bluuebunny/crossref_metadata_2025 huggingface dataset:
Total Calcanectomy for the Treatment of Chronic Calcaneal Osteomyelitis
Authors: Baumhauer Judith F. , Fraga Carlos J. , Gould John S. , Johnson Jeffrey E.
Published: March 2013

The purpose of this study is to present the surgical and functional results of a total calcanectomy procedure as a foot salvage alternative in patients with extensive chronic osteomyelitis of the calcaneus. A retrospective review identified eight patients treated with a total calcanectomy for a chronic nonhealing plantar ulcer of the heel and osteomyelitis of the calcaneus. The primary diagnosis was insulin-dependent diabetes mellitus (six patients), pneumococcal septicemia (one patient), and an open calcaneal fracture (one patient). The average age of the patients was 52 years. Prior procedures included irrigation and debridement of the heel ulcer (seven patients), partial calcanectomy (three patients), and split thickness skin grafting (two patients). The vascular status of each limb was assessed preoperatively. Distal extremity bypass surgery was performed on two patients before calcanectomy. Osteomyelitis of the calcaneus was diagnosed by magnetic resonance imaging alone in three patients, and by technetium/indium scans and magnetic resonance imaging in five patients. The average follow-up duration was 27.3 months (range, 6–57 months). Infection at the plantar heel was controlled in all patients. In all eight cases the incisions were closed primarily. During a prolonged time of total contact casting to facilitate wound healing, one patient developed an anterior tibial ulcer that progressed to osteomyelitis and underwent below-knee amputation. Talonavicular subluxation occurred as a late complication in one patient. This was treated with a talonavicular arthrodesis and subsequent bracing for a nonunion. An assessment of functional ambulation was performed on all eight patients. Four patients maintained the same ambulation level postoperatively in a modified heel-containment orthosis. Two patients decreased one functional ambulation level, and one patient decreased two levels. One patient underwent below-knee amputation and is currently ambulatory with a prothesis. Assessment of ankle strength and range of motion of the surgical limb demonstrated decreased dorsiflexion and plantarflexion strength and a variable range of motion compared to the contralateral limb. Total calcanectomy is an alternative procedure to transtibial amputation in patients with chronic osteomyelitis of the calcaneus. Eradication of infection and preservation of the functional ambulation is achieved.
Wound-Healing Risk Factors After Open Reduction and Internal Fixation of Calcaneal Fractures
Authors: Abidi Nicholas A. , Dhawan Sushil , Gruen Gary S. , Vogt Molly T. , Conti Stephen F.
Published: March 2013

This retrospective study investigated outcomes of wound healing in a series of 63 consecutive patients with 64 fractures of the calcaneus who underwent open reduction and internal fixation done by two surgeons experienced in this fracture during a 3-year period. Thirty-nine patients were managed preoperatively as outpatient referrals before surgery. Twenty-four patients were admitted directly to the trauma service and were managed as inpatients preoperatively. Minimum patient follow-up was 6 months, with an average follow-up of 18 months. A trend correlating the time between injury and operative intervention with the incidence of complications in wounds was noted; the incidence rose in patients who underwent surgery >5 days after their injury. Two-layered closures had a lower incidence of dehiscence compared to single-layered tension-relieving sutures. Patients with a higher body-mass index (BMI) (kg/ m2) took longer to heal their wounds. Strong trends were noted to link BMI and severity of fractures. In the outpatient group, a history of active smoking preoperatively correlated with increased time to wound healing. In 43 patients, there were no wound-healing complications. In 21 feet, there were varying degrees of wound dehiscence. Average wound healing took 47 days. Risk factors for complications in the wound after calcaneal open reduction and internal fixation include single layered closure, high BMI, extended time between injury and surgery, and smoking. Age, type of immobilization, medical illness (including diabetes), type of bone graft, or use of a Hemovac did not influence wound healing.
Results of in Situ Subtalar Arthrodesis for Late Sequelae of Calcaneus Fractures
Authors: Chandler James T. , Bonar Susan K. , Anderson Robert B. , Davis W. Hodges
Published: March 2013

A retrospective review was performed on all patients who had an in situ subtalar arthrodesis for painful sequelae of calcaneus fractures between 1989 and 1994. Nineteen feet were available for evaluation, with a mean follow-up of 27 months (range, 12–62 months). Lateral calcaneal wall decompression was performed in seven feet. Although loss of ankle dorsiflexion was associated with anterior ankle tenderness, loss of ankle dorsiflexion was not correlated with either talar declination angles or talar height differences. There was no correlation between American Orthopaedic Foot and Ankle Society hindfoot score and talar declination, talar height, or calcaneal width. Peroneal tendon/subfibular impingement, ankle tenderness, sural nerve injury and patient smoking were all statistically associated with lower scores. The calcaneocuboid joint was frequently involved in the fracture but was not painful at follow-up. Late pain after a calcaneal fracture is not caused by only subtalar arthrosis. Radiographic criteria alone cannot be relied upon for surgical decision making. Careful physical evaluation should be used to determine sources of pain. Distraction arthrodesis should be considered only if findings of anterior ankle impingement are present. If sural nerve symptoms are present, a sural neurectomy may be added to the procedure. Pain localized to the plantar fat pad should be managed nonoperatively. Radiographic changes in the calcaneocuboid joint rarely require surgical intervention. Based on these results, in situ subtalar arthrodesis with lateral wall decompression is the procedure of choice in most cases of subtalar traumatic arthritis with lateral wall impingement.
Biomechanical Evaluation of Two Different Screw Positions for Fusion of the Calcaneocuboid Joint
Authors: Kann N. Jeffrey , Parks Brent G. , Schon Lew C.
Published: March 2013

