bluuebunny/crossref_metadata_2025 huggingface dataset:
Estimating the Insertion Site During Retrograde Intramedullary Tibiotalocalcaneal Arthrodesis
Authors: Stephenson Kenneth A. , Kile Todd A. , Graves Stanley C.
Published: March 2013

Intramedullary tibiotalocalcaneal arthrodesis (IMTCA) is an increasingly used procedure for salvage of complex hindfoot and ankle disorders. 1 , 2 To avoid injury to vital plantar neurovascular structures, it is important to begin with an appropriate insertion site during retrograde IMTCA. We use a simple, reproducible method to determine this site based on anatomic landmarks.
Application of the Tension Band Technique for Arthrodesis of the Forefoot and Midfoot
Authors: Kupcha Paul C. , Fitzpatrick Michael J.
Published: March 2013

Numerous techniques have been described for the arthrodesis of various forefoot and midfoot joints. These techniques include the use of plates, screws, wires, staples, and Steinman pins. The ease of the dorsal approach in instituting these techniques has persuaded most orthopaedic surgeons to instrument the dorsal, or compression, side of the arthrodesis. By instrumenting the compression side, the deforming forces of the arthrodesis may cause distraction on the plantar side. The use of the tension band technique in foot arthrodeses changes the plantar distraction forces to a compressive force without necessitating the exposure of the plantar surface.
The Mayday Distal First Metatarsal Osteotomy for Hallux Valgus: A Review After the Introduction of a New Instrument
Authors: Terzis G.D. , Kashif F. , Mowbray M.A.S.
Published: March 2013

We present the short-term follow-up of 55 symptomatic hallux valgus deformities in 38 patients, treated operatively with a modification of the spike distal first metatarsal osteotomy, as described by Gibson and Piggott in 1962. The age range of the patients was 17 to 72 years at the time of surgery. The postoperative follow-up period was 12 to 55 months.

Excellent and good clinical and radiographic results were recorded in 96.2% of our patients. Two of the patients (3.8%) were dissatisfied; one of them complained of metatarsalgia after the procedure, and the other had stiffness of the metatarsophalangeal joint and metatarsalgia that had been present before surgery. Three others (5.45%) required revision after early postoperative displacement but were asymptomatic subsequently. We concluded that our technique is an effective method of treating mild hallux valgus deformities with the advantages of simplicity, no shortening of the first metatarsal, and no risk of dorsal tilting of the distal fragment.

Hallux valgus (lateral deviation of the great toe) is not a single disorder, as the name implies, but a complex deformity of the first ray that sometimes may involve the lesser toes. More than 130 procedures exist for the surgical correction of hallux valgus, which means that no treatment is unique. No single operation is effective for all bunions. 5 , 22 , 29 The objectives of surgical treatment are to reduce pain, to restore articular congruency, and to narrow the forefoot without impairing function, by transferring weight to the lesser metatarsals either by shortening or by dorsal tilting of the first metatarsal. 5 , 19 , 24 , 27 Patient selection is important for a satisfactory outcome after surgery of any kind, and our criteria were age, degree of deformity, presence of arthrosis, and subluxation of the first metatarsophalangeal joint. 1 , 5 , 13 , 19 – 21 , 24 , 29

In this study, we present a new method of treating hallux valgus that has been used at Mayday University Hospital since 1990. The technique was first described at the British Orthopaedic Foot Surgery Society, Liverpool, November 1990, 7 and we now present the short-term follow-up results. The procedure is essentially a modification of the spike osteotomy of the neck of the first metatarsal, as described by Gibson and Piggott. 9 It has the advantages of simplicity, no shortening of the first metatarsal, and no risk of dorsal displacement of the distal fragment.
Mechanical Behavior of the Foot and Ankle After Plantar Fascia Release in the Unstable Foot
Authors: Kitaoka Harold B. , Luo Zong Ping , An Kai-Nan
Published: March 2013

The change in position of the bones of the foot was studied in three dimensions after plantar fascia release in intact and destabilized feet. Fifteen fresh-frozen human foot specimens were used. Physiologic loads of 445 newtons were applied axially to simulate standing at ease, and the three-dimensional position of tarsal bones was determined with a magnetic tracking device. The positions were presented in the form of screw axis displacements, quantitating rotation, and axis of rotation orientation.

After fasciotomy in the six intact feet, significant differences in rotation were observed at the talotibial and calcaneotalar levels. After fasciotomy in the four unstable feet with three supporting elements sectioned, significant differences in position were observed at the talotibial joint and a significant decrease in arch height was observed. After fasciotomy in the five unstable feet with five supporting elements sectioned, significant differences in rotation were observed at the talotibial joint (mean, 5.5 ± 1.6° P = 0.001), calcaneotalar joint (mean, 6.1 ± 2.1° P = 0.003), and metatarsotalar level (mean, 9.3 ± 4.1° P = 0.007). The average decrease in arch height was 7.4 ± 4.1 mm ( P = 0.015).

