bluuebunny/crossref_metadata_2025 huggingface dataset:
Traumatic Dislocations of the Lesser Toes
Authors: Brunet Jacques A. , Tubin Stanislaw
Published: March 2013

Traumatic dislocations of lesser metatarsophalangeal joints (DLMTPJ) and lesser interphalangeal joints (DLIPJ) are very uncommon. A retrospective analysis of 31 cases and of the 16 reported cases was conducted to clarify our understanding of the pathomechanics, the role of associated injuries, recommended treatment, and outcome. Hyperextension with axial loading produces the injuries. Ipsilateral foot fractures or dislocations often occur and thus may compromise the outcome. Thirty percent of DLMTPJ and virtually all DLIPJ require open reduction; most often, the plantar plate prevents closed treatment of either DLMTPJ or DLIPJ. At follow-up, treated isolated DLMTPJ have few or no complaints; disability persists in patients who suffered concomitant displaced ipsilateral midfoot or forefoot fractures or dislocations. Neglected DLMTPJ remain symptomatic. All reduced DLIPJ are pain free.
Analysis of Clinical Grading Scales for the Foot and Ankle
Authors: Kitaoka Harold B. , Patzer Gary L.
Published: March 2013

To evaluate grading methods used to report clinical results, we reviewed 1,607 articles related to the foot and ankle published in six orthopaedic journals from 1980 through July 1993. Many clinical studies use criteria such as patient satisfaction to grade results. A numeric score or grade was used in 346 articles: 238 used a grade only, 90 used a numeric score and grade, and 18 used a numeric score only. The numeric score or grade was usually, but not always, reported with details of the individual clinical factors that composed the score or grade. Twenty-three articles used a score before and after treatment. Statistics were used in 62 articles, and in 6 of those the statistics were used to compare clinical condition before and after treatment. This study demonstrated the array of grading methods used in selected orthopaedic journals and indicated the need for standardized grading techniques to allow for more meaningful interpretation of the orthopaedic literature.
Clinical and Radiographic Outcome of Revision Surgery for Failed Triple Arthrodesis
Authors: Haddad Steven L. , Myerson Mark S. , Pell Richard F. , Schon Lew C.
Published: March 2013

Between 1987 and 1994, we treated 33 patients with surgical revision for failed triple arthrodesis, 28 (29 feet) of whom returned for final examination (mean, 4.4 years; range, 2–7 years). The average age of these 16 women and 12 men was 46 years (range, 14–69 years). Before the revision procedure, patients had undergone nonoperative therapies for an average of 3.7 years (range, 0.5–12 years) and an average of three foot operations (range, 1–6 operations) after the primary triple arthrodesis.

All patients were managed with rigid internal fixation via cannulated screws and power staples. Calcaneal osteotomy and/or revision of the transverse tarsal arthrodesis via appropriate saw cuts and bone wedges were used. Iliac crest bone graft was added, when a bone block arthrodesis was required, for those patients with nonunion or ankle impingement.

Arthrodesis was achieved in all 29 feet, although 4 patients (4 feet) (14%) required additional procedures for malunion (2 patients), deformity recurrence (1 patient), deep infection (1 patient), and skin graft (1 patient). Comparison of the average pre- (retrospective) and postoperative American Orthopaedic Foot and Ankle Society 94-point hindfoot and ankle scores showed a significant improvement: 31 points (range, 13–61 points) versus 59 points (range, 24–91 points), respectively ( P < 0.05). On a scale of 0 to 10 points, average patient satisfaction was 7.8 points (range, 2–10 points).

This study demonstrated a satisfactory improvement in patient outcome after surgical correction of failed triple arthrodesis. We conclude that such a revision, although complex, may be attempted to establish a plantigrade foot free of infection and able to wear shoes without an orthosis or brace.
Action of the Peroneus Longus Tendon on the First Metatarsal Against Metatarsus Primus Varus Force
Authors: Bohne Walther H.O. , Lee Kyung-Tai , Peterson Margaret G.E.
Published: March 2013

A medially directed force was applied to the first metatarsal in 10 cadaver feet. The peroneus longus tendon was subjected to a pull of 5 pounds. The soft tissues between the first and second metatarsals were cut sequentially, starting with the skin on the dorsal and plantar aspect, followed by the intermetatarsal ligament and adductor hallucis tendon, and, finally, the peroneus longus tendon at its distal insertion. Dorsoplantar radiographs while weightbearing were taken after each sectioning. A statistically significant varus displacement of the first metatarsal was observed only after transection of the peroneus longus tendon. It was concluded that the peroneus longus tendon is a strong retaining mechanism of the first metatarsal.
Viladot's Operation in the Treatment of the Child's Flatfoot
Authors: Carranza-Bencano A. , Zamora-Navas P. , Fernandez-Velazquez J.R.
Published: March 2013

We present the results of observations on a series of 77 flat feet treated by Viladot's surgical technique and prosthesis between 1981 and 1989. The correction was evaluated by photopodograms and radiographs. In the final evaluation, 45 cases (58.44%) were judged to have excellent results, 24 (29.87%) good results, 2 (2.59%) fair results, and 7 (9.09%) poor results.
Primary Repair Without Augmentation for Early Neglected Achilles Tendon Ruptures in the Recreational Athlete
Authors: Porter David A. , Mannarino Frank P. , Snead Dale , Gabel Steve J. , Ostrowski Mary
Published: March 2013

