Anthony Perera

The pathogenesis of hallux valgus.

The first ray is an inherently unstable axial array that relies on a fine balance between its static (capsule, ligaments, and plantar fascia) and dynamic stabilizers (peroneus longus and small muscles of the foot) to maintain its alignment. In some feet, there is a genetic predisposition for a nonlinear osseous alignment or a laxity of the static stabilizers that disrupts this muscle balance. Poor footwear plays an important role in accelerating the process, but occupation and excessive walking and weight-bearing are unlikely to be notable factors. Many inherent or acquired biomechanical abnormalities are identified in feet with hallux valgus. However, these associations are incomplete and nonlinear. In any patient, a number of factors have come together to cause the hallux valgus. Once this complex pathogenesis is unraveled, a more scientific approach to hallux valgus management will be possible, thereby enabling treatment (conservative or surgical) to be tailored to the individual.

Consensus in chronic ankle instability: Aetiology, assessment, surgical indications and place for arthroscopy

Ankle sprains are the most common injuries sustained during sports activities. Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. This paper summarises a consensus on identifying which patients may require surgery, the optimal surgical intervention along with treatment of concomitant pathology given the evidence available today. It also discusses the role of arthroscopic treatment and the anatomical basis for individual procedures.

Calcaneal Osteotomy in the Treatment of Adult Acquired Flatfoot Deformity

Calcaneal osteotomies are an essential part of our current armamentarium in the treatment of AAFD. Soft tissue correction or bony realignment alone have failed to adequately correct the deformity; therefore, both procedures are used simultaneously to achieve long-term correction. Medial displacement and lateral column lengthening osteotomies in isolation or in combination and the Malerba osteotomy have been employed along with soft tissue balancing to good effect by various authors. The goal is to create a stable bony configuration with adequate soft tissue balance to maintain dynamic equilibrium in the hindfoot. In “pronatory syndromes,” the relation of the osteotomy to the posterior subtalar facet modifies the biomechanics of the hindfoot in different ways. Anterior calcaneal osteotomies correct deformities in the transverse plane (forefoot abduction), whereas posterior tuberosity osteotomies result in “varization” of the calcaneus and correct the frontal plane deformity. The choice of osteotomy depends on the plane of the dominant deformity. If the subtalar axis is more horizontal than normal, transverse plane movement is cancelled out and the frontal plane eversion–inversion is predominant. The patient presents with marked hindfoot valgus without significant forefoot abduction. Conversely, if the subtalar axis is more vertical than normal, transverse plane movement is predominant and the patient presents with forefoot abduction and instability of the medial midtarsal joints, although without significant hindfoot valgus. In this situation, a lateral column lengthening procedure is recommended to decrease the uncovering of the talar head and improve the height of the arch while correcting the forefoot abduction. With a predominant frontal plane deformity, medialization of the calcaneal tuberosity is used to displace the calcaneal weight bearing axis medially, aligning it with the tibial axis and restoring the function of the gastrosoleus as a heel invertor. An essential prerequisite for this is the absence of arthritis affecting the subtalar joint. The Achilles tendon may need to be lengthened at the same time.

Radiological assessment of metatarsus adductus

Metatarsus adductus is the most common congenital foot abnormality. Whilst there is a growing body of evidence describing many aspects of this condition, basic questions regarding aetiology, management and treatment remain controversial. Diagnosis is achieved with clinical and radiological examination. The latter is particularly important for the diagnosis of mild cases. An extensive literature review is presented outlining the development of various radiological methods of angular measurement used in the diagnosis and classification of metatarsus adductus. In addition, the review highlights a spectrum of values obtained for each angle and the validity were reported.

Reliability of metatarsus adductus angle and correlation with hallux valgus

BACKGROUND Metatarsus adductus is a common congenital foot deformity. Variable prevalence values were reported using different techniques in different populations. Numerous radiological measurements have been proposed to assess this deformity with a paucity of studies reporting the reliability of these methods. The metatarsus adductus angle was shown to correlate with the severity of hallux abductovalgus in normal feet and preselected populations of juvenile hallux valgus. MATERIALS AND METHODS Weight bearing dorsoplantar radiographs of 150 feet were examined for 5 angles commonly used in assessing metatarsus adductus: angle between the second metatarsus and the longitudinal axis of the lesser tarsus (using the 4th or 5th metatarso-cuboid joint as a reference), Engels angle and modified Engles angle. The prevalence of metatarsus adductus was assessed according to published criteria for different techniques. Inter and intra-observer reliabilities of these angles were evaluated on 50 X-rays. Linear regression tests were used to assess the correlation between hallux valgus and different angles used in assessing metatarsus adductus. RESULTS Intraclass correlation coefficients were high for intra- as well as inter-observer reliability for the 5 angles tested. Prevalence of metatarsus adductus ranged (45-70%) depending on the angle used in the same population. Only the metatarsus adductus angle using the 4th metatarso-cuboid joint as a reference demonstrated significant correlation between metatarsus adductus and hallux abductovalgus angles. CONCLUSION Five techniques commonly used in assessing metatarsus adductus demonstrated high inter and intra-observer reliability values. Prevalence of metatarsus adductus and the correlation between the severity of this deformity and hallux valgus angle is sensitive to the assessment method.

