Does foot shape really matter? Correlation of patient reported outcomes with radiographic assessment in progressive collapsing foot deformity reconstruction: A systematic review.

BACKGROUND: In progressive collapsing foot deformity (PCFD), the goal of surgery is to obtain a well-balanced plantigrade foot. It remains unclear if restoration of the alignment and subsequent improvement in radiological parameters is associated with improved patient-reported outcome measures (PROMs). The aim of the current systematic review was to investigate whether there is a correlation between radiographic assessment and PROMs in patients treated surgically for flexible PCFD. MATERIALS AND METHODS: The study was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. A comprehensive literature search was performed in Pubmed, EMBASE, Cochrane Central Register of Controlled Trails (CENTRAL), and KINAHL. We included all the studies reporting both PROMs and radiological outcomes in patients treated surgically for PCFD. The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal tool. RESULTS: Six retrospective studies were included. Radiological parameters related to forefoot plantarflexion were associated with statistically significant differences in postoperative PROMs. A neutral hindfoot and midfoot position was positively correlated with postoperative PROMs but a statistically significant difference could not be established in all studies. The medial arch height was positively correlated with PROMs, but in one study this was the case only in revision surgeries. CONCLUSION: The literature so far suggests restoration of the alignment may be associated with improved PROMs. Future prospective studies that investigate possible radiological and clinical correlations in PCFD surgery are needed. LEVEL OF EVIDENCE: III.

Systematic review of tendon transfers in the foot and ankle using interference screw fixation: Outcomes and safety of early versus standard postoperative rehabilitation.

AIMS: To compare the outcomes of early and standard rehabilitation protocols following tendon transfers in the foot and ankle using interference screw fixation (ISF). METHODS: A systematic review was performed for relevant articles (1998 to 2020) reporting foot tendon transfer using ISF in adults. The primary outcome was early tendon failure. Secondary outcomes included function and complications. RESULTS: In total, 21 studies met the inclusion criteria, totalling 494 patients. Seven studies reported early rehabilitation protocols. The rate of early tendon failure was zero for each protocol and studies consistently reported a significant improvement in function. No differences were found comparing different rehabilitation protocols for tendon transfer for Achilles tendon pathology and foot drop. CONCLUSION: Both early and standard rehabilitation protocols are associated with high patient satisfaction and low complication rates, but currently there is a lack of evidence to support early loaded activities or motion. LEVEL OF EVIDENCE: IV Systematic review including case series.

A Prospective Evaluation of First Metatarsophalangeal Fusion Using an Innovative Dorsal Compression Plating System.

Numerous techniques have been described for first metatarsophalangeal joint (MTPJ) fusion. The aim of this study was to prospectively evaluate an innovative plating system which uses a cross plate compression screw. Thirty consecutive first MTPJ fusions in 28 patients were evaluated. All procedures were performed by a single fellowship trained consultant foot and ankle surgeon. Patient function was evaluated preoperatively at 6 and at 12 months using the Manchester-Oxford Foot Questionnaire (MOXFQ). Union rates and complications were recorded. Postoperative MOXFQ scores demonstrated significant improvement in all domains, with mean improvement at 12 months of 35, 27, 17 and 106 points for pain, walking/standing, social interactions and combined scores respectively (p value ≤.0001). In all 30 cases, clinical and radiological evidence of union was achieved by 6 months. Superficial infection occurred in 1 (3%) case. One (3%) case required plate removal due to soft tissue irritation. There were no plate failures. This evaluation study demonstrates that this cross-plate compression plating system is safe, provides high patient satisfaction and reliable union, with low complication rates. Prospective comparative research is now required to determine the optimal technique for first MTPJ fusion.

Simulated weight reduction using an anti-gravity treadmill - A pilot study of the impact of weight loss on foot and ankle arthritis.

