bluuebunny/crossref_metadata_2025 huggingface dataset:
Biomechanical Characteristics of Human Ankle Ligaments
Authors: Attarian David E. , McCrackin Hugh J. , DeVito Dennis P. , McElhaney James H. , Garrett William E.
Published: March 2013

The purpose of this study was to define the biomechanical characteristics of the isolated, individual bone-ligament-bone complexes of the human ankle. Twenty human ankles were dissected of all soft tissues to leave only the tibia, fibula, talus, and calcaneus with their intact anterior talofibular, calcaneofibular, posterior talofibular, and deep deltoid ligaments. Specimens were mounted and tested in a Minneapolis Testing System. Protocol consisted of cyclic loading of each isolated bone-ligament-bone preparation, followed by several constant velocity load-deflection tests at varying deflection rates, followed by a final, extremely rapid load to failure test.

All ligaments exhibited nonlinearity and strain rate dependence in their load-deflection data. These properties were correlated with ligament function and trauma. The anterior talofibular ligament, the most commonly injured ankle ligament, had the lowest mean maximum load of the specimens tested, whereas the deep deltoid ligament, the least frequently completely disrupted ankle ligament, had the highest load to failure.
Foot and Ankle Injuries in Theatrical Dancers
Authors: Hardaker William T. , Margello Susan , Goldner J. Leonard
Published: March 2013

The theatrical dancer is a unique combination of athlete and artist. The physical demands of dance class, rehearsal, and performance can lead to injury, particularly to the foot and ankle. Ankle sprains are the most common acute injury. Chronic injuries predominate and relate primarily to the repeated impact loading of the foot and ankle on the dance floor. Contributing factors include anatomic variation, improper technique, and fatigue.

Early and aggressive conservative management is usually successful and surgery is rarely indicated. Orthotics play a limited but potentially useful role in treatment Following treatment, a structured rehabilitation program is fundamental to the successful return to dance.
Lateral Decompression for Malunited Os Calcis Fractures
Authors: Braly W. Grant , Bishop John O. , Tullos Hugh S.
Published: March 2013

Nineteen heels in 19 patients underwent a lateral decompression for hindfoot pain secondary to a malunited os calcis fracture with subtalar intra-articular involvement. The operative procedure consisted of a lateral calcaneal bony prominence removal (ostectomy) and sural nerve release or transection. In addition, the peroneal tendons were released, relocated, and lengthened as necessary, with repair or reconstuction of their retinaculum. Eight patients (group I) had previously undergone a late subtalar fusion without relief of lateral symptoms. Eleven patients (group II) underwent a lateral decompression as an alternative to late subtalar fusion. In both groups combined, there were 14 males and 5 females with an average age of 40 years. The average follow-up was 28 months in group I and 17 months in group II. A satisfactory result was obtained in 75% (6 of 8) of the patients in group I and in 82% (9 of 11) of the patients in group II. This compares to a published success rate of approximately 50% in selected series in the literature and the authors' similar success rate of 46% for late subtalar fusion for the same pathology. The results suggest that the lateral decompression procedure offers a technically simpler yet effective alternative to late subtalar fusion for lateral pain following a malunited os calcis fracture with subtalar intra-articular involvement.
The Jones' Fracture in the Nonathlete
Authors: Seitz William H. , Grantham S. Ashby
Published: March 2013

A review of the literature concerning Jones' fractures yields a relatively recent description of the entity as a chronic condition frequently arising as a stress fracture in young athletes and not infrequently requiring surgical correction. Over a 5-year period, we have treated 53 patients with Jones' fracture. All patients were nonathletes. Each described, as Jones did originally, an acute injury. Thirty-six patients were followed to union. There were two delayed unions and no nonunions.
Limb Salvage in a Diabetic with Necrotizing Fasciitis: Case Report and Literature Review
Authors: Carlow Steven B. , Jacobs Richard L. , Vedder Danica K.
Published: March 2013

Necrotizing fasciitis must be considered in a diabetic with cutaneous ulceration. A case report of limb salvage in a 48-year-old diabetic female with progressive necrotizing fasciitis is presented. Methods of early diagnosis including clinical signs, radiographs, and soft tissue biopsy of the involved extremity are reviewed. The microbiology of the disease is also discussed. A modification of the Orr technique using infrequent dressing changes in the management of necrotizing fasciitis is presented. In our case this resulted in preservation of life and a functional limb.
Dowel Arthrodesis for Degenerative Arthritis of the Tarsometatarsal (Lisfranc) Joints
Authors: Johnson Jeffrey E. , Johnson Kenneth A.
Published: March 2013

A late complication of fracture with dislocation involving the tarsometatarsal joints of the foot (Lisfranc fracture) is progressive degenerative arthritis and pain. A dowel-graft arthrodesis technique is described that uses percutaneous bone graft from the iliac crest supplemented by crossed-wire fixation. The cases of 15 patients who underwent surgery between 1979 and 1982 in which this technique was used were reviewed retrospectively. These patients suffered from painful posttraumatic degenerative arthritis after tarsometatarsal joint fracture-dislocation. Follow-up evaluation (mean, 37 months) of 13 of the 15 patients demonstrated satisfactory pain relief in 11 patients, whereas 2 were dissatisfied. Complications included three instances of nonunion and one postsurgical reflex sympathetic dystrophy syndrome.
Computerized Tomography of Talocalcaneal Tarsal Coalition: A Clinical and Anatomic Study
Authors: Herzenberg John E. , Goldner J. Leonard , Martinez Salutario , Silverman Paul M.
Published: March 2013