Displacement of all joints tested occurred after fasciotomy, with rotation about all three axes. These changes in displacement were more pronounced in unstable or destabilized feet. The data suggest that operations involving fasciotomy affect arch stability and should not be performed in patients with evidence of concomitant pes planus deformity, because of the likelihood of further deformation.
Osteolytic Changes After Polyglycolide Pin Fixation in Chevron Osteotomy
Authors: Pelto-Vasenius Kia , Hirvensalo Eero , Vasenius Jarkko , Rokkanen Pentti
Published: March 2013

Absorbable polyglycolide pins were used for fixation of 94 chevron osteotomies in 70 patients at the Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, between 1986 and 1992. Postoperative osteolytic changes around the degrading pin occurred in 21 of 94 (22%) metatarsal heads. In 17 of 21 metatarsal heads, polydioxanone-coated polyglycolide pins were used. This type of pin has not been used since 1988. At follow-up, 16 of 21 osteolytic changes resolved completely and four partially resolved. In the remaining one, the osteolytic area remained visible after 6 years. Cystic changes in the metatarsal head, not attributable to the location of the absorbable implants, occurred in seven (7.4%) metatarsal heads and avascular necrosis of the entire metatarsal head in one (1.1%). Foreign body reaction occurred in six (6.3%) metatarsal heads and wound infection in three (3.2%) metatarsal heads. No association was observed between osteolytic changes and foreign body reaction or infection. Osteolysis in patients receiving polyglycolide implants only require observation, because associated symptoms with the radiographic findings are transient.
Ultrasonographic Examination of the Posterior Tibial Tendon
Authors: Hsu Tsz-Ching , Wang Chung-Li , Wang Tyng-Guey , Chiang I-Ping , Hsieh Fon-Jou
Published: March 2013

The posterior tibial tendons (PTTs) of 16 patients with PTT dysfunction and 10 age-matched healthy subjects were examined ultrasonographically, using a 10-MHz linear-array transducer. Normal PTTs appeared hyperechoic (more echogenic) and oval, with an average diameter of 7.8 mm × 3.7 mm at the medial malleolar level. Degenerated PTTs appeared hypoechoic (less echogenic) and swollen (9.8 mm × 5.0 mm). Peritendinitis presented as a hypoechoic rim on the longitudinal sonogram (along the long axis of the tendon) and a “target sign” (hyperechoic central structure with a hypoechoic halo) on the transverse sonogram (at the right angle to the long axis of the tendon). Complete rupture of the PTT revealed an empty tibial groove at the level of the medial malleolus on the transverse sonogram and a wavy fibril pattern over the distal end on the longitudinal sonogram. Compared with the operative findings or the results of the magnetic resonance imaging, ultrasonography was sensitive and specific in diagnosing tenosynovitis and complete rupture of the PTT.
Myositis Ossificans: An Unusual Presentation in the Foot
Authors: Allard Mark Michael , Thomas Ruth Lourdes , Nicholas Richard Wallace
Published: March 2013

Myositis ossificans is a non-neoplastic lesion characterized by heterotopic ossification of soft tissue. At varying stages of maturity, it shares similar histologic characteristics with sarcomatous lesions or maturing bone. Misdiagnosis can result in unnecessary radical treatment. This lesion has only rarely been reported in the foot. 8 – 10 , 13 , 22 We present the case of a patient with plantar forefoot myositis ossificans.
Effect of the Posterior Tibial Tendon on the Arch of the Foot During Simulated Weightbearing: Biomechanical Analysis
Authors: Kitaoka Harold B. , Luo Zong Ping , An Kai-Nan
Published: March 2013

A cadaver study was performed to determine the effect of the posterior tibial tendon (PTT) on the stability of the foot in simulated midstance phase of gait. Thirteen fresh-frozen human foot specimens were used. Loads were applied axially and to each tendon. Three-dimensional positions of tarsal bones before and after tendon loading were determined with the use of a magnetic tracking device.

Significant differences in tarsal bone positions were observed with application of loads to the Achilles, posterior tibial, flexor digitorum longus, peroneus longus, and peroneus brevis tendons at the metatarsotalar, calcaneotalar, and talotibial joints and in overall arch height. These tendon loads caused position changes toward arch flattening or mild pes planus deformity. Significant differences in tarsal bone positions were observed with PTT loading compared with no PTT loading in metatarsotalar, calcaneotalar, and talotibial levels as well as arch height. The PTT caused position changes toward restoring the arch alignment. These data suggest that the PTT is an important stabilizer of the arch of the foot.
Closed Complete Rupture of the Flexor Hallucis Longus Tendon at the Groove of the Talus
Authors: Inokuchi Suguru , Usami Norio
Published: March 2013

A rare case of closed complete rupture of the flexor hallucis longus tendon at its groove in the posterior process of the talus is reported in a soccer player who developed pseudarthrosis of the posterolateral tubercle of the talus after a Shepherd's fracture. Partial rupture or tenosynovitis of the flexor hallucis longus tendon at this level is well known in classical ballet dancers and soccer players. Three cases of complete rupture of the flexor hallucis longus tendon near the metatarsophalangeal joint and three under the sustentaculum tali have been reported, but there have been no reports at the groove of the talus. Repair was accomplished by tendon graft, and active flexion of the interphalangeal joint is now possible.
Intraosseous Lipoma of the Calcaneus
Authors: Greenspan Adam , Raiszadeh Kamshad , Riley Geoffrey M. , Matthews Donald
Published: March 2013

We present two patients with pathologically proven intraosseous lipoma of the os calcis. A review of the literature, the radiologic criteria, and the differential diagnosis are provided.
Arthrodesis of the First Metatarsophalangeal Joint for Hallux Valgus in Rheumatoid Arthritis
Authors: Mann Roger A. , Thompson Francesca M.
Published: March 2013

