Progressive collapsing foot deformity (PCFD) is pathological condition consisting of various deformities in foot and ankle which can be rigid or flexible. Recently Consensus Group of American Orthopaedic Foot and Ankle society gave classification system on PCFD (I- Flexible, II- Rigid, A- Hindfoot valgus, B- Midfoot/ Forefoot abduction, C- Forefoot varus, D- Peritalar subluxation, E- Ankle instability). We have done prospective study to see reliability of new classification system in Asian population.
Methods: This was a single centered, prospective study conducted from April 2021 to March 2022. Patients with PCFD were classified according to the Consensus group classification. Patients below 18 yrs, with previous foot surgery and peripheral neuropathy were excluded. Total of 50 feet in 38 patients were included and assessed clinico-radiologically. Frequencies of each Stage and Class were assessed.
Results: Mean age was 57.9 years. 68% patients were female while 32% were male. Most common group was IABC(46%) followed by IAC(24%) and IABCD(18%). Most common class was A(92%) followed by Class C(80%). One patient had class C deformity with hindfoot varus clinically which doesn’t fit into new classification.
Conclusion: Most of the patients had deformity of Hindfoot valgus with different combination of Midfoot and Forefoot deformity. Subtalar Joint involvement and Ankle Joint involvement were in lower proportion. The new system of classification does cover most of the possible combination of deformities. We observed deformity like hindfoot varus seen in some of our patients doesn’t fits in classification, which has some scope of change to apply for Asian population.

A novel-designed embedded calcaneal plate specially designed for medial displacement calcaneal osteotomy (MDCO) in the surgical correction of flatfoot. This study is aimed to investigate the biomechanical differences accompanied by diagonal screw numbers on the embedded calcaneal plate using finite element analysis. Four groups including normal calcaneus, non-diagonal screw, one-diagonal screw, and two-diagonal screws groups were set depending on the varied diagonal screw number. Under a simulated 450 N load on anterior calcaneus for testing, the stress on the calcaneal cortical and cancellous bone surrounding the implant, the plate as well as screws and the overall stability in different groups were evaluated. The worst overall stability and very high stress concentration in non-diagonal screws group were noted on the cortical (62.774 MPa) and cancellous bone (43.98 MPa) around the embedded tail of the plate, on the plate (694.55 MPa) and screws (2627.10 MPa), respectively. In comparison to one-diagonal screw group, the stress of two-diagonal screw group was significant lower on surrounding cortical bone, cancellous bone of calcaneus and the plate by 36.4%, 50.8% and 40.1%, respectively. For reducing the stress concentration on the implant as well as its surrounding bone and enhancing the overall stability, one diagonal screw is necessary and sufficient even if two diagonal screws design is superior to the non or one-screw designs.

Background: Arthrodesis and total ankle arthroplasty have emerged as the favoured surgical interventions for end stage ankle osteoarthritis. An emerging treatment option is distraction arthroplasty, which involves separation and unloading of the ankle joint, using an external fixator. This systematic review aims to evaluate the outcomes of distraction arthroplasty in ankle osteoarthritis, guiding clinicians as to whether it represents an effective management option in such patients. Methods: A systematic review was performed according to PRISMA guidelines. An electronic search was conducted in PubMed, Cinahl, Embase, Scopus and ISI Web of Science. Title/abstract and full text screening was performed independently by two reviewers. English language case series, cohort studies and randomised control trials evaluating patient reported outcome measures or re-operation rate in patients undergoing distraction arthroplasty were included. Quality assessment was performed using The Methodological Index for Non-Randomized Studies (MINORS). Results: Of the 15 studies included in this review, all those reporting clinical outcome scores reported significant (P<0.05) improvements in these scores. However, this does not necessarily reflect the clinical outcome, with most studies reporting inconsistent improvements, often below minimally clinically important difference (MCID). Although minor superficial infections were the most common complication, up to 52% of patients required conversion to arthrodesis or ankle arthroplasty Conclusions: Given the inconsistent improvements in outcome measures, which are likely inflated by substantial bias, together with high rates of conversion to arthroplasty /arthrodesis, we suggest distraction arthroplasty is not an effective operative intervention for ankle osteoarthritis and should not be used in clinical practice