Consistently accurate radiographic diagnosis of talocalcaneal tarsal coalitions is difficult because of the complex anatomy of the subtalar articulations. Standard techniques that include special radiographic views and plain tomography are useful but often inconclusive. In this study, computerized tomography (CT) was used to evaluate suspected talocalcaneal coalitions in patients with the clinical diagnosis of peroneal spastic flatfoot. CT demonstrated bony and nonbony coalitions in 14 of 22 patients studied. In the remaining eight patients, CT effectively ruled out the diagnosis of subtalar coalitions. If the coalition is obvious, CT will confirm it; if the clinical syndrome exists but standard radiographic procedures do not document the lesion, CT scan will be helpful in establishing a diagnosis.

Anatomic studies of fresh cadaver feet compared CT, plain tomography, and plain radiographs for efficacy in visualizing the three subtalar facet joints. CT was superior to the other modalities for clearly identifying all aspects of the subtalar joint and talocalcaneal coalitions in patients and cadavers.
Charcot Foot—A Technique for Treatment of Chronic Plantar Ulcer by Saucerization and Primary Closure
Authors: Leventen Edward O.
Published: March 2013

A series of four cases of refractory plantar ulcer in Charcot feet was successfully treated by a wide plantar exposure, excision of the ulcer, and primary closure over suction drainage. Thorough saucerization of the underlying convexity in the tarsals is thought to be necessary to achieve healing and prevent recurrence. Surgical intervention is considered worthwhile in those cases that show a marked rocker-bottom foot deformity on lateral radiography and have a persistent ulcer after conservative treatment in a plaster cast.
Effect of Surface Replacement Arthroplasty on Stability of the Ankle
Authors: Burge Peter , Evans Mervyn
Published: March 2013

Loosening after total ankle arthroplasty may result from absorption of tensile and shear forces by relatively small bone-cement interfaces. A surface replacement arthroplasty similar in principle to the Oxford knee arthroplasty offers theoretical advantages over other designs. The ability of such a prosthesis to provide a stable articulation was tested by examination of ankle laxity before and after replacement of the tibiotalar articular surfaces. The motion response characteristics of four specimens were measured for internal-external rotation moment (±3 nm), inversion-eversion moment (±3 nm), and anteroposterior displacement (±50 N). The prosthesis restored normal internal-external and inversion-eversion rotatory stability, but the mean anteroposterior laxity was increased from 5.5 to 9.7 mm ( P < 0.05). Anteroposterior stability could not be restored by increasing the thickness of the bearing interposed between the prosthetic surfaces. The findings can be explained by consideration of the anatomy of the ligaments in relation to the contour of the normal and prosthetic articular surfaces. The normal tibial articular surface, which is concave in the sagittal plane, provides restraint against anteroposterior motion which is lost when the surface is replaced by the flat prosthetic surface. The findings question the suitability of this type of prosthesis for the ankle.
A Biomechanical Study Using Cadaveric Toes to Test the Stability of Fixation Techniques Employed in Arthrodesis of the First Metatarsophalangeal Joint
Authors: Sykes Alan , Hughes Angus W.
Published: March 2013

Arthrodesis of the first metatarsophalangeal joint of 15 pairs of cadaveric big toes were performed. The arthrodesis site was shaped with either a dome and socket or planar surface contact between the metatarsal head and proximal phalanx. A template was used to standardize the position of arthrodesis in 20° of valgus and 20° dorsiflexion. Various fixation devices were used to hold this position in corresponding pairs of specimens, and these fixation devices were tested to determine their relative effectiveness to prevent displacement on loading. Force-deflection curves were obtained for the various techniques tested, and by comparing these curves, the stability of the metatarsophalangeal arthrodesis site was found to be maintained most effectively using the cancellous screw fixation device with planar metatarsophalangeal surfaces.
Delayed Neural Reconstruction in the Lower Extremity: Results of Interfascicular Nerve Grafting
Authors: Hattrup Steven J. , Wood Michael B.
Published: March 2013

During a 4-year period, one of the authors (M.B.W.) performed 16 nerve reconstructions by interfascicular grafting in the lower extremities of 13 patients. Three patients were excluded from the study: one was lost to follow-up and two had less than 1-year follow-up. At an average follow-up of 30 months, the results of 13 procedures in 10 patients were evaluated. Results were good after five procedures, fair after five, and poor after three. Superior results were evident with shorter graft lengths and after nerve transection injuries.
Results of Surgery in Athletes with Plantar Fasciitis
Authors: Leach Robert E. , Seavey Mitchell S. , Salter Daniel K.
Published: March 2013

Plantar fasciitis is a common cause of pain, particularly in runners and certain other athletic groups. This syndrome must be distinguished from certain other conditions, such as the tarsal tunnel syndrome and achillodynia. Conservative therapy including rest, orthotics, heel cups, anti-inflammatory agents, and icing reduce symptoms in most patients. A few athletes may need surgery to continue running. The authors released the plantar fascia and excised areas of mucinoid degeneration in 15 athletes. Fourteen returned to full athletic activity.
Surgical Management of Tarsal Coalition in Adolescent Athletes
Authors: Morgan Randall C. , Crawford Alvin H.
Published: March 2013

