bluuebunny/crossref_metadata_2025 huggingface dataset:
The Association Between Body Mass Index and Foot Disorders in Diabetic Patients
Authors: Pinzur Michael , Freeland Ryan , Juknelis Danius
Published: January 2017

Background: Fifteen percent of individuals with diabetes develop a foot ulcer during their lifetime, and 85% of lower extremity amputations are preceded by an ulcer with or without infection. This study was done to determine the association between morbid obesity and foot ulcer or infection in patients with diabetes. Methods: During a 66-month period, 133 patients were admitted to a tertiary care university medical center with a diagnosis of foot ulcer or foot infection. There were 79 men and 54 women, with an average age of 62 ± 12 years. During hospitalization, 52 patients had peripheral angiography, 18 patients had invasive cardiac procedures, and 13 patients had peripheral vascular surgery. Twenty-two patients were receiving chronic hemodialysis. Seventy-four patients had surgical debridement of an ulcer. Thirty-two patients had bony stabilization of a Charcot foot. Partial or Syme amputations were done on 36 patients, and 26 patients had a transtibial or more proximal level of amputation. Medical records data allowed calculation of body mass index (BMI) for 82 patients. Results: Mean BMI was 31 ± 7 kg m 2 . Forty-six patients were obese (BMI ≥ 30.0 kg m 2 ), which is significantly higher than the national prevalence in adults (20.9%, p < 0.001). There was no correlation between BMI and length of hospitalization in the study patients. Conclusions: In a tertiary care medical center with a high proportion of very ill patients, there appeared to be a strong correlation between diabetes-associated foot morbidity and morbid obesity.
The Peroneal Reaction Time (PRT) - Reference Data in a Healthy Sample Population
Authors: Schmidt Roland , Gergrou¨ Heinz , Friemert Benedikt , Herbst Anne
Published: January 2017

Background: Acute ankle sprains can result in severe residual symptoms, such as chronic ankle instability from weakness of the ligamentous complex or neuromuscular deficits. Measuring peroneal reaction time (PRT) has become a commonly accepted procedure for evaluating proprioceptive deficits. Methods: The present experimental study was conducted to determine the effects of anthropometric factors on PRT in 120 healthy volunteers. The patients were asked to stand on a platform with a tilting mechanism. Surface electrodes were used to record peroneal muscle activity in response to sudden inversion stress. The reaction of the peroneal muscles was analyzed using electromyography. Results: The statistical analysis showed similar intra-individual and inter-individual values for PRT. The results for the muscle groups measurements, however, varied considerably. PRT seems to increase significantly with age (long peroneal muscle: p < 0.0001, short peroneal muscle: p = 0.004). Conclusions: PRT was found to be an objective parameter that is unaffected by extrinsic and intrinsic factors. The present study, however, also showed that PRT significantly increases with age. As for studies on PRT, as well as for clinical routine, it is important to consider the patients' ages.
The Peroneal Groove Deepening Procedure: A Biomechanical Study of Pressure Reduction
Authors: Title Craig I. , Jung Hung-Geun , Parks Brent G. , Schon Lew C.
Published: January 2017

Background: The goal of this study was to identify pressure changes throughout the peroneal groove after a groove deepening procedure. We hypothesized that pressures would decrease. Methods: Twelve fresh-frozen foot and ankle specimens were used. A thin pressure strip containing four sensor pads was secured within the peroneal groove with pads 1 through 4 positioned at the calcaneofibular ligament (CFL) and at the distal, middle, and proximal groove, respectively. The midstance phase of gait was simulated with loads applied to the plantar foot and posterior tibial tendon and to the peroneus longus and brevis tendons. Pressures were recorded with the ankle in neutral, plantarflexion, dorsiflexion, inversion, and eversion. Groove deepening was done by osteotomizing the posterior fibular wall. Pressure readings were then recorded. Average pressures for each of the four sensor pads after the procedure were compared to those obtained before the procedure. Results: The mean pressure overlying the CFL increased at all five ankle positions; however, these changes were not significant. Significant decreases in pressure were noted within the distal and middle groove at all ankle positions after the peroneal groove deepening procedure. Pressure within the proximal groove increased at all but one position, with a significant difference noted in neutral and plantarflexion. Conclusion: Pressures within the middle and distal peroneal groove significantly decreased after a groove deepening procedure. Combining this technique with peroneal tendon debridement may be advantageous for treatment of partial peroneal tendon tears or recalcitrant peroneal tendinitis.
Local Bone Graft Harvested From the Distal Tibia or Calcaneus for Surgery of the Foot and Ankle
Authors: Raikin Steven M. , Brislin Kenneth
Published: January 2017

Background: Numerous operative procedures around the foot and ankle use bone graft to augment healing. Autologous bone graft remains the preferred type for these procedures. This can be harvested from the iliac crest, but complications are frequent. The purpose of our study was to investigate the option of harvesting the bone graft from the ipsilateral distal tibia or calcaneus. Method: Bone graft was harvested in 114 patients from the distal tibia (70 patients) or calcaneus (44 patients). The patients were followed postoperatively for an average of 16 (range 5 to 28) months and were evaluated for complications (minor and major), satisfaction, and healing rates. Results: There were no major complications. Ten patients (8.7%) had minor complications including initial incisional sensitivity or local numbness, none of which affected function or required additional treatment. Satisfaction rate for the procedure was 100%. Conclusion: Use of autologous bone graft harvested from the ipsilateral distal tibia or calcaneus is a safe and reliable alternative to iliac crest bone graft harvest for operative procedures of the foot and ankle.
The Modified Distal Horizontal Metatarsal Osteotomy for Correction of Bunionette Deformity
Authors: Radl Roman , Leithner Andreas , Koehler Wolfgang , Scheipl Susanne , Windhager Reinhard
Published: January 2017

