bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Results of Simultaneous Adjacent Interdigital Neurectomy in the Foot
Authors: Benedetti Roy S. , Baxter Donald E. , Davis Pamela F.
Published: March 2013

Fifteen patients (19 feet) who underwent simultaneous surgical excision of two primary interdigital neuromas in adjacent web spaces of the foot were studied retrospectively. There were 11 female patients (73%). The average age of the patients was 54.4 years. Other causes of multiple web space tenderness were excluded prior to surgical resection of both neuromas. At an average follow-up of 68.6 months (range, 32–113 months), 10 feet (53%) had complete resolution of symptoms and six feet (31%) had minimal residual symptoms. Three feet in two patients (16%) continued to have significant pain after surgery.

One sequela of the procedure was dense sensory loss of the plantar aspect of the third metatarsal head to the tip of the third toe. There was also proximal dorsal sensory loss to the second, third, and fourth toes which was a function of the type of incision used. The sensory loss did not cause disability in the patients, but did cause some awkwardness with nail care.

Resection of adjacent interdigital neuromas, although rarely indicated, can be expected to provide significant pain relief in 84% of patients, which is similar to results reported for resection of a single neuroma.
Tibiotalar Contact Area and Pressure Distribution: The Effect of Mortise Widening and Syndesmosis Fixation
Authors: Pereira David S. , Koval Kenneth J. , Resnick Ronald B. , Sheskier Steven C. , Kummer Frederick , Zuckerman Joseph D.
Published: March 2013

An unconstrained cadaver ankle model was designed to reevaluate the effect of ankle mortise widening and syndesmotic fixation on the load-bearing characteristics of the tibiotalar joint. Tibiotalar contact area, centroid shift, and mean contact pressure were quantified using a pressure-sensitive film technique. Six fresh-frozen below-knee amputation specimens were axially loaded with 500 N in three positions: neutral, 10° of dorsiflexion, and 20° of plantarflexion. The tibiotalar contact area and centroid position for each specimen in its intact state were first determined and then compared with values obtained after syndesmotic fixation, mortise widening of 2 and 4 mm, and deep deltoid ligament transection. Syndesmotic fixation significantly decreased joint contact area but did not consistently affect centroid position. However, unlike earlier studies, which used more constrained ankle fracture models, mortise widening with or without deltoid rupture was not found to significantly affect contact area, centroid position, or joint contact pressure. When statically loaded, the talus moved to its position of maximal congruence in the mortise, rather than displacing laterally along with the lateral malleolus.
Osteonecrosis of the Talus: Treatment by Hindfoot Fusion
Authors: Urquhart Marc W. , Mont Michael A. , Michelson James D. , Krackow Kenneth A. , Hungerford David S.
Published: March 2013

The results were reviewed for 11 ankles (10 patients) that had been treated with various hindfoot arthrodeses because of symptomatic osteonecrosis of the talus. Follow-up averaged 6.5 years (range, 2–15 years). A functional assessment using a modified Mazur grading system was performed both before surgery and at final follow-up. Data were also collected on the duration of the procedure, intraoperative findings, and the patient's assessment of postoperative cosmesis (excellent, good, fair, or poor). Radiographs were analyzed to determine the interval from the procedure until bony union.

Nine of the 11 arthrodeses (82%) fused with the primary procedure and achieved excellent Mazur ratings (mean, 86 points; range, 81–90 points). The average interval until radiographic fusion was 7 months (range, 4–13 months). All eight patients (nine fusions) with successful fusions graded their cosmetic outcomes as excellent or good. The average length of the procedure was 148 minutes (range, 130–300 minutes), compared with an average of 92 minutes (range, 62–151 minutes) for ankle arthrodeses performed by the same surgeons in rheumatoid or osteoarthritic ankles ( P < 0.001) and 102 minutes (range, 75–164 minutes) from a report in the literature. Two of the procedures were complicated by nonunions secondary to infections. In one patient, after treatment by debridement and intravenous antibiotics, reinfection and chronic osteomyelitis developed with a subsequent below-knee amputation. The other patient was treated successfully with debridement, antibiotics, and subsequent revision arthrodesis, which fused solidly at 9 months with an excellent result.

We conclude that hindfoot arthrodeses for osteonecrosis can be technically demanding, but, despite having a long time to bony union, they can have an excellent clinical outcome.
Multiple Lower Limb Osteophytosis with Macrodactyly: A Case Report
Authors: Mullins Anthony Michael
Published: March 2013

A 39-year-old woman with restriction of movement and macrodactyly of the great toes was found to have severe juxta-articular multiple osteophytosis of the lower limbs. The pathogenesis of this unusual condition is unknown. It may be a variant of diffuse idiopathic skeletal hyperostosis.
Prospective, Randomized Comparison of Proximal Crescentic and Proximal Chevron Osteotomies for Correction of Hallux Valgus Deformity
Authors: Easley Mark E. , Kiebzak Gary M. , Davis W. Hodges , Anderson Robert B.
Published: March 2013

In this study, intermetatarsal angle (IMA) correction, functional outcome, and healing time for the proximal crescentic and proximal chevron osteotomies in moderate to severe hallux valgus deformity were prospectively compared.

Seventy-five patients (97 feet) were prospectively randomized to either a proximal crescentic or proximal chevron osteotomy for the correction of moderate to severe hallux valgus deformity with associated metatarsus primus varus. Criteria for study entry included age (adult patients), IMA greater than or equal to 13°, persistent symptoms despite nonoperative treatment, and minimum follow-up of 12 months.