In triple arthrodesis performed for severe deformity and neuroarthropathy in poorly compliant patients with os-teoporotic bone, fixation of the arthrodesis is critical. We biomechanically tested an alternative means of stabilization for calcaneocuboid fusions. In seven matched pairs of fresh-frozen cadaver feet, we removed the soft tissue from around the calcaneocuboid joint, except for the capsule, and we did not resect the articular cartilage. One joint of each pair was fixed with an oblique standard screw, and the contralateral joint was stabilized with an axial screw placed perpendicularly to the joint surface. Testing on an MTS Mini Bionix Test Frame (MTS Systems Corp., Eden Prairie, MN) demonstrated that the axial screw provided significantly higher initial stiffness and maximum load to failure. We concluded that an axial screw provided better fixation of the calcaneocuboid joint.
Treatment of Complex Calcaneal Fractures with Bony Defects from Land Mine Blast Injuries with a Circular External Fixator
Authors: Gür Ethem , Ateşalp Sabri , Başbozkurt Mustafa , Aydoğan Nevres , Erler Kaan
Published: March 2013

Four calcanei, which were massively destroyed as a result of blasting injuries from land mines, and 18 severely comminuted calcaneal fractures with bony defects (in one patient, both feet), also from land mines, were treated using a circular external fixator for reconstruction by osteogenic distraction. Because of the severe destruction of tissue to be treated, definitive orthopaedic treatment was delayed for 3 to 28 months (average, 10.1 months) after injury. Time from first use of the circular external fixator to removal of the apparatus ranged from 110 to 175 days (average, 143.7 days). Mean follow-up was 18 months. Of the 22 calcaneal injuries, 4 had excellent results, 11 good, 5 fair, and 2 had poor results. Better results were achieved in cases with lesser defects in bone and where definitive orthopaedic treatment was delayed until problems in soft tissue could be treated.
Idiopathic Pseudoaneurysm of the Dorsalis Pedis Artery Mimicking Pigmented Villonodular Synovitis
Authors: Millett Peter J. , Potter Hollis , O'Malley Martin J.
Published: March 2013

Pseudoaneurysm of the dorsalis pedis artery is uncommon and is usually associated with a history of trauma to the vessel. Without such a history, the diagnosis may be challenging, because the mass may be confused with other common soft tissue masses in the foot. This case report describes a 67-year-old man with an idiopathic pseudoaneurysm of the dorsalis pedis artery that mimicked pigmented villonodular synovitis.
Rank Order Analysis of Tibial Plafond Fractures: Does Injury or Reduction Predict Outcome?
Authors: DeCoster T.A. , Willis M.C. , Marsh J.L , Williams T.M. , Nepola J.V. , Dirschl D.R. , Hurwitz S.R.
Published: March 2013

We investigated the effects of severity of initial injury pattern and the quality of the articular reduction on outcome of displaced intra-articular distal tibial fractures, using a series of 25 patients who were treated with articulated external fixation and limited internal fixation, which provided a spectrum of reduction quality. Outcome was assessed by clinical ankle scores and radio-graphic arthrosis. The results demonstrate the rank order method to be a reliable means of stratifying severity of injury and quality of reduction. Neither injury nor reduction correlated with clinical ankle score. Reduction had a significant correlation with radiographic arthrosis. We conclude that the rank order method is useful in stratification of fracture patients, and that factors other than injury pattern and quality of articular reduction are important in determining outcome of patients with this severe articular injury.
Natural Selection and High Heels
Authors: Smith Euclid O. , Helms Whitney S.
Published: March 2013

EDITORIAL COMMENT

This new section of the journal has been added to provide readers with a broader contact with specific information. In many cases, information which is of interest to the reader but does not conform to the strict peer review guidelines is available. We welcome submissions from our readers with opinions, ideas, or essays that are of interest to the readers of Foot & Ankle International. Lowell D. Lutter, M.D. Editor-in-Chief Foot & Ankle International
Comparison of the Results of the Weil and Helal Osteotomies for the Treatment of Metatarsalgia Secondary to Dislocation of the Lesser Metatarsophalangeal Joints
Authors: Trnka Hans-Jörg , Mühlbauer Michaela , Zettl Reinhard , Myerson Mark S. , Ritschl Peter
Published: March 2013

We retrospectively reviewed the outcome of 30 patients who were treated surgically for metatarsalgia resulting from dislocation of one or more lesser metatarsophalangeal (MTP) joints. We used two treatments, including an osteotomy of the metatarsal head (Weil osteotomy, N = 15) or an osteotomy of the metatarsal shaft (Helal osteotomy, N = 15). Before surgery, all patients had been treated with various nonoperative modalities for a minimum of 6 months. Between 1991 and 1993,15 consecutive patients underwent a Helal osteotomy (22 metatarsals), and 15 consecutive patients were subsequently treated between 1994 and 1995 with a Weil osteotomy (25 metatarsals). All patients were evaluated clinically and radiographically at a mean follow-up period of 22 months (range, 12–39 months), noting especially persistent subluxation or dislocation, recurrent metatarsalgia, and transfer lesions. Patients managed with a Weil osteotomy had significantly higher satisfaction ( P = 0.049), lower incidence of recurrent metatarsalgia (0 vs 27%, P = 0.107), and fewer transfer lesions (0 vs 41%, P = <0.001) than those managed with a Helal osteotomy. Furthermore, those managed with the Weil procedure had a higher percentage of radiographic reduction and maintenance of the MTP joint dislocation (21 of 25, 84% vs 8 of 22,36% P = 0.002) than those managed with the Helal procedure. In the Weil group, there was also no malunion or pseudoarthrosis; in the Helal group there were five malunions and three pseudoarthroses.