Background: Bunionette is a common deformity for which a number of operative procedures have been described. The objective of this study was to evaluate the results of a modified distal horizontal metatarsal osteotomy in the correction of symptomatic bunionette. Methods: Metatarsal osteotomies were done in 21 feet in 14 patients (11 females, three males) with an average age of 44 (range 20 to 67) years at the time of operation. The average followup was 32 (range 12 to 52) months. Results: The average Lesser Toe Metatarsophalangeal-Interphalangeal Score of the American Orthopaedic Foot and Ankle Society increased from 42 points (range 24 to 50) preoperatively to 87 points (range 60 to 100) at the last followup. The fifth metatarsophalangeal angle averaged 18 degrees (5 to 38 degrees) preoperatively and 5 degrees (−5 to 26 degrees) at final followup. The 4–5 intermetatarsal angle averaged 14 degrees (10 to 20 degrees) preoperatively and 9 degrees (5 to 12 degrees) at final followup. Hardware was removed from two feet and scheduled for a third foot because of symptomatic skin irritation. Conclusions: The modified distal horizontal metatarsal osteotomy is a stable and reliable method for correction of bunionette. Unsatisfactory results in our patients were related to prominent hardware.
Tibiotalocalcaneal Arthrodesis: A Biomechanical Assessment of Stability
Authors: Bennett Gordon L. , Cameron Brian , Njus Glen , Saunders Marnie , Kay David B.
Published: January 2017

Background: Combined ankle and subtalar (tibiotalocalcaneal) arthrodesis is a procedure that can be used to successfully treat disabling foot and ankle arthropathy and is a reasonable salvage alternative to amputation for the treatment of nonbraceable neuropathic, diabetic, degenerative, or rheumatoid joints. Although many methods of tibiotalocalcaneal (TTC) arthrodesis have been described in the literature, the most popular current methods involve the use of crossed cancellous bone screws, plates, or a locked retrograde intramedullary rod. Fusion in these patients can be difficult, with significant complications including infection, malunion, and nonunion. A persistent nonunion can lead to failure of the hardware and recurrent deformity. Methods: We biomechanically tested the stability and micromotion in four methods of TTC arthrodesis using liquid metal strain gauges and Instron (Norwood, MA) material testing systems. Anatomically identical synthetic bones with properties very similar to human bone were instrumented and tested. Four instrumentation techniques were tested: 1) three crossed 6.5-mm cancellous screws, 2) two crossed 6.5-mm cancellous screws, 3) locked retrograde intramedullary rod, and 4) locked retrograde intramedullary rod augmented with a single anteromedial bone staple. Six separate specimens for each technique were tested. Results: The three crossed cancellous screw technique provided the greatest stability with respect to micromotion ( p < 0.05). The addition of a tibiotalar staple to the locked intramedullary rod conferred stability nearly equal to that of the three crossed cancellous screw fixation ( p < 0.05). The locked intramedullary rod group and the two crossed cancellous screw group allowed significant micromotion at the arthrodesis sites, which was a full order of magnitude higher ( p < 0.05) than in the three crossed cancellous screw group and the staple augmented intramedullary rod group. Conclusions: Biomechanically, a staple augmented locked intramedullary rod for TTC arthrodesis confers excellent stability nearly equal to the three crossed cancellous screw technique for TTC arthrodesis.
Functional Limitations of Patients with End-Stage Ankle Arthrosis
Authors: Agel Julie , Coetzee J. Chris , Sangeorzan Bruce J. , Roberts Matthew M. , Hansen Sigvard T.
Published: January 2017

Background: Arthritis and other rheumatic conditions are the leading causes of disability among adults in the United States. The purpose of this report was to describe the self-reported functional limitations of a group of patients with end-stage ankle arthrosis. Method: Patients who presented for operative management of end-stage ankle arthrosis at the University of Minnesota and Harborview Medical Center completed a Musculoskeletal Functional Assessment (MFA) as part of their preoperative clinical evaluation. Data from patients evaluated during the time period April, 1995, through May, 2004, were used for this project. Results: Four hundred and twenty-six patients with the diagnosis of end-stage ankle arthrosis completed baseline questionnaires. Six of the 426 patients received care on both ankles during the time of this project. The average age of patients at the time of completion of the questionnaire was 56.7 years. There were 241 men and 185 women. The primary underlying causes identified by the treating surgeon at the time of surgery were primary osteoarthritis with no known prior trauma (66), previous trauma (tibial fracture, foot fractures, or ankle ligamentous disruption) (296), rheumatoid arthritis (24), no known cause (21), and a variety of diseases or infections (19). In all domains, the patients with end-stage ankle arthrosis showed statistically significant differences from a general population sample. Conclusions: The effects of ankle arthritis as demonstrated by this data are severe. Most of these patients were severely limited in function. Without a data-driven understanding of the limitations the patients have, it is difficult to make an effective argument for focused research to solve the problems. Without understanding the patients' needs, it is impossible to assess the effect of treatment. The information in this paper provides a baseline understanding of effect of the current functional limitations of patients with end-stage ankle arthrosis.
Morton Neuroma: Comparative Results of Two Conservative Methods
Authors: Saygi Baransel , Yildirim Yakub , Saygi Evrim K. , Kara Hasan , Esemenli Tanil
Published: January 2017

