bluuebunny/crossref_metadata_2025 huggingface dataset:
Should the Amputations of the Great Toe Be Replanted?
Authors: Ademoĝlu Yalçin , Ada Sait , Kaplan Ibrahim
Published: January 2017

Seventeen great toes, amputated at the distal phalangeal to the level of the MTP joint, were replanted between 1990 and 1998, at Izmir Hand and Microsurgery Hospital. Replantation in five out of six complete amputations, and seven out of eleven incomplete amputations were successful, and the overall survival rate was 76.4%. In failed replantations, the base of the proximal phalanx of the great toe was preserved during closing of the stump. Nine of 17 patients were available for review in the follow-up period of mean 3.5 years (range 1-6.5 years). Clinical and biomechanical evaluations of the operated feet were carried out in five patients who had replanted great toe, and in four patients who had amputated one. The uninjured sides were used as control group.

The patients in the two groups had no significant subjective symptoms, nearly normal ROM of the MTP joint and protective sensation was achieved in the replanted great toes. With the numbers available, while radiographical parameters of the involved and the control sides demonstrated no significant differences in either groups, pedographical studies revealed consistent changes in weightbearing distribution of the feet with amputated great toes. Although the great toe amputation causes no disturbance in gait, it alters the load distribution of the foot.
The ANK Device: A New Approach in the Treatment of the Fractures of the Lateral Malleoulus Associated with the Rupture of the Syndesmosis
Authors: Kabukcuoglu Yavuz , Kucukkaya Meting , Eren Tugrul , Gorgec Mucahit , Kuzgun Unal
Published: January 2017

The ANK device was developed for the treatment of fractures of the lateral malleolus occurring with rupture of the syndesmosis. While it provides the anatomic reduction of the fracture and the syndesmosis, it allows the physiologic movements of the fibula. It is not used for comminuted fractures of the lateral malleolus and in cases where fibular medullary canal is narrow.

We included forty-nine patients who had the ANK device applied and at least 2 years follow-up. The mean follow-up was 41 months (range 24–124). The fractures were evaluated according to the Lauge Hansen classification; 25 cases were evaluated as supination-external rotation, 11 cases were pronation-abduction, and 13 cases were pronation-external rotation type fractures. There were also 46 fractures of the medial malleolus and three ruptures of the deltoid ligament. Twenty-nine (59,2%) patients were evaluated as excellent, 12 (24,5%) as good, 5 (10.2%) as fair and 3 (6.1%) as poor. Arthrosis was observed in 3 (6.1%) of the patients.
Effects of Lower Extremith Rotation on Porgnosis of Flexible Flatfoot in Children
Authors: Akçali ömer , Tiner Mehmet , Özaksoy Dinç
Published: January 2017

The aim of this study is to search the effects of tibial torsion on flexible flatfoot. For this purpose, 20 children with flexible flatfoot and external tibial torsion were determined as a study group. The control group which consisted of 10 children with flexible flatfoot without rotational problems was included in the study. Plantar flexion angle of talus, talo-1. metatarsal angle and dorsoplantar talocalcaneal angle were measured on standing foot radiographs. Tibial torsion was measured by computed tomography. Plantar flexion angle of talus and dorsoplantar talocalcaneal angle were found significantly lower in the study group (p<0.005 and p<0.005 respectively), although talo-1. metatarsal angle was not significantly different between the groups (p=.2917). Naviculo-cuneiform sag was prominent in all cases of study group. In conclusion, abnormal external tibial torsion may affect the foot deformity and this can change the benign nature of the flexible flatfoot.
A Technique for Distal Tibial Bone Graft for Arthrodesis of the Foot and Ankle
Authors: Brown Christopher H.
Published: January 2017

Hindfoot and forefoot arthrodeses procedures are commonly performed using autogenous bone graft harvested from the distal tibia. A new technique is described for obtaining cancellous bone graft from the distal tibia using a bone graft harvesting system specifically designed to obtain morsellized material through a small incision site. The use of this device in association with low dose fluoroscopy and backfilling of the defect with osteoconductive synthetic graft material is also discussed.
Delayed Reduction and Stabilization of the Tibiofibular Syndesmosis
Authors: Harper Marion C.
Published: January 2017

Six patients with chronic widening and instability of the tibiofibular syndesmosis subsequent to pronation-external rotation ankle fractures were reviewed as regards diagnosis and treatment. An evaluation of the syndesmotic interval was best done by CT scans using axial cuts. Delayed reduction and stabilization using primarily large screw fixation resulted in maintenance of the reduction and satisfactory results in 5 of 6 cases. In one case, an arthrodesis of the tibiofibular interval was done because of significant incongruity.
Extrinsic Muscle Activity, Foot Motion and Ankle Joint Moments During the Stance Phase of Walking
Authors: Hunt Adrienne E. , Smith Richard M. , Torode Marg
Published: January 2017

