bluuebunny/crossref_metadata_2025 huggingface dataset:
Computed Tomographic Demonstration of the Vacuum Phenomenon in the Subtalar and Tibiotalar Joints
Authors: Lee Thomas H. , Wapner Keith L. , Mayer David P. , Hecht Paul J.
Published: March 2013

Gas has been identified within diarthrodial joints for more than eight decades. From a radiologic standpoint, the so-called “vacuum phenomenon” is the most common demonstration of gas. We retrospectively reviewed computed tomographic scans of 495 feet and ankles performed over a 24-month period. We found 12 patients (2.4%) with clearly demonstrable gas within the tibiotalar or subtalar joints. This gas was not associated with the presence of fixation hardware or infection. Each patient with gas in the subtalar joint had plain radiographic changes consistent with subtalar arthritis. We conclude that gas in the subtalar joint can be effectively demonstrated by high-resolution CT techniques in the subtalar and tibiotalar joints in patients with advanced degenerative disease.
A Skin Suture for Foot and Ankle Surgery
Authors: Multhopp-Stephens Heidi , Michael Roger H.
Published: March 2013

Severe swelling and skin necrosis are not uncommon following foot and ankle surgery, particularly trauma surgeries. A skin suture technique is presented that has the advantages of being simple, providing good skin eversion and apposition with minimal tension and risk of ischemia, and being easy to remove. The suture technique has been used by the authors for the past 2 years on all foot and ankle trauma and reconstructive cases in which severe swelling was anticipated. There have been no instances of skin necrosis, significant epidermolysis, or dehiscence, and the appearance of the scar is acceptable.
A Biomechanical Comparison of Four Fixation Methods of First Metatarsophalangeal Joint Arthrodesis
Authors: Rongstad Kurt M. , Miller Gary J. , Griend Robert A. Vander , Cowin David
Published: March 2013

A simulated metatarsophalangeal joint arthrodesis was performed on 18 pairs of cadaveric great toes. One toe of each pair was fixed with a 4.0-mm oblique AO cancellous screw. The contralateral toe was fixed with one of three techniques: (1) a miniplate placed dorsally; (2) a 4.5-mm Herbert cannulated screw placed from the metatarsal neck into the medullary canal of the proximal phalanx; or (3) a 3/32-inch Steinmann pin placed longitudinally. An oblique 0.045 Kirschner wire was added with each method. The specimens were tested to failure in dorsiflexion. The mini-plate was significantly stronger than the AO screw in force to failure and initial stiffness. The Herbert cannulated screw was also significantly stronger in force to failure than the AO screw. There was no significant strength difference between the Steinmann pin and the AO screw.
Anatomy of Second Muscular Layer of the Foot: Considerations for Tendon Selection in Transfer for Achilles and Posterior Tibial Tendon Reconstruction
Authors: Wapner Keith L. , Hecht Paul J. , Shea John R. , Allardyce Thomas J.
Published: March 2013

Controversy exists regarding tendon choice to substitute for a ruptured posterior tibial tendon. A similar debate about late Achilles tendon reconstruction also persists. To establish priorities and aid the surgeon's decision-making process, we studied 85 en bloc dissections of the second muscular layer of the sole. Muscular and tendinous interconnections were evaluated.

Location and minimal donor deficit following harvest of the flexor digitorum longus make it the transfer of choice for posterior tibial tendon reconstruction. We suggest that relative strength, anatomic location, and available length of tendon make the flexor hallucis longus the superior choice for late Achilles tendon reconstruction.
Arthroscopy of the Subtalar Joint
Authors: Frey Carol , Gasser Seth , Feder Keith
Published: March 2013

The purpose of this study was to determine the position and relative safety of the anterior, posterior, and newly defined middle portals by measuring their distance from the neurovascular structures and tendons on the lateral side of the foot and ankle. Furthermore, this study demonstrates specific components of the posterior subtalar joint and arthroscopic access to each utilizing a technique that allows direct anatomic correlation.

The 15 specimens were divided into three groups of five feet each, with one arthroscopic portal site and one instrumentation portal site per group. Group I used the anterior portal for the arthroscope and the posterior portal for the curette. Group II used the posterior portal for the arthroscope and the anterior portal for the curette. In group III, the arthroscope was inserted through the anterior portal and the curette through the middle portal.

The sural nerve and small saphenous vein were at risk with posterior portal placement. The anterior portal presented a minor risk of injury to the dorsal intermediate cutaneous branch of the superficial peroneal nerve. The middle portal was without risk to surrounding structures.

Group I provided the best access to the posterior facet of the subtalar joint. Group II provided excellent arthroscopic visualization of the posterior facet, but poor access for instrumentation via the anterior portal. Group III provided the best access to the sinus tarsi. No combination of portals allowed visualization or instrumentation of the middle or anterior facets.
Closed Rupture of the Flexor Hallucis Longus Tendon in a Long Distance Runner: Report of a Case and Review of the Literature
Authors: Romash Michael M.
Published: March 2013

A unique case report of rupture of the flexor hallucis longus tendon at the great toe metatarsal head level is reported in a well-trained marathon runner. The literature regarding interruptions of the flexor hallucis longus tendon is reviewed. There is an identifiable trend: Closed ruptures of the tendons when repaired, do not permit pull-through of the tendon, whereas open lacerations have some potential to restore this function.
Detection of Wooden Foreign Bodies in Muscle Tissue: Experimental Comparison of Computed Tomography, Magnetic Resonance Imaging, and Ultrasonography
Authors: Mizel Mark S. , Steinmetz Neil D. , Trepman Elly
Published: March 2013

