4/5 S1-3

- emerges at G. sciatic notch

- usually tibial and peroneal components combined

- below piriformis

- below gluteals and above short ER



- can be in tibial and CPN divisions

- one or both divisions can run through piriformis

- both emerge above pirifomis

- always treat pirifomis with care in posterior approach


Runs over long head of biceps femoris under gluteal insertion

- passes between LHB and adductor magnus

- SHB only thigh muscles supplied by CPN component



- CPN: DF and evertors

- Tibial: PF and invertors



- Sural: medial sural from tibial / lateral sural from CPN

- Superficial and Deep Peroneal nerve

- Tibial nerve





- > 4cm lengthening in DDH 30% nerve palsy

- 0% if less than 4 cm



- posterior retractors / posterior acetabular wall

- post operative haematoma (CT scan)

- wires or cables (around femur)

- sutures (in closure at end of case)


Direct laceration

- revision surgery

- posterior approach

- DDH, Protrusio (nerve in abnormal position)




CPN division


More vulnerable than Tibial branch

- fixed at fibular head

- more superficial than sciatic nerve

- less surrounding connective tissue




Sciatic nerve / CPN only / Tibial nerve only (very rare)




Determine if CPN at level of hip or knee

- function of short head of biceps




Explore if cause is haematoma

- delayed onset or late progression of palsy in setting of haematoma 

- CT may be useful to diagnose


Explore if believe major direct injury

- transection or entrapment in cerclage wires

- sutured


Otherwise few indications to explore


Femoral Nerve





- enters femoral triangle between psoas and iliacus

- power to quadriceps

- sensation to medial thigh and calf





- anterior retractors above psoas in anterior approaches to the hip

- iliacus hematoma / bleeding tendencies


Femoral nerve blocks



- cement extrusion / screws AS quadrant




Anteromedial numbness

Difficulty climbing stairs




Very rare 0.4%

- usually recovers in full






Periprosthetic Fracture

TypesTHR Periprosthetic Fracture



- incurred during operation


Post operative

- related to osteolysis / trauma / infection


Follow up


1994 National Institutes of Health Consensus on THR


Regular radiographic follow-up to avoid massive osteolysis & fracture






0.6% cemented

0.4% uncemented




2.5% cemented revision

1.5% uncemented revision




1. Bone damage at insertion

- eccentric reaming

- perforation

- fracture


2. Osteolysis


3. Trauma


4. Infection


5. Osteoporosis


Vancouver Classification


Type A (4%)


Avulsion GT or LT


A1 Stem well fixed

A2 Stem loose


Type B (87%)


Fracture near stem tip or around stem


B1 Stem well fixed (20%)

B2 Stem loose (44%)

B3 Stem loose with marked osteolysis (36%)


Type C (10%)


Fracture distal to tip




Most important is whether prosthesis is stable

- if loose requires revision


Type A


Avulsion GT or LT





- undisplaced - no treatment required

- ORIF GT if displaced > 2.5 cm / disruption to abductors


THR Periprosthetic Type A THR Periprosthetic Fracture A PlatingVancouver A Displaced GTVancouver A GT Wire Fixation



- cerclage LT if large and supportive


Type B1 


Fracture around stem, likely well fixed


THR Periprosthetic Fracture B1THR Periprosthetic Fracture B1 Lateral




1.  ORIF with cable plate + proximal unicortical locking screws +/- Cortical strut graft


Cable plate alone

- 90% union


Locking Cable plate + single strut graft

- 98% union

- distal bicortical screws

- proximal unicortical screws supplemented with cables


Cortical Strut Graft


2.  Long stem revision




THR Periprosthetic Revision Long Cemented FemurTHR Periprosthetic Revision Cemented Femur 2




THR Periprosthetic Fracture Type B1THR Fracture Long Stem Revision


Type B2


Fracture around stem, femoral component loose


THR Periprosthetic Fracture B2Periprosthetic Fracture Vancouver B2




Long stem revision

- distal fit (cemented / uncemented)

- must bypass distal extent of fracture by at least 2 cortical diameters


THR Periprosthetic Fracture B1 Long stem cemented revision


May in addition use

- cable plate + unicortical locking screws

- 1 x strut allograft

- autogenous BG + BMP to fracture site


Revision THR Periprosthetic Fracture Uncemented Stem Strut GraftRevision THR Periprosthetic Fracture Uncemented Stem Strut Graft 2Revision THR Periprosthetic Fracture Uncemented Stem Strut Graft 3Revision THR Periprosthetic Fracture Uncemented Stem Strut Graft 4


Vancouver B2 PFFRevision PFF with Modular Uncemented and Strut Allograft


Type B3


Fracture around stem with marked osteolysis


THR Vancouver B3 APTHR Vancouver B3 Lateral




Young patient

- segmental allograft / prosthesis composite



- tumour type proximal femoral replacement


Type C 


Fracture distal to tip of stem




1.  ORIF Cable Plate

- can use MIPO

- overlap femoral stem to avoid stress riser


THR Periprosthetic Type C Plating


2.  ORIF Cable Plate + cortical strut graft


2.  Strut allograft alone

- use 2 x 1/2 femurs fresh frozen

- span fracture 10cm above & below

- 4 wires above & below

- preserve blood supply to linea aspera

- autogenous graft to fracture site


THR Consent


THR Complications




Infection (1% risk deep infection)

Wound Haematoma

Bleeding / Transfusion

Dislocation (2 - 3% recurrent)



DVT/PE (Fatal PE 1/1000 with chemoprophylaxis)

LLD (average 1cm, stability more important)

Medical complications

- pneumonia, UTI, CVA. IHD





Limp (LLD, 1 year with anterolateral approach)

Loosening / Revision (95% 10 year survival)

HO (1% Problematic)

Thigh pain (uncemented stems)

Continued pain

Thigh Pain Uncemented Femur




- up to 4%




Focal pain

- typically anterolateral thigh

- often tender

- corresponds to tip of stem




1.  Instability



- early

- late / failed bony ingrowth



- micromotion at distal stem

- disadvantage of proximal coating


2.  Mismatch modulus of elasticity


A.  Component material

- mismatch between femoral component and surrounding bone

- lower with titanium stems compared with cobalt chrome stems

- titanium components less stiff & tend to have lower incidence of thigh pain


B.  Stem size

- more commonly seen in larger stems

- increases relative stiffness of stem compared to bone


3.  Stem design

- distal flutes can decrease distal stiffness

- fully porous coating decreases incidence, but increases proximal stress shielding


4.  Osteoporotic bone

- more commonly seen with lower bone quality





- start up pain







- migration

- progressive radiolucent lines

- abscence of spot welds


Bone Scan


No correlation of findings with thigh pain




Non operative


Up to 2 years

- allows for remodelling







1.  Cerclage wire cortical strut grafts



- improve bony rigidity over distal stem



- application to lateral femur

- overlap tip proximally and distally 8 cm

- must get host bone integration

- periosteal elevation / bone graft / rigid fixation

- TWB 6 weeks post op



- good results reported


2.  Revision






Vascular Injury

Vessels at risk


Extra-pelvic blood vessels


Femoral Artery



Profunda Femoris

Obturator artery


Intrapelvic vessels


External iliac artery and vein

Obturator artery

Superior and inferior gluteal


External Iliac Vessels



- anterior division of common iliacs / L5-S1

- runs down medial border of Psoas

- some psoas between EIA & intrapelvic surface of anterior column

- EIV accompanies EIA









Screws may penetrate VAN

- can be delayed diagnosis

- significant intrapelvic bleeding may occur before diagnosis

- AS quadrant: minimal protective ST interposition and often poor bone stock

- vein more at risk than artery


CementIntrapelvic cement THR



- heat

- kinking or occlusion from bolus

- erosion from spicule

- avulsion secondary to removal


Avoid cement intrusion into pelvis with wire mesh 


Removal of intrapelvic cement

- required in revision for infection

- define NV relationships

- angiography / MRA preoperatively

- may require separate intrapelvic exposure

- alert general surgeons / vascular surgeons


Femoral blood vessels


Most commonly injured



- common femoral artery is continuation of EIA as passes under inguinal ligament

- passes anterior to hip capsule

- separated from it by psoas




Anterior retractors / dissection

Anterior quadrant screws and drills


Obturator AV




VAN traverse lateral wall together

- separated from quadrilateral plate by obturator internus

- lie at superolat aspect of obturator foramen

- exit pelvis via obturator canal




Screws in AI quad

Retractor under transverse acetabular ligament




Bleeding at inferior transverse ligament

- can be very difficult to ligate

- pack with swab

- hold swab with inferior retractor

- finish acetabulum

- will usually be controlled


Other option is to embolise if still bleeding


Superor Gluteal BV




Branch Posterior Division IIA

- close to posterior column

- exits greater sciatic notch above piriformis




Screw near sciatic notch


Inferior Gluteal & Internal Pudendal AV




Branch anterior division IIA

- exit pelvis between piriformis & coccygeus

- close to posterior column near ischial spine

- internal pudendal artery re-enters pelvis through lesser notch

- IGA pass under piriformis




Very long screws through posterior column


Management on table torrential bleeding


Pack wound, tell anaesthetist & vascular surgeon & obtain proximal & distal control


Notify anaethetist


IV fluids

Coags,  FBC, platelets,  cross match

Transfuse blood

Organise cell saver


Control bleeding


Pack & wait

- uncontrollable, get proximal control


Call Vascular surgeon


Ilioinguinal approach

- clamp IIA, vessiloop IIV


Retro-peritoneal approach

- Rutherford-Morrison incision

- retroperitoneal approach



- angiography

- transcatheter embolisation



THR Difficult

Arthrodesis Conversion



Severe LBP 

- most common indication


Ipsilateral knee pain

- less beneficial



- especially abduction




Absent abductor mechanism


Active infection

Insufficient bone stock






Assessment abductor function


1.  Palpation whilst asking patient to contract

2.  MRI




1.  Difficulty prepping & draping


2.  Exposure

- identify sciatic nerve

- perform GT osteotomy

- may require adductor & psoas tenotomy


3.  LLD

- maximum 4cm lengthening 

- use ASIS pin as LLD guide




Hip Fusion 1Hip Fusion THR 1


Hip Fusion 2Hip Fusion THR 2


Hip Fusion 4Hip Fusion THR 4


Hip Fusion 5HIp Fusion THR 5




Joshi et al JBJS Am 2002

- 208 hips converted at average 51 years

- average follow up 9 years

- 83% good to excellent function

- 96% 10 year survival

- 15 nerve palsies






Sciatic nerve palsy


Residual LLD

Poor abductor function




ConceptTHR Dysplasia Subtrochanteric Osteotomy + Mesh Impaction Bone Graft


THR in dysplastic hips has a higher failure rate

- due to anatomic abnormalities

- due to generally younger age




Restore normal biomechanics and preserve bone stock




Soft tissues


Sciatic nerve in abnormal position / danger

Hamstring  / adductors / RF tight

Horizontal abductors - function less efficiently

Thick hourglass capsule

Thickened psoas tendon




Low subluxation

- shallow with wide opening

- small

- deficient anterior / lateral / superior

- better bone stock posteriorly


DDH Anterior Acetabular Insufficiency


High dislocation

- small pelvis

- thin & soft acetabular wall

- gross anteversion




Increased anteversion

- valgus neck shaft angle


Narrow tapered femoral canal

- tight isthmus

- AP diameter > ML


Posterior displacement of the greater tuberosity




Can be very short

- maximum sciatic nerve can be lengthened is 4 cm


Crowe Classification


Based on extent of proximal migration of femoral head compared to the height of the undeformed femoral head

- femoral head is 20% height of pelvis

- measure the vertical distance between the inter-teardrop distance and the head neck junction

- this distance as a ratio of the femoral head


Crowe I:  Proximal displacement < 50% femoral head (10% pelvis)


DDH Crowe 1


Crowe II:  Proximal displacement femoral head 50-75%                            


DDH Crowe 2Crowe 2 DDHCrowe 2 DDH Lateral


Crowe III: Proximal displacement femoral head 75 - 100%


DDH Crowe 3DDH Crowe 3DDH Crowe 3 Lateral


Crowe IV:  Proximal displacement femoral head >100% (20% pelvis)


Efekhar Classification


A Elongated dysplastic acetabulum

B Intermediate acetabulum

C High false acetabulum

D High but no false acetabulum




Pelvic tilt

Lumbosacral flexibility

Fixed hip deformities

Real and apparent LLD

Previous scars


Operative Management




Restore hip centre

Acetabular bony coverage

Restore LLD


Technical Factors


Soft tissue release

- capsule / psoas / adductors / abductors

- abductor slide or release from ilium

- protect sciatic nerve



- need small components

- restore centre of rotation / bring down to true floor

- may need to augment superolateral acetabulum



- small components

- correct femoral anteversion

- restore offset as best able

- may require trochanteric slide



- > 4 cm need femoral osteotomy


Acetabular component




1.  Restore normal hip centre

2.  High hip centre

3.  Medialise cup 


Restore normal hip centre


A.  Recreate centre of rotation


Place in true acetabulum

- transverse ligament is anatomical landmark


Template hip centre

- inter-tear drop line is inferior margin

- ilio-ischial line is medial margin

- superior edge acetabulum lateral margin


B.  Need for augmentation


Superior defect must be < 30%



- bulk femoral head autograft

- mesh + impaction bone graft

- reinforcement rings / cages

- augmented cups


Acetabulum Reconstruction


Bulk Femoral Head Autograft 


DDH Bulk Femoral Head Autograft



- restore hip centre

- improve bone stock for revisions



- fashion femoral head into 7 graft

- screw into place with 2 x 6.5 mm cancellous screws

- ream into inferior aspect of graft


Spangehl et al JBJS Am 2001

- 44 hips followed up for 7.5 years

- femoral autograft with uncemented cup

- 4 revisions / 10%

- acceptable early results


Harris JBJS 1997

- 55 autogenous bulk autograft + cemented acetabulum

- average follow up 16.5 years

- average age of patient at time of surgery 42 years

- average size of acetabulum 40mm

- average coverage of cup by graft 49%

- 29% (16/55) revised and further 31% (17/55) radiographically loose

- those grafts 30% or less of cup coverage were well fixed at 16 years

- the greater the coverage of bone graft initially, the greater the rate of late revision

- most hips did well for initial 5 - 10 years


Mesh + Impaction Bone Grafting


DDH THR Rim Mesh Allograft


Reinforcement ring / cage + bone graft



- morcellised bone graft

- support with acetabular reinforcement ring

- usually screwed into ilium and ischium

- cement acetabular component into ring


Muller JBJS 1998

- 87 hips, majority Crowe 3

- Muller acetabular roof reinforcement ring

- autograft and cemented polyethylene cup

- 10% revision at 9.4 years


Ganz J Arthroplasty 2005

- 33 cases at 10.8 years

- 3 revisions (9%)