Background: The initial treatment of Morton neuromas consists of conservative methods that include shoe modifications and steroid injections. The purpose of this prospective study was to compare the efficacy of these two methods to determine which is more effective as the initial treatment method. Methods: Eighty-two patients with Morton neuromas were randomly assigned to receive either footwear modification with orthoses or steroid injections as initial treatment. Outcomes were evaluated at 1 month, 6 months, and 12 months. Results: Patient satisfaction was significantly better ( p < 0.01) in the group treated with steroid injections than those treated with shoe modifications at all three followup intervals. At 12-month followup, 82% of those treated with steroid injections had complete or partial relief of pain compared to 63% of those treated with footwear modifications alone. Conclusion: Steroid injections as initial treatment and shoe modifications with steroid injections at 6 months appear to give better results in Morton neuromas than shoe modifications alone, but the difference in the two groups were not statistically significant at one year followup.
The Anatomic Features of the Sural Nerve With an Emphasis on its Clinical Importance
Authors: iKiZ 'Z. Asli Aktan , üÇerler Hülya , Bilge Okan
Published: January 2017

Background: The sural nerve is formed by the union of the medial and lateral cutaneous nerves of the leg that originate from the tibial and common peroneal nerves. Operative procedures and traumatic injuries to the popliteal fossa, leg, ankle and foot place the sural nerve and its branches at risk. The aim of this study was to describe the course, variations and some clinically significant relations of the sural nerve. Methods: The sural nerve was dissected in 30 lower limbs (leg-ankle-foot) of 15 cadavers. The specimens were measured, drawn and photographed. Results: In 18 specimens (60%) the sural nerve originated from the union of the medial and lateral cutaneous nerves of the leg in the upper two-thirds of the leg (classic type). The union of the medial and lateral cutaneous branches was in the distal third of the leg in three specimens (10%). The lateral cutaneous nerve was absent in five (16.7%), and the medial cutaneous nerve was absent in 2 (6.7%) specimens. In two specimens (6.7%) the nerves had separate courses. The mean distance between the most prominent part of the lateral malleolus and the sural nerve was 12.76 ± 8.79 mm. The mean distance between the tip of the lateral malleolus and sural nerve was 13.15 ± 6.88 mm. The most common distribution of the sural nerve in the foot was to the lateral side of the fifth toe (60%), followed by the lateral two and a half toes (26.7%). Conclusions: These described variations and measurements should be helpful for planning operative approaches that minimize the risk of sural nerve injury.
The Response of the Flexor Digitorum Longus and Posterior Tibial Muscles to Tendon Transfer and Calcaneal Osteotomy for Stage II Posterior Tibial Tendon Dysfunction
Authors: Rosenfeld Peter F. , Dick Jonathan , Saxby Terence S.
Published: January 2017

Background: The purpose of this prospective study was to evaluate the response of the flexor digitorum longus (FDL) and posterior tibial (PT) muscles to FDL tendon transfer and medial displacement calcaneal osteotomy for stage II posterior tibial tendon dysfunction (PTTD). Methods: Twelve patients were divided into two groups, depending on whether the PTtendon was excised(Excised Tendon Group) or left intact (Intact Tendon Group). The muscle volumes of the FDL and PT muscles in both legs were measured and compared, using cross-sectional area (CSA) analysis of preoperative and postoperative MRI. Results: Preoperatively, there was an average 11% reduction in the PT muscle volume and a 17% increase in the FDL muscle volume from the normal contralateral side in both groups. One year after surgery (average 13.4 months) in both groups, the FDL muscle volume had increased by an average of 27% and the PT muscle volume had decreased by 23% compared to the contralateral normal side. The FDL volume increased by 44% in the Excised Tendon Group compared to 11% in the Intact Tendon Group. The PT muscle volumes were not assessed in the Excised Tendon Group because all PT muscle had been replaced by fatty infiltration. The PT volumes in the Intact Tendon Group decreased further from a 6% reduction preoperatively to a 23% reduction postoperatively compared to the normal contralateral side. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores increased from 50 preoperatively to 88 at 1 year after surgery. There was no difference in the scores between the Excised Tendon (47 to 87) and Intact Tendon (53 to 89) groups. Conclusion: We concluded that the FDL muscle hypertrophies in response to a failing PT muscle. This hypertrophy continues after FDL transfer and medial displacement calcaneal osteotomy. With excision of the PT tendon, the FDL undergoes greater hypertrophy than if the tendon is left attached. The PT muscle continues to atrophy and undergoes complete fatty replacement if the tendon is excised. Transfer of the FDL and medial displacement calcaneal osteotomy produce a satisfactory improvement in hindfoot function; the outcome was the same whether the PT tendon was sacrificed or left intact.
The Role of Toe Flexor-to-Extensor Transfer in Correcting Metatarsophalangeal Joint Instability of the Second Toe
Authors: Myerson Mark S. , Jung Hong-Geun
Published: January 2017