The authors studied 12 adolescent patients with a known diagnosis of tarsal coalition. These patients were also active participants in athletics. Of the 12 patients studied, there were eight with calcaneonavicular bars and four with talocalcaneal bars. Even though nonoperative treatment was not successful, only eight of the 12 elected to have surgery. Following surgical resection of the tarsal coalition, five of six patients who had calcaneonavicular bar excisions as well as two patients with talocalcaneal bar excisions were able to return to competitive athletics. Nonoperative treatment of the tarsal coalition did not result in alleviation of symptoms and full return to athletics. The surgical excision of the calcaneonavicular bar with extensor digitorum brevis arthroplasty afforded the best results.
Fractures of the Base of the Fifth Metatarsal Distal to the Tuberosity: A Review
Authors: Lehman Richard C. , Torg Joseph S. , Pavlov Helene , DeLee Jesse C.
Published: March 2013

Fractures of the proximal part of the fifth metatarsal can be separated into two types: (1) those involving the tuberosity, and (2) those involving the proximal part of the diaphysis distal to the tuberosity. Recently it has been recognized that the latter group, Jones' fractures, may be difficult to treat.

Although reports in the literature have indicated the potential difficulties in the treatment of Jones' fractures, prevailing guidelines for their management are ambiguous. Apparently the varied clinical and roentgenographic manifestations of these fractures have not been correlated with their response to treatment. In this paper we describe a classification of these fractures and a plan of treatment based on clinical and roentgenographic criteria that were developed to define acute fractures, delayed unions, and nonunions.

The treatment of choice for acute fractures is immobilization of the limb in a toe to knee cast with nonweightbearing. Fractures with delayed union may eventually heal if they are treated conservatively, but an active athlete with delayed union or an established nonunion will benefit from operative intervention. The procedures of choice are (1) medullary curettage and bone grafting, and (2) closed axial intramedullary screw fixation using a 4.0-mm ASIF malleolar screw.
Achilles Tendon Ruptures—Peroneus Brevis Transfer
Authors: Turco Vincent J. , Spinella Anthony J.
Published: March 2013

Peroneus brevis tendon transfer has been utilized in 40 individuals during the last 13 years. All cases consisted of complete Achilles tendon ruptures. In 34 cases the rupture was in the distal one-third of the tendon substance, in four cases bony avulsion of the calcaneal tuberosity occurred, and in two cases there was a diffuse tear in the proximal two-thirds of the tendon near the musculotendinous junction. The middle-aged athlete sustained the majority of these injuries during sports. Eleven patients were less than 30 years old, 23 patients were 30 to 40 years old, and six were over 40 years old. Five patients had reruptures that involved prior nonoperative treatment of cast immobilization, and one had undergone simple direct suture. This repair has been used in acute, chronic, and recurrent ruptures of the tendoachillis. Thirty-three patients presented within 1 week of injury, and seven after more than 1 week.

A. Perez Teuffer personally described the preferred technique in 1971 and subsequently published in 1978. The transfer of the peroneus brevis is combined with a direct end-to-end suture of the triceps surae tendon that allows a secure reconstruction with the foot at a right angle. The peroneus brevis tendon is detached from the base of the fifth metatarsal and then tunnelled through the distal Achilles tendon stump. The distal portion of the tendon transfer is then drawn proximally along the medial calcaneal tendon border. The proximal triceps surae tendon is pulled distally and secured to the peroneal tendon. The ruptured ends of the Achilles tendon are sandwiched between the U-shaped peroneal tendon transfer, which acts as a biologic scaffold for the reparitive process.

Several advantages are apparent when compared to nonoperative care and other operative techniques including simple Achilles tendon repair, plantaris tendon transfers, reconstructive fascial flaps, and synthetic substitutes. A strong repair with the foot at the neutral position is possible even when the Achilles tendon is shredded. The transfer provides an active motor, adds some power to the damaged triceps, and avoids the danger of rerupture. No reruptures have occurred after this surgical procedure. Calf weakness is minimized because the proximal fragment of the damaged Achilles tendon is sutured securely under physiologic tension into the peroneus brevis. Immobilization postoperatively in a short leg cast at a right angle and early weightbearing facilitate the rehabilitation period and avoid the many months necessary to regain dorsiflexion after 6 to 8 weeks of casting in plantarflexion. The bulk and profile of the repaired Achilles tendon is restored. A healthy tendon transfer is an additional benefit. Strength after the peroneus brevis U-shaped tendon transfer is superior to other methods of treatment and is particularly advantageous in the sports-oriented individual.
Pressure Distribution under Symptom-Free Feet during Barefoot Standing
Authors: Cavanagh Peter R. , Rodgers Mary M. , liboshi Akira
Published: March 2013