From 1987 to 1994, the senior author performed 41 Achilles tendon repairs. We identified 11 patients during this period (age, 35.3 years; range, 26–60 years) who fit the criterion for neglected Achilles tendon rupture (repair ≥ 4 weeks and ≤ 12 weeks from injury). All patients underwent proximal release of the gastrocsoleus complex, imbrication of the early fibrous scar without excision of any local tissue, and primary repair of the tendinous ends with two No. 5 Ticron sutures (5R, 6L). Several (three to five) No. 0 Vicryl sutures were used to augment the repair. The ankle was placed in a 20° plantarflexion nonweightbearing short leg cast for 3 weeks. All skin closures were primary. At 3 weeks, weightbearing as tolerated was initiated in a short leg cast. The cast was discontinued at 6 weeks, and physical therapy was initiated, consisting of range of motion exercises and closed kinetic exercises, progressing to functional exercises as swelling, strength, and pain allowed. Minimal follow-up was 18 months (mean, 3.5 years; range, 1.5–5.8 years). There have been no subsequent ruptures to date. All patients returned to a preinjury level of activity at a mean of 5.8 months (range, 2.5–9 months). Total range of motion was not different ( P > 0.05) between the involved (67°) and uninvolved (74°) ankle. Plantarflexion loss of strength in the involved ankle was the same (98.4%, 88.1%, and 87.6% respectively, involved to uninvolved) as that seen after acute repair at all speeds tested. Visual analog pain scale (0 to 10) revealed a mean score of 0.7 (range, 0–2) during activities of daily living and 1.0 (range, 0–3) during sports activity. The subjective and objective outcome was similar ( P > 0.05) to that seen after an acute repair by the same surgeon. There were no complications including skin sloughs or nerve damage. We believe this is the first article to report the results after primary repair without augmentation for the neglected Achilles tendon rupture. We conclude that this approach can result in excellent clinical and functional outcome, a low rate of subsequent rupture, and a high rate of return to sports in the recreational athlete whose repair is performed between 4 and 12 weeks after injury.
Foot and Ankle Severity Scale (FASS)
Authors: Manoli Arthur , Prasad Priya , Levine Robert S.
Published: March 2013

Increasing use of air bags and seat belts has led to the saving of many lives. However, the orthopaedic surgeon is now left to manage increasing numbers of serious foot and ankle trauma. It is important to injury prevention programs to have an injury severity scale for these injuries. The Abbreviated Injury Scale is used widely; however, it is intended primarily to gauge possibility of death after accidents. It is not sensitive enough to give meaningful data about the foot and ankle trauma epidemic.

The Trauma Committee of the American Orthopaedic Foot and Ankle Society has developed a rank order list of 91 foot and ankle injuries that commonly occur in vehicular crashes. The injuries are ranked according to severity (FASS-S). Estimated long-term impairment is also given for each injury (FASS-I). This scale is designed as a guideline to help rank importance and impairment of vehicular crash injuries. It is expected that the scale will be modified as future validity testing and other research dictates.
Isolated Talocalcaneal Interposition Fusion: A Prospective Follow-up Study
Authors: Fellmann J. , Zollinger H.
Published: March 2013

This is a prospective clinical and radiological study of the treatment of talocalcaneal deformity or degeneration by a modified technique of isolated talocalcaneal fusion. Thirty-six patients were evaluated with clinical examination, plain dorsoplantar and oblique radiographs, and computed tomography scanning or magnetic resonance imaging in a follow-up of 32.5 months (range, 20–62 months). Indications for arthrodesis were posterior tibial tendon rupture with secondary osteoarthritis (12 cases) and secondary posttraumatic osteoarthritis (24 cases). On a visual analog pain scale, the patients graded their pain at 4.4 before surgery and at 1.1 after surgery. The subjective results were 33% complete satisfaction, 28% satisfaction with minor reservation, 31% satisfaction with major reservation, and 9% dissatisfaction. The overall objective results were excellent in 47%, good in 31%, fair in 17%, and poor in 6% of cases. A further advantage of this type of talocalcaneal fusion is a large remaining range of motion in the neighboring joints, at the ankle (in 76% the same or better ROM than before surgery), and at Chopart's joint (in 69% the same or better ROM than before surgery). The fusion rate was high (95%).
A Biomechanical Comparison of Intramedullary Nail and Crossed Lag Screw Fixation for Tibiotalocalcaneal Arthrodesis
Authors: Berend Michael Edward , Glisson Richard Robert , Nunley James Albert
Published: March 2013

This study compared the mechanical bending and torsional properties of intramedullary nail fixation and lag screw fixation for tibiotalocalcaneal arthrodesis. Seven matched pairs of human cadaver lower extremities were studied, with one hindfoot in each pair stabilized with a 12 mm × 150 mm interlocked intramedullary nail inserted retrograde across the subtalar and ankle joints. The contralateral hindfoot was stabilized with two crossed 6.5 mm cannulated screws inserted across both the ankle and subtalar joints. Specimens were subjected to cantilever bending tests in plantarflexion, dorsiflexion, inversion, and eversion and to torsional tests in internal and external rotation. The intramedullary nail construct was significantly ( P < 0.05) stiffer than the crossed lag screw construct in all four bending directions and both rotational directions: plantarflexion (nail, 42.8 N/mm; screws, 16.4 N/mm; P = 0.0003), dorsiflexion (nail, 43.0 N/mm; screws, 10.3 N/mm; P = 0.0005), inversion (nail, 37.7 N/mm; screws, 12.3 N/mm; P = 0.0024), eversion (nail, 35.4 N/mm; screws, 10.8 N/mm; P = 0.0004), internal rotation (nail, 1.29 N-m/°; screws, 0.82 N-m/°; P = 0.01), external rotation (nail, 1.35 N-m/°; screws, 0.44 N-m/°; P = 0.0001). Intramedullary fixation is biomechanically stiffer than crossed lag screws in all bending and torsional directions tested and therefore this construct may aid in maintaining alignment of the hindfoot during union and may help increase fusion rate through increased stability of the internal fixation.
Posterior Tibial Tendon Dysfunction: Secondary MR Signs
Authors: Lim Philip S. , Schweitzer Mark E. , Deely Diane M. , Wapner Keith L , Hecht Paul J. , Treadwell Joseph R. , Ross Mark S. , Kahn Mitchell D.
Published: March 2013

