bluuebunny/crossref_metadata_2025 huggingface dataset:
Investigation of Muscle Imbalance in the Leg in Symptomatic Forefoot Pes Cavus: A Multidisciplinary Study
Authors: Tynan Martin C. , Klenerman Leslie , Helliwell T.R. , Edwards R.H.T. , Hayward Michael
Published: March 2013

The cross-sectional areas of the peroneal and anterior muscle compartments at the same level in the upper leg were measured using magnetic resonance imaging in 41 cases of forefoot pes cavus. The pes cavus group included idiopathic cases and pes cavus associated with Charcot-Marie-Tooth disease, Friedreich's ataxia, cerebral palsy, status postpoliomyelitis, nerve trauma, and spinal cord tethering. Thirty-nine of these cases were symptomatic. The results were compared with studies of 11 normal controls. It was found that in the majority of cases of forefoot cavus, the peroneal compartment was enlarged relative to the anterior compartment when compared with the normal controls. Biopsies of the tibialis anterior and peroneus longus muscles in 18 patients with forefoot pes cavus showed that any relative expansion of the peroneus longus was not due to pseudohypertrophy. Overaction of the peroneus longus in comparison to its antagonist the tibialis anterior is proposed as an important factor in the pathogenesis of the majority of symptomatic cases of forefoot pes cavus.
The Validity of Measurements Made on Standard Foot Orthoroentgenograms
Authors: Perry Mark D. , Mont Michael A. , Einhorn Thomas A. , Waller John D.
Published: March 2013

In certain clinical settings, standard x-rays may be misleading since they only provide two-dimensional representations of three-dimensional structures. After metatarsal osteotomy, the actual first metatarsal shortening may appear magnified on standard x-rays. We investigated variations in metatarsal and intermetatarsal angle (IMA) in a cadaver model and variations of first metatarsal length following in vivo Chevron osteotomies.

For skeletal models, changing the foot arch from pes planus to pes cavus changed the first metatarsal length by as much as 19%, whereas the measured IMA remained relatively unchanged. Pronation of the first metatarsal was found to alter the IMA (decreased for planus, increased for cavus). In vivo studies revealed a 3.2-fold difference when actual metatarsal length change following chevron osteotomy was correlated to corrected x-ray change in length (9.5% versus 2.9% P ≤ .005).

Previous investigators have evaluated hallux valgus deformities with emphasis on metatarsal lengths and IMAs to determine choices of procedure. 3 , 5 , 10 Based on the results of this study, treatment plans and further evaluation for forefoot surgery may be inaccurate if based solely on x-ray measurements.
Medial Deviation of the First Metatarsal Head as a Result of Flexion Forces in Hallux Valgus
Authors: Sanders Antal Petrus , Snijders Christiaan Johannes , van Linge Bert
Published: March 2013

Several questions with regard to the hallux valgus complex, which includes metatarsus primus varus, give rise to discussion. How do bunions develop? Is disturbed muscle balance at the first metatarsophalangeal joint important in the pathogenesis of the hallux valgus complex? What is the relation between dynamic plantar load distribution and pain in the ball of the foot? What is the cause of recurrences of deformity after surgery?

To answer these questions, we started with the bio-mechanical model of Snijders et al., 31 which states that contraction of flexor muscles of the hallux worsens its valgus angle and causes medial deviation of the first metatarsal head. The present study was designed to validate the model on patients. When pressing the hallux downward, simultaneously the force under the toe and the medial deviation of the first metatarsal head were measured on preoperative patients and on controls (35 subjects in all).

We could demonstrate with statistical significance that (1) when the subjects with hallux valgus push the great toe on the ground, the first metatarsal head moved in medial direction; in other words the foot widened. In the controls, as an average, the foot became narrower. (2) The greater the valgus deviation of the hallux, the greater the effect of the toe flexors, and (3) the greater the valgus deviation of the hallux, the less maximal flexion force it can apply.

Implications of these findings on conservative and surgical therapy are discussed. The recurrences of deformity after first metatarsal osteotomies are explained by the action of the hallux flexors. The stable result of arthrodesis of the first metatarsophalangeal joint is expected to be accompanied by narrowing of the foot as a result of contraction of the flexor muscles.
Calcaneal Fracture after Cortical Bone Removal
Authors: Manoli Arthur , Harper Marion C. , Fitzgibbons Timothy C. , McKeman Daniel J.
Published: March 2013

Four patients developed calcaneal fractures while walking, soon after bone removal from the undersurface of the calcaneus. Heel spur or osteomyelitic bone removal can lead to this complication.
Transfer versus Lengthening of the Posterior Tibial Tendon in Duchenne's Muscular Dystrophy
Authors: Greene Walter B.
Published: March 2013

Transfer of the posterior tibialis tendon to the dorsum of the foot was compared with lengthening of this tendon in 15 patients with Duchenne's muscular dystrophy.