The plantar pressure distributions for a large heterogeneous sample of feet (N = 107) were collected during barefoot standing using a capacitance mat. From these data, the function of the foot during standing was characterized. Peak pressures under the heel (139 kPa) were, on average, 2.6 times greater than forefoot pressures (53 kPa). Forefoot peak pressures were usually located under the second or third metatarsal heads. No significant relationship was found between body weight and the magnitude of peak pressure. The concepts of a transverse arch at the level of the metatarsal heads and a “tripod” theory of load distribution were not substantiated by this study. Load distribution analysis showed that the heel carried 60%, the midfoot 8%, and the forefoot 28% of the weightbearing load. The toes were only minimally involved in the weightbearing process. Examples of unusual distributions are shown; finally, a checklist is provided to aid the clinician in evaluating plantar pressure findings.
A Clinician's View of Foot Pressure: A Comparison of Three Different Methods of Measurement
Authors: Hughes Janet , Kriss Stephen , Klenerman Leslie
Published: March 2013

The measurement of the pressure distribution under the foot can provide permanent records which can be used to monitor patients' progress and the effects of surgical operations. It can be utilized in the assessment of foot disorders and the results of treatment. It is also of value in the study of the function of the normal foot. Three commercially available systems have been compared by measuring ten “normal” subjects with these different techniques. The results are not directly comparable but are described to show the differences between the equipment and the results and help investigators interested in foot problems to choose the best system for their particular needs.
Treatment of the Congenital Vertical Talus: A Retrospective Review of 36 Feet with Long-Term Follow-up
Authors: Dodge Larry D. , Ashley R. Kirklin , Gilbert Robert J.
Published: March 2013

To ascertain whether one type of treatment of the congenital vertical talus was superior to others, we conducted a retrospective analysis of 36 congenital vertical tali in 21 patients whose average follow-up of 14 years was considered to be unusually lengthy. Ten patients (48%) had an underlying primary diagnosis, and 13 patients (62%) had at least one other secondary congenital abnormality. None of the surgical techniques produced significantly better results than any other one according to criteria involving shoewear, range of motion, and degree of pain. Subtalar and talotibial motion were frequently restricted, with or without prior arthrodesis. Pain generally was not an immediate or long-term problem. To maintain maximal foot mobility, we recommend a one-stage soft tissue correction alone in the child under 3 years of age. In older, untreated children or those in whom conservative treatments have failed, a subtalar or triple arthrodesis may be necessary.
Intrinsic Toe Flexion Deformity Following Correction of Spastic Equinovarus Deformity in Adults
Authors: Keenan Mary Ann E. , Gorai A. Patricia , Smith Carl W. , Garland Douglas E.
Published: March 2013

In the treatment of spastic equinovarus foot deformities in adults with neurologic impairment, various surgical procedures are used including the split anterior tibialis tendon transfer and tendo achillis lengthening. Release of the flexor hallucis longus and flexor digitorum longus tendons in the midfoot is routinely included with these procedures to correct or prevent toe curling. In follow-up, residual toe curling has been observed in some patients despite release of the long toe flexor tendons. This study was undertaken to investigate this problem and its consequences, treatment, and treatment success.

Forty-one feet in 34 consecutive patients were examined for residual toe curling an average of 2.5 years postoperatively. Thirty-two feet (78%) were noted to have significant flexion deformities of the lesser toes. The residual toe curling caused pain in 72% of the feet and was associated with callosities on the dorsum of the toes in 59%. The incidence of residual toe curling secondary to spasticity of the flexor digitorum brevis and intrinsic muscles of the foot was similar in the patients who had sustained traumatic brain injury and in those who had suffered a cerebrovascular accident.

Twelve of these feet (37%) underwent surgical release of the flexor digitorum brevis and intrinsic tendons to correct the toe curling. There were no complications of surgery and no recurrences of deformity following the surgery. A second surgical procedure to release the flexor digitorum brevis and intrinsic tendons to correct the toe curling was more commonly performed in the younger more active brain-injured patients than in the older stroke patients (44% versus 20%, respectively). The second surgical procedure was also more common in the ambulatory patients compared with the nonambulators (44% versus 14%).

Based on the results of this study, we recommend that release of the flexor hallucis longus, flexor digitorum longus, flexor digitorum brevis, and intrinsic tendons be performed at the base of each toe as part of the procedure to correct spastic equinovarus deformities in the adult neurologically impaired patient.
Deltoid Ligament: An Anatomical Evaluation of Function
Authors: Harper Marion C.
Published: March 2013

A cadaver study done to evaluate function of the deltoid ligament and its major subdivisions, the superficial and deep components, revealed that the deltoid ligament is the primary restraint against valgus tilting of the talus, with superficial and deep components being equally effective in this regard. The deep deltoid ligament appeared to be the secondary restraint against both lateral and anterior talar excursion, with the lateral malleolus and supporting ligaments being the primary restraint.
Crossover Second Toe Deformity
Authors: Coughlin Michael J.
Published: March 2013

The crossover second toe deformity occurs when the lateral collateral ligament and joint capsule of the second metatarsophalangeal joint deteriorate. The second toe initially deviates in a medial direction but with time deviates dorsally and crosses up and over the great toe. A total of 17 patients (22 toes) were evaluated and 11 patients (15 toes) underwent surgical correction. A 90° satisfactory rate was noted at 42 months follow-up.
Basal Osteotomy of the Fifth Metatarsal with Intermetatarsal Pinning: A New Approach to Tailor's Bunion
Authors: Diebold P. F. , Bejjani F. J.
Published: March 2013