We evaluated four potential secondary magnetic resonance imaging signs to aid in clinical diagnosis of posterior tibial tendon (PTT) tears. Seventy-one ankles (25 PTT tears and 46 controls) were evaluated for the following secondary signs: (1) PTT sheath fluid, (2) a distal tibial spur located just anterior to the PTT, (3) unroofing of the talus, and (4) “bone bruise”-like medullary lesions. Two musculoskeletal radiologists rated their confidence using a scale and were compared for level of agreement. The presence of PTT sheath fluid had modest specificity and fair to moderate sensitivity. Tibial spurring and unroofing of the talus had excellent specificity and fair sensitivity. Bone bruise-like lesions were commonly seen in cases and controls. Examination of divergence of opinion between the two radiologists revealed pitfalls in interpretation of PTT sheath fluid and bone bruise-like lesions, which were commonly the result of adjacent vessels and inhomogeneous fat saturation, respectively. We conclude that secondary signs of PTT tears with high specificities include unroofing of the talus, tibial spurring, and PTT sheath fluid.
Glomus Tumor of the Plantar Arch: A Case Report with Magnetic Resonance Imaging Findings
Authors: Mohler David G. , Lim Charles K. , Martin Brian
Published: March 2013

A 55-year-old woman with a 12-year history of a painful nodule in the subcutaneous fat layer of the plantar arch was evaluated with magnetic resonance imaging, followed by excisional biopsy. Pathology revealed a glomus tumor, which is extremely rare in the plantar surface of the foot. The magnetic resonance imaging studies are presented. The literature on glomus tumors in the foot is reviewed. This entity should be considered in the differential diagnosis of solitary plantar nodules when marked sensitivity to temperature or pressure is exhibited.
Fractures of the Calcaneus: Open Reduction and Internal Fixation From the Medial Side a 21-Year Prospective Study
Authors: Burdeaux Billie D.
Published: March 2013

Since 1974, 61 displaced fractures of the calcaneus have been treated by open reduction and internal fixation by a modified medial approach technique. Surgery was performed through a 5-cm incision posterior to the neurovascular bundle. A single threaded pin was passed longitudinally through the tuberosity and into the sustentacular fragment, giving stable fixation. Reduction of the depressed posterior facet fragments was accomplished from the medial side in 77% of cases, occasionally assisted by fluoroscopy. Postoperatively all fractures were immobilized in a cast for 4 weeks. At the end of 4 weeks the pin was removed, and full weight bearing in a walking cast was started and continued for 4 weeks. At 8 weeks after surgery, the walking cast was removed, and the patient began walking in a shoe.

These cases were evaluated at a mean follow-up of 4.4 years. There were 49 successful cases (80.3%) and 12 unsuccessful cases (19.7%). A high number of superior results was found in the successful group as shown by the mean score of 94.7 (American Orthopaedic Foot & Ankle Society Scoring System). Time to return to work was a mean of 4.9 months.
Radiographic and CT Evaluation of Tibiofibular Syndesmotic Diastasis: A Cadaver Study
Authors: Ebraheim Nabil A. , Lu Jike , Yang Hua , Mekhail Anis O. , Yeasting Richard A.
Published: March 2013

Twelve cadaver lower limbs were used for radiographic and CT assessment of the tibiofibular syndesmosis. Plastic spacers were placed in the distal tibiofibular intervals of each specimen in successive 1-mm increments until diastasis could be appreciated on the plain radiographs. All 2- and 3-mm diastases could be noted and clearly identified on CT scans, while the 1-, 2-mm, and half of the 3-mm syndesmotic diastases could not be appreciated with routine radiographs. CT scanning is more sensitive than radiography for detecting the minor degrees of syndesmotic injuries. Therefore, a CT scan can be performed in cases of syndesmotic instability after ankle injuries and for preoperative or postoperative evaluation of the integrity of the distal tibiofibular syndesmosis in cases of doubtful condition of the syndesmosis.
Charcot Ankle Fusion with a Retrograde Locked Intramedullary Nail
Authors: Pinzur Michael S. , Kelikian Armen
Published: March 2013

Twenty patients with severe neuropathic (Charcot) ankle deformities underwent 21 attempted ankle fusions with a retrograde locked intramedullary nail as an alternative to amputation. All had insensate heel pads and had failed at nonoperative methods of accommodative ambulatory bracing. In 11, the talus was either absent, or the deformity was of sufficient magnitude to require talectomy to align the calcaneus under the tibia for plantigrade weightbearing. Ages ranged from 28 to −68 (average 56.3) years. Nineteen were diabetic, 12 being insulin-dependent. Their average body weight was 102 kg, with 11 greater than 90 kg at the time of surgery. Eight had chronic large full thickness ulcers overlying, but not involving bone of the medial malleolus, medial midfoot, or proximal fifth metatarsal, at the time of surgery.