This study examined stance phase foot kinematics, kinetics and electromyographic (EMG) activity of extrinsic muscles of 18 healthy males. Three-dimensional kinematic and kinetic data were obtained via video analysis of surface markers and a force plate. Ankle joint moments are described about orthogonal axes in a segmental coordinate system. Kinematic data comprise rearfoot and forefoot motion, described about axes of a joint coordinate system, and medial longitudinal arch height. Surface EMG was obtained for tibialis anterior, soleus, gastocnemius medialis and lateralis, peroneus longus and peroneus brevis and extensor digitorum longus. It was concluded that the demands on the controlling muscles are greatest prior to foot flat and after heel rise. Tibialis anterior restrained rearfoot plantarflexion from heel contact to 10% stance, and eversion between 10% stance and footflat. Activity in peroneus longus was consistent with its role in causing eversion after heel contact, then as a stabiliser of the forefoot after heel rise. Activity in peroneus brevis suggested a role in restraining lateral rotation of the leg over the foot, late in stance.
Dorsiflexion contracture after the Weil Osteotomy: Results of Cadaver Study and Three-Dimensional Analysis
Authors: trnka Hans-Jörg , Nyska Meir , Parks Brent G. , Myerson Mark S.
Published: January 2017

For metatarsalgia caused by a dislocated lesser metatarsophalangeal (MTP) joint and isolated over-long lesser metatarsals, surgical treatment options without sacrificing the joint are limited. Recently, the Weil osteotomy has been advocated for the treatment of this deformity. In our experience, preliminary results with this technique have revealed a high rate of dorsiflexion contracture of the MTP joints at follow-up. We performed a cadaver study and a three-dimensional analysis on sawbones to investigate this phenomenon.

In the cadaveric portion of this study, the second MTP joints of two fresh-frozen cadavers were dissected; the entire ray, with the metatarsal shaft, MTP joint, toe, and plantar fascia, was removed en bloc. After gross anatomic structures were photographed, a Weil osteotomy was performed at 25 relative to the long axis of the metatarsal shaft. The positions of muscles°, ligaments, and tendons were noted and photographed before and after the osteotomy.

In the sawbones portion of this study, a Weil osteotomy was performed at four different angles (25°, 30°, 35°, and 40°) relative to the long axis of the metatarsal. To ensure reproducibility, the sawbone models were fixed proximally to a vertical milling machine with the second metatarsals inclined 15° to simulate the anatomic position. After making the cut, the plantar fragment was translated along the dorsal fragment proximally for a distance of 5 mm. Before and after the osteotomy, selected x, y, and z coordinates were obtained using a Microscribe 3D digitizer. Data analysis was performed with Microsoft Excel, and ANOVA was used to determine significant differences (p <0.05) between the various osteotomies.

Analysis of the cadaver dissection revealed that after the Weil osteotomy, the tendons of the interosseous muscles move dorsally with respect to the axis of the MTP joint due to the depression of the plantar fragment of the metatarsal. The loss of their flexion effect on the joint permits the pull of the extensor to dorsiflex the toe. The size of the depression for the various osteotomies averaged: 25° osteotomy, 3.03 mm (range, 1.8 to 3.8 mm); 30° osteotomy, 3.2 mm (range, 1.9 to 4.0 mm); 35° osteotomy, 3.5 mm (range, 1.7 to 5.7 mm); and 40° osteotomy, 4.2 mm (range, 2.8 to 6.4 mm). Amounts of shortening relative to the long axis of the metatarsal for the various osteotomies averaged: 25° osteotomy, 5.03 mm (range, 4.77 to 5.30 mm); 30° osteotomy, 4.59 mm (range, 3.47 to 5.19 mm); 35° osteotomy, 4.27 mm (range, 2.87 to 5.00 mm); and 40° osteotomy, 3.65 mm (range, 3.20 to 4.31 mm).

According to our analysis, depression of the plantar fragment always occurs after a Weil osteotomy. This depression changes the center of rotation of the MTP joint, and the interosseous muscles then act more as dorsiflexors than as plantarfexors.
Fibroma of a Tendon-Sheath Presenting as Toe Deformity
Authors: Yamamoto Tetsuji , Marui Takashi , Mizuno Kosaku
Published: January 2017

We describe a rare manifestation fibroma in a tendon-sheath in an 83-year-old man. The patient complained initially of a slowly progressive spreading, apart of the right second and third toes. A mass was found in the plantar aspect of the foot. It was completely excised at surgery. Histological examination revealed sparse spindle or stellate cells with slit-like vessels in the dense collagenous matrix. There had been no recurrence at follow-up 17 months after surgery.
Lateral Premalleolar Bursitis as a Result of Sitting on the Foot
Authors: Avci Sinan , Şayli Uğ
Published: January 2017

Lateral premalleolar bursitis develops on the dorsolateral aspect of the foot in people who sit on their feet for prolonged periods. Twenty-nine premalleolar bursae in 21 patients were diagnosed. The patients presented with one or more of the complaints of swelling, pain and difficulty in wearing shoes. One bursa was infected. Initial treatment was non-surgical. With avoidance of the sitting position, the problem resolved in eight of the sixteen patients who were followed. Four bursae were injected with cortisone, three without success. Six bursae were surgically excised, and four of them, with a minimum of one year follow-up were doing well.
Digital Photography in Orthopaedic Surgery
Authors: Elbeshbeshy Basil , Trepman Elly
Published: January 2017

Digital photography has become a practical alternative to film photography for documentation, communication, and education about orthopaedic problems and treatment. Digital cameras may be used to document preoperative and postoperative condition, intraoperative findings, and imaging studies. Digital photographs are captured on the charged coupler device (CCD) of the camera, and processed as digital data. Images may be immediately viewed on the liquid crystal display (LCD) screen of the camera and reshot if necessary. Photographic image files may be stored in the camera in a floppy diskette, CompactFlashTM card, or SmartMedia card, and transferred to a computer. The images may be manipulated using photo-editing software programs, stored on media such as ZipTM disks or CD-R discs, printed, and incorporated into digital presentations. The digital photographs may be transmitted to others using electronic mail (e-mail) and Internet web sites. Transparency film slides may be converted to digital format and used in digital presentations. Despite the initial expense to obtain the required hardware, major cost savings in film and processing charges may be realized over time compared with film photography.
Intra-articular Load Distribution in the Human Ankle Joint During Motion
Authors: Michelson James D. , Checcone Mark , Kuhn Tonya , Varner Kevin
Published: January 2017