Twenty-nine patients (41 feet) in the crescentic group and 37 patients (43 feet) in the chevron group returned for follow-up at an average of 24 and 20 months, respectively. Good results were achieved with both procedures. No statistically significant differences were found with respect to correction of the IMA or to functional outcome between the two groups. Results held true irrespective of patient age, severity of disease, or bilateral involvement. A statistically significant shorter healing time of the first metatarsal was found after proximal chevron osteotomy. Other potential benefits of the chevron procedure included avoidance of dorsiflexion of the first metatarsal, tendency toward less shortening of the first metatarsal, and more medial distribution of tibial sesamoids following surgery, all of which may reduce the potential for development or persistence of transfer lesions.
Radiographic Assessment of the Second Metatarsal: Measure of First Ray Hypermobility
Authors: Prieskorn David W. , Mann Roger A. , Fritz Germaine
Published: March 2013

Hypermobility of the first metatarsal cuneiform joint has been implicated as a cause of the hallux valgus deformity. The objective definition of hypermobility at this joint, however, has not been clearly defined. We used a modified Coleman block test to accentuate motion at the first metatarsal cuneiform joint in order to measure physiologic limits of motion in vivo. This motion was compared with radiographic analysis of the feet, which included the hallux valgus angle, intermetatarsal angle, and medial cortical thickening at the midshaft of the second metatarsal. This assessment was performed on 100 feet (50 right feet and 50 left feet in 50 patients). The average intermetatarsal angle was 8.7° (range, 4–14°), the average hallux valgus angle was 11° (range, 4° of varus to 30° of valgus), and the average midshaft medial cortical thickness was 3.2 mm (range, 2.0–5.5 mm). Pearson's correlation coefficient was calculated to compare these factors. The relationship between variables was found to be small ( r ≤ 0.2). Motion was noted to occur in the normal foot at this joint and a range of normal values for medial cortical thickness was identified.
Surgical Correction of Talipes Equinovarus Following Foot and Leg Compartment Syndrome
Authors: Dávid A. , Lewandrowski K U. , Josten C. , Ekkernkamp A. , Clasbrummel B. , Muhr G.
Published: March 2013

Between 1984 and 1994, 40 patients with a posttraumatic compartment syndrome of the lower leg and foot were treated for talipes equinovarus adductus foot deformity, which subsequently developed. Twenty patients had a wedge osteotomy followed by arthrodesis of the midtarsal joint (Chopart joint). Another 17 patients had an arthrodesis of the midtarsal and subtalar joints. In the remaining three patients, in addition to arthrodesis, lengthening of the tendons of the long flexors and the Achilles tendon was performed. Complications included wound infections (six cases), drill hole infections (three cases), chronic osteomyelitis (one case), and an ankle joint infection (one case). The clinical result was assessed as good in 37.5%, fair in 52.5%, and poor in 10% of the patients. Before the operation, 37 patients required modified footwear. After the operation, only eight patients needed them. Wedge osteotomy of the midtarsal and subtalar joints followed by an arthrodesis is an advantageous treatment modality for the correction of severe postischemic equinovarus adductus foot deformities. In our study, patient satisfaction was high. While complications frequently occur, it is not extraordinary considering the salvage nature of the procedure.
Complications Following Arthroscopic Ankle Arthrodesis
Authors: Crosby Lynn A. , Yee Ted C. , Formanek Teri S. , Fitzgibbons Timothy C.
Published: March 2013

Forty-two patients underwent an arthroscopic ankle arthrodesis utilizing a bi-framed distraction technique and demineralized bone matrix-bone marrow slurry as a graft substitute. The average follow-up was 27 months (range, 12–64 months). The overall complication rate was 55%, including three nonunions (7%), two fractures (4.8%), four pin site infections (9.5%), one deep infection, four hardware problems (9.5%), and four symptomatic painful subtalar joints (9.5%).

Overall, 85% of patients were satisfied with their final result. The complication rate was high but most complications were minor and manageable. The demineralized bone matrix and bone marrow did not seem to increase the fusion rate over what has been documented previously for arthroscopic ankle fusions without the use of this graft substitute.
Popliteal Sciatic Nerve Block for Postoperative Analgesia
Authors: Rongstad Kurt , Mann Roger A. , Prieskom David , Nichelson Steve , Horton Greg
Published: March 2013

Eighty-six patients were evaluated prospectively following the placement of a sciatic nerve block in the popliteal fossa after a major foot or ankle operation. Needle placement was guided by a peripheral nerve stimulator and 30 ml of 0.5% bupivacaine with epinephrine was used. Ninety-seven percent of patients had a successful block. Only one patient had severe discomfort during the block placement. The block lasted an average of 20 hours. During the first 24 hours after surgery, patients took an average of three hydrocodone tablets. Twenty-two of the 23 patients who had had previous major foot or ankle surgery found that the block was better than their previous pain control regimen. No patient had complications related to the block and 95% were satisfied and would have the block again.
Calcaneal Malunions: Results of a Prognostic Computed Tomography Classification System
Authors: Stephens Heidi Multhopp , Sanders Roy
Published: March 2013

Following nonoperative treatment of calcaneal fractures, some patients may develop a disabling malunion with associated posttraumatic arthritis of the subtalar joint, impingement of the peroneal tendons, and hindfoot malalignment. We present a computed tomography classification system for calcaneal malunions which guides treatment and is of prognostic significance. A prospective study was performed using this classification system on a series of 26 malunions treated over a 45-month period. Three distinct types of malunions were identified: type I, lateral wall exostosis without subtalar arthrosis; type II, lateral wall exostosis with subtalar arthrosis; and type III, lateral wall exostosis, subtalar arthrosis, and a varus malunion.