Although the follow-up period for the Weil osteotomy (15 months) was shorter than that for the Helal osteotomy (26 months), the former group had higher American Orthopaedic Foot and Ankle Society forefoot scores, which were significantly different from the results attained with the Helal osteotomy. A telephone update was performed on the Weil osteotomy group at an average of 27 months postsurgery, and no patient had experienced changes since the clinical follow-up. We concluded that the Weil procedure is a satisfactory method for correcting metatarsalgia caused by dislocation of the MTP joint and that, because of the high complication rate, the Helal osteotomy is not an acceptable procedure for correcting this condition.
Involvement of the Foot and Ankle in Patients with Gaucher Disease
Authors: Katz Kalman , Kornreich Liora , Horev Gadi , Ziv Nitza , Soudry Michael , Cohen Ian J.
Published: March 2013

Of 48 children with type I Gaucher disease treated at our hospital, 11 had involvement of the foot and ankle that first appeared in adolescence. Follow-up ranged from 3 to 27 years (average, 10 years). We reviewed their clinical and radiographic histories. Patients presented with four types of pain: six (7 events of pain) complained of dull pain defined as nonspecific; seven (11 events) had severe pain caused by bone crisis; two (2 events) had moderate progressive pain caused by pathological fractures; and one had painful swollen ankles caused by degenerative arthritis. Greater awareness of these complications in patients with Gaucher disease will prevent misdiagnosis and lead to early treatment.
Medial Longitudinal Arch of the Foot: Stationary Versus Walking Measures
Authors: Cashmere Trisha , Smith Richard , Hunt Adrienne
Published: March 2013

We describe the characteristics of the medial longitudinal arch (MLA) of the right foot in 19 healthy men while sitting/partial bodyweight, standing/full bodyweight, and during the stance phase of walking. Three measurements were selected as representative of the MLA, including: height of the arch, length of the arch, and supranavicular angle. Mean values were calculated in three dimensions for each measure in the sitting and standing conditions and for the minimum value of each measure in the walking condition. Patterns measured during walking had high association ( r = 0.999) and could be related to phases of stance. In the stationary conditions, the MLA varied significantly ( P <0.001). No significant relationship of arch height, arch length, or supranavicular angle was found between sitting and standing or between stationary and walking conditions. It was concluded that none of the static variables could be used to predict others and that static measures of the MLA do not predict the dynamic motion of the MLA. The MLA may not be a reasonable indicator of behavior or motion of the foot.
Natural History of the Rearfoot Angle: Preliminary Values in 150 Children
Authors: Sobel Ellen , Levitz Steven , Caselli Mark , Brentnall Zina , Tran Michael Q.
Published: March 2013

The degree of valgus in the heel during weightbearing (the rearfoot angle) is commonly used as an angular criterion in the evaluation and treatment of flatfoot in children and adults. The rearfoot angle has been frequently reported to reduce with age to a vertical heel position attained at approximately 7 years old. The present study evaluated the rearfoot angle in 150 healthy children (age range, 6-16 years). The average rearfoot angle for all children in this study was 4° of valgus (SD, 1.1° range, 0°-9° of valgus). There was no significant difference in the rearfoot angle in children of different ages. The rearfoot angle did not reduce to the vertical heel position by age 7 as had been reported previously.
Effect of Ankle and Knee Position on Tension in the Achilles Tendon
Authors: Davis William L. , Singerman Robert , Labropoulos Panagiotis A. , Victoroff Brian
Published: March 2013

The purpose of this study was to evaluate the relative contributions of ankle and knee position to tension in the Achilles tendon and to determine whether there exists a position of plantarf lexion at which the passive tensioning effect of knee extension is eliminated. Seven matched pairs of fresh-frozen cadaver lower extremities were tested. A buckle transducer was used to measure forces in the tendon throughout the full range of knee motion, with the hindfoot fixed.