The rational treatment of injuries to the ankle is predicated on an understanding of biomechanics of the ankle. While several investigators have reported on three-dimensional dynamic kinematics of the ankle and on the static distribution of pressure within the ankle, it has not been possible to measure intra-articular forces reliably under dynamic conditions. The assumption that the distribution of forces under dynamic conditions is well represented by statically determined forces has not been validated, leaving in question the applicability to dynamic conditions of data obtained under static conditions. This study characterizes an electro-mechanical thin-membrane force transducer with potential for intra-articular use. The sensor was found to yield a reproducible linear response to loads experienced in the ankle, and was insensitive to both a moist environment and shearing forces. On the basis of these results, these force-transducers were placed in axially loaded cadaveric ankles that were either statically or dynamically cycled through a physiologic range of motion. In each of six specimens, sensors were secured to the medial and lateral malleolar articular surfaces, and to articular surfaces of the medial and lateral tibial plafond.

Both medial and lateral malleolar-talar forces increased with dorsiflexion. Moving from plantarflexion to dorsiflexion caused an increase in lateral tibio-talar load accompanied by a decrease in the medial tibio-talar loading. There was no significant hysteresis in force-distribution with respect to the direction of sagittal motion. There was no difference between the forces measured under static or dynamic conditions.

This study validates the use of static loading methodlogies in future studies of force-distribution. Our data in intact ankles closely corresponded to data on forces under dynamic conditions. Dorsiflexion caused an increase in both medially and laterally directed forces towards the malleoli. This is the first demonstration of such forces, which are responsible for the external rotation and lateral translation of the distal fibula that occurs in dorsiflexion of the ankle.
The Effects of Adult Acquired Flatfoot Deformity on Tibiotalar Joint Contact Characteristics
Authors: Friedman Mark A. , Draganich Louis F. , Toolan Brian , Brage Michael E.
Published: January 2017

Changes in the tibiotalar contact characteristics were investigated using eight fresh frozen cadaver ankle specimens to further develop an established model of the acquired flatfoot deformity. The deformity was simulated by sectioning the tendons and ligaments of the ankle and foot that normally support the longitudinal arch. Axial loads of 1,350 N were applied to the foot in a neutral position in both the intact specimen and flatfoot model. The flatfoot condition resulted in significant lateral shifts of 5.28 mm in global contact area and 11.26 mm in the location of peak pressure, and in a small but significant posterior shift of 1.14 mm in global contact area. The flatfoot condition also resulted in a significant, 35%, reduction in contact area. Significant increases in mean pressure, 14%, and peak pressure, 13%, were also found, but were not in proportion to the relatively large decrease in contact area. This suggests a transfer of load off of the talar dome. Increased loading of the lateral facet and fibula are suspected. The lateral shift in the contact region created a local increase in mean contact pressure that may be responsible for long term degenerative changes in patients with this deformity.
Bacterial Recolonization During Foot Surgery: A Prospective Randomized Study of Toe Preparation Techniques
Authors: Brooks RA , Hollinghurst D , Ribbans WJ , Severn M
Published: January 2017

Fifty patients undergoing foot or ankle surgery were randomized into two groups for the purposes of toe preparation. Twenty-four patients underwent a standard preparation which included placing antiseptic between the toes while 26 were additionally cleaned by sliding a gauze swab soaked in topical antiseptic back and forth several times. Povidone iodine followed by chlorhexidine in alcohol was used in both groups. All toes were covered by a sterile glove during surgery unless the toes themselves were to be operated upon.

Bacteria were cultured from the toe clefts in 4% of all patients immediately following preoperative disinfection. Significantly fewer patients whose toes had been additionally scrubbed (group 1) showed bacterial recolonization at the end of surgery compared with those undergoing a standard prep (group 2) (7.7% vs 20.8%). We conclude that additional scrubbing of toe clefts prior to surgery reduces the incidence of recolonization of bacteria during the surgical procedure.
The Reliability of Angular Measurements in Hallux Valgus Deformities
Authors: Coughlin Michael J. , Freund Elisha
Published: January 2017

The purpose of this study was to determine the intra-observer and inter-observer reliability of physicians on a repetitive basis in making angular measurements of hallux valgus deformities. The hallux valgus angle, the 1–2 intermetatarsal angle, and the distal metatarsal articular angle and the assessment of congruency/subluxation of the first MTP joint were evaluated on a repetitive basis. Physicians were provided with a series of black and white photographs of radiographs with a hallux valgus deformity. Three different sets of photographs randomly ordered were sent at a minimum interval of six weeks to the participants.