- 2 of the revisions had structural allograft


DDH augmented cups


High Hip Centre


DDH THR High Hip Centre



- allows coverage by native bone

- decreases need for femoral shortening



- very small acetabular component

- very thin poly

- abnormal hip biomechanics

- risk of bony impingement 

- may lateralise hip centre




Kaneuji et al J Arthroplasty 2009

- 30 hips followed up for 15 years

- mild superior hip centre compared to contralateral normal hip (13 mm average)

- 1/30 revised


Socket medialisation / acetabuloplasty / medial protrusio technique



- controlled medialisation with deliberated over-reaming

- can deliberately fracture medial wall



- improves lateral coverage

- decreases JRF through medialisation



- loss of medial bone stock compromising future revision

- risk of early catastrophic component migration medially into pelvis








Small and narrow

Excess anteversion




Small components




Need to be modular


A.  Abnormal shape of proximal femur

- difficult to obtain press fit / risk fracture

- diaphyseal press fit

- small modular metaphyseal component


B.  Need modularity to adjust anteversion

- SROM prosthesis

- dial in version


Cemented DDH prothesis



- smaller with minimal metaphyseal flare

- this allows stem to be orientated independently of patients anteversion


LLD / Abductor Tension




Only lengthen sciatic nerve 4cm

Abductors very tight and prevent lengthening

Difficulty reducing hip


Difficulty reducing hip


1.  Psoas release

2.  Subtrochanteric osteotomy

3.  GT osteotomy


Tight abductors


Trochanteric slide allows

- acetabular exposure

- retensioning abductors

- reposition abductor insertion to correct anteversion




Subtrochanteric osteotomy


THR DDH Subtrochanteric Osteotomy



- acetabular exposure (lift up)

- correction anteversion

- shortening femur 



- mark rotation with 2 x small drill holes

- make osteotomy

- transverse osteotomy allows rotational adjustment

- step cut more difficult but gives rotational stability

- insert trial femur proximally

- reduce hip joint

- calculate resection based on overlap of proximal and distal femoral segments

- uncemented or cemented stem

- use bone resected as onlay


Management Algorithm




Crowe I


Mildly dysplastic

- minimal deformity, good bone stock

- small standard cup medialised for coverage

- < 30% uncovering allowed

- small femoral stem


Crowe II / III


Usually very deficient laterally

- due to femoral head eroding acetabulum

- restore hip centre by reaming medially

- then need to provide superolateral coverage

- autograft + mesh / allograft / DDH cup / tantalum


Crowe IV


Usually good bone stock in true acetabulum

- femoral head has not eroded bone

- recreate acetabulum and place small component

- use teardrop and fovea as landmarks




Crowe I/II


Minimal LLD

- sess femoral shortening required

- avoid excessive anteversion based on abnormal femoral neck

- otherwise get anterior instability and loss ER


Crowe III/IV


If greater than 4cm LLD

- need to shorten femur




Decreased tone

- Polio

- Down's syndrome

- spina bifida


Increased tone

- cerbral palsy

- Parkinson's






- case reports only


Down's Syndrome


Acetabular dysplasia not uncommon in this group




Kloschos et al JBJS Br 2002

- 6 patients

- 7 year follow up

- all doing well


Cerebral Palsy




- resection arthroplasty

- pelvic support osteotomy

- arthrodesis


THR offers best pain relief and function




Young patient

- abnormal muscle strength

- spasticity and contractures

- co-operation issues

- functional demand is low




Schroeder et al Int Orthop 2010

- 18 THR in ambulatory patients

- 10 year follow up

- 1 recurrent dislocation

- 3 aseptic loosenings


Parkinson's disease



- poor neurological status

- progressive worsening with dementia

- high risk dislocation




Weber Int Orthop 2002

- no dislocations in 58 primary THR for Parkinson's


Osteogenesis Imperfecta











Multiplanar deformity

- worsend by previous surgery

- may require osteotomy




Dysplasia often present

- not as severe as in DDH




Can be significant




Have been short for long time

- difficult to restore length

- may require trochanteric slide


Perthes OA previous osteotomyPerthes THR



Bilateral Severe Perthes Hip OABilateral Perthes THR





Migration of the femoral head past the medial wall of the acetabulum / ilioischial line 


Centre edge angle > 40o






Otto's Disease

- bilateral in one third

- middle aged females

- pain & decreased ROM early 

- coxa vara & OA common

- ? causally related to osteomalacia


Bilateral Hip Protrusio





- Paget's

- RA

- osteomalacia / OI

- fracture / central dislocation

- septic arthritis especially TB

- hemiarthroplasty

- Ankylosing Spondylitis 

- Marfan's syndrome, malignancy

- Neurofibromatosis


Charnley classification 1978


Defined medial wall of acetabulum as ilioischial line


Grade I  1-5mm                                Grade II  6-15 mm                            Grade III   >15 mm


Hip Protrusio Grade 1                                                               Hip Protrusio Grade 3


Eldstein & Murphy 1983


Medial wall is acetabular line & ilio-ischial line

- men acetabular line 2mm lateral to ilioischial line

- women 1mm medial to ilio-ischial line is normal


Grade Men Women  
I 3 - 8 mm 6 - 11 mm  
II 8 - 13 mm 12 - 17 mm  
III > 13 mm > 17 mm with fragmentation  



Inexorable progression of deformity

- axis of migration is same direction as joint reaction force in stance phase 




Medical Workup


Identify and treat any underlying cause





A.  Skeletally immature 


Triradiate fusion

- can combine with valgising osteotomy


Steel et al JPO 1996 

- 22 patients with Marfan's syndrome

- 12 of 19 restored to normal

- 4 improved

- 3 unchanged


B.  Young adult 


Valgising intertrochanteric femoral osteotomy (VITO)

- patient < 40, minimal OA 

- may delay THR for 10 years


Aim for 20-30° valgus correction

- if neck shaft angle is 130° aim for 155°

- trapezoid shortening to minimise LLD


Lateralization of femur to restore mechanical alignment


Require soft tissue release especially psoas


C.  Middle aged / elderly




THR Protrusio




Place hip center anatomically 


Restore joint biomechanics

- outcome depends on cup position

- adequacy of correction of the deformity & biomechanics correlates with long-term prosthetic survival

- medial joint positioning leads to high medial stresses




Ranawat JBJS Am 1980 

- 35 hips with protrusio secondary to RA

- 16 of 17 THR >10 mm from hip centre loosened

- 13 THR with <5 mm out good survival


Determine Hip Centre 


1.  Teardrop

- average 2 cm vertical & 4 cm horizontal from teardrop

- average coordinates reported in normal adults 14 mm vertical & 37 mm horizontal


Hip Protrusio Teardrop Method Centre Rotation


2.  Ranawat Method 


Hip Protrusio Ranawat Method Centre Rotation


Draw parallel horizontal lines at the levels of the iliac crests and ischial tuberosity and mark 3 points

- Point 1: 5mm lateral to intersection of Shenton's and Kohler's lines

- Point 2: located superior to point 1 by a distance 1/5 of the pelvic height

- Point 3: similar distance horizontally from vertical line


Isosceles triangle between 1/2/3 locates the acetabulum 

- line 2/3 through subchondral bone


Management Bone Defects


1.  Assess medial wall integrity with CT


Hip Protrusio CT Medial Wall IntactHip Protrusio CT Medial Wall Intact 2


2.  Algorithm / Ranawat J Arthroplasty 1986


A.  < 5mm - no graft required


Hip Protrusio Grade 1THR Protrusio Type 1


B.  > 5mm but medial wall intact - morcellised bone graft


Hip Protrusio Type 3THR Protrusio Medial Morcellised Bone Graft


C.  No medial wall - mesh / cage + morcellised bone graft





- template LLD (max 4cm)

- define acetabular defect with CT

- ensure intact medially




1.  Sciatic nerve is nearer the joint than normal

- identify and protect early


2.  Dislocation of the hip can be difficult

- femoral osteotomy in situ + femoral head removal piecemeal may be required

- trochanteric osteotomy may be required for exposure



- enlarge rim only

- avoid creating peripheral defect


Contained acetabular defect


Morcellised bone graft

- rim fit uncemented cup

- cemented cup


Uncontained acetabular defect


A.  Wire mesh / bone gaft / cemented cup

B.  Wafer bone graft / morcellised bone graft / cage / cemented cup



THR Primary

Background & Technique

IssuesTHR Uncemented





Bearing Surface

Head Size





Disabling hip pain

Severe functional impairment

Failed non operative management


Not Indicated 


Painless deformity






1° OA


2° (accounts for maybe 50% OA hip)


Secondary OA




Hip OA Post SUFEBilateral SUFEHip OA Post Sufe 2




DDH Crowe 1




Hip OA PerthesHip OA Perthes 2Hip OA Perthes 3Hip OA Perthes previous osteotomy




Hip OA post Acetabular FractureHip OA post displaced Acetabular FractureHip OA Post NOF FractureHip OA post subcapital fracture




Hip OA PagetsPagets Bone Scan  




HIp OA Bilateral AVN


Coxa Vara                                                                                                                     


Hip OA Coxa VaraHip OA Coxa Vara 2                                              




Hip OA Post Sepsis







1.  Five Absolute


Active infection


Flail / Neuromuscular impairment


Inadequate soft tissue cover


2.  Five Relative


Young patient

Heavy demand


Poor compliance

Poor mental state


Pre-op Evaluation



- mobility

- life expectancy

- fitness for anaesthetic - ardiopulmonary

- urinary status / TURP before THR

- teeth

- NSAID / aspirin / plavix / warfarin



- abductor strength


- contractures

- vascularity 

- check skin / scars


Medical workup



- DM / RA / Hemophilia / Marfan's etc


Beware difficult hip



Medical / Anaesthetic Review


CXR / ECG / FBC / UE / Coags / GP&H



- cease Aspirin / Warfarin

- steroids

- diabetic medications


Education & Advice


Informed consent

- infection


- blood transfusion


- dislocation

- fracture

- DVT / PE

- limp

- revision


Rehab starts pre-operatively

- home modifications

- discuss precautions (high chair, pillow at night)

- physio

- driving (usually not for 6 weeks)

- social worker / occupational therapy

- work arrangements








1.  AP pelvis / AP of hip showing proximal femur / Lateral


2.  Lower extremities internally rotated 15° to 20° 

- to allow proper offset templating

- can roll patient if severe OA


3.  Magnification marker

- most XR departments use bulky tray placed in compartment

- 2 inches below table top

- resulting in magnification of 15% to 20%

- degree of magnification directly related to distance from bone to cassette

- obese magnification can be > 25%

- thin patient can be < 15%




Component Position


Leg length 


Neck-shaft angle 


Femoral offset 


Degree of acetabular dysplasia 


Acetabular bone defects


CT scan


Hip OA previous Acetabular fractureHip OA CT Anterior wall discontinuousHip OA Posterior Wall Intact




Fixation - cemented v uncemented


Bearing surfaces


THR Technique



- on side on bed

- pressure area care / CPN / ulna nerve

- pelvis perpendicular to bed

- completely stable

- Charnley hip supports

- able to palpate both knees and feet for leg length

- small pillow between legs / comparable position

- saline bag under armpit

- TEDS / SCDs lower leg




Antibiotics at induction

- broad spectrum: first generation cephalosporin

- allergy: vancomycin / clindomycin

- repeat if operation longer than half life / 2 hours





- Posterior / Kocher-Langenbech

- Lateral / Hardinge

- Transtrochanteric / Charnley 

- Anterior / Smith Petersen




1.  Position of knees

- comparable position

- check LLD prior to incision

- aim to recreate equal LLD

- note:  adduction of superior leg will artificially shorten leg in this position


2.  Intra-operative

- pin in superior acetabulum

- mark on femur

- recheck with femur always in same position

- can measure LLD and offset





- anterior acetabular retractor / beware femoral nerve

- inferior acetabular retractor / beware obturator artery

- avoid posterior retractors / beware sciatic nerve



- remove labrum and capsule

- may need to remove curtain osteophytes

- define true floor with gouge at transverse notch 



- medialise initially to true floor

- medialisation decreases JRF

- to bleeding bone

- preserve anterior and posterior walls


Cemented cup

- ream 2 mm > cup size for cement mantle

- leave transverse ligament intact

- low viscosity cement / Palacos


Uncemented cup

- young ream 1 mm < cup size

- old ream 2 mm < cup size


Acetabular Orientation



- 40+/-10°

- 45o to bed



- 15 - 30°

- increase in posterior approach

- use pelvis as perpendicular to floor

- use inferior transverse ligament


Femoral Stem


Entry point

- bow chisel

- start lateral and posterior

- follow bow of femur

- pass reamers

- find centre of femur

- check not perforating femur 


Incremental increase in broaches



- until broach rotationally stable

- don't wash away good cancellous bone



- leave some cancellous bone

- allows cement interdigitation



- anatomical anteversion 15°

- neutral or slight valgus



- offset / neck length / head size / LLD / stability


Insert definitive component and retrial

- ensure stability / LLD

- apply definitive head



- irrigate to remove particles

- +/- drain

- pressure dressings


Post-operative Management


4 x doses broad spectrum antibiotics

Check Hb and electrolytes next day


Abduction Pillow - 6/52 nightime

TEDS / Compression - 6/52

Anticoagulation - 6/52


Early mobilisation with Physio


Precautions until pseuodocapsule forms

- no flexion >90°  6/52

- limit IR / adduction

- sit in high chair 6/52

- no driving / 6/52

Bearing Surfaces



The removal of material, with the generation of wear particles under an applied load and in relative motion


Tribology is the study of wear and lubrication


Wear mechanisms



- bonding of the surfaces when pressed together

- may pull away material from the weaker surface



- asperities on the harder surface cut and plough 

- remove materials from the softer surface



- repetitive local stresses exceed fatigue strength


Wear Modes


Mode 1

- from motion of two surfaces rubbing together

- as intended


Mode 2

- primary surface against a non intended secondary surface

- head eroded through poly and up against metal backing


Mode 3

- two primary surfaces with a third body

- roughens surface

- increases mode 1 wear


Mode 4

- two secondary surfaces / backside wear

- creates third bodies

- i.e. screw fretting or between liner and metal backing


Wear types


Linear Wear 

- radiographic change in thickness of socket at maximal point of wear  

- based on 2D Xray


Volumetric Wear 

- volume of particulate poly created

- calculated based on trigonometric formula

- in turn based on measured linear wear & square of radius of articulating head

- probably represents underestimation of actual volume of wear particles produced 