BACKGROUND: Despite a paucity of evidence, obesity is frequently cited as an exacerbator of symptoms in foot and ankle arthritis. The aims of the current study were to determine whether simulated weight loss would improve symptoms in obese patients with foot and ankle arthritis. METHODS: Patients walked on an "anti-gravity" treadmill allowing simulated weight reduction. Pain was recorded at baseline weight and then compared with pain at simulated normal BMI. RESULTS: Simulated reduction to BMI 25 caused a significant reduction in pain. Mean pain scores improved from baseline to BMI 25 by 32% (15.9 points, p=0.04). Paired analysis showed a significant improvement in pain scores (p=0.016) from BMI of 30 to 25. CONCLUSION: Simulated weight loss from high to normal BMI improved arthritic symptoms. This could be used to power future studies to further investigate the effects of weight loss in foot and ankle patients. Level of evidence Level II - repeated measures cohort study.

Delayed stabilisation of dynamically unstable syndesmotic injuries results in worse functional outcomes.

PURPOSE: Patients with primarily ligamentous injuries of the distal tibiofibular joint comprise up to 12% of all ankle sprains. Patients frequently present late after a syndesmosis injury and delayed treatment potentially leads to pain, prolonged disability and arthritis in the long term. This study aimed to assess clinical outcomes in patients who required syndesmosis fixation in the presence of arthroscopically proven instability, the hypothesis being that a delay to treatment would be associated with worse function. METHOD: A retrospective cohort study was performed of patients with dynamic instability requiring fixation between the years of 2010-2016. The procedures were performed by two foot and ankle fellowship trained orthopaedic surgeons, over three hospital sites. Patients were classified into three groups based on the time since injury to surgery, acute syndesmotic injury (< 6 weeks), sub-acute (6 weeks-6 months) and chronic syndesmotic injury (> 6 months). Functional scores were retrospectively collected using the Foot and Ankle Outcome Score (FAOS). RESULTS: Compared to patients with acute injuries, those with chronic injuries had significantly lower FAOS subscales (p < 0.001), with the greatest difference in quality of life (- 20.7, 95% CI - 31.6 to - 9.8, p = 0.012). There was a mean follow-up of 4.3 years. Although the average FAOS subscales in those with sub-acute injuries were lower than in those with acute injuries, the difference was not statistically significant. CONCLUSION: The results of this study suggest that delayed surgical stabilisation (> 6 months) is associated with significantly worse clinical function, and thus timely identification and early referral of those patients with potentially unstable syndesmotic injuries is recommended. LEVEL OF EVIDENCE: Level III.

Flexor digitorum longus tendon transfer to the navicular: tendon-to-tendon repair is stronger compared with interference screw fixation.

PURPOSE: To assess whether early rehabilitation could be safe after flexor digitorum longus (FDL) tendon transfer, the current biomechanical study aimed to measure tendon displacement under cyclic loading and load to failure, comparing a traditional tendon-to-tendon (TT) repair with interference screw fixation (ISF). METHODS: 24 fresh-frozen cadaveric below knee specimens underwent FDL tendon transfer. In 12 specimens a TT repair was performed via a navicular bone tunnel. In a further 12 specimens ISF was performed. Using a materials testing machine, the FDL tendon was cycled 1000 times to 150 N and tendon displacement at the insertion site measured. A final load to failure test was then performed. Statistical analysis was performed using two-way ANOVA and an independent t test, with a significance level of p < 0.05. RESULT: No significant difference in tendon displacement occurred after cyclic loading, with mean tendon displacements of 1.9 ± 1.2 mm (mean ± SD) in the TT group and 1.8 ± 1.5 mm in the ISF group (n.s.). Two early failures occurred in the ISF group, none in the TT group. Mean load to failure was significantly greater following TT repair (459 ± 96 N), compared with ISF (327 ± 76 N), p = 0.002. CONCLUSION: Minimal tendon displacement of less than 2 mm occurred during cyclic testing in both groups. The two premature failures and significantly reduced load to failure observed in the ISF group, however, indicate that the traditional TT technique is more robust. Regarding clinical relevance, this study suggests that early active range of motion and protected weight bearing may be safe following FDL tendon transfer for stage 2 tibialis posterior tendon dysfunction.