Participating physicians were extremely reliable in the measurement of the 1–2 metatarsal angle. 96.7% of the photographs were repeatedly measured within a range of 5 degrees or less. The angular measurements to determine the hallux valgus angle were slightly less reliable, but 86.2% of photos were repeatedly measured within a range of 5 degrees or less. In the measurement of the distal metatarsal articular angle, 58.9% of photographs were repeatedly measured within a range of 5 degrees or less. There was a wide range within physician evaluators who recognized very few congruent joints (2 of 21) and those who recognized several congruent joints (11 of 21). Most physicians appeared to be internally consistent in the assessment of MTP congruency; however, some photographs were much more difficult to assess than others. This study validates the reliability of the measurement of the hallux valgus and the 1–2 metatarsal angle. The inter-observer reliability in the measurement of the distal metatarsal articular angle is questioned.
Fractures and Fracture Dislocations of the Midfoot: Occurrence, Causes and Long-term Results
Authors: Richter Martinus , Wippermann Burkhard , Krettek Christian , Schratt Hanns Eberhard , Hufner Tobias , Thermann Hajo
Published: January 2017

Etiology and outcome of 155 patients with midfoot fractures between 1972 and 1997 were analyzed to create a basis for treatment optimization.

Cause of injuries were traffic accidents (72.2%), falls (11.6%), blunt injuries (7.7%) and others (5.8%). Isolated midfoot fractures (I) were found in 55 (35.5%) cases, Lisfranc fracture dislocations (L) in 49 (31.2%), Chopart-Lisfranc fracture dislocations (CL) in 26 (16.8%) and Chopart fracture dislocations (C) in 25 (16%). One hundred and forty eight (95%) of the midfoot fractures were treated operatively; 30 with closed reduction, 115 with open reduction, 3 patients had a primary amputation. Seven (5%) patients were treated non-operatively. Ninety seven (63%) patients had follow-up at an average of 9 (1.3–25, median 8.5) years. The average scores of the entire follow-up group were as follows: AOFAS – sum of all four sections (AOFAS-ET): 296, AOFAS-Midfoot (AOFAS-M): 71, Hannover Scoring System (HSS): 65, and Hannover Questionnaire (Q): 63. Regarding age, gender, cause, time from injury to treatment and method of treatment no score differences were noted (t-test: p > 0.05). L, C or I showed similar scores and CL significantly lower scores (AOFAS-ET, AOFAS-M, HSS, Q). The highest scores in all groups were achieved in those fractures treated with early open reduction and operative fixation.

Midfoot fractures, particularly fracture dislocation injuries, effect the function of the entire foot in the long-term outcome. But even in these complex injuries, an early anatomic (open) reduction and stable (internal) fixation can minimize the percentage of long-term impairment.
Long-Term Outcome of Anatomical Reconstruction Versus Tenodesis for the Treatment of Chronic Anterolateral Instability of the Ankle Joint: A Multicenter Study
Authors: Krips Rover , van Dijk C. Niek , Halasi Tamas , Lehtonen Hannu , Corradini Constantino , Moyen Bernard , Karlsson Jon
Published: January 2017

The long-term clinical outcome after anatomical reconstruction and tenodesis in the treatment of chronic anterolateral ankle instability was assessed in a retrospective multicentre study.

The first group (AR) consisted of 25 patients (mean age at operation 22 yrs ± 5.7) who underwent anatomical reconstruction and the second group (TE) of 29 patients (mean age 23 yrs ± 6.6) who underwent tenodesis. For both groups, the mean follow-up period was 12.3 yrs (AR ± 2.5 yrs, TE ± 2.7 yrs). At physical examination, there were significantly more patients in the TE group (n = 18) with a positive anterior drawer sign as compared with the AR group (n = 7) (p = 0.02). Medially located degenerative changes in the ankle joint as seen on standard radiographs were seen more often in the TE group (n = 7) than in the AR group (n = 1) (p = 0.03). The mean talar tilt, 4.7° in the AR group vs 6.9° in the TE group, (p = 0.02) and anterior talar translation, 2.9 mm in the AR group vs 4.3 mm in the TE group, (p = 0.04) were significantly higher in the TE group at radiographic stress examination. According to the rating system developed by Good et al. (1975), significantly fewer patients in the TE group (n = 8) had an excellent result as compared with the AR group (n = 15) (p = 0.03) and more patients in the TE group (n = 9) had a fair or poor result (p = 0.04) as compared with the AR group (n = 2).

We conclude that a tenodesis procedure does not restore the normal anatomy of the lateral ankle ligaments. When compared with anatomical reconstruction, a tenodesis leads to inferior results in terms of functional and mechanical stability, as well as overall satisfaction at long-term follow-up.
When Does the Flat-Top Talus Lesion Occur in Idiopathic Clubfoot: Evaluation with Magnetic Resonance Imaging At Three Months of Age
Authors: Sullivan Raymond J. , Davidson Richard S.
Published: January 2017

