bluuebunny/crossref_metadata_2025 huggingface dataset:
Blood Supply of the Flexor Hallucis Longus Tendon with Regard to Dancer's Tendinitis: Injection and Immunohistochemical Studies of Cadaver Tendons
Authors: Petersen Wolf , Pufe Thomas , Zantop Thore , Paulsen Friedrich
Published: January 2017

The flexor hallucis longus is the most common site of lower extremity tendon disorders in ballet dancers. Reduced vascularity is an important factor contributing to tendon degeneration and rupture under strain. A study was conducted on the vascular pattern of the human flexor hallucis longus tendon with injection techniques and immunohistochemically by using antibodies against laminin. Blood supply arose from the posterior tibial and the medial plantar artery. Peritendinous blood vessels penetrated the tendon and anastomosed with a longitudinally oriented intratendinous network. Injection specimens and immunohistochemistry revealed one avascular zone in which the tendon passed behind the talus and a second in which the tendon wrapped around the first metatarsal head. These are the most typical areas for tendon degeneration and rupture.
Ankle Arthroscopy in the Lateral Decubitus Position
Authors: Harbach Gregory P. , Stewart Joel D. , Lambert Edward W. , Anderson Claude
Published: January 2017

Ankle or subtalar arthroscopy is a commonly performed procedure. It is often desirable to perform a diagnostic or therapeutic ankle arthroscopy followed by an open lateral ankle or hindfoot surgery. Standard positioning for ankle or subtalar arthroscopy is supine with or without the use of noninvasive distractor. In order to save operative time and avoid repositioning and redraping the patient intraoperatively, the authors have developed a positioning technique for performing ankle or subtalar arthroscopy, as well as anterior or medial procedures, followed by sequential procedures of the lateral ankle or hindfoot.
In Vitro Simulation of Stance Phase Gait Part I: Model Verification
Authors: Hurschler Christof , Emmerich Judith , Wülker Nikolaus
Published: January 2017

An in vitro simulator was developed to reproduce the kinematics and kinetics of stance phase gait on cadaver foot specimens. Ground reaction force was applied by a tilting angle- and force-controlled translation stage upon which a pressure measuring platform was mounted; tibial rotation was reproduced by a servomotor. Force was applied to nine tendons of the foot flexor and extensor muscle groups, and three-dimensional hind- and forefoot motion was measured. The model was verified based on in vivo kinematic and kinetic measurements. It was found to be in good general agreement with some exceptions which include a slightly more lateral gait line.
Effect of Arch Supports on Ankle—Subtalar Complex Instability: A Biomechanical Experimental Study
Authors: Tochigi Yuki
Published: January 2017

Background:

Subtalar instability, which may cause persistent symptoms after severe inversion ankle sprains, often involves failure of the interosseous talocalcaneal ligament (ITCL). While several clinicians have reported surgical treatment for this pathology, nonsurgical management policy has not been well considered. Previously, it was proposed that ITCL failure possibly causes looseness of the tarsal arch construction resulting in abnormal ankle—subtalar kinematics occurring with axial forces. In the current study the author hypothesized that arch-support insole functions to improve abnormal joint kinematics in ankle—subtalar complex instability.

Methods:

Five fresh-frozen cadaver lower extremities with simulated ankle—subtalar complex instability, which was created by combined sectioning of the anterior talofibular ligament (ATFL) and the ITCL, were subjected to a biomechanical experiment. Cyclic axial loading from 9.8 to 668 N was applied with a material testing machine, while three-dimensional angular displacements in both the ankle and subtalar joints were determined with electric goniometers. The specimens were tested before and after inserting an arch-support insole that supports the medial-longitudinal and transverse arches of the foot.

Results:

Inserting the insole decreased the maximum ankle internal rotation, from 3.3° ± 0.9° to 2.3° ± 0.4° ( p = .028), while subtalar rotation was not significantly changed.

Conclusions:

The medial longitudinal arch-support insole reduced abnormal ankle internal rotation created by combined sectioning of the ATFL and ITCL, likely due to improved arch configuration stability.
Functional Outcome After Modified Blair Tibiotalar Arthrodesis for Talar Osteonecrosis
Authors: Van Bergeyk Anthony , Stotler Wesley , Beals Timothy , Manoli Arthur
Published: January 2017

Background: Osteonecrosis of the talar body is a challenging problem for both patient and surgeon. One reconstruction option is an arthrodesis of the tibia to the talar neck, as described by Blair, 2 which has the theoretical advantages of salvaging some hindfoot height and motion of the subtalar joint. A few case series have been published describing outcome after modified Blair fusions, none with validated functional outcomes. The purpose of this article is to describe a modification of Blair's original technique, and report the functional outcomes in a series of patients undergoing this procedure. Method: A retrospective review of seven patients with talar osteonecrosis undergoing modified Blair tibiotalar arthrodesis was performed. The median patient age was 51 (range, 39–78). Median follow-up was 20 months (range, 12–112). Two patients required a repeat procedure for delayed/nonunion, with subsequent uneventful union. In all patients the procedure included compression screw fixation of the talar head to the anterior distal tibia, with the two repeat procedures and the most recent patient having an additional anterior compression plate and bone graft. Functional outcome measures using both the AOFAS ankle-hindfoot score and the SF-36® global health outcome measure were obtained at latest follow-up. In addition, radiographic assessment of bone union and time to union was determined. Results: Median SF-36® physical and mental component scores were 46 and 61, respectively. The median AOFAS ankle-hindfoot score was 67 out of 100. Median visual analog scales for postoperative pain and function were 7.1 and 6.0 respectively, out of a best possible score of 10. Conclusion: Functional outcome scores after modified Blair arthrodesis are lower than similar scores after conventional tibiotalar fusion, and much lower than “normal” values; however, the procedure has similar, if not lower, complication rates to alternative complex hindfoot reconstructions, and this procedure is a valuable alternative in the management of talar osteonecrosis with arthrosis.
The Effects of Cycling Shoe Stiffness on Forefoot Pressure
Authors: Jarboe Nathan Edward , Quesada Peter M.
Published: January 2017

