bluuebunny/crossref_metadata_2025 huggingface dataset:
Toe Flexor Forces in Dancers and Non-Dancers
Authors: Nihal Aneel , Goldstein Jeffrey , Haas Judith , Hiebert Rudi , Kummer Frederick J. , Liederbach Marijeanne , Trepman Elly
Published: January 2017

Toe flexor force (hallux and second toe) was determined in the right and left feet of 24 dancers and 29 non-dancers (sitting and standing positions) using a commercially-available pressure sensor connected to a voltmeter. For the hallux and second toe combined (all trials combined), average toe flexor force was slightly greater for dancers than non-dancers (dancers, 7±4 N; non-dancers, 6±4 N; p<0.049). For dancers and non-dancers combined (all trials), the average toe flexor force of the hallux was more than twice that of the second toe (hallux, 9±4 N; 2nd toe, 4±1 N; p<0.0001); average toe flexor force was slightly greater in standing than sitting positions (standing, 7±4 N; sitting, 6±3 N; p<0.0001); and the average toe flexor force was slightly greater for the right than left foot (right, 7±4 N; left, 6±4 N; p<0.012). The average toe flexor force was greatest for the first repetition and slightly decreased for the second and third repetitions (first repetition, 7±4 N; second and third repetitions each, 6±4 N; p<0.0013). Toe flexor force measurement may potentially be applicable to clinical practice as a guide to rehabilitation after injury or as a screening parameter for readiness to advance dance or other athletic training, performance, or competition.
The Main Function of Ankle Braces is to Control the Joint Position before Landing
Authors: Eils Eric , Rosenbaum Dieter
Published: January 2017

The aim of the present investigation was to evaluate the stabilizing effect of 10 different ankle braces during simulated inversion on a tilting platform. Twenty-five subjects participated in the study (23±3 yrs, 71±12 kg, 177±9 cm). Ten commercially available ankle braces and a trapdoor in combination with a goniometer system that measured hindfoot inversion inside the shoe were used. Inversion was subdivided into a free fall and a maximum inversion phase. Results showed that all braces restricted inversion significantly between 51% and 15% compared to the no-brace condition but distinct differences between models were found. Maximum inversion angle and inversion velocity were lower for those braces that restricted inversion most effectively during the free fall phase. Reaction times of the peroneus longus did not appear to influence the degree of inversion. Relatively constant differences between free fall and maximum inversion angles for all models (between 6° and 10°) and a high correlation between these two parameters suggests that the main function of ankle braces is to restrict inversion during the free fall phase and not at the extremes of motion.
Anticardiolipin Antibody Associated Arterial Thrombosis following Fibula Fracture
Authors: Vikoren Thomas H. , Fenwick James A. , Cross B.J. , Ragni Margaret V. , Gruen Gary S.
Published: January 2017

A case is described of a 20-year-old college student in whom open reduction and internal fixation of a Weber B fibula fracture was complicated by arterial thrombosis and gangrene of the foot. The patient subsequently required a below-knee amputation. A hypercoagulability workup revealed the presence of an anticardiolipin antibody. Although this is an extremely unusual complication, young female patients with a positive personal or family history of early thrombotic events, such as DVT, multiple pregnancy loss, or early myocardial infarction, should be viewed as being at increased risk. Additional risk factors such as oral contraceptive use, should be sought during the initial history.
Cold Weather Training: A Risk Factor for Achilles Paratendinitis among Recruits
Authors: Milgrom C. , Finestone A. , Zin D. , Mandel D. , Novack V.
Published: January 2017

In a prospective study of risk factors for Achilles tendinopathy among four induction cycles of infantry recruits, 95 out of 1405 recruits, (6.8%) were found to suffer from Achilles tendinopathy. In more than 94% of the cases, the tendinopathy was considered to be paratendinitis. Training season had a statistically significant effect on the incidence of Achilles paratendinitis with 3.6% suffering in the summer and 9.4% in the winter ( p = .001). This increased risk for Achilles paratendinitis in cold weather outdoor training can be explained by a fall in temperature of the Achilles paratenon whose membranes are rich in mucopolysaccharides and serve as a lubricant for gliding of the tendon and epitenon. Decreased temperature may increase the viscosity of the lubricant and thereby increases friction and risk for Achilles paratendinitis. This same relationship illustrates why “warming up” before exercising may be important in lowering the incidence of Achilles paratendinitis.
Return to Activity after Sesamoidectomy in Athletically Active Individuals
Authors: Saxena Amol , Krisdakumtorn Tom
Published: January 2017

Sesamoidectomy of the first metatarsophalangeal joint in athletically active patients may be indicated in cases of chronic sesamoiditis resistant to nonsurgical care or symptomatic displaced fractures or nonunion. Painful scar, hallux deviation, and delayed return to activity are all potential complications. These need to be considered especially when performing surgery in the athletically active individual. Twenty-six sesamoidectomies in 24 patients (21 females and 3 males) were reviewed for type of sesamoidectomy, incision location, time to return to activity, and complications. Mean age was 35.4 years (range, 16–68 years) with mean follow-up 86.4 months. Eleven athletes (defined as professional or varsity level sports) operated on had a mean return to activity of 7.5 weeks (range, 4–10 weeks), while 13 “active” patients had a mean return to activity of 12.0 weeks. This difference was statistically significant using the t-test, ( p <.02). There were 10 fibular and 16 tibial sesamoids excised. Complications included one hallux varus and two cases of postoperative scarring with neuroma-like symptoms, all associated with fibular sesamoidectomy; there was one case of hallux valgus deformity with tibial sesamoidectomy. Despite the functional importance of tibial and fibular sesamoids, athletically active individuals can return to sports after a sesamoidectomy as early as 7.5 weeks.
Limb Salvage: The Infected Retrograde Tibiotalocalcaneal Intramedullary Nail
Authors: Bibbo Christopher , Lee Simon , Anderson Robert B. , Davis W. Hodges
Published: January 2017

