bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing Sesamoid Subluxation: How Good Is the AP Radiograph?
Authors: Talbot Kyle D. , Saltzman Charles L.
Published: March 2013

Subluxation of the metatarsosesamoid joints frequently occurs with the development of hallux valgus deformity, and the restoration of a normal metatarsosesamoid articulation has been proposed as essential for achieving a biomechanically sound operative result. The position of the sesamoid bones on the AP radiograph is used often to assess the pre- and postoperative relationship between the hallucal sesamoids and the metatarsal sulci. We evaluated the validity of this approach. Thirty subjects with hallux valgus and 30 control subjects participated in this study by undergoing both AP and tangential weightbearing radiographs. The sesamoid station on the AP radiographs was compared with the position of the sesamoids on tangential radiographs, using a new continuous measure to estimate subluxation. In approximately half of the cases, we found a difference between the apparent sesamoid station on the AP radiograph and the true position on the tangential one. Increased metatarsal rotation was associated with misclassification of the sesamoid station on the AP radiograph. We conclude that the standard method for measuring the sesamoid station on the AP radiograph is not valid. Surgeons wishing to evaluate the metatarsosesamoid joint should obtain weightbearing tangential radiographs.
Ruptures of the Achilles Tendon: Relationship to Inequality in Length of Legs and to Patterns in the Foot and Ankle
Authors: Leppilahti Juhana , Korpelainen Raija , Karpakka Jarmo , Kvist Martti , Orava Sakari
Published: March 2013

We studied 101 patients who were operated on at Oulu University Hospital for ruptured Achilles tendon from 1987 to 1992 (inclusive), and 87 healthy control patients from among Army conscripts. The mean inequality in length of legs (ILL) was 5 ± 4 mm. Among the 48 patients with ILL ≤ 5 mm, the side affected with ruptured tendon was longer in 48% of cases and shorter in 52%. An underpronating alignment of the ankle and foot (based on β45 measurement of the angle ≤ 4°) was found in 21 % of patients and 5% of controls ( P < 0.001). A combination of high longitudinal arch and underpronating alignment of the ankle was seen in 10% of patients and 1% of controls ( P < 0.001). About 37% of the patients' feet and 29% of feet in controls were classified as having a high arch ( P = 0.001). ILL or hyperpronation of the ankle seem to not be predisposing factors for ruptures of the Achilles tendon. High longitudinal arches were somewhat overrepresented, being associated with less pronation of the ankle and less varus in the forefoot than was seen in controls.
Oral Analogue Scale as an Outcome Measure After Displaced Intra-articular Calcaneal Fractures
Authors: Morin Paul , Buckley Rick , Stewart Rena , Gutche Rob Vandey
Published: March 2013

Functional outcome measures of displaced intra-articular calcaneal fractures have been documented using general health surveys (SF36) and disease-specific health surveys (Visual Analogue Scale). A simple oral analogue scale (OAS) was collected on 115 patients with 124 displaced intra-articular calcaneal fractures at 2 years or more after fractures. There was a high correlation ( r = 0.72, P < 0.0001) between the verbal OAS and the written Visual Analogue Scale. We believe that the OAS may assist in follow-up outcome assessment and management in this difficult trauma patient population. Outcomes may be accomplished verbally rather than in written form.
Sagittal Plane Motion of the Human Arch During Gait: A Videofluoroscopic Analysis
Authors: Wearing Scott Cameron , Urry Stephen , Perlman Phillip , Smeathers James , Dubois Philip
Published: March 2013

Despite an abundance of literature investigating arch structure and musculoskeletal injury, there seems to be little consensus regarding the most appropriate technique of measuring dynamic arch motion. In this study, digitized videofluoroscopy was used to determine the sagittal plane motion of the medial longitudinal arch during dynamic gait. Nine female subjects requiring diagnostic foot radiographs underwent videofluoroscopy during a normal gait cycle. The calcaneal inclination angle, calcaneal-first metatarsal angle (CI-MT1) and height-to-length ratio of the arch, all reputed to measure arch alignment, were digitally analyzed from static radiographic images. Both the calcaneal inclination angle (0.96) and CI-MT1 (−0.98) angles were highly correlated with the criterion measure of height-to-length ratio. Repeated measures analysis of variance (ANOVA) identified a significant increase in the mean CI-MT1 angle during stance, suggesting a continual lowering and elongation of the arch. This study questions the validity of characterizing foot motion based on static measures of arch shape and recommends that further research be conducted to establish whether the observed trends reflect normal or pathological foot function.
Anatomic Relations Between Ankle Arthroscopic Portal Sites and the Superficial Peroneal and Saphenous Nerves
Authors: Saito Akira , Kikuchi Shinichi
Published: March 2013