Plantar pressure data were recorded in two different shoe types to determine the effect of cycling shoe stiffness on peak plantar forefoot pressure in cyclists. Two pairs of shoes of the same size and manufacturer, identical except for outsole material and stiffness, were tested. Shoe stiffness measurements were collected under controlled conditions and in two different configurations using a dynamic hydraulic tensile testing machine. Measurements of plantar pressure were done using Pedar™ capacitive-based sensor insoles while subjects pedaled in a seated position at a controlled power output. Power output was set at a constant value of 400 W across all subjects by a magnetic resistance trainer unit. The pressure distribution in carbon-fiber-composite shoes during cycling was compared to cycling shoes made with plastic soles. Carbon fiber shoes presented stiffness values 42% and 550% higher than plastic shoes in longitudinal bending and three-point bending, respectively. The shoes made with carbon fiber produced peak plantar pressures 18% higher than those of plastic design (121 kPa vs. 103 kPa, p = .005). Competitive or professional cyclists suffering from metatarsalgia or ischemia should be especially careful when using carbon fiber cycling shoes because the shoes increase peak plantar pressure, which may aggravate these foot conditions.
Locked Fracture Dislocation of the Calcaneus Treated with Minimal Open Reduction and Percutaneous Fixation: A Report of Two Cases and Review of the Literature
Authors: Turner Norman S. , Haidukewych George J.
Published: January 2017

Fractures of the calcaneus with associated locked dislocation of the posterior facet have been previously described. Two patients with a calcaneal fracture with a locked dislocation of a portion of the posterior facet were treated with minimally invasive open reduction and percutaneous screw fixation of the fragment with cannulated screws. Both patients had satisfactory reductions and healed the fractures without any soft-tissue complications. This technique can be a useful addition to the armamentarium of the surgeon treating these injuries, especially in the patient at high risk for wound complications.
Charcot Osteoarthropathy in a Case of Klippel–Trenaunay–Weber Syndrome
Authors: Sella Enzo J. , Ortega Gil R.
Published: January 2017

A case of a patient with Klippel-Trenaunay-Weber syndrome (KTW) with Charcot osteoarthropathy is presented. A medline literature review was performed using the words Klippel-Trenaunay, orthopaedic, ankle, foot, and Charcot joint. Seven articles reported orthopaedic manifestations of KTW. They included limb hypertrophy and atrophy, limb-length discrepancies, digital anomalies, ulcerations, and spine and hip abnormalities, but no mention of Charcot osteoarthropathy. After many years of chronic nonhealing ulcers and repeated incision and drainage procedures the patient developed Charcot osteoarthropathy of the ankle without evidence of osteomyelitis or peripheral neuropathy but with severe deformity that required transtibial amputation.
Bilateral Chronic Proximal Plantar Fasciopathy: Treatment with Electrohydraulic Orthotripsy
Authors: Ogden John A. , Cross G. Lee , Williams Sharrona S.
Published: January 2017

Background:

Patients presenting for treatment of chronic plantar fasciopathy often have bilateral involvement. When various nonoperative treatments fail, subsequent intervention may be problematic, especially since bilateral surgery (bilateral fascial release) may not be realistic because of variable, frequently restrictive postoperative weightbearing limitations.

Methods:

Twenty-three patients (46 heels) were treated with electrohydraulic high-energy orthotripsy to the plantar entheses of both feet while under the same anesthesia (conscious sedation). Following orthotripsy, all patients immediately were fully weightbearing and resumed normal activities of daily living and work, usually within 24 hours. Progressive return to athletic activities was allowed. Patients were assessed by three outcome parameters: (1) pain measured objectively by a dolorimeter combined with the patient's subjective evaluation of the level of pain; (2) pain after 5 minutes of walking upon arising; and (3) pain with daily activities. All pain measurements were done by the visual analog scale.

Results:

Patients initially experienced varied pain relief responses. This included earlier pain relief in one heel compared to the other, as well as better pain relief in one heel than the other at the 6- and 12-week evaluations, but with much less variance at the 1-year evaluation. By 3 months following orthotripsy, 28 heels (61%) had good or excellent results. These results were maintained or improved at 1 year. In 18 heels (39%), the outcome was fair or poor. Nineteen heels received a second orthotripsy application; one patient requested a second orthotripsy treatment of only one heel, while nine patients requested a second treatment of both heels. The outcome showed further improvement following the second application of orthotripsy. At 1 year after one or two orthotripsy applications, 19 patients (38 heels) were satisfied with the results in both heels (83%), while four patients (eight heels) still had an unsatisfactory outcome (17%).

