bluuebunny/crossref_metadata_2025 huggingface dataset:
Chronic Lateral Ankle Instability
Authors: Peters J. Wesley , Trevino Saul G. , Renstrom Per A.
Published: March 2013

Chronic lateral ankle instability may be present in as many as 10% to 30% of people suffering from acute lateral ankle ligament injuries. Ankle instability has been referred to as either functional instability or mechanical instability. Management options consist of either nonoperative or operative treatment, with the majority of the literature emphasizing operative management for chronic instability. Long-term studies assessing the different types of available operative repairs have now been published.

This review article discusses chronic lateral ankle ligament instability from a functional, anatomical point of view. The indications for treatment, nonoperative and operative treatment, as well as the biomechanical information available regarding these methods of treatment are considered. The major emphasis of this review is discussion and analysis of the many different surgical treatment options. Following this review, we presently recommend anatomical repair to the bone of both the anterior talofibular ligament and the calcaneofibular ligament, together with imbrication of the ligaments. In patients with hypermobility, long-standing instability, or arthritis, reconstruction using the Chrisman-Snook technique is recommended.
Triple Arthrodesis in the Treatment of Fixed Cavovarus Deformity in Adolescent Patients with Charcot-Marie-Tooth Disease
Authors: Mann David C. , Hsu John D.
Published: March 2013

Ten adolescent patients with Charcot-Marie-Tooth disease (12 feet) were evaluated an average of 7 years, 7 months following triple arthrodesis (TA) for the treatment of cavovarus deformity. The TA was the primary or index bone procedure. At follow-up, five feet were plantigrade, asymptomatic, and radiographically fused at all three joints. Three feet were plantigrade and asymptomatic, but two had talonavicular pseudarthrosis and one had calcaneocuboid pseudarthrosis. Three feet were radiographically fused at all three joints, but in nonplantigrade positions and symptomatic. One foot required a revision TA. In general, TA offers adolescent Charcot-Marie-Tooth patients a stable plantigrade foot in the face of a progressive disorder. The residual deformity, revision, and pseudarthrosis rates are similar to those for adults. Postoperative pain was related to a nonplantigrade foot and not to the presence of pseudarthrosis. It is not known whether a nonplantigrade foot was a result of incomplete surgical correction or recurrent deformity due to progressive muscle imbalance.
Ankle Reconstruction for Malunion by Fibular Osteotomy and Lengthening with Direct Control of the Distal Fragment: A Report of Three Cases and Review of the Literature
Authors: Roberts Craig , Sherman Orrin , Bauer David , Lusskin Ralph
Published: March 2013

Malunion of ankle fractures will lead to severe osteoarthritis when the architecture and mechanics of the talocrural joint are deranged. When fibular shortening is present, ankle reconstruction can be achieved by fibular lengthening and can provide an alternative to early arthrodesis for deformity and pain. Acceptable clinical and radiographic results can be achieved, provided that accurate reconstruction is achieved and intra-articular osteochondral injury is minimal. Restoration of fibular length, necessary for a good clinical result, can be estimated radiographically by the bimalleolar angle. We report three cases of ankle reconstruction by fibular lengthening with an average follow-up of 33 months.
The Patellar Tendon-Bearing Brace as Treatment for Neurotrophic Arthropathy: A Dynamic Force Monitoring Study
Authors: Saltzman Charles L. , Johnson Kenneth A. , Goldstein Ronald H. , Donnelly Richard E.
Published: March 2013

The effects of shoe wear, custom-made inserts, patellar tendon-bearing (PTB) braces, and extra-padded PTB braces on load transmission to neuroarthropathic (Charcot) feet of six diabetic patients were assessed. A PTB brace with a free ankle and an extradepth shoe without external modifications was used. Four distinct anatomical regions were evaluated by an in-shoe technique measuring vertical force. The mean peak force transmitted to the entire foot was higher in the affected than in the unaffected extremity barefoot and shod. The mean peak forces under the midfoot were higher for the affected than for the unaffected extremity for all tested circumstances. In the affected foot, use of the standard PTB brace reduced mean peak force to the entire foot by 15%. Adding extra padding to the brace decreased the mean peak force 32%. The effect of padding on vertical load transmission was greatest for patients who had worn the brace the longest. For the patients who had worn it longer than average, the addition of padding decreased the mean peak force to the entire foot by 19%, to the hindfoot by 37%, and to the midfoot by 20%. Clinical Relevance: In this preliminary study, we found that a properly fitted PTB brace can reduce load transmission to the Charcot foot. Specifically, load transmission was reduced to the hindfoot, but not to the midfoot or forefoot. Based on these results, we cannot recommend its use to reduce vertical force transmission to the Charcot midfoot or forefoot. Long-term PTB brace use, especially in the limited weightbearing patient, should be regularly adjusted to ensure adequate brace fit.
Footprint Parameters as a Measure of Arch Height
Authors: Hawes Michael R. , Nachbauer Werner , Sovak Daniela , Nigg Benno M.
Published: March 2013

