bluuebunny/crossref_metadata_2025 huggingface dataset:
Subtalar Arthroscopy for Persistent Subfibular Pain After Calcaneal Fractures
Authors: Elgafy Hossein , Ebraheim Nabil A.
Published: March 2013

This is a report of 10 consecutive patients who had subtalar arthroscopy for persistent pain in the subfibular area after open reduction and internal fixation for intraarticular calcaneal fractures. The average period between the injury and the subtalar arthroscopy was 14.3 months (range, 6–36 months). The average follow-up period after subtalar arthroscopy for the patients who did not require further treatment was 16.7 months (average, 11–35 months). All the patients except two had chondromalacia. Three had grade II, three had grade III, and two had grade IV. Five patients had intra-articular adhesion. Two patients had a loose body. The power shaver has been used for debridement of the damaged cartilage and excision of the adhesion. Eight patients (80%) had considerable pain relief and did not require further local injection or surgical management. The two patients who required subtalar fusion had grade IV chondromalacic lesions. Only four patients had improvement in the range of motion of the subtalar joint. The preoperative American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score for the whole group was 69.9 points (range, 68–74 points), which was improved postoperatively to 77.2 points (range, 48–90 points). Subtalar arthroscopy for persistent pain after calcaneal fractures should be considered, especially if the radiological examination shows mild degenerative changes in the subtalar joint.
Subtalar Joint Movement: Clinical and Computed Tomography Scan Correlation
Authors: Pearce Timothy J. , Buckley Richard E.
Published: March 2013

The purpose of this study was to compare subtalar motion measured externally (representing clinical assessment) with subtalar motion measured by computed tomography (CT), in normal individuals. Ten recreationally active subjects (20 lower extremities), aged 20 to 35 years with no lower extremity pathologic condition, were involved in the study. External subtalar inversion and eversion was assessed using a goniometer. By overlaying CT images of the subtalar joint in inversion and eversion on neutral images, angular subtalar motion was measured directly. Subtalar motion measured by CT ranged from 5° to 16° (mean, 11°). External subtalar motion ranged from 39° to 54° (mean, 46°), overestimating CT measurement of subtalar motion by approximately three-fold. This discrepancy is probably secondary to soft tissue motion and talocrural motion that is not isolated from subtalar motion at clinical examination. This solidifies our belief that clinical assessment of subtalar motion should no longer be used to determine or document the measurement of subtalar motion.
Risk of Avulsion of the Achilles Tendon After Partial Excision for Treatment of Insertional Tendonitis and Haglund's Deformity: A Biomechanical Study
Authors: Kolodziej Patricia , Glisson Richard R. , Nunley James A.
Published: March 2013

Surgical treatment of posterior heel pain caused by insertional (calcific) Achilles tendonitis or retrocalcaneal bursitis includes resection of diseased tendon or exostectomy. Currently, no guidelines exist to determine how much tendon may be excised without risking rupture of the Achilles tendon. Anatomic dissections revealed the average height of the insertion measured 19.8 mm (range, 13–25 mm). Average width at the proximal aspect of the insertion measured 23.8 mm (range, 17–30 mm) and distally measured 31.2 (range, 25–38 mm). To assess the risk of avulsion, the tendon insertion was partially released in 25% increments of its measured height or width by one of the four methods: (1) from superior to inferior, (2) from the central portion outward, (3) from medial to lateral, and (4) from lateral to medial. Repeated cyclic loading of body weight × 3 was applied, and, if the tendon remained intact, the next 25% increment was released. This process was repeated until failure occurred. Failure occurred in all specimens by an oblique intratendonous separation or shear between the intact portion remaining on the calcaneus and the resected fibers remaining in the clamp. Fibers inserting into the bone did not avulse. Superior-to-inferior resection was found to be superior to the other three methods with eight of nine specimens remaining intact after 75% resection. We therefore conclude that superior-to-inferior offers the greatest margin of safety when performing partial resections of the Achilles insertion, and as much as 50% of the tendon may be resected safely.
Asymmetrical Loading of the Human Triceps Surae: I. Mediolateral Force Differences in the Achilles Tendon
Authors: Arndt Anton , Brüggemann Gert-Peter , Koebke Jürgen , Segesser Berni
Published: March 2013

An in vitro experiment was designed to identify whether tensile force on different triceps surae components would result in nonhomogenous force distribution across the human Achilles tendon. Medial tendon forces were significantly higher than lateral (23.2 ± 6.6%; P ≤ 0.05) when only the gastrocnemius medialis was subjected to force. Lateral forces were significantly higher when both gastrocnemii (30.6 ± 16.5%) or all three muscles (20.7 ± 10.9%) were loaded. Experimental identification of force concentrations in the human Achilles tendon contributes to the understanding of the origin of its injury.
Asymmetrical Loading of the Human Triceps Surae: II. Differences in Calcaneal Moments
Authors: Arndt Anton , Brüggemann Gert-Peter , Koebke Jürgen , Segesser Berni
Published: March 2013

An in vitro experimental study is presented investigating differences in moments calculated at the calcaneus, resulting from tensile forces input in various configurations of triceps surae muscles. Results indicated significantly higher values for plantarflexion moments when forces were input in both gastrocnemii than in the soleus ( P ≤ 0.05). Tensile force applied solely to the gastrocnemius lateralis produced a mean eversion moment at the calcaneus, whereas all other configurations demonstrated the expected inversion moment. An abduction moment was reported throughout. The presented data provides valuable input for optimizing future biomechanical models.
Stenosing Tenosynovitis and Impingement of the Peroneal Tendons Associated with Hypertrophy of the Peroneal Tubercle
Authors: Bruce W. David , Christofersen Mark R. , Phillips Daniel L.
Published: March 2013