An experimental study was performed to compare computed tomography (CT), magnetic resonance imaging (MRI), and real-time, high resolution ultrasonography (US) for the detection of wooden foreign bodies in muscle tissue. Wooden splinters were prepared, measured for size, soaked in saline, and placed in porcine muscle distant from and adjacent to bone. The specimens were then examined using roentgenography, CT and MRI in planes parallel and perpendicular to the splinters, and US. The largest wooden foreign bodies (minimum smallest width = 10 mm) were easily detected by CT, MRI, and US. Almost all splinters of various sizes, small and large, soaked in saline for 5 months were easily detected by MRI. Smaller splinters (minimum smallest width = 1–4 mm) soaked for only 3 days and placed distant from bone were most easily detected by US; those soaked for 5 months were most easily detected by either US or MRI. The smaller splinters soaked for only 3 days and placed near bone were not reliably detected by any of the imaging methods; CT and MRI were both more sensitive than US in this situation. MRI scanning was more sensitive perpendicular than parallel to the long axis of the splinters. Therefore, either US or MRI may be the best initial imaging modality for evaluation of a suspected wooden foreign body, depending on availability of imaging method, chronicity of symptoms, and proximity to bone.
The Fracture Table as a Distraction Mode in Ankle Arthroscopy
Authors: Manderson Easton L. , Nwaneri Uchenna R. , Amin Kumar B.
Published: March 2013

Adequate distraction can be obtained in ankle arthroscopy by placing a Steinmann pin transversely in the calcaneus and using the fracture table in a hip or tibial nailing mode. A sterile traction bow is attached to the calcaneal pin and then to the traction crank apparatus of the fracture table. Gross traction is first applied through the leg in the usual manner and then fine traction tension may be increased or decreased intraoperatively through the traction crank. This method of using the fracture table is easy to perform and is familiar to the orthopaedist, as it is used in intramedullary nailing procedures. The primary advantage is that it allows for excellent exposure while avoiding the morbidity associated with a distraction pin through the distal tibia.
Distal Chevron Osteotomy with Lateral Release for Treatment of Hallux Valgus Deformity
Authors: Pochatko David J. , Schlehr Frank J. , Murphey Mark D. , Hamilton James J.
Published: March 2013

From 1986 to 1990, 42 feet in 30 patients had a combined chevron osteotomy and lateral release to correct their painful bunion deformity. Seventeen patients, 23 feet, were available for follow-up. The purpose of this study was to evaluate the outcome of this procedure and to determine the incidence of avascular necrosis. The patients were examined by an independent examiner, radiographs obtained, and questionnaires filled out. Avascular necrosis was determined using plain films read by a musculoskeletal radiologist who did not know the outcomes.

The average age was 45 years at the time of the procedure. Average follow-up was 50 months. The preoperative intermetatarsal angle averaged 13° and the hallux valgus angle averaged 31°. At study follow-up, the intermetatarsal angle averaged 8° and the hallux valgus angle averaged 17.5°. The results were graded by the Mayo Clinic Forefoot Scoring System (75-point scale) and a subjective scoring system. Average postoperative Mayo Clinic score was 67. Fifteen feet were subjectively rated as excellent, six as good, and two as fair.

Complications occurred in four feet. Hallux varus occurred in two feet, extension contracture in one foot, and an infection in one foot. None of the feet developed definite radiographic evidence of avascular necrosis.

Distal chevron osteotomy combined with a lateral release for corrective bunion surgery has come under scrutiny, because of the risk of avascular necrosis of the first metatarsal head. However, our study showed no evidence of avascular necrosis on radiographs. In addition, 91% of patients had good to excellent results at an average 50-month follow-up.
The Ankle Joint Prosthetic Replacement: Clinical Performance and Research Challenges
Authors: Lewis Gladius
Published: March 2013

This article presents an up-to-date summary of ankle joint biomechanics and various aspects relevant to the endoprosthetic replacement of this joint (specifically, the tibiotalar articulation) when indicated. These aspects are: the design requirements, choice of materials, and clinical studies involving various designs. The reasons for the disappointing in vivo performance of most ankle implants, to date, are suggested and areas for research and development, aimed at introducing a new generation of these implants, are identified.
The Sural Nerve in the Foot and Ankle: An Anatomic Study with Clinical and Surgical Implications
Authors: Lawrence Steven J. , Botte Michael J.
Published: March 2013

Operative procedures and traumatic injuries of the lateral foot and ankle place the sural nerve and its branches at risk. Anatomic studies quantifying the course of this nerve are sparse. In this study, 17 cadaver specimens were dissected to clarify its course and branching patterns. Despite multiple variations of the nerve and its branches, description of the course of a “typical” nerve trunk was possible. The nerve was found to lie in close proximity to the Achilles tendon at a level of 7 cm above the tip of the lateral malleolus. In the hindfoot, the nerve coursed 14 mm posterior and 14 mm inferior to the malleolus. Distally, it crossed superficial to the peroneus longus and brevis tendons. An anastomotic branch coursing into the sinus tarsi area was observed in 24% of specimens. An understanding of the course and distribution of the sural nerve may lessen the risk of iatrogenic injury.
Outpatient Foot Care: Correlation to Amputation Level
Authors: Weaver Frances M. , Burdi Michael D. , Pinzur Michael S.
Published: March 2013

A retrospective analysis of Department of Veterans Affairs automated inpatient and outpatient records was performed for 3945 patients who underwent lower extremity amputation surgery due to peripheral vascular disease during fiscal year 1991. Demographic and clinical data were collected from reviewing patient database information for all Department of Veterans Affairs Hospitals nationwide. Patients were identified from the Physicians' Current Procedural Terminology codes for lower extremity amputations, and then divided into three groups (above the knee, below the knee, and foot and ankle) based on the most proximal level of amputation performed.

