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


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 Injuries

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 Fracture


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 MRI

Deltoid Ligament


Deep Deltoid Ligament


Ankle Coronal MRI


Superficial Deltoid Ligament


Ankle MRI Superficial Deltoid LigamentSuperficial Deltoid MRI


Lateral Ligament Complex








Lateral Ligaments






Peroneal Tendons


Ankle Sagittal MRI





Ankle OA

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






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 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







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 Fracture


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


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


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





AKJ and STJ arthritis



Talar AVN





- 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

- AKJ 5o valgus, plantigrade, ER 10o

- STJ 5o valgus


Pantalar Fusion Talus AVN APPantalar Fusion Talus AVN Lateral


Fusion with IM nail

- insertion point

- in line with 2nd MT

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

- should pass through anterior aspect posterior subtalar joint

- insert nail

- distal locking screws calcaneum

- insert bone graft

- compress

- proximal locking



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




Often with rotation 

- with DF body of talus locks in mortice 

- fracture neck on tibia

- remainder of foot displaces medially thru STJ 

- disrupt inter-osseous and lateral / posterior ligaments 

- dislocation of STJ and AKJ 


Body of talus is forced out postero-medially swinging on intact deltoid

- comes to lie posterior to medial malleolus & anterior to T achilles

- often associated medial +/- lateral malleolus fracture


Classification Hawkins 1970


1.  Undisplaced 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 10%


2.  Subluxation / dislocation STJ

- subluxed posteriorly or medially

- blood supply through neck and in canal disrupted

- blood supply through medial body usually maintained


AVN 39% Vallier et al JBJS Am 2004


Talar Neck Fracture


3.  Subluxed STJ &  AKJ 


Body extruded postero-medially

- head maintains relationship with navicular

- 25 % open 

- all three blood supplies are disrupted


Talus Fracture Type 3


AVN 67% Vallier et al JBJS Am 2004


4.  Type 3 + subluxed TNJ


Dislocation of head and neck

- poor outcome

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


AVN 90 - 100%


Hawkins 4 Talar Neck FractureHawkins 4 Talar Neck Fracture AP




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


Occasionally need to do closed reduction

- pressure on skin

- vascular compromise

- patient severely injury



- flex knee to relax gastrocnemius

- traction on plantarflexed foot to realign head and body

- varus / valgus correct as required

- place temporary percutaneous K wires


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 and open fractures

- recommend is reasonable to wait for swelling to subside


Sanders 2004 JBJS Am

- similar conclusion

- 29 patients

- delay in surgery did not affect union or AVN rates


Surgical Technique


1.  Closed Type 2 - 4



- supine on radiolucent table

- tourniquet, IV Abx, II available



- 2 incision technique



- just medial to T anterior tendon 

- begin at TNJ

- can extend to MM

- no stripping of dorsal neck

- preserve deep deltoid for blood supply

- may require medial malleolar osteotomy

- in this case can curve incision up and around medial malleolus



- allows assessment of reduction

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

- lateral to EDL, mobilise EDB

- > 7 cm skin bridge

- expose lateral talar neck


Reduce and ORIF

- only accept anatomical reduction

- avoid varus and shortening medial neck

- anteromedial and anterolateral K wires

- insert proximal to articular surface of head

- aim into posterior body

- parallel

- check II

- cannulated lag screws (titanium for future MRI)

- minifragment screws for osteochondral fragments


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

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)