Positioning the hindfoot in 20° to 25° of plantarflexion effectively eliminates tension in the Achilles tendon, regardless of knee position. This information is directly applicable both to the nonoperative treatment of ruptures of the Achilles tendon employing a short leg cast and to surgical repairs, in which tension must be controlled precisely.
Risk of Sural Nerve Injury with Intramedullary Screw Fixation of Fifth Metatarsal Fractures: A Cadaver Study
Authors: Donley Brian G. , McCollum Michael J. , Murphy G. Andrew , Richardson E. Greer
Published: March 2013

The risk of injury to the sural nerve and its branches during operative procedures performed on the lateral foot and ankle is well recognized; however, there have been no anatomic studies demonstrating the proximity of the sural nerve branches to the head of an intramedullary screw used for fixation of fractures of the proximal fifth metatarsal. Dissection of 10 cadaver specimens, after insertion of 4.5-mm screws, demonstrated that the screw head was within 2 mm of the dorsolateral branch of the sural nerve in five specimens and within 3 mm of eight specimens. Irritation of or injury to the nerve during screw insertion may explain the persistence of pain after screw removal in some patients. Furthermore, patients could sustain injury to the sural nerve at the time of screw removal. Careful surgical technique, including the use of drill guides and tissue protectors, may help lessen the risk of sural nerve injury and subsequent neuroma formation.
Arthroscopic Evaluation of the Subtalar Joint: Does Sinus Tarsi Syndrome Exist?
Authors: Frey Carol , Feder Keith S. , DiGiovanni Christopher
Published: March 2013

This is a retrospective review of 49 subtalar arthrosco-pies performed between 1989 and 1996. Patients were evaluated in the following areas: (1) preoperative diagnosis, (2) preoperative tests and clinical evaluation, (3) intraoperative findings, (4) postoperative diagnosis,(5) complications, and (6) clinical outcome. Particular attention was paid to the accuracy of the preoperative diagnosis, subtalar instability, intraoperative findings in sinus tarsi syndrome, and clinical outcome. Overall, this study demonstrated a success rate of 94% good and excellent results in the treatment of various types of subtalar pathologic conditions with arthroscopic techniques. The Workers’ Compensation cases reported 90% good and excellent results. The complication rate was low, with five minor complications reported. The most common complication was a transient neuropraxia involving branches of the superficial peroneal nerve.

Of the 14 feet that had a preoperative diagnosis of sinus tarsi syndrome, all the diagnoses were changed at the time of arthroscopy. The postoperative diagnoses included 10 interosseous ligament tears, two cases of arthrofibrosis, and two degenerative joints. Based on these findings, “sinus tarsi syndrome” seems to be an inaccurate term that should be replaced with a specific diagnosis. Arthroscopy is the tool that will allow the orthopaedic surgeon to make a more accurate diagnosis.
Osteotomy for Malunion of a Talar Neck Fracture: A Case Report
Authors: Monroe Michael T. , Manoli Arthur
Published: March 2013

A malunion of the talar neck after a Hawkins type II fracture/dislocation of the talar neck occurred in a 34-year-old man after nonoperative treatment. Rigid varus deformity of the forefoot was a source of severe pain and disability in this patient. We describe our surgical technique for osteotomy of the talar neck with insertion of a tricortical iliac crest bone graft to correct the deformity. At follow-up (56 months), the patient had consistent relief of pain and was employed at his preinjury job doing heavy labor. The score on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale improved from 11 points, preoperatively, to 85 points, postoperatively. Radiographs showed maintenance in the position of the osteotomy and no evidence of avascular necrosis in the talar body. Evidence of arthrosis of the talonavicular joint was apparent radiographically, but the patient did not complain of symptoms referable to this area.
Inferomedial (Subsustentacular) Dislocation of the Navicular: A Case Report
Authors: Dhillon Mandeep S. , Gupta Ravi , Nagi Onkar N.
Published: March 2013

A unique case of subsustentacular dislocation of the navicular is presented. The authors propose that such a severe displacement cannot occur until there is complete instability across the whole midfoot. The mechanism of injury and the treatment options are discussed. In the present case, there was late collapse of the foot into abduction because the lateral column was not primarily stabilized. Avascular necrosis is a common complication which leads to navicular collapse. A midfoot arthrodesis gave a good result in our patient.
Comparison of Custom and Prefabricated Orthoses in the Initial Treatment of Proximal Plantar Fasciitis
Authors: Pfeffer Glenn , Bacchetti Peter , Deland Johnathan , Lewis AI , Anderson Robert , Davis William , Alvarez Richard , Brodsky James , Cooper Paul , Frey Carol , Herhck Richard , Myerson Mark , Sammarco James , Janecki Chet , Ross Steven , Bowman Michael , Smith Ronald
Published: March 2013

Fifteen centers for orthopaedic treatment of the foot and ankle participated in a prospective randomized trial to compare several nonoperative treatments for proximal plantar fasciitis (heel pain syndrome). Included were 236 patients (160 women and 76 men) who were 16 years of age or older. Most reported duration of symptoms of 6 months or less. Patients with systemic disease, significant musculoskeletal complaints, sciatica, or local nerve entrapment were excluded. We randomized patients prospectively into five different treatment groups. All groups performed Achilles tendon- and plantar fascia-stretching in a similar manner. One group was treated with stretching only. The other four groups stretched and used one of four different shoe inserts, including a silicone heel pad, a felt pad, a rubber heel cup, or a custom-made polypropylene orthotic device.

Patients were reevaluated after 8 weeks of treatment. The percentages improved in each group were: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4)stretching only, 72%; and (5) custom orthosis, 68%. Combining all the patients who used a prefabricated insert, we found that their improvement rates were higher than those assigned to stretching only ( P = 0.022) and those who stretched and used a custom orthosis ( P = 0.0074). We conclude that, when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symp-toms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device.
Results After Cheilectomy in Athletes with Hallux Rigidus
Authors: Mulier Thomas , Steenwerckx Annie , Thienpont Emanuel , Sioen Wouter , Hoore Karl D. , Peeraer Louis , Dereymaeker Greta
Published: March 2013

From 1987 to 1993, 20 athletes (22 feet) underwent cheilectomy 10 for Regnauld grade I, 7 grade II 16 hallux rigidus. Average age was 31 years (10 men and 12 women); mean follow-up was at 5.1 years. All patients performed high-level sports (judo, track & field, soccer, and skating). Indications for surgery included failure of nonsurgical treatment with persistent pain during sports activities, shoefitting problems, and recurrent bursitis.