Conclusion:

Electrohydraulic high-energy orthotripsy is a reasonable nonincisional method for treating patients with bilateral chronic proximal plantar fasciopathy under a single anesthetic without the prolonged nonweightbearing status often recommended for patients following unilateral open or endoscopic fascial release.
Squamous Cell Carcinoma Arising in Chronic Osteomyelitis in Foot and Ankle
Authors: Altay Murat , Arikan Murat , Yildiz Yusuf , Saglik Yener
Published: January 2017

Background:

Squamous cell carcinoma arising from chronic osteomyelitis is uncommon, and although most occur in the lower extremities, occurrence in the foot and ankle is rare.

Methods:

Between February, 1991, and May, 2003, we treated 14 patients (13 men and one woman) with squamous cell carcinomas arising in chronic osteomyelitis. The foot and ankle were affected in seven patients, and these comprised our study group. All seven patients were male, with a mean age of 59.5 (range 54 to 63) years. An average of 27 (range 4 to 50) years passed between draining of the osteomyelitis and the diagnosis of the malignancy. Average followup was 68 (22 to 147) months.

Results:

Six patients had amputations and one had limb salvage. Regional lymph node clearance was done in four patients, but metastasis occurred in only one patient who later died of the disease.

Conclusion:

In treating recalcitrant ulcers that have not responded to conventional modes of therapy, malignancy should be ruled out and a biopsy done. The treatment of choice for squamous cell carcinoma is amputation. Routine regional lymphadenectomy at the time of amputation seems unnecessary, but regional lymphadenopathy persisting for 3 months after amputation warrants surgical intervention.
The Effect of Walking Speed on Peak Plantar Pressure
Authors: Segal Ava , Rohr Eric , Orendurff Michael , Shofer Jane , O'Brien Matthew , Sangeorzan Bruce
Published: January 2017

Background: Plantar pressure measurements often are used as a tool to evaluate pathologic gait. Previous studies, often done at self-selected walking speeds, have used peak plantar pressure to try to predict ulcer formation, compare surgical outcomes, and evaluate orthotic device efficacy. However, the relationship between walking speed and plantar pressures at specific plantar regions has not been clearly defined. Methods: Twenty normal subjects walked on a treadmill at six speeds (0.75 to 2.00 m/s). In-shoe peak plantar pressure was measured at five plantar regions and compared across the range of speeds. Results: Walking speed affected peak plantar pressure differently at the five examined plantar regions. The hallux and heel regions had the highest pressures, which increased linearly with faster speeds. The central and medial forefoot pressures initially increased but plateaued at the faster speeds, while the lateral forefoot had the lowest overall peak pressures, which decreased at the faster walking speeds. Therefore, significant quadratic effects were found at the forefoot. Best-fit regression equations defined distinct pressurespeed relationships at each plantar region ( p < 0.0001). Conclusion: The effect of walking speed on peak plantar pressure varied with plantar region. To achieve more robust peak plantar pressure measurements, walking speed should be controlled. Determining the normal plantar function across a range of speeds can aid in the development of shoes and foot orthoses. The pressurespeed relationships presented in this study can be used as a comparative tool for evaluating the efficacy of clinical interventions for pressure reduction, especially when walking speed changes may confound the outcomes.
Effects of the Subtalar Sling Ankle Taping Technique on Combined Talocrural-Subtalar Joint Motions
Authors: Wilkerson Gary B. , Kovaleski John E. , Meyer Mark , Stawiz Christopher
Published: January 2017

Background: The findings of research on the effectiveness of ankle taping for protection against ligament injury have been inconsistent, and the topic remains controversial. The precise orientation of the force vectors created by tension within the various tape strip components of an ankle taping procedure may be a critical factor influencing the degree of motion restraint that is provided. We hypothesized that the addition of the subtalar sling component to the widely recognized standard (Gibney) ankle taping procedure would enhance restraint of ankle motion. This was a controlled laboratory study, with fully repeated measures (subjects served as their own controls). Methods: An ankle arthrometer was used to quantify anteroposterior (AP) translation and frontal plane inversion-eversion (I-E) tilt of the talocrural-subtalar joints under untaped and taped conditions in normal subjects. A 15-minute exercise session was conducted to loosen the tape before measurement of its effect on motion restraint. Results: The ankle taping procedure that incorporated the subtalar sling provided significantly greater restriction of postexercise AP translation (p < 0.001, η2 = 0.63) and postexercise I-E tilt (p < 0.001, η2 = 0.66). Conclusions: The subtalar sling ankle taping procedure provides greater restriction of motions associated with ankle instability than the more widely used Gibney procedure.
Removal of the Second Toe for Severe Hammertoe Deformity in Elderly Patients
Authors: Gallentine James W. , DeOrio James K.
Published: January 2017

Background: Our hypothesis was that amputation of an isolated, painful second hammertoe is beneficial and has less morbidity than forefoot reconstruction when other associated deformities are not clinically painful. The objective was to evaluate the clinical outcomes of elderly patients undergoing amputation of painful second hammertoes instead of advanced reconstructive procedures. Methods: We retrospectively reviewed all cases of removal of the second toe through the MTP joint for painful hammertoe deformities from May, 1998 to May 2004. Amputation for ischemic disease was excluded from the study. No patient had a concurrent hallux valgus reconstruction. The study group included 12 patients (17 amputations). A clinical questionnaire was used to determine patient satisfaction and postoperative changes in forefoot alignment. Results: Ten patients were satisfied with the results, and the other two were satisfied with reservations. The activity level improved for nine patients. Eight patients noted continued valgus drift of the great toe. Nine patients would have the procedure again, and 11 thought that it met their expectations and would recommend it. No important complications were noted. Conclusions: Amputation of the second toe in elderly patients is acceptable for complaints of pain related solely to the hammertoe. The morbidity associated with more advanced reconstruction is avoided, while eliminating pain and improving shoewear and function. Patient satisfaction was high, and complications were minimal. Drift of the great toe into valgus did not appear to be a clinical problem.
Gait Instability in Older People with Hallux Valgus
Authors: Menz Hylton B. , Lord Stephen R.
Published: January 2017