Results indicate that increased use of designated foot care clinics was significantly associated with more distal level amputation surgery. Patients with above-the-knee amputations averaged 1.0 foot care clinic visit in the 2 years prior to amputation, whereas below-the-knee and foot and ankle amputees averaged 2.8 and 5.3 foot care clinic visits, respectively ( F [ df = 2,3939] = 94.20, P < .05). The same finding was noted when only users of foot care clinics were examined. Patients with a codiagnosis of diabetes were more likely to undergo distal amputation than those with other diagnoses ( P < .05).

The results of this study suggest the potential effectiveness of designated foot care clinics in preserving limb length in individuals with peripheral vascular disease and diabetes.
Asymmetric Bifurcation of the Extensor Digitorum Longus Tendon in a Case of Congenital Digitus Minimus Varus
Authors: O'Neal Michael L. , Ganey Timothy M. , Ogden John A.
Published: March 2013

Congenital digitus minimus varus (overlapping of the fifth toe) is often bilateral and may result from an anatomic deformity of the extensor digitorum longus tendon. Although bifurcation of the tendinous slip to the fifth toe has been reported as an anatomical variant, in those patients affected with overlapping fifth toe, a pronounced asymmetry between the medial and lateral components may occur. Not only do the two slips to the fifth toe differ in girth, but the morphology of the separate tissues reflects a dissimilar level of organization. Surgical techniques for correction of secondary overlap should consider the possibility of altered gross and histologic anatomy of the extensor tendon when attempting to preserve function.
Jones Transfer to the Lesser Rays in Metatarsalgia: Technique and Long-Term Follow-Up
Authors: Mulier Tom , Dereymaeker Greta , Fabry Guy
Published: March 2013

Thirty-three feet in 29 patients with metatarsalgia were reviewed after Jones transfer to the lesser rays to evaluate the long-term results and the indications for these procedures.

Transfer of the long extensor tendons to their respective metatarsal necks and fusion of the interphalangeal joints with shortening of the toe were performed. The procedures were performed in patients with symptoms of metatarsalgia, secondary to anterior pes cavus deformity (clawfeet, 16 patients), and in patients with mild or severe spreadfoot deformity with fall of the central metatarsals (12 patients). In all of our patients, the striking clinical sign was the long toes.

Rating of the results was based on (1) the presence of pain or calluses and (2) residual deformity of the forefoot and toes. Symptoms of metatarsalgia were relieved in 25 feet, occasionally present in 6 feet, and unchanged in 2 patients. Complete correction of the deformity was achieved in 26 patients, 6 patients had slight residual deformities, and in the 1 poor result, overcorrection was present after the procedure.

This operation is believed to be an excellent choice for patients with metatarsalgia due to (simple) pes cavus deformity and in patients with clawing and metatarsalgia secondary to excessively long toes.
Painful Heel Syndrome: Results of Nonoperative Treatment
Authors: Davis Pamela F. , Severud Erik , Baxter Donald E.
Published: March 2013

One hundred five patients (70% female and 30% male; average age, 48 years) with 132 symptomatic heels were treated according to a standard nonoperative protocol and then reviewed at an average follow-up of 29 months. The treatment protocol consisted of nonsteroidal anti-inflammatory medications, relative rest, viscoelastic polymer heel cushions, Achilles tendon stretching exercises, and, occasionally, injections. Obesity, lifestyle (athletic versus sedentary), sex, and presence or size of heel spur did not influence the treatment outcome. Ninety-four patients (89.5%) had resolution of heel pain within 10.9 months. Six patients (5.7%) continued to have significant pain, but did not elect to have operative treatment, and five patients (4.8%) elected to have surgical intervention. Despite attention to the outcome of surgical treatment for heel pain in the current literature, initial treatment for heel pain is nonoperative. The treatment protocol used in this study was successful for 89.5% of the patients.
Treatment of Delayed Unions and Nonunions of the Proximal Fifth Metatarsal with Pulsed Electromagnetic Fields
Authors: Holmes George B.
Published: March 2013

Nine delayed unions and nonunion of the proximal fifth metatarsal were treated with pulsed electromagnetic fields (PEMF). All fractures healed in a mean time of 4 months (range 2–8 months). Those fractures treated with both pulsed electromagnetic fields and a nonweightbearing cast healed in a mean time of 3 months (range 2–4 months). The average duration of follow-up was 39 months (range 24–60 months). There were no refractures.