We report three patients with lateral ankle and foot pain, with the diagnosis of stenosing tenosynovitis of the peroneus longus tendon associated with a markedly enlarged peroneal tubercle. Stenosing tenosynovitis of the peroneus longus tendon associated with an atraumatically enlarged peroneal tubercle has rarely been reported, and these reported cases were associated with an os peroneum. 4 , 6 One of our patients had no demonstrable associated os peroneum but did have a bony tunnel enveloping the peroneus longus tendon. Our other two patients had an os peroneum, but were asymptomatic at the lateral outer border of the cuboid tunnel; one patient had involvement of the peroneus longus and brevis tendons.
Retrograde Drilling of Osteochondral Lesions of the Medial Talar Dome
Authors: Taranow Warren S. , Bisignani Gregory A. , Towers Jeffrey D. , Conti Stephen F.
Published: March 2013

Sixteen patients (16 ankles) with symptomatic osteochondral lesions of the medial talar dome were treated arthroscopically with percutaneous retrograde drilling through the sinus tarsi. The surgical technique allows preservation of intact articular cartilage, in contrast to traditional methods. All patients treated with this technique during a 24-month period were included in the study. Patient age ranged from 16 to 44 years (mean, 33 years). Follow-up ranged from 19 to 38 months (mean, 24 months). A staging system based on magnetic resonance imaging examination was used to grade the lesions preoperatively. Outcome was evaluated using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale. Preoperative scores ranged from 35 to 75 points, with a mean of 53.9 points. Postoperative American Orthopaedic Foot and Ankle Society scores ranged from 48 to 100 points, with a mean of 82.6 points. Mean improvement was 25 points. There were no surgical complications. Short-term results were comparable to results reported with other available techniques
Analysis of the Heel Pad Fat in Rheumatoid Arthritis
Authors: Resnick Ronald B. , Hudgins Lisa C. , Buschmann William R. , Kummer Frederick J. , Jahss Melvin H.
Published: March 2013

The heel fat pad is organized, both in structure and in composition, to bear the stresses and strains of normal activities and to permit pain-free weightbearing. The fatty acid composition of heel pads in 11 patients with rheumatoid arthritis, a disease process frequently associated with heel fat pad atrophy, was analyzed using gas-liquid chromatography and was compared with that of patients without systemic disease. The heels of patients with rheumatoid arthritis demonstrated a significant change in the composition of saturated fatty acids when compared with heels of nonrheumatoid patients. This composition reflects an increased fat viscosity, which decreases the ability of the heel to absorb and dissipate the energy generated during ambulation. This factor could cause degeneration of the heel septal system, with resulting fat pad atrophy.
Ankle Arthrodesis in Rheumatoid Arthritis Using an Intramedullary Nail with Fins
Authors: Fujimori Juhro , Yoshino Shinichi , Koiwa Masahito , Nakamura Hiroshi , Shiga Hiroo , Nagashima Shoichi
Published: March 2013

We describe an intramedullary nail with fin-like longitudinal ridges that we have developed for arthrodesis of the ankle in rheumatoid arthritis. Four fins with sharp tips were attached to the distal part of a cylindrical nail to stabilize the tibiotalar and subtalar joints. We used this nail in 15 feet of 15 patients with rheumatoid arthritis who were followed for an average of 34.9 months. Postsurgery, 13 patients were allowed to bear weight immediately, as tolerated, without immobilization. By 3 weeks, these patients were able to bear weight fully. Solid fusion of the ankle joint in an acceptable position and good clinical results were obtained in all patients. The only complications were two cases of delayed wound-healing.
Ankle Fusion in a High Risk Population: An Assessment of Nonunion Risk Factors
Authors: Perlman Mark H. , Thordarson David B.
Published: March 2013

Between July 1992 and April 1996, 88 ankle fusions were performed at our institution. Sixty-seven of these had adequate follow-up for evaluation for union of the fusion, including adequate records and/or radiographs. The average age of patients was 43 years. There were 37 men and 24 women. The charts were reviewed to determine what level of trauma had resulted in posttraumatic arthritis (low energy, high energy, or open fracture). Alcohol use, drug abuse, diabetes, peripheral vascular disease, psychiatric history, smoking, or technical problems were also assessed. A chi-square analysis was used to evaluate the statistical significance.