Now more sophisticated computer based systems more accurately estimate wear


Fluid-film lubrication


Completely separates surfaces

- when fluid film height is thicker than height of asperities on the surface

- decreases roughness

- decreases wear


Variables in amount of wear


Type of bearing surface 

Head size 

Acetabular orientation






Repeating chain of ethylene monomers



- low cost

- multiple options i.e. elevate rim

- high wear resistance

- no toxicity




Wear particles very bioactive


Factors in Poly wear


1.  Preparation of poly effects longevity 

A.  Machined from extruded polyethylene bar stock 

B.  Compression moulded directly from the polyethylene resin


2.  Sterilisation & Aging

A.  Surface treatment

- ethylene oxide gas

B  Gamma irradiation

- in vacuum causes cross linking which decreases wear

- in air get oxidation which increases wear


3.  Highly cross linked


Occurs when free radicals from a covalent bond between PE molecules



- improved wear resistance

- up to 95% wear reduction compared with normal poly

- ability to use larger head sizes

- normal liner must be 8 mm

- can decrease this thickness to allow larger heads



- decreased yield and tensile strength

- like ceramic, is more brittle with increased wear resistance



- ultra high molecular weight polyethylene


5.  Poly thickness


Thicker poly diminishes stresses in subchondral bone & within poly


Metal heads / CoCr


THR Metal on Poly


Ceramic heads on poly


THR Ceramic on Poly



- Alumina AL2O2

- Zirconia ZrO2



- more difficult to scratch

- reduce abrasive wear



- can be polished to lower surface roughness



- hydrophilic

- improved lubrication and lower friction



- 0.2 mm / yearr on 2D& 3D models

- may be reduced by 50% compared with metal on poly


Ceramic on ceramic




Highest wear resistance

- invitro 0.007mm3 / million cycles

- CoCr / poly 70-90mm3 / million cycles



- excellent lubrication



- can be highly polished


No toxicity




Position sensitivity


Liner chipping

- must take care during insertion


Fracture risk

- was a worldwide recall of zirconia heads in 2001

- due to unexpectedly high fracture rate in zirconia heads from one manufacturer

- now about 1 / 10 000


No hooded liner available


May need to revise ceramic with ceramic

- particles remaining may be hard than new bearing surgace




Trunion damage in revision

- new ceramic head may not lock to new trunion

- can use ceramic head with metal neck augment inside it


Metal on Metal


THR Metal on Metal




Popular in the 1960's

- McKee-Farrar replacements

- abandoned

- partly because of poorer results than Charnley low friction arthroplasty

- partly metal sensitivity concerns


Interest was aroused when it was noticed in some patents very good survival rates at 20 years and beyond

- discrepancy between some patients doing very poorly and some patients doing very well


Second generation design


Important concept of clearance


Difference in radius between the two surfaces

- reducing clearance and producing an exact fit is worse

- creates equatorial contact with cold welding and seizure


Prefer controlled clearance 0.06-0.1mm

- creates polar contact rather than equatorial contact


New machining far superior




Decrease wear


Reduced linear and volumetric wear

- initial run in perior then steady state

- linear wear < 0.003 mm / year



- increase smoothness

- thicker film

- polar bearing not circumferential


Strict control over manufacture essential

- early failures due to poor manufacturing




Very high wear resistance

- 1 / 60 of metal / poly


Large heads

- decreases dislocation / improves ROM / function




Increased ion levels


Serum / blood / RBC / urine increased levels Co & Cr

- up to 500 times the number of poly particles per year

- tends to decrease with time

- effects unknown


Best to measure serum levels in Nmols/l

- range for well functioning implant is 15 - 30 for Co and Cr

- increasing levels or levels several time normal of concern

- can imply a failing implant



- no evidence for this

- metal on metal follow up for 50 years (McKee-Fararr)


Delayed type hypersensitivity


Cause unknown

- lymphocyte reaction

- very rare (1/1000)

- may cause unexplained pain


Patient can get large inflammatory reaction

- can cause tissue destruction +++

- lose abuctors etc

- difficult salvage


AJR 7 years


Ceramic / Ceramic  3.9%

Metal / Poly             3.2%

Ceramic / Poly         4.1%

Metal / Metal           7.7% (Head sizes > 28mm)






Peak pressures during gait

- between heel strike and early mid stance

- increases in both JRF and abductor activity


Chair rising 

- triples pressures


Hip forces


Single Leg Stance / Free Body Diagram of the hip



- force exerted by the abductors

- balance effective body weight acting on the head of the femur

- equal magnitude, opposite direction


Abductor muscle force

- both a horizontal and a vertical component  

- assumed to be oriented at 30° with respect to a vertical axis

- this adds to the forces across the hip



- only G medius tension is calculated 

- a gross oversimplification

- need to consider G max. & other muscles

- ground reaction force is under calculated

- GRF recorded in prosthetic femur is much higher than FBD would suggest




Body weight during one-legged stance 

- 5/6 BW (1/6 BW is weight of leg patient standing on)

- effective body weight will act in a vertical direction


Single leg stance 3x BW

Walk ~4x BW

Jog~ 6x BW

Stumble ~9x BW


Adbuctor lurch


Shifting the body weight over the centre of the hip joint

- eliminating the need for the abductors to balance body weight

- reduce joint reaction force


Impact of walking aids


Walking with cane in contralateral hand

- analytical and in vivo studies 

- clearly shown reduces the joint force



- moment arm of the cane is much larger than that of the abductor muscles

- lower muscle forces are now required to balance the effective BW moment


Implications of rotational moments


Longitudinally and posteriorly directed loads

- most critical in generating stem fractures

- most fractures start at the anterolateral corner.


Posteriorly directed forces

- occur when the hip is flexed

- result in retroversion of the stem

- may play a significant part in loosening femoral stems


Clinical implications of hip joint geometry


Mechanical ability of the abductors are affected by

- head-neck angle

- neck length

- joint centre position



- recreate centre of rotation

- decrease JRF

- increase offset

- Increase abductor strength


Joint centre


Joint forces are minimized when the joint centre is moved medially, inferiorly, and anteriorly

- maximizes the moment-generating capacity of the abductors 


OA displaces femoral head laterally, superiorly, and posteriorly

- largest joint forces and moments are generated in this position


Lateral and distal joint centre 

- decreases the abductor's moment arm 

- therefore preventing contralateral pelvic drop now requires an increased muscle force

- increases the joint's compressive force


Superior joint centre

- inferior functional outcome

- decreased abductor strength

- loss of passive hip flexion

- can compensate with increased neck length   


Higher contact force / increased wear and loosening

- superior and lateral joint centre

- decreased femoral offset

- decreased abductor moment arms 


Head Neck Angle


Varus hip

- decreased head-neck angle 

- increases the mechanical advantage of the abductors

- therefore should minimise joint contact forces

- also improves stability with increased congruence


Valgus Stem

- decreased bending moment or shear on stem

- increased axial stem loading


If excessive

- increases knee valgus strain

- lengthens limb

- superior dislocation


Varus Stem

- increases shear on neck

- decreases axial loading


If excessive

- shortens femur

- increases dislocation


Neck length


Decreasing the neck length 

- similar to increasing the head-neck angle (valgus) 

- compromise the abductor function and increase the joint reaction force



Cemented Exeter Technique

Cemented cup and femur via posterior approachTHR Cemented Exeter


Set up

- on side

- charnley supports posterior on sacrum

- anteriorly on ASIS

- patient slightly tilted backwards

- avoids cup retroversion


Posterior Approach

- identify short ER

- open interval between G medius and piriformis with scissors, insert anterior retractor

- do the same with inferior aspect of quadratus

- diathermy all visible bleeders now

- 2 x stay sutures in short ER with 1 ethibond, clip and cut

- take off short ER and capsule with diathermy, superior radial cut in capsule to labrum

- dislocate hip

- second running stay suture in capsule with Ethibond



- release posterior capsule from short ER to mobilise better as flap for repair

- release superior capsule from labrum, also anterior capsule from labrum delicately with knife

- place specific Exeter anterior retractor

- divide inferior capsule delicately with diathermy, leave inferior transverse ligament intact

- place rolled swab here, place inferior retractor

- anterior retractor is tied to charnley support with weight and chain

- inferior retractor has weight attached, supported by assistant

- insert Norfolk-Norwich retractor superiorly




Remove labrum

- identify floor by removing osteophyte / reaming medially /  or can use 2.5 mm drill and measure floor depth

- ream in increased sized until fits in AP diameter

- need to remove all cortical bone, can do so with smaller reamer

- many drill holes required superiorly, this is the area where good interdigitation is critical and important

- drill holes in ischium and superior pubic rami as per charnley

- dry acetabulum with swabs and peroxide

- place reamings with spoon at inferior acetabular ligament and compress, this prevents cement leaking inferiorly

- trial cup, can use cup with peripheral poly lip to pressurise, cut to size

- insert ball of cement when no longer sticky

- compress till 5 minutes, twist pressuriser to remove

- dry blood with swab on a stick

- insert cup on insertion device

- place inferior cup first, medialise +++, then set closure and anteversion




THR Cemented Exeter Inferior Cement LeakTHR Cemented Cup Excessively OpenTHR Cemented Exeter Medial Cement Penetration


Femoral Stem



- held vertical by assistant

- fish mouth elevator to elevate femur

- gluteal retractor holds gluteals


Entry point

- box chisel

- start lateral and posterior

- follow bow of femur

- pass 2 x reamers

- find centre of femur

- check not perforating femur 


Incremental increase in broaches

- leave some cancellous bone

- allows cement interdigitation



- anatomical anteversion 15°

- in neutral or slight valgus

- >5° varus increases failure

- line up with patella as insert



- offset

- neck length

- head size

- check stability and LLD




1st generation 

- all by hand



- plug, lavage, retrograde fill   



- vacuum centrifuge, pressurisation 



- cement restrictor 1 cm beyond tip

(makes easier to get out if needed)

- wash cancellous bone with water

- H2O2 gauze (lyses RBC), suction

- vacuum centrifuge Abx impregnated high viscosity cement

- baby suction catheter

- retrograde filling with cement gun

- fill at 1 minute

- pressurisation til fat emerges (warn anaesthetist)

- slow insertion stem at 4 minutes, follow lateral wall

- clean cement away

- maintain constant pressure til hard



- ensure stability / LLD

- apply definitive head



- capsule and ER sutures passed through drill holes in GT

- use suture passer


Clinical History






Other joints / other specific


Interventions (surgery, physio, injections)


PMHx / PSHx / Meds / Allergies


Social History

- occupation

- dwelling

- smoking / alcohol




"What is your problem?"




Nature (Sharp or Dull)

Intensity (1-10)

Location - point for me?

Duration - how long?


- specific details of injury ?

- rest / night / start-up

Concomitant Factors 

- locking / clicking / swelling

Aggravating Factors

Relieving Factors


Pattern / frequency


Associated symptoms

- leg lengths

- stiffness


Causal factors 

- AVN -> steroids, alcohol, RTx / CTx

- RA / other inflammatory conditions

- CDH / DDH / SUFE / Perthes


Other joints


Knee / Back

Signs inflammatory condition


Functional Assessment


Lower limb (Modified Harris Hip Score)

1.  Shoes & socks

2.  Stick / Walking aid

3.  Limp

4.  Stairs

5.  Walking time/distance

6.  Public transport / In or out of Car?

7.  Run or Squat if young adult

8.  Prop at speed if sportsman


Little old lady gets out of bed, puts her shoes on, picks up her stick, & limps to the door

- climbs down the stairs, walks two blocks to the bus, & pushes over the jogger doing squats



"What can't you do that you used to be able to do?"


1.  Occupational

2.  Recreational - sports, hobbies

3.  ADL's

- recreational

- showering / toileting / cooking / shopping








Lifestyle modification

- weight loss




Orthotics - stick



- symptomatic (NSAIDS, narcotics)

- disease modifying (steroids, anti-rheumatoid)







Cemented Acetabulum

IndicationsTHR Cemented Acetabulum


Neoplastic / metastatic

Severe osteoporosis






- longevity directly related to quality of cement penetration into acetabulum




Reflection all Poly (S&N)

Exeter all Poly (Stryker)

Zimmer ZCA


Cemented ZCA cup




Retrieval studies from successful THR's

- fibrous membrane found at least in part

- begins at periphery of bone-cement interface 

- mechanical testing shows the most stable are those with least membrane


Metal Backing


Theory that more rigid implant construct could more evenly distribute stresses to surrounding acetabulum 

- cement & subchondral bone would be protected from fatigue failure


Actually perform poorly compared with all poly

- reasons for inferior clinical outcomes not well understood

- accelerated wear of polyethylene suggested as cause




Process of loosening may be result of cellular rather than mechanical process

- determined by host reaction to polyethylene debris



- obvious migration in comparison previous films

- cement mantle fracture

- progressive > 2 mm lucency cement / poly interface

(c.f. cement-bone interface)


Charnley & De Lee - 3 zones

1 - superior 1/3

2 - middle 1/3

3 - inferior 1/3


Cemented Cup 3 Zone LysisCemented Cup Lysis Zone 1




AJR 2010


9 year


Exeter / Contemporary   6.0%

Exeter / Exeter              4.9%

Spectron Reflection        9.0%

MS30 / Low Profile Cup  1.7%


CPT / ZCA 7 year            %2.9



Cemented Femur

THR Cemented Femur

Goals in femoral cementing


Optimize cement-bone interface

Cement mantle free of defects

Minimum 2 mm thickness

Femoral component centred in cement mantle




Swedish Joint Registry


Reflection All Poly / Spectron 92% 10 year


Exeter All Poly / Exeter 93% 14 year




1.  Polished

- Ra less than 1 micrometer

- polished stems create little abrasion

- allow subsidence and keep cement in compressive loading 


2.  Matte 

- Ra less than 2 micrometer

- matte finish will not create excessive abrasion unless stem allows large micromotion 

- allows some mechanical interlock with cement


3.  Rough 

- Ra greater than 2 micrometer

-  expected to cause excessive abrasion


Studies have shown increase aseptic loosening and revision rate with matte finish

- failed ~10% at 10 years

- c.f. 4% at 20 years for polished




Creep is time dependent deformation

- creep of cement is related to age

- creep at 1 day is 3.25 x at 7 days

- creep allows stabilization

- cycles of creep, followed by stress relaxation leads to stem subsidence in the mantle

- Matte finish prevented subsidence




Controversy exists over the use of collared prosthesis

- results in increased load transfer from implant to proximal femur compared to collarless implants


A.  May reduce stress shielding of proximal femur & reduce strain in proximal medial cement mantle


B.  Prevents subsidence


Exeter stem 


Behaves as a Morse taper in the cement mantle

- transmits both torsional & compressive loads

- generates hoop stresses in the cement which allows it to expand slightly




1.  Smooth polished surface

- no sites of stress concentration


2.  Broader laterally than medially 

- helps to diffuse the compressive stress medially 


3.  Tapered shape from proximal to distal 

- allows controlled subsidence within the cement column; 


4.  Cobalt-chromium alloy stems 

- are used in most stems

- generate less particulate debris than titanium implants


5.  Triple taper concept

- femoral component tapers to a point in both the AP and lateral planes

- in addition, the stem is more narrow medially and widens laterally


Advantage low porosity cement

- Cement fails in fatigue

- Centrifugation decreases pore size in cement 

- approximately 200 to 400 nm in diameter 

- results in an increase in cross-sectional area

- 25% increase in ultimate tensile strain 

- 125% increase in tension-compression fatigue strength  

- Similar benefits demonstrated with vacuum mixing


Cement Issues


Cement viscosity

- in vitro and in vivo tests 

- structural superiority of high viscosity over low viscosity cement

- i.e. Simplex (highly viscous) v Palacos (low viscosity)