The surgical treatment was determined by a protocol based on the specific type of malunion encountered. Results were evaluated using the Maryland Foot Score. There were 18 excellent, 5 good, and 3 fair results. Although outcomes deteriorated as malunion complexity increased, significant clinical improvement as a result of reconstructive surgery was noted in even the worst types of malunion. This algorithm is consistent, prognostic, and useful for the orthopaedic surgeon presented with a symptomatic calcaneal malunion of one of these types.
Primary Leiomyosarcoma Affecting the Ankle Joint
Authors: Delsmann Burkhard M. , Pfahler Manfred , Nerlich Andreas , Refior Hans Jürgen
Published: March 2013

In a 50-year-old patient with a malignant tumor of the left distal tibia (stage la, according to Enneking) undermining the cartilage of the ankle joint, an extremely rare primary leiomyosarcoma of bone was diagnosed. The diagnosis of a primary leiomyosarcoma of bone is possible only after a secondary (metastatic) leiomyosarcoma has been excluded. Furthermore, typical histopathological features, including immunohistochemical staining results, are required for the diagnosis. Surgery is the therapy of choice. An RO resection should always be attempted.
Plantar Pressure Measurements During Ambulation in Weightbearing Conventional Short Leg Casts and Total Contact Casts
Authors: Conti Stephen F. , Martin Rob L. , Chaytor E. Ruth , Hughes Christopher , Luttrell Leslie
Published: March 2013

Total contact casts have been shown to be effective in healing plantar neuropathic ulcerations. The proposed mechanism of action is reduction of pressure over the ulcer during ambulation. However, there is little information to support this contention. Plantar pressure distribution was studied using standard short leg casts and total contact casts in normal feet. Both types of casts reduced forefoot pressure in study subjects. This occurred because of an increase in plantar surface area exposed to weightbearing forces. While increased force was shifted to the midfoot, there was no increase in pressure due to a corresponding increase in midfoot surface area exposed to this force. No significant difference was noted between standard short leg casts and total contact casts.
Quantitative Analysis of Cancellous Bone Graft Available from the Greater Trochanter
Authors: Lindberg Eric J. , Katchis Stuart D. , Smith Ronald W.
Published: March 2013

To quantify the amount of cancellous bone graft available from the greater trochanteric region, 20 paired iliac crest-proximal femur specimens were harvested and compared in 10 adult pelvises. A 1.3 × 1.3-cm cortical window was made in the lateral aspect of the proximal femur 2 cm distal from the tip of the greater trochanter. Cancellous bone evacuation was performed by curettage. The extent of harvest was mechanically limited by the medial wall of the trochanter and by curette impingement on the margins of the cortical window. The graft was quantitated after maximal digital compression in a 10-ml syringe and compared with cancellous graft obtained from the paired anterior iliac crest.

The average compressed volume of cancellous bone harvested from the greater trochanter was 6.5 ml (range, 4.2–9.6 ml). The average iliac crest cancellous bone volume was 6.0 ml (range, 2.7–8.8 ml). Differences in graft volume between the anterior iliac crest and the trochanter were not statistically significant. The resulting defect in the proximal femur remained isolated to the trochanteric region.

In this study, we demonstrate that cancellous bone is available from the greater trochanteric region in an amount similar to that available from the anterior iliac crest. We also show that it is obtainable in a reproducible manner. Our clinical experience of over 100 cases has demonstrated acceptable morbidity associated with this technique. The greater trochanteric region may be used as a secondary source of autogenous cancellous bone graft when specific procedures demand more bone graft than available from the iliac crest alone, or in patients who have had previous iliac crest graft harvest.
Partial Achilles Tendon Ruptures Associated with Fluoroquinolone Antibiotics: A Case Report and Literature Review
Authors: McGarvey William C. , Singh Dishan , Trevino Saul G.
Published: March 2013

Fluoroquinolone antibiotics (such as ciprofloxacin, pefloxacin, ofloxacin, norfloxacin, temafloxacin, etc.) have recently been implicated in the etiology of Achilles tendinitis and subsequent tendon rupture. We report on a patient with bilateral partial Achilles tendon ruptures associated with ciprofloxacin therapy and present a review of the current literature on this increasingly recognized complication. Treatment with fluoroquinolones should be discontinued at the first sign of tendon inflammation so as to reduce the risk of subsequent rupture. Magnetic resonance imaging is useful in distinguishing between Achilles tendinitis and partial tendon rupture.
The Subtalar Angle: A Proposed Measure of Rearfoot Structure
Authors: McClay Irene , Bray James
Published: March 2013