At a follow-up of 12 to 31 months, 19 achieved bony fusion. In the 10 patients where talectomy was not required, fusion was achieved at an average of 5.3 months without complications. In the patients who required talectomy, six of the patients required eight additional operations to achieve fusion. Three achieved fusion following removal of the nail and prolonged bracing. One opted for ankle disarticulation for chronic persistent infection, rather than attempt reoperation. One died of unrelated causes during the early postoperative period.

Retrograde locked intramedullary ankle fusion is a reasonable alternative to amputation in the neuropathic (Charcot) ankle that cannot be controlled with standard bracing techniques. The potential for morbidity requiring reoperation is greatly increased when the deformity is of sufficient magnitude to require talectomy to achieve alignment of the calcaneus in a plantigrade weight-bearing position under the tibia or when there are large open ulcers.
Arthrodesis of the Ankle: A Critical Analysis
Authors: Mann Roger A. , Rongstad Kurt M.
Published: March 2013

Arthrodeses of 81 ankles performed by a single surgeon were reviewed after a 12- to 74-month follow up. Average time to union was 13.8 weeks, and 71 (88%) of 81 ankles healed without a second surgery. Ten (12%) of the 81 ankles failed to unite. Of the 10 nonunions, two developed a dense fibrous union without screw failure, and eight underwent revisional surgery. Seven of the revisions united and one has a persistent nonunion. The transfibular approach was utilized, and specific factors related to this approach were assessed. A greater resection of the medial malleolus correlated to a longer healing time and to an increased rate of nonunion. Sixty (96%) of the 63 patients who returned for follow up had no signs or symptoms attributable to malalignment. The average postoperative score for ankle-hindfoot on the AOFAS evaluation was 74 points, and rate of the patient satisfaction was 65 (89%) of the 73 patients. There was no correlation between outcomes and patients ages. Greater tarsal mobility correlated with a higher postoperative score and to higher level of satisfaction.
A Comparison of the Effect of Shoes on Human Tibial Axial Strains Recorded during Dynamic Loading
Authors: Milgrom Charles , Burr David , Fyhrie David , Hoshaw Susan , Finestone Aharon , Nyska Meir , Davidson Roni , Mendelson Steven , Giladi Miki , Liebergall Meir , Lehnert Bruce , Voloshin Arkady , Simkin Ariel
Published: March 2013

Percutaneous axial extensometers were mounted on the medial cortex of the midtibial diaphysis in seven male volunteers and the effect of three different shoes on in vivo peak-to-peak axial compression-tension strains measured during dynamic loading. Zohar shoes had lower axial strains and strain rates during treadmill walking than Nike Air Max running shoes or Israeli infantry boots. During running on a running track, there was no statistically significant difference between the axial strains or strain rates between the shoes tested. Shoe gear can modify tibial strains and strain rates that contribute to the development of tibial stress fractures.
Triggering of the Lesser Toes at a Previously Undescribed Distal Pulley System
Authors: Martin Michael G. , Masear Victoria R.
Published: March 2013

We have treated five patients with metatarsalgia and triggering of the lesser toes. This paper describes a mechanism of triggering that involves a previously undescribed flexor pulley system in the toes that is very similar to the pulley system in the fingers.

The specific anatomy of the toe flexor pulleys is described based upon the dissections of 50 fresh-frozen cadaver toes. These pulleys were composed of transverse to obliquely oriented fibrous bands within the flexor sheaths from the metatarsal heads to the distal phalanges. We found a system of pulleys in the lesser toes and the great toe, analogous to that found in the hand.

Trigger toe is a rare entity and is only briefly described in the literature. We believe it is more common than is now recognized and may be an important underdiagnosed cause of metatarsalgia. The diagnosis is made when active plantarflexion causes the toes to catch in flexion and the patient is then unable to extend them. Nonsurgical therapy consisting of steroid injection, NSAIDs, or changing footwear may be effective, otherwise surgical release of the A1 pulley may be required.
Plantar Lateral Dislocation of the Medial Cuneiform: A Case Report
Authors: Levine Benjamin P. , Stoppacher Robert , Kristiansen Thomas K.
Published: March 2013

This case report describes an isolated plantar lateral dislocation of the medial cuneiform. We were able to find only one other similar case reported in the literature. That case had a delayed diagnosis of 5 months and with an associated an avulsion fracture of the second metatarsal base. 4 Dines et al. 3 reported an isolated dorsomedial dislocation at the medial cuneonavicular joint. An irreducible dorsomedial dislocation with the anterior tibialis tendon being trapped between the medial cuneiform and the navicular has been reported. 2 A distal and lateral dislocation of the medial cuneiform was reported in association with displacement of the second to fourth metatarsal and medial fractures of the navicular and cuneiform. 1 The current report differs from previous cases. There was not an associated fracture; the direction of the dislocation was unique and could be reduced closed.
Effect of Medial Displacement Calcaneal Osteotomy on Ankle Kinematics in a Cadaver Model
Authors: Michelson James D. , Mizel Mark , Jay Peter , Schmidt Guy
Published: March 2013

Although medial displacement calcaneal osteotomy has been advocated for treatment of acquired pes planus, no studies have determined the biomechanical consequences at the ankle of such a procedure. The present investigation examined the alteration in ankle motion that resulted from a medial sliding calcaneal osteotomy.