Nineteen of sixty-seven ankle fusions progressed to nonunion (28%). Eighty-five percent of the patients had posttraumatic arthritis. Among 17 patients with a history of open trauma, nine patients developed a nonunion ( P < 0.03). A trend toward significance was noted for patients who were smokers, drank alcohol, had diabetes, had a psychiatric disorder, or used illegal drugs. Even with current techniques, this study demonstrates that a high risk population in a trauma center is at risk for nonunion after an ankle fusion caused by multiple risk factors, including a history of open trauma, tobacco use, alcohol use, illegal drug use, a history of psychiatric disorders, or diabetes.
Stress Fractures and Tibial Cortical Hypertrophy After Tibiotalocalcaneal Arthrodesis with an Intramedullary Nail
Authors: Thordarson David B. , Chang Dennis
Published: March 2013

Twelve patients underwent successful tibiotalocalcaneal arthrodesis using a locked intramedullary nail with posterior moldable bone grafting. Two of the patients developed a nondisplaced stress fracture around the proximal interlocking screws, which responded to immobilization at 8 and 15 months after surgery. In 7 of 12 patients, ≥2 mm of cortical hypertrophy was noted between the proximal interlocking screws along the medial and/or lateral aspect of the tibia. Although intramedullary nailing can achieve satisfactory tibiotalocalcaneal arthrodesis, the stress risers in the tibial diaphyses do result in a stress reaction in a significant number of patients.
Relationship Between Foot Pronation and Rotation of the Tibia and Femur During Walking
Authors: Reischl Stephen F. , Powers Christopher M. , Rao Sreesha , Perry Jacquelin
Published: March 2013

The purpose of this study was to test the hypothesis that the magnitude and timing of peak foot pronation would be predictive of the magnitude and timing of peak rotation of tibia and femur. Thirty subjects who demonstrated a wide range of pronation participated. Three-dimensional kinematics of the foot, tibia, and femur segments were recorded during self-selected free walking trials using a six-camera VICON motion analysis system. Regression analysis demonstrated that the magnitude and timing of peak pronation was not predictive of the magnitude and timing of tibial and femoral rotation. The lack of a relationship between peak foot pronation and the rotation of the tibia and femur is contrary to the clinical hypothesis that increased pronation results in greater lower extremity rotation. It would seem, therefore, that the relationship between foot pronation and rotation of the lower extremity segments should be assessed on a patient-by-patient basis.
Divot Sign: A New Observation in Anterior Impingement of the Ankle
Authors: Raikin Steven M. , Cooke Paul H.
Published: March 2013

Anterior impingement of the ankle results from osteophyte formation on the anterior edge of the distal tibia. Classically, subsequent degeneration results in an osteophyte forming on the anterior neck of the talus. This results in limited dorsiflexion and impingement seen in the ankles of athletes. Recent clinical observation in high performance soccer players has revealed a previously unrecognized pattern of a localized divot forming in the talar neck in place of the osteophyte. This accepts the tibial osteophyte during dorsiflexion, which is therefore not limited in these patients.
Functional Outcome and Gait Analysis After Triple or Double Arthrodesis
Authors: Beischer Andrew D. , Brodsky James W. , Polio Fabian E. , Peereboom Jeffery
Published: March 2013

Thirteen patients who had undergone unilateral triple or double arthrodesis were studied an average of 5.2 years after surgery. Patients with a neuromuscular disorder; inflammatory arthritis; or any other focus of lower extremity arthritis, deformity, or joint dysfunction were excluded from the study. Clinical and radiological assessment of the patients was performed in addition to three-dimensional kinematic and kinetic gait analysis.

Objective clinical outcome based on the American Orthopaedic Ankle and Foot Society score was rated as good or excellent for 10 patients, fair for 2, and poor for 1. Two patients developed radiological evidence of arthrosis affecting other tarsal joints that was not apparent on preoperative radiographs. Two other patients had some progression of radiological arthrosis that was identified before the index surgery. The presence of radiological ankle or tarsal arthritis did not correlate with the level of the patient's pain or functional disability.

Gait analysis demonstrated a 13% increase in range of flexion of the ipsilateral knee during the third rocker period of stance. At the ankle, range of motion during the same period of stance was reduced by 33%. This was mostly the result of a 6° (53%) loss of plantarflexion at toe-off.

Analysis of the ankle kinetic data identified a mean 13% reduction in the peak external ankle dorsiflexion moment and a 45% reduction in mean maximum power generation at the ankle in comparison to the normal side.

Unilateral triple or double arthrodesis was shown to predictably result in decreased pain and increased function in otherwise normal individuals.
Effect of Anesthesia of the Sinus Tarsi on Peroneal Reaction Time in Patients with Functional Instability of the Ankle
Authors: Khin-Myo-Hla  , Ishii Tomoo , Sakane Masataka , Hayashi Koichiro
Published: March 2013

We investigated peroneal reaction time (PRT) of 18 patients (21 ankles) with functional instability of the ankle and 8 healthy volunteer controls (9 ankles) before and after injecting local anesthetic into the sinus tarsi. The median PRT in patients before the injection was 82.0 ms, a significant delay from 71.0 ms in controls. After the injection, PRT in controls did not change, but PRT in patients significantly shortened to 69.3 ms. The sense of instability and the functional instability improved simultaneously. A disorder of the gamma-muscle-spindle system, induced by proprioceptive deficit after damage to a ligament, has been advocated as a cause of prolonged PRT. We suggest that irritability of mechanoreceptors or nociceptors or both, induced by inflammation at the sinus tarsi, may suppress the activities of gamma motor neurons of peroneal muscles, which in turn might cause the symptoms of functional instability and prolonged PRT.
Intramedullary Screw Fixation of Jones Fractures: A Biomechanical Study
Authors: Pietropaoli Marc P. , Wnorowski Daniel C. , Werner Frederick W. , Fortino Maria D.
Published: March 2013

The management of proximal fifth metatarsal (“Jones”) fractures in athletes has become increasingly more aggressive, despite a lack of biomechanical data in the literature. A cadaver biomechanical study was conducted to evaluate the strength of intramedullary fixation of simulated Jones fractures loaded to failure via three-point bending on a Materials Testing System machine. In a series of eight intact fifth metatarsal control specimens, the force to failure (fracture) was measured for comparison with repaired specimens.