Background: The purpose of the study was to evaluate the outcome of flexor digitorum longus (FDL) transfer to the dorsum and to identify a possible continued role for this transfer in conjunction with additional surgeries for second metatarsophalangeal joint (MTPJ) instability. Methods: We carried out a retrospective analysis on patients with second MTPJ instability for which the FDL transfer was done as the primary procedure between 1996 and 2001. The patients were examined for functional status, residual pain, and satisfaction. Results: A total of 64 feet (59 patients) were evaluated, with an average followup period of 45.2 (16 to 82) months. A cross-over second toe deformity was present in 56 feet (87%) with a stage II deformity being the most common (18 feet). There also were seven feet with vertical subluxation. An additional second metatarsal Weil osteotomy was done in 29 feet (45%), a proximal interphalangeal (PIP) joint resection arthroplasty in 22 feet, and a PIP joint fusion in nine feet. At final followup of the 59 feet that were physically examined, 22 (37%) had residual second MTPJ dorsiflexion contracture and 16 feet had persistent medial deviation. The second toe was stable to stress manipulation in 46 feet (78%). The mean toe pulp to ground distance on standing was 3 mm, and strong toe grasp was possible in 45 feet. There were 20 complications in 64 feet. Twenty-five patients (29 feet) were very satisfied, 15 satisfied with minor reservations, six with major reservation, and 14 patients were unhappy with the outcome. The American Orthopaedic Foot and Ankle Society functional score was on average 82 points (47 to 100) at final followup. Conclusion: Although the function of the second toe improved in most patients as a result of pain relief, a substantial number of the patients in this study remained dissatisfied because of residual stiffness of the toe. The flexor tendon transfer remains an important procedure in correction of second toe instability but must be used with a full understanding of potential complications and patient dissatisfaction.
Nonoperative Treatment of Fifth Metatarsal Fractures in an Orthopaedic Suburban Private Multispeciality Practice
Authors: Konkel Kurt F. , Menger Andrea G. , Retzlaff Sharon A.
Published: January 2017

Background: The purpose of this study was to review consecutive fifth metatarsal fractures in the author's (KFK) practice from August, 1999, to November, 2003. Methods: During this period 64 patients (66 fractures; 35 tuberosity fractures, 10 Jones fractures, three stress fractures, two segmental shaft fractures and 16 oblique distal shaft/neck fractures) were treated nonoperatively. Initial treatment was started from the day of injury to as long as 8 weeks after injury. All patients were treated ambulatory with immediate weightbearing. Results: The time to bony union averaged 3.7 months. The union rate was 98.5% with a satisfaction rate of 100%. Conclusions: By using closed treatment techniques bony union was predictable with minimal cost and a high satisfaction rate. We recommend nonoperative treatment of fifth metatarsal fractures for patients in whom the time to return to full activities is not critical.
Assessment of Talar Flattening in Adult Idiopathic Clubfoot
Authors: Bach Christian M. , Goebel Georg , Mayr Eckart , Biedermann Rainer , Rachbauer Franz
Published: January 2017

Background: The radius/length (R/L) ratio was developed to evaluate the convexity of the talar dome in idiopathic clubfoot. However, the index has not been tested for its reliability and reproducibility. Methods: The R/L ratio was determined by three independent observers on the radiographs of 21 adult patients with idiopathic clubfoot and 30 adult subjects with normal feet. The reproducibility and the reliability of the R/L ratio were calculated. Results: For the normal feet the reproducibility and the reliability of the R/L ratio was high (correlation coefficient > 0.87). For the patients with clubfoot, the reliability and reproducibility depended on the severity of talar flattening. For a radius of less than 45 mm the mean intraobserver correlation coefficient was 0.74 (range 0.54 to 0.83) and the mean interobserver correlation coefficient was 0.58 (range 0.49 to 0.75). For a radius of more than 45 mm no statistically significant intraobserver and interobserver correlations were found. Conclusion: The current results indicate that the R/L ratio of talar flattening is reliable and reproducible for mild talar deformity but not for severe flattening (radius of more than 45 mm).
Radiographic Assessment of Adult Flatfoot
Authors: Younger Alastair S. , Sawatzky Bonita , Dryden Peter
Published: January 2017

Background: The accurate measurement of flatfoot on standing radiographs allows correct diagnosis of the condition and evaluation of reconstructive procedures. Method: The standing radiographic measurements of patients with symptomatic, adult flatfoot were compared to controls using blinded observers. Results: On the lateral radiograph, the talar-to-first metatarsal angle, the calcaneal pitch angle, and the medial cuneiform-fifth metatarsal height differed significantly between the patient group and the controls. The difference in the talar-to-first metatarsal angles on lateral radiographs was the most statistically significant (patient group 21.1 ±10.8 degrees and control 7.1 ± 10.7 degrees, p < 0.0001) with good correlation between readings (intraobserver 0.75, interobserver 0.83). On the anteroposterior (AP) radiograph, the talar head uncoverage distance was the most significantly different measurement between these groups. Conclusions: These findings support the hypothesis that the talar-first metatarsal angle is an accurate radiographic identifier of patients with symptomatic, adult flatfoot.
Treatment of Rupture of the Achilles Tendon with Fibrin Sealant
Authors: Kuskucu Mesih , Mahirogullari Mahir , Solakoglu Can , Akmaz Ibrahim , Rodop Osman , Kiral Ahmet , Kaplan Haluk
Published: January 2017