In dorsiflexion, the ankle specimens were found to have altered internal rotation and varus alignment. At maximal dorsiflexion, there was a 76% increase in internal rotation (4.4° ± 2.5° versus 2.5° ± 1.7° for intact ankles, P < 0.0004) and an increase of 425% in varus (0.42° ± 0.56° versus 0.08° ± 0.34° for intact ankles, P < 0.003). There were no significant differences seen in plantar flexion.

Based on these results, caution is advised in the indiscriminate use of medial sliding osteotomies, because this procedure may predispose the patient to premature ankle arthritis as a consequence of the altered ankle motions.
Piperacillin/Tazobactam Therapy for Diabetic Foot Infection
Authors: Zeillemaker Anneke M. , Veldkamp Karin-Ellen , van Kraaij Marian G.J. , Hoekstra Joost B.L. , van Papendrecht Arthur A.G.M. Hoynck , Diepersloot Rob J.A.
Published: March 2013

In this study, 29 patients were hospitalized with a diabetic foot infection and were treated with piperacillin/tazobactam. Of these 23 patients who were evaluated for efficacy of treatment, 22 patients improved or were clinically cured. In seven patients (30%), there was persistence of one of the baseline pathogens. Adverse events were reported in 15 patients (58%), three of which were serious. Piperacillin/tazobactam may be useful as monotherapy in diabetic foot infection giving an adequate clinical response and the level of side effects equivalent to those of other broad-spectrum antibiotics.
Treatment of Displaced Pylon Fractures with Circular External Fixators of Ilizarov
Authors: Aktuǧlu Kemal , Özsoy M. Hakan , Yensel Uǧur
Published: March 2013

Twenty cases of pylon fractures were treated with Ilizarov circular external fixators using the technique of ligamentotaxis. Fourteen men and six women, ranging in age from 20 to 59 years, with open or closed distal tibial fractures were included in this study. The fractures were classified according to the AO system and distributed as seven C1, eight C2, and five C3 fractures. Independent from the type of fracture, six were grade II open according to the Gustilo-Anderson classification. For all fractures, an external fixator was constructed, after reduction by traction and olive wires. Mean follow-up was 29 months. All fractures healed by 14 weeks postreduction. The results were assessed using Weber's criteria: 5 (25%) had excellent results, 10 (50%) good, and 5 (25%) poor results.

This technique lowers the rated complications of open reduction and internal fixation, and allows restoration of joint-surfaces, reconstruction of length, and alignment of the extremity while maintaining a sufficient range of motion at the joint. We concluded that use of the Ilizarov circular external fixator enables good results in selected ankle traumas when applied with good indications, planning, and surgical experience.
Paget Disease of the Calcaneus: Findings on MR Imaging
Authors: Chung Christine , Yu Joseph S. , Becker William
Published: March 2013

We present a case of Paget disease of the calcaneus with an emphasis on its magnetic resonance imaging features.
Elongation Behavior of Calcaneofibular and Cervical Ligaments during Inversion Loads Applied in an Open Kinetic Chain
Authors: Martin Lewis P. , Wayne Jennifer S. , Monahan Timothy J. , Adelaar Robert S.
Published: March 2013

The cervical ligament plays a significant role in lateral stability of the subtalar joint but has received little attention compared with other ankle and subtalar joint ligaments. The purpose of this research was twofold. First, the elongation behavior of the cervical ligament was assessed with the calcaneofibular ligament intact and cut during two different types of inversion loads (manual and mechanical). Second, inversion range of motion was determined concomitantly with inversion loading and the difference in inversion range of motion between the calcaneofibular ligament intact to cut state was compared.

The mean elongation of the cervical ligament with the calcaneofibular intact was 0.58 mm (± 0.33 mm) and 0.46 mm (± 0.23 mm) for manual and mechanical methods, respectively, and 0.88 mm (± 0.37 mm) and 0.78 mm (± 0.37 mm), respectively, for the same methods in the absence of the calcaneofibular ligament. This difference was statistically significant ( P < 0.05 manually and P < 0.02 mechanically). An average increase in the inversion range of motion was noted with both methods [7.5° manually (± 2.75°) and 7.7° mechanically (± 2.95°)] after lesioning of the calcaneofibular ligament. This difference was statistically significant ( P < 0.001) for both manual and mechanical range of motion testing.

The results of this study indicate that there is a significant increase in elongation of the cervical ligament in the absence of the calcaneofibular ligament during manual and mechanically applied inversion loads in a open kinetic chain. Clinical and theoretical implications of this data are discussed.
Intratendinous Alterations as Imaged by Ultrasound and Contrast Medium-Enhanced Magnetic Resonance in Chronic Achillodynia
Authors: Movin Tomas , Kristoffersen-Wiberg Maria , Shalabi Adel , Gad Adel , Aspelin Peter , Rolf Christer
Published: March 2013

Objectives: We performed a comparative study of ultrasonography and gadolinium imaging contrast-enhanced T1-weighted magnetic resonance to evaluate tendon pathology in chronic Achilles tendon disorder. Another main issue was to evaluate the structural basis as defined by histopathology from hypoechoic compared with normoechic areas within the same tendon.

Materials and Methods: Twenty patients (16 male, 4 females, median age 40 years) with chronic achillodynia participated in the study. Clinical examination revealed swelling and tenderness localized to the midportion of the Achilles tendon. Contrast medium-enhanced magnetic resonance imaging (CME-MRI) was performed in all patients. Ultrasonography-guided core biopsies were taken from regions with a clear widening of the tendon and a pathologic low-echo signal as well as from normoechoic areas. The specimens were analyzed with a standardized protocol giving a total tendon score (0–24), and a stereologic method for quantification of glycosaminoglycan (GAG)-rich areas.