Acute fractures were simulated in 10 pairs of feet via osteotomy at the typical fracture location and were fixed with either a 4.5-mm malleolar screw or a 4.5-mm partially threaded, cancellous, cannulated screw, both placed using conventional intramedullary techniques. Force at initial displacement averaged 73.9 N (SD, 64.7 N) for the malleolar screws and 72.5 N (SD, 42.3 N) for the cannulated screws. Force at complete displacement averaged 519.3 N (SD, 226.2 N) for the malleolar screws and 608.4 N (SD, 179.7 N) for the cannulated screws. The force to failure of the intact specimens was significantly greater than the initial and complete forces to failure for the fixed specimens ( P <0.05, independent measures analysis of variance). There was no statistical difference between the average forces at initial displacement or at complete displacement in the fixed metatarsal specimens for the two different types of screws, but the forces at complete displacement for each screw type were significantly greater than the forces at initial displacement ( P <0.05).

On the basis of literature review and data generated from this study, it is apparent that the forces necessary to cause displacement of the stabilized Jones fracture are above what would be transmitted within the lateral midfoot during normal weightbearing. The choice of screw and intramedullary technique of fixation is a matter of surgeon preference, because the choice of screw makes no biomechanical difference.
Benchmark Analysis of Diabetic Patients with Neuropathic (Charcot) Foot Deformity
Authors: Pinzur Michael S.
Published: March 2013

During a 10-year period, 237 patients (129 women, 108 men) with a diagnosis of neuropathic (Charcot) arthropathy of the foot and ankle were treated in a tertiary care university hospital medical center. During this period, 115 of the patients (48.5%) were treated nonoperatively as outpatients with local skin and nail care, accommodative shoe wear, and custom foot orthoses. A total of 120 (50.6%) underwent 143 operations. Surgery included 21 major limb amputations, 29 ankle fusions, 26 hindfoot fusions, 23 exostectomies, and 23 debridements for osteomyelitis.

It is widely accepted that patients with diabetes are at risk for developing foot ulcers, which can lead to lower extremity amputation. Within the population of diabetic patients, it is widely accepted that patients with neuropathic (Charcot) arthropathy of the foot and ankle have one of the highest likelihoods of having to undergo lower extremity amputation. The current emphasis in care of the foot of a diabetic patient involves a multidisciplinary team approach combining patient education, skin and nail care, and accommodative shoe wear. As data from prophylactic programs become available, resource allocation and cost of care can be compared with this benchmark baseline.

This benchmark analysis can be used by those who are responsible for allocating resources and projecting healthcare costs for this “high utilization”/high risk patient population.
Outcomes After Partial Neurectomy of Morton's Neuroma Related to Preoperative Case Histories, Clinical Findings, and Findings on Magnetic Resonance Imaging Scans
Authors: Biasca Nicola , Zanetti Marco , Zollinger Hans
Published: March 2013

Our purpose was to evaluate the reliability of preoperative case histories, clinical findings, and magnetic resonance imaging (MRI) scans in substantiating the diagnosis of Morton's neuroma and in predicting clinical outcomes after surgical intermetatarsal neurectomy.

We studied 19 consecutive patients with histologically proved Morton's neuroma. All had preoperative MRI of the forefoot. Partial neurectomy was performed when there was forefoot pain with transmetatarsal compression and positive findings on MRI scans. Case histories, clinical findings, and findings on MRI scans were correlated with clinical outcomes.

Preoperative clinical findings including localization correlated with intraoperative findings in 11 of 19 patients (58%), and MRI scans correlated in 16 of 19 patients (84%). Of the 19 patients, 74% achieved satisfactory outcomes. Neither reliable clinical findings or findings on MRI scans nor confirmation of clinical findings by MRI correlated with a superior result, but 77% of patients with neuromas measuring more than 5 mm in transverse measurement on MRI scans had good outcomes; only 17% with neuromas measuring 5 mm or less had good outcomes.

Preoperative localization and diagnosis of Morton's neuroma is better achieved with MRI than through clinical findings. A more favorable clinical outcome can be expected after surgical intermetatarsal neurectomy when a Morton's neuroma has a transverse measurement larger than 5 mm on MRI scans.
Tension Neuropathy of the Superficial Peroneal Nerve: Associated Conditions and Results of Release
Authors: Johnston Eric C. , Howell Steven J.
Published: March 2013

We reviewed eight patients who sustained superficial peroneal nerve neuralgia after an inversion ankle sprain. Surgical exploration found anatomic abnormalities that tethered the nerve from movement during plantarflexion and inversion of the ankle. Most patients' pain improved dramatically after release and anterior transposition of the nerve. Seven joints also underwent arthroscopy, which showed intra-articular disease that was consistent with the original trauma. Five patients had reflex sympathetic dystrophy, three of which resolved after nerve release. Nerve conduction studies were not helpful. Careful physical examination and local nerve blocks were most important in making the diagnosis and prescribing treatment. All conservative measures should be exhausted before surgery is considered.
Midfoot Field Block Anesthesia with Monitored Intravenous Sedation in Forefoot Surgery
Authors: Ptaszek Amy Jo , Morris Scott G. , Brodsky James W.
Published: March 2013