The aim of our study was to evaluate the results clinically, radiographically, and objectively, using dynamic and static pedodynographic measurements. After a mean follow-up of 5 years, cheilectomy was demonstrated to be a reliable treatment method in athletes with Regnauld grades 1 and 2 hallux rigidus. Functionally, 14 excellent, seven good, and one fair result were noted. Radiological progression was noted in 7 of 13 patients, with a follow-up of >4 years.

Postoperative dynamic pedodynographic findings demonstrated moderate but significant changes in peak pressures under the first metatarsal head, the hallux, and in the center of pressure distribution under the forefoot.
Plantar Fibromatosis: An Immunohistochemical and Ultrastructural Study
Authors: de Palma Luigi , Santucci Attilio , Gigante Antonio , Di Giulio Alessandro
Published: March 2013

The analogies between plantar fibromatosis and Du-puytren's disease (palmar fibromatosis) are well known. The latter is clinically more frequent and has been the object of extensive immunohistochemical and ultra-structural studies, with a view to investigating its patho-genesis. By contrast, such data on plantar fibromatosis are quite scarce. A histochemical, immunohistochemical, and ultrastructural study was performed on nodule tissue from six patients who were subjected to total fasciectomy for plantar fibromatosis. The study of myo-fibroblasts revealed features suggestive of their fibro-blastic origin and evidenced a cytoskeleton and an extracellular filamentous system that could enable myofibroblasts to generate and exert the intracellular forces that contribute to the contraction of the aponeu-rosis. These aspects are similar to those observed in Dupuytren's disease and seem to lend support to the theory that the two diseases are expressions of the same disorder.
Levels of High Energy Phosphate in the Dorsal Skin of the Foot in Normal and Diabetic Adults: The Role of 31P Magnetic Resonance Spectroscopy and Direct Quantification with High Pressure Liquid Chromatography
Authors: Smith Douglas G. , Mills William J. , Steen R. Grant , Williams David
Published: March 2013

Determining viability of tissues and wound-healing potential in diabetic patients remains a significant challenge. Current methods for preoperative assessment of wound-healing potential (pressures in the ankle, temperature of tissues, transcutaneous measurements of oxygen, and systemic nutritional status) are indirect, in that they characterize the delivery of oxygen or other nutients to the cells. A noninvasive means to measure adenosine triphosphate (ATP) and phosphocreatine (PCr), the fundamental high energy phosphate substrates of oxidative energy-metabolism in the skin, has been devised by using magnetic resonance spectroscopy (MRS). The signal-to-noise ratio of bioenergetic metabolites in the skin was 86% lower in five patients with diabetes who had ischemia of the lower extremity compared with five control subjects (P < 0.0001), suggesting that the concentration of high energy metabolites in diabetic patients was reduced. The ratio of ATP/phosphocreatine (PCr) in patients with diabetes was also significantly lower than in controls (P < 0.01). Chewing a single piece of nicotine gum reduced the measured concentrations of ATP and PCr in control subjects by an average of 18% and by an average of 75% in subjects with diabetes. To verify these results in a second experiment, skin was harvested from the surgical wound sites in eight patients with diabetes undergoing elective amputation, eight patients with diabetes undergoing elective foot surgery, and ten age-matched control (nondiabetic) patients undergoing elective foot surgery. Analysis of ATP and PCr using high pressure liquid chromatography corroborated MRS findings, showing a significant reduction in ATP and PCr in diabetic skin. Depression of metabolites was more severe in the patients with diabetes undergoing amputation than in the ones undergoing elective surgery. Results demonstrate depression of metabolites in the skin of patients with diabetes and suggest that MRS with 31P may be useful in characterizing metabolites in the skin.
Does Arch Height Affect Impact Loading at the Lower Back Level in Running?
Authors: Ogon Michael , Aleksiev Assen R. , Pope Malcolm H. , Wimmer Cornelius , Saltzman Charles L.
Published: March 2013

The purpose of this study was to evaluate the influence of the medial longitudinal arch height on the shock wave that repetitively reaches the lower back in running. Impact forces were measured simultaneously at the ground by a force plate and at the level of the low back, by means of an accelerometer, skin-mounted at the L3 spinal process. The medial longitudinal arch height was calculated as navicular height + foot length. Twelve healthy subjects ran barefoot and with an identical sport shoe at a constant speed. The sample size was divided equally into a low-arch and a high-arch group. Statistical analysis was performed by multivariate analysis of variance and Pearson's correlation. At low back level, there was a significantly lower acceleration amplitude and rate in the high-arch group (amplitude = mean, 1.74 g and SD, 0.94 g; rate = mean, 71.2 g/sec and SD, 58.0 g/sec) compared with the low-arch group (amplitude = mean 2.25 g and SD, 1.11 g; rate = mean, 111.5 g/sec and SD, 68.6 g/sec) (P < 0.001, each). At the ground, there was a slight negative correlation between arch height and initial loading rate in AP (−0.19; P < 0.01) and vertical (−0.22; P < 0.001) directions and a positive correlation between arch height and initial loading rate in the medial direction (0.22, P < 0.05). The results indicate that the high-arch foot is a better shock absorber with regard to the low back level than the low-arch foot.
Guidelines for Teaching the Foot and Ankle in an Orthopaedic Residency
Authors: Hurwitz Shepard R.
Published: March 2013