When compared with reported healing times and morbidity for conventional casting, medullary curettage with inlay bone, and closed axial intramedullary screw fixation, pulsed electromagnetic fields provided an effective alternative for the treatment of delayed unions and nonunion of the proximal fifth metatarsal.
Material Properties of the Plantar Aponeurosis
Authors: Kitaoka Harold B. , Luo Zong Ping , Growney Eric S. , Berglund Lawrence J. , An Kai-Nan
Published: March 2013

Material properties of the plantar aponeurosis were determined by a two-dimensional video tracking method to simultaneously measure the aponeurosis deformation. Failure loads averaged 1189 ± 244 N and were higher in men. Average stiffness of the intact fascia was 203.7 ± 50.5 N/mm at a loading rate of 11.12 N/sec and it did not vary significantly for the loading rates of 11.12 to 1112 N/sec. The high tensile loads required for failure were consistent with clinical and biomechanical studies and indicated the importance of the aponeurosis in foot function and arch stability.
Effect of Metatarsal Pads and Their Positioning: A Quantitative Assessment
Authors: Hayda R. , Tremaine M. David , Tremaine K. , Banco S. , Teed K.
Published: March 2013

Many conditions of the foot have been related to pressure maldistribution. Alteration of plantar pressure through improvements of shoe fit, orthoses, and surgery are presumed to correct pressure maldistribution.

We evaluated 10 volunteers with normal, asymptomatic feet. With the use of an ultrathin in-shoe sensor, plantar pressures were measured within the shoe at the shoe/foot interface. Test conditions included three pad types: large foam, large felt, and small felt. They were evaluated in three positions: normal (at the metatarsal head base) and 5 mm proximal and 5 mm distal to the normal position. When compared with the control condition without the pad, each pad type and position caused a variable effect upon plantar pressure. On average, the small felt pad caused the greatest and most consistent decrease in pressure at the metatarsal heads (19.15%). Distal positioning tended to cause the greatest decreases in pressure for all pad types.

A pad type and position was found to decrease metatarsal pad pressure in each subject. Metatarsal pads can effectively decrease plantar pressures within the shoe.
Acute Rupture of the Peroneal Longus Tendon in a Runner: A Case Report and Review of the Literature
Authors: Kilkelly Capt. Francis X. , McHale Lt. Col. Kathleen A.
Published: March 2013

Traumatic rupture of the peroneal longus tendon is rare and the diagnosis may be difficult. Swelling and tenderness about the lateral aspect of the ankle, increased hindfoot varus, and pain with active eversion are helpful clinical signs. Magnetic resonance imaging may be helpful in making the diagnosis. We present the case of a patient who sustained an acute rupture of the peroneal longus tendon. The tendon was repaired primarily and the patient was able to return to running. A high index of suspicion is required to prevent a delay in the diagnosis and further disability.
A Metallic Hemiarthroplasty Resurfacing Prosthesis for the Hallux Metatarsophalangeal Joint
Authors: Townley Charles O. , Taranow Warren S.
Published: March 2013

Two-hundred seventy-nine arthritic hallux metatarsophalangeal joints treated surgically with a metallic resurfacing hemiarthroplasty over a 40-year period were reviewed. The implant, which is made available in three evenly graded sizes, is designed to replace only the articular surface of the proximal phalanx, with minimal resection of bone stock. The pathologic indications for surgery included classical hallux rigidus, rheumatoid arthritis, and degenerative changes associated with hallux valgus and bunion deformity. Follow-up at 8 months to 33 years after surgery revealed good or excellent clinical results in 95%. The time to follow-up was in excess of 5 years in 101 (36%) of the procedures, beyond 10 years in 62 (22%), and longer than 20 years in 23 (8%). Unlike other available surgical options for this debilitating condition, biomechanics of the hallux metatarsophalangeal joint remained unaffected and problems associated with prosthetic wear or mechanical failure were not encountered.
A Review of Ankle Arthrodesis: Predisposing Factors to Nonunion
Authors: Frey Carol , Halikus Nicholas M. , Vu-Rose Taryn , Ebramzadeh Edward
Published: March 2013

The purpose of this study was to review 15 years of experience with ankle fusions, specifically addressing the underlying etiology of ankle pathology, incidence of nonunion, and associated predisposing conditions that can lead to nonunion. Seventy-eight ankle fusions, performed between 1975 and 1990, were reviewed for this study. The average follow-up was 4 years. Patients with nonunion were evaluated separately to look at the predisposing factors that may have lead to nonunion. Factors associated with nonunion included fracture type, evidence of avascular necrosis, infection, major medical problems, and open injuries. Factors that were not associated with nonunion included age, past history of subtalar or triple arthrodesis, and technique.
Forefoot Arthroplasty and Changes in Plantar Foot Pressures
Authors: Phillipson Andrew , Dhar Sunil , Linge Keith , McCabe Christopher , Klenerman Leslie
Published: March 2013

The aim of this study was to determine how effective forefoot arthroplasty is at reducing the pressures under the forefoot. The EMED F pressure measuring system was used. Fifteen patients (23 feet) were included in the study. All patients had foot pressure studies performed before and after surgery. Our results show a significant increase in total pressure and pressure-time integral under the foot after surgery. This increase was most marked under the first metatarsal head region ( P < .005). However, the midmetatarsal region showed a slight decrease in pressure, but this was not significant. Symptomatically, 13 patients felt improved by the operation. The results suggest that the procedure is successful because it transfers the pressure to areas better able to tolerate it, rather than reduces the total pressure.
Foot and Ankle Problems in Rheumatoid Arthritis
Authors: Michelson James , Easley Mark , Wigley Fredrick M. , Hellmann David
Published: March 2013

The purpose of this study was to examine the prevalence of foot and ankle problems in 99 patients with clinically proven rheumatoid arthritis. Patients were recruited from outpatient rheumatology clinics; no attempt was made to select patients on the basis of the severity of their disease, duration of disease, or symptom constellation. Each patient was examined by an investigator utilizing a predesigned protocol to assess their functional status, functional capacity, and overall joint involvement. Ninety-three of 99 patients had complaints referable to the foot or ankle at some time since diagnosis of rheumatoid arthritis. Ankle problems were paramount in 42%, forefoot difficulties in 28%, and equal ankle and forefoot problems in another 14%. Only four patients had had any treatment involving foot orthotic devices or special shoe wear. The prevalence of foot and ankle symptoms was related to the duration of systemic illness, but was present in > 50% of patients at any time after diagnosis of rheumatoid arthritis.