Patients undergoing tendon transfer ( N = 9) had a longer operating time and two perioperative complications, but retained plantigrade posture of their feet even after walking ceased. By contrast, lengthening of the posterior tibialis tendon (A/ = 6) was associated with a recurrent equinovarus foot deformity that frequently interfered with shoe wear. Although transfer of the posterior tibialis is out of phase and technically more demanding, the unique prolongation of posterior tibialis strength in Duchenne's muscular dystrophy makes this operation a better option for these patients.
Quantitative Determination of Intermetatarsal Pressure
Authors: Holmes George B.
Published: March 2013

Pain, plantar to the metatarsophalangeal joints, is a common location for the presentation of pain in the forefoot. In the absence of fractures or specific inflammatory conditions common causes of pain in this area include: (1) nonspecific metatarsalgia, (2) plantar fat pad atrophy, and (3) interdigital (intermetatarsal) neuroma. The aggravation and possibly the etiology of these forms of forefoot pain may be related to acute or chronic extrinsic pressure to the forefoot. The role of nonweightbearing, compression of the metatarsal heads, weightbearing, and toe-stance (on the metatarsal heads) on the intermetatarsal pressure of the third interspace was measured in eleven asymptomatic volunteers. Intermetatarsal pressures were recorded using the Stryker Miniaturized Digital Fluid Pressure Monitor. Intermetatarsal pressures for nonweightbearing, nonweightbearing with medial-lateral compression of the metatarsal heads, weightbearing, and toe stance averaged 21 mm Hg, 22 mm Hg, 29 mm Hg, and 36 mm Hg, respectively. In comparison to nonweightbearing, significant increases in intermetatarsal pressures were measured with weightbearing (P = .0027) and toe stance (P = .0002). The change noted from weightbearing to toe-stance was also significant (P = .0005). These findings support the proposition that increases in forefoot plantar pressures convey greater pressures to the intermetatarsal space and metatarsal heads. Increased pressures to the intermetatarsal space may likewise lead to or exacerbate the symptoms of patients with fat pad atrophy, nonspecific metatarsalgia and Morton's neuroma.
Metatarsal Lengthening by Distraction Osteogenesis: A Report of Two Cases
Authors: Saxby Terence , Nunley James A.
Published: March 2013

Two cases of lengthening of metatarsals by distraction osteogenesis are reported. One of these cases is an acquired deformity of the first metatarsal; the other is a congenital short fourth metatarsal. By following the principles set forth by llizarov, it was possible to lengthen the metatarsal bones and surrounding soft tissues without open lengthening of tendons or secondary bone grafting of the distraction gap. We believe this method is an improvement over previously described methods of metatarsal lengthening.
A New Type of Dislocation of the First Metatarsophalangeal Joint: A Case Report
Authors: Hall Reginald L. , Saxby Terence , Vandemark Robert M.
Published: March 2013

We are reporting a case of traumatic dislocation of the first metatarsophalangeal joint that does not correspond to any previously reported type. This new type of dislocation was associated with a rupture of the lateral short sesamophalangeal ligament/plantar plate, partial rupture of the intersesamoid ligament, and separation of a previously bipartite tibial sesamoid. Closed reduction was easily performed; however, the distal portion of the tibial sesamoid remained trapped within the joint. The rationale for and result of surgical treatment are presented.
Bunion Correction Using Proximal Chevron Osteotomy
Authors: Sammarco G. James , Brainard Bradley J. , Sammarco Vincent James
Published: March 2013

Fifty-one cases of moderate to severe bunion deformity with hallux valgus and metatarsus primus varus in 43 patients were treated by bunionectomy, proximal Chevron metatarsal osteotomy, lateral capsulotomy, adductor tenotomy, and lashing of first and second metatarsals together. The hallux valgus angle improved an average of 19° from 33° (mean) preoperatively to 14° (mean) postoperatively. The intermetatarsal angle improved an average of 7.3° from an average of 14° preoperatively to an average of 6° postoperatively. The position of the sesamoids was realigned to beneath the first metatarsal head and the metatarsal length remained essentially unchanged. Union occurred in 9 weeks (mean). No malunions occurred. Foot score profiles revealed a significant improvement in subjective evaluation from 69/100 preoperatively to 83/100 postoperatively with respect to pain, deformity, motion, disability, and cosmesis. Seventy-eight percent of patients had a good to excellent result. Improved subjective evaluations indicated that proximal Chevron osteotomy combined with bunionectomy, capsulotomy, tenotomy, and metatarsal lashing provides a reliable method with respect to stability, technical ease, low complication, and satisfactory surgical outcome for correction of moderate and severe bunion deformity, both as a primary and revision procedure.
Evaluation of Magnetic Resonance Imaging in the Diagnosis of Osteomyelitis in Diabetic Foot Infections
Authors: Weinstein David , Wang Angela , Chambers Richard , Stewart Charles A. , Motz H. Andrew
Published: March 2013

To assess the role of magnetic resonance imaging (MRI) in diagnosing osteomyelitis in diabetic foot infections, 47 diabetic patients with clinical suspicion of osteomyelitis, nonhealing foot ulcer, or soft tissue infection of the foot were examined prospectively by MRI and plain radiographs. Pathological confirmation of diagnosis was obtained in 62 bones from 32 patients. In addition, 14 patients with pathological confirmation of diagnosis underwent technetium-99 MDP triple-phase bone and gallium-67 citrate scans. MRI was significantly more sensitive and accurate (P < .01), with equal specificity in comparison to plain radiographs and technetium and gallium scans. MRI also provided a more detailed and accurate depiction of the anatomy. At early clinical follow-up, complete resection of abnormal bone on an MRI scan correlated with clinical healing. In summary, MRI is indicated when plain radiographs are negative for osteomyelitis or when the extent and accurate depiction of the infective process will facilitate surgical planning.
Factors that Affect Surgical Correction in Congenital Talipes Equinovarus
Authors: Porter R.W. , Youle Karen
Published: March 2013

