THE
BALL
AND
G.
From
the
Department
of
paper
reports
fifteen
years.
All patients
This
oftwelve
the
hmdfoot
and nine
anomalies
perhaps
associated
malformation,
intervention
The
received
ball
was
and
little
socket
by
an
of the
Lamb
abnormal
talus
changed.
The
normally
convex
and
form
cases
in any
of the
English
ofleg
patient
ankle
Surgery,
Cardtff
articulation
length.
trochlear
which
tibia
had
surface
before
five
in
patients
of the
backwards
and
Review
talus
of
is
up for an average
coalitions
and
German
ofthe
bones
recent
and
Engelke
K#{246}lbeland
of
by
Hermann
and
Fischer
(1975)
(1960,
1970),
Refior
(1972)
and
has
this
(1931),
Wertheman
Imh#{228}user
(1 970),
that
Politzer
(1934)
work
purpose
who
of
have
to give
suggest
shows
by
concentrated
on
aetiology.
The
ankle,
earlier
Kewesch
More
probable
patients
literature
described
(1933),
(1952).
the
concave
the
was
Henssge
been
followed
showed
Cardiff
series.
Korvin
the
infirmary,
of bony elements
of the forefoot.
Other
to be part
of a congenital
short-limb
with rigidity
of the hindfoot.
Surgical
condition
cases
Royal
at the ankle
Ten
has
It was
reviewing
of the
in the
joint
literature.
On
mortice
of the
Orthopaedic
inequality
articulation
the
from
and
JOINT
B. J. BROTHERTON
of ball and socket
showed
deformity
in 1958.
described
described
Traumatic
required
in the
he
CHANNON,
ANKLE
patients
had a reduction
in the number
are described.
The abnormality
seems
modffied
by adaptive
change
associated
attention
first
shape
not
M.
SOCKET
an
the
this
ball
paper
and
account
of the
aetiology
is to
socket
describe
associated
and
fifteen
articulations
to
at
the
anomalies,
report
on
to
long-term
follow-up.
MATERIAL
Fifteen
cases
description
showing
time
were
available
together
the
foot,
the
of diagnosis.
Wales
area,
sixteen
years,
and
three
to
years.
Eight
ankle
and
twenty-five
ranged
of
male
Fig.
Anteroposterior
of the talus.
from
side
and
the
shape
to
Note
side.
In
superior
of
into
assumes
the
hindfoot
shape
of
No.
of
the
mortice
the
talus
for
cavity
a ball
and
coalition
concavity
the
socket
joint
the
bones
in the
F.R.C.S.Ed.,
F.R.C.S.Ed.,
Senior
Registrar,
Prince
Consultant
Orthopaedic
should
1. FEBRUARY
be
sent
1979
to Mr
G.
(Fig.
are
rather
1).
in
of Wales
Surgeon,
the
to
the
inequality
of leg
was
in the
found
abnormalities
foot,
presented
other
limb.
M.
abnormalities
related
short
becomes
joint
involved
the
articulation
shortening
reprints
is lost
talus
the
of the
of
toms
approaches
and
of these
length,
that
because
of the
Orthopaedic
York
District
Hospital,
Hospital,
seven
than
the
of the
foot:
one
had
other
was
abnormal
patients
the
child
absence
a club
Rhydlafar,
Wigginton
had
been
toes
Cardiff
Road,
of
foot.
with
with
arched
and
One
patient
of the
forefoot
absence
of
of relatives
brought
but
of
symp-
articulation
a high
Abnormalities
of two
because
presented
found,
nine patients
showing
(Fig. 2). Closer
questioning
one
twelve
presented
Two
scoliosis.
of
female.
because
patients
and
to
from
FINDINGS
limb.
were commonly
at least one toe
showed
average
the
seven
varied
patients
All
from
from
an
short
and
with
ankle.
at the
came
and
AND
presentation
associated
the typical
appearance
of the affected
limb.
condition
abnormality
particularly
and
for
61-B,
The
this
G. M. Channon,
B. J. Brotherton,
Requests
this
a cup-like
Accompanying
changes,
to show
shortening
surface
a sphere.
moulded
VOL.
radiograph
also the
1
initial
clinical
available
skeleton
follow-up
with
were
PRESENTATION
The
axial
ages
years
patients
the
patients
time
A
were
all the
their
the
review.
radiographs
Almost
South
for
with
this
for
had
advice
not
been
CF5 6XG,
Wales.
York,
England.
Channon.
85
86
G.
followed
up
noticed
on
One
at that
one
tion
had
restriction
Examination
Syndactyly
CHANNON,
of three
toes
B. J.
was
occasion.
patient
of some
time.