The human foot has frequently been categorized into arch height groups based upon analysis of footprint parameters. This study investigates the relationship between directly measured arch height and many of the footprint parameters that have been assumed to represent arch height. A total of 115 male subjects were measured and footprint parameters were calculated from digitized outlines. Correlation and regression analyses were used to determine the relationship between footprint measures and arch height. It may be concluded from the results that footprint parameters proposed in the literature (arch angle, footprint index, and arch index) and two further parameters suggested in this study (arch length index and truncated arch index) are invalid as a basis for prediction or categorization of arch height. The categorization of the human foot according to the footprint measures evaluated in this paper represent no more than indices and angles of the plantar surface of the foot itself.
The Bridle Procedure in the Treatment of Paralysis of the Foot
Authors: Rodriguez Raoul P.
Published: March 2013

The Bridle procedure consists of a posterior tibial tendon transfer through the interosseous membrane to the dorsum of the foot with a dual anastomosis to the tendon of the anterior tibial and a rerouted peroneus longus in front of the lateral malleolus. This procedure is performed to restore loss of dorsiflexion and to balance the foot, preventing a secondary varus or valgus deformity. The procedure was performed in 10 patients with 11 feet with paralysis of dorsiflexion of the foot. All are brace-free. The results are better in patients with peroneal nerve palsy secondary to trauma.
Possible Epidemiological Factors Associated with Rupture of the Posterior Tibial Tendon
Authors: Holmes George B. , Mann Roger A.
Published: March 2013

Rupture of the posterior tibial tendon has been postulated to occur, in part, as a result of degenerative changes to the tendon. This possibility was examined by a review of 67 patients (average age 57 years) diagnosed with rupture of the posterior tibial tendon. Forty-five of the 67 patients (60%) had one or more of the following positive medical histories: (1) hypertension, (2) obesity, (3) diabetes mellitus, (4) previous surgery or trauma about the medial aspect of the foot, or (5) steroid exposure. Thirty-five patients (52%) had either hypertension, diabetes mellitus, or obesity. A statistical correlation was demonstrated between rupture of the posterior tibial tendon and obesity ( P = .005) and to a lesser extent hypertension ( P = .025). These disorders have been uniformly associated with an acceleration of the degenerative processes associated with aging, commonly via an acceleration of microvascular and macrovascular diseases. An additional vascular risk is implicated by the known zone of hypovascularity of the posterior tibial tendon and risk of rupture secondary to systemic or local injections of corticosteroids. The prevalence of posterior tibial tendon rupture parallels the degenerative processes of aging, hypertension, diabetes mellitus, and obesity. Additionally, the effects of corticosteroids and local surgical procedures may further be associated with local vascular impairment and eventual rupture.
Histochemistry of the Triceps Surae Muscle in Idiopathic Congenital Clubfoot
Authors: Maffulli Nicola , Capasso Giovanni , Testa Vittorino , Borrelli Luigi
Published: March 2013

The histochemical composition of the triceps surae muscle was investigated in 13 previously unoperated children (age 9–24 months) with unilateral idiopathic clubfoot. On both the normal and the affected side, the percentage of type I fibers was significantly higher than that of the other fiber types. The muscle biopsies from the clubfoot side showed an increase in their connective tissue content. The affected side showed a nonsignificant higher percentage of type I fibers, whereas the average capillary density and capillary to fiber ratio were significantly lower.
Metatarsocuneiform Arthrodesis for Management of Hallux Valgus and Metatarsus Primus Varus
Authors: Myerson Mark , Allon Steven , McGarvey William
Published: March 2013

Sixty-seven closing wedge arthrodesis procedures of the first metatarsocuneiform joint were performed in 41 females and 12 males. Follow-up averaged 28 months (range 16–49 months) and was performed in 51 of 53 patients with a questionnaire, clinical examination, and comparison of pre- and postoperative weightbearing radiographs. The average hallux valgus angle was 34.5° (range 20°–75°) and was corrected to 13.0° (range −10°–22°) postoperatively. The average intermetatarsal angle was 14.3° (range 9.5°–34°) and was corrected to an average of 5.8° (range 0°–12°) postoperatively. Complications included seven superficial pin tract infections, three symptomatic dorsal bunions, one of which required repeat surgery, seven nonunions, one of which was symptomatic, one hallux varus, and three neuromas of the deep peroneal nerve. The range of motion of the hallux metatarsophalangeal joint was 85% of normal postoperatively. A total of 77% of the patients were totally relieved, 15% partially relieved, and 8% not relieved with respect to pain, comfort, appearance of the foot, and shoewear following surgery. The specific indications for performing this operation are discussed.
Anterior Tibiotalar Spurs: A Comparison of Open versus Arthroscopic Debridement
Authors: Scranton Pierce E. , McDermott John E.
Published: March 2013

We compared the difference in operative time, hospitalization and recovery time in two groups of patients who underwent open or arthroscopic resection of anterior, tibiotalar, impinging spurs. The operative time was approximately the same, but the average length of hospitalization and time to recovery were shorter in the arthroscopic group. A classification system is proposed that grades the degree of spur formation and assists in predicting the length of recovery time and whether the patient is a candidate for open or arthroscopic spur resection. In this series, grade I spur patients recovered and resumed full activity at 5.0 weeks, grade II at 5.6 weeks, grade III at 6.4 weeks, and grade IV at 10.0 weeks postoperatively. Grade IV patients are not suitable candidates for an arthroscopic debridement.
The Stabilizing Role of the Lateral Ligament Complex around the Ankle and Subtalar Joints
Authors: Stephens Michael M. , Sammarco G. James
Published: March 2013