Tibiotalocalcaneal arthrodesis utilizing a retrograde intramedullary nail has been used for nearly a decade. The indications for retrograde intramedullary nailing to achieve a tibiotalocalcaneal arthrodesis have expanded from systemic arthritides and post-traumatic arthritis to use in diabetic patients with severe Charcot neurarthropathy and hindfoot malalignment. Results with this procedure have been good, with low infection rates when used in nonimmunocompromised hosts. As indications have expanded to include diabetic deformities, infection rates may increase. We report on the results of a salvage technique and management plan utilized in the treatment of infected tibiotalocalcaneal arthrodesis in five high-risk (immunocompromised) patients. The majority of these patients had diabetes with Cierny-Mader IVB osteomyelitis, and would have required an above-knee or below-knee amputation due to their infection.
Pressure Distribution Patterns under the Feet of New Walkers: The First Two Months of Independent Walking
Authors: Hallemans Ann , D'Août Kristiaan , De Clercq Dirk , Aerts Peter
Published: January 2017

In order to describe foot function during the first weeks of independent walking, spatio-temporal pressure distribution patterns were measured. These data give detailed information about roll-off of the foot, by determining the course of the center of pressure, and about load bearing, by calculating relative vertical impulses under the feet. During those first weeks of independent walking, roll-off is very unstable. Although infants can occasionally perform a mature roll-off, a consistent pattern has not yet developed and there is instability. To improve stability the entire plantar surface area contributes to load bearing – first, because a larger contact area will improve stability, and second, because a forward shifting of the load allows more muscular control to compensate for minor imbalances under the foot.
Anatomic Study of the Gastrocnemius–Soleus Junction and its Relationship to the Sural Nerve
Authors: Tashjian Robert Z. , Appel A. Joshua , Banerjee Rahul , DiGiovanni Christopher W.
Published: January 2017

Background:

Gastrocnemius recession is performed for equinus contracture of the ankle and as an adjunct treatment for various foot pathologies. Successful release relies on many factors, including a thorough knowledge of the anatomy of the gastrocnemius-soleus junction and its relationship to the sural nerve which may be vulnerable to iatrogenic injury. Neither the average width of the tendon at the gastrocnemius-soleus junction, the anatomy of the sural nerve with respect to the gastrocnemius-soleus junction, nor appropriate landmarks for accurate incision placement at this level to avoid undesirable vertical extension, however, have yet to be acceptably defined.

Methods:

Fourteen fresh-frozen cadavers were dissected and the width of the tendon at the gastrocnemius-soleus junction, the distance of the sural nerve from the lateral border of the tendon at this level, the length of the fibula, and the distance from the distal tip of the fibula to the gastrocnemius-soleus junction were measured.

Results:

The average width of the gastrocnemius-soleus complex at the junction was 58 mm (range, 44–69 mm), the average distance of the sural nerve from the lateral border of the gastrocnemius-soleus complex at the level of the gastrocnemius-soleus junction was 12 mm (range, 7–17 mm), the average percentage of this distance as compared to the entire width of gastrocnemius-soleus junction was 20% (range, 13%-27%), and the ratio of the distance of the gastrocnemius-soleus junction from the distal tip of the fibula divided by the length of the fibula was 0.5 (range, 0.5–0.6).

Conclusion:

These results provide some guidelines as to the approximate size of the gastrocnemius–soleus complex at the site of gastrocnemius recession along with the location of the sural nerve at the musculotendinous junction. Also, the results indicate that the fibula can serve as a reproducible anatomic landmark to enable localization of the gastrocnemius–soleus junction at the time of gastrocnemius recession.
Arthrodesis of the Fourth and Fifth Tarsometatarsal Joints of the Midfoot
Authors: Raikin Steven M. , Schon Lew C.
Published: January 2017

Maintaining mobility of the fourth and fifth tarsometatarsal joints has been reported to be important in arthrodesis of the midfoot. A review of the records at a tertiary care center of 23 patients (28 feet) with arthrodesis of these joints and a minimum 2-year follow-up showed that 22 complete midfoot arthrodeses were performed as part of the correction for a neuroarthropathic rockerbottom deformity. Six arthrodeses of the fourth and fifth metatarsal joints were performed on normosensate feet with painful arthritis involving the lateral joints. Clinical and radiographic fusion occurred in 26 of 28 feet. Comparing average preoperative and postoperative scores, functional incapacity from lateral midfoot pathology decreased (8.4/10 to 2.2/10), overall pain scores improved (5.1/10 to 1.3/10), pain scores in the arthritic subgroup decreased (8.2/10 to 2.4/10), and the modified overall AOFAS midfoot score improved (35/100 to 78/100).
Endoscopic Gastrocnemius Recession: Evaluation in a Cadaver Model
Authors: Tashjian Robert Z. , Appel A. Joshua , Banerjee Rahul , DiGiovanni Christopher W.
Published: January 2017