- strength of cement-bone interface directly related to depth of penetration of cement into bone

- pressurization increases penetration



- achieve more uniform cement mantle 

- especially zone 5 & 6


Cement Mantle


Ideal cement mantle thickness has not been defined

- autopsy studies - crack incidence greatest when mantle < 2 mm

- issues with the varus stem


Varus stem 

- associated with higher incidence of aseptic loosening

- results in thin or nonexistent cement mantle in proximal medial & distal lateral zones



- in relatively small doses effect on mechanical characteristics of PMMA negligible

- must be heat labile

- vancomycin / tobramycin / gentamicin


Cementing techniques



- finger-packing doughy cement 

- no cement restrictor



- cement restrictor

- cleaning with pulsatile lavage  

- cement inserted retrograde using cement gun 



- vacuum centrifuge (reduce porosity)

- pressurization of cement mantle 

- surface modifications on implants 



- stem centralization proximal & distally

- ensure adequate & symmetric cement mantle


Barrack grading system for cement technique


Aseptic loosening correlates with cement technique


A. Complete filling of proximal portion of diaphysis 

- difficult to distinguish cortex from cement

- commonly referred to as "white-out"


THR Type 1 Cemented Femur


B. Near complete filling of diaphysis 

- can distinguish cortex from cement in some areas


Type 2 Cemented Femur


C. Divided into C1 & C2



- Incomplete cement mantle in proximal portion

- > 50% of cement-bone interface demonstrates radiolucencies


THR Type 3 Cemented Femur



- Mantle < 1 mm thick or metal is up against bone


THR Type 3b Cemented Femur


D. Cement mantle with gross deficiencies 

- no cement below the stem, major defects in the mantle, or multiple large voids in the mantle





- need for revision surgery

- clinical failure (a painful arthroplasty)

- radiographic failure (loose implant)


Mechanisms of Failure


Mechanical factors

- debonding between stem & cement initially occurs at cement-metal interface

- produces high peak stresses in cement mantle proximally & near distal tip of stem 

- initiates cement cracks esp areas of thin cement / adjacent to mantle defects / pores initiate & propagate 


Biologic processes 

- then become more important

- particulate polymeric debris gains access to endosteal bone

- stimulates foreign-body reaction 

- bone resorption with fibrous tissue membrane beginning at pseudo-capsule extending along cement-bone interface


Harris Categories 


"Definitely loose"

- migration of prosthesis

- cement mantle fracture


Cemented Femur Definitely Loose


"Probably loose" 

- continuous radiolucent line at cement-implant


Cemented Femur Probably Loose


"Possibly loose" 

- radiolucent line cement - bone


Cemented Femur Possibly Loose


Autopsy studies 


Radiolucencies most commonly related to skeletal remodelling

- not to the formation of soft-tissue membrane between cement & bone

- inner cortex commonly forms adjacent to cement mantle

- not distinguishable from cement on Xray

- 2nd medullary canal forms between inner & outer cortex 

- appears as radiolucency on Xray

- non-progressive


Uncemented Acetabulum

GoalTHR Uncemented


Initial mechanical stability

- adequacy of locking between component and bone


Need initial press fit for mechanical stability

Long term require biological fixation




Can change liner

- multiple revision options i.e. for dislocation


Simple to remove

- Zimmer Xplant




1.   Smooth

- relied on mechanical interlock for stability and long term fixation

- unacceptable early revision rates

- initial press fit, but no biological fixation


2.  Threaded

- universally bad results

- due to small contact area between bone and implant


3.  Smooth HA coated

- improved but still inferior results


4.  Porous coated

- allows ingrowth

- much better results compared to smooth components

- titanium or HA


5.  Hemispherical

- oversized cup

- initial press fit


6.  Flattened hemispherical

- rim fit




1.  Material must be biocompatible

- titanium mesh

- cobalt chromium beads

- HA

- all of these materials have been shown to be adequate provided pore size is correct


2.  Surface must have optimal pore size

- between 100 and 400um


3.  Component must be placed in intimate contact with viable host bone


Press fit

- < 0.5 mm gaps 

- require tight peripheral press fit with complete seating

- maximises surface are available for ingrowth

- maximises area for stress transfer



- 1-2 mm underream

- risks are acetabular fracture and underseating


Acetabular Underseating


4.  Adequate initial stability to allow reliable ingrowth

- micromotion > 40 um generates fibrous tissue 



- press fit with supplemental screw fixation

- line to line reaming with supplemental screws

- spikes

- pegs


Supplemental screw fixation

- 2 x bicortical screws

- provide similar stability as press fit


Uncemented Cup with screws


Screw problems

- can get backside wear / fretting

- holes can provide route for particle wear


Technique Uncemented Cup


Centre reamer in desired hemisphere of acetabulum

- begin 6 - 10 mm below templated size (44)

- medialise initially

- remainder reaming in direction of final component position

- 45o abduction

- 20 - 30o abduction

- increase until contact anterior and posterior

- AP diameter is what determines cup size

- petechial bleeding

- don't take away all subchondral bone

- continually assess posterior / anterior walls - must preserve


Can bone graft base and reverse ream

- especially with flattened hemisphere


Insert component 1 - 2 mm larger

- ensure seating (remove insertion handle and probe base)

- ensure stability

- add screws if any doubt


Screw placement


 Acetabulum Wasielewski Safe Zones


Wasielewski et al JBJS 1990

- anatomical cadaveric study

- line ASIS to centre acetabulum & ischial tuberosity

- line perpendicular to this 

- four quadrants 

- safe quadrants = 2 posterior quadrants

- posterior screws do not emerge within pelvis


Structures at risk


AS quadrant

- external iliac vein > artery

- vessels can be within 0.5 cm of the inner cortex of the pelvis

- become closer with increasing age

- in the anterior quadrants 25mm screws often too large


AI quadrant

- obturator nerve & vessels

- femoral artery 


PS quadrant

- sciatic nerve / superior gluteal nerve & vessels in danger at greater sciatic notch

- aim screw between 2 cortices of ilium

- direct towards SIJ

- can tolerate 85 mm


PI quadrant

- internal pudenal vessels

- inferior gluteal nerve & vessels

- maximum screw length is 25 mm




Acetabular fracture


Increased risk

- > 2 mm underream

- acetabular sizes < 52

- elderly (consider line to line reaming and use of screws, or use cement)



- screws

- posterior column plating

- cage


THR Uncemented Cup Acetabular Fracture


Failure of liner fixation / acetabular fixation


Acetabular spin out

- insufficient initial fixation

- failure biological fixation


THR Uncemented Cup Spin out


Liner spin out

- must ensure fixation method is sufficiently engaged


Errant Screw placement


Anterior quadrants

- can cause catastrophic haemorrhage



- angiogram  / embolism

- laparotomy / pelvic packing




Loosening Uncemented Cup


Can be very difficult to identify with uncemented acetabulum





Uncemented Femur

GoalTHR Uncemented


Initial press fit

- implant geometry fits the cortical bone in the proximal femur

- good initial mechanical stability


Biological fixation for success

- good press fit

- minimal micromotion

- bony or fibrous tissue ingrowth or ongrowth



- avoidance adverse stem bone stiffness ratios

- fixation surface that provides a transitional stress transfer from the proximal femur to the diaphysis

- avoid extreme stress shielding or excessive rigidity


Press fit


True Press-Fit in Bone 


Bone is a viscoelastic material

- implies that its elastic recoil will become less with time

- the amount that bone will "creep" or undergo stress-relaxation depends on its density

- cortical bone has less viscoelastic behavior than cancellous bone

- the fact that bone will relax and lose elasticity over time limits the amount of time over which a true press-fit can be maintained in bone

- once the initial press-fit dissipates,a prosthesis may move under load in the bone and either re-establish a press-fit or become loose


Non porous coated uncemented implants are commonly referred to as press fit implants




Proximal metaphyseal filling

- curved, anatomic stem

- most common

- tight proximal fit


Distal isthmus filling

- straight stem

- used more commonly in revision


Techniques of Initial Fixation


Definition Rigid Fixation

- micromotion <150 microns

- ideal 50-100


A.  'Press fit' (1-2mm undersized) technique

- bone expands around prosthesis

- generates hoop stresses

- femur and acetabulum


B.  Line to line fit

- bone is prepared to same size as implant

- extensive porous coating with stem




Stove pipe femurs (Dorr < 0.75)

Poor bone stock


Proximal femoral geometry / Dorr calcar-to-canal ratio


Important if considering uncemented prosthesis


3 types - 501's, Stove pipe, Flares

- measure canal at LT & 10cm below 

- inner diameter at midportion of LT divided by diameter 10 cm distal

- must be <75% for uncemented prosthesis


Type A 

- ratio < 0.5 

- cortices seen on both AP & lat

- most amenable to uncemented component


Dorr A Femur


Type B 

- between 0.5 and 0.75 

- thinning of post cortex on lateral

- intermediate


Dorr B Femur


Type C 

- > 0.75 

- thinning of cortices on both views 

- "stovepipe" femur

- favours use of cemented stem


Biologic fixation


Two types


1.  Ingrowth 

- porous coating

- HA coated

- combinations


2.  Ongrowth 

- grit blasted

- increases roughness

- typically needs to be entire surface 




Pore size

- optimum pore size 50-350 microns (ideal 50-150)



- 40-50%


Pore depth

- deeper pores better

- increased shear strength with loading


Mechanism of porous coating


Titanium plasma sprayed

- often used to create pores

- then covered with HA to supplement


Tricalcium phosphate

- also used


HA coating

- sprayed on as a porous coating

- osteoconductive

- surface dissolution to Ca and Phosphate

- stimulates osteoblasts


Extent of Porous coating


Complete / incomplete

- both proximal and distal fixation are important

- is a trade off between fixation and shielding


Extensively coated implants

- improve likelihood of solid fixation

- distal loading of bone

- get mainly diaphyseal spot welding

- increase proximal stress shielding

- same problem with cemented implants


Femur Fully Coated Proximal Shielding


Proximal porous coating

- proximal loading of bone

- minimises proximal shielding

- more common






Want less rigidity to minimise stress shielding


Stiffness related to 

- modulus

- fourth power of the stem radius

- solid v slotted / fluted stems


Young's modulus of Elasticity


Bone 12

Titanium 117

Cobalt-chromium 210


Minimise rigidity


1.  Titanium alloy v cobalt chromium

- less structural rigidity

- lower modulus of elasticity

- 2 - 3 x less stiff


2.  Implant size

- as size increases, rigidity increases


3.  Design

- some stems have a coronal slot to decrease rigidity




Engh et al categories


1.  Osseointegration

2.  Stable Fibrous ingrowth

3.  Unstable fixation


A.  Signs of osteo-integration


Take 1 year to see


1.  Spot welds

- densification of endosteal bone

- usually in the region of termination of the porous coating on the implant


THR Spot Weld


2.  Absence of any radiodense reactive lines

- may occur around the smooth portion of the implant

- this is where bone ingrowth is not expected to occur

- they should not be present adjacent to the porous coating


3.  Calcar atrophy

- this change is sometimes subtle


4.  Increased cancellous density / cortical hypertrophy distal to the coated region


B.  Failed bone ingrowth / successful stabilization by fibrous tissue ingrowth 


1. Parallel Sclerotic lines 

- remodelling signs around the porous surface 


2.  Less atrophy of the medial femoral neck


2.  No progressive migration 


3.  No local cortical hypertrophy / spot welding


C. Signs of frank implant instability 


1.  Component migration

- usually by subsidence and varus tilt


2. Progressive luceny on serial radiographs


3.  Development of inferior pedestal


THR Subsidence Uncemented Component





- slow careful insertion / make sure is advancing with each blow

- can prevent or treat with cerclage wire

- assess stability

- revert to cemented stem if unable to obtain stability with press fit


Uncemented Femur Intraoperative Fracture


Thigh pain




1.  Initial instability (lack of press fit)

2.  Failed bony ingrowth / Late instability

3.  Micromotion at distal stem

- disadvantage of proximal coating

- will usually resolve over 2 years

- only 1% severe pain

4.  Mismatch modulus of elasticity

- lower with titanium

- tend to have lower incidence of thigh pain

- smaller stems

5.  Osteoporotic bone



- can cerclage wire cortical strut grafts

- improve bony rigidity over distal stem


Stress shielding


Most common with distal press fit / fixation


THR Proximal Stress Shielding



Head size

THR Large Head





Normal feel of hip

Increased ROM




Large head

- increase volumetric wear

- less penetrative / linear  wear


Small head

- increased linear wear

- decreased volumetric wear


Livermore's studies showed

- 32mm highest volumetric wear

- 22mm highest linear wear

- determined 28 mm optimal size


High volumetric wear in metal on poly generates high levels of particles stimulating osteolysis




Head size affects dislocation because of two variables


1.  Primary arc range


Distance head can move before impinging and levering out


Increase by

A.  Increasing head:neck ratio - increases the primary arc range

B.  Tapering neck

C.  Modifying rim of cup


2.  Excursion distance


The distance the head must travel in order to dislocate once the neck begins to impinge

- jump distance

- half head diameter




Large head size does not exclude dislocation


THR Dislocated Birmingham


Methods to increase head size


Ceramic on ceramic

- size currently limited

- maximum is 36 mm alumina heads


Metal on metal

- potentially decrease wear with increased size

- due to improved fluid film and boundary lubrication


Australian Joint Registry 2010

- increased revision rates with metal on metal

- most evident with larger sizes > 32 mm

- many company's prosthesis, not just one

- especially in females and younger patients


Metal on highly cross linked poly

- increased wear resistance

- can use thinner liners

- able to use larger heads







The perpendicular distance from the centre of the femoral head to the long axis of the femur


Harris 1992

- aim for supra-physiologic offset 

- avoid making offset less than original at all costs & makes longer if possible


Soft tissue balancing equals restoring femoral offset


Effect of short offset


1.  Abductor lurch / Trendelenburg gait

2.  Increased JRF / increased wear rates

3.  Weak abduction increases O2 consumption

4.  Impingement

5.  Lax soft tiiues can cause dislocation


Decreased offset leaves the abductors lax  

- doing so means they have to act with increased force

- increases the joint reaction forces across the hip.