Children with congenital talipes deformity were assessed photographically at birth, and radiologically prior to a standard staged surgical procedure, carried out by one surgeon. A total of 111 feet of 86 children were assessed clinically and radiologically at 4 years of age. Feet with more deformity at birth and poorer preoperative calf muscle required more surgery and had less satisfactory results. Unilaterally affected feet required less surgery and had significantly better postoperative clinical results than bilaterally affected feet. There was a trend toward poorer results in children with a positive family history of talipes, but gender did not affect the outcome.
Bilateral Dysplasia Epiphysealis Hemimelica: A Case Report
Authors: Gregory Paul R. , Rooney Ronald J.
Published: March 2013

Dysplasia epiphysealis hemimelica is a rare disorder of cartilage growth. Classically, the disease involves a single limb and is isolated to the medial or lateral half of that limb. A patient is described who presented with classic findings of this disease but involvement of both ankles.
Osteochondral Lesions of the Talar Dome
Authors: Shea Michael P. , Manoli Arthur
Published: March 2013

Osteochondral lesions of the talar dome are a common cause of ankle disability. Management options are as numerous as the terms used to describe these lesions. The recognition of a traumatic etiology has increased our understanding and management of these disorders. Modern imaging technology has enhanced the ability to fully evaluate and accurately classify this lesion, which is fundamental for proper treatment.
Tarsal Tunnel Syndrome and Additional Nerve Lesions in the Same Limb
Authors: Sammarco G. James , Chalk David E. , Feibel John H.
Published: March 2013

Compression neuropathy in the lower extremity is common. The occurrence of more than one lesion of the nerve in the same limb is less frequent. Thirteen patients with 15 cases of tarsal tunnel syndrome associated with one or more additional lesions of the sciatic nerve or its branches of the same lower extremity are presented. Electrodiagnostic studies confirmed tarsal tunnel syndrome with conduction abnormalities at a number of lo cations along the sciatic, common peroneal, posterior tibial, or plantar nerves by mechanical impingement, met abolic axonal abnormality, or both. Seven of the 13 patients were treated with tarsal tunnel release. Six cases treated operatively improved significantly. Surgery on a previously operated foot or the existence of diabetes mellitus carried a fair prognosis. The association of back pain with or without previous surgery did not appear to affect the outcome of the tarsal tunnel release. No improvement in symptoms was apparent in the six unoperated patients during the period of the study. Multiple lesions of the nerves of a single extremity may account for the variable success rate of tarsal tunnel release.
American Orthopaedic Foot and Ankle Society Women's Shoe Survey
Authors: Frey Carol , Thompson Francesca , Smith Judith , Sanders Melanie , Horstman Helen
Published: March 2013

Shoes have been implicated as being responsible for the majority of foot deformities and problems that physicians encounter in women. A total of 356 women were studied in this investigation to evaluate trends in women's shoe wear and their effect on the development of foot deformities and pain. The majority of women in this study wore shoes that were too small for their feet, had foot pain and deformity, and had increased shoe size since the age of 20. Few women had their feet measured in over 5 years. The women without foot pain or deformities also wore shoes that were smaller than their feet but to a lesser degree.
Influence of Metatarsal Head Displacement on Metatarsal Pressure Distribution after Hallux Valgus Surgery
Authors: Wanivenhaus Axel , Brettschneider Wolfgang
Published: March 2013

We reviewed 63 feet after plain subcapital osteotomy for simultaneous correction of hallux valgus and metatarsus primus varus. Results were evaluated clinically and by radiographs and force plate measurements. Eighty-three percent of the patients were satisfied with their surgery. The hallux valgus angle was improved by 9.3° and the intermetatarsal angle by 6°. The osteotomy resulted in a displacement of the metatarsal head in the lateral direction(10 mm) and in the plantar direction (11.3 mm). Nor malization of the load distribution on the metatarsal head was achieved in the group with 11 to 15 mm of plantar displacement. Basedon our results, we recommend plain subcapital osteotomy for hallux valgus deformities with moderate metatarsus primus varus. After correction of the intermetatarsal angle and sufficient plantar displacement a physiological distribution of load on the metatarsal head can be expected.
High Pressure Water Injection Injuries of the Foot: A Report of Two Cases
Authors: Shea Michael P. , Manoli Arthur
Published: March 2013

Few cases of high pressure water injection injuries of the foot have been reported. These cases suggest that only minimal soft tissue destruction results and that, with con servative or limited surgical management, full recovery should be expected. 1 , 9 This is a report of two cases of this “benign variant” of high pressure water injection injury that resulted in toe amputations.
Circumferential Toenail
Authors: Chavda Deepak V. , Crosby Lynn A.
Published: March 2013

Congenital deformities occur in approximately 1% of all live births. 7 The exact incidence of congenital foot deform ities is unknown. The presence of a circumferential nail of the toe is a very rare deformity. In our review of the literature, we have encountered only two previously re ported cases of circumferential toenails. 1 , 6 In these cases the patients were siblings and also had circumferential fingernails. This report describes circumferential toenails without other hand or other congenital deformities.
Excision of the Posterior Tibial Tendon During Clubfoot Release
Authors: Atar Dan , Lehman Wallace B. , Grant Alfred D.
Published: March 2013