Flat-top talus has been described as a pathologic change secondary to idiopathic clubfoot condition and/or as a direct result of nonoperative manipulation involving forced dorsiflexion and molding of the cartilaginous talus. No definitive study, however, on the etiology and the timing of the flat-top talus deformity has been performed to date. The authors evaluated the magnetic resonance images of eleven patients with idiopathic clubfoot deformities treated with 2 to 3 months of casting to assess if flattening of the talar dome occurred at this age with this amount of casting. All children were 3 months of age, were casted for a maximum of 2 to 3 months, and sedated before MRI examination. The images were evaluated for maximum talar head height, maximum talar body height, and deviation of the talar body from a perfect circle. Maximum talar head height ranged from 4 to 9 mm, maximum talar body height ranged from 6 to 10mm. Eight of the eleven had maximum talar body measurements 3 to 5mm greater than maximum talar head height. Three of the eleven patients had head and body size of equal proportion. Two of the eleven had a talar body that was within 1mm of a perfect circle. The remaining nine patients had perfectly round talar bodies. In the senior author's (RSD) experience with treating clubfeet, a substantial increase has been seen at operation in flat-top tali among children that were casted for more than 1 year before surgical correction, compared to children casted for 3 months before surgical correction. The current investigation indicated that although tali of children with clubfeet are abnormally shaped, the talar body remains larger than the talar head and maintains its roundness after two to three months of corrective casting. Maintenance of cast treatment for more than three months may lead to the flat-top talus deformity. The authors recommend surgical intervention following three months of failed manipulation and casting to prevent this deformity.
Intramedullary Screw Fixation of Jones Fractures
Authors: Kelly Ian Peter , Glisson Richard R. , Fink Christian , Easley Mark E. , Nunley James A.
Published: January 2017

Background: Jones fractures of the fifth metatarsal can be stabilized using intramedullary screw fixation techniques. A range of screw diameters from 4.5 mm to 6.5 mm can be used, but the optimal screw for this procedure has yet to be defined. In clinical practice, we have observed that failure is more likely when smaller diameter screws are used.

Methods: Experimental Jones fractures were created in 23 pairs of human cadaver fifth metatarsals, which were fixed using either 5.0 mm or 6.5 mm screws. Fracture stiffness and pull-out strengths were measured for either screw type and their relationships with bone mineral density and medullary canal diameter were determined.

Results: There was no significant difference in the bending stiffness of fractures stabilized with 5.0 mm and 6.5 mm screws; however, different mechanisms of failure were noted for either screw type. Poor thread purchase within the medullary canal was noted with the 5.0 mm screws, while excellent purchase was noted with 6.5 mm screws. Pull-out strength testing revealed significantly higher pull-out strengths for the larger 6.5 mm screws. There was no significant difference in bone mineral density or medullary canal diameter between right and left metatarsals.

Conclusions: Fifth metatarsals can often accommodate a 6.5 mm screw for the stabilization of Jones fractures. Larger diameter screws did not result in greater fracture stiffness in our model, but did result in significantly greater pull-out strengths.

Clinical Relevance: Larger diameter screws may be more appropriate for intramedullary screw fixation of Jones fractures.
The Effects of Medial and Lateral Displacement Calcaneal Osteotomies on Ankle and Subtalar Joint Pressure Distribution
Authors: Davitt James S. , Beals Timothy C. , Bachus Kent N.
Published: January 2017

We compared the pressure distribution in the ankle and posterior facet of the subtalar joint following 1 cm medial and lateral displacement calcaneal osteotomies to the pressure distribution in the intact foot. Six cadaver specimens were loaded in neutral alignment while pressure measurements were recorded. A 1-cm medial displacement osteotomy shifted the average center of force in the ankle 1.0 mm medially (p = 0.36) while a lateral displacement osteotomy shifted the center of force 1.1 mm laterally (p = 0.42). There was also a slight shift in the percentage of pressure toward the side of the talus to which the calcaneus was shifted. For the lateral displacement osteotomy, the pressure increased 4.0% in the lateral-most quadrant (p = 0.05), while the medial osteotomy increased the pressure 1.3% in the medial quadrant (p = 0.30). In the subtalar joint, a medial displacement osteotomy shifted the pressure distribution slightly medially (5.9%, p = 0.06) and more anteriorly (9.6%, p = 0.02) while the distribution was shifted laterally (5.9%, p = 0.17) and anteriorly (5.6%, p = 0.03) with a lateral displacement osteotomy. These shifts of percentage of pressure between quadrants of the joints were slight—less than 5% in the ankle and less than 10% in the subtalar joint. Significant translation of the calcaneal tuberosity appears to have only a small effect on pressure distribution in the ankle and posterior facet of the subtalar joint in a weighted cadaver model.
Surgical Management of Severe Deformity Resulting from Posterior Tibial Tendon Dysfunction
Authors: Coetzee J. Chris , Hansen Sigvard T.
Published: January 2017

A retrospective case study format was used to evaluate the results of surgical treatment of severe deformities due to long-standing tibialis posterior tendon dysfunction. To be included in the study, the peri-talar (talonavicular) subluxation on a weight-bearing AP X-ray should have been at least 75%. This criterion limited the field to patients with long-standing, rigid, severe deformities.

Surgical correction was obtained through a two-incision approach, dorsomedial and dorsolateral. Significant shortening of the medial column and extensive removal of adaptive bone formation was necessary to allow reduction of the hind- and midfoot deformity. Stable internal fixation using multiple screws was used to secure the reduction. Eleven patients, 12 feet were evaluated.

The patients were evaluated using the American Orthopedic Foot and Ankle Society Ankle and Hindfoot Score as well as a questionnaire on footwear and satisfaction rating.

The average score improved from 30 points pre-op to 74 points post-op (out of 100). P-value 0.0001.

Pain score improved from 11/40 to 33/40. Function improved from 19/50 to 33/50. Alignment improved from 0/10 to 8/10.

The radiological parameters showed an average improvement of 31° in the lateral talo-1st metatarsal angle, 11° in the calcaneal pitch, and 35° in the AP talo-1st metatarsal angle. All three parameters were highly significant with P-values of 0.0001.

Multiple complications occurred. This included two delayed unions with breakage of screws and partial loss of correction, four wound problems, two sural nerve impairments and three patients requiring hardware removal.

