We evaluated whether moving the "line of crush" from thigh to the calf before onset of tourniquet-mediated hypertension would prevent or diminish it. We also evaluated any change in pain or functional outcome. Twenty adult patients were recruited and randomly assigned to either control or intervention groups. Inclusion criteria: any willing participant >18 years old with foot and/or ankle pathology requiring an operation lasting >90 minutes. Exclusion criteria included contraindication to general anesthesia, peripheral neuropathy affecting lower limbs of any etiology, or chronic pain requiring regular opiate analgesia. The intervention group received a thigh tourniquet for 60 minutes, after which a calf tourniquet was inflated and the thigh tourniquet was deflated. The control group received only a thigh tourniquet throughout surgery. At 90 minutes, the control group had mean arterial pressure of 86.8 mmHg, compared with the intervention group at 76.3 mmHg (p ≤ .014). At end of surgery, the difference had increased further (control 98.1 mmHg, intervention 78.3 mmHg (p ≤ .001). Moving the line of crush during limb tourniquet application prevents development of the hypertensive response. For cases in which a prolonged tourniquet application is required, a dual-tourniquet technique will prevent intraoperative hypertension and may influence long-term pain and function.

•Six pairs of fresh frozen cadaveric specimens in a standardised and reproducible manner were examined.•Mean lateral translation measured as surrogate for assessing integrity of repair or reconstruction.•Traditional repair models fail to provide sufficient resistance to planovalgus.•Using an augmented device such as the internalbrace provides optimal resistance to planovalgus.

In this retrospective study, a series of 10 elective patients treated with transfer of the tibialis posterior (TP) tendon for pes cavus and drop foot are described. Since TP transfer completely subtracts the role of this tendon, this cohort of patients provides an opportunity to examine the consequences of tibialis posterior (TP) deficiency. After a mean follow up period of 44.7 months, only one patient showed evidence of strain in the spring ligament but none of the patients in this series developed clinical or radiological evidence of planovalgus deformity. The authors conclude that planovalgus deformity is not an inevitable sequelae of TP Tendon transfer and that established theory underestimates the role of static soft tissue restraints such as spring ligament in hindfoot stability.

multiligament complex whose primary role is to stabilise the medial longitudinal arch