In 50 patients (72 clubfeet), the posterior tibial tendon was excised during complete soft tissue clubfoot release. The end results after an average of 3 years were graded as follows: 55.5% excellent, 29.3% good, 8.3% fair, and 6.9% poor. Heel varus and forefoot adduction were the main causes for recurrence. Heel valgus occurred in one foot. Excision of the posterior tibial tendon is safe, does not lead to overcorrection, and may prevent further scarring created when the tendon is lengthened.
Effect of Calcaneal Lengthening on Relationships among the Hindfoot, Midfoot, and Forefoot
Authors: Sangeorzan Bruce J. , Mosca Vincent , Hansen Sigvard T.
Published: March 2013

To better understand the bony component of pes planus and the means by which the Evans calcaneal lengthening corrects them, we studied the standing radiographs of seven adult patients who had undergone calcaneal lengthening to treat symptomatic pes planus. Weightbearing AP and lateral views done preoperatively and postoperatively were used for the study. For each set of films, the following parameters were measured: on the lateral view; overall length of the calcaneus, lateral talometatarsal angle, lateral talocalcaneal angle, and the calcaneal pitch angle; and on the dorsoplanar view, the talometatarsal and talocalcaneal angle. In addition, the relative coverage of the talus by the navicular was described by an angular measurement based on the relationship of the center of the talus to the center of the navicular. The average improvements in lateral talocalcaneal angle (a reflection of hind-foot valgus) was 6.4° when the long axis of the calcaneus was used and 6.8° when the inferior surface of the calcaneus was used for the measurement. The lateral talometatarsal angle improved an average 11.3° (from an average of 19.7° to 8.4°). The dorsoplantar talometatarsal angle (a measure of forefoot adduction/abduction) improved 15.8° (preoperative average 26.8°, postoperative average 11°). The calcaneal pitch angle improved an average 10.8° (preoperative average 3.2°, postoperative average 14°). The relationship between the talus and navicular was defined by an angular measurement based on the center of each articular surface before and after correction using this measurement. An average improvement of 26° occurred in the alignment of these two articular surfaces. This study confirms Evans' belief that significant correction can be obtained by lateral column lengthening, that the relationship between navicular and talus can be restored without fusion, and that the forefoot position corrects without operative intervention to the medial side of the foot. This study also provides numerical guidelines for the surgeon planning surgical correction of symptomatic pes planus, and since bony relationships can be observed before and after correction, some insight may be gained into tarsal morphology of pes planus.
Anatomic Study of Arthroscopic Portal Sites of the Ankle
Authors: Feiwell Lawrence A. , Frey Carol
Published: March 2013

Numerous anatomic structures are at risk when performing ankle arthroscopy through the more commonly utilized portals. The purpose of this paper was to demonstrate the relative safety of each of the arthroscopic portal and Acufex external ankle distractor pin sites by measuring their proximity to the neurovascular structures surrounding the ankle joint.

Six fresh cadaver specimens and 12 fresh-frozen, be-low-knee amputations were utilized for this study. An Acufex ankle distractor was applied using the standard technique. Anteromedial, anterolateral, anterocentral, posterolateral, and posteromedial portals were placed using an 11-blade scalpel to make 5-mm longitudinal incisions. The joint capsule was penetrated and a 3-mm arthroscope was placed into the ankle joint. The skin surrounding each of the portals was carefully removed and the proximity of any nerves or vessels was measured with respect to the arthroscope. At least one incidence of contact or penetration of a nerve or vessel was noted for each site. The anterocentral portal was at greatest risk for nerve or vessel damage. The anterolateral, anteromedial, and posterolateral portals were the safest areas for portal placement, with no penetration of neurovascular structures in any case.
Effect of Heel Height on Forefoot Loading
Authors: Corrigan John P. , Moore David P. , Stephens Michael M.
Published: March 2013

Sixty feet of 30 normal subjects were investigated to determine the effect of changing the heel height on forefoot loading. Subjects walked across footplates barefoot and with rigid polyurethane heels attached to the foot with a tubular bandage. The total load on the forefoot remained unchanged at all of the heel heights, but the distribution of the load changed as the heel was raised. The area of forefoot contact with the footplates decreased and there was a deviation of load toward the medial side of the forefoot with a resultant increase in pressure. These effects could contribute to overload of the distal forefoot and especially of the first ray.
Peroneus Longus Tendon Sling in Revision Surgery for Congenital Vertical Talus: A New Surgical Technique
Authors: Masterson Eric , Borton David , Stephens Michael M.
Published: March 2013

When faced with revision surgery for recurrent congenital vertical talus deformity, the tibialis anterior tendon may be deficient or absent as a result of the initial procedure. This tendon cannot then be used as a dynamic sling to dorsiflex the talar neck. We present two cases in which the peroneus longus tendon was transferred dorsally into the talar neck as an alternative to an absent tibialis anterior tendon. Excellent corrections were achieved and maintained. The use of this tendon has not been described previously in surgery for this condition.
Clinical Applications of a Pneumatic Intermittent Impulse Compression Device after Trauma and Major Surgery to the Foot and Ankle
Authors: Myerson Mark S. , Henderson Michael R.
Published: March 2013

A prospective study was designed to evaluate the effect of a pneumatic intermittent impulse device in the treatment of postsurgical and posttraumatic swelling of the adult foot and ankle.