The stabilizing role of various ligaments in the lateral side of the ankle and hindfoot was examined experimentally and sequentially using 10 fresh amputated lower limbs. The anterior talofibular ligament contributed to ankle stability in plantarflexion and the calcaneofibular, the fibulotalocalcaneal, and posterior talofibular ligament in all positions. The lateral root of the inferior extensor retinaculum contributed to subtalar stability in neutral and dorsiflexion. The calcaneofibular, fibulotalocalcaneal, and cervical ligaments and the ligament of the anterior capsule of the posterior talocalcaneal joint and the interosseous ligaments contributed to subtalar stability in all positions. The subtalar joint accounted for upward of 50% of ankle/hindfoot inversion after ligament division in the intermalleolar plane.
Circulatory Disturbance of the First Metatarsal Head after Chevron Osteotomy as Shown by Bone Scintigraphy
Authors: Resch Sylvia , Stenström Anders , Gustafson Torbjørn
Published: March 2013

Distal osteotomies, such as Chevron osteotomies, have a potentially high risk for circulatory disturbance, since they transect part of the circulatory apparatus. An increased risk of up to 40% of avascular necrosis diagnosed radiographically has been reported when the osteotomy is combined with adductor tenotomy. On the other hand, new circulatory studies indicate that the circulation does not go in direct proximity to the adductor tendon. In this prospective study, 38 consecutive patients (41 feet) were randomized to Chevron osteotomy alone or Chevron osteotomy with adductor tenotomy. They were investigated 2 to 9 days postoperatively with 99mTc-methylene diphosphonate scintigraphy as well as x-rays and clinical examination. The average follow up was 19 months (range 12–48 months). Three defects were found in those operated with Chevron osteotomy alone, and one defect was found in a patient operated with Chevron osteotomy and adductor tenotomy. None of the patients had symptoms attributable to reduced circulation of the metatarsal head. Repeat scans showed healing in all four cases. Radiographs failed to show any signs of necrosis. Thus, Chevron osteotomy is a safe method in the treatment of hallux valgus which can be combined with adductor tenotomy without increasing the risk for circulatory disturbance.
Report on the 1989 American Orthopaedic Foot and Ankle Society Fellow Scholarship
Authors: Manoli Arthur
Published: March 2013

In 1989, the American Orthopaedic Foot and Ankle Society, Inc., sponsored a scholarship for a member to return to training to do a fellowship in foot and ankle surgery. The following is the account of Arthur Manoli, II, M.D., who served 3 months with Sigvard T. Hansen, Jr., M.D., at the Harborview Medical Center, University of Washington, Seattle, Washington, and 9 months with Marion C. Harper, M.D., at Vanderbilt University, Nashville, Tennessee.
Marginal Fractures of the Lateral Malleolus in Association with other Fractures in the Ankle Region
Authors: Ebraheim Nabil A. , Zeiss Jacob , Skie Martin C. , Dwight Richard
Published: March 2013

Eight cases of avulsion-type fracture of the distal fibula associated with fracture of the calcaneus, talus, or ankle region were identified. This avulsion fracture can be identified on routine radiographs as well as on CT scans of the ankle and is pathognomonic of rupture of the superior peroneal retinaculum with or without peroneal tendon displacement. Recognition of this avulsion fracture, with subsequent proper management of the underlying peroneal tendon pathology by immobilization or surgery, may prevent future tendon dysfunction. It may also alter the treatment of other associated injuries.
Stabilization of the Interphalangeal Joint of the Big Toe: Comparison of Three Methods
Authors: Asirvatham Rajan , Rooney Ronald J. , Watts H. G.
Published: March 2013

Three methods of stabilizing the IP of the big toe were compared. In group A, 10 patients underwent tenodesis of the extensor hallucis longus to the extensor digitorum brevis tendon. All of them developed a toe-drop; two patients had significant symptoms that required IP fusion. In group B, 19 patients underwent IP fusion using smooth or threaded intramedullary Kirschner wire fixation. There were nine nonunions, three requiring refusion. In group C, 32 patients underwent IP fusion using intramedullary screw fixation. There was one nonunion with screw failure that required revision.

Although none of our patients considered the toe-drop after extensor hallucis longus tenodesis cosmetically unacceptable, this may not be so in other cultures. All complications following IP fusion with screw fixation were technical and are avoidable. When stabilization of IP is required, we recommend fusion of IP with screw fixation.
The Distal Course of the Sural Nerve and its Significance for Incisions around the Lateral Hindfoot
Authors: Eastwood Deborah M. , Irgau Isiahs , Atkins Roger M.
Published: March 2013

Twenty preserved cadaver limbs were dissected to show the distal course of the sural nerve and the number and site of origin of its branches. The mean position of the main nerve trunk was calculated at various points related to bony landmarks of the fibula and the fifth metatarsal base. Ninety-five percent confidence limits for the course of the main nerve trunk could be described. A fibula incision may damage the nerve if it extends more than 7 mm inferior to the lateral malleolar tip with the foot in equinus. Dorsolateral foot incisions may damage both the main trunk and the major anterior branch.
The Retrocalcaneal Bursa: Anatomy and Bursography
Authors: Frey Carol , Rosenberg Zehava , Shereff Michael J. , Kim Hose
Published: March 2013

The retrocalcaneal bursae, located between the posterior angle of the os calcis and the Achilles tendon, may become inflamed and hypertrophied. There are few objective tests available for the diagnosis of pain syndromes involving the hindfoot and it is often difficult to differentiate Achilles tendinitis and retrocalcaneal bursitis. Retrocalcaneal bursograms can provide further insight into chronic changes in the bursae associated with traumatic and inflammatory conditions. This report describes the anatomy of the retrocalcaneal bursa, the technique of its opacification, and the application of this technique to the diagnosis and treatment of painful hindfoot syndromes. In addition, the anatomy of the retrocalcaneal bursa was investigated further using latex casting techniques.