We reviewed the results of reconstruction of the fore part of the foot in rheumatoid patients by arthrodesis of the first metatarsophalangeal joint. The follow-up averaged 4.1 years (range, 2.0 to 7.25 years). Eighteen feet in eleven women were operated on. Twelve feet underwent total reconstruction of the fore part: arthrodesis of the first metatarsophalangeal joint and excision of all of the lesser metatarsophalangeal joints. Six feet underwent subtotal reconstruction, which included arthrodesis of the first metatarsophalangeal joint. The results were classified as excellent in fourteen feet, good in two, and fair in two. There were no poor results. Metatarsophalangeal bone fusion was achieved in all but one foot (fusion rate, 94 per cent). The one fibrous ankylosis was painless, with satisfactory function. Interphalangeal degenerative joint disease was a radiographic but not a clinical sequela. Arthrodesis of the first metatarsophalangeal joint provided stability that permanently corrected deformity, permitted the patients to wear ordinary shoes, and, in combination with excisional arthroplasty of involved lesser metatarsophalangeal joints, relieved disabling pain in the fore part of the foot.
Pes Planus in Patients with Posterior Tibial Tendon Insufficiency: Asymptomatic Versus Symptomatic Foot
Authors: Dyal Cherise M. , Feder John , Deland Jonathan T. , Thompson Francesca M.
Published: March 2013

Bilateral weightbearing anteroposterior and lateral radiographs were analyzed in 43 patients with a clinical diagnosis of posterior tibial tendon insufficiency by two independent observers. The radiographs of each patient's asymptomatic foot was considered to serve as the control for the preexistance of pes planus. The radiographs were assessed for the severity of flatfoot deformity, the degree of talonavicular coverage, the talometatarsal angle, the calcaneometatarsal angle, the cuneiform to ground height and the cuneiform to fifth metatarsal height. Interobserver correlatations were assessed. Results indicated that there was a high interobserver correlation for the values measured, making these angles reproducible among observers. Strong correlations were found in the degree of severity of flatfoot deformity between the asymptomatic and symptomatic feet as well as the values used to assess pes planus (i.e., similar radiographic measurements on the opposite side). The data suggest that patients with posterior tibial tendon insufficiency often have a preexisting flatfoot. This substantiates our belief that a preexisting flexible flatfoot, although far from the determining factor, is one of several etiological factors in the development of posterior tibial tendon insufficiency.
Modified Austin Procedure for Correction of Hallux Valgus
Authors: Trnka Hans-Jörg , Zembsch Alexander , Wiesauer Hermann , Hungerford Marc , Salzer Martin , Ritschl Peter
Published: March 2013

The Austin osteotomy is a widely accepted method for correction of mild and moderate hallux valgus. In view of publications by Kitaoka et al. in 1991 and by Mann and colleagues, a more radical lateral soft tissue procedure was added to the originally described procedure. From September 1992 to January 1994, 85 patients underwent an Austin osteotomy combined with a lateral soft tissue procedure to correct their hallux valgus deformities. Seventy-nine patients (94 feet) were available for follow-up.

The average patient age at the time of the operation was 47.1 years, and the average follow-up was 16.2 months. The average preoperative intermetatarsal angle was 13.9°, and the average hallux valgus angle was 29.7°. After surgery, the feet were corrected to an average intermetatarsal angle of 5.8° and an average hallux valgus angle of 11.9°. Sesamoid position was corrected from 2.1 before surgery to 0.5 after surgery. The results were also graded according to the Hallux Metatarsophalangeal Interphalangeal Score, and the functional and cosmetic outcomes were graded by the patient. Dissection of the plantar transverse ligament and release of the lateral capsule repositioned the tibial sesamoid and restored the biomechanics around the first metatarsophalangeal joint. There was no increased incidence of avascular necrosis of the first metatarsal head compared with the original technique.
Polyglycolide Bioabsorbable Screws in the Treatment of Ankle Fractures
Authors: Hovis W. David , Bucholz Robert W.
Published: March 2013

Twenty-one patients with unstable medial malleolar, bimalleolar, or trimalleolar ankle fractures underwent open reduction and internal fixation of the medial malleolus with 4.5-mm polyglycolide screws. All lateral malleolar fractures were internally fixed with standard metallic implants.

Radiographic and clinical follow-up results were available on 16 of 21 patients. All fractures healed at an average of 3.4 months (range, 3–6 months), and there were no medial wound infections. Eight of 16 patients developed an inflammatory reaction to the biodegradable polyester at 3 to 4 months after implantation, including one who developed a sterile draining sinus tract. No surgical or nonsurgical treatment was required in those eight patients.