Patients with longstanding rheumatoid arthritis have a high prevalence of foot and ankle symptoms. Unlike previous reports, the present study found a high prevalence of ankle and hindfoot symptoms, as opposed to forefoot complaints. Despite this finding, the patients had been treated infrequently by either conservative nonoperative management directed at accommodating footwear or surgical intervention to favorably alter their foot and ankle mechanics.
Closed Posteromedial Dislocation of the Tibiotalar Joint Without Fracture or Diastasis: A Case Report
Authors: Soyer LT Adam D. , Nestor Bryan J. , Friedman Shep J.
Published: March 2013

Tibiotalar dislocation without fracture is an unusual injury. Seventy-three cases have been reported in the literature. Closed posteromedial dislocation of the tibiotalar joint without fracture or diastasis is a very rare phenomenon. Eight cases have been reported. A case of this unique injury is presented, along with a literature review of purely ligamentous ankle dislocations. The proposed mechanism and classification of these injuries are summarized.
Irreducible Dislocation of the Fifth Metatarsophalangeal Joint: A Case Report
Authors: Hynes Darragh , D'Souza Lester G. , Stephens Michael
Published: March 2013

Metatarsophalangeal joint dislocations are unusual in children and usually occur in the hallux. We are reporting a case of irreducible traumatic dislocation of the fifth metatarsophalangeal joint. At open reduction, the metatarsal head was incarcerated under the flexor digitorum longus. After returning the flexor digitorum longus tendon to its anatomical position, the metatarsophalangeal joint reduced and was stable.
Irreducible Proximal Interphalangeal Dislocation of the Fourth Toe: A Case Report
Authors: Weinstein Richard Neil , Insler Harvey Philip
Published: March 2013

Dislocation of the interphalangeal joints of the lesser toes is an uncommon injury, and complex (irreducible) dislocation has rarely been reported. All previous reports note that, during open reduction, the volar plate is interposed within the joint, thereby blocking reduction. In this case, the medial collateral ligament was the primary obstruction to reduction. Clinically, these dislocations are difficult to appreciate. It is recommended that x-ray studies be performed so that this diagnosis is not overlooked.
An Adult With Juvenile Hyaline Fibromatosis of the Foot
Authors: Hallock Geoffrey G.
Published: March 2013

An unusual consideration in the differential diagnosis of benign, solid tumors of the foot is juvenile hyaline fibromatosis, which only superficially resembles the better known myofibromatoses. The onset of the typical cutaneous lesions of this affliction, more frequently found in the head, trunk, or upper extremity, usually begins in childhood, with a progressive increase in their size and number. No cure is known, but early surgical excision of smaller lesions will minimize bony erosion and skin ulceration that otherwise risks toe amputation, thereby preserving function and a reasonable esthetic result. Incomplete excisions are doomed to recurrence, but, fortunately, this normally is a slowly growing tumor.
Modified Chevron Osteotomy for Hallux Valgus
Authors: Donnelly Richard E. , Saltzman Charles L. , Kile Todd A. , Johnson Kenneth A.
Published: March 2013

The chevron osteotomy for hallux valgus was modified by addition of screw fixation and change of the osteotomy angle. Thirty-six patients underwent this modified osteotomy. All had mild to moderate symptomatic hallux valgus deformities. No other forefoot procedures were performed. Standing radiographs were taken before surgery, at 1 month after surgery, and, for the 15 patients who returned for long-term follow-up, at 1 year or more after surgery. Overall, 35/42 procedures were rated as satisfactory without reservations and 7 were rated as satisfactory with mild reservations. All patients stated that they had some improvement in their preoperative symptoms, which included pain, cosmetic concerns, and shoe wear difficulties. Radiographically, none of the capital fragments displaced and there were no malunions, nonunions, nor evidence of avascular necrosis. The average metatarsophalangeal-1 angle improved 8° and the average intermetatarsal 1–2 angle improved 4°. This modification is relatively simple, increases stability, and allows early weightbearing. In our experience, the modified chevron osteotomy has been a very reliable procedure for mild to moderate symptomatic hallux valgus deformity.
Surgical Treatment of Stage I Posterior Tibial Tendon Dysfunction
Authors: Teasdall Robert D. , Johnson Kenneth A.
Published: March 2013