Twelve cadaver limbs were injected with radiopaque latex casting material or renografin into the retrocalcaneal bursae. AP, lateral, and oblique radiographs were then obtained on the specimens. The size, capacity, and configuration of the postmortem bursae were measured and recorded. Subsequently, the cadaver limbs injected with the latex material were cooled and dissection was made of the retrocalcaneal bursae. The latex bursal molds were measured, graphically recorded, and photographed.

Fifteen patients with signs and symptoms of retrocalcaneal bursitis and eight asymptomatic patients were selected for this study and injected with radiopaque material into the bursae. Anteroposterior, lateral, and oblique radiographs were then obtained. The size, capacity, and configuration of the retrocalcaneal bursae were measured and recorded.

The anatomic characteristics noted from the latex bursal molds correlated well with the findings on bursography. Bursographic findings in patients with retrocalcaneal bursitis can provide insight into the diagnosis and clinical management of this disorder.
Dislocation of the Posterior Tibial Tendon
Authors: Ouzounian Tye J. , Myerson Mark S.
Published: March 2013

We have treated seven patients with dislocation or recurrent subluxation of the posterior tibial tendon. The diagnosis of dislocation was made based on the patient's symptoms, physical examination, and magnetic resonance scanning. All patients were treated with surgical repair, which was modified according to the operative findings. The operative findings included tenosynovitis, a shallow or incompetent flexor groove, and tearing or absence of the flexor retinaculum. At an average of 28 months following surgery, all patients were markedly improved and six returned to their preinjury level of activity.
A Technique for Measuring Absolute Toe Pressures: Evaluation of Pressure-Sensitive Film Techniques
Authors: Tuckman Alan S. , Werner Frederick W. , Fortino Maria D. , Spadaro Joseph A.
Published: March 2013

Although a number of pathologies of the forefoot in ballet dancers on pointe have been described, pressures and deforming forces have not been adequately measured. To evaluate the possible use of pressure-sensitive film (PSF) in measuring the pressures on the external soft tissues in such a confined space as the dancer's toe shoe, it was tested and calibrated with 20 cadaver toes. Each cadaver toe was internally stabilized and loaded longitudinally against PSF on a flat surface. The resultant films were analyzed with a video imaging system and the pressures and total forces were determined. Results showed that the linearity of the PSF to pressure had a regression value of 0.98. By using two sensitivity ranges of films, the total force measured by the PSF was found to be within 10% of the known applied force on each toe. The PSF, therefore, may very well be a useful and accurate method of measuring external soft tissue pressures on the forefoot.
Talocalcaneal Coalition: Diagnosis and Surgical Management
Authors: Salomão Osny , Napoli Manlio Mario Marco , de Carvalho Antonio Egydio , Fernandes Túlio Diniz , Marques Julio , Hernandez Arnaldo José
Published: March 2013

The authors studied 22 patients who had 32 feet with symptomatic talocalcaneal coalition. All feet were treated with excision of the bar and interposition of an autogenous free fat graft. These cases were assessed clinically and radiographically before and after the operation. They conclude that this technique is a good surgery with gratifying results. In the final outcome, 78.1% of feet became completely painless and 21.8% achieved relief of pain. There was improvement of the deformity in 68.7% and of range of motion in 75%.
The Art and Science of Fitting Shoes
Authors: Janisse Dennis J.
Published: March 2013

The two primary components of achieving proper shoe fit are shoe shape and shoe size. Shoe shape refers to the shape of both the sole and the upper. Proper fit is achieved when shoe shape is matched to foot shape. Shoe size is determined by arch length rather than overall foot length. The proper shoe size is the one that accommodates the first metatarsal joint in the widest part of the shoe.

A set of seven guidelines for achieving proper shoe fit is offered. Properly fitting shoes are important in avoiding foot discomfort and deformity, and are absolutely essential in patients with arthritis, diabetes, and other foot disorders.
Transcutaneous Oxygen as a Predictor of Wound Healing in Amputations of the Foot and Ankle
Authors: Pinzur Michael S. , Sage Ronald , Stuck Rodney , Ketner Larry , Osterman Helen
Published: March 2013

Thirty-eight amputations of the foot and ankle were performed in patients with peripheral vascular insufficiency over a 20-month period. Amputation level selection was based on clinical examination, a minimum ankle-brachial index of 0.5 as a measure of vascular supply, serum albumin of 3.0 gm/dl as a measure of tissue nutrition, and a total lymphocyte count of 1500 as a measure of immunocompetence. Transcutaneous oxygen tension was measured at the midfoot and ankle levels prior to surgery. Thirty-two of 38 patients (84.2%) healed their amputation wounds. When the transcutaneous oxygen tension was greater than 30 mm Hg, 24 of 26 patients (92.3%) healed. When the value was below 30 mm Hg, only eight of 12 patients healed.