Background: Hallux valgus is a common condition that may lead to considerable pain and disability. There is also evidence that hallux valgus may impair balance and increase the risk of falling in older people. Although a number of plantar pressure studies have been undertaken in people with and without hallux valgus, little is known about how hallux valgus affects basic gait patterns or the movement of the upper body when walking. Methods: Measurements of temporospatial parameters of gait and acceleration patterns of the head and pelvis were obtained in 71 people (24 men, 47 women) between 75 and 93 (mean 80 ± 4) years of age when walking on both a level surface and a specially designed irregular walkway. Foot problems, vision, peripheral sensation, strength, and reaction time also were evaluated. Results: After adjusting for potential confounders, subjects with moderate to severe hallux valgus were found to exhibit significantly reduced velocity and step length on both walking surfaces and less rhythmic acceleration patterns in the vertical plane when walking on the irregular surface compared to subjects with no or mild hallux valgus. Conclusion: These findings indicate that hallux valgus has a significant detrimental impact on gait patterns that may contribute to instability and risk of falling in older people, particularly when walking on irregular terrain.
Bone Suture Anchor Fixation in the Lower Extremity: A Review of Insertion Principles and a Comparative Biomechanical Evaluation
Authors: Scranton Pierce E. , Lawhon S. Michael , McDermott John E.
Published: January 2017

Background: Suture anchors have been developed for the fixation of ligaments, capsules, or tendons to bone. These devices have led to improved fixation, smaller incisions, earlier limb mobility, and improved outcomes. They were originally developed for use in shoulder reconstructions but are now used in almost all extremities. In the lower leg they are used in the tibia, the talus, the calcaneus, tarsal bones, and phalanges. Nevertheless, techniques for insertion and mechanisms of failure are not well described. Methods: Five suture anchors were studied to determine the pullout strength in four distal cadaver femurs and four proximal cadaver tibias from 55- and 62-year-old males. Eight hundred ninety Newton line was used, testing the anchors to failure with an Instron testing device (Instron, Norwood, MA). The anchor devices were inserted randomly and tested blindly (12 tests per anchor device, 60 tests in all). Results: Two anchors in each group tested failed at low loads. Both types of plastic anchors had failures at the eyelet. Average pullout strength varied from 85.4 to 185.6 N. Conclusions: Insertion techniques are specific for each device, and they must be followed for optimal fixation. In this study, in all five groups of anchors tested two of the 12 anchors in each group failed with minimal force. On the basis of this finding we recommend that, if suture anchor fixation is necessary, at least two anchors should be used. Since there appears to be a percentage of failure in all devices, the second anchor can serve as a backup. It is imperative that surgeons be familiar with the insertion techniques of each device before use.
Foot Pressure Measurement Differences Between Boys and Girls With Reference to Hallux Valgus Deformity and Hypermobility
Authors: Ferrari Jill , Watkinson David
Published: January 2017

Background: Previous studies that compared foot pressures in boys and girls found that girls had greater peak pressures under the hallux than did boys. Only one of these studies considered plantar pressure measurements in children. The purpose of the study was to investigate the effect of gender on foot pressure measurements in children. Methods: This is a comparative study using the F-Scan pressure platform (F-Mat; Texscan® Boston, MA) on a sample of children attending a podiatric clinic. Pressure measurements and temporal parameters were measured in 61 children between the ages of 5 and 16 years. Associations between joint hypermobility and hallux valgus angle also were investigated. Results: Girls were found to have significantly greater peak pressure under the hallux, faster timing of heel contact to first metatarsal head loading, and a more medially placed center of pressure trajectory. No associations were found between these significant variables and hypermobility scores or hallux valgus angle. Conclusion: The results indicate that there are differences in pressure measurements between boys and girls, but the reasons for these remain unclear. Differences in pressure measurements in the feet of boys and girls may be useful in establishing the cause of foot pathologies for which a prevalence has been shown in boys or girls, such as hallux valgus deformity, which is known to be more frequent in females of all ages.
The Use of Autologous Concentrated Growth Factors to Promote Syndesmosis Fusion in the Agility Total Ankle Replacement. A Preliminary Study
Authors: Coetzee J. Chris , Pomeroy Gregory C. , Watts J. David , Barrow Craig
Published: January 2017