The purpose of this study was to describe a new method of gastrocnemius recession using an endoscopic approach and to determine the accuracy of incision placement during gastrocnemius recession. Fifteen fresh-frozen cadaveric limbs underwent an endoscopic gastrocnemius recession utilizing a two-portal technique. All limbs were anatomically dissected after the procedure and each was examined for injury to the sural nerve. The ability to visualize the sural nerve intraoperatively, improvement in ankle dorsiflexion, time requirement for the procedure, incision size, and appropriateness of placement to facilitate recession were recorded for each specimen. An average of 83% of the gastrocnemius aponeurosis was transected in all 15 cadavers. After modifications of the technique, the final eight cadavers were noted to have had the entire (100%) gastrocnemius aponeurosis transected. Sural nerve injury occurred in one specimen (7%) in which the aponeurosis and the sural nerve were not well visualized. The sural nerve was definitively visualized during the procedure in 5 of 15 specimens (33%). No Achilles tendon injury was noted in any specimen. There was a mean improvement in ankle dorsiflexion of 20° (range, 10°–30°) during full knee extension. The average length of time to perform the procedure was 20 minutes (range, 10–35 minutes). The average medial and lateral incision lengths used in the two-portal technique were 18 mm (range, 14–22 mm) and 17 mm (range, 12–19 mm), respectively, and the average distance from the midpoint of the medial incision to the level of the gastrocnemius-soleus junction was 26 mm (range, 5–60 mm). These results indicate that a complete gastrocnemius aponeurosis transection may be obtained utilizing a modified endoscopic gastrocnemius recession, but visualization of the sural nerve is poor with possible risk of iatrogenic nerve injury.
Trevor's Disease Involving the Fifth Metatarsal of the Left Foot: A Case Report
Authors: Currie JoVan , Beall Douglas P. , Ly Justin Q.
Published: January 2017

Dysplasia epiphysealis hemimelica (Trevor's disease) is a rare developmental disorder of epiphyseal growth. A review of the literature reveals that metatarsal involvement has been described in only two cases and in these cases two metatarsals were reported as being only slightly enlarged. This article reports a case of dysplasia epiphysealis hemimelica involving the medial half of the epiphysis of the left fifth metatarsal.
Immediate, Full Weightbearing Cast Treatment of Acute Achilles Tendon Ruptures: A Long-Term Follow-up Study
Authors: Josey Robert A. , Marymont John V. , Varner Kevin E. , O'Connor Dan , Borom Andy , Oates Jay C.
Published: January 2017

Thirty-two patients with 33 ruptures were available for comprehensive evaluation, which included a questionnaire, physical examination, and manual as well as objective (Kin-Com) strength testing. Data excluding Kin-Com strength testing were available in an additional seven patients with seven ruptures; hence, the data are based on these 39 patients with 40 ruptures. Five patients with eight ruptures were excluded from strength testing but were included in our rerupture data, which totaled 44 patients with 48 ruptures. All patients were treated using a standard protocol by a single surgeon. All patients were treated within 11 days of injury, and the average follow-up was 55 months (range, 24–133). Ninety-five percent (38/39) of patients were completely satisfied with their treatment. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot scores were >80 in 97.4% of patients, and the rerupture rate was 6.25% (3/48). Calf circumference and ankle range of motion were not statistically different between the two legs. The injured leg tended to be slightly weaker than the uninjured leg, but the difference was not significant for most of the quantitative strength measurements. This study provides data for the Achilles rupture patient who asks, “Is there a treatment option other than surgery?” In addition, the standardized protocol can be utilized to obtain successful outcomes in those who choose nonoperative treatment or are poor surgical candidates.
Perioperative Complication Rate of Total Ankle Replacement is Reduced by Surgeon Experience
Authors: Haskell Andrew , Mann Roger A.
Published: January 2017

Background:

Recent studies suggest the perioperative complication rate of total ankle arthroplasty decreases as a surgeon becomes familiar with the procedure. This study tests the hypothesis that the number of perioperative adverse events will decrease as surgeon experience with total ankle replacement increases.

Methods:

Ten surgeons completed retrospective chart and radiographic reviews of their first 10 cases as well as 10 subsequent cases of the Scandinavian Total Ankle Replacement (STAR). Not all surgeons completed 10 cases within the allotted time periods, and two patients were excluded for less than 3-month follow-up, resulting in 187 cases for review. The surgeons performed an average of 12.8 (range, 0–61) STARs between these two time periods. Cases were divided into Early Group if they were among the first five STARs a surgeon performed and Late Group if they were after the first five.

Results:

The average patient age was 60.4 ± 12.8 years. The etiology of arthrosis included 96 (51%) of 187 posttraumatic, 49 (26%) idiopathic, and 33 (18%) rheumatoid. Patients in Early Group had a 3.1 times greater chance of having a perioperative adverse event (95% CI 1.6–6.1, p < .001), and a 3.2 times greater chance of having a perioperative wound problem (95% CI 1.5–6.8, p = .002) than patients in Late Group. Patients in Early Group took 1 week longer to heal their wounds than patients in Late Group (4.5 vs. 3.5 weeks, p = .046).