The direct approach to the fifth metatarsophalangeal joint for the treatment of metatarsus quintus valgus often has been unsuccessful, mainly because of technical difficulties in the osteotomy of the narrow fifth metatarsal neck and the fixation of the unstable head fragment. Complications such as delayed union, nonunion, or recurrence have been reported. This paper describes a surgical technique for optimal correction of this deformity. The technique has a biomechanically sound fixation and a shortened bone healing time with minimum complications. Results of 12 patients presenting severe deformities are reported, with 1-year average follow-up.
Gait Analysis before and after Osteotomy for Hallux Valgus
Authors: Vittas Dimitrios , Jansen Erik C. , Larsen Tommy K.
Published: March 2013

Twenty-one female patients with bunions were treated by Mitchell osteotomy. Nineteen had clinically excellent or good results. This included no pain on walking, normal ambulation, and improved appearance. Two patients were dissatisfied.

By using an instrumented treadmill the gait function was tested before and a median of 6 ½ months after operation. No significant improvements or losses were found in a large series of gait parameters. The benefits of operation were not due to an improved gait function and other factors must have influenced the final result.
Pathomechanics of Congenital and Acquired Hallux Varus: A Clinical and Anatomical Study
Authors: Joseph Benjamin , Chacko Verghese , Abraham Thomas , Jacob Mary
Published: March 2013

Hallux varus was observed in 69 feet among patients from a rural Indian population. This included three types of congenital hallux varus. The congenital “primary” type was the commonest and was not associated with any other foot deformity. Among the acquired forms was idiopathic hallux varus of middle age, which developed spontaneously in unshod persons and progressed gradually. Hallux varus following chronic arthritis was part of a consistent pattern of foot deformities in which the first ray collapsed in a zig-zag manner in two planes.

Although the development of hallux varus is often due to intrinsic muscle imbalance, hallux varus secondary to chronic arthritis seems to occur as a result of both intrinsic and extrinsic muscle imbalance associated with midtarsal and subtalar arthritis. Muscular factors contribute to progression of the deformity also.

No anatomical basis for a racial prediliction for the deformity was noted. Failure to use footwear could account for the higher incidence of hallux varus in India.
Magnetic Resonance Imaging in the Diagnosis of Disruption of the Posterior Tibial Tendon
Authors: Alexander Ian J. , Johnson Kenneth A. , Berquist Thomas H.
Published: March 2013

Magnetic resonance imaging (MRI), a useful technique of studying soft tissues of the body, can be very effective in assessing the integrity of tendons. Usually a patient with a complete tear of the posterior tibial tendon has characteristic physical findings. In the patient presented, MRI demonstrated a complete disruption of the posterior tibial tendon, despite the absence of the commonly associated clinical findings. In view of the difficulties encountered with attempted tenography of the completely torn posterior tibial tendon, MRI provides a sensitive alternative diagnostic technique.
Total Ankle Arthroplasty in Rheumatoid Arthritis: A Long-term Follow-up Study
Authors: Unger Anthony S. , Inglis Allan E. , Mow Christopher S. , Figgie Harry E.
Published: March 2013

Patients with rheumatoid arthritis who had undergone total ankle arthroplasty and had a minimum of 2 yr follow-up were studied. Of the original 21 patients 17 were available for review. Twenty-three ankle replacements with an average follow-up of 5.6 yr were studied. On follow-up 2 ankles were rated excellent, 13 were rated good, 4 were rated fair, and 4 were rated poor. Thus, 83% were satisfactory on follow-up. Radiographic analysis revealed migration and settling of the talar component in 14 of 15 cases. Bone cement radiolucencies were found in 14 of 15 cases. Bone cement radiolucencies were found in 14 of 15 tibial components with tilting in 12 of these components. The postoperative position of the implant did not correlate with the development of radiolucencies or migration of the implant.
Tensile Strength Comparison of Dowel Plug Technique to Standard Techniques of Tendon-Bone Attachment
Authors: Ward John J. , Meyer Richard D. , Lemons Jack E.
Published: March 2013

Since tendon transplantation relies on successful fixation of the tendon transplant, a quantitative comparison of various methods of tendon attachment to bone was investigated in mongrel dogs. The methods included attaching tendon to periosteum, suturing a tendon to itself after passing through bone, stapling, and wedging a dowel plug into a hole with the tendon. Tests to failure were conducted at 0, 10, 28, and 63 days of healing. The dowel plug technique provided strong immediate fixation. After 63 days the staple, the tendon passed through bone, and the dowel plug techniques showed significant increases in strength. On tendons of similar size, the dowel plug method showed the greatest tensile strength when compared to the staple fixation. This method was a simple, reproducible technique.
Combined Anteroposterior Tibial Tendon Transfer in Post-traumatic Peroneal Palsy
Authors: Pinzur Michael S. , Kett Nancy , Trilla Maura
Published: March 2013