Background: The Agility (DePuy, Warsaw, Indiana) total ankle replacement has been in use since 1984. One of the most common complications continues to be delayed union or nonunions of the distal tibiofibular syndesmosis. In the reported studies on the Agility ankle the delayed union and nonunion rate can be as high as 38%. Methods: Since 1999, 114 Agility total ankle replacements were done at two centers in the United States without the use of autologous concentrated growth factors. Since July of 2001, 66 Agility ankles were implanted with Symphony (DePuy, Warsaw, Indiana) augmented bone grafting. The standard operative technique was followed in all the patients. Prospective data was collected on all patients. The standard ankle radiographs were taken preoperatively and postoperative at 8 weeks, 12 weeks, 16 weeks, 6 months, and yearly. CT scans were obtained at 6 months if fusion at the syndesmosis was questionable. The Graphpad Instat software (Graphpad Software Inc., San Diego, CA) was used for statistical analysis. The two-tailed unpaired t-test was used, and the value <0.05 was considered significant. Results: There was no statistical difference in the demographic data for the two groups. In 114 ankle replacements without autologous concentrated growth factors 70 fused at 8 weeks (61%), 14 fused at 12 weeks (12%), 13 fused at 6 months (12%). There were 17 nonunions (15%); delayed unions (3 to 6 months) and nonunions, therefore, equaled 27%. The syndesmosis fused in 50 of the 66 ankle replacements (76%) that had autologous concentrated growth fractures at 8 weeks (76%); 12 fused at 3 months (18%), 2 fused at 6 months (3%), 2 had nonunions (3%). Delayed unions (3 to 6 months) and nonunions equaled 6%. There was a statistically significant improvement in the 8- and 12-week fusion rates, and a statistically significant reduction in delayed unions and nonunions. Conclusion: Autologous concentrated growth factors appear to make a significant positive difference in the syndesmosis union rate in total ankle replacements.
The Effect of Terrain on Foot Pressures During Walking
Authors: Mohamed Olfat , Cerny Kay , Jones Wendy , Burnfield Judy M.
Published: January 2017

Background: High plantar pressures are associated with the development of foot ulcers in people with diabetic neuropathy. The effect of terrain on plantar pressures during walking has not been fully explored. Methods: Twenty 23- to 40-year-old subjects with no known musculoskeletal pathology walked across three terrains: padded carpet (R), grass (G), and concrete (C) while wearing Novel Pedar (Novel Electronics Inc. GMBH, Munich, Germany) insoles with and without shoes. Pressures were collected at 50 Hz. The sole of the foot was divided into: heel (H), lateral midfoot (LM), medial midfoot (MM), big toe and first metatarsal head (BT), and lateral toes and metatarsal heads (LT). Repeated measures ANOVA identified differences in pressures, forces, and contact areas across terrains. Post hoc Bonferroni adjustments were used to accept an overall alpha level of 0.05. Results: Peak pressure (PP), maximal mean pressure (MMP) and pressure time integral (PTI) were significantly higher ( p < 0.01) when walking barefoot on concrete than on grass or carpet for all foot regions except MM and LM. The percent increase in the three pressure variables ranged from 21% to 43%. Grass and carpet PP, MMP, and PTI were similar for the BT and LT. Wearing shoes significantly increased contact area and decreased all pressure variables on all three terrains. Conclusion: Walking barefoot, especially on concrete was associated with higher plantar pressure variables. Wearing shoes eliminated terrain differences in pressure except under the lesser toes. Persons with insensate feet should avoid walking barefoot on hard surfaces to avoid excessive plantar pressures. Wearing shoes and covering hard floors with nonslip, padded rugs may decrease plantar pressures and the risk of ulceration.
Joint Stabilizing Response to Expected and Unexpected Tilts
Authors: Morey-Klapsing Gaspar , Arampatzis Adamantios , Brueggeman Gert-Peter
Published: January 2017

Background: The results found in the literature regarding functional ankle joint stabilization are controversial possibly because of the testing methods used. Methods: The responses of 22 subjects to unexpected and expected sudden inversions of the foot were compared for all subjects together, as well as grouped by their self-perceived stability. A three-dimensional foot model was used to describe ankle and foot motion. Electromyographic signals of six muscles of the lower limb as well as the horizontal ground reaction forces were recorded. Results: Whereas unexpected and expected trials did not show significant differences ( p > 0.05) in kinematics, higher activation and horizontal force integrals were found for the unexpected trials. In addition, no differences in electromyographic or ground reaction force parameters were found between stable and unstable ankles; however, the kinematics revealed higher amplitudes and velocities for the stable group. Conclusions: The awareness of the instant of tilt enhances stabilization in that the same motion is achieved with a lower muscle activation. Evidence suggests that this is triggered at supraspinal levels. We found that timing of the EMG signal is not as relevant to stabilization as the amplitude (which has often been disregarded in the literature).
Ankle Alignment on Lateral Radiographs. Part 1: Sensitivity of Measures to Perturbations of Ankle Positioning
Authors: Tochigi Yuki , Suh Jin-Soo , Amendola Annunziato , Pedersen Douglas R. , Saltzman Charles L.
Published: January 2017