Conclusions:

This study shows a decrease in the perioperative adverse event rate commensurate with surgeon experience with STAR. In contrast to other reports, this study was unable to show a decrease in the number of perioperative fractures with increasing surgeon experience. This information is important for planning how best to train surgeons new to total ankle replacement and for patient counseling regarding the potential risks of the procedure.
Fibular Position in Relation to Lateral Ankle Instability
Authors: Berkowitz CPT Mark J. , Kim David H.
Published: January 2017

Background:

The position of the fibula within the ankle mortise may be a factor contributing to recurrent ankle instability. The current study was performed to determine whether significant differences in fibular position exist in a population of patients who underwent lateral ankle stabilization procedures. The hypothesis that a fibula positioned posteriorly within the mortise predisposes the ankle to chronic instability was evaluated.

Methods:

Sixty-five CT/MRI scans of patients who underwent lateral ankle stabilization procedures from 1998 to 2001 were reviewed. The position of the fibula in relation to the tibia at the ankle mortise was expressed as the axial malleolar index (AMI). A greater AMI corresponds to a more posterior fibula. The AMI was also calculated from 65 CT/MRI scans performed on control patients who had no ankle instability.

Results:

The average AMI in the study group was 17° ± 6° (SD) compared with an average of 9° ± 4° (SD) in the control group ( p < .01). Therefore, the fibula was nearly twice as posterior in patients undergoing ankle reconstruction. In 42/65 (65%) study patients, the AMI was greater than 15°. Only 5/65 (8%) control patients had AMI values greater than 15°. This corresponds to an eightfold greater likelihood of AMI greater that 15° in the instability group than in the control group.

Conclusions:

This study supports the hypothesis that a posteriorly positioned fibula predisposes to ankle instability.
Stabilization of Lisfranc Joint Injuries: A Biomechanical Study
Authors: Lee Cassandra A. , Birkedal John P. , Dickerson Emilee A. , Vieta Paul A. , Webb Lawrence X. , Teasdall Robert D.
Published: January 2017

Background:

Lisfranc joint injuries are often misdiagnosed, leading to significant morbidity. Methods for anatomic reduction of the tarsometatarsal joint include closed reduction with casting or surgical stabilization with either Kirschner wires and/or cortical screw fixation. Controversy exists as to which fixation technique offers optimal stability. In the present study, the biome-chanical stability of three fixation methods was tested: (1) four Kirschner wires, (2) three cortical screws plus two Kirschner wires, and (3) five cortical screws.

Methods:

Ten matched pairs of fresh-frozen cadaveric feet were dissected to their ligamentous and capsular elements. The tarsometatarsal ligaments were completely transected to replicate a Lisfranc dislocation; the “injury” was reduced and stabilized using one of the three methods. Biomechanical studies were performed by applying a 100-N cyclic load physiologically distributed to the plantar aspect of the metatarsal heads. Displacement and force measurements were taken from the first and fifth metatarsal heads. Average stiffness of each construct was calculated from the force displacement curves.

Results and Conclusions:

Method 2 provided significantly more stability than Kirschner wire fixation. Method 3 created more stiffness than method 2 at the medial portion of the foot; no statistical difference between the two methods was evident at the lateral foot.

Clinical Relevance:

Cortical screw fixation provides a more rigid and stable method of fixation for Lisfranc injuries as compared to Kirschner wire fixation. This fixation method allows maintenance of anatomic reduction and possibly earlier mobilization with a decreased risk of posttraumatic arthrosis.
Revision of Failed Triple Arthrodesis With an Opening-Closing Wedge Osteotomy of the Midfoot
Authors: Toolan Brian C.
Published: January 2017

Background: This investigation reviewed the clinical and radiographic results of a biplanar opening-closing wedge osteotomy of the midfoot to revise failed triple arthrodeses with severe rocker-bottom deformity. Five cases were reviewed to determine if this osteotomy corrects the rocker-bottom deformity, improves function and provides satisfaction to the patient. Methods: American Orthopaedic Foot and Ankle Society (AOFAS) clinical ratings scores obtained before and after the procedure were compared to assess the functional outcome. The patients' satisfaction with their results of surgery was also determined. Three parameters of foot alignment were measured from preoperative and postoperative anteroposterior and lateral weightbearing radiographs to assess the correction of the rocker-bottom deformity and the effect of the osteotomy on valgus tilting of the talus was evaluated with weightbearing views of the ankle. Results: All clinical and radiographic measures of outcome significantly improved at a mean follow-up of 18 months (range, 13-32 months). The mean clinical rating score increased from 33 ± 14 points (range, 14-49 points) to 70 ± 11 points (range, 62-87 points) after the surgery ( p ≤ .05). Every patient was satisfied with the result and would repeat the procedure under the same circumstances. All four measures of foot and ankle alignment demonstrated significant correction after surgery. Conclusions: The osteotomy effectively realigned the rocker-bottom deformity. The procedure normalized the angular relationships of the foot by correction of the abduction and dorsiflexion deformities of the midfoot and valgus deformity of the hindfoot. The reduction in pain, increased functional capacity, and ability to wear conventional shoes, achieved without any major complication, account for the improved clinical rating scores and high rate of the satisfaction observed with this procedure
The Effect of Ankle Position on the Exam for First Ray Mobility
Authors: Grebing Brett R. , Coughlin Michael J.
Published: January 2017