- rsult of this is increased wear rates


Sakalkale et al Clin Orthop 2001

- 17 patients bilateral THR

- one STD, one high offset

- liner wear 0.21mm c.f. 0.01 mm /year


Increased offset



- decreases JRF

- tightens lax abductors



- theoretical increase in torque forces on stem and cement in flexion

- cadaver studies demonstrate increased offset doesn't increase torque forces on cement & bone

- torque increased in the stem but it is below the fatigue threshold modern stems


Factors affecting offset

- neck shaft angle

- head neck length

- anteversion

- femoral osteotomy level

- position of acetabulum


How to increase offset


1. Decreasing neck shaft angle

- more varus neck shaft angle

- increases torque on implant


2. Increasing Head /  Neck length

- improves abductor tension

- worsens LLD


3.  Medialising femoral neck whilst lengthening femoral neck

- technique in high offset stems

- maintains neck shaft angle


4.  Advancing GT

- increases abductor offset


5.  Acetabular component


Lateralised liners

- increase offset whilst preserving leg length

- can worsen body weight lever arm

- do so only when increasing femoral offset insufficient


Medialising centre of rotation

- decreases offset


Checking Soft Tissue Tension and Offset


1.  Preoperative templating

- normal side

- aiming to reproduce normal biomechanics


A.  Limb length

B.  Acetabular component

C.  Femoral component


2. Intraoperative measurement


Measurement jigs

- 2 fixed reference points

- limb in consistent position

- measure length and offset

- usually pin in supra-acetabular area

- second in GT


3.  Intraoperative maneuvers


Shuck test

- distraction of hip joint with in line traction


Dropkick test

- hip extended, bend knee to 90o

- if too tight, RF is taut and passively extends the knee


Leg to leg comparison

- feel knees when legs is similar positions

- feel tension of abductors



- external rotation in extension

- flexion




AimTHR Templating


Reproduce the normal anatomical centre of rotation

Restore femoral offset 

Maintain equal leg lengths 


Usually template off normal hip




1. LLD

2. Offset

3. Femoral component

4. Acetabular component

5. Osteotomy / femoral seating




AP pelvis

- hips internally rotated 10-15o

- accounts for anteversion

- allows true neck shaft angle

- otherwise will underestimate true femoral offset


AP centred femoral head


Lateral hip joint

- used for planning location of proximal femoral opening in the piriformis fossa



- product of distance between pelvis and film

- increased in obese patients

- less in thin patients

- can use magnification marker which is know to be 10 cm


Leg Length


1.  Horizontal line through two points at inferior aspect of ischial tuberosities

- compare to lesser tuberosity


THR Minimal LLD Template


2.  Acetabular teardrop

- vertical line to centre of femoral head

- calculate difference

- multiply by 0.8 to account for 20% magnification


THR Template Severe LLD


Tear drop more reliable

- less affected by rotation

- closer to centre of rotation of hip


Note: ensure one femur is not abducted, adducted


Acetabular component


THR Template Acetabulum


Always template before femoral component

- establish centre of rotation




Establish landmarks

- line through teardrops

- ilioischial line

- superolateral margin of acetabulum



- apex just lateral to the teardrop

- medial border just lateral to ilioischial line



- 45o relative to horizontal plane

- 20o anteversion on lateral x-ray

- sufficient superolateral cover

- reproduce any uncovering intra-operatively


Mark centre of rotation


Specific cases


1. Protrusio

- template to teardrop and ilioischial line

- ream only to obtain adequate peripheral support

- calculate amount of medial bone graft


2.  Medial osteophytes / lateralised cup

- again template from teardrop / ilioischial line

- ream medially

- ensure same amount of superolateral coverage as with templating


3.  Dysplastic acetabulum

- insufficient acetabular coverage

- superolateral migration of femoral head

- restore hip centre

- calculate SL uncoverage

- if sufficient posterior wall and only uncovered anterolateral bone graft not required

- otherwise augment with femoral head / high hip centre / augmented cups


Femoral component


THR Template Femur



- template size

- calculate LLD / neck cut

- restore offset



- AP with femur internally rotated 20o

- puts true neck shaft angle in plane of film


Component size



- 2 mm cement mantle



A.  Proximal coated / metaphyseal fit

- optimal medial and lateral endosteal cortical fit of proximal femur

B.  Fully porous coated

- optimal endosteal contact in diaphyses

- 4-5cm of scratch fit


LLD / Femoral Osteotomy


Calculate LLD

- place centre of femoral component measured amount above centre rotation

- mark neck cut




If femoral head medial to centre of rotation

- offset is increased and this will decrease JRF


If femoral head lateral to centre of rotation

- offset is decreased / avoid




Trochanteric Osteotomy



1.  Standard trochanteric osteotomy

2.  Sliding trochanteric osteotomy

3.  Extended trochanteric osteotomy


Standard Trochanteric osteotomy


Standard Trochanteric OsteotomyStandard GT Osteotomy Wire Fixation



- detach GT with only abductors attached



- increasing exposure to acetabulum in difficult cases

- retensioning abductors



- difficulty fixation / unstable

- most hip surgeons now use sliding osteotomy



- detach proximal attachment of vastus lateralis

- pass retractor deep to G medius / minimus and superficial to capsule

- saw osteotomy from lateral aspect of GT angled up towards retractor

- detach any short external rotators and reflect superiorly



- 3 - 4 intraosseous wires

- claw plate


GT Osteotomy Plate Fixation


Modification / Chevron Osteotomy

- increased stability

- decreased non union



- non union

- migration

- wire breakage / painful hardware


GT Osteotomy Broken WiresGT Osteotomy Broken WireGT Osteotomy Failed Plate


Trochanteric Slide



- PA osteotomy

- vastus lateralis and G medius left attached to fragment

- fragment retracted anteriorly



- increased inherent stability

- vastus lateralis prevents proximal migration



- retractor superiorly deep to minimus and superior to capsule

- posterior elevation of vastus lateralis

- retractor under vastus lateralis insertion

- oscillating saw anterior to posterior



- wires

- grip plate


Extended Trochanteric osteotomy




Osteotomy lateral 1/3 to 1/2 of trochanter & femur

- posterior to anterior longitudinal cut

- short distal transverse cut

- levers / hinges open anteriorly

- maintains anterior vasculature / muscle attachment



1.  Aid exposure
2.  Removal cement (especially infection)
3.  Removal well fixed uncemented prosthesis
4.  Removal cement plug / bone very poor / risk of perforation high
5.  Abnormalities of the proximal femur

Contraindications / Relative

1.  Impaction bone grafting
2.  Cementing revision prosthesis


Technique ETO

- measured from tip GT
- 2 – 15 cm long

- determined from preoperative template
- need to preserve diaphysis if using distal press fit uncemented stem

- usually after implant removal
- may not be possible

- elevate vas lateralis forward
- expose linea aspera
- expose posterior femur

- use drill holes to mark osteotomy

- drill both cortices
- thin oscillating saw
- cut down through anterior and posterior femur in line with GT
- through both cortices
- transverse cut distally through 1/3 diameter
- lever open

- 3 x cerclage cables
- protect sciatic nerve / palpate / pass wires posterior to anterior
- submuscular



98 – 100% union rate by 6/12



THR Resurfacing

ConceptBirmingham Hip Resurfacing



- removal of femoral head cartilage

- resurfacing with metal

- cemented / uncemented



- standard technique


Bearing surface

- metal on metal




Relatively young man (40 - 50)



Absolute Contra-indications


Severe bone loss femoral head

Large femoral neck cyst

Small acetabulum


Relative Contra-indications



Age > 65

BMI > 35






AVN femoral head


Advantages (many theoretical)


1.  Bone preservation

- preserves femoral bone stock

- however makes acetabular preparation more difficult


2.  Improved stress transfer to proximal femur

- less proximal stress shielding

- improved proximal bone density


3.  Reduced dislocation rates

- heads 36-54 have reduced rates compared with 22-32

- can occur though if poor technique or component loosening


Dislocated Birmingham Hip ResurfacingDislocated Birmingham Resurfacing


4.  Better kinetics

- faster walking speeds

- may be better ROM

- possible better proprioception

- may be element of selection bias (i.e. is done in younger, fitter patients)


4.  Easier revision of femoral component

- better bone stock

- simply recut and use stem


6.  Possible improved longetivity

- very low wear rates metal on metal




1.  Poor modularity

- difficult to adjust LLD

- difficult to adjust offset

- patients with very abnormal abnormality better off with conventional THA


2.  Not suitable for elderly / poor bone stock

- increased risk femoral neck fracture


3.  Femoral neck fracture



4.  Metal ions

- in serum, RBC, urine



- risk metal sensitivity

- risk carcinogenesis / teratogenesis

- CI in woman of child bearing age


5.  Loosening




Femoral Neck Fracture


Incidence 0-4%

- 1.5% in a study of 3500 BHR in Australia (JBJS Br 2005)

- early in learning curve

- early in prosthesis life


Risk Factors

- decreased bone mass / osteoporosis

- elderly

- inflammatory arthritis

- females (risk x2)(AJR)

- femoral head and neck cysts

- femoral neck notching

- varus femoral component (< 130o neck shaft angle)

- cup impingement on neck

- improper implant seating

- AVN femoral Head


BHR femoral neck notchingBHR Femoral Neck Notching 2



- relatively simple

- recut neck

- femoral implant with large metal head


Revision BHR


Early loosening




Initially due to poor early manufacturing

- decreased clearance

- inadequate polar bearing

- increased peripheral bearing, seizing, cold welding and loosening


Modern machining

- small surface asperities

- improved fluid film lubrication

- polar bearing with small clearances

- very low wear and little particle production




A.  Oversized heads / notching


BHR Oversized Femoral HeadBHR Loosening


B.  Varus Femoral Component


BHR Valgus v Varus Femoral Component


C.  Femoral head AVN


Due to extensive releases required to expose / surgically dislocate femoral head


BHR Femoral Head AVN


D.  Open Acetabular Component


Theorised to cause point loading

- increased metal wear

- best to close cup


BHR Open v Closed Acetabular Component


E.  Other


BHR Acetabular Component Protrusio


Australian Joint Registry 2010


13 300 procedures


Best outcome

- male < 65 with OA

- able to get > 50 mm head size

- 3.9% 9 year


Revision rate



- 7.2% 9 years for OA


Birmingham Resurfacing

- 6.2% 9 year


Reasons for revision

- fracture 36%

- loosening 33%

- metal sensitivity 7%


Revision by diagnosis 7 years

- OA 5.8%

- DDH 14%

- AVN 6%


Revision by prosthesis

- BHR 96.5% 5 year


Revision by age 7 years

- < 55     5.6%

- 55 - 64  5.8%

- > 65     7.3%


Revision by sex 7 years

- male 4.5%

- female 9.3%


Revision by head size 7 years

- < 44mm:    13.8%

- 45 - 49mm: 8.8%

- 50 - 54mm: 3.7%

- > 55mm:     2.2%

THR Revision

A Osteolysis and Loosening

DefinitionRevision THR Osteolysis


Biological response to particulate matter

- characterised by periprosthetic osteolysis

- stimulated by wear debris

- debris gains access to any area accessible by fluid


Sources of particulate debris


1.  Wear


Mechanisms of wear

A.  Adhesion

B.  Abrasion

C.  Fatigue


Modes of wear


1.  Motion between 2 surfaces designed for motion

2.  Primary bearing surface against an non intended bearing surface

- i.e. femoral head against acetabular shell when liner has worn out

3.  Interposed third body particles i.e. bone or cement

4.  Two non bearing surfaces together i.e. back sided fretting, morse taper fretting, screws


2.  Corrosion


Electrochemical process releasing metal ions

- modular interfaces i.e. head neck

- metal on metal bearings


Types of wear particles




Cobalt alloy

Titanium alloy


Morphology of wear particles


Usually less than 1um in size


Biological response to wear particles


Small particles phagocytosed by macrophages

- unable to digest

- stimulate release of cytotoxic factors


- aggregates more macrophages

- release TNF, IL1, IL6, PGE2

- stimulated osteoclastic bone resorption


Poly wear


THR Poly WearTHR Eccentric Poly Wear


Lucent Zones


Gruen Zones


Femur:  Gruen Zones


AP 1-7

Zone 1:   Greater trochanter

Zone 4:   Tip

Zone 7:   Lesser trochanter


Lateral 8-14

Zone 8:   Anterior-superior

Zone 11: Tip

Zone 14: Posterior-superior


Charnley Zones


Acetabulum: Charnley Zones


Zone 1:  Superior 1/3

Zone 2:  Middle 1/3

Zone 3:  Inferior 1/3






1.  Easier to identify loosening in femur than acetabulum

- femur 90% accuracy

- acetabulum 65% accuracy


2.  More difficult to identify in uncemented prosthesis


3.  Lucent lines don't necessarily represent problem

- may be present in well-fixed prosthesis (retrieval studies)

- often due to remodelling 


Cemented Femur


Signs of cemented femoral component loosening

O'Neil & Harris JBJS Am'84


1.  Possible


Bone-cement lucency < 50% total

- may be due to poor cementing technique

- loosening if progressive


Cemented Femur Possible Loose


2.  Probable


Cement-implant radiolucent line >2mm wide

- progressive


Cemented Femur Probably Loose


3.  Definite


1.  Cement fracture

2.  Femoral stem fracture

3.  New lucency cement - implant interface

4.  Stem migration 


THR Probably LooseTHR Exeter Stem Fracture


A.  Subsidence

- 1-2 mm normal in first year

- > 5 mm abnormal

- measure from tip GT to head neck junction


B.  Medial midstem pivot

- pivots about midstem

- proximal medial, distal lateral

- poor cement superomedial or inferolateral


C.  Calcar pivot / bending cantilever

- distal fix strong, but proximally loose

- breakdown of proximal cement

- bone destruction


Uncemented femur


Engh classification


Types based on presence of radiolucent lines (RLL)


I.  Stable bony ingrowth


Take one year to see

A.  Spot welds at end of porous coating

B.  Absence of RLL next to porous coating

- may have RLL next to non porous coated areas

C.  Calcar atrophy secondary to stress shielding


THR Uncemented Proximal Stress ShieldingTHR Uncemented Stem Spot Weld APTHR Uncemented Stem Spot Weld Lateral


II Stable fibrous ingrowth

A.  No spot welds

B.  Parallel sclerotic lines / RLL about porous coating

C.  No migration


THR Uncemented Stem Stable sclerotic lines


III Unstable fibrous ingrowth

A.  Component migration

B.  Progressive increase RLL

- divergent RLL

C.  Pedestal formation (bony hypertrophy at tip)


THR Uncemented Subsidence


Uncemented Acetabular Component




Bone ingrowth into component averages only 12% 

- even with 84% bone contact


Non continuous radiolucent lines 

- commonly found in press fit acetabular components 

- are often not progressive


Radiographic signs of ingrowth fixation


Moore et al CORR 2006

- 3 or more 97% stable

- 2 or less, 83% unstable


Five signs

- absence of radiolucent lines

- presence of a superolateral buttress

- medial bone stress-shielding

- radial trabeculae

- inferomedial buttress


THR Uncemented Cup Superolateral Buttress 2


Radiographic signs of loosening


5 signs

- radiolucent lines that appear after two years

- progression of radiolucent lines after two years

- radiolucent lines in all three zones

- radiolucent lines 2 mm or wider in any zone

- migration > 2mm


Loose Uncemented CupLoose Uncemented Cup 2


Engh Classification


I  Osse-ointegration



B  One RLL zone 1 or 2

C  RLL zones 1 & 2


THR Uncemented Cup Stable RLL Zone 1Uncemented Cup No RLL


II Stable fibrous ingrowth

- <2mm zone 3


Uncemented Cup Stable Fibrous Ingrowth


III Unstable fibrous ingrowth

- >2mm RLL in zone 3

B Assessment Bone Loss

IndicationsRevision THR CT scan Bone Defects


1.  Loosening
2.  Infection
3.  Instability
4.  Periprosthetic fracture


1.  Exclude infection
2.  Re-establish the structural integrity & bone stock
3.  Establish normal Joint mechanics
- restore the centre of rotation of the hip
4.  Initial rigid fixation of bone graft
5.  Adequate containment of the new prosthesis