When the propensity to support wound healing is factored out, with patients having the metabolic capacity to heal an amputation wound in the foot and ankle, it appears that transcutaneous oxygen tension is an accurate measure of vascular inflow to support amputation wound healing.
Silicone Lymphadenopathy Associated with Failed Prosthesis of the Hallux: A Case Report and Literature Review
Authors: Sammarco G. James , Tabatowski Katherine
Published: March 2013

Three years after replacement of a first metatarsophalangeal joint with a silicone prosthesis, a tennis player developed an enlarged ipsilateral femoral lymph node. The implant was also noted to have failed. Fine needle aspiration of the node revealed a foreign body giant cell reaction to particulates morphologically compatible with silicone elastomer. This finding suggests the potential utility of fine needle aspiration in the evaluation of patient response to foreign materials used in prosthetic devices. The lymphadenopathy also suggests that prosthetic metatarsophalangeal replacement in patients with high demand activities run the risk not only of failure of the prosthesis, but also of central migration of the particulate debris resulting from silicone elastomers.
Excision of the Fractured Os Peroneum: A Report on Five Patients and Review of the Literature
Authors: Peterson David A. , Stinson Warren
Published: March 2013

Five patients sustained fractures of the os peroneum after supination and plantarflexion injuries. Two of the injuries involved the knee in hyperflexion and the foot under the buttock. Four of the five were treated with immobilization for 6 weeks. All five required operative excision of the fractured sesamoid 8 months to 8 years after the initial injury. Three fractures were bipartite and there were two multipartite fractures. At 12- to 28-month follow-up, all patients were pain-free over the lateral midfoot and four patients returned to preinjury activity levels.
Regional Anesthesia for Foot and Ankle Surgery
Authors: Myerson Mark S. , Ruland Charles M. , Allon Steven M.
Published: March 2013

We present our experience with the use of regional anesthesia in 1295 of 1862 (69.5%) surgical procedures of the foot and ankle between 1986 and 1989. Regional anesthesia was used for surgical procedures of the forefoot, midfoot, hindfoot, and ankle in the setting of elective surgery and trauma. From the viewpoint of the surgeon, regional anesthesia was completely successful in 95% of the procedures performed. Sample patient surveys confirmed that 87% of patients were satisfied with the use of regional anesthesia for their operative procedure. There were four (0.3%) minor complications, one being lidocaine toxicity. With increasing experience, the expanded indications and uses of regional anesthesia for foot and ankle surgery are proving to be simple, safe, reliable, and well tolerated by the patient.
Long-term Follow-up of the Conaxial (Beck-Steffee) Total Ankle Arthroplasty
Authors: Wynn Audrea H. , Wilde Alan H.
Published: March 2013

Between 1975 and 1977, 30 patients with traumatic arthritis or rheumatoid arthritis underwent 36 Conaxial (Beck-Steffee) ankle replacements (DePuy, Warsaw, IN). Thirty-two were primary replacements and four were revisions of previous ankle arthroplasties. Twelve patients had traumatic osteoarthritis and 18 patients had rheumatoid arthritis. The average age at operation of patients with rheumatoid arthritis was 61 years (range 28–67 years) and with osteoarthritis was 52.9 years (range 32–72 years). The average follow-up was 10.8 years, with a range of 10 to 13 years. Early postoperative complications included wound dehiscence in 39% of patients (14 patients), deep wound infection in 6%, fractures of the medial or lateral malleolus in 22%, and painful talofibular impingement in 14%. At 2-year follow-up, 27% of the ankle replacements were loose. Sixty percent were loose at 5 years and 90% were loose at the 10-year follow-up. Ten patients had implant removal and attempted fusion. Six, or 60%, fused in an average of 5 months. Of those patients who achieved ankle fusion, four had internal fixation and iliac crest autografting, one had a Charnley compression apparatus with allograft bone, and one had internal fixation with allograft bone. The constrained Conaxial ankle replacement should no longer be implanted because of a 90% loosening rate at 10 years and an overall complication rate of 60%.
Ankle Arthrodesis: A Long-term Study
Authors: Abdo Richard V. , Wasilewski Stephen A.
Published: March 2013

Few studies of ankle arthrodesis have assessed tarsal mobility. This study was performed to evaluate radiographically the effect of ankle arthrodesis on tarsal motion. Thirty patients (31 ankles) returned for clinical and radiographic examination, review of charts, and completion of questionnarie forms. Radiographs were evaluated for success of fusion, position of fusion, tarsal motion, hindfoot position, and subtalar and midtarsal arthritis. The median follow-up time was 7.0 years (range 2–20 years). Results showed that fusion was achieved in 22 patients (71%). The evaluation score based on the grading system of Mazur et al. 16 correlated with success of fusion and patient satisfaction. However, no correlation existed between evaluation score and tarsal motion or position of fusion in the sagittal or coronal planes. Radiographic evaluation showed no significant difference between tarsal motion of the fused side and the unfused side. Tarsal mobility was not affected by ankle arthrodesis or by the techniques performed to achieve fusion.
Talonavicular Arthrodesis in the Rheumatoid Foot
Authors: Ljung Peter , Kaij Jakob , Knutson Kaj , Pettersson Holger , Rydholm Urban
Published: March 2013