Purpose: The clinical assessment of first ray motion in the sagittal plane, as originally described by Morton, is difficult to quantify. Different reports have shown inconsistent values and variability between the manual exam and examination using an external measuring device. The authors hypothesize that when performing a manual examination for evidence of increased first ray motion, the magnitude of first ray mobility varies as the position of ankle dorsiflexion/plantarflexion varies. Methods: Using an external caliper (a modified Klaue device), the authors quantified first ray motion in reference to variable ankle positions in a group of normal patients, a group of patients with untreated moderate and severe hallux valgus, a group who had undergone a successful metatarsophalangeal joint arthrodesis for hallux valgus, and a small group who had previously undergone a plantar fasciectomy. A total of 119 feet (109 patients) were measured. In addition to first ray motion, radiographic data were compared between groups. Results: With the ankle in the neutral dorsiflexion position, the mean first ray motion was 4.9 mm for the control group, 7.0 mm for the hallux valgus group, 4.4 mm for the metatarsophalangeal fusion group, and 7.7 mm for the plantar fasciectomy group. There was a significant decrease ( p <.05) in first ray motion when the ankle was moved to the dorsiflexed position for all four groups. There was a significant increase in first ray motion when the ankle was moved to the plantarflexed position ( p < .01) for all groups except the plantar fasciectomy group. No significant difference in first ray motion was observed for the plantar fasciectomy group between the neutral and plantarflexed ankle positions ( p < .05). Conclusion: The exam for first ray mobility is influenced by the position of the ankle and may explain the discrepancy between the manual exam and measurement with an external device. Recommendations for the manual exam of first ray mobility are given.
The Treatment of Painful Neuroma on the Lower Extremity by Resection and Nerve Stump Transplantation Into a Vein
Authors: Koch Horst , Hubmer Martin , Welkerling Heike , Sandner-Kiesling Andreas , Scharnagl Erwin
Published: January 2017

Lower extremity neuroma resection with nerve stump transposition into a vein was employed in eight patients (five male, three female). The neuromas resulted from amputations (four patients), vein stripping procedures (two patients), tumor resection, and toe-harvest for thumb reconstruction. Follow-up averaged 17 months (range, 8-37). Four of the patients experienced complete and permanent relief of pain; in three patients mild pain recurred within 3 months. All of these patients were satisfied with the result and did not request further treatment. In one case, a painful neuroma recurred. Our results suggest the possibility of inhibiting the formation of painful neuromas by nerve transposition into a vein. Further use of this method is encouraged.
Tibiofibular Synostosis Stress Fracture: A Case Report
Authors: Horst Frank , Nunley James A.
Published: January 2017

A case of tibiofibular synostosis stress fracture is reported with its clinical and radiographic appearance as well as treatment.
PEMF as Treatment for Delayed Healing of Foot and Ankle Arthrodesis
Authors: Saltzman Charles , Lightfoot Andrew , Amendola Annunziato
Published: January 2017

Background:

Arthrodesis is the most common surgical treatment for foot and ankle arthritis. In adults, these procedures are associated with a 5% to 10% rate of nonunion. Pulsed electromagnetic field (PEMF) stimulation was approved by the Federal Drug Administration (FDA) for treatment of delayed unions after long-bone fractures and joint arthrodesis. The purpose of this study was to examine the results of PEMF treatment for delayed healing after foot and ankle arthrodesis.

Methods:

Three hundred and thirty-four foot and ankle arthrodeses were done. Nineteen resulted in delayed unions that were treated with a protocol of immobilization, limited weightbearing, and PEMF stimulation for a median of 7 (range 5 to 27) months. All patients were followed clinically and radiographically.

Results:

The use of PEMF, immobilization, and limited weightbearing to treat delayed union after foot and ankle arthrodesis was successful in 5 of 19 (26%) patients. Of the other 14 patients with nonunions, nine had revision surgery with autogenous grafting, continued immobilization, and PEMF stimulation. Seven of these eventually healed at a median of 5.5 (range 2 to 26) months and two did not heal. One patient had a below-knee amputation, and four refused further treatment.

Conclusions:

The protocol of PEMF, immobilization, and limited weightbearing had a relatively low success rate in this group of patients. We no longer use this protocol alone to treat delayed union after foot and ankle arthrodesis.
Subtalar Joint Arthrodesis Using a Single Lag Screw
Authors: Haskell Andrew , Pfeiff Cynthia , Mann Roger
Published: January 2017

Background:

This study tested the hypotheses that fusing the subtalar joint with a single lag screw from the posteroinferior calcaneus to the anterior talar neck is an effective technique and that factors affecting the time to fusion can be identified.

Methods:

Between October, 1995, and July, 2002, the senior author (RAM) performed 101 isolated subtalar arthrodeses using a technique of single lag-screw fixation from posteroinferior to anterosuperior across the posterior facet of the subtalar joint combined with the application of an autograft taken from the floor of the sinus tarsi and anterior process. The average patient age was 52 (range 17 to 82) years. There were 52 women (53 arthrodeses) and 48 men (48 arthrodeses). Eight of 101 (8%) arthrodeses were revisions. The indications included posttraumatic arthritis (45), posterior tibial tendon dysfunction (18), failed prior ankle joint fusion (14), idiopathic disorders (12), hindfoot coalition (7), rheumatoid arthritis (3), and Charcot-Marie-Tooth disease (2). Fifteen of 101 patients (15%) smoked an average of 0.9 ± 0.5 pack of cigarettes per day.