Nineteen patients underwent surgical synovectomy and debridement for the clinical diagnosis of stage I posterior tibial tendon (PTT) dysfunction. Stage I PTT dysfunction is characterized by pain and swelling along the medial aspect of the ankle. Fourteen patients (74%) reported complete relief of pain, 3 patients (16%) reported minor pain, and 1 patient (5%) had moderate pain, and 1 (5%) had continued severe pain. Sixteen (84%) of the patients subjectively reported being “much better” and had a return of function of the PTT, as evidenced by their ability to perform a single limb-heel-rise test. Two patients (10%) underwent subtalar arthrodesis for progressive foot deformity and continued pain. Based on these results, surgical release, tenosynovectomy, and debridement are recommended for the treatment of stage I PTT dysfunction.
Arthrodesis of the Ankle with Lateral Plating
Authors: Braly W. Grant , Baker James K. , Tullos Hugh S.
Published: March 2013

A modification of internal fixation compression arthrodesis for ankle fusion is described using two 6.5-mm cancellous bone screws and a lateral T plate. Using this technique, 20 consecutive arthrodeses by one surgeon were reviewed. Solid union was attained in 19 of 20 patients (95%). Average follow-up was 18 months (range 6–59 months). Time to obtain solid arthrodeses averaged 18 weeks. In 11 patients who returned for follow-up, clinical grading using the Mazur scale score averaged 70 of 90 points. Diagnoses included posttraumatic degenerative arthritis, failed ankle arthrodesis and rheumatoid arthritis (2 each), failed ankle arthroplasty, and posttuberculous arthritis (1 each). Complications included one malunion and one asymptomatic screw malposition. All patients attaining union were pleased with the procedure.
Multistep Measurement of Plantar Pressure Alterations Using Metatarsal Pads
Authors: Chang An-Hsiung , Abu-Faraj Ziad U. , Harris Gerald F. , Nery Joe , Shereff Michael J.
Published: March 2013

Metatarsal pads are frequently prescribed for nonoperative management of metatarsalgia due to various etiologies. When appropriately placed, they are effective in reducing pressures under the metatarsal heads on the plantar surface of the foot. Despite the positive clinical reports that have been cited, there are no quantitative studies documenting the load redistribution effects of these pads during multiple step usage within the shoe environment. The objective of this study was to assess changes in plantar pressure metrics resulting from pad use. Ten normal adult male subjects were tested during a series of 400-step trials. Pressures were recorded from eight discrete plantar locations at the hindfoot, midfoot, and forefoot regions of the insole. Significant increases in peak pressures, contact durations, and pressure-time integrals were noted at the metatarsal shaft region with pad use ( P ≤ .05). Statistically significant changes in metric values were not seen at the other plantar locations, although metatarsal pad use resulted in mild decreases in mean peak pressures at the first and second metatarsal heads and slight increases laterally. Contact durations decreased at all metatarsal head locations, while pressure-time integrals decreased at the first, second, third, and fourth metatarsal heads. A slight increase in pressure-time integrals was seen at the fifth metatarsal head. The redistribution of plantar pressures tended to relate not only to the dimensions of the metatarsal pads, but also to foot size, anatomic foot configuration, and pad location. Knowledge of these parameters, along with careful control of pad dimensions and placement, allows use of the metatarsal pad as an effective orthotic device for redistributing forefoot plantar pressures.
Reliability of Standard Foot Radiographic Measurements
Authors: Saltzman Charles L. , Brandser Eric A. , Berbaum Kevin S. , DeGnore Lisa , Holmes James R. , Katcherian David A. , Teasdall Robert D. , Alexander Ian J.
Published: March 2013

Fifty standing dorsoplantar and lateral foot radiographs were obtained on a consecutive series of patients seen in an orthopaedic foot and ankle clinic. These radiographs were duplicated, and eight common foot measurements were made on each pair by six experienced examiners. Measurements were made in two ways: first by a subjective visual assessment, and second by quantitative evaluation made according to strictly defined criteria. All measurements were made under controlled, ideal conditions with similar high quality goniometers. The results demonstrated overall greater reliability in the quantitative methods than the non-quantitative methods. For each of the quantitative techniques, a cumulated frequency distribution of differences between examiners was calculated. The approximate 95% bounds for these measures were: hallux-metatarsophalangeal angle = 6°, first intermetatarsal angle = 4°, metatarsophalangeal-5 angle = 11°, fourth intermetatarsal angle = 4°, AP talocalcaneal angle = 20°, lateral talocalcaneal angle = 12°, sesamoid station = 2 grades, and forefoot width = 5 mm. Physicians using these parameters to make decisions regarding patient care and clinical outcomes need to keep in mind these potential errors in making foot radiographic measurements.
Dermal Nerve Sheath Myxoma of the Hallux: A Case Report
Authors: Gehrke Jon Craig , Hamson Karl Robert , Havey Ann D.
Published: March 2013

Dermal nerve sheath myxoma is a rare tumor with a predilection for the upper extremity, head, neck, and shoulder. It usually arises during childhood or early adult life. We present a case of a young woman who has this type of myxoid tumor of the hallux. To preserve viability of the hallux, debulking of the tumor was performed rather than complete marginal excision. This case and a literature review suggest that this tumor may be satisfactorily managed with debulking or marginal resection. Histology and pathology of dermal nerve sheath myxoma are reviewed.
Deltoid Ligament Forces after Tibialis Posterior Tendon Rupture: Effects of Triple Arthrodesis and Calcaneal Displacement Osteotomies
Authors: Resnick Ronald B. , Jahss Melvin H. , Choueka Jack , Kummer Fred , Hersch Jonathan C. , Okereke Enyi
Published: March 2013

Deltoid ligament forces were studied after observing deltoid ligament insufficiency in several post-triple arthrodesis patients. Six fresh-frozen, below-knee amputation specimens were axially loaded. The results demonstrate that a properly positioned triple arthrodesis produced deltoid ligament forces that were similar to those seen with an intact tibialis posterior tendon. A triple arthrodesis in combination with a lateral displacement calcaneal osteotomy produced deltoid ligament forces that were 76% greater than those seen with the intact tibialis posterior tendon ( P < .05). A triple arthrodesis in combination with a medial displacement calcaneal osteotomy produced deltoid ligament forces that were 56% less than those seen with the lateral displacement calcaneal osteotomy ( P < .01).