Results: The volume of the intratendinous abnormality was larger in 13 of 20 when imaged by CME-MR ( P < 0.05), whereas the shape and enlargement of the tendon per se were similarly imaged by ultrasound (US) and CME-MR. Tendon pathology as imaged by US was graded as severe from hypoechoic regions and moderate from normoechoic regions. The corresponding quantification of GAGs was 0.36 compared with 0.17, respectively ( P < 0.001).

Conclusion: CME-MR imaging revealed greater sensitivity in demonstrating intratendinous pathology than the ultrasound; this was documented by the larger size of the corresponding lesion and the fact that the pathology was occurring in areas that were considered normal by ultrasonography. US hypoechoic areas showed a markedly abnormal tendon structure including an increased amount of GAG-rich areas. However, moderate pathology was also found in the neighboring normoechogenous areas within the same tendon, indicating a more generalized disorder than depicted by echogenic properties.
The Fibular Incisure of the Tibia on CT Scan: A Cadaver Study
Authors: Ebraheim Nabil A. , Lu Jike , Yang Hua , Rollins Jim
Published: March 2013

Twenty cadaver lower limbs were used for CT assessment of the fibular incisure of the tibia. The length of the syndesmotic facet is shorter in the anterior (11.20 ± 1.90 mm) than in the posterior (14.89 ± 2.72 mm) ( P < 0.001). The angle between anterior and posterior facets is 135.18 ± 9.27°. The depth of the fibular incisure of the tibia is 4.29 ± 1.26 mm. The vertical distance of tibiofibular overlapping is 7.81 ± 1.93 mm. The distance between anterior margin of the tibia and anterior margin of the fibula is 17.40 ± 3.61 mm. The distance between the medial fibular border and the lateral border of the posterior tibia is 2.01 ± 0.49 mm. The syndesmotic notch could be divided into two groups: significant concave surface and shallow concave surface. The position of the fibula in the incisural notch may depend on the depth of the fibular incisure of the tibia during traumatic forces applied on the syndesmosis. CT can display the tibial tubercles and clearly demonstrates the fibular incisure of the tibia and the interior of the tibiofibular space.
A New Modified Technique for Harvest of Calcaneal Bone Grafts in Surgery on the Foot and Ankle
Authors: Biddinger Kent R. , Komenda Gregory A. , Schon Lew C. , Myerson Mark S.
Published: March 2013

Reported sites for retrieval of cancellous bone for grafts include the iliac crest, greater trochanter, proximal tibia, and distal tibia. A new lateral technique for retrieval of cancellous bone from the calcaneus is evaluated through anatomic review, quantitative analysis, and retrospective clinical assessment. Of 22 patients managed with this technique over a 2-year period, 17 returned for an evaluation by questionnaire, physical examination, and radiographic follow-up at an average of 7 months after surgery (range, 4–16 months). Complaints/complications were minor: three had minor incisional symptoms, five had medial heel pain (3 caused by plantar fasciitis), and one had unchanged preoperative heel pain secondary to clubfoot deformity. Compared with more extensive bone-grafting procedures, this procedure offers the advantages of bone harvested under local anesthesia using a readily accessible ipsilateral extremity and producing minor complications.
Oblique Metatarsal Osteotomy for Intractable Plantar Keratosis: 10-Year Follow-up
Authors: Idusuyi Osaretin B. , Kitaoka Harold B. , Patzer Gary L.
Published: March 2013

Twenty patients (14 women and 6 men) (23 feet) had a single oblique osteotomy operation of the 2nd, 3rd, or 4th metatarsal without fixation during an 8-year period. The mean age was 46 years (range, 21–64 years). Each patient had a painful intractable plantar keratosis preoperatively. The average follow-up was 10 years (range, 3–14 years). Postoperatively, reoperation was performed in four feet because of painful callosities. For 13 of the 19 feet that did not have reoperation, patients were limited in footwear or required a shoe insert. Overall results were good for 10 feet, fair for 7 feet, and poor for 6 feet. The only complication was a deep infection that occurred in one foot (good result). Nonunion occurred in one foot and delayed union in one. The average decrease in metatarsal length after osteotomy was 6 ± 6 mm. The single oblique lesser metatarsal osteotomy may be successful, but one half of the patients continued to have some degree of pain and most patients had limitations in footwear. Overall results were disappointing, and patients who are offered this procedure should be advised of its limitations.
Effect of Calcaneal Osteotomy and Plantar Fasciotomy on Arch Configuration in a Flatfoot Model
Authors: Thordarson David B. , Hedman Thomas , Lundquist Davin , Reisch Robert
Published: March 2013

Seven fresh-frozen cadaver specimens had a calcaneal osteotomy performed obliquely through the posterior portion of the calcaneus. Angular relationships between the first metatarsal and talus were recorded with the use of a motion-analysis system in the transverse, sagittal, and coronal planes. The specimen was mounted in a testing machine and loaded via an intramedullary rod to 150, 350, and 550 N. A flatfoot model was created, and repeat measurements were obtained. The calcaneal osteotomy was then displaced 1 cm medially, and repeat measurements were made at each of the three load levels. The calcaneal osteotomy was then returned to its original position, the plantar fascia was divided, and the new angular measurements were obtained. The calcaneal osteotomy was again displaced 1 cm, and repeat angular measurements were obtained.