The purpose of this study was to propose a new measure of rearfoot structure to further enhance the understanding of the function of the foot. Landmarks visible on sagittal plane radiographs were used to represent the approximate direction of the subtalar joint axis in the sagittal plane based upon descriptions from the literature of its orientation. Four landmarks were chosen, resulting in four calculated angles. One hundred lateral view radiographs were analyzed. The mean values ranged from 28.7° to 47.7°. These values are within the ranges reported from both cadaver and in vivo studies. Tests of repeatability of the measures resulted in intraclass coefficient values between 0.94 and 0.98, suggesting good reliability. All four angles correlated highly among each other ( r = 0.88–0.97). Examination of the validity of any one of these measures is left to those who are able to accurately calculate the orientation of the subtalar joint axis.
The Foot Function Index for Measuring Rheumatoid Arthritis Pain: Evaluating Side-to-Side Reliability
Authors: Saag Kenneth G. , Saltzman Charles L. , Brown C. Kice , Budiman-Mak Elly
Published: March 2013

The Foot Function Index is a validated and reliable instrument for measuring foot pain, disability, and activity restriction in patients with rheumatoid arthritis. For the purposes of orthopaedic studies in which one foot serves as an internal control, we assessed the side-to-side reliability of the seven-question Foot Function Index pain subscale. Thirty patients with rheumatoid arthritis completed visual analog scale pain questionnaires for both feet on two occasions 8 days apart. Internal reliability of the scale was high, with Cronbach's alphas ranging from 0.94 to 0.98, suggesting good left versus right discriminatory abilities. Principal component factor analysis segregated the questions into two large clusters containing predominately either left or right foot items. Intraclass correlation coefficients were examined for test-retest reliability (separated by side) and for side-to-side reliability (separated by the day of test). The resultant intraclass correlation coefficients were nearly equivalent, ranging from 0.79 to 0.89. Generalizability analysis yielded similar results. Intraclass correlation coefficients and generalizability analysis demonstrate that the majority of variation is best explained by the differences within subjects or between subjects rather than by test-retest or side-to-side differences. We recommend the Foot Function Index as a reliable measurement scale for use in orthopaedic interventional trials.
Talar Neck Fractures: Anatomic Considerations for Posterior Screw Application
Authors: Ebraheim Nabil A. , Mekhail Anis O. , Salpietro Benjamin J. , Mermer Matthew J. , Jackson William T.
Published: March 2013

The bony window available for posterior screw placement in the talus and the morphology of the talar neck were studied in 50 dry tali. In addition, 12 cadaver specimens were used to study the posterolateral approach. The bony window was bounded medially by the lateral tubercle of the posterior process of the talus, laterally by the fibular facet, superiorly by the trochlear articular surface, and inferiorly by the posterior calcaneal facet. The average vertical thickness at 2-mm increments was recorded across the talar neck to define the bony mass available for screw insertion. The smallest thickness of the talar neck was at a point 2 mm medial to the lateral border. The thickness progressively increased in a medial direction. The superior talar neck surface was found to have an average width of 18.4 ± 1.6 mm. The angle formed between the superior and lateral surfaces of the talar neck averaged 29.3°, which would account for the better delineation of the lateral border of the neck under fluoroscopy of the talus with the foot in pronation. The diameter of the screw in relation to the window height should be considered.
Ultrasound in the Diagnosis of Posterior Tibial Tendon Pathology
Authors: Miller Stuart D. , Van Holsbeeck Marnix , Boruta Peter M. , Wu Kent K. , Katcherian David A.
Published: March 2013

We retrospectively evaluated the effectiveness of ultrasonography as a diagnostic tool for investigating pathology in the posterior tibial tendon by comparing the preoperative ultrasonograms for 17 patients with their recorded surgical findings. In all cases, the surgical findings confirmed the ultrasonographic diagnoses: 3 inflammations, 4 partial tears, and 10 ruptures. Interestingly, two ruptures had been undiagnosed by magnetic resonance imaging. Ultrasonography, which seems to be a reliable means of visualizing the extent of pathology of the symptomatic posterior tibial tendon, may be a valuable tool in surgical planning.
Peroneal Tendon Bupivacaine Injection: Utility of Concomitant Injection of Contrast Material
Authors: Mizel Mark S. , Michelson James D. , Newberg Arthur
Published: March 2013

Twenty patients received the installation of contrast material into the peroneal tendons while local anesthetic was injected as a diagnostic test. In three patients (15%), communication with the ankle joint and subtalar joint was noted, as well as failure of the contrast to fill the distal tendon. Injection of local anesthetic into the peroneal tendons as a diagnostic measure, therefore, may not have 100% sensitivity or specificity. Simultaneous injection of contrast material can be used to alert the clinician to a lack of specificity of the anesthetic test injection.
Success of Calcaneonavicular Coalition Resection in the Adult Population
Authors: Cohen Bruce E. , Davis W. Hodges , Anderson Robert B.
Published: March 2013

Twelve adult patients (13 feet), average age 33 years (range, 19–48 years), with calcaneonavicular coalitions remained symptomatic after a trial of conservative treatment. Surgical resections were performed. Before surgery, there was <5° of inversion/eversion in 11 patients, radiographic evidence of degenerative arthritis in 10 feet (77%), and talar beaking in 7 feet. At an average postoperative follow-up of 36 months, subjective relief of preoperative symptoms was achieved in all but two patients. Two patients required subsequent hindfoot arthrodesis. Resection of calcaneonavicular coalition in the adult can be successful and provides an option to arthrodesis after nonoperative methods have failed.
Plantarflexion Injury to the Metatarsophalangeal Joint (“Sand Toe”)
Authors: Frey Carol , Andersen G. Douglas , Feder Keith S.
Published: March 2013

This is a retrospective study of 12 cases of hyperplantarflexion injuries to the great toe and the lesser toes sustained in professional beach volleyball players. The hyperplantarflexion injury to the metatarsophalangeal joint, referred to as “sand toe,” can result in significant functional disability. Push-off, forward drive, running, and jumping are compromised. The average player in this series took 6 months to fully recover from the injury, and the most common problem after injury was the loss of dorsiflexion, seen in six players. Five players had residual discomfort in the injured toe, and two demonstrated an unstable toe.