Patients with longstanding ruptures of the tibialis posterior tendon and associated peritalar subluxation/dislocation may have less than optimal clinical results after triple arthrodesis, unless the hindfoot can be properly reduced, due to persistent elevated forces in the deltoid ligament and resulting ligament laxity. This study suggests that a medial displacement calcaneal osteotomy in combination with a triple arthrodesis may be a viable treatment when the hindfoot cannot be positioned properly.
Branches of the Tibial Nerve: Anatomic Variations
Authors: Davis Thorp J. , Schon Lew C.
Published: March 2013

Anatomic variations in tibial nerve branches may help explain discrepancies between clinical examination and electrophysiologic tests as to the location of neuronal lesions. Dissection of 20 cadaveric feet (10 pair) along the course of the tibial nerve and its branches confirmed that it bifurcates within 2 cm of the medio-malleolar-calcaneal axis in 90% (18/20) and that it gives off frequent small branches with its accompanying vascular structures. Unlike other studies, however, we found that 60% had multiple calcaneal branches off the tibial nerve and that 20% evidenced previously undescribed accessory innervation to the abductor hallucis muscle from other than the medial plantar nerve.
Fracture of a Bipartite Medial Cuneiform Synchondrosis
Authors: O'Neal Michael L. , Ganey Timothy M. , Ogden John A.
Published: March 2013

We report the occurrence of a bipartition and occult growth plate fracture in the medial cuneiform of a 5-year, 11-month-old traumatic amputee. Initial radiographs of the foot taken in an oblique projection revealed what appeared to be an osseous fracture of the medial cuneiform. Histologic examination of the pathologic specimen showed that the radiolucent cleft separating the two foci of ossification was actually a hyaline synchondrosis (growth plate) functioning in the normal endochondral transformation of the bone. Histology also detailed a previously undetected fracture traversing the synchondrosis that was sustained during the accident. This unusual case demonstrates that radiographic discontinuity often does not correspond to anatomic discontinuity and should not be misdiagnosed as an osseous fracture. Yet, as with all growth plates of the chondro-osseous skeleton, occult injury to the growth mechanism should be suspected in instances of obvious trauma. Discriminating between normal development of the skeleton and skeletal pathology can be a challenge to the treating physician. Therefore, an awareness of possible anatomic variations will enhance diagnostic evaluations.
Acute Rupture of the Extensor Hallucis Longus Tendon
Authors: Poggi J. Jeffrey , Hall Reginald L.
Published: March 2013

A 40-year-old man with a history of previous cheilectomy and two steroid injections for first metatarsophalangeal degenerative joint disease sustained an acute rupture of the extensor hallucis longus tendon. He was treated successfully with delayed primary repair of the tendon.
Talar Neck Fracture with Talar Head Dislocation and Intact Ankle and Subtalar Joints: A Case Report
Authors: Khazim Rabi , Salo Paul T.
Published: March 2013

The authors describe a rare case of fracture of the neck of the talus associated with talonavicular dislocation but no disruption of the ankle and subtalar joints. The fracture united after open reduction and internal fixation. The head of the talus revealed avascular necrosis but the body did not. A literature review retrieved one previous report of a similar injury, but it was open and became infected. The unique features of this injury pattern and its specific complication, isolated avascular necrosis of the talar head, are discussed.
Stress Fractures of the Medial Malleolus: A Case Report
Authors: Okada Kyoji , Senma Seietsu , Abe Eiji , Sato Kozo , Minato Shosaku
Published: March 2013

The findings for stress fracture of the medial malleolus in two patients are presented. In case 1, a 54-year-old woman complained of gradual onset of pain over the medial malleolus after prolonged walking. Magnetic resonance imaging was useful in the early detection of the stress fracture of the medial malleolus. In case 2, a 16-year-old male developed stress fracture of the medial malleolus during repetitive Kendo fencing activity. Good clinical results were obtained with nonsurgical therapy.
Dorsal Dislocation of the Metatarsophalangeal Joint of the Great Toe: A Case Report
Authors: Nabarro Mark N. , Powell James
Published: March 2013

Dorsal dislocation of the first metatarsophalangeal joint without a fracture is a rare injury, although it has been well described in the literature. The pathologic anatomy of the case presented has not been documented previously. We suggest a new method of open repair using a sling procedure.
Ankle Performance after Ankle Fracture: A Randomized Study of Early Mobilization
Authors: Tropp Hans , Norlin Rolf
Published: March 2013

In a prospective, randomized study, 30 patients were evaluated after ankle fracture treated by means of open reduction and internal fixation. The patients were randomized to either postoperative immobilization in a plaster cast for 6 weeks or early mobilization (1–2 weeks after surgery) in an ankle brace. Both regimens allowed weightbearing. Evaluation after 10 weeks and after 12 months included clinical assessment and isokinetic muscle strength measurements. Patients with impaired ankle function, as shown by means of an ankle score at 12 months, were followed for 3 years.