MRI for high ankle sprains with an unstable syndesmosis: posterior malleolus bone oedema is common and time to scan matters.

PURPOSE: Early clinical examination combined with MRI allows accurate diagnosis of syndesmosis instability after a high ankle sprain. However, patients often present late. The aims of the current study were to describe MRI characteristics associated with syndesmosis instability and to test the hypothesis that MRI patterns would differ according to time from injury. METHODS: Over a 5-year period, 164 consecutive patients who had arthroscopically proven syndesmosis instability requiring fixation were retrospectively studied. Patients with distal fibula fractures were not included. Injuries were classified as acute in 108 patients (< 6 weeks), intermediate in 32 (6-12 weeks) and chronic in 24 patients (> 12 weeks). RESULTS: Posterior malleolus bone oedema was noted in 65 (60.2%), and posterior malleolus fracture in 17 (15.7%) of acute patients, respectively, which did not significantly differ over time. According to MRI, reported rates of posterior syndesmosis disruption significantly differed over time, observed in 101 (93.5%), 28 (87.5%) and 13 (54.2%) of acute, intermediate and chronic patients, respectively (p < 0.001). Apparent rates of PITFL injury significantly reduced with time (p < 0.001). CONCLUSIONS: MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. The clinical relevance of this study is that posterior malleolus bone oedema may be the only marker of a complete syndesmosis injury and can help clinically identify those injuries which require arthroscopic assessment for instability. If suspicious of a high ankle sprain, we advocate early MRI assessment to help determine stable versus unstable injuries as MRI becomes less reliable after 12 weeks. LEVEL OF EVIDENCE: III.

Early return to playing professional football following fixation of 5th metatarsal stress fractures may lead to delayed union but does not increase the risk of long-term non-union.

PURPOSE: 5th metatarsal stress fractures are frequently encountered in professional football. There is concern that early return to play following intra-medullary screw fixation may lead to an increased risk of delayed union. The purpose of the study was to assess whether an early return to play after surgical fixation of 5th metatarsal fractures in professional football players is a risk factor for delayed union and the effect of this on the ultimate clinical outcome. METHODS: Retrospective review of prospectively collected data of a series of 37 professional football players following intramedullary screw fixation of 5th metatarsal stress fractures. End points included time of return to play and to radiological union of the fracture. RESULTS: At a minimum follow-up of 24 months the mean return to play was 10.5 weeks and mean time to complete radiological union was 12.7 weeks. Return to play at 8 weeks or less resulted in a higher risk of delayed radiological union (24% at 3 months), but this neither prevented the athlete from continuing to play football nor did it affect the ultimate risk of non-union (3% overall). A re-fracture occurred in 1 patient (3%) at 10 months who previously had complete radiographic union at 9 weeks. CONCLUSION: Intramedullary screw fixation of 5th metatarsal stress fractures leads to a predictable time of return to play and a low rate of non-union. If players return to play at 8 weeks or less a persistent line may be expected in up to a quarter of patients. However, if asymptomatic this radiological finding does not mean that athletes must avoid playing football as ultimately a good outcome is expected with low rates of non-union and refracture. LEVEL OF EVIDENCE: Case series, Level IV.

Minimally Invasive Tendon Release for Symptomatic Accessory Soleus Muscle in an Athlete: A Case Report.

The accessory soleus muscle can pose a diagnostic dilemma for exertional ankle pain, especially in athletes. Once diagnosed, the current treatment options require an extensile approach and can be associated with substantial risk and a slow recovery. We describe a minimally invasive, safe method that has proved successful in our practice.

Full text publication rates of papers presented at the British Foot and Ankle Society.