Two groups of patients and their respective controls were studied. Group A consisted of 19 patients and 19 controls with acute swelling of the foot and ankle after major elective or posttraumatic surgery. Group B comprised 18 patients and 16 controls with chronic postsurgical or posttraumatic swelling. The pneumatic intermittent impulse device was used according to a predetermined daily regimen in both the control and experimental groups. The control patients were treated identically, except that their impulse device was modified to prevent effective compression. Reduction in swelling was measured by volumetric analysis with water displacement at selected intervals for each group. When compared with their respective controls, those patients who used an active impulse device had a statistically significant reduction in swelling. We conclude that this device is effective in the control of both acute and chronic swelling after trauma and surgery of the foot and ankle.
Morphometric Analysis of the Plantar Plate Apparatus of the First Metatarsophalangeal Joint
Authors: Prieskorn David , Graves Stanley C. , Smith Richard A.
Published: March 2013

Reliable and reproducible radiographic assessment of plantar plate integrity of the great toe is possible with standard radiographic techniques. Normal values in 100 pairs of feet (200 feet) are defined for comparison of one foot to the other and absolute values emerge if comparison is not possible. Bipartite sesamoids occurred in 13.5% of 200 feet with a 37% bilaterality.
Defining How the Prescription Footwear Association and the Board for Certification in Pedorthics Can Help the Medical Profession
Authors: Emmel Cynthia
Published: March 2013

Dorland's Medical Dictionary defines pedorthics as the art concerned with the design, manufacture, fit, and modification of shoes and related foot appliances as prescribed for the amelioration of painful or disabling conditions of the foot and limb.
Distal Blood Pressure as a Predictor for the Level of Amputation in Diabetic Patients with Foot Ulcer
Authors: Larsson Jan , Apelqvist Jan , Castenfors Jan , Agardh Carl-David , Stenström Anders
Published: March 2013

The predictive value of distal blood pressure measurements for the level of amputation was studied prospectively in 161 consecutive diabetic patients with foot ulcers. The patients were treated as outpatients except for periods of surgery and when complications requiring hospital care occurred. All patients were treated pre- and postoperatively by the same multidisciplinary foot care team. Either ankle or toe blood pressure measurement was available in 86% of the patients. Incompressible arteries, ulcer or gangrene at the measuring site, previous amputation, poor general condition, and an emergency situation were factors that excluded standardized ankle and toe blood pressure measurements in 24% and 27% of the patients, respectively. An absolute lower ankle pressure level of 50 mm Hg was found, below which a minor amputation was never sufficient to achieve healing. An ankle pressure below 75 mm Hg was seldom sufficient, and at or above that pressure level, the ankle pressure had no predictive value in this respect. At a toe pressure below 15 mm Hg, a minor amputation was seldom sufficient. Ankle and toe pressure indices gave no further information.
An Anatomical Study of the Tarsal Tunnel Using Low Pressure Compartmental Infusion
Authors: Richli William R. , Roger Douglas J. , Carrasco C. Humberto , Charnsangavej Chusilp , Rosenthal Daniel I. , Wallace Sidney
Published: March 2013

The anatomy of the tarsal tunnel is demonstrated using a low-pressure compartmental infusion technique. This is done by infusing colored radiopaque contrast material into three fresh cadaveric specimens. Thin section photography and computed tomography are then used to identify the boundaries and contents of the tarsal tunnel as it traverses the ankle, hindfoot, and midfoot. The tarsal tunnel is shown to communicate proximally with the deep posterior compartment of the leg and distally with the intermediate compartment of the forefoot. The relationships of the structures contained within the tarsal tunnel are shown in detail.
Management of Giant Cell Tumor of the Tarsal Bones: A Report of Nine Cases and a Review of the Literature
Authors: Dhillon Mandeep S. , Singh Baldev , Gill Shivinder S. , Walker Ranjana , Nagi Onkar Nath
Published: March 2013

Giant cell tumor of the tarsal bones is uncommon and therapeutic options are ill defined. We report on nine cases of giant cell tumors of the tarsal bones treated by excision of the complete bone in 6 cases, partial excision in 1 case, and curettage and bone grafting in two cases. There was no recurrence at an average 25.8-month follow-up. Function after calcanectomy was satisfactory. Excision of the talus may or may not be followed by arthrodesis, but arthrodesis is essential after excision of all the other tarsal bones except the calcaneus. We advocate aggressive surgical measures in these cases; amputation should be reserved for recurrences only. Satisfactory function may be expected after excision of tarsal bones.
Reflex Sympathetic Dystrophy in an Adolescent
Authors: Koman L. Andrew , Barden Anne , Smith Beth P. , Pollock F. Edward , Sinal Sara , Poehling Gary G.
Published: March 2013

The clinical course of an adolescent with reflex sympathetic dystrophy of the foot is presented. The potential problems of establishing objective diagnostic criteria for reflex sympathetic dystrophy are related to the dynamic nature of the disorder. Serial radiographic studies, radionuclide scans, and quantitative densitometric measurements may be useful in combination; isolated cold stress testing and laser Doppler fluxmetry are useful in assessing thermoregulation and vasomotor instability. A regimen of amitriptyline and phenytoin plus physical therapy with stress loading was useful in this patient, but in many patients the course is progressive, leading to chronic pain and debilitation.
The Safety of the Esmarch Tourniquet
Authors: Biehl William C. , Morgan James M. , Wagner F. William , Gabriel Rodney A.
Published: March 2013

The use of an Esmarch bandage as a tourniquet in surgery has been criticized. Many authors claim that the pressures under the Esmarch are inconsistent and may be extremely high. We have seen few, if any, problems from the use of an Esmarch in surgery of the foot and ankle. The purpose of this study was to evaluate the pressures generated under the Esmarch tourniquet in a situation that mimics its clinical application, and to determine whether pressures of appropriate magnitude and consistency are obtained in order to recommend its continued use in surgery.