Even though it is an extensive procedure with multiple potential complications it still offers a substantial improvement in quality of life.
Mobility of the First Tarsometatarsal Joint in Hallux Valgus Patients: A Radiographic Analysis
Authors: Faber Frank W.M. , Kleinrensink Gerrit-Jan , Mulder Paul G.H. , Verhaar Jan A.N.
Published: January 2017

Hypermobility of the first tarsometatarsal (TMT 1) joint in the sagittal plane plays a role in the etiology and treatment of the hallux valgus complex. However, objective quantification of this mobility is still a problem. We performed a radiographic analysis of TMT 1 mobility in the sagittal plane in 94 hallux valgus patients aged 15 to 65 years. We examined 94 feet with symptomatic hallux valgus deformity requiring operative correction. Excluded were patients with osteoarthritis, inflammatory diseases or previous operations on the foot. The TMT 1 mobility was tested with a clinical test and by radiographic measurement using the modified Coleman block test.

The mean mobility of the TMT 1 joint in the sagittal plane in the patient group was 12.9° (SD 4.80). In addition, there was a statistically significant difference between two sub-groups: patients with and without clinical TMT 1 hypermobility. No correlation of TMT 1 (hyper)mobility and radiographic second ray hypertrophy was found.

This simple method can produce additional information to the clinical TMT 1 hypermobility test in the sagittal plane.
Shockwave Therapy for Patients with Plantar Fasciitis: A One-Year Follow-up Study
Authors: Wang Ching-Jen , Chen Han-Shiang , Huang Ting-Wen
Published: January 2017

The effect of shockwave therapy was investigated in 79 patients (85 heels) with plantar fasciitis with one-year follow-up. There were 59 women and 20 men with an average age of 47 (range, 15-75) years. Each patient was treated with 1000 impulses of shockwave at 14 kV to the affected heel. A 100-point scoring system was used for evaluation including 70 points for pain and 30 points for function. The intensity of pain was based on a visual analogue scale from 0 to 10. The overall results were 75.3% complaint-free, 18.8% significantly better, 5.9% slightly better and none unchanged or worse. The effect of shockwave therapy seemed cumulative and was time-dependent. The recurrence rate was 5%. There were no device-related problems, systemic or local complications. Shockwave therapy is a safe and effective modality in the treatment of patients with plantar fasciitis.
Uremic Tumoral Calcinosis of the Foot Mimicking Infection
Authors: García Sebastián , Cofán Federico , de Retana Pablo Fernández , Sala Pedro , Oppenheimer Federico
Published: January 2017

Uremic tumoral calcinosis is an uncommon, benign condition characterized by slow-growing calcified periarticular soft tissue masses of varying size. We describe two patients with chronic renal failure on hemodialysis presenting uremic tumoral calcinosis, one in the fifth toe of the right foot and the other in the dorsum of the left foot between the first and second metatarsals. Excision of the calcic masses and parathyroidectomy were successfully performed in both patients. These cases are unusual in their rapid onset, mimicking acute infection. Differential diagnosis, radiological features and therapy are discussed.
New Radiographic Analysis of Sesamoid Rotation in Hallux Valgus: Comparison with Conventional Evaluation Methods
Authors: Kuwano Takashi , Nagamine Ryuji , Sakaki Kazuhiro , Urabe Ken , Iwamoto Yukihide
Published: January 2017

The position of the hallucal sesamoids needs to be included in evaluation of hallux valgus. In order to quantify the rotational position of the hallucal sesamoids, a new weightbearing tangential radiograph was established by means of a specially designed tangential positioning device. This device has a depression, and a tangential radiograph is taken with the metatarsophalangeal joint at 45° dorsiflexion. A lead marker plate is placed on the depression to show the horizontal plane, and the sesamoid rotation angle (SRA) is measured. The SRA is the angle between the tangential line of the most inferior aspect of the medial-lateral sesamoids and the lead marker line. The SRA was compared with values of the four-grade scale and seven-position scale which were measured from the antero-posterior view, with respect to the hallux valgus angle (HVA), by means of conventional methods. Measurements were made of 58 feet in 29 patients with hallux valgus and 64 feet in 32 normal subjects.

The SRA showed the highest correlation among the three parameters (r = 0.817). Some cases had a disparity regarding the position of the sesamoids between the tangential view and the AP view due to misclassification on the AP view. We conclude that the scale of position of the sesamoid on the AP view is not valid in some cases, whereas the SRA is useful for assessing quantitatively the rotational position of the hallucal sesamoids in cases of hallux valgus.
Percutaneous Plating of Distal Tibial Fractures
Authors: Khoury Amal , Liebergall Meir , London Eli , Mosheiff Rami
Published: January 2017

This article presents our experience with 24 patients who had distal tibial fractures and were treated by percutaneous plate fixation. Distribution of the fractures according to the AO/OTA classification was as follows: five patients suffered from a 43 A type fracture, six from a 43 B type fracture, and 13 from a 43 C type fractures. Four of the fractures were open. Exclusion criteria included 43 C3 fractures and Gustilo III open fractures. All fractures showed radiographic signs of union enough to enable full weightbearing within an average time of 12.3 weeks. All patients showed a good range of motion (average dorsiflexion 12° and average plantiflexion 18°). Two fractures united with mal-union: one with an 8° valgus deformity and another with a 7° varus deformity. Both cases, which had a metaphyseal component, were treated by means of a “soft” (flexible and manually adjustable) AO 3.5 mm reconstruction plate. Except for one case of superficial infection, no infections were detected in any of the patients.