Results:

Two of 101 joints did not fuse, resulting in an overall fusion rate of 98%. The average time to fusion was 12.3 ± 3.4 weeks. The presence of a prior ankle fusion significantly prolonged the time to fusion of the subtalar joint (11.9 ± 2.3 vs. 14.9 ± 7.0, p = .003). Other factors, including smoking, revision surgery, patient age, and patient sex, did not affect time to fusion. The fixation screw was removed in 13 of 101 (13%) joints at an average of 8.8 ± 0.5 months.

Conclusions:

Using a single 7.0-mm lag screw across the posterior facet of the subtalar joint results in fusion of the subtalar joint in 98% of patients. A prior ankle arthrodesis delays the time to fusion of the subtalar joint by 3 weeks. This is a simple and reliable technique for achieving fusion of the subtalar joint.
Acceptability of Ankle Tourniquet Use in Midfoot and Forefoot Surgery: Audit of 1000 Cases
Authors: Rudkin Adam K. , Rudkin Glenda E. , Dracopoulos George C.
Published: January 2017

Background:

While use of a thigh tourniquet with general anesthesia is widely accepted, use of an ankle tourniquet in the awake patient is more controversial. In particular, it is not clear how long patients tolerate this device or what the consequences are of intraoperative tourniquet pain.

Method:

A prospective audit was done of 1000 patients undergoing midfoot and forefoot surgery using an ankle block. We examined the intraoperative problems associated with the use of an ankle tourniquet, particularly the role and consequences of intraoperative tourniquet pain. Risk factors for tourniquet pain were statistically examined, and patient acceptance was gauged through followup questions.

Results:

With correct application and the option of sedation, 3.1% of patients complained of tourniquet pain. In 0.4% of patients tourniquet pain necessitated a conversion to general anesthesia. A significant association was found between tourniquet pain and both age and tourniquet time. We found that for patients younger than 70 years of age, the tourniquet can be applied comfortably for up to 30 minutes in over 97%. For each 11 minutes beyond this, another 1% of patients reported tourniquet pain. However, patients 70 years or older had an average 3.5 times increase in tourniquet pain. In this age group the tourniquet can be applied comfortably for up to 30 min in 91%. For each 3.2 minutes beyond this, another 1% reported tourniquet pain. When questioned, 97.2% of our patients reported that they would have surgery again with an ankle tourniquet.

Conclusions:

Our audit shows that with correct application and the option of sedation the ankle tourniquet is well tolerated by most patients. However, clinicians need to be mindful that patients 70 years of age or older are at greater risk of tourniquet pain and that in all patients the risk of tourniquet pain gradually increases when application times exceed 30 min.
Reconstruction of the Chronically Failed Deltoid Ligament: A New Technique
Authors: Deland Jonathan T. , de Asla Richard J. , Segal Ayal
Published: January 2017

Background:

Chronic deltoid ligament insufficiency that results in valgus tilt of the talus within the ankle mortise (stage IV adult acquired flatfoot) represents a difficult and so far unsolved problem in foot and ankle surgery. If left uncorrected, the deltoid failure with malalignment predisposes to early ankle arthritis and the need for ankle arthrodesis or possibly ankle arthroplasty.

Methods:

Five consecutive patients with deltoid ligament insufficiency resulting in a valgus tilt were treated with a deltoid reconstruction. Reconstruction of the deltoid ligament was done by passing a peroneus longus tendon graft through a bone tunnel in the talus from lateral to medial and then through a second tunnel from the tip of the medial malleolus to the lateral tibia.

Results:

At a minimum 2-year followup, all patients had correction of the talar tilt. One patient had 9 degrees of valgus tilt remaining compared to 15 degrees preoperatively, and the procedure was considered a failure. The remaining four patients had correction of the valgus tilt to 4 degrees or less.

Conclusion:

Although not uniformly successful, deltoid ligament reconstruction using a tendon graft through appropriate bone tunnels can reconstruct the deltoid ligament and correct the valgus talar tilt. Successful results were achieved when combined with correction of flatfoot deformity, which is considered a necessary part of the procedure.
Pigmented Villonodular Synovitis about the Ankle: A Review of the Literature and Presentation in 10 Athletic Patients
Authors: Saxena Amol , Perez Hugo
Published: January 2017

Background:

Pigmented villonodular synovitis (PVNS) is relatively uncommon. The disorder results in increased proliferation of synovium causing villous or nodular changes of synovial-lined joints, bursae and tendon sheaths. This study examines the occurrence of PVNS about the ankle and its association with trauma.

Methods:

Ten patients over a 10-year period were identified as having PVNS of the ankle. The average age was 40.2 (range 27 to 62) years. There were four women and six men. Average followup was 4.5 (range 1 to 11) years from the initial surgery. Four patients had bone involvement. All patients who were athletically active before symptoms arose complained of persistent pain and swelling in the lateral ankle. Their initial clinical symptoms were indistinguishable from commonly associated pathologies with persistent lateral ankle pain (i.e. tenosynovitis, osteochondral defects, os trigonum injury, and tendon tears). All patients had magnetic resonance imaging (MRI) revealing PVNS, which is represented by low-signal appearing masses on T1-and T2-weighted images. All patients' histopathology results revealed multinucleated giant cells and foam cells laden with hemosiderin deposits. All patients had synovectomy and tenosynovectomy.