At 10 weeks, impaired muscle torque and restricted range of motion was found on the affected side. This impairment was significantly less in the brace group. At 12 months, range of motion of the ankle and subtalar joints was restored, but dorsiflexion was still better in the brace group. Score values from a functional score did not correlate with muscle strength.
Determination of In Vitro Metatarsocuneiform Pressure Before and After Surgical Modification of the Great Toe
Authors: Miller Richard A. , Firoozbakhsh Keikhosrow , Naraghi Fred , Ferries James
Published: March 2013

In vitro contact pressures were measured at the first metatarsocuneiform joint in order to determine the effect of resectional arthroplasty and arthrodesis of the metatarsophalangeal joint of the great toe. Eight fresh cadaver feet were loaded with the Instron machine to determine the pressure seen at the first metatarsocuneiform joint. The specimens were subsequently modified by performing either an arthrodesis of the great toe metatarsophalangeal joint or an arthroplasty of this joint by removal of the proximal one third of the proximal phalanx. A second test was then performed. Pressure-sensitive film was analyzed to determine maximum pressure and total transmitted force. No significant pressure change was seen after the arthrodesis. After the resection arthroplasty, there was a significant decrease in both the maximum pressure and the total force measured at the first metatarsocuneiform joint.
Subungual Exostosis: A Simple Technique of Excision
Authors: Multhopp-Stephens Heidi , Walling Arthur K.
Published: March 2013

Subungual or Dupuytren's exostosis is a benign lesion of the distal phalanx that is prone to recurrence if incompletely excised. We report on a series of five patients treated with our simple excision technique. Despite sacrifice of a portion of the nail bed, the cosmetic appearance of the nail was excellent in four patients and good in one patient. There were no recurrences.
Hallux Valgus Correction with Metatarsal Osteotomy: Effect of a Lateral Distal Soft Tissue Procedure
Authors: Granberry William M. , Hickey C. Hugh
Published: March 2013

The purpose of this study was to compare the results of hallux valgus correction using a proximal metatarsal osteotomy with or without a lateral distal metatarsophalangeal soft tissue procedure. This procedure included release of the lateral joint capsule and transfer of the adductor tendon into the neck of the metatarsal. Two groups of patients were reviewed retrospectively. In the first group (17 patients and 25 feet), a proximal closing wedge osteotomy and an Akin osteotomy were performed. In the second group (22 patients and 31 feet), in addition to the osteotomies, the adductor tendon and lateral capsule were released from the sesamoid and the adductor tendon was sutured into the neck of the first metatarsal. Exostectomy and plication of the medial capsule were done in all cases.

Physical examination at follow-up revealed significantly more first metatarsophalangeal stiffness in the second group. The average arc of motion was 62° in the first group and 46° in the second. Radiographically, however, results were significantly better in the second group. The average intermetatarsal angle was 9.6° for group 1 and 6.1° for group 2. The average hallux valgus angle was 15° for group 1 and 10° in group 2. Complications included three pin tract infections and four dorsal malunions.

The lateral distal soft tissue procedure ensured a more reliable correction of the bunion deformity. However, it resulted in a significant amount of postoperative first metatarsophalangeal stiffness.
Comparative Radiographic Analysis of Parameters in Feet With and Without Hallux Valgus
Authors: Saragas Nikiforos Pandelis , Becker Petrus Johannes
Published: March 2013

This study involved the radiographic examination of 118 feet from 110 urban African female patients. Fifty-two of the 118 feet showed radiographic evidence of hallux valgus (valgus angle >15°). The parameters compared between feet with and without hallux valgus were sesamoid position, pes planus deformity, metatarsal length, and the cuneiform-metatarsal articulation. All radiographs were standardized, weightbearing anteroposterior and lateral views. The results were statistically analyzed. The findings showed no difference between the hallux valgus and control groups with respect to sesamoid position relative to the second metatarsal, incidence of pes planus, relative length of the first metatarsal, and the first metatarsal-medial cuneiform articulation.
Fracture of the Posterior Medial Tubercle of the Talus Treated by Internal Fixation: A Report of Two Cases
Authors: Kanbe Katsuaki , Kubota Hitoshi , Hasegawa Atsushi , Udagawa Eiichi
Published: March 2013

A fracture through the posterior medial tubercle of the talus is quite rare. Although excision of the bone fragments has been reported previously in this fracture, cases of internal fixation of the posterior medial tubercle of the talus have not been reported. Two patients are described who presented with a fracture through the posterior medial tubercle of the talus which was treated with internal fixation. Our patients appeared normal on physical examination and returned to work, with no evidence of avascular necrosis of the fragments.
Tuberculosis of the Foot as the Initial Manifestation of Acquired Immune Deficiency Syndrome: A Report of Two Cases
Authors: Lonner Jess H. , Sheskier Steven C.
Published: March 2013

Two cases of tuberculosis of the forefoot are presented to highlight a growing threat in our Western communities. Each represents an initial manifestation of occult infection with the human immunodeficiency virus. Delays in diagnosis and treatment existed because of equivocal and nonspecific clinical, radiographic, and laboratory findings. It is imperative that tubercular infection be considered when evaluating often nonspecific lesions of the foot, particularly in the immunocompromised population.