We conclude that whereas polyester screws yield union rates and functional results similar to those of metallic screws in the treatment of medial malleolar fractures, the use of polyglycolide screws is associated with an unacceptable rate of inflammatory reactions.
Kinematics of the First Metatarsophalangeal Joint in Intact and Surgically Altered Cadavers
Authors: Nevin Craig
Published: March 2013

The kinematics of the first metatarsophalangeal joint were investigated in five embalmed cadaver feet (three normal, one hallux valgus, one hallux rigidus). Sagittal displacements of the first metatarsal relative to the proximal phalanx were measured during first metatarsophalangeal joint dorsiplantarflexion; first in intact cadavers, then with an intact capsule sans extracapsular soft tissues (hallux amputated at the first metatarsal cuneiform joint), and finally with a double-stem silicone prosthesis inserted. In the intact cadaver, the base of the metatarsal is raised by FMTP dorsiflexion in a manner similar to a cam. However, this effect ceased when the extracapsular soft tissues were removed. Silicone arthroplasty did not restore cam function.
Results of Ankle Arthrodesis for Treatment of Supramalleolar Nonunion and Ankle Arthrosis
Authors: Marsh J.L. , Rattay Richard E. , Dulaney Tom
Published: March 2013

Seven patients with supramalleolar nonunions after tibial plafond fractures underwent ankle arthrodesis combined with surgical treatment of the nonunion. Stabilization of the nonunion and the ankle consisted of medial and lateral plating for two hypertrophic cases and medial external fixation for five atrophic cases. Two of the atrophic nonunions were infected, and the distal tibia below the nonunion was resected and distraction osteogenesis from a proximal level was used to fill the resulting defect. Both the nonunion and ankle arthrodesis healed in six patients in an average of 7.9 months (range, 4–20 months). The nonunion failed to heal in one patient and required a below-knee amputation. The average cost of care was $66,491 per patient. Before surgery, the average patient ankle score was 25 (range, 15–50), and at a median of 35 months' follow-up the average score was 64 (range, 18–79 months). Three patients had scores in the “good” range, two in the “fair” range, one in the “poor” range, and one was rated a treatment failure. The SF-36 scores were significantly lower than age-matched population-based normal subjects. Limb salvage was possible in six of these seven patients, but the treatment times were long, complications frequent, and the cost of care high.
Effectiveness of External Orthotic Support on Passive Soft Tissue Resistance of the Chronically Unstable Ankle
Authors: Hartsell H.D. , Spaulding Sandi J.
Published: March 2013

Functional ankle instability, orthoses, and passive resistive torque tolerated have not been researched. The purpose of the study was to evaluate the passive resistance torque exerted by a flexible and semirigid orthosis for individuals with chronic instability. Twenty-two subjects were evaluated on the passive ankle resistance unit during unbraced, flexible, and semirigid brace conditions. Data from the final three trials for each condition were analyzed using a multiple analysis of variance with repeated measures for resistive torque and inversion range of motion. The semirigid and flexible braces tolerated significantly greater torque forces and less inversion range than the unbraced condition ( P < 0.000). External orthotic support, in particular that of a semirigid orthosis, may be beneficial toward reducing injury or be an effective prophylactic for the healthy population.
Salvage of the Septic Ankle with Concomitant Tibial Osteomyelitis
Authors: Thordarson David B. , Patzakis Michael J. , Holtom Paul , Sherman Randy
Published: March 2013

Five patients with concomitant distal tibia osteomyelitis and ankle sepsis with an open, draining wound were treated. All of the patients were men with an average age of 54.8 years. All of the bone infections were polymicrobial and had open draining wounds. A standardized protocol of radical soft tissue and bone debridement, soft tissue transfer, intravenous antibiotics, and delayed ankle fusion was employed. All five fusions were successful on first attempt, with an average time to fusion of 3.5 months. All patients were free of infection at an average follow-up of 27 months. We believe our aggressive treatment protocol can salvage these extremities and preclude amputation in properly selected cases.
Treatment Algorithm of Chronic Ankle and Subtalar Instability
Authors: Thermann Hajo , Zwipp Hans , Tscherne Harald
Published: March 2013

From 1981 to 1984, 131 reconstructive procedures and 113 Evans tenodesis procedures (1972–1984) were performed for patients with chronic instability of the ankle joint. From 1981 to 1985, 42 Christman/Snook procedures were performed for patients with isolated or combined subtalar instability.

Reevaluation was conducted for 223 patients (102 reconstructive procedures, 87 Evans tenodesis procedures, and 34 Christman/Snook tenodesis procedures). The follow-up protocol comprised standard and stress radiograms, subjective patient evaluation, and objective functional data.

No patient in either treatment group had clinically important ankle instability. Patients who had undergone the Evans tenodesis had a 3.3° mean less talar tilt than did patients treated with reconstructive procedure. Of 87 patients who underwent Evans tenodesis, 33 had a mean supination deficit of 7.5°. According to the ±100 points classification, 90% of the patients in both groups achieved good or excellent results.

For subtalar instability, the Christman/Snook techniques resulted in a mean supination deficit of 7.2° in 20 patients. Of 34 patients, 31 were rated good or excellent.
Kinematics and Contact Characteristics of the First Metatarsophalangeal Joint
Authors: Ahn Tae-Kun , Kitaoka Harold B. , Luo Zong-Ping , An Kai-Nan
Published: March 2013

We studied six fresh frozen cadaver feet to define the three-dimensional motion of the hallux proximal phalanx in relation to the first metatarsal and to describe the contact features of the first metatarsophalangeal joint. Six tendons to the hallux were loaded to simulate dynamic loading of the hallux. A magnetic tracking system was used to monitor the three-dimensional movement of the proximal phalanx while the toe position was changed from a neutral position to full extension by adjusting the tendon loads. The average surface area was 0.38 ± 0.08 cm2 in the neutral position; it decreased with toe extension and was the lowest (0.04 ± 0.03 cm2) at the full extension position. Contact distribution of the proximal phalanx did not change substantially throughout the arc of motion. However, for the metatarsal articular surface, the contact distribution shifted dorsally with increasing degrees of extension.