Ten volunteers performed numerous applications of the Esmarch. The number of wraps and the width of the Esmarch bandage used were varied. The Esmarch was applied as it would be for a surgical case. Pressures directly beneath the Esmarch were recorded 8 cm proximal to the distal tip of the medial malleolus.

Considering all volunteers and all pressures generated, a 3-in Esmarch applied with three wraps gave a mean pressure (±SD) of 225 ± 46 mm Hg. A 3-in Esmarch applied with four wraps gave a mean pressure of 291 ± 53 mm Hg. A 4-in Esmarch applied with three wraps gave a mean pressure of 233 ± 35 mm Hg, and a 4-in Esmarch with four wraps gave a mean pressure of 284 ± 42 mm Hg. The maximum pressures generated by any individual were as follows: 3-in three wraps, 321 mm Hg; 3-in four wraps, 413 mm Hg; 4-in three wraps, 328 mm Hg; and 4-in four wraps, 380 mm Hg. There was no significant difference in the magnitude or consistency of pressures generated between the experienced and inexperienced wrappers. There did not appear to be a learning curve for the application of the Esmarch bandage.

We conclude that an Esmarch bandage, used as a tourniquet, can generate safe and reliable pressures. Either a 3-in or 4-in Esmarch bandage applied above the ankle with three circumferential overlapping wraps consistently results in pressures that are in a safe range.
Second Metatarsophalangeal Joint Instability in the Athlete
Authors: Coughlin Michael J.
Published: March 2013

In a group of athletically active patients, second metatarsophalangeal joint Instability was diagnosed in nine patients (11 toes). A positive drawer sign was pathognomonic of early second metatarsophalangeal joint instability. A soft tissue realignment procedure was used to stabilize the second metatarsophalangeal joint in seven toes. In five of seven cases (71%), good to excellent results were noted at an average follow-up of 20.4 months.
Comparative Study of Therapies for Fibular Ligament Rupture of the Lateral Ankle Joint in Competitive Basketball Players
Authors: Klein Jürgen , Höher Jürgen , Tiling Thomas
Published: March 2013

This retrospective study compares the results of different therapies for fibular ligament rupture in a homogenous group of professional athletes. The endpoint “competitive sports” was an outcome consideration. Subjects were examined by means of a standardized questionnaire and a structured interview. One hundred and seventy-nine of the questionnaires were completed and returned for evaluation. All of the basketball players with severe ankle sprain (supination trauma with swelling, pain, and inability to bear stress) were included. Those players with fractures of the foot, pronation trauma, or additional distal fibula or tibia fractures were excluded from this study. Of the 179 basketball players 160 (89%) had suffered severe ankle sprain. The treatment was divided into three groups: primary surgery (N = 35), plaster cast (N = 39), and functional treatment (N = 89). While simple ligament injuries (Grade I and II) were mostly treated functionally, complex ligament injuries (Grade III) were usually operated on. A total of 119 (74%) of the players reported no further pain. For pain reduction surgical and functional treatments showed advantages over plaster treatment. In the surgical group 63% of the players judged their regained stability to be equivalent to that of their healthy leg. Only 50% of the players in the plaster and functional groups believed their ankle joints to have regained the same stability as before their injuries. Despite the achievement of good results through surgery, there were clear differences in the players' assessments of their performance in competitive sports. Most subjects (92%) did not have any problems in everyday life regardless of which kind of therapy had been chosen. Of the players surgically or functionally treated, 80% regained their full ability to play, compared with only 46% of the plaster group. The results of plaster treatment are poorer than results of primary surgery and functional treatment concerning the endpoint “competitive sports.”
Surgical Treatment for Mild Deformities of the Rheumatoid Forefoot by Partial Phalangectomy and Syndactylization
Authors: Saltzman Charles L. , Johnson Kenneth A. , Donnelly Richard E.
Published: March 2013

Thirteen patients (14 feet) were treated for mild rheumatoid forefoot deformities with lesser toe partial proximal phalangectomies and partial syndactylizations. Eleven patients (85%) were reviewed at an average of 8 years postoperatively. The results were completely satisfactory in four patients, satisfactory with minor reservations in three patients, satisfactory with major reservations in one patient, and unsatisfactory in three patients. The major cause of reservations and lack of satisfaction was metatarsalgia. Seven patients (64%) reported that their activities were limited by intermittent metatarsalgia. Four patients (36%) considered the cosmetic appearance of the forefoot to be unsatisfactory. All but one patient required some form of shoewear modification. Based on this study, we believe the indications for this procedure are limited. These include rheumatoid patients with mild forefoot deformities without significant metatarsalgia or ongoing disease who have failed nonoperative treatment. Relative contraindications to this operation appear to include the recent onset of rheumatoid arthritis, active disease, significant metatarsalgia, and strong cosmetic concerns regarding outcome. In borderline clinical decisions that involve whether or not to leave or excise the lesser metatarsal heads, they probably should be excised to decrease late metatarsalgia.
Lateral Ankle Instability as a Cause of Superior Peroneal Retinacular Laxity: An Anatomic and Biomechanical Study of Cadaveric Feet
Authors: Geppert Mark J. , Sobel Mark , Bohne Walther H.O.
Published: March 2013