Results:

Eight patients were able to return to some sports (range 4 to 12 months); two had continued pain, disability, and inability to return to sports because of recurrence.

Conclusions:

PVNS should be considered in athletically active patients with persistent lateral ankle pain and swelling, particularly if bone erosions are visible on plain radiographs.
Uniportal Endoscopic Plantar Fasciotomy: A Prospective Study on Athletic Patients
Authors: Saxena Amol
Published: January 2017

Background: Endoscopic techniques have been described to surgically treat plantar fasciitis in the general patient population. A prospective, single-surgeon study was conducted to evaluate if a uniportal endoscopic plantar fasciotomy technique is effective in allowing athletic patients to return to their desired activities. Methods: Sixteen patients with plantar fasciitis who were athletically active were compared to a control group that consisted of 10 patients who did not engage in sports. Most of the athletic patients were runners. Mean age at time of surgery was 39.8 ± 13.1 years for the athletic group and 51.2 ± 5.5 years for the control group ( p < .01). All patients had conservative treatment for a minimum of 8 months (mean 19.4 months; range 8 to 50). All patients were rated for body mass index (BMI), and the Modified Plantar Fascia Score (MPFS) was obtained before and after endoscopic release. The preoperative MPFS was 42.0 ± 2.5 for the athletic group and 23.6 ± 15.7 for the control group ( p < .01). All patients had uniportal endoscopic plantar fasciotomy with transection of the medial 50% of the plantar fascia. Postoperatively patients were kept in a low, below-knee, removable cast-boot for a total of 4 weeks, nonweightbearing for the first 2 weeks. Results: The mean return-to-activity time after surgery was 2.6 ± 0.7 months. The mean postoperative MPFS was 93.3 ± 2.4, which was a significant improvement ( p = .00001). Using this scoring system score, all results in athletes were excellent or good. The control group had a mean postoperative MPFS of 63.6 ± 27.1, also significantly improved ( p = .0006) but lower than the athletic group ( p = .00001). All five poor results in the controls had a BMI of more than 27. Good or excellent results in the control group were obtained only in patients who walked for exercise. The BMI was statistically lower in the athletic group than in the control group ( p = .00001). The average BMI in women was significantly higher ( p = .02) than in men, and they required a longer time to return to activity ( p = .01). Conclusion: Athletic patients undergoing uniportal endoscopic plantar fasciotomy can expect good to excellent results based on the MPFS. Fifty percent of the patients with a BMI of more than 27 had poor results.
Preoperative Imaging of Charcot Neuroarthropathy in Diabetic Patients: Comparison of Ring PET, Hybrid PET, and Magnetic Resonance Imaging
Authors: Höpfner Stefan , Krolak Christoph , Kessler Stefan , Tiling Reinhold , Brinkbäumer Kirsten , Hahn Klaus , Dresel Stefan
Published: January 2017

Introduction: The treatment of Charcot neuroarthropathy in the feet of diabetic patients has undergone fundamental changes in the last few years. Formerly, treatment was almost exclusively limited to nonoperative measures; since the late 1990s, however, current practice has shifted to early, stage-appropriate surgical therapy. The objective of this prospective study was to investigate the value of two types of positron emission tomography (PET) in the preoperative evaluation of diabetic patients with Charcot foot deformities. Materials and Methods: Ring [18F]FDG (2-fluoro-2-deoxy-glucose) and hybrid PET were compared to magnetic resonance imaging (MRI). MRI, ring PET, and hybrid PET imaging were used as part of the preoperative evaluation of 16 patients with type II diabetes mellitus. The diagnosis of Charcot neuropathy of the foot requiring operative treatment had been made on the basis of clinical and radiographic criteria. Results: Of 39 Charcot lesions confirmed at surgery, 37 were detected by ring PET, 30 by hybrid PET, and 31 by MRI. Conclusions: PET (ring or hybrid) can be used in the evaluation of patients with metal implants that would compromise the accuracy of MRI. Another advantage of PET is its ability to distinguish between inflammatory and infectious soft-tissue lesions, and between osteomyelitis and Charcot neuroarthropathy. The differentiation between Charcot neuroarthropathy and florid osteomyelitis provides the surgeon with important additional information that often is unavailable from MRI. Because it provides important additional data, ring PET may be preferable to radiography and MRI in the preoperative evaluation of patients with Charcot neuroarthropathy of the foot. Hybrid PET, because of its poorer resolution compared to ring PET, appears less suitable for routine clinical application.
Comparison of the Syndesmotic Staple to the Transsyndesmotic Screw: A Biomechanical Study
Authors: Marqueen Timothy , Owen John , Nicandri Gregg , Wayne Jennifer , Carr James
Published: January 2017