Individuals who experience sand toe injuries should be treated conservatively, with taping, anti-inflammatory medications, shoe wear modification, ice, and rest. A toe strengthening program is also presented.
Subtalar Arthrodesis Using Interposition Iliac Crest Bone Graft after Calcaneal Fracture
Authors: Amendola Annunziato , Lammens P.
Published: March 2013

Fifteen consecutive patients with hindfoot pain after calcaneal fracture underwent subtalar arthrodesis using interposition iliac crest bone graft. Outcome and correction of calcaneal collapse were assessed before and after surgery with clinical examination, visual analogue scores, and standard x-rays while weightbearing. Eleven of the 15 patients were satisfied with the procedure. There were four failures due to transverse tarsal joint arthritis, overcorrection, and reflex sympathetic dystrophy. Radiographic examination revealed restoration of heel height, with 100% union rate of the arthrodesis. The described technique allows arthrodesis and correction of calcaneal collapse after calcaneal fracture.
Bridle Transfer for Paresis of the Anterior and Lateral Compartment Musculature
Authors: Prahinski John R. , McHale Kathleen A. , Temple H. Thomas , Jackson Joseph P.
Published: March 2013

In the Riordan (bridle) transfer, the posterior tibialis muscle as motor is routed through the interosseous membrane and anastomosed into a “bridle” formed by the distal tibialis anterior and peroneus longus muscles. In theory, the bridle provides inversion/eversion balance even if the transfer effects only tenodesis. However, the procedure has been criticized because its insertion is not into bone. This review analyzes the use of bridle transfer in flaccid paresis involving musculature innervated by the peroneal nerve. Surgery was performed 1 to 3 years after injury for patients with traumatic etiology. Ten patients are reviewed at 61 months’ mean follow-up. Eight patients had traumatic peroneal nerve loss. Two had neuromuscular etiology. Evaluation included review of records, telephone interviews, and physical examinations. Data on functional status included walking barefoot, running, need for bracing, return to duty, and patient satisfaction. Physical examination recorded ankle position and motions, gait findings, and results of static electromyograms.

All patients were able to walk barefoot, but 6 of 10 had a mild to moderate limp. Five patients returned to running initially; only two were able to keep running. Nine patients were brace-free initially (polio sequela required bracing initially), and four others returned to bracing. Of these, two experienced an acute “tearing” and dorsiflexion loss, one sustained a prolonged gradual loss of dorsiflexion, and one sustained a contralateral cerebrovascular accident. Only three of seven patients returned to active duty, and one is on jump status. All patients were satisfied with their initial result. Only two patients had no detectable swing phase problems (both returned to active duty). Five patients had peroneal nerve exploration with repair or neurolysis; two of them sustained complete transections. Postoperative electromyograms showed insignificant, if any, nerve return.

The Riordan transfer works well for neuromuscular flaccid paresis and in patients with peroneal nerve injuries with low demands. It may stretch out over time to the point of acute failure in patients with high demands. Concurrent peroneal nerve exploration and repair did not seem to be beneficial in this small study.
Origin and Course of the Dorsomedial Cutaneous Nerve to the Great Toe
Authors: Miller Richard A. , Hartman Gregg
Published: March 2013

The purpose of this study was to describe the course of the dorsomedial cutaneous nerve (DMCN) to the great toe. The DMCN is a branch of the medial dorsal cutaneous nerve, which originates from the superficial peroneal nerve. Injury to the DMCN may result in a painful neuroma. Identifying and protecting the DMCN to the great toe during surgical procedures near these areas may decrease the rate of painful neuroma formation.
Two-point Discrimination of Vibratory Perception on the Sole of the Human Foot
Authors: Kowalzik R. , Hermann Birgit , Biedermann H. , Peiper U.
Published: March 2013

The capability for discrimination of vibratory stimuli of the sole of the foot was tested on 12 subjects (6 men, 6 women). Two vibratory stimuli (sinusoidal impulse: frequency, 200 Hz; amplitude, 0.1 mm; duration, 2 sec) were applied at different sites to the sole of the foot. Subjects were asked whether they detected one or two vibratory sensations. The discrimination threshold was defined as the shortest distance at which two vibrations can be differentiated at repeated trials. In addition, the absolute threshold was measured by one plunger (sinusoidal vibration: frequency, 200 Hz; variable amplitude). The values of the absolute threshold (average value, 1.2 μm) were in accordance with the results of other authors.

A decrease of discrimination capability was observed along the longitudinal axis of the foot from distal to proximal parts and was about 15 mm at the big toe and 34 mm at the heel. Discrimination at the medial longitudinal arch was inferior to that at the lateral longitudinal arch. This was also true for inverse vibration in which all subjects showed lower thresholds. No relationship was found with respect to thickness of the skin (measured by ultrasound), side of foot, or gender.