Fifty consecutive patients, studied prospectively, underwent an elective first metatarsophalangeal joint arthrodesis or proximal metatarsal osteotomy and modified McBride bunionectomy, with or without concomitant lesser toe procedures. A field block was administered only at and distal to the level of the tarsometatarsal joints using 30 cc equal parts 0.25% bupivacaine and 1% lidocaine without epinephrine. Before injection, the monitoring anesthesiologist gave the patient intravenous (IV) sedation, usually an amnestic agent. Narcotic analgesia was not given to any patient before or during surgery to evaluate the efficacy of the block. Detailed records were kept of all intraoperative medication and its dosage, including supplemental local anesthetic. Efficacy and outcome were measured via direct patient monitoring during surgery and by direct interview after surgery, first in the recovery area (visual pain analogue applied) and again at 24 to 48 hr after surgery (recollection of events, duration of block, use of narcotics after surgery, subjective patient satisfaction).

Supplemental local anesthetic was required for 15 patients (primarily for those who underwent lesser toe procedures), IV narcotic was required for 3 patients, and conversion to general anesthesia was required for 4 patients for agitation, not pain. The average duration of the local block was 8 hr (range, 5–14 hr); none of the patients had recall of negative events, and overall patient satisfaction was 98%.

Midfoot blocks are easy to administer and provide reliable anesthesia for reconstructive forefoot surgery. Monitored IV sedation enhances patient acceptance, facilitates block administration, and provides a valuable measure of patient safety and comfort.
Checkrein Deformity–An Unusual Complication Associated with a Closed Salter-Harris Type II Ankle Fracture: A Case Report
Authors: Rosenberg Gary A. , Sferra James J.
Published: March 2013

This article presents a case of tethering of the flexor hallucis longus (FHL) tendon (checkrein deformity) and rupture of the posterior tibialis tendon after a closed Salter-Harris Type II ankle fracture. Delayed repair was affected by tenolysis of the FHL and flexor digitorum longus tendons and tenodesis of the posterior tibialis to the flexor digitorum longus tendon. This case represents the first such report of concomitant entrapment of the FHL tendon and rupture of the posterior tibialis tendon after a closed ankle fracture.
Diagnosis and Treatment of Fractures of the Talus: A Comprehensive Review of the Literature
Authors: Higgins Thomas F. , Baumgaertner Michael R.
Published: March 2013

Fractures of the head, neck, and body of the talus present difficult treatment challenges. The vulnerable blood supply and abundant articular surfaces may lead to long-term problems with osteonecrosis and osteoarthrosis. Previous studies of these relatively rare injuries have been mostly small, inconsistent, or anecdotal, leading to confusion and controversy regarding the optimum treatment of various types of talus fractures. The surgeon who treats these injuries must be prepared to address meticulous reduction and fixation, maintain attentive follow-up, and manage the complications that may result despite appropriate treatment. This review summarizes the findings of the literature on each type of talus fracture to provide a clearer picture of their recommended management.
Metatarsal Neck Osteotomy with Rigid Internal Fixation for the Treatment of Lesser Toe Metatarsophalangeal Joint Pathology
Authors: Davies Mark S. , Saxby Terence S.
Published: March 2013

Metatarsalgia associated with metatarsophalangeal (MTP) joint instability and/or plantar callosity formation is a difficult problem to treat. During a 15-month period, we performed 50 osteotomies of the metatarsal neck with rigid internal fixation in 47 feet of 42 patients. Three patients were excluded from the study, leaving 47 osteotomies in 44 feet of 39 patients for review. There were 6 men and 33 women, with a mean age of 57 years. In addition to lesser MTP joint pain with or without instability, the majority of patients had first ray pathologic condition, which was also addressed at the time of surgery. All but one of the osteotomies were united radiologically at 6 weeks. The mean shortening was 4.1 mm (range, 2–12 mm), and the mean follow-up was 9 months. There were no cases of malunion, nonunion, or avascular necrosis. At follow-up, 33 patients were asymptomatic. Eight patients (nine feet) had a degree of persisting pain at follow-up (seven mild and two moderate), but the source of this pain was only the metatarsal or MTP joint that was operated on in three cases. In this article, we describe the indications, the technique, and the results of the osteotomy.
Clinical and Functional Outcome After Anatomic and Nonanatomic Ankle Ligament Reconstruction: Evans Tenodesis Versus Periosteal Flap
Authors: Rosenbaum Dieter , Engelhardt Michael , Becker Horst-Peter , Claes Lutz , Gerngroß Heinz
Published: March 2013

The present study investigated the effects of two different surgical procedures for the treatment of chronic ankle instability. Ten patients treated with an anatomic reconstruction using a periosteal flap were compared with a second group that received an Evans tenodesis. All patients were evaluated before and after surgery with clinical and radiographic examinations as well as dynamic pedobarography. Patient satisfaction and radiographic and functional results were comparable in both groups and revealed a good restoration of joint stability and gait symmetry. Our results indicate that both methods of ankle ligament reconstruction achieve a comparable clinical and functional outcome within 1 year after surgery.
Mobility of the First Tarsometatarsal Joint in Relation to Hallux Valgus Deformity: Anatomical and Biomechanical Aspects
Authors: Faber Frank W.M. , Kleinrensink Gerrit-Jan , Verhoog Menno W. , Vijn Annemieke H. , Snijders Christiaan J. , Mulder Paul G.H. , Verhaar Jan A.N.
Published: March 2013

Hypermobility of the first tarsometatarsal (TMT 1) joint is suggested to be an important factor in the cause and progression of hallux valgus deformity. Hypermobility of the TMT 1 joint is tested clinically in the sagittal plane, but an important deformation also exists in the transversal plane: metatarsus primus varus. This in vitro study was undertaken to investigate the relation between the mobility of the TMT 1 joint in these two planes and to investigate the correlation of the mobility with morphological variables. A second aim was to study the possible stabilizing effect of the tibialis anterior muscle, flexor hallucis longus muscle, and peroneus longus muscle on the TMT 1 joint.