Background: In ankles with end-stage osteoarthritis or with total ankle replacement (TAR), radiographic landmarks based on joint surface morphology usually are obscured and inadequate for radiographic measurement. Furthermore, because of difficulty in reproducibly positioning the ankle for a standing radiograph, any radiographic measure to accurately describe ankle alignment must tolerate perturbations of ankle positioning on clinical radiographs. To identify a radiographic measure of anteroposterior tibial-talar alignment that meets those requirements, three methods were compared to determine their sensitivity to perturbations in ankle positioning. Methods: Ten cadaver ankles had lateral radiographs taken in varying ankle positions in nine prespecified positions in the transverse plane and in seven positions in the sagittal plane. The anteroposterior tibial-talar alignment was quantified by three methods. Sensitivities to changes of ankle position in each plane were then compared. Results: With the tibial-axis-to-talus ratio (T-T ratio: the ratio into which the midlongitudinal axis of the tibial shaft divides the longitudinal talar length), sensitivity to ankle positional changes in either plane was lowest, with errors associated with 10 degrees of ankle malpositioning being 2.2%. The posterior-tibial-line-to-talus ratio (P-T ratio: a similar ratio, but using the posterior longitudinal line of the tibial shaft) showed higher sensitivity in the transverse plane than the T-T ratio, though the associated errors in either plane were nearly comparable. The tibial-axis-to-lateral-process distance (T-L distance: the perpendicular distance from the tibial axis to the tip of the lateral talar process) showed highest sensitivity in both planes. Conclusions: The T-T ratio tolerated perturbations of ankle positioning best among the tested measures. This measure is potentially applicable to clinical radiographic measurement when determining the anteroposterior tibial-talar alignment in ankles with articular degeneration or TAR. The P-T ratio also appears to have reasonable tolerance.
Suture Holding Capacity of the Achilles Tendon during the Healing Period: An In Vivo Experimental Study in Rabbits
Authors: Yildirim Yakup , Kara Hasan , Çabukoglu Cengiz , Esemenli Tanil
Published: January 2017

Background: Early motion and weightbearing is known to promote the healing of Achilles tendon repair. It is important to be informed about the repair strength for a secure rehabilitation. There are reports about the initial repair strength of Achilles tendons; however, they are mainly in vitro studies that represent the time zero strength of the repair. Softening of the tendon observed during the biological process of the tendon healing, which may effect the suture holding capacity and in turn the repair strength of the tendon has not been evaluated before. Methods: In the current study, the suture holding capacity of rabbit Achilles tendon was observed at various times during the healing period. Results: The suture holding capacity of the tendon at the end of the first and third weeks after surgery was found to be similar within 30% of the control tendon. However, at the end of the fourth week it was doubled reaching 65% of the control tendon. Conclusions: Intrinsic tendon insufficiency which causes a decrease in the suture holding capacity of the tendon may lead to pull-out of the suture material during the postoperative third week. This period is precarious for early motion and weightbearing since the suture holding capacity of the tendon doubled relative to the previous three weeks.
Extensor Hallucis Capsularis: Frequency and Identification on MRI
Authors: Boyd Nathan , Brock Hugh , Meier Albert , Miller Richard , Mlady Gary , Firoozbakhsh Keikhosrow
Published: January 2017

Background: The extensor hallucis capsularis (EHC) is the most common name given to the accessory tendon sporadically seen medial to the extensor hallucis longus (EHL). We performed cadaver dissections and MRI evaluation to determine the frequency of its occurrence, the pattern of its origin and insertion, and its potential suitability as tendon graft. Methods: The EHC was examined by dissection in 81 cadaver feet. Physical parameters pertaining to EHC size and location were recorded. MRI was performed on six cadaver legs to determine if the EHC can be identified radiographically. MRI images were evaluated independently by a foot and ankle specialist and a radiologist. Results: The EHC was present in 71 (88%) of the specimens. It originated from the EHL tendon or muscle in 93% and inserted into the first metatarsophalangeal joint capsule in 99% of cases. All EHC tendons were less than or equal to 4 mm in width; only 16% were more than 2 mm wide. Correct prediction of the presence or absence of EHC by MRI varied according to EHC width: two of two in tendons more than 2 mm, five of eight in tendons 1 to 2 mm, and zero of two in tendons 1 mm or less. Conclusion: Up to 14% of the population may have an EHC tendon suitable for grafting in reconstructive surgeries, particularly surgeries related to hallux dysfunction. MRI may have a role in the preoperative identification of the EHC.
Rupture of the Anterior Tibial Tendon: Three Clinical Cases, Anatomical Study, and Literature Review
Authors: Anagnostakos Konstantinos , Bachelier Felix , Fürst Oliver Alexander , Kelm Jens
Published: January 2017

Background: We report three cases of anterior tibial tendon ruptures and the results of an anatomical study in regard to the tendon's insertion site and a literature review. Methods: Three patients were referred to our hospital with anterior tibial tendon ruptures. In the anatomical study, 53 feet were dissected, looking in particular for variants of the bony insertion of the tendon. Results: Two patients had surgical treatment (one primary repair and one semimembranosus tendon graft) and one conservative treatment. After a mean followup of 14 weeks all patients had satisfactory outcomes. In the anatomical study, we noted three different insertion sites: in 36 feet the tendon inserted into the medial side of the cuneiform and the base of the first metatarsal bone and in 13 feet only into the medial side of the cuneiform bone. In the remaining four feet the tendon inserted into the cuneiform and the first metatarsal bone, but an additional tendon was noted taking its origin from the anterior tibial tendon near its insertion into the medial cuneiform and attaching to the proximal part of the first metatarsal. Conclusions: According to literature, surgical repair is the treatment of choice for acute ruptures and for patients with high activity levels. For chronic ruptures and patients with low demands, conservative management may lead to an equally good outcome. Knowledge of the anatomy in this region may be helpful for diagnosis and for the interpretation of intraoperative findings and choosing the most appropriate surgical procedure.
Correction of Moderate to Severe Hallux Valgus Deformity by a Modified Chevron Shaft Osteotomy
Authors: Sanhudo José Antonio Veiga
Published: January 2017