Aetiology Bone Loss

1.  Osteolysis
2.  Surgical / iatrogenic (with implant removal)
3.  Acetabular dysplasia
4.  Fracture
5.  Infection


Preoperative Assessment

1.  Exclude infection
2.  Quantify bone loss





- Paprosky




- Paprosky


Femoral Bone Loss


Paprosky Classification

I Minimal metaphyseal cancellous bone loss / intact diaphysis
- i.e. seen after removal of uncemented component without biological ingrowth on surface

II Extensive metaphyseal cancellous bone loss / intact diaphysis
- often seen after removal of cemented prosthesis


Revision THR Paprosky II FemurRevision THR Paprosky II

IIIA Metaphysis severely damaged / > 4cm diaphyseal bone for distal fixation
- grossly loose femoral component
- first generation cementing techniques


Revision THR Paprosky IIIA FemurRevision THR Paprosky IIIA 3

IIIB Metaphysis severely damaged / < 4cm diaphyseal bone for distal fixation
- cemented with cement restrictor
- uncemented with substantial distal osteolysis


Infected THR Paprosky Type IIIA

IV Extensive metaphyseal and diaphyseal bone loss / isthmus non supportive


AAOS Classification

I Segmental
- proximal (partial or complete)           
- intercalary
- greater trochanter

II Cavitary
- cancellous
- cortical
- ectasia (dilatation)

III Combined segmental and cavity

IV Malalignment
- rotational
- angular

V Femoral Stenosis

VI Femoral Discontinuity


Acetabular Bone Loss

AAOS Classification

Type I    Segmental deficiencies

Peripheral -  superior / anterior / posterior

Central - medial wall absent


Revision THR Anterior wall segmental defect

Type II    Cavitary deficiencies

Peripheral  -  superior / anterior / posterior
Central - medial wall intact


Revision THR Cavitatory Deficiency CupRevision THR Contained Defect Cup CTRevision THR Cemented Cup Anterior Wall Intact

Type III    Combined deficiencies

Type IV     Pelvic discontinuity


Separation of anterior and posterior columns

Type V    Arthrodesis


Paprosky Classification

Based on ability of the remaining host bone

- to provide initial stability to a hemispherical cementless acetabular component

- until ingrowth occurs

Type 1    


Undistorted rim
- anterior and posterior columns intact
- no superior migration

- may have some contained deformities
- ishium, teardrop and Kohlers line intact

Type 2


Distorted but intact rim
- can support a hemispherical cementless implant


Revision THR Paprosky Type 2 Cup


Some distortion, minimal superior migration
- at least 50% good support by host bone
- anterior and posterior columns intact
- no substantial osteolysis of ischium or teardrop



- superomedial migration but superior rim intact


Revision Acetabulum Paprosky Type IIA



- < 1/3 superior deficit

- remainder is still supportive

- replace with allograft for bone stock



- medial migration to Kohlers, but wall intact

- rim is supportive

- manage as for protrusio


Revision Acetabulum Paprosky Type IICRevision THR Superior Migration Cup but Rim intact

Type 3


Non supportive rim
- columns not supportive, superior migration> 3 cm

- require structural allograft for support


Revision THR Type 3 Acetabulum

4 radiographic criteria

1.  Superior migration of the hip centre
- indicates damage to anterior and posterior columns
- supero-medial indicates greater damage to anterior column
- supero-lateral indicates greater damage to posterior column

2.  Ischial osteolysis
- bone loss inferior posterior column

3.  Teardrop osteolysis
- inferior anterior column and medial wall

4.  Position of the implant relative to Kohler’s line
- deficiency of anterior column



-  > 40% host bone contact

-  < 50% rim missing



- < 40% host bone contact

- > 50% rim missing



C Approach and Implant Removal

Pre-operative Planning

CT / quantify bone loss
X match 4 units
Cell saver
Anaesthetic review
Bone graft (cortical, cancellous)
Component removal gear

- extraction gear for femur / liners

- cement removers for cemented femur

- curved osteotomes for cemented cup

- X-plant for uncemented cup
Revision long stem femoral implants
Revision acetabular implants including cages



Posterior approach
- often easiest in revision
- good for ETO


Recreate fascial and muscular layers

- aids exposure and closure

Wide exposure of hip joint
- removal of all pseudocapsule
- expose entire proximal femur & acetabulum


Extended Trochanteric osteotomy




Osteotomy lateral 1/3 to 1/2 of trochanter / femur

- posterior to anterior longitudinal cut

- short distal transverse cut

- levers / hinges open anteriorly

- maintains anterior vasculature / muscle attachment



1.  Aid exposure
2.  Removal cement (especially infection)
3.  Removal well fixed uncemented prosthesis
4.  Removal cement plug / bone very poor / risk of perforation high
5.  Abnormalities of the proximal femur

Contraindications / Relative

1.  Impaction bone grafting
2.  Cementing revision prosthesis


Technique ETO

- measured from tip GT
- 2 – 15 cm long
- need to preserve diaphysis if using distal press fit uncemented stem

- usually after implant removal
- may not be possible

- elevate vas lateralis forward
- expose linea aspera
- expose posterior femur

- use drill holes to mark osteotomy

- drill both cortices
- thin oscillating saw
- cut down through anterior and posterior femur in line with GT
- through both cortices
- transverse cut distally through 1/3 diameter
- lever open

- 3 x cerclage cables, tension
- protect sciatic nerve
- submuscular



98 – 100% union rate by 6/12


Removal Femoral Implant

A.  Cemented



- must clear shoulder of prosthesis
- must ensure no GT overhang or will fracture on removal

Extraction devices
- stem often easily removed if cemented
- extraction devices hook around proximal prosthesis & backslap
- can release cement – implant interface
- combination flexible osteotomes, micro sagittal saw, small burr

Cement removal
- aided by ETO
- use arthroscopy light down femur

Cement removal kit
- flexible osteotomes, reverse hooks, cement splitters
- split cement radially & then removed
- can use high-speed burr
- may require distal window

Removal of cement plug
- remove proximal cement
- drill guide in centraliser
- insert tap, then extract


Need to be very careful to avoid inadvertant perforation

B.  Uncemented

Can be very difficult to remove a well fixed stem

- i.e. if removing for infection

Consider component design
- proximally coated
- extensively coated

Breakdown osseointegration
- flexible osteotomes
- sagittal saw
- very difficult
- can perform ETO about stem

Extraction devices

- company specific

- hook under neck


Broken Stems
- stem is invariably well fixed distally
- osteotomy to site of fracture
- +/- distal window

Acetabulum Removal


Acetabular revision only

1.  Leave femoral component in situ



- femur not loose / damaged / good orientation

- need to be able to match new cup / poly to femoral head


- can remove head if modular (use company device to lever off)
- make anterior pocket for femoral stem

- protect trunion with swab



- can be a problem putting a ceramic head on an old trunion

- if needed, can get a ceramic head with a metal liner for trunion

2. Removal of cemented Femoral component / Re-cement a smaller prosthesis into a well fixed cement mantle


Revision Cup Only Cement in Cement Femur PreRevision Cup Only Cement in Cement Femur Post

- as above


Re-cement prosthesis

- ensure cement mantle clean and dry

- trial small component

- cement in cement revison with high viscosity cement

- insert cement when very viscous

- put in new prosthesis very early


Removal Cemented Acetabulum

1.  General principle is to loosen poly cup from cement
- do so with curved gouges
- between cement & cup
- cement then removed piecemeal

2.  Can simply ream out the poly

3.  Insert threaded extractor through drill hole in poly
- then disimpact poly from cement


Uncemented Acetabulum

- may just be changing liner and leaving cup
- may need to remove well fixed cup i.e. infection

- may be removing loose cup


1.  Company specific removal instruments
- need to disengage locking mechanism

2.  Simply lever out liner with osteotomes

3. Drill hole in liner 4.5 mm
- insert 6.5 mm screw to push liner out

Metal Shell

1.  Curved osteotomes
- risk bone loss

2.  Zimmer Explant Acetabular Removal System
- 3 sizes depending on implant size
- central head to sit in liner
- must remove screws first, then replace liner
- diamond blades cut between cup and bone
- initial blade short
- second is thin and full radius

Intrapelvic acetabulum / cement


Intrapelvic Cement



Can be life threatening if just pulled out from standard approach


Preoperative contrast studies

General surgeon / vascular surgeon available



A.  No aneurysm
- lateral window of ilioinguinal
- elevate iliacus subperiosteally from table of ilium
- remove under direct vision

B.  False aneurysm
- Rutherford Morison approach
- general / vascular surgeon



D Reimplantation Acetabulum

Principles of Acetabular reconstructionRevision Acetabulum Post Paprosky Type IIIC


Restore centre of rotation
Restore acetabular integrity
Component containment
Secure fixation

Preoperatively planning

Know components in situ (esp if leaving femur)
Quantify and grade bone defects
Beware intrapelvic cement / cup (angiogram)


Basic Guidelines


> 50% host bone contact

- use press fit uncemented cup augmented with screws


< 50% host bone contact

- use metal augment in elderly to reconstruct defect

- use allograft augment in young to reconstruct defect

- press fit cup if able

- otherwise must use cage

Paprosky Type I, II A and B


I Rim intact

II A Mild superior migration / superior rim intact

II B < 30% superior rim missing

1.  Uncemented Jumbo rim fit cup

- > 50% host bone available for ingrowth
- > 2/3 rim intact

- implant in usual position
- preferentially ream anteriorly
- preserve posterior column
- some uncovering superiorly allowed
- usually augment with screws
- +/- postoperatively NWB 6/52

- 12-15 year survival between 81-96%


Revison THR Type I AcetabulumRevision THR Jumbo Cup 2


2.  Impaction Bone Graft +/- Mesh + Cemented Cup


Revision Acetabulum Type IIIBRevision Acetabulum Type IIB Superior Mesh and Impaction Bone Graft


Type IIC


Type IIC: Medial wall deficiency but intact


A.  Particulate graft medially, jumbo cup


Revision THR Type IIC AcetabulumRevision THR IIC Jumbo Cup + medial bone graft


B. Impaction bone graft, cemented cup


Revision Acetabulum Type IICRevision Acetabulum Type IIC Impaction Bone Grafting


C.  Cement +++


Indicated in elderly patients


Revision Acetabulum Type IIcRevision Acetabulum Cement +++


Segmental Medial Wall deficiency

A.  Allograft + Antiprotrusio Cages + Cemented Cup


- Ganz / Muller / Burch Schneider

- variations on them

- hook or screws into ilium

- hook or screws onto ischium

- can have extension for screws onto pubis


Revision THR Burch Schneider Cage

B.  Mesh + Impaction Bone grafting


Type IIIA defects



- Rim < 50% missing, > 40% host bone contact

- want to reconstruct defect but don't need cage


1.  Uncemented rim fit cup / screws / Structural bone graft

- defect superolateral rim < 50% to support cup
- > 50% host bone contact

- allograft will not grow onto uncemented cup

- allograft to reconstuct defect

- femoral head allograft reconstruction (no 7 shape)
- fix with 6.5 mm screws
- tap first to prevent fracture
- ream into bone

2.  Impaction bone graft +/- mesh + cemented cup

Revision THR Type IIC AcetabulumRevision THR Impaction Bone Graft Acetabulum



1.  If required, convert uncontained defect into contained defect
- use titanium mesh fixed with screws
- acetabular rim or medial wall mesh (Stryker)


Revision THR Type IIIC Acetabulum Mesh Impaction Bone GraftRevision THR Type IIIA Acetabulum Pre IBG

2.  Impact morcellised cancellous bone graft
- tamps or reverse reaming
- progressively smaller impactors
- need 5 mm of bone graft

3.  Insert prosthesis / Cemented poly liner


- 85% 12 year survival
- 80% 15 year survival

Important Points

1.  Rigorous technique important

2.  Fresh frozen allograft
- does this perform better than irradiated BG

3.  TWB 6 – 12/52


3.  Trabecular metal components

New material made of element tantalum

1.  Interconnecting porous material
- 80% porous
- allows 2-3 X bony ingrowth

2.  Less stiff
- improved remodelling of BG underneath

3.  High cancellous bone coefficient of friction
- excellent initial stability
- may need less than traditional 50% host bone contact
- may not need screws

Ream host bone for press fit cut
- trial then secure trabecular augment with screws
- press fit cup with cement between augment and cup
- screw augmentation of cup

4.  Bilobed uncemented acetabular components


Bilobed Revision Cup

- superolateral deficiency
- revision
- DDH cups

- can be difficult to get version right




- < 50% rim intact, < 40% contact

- must reconstruct for stability

- unable to use uncemented component

- use bone graft to reconstruct

- need cage for stability


1.  Structural Allograft + Cage


Revision Acetabulum Bulk Structural Allograft + Cage

- when inadequate bone stock precludes the use of uncemented acetabular components

- cannot implant onto allograft
- graft under the cage
- secure with cage
- cement poly into it

- allograft reconstruction of rim with femoral head
- allograft particulate material in base
- secure cage to posterior column ilium and ischium
- 3 screws in each
- cement all poly cup into cage

- 75% 10 – 15 year survival

Option:  Custom-made triflange components

CT guided model of pelvis
- custom made acetabular cage
- fits defect exactly
- flanges perfectly designed and not malleable to improve strength
- HA coated
- cement poly cup into it

- massive defects

- 90% 4.5 year survival in complicated patients


2.  Impaction Bone Graft +/- Mesh + Cage + Cemented cup


Revision THR Type 3B AcetabulumRevision THR Acetabular Mesh Bone Graft Cage


Pelvic discontinuity


Revision THR Pelvic Discontinuity0001Revision THR Pelvic Discontinuity 2Revision THR Pelvic Discontinuity 3

1.  Plate and bone graft posterior column


Revision THR Plate Posterior ColumnRevision THR Plate Posterior Column Lateral

2.  Plate + Cage reconstruction


3.  Cup Cage Reconstruction



- large tantalam cup inserted for reconstitution of discontinuity

- bone graft inserted

- cage, cement in cup


Revision THR Cup Cage0001Revision THR Cup Cage0002Revision THR Cup Cage0003


E Reimplantation Femur

Implant Options


1.  Long stem cemented revision femoral stem


Modern cementing techniques
- removal of neocortex

- use in all cases
- good with elderly fragile bone
- can use Abx cement (decreases infection rate)

