This is the first series specifically assessing patients who have had repeat arthroscopic debridement of osteochondral lesions of the talus, using the same debridement technique by a single surgeon. Our results question the assumption that repeat arthroscopic debridement yields poor results. They also provide a baseline for the newer chondral and osteochondral transplantation techniques to compare to at the medium term.

Distraction bone-block arthrodesis has been advocated for the treatment of the late sequelae of fracture of the os calcis. Between 1997 and 2003 we studied a consecutive series of 17 patients who had in situ arthrodesis for subtalar arthritis after fracture of the os calcis with marked loss of talocalcaneal height. None had undergone any previous attempts at reconstruction. We assessed the range of dorsiflexion and plantar flexion and measured the talocalcaneal height, talocalcaneal angle and talar declination angle on standing lateral radiographs, comparing them with the normal foot. The mean follow-up was for 78.7 months (48 to 94). The mean American Orthopaedic Foot and Ankle Society hindfoot score improved from 29.8 (13 to 48) to 77.8 (48 to 94) (Student's t-test, p < 0.001). The mean loss of talocalcaneal height was 10.3 mm (2 to 17) and the mean talar declination angle was 6.7 degrees (0 degrees to 16 degrees) which was 36% of the normal side. One patient suffered anterior ankle pain but none had anterior impingement. Two patients complained of difficulty in ascending slopes and stairs and four in descending. The mean ankle dorsiflexion on the arthrodesed side was 11.6 degrees (0 degrees to 24 degrees) compared with 14.7 degrees (0 degrees to 24 degrees) on the normal side, representing a reduction of 21.1%. The mean plantar flexion on the arthrodesed side was 35.5 degrees (24 degrees to 60 degrees) compared with 44.6 degrees (30 degrees to 60 degrees ) on the normal side, a reduction of 20.4%. These results suggest that anterior impingement need not to be a significant problem after subtalar arthrodesis for fracture of the os calcis, even when the loss of talocalcaneal height is marked. We recommend in situ arthrodesis combined with lateral-wall ostectomy for all cases of subtalar arthritis following a fracture of the os calcis, without marked coronal deformity, regardless of the degree of talocalcaneal height loss.

Removal of hardware alone is a reasonable option to offer as a relatively minor procedure following a failed arthrodesis of the first MTPJ. This must be accepted on the proviso that in this study four out of 11 (36%) patients proceeded to a revision first MTPJ fusion or first MTPJ replacement. We also found that the rate of non-union in primary first MTPJ fusion was significantly higher in males and those patients who had undergone previous surgery.

In children with obstetric brachial plexus palsy (OBPP) who develop an internal rotation deformity of the shoulder, release of subscapularis improves the range of external rotation of the shoulder and the strength of supination of the forearm. We studied the strength of supination in 35 healthy adult volunteers at 45 degrees of both internal and external rotation. The mean and maximum torques were greater in external than internal rotation by 8.7% and 7.5%, respectively. This was highly significant (p < 0.0001). The increased strength of supination in external rotation is probably because the maximum power of biceps, particularly the long head, may be exerted in this position. In children the difference may be even greater due to anatomical differences causing the dramatic increases in the strength of supination after surgery for OBPP. In adults our findings suggest that the supination exercises which are undertaken after injury or surgery to the forearm or wrist should be performed in external rotation.

Surgical correction of unilateral torsional deformity of the tibia is indicated in fewer than 1% of cases. Treatment is limited to those who have a progressive deformity, who are symptomatic and on whom conservative treatment has failed. We present the results of an osteotomy performed at the supramalleolar level leaving the fibula intact and held with staples. In 7 years, 13 children with a mean age of 13.4 years (range 10-16 years) underwent osteotomy. Six osteotomies were performed for internal tibial torsion (mean 25 degrees) and seven for external tibial torsion (mean 25 degrees). Seven participants were female and six male and all cases were idiopathic. One participant required antibiotics for a wound infection and five had the staples removed. All deformities were well corrected and symptoms improved. Numerous methods have been described to correct this deformity but all have been associated with major complications. We describe a supramalleolar osteotomy, leaving the fibula intact, that achieves good correction with minimal complications.