Orthopaedic graduate medical education includes evaluation and treatment of problems of the foot and ankle. The challenges of managed care, podiatry, and institutional resources have reshaped the way we educate orthopaedic residents as managers of disorders of the foot and ankle. The most useful tools acquired in residency will be those that establish a strong medical and surgical foundation in problems of the foot and ankle and foster lifelong adaptation of new knowledge and techniques.
Role of the Peroneal Tendons in the Production of the Deformed Foot with Posterior Tibial Tendon Deficiency
Authors: Mizel Mark S. , Temple H. Thomas , Scranton Pierce E. , Gellman Richard E. , Hecht Paul J. , Horton Greg A. , McCluskey Leland C. , McHale Kathleen A.
Published: March 2013

Ten patients were identified with traumatic, complete common peroneal nerve palsy, with no previous foot or ankle surgery or trauma distal to the knee, who had undergone anterior transfer of the posterior tibial tendon to the midfoot. Six of these patients had a transfer to the midfoot and four had a Bridle procedure with tenodesis of half of the posterior tibial tendon to the peroneus longus tendon. Average follow-up was 74.9 months (range, 18–351 months). All patients] feet were compared assessing residual muscle strength, the longitudinal arch, and motion at the ankle, subtalar, and Chopart's joint. Weightbearing lateral X-rays and Harris mat studies were done on both feet. In no case was any valgus hindfoot deformity associated with posterior tibial tendon rupture found. It seems that the pathologic condition associated with a posterior tibial tendon deficient foot will not manifest itself if peroneus brevis function is absent.
Late Results of Modified Mitchell Procedure for the Treatment of Hallux Valgus
Authors: Fokter Samo Karl , Podobnik Janez , Vengust Vilibald
Published: March 2013

From a total of 153 patients (251 feet), 64 (41.8%) patients, who had had 105 modified Mitchell procedures, were clinically and radiographically examined with follow-up periods ranging from 15 to 24 years (mean, 21 years). Mean age at operation was 41 years (range, 12–64 years).

The classic double osteotomies, which diverged slightly toward the plantar surface and the distal fragment, shifted laterally, and angled plantarward, were fixed with a smooth Kirschner wire. In this way, it was possible to achieve a reduction in the first intermetatarsal angle from an average of 22.5° preoperatively to 7.7° postoperatively, and the hallux valgus angle changed from an average of 33° to 17°, with an average shortening of the first metatarsal of 5.4 mm and an average lateral displacement of the first metatarsal head of 4.5 mm.

In 67 feet (64%), the results were graded good to excellent; in 23 feet (22%), satisfied; and in 15 feet (14%), poor. The results were worse than the results obtained on the same patient population with a follow-up ranging from 2 to 11 years, with 97% good-to-excellent results reported. Pain over bunion caused by recurrence of the hallux valgus deformity was the main reason for this late deterioration of the results.
Modification of the Mitchell Osteotomy
Authors: Freund Elisha I.
Published: March 2013

This technical modification of the Mitchell osteotomy facilitates the creation of the “step” in the distal fragment of the osteotomy and permits accurate alignment.
Chronic Achilles Tendinopathy in Athletic Individuals: Results of Nonsurgical Treatment
Authors: Angermann Peter , Hovgaard Dorrit
Published: March 2013

We report the results of nonsurgical treatment of chronic Achilles tendinopathy in 22 patients with a follow-up of 33 to 72 months. Immediately after the treatment period, 70% of the patients were either improved or cured. At follow-up, 65% were improved or cured, and 35% failed treatment or had a poor long-term result. In these patients, early surgery might have been considered, but only one patient received a peritendinitis operation in the follow-up period. In athletic individuals with chronic Achilles tendinopathy, nonsurgical treatment with emphasis on active training is recommended. Surgery should be considered if the athlete has been treated for 3 to 6 months without progress.
Open Versus Closed Repair of the Achilles Tendon: An Experimental Animal Study
Authors: Pneumaticos Spiros G. , Noble Philip C. , McGarvey William C. , Mody Dina R. , Trevino Saul G.
Published: March 2013

This experimental animal study compared the healing patterns between open and closed treatments of Achilles tendon tenotomies. Twenty-four male New Zealand rabbits underwent tenotomy of the left Achilles tendon and were randomized into two groups, treated with either open surgical repair or closed management. After the death of the animal, the retrieved tendons were submitted for biomechanical and histological testing. The total elongation of the open treatment group was 9.5 ± 1.0 mm compared with 21.2 ± 3.4 mm for the closed treatment group ( P = 0.008), and the regain of stiffness was 67.4 ± 2.0% and 48.9 ± 5.3%, respectively ( P = 0.132). Histological evaluation demonstrated similar healing patterns in both groups.
Xanthomas of the Achilles Tendon: Report of a Bilateral Case and Review of the Literature
Authors: Carranza-Bencano Andrés , Fernádez-Centeno Manuel , Leal-Cerro Alphonso , Duque-Jimeno Vitorio , Gomez-Arroyo José Antonio , Zurita-Gutierrez Miguel
Published: March 2013