Nine embalmed human specimens were tested under standardized conditions. A 30-N force was applied to the head of the first metatarsal (MT 1) to pull in either the dorsal or medial direction. To simulate muscle force, 21 N was applied to the three tendons: all seven possible combinations of muscle action were tested in each plane of motion. Angular displacements were measured using 2-dimensional LED video registration.

TMT 1 mobility is a relevant factor in MT 1 mobility in the sagittal and transversal planes, the peroneus longus has a stabilizing effect on this joint, and the effect of the flexor hallucis longus on this joint is different in both planes. When considering a Lapidus procedure for surgically correcting a hallux valgus, the mobility of MT 1 in the transversal plane should also be assessed, but so far no objective clinical test in this plane has been described.
Arthrodesis of the Distal Tibiofibular Joint for a Large Osteochondroma in an Adult
Authors: Ciampolini Jacopo , Gargan Martin F. , Newman John H.
Published: March 2013

A case of a large osteochondroma of the distal tibia with distortion of the distal tibiofibular joint is presented. This could not be managed by traditional means, as excision would have resulted in ankle and tibiofibular joint instability. The problem was overcome by performing an arthrodesis. Only enough bone from both the tibia and the fibula was excised to provide a host bed for bone graft. We believe that symptomatic osteochondromata should usually be excised. However, if this would result in damage, then the method described offers an alternative management strategy.
The Mechanical Properties of the Heel Pad in Unilateral Plantar Heel Pain Syndrome
Authors: Tsai Wen-Chung , Wang Chung-Li , Hsu Tsz-Ching , Hsieh Fon-Jou , Tang Fuk-Tan
Published: March 2013

Plantar heel pain syndrome has been attributed to entrapment neuropathy, plantar fasciitis, calcaneal spurs, and stress fractures of the calcaneus. Although deteriorated mechanical properties of the heel pads may play an important role in the pathogenesis of heel pain syndrome, this has received little notice. In this study, a specially designed compression relaxation device with a push-pull scale and a 10-MHz linear array transducer was used to determine thickness of the heel pad under different loading conditions. Twenty consecutive patients aged 29 to 77 years with unilateral plantar heel pain syndrome were enrolled. Thickness of heel pad bilaterally was measured when the heel pad was compressed by serial increments of 0.5 kg to a maximum of 3 kg and then relaxed sequentially. The load-displacement curve during a loading-unloading cycle was plotted, and the compressibility index and energy dissipation ratio of the heel pad were calculated accordingly. Phase I displacement of the heel pad (from 0 to 1 kg load) on the painless side was greater than that on the painful side ( P < 0.01), but there was no statistically significant difference between painless and painful sides in thickness of unloaded heel pads, compressibility index, or energy dissipation ratio ( P > 0.05). In conclusion, the affected heel pad in plantar heel pain syndrome was stiffer under light pressure than the heel pad on the painless side. The changed nature of chambered adipose tissue in a painful heel pad may be responsible for its increased stiffness under light pressure.
American Orthopaedic Foot and Ankle Society Shoe Survey of Diabetic Patients
Authors: Pinzur Michael S. , Shields Naomi N. , Goelitz Brian , Slovenkai Mark , Kaye Robert , Ross Steven D.K. , Suri Misty
Published: March 2013

A one-page written survey was completed by 402 randomly selected patients with diabetes in five cities during a scheduled visit to their endocrinologist. Patients averaged 61.5 years of age and had been diagnosed with diabetes for 27.3 years.

This study suggests that approximately 25% of adults with diabetes are at risk for developing foot ulcers, the precursor to deep infection leading to lower limb amputation. The goal at the inception of this project was to obtain benchmark data on the current level of prophylactic foot care being provided to adult patients with diabetes. The results of this survey suggest that most individuals with diabetes and their physicians are aware of potential diabetic foot morbidity, yet very few take advantage of prophylactic protective footware. Even fewer are presently taking advantage of benefits established through the Medicare Therapeutic Foot Bill. This survey highlights a substantial opportunity for improvement in the long-term care of individuals with diabetes.
Arthroscopic Findings Associated with the Unstable Ankle
Authors: Komenda Gregory A. , Ferkel Richard D.
Published: March 2013