Background
Displaced intra-articular calcaneal fractures (DIACF) are complex injuries requiring surgical fixation. Percutaneous fixation of these fractures have been developed to reduce high rates of post-operative complications. This systematic review assessed if percutaneous fixation, compared to open fixation techniques, have better clinical outcomes. Primary outcome measures were functional outcome scores, pain scores and complication rates. Secondary outcomes were mechanisms of injury and comparing sinus tarsi approach (STA) with extended lateral approach (ELA).
Method
A literature search of Pubmed/Medline, Embase and Cochrane were performed according to PRISMA guidelines. 81 articles were found, 8 of which met the inclusion criteria. Paediatric studies, open fractures, case reports and studies with follow up <1yr, were excluded.
Results
A total of 539 patients were included, totalling 581 fractures. 390 patients underwent percutaneous fixation. The majority of patients were male (70%) and the mean age was 40 years old. There was no significant differences in mean functional outcome scores between percutaneous and open procedures. Pain scores were significantly lower in the percutaneous groups. The most common post operative complication was wound complications, with significantly less wound complications in percutaneous groups when compared to open. The most common mechanism of injury was a fall from height. Higher rates of post-operative complications were reported with STA (27.8%, 28.9%) compared to ELA (20.8).
Conclusions
Less invasive percutaneous fixation techniques have reduced levels of post-operative pain and trends towards better functional outcomes when compared to open fixation treatment of DIACFs.

INTRODUCTION: In the past few years, there has been many discussions about the tendency to treat Achilles tendon ruptures conservatively rather than operatively. The aim of this retrospective study was to investigate the consistency of this recent tendency, with a detailed analysis of the gap threshold for surgical treatment. METHODS: We analysed 190 cases at Southampton University Hospital, age group from 17 onward, both sexes treated and/or followed for minimum 12 months. The side, type of treatment, outcome, presence of previous tendinosis and re rupture data was collected and analysed. RESULTS: From January 2016 to July 2020 (4years and 6 months) 136 (71.6%) were treated conservatively (various techniques), 54 (28.4%) were treated surgically (34 end-to-end, 18 percutaneous, 3 V-Y plasty). There were 8 re-ruptures; two a few weeks after repair, six following non-operative treatment; there was one infection and one dehiscence. One DVT with conservative treatment. Mean age was 51.9 years, males:female – 78.9%:21.1%. Left sided ruptures in 107 (56.3%) and right sided in 83 (43.7%). Gaps on scans were from 2-50mm. Most patients were able to single tip toe after 3 months. Previous tendinosis did not imply surgery.
CONCLUSION/FINDINGS: This study agrees that any method of conservative treatment has very good results in the short term outcome for ruptures with a gap of up to 3cm measured either clinically or, mostly during a scan. We suggest an extended conservative treatment indication of gaps in neutral postion between 2-3cm. A prospective study is needed to confirm this.

Introduction: Virtual fracture clinics (VFC) have reduced pressures on trauma services. There is paucity of evidence to support the use of a VFC model in the management of 5th metatarsal fractures; treatment remains controversial. This study aims to assess management of 5th metatarsal fractures via VFC analysing safety, cost-effectiveness, satisfaction levels, clinical and patient reported outcome measured (PROMS). Methods: Patients presenting to VFC at our major trauma centre with a 5th metatarsal base fracture between January 2019 and December 2019 were included. Patient demographics, clinic attendances, complication and operative rates were analysed. Patients received standardised VFC treatment; walker boot/full weight bearing, rehabilitation information and instruction to contact VFC if pain post 4 months. Minimum follow-up was one year; Manchester-Oxford Foot Questionnaires were distributed. Cost analysis was performed. Results: 126 patients met criteria. Average time to VFC review was 2 days. Fractures were classified according to the Lawrence and Botte Classification with 104 (82%) Type 1 fractures, 15 (12%) Type 2 fractures and 7 (6%) Type 3 fractures. At VFC, 125/126 were discharged. 12 patients (9.5%) arranged further follow-up after initial discharge; 75% regarding pain. There was 1 non-union identified. Average MOXFQ score post 1 year was 0.4/64, with only 11 patients scored more than 0. 252 clinic visits were saved with an approximate cost saving of £40,000. Conclusion: Our study supports the management of 5th metatarsal base fractures in the VFC setting. With a well-defined protocol it is safe, efficient, cost effective and yields good short term patient centred outcomes.