- Paprosky Types I – IV
- very versatile



- complete removal / debridement of neocortex

- modern cementing techniques

Howie JBJS Br 2007
- 219 patients, 9 year follow up
- collarless double taper
- 98% 10 year survival

- ? increased non union with ETO


2.  Extensively porous coated diaphyseal fitting uncemented stem

- Paprosky Types I, II, IIIA

- 90- 95% 10 year survival

- fracture
- stress shielding with additional proximal bone loss

3.  Modular diaphyseal fitting, proximal filling uncemented stem


Revision THR Modular Long Stem UncementedModular Revision Implants

- press fit metaphyseal segment
- slotted diaphyseal segment
- initial stability through distal fixation

- Paprosky Types I – IIIB

Smith J Athroplasty 1997
- nil revisions at 5 years
- 7% radiographically loose

Type 3 Revision Femur 2


4.  Impaction bone grafting

- morcellised bone graft is osteoconductive, not osteoinduction
- resorption and eventual replacement new bone
- 6 – 12 months
- process is incomplete

Van der Donk Clin Orthop 2002
- 30% complete 6/12

- 90% complete 12/12


1.  Particulate cancellous autograft 7-10 mm
2.  Contained defect
3.  Ability to convert uncontained into contained (i.e. mesh)

- technically demanding
- takes time
- need axial and rotational stability
- avoid stem subsidence > 5 mm

1. Uncemented distal fixation not possible (< 4cm diaphysis)
2. When reconstruction of proximal bone stock important
- young patient in whom biological solution more desirable


- choose stem 2 cortical diameters longer than most distal lytic area

- full exposure of proximal femur
- removal stem & cement


Can leave distal plug
- not infected
- > 2 cm past planned tip location

Create contained defect
- reconstitute femoral tube
- create contained defect
- wire mesh & cerclage wire
- prophylactically cerclage wire shaft if diaphysis flimsy

Distal Occlusion
- threaded intramedullary plug inserted on guide rod
- impacters tested to see max depth of insertion before abutment on canal
- morsellised allograft inserted
- impactor & slap hammer slid over guide wire
- graft impacted to predetermined depth
- continued by introducing more chips with larger impacters
- stopped when level is 10 cm from tip of GT

Proximal Impaction
- appropriate proximal impactor equivalent to selected stem used
- used to force chips against walls of canal
- then larger distal impactor used
- alternated till canal filled
- should be firm neo-canal

Trial Reduction
- trial stem inserted
- depth of insertion marked
- proximal impactor driven in another 5 mm
- creates room for cement

- cemented polished collarless double tapered stem

- NWB for ? 3/52
- then gradual inc over next 3/ 12


Halliday JBJS Br 2003
- 90.5% 10 year survival

Elting Clin Orthop 1995
- 93% graft incorporation
- stem subsidence in 48%

Elridge JBJS Br 1996
- > 5 mm subsidence in 22%


Management Plan

Assess Metaphyseal & Diaphyseal Bone Stock

Grade Paprosky, then manage appropriately

Paprosky Type 1



Minimal metaphyseal cancellous bone loss
Intact diaphysis     



Simple revision
- can use standard or any revision stems

A. Uncemented
- standard length proximal fit and fill
- need appropriate initial stability

B. Cemented standard length stem
- must remove neocortex
- need good cement interdigitation

Izquierdo JBJS Br 1994
- 90.5% 19 year survival


Revision Femur Type 1 Standard Cemented Stem Pre opRevision Femur Type 1 Standard Cemented Stem Post op

C. Cement onto old mantle
- clean and dry mantle critical
- thin layer of blood 85% reduction shear strength

Lieberman et al JBJS Br 1993
- 19 cases
- no loosening at 5 years in all


Revision Femur Paprosky 1 Revision Femur Paprosky 1 Cement in old Cement Mantle


Type 2



Extensive metaphyseal cancellous bone loss
Diaphysis intact



A.  Extensively porous coated diaphyseal fitting implant

Paprosky 90& osteointegrated


Calcar Replacement Uncemented Stem

B.  Long stem cemented revision stem


Revision Femur Long Stem Cemented Femoral Component

C.  Modular diaphyseal fitting, metaphyseal filling uncemented prosthesis

D.  Impaction bone grafting


Type 3A



Metaphysis non supportive
> 4 cm diaphysis proximal to isthmus


Type 3 A FemurType 3A Femur Lateral

A.  Extensively porous coated diaphyseal fitting implant


Type 3 Revision Femur

Paprosky 20/22 91% osseointegrated

B.  Long stem cemented revision stem


Revision Femur Long stem Cemented Component

C.  Modular uncemented


D.  Impaction bone grafting


Revision Femur Type IIIA Pre Impaction Bone GraftingRevision Femur Type IIIA Post Mesh and Impaction Bone Grafting


Type 3B



Metaphysis non supportive
< 4cm diaphysis proximal to isthmus



A.  Extensively coated diaphyseal fitting

Paprosky 4/8 failed

- i.e. need > 4cm of diaphysis for this to work

B.  Long stem cemented revision stem

C.  Modular uncemented, stem with flutes for rotational stability

D.  Impaction bone grafting


Revision Femur Type 3 Mesh and Impaction Bone Grafting


Type 4



Metaphysis and diaphysis extensively damaged
Isthmus non supportive



A.  Long stem cemented revision stem

B.  Impaction bone grafting


Management Bone Defects


1.  Segmental defects

A.  Must bypass any cortical defect by two cortical diameters to reduce fracture risk

B.  Cortical Strut onlay grafts

2.  Extensive proximal bone loss


A.  Calcar replacing


Calcar Replacing THRCalcar Replacing Hip Replacement

- proximal segmental defect < 3cm

McLaughlin JBJS Am 1996
- 38 hips 11 years
- 80% survival
- another 10% radiologically loose
- 20% dislocation rate


B.  Napkin ring  / Calcar graft Allograft

- circumferential proximal defects < 3cm

- poor
- 40-60% resorption


C.  Proximal Femoral Replacement / Tumour prosthesis

Results disappointing
- however design may be improving

Malkani JBJS Br 1995
- 33 hips 11 years
- poor function (50% severe limp or unable to walk)
- 64% 12 years survival
- 22% dislocation


D.  Bulk Structural Proximal Femoral Allograft

- proximal defect > 3 cm

- desired stem cemented into allograft
- press fit distally into host femur
- step cut graft host junction
- secure cerclage wire and onlay cortical strut
- proximal host bone wrapped around allograft with ABD preservation

- very important – abductor mechanism must be secured and protected

Gross 1998
- 200 patients, 5 years follow up
- 12.5% revision
- revised for infection, dislocation, graft-host non union


Transient Osteoporosis Hip



Self limiting syndrome of unknown aetiology

- hip pain associated with osteoporosis of proximal femur 





- AVN of the hip in pregnancy is rare but possible

- TOH tends to be diffuse on MRI, while AVN is localised

- extends to neck and metaphysis

- transient osteoporosis has normal bone scan





- M: F 3:1


Two Groups

1. Men 40-50 years old

2. Women usually 3rd trimester of pregnancy




Unknown / Theories

- ischaemia


- virus / toxin


Only predisposing factor is pregnancy




Biopsy shows many features in common with AVN, but it is non-specific

- edematous fluid & marrow

- inflammation

- fat necrosis

- reactive bone formation

- widely spaced trabeculae


Clinical Features


Acute onset

- AVN tends to be insidious


Mechanical hip pain

- usually FROM


Rarely sub-capital fracture results


Natural History


Three distinct temporal phases


1. Initial 

- sudden onset severe pain

- disability >> signs

- lasts 1/12


2. Plateau

- symptoms stabilise

- osteopenia seen on xray

- lasts 2/12


3. Regression

- lasts 3/12




Shows diffuse osteopenia of entire proximal femur 

- 1/12 after onset

- may have "Phantom" appearance of proximal femur 

- rarely the pelvis can be affected too




Key is that with TOH the MRI changes are diffusely affecting the proximal femur

- AVN it is localized to a portion of the head


Marrow oedema

- TI decreased SI 

- T2 increased SI due to oedema







Osteoporosis 2° joint disease

Metabolic cause osteopenia

Permeative - neoplasia 








Self limiting condition

- rapidly improves after delivery


Need to prevent fracture

- protected weight bearing in pregnancy





- simultaneous pinning & LSCS


Non pregnancy




Varenna et al Bone 2002

- 16 cases treated with IV pamidronate

- resolution of symptoms and normalisation of MRI findings




Trochanteric Bursitis & Gluteus Medius Tears

Trochanteric Bursitis




Repetitive friction of iliotibial tract over GT




Overuse in athletes

Common post THR


May be associated with gluteus medius tears




Pain over upper lateral thigh with activity

- often related to hip flexion




Localised tenderness & swelling over & posterior to GT


Pain with resisted abduction




Tears in gluteus medius

Stress fractures

Iliopsoas tendonitis

Intra-articular hip pathology

Spinal pathology





May demonstrate fluid in bursa


Non operative Management


HCLA injection

- virtually all respond to HCLA but may need several

- almost never need surgery


Operative Management




Baker et al Arthroscopy 2007

- arthroscopic resection bursa in 30 patients

- successful in all but one who went on to have a successful open bursectomy


Bursectomy + ITB lengthening


Craig et al ANZ J Surg 2007

- open proximal Z lengthening ITB in 17 patients

- one poor result

- one patient had a secondary repair gluteus minimus with excellent result


Distal ITB lengthening


Pretell Int Orthop 2009

- distal lengthening in 13 patients average age 50

- 12/13 good results

- 1 post op seroma


Tears Gluteus Medius and Minimus




Sporting injuries










Non operative Management


Rest / physio

- stretching +++

- eccentric exercises

- correction of LLD with shoe lift








Operative Management




Repair of tears + bursectomy

- open or arthroscopic




Voos et al Am J Sports Med 2009

- arthroscopic repair tendon tears in 10 patients

- all had complete resolution of symptoms


Lequesne Joint Bone Spine 2008

- open repair in 8 patients

- lateral tears of gluteus medius all seen on MRI

- 3 gluteus medius tears were not seen on MRI

- good results in 7/8 patients



A Assessment


ACL Normal ArthroscopyACL Normal Arthroscopy




Developmental Anatomy


Knee joint first appears as a mesenchymal cleft at 8 weeks gestation

- ACL and PCL separate entities by week 10

- cruciates principle determinants of  shape of tibiofemoral articulation 




Collagen and elastin arranged in less parallel configuration than tendons

- allows increase in length without large increase in internal stress


Ligaments attach to bone directly or indirectly


Cruciates attach directly / 4 histological zones

- ligament

- nonmineralised fibrocartilage

- mineralised fibrocartilage

- cortical bone


Indirect attachments via periosteum and fascia

- i.e. tibial insertion of MCL


Gross Anatomy


Intracapsular and extra-synovial




In full extension ACL

- subtends 45o angle in sagittal plane

- 25o angle in coronal plane



- 25-40 mm long

- 7-10 mm wide




Anteromedial and posterolateral bundles

- described regarding point of tibial insertion



- smaller

- tight in flexion

- test with anterior draw



- larger

- tight in extension

- test with Lachman / Pivot Shift



-  posterior articular nerve / branch tibial


Arterial supply 

- middle geniculate   



- medial wall LFC

- semicircular

- semicircular proximal insertion high and posterior on medial wall of LFC



- passes anteriorly, distally and medially

- oval shaped fossa anterior and between the tibial spines

- majority of ligament passes deep to transverse meniscal ligament

- a few fascicles blend with anterior horn of lateral meniscus

- variable and minor attachment to the posterior horn of the lateral meniscus

- wider and stronger than femoral insertion




1° Stabilizer

- prevents anterior translation


2° Stabilizer

- lateral & medial stability

- protector of menisci


4 important features of function


1. Carries load throughout entire range resisting AP and translational forces

- different fibres recruited at different times 


2. Carries only small loads during normal activity

- about 20% of failure capacity during normal loading


3. Highest loads are produced by quadriceps powered extension of knee (open chain exercises)

- but during any one exercise failure loads only reach about 5%


4. Much more complex behaviour than just a series of fibres

- exhibits viscoelastic properties allowing it to adapt to different loading patterns

- ACL consists of many fascicle subunits

- these are recruited as needed to accommodate strain




1:1500 - 1:3500




Non contact deceleration producing valgus twisting injury


Deceleration / ER / Valgus


Associated Injury


Meniscal Injury


60% lateral meniscus

- associated with acute ACL rupture

- classically posterior horn

- many will heal


Lateral Meniscus Posterior Horn Tear Post ACL RuptureLateral Meniscus Posterior Horn Tear Post ACL Rupture


40% medial meniscus

- associated with chronic ACL rupture



- 10-20%

- assciated with characteristic bone bruise patterns  on MRI

- see femoral chondral impressions from hyper-extension injury


Lateral Femoral Condyle Impaction Post ACL InjuryLFC Bone Bruise


Chondral Injuries


Chondral Lesion Post ACL InjuryChondral Lesion Post ACL Injury



- 10-20%




1.  50% describe a "Pop"


2.  75% haemarthrosis

- intraarticular swelling or effusion within the first 2 hours after trauma suggests hemarthrosis

- swelling that occurs overnight usually is an indication of acute traumatic synovitis / meniscal tear


3.  Immediate inability to weight bear


DDx hemarthrosis 


Rupture of a cruciate ligament

Osteochondral fracture

Peripheral tear in the vascular portion of a meniscus

Tear in the deep portion of the joint capsule




Laxity Grading Lachmans / Anterior Draw


1+: mild instability < 5mm

2+: moderate instability 5-10mm

3+: severe instability >10mm




20 - 30° Flexion

- removes effects of bony contour / menisci i.e. 2° constraints

- stabilise femur with one hand, other hand behind tibia with anterior force

- sublux the tibia forward


85% sensitivie when awake 

100% under anaesthetic


Lachmans PreLachman's Post


Anterior Draw


Knee at 90° Flexion with hamstring relaxed

- foot in neutral

- sit on foot to stabilise

- hands behind tibia and pull forward

- has to > 3mm different to contralateral knee


Anterior drawer 1Anterior Drawer 2


Foot in 15° of External Rotation

- medial structures tightened in this position

- reassess anterior draw

- if have positive anterior draw in this position suggests associated posteromedial injury

- ACL + MCL / Med Capsule / OPL


Foot in 30° of Internal Rotation

- lateral structures tight in this position

- reassess anteior draw

- if have positive anterior draw in this position suggests associated posterorlateral injury

- ACL / LCL / PLC Complex 


Pivot Shift



- ACL torn

- lateral tibia subluxed anteriorly in extension

- reduced in flexion



- knee moves from extension to flexion

- valgus force applied to knee

- apply axial load

- mimicking weight bearing



- in extension the LTC is subluxed anteriorly

- in extension ITB is in front of flexion axis and is extender of knee

- as the knee is flexed

- ITB moves behind the flexion axis and becomes flexor of knee (20-40°)