Before lateral ankle stabilization, arthroscopic surgery was performed on 54 patients (55 ankles) with chronic ankle instability. All patient charts, x-rays, operative reports, and surgical videotapes were reviewed. A detailed questionnaire was answered by all patients. The study population included 31 males and 23 females, with a mean age of 31 years (range, 14–64 years). The right ankle was involved in 64% of cases. Average follow-up was 9.6 months. Arthroscopic surgery was performed using small joint instrumentation including 30° and 70° 2.7-mm arthroscopes and a 30° 1.9-mm arthroscope. At surgery, 51 ankles (93%) had intra-articular abnormalities including loose bodies (12), synovitis (38), osteochondral lesions of the talus (9), ossicles (14), osteophytes (6), adhesions (8), and chondromalacia (12). The most common arthroscopic procedures were synovectomy, removal of loose bodies and ossicles, excision and drilling of osteochondral lesions, debridement of the lateral gutter, excision of osteophytes, and removal of adhesions and scar tissue. There was a 25% incidence of chondral injuries, which differs considerably from the results of Taga et al., who found chondral injuries in 95% of ankles with lateral instability. Overall, there were excellent or good results in 96% of ankles. The incidence of excellent results was lower in the worker's compensation patients because of a greater incidence of complaints of pain with activity. There was no correlation between the presence of osteochondral lesions or amount of talar tilt and results.
Reconstruction for Chronic Lateral Ankle Instability Using the Palmaris Longus Tendon: Is Reconstruction of the Calcaneofibular Ligament Necessary?
Authors: Okuda Ryuzo , Kinoshita Mitsuo , Morikawa Junichi , Jotoku Tsuyoshi , Abe Muneaki
Published: March 2013

The palmaris longus tendon was used to reconstruct the anterior talofibular ligament (ATFL) in 27 ankles with chronic lateral instability. The mean age of the patients at surgery was 23 years, and the follow-up was more than 2 years.

The functional evaluation showed excellent or good results in all ankles. Twenty-seven ankles were divided into two groups according to operative findings: group A consisted of 11 ankles with old isolated injury of the ATFL, and group B consisted of 16 ankles with old combined injuries of the ATFL and the calcaneofibular ligament. There were no significant differences in clinical results between group A and group B. The preoperative mean talar tilt angles on stress radiograph in group B were significantly larger than those in group A. At follow-up, there were no significant differences in the mean talar tilt angles between group A and group B.

We demonstrate that reconstruction of the calcaneofibular ligament along with the ATFL is not necessary for patients with chronic combined lateral ligament instability.
Mesenchymal Cells and Growth Factors in Bunions
Authors: Robinson Dror , Hasharoni Amir , Halperin Nahum , Yayon Avner , Nevo Zvi
Published: March 2013

Bunion formation in adults is an example of bone growth that occurs after physis closure. Bone is laid down secondary to mechanical irritation caused by foot deformity. It is a mechanism of ectopic bone formation unrelated to physeal growth. In this article, bone formation is analyzed using immunohistochemical and cell culture techniques. Using markers specific for mesenchymal cells (collagen type IIa and fibroblast growth factor receptor 3), a cell population is defined in the soft tissues that overlie the bunion and is isolated from explant cultures. The cells do not produce bone matrix in culture, and they do not express osteoblast-related antigens. Stimulation of the cells by fibroblast growth factor (FGF) 2 leads to rapid cell proliferation and phenotype change. The cells start to form humps and at the same time express alkaline phosphatase and collagen type I. Expression of collagen type IIa and fibroblast growth factor receptor 3 ceases. These series of experiments indicate that a specific population of mesenchymal cells occurs in the soft tissues that overlie the bunion. This population is capable of bone formation when stimulated by FGF, a common mediator of inflammatory processes. Thus, FGF stimulation of mesenchymal cells in soft tissues that overlie the head of the first metatarsal is a potential link between the biomechanical forces that cause hallux valgus and bunion formation.
Tibiotalar Motion — Effect of Fibular Displacement and Deltoid Ligament Transection: In Vitro Study
Authors: Sasse Marcus , Nigg Benno M. , Stefanyshyn Darren J.
Published: March 2013

The purpose of this study was to quantify tibiotalar translation and rotation under various stages of fibular displacement and injury to the syndesmotic and deltoid ligaments. Ten unpaired specimens amputated below the knee were studied using an unconstrained testing apparatus. The specimens were moved through a dorsiflexing and plantarflexing arc of 55° (20° dorsiflexion and 35° plantarflexion). Dorsiflexion of the intact lower leg was associated with an average of 4.2° of external talar rotation, and plantarflexion was associated with an average of 1.4° of internal talar rotation. Fibular osteotomy and displacement of the distal fibular fragment did not change the talar rotation significantly. Additional transection of the deltoid ligament, however, decreased external talar rotation significantly, to 1.4°, and decreased talar internal rotation to 0.6°. Talar shift was not affected in dorsiflexion or plantarflexion by fibular fracture, displacement of the distal fibular fragment, or transection of the deltoid ligament. These data may suggest that in dorsiflexion or plantarflexion, an intact lateral malleolus is not necessary for physiological talar tracking. They further suggest that in a fibular fracture with a significant injury to the deltoid ligament, healing of the ligament at its resting length is crucial to restoring physiological talar rotation.
Filariasis of the Ankle: Magnetic Resonance Imaging
Authors: Blacksin Marcia F. , Lin Sheldon S. , Trofa Andrew F.
Published: March 2013

Filariasis is a world health problem that is frequently seen in tropical and subtropical countries. In endemic areas, the clinical spectrum of extremity swelling, lymphangitis, or elephantiasis is usually recognized as filariasis. In the United States, diagnosis of the disease may be more difficult because of lack of familiarity with this infection. We present a case of filaremic arthropathy of the ankle joint and the magnetic resonance imaging (MRI) findings of this disease. It is the first reported case of MRI findings in a human patient. MRI has been done on animal models with filariasis, and the findings are similar.
Results of Flexor-to-Extensor and Extensor Brevis Tendon Transfer for Correction of the Crossover Second Toe Deformity
Authors: Haddad Steven L. , Sabbagh Ronald C. , Resch Sylvia , Myerson Brett , Myerson Mark S.
Published: March 2013

Between 1990 and 1995, 38 patients (42 feet) underwent repair for crossover toe deformity, 31 (35 feet) of whom returned for final examination at an average of 51.6 months (range, 24–81 months). Causes included trauma, iatrogenic, and unknown. Presenting complaints included dorsal pain with either metatarsalgia or joint pain, isolated metatarsophalangeal (MP) joint pain, metatarsalgia, painful plantar callus, metatarsalgia and joint pain, and painful dorsal callus.