M.
short
of
the
and
also
complained
movement
of the
ipsilateral
restricted
pronation
and
revealed
although
stature
radial
head
appeared
to
be
arm.
supina-
BROTHERTON
was
essentially
confined
femoral
and
in
divided
averaged
between
affected
normally
Foot.
the
of
side,
identified
tarsal
and
bones.
and
(Figs.
3
were
and
and navicular
involvement
was
hypoplastic
evidence
Appearance
of
and
with
diminution
talonavicular
joint
In nine
and
the
at
lower
Axial
limbs.
ball
all
lower
A number
One
Spina
and
Of
cases.
spine
socket
other
of
occulta
the
grid
(Figs.
bases
was
patients
3-Radiograph
is somewhat
the
had
talus
The
6
seen
also
and
7)
ray
were
was
also
toe although
the
cuneiform
and
one
commonly
metatarsal
fourth
and
talus
subtalar
5).
lateral
on
joint
the
of the
no fourth
were
ground.
of
found
one
side.
an
side
absent
of
lumbar
lower
present
in three
abnor-
twelfth
shortening,
rib
and
was
fusion
of
the
occasion.
of instability
ankle
and
also
In eight
all
patients
patients
the
showed
shortening
to show
hypoplastic.
hindfoot
One
One
in the
two
to which
his
normal
joint,
Clinical
assessment
of dorsiflexion
inversion
and eversion
normal
side.
with
an
In
the
abnormal
subtalar
joint,
subtalar
movement.
there
he
had
patient
had
complaints
complained
particularly
The other suffered
discomfort
after an industrial
injury,
and
physiotherapy
but
only
ankle.
range
vertebra.
limb
surveyed,
the
Fig. 3
Figure
The
subtalar
were
toe
them
present.
three
to
feeling
films
were
neurological
had
the
fifth
the
was
associated
on
In
on
no
patient
process
limb.
of
fifth
patient
was
the
ankle
Radiographs
as were
of abnormalities
bifida
was
sacralisation
three
with
(Fig.
forefoot
the
two
Another
resumed
there
transverse
shortening
in
the
skeleton.
mality.
form
on
RESULTS
sites.
patients;
Lower
The
present
showing
other
patients
in
in
spaces
of the
the
findings.
was
available
the
and
relating
articulation
of
of the
in size
Radiological
fusion,
elongated
metatarsal
foot. There
is overall
reducfifth toe is absent.
Radiologically
the
whole
of the
fifth
ray
was
absent.
Deformity
of remaining
toes is unusual.
of these.
appearing
metatarsal
tion
in two
occasions
absent
fusion
involved
two
missing.
was
a hypoplastic
was
on
Abnormalities
Fig. 2
it had
cuboid
abnormal
absent
were
of the
seen on eight occasions.
in the coalition
in four
appeared
found.
the
were seen to be fused in two cases without
of the
os calcis.
In patients
with
no
radiological
and
hindfoot
of coalitions
anomaly
of these
The
of
on
hypoplasia.
form
common
4).
failure
of the
talus which
was
was also included
in two
and
occasions
most
showed
fibular
in the
was
shortening
epiphysis
abnormalities
The
and
patient
had
mainly
The
femoral
another
these
the os calcis
The navicular
patients
One
it was
discrepancy
bones.
upper
patients
in two
the
two
the
and
In ten
tibia;
remainder
5 centimetres.
development
located.
to the
the
had
of
on
a
uneven
at the front of the
been treated
by
responded
well
and
had
occupation.
of patients
revealed
a normal
and plantar
flexion.
The range
of
was slightly
greater
than on the
patients
with
no
radiological
was
a reduction
hindfoot
coalition
appearance
in
the
of the
range
of
Fig. 4
coalition.
There
is fusion
of the os calcis,
talus
ray is absent.
Figure
4-Radiograph
showing
and navicular.
The talus as well as showing
spherical
coalition
of the os calcis.
talus
and navicular.
THE
JOURNAL
OF BONE
AND
JOINT
form
SURGERY
THE
BALL
AND
SOCKET
ANKLE
whereas
Imh#{228}user (1 960)
concentrated
that
87
JOINT
the
ankle
change
and
later
on the hindfoot
joint
brought
at the
subtalar
lower
limb
formation
about
lends
result
of the
to the
have
suggested
of
of inversion
A review
support
(1 974)
and
is the
by loss
joint.
Penrose
abnormality
adaptive
and
eversion
development
concept
of the
of a congenital
malformation.