- this reduces the LTC


“The relocation of the subluxed lateral tibial condyle as the extended knee is flexed”

“This occurs as the ITB line of function changes so as to become a flexor rather than an extensor of the knee”


Lachman 1Lachman 2


Need 4 things for a pivot shift

1. MCL to pivot about

2. ITB to reduce on flexion

3. Ability to glide ie no meniscal tear

4. °FFD




Jakob et al JBJS Br 1987

- 3 grades with foot in varying degrees of rotation


Grade 1:  Pivot shift with foot IR

Grade 2:  Pivot shift with foot neutral

Grade 3:  Pivot shift with foot ER




Usually normal


Segond Fracture

- small avulsion fracture of lateral proxima tibia

- is sign of lateral capsular avulsion

- pathognomonic of ACL tear


ACL Segond


Tibial avulsion

- more common in children

- can be seen in adults


ACL Bony Avulsion XrayACL Bony Avulsion CTACL Bony Avulsion AdultACL Bony Avulsion Sagittal MRI




Normal ACL on MRI


 Intact ACL T2Intact ACL T1MRI Normal ACL



- straight structure

- parallel to intercondylar notch

- no anterior subluxation of the tibia

- normal to have some increased signal due to adipose and synovial tissue

- able to see continuity of fibres from tibial to femur


Not always accurate

- ACL is helicoid shape

- sagittal MRI alone inaccurate in 10 - 20%

- sensitively increase to > 95% by using coronal and axial images


Torn ACL on MRI


ACL MRI Femoral ACL AvulsionACL MRI Rupture T2



- high signal intensity / oedema in ACL, especially accutely

- unable to identify continuous fibres from tibial to femur

- loss of taut, straight line of fibes

- loss of attachment onto LFC on axial


ACL Femoral Avuslion MRI


May see stump of ACL


ACL Torn with remnant stump MRI


May identify ACL healed onto PCL


MRI ACL torn and healed on PCL


May see tibia subluxed anteriorly


ACL Partial Tear


ACL Partial Tear


Bone bruising patterns

- pathognomonic

- caused by the knee pivot shifting

- terminal sulcus of LFC

- posterolateral tibial plateau


MRI ACL Rupture Bony Oedema Lateral Femoral CondyleMRI ACL Rupture Bone Oedema Terminal SulcusMRI ACL Rupture Bone Oedema Posterolateral Tibia


Mechanical Testing


KT 1000 

- Instrumented Lachman's and Anterior Draw

- > 3mm c.f. other knee 98% sensitive

- > 10mm absolute on one side




ACL Partial Tear ArthroscopyArthroscopy Empty Lateral Wall


ACL Rupture Empty Lateral WallRuptured ACL



- empty lateral wall

- ACL healed onto PCL

- partial tears

- ACL healed onto different part of LFC

B Management Options



Natural History of ACL deficient knee is variable

- functional instability 15% - 90%

- progression to OA is variable


Depends on level of patient demands / activity


1.  Late meniscal injury in ACL deficient knee




2.  Function


Daniels Am J Sports Med 1994

- 292 ACL defecients knees

- 50% of patients not reconstructed returned to sport / most at reduced level


Frobel et al NEJM 2010

- RCT of 120 patients

- early ACL reconstruction or functional rehab with option of delayed reconstruction

- no difference between two groups

- 1/3 of patients in ACL rehab group chose to have ACL reconstructed


3.  Osteoarthritis


Daniels Am J Sports Med 1994

- higher OA in reconstructed knee v non operative

- even if remove those knees that had meniscal surgery



- no OA in 97% of ACL reconstructed patients at 5 – 10 year follow up if

- no meniscal damage and normal cartilage at time of surgery



- 20% rate of OA in HS patients at 10 years

- higher in BPTB ligament


Non-operative Management




Patient able or willing to modify activities

No functional instability




Acute phase


RICE, Analgesics

Weight bear as tolerated 


ROM exercises started early

- aim to regain full flexion & extension early



- started once FROM achieved

- quads & hamstring

- closed chain exercise


Resumption of sport


ACL rehabilitation protocol



- quads and hamstring strength 90% other side

- able to perform single leg hop > 1m


Non-ACL Stressing ie. Bike / Swimming best


Avoid ACL Stressing activities

- pivoting sports

- open chain quads


ACL brace

- for pivoting sports


Operative Management




Recurrent symptomatic instability

Desire to return pivoting sport and inability to do so


+/- Repairable meniscus

- meniscus more likely to heal in setting of ACL Reconstruction


1.  ACL +  Torn Menisci 


Meniscal Repair


1.  ACL + Meniscal repair

- 60-70% success of meniscal repair without concomitant ACL reconstruction

- 90% success if repair meniscus & ACL together


2.  Timing 

- acute meniscal repair does better than delayed repair

- 90% heal if <8/52

- 70-80% heal if >8/52


3.  Side

- more medial than lateral are repairable




Known to predispose the knee to poorer outcome


Kartus et al Acta Orthop Scanda 2002

- multicentred trial of over 400 patients having ACL reconstruction

- compared normal meniscus to patients who had > 1/3 meniscus removed

- meniscectomy group had more pain / swelling / laxity

- meniscectomy group had worse knee scores and more likely to have reduced ROM


2.  Acute locked knee & ACL 



- inability to flex / extend knee

- due to flipped bucket handle meniscus



- ACL stump causing FFD

- arthroscopy to remove blockage



- Confirm locked bucket handle meniscal tear


Need to unlock knee




1.  Arthoscopy / reduce meniscus / rehab / repair both at 6 weeks

- avoids risk of arthrofibrosis

- two surgeries required

- may be best if patient has a FFD

- however the meniscus may redisplace


2.  Repair meniscus / rehab /  reconstruct ACL later

- problem is reduced rate of meniscus healing

- an unstable knee may retear the meniscus


3.  Acute ACL reconstruction and meniscal repair

- advantage is single surgery / high rate meniscus healing

- problem is risk arthrofibrosis


3.  Medial Collateral & ACL




Grade II MCL

- 75% chance ACL rupture




Rehab MCL

- perform delayed reconstruction of ACL if symptomatic instability


ROM knee brace to limit extension

- 2 weeks 30-60°

- 2-4 weeks 30-90°

- 4-5 weeks 15˚ - 90

- 6th week 0 – 90˚


Indication for surgery

- MCL torn off tibia (usually off femur) and flipped up and over the pes anserinus

- won't heal in this position

- MRI all patients with MCL tenderness over tibal insertion


Patient with MCL and ACL instability

- reconstruct ACL

- reassess MCL at end of case

- if mildly unstable, advance / imbricate MCL on femoral side +/- tighten medial head gastrocnemius

- if severely unstable, reconstruct with hamstring or tendoachilles allograft


MCL Advancement


4.  ACL + large medial chondral lesion


Consider HTO + ACL




Surgical Options


1.  Primary Repair


High failure rate



1. No clot formation 2° synovial fluid

2. Tension on ligament

3. Intrinsically poor healing potential


2.  Extra-Articular Augmentation


Lateral extra-articular procedures 

- prevent anterior subluxation LFC in extension

- unpopular due to poor long term results


1.  Ellison Procedure


A.  Strip of ITB Deep to LCL 

- placing it anterior in a bone trough

B.  Plication the capsular ligament


2.  MacIntosh Procedure


ITB left attached distally

- deep to LCL

- subperiosteal tunnel in LFC

- thru intermuscular septum

- back on itself distally


ACL Ellison APACL Ellison LateralMacIntosh ACL Scar ITB


3.  ACL Reconstuction


Graft Incorporation


1.  Central necrosis 

- 6 weeks post op

- strength of the graft if 70% of original at this time


2.  Synovialisation

- up to 6 months post op


ACL Graft 6 months0001ACL Graft 6 months0002


3.  Revascularisation


4.  Ligamentisation 

- 6 to 18 months

- longitudinal orientation of collagen

- normal tendon at 2 years



- acts as scaffold for fibroblasts

- graft undergoes ischaemic necrosis & then becomes enveloped with vascular synovial tissue

- occurs at 4-6 weeks post-op

- neovascularisation & cellular proliferation 3/12



C Surgical Reconstruction Issues

Timing of Surgery



- reported higher incidence with immediate reconstruction in acute phase

- reduced by settling inflammation / effusion and obtaining FROM

- always best to delay if not professional athlete

- problematic if patient has locked bucket handle mensical tear




Bottoni et al Am J Sports Med 2008

- RCT of early (average 9 days) v late reconstruction (average 85 days)

- no difference between the two groups


Autograft Choices


Middle 1/3rd BPTB




Potential Advantages

- stiffer / perhaps increased strength and stability in contact athlete

- potentially better fixation because of bone blocks



- risk of patella fracture

- increased anterior knee pain when kneeling


ACL BPTB Patella Fracture APACL BPTP Patella Fracture LateralACL BPTB Patella ORIF APACL BPTB Patella ORiF Lateral


4 Strand Hamstring Graft



- little functional deficit

- mild knee flexion weakness

- less PFJ pain



- ? more post operative laxity

- some weakness of hamstrings which may be important in some athletes



- generalised ligamentous laxity

- sprinters

- hamstring injury


Hamstring v BPTB




Spindler et al Am J Sports Med 2004

- systematic review

- no significant difference in graft failure between the two groups

- increased kneeling pain in BPTB group


Blau et al BMJ 2006

- meta-analysis

- some weak evidence that BPTB provides increased stability

- some evidence of lower morbidity in HS


Reinhardt et al Orthop Clin North America 2010

- level 1 systemic review

- failure defined as 2+ Pivot shift or revision surgery

- HS significantly higher failure rate

- significantly higher values of anterior laxity in HS

- significantly higher incidence of extension deficits in BPTB


3.  Allograft



- achilles


- quads tendon

- tibialis anterior / posterior



- nil graft site morbidity



- disease transmission 

- high costs ($5000 per graft)

- slower incorporation (Return at 12/12 vs 6/12)

- increased failure rate




Mehta et al Orthopedics 2010

- retrospective review of allograft v autograft BPTB

- 9% v <1% failure rate


Sun et al Arthroscopy 2009

- RCT of allograft v autograft BPTB in 156 patients

- average follow up 5 years

- no significant difference between the two groups



- revision

- older, lower function patients


4.  Synthetic



- no donor site morbidity



- poor history with regards rupture and synovitis




Gao et al Arthroscopy 2010

- 159 patients followed for average 4 years

- average side to side difference 1.5 mm

- 93% satisfied or very satisfied

- 3 ruptures, one of which developed synovitis


Tunnel Placement


1.  Intra-operative tunnels


Isometricity does not exist

- no point on femur that maintains fixed distance from point on tibia

- up to 3 mm elongation acceptable

- graft should tighten with increased extension


A. Tibial tunnel 


Sagittal plane

- 7 mm anterior to PCL & central

- posterior 1/2 ACL footprint


Coronal plane

- 2/3 way towards medial tibial spine from anterior horn of lateral meniscus


Tunnel angle

- usually 55o

- reduce angle to shorten tunnel if have short graft


B. Femoral tunnel 


More vertical placement of tunnel

- increased AP stability

- less rotational stability / pivot shift


Coronal plane

- 2 o'clock rather than 1 (right knee)

- 10 o'clock rather than 11 (left knee)


Sagittal plane

- want to be posterior

- identify back wall in flexion

- want 2mm of back wall behind tunnel


2.  X-ray assessment


Lateral x-ray


Femoral tunnel

- intersection of line posterior femoral cortex and Blumensaat's line


Tibial tunnel

- posterior to Blumensaat's line in full extension

- parallel to Blumensaat's line


ACL Reconstruction Femoral Tunnels SagittalACL Reconstruction Sagittal Tibial Tunnel


Pinczewski JBJS Br 2008

- 200 patients followed up over 7 years


1.  Posterior femoral tunnel placement

- 86% along Blumensaat's line 


2. Anterior tibia tunnel placement

- 48% along tibial plateau

- parallel to Blumensaat's


ACL Reconstruction Sagittal Tunnel Measurement


AP Xray


1.  Medial tibial tunnel placement

- 46% (towards medial)


2.  Lateral femoral tunnel placement

- 42% from lateral LFC


3.  Graft inclination

- 19o


ACL Reconstruction AP Tunnel MeasurementsACL Reconstruction Graft Inclination Measurement


11% rupture rate over 7 years

- associated with posterior tibial tunnel placement


Good rotational stability

- 19o inclination in coronal plane

- avoid too vertical orientation


3.  Incorrect tunnel positions


Tibial Tunnel


A.  Anterior tibial tunnel

- impingement / limits extension / cyclops lesion


B. Posterior tibial tunnel

- impinge on PCL

- extension strain in extension


C.  Lateral tibial tunnel

- impinges on lateral wall femoral condyle


Femoral Tunnel


A.  Anterior Femoral Tunnel

- limits flexion

- increased strain in flexion / stretches graft

- increases risk of failure


B.  Posterior Femoral Tunnel

- excessive strain in extension


C.  Vertical Graft


Fu etal Arthroscopy 2003

- cadaver study of graft in 10 v 11 o'clock position

- demonstrated increased rotational instability in 11 o'clock


Options for drilling femur


1.   Trans - tibial 


Traditional techique

- drill tibial tunnel first

- place guide up tibial tunnel onto femur


ACL Transtibial Tunnel



- cannot damage MFC


Potential disadvantage

- tibial tunnel sets position of femoral tunnel

- tends to make the graft more vertical



- drill femur with knee at 90o


2.  Anteromedial portal



- allows separation of femoral from tibial tunnel

- can place femoral tunnel lower on femoral wall


ACL Anteromedial Femoral Tunnel



- places drills and reamers close to MFC

- must be careful not to damage cartilage



- must hyperflex knee

- or femoral tunnel may exit in PFJ


Femoral Tunnel Back wall blow-out




Cannot use RCI screw to secure femoral side


Avoid by


1. Using posterior offset femoral guide

- divide tunnel size required in half and add 2

- 6mm for 7.5 mm hamstring tunnel

- 7mm for 10 mm BPTB tunnel


2.  Appropriate knee flexion when drilling femoral tunnel 

- hyperflexing knee if using AM portal

- 90o of flexion if using transtibial technique




1.   Endo-button 

- don't need back wall for fixation


2.  Redrill tunnel 

- change angle by flexing knee +++

- get in good bone stock


3.  Fix in over the top position

- pass graft around back of femoral condyle using curved hemostat

- may need medial parapatella approach

- lateral approach to femur

- fix to femur with screw / staple

- can pass around lateral intermuscular septum and LCL




ACL Large Notch OsteophyteACL Post Notchplasty



- smaller notch increases risk of re-rupture / stretching by causing graft impingement

- more necessary with larger grafts i.e. BPTB

- required if presence of notch osteophytes



- notchplasty can lateralise

- important to