Introduction: The aim of this study was to investigate the potential biomechanical benefit of joint fusion under dynamic loading in a TMT-1 human anatomical model using low-profile superelastic shape-memory Nitinol staples used as continuous compression implants (CCI) as compared to screws and locked plating. Methods:Thirty-two human anatomical lower legs were randomized to four groups for TMT-1 joint fusion using (1) crossed-screws in standard fashion, (2) plate-and-screw technique, (3) two two-leg staples placed orthogonally to each other, and (4) one two-leg staple and one four-leg staple placed orthogonally to each other. Each specimen was biomechanically tested under
progressively increasing cyclic loading until failure, accompanied by motion tracking. Results: Adduction and dorsiflexion movements at the TMT-1 joint in unloaded foot condition was associated with no significant differences among the groups, p≥0.13. In contrast, the amplitude of these movements between unloaded and loaded foot conditions within each cycle was significantly greater for the two CCI fusion techniques compared to both crossed-screws and plate-and-screw techniques, p≤0.04. Displacements at the superior and inferior aspects of the TMT-1 joint in unloaded foot condition, together with their amplitudes between unloaded and loaded foot conditions within each cycle, did not differ significantly among the groups,
p≥0.22. Conclusion: From a biomechanical perspective, the low-profile superelastic shape-memory Nitinol staples used for more elastic stabilization under active compression demonstrate comparable performance to established crossed-screws and plate-and-screw techniques for fusion of the first tarsometatarsal joint in an anatomical model and could allow full clinical joint coaptation by maximizing the footprint for fusion.

Abstract : Surgical treatment of neglected insertional rupture of tendoachillis is technically challenging as there is a large defect after proper debridement and scar excision. Different procedures and techniques were described for management of such patients. The aim of this study was to evaluate the functional outcomes of management of 13 patients presented with neglected insertional rupture of tendoachillis by Achilles' tendon turndown with flexor hallucis longus (FHL) tendon transfer.
Method: Between 2018 and 2021, 13 patients with neglected insertional rupture of tendoachillis were managed by Achilles' tendon turndown with flexor hallucis longus tendon transfer. Interference screw was used for fixation of FHL tendon and titanium anchors were used for reattachment of the Achilles' tendon turndown. The mean follow up period was 15 months. Visual Analogue Scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale were used to evaluate outcome.
Results: there was significant improvement in both VAS and AOFAS Ankle-Hindfoot scales. At one year, the mean VAS score was 0. The mean AOFAS Ankle-Hindfoot score was 95±10. The mean operative time was 90±15 minutes. Two cases had superficial wound infection that were managed by repeated dressing and antibiotic therapy.
Conclusion: Achilles' tendon turndown with flexor hallucis longus tendon transfer is a reliable and effective method in the management of Neglected Insertional Rupture of Tendoachillis.
Keywords: Flexor hallucis transfer, Achilles' turndown, Neglected Tendoachillis rupture.

Introduction: These Fractures are one of the most commonly diagnosed in the foot, they account for about 60% in total foot fractures, 90% of these are in Zone 1 that heal with conservative treatment with no complications, the rest (Zone 2&3) may require surgery. Follow ups mostly were unnecessary. This paper offers a protocol and guidance for that based on retrospective data collected in our hospital. Objectives: We aim to improve and simplify treatment process of these fractures by creating a protocol for Accident and Emergency (A&E) doctors and a patient self-treatment guide leaflet. Study Design & Methods: We identified 47 cases throughout 7 months, only one required surgery, the reminder conservative treatment. All were initially seen in A&E then referred to fracture clinic follow-ups, that resulted in occupying slots, mostly with no further imaging needed. By repeating the same simple instructions that we created on patient leaflets; most referred to physiotherapy could've be done by the patients themselves if instructed. Results: Most patients were eligible according to our protocol for discharge when seen first time in A&E, only 4 should have had further specialist follow up. Conclusion: We believe that a clear simplified written protocol for treatment decision for A&E doctors, in addition to self-care leaflets provided to patients in order to secure a safe recovery would result in reducing unnecessary patient flow in clinics, save them time and redirect financial as well as human resources to other health issue needs and massively improve the quality of patient care. 

Objective： To investigate the effect of minimally invasive osteotomy and tibial transverse transport technique（TTT） combined with ATLP on limb salvage and functional reconstruction in Wagner Stage 4 diabetic foot patients. Methods：From October 2017 to January 2021, 10 patients with diabetic foot who received limb salvage and functional reconstruction therapy in our department were selected. All patients were Wagner Stage 4. After thorough debridement, minimally invasive osteotomy of the upper tibia and transverse transport was performed, and we use an ALTP to repair soft tissue defect. Meanwhile, NPWT and Ilizarov techniques were combined. Results：Limbs were salvaged successfully in all 10 patients, and all flaps survived. No complications such as tibial fracture and nonunion occurred. The patients were followed up for 12-48 months, and the limb function was satisfactory without pain. One patient developed foot ulcer again 2 years later and healed after dressing change therapy. Conclusion：Tibial transverse transport can effectively improve blood flow of diabetic foot in a short term, TTT combined with ALTP can be used for limb salvage treatment of diabetic foot with severe ulcer and infection. Minimally invasive osteotomy can reduce fracture and other complications.Keywords: diabetic foot, limb salvage and reconstruction, ALTP，tibial transverse transport