These data are consistent with the observation that chondral erosions associated with hallux rigidus and degenerative arthritis initially affect the dorsal articular surface of the metatarsal, and implant arthroplasty often fails from component loading dorsally. The current technique of determining joint contact characteristics is applicable not only for the first metatarsophalangeal joint but also other joints that have not been studied because of shortcomings with more conventional methods.
Interphalangeal Dislocation of the Fourth Toe with Avulsion-Fracture in a Child: Report of a Case
Authors: Neubauer Thomas , Wagner Michael , Quell Michael
Published: March 2013

Phalangeal dislocations of toes are extremely rare in childhood and usually can be treated by closed reduction. We present a proximal interphalangeal dislocation of the fourth toe with an irreducible avulsion fracture of the middle phalanx requiring open reduction. To our knowledge concomitant avulsion fractures in this condition have not been reported thus far in pediatric patients. The pathological mechanism of this injury is discussed, and the significance of the plantar plate for joint stability is emphasized.
Calcaneocuboid Joint Pressures with Lateral Column Lengthening (Evans) Procedure
Authors: Cooper Paul S. , Nowak Michael D. , Shaer James
Published: March 2013

Calcaneocuboid joint pressures were evaluated with eight cadaver specimens. Real-time pressures were recorded using a TekScan 4200 sensor pad at lengths of 0, 5, and 10 mm in both unloaded and 350-newton loaded models. Recorded pressures exceeded 2.3 M Pa in the loaded model at 10 mm lateral column lengthening. Although an acceptable procedure in the pediatric population, application of the Evans lateral column lengthening procedure for management of adult acquired flatfoot may generate excessive pressures leading to joint arthrosis. Lengthening by calcaneocuboid distraction arthrodesis may avoid this problem.
An Anatomical Basis for the Degree of Displacement of the Distal Chevron Osteotomy in the Treatment of Hallux Valgus
Authors: Badwey Timothy M. , Dutkowsky Joseph P. , Graves Stanley C. , Richardson E. Greer
Published: March 2013

The purpose of this study was to define the amount of lateral displacement of the chevron osteotomy to obtain a 50% displacement of the capital fragment. While mathematical analyses exist to predict the degree of correction of the intermetartarsal 1–2 angle with a distal metatarsal osteotomy, no guidelines exist regarding the degree of displacement (translation) that allows sufficient bone contact to enhance union and maintain stability of the osteotomy. We have addressed this concern based on anatomical parameters.

The mean metatarsal width of the male specimens measured at 15 mm from the medial osteochondral junction was 15.3 mm (range, 13–18 mm; standard deviation, 1.6). The mean width among the female specimens was 14.5 mm (range, 11–18 mm; standard deviation, 1.6). This difference was statistically significant (P = 0.003).

From the results of this study, we have concluded that when using a distal metatarsal osteotomy of the chevron type, in 97.5% of the cases the distal fragment can be translated laterally 6.0 mm in males and 5.0 mm in females to displace it 50% of its diameter.
Effects of Age, Density, and Geometry on the Bending Strength of Human Metatarsals
Authors: Courtney Amy C. , Davis Brian L. , Manning Timothy , Kambic Helen E.
Published: March 2013

In this basic study, we investigated the relative roles of donor age, bone density, and bone geometry in determining structural strength of human metatarsals tested in a four-point bending configuration. Density measurements were made noninvasively using dual energy x-ray absorptiometry, and geometric measurements were made by digitally imaging cross-sections of specimens. Correlations between area bone mineral density and metatarsal strength were strong (r2 = 0.83,0.81 for second and third metatarsals, respectively) and were not improved by including cross-sectional area or minimum moment of inertia in multiple regression analyses. Increased donor age was associated with decreased bending strength (r2 = 0.51 and 0.45, respectively), which was expected because increased age correlated significantly with decreased bone density (r2 = 0.69 and 0.80, respectively). These results indicate that the strength of human metatarsals generally decreases with age and that this decrease is likely attributable to decreased bone density. Moreover, the results indicate that noninvasive dual energy x-ray absorptiometry measurements of metatarsal density are useful for assessing metatarsal strength and that additional measurements of bone geometry are not required.
Reliability of Clinical Measurement of Subtalar Joint Movement
Authors: Eric Buckley Richard , Hunt Daniel Vern
Published: March 2013

This study was designed to evaluate the intra- and inter-examiner reliability during repeated clinical measurements of subtalar movement. The study was a blinded experimental model in which 11 Royal College certified orthopaedic surgeons measured the subtalar movement of the 10 lower extremities of five normal subjects. The measurements were performed in accordance with previously published recommendations. Measurements of both inversion and eversion were recorded in degrees. Employing a variance component analysis, a coefficient of agreement between examiner measures was established. The coefficient of agreements were 0.107 for right lower extremities and 0.0656 for left lower extremities. An evaluation of means and ranges of individual examiner measures demonstrated a potential average loss of range of motion of 20% simply because of variability in measurement. It was also determined that a learning curve did not exist within examiners in this study. The reliability of clinical estimates of subtalar movement by this method is extremely poor. Both inter- and intraex-aminer reliability are so poor as to suggest that this method of examination no longer be used to determine or document the measurement of subtalar movement.
Heel Anatomy for Retrograde Tibiotalocalcaneal Roddings: A Roentgenographic and Anatomic Analysis
Authors: Flock Timothy J. , Ishikawa Susan , Hecht Paul J. , Wapner Keith L.
Published: March 2013

There is an increased interest in load-sharing devices for tibiotalocalcaneal arthrodesis. Although the neurovascular anatomy of the heel has been well described, the purpose of this study is to consider heel anatomy as it relates to plantar heel incisions and to well-defined fluoroscopic landmarks to prevent complications during these procedures.