The biological percutaneous plate fixation of distal tibial fractures with no extensive intra-articular involvement is a good soft tissue preserving technique. It provides a rigid and anatomical fixation in most cases. We conclude that type B fractures with one intact column can be fixed with either “soft” or “rigid” plates, and type A and C fractures with a metaphyseal component should be fixed with “rigid” plates (AO 4.5 mm Dynamic Compression Plate). In these fractures the reduction should be performed cautiously due to the tendency of sagittal plane mal-reduction.
Stress Fractures of the Ankle and Forefoot in Patients with Inflammatory Arthritides
Authors: Mäenpää Heikki , Lehto Matti U.K. , Belt Eero A.
Published: January 2017

Twenty-four stress fractures occurring in the metatarsal bones and ankle region were examined in 17 patients with inflammatory arthritides. There were 16 metatarsal, four distal fibular, two distal tibial, and two calcaneus fractures. Radiographic analyses were performed to determine the presence of possible predisposing factors for stress fractures. Metatarsal and ankle region stress fractures were analyzed separately. Stress fractures occurred most frequently in the second and third metatarsals. In metatarsal fractures, there was a trend for varus alignment of the ankle to cause fractures of the lateral metatarsal bones and valgus alignment of the medial metatarsal bones. Valgus deformity of the ankle was present in patients with distal fibular fractures in the ankle region group. Calcaneus fractures showed neutral ankle alignment. Malalignment of the ankle and hindfoot is often present in distal tibial, fibular, and metatarsal stress fractures. Additionally, patients tend to have long disease histories with diverse medication, reconstructive surgery and osteoporosis. If such patients experience sudden pain, tenderness, or swelling in the ankle region, stress fractures should be suspected and necessary examinations performed.
The Association between Diagnosis of Plantar Fasciitis and Windlass Test Results
Authors: De Garceau Denise , Dean Danielle , Requejo Susan Mais , Thordarson David B.
Published: January 2017

Twenty-two patients with plantar fasciitis, 23 patients with other types of foot pain, and 30 patients in a control group were evaluated with the Windlass test performed in a weightbearing and non-weightbearing position. In the non-weightbearing test, the first MP joint was maximally dorsiflexed with the ankle stabilized. The weightbearing test was performed with the toes hanging off the edge of a stool and dorsiflexion of the first MP was performed. Seven of the 22 patients in the plantar fasciitis group had a positive weightbearing Windlass test (31.8%), while only three had a positive test result in a non-weightbearing position (13.6%). None of the patients in the other foot pain group or control group had pain in the weightbearing and non-weightbearing positions. Despite its high rate of specificity, the low rate of sensitivity of the Windlass test may limit its usefulness in the clinical evaluation in patients with plantar fasciitis.
The Effect of Leg Length Discrepancy on Foot Loading Patterns and Contact Times
Authors: O'Toole G.C. , Makwana N.K. , Lunn J. , Harty J. , Stephens M.M.
Published: January 2017

The effect of a simulated leg length discrepancy on foot loading patterns and gait cycle times in normal individuals was investigated. Thirty feet of 15 normal volunteers were evaluated. Leg length discrepancy was simulated using flexible polyurethane soles. As leg length discrepancy increased, the total loading increased from 35.31 to 37.99 kg/cm 2 /sec, forefoot loading increased from 15.58 to 19 kg/cm 2 /sec, hindfoot loading remained the same. All subjects, except females with middle loading patterns, demonstrated increased hallux loading. The contact phase of gait decreased from 22% to 13%, the midstance phase remained the same, the propulsion phase increased from 44% to 50%. All findings were statistically significant. Leg length discrepancy has significant effects on the foot. Different adaptive loading patterns amongst subsets of individuals are seen.
Evaluation of the Fibular Incisura of the Tibia with Magnetic Resonance Imaging
Authors: Yildirim Hanifi , Mavi Ayfer , Büyükbebeci Orhan , Gümüşlburun Erdem
Published: January 2017

Knowledge of the distal tibiofibular syndesmosis should be helpful in determining the normal position of the fibula in the incisural notch. The purpose of this study was to determine the anatomic characteristics of the fibular incisura of the tibia on MR imaging. One hundred fifty lower limbs (43 male, 32 female volunteers) were examined with MRI. The length of the anterior facet was 10.4 mm in males and 8.9 mm in females, and the length of the posterior facet was 10.4 mm in males and 8.9 mm in females. The angle between anterior and posterior facets was 138.6° in males and 139.9° in females. The depth of the fibular incisura of the tibia was 3.6 mm in males and 2.9 mm in females. The vertical distance of tibiofibular overlapping was 7.9 mm in males and 7.0 mm in females. The distance between anterior margin of the tibia and anterior margin of the fibula was 14.3 mm in males and 12.5 mm in females. All of these parameters of men (except the angle between anterior and posterior facets) were significantly higher than the parameters of women ( p < .001, p < .001, p < .05, p < .05, p < .01, respectively).
Role of Passive Structures in the Mobility and Stability of the Human Subtalar Joint: A Literature Review
Authors: Stagni Rita , Leardini Alberto , O'Connor John J. , Giannini Sandro
Published: January 2017