From
with
the
staged
work
Fig. 5
However,
the talus
appears
space
at both the subtalar
and
joints.
way. Henssge
the articular
and
and Engelke
surfaces
during
found
that
differentiation
All
patients
to
The
were
patient
shoe
were
evidence
of
leg
with
general
length.
instability
had
a
surprisingly
their
ankle.
fifth
degenerative
little
Some
decade,
of
DISCUSSION
Interest
in
centred
the
ball
mainly
been
made
Discussion
polarised
on
of
the
of
into
his original
was
part
Figure
6-Comparative
its
two
socket
and
outlook
mechanism
avenues
a
articulation
little
for
of
of
suggested
of
ankle
aetiology
ultimate
the
article
tion
and
its
thought.
that
congenital
the
mention
these
Lamb
abnormal
short-limb
VOL.
61-B,
No.
1. FEBRUARY
ofthe
absent.
1979
weeks
and
of the ankle
and
seem
O’Rahilly
that
(1968)
the formation
at
subtalar
the
foot
itself,
the
approximately
weeks
of
1959).
As
all
the
by
the
studies
of
numbers
are
overgrowth
The
occurring
incidence
embryo
is
occurs.
stage
form
of
between
elements
earlier
than
coalitions
high.
In
seventh
0’ Rahilly
have
begun
number
before
to
time.
that
five
reduction.
in the
foetus
a
number
small
to
and
this
suggest
four
In
elements
and
their
animals
at
is well
cleft.
and
foot
determined
with
of
the
it does
ankle
fifth
week
have
of the
Differen-
subtalar
Gray
of
seventh
foot
end
adult-like
the
of
The
than
the
of the
into
degree
the
cavitation
determined
surprisingly
of
by the
at an earlier
the
shapes
of
of the foot
complete.
elements
(Gardner,
be
the
a high
was
formation
gestation
must
syndrome,
that
differentiation
occurs
was
arrangements
and
Comparative
in
there
cavity
before
joint
before
(1970)
studied
the development
occurs
arrangement
articula-
feet showing
the absence
Figure
7-Radiograph
seven
tiation
has
Fig.
radiographs
was
and
chondrify
has
(1958)
a
has
patients.
production
first
the
change.
ankle
before
shapes
delineated
yet
in the
conclusion
adult-like
symptoms.
in the
in
often
of
revealed
change
reviewed
no
of
his
assessment
patients
shoes,
inequality
relieved
of degenerative
showed
normal
the
complained
which
Radiological
the
for
who
high-sided
evidence
wearing
compensate
it would
the lower limb depends
on the critical
period
from three
to six weeks
after
fertilisation,
that is from just before
the limb buds appear
until differentiation
is well under
No coalition
was seen
in this patient.
elongated
and there
is a decreased
joint
the talonavicular
a raise
of Gardner
embryos
the
weeks,
and
of
7
ofthe
fourth
and fifth
showing
the absence
rays on the affected
of the fifth ray.
side.
The
lateral
cuneiform
is also
88
G.
embryos
talocalcaneal
seen.
In
the
well
third
in
abnormalities
and
calcaneonavicular
as those
between
metatarsal.
some
than
break
were
in the
lateral
tenuous.
Since
it has
been
forefoot
may
be
ovulation,
subtalar
the
cleft
shape
forms
and
assumed
by
of the ankle
at a later
five
also
all
these
stage
in
of
the
after
must be determined
are seen
at an
stage.
The occurrence
of the ball and socket
may be involved
in this overall
development
Early
studied
the
and
coalition
Wray
of
and
Herndon
hindfoot
bones
without
abnormalities
of the ankle
joint
itself.
Leonard
found
a familial
trait
and felt that hindfoot
coalitions
were inherited
as a unifactoral
disorder
with incomplete
penetrance,
this
concept
of
revealed
inherited
foetal
a familial
joint
hindfoot
and
Fischer
literature,
his
that
all
Refior
a high
present
not
and
twenty-five
in
talocalcaneal
ofhindfoot
of
the
particularly
fibula.
twenty-nine
number
the
altered
as
seen
on
two
to assume
at the
normal
shape
of the
that
the
that
level
ankle,
shape
occasions.
loss
would
but
account
there
had
was
been
It
would
of inversion
for
and
the
normal
of a
in the
defects
develop-
were
always
abnormality
fibula was
to
only
be
seen
that it
of the
limbs.
skeleton
may
had
complaints
were
managed
shoes
were
of
to
loss
with
this
be
and
complete
abnormality.
the lack
been
Only
ankles
no
problems
of
two
and
means.
and
a
may
the
of this series
to control
of
inversion
to their
exception
other
number
malformation.
In none
required
of
by simple
one
seen
ankle
for
predetermined
finding
has
Both
acting
been
present
It provides
the
allow
related
at any stage.
have
in a small
shape
satisfactorily
worn
We
a
A
defects,
of the foot.
abnormality
not always
aetiology.
thus
from
exhibited
ankle.
these
Normal
bracing
was
was
operative
of instability.