Twenty lateral radiographs of normal feet while standing were evaluated by two observers. The distance from the calcaneocuboid (CC) joint to a line parallel to the center of the intramedullary canal of the tibia was calculated. In the second part of the study, 14 dissections of the arterial and neural anatomy were performed. The distances from the CC joint to structures crossing the heel proximal to the CC joint were studied.

In the 20 standing radiographs, the mean distance from the CC joint to the middle of the intramedullary canal of the tibia was 2.1 cm (standard deviation, 0.55 cm). In the dissections, the only artery or nerve found to cross the plantar surface proximal to the CC joint was the nerve to the abductor digiti quinti (NAbDQ). The mean distance from the CC joint to the NAbDQ was 3.1 cm (standard deviation, 1.36 cm). Assuming reaming to 12 mm, NAbDQ would be at risk 42% of the time. We recommend careful dissection of the heel during retrograde roddings to avoid damage to NAbDQ and subsequent neurogenic heel pain.
Partial Tear of the Flexor Hallucis Longus at the Knot of Henry: Presentation of Three Cases
Authors: Boruta Peter M. , Beauperthuy Gilbert D.
Published: March 2013

The flexor hallucis longus (FHL) tendon is susceptible to injury along its entire course from the posterior aspect of the ankle to its insertion into the base of the distal phalanx of the great toe. Various lacerations, ruptures, longitudinal splits, and stenosing tenosynovitis have been noted. This report documents three cases of longitudinal split of the FHL at the knot of Henry. The diagnosis of this entity is based solely on history and physical examination. Patients with this problem have experienced either an acute or chronic repetitive hyperextension of the hallux metatarsophalangeal joint. They complain of pain with prolonged walking and running and have tenderness with palpation of the knot of Henry (the anatomical crossover between the FHL and the flexor digitorum longus) about one thumb-breadth lateral to the tuberosity of the navicular. Noninvasive imaging studies, including ultrasound and magnetic resonance imaging, are not helpful in establishing this diagnosis. Surgical treatment includes release of the knot of Henry, debridement and repair of the longitudinal split in the FHL, and excision of the interconnecting tendon between the FHL and the flexor digitorum longus. All three patients presented in this report have obtained long-term satisfactory relief of their symptoms with surgical treatment.
Syndesmotic Screw Placement: A Biomechanical Analysis
Authors: McBryde Angus , Chiasson Brett , Wilhelm Andrew , Donovan Frank , Ray Tamara , Bacilla Philip
Published: March 2013

At the present time, syndesmotic screw fixation is recommended when there is a tibiofibular diastasis, a Maisonneuve fracture, or syndesmotic instability after fixation of distal tibia-fibula fractures. The aim/purpose of this study was to demonstrate the optimal level of syndesmotic screw placement before creation of a Maisonneuve fracture. Legs of 17 embalmed cadavers underwent knee disarticulation. The legs were then dissected to expose the syndesmosis/interosseous membrane. The paired cadaver legs were tested in two groups. In group I (10 pairs), the left legs were tested without any syndesmotic fixation and the right legs were tested with the syndesmosis fixed at 2.0 cm above the tibiotalar joint. In group II (7 pairs), the syndesmosis in each left leg was fixed at 3.5 cm above the tibiotalar joint and the right leg syndesmosis was fixed at 2.0 cm above the tibiotalar joint. After ligament section and syndesmosis fixation, each leg was then jig mounted with transfixing wires through the proximal tibia and calcaneus. The ankle was placed in neutral with 15° of pronation and a load of 150 pounds and a strain gauge anchored medially and laterally. The proximal tibia was internally rotated while the ankle was held fixed until syndesmotic, bony, or hardware failure occurred. Torsional force, the degree of rotation and the amount of syndesmotic widening were quantitated. Two-tailed t-test comparing no fixation with fixation at 2.0 cm indicated less syndesmotic widening with screw placed at 2.0 cm ( P = 0.04). Two-tailed t-test comparing screw fixation at 2.0 cm and 3.5 cm indicated less syndesmotic widening with screw placed at 2.0 cm ( P = 0.07). It would seem reasonable to place a syndesmotic screw at 2.0 cm above tibiotalar joint.
Treatment of Fractures of the Fifth Metatarsal: A Prospective Study
Authors: Wiener Bradley D. , Linder Jeffrey F. , Giattini Joseph F.G.
Published: March 2013