Posterior tibial tendon transfer to the dorsum of the foot for correction of traumatic paralytic peroneal palsy is a well-accepted treatment option. A careful review of the literature reveals that the results of treatment in this specific patient group are not always encouraging. This paper reports the results of a combined anteroposterior tibial tendon transfer in nine patients with traumatic paralytic peroneal palsy who initially used an ankle-foot orthosis to ambulate. Percutaneous tendo achillis lengthening to correct fixed ankle equinus was performed in six of the patients. At a minimal 24-mo follow-up (range, 24–56), all nine patients were brace free and subjectively felt that the surgery was successful. While the surgery was initially planned to provide an active “tenodesis” of the ankle to resist passive ankle equinus during swing phase of gait, walking electromyography revealed “retraining” of the transferred posterior tibial muscle to function as an active swing-phase ankle dorsiflexor muscle in seven of the nine patients.
New Jersey Low Contact Stress Total Ankle Replacement: Biomechanical Rationale and Review of 23 Cementless Cases
Authors: Buechel Frederick F. , Pappas Michael J. , Iorio Louis J.
Published: March 2013

A congruent contact, unconstrained, multiaxial ankle replacement has been developed for use without cement. A talar onlay component with a trochlear surface and central fixation fin uses a cylindrical articulating axis that reproduces the lateral talar curvature. A tibial inlay component with a 7° anteriorly inclined short fixation stem uses a flat loading plate, recessed anatomically into the distal tibia to distribute tibial loads to the ankle joint. For both components, made of cast cobalt-chromium-molybdenum, a 275-μm pore-size, sintered-bead, porous coating is used to allow tissue ingrowth stabilization. A congruent ultrahigh molecular weight polyethylene bearing is inserted between the metallic implants. Its upper surface is flat, whereas its lower surface conforms to the trochlear surface, thereby providing unconstrained, sliding cylindrical motion with low contact stress on the bearing surfaces. Contact pressure and collateral ligaments maintain ankle stability during both static and dynamic loading conditions.

Clinically, 23 total ankle arthroplasties were performed in 21 patients. The follow-up period ranged from 24 months to 64 months with a mean of 35.3 months. Diagnoses included rheumatoid arthritis, 6 patients (26.1%); osteoarthritis, 4 patients (17.4%); post-traumatic arthritis, 10 patients (43.5%); avascular necrosis of the talus, 2 patients (8.7%), and painful ankle fusion, 1 patient (4.3%). Pain was the primary reason for surgery in all cases. Postoperatively, 87% of ankles had no pain or, at most, mild pain.

Postoperative complications included poor wound healing in four ankles, reflex sympathetic dystrophy in two ankles, deep infection in one ankle, and one bearing subluxation. No ankle replacements were removed and no fusions were performed for failed implants, although one bearing was exchanged without disrupting the metallic elements.

In this report, the suggestion is made that total ankle arthroplasty may have an improved application in various arthritis disorders when used with biologic fixation and unconstrained mobile bearings.
Treatment of Metatarsalgia by Sliding Distal Metatarsal Osteotomy
Authors: Winson Ian G. , Rawlinson John , Broughton Nigel S.
Published: March 2013

A consecutive series of 113 patients who had distal sliding metatarsal osteotomy performed between 1976 and 1983 at Winford Orthopaedic Hospital were reviewed. All patients originally had symptoms and signs of pressure metatarsalgia. A total of 124 feet in 94 patients were available for assessment. Review was performed using a symptomatic scoring system, clinical examination, AP and lateral standing radiographs, and walking foot pressure studies obtained from a Harris-Beath mat. The mean follow-up period was 3 years and 4 months (range nine to 102 months). Symptomatically, 58 feet (47%) were rated as good, 43 (34%) as fair, and 23 (19%) as poor. Eighteen feet (14%) had required revision procedures prior to the time of review because of persistent symptoms. Persistent tender prominence of one or more metatarsal heads associated with plantar callosities was seen in 49 feet (40%). Results were significantly worse in patients older than 65 years of age, when first and fifth metatarsal osteotomies were performed, and when plaster immobilization was used postoperatively.
Distal Oblique Osteotomy for Intractable Plantar Keratosis of the Middle Three Metatarsals
Authors: Pedowitz Walter J.
Published: March 2013

On the middle metatarsals of 49 patients with symptomatic intractable plantar keratosis, 69 distal oblique osteotomies were performed. With an average follow-up time of 16 months, 83% of the results were rated good. This procedure is contraindicated for an intractable plantar keratosis with an associated fixed metatarsphalangeal joint deformity, however.
Recurrent Pain following Interdigital Neurectomy—A Plantar Approach
Authors: Beskin James L. , Baxter Donald E.
Published: March 2013

Thirty patients with 39 recurrent interdigital neuromas were evaluated to determine the success of subsequent surgery. Two surgical techniques were used to resect the nerve over a 2.5-year period and their results were compared. One consisted of exposure through the previous dorsal incision and the other of exposure through a transverse plantar incision proximal to the metatarsal heads. Overall results revealed significant improvement for greater than 80% of patients after their final operation. Less than 50% gained complete relief, however, and 58% experienced persistent discomfort in certain types of shoes. The plantar approach offers a simplified, less traumatic exposure of the nerve in a more proximal location. No healing problems were encountered with the proximal plantar incision.
Tarsal Coalition: A Review of the Literature and Presentation of 13 Cases
Authors: Percy E.C. , Mann David L.
Published: March 2013

Tarsal coalition refers to the condition that exists when there is absent or restricted movement between two or more of the bones of the hindfoot. The usual cause of the restricted movement is a congenital abnormality with a fibrous (syndesmosis), cartilagenous (synchondrosis), or bony (synostosis) union between the adjoining involved bones. The commonest site of these congenital anomalous attachments are reported in the literature as being located at the calcaneonavicular, the talocalcaneal, and, less commonly, the talonavicular areas. Limited movement in the hindfoot can also result from trauma, arthritis, tumor, or injury involving those joints in the foot. The congenital form may often go unrecognized until such time as a twist or sprain of the ankle or foot leads to its diagnosis. On the other hand, the condition may go unrecognized as a cause for chronic pain or discomfort in the hindfoot or ankle.