The role of the competent superior peroneal retinaculum (SPR) as a primary restraint to peroneal tendon subluxation and mechanical attritional wear is clear. Injury to the SPR has classically been described as a dorsiflexion aversion movement of the ankle coupled with a forceful peroneal tendon reflex contraction. This mechanism, however, does not cause injury to the lateral collateral ligaments of the ankle and does not explain the coexistent findings of lateral ankle instability, laxity of the SPR, and concurrent peroneal tendon pathology. Anatomic studies reveal a parallel alignment of the calcaneal band of the SPR and the calcaneofibular ligament. A cadaveric model of ankle instability created by serial sectioning of the lateral collateral ligaments revealed increasing visual strain on the SPR with increasing degrees of ankle instability. These findings suggest the SPR serves as a secondary restraint to ankle inversion stress and that the force or forces that result in chronic ankle instability can also injure and attenuate the superior peroneal retinaculum.
Concurrent Compartment Syndromes of the Foot and Leg
Authors: Manoli Arthur , Fakhouri Anton J. , Weber Timothy G.
Published: March 2013

We reviewed the case summaries of eight patients who developed concurrent compartment syndromes of the foot and leg after trauma. Patients with multiple fractures of the lower extremities, particularly the tibia, femur, and foot, may develop this disorder. The obvious causes of the concurrent syndromes, concurrent fractures and generalized limb ischemia, were seen only in two patients. The communication between the compartments of the foot and leg may be an additional causative factor. Delayed fasciotomy resulted in muscle necrosis and/or tibial nerve dysfunction.

Suspected cases should have the diagnosis established by catheterization of the involved compartments. Prompt fasciotomies of the foot and leg should be performed if the pressures are significantly elevated.
Extensor Hallucis Longus Coaptation to Tibialis Anterior: A Treatment for Paralytic Drop Foot
Authors: Asirvatham Rajan , Watts Hugh G. , Gillies Hamish
Published: March 2013

Between June 1982 and April 1983, a procedure to coapt the extensor hallucis longus (EHL) to the tibialis anterior was performed in eight post-polio patients to correct drop foot and to enable the EHL to be a more efficient dorsiflexor of ankle. Although at early follow-up, every patient was able to actively dorsiflex the ankle against gravity, at final review, (mean follow-up 7.8 years), only two patients could still do so. Three patients developed a cock-up toe deformity or dorsiflexion deformity of great toe. We have attributed the poor final results to stretching of the coaptation. Use of splints or orthosis for a longer period postoperatively and a more carefully designed physical therapy may have yielded better results. Alternatively, if the EHL is anchored to navicular bone better results may be obtained.
Biomechanical Evaluation of Longitudinal Arch Stability
Authors: Huang Ching-Kuei , Kitaoka Harold B. , An Kai-Nan , Chao Edmund Y. S.
Published: March 2013

In spite of the common occurrence of pes planus and multiple operations that have been reported to relieve the associated symptoms, there is little published on the relative contribution of various structures to stabilization of the arch of the foot. Twelve fresh-frozen human cadaveric feet were loaded along the tibial axis with compressive loads of 230, 460, and 690 newtons with the specimens intact and after sequential sectioning of plantar fascia, plantar ligaments, and spring ligament. Structures were sectioned in six different sequences and changes in vertical and horizontal dimensions of the medial arch were measured. The highest relative contribution to arch stability was provided by the plantar fascia, followed by plantar ligaments and spring ligament. Plantar fascia was a major factor in maintenance of the medial longitudinal arch. Its division in the cadaveric feet decreased arch stiffness by 25%.
Treatment of Infected Pilon Nonunions with Small Pin Fixators
Authors: Stasikelis Peter J. , Calhoun Jason H. , Ledbetter Billy R. , Anger Diane M. , Mader Jon T.
Published: March 2013

Six consecutive patients with infected intra-articular fractures of the distal tibia were studied. They were treated with resection of all infected or necrotic bone, systemic antibiotics, and instrumentation with a small pin fixator (llizarov external fixator). The fixator was used to perform an ankle arthrodesis and to fill the defect created by bone resection with distraction osteogenesis.

In all cases, the infections were eradicated, and a solid arthrodesis was attained. The patients required from zero to two revision procedures (average 1.3), and their time in the fixator varied from 3 to 13 months (average 8 months). All of the patients experienced at least minor complications during treatment (superficial pin tract infections).