Successful treatment of avulsion fractures of the base of the fifth metatarsal has been achieved using both short leg casts and soft (Jones) dressings. Sixty patients who presented to our institution were prospectively randomized to be treated with either a short leg cast or a soft (Jones) dressing for the purpose of assessing the efficacy of each treatment modality. Our results demonstrated that radiographic evidence of fracture healing was present in all patients by 65 days with 44 days representing the average elapsed time for such change. All patients returned to full weightbearing and full physical activity within 96 days. Significantly, the average length of recuperation for patients treated with a soft (Jones) dressing was 33 days as compared to 46 days for those treated with a short leg cast. Also, the average modified foot score for patients treated in a soft dressing was 92 (excellent) compared to 86 (good) for patients treated in a short leg cast. We conclude that a soft dressing allows patients to return to pre-injury levels of activity faster than when treated in a short leg cast and without compromising clinical or radiographic union of avulsion fractures of the base of the fifth metatarsal.
Pedodynographic Measurements After Forefoot Reconstruction in Rheumatoid Arthritis Patients
Authors: Dereymaeker Greta , Mulier T. , Stuer P. , Peeraer L. , Fabry G.
Published: March 2013

From January 1987 to December 1992, 38 patients (59 feet) with rheumatoid arthritis underwent reconstruction of the forefoot using Keller-Lelièvre arthroplasty of the first metatarsophalangeal joint and Hoffman resection of the lesser metatarsal heads. The average age of the patients was 61.3 years, with both feet involved in 21 patients and 17 with single foot involvement. The aim of our study was to evaluate the results both on a functional and an objective basis using dynamic and static pedodynographic measurements. Attention was given to dynamic pressure measurements under the metatarsal heads, the center of pressure distribution, gait analysis, and peak loads taken on different areas of the forefoot during normal walking. Correlations were made between these measurements and symptoms.

After a mean follow-up time of 35 months, the clinical results were satisfactory in 54%, satisfactory with some reservations in 39%, satisfactory with major reservations in 3%, and unsatisfactory in 3% of patients.
Treatment of Morton's Neuroma by Neurolysis
Authors: Okafor Ben , Shergill Gurd , Angel John
Published: March 2013

Thirty-five patients who had undergone neurolysis for Morton's neuroma were reviewed at a mean of 21.4 months. Those patients who had received diagnostic lidocaine (local anesthetic) injections as an evaluation tool before the operation did extremely well after this operation. Overall patient satisfaction was found to be extremely high, with 17 of 35 patients enjoying complete relief of their pain and 12 of 35 reporting minimal discomfort with activity. The likelihood of persistent symptoms seemed to be related to the presence of associated foot disorders.
Autogenous Bone Grafting of Hallux Sesamoid Nonunions
Authors: Anderson Robert B. , McBryde Angus M.
Published: March 2013

We first performed autogenous bone grafting for lesions of the hallux sesamoid in 1984. During the next 9 years, 21 patients (11 men and 10 women with an average age of 34 and 32 years, respectively) underwent this surgical procedure for symptomatic tibial hallux sesamoid nonunions. Successful bony union was achieved in all but two patients. The majority of patients obtained concomitant relief of preoperative symptomatology and returned to their preinjury level of activity. We believe that this procedure serves as an alternative to hallux sesamoid excision in selected cases.
Revision Ankle Fusion Using Internal Compression Arthrodesis with Screw Fixation
Authors: Anderson John G. , Coetzee J. Chris , Hansen Sigvard T.
Published: March 2013

We reviewed 20 revision ankle fusions performed using internal compression arthrodesis with screw fixation. Clinical, functional, and radiographic results were measured at an average follow-up of 30 months (range, 12–50 months). The reasons for the index procedures were nonunion in 11, malunion in 7, infected nonunion in 1, and nonunion associated with avascular necrosis of the talus in 1 case.

Fusion occurred in 15 of 20 patients. Two additional patients obtained fusion after subsequent procedures, for a final union rate of 85%. The average time to fusion was 6 months (range, 2–32 months). Nineteen additional operations were necessary in 12 patients, including three amputations for chronic infection (two infected nonunions and one chronic osteomyelitis). All but one patient had a plantigrade limb at follow-up.

Seventeen of 20 patients were satisfied with their ultimate outcome, including all three patients with amputations. The three dissatisfied patients were bothered by chronic pain.

Revision ankle fusion for nonunion or malunion using internal compression arthrodesis with screw fixation is beneficial for most patients. It is a technically demanding procedure that is associated with a high complication rate. Many patients can be expected to have residual pain. We emphasize the need for accurate alignment and early, aggressive treatment of infectious complications. Amputation should be considered a viable option to improve functional outcome in patients with solid, well-aligned fusions who are disabled by severe chronic pain.
Replacement of the Lateral Malleolus of the Ankle Joint with a Reversed Proximal Fibular Bone Graft
Authors: Herring Charles L. , Hall Reginald L. , Goldner J. Leonard
Published: March 2013

Infrequently, prior reports have described the use of the ipsilateral proximal fibula to replace an absent distal fibula caused by either trauma, infection, or resection for tumor. 3 , 4 This is a 27-year follow-up of a 12-year-old patient who lost the distal 7.5 cm of her fibula secondary to trauma. The soft tissue defect was replaced early by an abdominal flap and the bone defect was eventually replaced with 7.5 cm of proximal fibula. The lateral ankle ligaments were reconstructed with the peroneus brevis, and the ankle joint has remained stable. Although traumatic arthrosis has progressed slowly, the patient at age 39 has a relatively painless, mobile ankle joint.
Observer Reliability in Ankle Radiographic Measurements
Authors: Brage Michael E. , Bennett Craig R. , Whitehurst Jon B. , Getty Patrick J. , Toledano Alicia
Published: March 2013