Determining factors for vibratory threshold might be the density of the Pacinian corpuscles per cm2 as well as their peripheral and central representation. Anatomical or physical factors (e.g., thickness of the skin, impedance of the deeper tissue) can probably be disregarded.
Isolated First Naviculocuneiform Joint Coalition
Authors: Kumai Tsukasa , Tanaka Yasuhito , Takakura Yoshinori , Tamai Susumu
Published: March 2013

Clinical analysis was performed on 60 feet in 40 patients with isolated first naviculocuneiform coalitions. The most common symptom was a mild pain at the medioplantar site of the first naviculocuneiform joint. Fifteen feet (25%) were asymptomatic. Some cases had been treated erroneously as osteoarthritis or bony cyst before diagnosis. We divided coalitions morphologically into three patterns based on computed tomography findings: irregular, cystic, and combined pattern. Based on the mean age of each pattern, we hypothesized that initial irregular coalitions gradually develop into cystic and, finally, combined patterns.

Considering the modest number of reported cases, this condition might easily be overlooked in many patients or may be related to ethnic characteristics. We suggest that the actual incidence of first naviculocuneiform coalitions should be investigated again.
Recurrent Tarsal Tunnel Syndrome and the Radial Forearm Free Flap
Authors: Novotny David A. , Kay David B. , Parker Michael G.
Published: March 2013

Tarsal tunnel syndrome results from posterior tibial nerve entrapment beneath the flexor retinaculum and the deep fascia. The syndrome consists of pain, paresthesias, and vasomotor changes. Surgical correction via release of the flexor retinaculum is the treatment of choice. There is however, a 10% to 20% failure rate, with little in the literature addressing treatment options in this subset of individuals. Two patients with recurrent tarsal tunnel syndrome were treated with re-release of the retinaculum, followed by nerve coverage with a radial forearm free flap. At 15 and 27 months, both patients were pain-free, ambulatory, and able to return to work.
Plantar Foot Pressures During Treadmill Walking with High-Heel and Low-Heel Shoes
Authors: Nyska Meir , McCabe Chris , Linge Keith , Klenerman Leslie
Published: March 2013

The effect of walking with high-heel shoes on plantar foot pressure distribution was investigated. Ten normal women walking in shoes with low heels were compared to women walking in high-heel shoes. It was shown that high-heel shoes increased the load on the forefoot and relieved it on the hindfoot. The load passed toward the medial forefoot and the hallux. The lateral side of the forefoot showed a decrease in contact area, reduced forces, and peak pressures. The medial side of the forefoot had a higher force-time and pressure-time integral. It is suggested that these higher loads on the medial forefoot may aggravate symptoms in patients with hallux valgus deformity.
Plantar Fibromatosis: Treatment of Primary and Recurrent Lesions and Factors Associated with Recurrence
Authors: Aluisio Frank V. , Mair Scott D. , Hall Reginald L.
Published: March 2013

Plantar fibromatosis is a benign but often problematic foot disorder which, when surgically treated, is difficult to eradicate. The purpose of this investigation was to identify epidemiologic factors associated with disease recurrence and to determine which method of treatment most successfully eliminated recurrence.

A retrospective review of surgical pathology reports and clinical histories from 1979 to 1993 was performed to identify all patients who underwent surgery for plantar fibromatosis at our institution during that time. Thirty-three feet of 30 patients were identified with a minimum 2-year follow-up.

Seventeen feet underwent surgery for primary lesions, and 4 of 10 that had local excision, 1 of 3 that had wide excision, and 2 of 4 that had subtotal fasciectomy (with or without skin grafting) had recurrence.

All 16 feet in patients presenting with recurrent lesions had undergone prior local excision at other institutions. When combined with patients from our institution who underwent a second procedure, 21 feet had surgery for recurrent plantar fibromatosis. Of these, three of four had further recurrence when treated with local or wide excision. In feet with recurrences treated with subtotal fasciectomy, only 4 of 17 had recurrence after the first attempt at such treatment.

Average follow-up for all patients was 7.7 years, and all patients with postoperative recurrences showed evidence of disease within 14 months after surgery (mean, 6.9 months). Factors identified with an increased risk for recurrence were multiple nodules, bilateral lesions, and positive family history. In treating recurrent disease, subtotal fasciectomy was more effective than local or wide excision.

This study identified factors associated with a significant likelihood of postoperative recurrence in treating plantar fibromatosis and found subtotal fasciectomy to provide the most successful treatment in eradicating disease in recurrent cases.
Stable Lateral Malleolar Fractures Treated with Aircast Ankle Brace and DonJoy R.O.M.-Walker Brace: A Prospective Randomized Study
Authors: Brink Ole , Staunstrup Henrik , Sommer Jørgen
Published: March 2013

Stable lateral malleolar fractures can be treated with dynamic braces and early mobilization. In a randomized clinical trial, 66 patients with supination-eversion stage II fractures were treated with Aircast Air-Stirrup ankle braces or DonJoy R.O.M.-Walker braces. Average bracing time was 5 weeks, and average time until return to work was 6 weeks. At 4 weeks, 70% to 80% of patients were able to walk without pain. Subjective satisfaction with comfort and ease of use was significantly higher with Aircast, although it was high in both groups. Pain relief and an inflammatory score were significantly better in the R.O.M.-Walker group after 4 weeks. Three months after injury, no differences were observed in grade of ambulation, pain, swelling, range of motion, or inflammatory score. Both braces can be recommended.
Computer Evaluation of Second Tarsometatarsal Joint Dislocation
Authors: Ebraheim Nabil A. , Yang Hua , Lu Jike , Biyani Ashok
Published: March 2013