BACKGROUND: Techniques in foot and ankle surgery have expanded rapidly in recent years, often presented at national society meetings. It is important that research is published to guide evidence based practice. Many abstracts however do not go on to full text publication. METHODS: A database was created of all abstracts presented at BOFAS meetings from 2009 to 2013. Computerised searches were performed using PubMed and Google search engines. RESULTS: In total 341 papers were presented, with an overall publication rate of 31.7%. Of 251 clinical papers, 200 were case series (79.6%). Factors associated with publication success included basic science studies, papers related to arthroscopic surgery and research performed outside the UK. CONCLUSION: A relatively low conversion rate from presentation to publication could be as a result of papers failing to pass the scrutiny of peer review, or that the work is never formally submitted for publication. The information from this study could be used to prioritise future research and promote higher quality research.

Fusion of the First Metatarsophalangeal Joint: Precontoured or Straight Plate?

Precontoured, low-profile plates with fixed dorsiflexion angles are becoming increasingly popular for first metatarsophalangeal joint fusion. We have concerns that the routine use of a precontoured plate can lead to excessive clinical dorsiflexion. The aim of our study was to investigate the relationship between the first metatarsophalangeal joint dorsiflexion intramedullary angle and the angle formed at the dorsal cortices where the plate is applied. We hypothesized that the dorsal cortical angle was significantly less dorsiflexed than the intramedullary angle. We measured both angles on lateral weightbearing radiographs of 40 consecutive individuals presenting with forefoot symptoms. The results demonstrated that the mean dorsal cortical angle was significantly smaller (mean 0.2° plantarflexion) compared with the intramedullary angle (mean 10.6° dorsiflexion; p < .001). The interobserver and intraobserver reliability of both the intramedullary and the dorsal cortical measurements was very good. In conclusion, the dorsal cortical angle is, on average, 10.8° smaller than the intramedullary angle, with a mean angle of almost 0°. This finding should be considered when selecting plates for first metatarsophalangeal joint fusion.

Biomechanical analysis of posterior intrafocal pin fixation for the pediatric supracondylar humeral fracture.

BACKGROUND: Controversy remains regarding the optimal fixation for displaced pediatric supracondylar humeral fractures. The clinical results of a recently described technique using a posterior intrafocal pin have been good to excellent. The aim of our study was to compare, in a cadaveric model, the stiffness provided by posterior intrafocal pin fixation versus crossed medial and lateral pin fixation and divergent lateral entry pin fixation for the treatment of Gartland-Wilkins type 3 supracondylar humeral fractures. METHODS: In 15 pairs of nonosteoporotic adult cadaver specimens, simulated Gartland-Wilkins type 3 supracondylar fractures were created and stabilized using: (1) the posterior intrafocal pin method; (2) medial and lateral crossed pins; or (3) 2 divergent lateral entry pins. Specimens were then subjected to internal rotation to measure the fixation stiffness of each construct. The effects of treatment and cycle number on torsional stiffness and peak torque were assessed for significance using a linear regression model with random effects to account for specimen pairing. Significance was set at P<0.05. RESULTS: The stiffest fixation was provided by crossed pins (2.4 N m/degree), followed by divergent lateral pins (1.9 N m/degree) and the posterior intrafocal pin (1.9 N m/degree), but none of the differences was statistically significant (P>0.9). Peak torque was not significantly different between fixations, although the trend suggested that crossed pins were strongest (34.6 N m), followed by divergent lateral pins (30.3 N m) and then posterior intrafocal pin fixation (26.1 N m). CONCLUSIONS: Our results suggest that posterior intrafocal pin fixation offers resistance to internal rotation equivalent to that of crossed medial and lateral pins and divergent lateral entry pins. CLINICAL RELEVANCE: The current biomechanical study supports the use of the posterior intrafocal posterior Kirschner pin for rotationally unstable supracondylar fractures because it is not significantly more compliant than standard techniques. LEVEL OF EVIDENCE: Level III.