A mild consistent flatfoot deformity was created in all three axes before the plantar fascia was cut. A statistically significant increase in deformity was noted after cutting the plantar fascia. A correction of the flatfoot deformity in all three planes occurred with the medial displacement of the calcaneal osteotomy, which was greater at the lower load levels.

We noted that a medial displacement calcaneal osteotomy partially corrected a flatfoot deformity in all three planes. The correction occurred with or without an intact plantar fascia and, therefore, is independent of the structure. We also noted an increased deformity after dividing the plantar fascia. This study provides some biomechanical insight as to the corrective effect of a medial displacement calcaneal osteotomy in correcting a flatfoot deformity.
Osteoid Osteoma of the Phalanx: Enlargement of the Toe—Two Case Reports
Authors: Barca Francesco , Andrea Leti Acciaro , Maria Daniela Recchioni
Published: March 2013

After a review of the literature, two cases of osteoid osteoma involving phalanges of the toes are reported. Physical findings of osteoid osteoma vary with the site of the tumor; in the foot, particularly the toes, it presents various atypical and characteristic features.

Its more frequent cancellous and subperiosteal localization in the small bones of hand and foot, showing atypical roentgenographic findings, poses particular problems in diagnosis. In the osteoid osteoma of the phalanges, characteristic enlargement of the toe or finger seems to be frequent and with a typical clinical history may be considered a reliable sign of suspected osteoid osteoma. Specialized imaging techniques may hasten diagnosis, but only an accurate clinical history and the characteristic findings with a high index of suspicion can allow for a proper diagnosis.
Radiographic and Clinical Classification of Acquired Midtarsus Deformities
Authors: Schon Lew C. , Weinfeld Steven B. , Horton Greg A. , Resch Sylvia
Published: March 2013

To develop a classification of midtarsus deformities, clinical examination and weightbearing radiographs were used to evaluate 131 feet in 109 patients (average age, 59 ± 11 years) with those deformities. Patients were classified into four types based on anatomic location of the maximum deformity. Type I (N = 43) showed deformity at the metatarsocuneiform joints medially and the fourth and fifth metatarsocuboid joints laterally, with plantarmedial and/or medial prominence. Type II (N = 60) had deformity at the naviculocuneiform joint medially and the fourth and fifth metatarsocuboid joints laterally; plantarlateral prominence was characteristic, although one-third had isolated or additional medial prominences. Type III (N = 17) had major deformity in the perinavicular region, with a prominence plantarcentrally or plantarlaterally. Type IV (N = 11) had deformity at the transverse tarsal joints with variable prominences. Each type was further subdivided into stages A, B, and C based on the severity of the deformity. In stage B, the midtarsus was coplanar with the metatarsocalcaneal plane. In stage A, the midtarsus was above this plane. In stage C, the midtarsus was below this plane. We concluded that midtarsus deformities can be classified as one of four types and one of three stages. Additional study is warranted to correlate this system with prognosis and treatment for this pathologic process.
Comparison of Two Proximal Osteotomies for the Treatment of Hallux Valgus
Authors: Earll Mark , Wayne Jennifer , Caldwell Paul , Adelaar Robert
Published: March 2013

Moderate to severe deformities of hallux valgus can be corrected with combination procedures, such as a proximal crescentic metatarsal osteotomy and a distal soft tissue procedure. Because crescentic osteotomy allows for motion in all planes, inadvertent metatarsal elevation can result in metatarsalgia. The crescentic shelf osteotomy (CSO) provides a plantar shelf, decreasing the complication of dorsiflexion fixation. Eighteen polyurethane foam specimens in three groups were prepared and tested to failure on a servohydraulic Instron testing machine. The mechanical characteristics of stiffness, deformation, ultimate failure load, and stored energy were compared between single-screw fixation crescentic osteotomies and single- and dual-screw CSOs in molded polyurethane foam metatarsal sawbones. In addition, 12 cadaver specimens were randomly divided, and a CSO or crescentic osteotomy was performed. Preosteotomy and postosteotomy intermetatarsal, dorsiflexion, and pronation angles were compared from radiograph measurements. The results showed comparable mechanical characteristics among the groups, as measured by the area under the curve ( P = 0.95), ultimate failure load ( P = 0.35), deformation ( P = 0.63), and stiffness ( P = 0.21). Greater improvements were seen in the CSO group compared with the crescentic osteotomy group in correction of the intermetatarsal angle (4.8° compared with 3.2°) and of the first metatarsal plantarflexion (2.3° compared with 3.2° of dorsiflexion). However, these differences were insignificant ( P = 0.10 and P = 0.41) with the numbers available. Compared with the crescentic osteotomy, a CSO may possibly provide easier initial fixation but similar mechanical properties.
Clinical Outcome After Subtalar Arthroscopy
Authors: Goldberger Michael I. , Conti Stephen F.
Published: March 2013

We investigated the clinical outcomes of patients with specific symptoms and physical findings of subtalar pathology with nonspecific radiographic findings after subtalar arthroscopy. Preoperative workup included plain radiographs in all of the patients, magnetic resonance imaging in seven patients, and bone scan in six patients. Based on these studies, no patient had significant subtalar arthrosis. Twelve patients underwent subtalar arthroscopy. Clinical outcome was rated with the American Orthopaedic Foot and Ankle Society Hindfoot Score. Preoperatively, the score ranged from 54 to 75, with a mean of 60. Postoperative scores ranged from 53 to 85, with a mean of 71. The follow-up averaged 17.5 months. Preoperative magnetic resonance imaging and bone scan uniformly underestimated the degree of articular damage. There were no operative complications. Three patients improved their scores by 10 points or greater. Two of these patients had debridement of a cartilage flap to a stable base performed. The third patient had an arthroscopically assisted removal of a loose body. Three of the four patients whose scores decreased have progressed to subtalar arthrodesis. We conclude from this small series of patients that arthroscopy is the most accurate method of diagnosing subtalar articular cartilage damage, but that it has limited therapeutic benefit in the treatment of early degenerative joint disease.
Ankle Osteoarthritis Scale
Authors: Domsic Robyn T. , Saltzman Charles L.
Published: March 2013