In this article, a series of 13 feet in 11 patients with this condition that have been noted in the sports medicine clinic at the University of Arizona Health Sciences Center during the past 8 years is described. A detailed historical, clinical, and biomechanical account is also included.
Ankle Dislocation without Fracture
Authors: Wroble Randall R. , Nepola James V. , Malvitz Thomas A.
Published: March 2013

Dislocation of the ankle without accompanying malleolar fracture has been regarded as a rare lesion, with few cases reported in the literature. To date, there has been no precedent for accurate descriptions of the mechanisms, optimum treatment, and long-term prognosis of this injury. Our goal was to evaluate these variables by a retrospective review of cases from our institution. We identified eight patients who had sustained ankle dislocation without fracture and were treated at the University of Iowa during the period 1958 to 1986. We interviewed and examined each patient and obtained ankle radiographs at an average of 11.5 years postinjury (range 2 to 24 years). After analyzing our cases and others reported in the literature, we have found that this injury is most common in young people (average age 31 years, range 10 to 73 years) and males (72%), and occurs most frequently in falls, motor vehicle accidents, and sports (86%). Medial displacement occurs most frequently (27%). Disruption of the mortise occurs variably. The most likely mechanism appears to be anterior or posterior extrusion of the talus from the mortise secondary to a force applied to the plantarflexed foot. Final displacement is then determined by the position of the foot and the direction of the force applied. Physical findings are commensurate with the deformity. Neurovascular compromise is uncommon (10%). Closed reduction is almost invariably accomplished easily unless the deformity is accompanied by posterior tibiofibular dislocation. Optimum treatment appears to be immobilization in a short leg cast for 6 weeks with no weightbearing for the first 3 weeks. Long-term follow-up revealed the following. Results were all good to excellent considering the following variables: return to work and sports activities, pain, instability, swelling, and ankle and subtalar joint motion. No patient reported instability and all returned to work and sports participation. We noted mild pain and swelling that was not severe enough to require medication in 25% of patients. Range of motion was normal in all but four patients; none of these lacked more than 10° of motion in any plane. Radiographic abnormalities consisted of minor ligamentous or capsular calcification in all patients, small osteophytes in four patients, and minimal joint space narrowing in one patient. No patient had normal radiographs.
Plantar Excision of Primary Interdigital Neuromas
Authors: Karges David E.
Published: March 2013

A retrospective study was done of 51 patients (6 males and 45 females) who had 57 primary interdigital neurectomies performed through a plantar incision. The surgical technique is described. The results were divided into three categories, in which 26 feet were judged excellent, 27 feet rated good, and 4 feet were classed as poor. The author concludes that the plantar approach is technically simple and results in a comfortable scar. Poor results occurred in 4 of 57 feet. This failure rate compares favorably with those failure rates in reported series done through a dorsal incision. In the author's opinion, the ability to do a more proximal resection of the nerve—as compared with the dorsal approach—is responsible for the higher rate of success with this method.
Arthrography of the Metatarsophalangeal Joint
Authors: Karpman Robert R. , MacCollum Maxwell S.
Published: March 2013

Arthrography has been an extremely useful tool in the diagnosis of various intra-articular disorders of multiple joints. To date, little has been written regarding the technique and value of arthrography of the metatarsophalangeal (MTP) joints of the foot. The purpose of this paper is to briefly describe the technique, demonstrate a normal arthrogram of the MTP joint, and provide case descriptions in which arthrography has been useful in diagnosis of intra-articular problems related to the MTP joint.
Excision of Posterolateral Talar Dome Lesions through a Medial Transmalleolar Approach
Authors: Ove P. Norman , Bosse Michael J. , Reinert Charles M.
Published: March 2013

Posterolateral osteochondral fractures of the talus are rare. Although arthroscopy is becoming an increasingly important method of evaluating and treating lesions of the ankle, these techniques may not always be feasible, especially for posterolateral lesions. Classic treatment of displaced or symptomatic chronic lesions is excision, usually with a distal fibular osteotomy and turndown procedure. Subsequent removal of the syndesmosis screw is required. The surgical dissection of the distal fibula is extensive and devascularizing. An alternate technique for debriding posterolateral talar dome lesions through a medial transmalleolar approach is described. Exposure of the lateral talar dome is sufficient to allow debridement and curettage of the lesion. Anatomic rigid fixation of the medial malleolus allows for rapid healing of the osteotomy site and immediate ankle rehabilitation. For those ankle lesions that are not accessible to arthroscopy or an anterolateral arthrotomy, this approach is preferable to the distal fibular osteotomy and turndown.
Dowel Bone Graft Technique for Triple Arthrodesis in Talocalcaneal Coalition—Report of a Case with 12-Year Follow-up
Authors: Peterson Hamlet A.
Published: March 2013