Biomechanical analysis of endobutton versus screw fixation after Lisfranc ligament complex sectioning.

BACKGROUND: Our goal was to compare diastasis after endobutton and screw fixation after Lisfranc ligament complex sectioning. METHODS: Twenty-four (12 pairs) fresh-frozen cadaveric feet were assigned to endobutton or screw fixation and loaded to 343N. Displacement (first-second metatarsal bases) was measured in intact feet and after ligament sectioning (Lisfranc, medial-intermediate cuneiform ligaments), fixation, and 10,000 cycles. RESULTS: The mean change in diastasis for endobutton and screw fixation under initial loading was 1.0mm (95% CI, 0.2-1.9mm) and 0.0mm (95% CI, -0.4 to 0.4mm), respectively (p=0.017). After cyclic loading, diastasis decreased (mean, -0.7mm, 95% CI, -1.2 to -0.1mm) in the endobutton group but was unchanged in the screw group (p=0.035). CONCLUSIONS: Diastasis after endobutton fixation was significantly greater than after screw fixation under initial loading but did not increase further after cyclic loading.

The saphenous nerve in foot and ankle surgery: its variable anatomy and relevance.

BACKGROUND: Several studies have raised doubt regarding the role of the saphenous nerve (SN) in the foot, and some authors omit the SN from ankle blocks. Our aim was to assess the SN anatomy with reference to foot and ankle surgery. METHODS: In 29 cadaveric feet the SN was traced to its termination. At the ankle, the distances from the SN to the tibialis anterior tendon (TAT) and the long saphenous vein (LSV) were recorded. RESULTS: In 24 specimens, a SN was present at the ankle, and in 19 specimens extended to the foot. The mean distances from the nerve to the TAT and LSV were 15 mm and 4mm respectively. The nerve reached the first metatarsal (MT) in 28% of specimens. CONCLUSION: Although the SN anatomy is less extensive than previously described, it often reaches the first MT and therefore should routinely be included in ankle blocks for forefoot surgery.

Nonoperative management of lisfranc injuries - A systematic review of outcomes.

BACKGROUND: Historically, most Lisfranc injuries have been considered to be unstable and treated with surgical intervention. However, with better access to cross-sectional imaging, stable injury patterns are starting to be recognised. The aims of the current study were to perform a systematic review of outcomes of Lisfranc injuries treated non-operatively. METHODS: A literature review was performed of studies reporting nonoperative management of Lisfranc injuries (PROSPERO registered and following PRISMA guidelines). Following exclusions, 8 papers were identified: 1 prospective and 7 retrospective studies. A total of 220 patients were studied with a mean age of 39.8 years and a mean follow-up of 4.3 years. Outcomes included function, displacement, and rates of surgery. RESULTS: High heterogeneity was observed with variable outcomes. Four papers reported good outcomes, with adjusted functional scores ranging from 82.6 to 100 (out of 100). However, one study reported late displacement in 54 % of patients. Rates of secondary osteoarthritis ranged from 5 % to 38 %. Rates of surgical intervention were as high as 56 %. Several studies compared operative to non-operative treatment, reporting superior outcomes with surgery. Those injuries with no displacement on CT, measured at the medial cuneiform-second metatarsal had the best outcomes. CONCLUSION: Reported outcomes following nonoperative treatment of Lisfranc injuries vary widely, including high rates of conversion to surgery. In contrast, some studies have reported excellent functional outcomes. CT seems to be an important diagnostic tool in defining a stable injury. Due to limited data and lack of a clear definition of a stable injury or treatment protocol, prospective research is needed to determine which Lisfranc injuries can be safely treated nonoperatively.

Enhanced biomechanical stiffness with large pins in the operative treatment of pediatric supracondylar humerus fractures.