We analyzed 50 sets of ankle radiographs to determine the interobserver and intraobserver reliability when obtaining common linear and angular measurements. The radiographs were divided into two groups: one group included 25 normal ankles, and the second group included 25 fractured ankles. Each set of radiographs was evaluated independently by four different observers on two separate occasions under controlled conditions. Six radiographic parameters were measured on all 50 sets of films: syndesmosis A, syndesmosis B, syndesmosis C, the medial clear space, and the talocrural and bimalleolar angles. On the 25 sets of fracture films, four additional measurements of fracture displacement were included: displacement of the medial malleolus (mortise), displacement of the lateral malleolus (AP and lateral), and displacement of the posterior malleolus. Reliability was evaluated with an analysis of variance intraclass correlation coefficient. Among the examiners, 9 of the 10 parameters could be measured reliably. Intraobserver reliability was found to increase with the experience of the examiner.
Anterior Sliding Graft for Tibiotalar Arthrodesis
Authors: Patterson Brendan M. , Inglis Allan E. , Moeckel Bruce H.
Published: March 2013

The results using the anterior sliding graft technique with rigid internal fixation for tibiotalar arthrodesis were reviewed. The indications for anterior sliding graft technique included posttraumatic arthritis, rheumatoid arthritis, pseudarthrosis following prior attempt at arthrodesis, and postinfectious arthrosis. The arthrodesis rate was 95%. The overall prevalence of complications was 33%. The complications related to this method were minor and easily managed. The authors concluded that the anterior sliding graft technique is performed with readily available resources, has a high rate of union, and avoids the routine use of iliac bone graft.
Kinematic and Neuromuscular Changes of the Gait Pattern After Achilles Tendon Rupture
Authors: Neumann Daniela , Vogt Lutz , Banzer Winfried , Schreiber Udo
Published: March 2013

After long immobilization periods in equinovalgus with operated Achilles tendon rupture, long-lasting changes of motor patterns in functional movement can be expected. In the present study, possible alterations in gait pattern have been analyzed based on kinematic and neuromuscular parameters. Ten patients 1 year after surgery and a healthy control group performed 10 gait cycles in natural walking cadence. Ankle motion, pressure distribution, and electromyographic data were recorded and analyzed in defined phases. Kinematic and neuromuscular changes are still evident 1 year after surgery with a temporal phase shift and a neuromuscular deficit of the lateral gastrocnemius muscle. The objective of rehabilitation should be the facilitation of the temporal innervation pattern of the lateral gastrocnemius muscle in the functional movement.
Intermittent Pneumatic Pedal Compression and Edema Resolution After Acute Ankle Fracture: A Prospective, Randomized Study
Authors: Thordarson David B. , Ghalambor Navid , Perlman Mark
Published: March 2013

Thirty patients with an acute Weber B or C ankle fracture were enrolled after signing an informed consent. Fifteen patients were randomized to a control group where they received a posterior splint, ice, and elevation before surgery. Fifteen patients were randomized to a pneumatic pedal compression group where they received the same treatment plus a pneumatic pedal compression device which was used full-time before surgery. Baseline volumetric measurements of the injured foot were obtained, followed by measurements at 24-hour increments until surgery. On average, the patients in the pneumatic pedal compression group had an 88 mL decrease in volume in the first 24 hours versus a 33 mL increase in the control group ( P < 0.03) and a 31 mL decrease in the first 48 hours of treatment versus a 32 mL increase for the control group ( P <0.05). The pneumatic pedal compression was well tolerated by the majority of patients (only one did not tolerate its use because of pain) and, we believe, serves as a useful adjunct in preoperative edema resolution after ankle fracture.
Radiographic and Computed Tomographic Evaluation of Lisfranc Dislocation: A Cadaver Study
Authors: Lu Jike , Ebraheim Nabil A. , Skie Martin , Porshinsky Brian , Yeasting Richard A.
Published: March 2013

Six cadaver feet were used for radiological and computed tomographic (CT) evaluation. The tarsometatarsal joints of each specimen were displaced dorsolaterally in successive 1-mm increments. None of the 1-mm and two thirds of the 2-mm dorsolateral Lisfranc dislocations could be visualized on routine radiographs; they could all be noted on CT scans. There was good assessment on CT scan for the extent of the minor lesions that are normally obscured by overlapping projection in routine radiographs. A Lisfranc injury that appears undisplaced on radiographs or acceptable after closed reduction may still have an unpredictable outcome because of the presence of an occult joint subluxation. CT scanning is more sensitive than radiography for detecting the minor amounts of Lisfranc displacement. If there is any doubt on the radiographs, a CT scan should be performed. The early diagnosis and treatment of Lisfranc injuries may minimize development of post-traumatic degenerative arthritis.
Anatomy of the Lisfranc Joint Complex
Authors: de Palma Luigi , Santucci Attilio , Sabetta Silvio P. , Rapali Stefano
Published: March 2013

The authors studied the Lisfranc joint complex using gross dissection and examination of anatomical sections of frozen samples in the frontal and sagittal planes. They distinguished a medial compartment, a central compartment, a lateral compartment, the secondary joint line, and the connections with the cuneoscaphoid articulation. The ligaments were divided on the basis of topography (dorsal, interosseous, and plantar) and course (longitudinal, oblique, and transverse). The dorsal and plantar ligaments reinforce the articular capsules. The interosseous ligaments are the strongest. A common characteristic of these ligaments is that they vary considerably in course, number, and insertions.