More than 130 operations have been described for the treatment of hallux valgus. The plethora of techniques indicates that no single operation is perfect, and none will address all cases. Treatment which is poorly planned or executed leads to high levels of patient dissatisfaction. In recent years, a number of new osteotomies have been described. Determining which to use can be difficult. This review will examine the important factors in choosing the most appropriate techniques. Aetiology and pathogenesisThe wearing of constricting and high heel shoes are extrinsic factors which are important in the development of hallux valgus. 1,2 Heredity is likely to be a major predisposing factor in some patients, with up to 68% of patients showing a familial tendency. 3 The role of pes planus is complex. It is unlikely that it is an important initiating factor in hallux valgus but in the presence of pes planus the progression of hallux valgus is more rapid. This is particularly so in those patients with a compromised medial joint capsule as in rheumatoid arthritis, collagen deficiency or a neuromuscular disorder. 4 The presence of pes planus does not reduce the rate of success of operations for hallux valgus. 5,6 Hypermobility of the first tarsometatarsal joint is thought by some 7,8 to be a causative component in some cases of hallux valgus. In these patients a fusion of the first tarsometatarsal joint (the Lapidus procedure), should be considered for surgical correction as opposed to an osteotomy. There is a correlation between hypermobility of the first ray and hallux valgus, 8-10 and a higher incidence of hypermobility at this site causes a hallux valgus deformity which is painful. 8,11 The accurate clinical assessment of hypermobility of the first ray is difficult. 9 However, a recent cadaver study 12 has shown that correction of a hallux valgus deformity by a distal soft-tissue procedure and a basal crescentic osteotomy significantly reduces hypermobility of the first ray, implying that the hypermobility maybe a secondary phenomenon in some cases.The pathogenesis of hallux valgus has been well described by Stephens. 13 Weakening of the tissues on the medial side of the first metatarsophalangeal joint and erosion of the ridge on the metatarsal head between the medial and lateral sesamoids occur early (Fig. 1). The proximal phalanx drifts into valgus and the metatarsal head into varus. A groove appears on the medial side of the articular cartilage of the metatarsal head as it atrophies from the lack of normal pressure and this gives rise to the apparent prominence of the medial exostosis. The medial bursa develops in response to the excessive pressure of shoes over this prominence. As the soft tissues on the medial side become further attenuated, the metatarsal head moves medially so that the medial sesamoid lies under the eroded metatarsal ridge and the lateral sesamoid articulates with the lateral side of the metatarsal head in the first intermetatarsal space. The tendons of extensor hallucis longus and flexor halluci...

We performed two independent, randomised, controlled trials in order to assess the potential benefits of immediate weight-bearing mobilisation after rupture of the tendo Achillis. The first trial, on operatively-treated patients showed an improved functional outcome for patients mobilised fully weight-bearing after surgical repair. Two cases of rerupture in the treatment group suggested that careful patient selection is required as patients need to follow a structured rehabilitation regimen. The second trial, on conservatively-treated patients, provided no evidence of a functional benefit from immediate weight-bearing mobilisation. However, the practical advantages of immediate weight-bearing did not predispose the patients to a higher complication rate. In particular, there was no evidence of tendon lengthening or a higher re-rupture rate. We would advocate immediate weight-bearing mobilisation for the rehabilitation of all patients with rupture of the tendo Achillis.

Infrared neural stimulation (INS) has received considerable attention over the last few years. It provides an alternative method to artificially stimulate neurons without electrical current or the introduction of exogenous chromophores. One of the primary benefits of INS could be the improved spatial selectivity when compared with electrical stimulation. In the present study, we have evaluated the spatial selectivity of INS in the acutely damaged cochlea of guinea pigs and compared it to stimulation with acoustic tone pips in normal hearing animals. The radiation was delivered via a 200 μm-diameter optical fiber, which was inserted through a cochleostomy into the scala tympani of the basal cochlear turn. The stimulated section along the cochlear spiral ganglion was estimated from the neural responses recorded from the central nucleus of the inferior colliculus (ICC). ICC responses were recorded in response to cochlear INS using a multichannel penetrating electrode array. Spatial tuning curves were constructed from the responses. For INS, approximately 55% of the activation profiles showed a single maximum, ~22% had two maxima, and ~13% had multiple maxima. The remaining 10% of the profiles occurred at the limits of the electrode array and could not be classified. The majority of ICC spatial tuning curves indicated that the spread of activation evoked by optical stimuli is comparable to that produced by acoustic pips.

W e studied 54 patients operated on for combined supraspinatus and infraspinatus rotator-cuff tears. The presence or absence of the dropping and hornblower's clinical signs of impaired external rotation were correlated with Goutallier stage-3 or stage-4 fatty degeneration of infraspinatus and teres minor. These grades of fatty degeneration have previously been correlated with a poorer outcome from reconstructive surgery. We found that hornblower's sign had 100% sensitivity and 93% specificity for irreparable degeneration of teres minor and the dropping sign 100% sensitivity and 100% specificity for similar degeneration of infraspinatus. In seven patients, teres minor showed hypertrophy. This muscle can give useful function for the activities of daily living in patients with rotator-cuff tears in whom it is intact.

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