Using computer-assisted techniques, this study analyzes the mean contact area of the articular surface of the second tarsometatarsal joint. The articular contact area decreased proportionate to the displacement in both males and females, but it was consistently greater in males than in females for all simulated displacements. The reduction in the contact area was the highest with dorsolateral displacement compared with the lateral and dorsal displacements. Dorsolateral displacement of the second metatarsal of 3 mm led to 38.6% reduction in the contact area, compared with 33.1% and 20.2% reduction with lateral and dorsal displacements, respectively. This study shows that even minor degrees of displacement not apparent on plain radiographs lead to significant decrease in the contact area of the second tarsometatarsal joint. Careful evaluation of second tarsometatarsal injuries with computed tomography is recommended to detect minor degrees of displacement.
Benchmark Analysis on Diabetics at High Risk For Lower Extremity Amputation
Authors: Pinzur Michael S. , Stuck Rodney , Sage Ronald , Pocius Lisa , Trout Bryan , Wolf Brian , Vrbos Lori
Published: March 2013

After the 1990 establishment of a multidisciplinary foot salvage clinic, 1346 diabetic patients, at high risk for the development of foot ulcers and eventual lower limb amputation, were followed for 4 years. Of the 224 high-risk patients admitted to the hospital, 74 amputations (5.5%) of all or part of a lower limb were performed. Patients undergoing amputation were younger, more severely ill, and required more frequent hospitalizations because of greater organ system involvement. They were also more likely to be institutionalized after discharge. Overall, patients with long-standing adult-onset diabetes, identified as at high risk for foot ulcer development, have a substantially increased risk for lower limb amputation, multiple organ system failure, hospitalization, and institutionalization than do diabetic patients as a whole. Clinical benchmarking facilitates the identification and reduction of unnecessary variations in patient care practices. Here, a formal benchmark analysis provides the current outcome expectations for amputation rates and co-morbidities in patients with diabetes who are classified as at high risk for lower extremity amputation. Management of these patients in a structured, multidisciplinary foot salvage clinic, augmentation of baseline services, and preliminary benchmark data may provide a standard for the measurement of therapeutic interventions that improve patient care.
Ipsilateral Fractures of the Talus and Calcaneus
Authors: Gregory Paul , DiPasquale Thomas , Herscovici Dolfi , Sanders Roy
Published: March 2013

Nine ipsilateral fractures of the talus and calcaneus were treated at Tampa General Hospital between 1991 and 1994 and entered into the trauma registry of this level I trauma center. During this same period, a total of 78 talar fractures and 334 calcaneal fractures were entered into the registry. The patients who sustained this rare combined injury were studied retrospectively to characterize the fractures that occurred, examine the treatments instituted, and determine outcomes. Four patients had severe intra-articular damage of the subtalar joint surfaces and underwent either primary or delayed arthrodesis. This subgroup of patients was followed for an average of 39 months (range, 25–45 months), and all had excellent or good outcome as assessed by the Maryland Foot Score. Three patients had nondisplaced or avulsion-type fractures of both bones, which were treated with immobilization. These all healed well. One patient had a Hawkins type 2 talus fracture with an extra-articular avulsion fracture of the Achilles tendon. This patient did well with open reduction and internal fixation of both fractures. The final patient had a crushed lower extremity in association with her hindfoot injury, which resulted in primary below-knee amputation. In general, we believe each individual fracture in this combined injury can be addressed with standard treatment regimens.
A Method for the Investigation of the Effects of Outsole Modifications in Therapeutic Footwear
Authors: Cavanagh Peter R. , Ulbrecht Jan S. , Zanine William , Welling Ronald L. , Leschinsky David , Schie Carine van
Published: March 2013

Experiments to determine the effects of therapeutic shoe outsole modifications frequently require the examination of many different configurations and typically use in-shoe pressure measurement to determine the optimal design. A method is presented here to allow the foot-shoe interface to remain undisturbed as different outsole designs are used in the same patient. A standard extra-depth (or super extra-depth) shoe is modified to house three receptacles for quarter-turn fasteners in a carbon fiber plate. The fasteners pass through the outsole unit and secure it firmly to the plate. Results from a typical experiment are presented to illustrate the effectiveness of the approach. It is possible that a large clinic could use this approach in complex cases to assist with optimal footwear prescription.
Neural Fibrolipoma of the Foot: A Case Report
Authors: Donley Brian G. , Neel Michael , Mitias H.M.
Published: March 2013

Neural fibrolipoma is a benign mass of fibrofatty tissue intermixed with nerve tissue. It most commonly occurs in the upper extremity in infants and children, usually affecting the median nerve. This report describes surgical resection of a rare neural fibrolipoma of the foot in a 32-year-old woman.
Treatment of Plantar Fasciitis with a Night Splint and Shoe Modification Consisting of a Steel Shank and Anterior Rocker Bottom
Authors: Mizel Mark S. , Marymont John V. , Trepman Elly
Published: March 2013