At final follow-up, no patient demonstrated shortening of more than 1.5 cm. One patient has an internal rotation deformity of 15°; a second has a varus deformity of 10° and occasionally uses lateral support (a cane) secondary to unsteadiness on uneven ground; and one patient uses aspirin occasionally for subtalar pain. All are pleased with their results and would undergo the same procedure again without reservation.
Fatty Acid Composition of Normal and Atrophied Heel Fat Pad
Authors: Buschmann William R. , Hudgins Lisa C. , Kummer Frederick , Desai Panna , Jahss Melvin H.
Published: March 2013

Capillary gas-liquid chromatography was used to analyze the fatty acid composition of normal heel fat pads from subjects without systemic disease (N = 8) and atrophied heels from patients with diabetic peripheral neuropathy (N = 4), rheumatoid arthritis (N = 1), peripheral vascular disease (N = 1), and hereditary sensory neuropathy (N = 1). In the normal subjects, the fatty acid composition of subcutaneous abdominal fat was also obtained for comparison. Three saturated fatty acids (myristate, palmitate, and stearate) and four unsaturated fatty acids (palmitoleate, oleate, vaccenate, and linoleate) comprised over 90% of the total fatty acid composition. Higher percentages of unsaturated fatty acids and lower percentages of saturated fatty acids were found in the normal heel fat pads when compared to subcutaneous abdominal fat. The increase in the ratio of unsaturated fatty acids to saturated fatty acids (4.4 versus 2.5, P < .01) may decrease triglyceride viscosity and enhance the biomechanical efficiency of the heel fat pad. Though the number of patients is small, no statistically significant compositional differences were noted between the heel fat from normal subjects and from subjects with peripheral neuropathies, rheumatoid arthritis, or peripheral vascular disease. However, the heel fatty acid composition of the one subject with a hereditary sensory neuropathy was less unsaturated and more saturated than normal with a ratio of unsaturates to saturates similar to that of the abdomen (2.8).
Tarsal Tunnel Syndrome Secondary to Cosmetic Silicone Injections
Authors: Frey Carol , Naritoku Wesley , Kerr Roger , Halikus Nick
Published: March 2013

Silicone has been implicated as a cause of inflammatory disorders in the body including synovitis and lymphangitis. Silicone particulate matter has been shown to cause a fairly severe chronic foreign body reaction with the use of silicone prosthesis in the foot. 10 , 15 , 16 This reaction was often overlooked for years because of the limited number of subjective complaints. There are case reports of granulomatous inguinal lymphadenopathy following first metatarsophalangeal joint silicone arthroplasty. 14 , 15 Similar findings have been noted in the axilla with hand implants 2 , 5 , 7 , 9 and breast implants. 19 Of greater significance are two reports of malignant lymphoma found with silicate lymphadenopathy. 8
The Rochester Bone Trephine for Small Joint Arthrodesis in the Foot
Authors: Teasdall Robert D. , Johnson Kenneth A. , Hickman Marion L.
Published: March 2013

The Rochester bone trephine is a useful instrument for performing small joint arthrodesis in the foot. The technique involves harvesting a dowel graft from the iliac crest and then inserting the graft into a recipient bed across the small joints in the foot. Minimal surgical trauma and patient discomfort result from this technique. Three cases are presented to illustrate the usefulness and diversity of this system.
Diastasis of Bipartite Sesamoids of the First Metatarsophalangeal Joint
Authors: Rodeo Scott A. , Warren Russell F. , O'Brien Stephen J. , Pavlov Helene , Barnes Ronnie , Hanks Gregory A.
Published: March 2013

Injury to the metatarsophalangeal (MP) joint of the great toe, often termed “turf-toe”, is a common occurrence in football. We have identified four cases of first MP plantar capsular injury with diastasis of a bipartite sesamoid. In three cases, observation and protection resulted in progressive widening of the fragments associated with pain and disability. These players required resection of the distal sesamoid fragment and repair of the volar capsule. The fourth player underwent acute repair of the medial retinaculum and capsule. All players have had a full return to sports activity. Diastasis of components of a partite sesamoid provides objective evidence of disruption of the plantar capsular mechanism. Early recognition of this condition confirmed by stress radiographs is recommended. Treatment may include early protection followed by resection, if painful, or acute repair of the retinaculum. Previous descriptions of turf-toe have not included injuries to the sesamoid complex of the first MP joint. In our opinion, the term turf-toe should represent the consequences of a hyperextension injury to the first MP joint in which the volar capsule has been disrupted proximal to the sesamoid. A classification for first MP joint injuries is presented.
An Anatomic and Radiographic Investigation of the Tibiofibular Clear Space
Authors: Harper Marion C.
Published: March 2013

The tibiofibular clear space, a commonly used parameter in assessing the reduction of the syndesmosis in the management of ankle injuries, its anatomic boundaries, and resultant diagnostic ramifications were evaluated. This interval is seen to reflect the posterior aspect of the distal tibiofibular relationship and to vary not only with direct lateral displacement of the distal fibula but also potentially with rotational abnormalities of the fibula.
Stress Diagnostics of the Sprained Ankle: Evaluation of the Anterior Drawer Test With and Without Anesthesia
Authors: Becker Horst-Peter , Komischke Anja , Danz Burkhard , Bensel Rolf , Claes Lutz
Published: March 2013

This study investigated the effect of anesthesia of the peroneal communis nerve on stress diagnostics in acute ankle ligament rupture. Using a special holding device, the anterior drawer sign was measured under loading of 4 to 15 kg with and without a peroneal nerve block. In 65 patients, we found a highly significant difference between these two conditions. In a total of 110 patients, the measurement of anterior drawer sign was correlated to other diagnostic procedures. Absolute values of mechanical anterior drawer sign had a correlation of 0.479, whereas the difference of the measurements in injured and noninjured feet correlated with 0.582. We suggest anesthesia in stress diagnostics to increase accuracy. The anterior drawer sign alone, even under anesthesia, is not reliable to detect the full extent of the ligament damage.