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Category: Midfoot/Forefoot Introduction/Purpose: Müller Weiss disease is becoming increasingly recognized and is of unknown etiology. Maceria et al. formulated a classification based upon the Méary-Tomeno talo-first metatarsal angle and coined the term ‘paradoxical pes planus varus’ proposing hallmark deformities. Acknowledging there is no gold standard for treatment, various surgical modalities have been advocated in the literature e.g. isolated lateral displacement calcaneal osteotomy as sole treatment. The question subsequently arises; which joints to fuse in Muller-Weiss disease? Although no consciences prevails, one must postulate fusion should include those affected. For the purpose of establishing an algorithm in the surgical treatment of Muller-Weiss disease, we therefore set out to study its clinical and radiographic features, including pathoanatomy and metabolism as determined by SPECT- CT. Methods: We studied 63 consecutive feet presenting with Muller-Weiss disease (15 to 86 years, 18 men, 26 women). History and examination by consultant in all cases. Plain radiographs included standing anteroposterior both ankles, hindfoot alignment views, lateral standing of both ankles and feet, medial oblique both feet and dorsoplantar standing and SPECT-CT. Surgery performed on significantly symptomatic feet unresponsive to minimum of six months conservative measures. Méary’s talo-first metatarsal angles measured. On dorsoplantar radiographs the anteroposterior thickness of the navicular was measured at each naviculo-cuneiform joint perpendicular to transverse axis of the medial pole of the navicular. The percentage compression was calculated at each joint and the degree of extrusion of the medial pole. Hindfoot alignment measured using method of Saltzmann. Study approved by our local research and ethics department and in accordance with General Data Protection Regulation guidelines. Statistical analysis was performed using SPSS software. Results: Using R2 coefficient of determination we found no correlation at any level between extrusion and the degree of compression. With respect to hindfoot alignment and Méarys angle there was no significant correlation (R2=0.003) Shapiro-Wilk test demonstrates a normal distribution of extrusion in both unilateral and bilateral cases. In 95.2% of unilateral cases extrusion significantly greater on affected side (P<0.001 Fisher exact test), in bilateral cases extrusion greater on the side with more compression 55.6%. Degree of extrusion significantly greater in bilateral than in unilateral cases (P=0.004 unpaired T-test) ‘Paradoxical pes planus varus’ present in 27% with heel valgus and Méary’s negative in 47% cases. Almost half of patients treated conservatively consistent with literature with surgical intervention specific to involved joints from clinical and radiological parameters. Conclusion: Lack of correlation between Méary angle and degree of compression or extrusion invalidates principle classification; it fails to reflect the severity of compression of the lateral navicular and amount of extrusion of the medial pole and has no prognostic value. It provides no guide as to what joints to fuse. Proposed hallmark deformities only present in 27% of advanced disease therefore caution advised with surgical modality. SPECT-CT influenced operative planning and authors advocate its use. We observed greater incidence of fracture with advanced disease and subclinical degenerative changes. With failed non-operative management figure 1 is our proposed treatment algorithm.

Category: Ankle, Ankle Arthritis Introduction/Purpose: The optimal management of severe ankle arthritis is still debated. Some maintain that arthrodesis is the reference standard. However, with appropriately selected patients modern Total Ankle Replacements (TAR) can offer good to excellent patient reported outcomes. First generation TARs were highly constrained and prone to accelerated wear, loosening and subsidence and failure. Subsequent reincarnations have led to the development of reduced constraint, mobile bearing prostheses with reliance on ligamentous balancing. New generation TARs report 10-year survival of up to 89%, however many studies are from design centres and not uniformly replicated elsewhere. The largest long-term Hintegra TAR study is from a designer’s centre, reporting 84% survival at 10 years. This paper reports multicentre results on the intermediate (6 years +) outcomes of the Hintegra TAR. Methods: TARs performed by two senior consultant surgeons from 30/03/2004-18/01/2013 were reviewed. Prospective review of patients included; review of current and or new symptoms, an updated past medical history, AOFAS Hindfoot scores and radiological imaging. We used the AOFAS hindfoot score for our functional assessment as it validated and also the most frequently cited scoring system in the literature. Radiographs were reviewed for loosening and this was defined by a validated assessment method with a suitably low inter-observer variability. In our study all images were reviewed by at least two authors for a consensus opinion. The Charlson Comorbidity Index (CCI) was utilised to evaluate and risk stratify co-morbidities and their influence on other illnesses and surgical outcomes. This study was considered to be service evaluation by our local research and ethics department and approved in accordance with General Data Protection Regulation guidelines. Statistical analysis was performed using SPSS software. Results: 62 TARs were performed on 58 patients. Excluding the deceased (n=9) and patients lost to follow up (n=1), mean follow up was 12years 3months. AOFAS score did not decline with age of TAR (Spearman Rho co-efficient 0.339). During the first 4 years Hintegra TARs were performed 11/23 (48%) patients underwent additional surgery highlighting the already published learning curve with TAR. 5-year and 10-year survival was 84% (52/62) and 71% respectively (27/38). Predictors for revision included obesity with a BMI>30 versus those with a BMI of 18.5-25 (Chi-Sq P-value 0.006) and previous smoking history (Chi-Sq P-value 0.027). No association was found between CCI scores and revision (One-way ANOVA P-value 0.4). Interestingly lower ASA scores were significantly more likely to require revision (One-way ANOVA P-value 0.034). Conclusion: The Hintegra Total Ankle Replacement offers good sustained pain relief and function. 71% of implants were retained with an average AOFAS score of 78 (36-100 range) after 10 years. We do recommend caution in patients who are obese, smokers, ex-smokers and those with a high functional demand. We stress the importance of achieving correct alignment of the TAR to maximise longevity. There is a steep learning curve when performing a TAR and we would suggest operating with another experienced surgeon for at least the first 20 cases.