BACKGROUND: Various pin configurations have been recommended for the treatment of supracondylar humerus fractures on the basis of the choice between stability versus the risk of iatrogenic nerve injury. However, little attention has been paid to pin size. The purpose of this study was to evaluate the stability of large (2.8 mm or 0.110 inch) and small (1.6 mm or 0.062 inch) pin constructs in 6 configurations. METHODS: A transverse fracture pattern was created by sectioning synthetic humeri in the midolecranon fossa. The specimens were then reduced and pinned in one of 6 configurations: 2 small pins (Kirschner wires) placed crossed or lateral divergent, 2 large pins (Steinmann pins) placed crossed or lateral divergent, or 3 small pins placed crossed or lateral divergent. All specimens were then tested in sagittal extension bending. We investigated the effect of pin configuration and cycle on the sagittal stiffness using multiple linear regression. RESULTS: The 2 small lateral divergent pin configuration was significantly less stable than small crossed pins and large pins in a crossed or a lateral configuration. The addition of a third (lateral) pin to the small crossed pin construct made it significantly less stable than 2 large crossed pins. Although the stability between the remaining configurations was not significantly different, the 2 large crossed pins required the greatest torque to rotate the fragment 20 degrees. There was a significant reduction in torque as a function of cycle, suggesting a loss of fixation during cycling (P<0.05). CONCLUSIONS: Large pins (2.8 mm) in any configuration and the placement of small pins (1.6 mm) in a crossed configuration provided more stable reduction in sagittal extension bending than did the conventional 2 small pins in a lateral divergent pin configuration. The most stable configurations involve crossing the medial and lateral pins. CLINICAL RELEVANCE: There are more stable options than the traditional 2 small lateral pin configuration for fixation of unstable supracondylar fractures. The addition of a third pin is not always advantageous.

A Systematic Review of Outcomes Following Lisfranc Injury Fixation: Removal vs Retention of Metalwork.

Background: Following Lisfranc injury fixation, no consensus exists on whether to routinely remove metalwork. The aim of this study was to evaluate functional outcomes and complications in patients following routine removal of metalwork and in those with retained metalwork. Methods: A systematic review of literature (1999-2020) reporting results of metalwork removal vs retention following Lisfranc injury fixation, was undertaken. The primary outcome was functional outcomes at 1 year following index surgery. Secondary outcomes were rates of complications including unplanned removal of metalwork. Results: No studies directly comparing routine metalwork removal vs retention were found. A total of 28 studies reporting on 1069 patients were included. Of these, 10 studies (317 patients) reported on retention and 18 (752 patients) on routine removal of metalwork. The difference in the American Orthopaedic Foot & Ankle Society (AOFAS) score between removal and retention groups was 3.38 (95% CI 6.3-0.48), P = .02 (removal 79.97 [±16.09; 71-96]; retention 76.59 [±20.36; 65.4-94]). No difference in reported rates of infection was found between the 2 groups (0%-12% for both groups). Of the 317 patients in the retention group, metalwork was removed in 198 cases, resulting in a 62.5% unplanned removal rate. Conclusion: In conclusion, this systematic review found limited evidence comparing different strategies of metalwork management after Lisfranc injury fixation. A randomized controlled trial is necessary to elucidate if routine removal of metalwork confers any true benefit. Level of Evidence: Level IV, systematic review including case series.

Arthroscopically assisted fixation of glenoid fractures: a cadaver study to show potential applications of percutaneous screw insertion and anatomic risks.