Background: The optimal management strategy for acute Achilles tendon ruptures is controversial. These injuries historically were treated by nonoperative methods (cast immobilization, bandaging); however, operative repair of the ruptured tendon has become popular. Methods: Thirty-two patients who had rupture of the Achilles tendon were treated operatively with use of fibrin sealant, and clinical and functional performance measures were assessed after a mean followup of at least 6 months between November, 1998, and July, 2003. All of the patients were male. Average age was 38.18 (30 to 45) years. All of the patients were followed for at least 18 months after surgery. Average followup time was 22.4 (18 to 56) months. We evaluated all patients according to the scoring system of Thermann et al. Results: Our results were excellent in 24 patients and good in eight patients. One patient had rerupture 3 weeks after surgery. Conclusion: Fibrin sealants are biologically compatible, hemostatic agents derived from human plasma that can be used instead of suture or suture support. We think that the treatment of rupture of the Achilles tendon with fibrin sealant is a useful treatment, and there is less risk of complications, such as deep infection, than in other operative procedures. We had no wound closure problems, the incision size was small, and the operating time was short. However, it must be remembered that the risk of disease transfer by fibrin sealant application is still present.
Revision Lateral Ankle Reconstruction
Authors: Kuhn Michael A. , Lippert Frederick G.
Published: January 2017

Background: Symptomatic lateral ankle instability is a common source of disability in an active population. While most incidences are successfully treated by conservative measures, some individuals require lateral ankle reconstruction. A commonly performed procedure is the Gould modification of the Broström lateral ankle reconstruction. Despite its success, some individuals experience recurrent instability through reinjury. Revision surgery often involves nonanatomic reconstruction using tendon grafts that may restrict normal ankle and subtalar motion and can result in persistent postoperative pain and disability. The purpose of this study was to demonstrate an equivalent success rate using a more anatomic revision lateral ankle reconstruction based on the Gould modification of the Broström concept. Methods: We retrospectively reviewed 15 consecutive patients who had a revision lateral ankle reconstruction between 1992 and 2000. All procedures were done by a single surgeon (FGL). Patients who exhibited hindfoot varus and dynamic heel rollout had a valgus calcaneal osteotomy. Patients were asked to complete a 100-point questionnaire postoperatively. Results: All patients reported improvement in ankle function, decreased pain, and no episodes of instability compared to preoperative assessments. Excellent results were achieved in 12 of 15 patients which was consistent with published data from index Broström reconstructions. Four patients who had fixed hindfoot varus and dynamic ankle rollout had valgus calcaneal osteotomies. All patients returned to an active lifestyles including sports and military service. Conclusion: Our findings suggest that a revision anatomic lateral ankle reconstruction is an effective option. A thorough clinical evaluation was mandatory to assess hindfoot valgus with dynamic ankle rollout for which a valgus calcaneal osteotomy was included in the procedure. We believe that tendon sacrificing procedures can be avoided in most patients, but soft-tissue structures must be assessed intraoperatively and the surgical approach planned to allow for conversion if necessary.
Ankle Alignment on Lateral Radiographs. Part 2: Reliability and Validity of Measures
Authors: Tochigi Yuki , Suh Jin-Soo , Amendola Annunziato , Saltzman Charles L.
Published: January 2017

Background: In ankles with end-stage osteoarthritis or after total ankle replacement (TAR), radiographic landmarks based on joint surface morphology usually are obscured and inadequate for measurement. Two methods for quantifying anteroposterior tibial-talar alignment without relying on those landmarks were identified in a corollary cadaver-based study. This study aimed to verify reliability and validity of those candidate measures. Methods: On clinical radiographs of 33 nonarthritic and 35 arthritic ankles, the anteroposterior tibial-talar alignment was quantified by the two methods; the tibial-axis-to-talus ratio (T-T ratio: the ratio into which the midlongitudinal axis of the tibial shaft divides the longitudinal talar length) and the posterior-tibial-line-to-talus ratio (P-T ratio: a similar ratio, but using the posterior longitudinal line along the tibial shaft). Two observers performed every measurement twice to evaluate intraobserver and interobserver reliability of the candidate measures. For nonarthritic ankles, the anteroposterior tibial-talar alignment was further determined by a control measure that directly quantified orientation of the talar dome relative to the tibial shaft. Correlation of the T-T and P-T ratios with the control measure was then evaluated for validity. Results: Measurement of the T-T ratio with arthritic ankles was highly reproducible with the coefficients of determination (R 2 ) greater than 0.95, for either interobserver or intraobserver. Correlation between this measure and the control measure was supported (R 2 = 0.60, p < 0.0001). Reliability of the P-T ratio also was strong (R 2 > 0.91), although both reliability and validity of this measure were relatively inferior to the T-T ratio. Conclusions: The T-T ratio reliably and validly described the anteroposterior tibial-talar alignment on clinical radiographs, regardless of the condition of ankle joint surface. This measure appears to be a reliable radiographic measure for determining the magnitude of anteroposterior talar subluxation in ankles with articular degeneration or after TAR and can facilitate clinical investigations.
Total Ankle Arthroplasty With the Agility Prosthesis: Clinical and Radiographic Evaluation
Authors: Kopp Franz J. , Patel Mihir M. , Deland Jonathan T. , O'Malley Martin J.
Published: January 2017