Background: Controversy still exists about treatment of syndesmotic injuries. This study compared the fixation strengths and biomechanical characteristics of two types of ankle fracture syndesmotic fixation devices: the barbed, round staple and the 4.5-mm cortical screw. Methods: Cadaveric testing was done on 21 fresh-frozen knee disarticulation specimens in biaxial servohydraulic Instron testing equipment. Submaximal torsional loads were applied to specimens in intact and Weber C bimalleolar fracture states. The specimens were then fixed with one of two techniques and again subjected to submaximal torsion and torsion to failure. Biomechanical parameters measured included tibiofibular translation and rotation, maximal torque to failure, and degrees of rotation at failure. Results: Compared to the intact state before testing, the staple held the fibula in a more anatomic position than the screw for mediolateral and anterior displacements (p < 0.01). With submaximal torsional testing, the staple restored 85% of the tibiofibular external rotation and all of the posterior translation values as compared to the intact state. The screw resulted in 203% more tibiofibular medial translation and 115% more external rotation than the intact state. The degree of tibial rotation during submaximal torsional loading was restored to within 15% of intact values but was 21% less with the screw. There was no statistical difference between the screw and staple when tested in load to failure. Tibio-talar rotation at failure was statistically different with the staple construct, allowing more rotation as compared to the screw. Conclusion: The staple restored a more physiologic position of the fibula compared to the syndesmotic screw. Both provided similar performance for the load to failure testing, while the screw reduced tibial rotation more after cyclic loading. There was more tibial rotation before failure for the staple, suggesting a more elastic construct. This study provides biomechanical data to support the clinical use of the syndesmotic staple.
Goniometric Versus Computerized Angle Measurement in Assessing Hallux Valgus
Authors: Farber Daniel C. , DeOrio James K. , Steel Maxwell W.
Published: January 2017

Background: Digital workstations with high-resolution monitors are replacing standard radiographs for image evaluation and interpretation. Radiographic angles in the foot have been evaluated for interobserver and intraobserver reliability with plain films, but use of digital workstations has not been validated. Because the 1-2 intermetatarsal (IM) and hallux valgus (HV) angles help determine the most appropriate bunion procedure, the reliability of these measurements is important. Methods: The HV and 1-2 IM angles were evaluated on preoperative radiographs of 25 patients who subsequently underwent bunion procedures. A standardized technique using a film marker and goniometer on plain film was compared with use of a mouse and computerized angle measurement software at a digital workstation. Three foot and ankle surgeons conducted these measurements at various intervals. Completion of three readings of each radiograph in each format by each observer totaled 1,800 measurements. Results: Computerized measurement gave better overall reliability. For the HV angle, inter-observer agreement (measurements within 2 degrees) improved from 66% with plain films to 81% with the digital workstation (p < 0.001). Intraobserver agreement increased from 72% to 80%. The 1-2 IM angle was similarly reliable with both methods for inter- and intraobserver agreement. Conclusions: This study validates the use of computer-assisted angle measurement on digital radiographs for assessment of HV and 1-2 IM angles. Computerized measurement may result in more reliable readings because it eliminates the error inherent with use of a goniometer and facilitates adjustment of radiographic lines on the computer to ensure correct alignment.
Effect of Metatarsophalangeal Joint Position on the Reliability of the Tangential Sesamoid View in Determining Sesamoid Position
Authors: Yildirim Yakup , C¸abukoglu Cengiz , Erol Bulent , Esemenli Tanil
Published: January 2017

Background: Lateral displacement of the sesamoids of the first toe relative to the metatarsal head is a common finding in hallux valgus deformity. Several methods have been described for quantifying the amount of subluxation from anteroposterior radiographs but a tangential sesamoid radiograph has been determined to be the best view to evaluate sesamoid displacement. Method: We evaluated the sesamoid position at different angles of the first metatarsophalangeal (MTP) joint to determine the effect of first MTP joint dorsiflexion on sesamoid position when tangential sesamoid view radiographs are made. Sesamoid positions of 22 feet with hallux valgus were graded from the short axis computed tomography (CT) images obtained with the MTP joint in 0, 35, and 70 degrees of dorsiflexion. Results: Approximation of the sesamoids to reduction was apparent as dorsiflexion of the first MTP joint increased. Conclusion: Different dorsiflexion degrees of the first MTP joint when tangential sesamoid radiographs are made modulate the position of the sesamoids and may lead to misclassification on grading.
A Radiographic Technique for the Assessment of Ankle and Midfoot Equinus
Authors: Elomrani Naser , Kasis Ata , Saleh Michael
Published: January 2017

Background: Both clinical and radiographic techniques have been used to evaluate foot and ankle position and orientation. Clinical measurements have been shown to be less reliable than radiographic measurements. Because midfoot equinus deformity may coexist with ankle joint equinus deformity, a radiographic method of separating and measuring these two components is desirable. The purpose of this study was to evaluate a new radiographic technique, the Lateral Mid-Tibia to Toes (LMTT), weightbearing view of the foot and ankle. Method: Twenty LMTT images were randomly selected from the study population of patients treated in our center for lower limb equinus deformity. Validation was achieved by a study involving three observers, assessing 20 images on two consecutive occasions, 4 weeks apart. Analysis was performed using Kappa statistics. Results: The plantigrade and midfoot equinus angles provided substantial ( p = 0.000) and moderate ( p = 0.005) agreement, respectively. Conclusions: Awareness of midfoot equinus and its correction may avoid residual deformity when surgery is performed to correct equinus deformity of the ankle.