We report a case of bilateral Achilles tendon xanthoma as the first clinical manifestation of familial hypercholesterolemia. We review the literature and stress the need for orthopaedic surgeons to be familiar with this disease. An early diagnosis of this metabolic disorder is important to institute medical therapy and to alter the course of the disease before the onset of coronary artery disease.
Evaluation of Ankle Instability Using the Biodex Stability System
Authors: Testerman Chris , Griend Robert Vander
Published: March 2013

Ten patients with chronic unilateral functional lateral instability of the ankle were evaluated using the Biodex Stability System. This system uses a multiaxial testing platform which can be set at variable degrees of instability. Patients are then tested for their ability to “balance” the platform during single-limb stance, and a stability index is electronically generated. This stability index is believed to be an objective measurement that correlates with proprioceptive status of the ankle.

Instability of the ankle was confirmed in all 10 patients, using stress radiographs. Two levels of platform stability were tested. With the platform in its most stable configuration, there was minimal difference between the previously injured and the uninjured ankle. With the platform set to permit up to 20° of tilt in any plane, 6 of 10 patients had more difficulty balancing the platform with their injured ankle (higher stability index). This preliminary study suggests that the Biodex Stability System may be a useful tool in trying to objectively measure proprioceptive function.
Pigmented Villonodular Synovitis of the Foot And Ankle: A Review of Six Cases
Authors: Ghert Michelle A. , Scully Sean P. , Harrelson John M.
Published: March 2013

Pigmented villonodular synovitis is a rare but well recognized proliferative lesion of synovial tissue. It has been most commonly described in the knee and hip, with most series reporting <5% occurrence in the foot and ankle. Six patients with pigmented villonodular synovitis of the foot and ankle that was treated between 1978 and 1997 were reviewed. Four of the patients had not been previously diagnosed, and two patients presented with recurrent disease. All six were women. Two patients] disease presented isolated to the ankle joint. The other four involved more than one joint: subtalar joint and midfoot in two, and the metatarsal region in two. The histology of the primary and recurrent lesions did not differ. The recurrent lesions were more diffuse and locally destructive. Five were found on magnetic resonance imaging to be a low-to-medium signal intensity mass on T1- and T2-weighted images. Surgical management ranged from simple excision to synovectomy to Lisfranc amputation. Average follow-up was 13 months (range, 3 weeks to 51 months). One of the lesions recurred 4 years later.
Excrescent Lesion: A Diagnosis of Lateral Talar Exostosis In Chronically Symptomatic Sprained Ankles
Authors: Dixon David J. , Monroe Michael T. , Gabel Steve J. , Manoli Arthur
Published: March 2013

The excrescent lesion is a symptomatic anterolateral exostosis at the insertion of the anterior talofibular ligament. It is found in patients with chronic ankle pain after inversion injuries. It is most reliably diagnosed by computed tomography scan, but physical examination and oblique radiographs are suggestive in most cases. A technique for surgical excision and, in some cases, repair of the anterior talofibular ligament is described.

Five patients having a history of inversion sprains of the ankle, without significant symptomatic improvement for a mean of 21 months after the injury, were evaluated. None had significant instability in the ankle or subtalar joints, clinically or with stress radiographs. The diagnosis of excrescent lesion was confirmed with computed tomography scan in all five patients. Each underwent excision of the exostosis. Removal of the exostosis produced laxity of the anterior talofibular ligament in four of the patients and required an additional modified Broström procedure to tighten the anterior talofibular ligament.

Clinical results were evaluated at a mean of 33 months postoperatively, using the Ankle-Hindfoot scale from the American Orthopaedic Foot and Ankle Society. The three patients without pending claims for Workers] Compensation or related litigation all had excellent results (mean score, 93 points). Two patients with active legal claims had fair and poor results (mean score, 53 points).
Efficacy of Three-Phase Bone Scans in Evaluating Diabetic Foot Ulcers
Authors: Jay Peter R. , Michelson James D. , Mizel Mark S. , Magid Donna , Le Tung
Published: March 2013

To evaluate the utility of bone scans in determining the treatment of diabetic patients with foot ulcers, a retrospective study was conducted. Medical records were reviewed for clinical signs of infection, laboratory data, and the radiologists' interpretations of imaging studies. During the study period, 34 bone scans were obtained by the treating physicians to evaluate diabetic foot ulcers. Among these, 22 of 34 bone scans were markedly confirmatory of being “consistent with osteomyelitis,” 8 of 34 were moderately confirmatory (“indeterminate with regard to osteomyelitis”), and 4 of 34 were not confirmatory (“not consistent with osteomyelitis”). Of the 22 patients in the markedly confirmatory group, eight patients with clinical findings of uncontrolled infection or gangrene were treated with partial or complete amputation, whereas all others (14 patients) were treated with local wound care ± intravenous antibiotics. Among the eight bone scans interpreted as indeterminate, three patients required partial or complete amputation, whereas the other five patients were managed with local wound care. Of the four patients with nonconfirmatory bone scans, two patients had evidence of dry gangrene and required amputation, whereas the other two patients did not have clinical evidence of infection or gangrene and were treated with local wound care.