All patients were treated with one of two operative techniques, either the flexor-to-extensor tendon transfer or the extensor brevis tendon transfer. Choice of procedure depended on the stage of preoperative deformity.

Twenty-four patients were completely satisfied with the surgical correction, 6 were satisfied with reservations, and 1 was dissatisfied. The average postoperative AOFAS score for all patients was 85 points (range, 54–100 points), which correlated strongly with patient satisfaction. Twenty-two patients stated that they had no postoperative pain, 8 reported some pain, and 1 had frequent pain at the corrected toe. In 30 feet, there was no recurrence; three patients had mild residual crossover toe deformity, and two patients had recurrent deformity, although all MP joints were stable. Follow-up radiographs demonstrated substantial reduction in MP joint angles in both the AP (from 7° to −1°) and lateral (from 45° to 25°) projections.

This article reviews the surgical technique of both procedures, proposes specific indications for each, and presents outcomes. Based on our findings, the extensor brevis tendon transfer is appropriate for stage 1, stage 2, and flexible stage 3 deformities. Flexor-to-extensor tendon transfer is appropriate for rigid stage 3 and stage 4 deformities and for all patients with a symptomatic neuroma of the second web space (where the extensor brevis transfer is not possible). Stiffness of the MP joint is a potential problem with the flexor-to-extensor tendon transfer.
Internal Architecture of the Talus: Implication for Talar Fracture
Authors: Ebraheim Nabil A. , Sabry Fady F. , Nadim Yasser
Published: March 2013

The internal architecture of the talus has not previously been well described even though the morphological anatomy and the blood supply have been studied extensively. This study describes the internal architecture of the talus regarding its trabecular orientation, using high-resolution x-ray images of 13 dry tali and thick sections in the coronal, sagittal, and axial planes. The trabecular arrays and their relationship to talar fractures are described. The trabecular content of the neck of the talus is less than that of the head or the body. The direction of the trabecula in the neck is different from the orientation of the talar body trabeculae.
Hindfoot Coronal Alignment: A Modified Radiographic Method
Authors: Johnson Jeffrey E. , Lamdan Ron , Granberry William F. , Harris Gerald F. , Carrera Guillermo F.
Published: March 2013

Accurate clinical evaluation of the alignment of the calcaneus relative to the tibia in the coronal plane is essential in the evaluation and treatment of hindfoot pathologic condition. Previously described radiographic views of the foot and ankle do not demonstrate the true coronal alignment of the calcaneus relative to the tibia. Some of these views impose on the patient an unnatural posture that itself changes hindfoot alignment, whereas other methods distort the coronal alignment by the angle of the x-ray beam. Our purpose was to develop a modified radiographic view and measurement method for determining an angular measurement of hindfoot coronal alignment based on a cadaver study of the radiographic characteristics of the calcaneus and motion analysis of standing subjects.

The view was obtained by having the subject stand on a piece of cardboard to create a foot template. The template was then positioned so that each foot was x-rayed perpendicular to the cassette while still maintaining the natural base of support. A method using multiple ellipses was developed to determine more accurately the coronal axis of the posterior calcaneus.

A study using cadavers was performed in which radio-opaque markers were placed on multiple bony landmarks on the calcaneus. The tibia was held fixed in a vertical position, and the foot was x-rayed using the above techniques in different degrees of rotation without changing the relation of the calcaneus to the tibia. The radiographs of the modified Cobey and our view were examined to verify which markers were visible at different angles of rotation and how the hindfoot alignment measurements changed with foot rotation.

To define further the differences between the views, an analysis of postural stability was conducted while the subjects were standing with the feet in the positions for imaging both the Buck modification of the Cobey view and our hindfoot alignment view.

The combined results of the cadaver, radiographic measurement, and postural stability segments of the study reveal that this coronal hindfoot alignment view and measurement method is reproducible, more closely measures “true” coronal hindfoot alignment, and is more clinically applicable because the alignment is measured while the patient is standing with a normal angle and base of stance. The modified radiographic measurement method relies on posterior calcaneal anatomic landmarks, is less affected by rotation of the foot and ankle, and is reproducible between observers.
Monetary Policy Considerations after the Crisis: Practitioners’ Perspectives
Authors: Gokarn Subir
Published: March 2013

In this article, I would like to explore some of the thinking around issues in inclusive growth and development in the face of recent economic and financial crisis. We use recent articulations by a cross-section of central bankers and use this as a backdrop for the way the Reserve Bank of India and the Government of India deal with challenges to macroeconomic stability. The article lays out a simple framework, which I find useful to think about monetary policy and central banking and then use it to discuss issues that have emerged in the post-crisis debates.