Arthrodesis of the talonavicular joint with a cylindrical dowel was performed in 19 feet in 17 rheumatoid patients with arthritic destruction of the talonavicular joint, but without fixed hindfoot deformity. Osseous union was achieved in 12 feet, but all patients experienced pain relief and no foot showed progressive valgus deformity of the hindfoot during follow-up. Staple fixation seemed to promote osseous union. The procedure, easy to perform and requiring only 6 weeks of immobilization, may, in the absence of fixed hindfoot deformity, supersede triple arthrodesis in rheumatoid patients with hindfoot arthritis.
Excision Arthroplasty for Hallux Valgus in the Elderly: A Comparison between the Keller and Modified Mayo Operations
Authors: Majkowski Richard Stephen , Galloway Simon
Published: March 2013

A retrospective clinical and radiological review of 51 patients (mean age 66 years) was performed to assess the outcome of excision arthroplasty for hallux valgus in an elderly population and to compare the results of the Keller, which is still used frequently in many centers in the United Kingdom, and modified Mayo operations. Although significant correction of the deformity was obtained with both procedures, this was incomplete and the mean residual hallux valgus angle was greater than 20°. Lateral metatarsalgia was present in over 40% of patients. Both procedures provided good pain relief, and considerable narrowing of the forefoot was obtained with the modified Mayo operation. Excision arthroplasty in the elderly should be reserved for the low demand patient with symptomatic degenerative changes in the first MP joint in the absence of lateral metatarsalgia.
Adult Acquired Flatfoot Deformity at the Talonavicular Joint: Reconstruction of the Spring Ligament in an in Vitro Model
Authors: Deland Jonathan T. , Arnoczky Stephen P. , Thompson Francesca M.
Published: March 2013

The mobile unilateral flatfoot deformity of chronic posterior tibial tendon insufficiency has been difficult to correct by soft tissue procedures. The procedures can decrease pain, but they do not always correct the longitudinal arch or relieve all the symptoms. Using 10 fresh frozen cadaveric specimens and a rig for stimulation of weightbearing, the deformity associated with chronic posterior tibial tendon insufficiency was produced by multiple ligamentous release and documented by AP and lateral radiographs.

Reconstruction of the spring ligament using a ligament bone autograft from the superficial deltoid ligament was then performed and tested under load. The mean correction was within 2.5° of normal (over or undercorrection) on both the AP and lateral radiographs with the specimens under load.

Clinical Relevance.

In posterior tibial tendon insufficiency, it may be possible to address the ligament as well as tendon insufficiency to gain a corrected arch. The success of such a procedure will depend upon adequate tendon and ligament reconstruction in a fully mobile deformity. Questions remain as to the adequacy of this ligament graft, and a stronger free ligament graft, as well as correction of any bony malalignment, may be required.
Range of Motion of the Foot as a Function of Age
Authors: Nigg B.M. , Fisher V. , Allinger T.L. , Ronsky J.R. , Engsberg J.R.
Published: March 2013

Movement of the foot is essential for human locomotion. The purpose of this paper was to quantify the range of motion of the foot as a function of age and to compare the rage of motion measurements for the foot in a laboratory coordinate system and a coordinate system fixed to the tibia. The measurements were taken in vivo using a range of motion instrument developed by Allinger (University of Calgary, Canada, 1990) from 121 subjects. The results suggest that: (1) the range of motion in general is greater for women than for men in the young adult group; (2) the range of motion in general is in the same order of magnitude for women and men in the oldest age group; and (3) the range of motion is about 8° smaller in dorsiflexion and about 8° higher in plantarflexion for women than for men in the oldest age group. It is speculated that physical activity and common shoe wear are factors influencing the age- and gender-dependent differences in range of motion. Furthermore, it has been shown that the range of motion values measured in a laboratory coordinate system and in a coordinate system fixed in the tibia are different in all directions except inversion. The differences in plantarflexion and dorsiflexion and inversion and eversion are relatively small. However, they are substantial for adduction and abduction. In all cases, the results were bigger for measurements in the laboratory coordinate system compared with the tibia coordinate system, because the movement of the lower leg was included in the measurements in the laboratory coordinate system.

The data indicate that foot range of motion is different for women and men. Consequently, it is speculated that these differences may be related to possible overloading of the locomotor system, especially in sporting activities in which the loading of the foot is significant. The differences in the plantarflexion and dorsiflexion direction were assumed to influence the loading of the Achilles tendon, and it is suggested that some of the Achilles tendon problems may be predictable based on range of motion measurements.
Calcaneal Spurs in a Black African Population
Authors: Banadda Bezarel M. , Gona Ophelia , Vaz Raquel , Ndlovu Dumisani M.
Published: March 2013

The radiological incidence of calcaneal spurs in a black African population was studied. Our findings show that spur incidence increased with age and was greater in females than in males. These results, the first from a large, exclusively African population, are similar to those from previous studies of individuals from other continents.
Coalition of the Hallux Sesamoids: A Case Report
Authors: Saxby Terence , Vandemark Robert M. , Hall Reginald L.
Published: March 2013

Multiple variations in partition of the hallux sesamoids have been described; however, to our knowledge, a coalition of the hallux sesamoids has never been presented. A case of coalition of the hallux sesamoids is presented and the literature is reviewed with respect to the possible significance of this anomaly.
The Microvasculature of the Sesamoid Complex: Its Clinical Significance
Authors: Sobel Mark , Hashimoto Jun , Arnoczky Steven P. , Bohne Walther H.O.
Published: March 2013

The microvascular anatomy of the sesamoid complex was investigated in 15 cadaver specimens using histology and tissue clearing (Spalteholz) techniques. It was found that both sesamoids appeared equally well vascularized and the vascular supply to each sesamoid originated from two major sources (proximal and plantar) and one minor source (distal). Proximally, vessels originating from the first plantar metatarsal artery enter the sesamoid at its attachment to the flexor hallucis brevis. In addition, vessels enter the plantar surface of the sesamoid near the midline and arborize throughout the bone, anastamosing with the proximal vessels. The distal vascular supply to the sesamoids originates from its distal capsular attachment and appears to contribute minimally to the overall vascular scheme. The lateral attachments of the sesamoids to the plantar plate and joint capsule were relatively avascular. In two bipartite specimens examined, the major blood supply originated from the proximal and distal poles of the sesamoid. No vessels were observed entering the plantar surface of these specimens.