Seventy-one feet in 57 patients with plantar fasciitis were treated with the combination of a night splint and a shoe modification consisting of a steel shank and anterior rocker bottom. At average follow-up of 16 months, symptoms were resolved in 42 (59%), improved in 13 (18%), not changed in 11 (15%), and worse in 5 (7%) of the feet. No relation was found between outcome and age, gender, duration of symptoms, and bilateral involvement. The method is effective for the treatment of plantar fasciitis.
Nonoperative Management of Posterior Tibial Tendon Dysfunction
Authors: Chao Wen , Wapner Keith L. , Lee Thomas H. , Adams Jeffrey , Hecht Paul J.
Published: March 2013

Forty-nine patients with posterior tibial tendon dysfunction (4 patients had bilateral involvement) were treated with orthoses. Forty feet were treated with molded ankle-foot orthoses, and 13 feet were treated with University of California Biomechanics Laboratory shoe inserts with medial posting. A total of 37 women and 12 men were included in the study. The mean follow-up period was 20.3 months (range, 8–60 months). The average age of the patients was 66 years (range, 42–89 years).

Sixty-seven percent of patients had good to excellent results, according to a functional scoring system based on pain, function, use of assistive device, distance of ambulation, and patient satisfaction. The average period of orthosis use was 14.9 months (range, 1.5–29 months), with an average length of daily orthosis wear of 12.3 hours. One patient elected to undergo surgical treatment rather than continuing with long-term orthosis use.

Thirty-three percent of patients had discountinued using the orthosis at the time of follow-up evaluation. Three patients were unable to wear the orthosis because of concurrent medical conditions. Nine patients stopped wearing the orthosis after experiencing discomfort and inconvenience. Although these patients continued to exhibit signs and symptoms of posterior tibial tendon dysfunction, they were not disabled enough to consider further treatment. Four patients tolerated orthosis treatment poorly and were treated surgically.

Patients with posterior tibial tendon dysfunction can be treated by aggressive nonoperative management using molded ankle-foot orthoses or University of California Biomechanics Laboratory shoe inserts with medial posting. Surgical treatment can be reserved for patients who fail to respond to an adequate trial of brace treatment. Nonoperative management using an orthosis is particularly useful for elderly patients with a sedentary lifestyle or for patients at high risk because of medical problems.
Magnetic Resonance Imaging to Detect Avascular Necrosis After Open Reduction and Internal Fixation of Talar Neck Fractures
Authors: Thordarson David B. , Triffon Mark J. , Terk Michael R.
Published: March 2013

Twenty-one consecutive patients with displaced talar neck fractures (12 Hawkins type II, 9 Hawkins type III) were prospectively evaluated with magnetic resonance (MR) scans performed between 3 days and 12 months after surgery. All patients underwent open reduction and internal fixation with titanium screws, except two who underwent fixation with stainless steel implants that were subsequently removed. All patients had plain radiographs. We classified the scans as follows: type A, no abnormal signal changes in the body of the talus; type B, signal changes in less than 25% of the body; type C, signal changes in 25% to 50% of the body; and type D, signal changes in greater than 50% of the body. Plain anteroposterior radiographs correlated well with MR scans in patients with type D scans, but an inconsistent correlation was noted with lesser degrees of signal changes (types A–C), with the MR scans being more accurate in displaying the volume of avascular bone. Scans obtained less than 3 weeks after injury were not helpful in assessing for avascular necrosis. We found that high-quality MR images of the talus were consistently obtained in the presence of titanium screws in contrast to images obtained with stainless steel implants. We use titanium screws in all talar neck fracture repairs, because they permit high-quality MR images. We believe that further study of patients with Hawkins type III fractures and Hawkins type II fractures with equivocal radiographic evidence of avascular necrosis is warranted to try to identify those patients at risk for collapse and perhaps to guide weightbearing recommendations.
Subungual Exostosis of the Foot
Authors: Palma Luigi de , Gigante Antonio , Specchia Nicola
Published: March 2013

Eleven subungual exostoses of the foot (10 on the hallux, 1 on the third toe) were studied. The initial symptom was subungual pain. When a subungual mass of fibrous tissue appeared, the nail was pushed up and in one case the mass became infected. X-rays exhibited a bone mass protruding from the terminal phalanx on the dorsomedial aspect of the toe in all cases. All patients underwent surgical excision of the lesions with partial onychectomy. Three layers were identified in five cases: a cap of fibrous tissue, a middle zone of hyaline cartilage with enchondral ossification, and a deep zone of cancellous bone. In three other cases, the histological pattern was pleomorphic and poorly characterized. The study shows that most subungual bone masses exhibited the pathological features of conventional osteochondromas. Nonetheless, a small number of lesions were pleomorphic and differed from osteochondromas, with abundant fibrous tissue merging irregularly into scattered islets of cartilage that was not organized in columns. Radical excision of the mass achieved complete relief of symptoms and recovery without recurrences in all cases.
Glomangioma of the Ankle Simulating Injury to the Flexor Hallucis Longus: A Case Report
Authors: Miyano John A. , Fitzgibbons Timothy C.
Published: March 2013

The glomangioma is one of a group of benign tumors of glomus body origin. Commonly found in the distal extremities, they may present with pain, tenderness to palpation, and sensitivity to temperature. Histologically, varying proportions of glomus cells, as well as vascular and smooth muscle elements, are found. Complete surgical excision is usually curative. We report on a glomangioma of the ankle in a 12-year-old male patient that simulated injury to the flexor hallucis longus tendon.