The subtalar joint plays a fundamental role in the transmission of loads between the leg and the foot. Although anatomical structures of this joint have been described extensively, much ambiguity about their location, shape, and function still persists. There is also disagreement regarding mobility, for example, whether the joint can be considered a hinge, screw-like, or a multiaxial joint. The most relevant studies from the literature are reported and the main experimental observations discussed. Recent studies have described the subtalar joint as a structure with no degrees of unresisted freedom, i.e., motion from the single neutral position is attained only by deformation of the ligaments and of the articular surfaces.
Anatomical Reconstruction of the Spring Ligament Using Peroneus Longus Tendon Graft
Authors: Choi Kyungjin , Lee Samuel , Otis James C. , Deland Jonathan T.
Published: January 2017

Posterior tibial tendon insufficiency is often associated with failure of the spring ligament and flatfoot deformity. Arch correction procedures involving bony realignment, such as lateral column lengthening or joint fusions, can predispose to arthritis. Soft tissue reconstruction may provide a more anatomical correction without these complications. The purpose of this investigation was to compare the ability of three different spring ligament reconstruction procedures to correct flatfoot deformity. A deformity model of 5°–15° talonavicular abduction was created in 10 cadaver foot-ankle specimens. Three reconstructions utilizing the peroneus longus tendon were evaluated for their ability to correct talonavicular abduction and subtalar eversion under 357 N vertical GRF load. A superomedial/plantar passage of the tendon through the calcaneus and navicular was shown to be more effective than either of the other two approaches, correcting the talonavicular joint from 9.1° ± 8.1° abducted to 1.0° ± 6.8° adducted, and the subtalar joint from 3.1° ± 3.3° everted to 0.4° ± 4.2° inverted. Thus, an anatomical reconstruction of a model of a failed spring ligament was demonstrated to be effective in the correction of a flatfoot deformity produced in cadaver foot–ankle specimens.
Achilles Tendon Ruptures: Functional Outcome of Surgical Repair with a “Pull-out” Wire
Authors: Richardson Lars C. , Reitman Richard , Wilson Michael
Published: January 2017

This is a retrospective review of 30 consecutive patients with acute Achilles tendon ruptures treated surgically by a single surgeon between 1992 and 1999. Repair was effected with a 26-gauge “pull-out” wire technique. A compressive dressing reinforced with plaster was employed to immobilize the ankle in neutral for 6 weeks. The hardware was removed 6 weeks postoperatively under local anesthesia. Intensive physical therapy was employed until ankle motion was symmetric and single heel raise was possible. Average follow-up was 4 years (range, 1–8 years). Nearly all patients (29/30) report satisfaction with their outcome. Most patients (29/30) had AOFAS Ankle-Hindfoot Scores greater than 90. Twenty-three (77%) returned to preoperative levels of athletic activities. Isometric testing documented 81% plantarflexion strength compared to the normal ankle at a mean of 32 months postoperatively. Five of eight women reported shoe wear difficulties related to the incision. There were no reruptures or deep infections. The “pull-out” wire technique is recommended for patients who wish to return to an active lifestyle. This method provides rigid approximation of tendon length, minimizes strangulation of tissue, repairs large gaps, and avoids late foreign-body reactions.
Ten-Year Evaluation of Cementless Buechel-Pappas Meniscal Bearing Total Ankle Replacement
Authors: Buechel Frederick F. , Buechel Frederick F. , Pappas Michael J.
Published: January 2017

A porous-coated, cementless, congruent-contact, three-piece, meniscal-bearing total ankle replacement was developed and used clinically over a 2- to 10-year period for patients with disabling ankle arthritis. Polished titanium-nitride ceramic-coated Ti6Al4V tibial and talar components with a deep-sulcus trochlear groove and two lateral fixation fins for the talar onlay component were used. The ultra-high-molecular-weight polyethylene (UHMWPe) meniscal bearing congruently conformed to the flat upper tibial component surface and the deep sulcus and cylindrical geometry of the lower talar component surface. Fifty deep-sulcus (Buechel-Pappas™) total ankle replacements were implanted in 49 patients. Diagnoses were 8 osteoarthritis (16%), 7 rheumatoid arthritis (14%), 2 avascular necrosis (4%), and 33 post-traumatic arthritis (66%). Ages ranged from 26 to 71 years (mean 49 years). Clinical results using a strict ankle scoring system demonstrated good/excellent results in 88% of cases. Postoperative ankle motion ranged from 12° to 46° total arc (mean 28°), which was similar to the preoperative motion. Revision for malalignment was necessary in two cases (4%). Mechanical complications included one case of meniscal bearing wear (2%) in a patient with posttraumatic arthritis with component malalignment and one case of talar component subsidence (2%) in a patient with avascular necrosis of the talus. No tibial component loosening was seen. Cumulative survivorship using an end point of revision of any component for any reason was 93.5% at 10 years (confidence interval 61–100%).
Outcome of Orthoses Intervention in the Rheumatoid Foot
Authors: Kavlak Yasemin , Uygur Fatma , Korkmaz Cengiz , Bek Nilgün
Published: January 2017

This study was carried out to determine the effect of foot orthoses on pain, gait, and energy expenditure in patients with rheumatoid arthritis. Eighteen patients were evaluated for these parameters. Each patient was given a foot insert or shoe modification suitable for his or her foot deformity. Following 3 months of orthosis use, a significant difference was found in regards to pain ( p <.05), step length and stride length ( p <.05), and physiological cost index ( p <.05). The results suggest that foot orthoses are an important feature in the rehabilitation of the rheumatoid foot.