Background: Although ankle arthrodesis remains a standard operative procedure for disabling ankle arthritis, it has potential long-term problems. Total ankle arthroplasty offers preserved joint motion and may be a more favorable option in select patients. The purpose of this study was to report the intermediate-term clinical and radiographic results of total ankle arthroplasty using the Agility prosthesis. Methods: We retrospectively reviewed the results of total ankle arthroplasty in 41 consecutive patients (43 ankles). Evaluation included preoperative and postoperative questionnaires, physical examination, and radiographs. Results: At the time of followup, 38 patients (40 ankles) were available for review. The most common preoperative diagnoses included posttraumatic arthritis (24 of 40 ankles, 60%) and rheumatoid arthritis (eight of 40 ankles, 20%). Average age at surgery was 63 (range 32 to 85) years. Average followup was 44.5 (range 26 to 64) months. Preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scores averaged 33.6 and 83.3, respectively, demonstrating significance ( p < 0.001). Postoperative Medical Outcomes Study Short Form-36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores averaged 49.5 and 56.1, respectively. Although 34 of 40 ankles demonstrated radiographic lucency or lysis, the degree of involvement varied. Migration or subsidence of components was noted in 18 ankles. Overall, 37 of 38 patients were satisfied with the outcome of their surgery and would have the same procedure under similar circumstances. Conclusions: Agility total ankle arthroplasty results in a favorable clinical outcome and patient satisfaction in most patients at intermediate-term followup. However, total ankle arthroplasty is associated with potential complications and the need for subsequent operative intervention. Radiographic followup commonly reveals periprosthetic lucency, lysis, and component migration or subsidence, but this does not appear to adversely affect the intermediate-term clinical outcome. The long-term consequences of such radiographic findings are of concern, and surgeons and patients choosing this procedure need to be cautious.
Consequences of Partial and Total Plantar Fascia Release: A Finite Element Study
Authors: Cheung Jason Tak-Man , An Kai-Nan , Zhang Ming
Published: January 2017

Background: Plantar fasciotomy, a common operative procedure to relieve chronic heel pain, has been suggested to decrease foot arch stability. A systematic evaluation of the biomechanical consequences of partial or total plantar fascia release is essential to the understanding of the biomechanical rationale behind these operative procedures. Methods: A geometrical detailed three-dimensional (3-D) finite element (FE) model of the human foot and ankle, incorporating geometrical and contact nonlinearities, was constructed by 3-D reconstruction of MR images. Partial and complete plantar fascia releases were simulated to evaluate the corresponding biomechanical effects on load distribution of the bony, ligamentous, and encapsulated soft-tissue structures. Results: Partial and total plantar fascia release may decrease arch height but did not necessarily cause total collapse of the foot arch even with additional dissection of the long plantar ligament. Operative release of the plantar fascia was compromised by increased strains of the plantar ligaments and intensified stress in the midfoot and metatarsal bones. Load redistribution among the centralized metatarsal bones and focal stress relief at the calcaneal insertion were predicted with different types of fasciotomy. Conclusions: The FE model suggested that plantar fascia release may provide relief of focal stress and therefore could relieve associated heel pain. However, these operative procedures may pose a risk to arch stability and clinically may produce dorsolateral midfoot pain. The initial strategy for treating plantar fasciitis should be nonoperative. If surgery is necessary, partial release of less than 40% of the fascia is recommended to minimize the effect on arch instability and maintain normal foot biomechanics.
Osteochondral Lesions of the Talus: Change in MRI Findings Over Time in Talar Lesions Without Operative Intervention and Implications for Staging Systems
Authors: Elias Ilan , Jung Jennifer W. , Raikin Steven M. , Schweitzer Mark W. , Carrino John A. , Morrison William B.
Published: January 2017

Background: MRI findings are used in several staging systems to help determine appropriate treatment. The purposes of this study were to evaluate longitudinal changes in MRI characteristics of osteochondral lesions of the talus (OLT) and to evaluate published staging systems in a cohort of nonoperatively treated patients. Methods: Twenty-nine patients were identified; MR images were reviewed for location, size, and interface signal of OLT as well as cysts, marrow edema and osteoarthritis. Lesions were classified as unchanged, progressed, or improved based on changes in size or interface signal. Each lesion was assigned a stage based on four different staging systems. Results: Of the 29 lesions, 13 progressed, seven improved, and nine were unchanged over an average followup of 13.7 months. In the 13 that progressed, marrow edema remained present in ten and developed in two. Four had persistent cysts and four developed new cysts. Two had progression of osteoarthritis and two developed it anew. In the seven that improved, six had some degree of marrow edema that persisted and one had a persistent cyst. Initial staging changed for at least one classification system in 16 (55%) of the 29 lesions at followup. Change in stage was primarily due to development (four of 16) or disappearance of cysts or progression of the lesion in the extent of bone marrow edema (five of 16). Conclusions: OLT did not invariably progress over the short-term without operative intervention. Because some cysts and bone marrow edema resolved on MRI, they may not be reliable signs of lesion severity nor show progression of degenerative changes. Since these findings determine the stage and severity of OLT in some staging systems, they may require reconsideration and adjustment of the current staging systems.
Classification of Postaxial Polydactyly of the Foot
Authors: Lee Ho Seong , Park Soo Sung , Yoon Jun O. , Kim Jin Sam , Youm Yoon Seok
Published: January 2017