Although there is a wide array of outcome tools for assessing patients with symptomatic ankle arthritis, no disease-specific instrument for ankle arthritis has been shown to be reliable and valid. The purpose of this study was to develop a simple, reliable, and validated outcome measure for the clinical assessment of ankle osteoarthritis. We modified the Foot Function Index, a visual analog-based scale used to assess rheumatoid foot problems, to measure patient symptoms and functional limitations stemming from osteoarthritis of the ankle joint. Test-retest reliability and criterion and construct validity were determined for the overall Ankle Osteoarthritis Scale and its two subscales (pain and disability). Overall reliability ( r = 0.97; 95% confidence interval [CI], 0.94–0.99), pain subscale reliability ( r = 0.95; 95% CI, 0.90–0.98), and disability subscale reliability ( r = 0.94; 95% CI, 0.88–0.97) were excellent. Criterion validity testing of the instrument with the WOMAC (a disease-specific scale for osteoarthritis) and the SF-36 (a general health survey) showed a high degree of concordance for related subscales. Construct validity using a physical measure of ankle function demonstrated sensitivity of the instrument to the degree of joint dysfunction. Normative data were obtained from 562 individuals who were not patients (264 men and 298 women). The responses were analyzed for trends in gender, body mass index, presence of arthritis, history of fracture in relation to the response levels, and age. A small but statistically significant main effect for gender was found, with women consistently reporting higher pain, disability, and total index scores. Body mass index and arthritis were also found to correlate with response answers across the subscale and total index scores; however, these factors only accounted for 12% of the variation. The Ankle Osteoarthritis Scale is a reliable and valid self-assessment instrument that specifically measures patient symptoms and disabilities related to ankle arthritis.
Late Syndesmosis Reconstruction: A Case Report
Authors: Beals Timothy C. , Manoli Arthur
Published: March 2013

Late syndesmosis reconstruction was performed on a recreational athlete. The functional outcome of the patient after 2 years is reported, and the relevant literature is discussed.
A Biomechanical Analysis of the Squeeze Test for Sprains of the Syndesmotic Ligaments of the Ankle
Authors: Teitz Carol C. , Harrington Richard M.
Published: March 2013

The “squeeze test” is a clinical test for detecting “stable” syndesmosis injuries. The test is positive when proximal compression of the calf produces pain in the area of the distal tibiofibular and interosseous ligaments. The purpose of this study was to examine what fibular movement, if any, occurs at the level of the ankle mortise when compression is applied proximally. A differential variable reluctance transducer was inserted into the origin and insertion of the anterior tibiofibular ligaments of fresh cadaver human lower limbs which had been prepared to simulate the clinical conditions of the squeeze test. Compression was applied both manually and with a specially designed clamp. Squeezing the calf caused separation of the distal fibula and tibia.
Histopathological Study of Nonosseous Tarsal Coalition
Authors: Kumai Tsukasa , Takakura Yoshinori , Akiyama Kouichi , Higashiyama Ichiro , Tamai Susumu
Published: March 2013

Histopathological analysis was performed on 55 feet in 48 patients with nonosseous tarsal coalitions. Histological findings were similar to those observed at the tendinous attachment site of Osgood-Schlatter disease, accessory navicular, and bipartite patellae. No nerve elements were observed in the fibrocartilaginous tissue at the coalition. Nerve elements were present only in periosteum and articular capsule surrounding the coalition. Pain in the tarsal coalition is not mediated by nerve elements at the coalition site itself. It is assumed that the pain is caused by mechanical abnormality that results from incomplete coalition. Incomplete coalition produces microfractures and re-modelings on the boundaries between bone and the coalition, which then lead to degenerative changes. This mechanical abnormality seems to induce pain via free nerve endings in the periosteum and in the articular capsule surrounding the coalition.
Abduction Stress and AP Weightbearing Radiography of Purely Ligamentous Injury in the Tarsometatarsal Joint
Authors: Coss LCDR H. Steven , USNR MC , Manos LCDR Richard E. , USNR MC , Buoncristiani LT Anthony , USNR MC , Mills LCDR William J. , USNR MC
Published: March 2013

Twenty volunteers (40 feet) with no prior foot injury underwent standardized abduction stress and standing AP radiographs. Subsequently, the Lisfranc and dorsal tarsometatarsal ligaments in nine feet from cadavers were sectioned in a varying sequential manner, and interval standardized radiographs of abduction stress and AP simulated weightbearing were obtained. On abduction stress radiographs in 39 of 40 feet of volunteers and nine of nine feet of cadavers before sectioning, a line tangential to the medial aspect of the navicular and medial cuneiform (medial column line) intersected the base of the first metatarsal. Combining the sectioning of the Lisfranc and dorsal tarsometatarsal ligaments produced a disruption of the medial column line in all feet from cadavers. Disruption of this medial column line may be a simple and valuable diagnostic tool for determining significant ligamentous injury to the tarsometatarsal interval.