The Effect of Lower Limb Cast Immobilization on Calf Muscle Pump Function A Simple Strategy of Exercises Can Maintain Flow

Background: We have investigated the role of the calf muscle pump in casted patients. An audit of venous thromboembolism (VTE) in casted patients showed that the thrombosis occurred in the casted leg; this has not been previously assessed. We postulated that local factors play a major role, and we set out to assess the calf muscle pump in casted patients and to determine whether this can be optimized despite below-knee cast immobilization. Methods: We measured the flow in the popliteal vein using a validated method of Doppler ultrasound measurement of peak velocity with and without a below-knee plaster cast. Results: We demonstrated that a simple strategy of toe and ankle exercises can maintain venous return despite below-knee cast immobilization. Conclusion: This is the first study to examine the effect of the calf muscle pump in the presence of a plaster cast. Major muscle groups such as the flexor hallucis longus and gastrocsoleus extend beyond the field of control of the cast and can still be recruited. Clinical Relevance: We recommend that all patients treated with a below-knee cast be given a program of exercises that can be comfortably performed with the cast; this could provide a useful, inexpensive, and safe thromboprophylaxis strategy acting at the site of greatest risk and targeting a major cause of VTE.

Percutaneous Ankle Reconstruction of Lateral Ligaments (Perc-Anti RoLL).

Summary Chronic ankle instability following ankle sprains causes pain and functional problems such as recurrent giving way. If non-operative treatments fail, then operative ankle stabilization may be required to improve pain and function. Operative options include both anatomic repair and reconstruction techniques. Anatomic repair techniques utilize pre-existing ligament remnants that are either reattached or tightened to improve stability of the ankle. If pre-existing ligament structures have been damaged beyond repair or are insufficient to allow repair, then it is appropriate to choose an anatomic reconstructive technique. These procedures have traditionally been performed using open techniques and have been successful in restoring function and decreasing pain. In 2005, an open anatomic reconstruction technique using a gracilis Y-graft and Inside-out technique was reported with good results. In the current paper we describe a Percutaneous Reconstruction of the Lateral Ligaments (Perc-Anti RoLL), which is a new minimally invasive surgical technique for anatomic reconstruction of the lateral ligaments of the ankle that utilizes the anatomic Y-graft and Inside-out technique. The Perc-Anti RoLL technique can be performed percutaneously using fluoroscopic guidance.

Monoarticular pseudogout of the hip presenting as septic arthritis: a case report

Calcium pyrophosphate dihydrate (CPPD) disease is the second most common crystal-induced form of arthropathy, frequently seen in the knee, shoulder, wrist, elbow, and ankle. The acute form of the disorder is referred as pseudogout, which can cause a severe joint inflammation. We present a case of monoarticular pseudogout of the hip joint whose symptoms mimicked septic arthritis. The definitive diagnosis was only confirmed after the microscopic analysis of joint aspirate.

Clinical and radiographic evaluation of the cavus foot: surgical implications.

The key to successful management of the cavovarus foot is identifying the pathoanatomy and dysfunction that are driving the deformity and producing the symptoms. There is no substitute for a thorough clinical evaluation of the foot, evaluating the static alignment and dynamic function. Plain films alone are not sufficient to determine the diagnosis, but they are necessary for procedure selection and correction planning. This is especially true for assessing the degree of hindfoot varus. Some issues are difficult to diagnose, and imaging plays an important role.

Osteochondral Lesions of the Talus: Defining the Surgical Approach

It has become clear that contrary to the previously held belief that osteochondral lesions of the talus occurred anterolaterally and posteromedially, there is a much wider spread across the talus. Lesions can now be mapped by their biology and geography, and from this the ideal procedure and the ideal surgical approach can be selected. Familiarization with a range of skills, such as posterior ankle arthroscopy and malleolar osteotomies, are required to be able to perform this surgical plan.