Symptomatic talocalcaneal coalition can be treated surgically by either excision of the coalition or arthrodesis. The arthrodesis may be talocalcaneal, talonavicular and calcaneocuboid, or include all three joints (triple arthrodesis). Arthrodesis is indicated in talocalcaneal coalition when there is persistent pain, particularly if it is associated with deformity or degenerative changes. Arthrodesis that maintains normal contours of the foot, including its length and height, can be accomplished by the dowel technique described in this article.
Metabolic Bone Disease Presenting as Multiple Recurrent Metatarsal Fractures: A Case Report
Authors: Harper Marion C.
Published: March 2013

A case of adult hypophosphatasia involving a patient with recurrent bilateral metatarsal fractures is presented. This disorder, although relatively uncommon, is often associated with multiple pseudofractures and complete pathologic fractures of the lower extremity. It can be detected with routine laboratory analysis. Metabolic bone disease should be considered as a possible causative factor in patients with multiple “stress” fractures of the foot.
Metatarsal Osteotomy for Primary Metatarsalgia: Radiographic and Pedobarographic Study
Authors: Dreeben Sharon M. , Noble Philip C. , Hammerman Steven , Bishop John O. , Tullos Hugh S.
Published: March 2013

The effect of surgical procedures for primary metatarsalgia on the load distribution and bony architecture of the forefoot is poorly understood. A prospective study was performed on 45 feet with this diagnosis treated by dorsal wedge osteotomy and compared with 29 symptom-free contralateral feet. Each foot was evaluated preoperatively and postoperatively with quantitative radiographic analysis, a pedobarographic study, and by physical examination. Following osteotomy there was a 4.5-mm increase in average height from ground and a 7.0 psi decrease in pressure. The symptom-free control group demonstrated no statistically significant changes. Residual pain occurred with an average height increase of less than 3.5 mm and an average pressure decrease of less than 1.5 psi. Transfer lesions developed in three of four patients with a height increase of greater than 4.5 mm. The symptoms of metatarsalgia are altered by changes in height of the metatarsal or the pressure beneath it. It is not possible to predict the surgical elevation of the metatarsal head required to precisely decrease the pressure beneath the metatarsal head, thereby eliminating symptoms.
Ankle Fusion: A New Technique of Internal Fixation Using a Compression Blade Plate
Authors: Sowa David T. , Krackow Kenneth A.
Published: March 2013

A new technique of tibiotalar arthrodesis has been developed offering wide exposure, excellent correction of deformity, good bony apposition, and blade plate fixation. This technique has even been effective in cases of ischemic necrosis of the talus. A modified pediatric blade plate is used to effect compression of the talus to the tibia and to provide stability against flexion/extension and varus/valgus movement. Fixation is augmented by a lateral fibular strut screwed to the tibia and talus.

In this series, 17 compression blade plate tibiotalar arthrodeses were performed. Follow-up averaged 48 months (range 13 to 85 months). Preoperative diagnoses included postraumatic degenerative arthritis, rheumatoid arthritis, and ischemic necrosis of the talus. Solid fusion was achieved in 16 of 17 patients (94%) with a painless, stable pseudarthrosis in the remaining one. Time to fusion averaged 4 months (range 2 ½ to 6 months). Functional clinical results were excellent in 12 and good in 4 patients. Of 14 patients evaluated by the Mazur scale, 10 scored within the range of excellent; 2, good; and 2, fair.
Development of the Child's Arch
Authors: Gould Nathaniel , Moreland Morey , Alvarez Richard , Trevino Saul , Fenwick James
Published: March 2013

The purposes of the project were to monitor the development of the lower extremities and the longitudinal arch of the foot and to determine whether or not arch support footwear (three types) affected development of a neutral arch in toddlers 11 to 14 months of age until age 5 years. A total of 125 beginner walkers were recruited through the pediatrics department during a period of 1 ½ years and divided by lot into four different footwear groups (one nonarch supportive). The group was studied for 4 years by physical examinations, x-ray films, and pedotopography (a Moire fringe technique of photography). At initial examination all of the apparently normal toddlers had pes planus by all clinical, roentgenographic, and photographic measurements. There were no cavus feet at that time or at 5 years of age. Arches developed regardless of the footwear worn but development was faster during the first 2 years (until age 3 years) with arch support footwear. The rapidity of arch development until 5 years of age continued in those children who wore longitudinal arch cookies. Ossification of the sustentaculum tali begins at approximately 5 years of age but is not complete for at least another 1 to 2 years. Hyperpronation was present in 77.9% and genu valgum in 92.3% of the 5-year-old children. These conditions are apparently the norm at this age in both boys and girls.
Laser Matricectomy in the Toes
Authors: Wright Gilbert
Published: March 2013

Methods and results are described for a series of laser matricectomy cases in the toes, 23 partial matricectomies and 58 total matricectomies. A high incidence of nail recurrence was experienced, 48% for partial matricectomy and 50% for total matricectomy. After review of results, the laser method seemed to be less satisfactory than traditional surgical methods.