Background: Hallux valgus is one of the most common foot deformities in women. Despite the large number of techniques described for hallux valgus correction, there has been much controversy regarding the best procedure to use, especially for severe deformities. Proximal osteotomies have long been done for severe deformities; however, diaphyseal osteotomies have gained popularity because of the greater degree of correction and stability obtained. Methods: This study retrospectively assessed the radiographic and clinical outcomes in 50 feet (34 patients) that had a modified chevron shaft osteotomy for moderate to severe hallux valgus. Additionally, an Akin medial closing wedge osteotomy of the proximal phalanx was done in most patients. Mean followup was 30 months (minimum 13 months). All patients in the study had either moderate or severe deformities. Patients with mild deformities had correction by other techniques. Results: There was a mean AOFAS score improvement of 39.6 (44.5 to 84.1) points. The hallux valgus angle and intermetatarsal angle improved a mean of 22.7 degrees and 10.4 degrees, respectively. Hallux valgus persisted in one foot; however, the patient was not dissatisfied. Two feet developed hallux varus. Revision was necessary in two patients; one needed revision because of loss of fixation and the other because of symptomatic hallux varus. Conclusion: Based on radiographic correction and clinical outcomes, this procedure is indicated for the treatment of moderate to severe hallux valgus deformities.
Observations on the Fibrous Retinacula of the Heel Pad
Authors: Snow Stephen W. , Bohne Walther H.O.
Published: January 2017

Background: The original purpose of the study was to clarify whether or not there is continuity of the Achilles tendon and the plantar fascia. Those findings have been previously published. In the course of that study, observations of the anatomy of the retinacular tethers of the heel pad were made. These observations included the discovery of the medial calcaneal retinaculum. Methods: Ten adult cadaver feet were dissected. A longitudinal midline incision was made along the Achilles tendon and on the plantar surface of the foot. The heel pad was incised and the skin and heel pad were reflected side-to-side to reveal the calcaneal tuberosity. In this way the retinacular tethers of the heel pad could be seen. Results: Two types of retinacular fibers were observed. Abundant small retinacula were seen coming off the plantar fascia and calcaneal tuberosity. Less abundant larger retinacula originated from the calcaneus only. Both types anchored the heel pad by branching into the fibrous stroma of the heel pad. In nine of 10 feet, a much larger retinacular structure was the principle tether of the heel pad to the medial process of the calcaneal tuberosity. We named this the medial calcaneal retinaculum. Conclusions: The heel pad is anchored by retinacula that vary in number, location, and size. The most consistent and significant tether of the heel pad appears to be the medial calcaneal retinaculum. Clinical relevance: Dislocation of the fat pad of the heel is a relatively rare but potentially devastating injury. An understanding of the anatomical anchoring of the heel pad and its mechanical function can lead to a surgical procedure to restore stability to the heel pad.
Comparison of Radiographs and CT Scans in the Prospective Evaluation of the Fusion of Hindfoot Arthrodesis
Authors: Coughlin Michael J. , Grimes Jerry S. , Traughber Paul D. , Jones Carroll P.
Published: January 2017

Background: This prospective study compared radiographs and CT scans for the quantitative evaluation of healing of hindfoot arthrodeses. Methods: Patients undergoing subtalar or triple arthrodesis were prospectively evaluated. Serial radiographs and CT scans were obtained after surgery. The percent of fusion of the joints was sequentially measured on all radiographs and CT scans. At 6 and 12 months after surgery, the patients completed American Orthopaedic Foot and Ankle Society (AOFAS) and Short Form-12 (SF-12) instruments and a visual analog scale (VAS). Results: The mean observed fusion of the posterior facet of the subtalar joint ranged from 41% at 6 weeks to 61% at 12 weeks and to 86% at 6 months on the radiographs; the mean fusion of the posterior facet on the CT scans ranged from 23% to 48% to 64% at the same time intervals. The agreement between the two methods was poor. The clinical results based on the AOFAS, VAS and SF-12 scores were compared to the percent of joints fused on the CT scans. Clinical results appeared to be independent of radiographic results. Conclusions: We believe the progress of the fusion cannot be determined accurately from standard radiographs. CT scanning appears to be significantly more reliable. The concept of what constitutes an adequate fusion deserves more extensive study.
Efficacy and Tolerability of Low-dose Simvastatin and Niacin, Alone and in Combination, in Patients With Combined Hyperlipidemia: A Prospective Trial
Authors: Stein Evan A. , Davidson Michael H. , Dujovne Carlos A. , Hunninghake Donald B. , Goldberg Ronald B. , Illingworth D. Roger , Knopp Robert H. , Miller Valery T. , Frost Philip , Isaacsohn Jonathan L. , Mitchel Yale B. , Melino Michael R. , Shapiro Deborah , Tobert Jonathan A.
Published: January 2017

Background: Combination lipid-lowering therapy may be desirable in patients with elevated low-density lipoprotein cholesterol, high triglycerides, and low high-density lipoprotein cholesterol. This study was conducted to determine the lipid-lowering efficacy of the combination of low-dose simvastatin and niacin in patients with combined hyperlipidemia and low high-density lipoprotein cholesterol.