The results of this study suggest that injury to the proximal or plantar aspects of the sesamoids could disrupt the vascular supply to these bones. These areas should, therefore, be avoided during the surgical approach to the sesamoids.
Great Toe Metatarsophalangeal Joint Arthrodesis: A User-Friendly Technique
Authors: Smith Ronald W. , Joanis Terry L. , Maxwell Phyllis D.
Published: March 2013

Thirty-four feet (23 patients) were treated with a metatarsophalangeal (MP) joint fusion of the hallux using five threaded 0.062-in K wires for fixation. Operations were done for the following diagnoses: rheumatoid arthritis (26 procedures), hallux rigidus (1), salvage of previous bunionectomies (3), hallux valgus with absent toe, bilateral fusion (2), severe hallux valgus with chronic MP joint synovitis (1), and congenital hallux varus (1). The ages ranged from 17 to 73 years, with an average of 55 years.

Follow-up was available on 31 of the fusions by questionnaire and telephone contact, with an average follow-up of 24 months and a minimum of 1 year.

The successful arthrodesis rate was 97%. In 9% of the procedures (three cases), the patients were dissatisfied: This was due to pain under the first metatarsal head in two cases and to impingement between the first and second toes in a third case. In 91% of the fusions (29 of 32 patient responses), the patients stated that they would have the surgery if they had to choose again. Patients indicated “complete satisfaction” in 15 fusions and “satisfaction with reservations” in 14.

Patients felt that their ability to wear desired shoes was improved in 48% of the procedures, was unchanged by the fusions in 26%, and was worse than before the operation in 26%.

Based on this study and review of the literature, a recommendation is made for fusing the rheumatoid hallux with 25° to 30° of valgus and 10° of extension. In general, selection of toe position for fusion is based on reducing stress on the hallux interphalangeal joint and accommodating the position of the second toe.

The multiple pin fixation technique gives a high incidence of fusion, it is easy to perform, and it is adaptable to the varying requirements for toe position.
Chevron Osteotomy for Hallux Valgus
Authors: Rossi Wilson Roberto , Ferreira Jose Carlos Affonso
Published: March 2013

A retrospective study of the Chevron osteotomy procedure for hallux valgus was carried out on 112 patients (168 feet) with an average age of 39.7 years (range 19 to 61 years). The average follow-up was 4.4 years (range 13 months to 7.5 years). The preoperative diagnosis was symptomatic hallux valgus. The average preoperative intermetatarsal 1–2 angle was 15.5° (range 11° to 18°) and the hallux valgus angle was 28.1° (range 21° to 42°). The operation was effective in improving symptoms, cosmesis, and function and in decreasing the deformity.
The Use of Ultrasonography in the Foot and Ankle
Authors: Thermann H. , Hoffmann R. , Zwipp H. , Tscherne H.
Published: March 2013

Ultrasonography of the soft tissue has achieved an increasing importance in the last years. Since sonography of the shoulder, knee, muscles, and tendons has become a routine method, there is less application of ultrasound in foot and ankle pathology. Since 1985, ultrasonography has been the routine examination technique in the Trauma Department of Hannover Medical School, Hannover, Germany. We now have a series of more than 4000 sonographic examinations. This paper gives a comprehensive overview of the possibilities in application and technique of ultrasonography in foot and ankle disorders. The sonographic patterns of the pathological changes of the main structures are described.
Collateral Ligament Reconstruction of the Unstable Metatarsophalangeal Joint: An in Vitro Study
Authors: Deland Jonathan T. , Sobel Mark , Arnoczky Steven P. , Thompson Francesca M.
Published: March 2013

Anatomic reconstruction of the collateral ligaments of the lesser metatarsophalangeal joints is proposed for certain cases of metatarsophalangeal instability. The suggested reconstruction involves replication of the attachments of the collateral ligaments. As an example of such a reconstruction, the interosseous tendon was used in this study as a graft for anatomic replacement of the collateral ligaments. The tendon was left attached distally where its attachments include the volar plate and proximal phalanx, thereby resembling the distal attachment of the collateral ligament. The proximal portion of the tendon was inserted into the metatarsal head, replicating the attachment of the collateral ligament at that location. Preliminary testing of such a reconstruction shows that it can re-establish stability caused by loss of the collateral ligaments. Such a procedure may be applicable in select cases of crossover toe deformity and straight vertical instability.
The Morbid Anatomy of Congenital Deficiency of the Tibia and its Relevance to Treatment
Authors: Miller Lisa S. , Armstrong Peter F.
Published: March 2013