The development
of arthritic
changes
which
one would
expect
at an early stage does not seem to take place.
One
patient
had complaints
suggestive
of early degenerative
change,
but radiologically
the joint
surfaces
appeared
seem
in
evidence
before
the
the
resulting
intervention
eversion
alteration
no convincing
is
a malformation
developmental
axial
of an already
interesting
most
symptoms
accounted
for
joint without
It
would
suggest
rather
than
part
other
adaptation
and
required
was
an
eversion,
exhibited
reasonable
of
whereby
age
fusion
had
of the
patients
hindfoot
although
talonavicular
fusions
two of these.
Abnormality
of the subtalar
of
fibular
use of an
cartilage
the formation
part
Its infrequency
abnormality
have
mechanism
in the
in
and
is developed
immobility
may
to defects
series,
formation
two and four years of age.
a case in which
adaptation
Green
arthrodesis
at the
coalitions
our
mechanism.
formation
took place between
Fischer
and Refior
described
had taken
place
after
a Grice
patients
related
their
in this series.
be a related
development
The
of our
of
defined.
saw
as
Other
series
show
this
infrequent.
A hypoplastic
the ankle
joint
adapts
to the relative
loss of subtalar
movement
caused
by the hindfoot
coalition
and adopts
the ball and socket
shape.
Imh#{228}user suggested
that this
Ten
In
clearly
(1970)
joint
cases.
Hindfoot
coalition
has
and it may
have
a separate
collected
cases.
Similarly
Penrose
(1974)
in his series
found
an incidence
of hindfoot
coalition
of 75 per cent.
It is suggested
that when
normal
weight-bearing
starts,
of six.
ankle
abnormalities
coalition,
of
socket
be
particularly
reduction
malformations
of these features
suggest
a congenital
of the
in a review
joint
with
of
form
of articulation
so that hindfoot
development.
Engelke
and
Only
shape
All the patients
we have studied
have
short
leg on the same
side as their
abnormal
of the
of mobility
showed
(1972),
incidence
in
remodelling
of loss
patients
and
was
has
ankle
a secondary
Henssge
causative
the
study
one
the
of
large
suggested
as a result
showed
which
Our
for
of this. Leonard
saw no ball
model
once
may
characteristic.
occurred
fusions.
supporting
maldevelopment.
Imh#{228}user (1960)
ankle
characteristic
available
was no indication
of tarsal
coalition,
he
at an early
the
the
present.
relatively
occurring
epiphysis
have been reported.
would
the actual
syndrome
(1963)
tibia!
were
tarsal
and
such cases
arthrogram
ing
(1974)
radiographs
of
coalition
to find a ball
have
had an
However,
no
ball
articulation
abnormal-
grouping
socket
ankle
joints.
One might
also expect
and socket
articulation
in patients
who
arthrodesis
for the treatment
of club feet.
be
by
early
close
subsequent
lower
conceivable
that the
before
weight-bearing
ity.
Leonard
a hypoplastic
patients
but there
his series
of cases
by seven
weeks.
The
stage.
The
reduced
development
of one lower
limb
the end of six weeks.
Coalitions
noted
that
herald
stage.
was
weeks
might
the
some
that
suggested
nuclei
and
that
a very
early
of elements
determined
seen
incidence
seem
may
develop
at
life.
The
reduction
Penrose
bone
complete
the
J. BROTHERTON
were
being
always
B.
common,
cuneiform
not
down
on weight-bearing.
From
this
work
it would
abnormalities
intra-uterine
more
fusions
were
adult,
CHANNON,
fusions
were
the
Fusions
cases
higher
calcaneocuboid
foetus
talocalcaneal
as
and
M.
intact.
then
regular
Should
fusion
treatment
weight-bearing.
patients
of
the
require
ankle
operation
joint
in
would
the
seem
to
future
be
the
of choice.
REFERENCES
Fischer,
V.,
278-285.
and
Gardner,
Joint
E., Gray,
Surgery,
Gardner,
E.,
and
Reflor,
D. J.,
41-A,
O’Rahilly,
H. J. (1972)
and
O’RahiHy,
Talo-crurales
R. (1959)
Kugelgelenk
The
prenatal
bei
Ruckfufisynostosen.
development
of the skeleton
Archiv
and
f#{252}rOrthop#{228}dische
joints
of the
und
human
Unfall-Chirurgie,
73,
foot.JournalofBone
and
847-876.
R. (1968)
The
early
development
of the
knee
joint
in staged
human
THE
embryos.
JOURNAL
Journal
ofAnatomy,
OF BONE
AND
102,
JOINT
289-299.
SURGERY
THE
Henssge,
J.,
Zeitschrift
and
fi.r
Engelke,
B. (1970)
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