Methods and Results: In this multicenter, prospective, randomized trial, 180 patients with hyper cholesterolemia and hypertriglyceridernia and/or low high-density lipoprotein cholesterol were randomized to combination simvastatin (10 mg/day) and niacin (0.75 g/day) or to either drug alone for 9 weeks. The dose of niacin was doubled (from 0.75 g/day to 1.5 g/day) in both the combination and niacin arms for the remaining 8 weeks. The combination of simvastatin, 10 mg/day, and niacin, 1.5 g/day, reduced total. low-density lipoprotein, and very low-density lipoprotein cholesterol and triglycerides by 248, 29%, 45%, and 31%, respectively, while increasing high-density lipoprotein cholesterol by 31%. The addition of niacin to simvastatin did not enhance the low-density lipoprotein cholesterol-lowering effect of simvastatin; however, the combination was more effective than either monotherapy at raising high-density lipoprotein cholesterol and lowering very low-density lipoprotein cholesterol ( P <.05). More patients discontinued treatment because of an adverse event in the niacin ( P <.03) and combination groups ( P =.06) than the simvastatin group.

Conclusions: Treatment of patients with combined hyperlipidemia and/or low high-density lipoprotein with combination low-dose simvastatin and niacin resulted in large reductions in total, low-density lipoprotein, and very low-density lipoprotein cholesterol and increases in HDL cholesterol. Although the combination was well tolerated in the current trial, its safety needs to be evaluated in larger trials of longer duration.
Cardioprotective Effects of Red Blood Cells on Ischemia and Reperfusion Injury in Isolated Rat Heart: Release of Nitric Oxide as a Potential Mechanism
Authors: Yang B.C. , Nichols W.W. , Mehta J.L.
Published: January 2017

Background: Circulating cells influence myocardial function during ischemia and reperfusion. (eg, neutrophils exacerbate, and platelets protect the myocardium from deterioration). This study was designed to determine the role of red blood cells on myocardial function following ischemia and reperfusion in isolated rat hearts.

Methods and Results: Exposure of buffer-perfused hearts to 40 minutes of total ischemia followed by 30 minutes of reperfusion resulted in myocardial dysfunction and injury, indicated by decrease in the force of cardiac contraction (FCC, −25 ± 4%). increase in the coronary perfusion pressure (CPP, +20 ± 3%) and decrease in myocardial superoxide dismutase (SOD, 2.5 ± 0.2 vs 3.5 ± 0.4 U/mg protein in sham ischemic hearts, P < .05). Perfusion of the hearts with washed rat red blood cells showed significant protective effects against ischemia and reperfusion, indicated by minimal change in FCC (-10 ± 4%) and CPP (+3 ± 3%) (both P < .01 vs buffer alone perfused hearts) and preservation of myocardial SOD activity (2.8 ± 0.4 U/mg protein, P < .05 vs buffer alone perfused hearts). The cardioprotective effects of red blood cells were attenuated when the red blood cells were preincubated with the nitric oxide synthase inhibitors Nw-nitro-L-arginine (L-NNA, 5 times 10-4M) or Nw-nitro-L-arginine methyl ester (L-NAME, 5 times 10-1M) at 37°C for 60 minutes before perfusion of the heart. Perfusion of hearts with the nitric oxide precursor L-arginine (2 times 10-4M) also exerted significant protective effects on FCC (-14 ± 4%). CPP (+12 ± 3%) and myocardial SOD activity (2.9 ± 0.2 U/mg protein) following ischemia and reperfusion. In other studies, washed rat red blood cells expressed nitric oxide synthetase activity which was inhibited by both l-NNA and L-NAME.

Conclusions: These results suggest that red blood cells exert cardioprotective effects against ischemia and reperfusion at least in part by the L-arginine-nitric oxide pathway in isolated rat hearts.
Tedisamil Attenuates Ventricular Fibrillation in a Conscious Canine Model of Sudden Cardiac Death
Authors: Friedrichs G.S. , Abreu J.N. , Cousins G.R. , Chi L. , Borlak J. , Lucchesi B.R.
Published: January 2017

Background: The electrophysiologic and antifibrillatory properties of tedisamil (KC-8857;3,7-di-(cyclopropylmethyl)-9,9-tetramethylene-3,7-diazabicyclo[3.3.1]-nonane dihydrochloride) were studied in a conscious canine model of sudden cardiac death.

Methods and Results: Three to five days after surgically induced myocardial infarction (2-hour occlusion of the left anterior descending coronary artery), animals were subjected to programmed electrical stimulation to identify those at risk for ischemia-induced ventricular fibrillation. Sixty minutes after tedisamil (10 mg/kg, administered orally) PES was repeated. Tedisamil increased the ventricular effective refractory period from 106 ± 6 to 134 ± 7 ms (P < .05) compared to placebo treatment. which did not alter the ERP (123 ± 6 to 116 ± 5 ms). Tedisamil prolonged the QTc interval. from a predrug value of 308 ± 14 to 327 ± 14 ms, postdrug. The extent of the surgically induced anterior wall myocardial infarct did not differ between groups. tedisamil, 29 ± 2%, and placebo, 28 ± 2% of the left ventricle.

Conclusions: Tedisamil conferred protection against ischemia induced ventricular fibrillation; 7 of 10 tedisamil-treated dogs survived. compared to 4 of 14 surviving in the vehicle treated group (P < .05). Although we observed instances of vomiting and/or diarrhea in several dogs after a single oral administration of tedisamil. the data indicate that oral administration of tedisamil provides protection from ischemia-induced ventricular fibrillation in the postinfarcted conscious canine. The mechanism by which tedisamil achieves its antifibrillatory effect may be related to its ability to prolong the ERP of the ventricular myocardium without altering ventricular conduction velocity.