Two specimens obtained from a 5-month-old boy with bilateral type 1a congenital tibial deficiency were dissected to describe their morbid anatomy. Examination revealed a rigid equinovarus deformity, absence of a tibial remnant, an abnormal saddle-shaped talus, and several tarsal coalitions. Observation of the arterial pattern during surgery supported the previously reported finding that persistence of an immature arterial structure is inherent in this condition. Knowledge of potential structural anomalies is essential during the planning of an amputation or of a knee or an ankle reconstruction. Anatomic abnormalities may affect the design of soft-tissue flaps in an amputation and plantigrade positioning and foot biomechanics in reconstructive procedures.
Radiological Assessment of a Modified Anterior Drawer Test of the Ankle
Authors: Nyska M. , Amir H. , Porath A. , Dekel S.
Published: March 2013

Chronic ankle instability is a common complication of ankle sprain. The clinical assessment of ankle instability is usually incomplete and difficult to interpret. Recently, more attention has been paid to the value of the anterior drawer test of the ankle. We assessed the accuracy of a modification of the anterior drawer test, comparing it with radiological stress view of the ankle in 25 patients with recurrent ankle sprain. The radiological examinations were performed by a TELOS instrument and included lateral and anteroposterior stress views.

We found that the modified anterior drawer test correlated with the posterior opening of the tibiotalar joint and with the lateral tilt of the talus.

We conclude that a slightly positive modified anterior drawer test may indicate injury to the anterior talofibular ligament. A significant movement of the ankle elicited by the modified anterior drawer test may indicate combined injury to anterior talofibular and calcaneofibular ligaments.
Kinematics of the Ankle: A Hinge Axis Model
Authors: Singh Anoop K. , Starkweather Keith D. , Hollister Anne M. , Jatana Sanjay , Lupichuk Andrei G.
Published: March 2013

We used a mechanical method to locate the axis of rotation of the talocrural joint. A single constant axis of rotation was found just distal to the tips of the malleoli. The paths of light-emitting diodes mounted on a talar pin were recorded with time lapse photography during flexion-extension. These paths were analyzed both in the sagittal plane and in a plane perpendicular to the axis of rotation. Sagittal plane studies were distorted by perspective error. The plane used to analyze joint motion or shape must be the plane of motion. Models of the talocrural joint for gait analysis, reconstructive surgery and prosthetic design should have a single offset axis of rotation.
Treatment of Hallux Valgus by Oblique Osteotomy of the First Metatarsal
Authors: Mizuno Kosaku , Hashimura Masataka , Kimura Mayako , Hirohata Kazushi
Published: March 2013

This paper describes a simple technique of oblique osteotomy of the first metatarsal for treatment of symptomatic hallux valgus deformity. The osteotomy is performed at a 30° angle from the long axis of the metatarsal shaft. The head of the metatarsal is then displaced laterally to provide correction of the hallux valgus. This is an uncomplicated procedure for the treatment of hallux valgus.

From 1984 through 1989, 53 feet in 31 patients were treated with an oblique osteotomy of the first metatarsal. A total of 49 feet in 27 patients were followed up more than 2 years. The follow-up x-rays and clinical examinations revealed a good result in 43 feet. In six feet of three patients, all of whom had simultaneous oblique osteotomies of both the first and second metatarsals, a fair or poor result was obtained. It was learned that oblique osteotomy for hallux valgus greater than 40° provided insufficient correction of the valgus angle or limitation of motion at the metatarsophalangeal joint of the great toe.
Excision of Ununited Fractures of the Posterior Process of the Talus: A Treatment for Chronic Posterior Ankle Pain
Authors: Veazey Barry L. , Heckman James D. , Galindo Mayo J. , McGanity Peter L. J.
Published: March 2013

The cases of nine patients with ununited fracture of the posterior process of the talus were reviewed. The most common mechanism of injury was forced plantarflexion. All patients had pain in the posterior ankle region. Common physical findings included tenderness between the lateral malleolus and the Achilles tendon and pain on forced plantarflexion. Of the radiographic imaging modalities used, 99Tc bone scan was found to be the most helpful in diagnosis.

All nine patients eventually underwent surgical excision at a mean period of 9.4 months post injury. At average follow-up of 27 months after surgery (range 7–69 months), six of nine patients had good or excellent results with respect to pain relief and return to function. There were two complications of sural neuroma formation, one of which resulted in severe persistent pain after surgery.

Based on these findings, we believe the differential diagnosis of chronic posttraumatic ankle pain should include fracture of the posterior process of the talus. Furthermore, excision of an ununited fragment through a lateral approach, taking care to preserve and protect the sural nerve, should lead to the return of painless function in the majority of cases.
The Harris and Beath Footprint: Interpretation and Clinical Value
Authors: Welton E. Ann
Published: March 2013

The Harris and Beath footprint is an inexpensive, noninvasive method of recording foot/ground pressure patterns to aid clinical diagnosis, decision making, and follow-up. Studies of normal children and skeletally mature individuals have identified the wide variations found in normal feet, a knowledge of which is fundamental to the interpretation of the footprint in the clinical situation.
Achilles Tendinitis
Authors: Clain Michael R. , Baxter Donald E.
Published: March 2013

Achilles tendinitis is a problem encountered frequently. There are certain anatomical and biomechanical principles that help explain the etiology of this entity. We prefer to separate our thinking into “insertional” and “noninsertional” Achilles tendinitis. This is helpful because it allows nonoperative and operative treatment to be problem specific and systematic.