Background: The origins and shapes of accessory digits in postaxial polydactyly of the foot were analyzed morphologically and radiographically, and their characteristics were determined. A simple classification method was then devised to assist in determining the most appropriate treatment options. Methods: We evaluated 113 feet of 95 patients who had surgery for the treatment of postaxial polydactyly between 1998 and 2002. Based on the morphologic, radiographic, and operative findings, the cases were classified according to the origin of the accessory digit: middle phalangeal, proximal phalangeal, floating, fifth metatarsal, or fourth metatarsal. The proximal phalangeal type was further divided into three subtypes: proximal phalangeal lateral type, proximal phalangeal medial, and proximal phalangeal head. Results: Of the 113 feet, 36 were middle phalangeal type, 45 were proximal phalangeal type, 5 were floating type, 15 were fifth metatarsal type, and 12 were fourth metatarsal type. Of the proximal phalangeal types, 15 were laterally duplicated supernumerary sixth digits, and 17 were medially duplicated supernumerary fifth digits. The duplicated digits of the remaining 13 originated at the distal portion of the proximal phalanx. In the middle phalangeal, proximal phalangeal head, proximal phalangeal medial, and fourth metatarsal types, the medial accessory fifth digit was an abnormally duplicated digit, which was excised. In the proximal phalangeal lateral, floating, and fifth metatarsal types, the lat eral accessory sixth digit was excised. For the children in this study, we did not perform reconstruction of the deep transverse metatarsal ligament or collateral ligament. Also, we did not use longitudinal pin fixation. Skin necrosis occurred in 10 feet that resolved, and in five of the 15 feet of the 5th metatarsal medial deviation occurred. Conclusions: Based on the morphologic, radiographic, and operative findings, we suggest a classification method of postaxial polydactyly of the foot. We believe this is a straightforward and useful method for the treatment of postaxial polydactyly.
The Effect of Demineralized Bone Matrix-Calcium Sulfate with Vancomycin on Calcaneal Fracture Healing and Infection Rates: A Prospective Study
Authors: Bibbo Christopher , Patel Dipak V.
Published: January 2017

Background: Displaced intraarticular calcaneal fractures may have a central cancellous bone defect area. We hypothesized that human demineralized bone matrix (DBM) calcium sulfate (CaSO4) might act as a reasonable alternative to autograft in calcaneal fractures. When combined with antibiotic powder, this bone graft substitute also may act as a local antibiotic delivery device. This is the first clinical study evaluating bone healing and complications associated with DBM-calcium sulfate bone graft substitute in the treatment of displaced intraarticular calcaneal fractures with a central cancellous bone defect. Methods: Over a 29-month period, 33 displaced intraarticular calcaneal fractures with central cancellous defects were treated with open reduction and internal fixation (ORIF) and grafting with vancomycin/DBM-calcium sulfate bone graft substitute. Eleven fractures without bone defects were treated with ORIF only. Patient demographics, medical history, and CT fracture classification were recorded. Postoperatively, fractures were monitored every 2 weeks for healing and complications. Results: The mean time to union was 8.2 weeks in the grafted, while the control group mean time to union was 10.4 weeks ( p = 0.0117). Wound problems occurred in five (15%) of the 33 patients with grafting, all in type III fractures with severe soft-tissue swelling, and included two minor wound healing delays, and three serious wound problems. At a mean followup time of 22.4 months, no DBM-calcium sulfate grafted calcaneus demonstrated evidence of osteomyelitis. Conclusions: This is the first study examining human DBM-calcium sulfate bone graft substitute to treat displaced intraarticular calcaneal fractures. Based on these initial data, human DBM-calcium sulfate acted as an acceptable and safe autograft alternative in displaced intraarticular calcaneal fractures with moderate (5 cc to 10 cc) central cancellous bone defects.
Theoretical Model and Rasch Analysis to Develop a Revised Foot Function Index
Authors: Budiman-Mak Elly , Conrad Kendon , Stuck Rodney , Matters Michael
Published: January 2017

Background: The Foot Function Index (FFI) is a widely used self-reported measure of health-related foot function. Several areas have been identified for potential improvement, and this study responds to such criticisms. The objectives of this study were to: (1) develop a theoretical model of foot functioning, (2) develop a revised FFI (FFI-R), and (3) field-test the FFI-R. Methods: A literature review was conducted to develop the theoretical model. The FFI-R items were developed from the original 23 FFI items, and more items were added as a result of the literature review. A focus group discussion with clinicians and pilot interviews with patients resulted in a final draft of the FFI-R. This draft consisted of four subscales and comprised 68 items with a six-point response scale. The FFI-R was field tested on 92 patients in the podiatry clinic of a Veterans Administration Hospital in the Midwest. Psychometric analyses were conducted with modern item response theory (IRT) methods. Results: A theoretical model of foot functioning was developed. The FFI-R response scale was revised from six to five categories since confusion was found between categories 4 and 5. Rasch analyses indicated a person reliability of 0.96 and item reliability of 0.93. The subscale reliability of pain and stiffness, psychosocial, and disability were all >0.80; the exception was assistive devices (>0.50). Construct validity of FFI-R was supported based on the correlation of 50-ft walk time with an FFI-R total of 0.306, p = 0.018, N = 59. Rasch analyses indicated several items with poor fit statistics and a short form with 34 items was developed. Conclusion: The FFI was revised, and new items were added to compose the FFI-R. The chief theoretical change was adding a psychosocial scale. Both long and short forms had very good psychometric properties.
Distal Anatomical Relationship of the Flexor Hallucis Longus and Flexor Digitorum Longus Tendons
Authors: LaRue Bernard G. , Anctil Éric P.
Published: January 2017