There was no significant difference in the amputation rate for patients with confirmatory, indeterminate, or nonconfirmatory bone scans for osteomyelitis (36%, 37%, and 50%, respectively) ( P > 0.5). Therefore, the authors concluded that the ultimate treatment should be based on clinical indicators of the presence of uncontrolled infection or gangrene rather than on bone scan findings.
Open Versus Arthroscopic Ankle Arthrodesis: A Comparative Study
Authors: O'Brien Timothy S. , Hart Timothy S. , Shereff Michael J. , Stone James , Johnson Jeffrey
Published: March 2013

A retrospective review was undertaken for 36 patients who underwent ankle arthrodesis. Nineteen patients underwent an arthroscopic ankle arthrodesis, and 17 patients underwent an open arthrodesis. Only patients with limited angular deformities were suitable candidates for an arthroscopic arthrodesis. The open arthrodesis group inclusion criteria were defined by the maximum coronal and sagittal plane deformity in the arthroscopic group. Perioperative parameters were compared and analyzed.

Arthroscopic ankle arthrodesis yielded comparable fusion rates to open ankle arthrodesis, with significantly less morbidity, shorter operative times, shorter tourniquet times, less blood loss, and shorter hospital stays. Arthroscopic ankle arthrodesis is a valid alternative to traditional open arthrodesis of the ankle for selected patients with ankle arthritis.
Intraosseous Ganglion Cysts of the Ankle: A Report of Three Cases with Long-term Follow-up
Authors: Ferkel Richard D. , Field Justin , Scherer William P. , Bernstein Mark L. , Kasimian Dennis
Published: March 2013

Three cases of intraosseous ganglion cysts of the ankle are presented with an average follow-up of 68 months (range, 48–78 months). Review of the literature revealed 251 cases of intraosseous ganglion cysts, with 75 located in the ankle and a recurrence rate of 6.1%. In the three cases presented, a satisfactory long-term result was obtained with bone graft and curettage in two cases and currettage alone in one case. No recurrences or complications occurred.
Bandage Distraction Technique for Ankle Arthroscopy
Authors: Takao Masato , Ochi Mitsuo , Shu Naotaka , Naito Kohei , Matsusaki Masahiko , Tobita Masatoshi , Kawasaki Kenzo
Published: March 2013

In ankle arthroscopy, the joint space of the talocrural joint is often too narrow for insertion of the scope and instruments. Various distraction devices for this procedure have been used to widen the joint space. Bandage distraction is effective and noninvasive, but it is difficult to extend the posterior joint space sufficiently for insertion of the scope. Here we describe a new bandage distraction method that can extend the posterior joint space adequately. Using our method, the anterior and posterior joint spaces on direct lateral radiographs were measured after adding the distraction force in nine healthy volunteers (18 ankles; three men and 6 women). This was compared to a previously reported method. The posterior joint space was widened a greater amount when our new bandage distraction technique was used.
Nonoperatively Treated Displaced Bimalleolar and Trimalleolar Fractures: A 20-Year Follow-Up
Authors: Wei Steven Y. , Okereke Enyi , Winiarsky Raz , Lotke Paul A.
Published: March 2013

This study evaluates the long-term results of displaced bi- and trimalleolar fractures treated closed. Few reports exist in the literature regarding the long-term outcomes of ankle fractures, and none of these specifically addresses displaced bi- and trimalleolar fractures treated nonoperatively. This study analyzed the results of bi- and trimalleolar fractures treated by a single surgeon from 1973 to 1981. As was the standard of care at that time, these fractures were treated nonoperatively if a stable reduction was achieved and maintained. Serial radiographs confirmed the maintenance of reduction in a nonweightbearing long leg cast for 6 weeks and then a short leg walking cast for 6 weeks. Of the 34 patients in this series, 19 were available for review, 10 were deceased, and five were lost to follow-up. The average age at the time of injury was 39 years (range, 17–79 years), and the average length of follow-up was 20 years (range, 16–24 years). At the time of review, only two patients with trimalleolar fractures were minimally symptomatic or had radiographic evidence of mild degenerative changes. The average American Orthopaedic Foot and Ankle Score was 98 of 100 points (range, 87–100 points). This long-term follow-up shows that bi- and trimalleolar fractures can be treated nonoperatively if an anatomic reduction is maintained and closely followed. With reports indicating as much as a 5% deep infection rate and a 10% incidence of loss of reduction after internal fixation, universally recommending an operation for these injuries should be reconsidered, especially in high surgical risk patients.
Long-term Results of Subtalar Fusions After Operative Versus Nonoperative Treatment of Os Calcis Fractures
Authors: Thermann Hajo , Hüfner Tobias , Schratt Eberhard , Held Christina , Glinski Sabine von , Tscherne Harald
Published: March 2013

From 1984 to 1994, 40 patients with a subtalar fusion were reexamined in long-term follow-up. The evaluation of the overall results was carried out with three different scoring systems. The calcaneal fractures were primarily treated nonsurgically in 23 patients (57.5%), and 17 patients (42.5%) had undergone ORIF. Complete pain relief was achieved in 52.5% of patients; 65% revealed a restriction in a range of motion in the ankle joint, and in 62% a grade 1 arthritis of the ankle joint was found. The statistical analysis could only reveal a tendency for a better outcome in the operative group compared with the nonsurgical group, although within the operated group, the majority of the os calcis fractures were more severe than in the nonsurgical group.