BACKGROUND: Displaced glenoid fractures require reduction and internal fixation to avoid chronic instability or degenerative changes. Arthroscopically assisted percutaneous fixation has been performed successfully for such fractures, avoiding extensive surgical dissection. To assess the application of this new technique, our cadaveric study was designed to show 1) the safe zones of percutaneous screw insertion and 2) the position of bony obstructions to the glenoid. METHODS: In 18 cadaver shoulders, we performed arthroscopically assisted percutaneous wire insertion into the glenoid using anterior, superior, and posterior approaches. After dissection, distances from wires to the relevant neurovascular structures were recorded, and 95% confidence intervals were calculated. A safe distance was defined as 15 mm. The entry point of each wire and angle of insertion relative to the glenoid clock face was also recorded. RESULTS: Superior and posterior percutaneous approaches appear to be safe, with minimal risk to the suprascapular vessels and axillary nerve, respectively. The anterior approach injured the cephalic vein in 30% of specimens, and there was a clinically significant risk to the musculocutaneous nerve and inferior branch of the suprascapular nerve. The superior portion of the glenoid is accessible by percutaneous screw insertion between the clock times 7:40 and 2:50, apart from positions occupied by the coracoid (1:05-2:00) and acromion (9:35-10:55). CONCLUSIONS: Arthroscopic fixation of complex glenoid fractures has had good outcomes in clinical case studies. This cadaveric study shows that percutaneous screw insertion is safe via superior and posterior approaches and feasible for a range of fracture configurations.

Calcaneal traction pin placement simplified: a cadaveric study.

BACKGROUND: The tibial neurovascular bundle and sural nerve are at risk with errant pin placement during transcalcaneal pin placement. The purpose of this study was to determine a relative safe zone using a single osseous landmark to establish a technique applicable in the presence of trauma. We describe the neural anatomy anatomically and radiographically, giving surgeons a reliable and relatively safe technique for transcalcaneal pin placement. MATERIALS AND METHODS: Twenty-four cadavers were dissected for the major medial neurovascular structures and the sural nerve. The closest distance from the neurovascular structures to the posterior inferior calcaneus was measured. RESULTS: The mean distance from the posterior inferior calcaneus to the closest major medial neurovascular structure was 3.4 cm (SD ± 0.36; range, 2.6 to 4.1 cm). The mean distance to the sural nerve was 3.4 cm (SD ± 0.54; range, 2.3 to 4.6 cm). According to the 95% confidence intervals, a relative safe zone of 3.1 cm as a radius from the posterior inferior calcaneus was determined. CONCLUSION: A relatively safe zone of 3.1 cm based on 95% confidence intervals as described as a radius from the posterior inferior calcaneus can be used for transcalcaneal pin placement in most cases without injury to the medial neurovascular bundle or sural nerve. However anatomic variation may result in the neurovascular bundle being within this zone. CLINICAL RELEVANCE: We describe a surgical technique for reliable placement of a transcalcaneal pin within this relative safe zone and a safe distance from the closest neurovascular structure.

Elective removal of metalwork following Lisfranc injury fixation: Results of a national consensus survey of practice.

No consensus exists regarding whether metalwork should be routinely removed following fixation of a Lisfranc injury. When metalwork is removed, notable variation in the timing of surgery is reported in current literature. With the support of the British Orthopaedic Foot & Ankle Society (BOFAS) and the Orthopaedic Trauma Society (OTS) an online 10-question survey was distributed and completed by a total of 205 consultant surgeons in the UK between April-June 2020. Excluding the 20 consultant responses from a regional pilot survey, 185 responses were used to form the main analysis. Over one third (69/183, 37.7%) of surgeons reported they routinely remove metalwork following Lisfranc injury fixation at a median time of 6 months post fixation (interquartile range 4-10). The two most commonly chosen reasons for removal of metalwork were 'to optimise physiological function' and 'to reduce the risk of broken metalwork and risk of making subsequent surgery more difficult' (55/78 responses, 70.5%). Over two thirds of survey respondents (126/184, 68.5%) expressed interest to participate in a randomised controlled trial to compare outcomes of metalwork retention versus removal following Lisfranc injury fixation. Community clinical equipoise exists nationally regarding routine metalwork removal following Lisfranc injury fixation. Considering the paucity of literature, the current survey supports the development of a randomised controlled trial to establish the risks and benefits of metalwork retention versus removal, and would be of value to foot & ankle and trauma surgeons in the UK.