Background: The distal attachment of the flexor hallucis longus (FHL) tendon with the flexor digitorum longus (FDL) tendon varies antomically. The presence of a strong link between the two tendons can preserve distal function if one of the tendons is used for transfer. Methods: Twenty-four cadaver legs were dissected, and the distal relationship of the FHL tendon with the FDL tendon was analyzed. The width of the tendons and their attachments were measured to the closest 0.5 mm. Results: Three different configurations were found. In type 1, a tendinous slip branched from the FHL to the FDL (10 of 24 feet). In type 2, a slip branched from the FHL to the FDL and another from the FDL to FHL (10 of 24). In type 3, no attachment was present (four of 24). In four cadavers the attachment was different in the right and left feet. Conclusion and Clinical relevance: The absence of a cross connection between the two tendons in the foot may be more frequent than previously reported. Three configurations of the anatomical relationship of the distal FDL to FHL tendons were found in this study with a small sample size. Based on these findings, to preserve the distal function of the FDL after transfer of the proximal FDL tendon, routine tenodesis should be done or a wider exposure and tenodesis in type 3 variations.
Anatomy of Ligamentous Structures in the Tarsal Sinus and Canal
Authors: Jotoku Tsuyoshi , Kinoshita Mitsuo , Okuda Ryuzo , Abe Muneaki
Published: January 2017

Background: The descriptive morphology of the interosseous talocalcaneal ligament and other structures in the tarsal sinus and canal vary. An anatomical investigation of the ligamentous structures in the tarsal sinus and canal identified two distinct ligaments, the interosseous talocalcaneal ligament and the anterior capsular ligament, and three components of the medial root of the inferior extensor retinaculum. Methods: Forty embalmed cadaver feet were examined. After disarticulation of the ankle joint, the posterior half of the talus was removed. The length, width, and thickness of the two ligaments and the three components of the extensor retinaculum in the tarsal canal and sinus were measured with calipers. Anatomical variations were recorded. Results: The interosseous talocalcaneal ligament was band-like in 92.5% (38 of 40) of examined specimens, and the anterior capsular ligament was present in 95% (39 of 40) of specimens. The interosseous talocalcaneal ligament, the medial component of the inferior extensor retinaculum, and the talar component of the inferior extensor retinaculum had one or two distinct anatomical variations of morphology and attachments. The interosseous talocalcaneal ligament and the medial component of the extensor retinaculum formed a V shape in the tarsal sinus and canal. Conclusion and Clinical Relevance: We demonstrated the morphology and dimensions of the ligaments and components of the extensor retinaculum in the tarsal sinus and canal. Precise anatomy of the structures in the tarsal sinus and canal will strengthen our understanding of their function in the motion or stabilization of the subtalar joint. There may be a functional link between the medial component of the inferior extensor retinaculum and the interosseous talocalcaneal ligament.
Syndesmosis Fixation: A Comparison of Three and Four Cortices of Screw Fixation Without Hardware Removal
Authors: Moore Joel A. , Shank John R. , Morgan Steven J. , Smith Wade R.
Published: January 2017

Background: Great variability exists in methods of stabilization for syndesmotic disruptions of the ankle. We hypothesized that syndesmotic screw fixation with 3.5-mm fully threaded cortical screws through either three or four cortices would have similar strength and rate of mechanical failure and that retention of screws after fracture healing would not result in adverse clinical symptoms. Methods: In a prospective, surgeon-randomized study at a Level-one trauma center, 127 patients with syndesmotic disruptions were treated surgically. Seven patients were lost to followup, leaving 120 for review. Syndesmotic disruptions were stabilized with 3.5-mm fully threaded cortical screws placed through three or four cortices. Screws were removed only if symptomatic. Outcome criteria were screw failure, loss of reduction, and need for hardware removal. Results: Fifty-nine patients received fixation through three cortices and 61 patients received fixation through four cortices. Mean follow-up was 150 days. In the group with stabilization through three cortices, hardware failure occurred in five patients (8%) and three had a loss of reduction. In the group with stabilization through four cortices, hardware failure occurred in four patients (7%); all were asymptomatic and did not require screw removal. There was no loss of reduction in that group. Comparing the two groups using binary logistic analysis, there was no difference in loss of reduction ( p = 0.871), screw breakage ( p = 0.689), or need for hardware removal ( p = 0.731). Conclusion: The data suggest that either three or four cortices of fixation can be used when stabilizing syndesmotic injuries of the ankle. There was a trend towards higher loss of reduction in the group with tricortical fixation when weightbearing restrictions were not followed. Retention of the syndesmotic screws, even with mechanical failure, does not pose a clinical problem. Weightbearing can be allowed at 6 to 10 weeks without routine removal of screws.