Ankles from 100 cadavers were dissected to evaluate the risk of nerve injury from an arthroscopic procedure. A total of 65 cadavers (104 ankles) were examined to assess the course of the peroneal nerve, and 35 cadavers (77 ankles) were examined for the saphenous nerve (SN). In 82% of specimens, the superficial peroneal nerve ran between the lateral border of the talocrural joint and the peroneus tertius tendon at the talocrural joint level, where the anterolateral portal was placed. Therefore, the superficial peroneal nerve was at high risk for injury with anterolateral portal placement. At the anteromedial portal site, between the medial border of the talocrural joint and the tibialis anterior tendon, the SN coursed an average of 6 ± 5 mm medial to the medial border of the talocrural joint. SNs in this area were all terminal branches; therefore, anteromedial portal placement avoids nerve injury.
Biomechanical Consequences of Plantar Fascial Release or Rupture During Gait: Part I - Disruptions in Longitudinal Arch Conformation
Authors: Sharkey Neil A. , Ferris Linda , Donahue Seth W.
Published: March 2013

To examine whether conformational changes induced by plantar fascial division may progress during gait, we loaded the feet of seven cadavers using an apparatus that simulates the actions of the extrinsic plantarflexors. We measured the effects of plantar fasciotomy at two instants in the terminal-stance phase of gait. Radiographic measurements of height of the arch, base length of the arch, and talo first-metatarsal angle were used to assess contributions to arch support made by the plantar fascia, tibialis posterior, peroneus longus and brevis, and digital flexor muscles. Complete fasciotomy caused significant collapse of the arch in the sagittal plane. Early in terminal stance, at the instant after heel-off, mean height of the arch decreased from 47 to 45 mm. Late in terminal stance, at the instant preceding contralateral heel strike, mean height of the arch decreased from 46 to 43. Effects of division of the central band, though significant, were mild. Medial base length of the arch increased from 163 to 167 mm in the absence of tibialis posterior contraction at late terminal stance. Arch-supporting abilities of the other extrinsic muscles were insignificant.
Evaluation of Multidensity Orthotic Materials Used in Footwear for Patients with Diabetes
Authors: Foto James G. , Birke James A.
Published: March 2013

Selected combinations of multidensity orthotic materials were tested under simulated walking conditions found in the forefoot of diabetic patients. Materials were compared for therapeutic effectiveness by their stress/strain properties and dynamic compression set. Results showed that all of the multidensity materials experienced losses in performance throughout the testing period of 100,000 cycles, with the greatest losses occurring within the first 10,000 cycles. Of the materials tested, Poron + Plastazote #2 and Spenco + Microcel Puff Lite had the highest dynamic material strain and the lowest dynamic compression set over 100,000 cycles. In comparison, these are better multidensity combinations than the others tested to use as therapeutic orthoses in footwear for diabetic patients.
Proximal Phalanx Osteotomy for the Surgical Treatment of Hallux Rigidus
Authors: Thomas Patrick J. , Smith Ronald W.
Published: March 2013

This study reviewed 17 patients (24 great toes) treated by a single surgeon for hallux rigidus with a dorsal-closing wedge osteotomy of the proximal phalanx in conjunction with a moderate cheilectomy. The average age of patients was 47 years (range, 20–69 years). The minimum follow-up was 1 year (range, 1–16 years; median follow-up, 30 months), and all but five patients were studied for 2 years or more. Ninety-six percent of patients affirmed their decision to have surgery if they had to make the choice again. Subjectively, all patients improved. Preoperatively, 67% of the cases had severe pain by American Orthopaedic Foot and Ankle Society criteria. Postoperatively, 58% had no pain and 42% had mild pain. There was 100% union rate of the osteotomy. Seven of 10 women and 1 of 7 men still had some restrictions on footwear options postoperatively. Recovery time from the patients' perspective was 2 to 12 months (average, 5.6 months). Based on the results of this study, the authors suggest that the addition of a dorsal-closing wedge osteotomy of the proximal phalanx increases patient satisfaction, compared with their review of patients treated by cheilectomy alone. The procedure provides good pain relief and has few complications.
Radiographic Evaluation of Talonavicular Joint After Talar Screw Placement: A Cadaver Study
Authors: Ebraheim Nabil A. , Tosic Aleksandar , Lu Jike , Haman Steve , Nadim Yasser
Published: March 2013

Twelve cadaver feet were used for a radiographic assessment of the talonavicular joint. A 4.0- or a 6.5-mm screw was inserted through the posterior tubercle of the talus, directed anteriorly into four quadrants of the talar head. Lateral, dorsoplantar, lateral oblique, and medial oblique radiographic views were obtained for each specimen, to assess the position of the screw tip in relation to the talonavicular joint. The lateral view consistently demonstrated the screw tip violation when the screw was directed through the center of the talar head, but it failed when screws were passed into the medial or lateral quadrants of the talar head. The dorsoplantar view consistently demonstrated a screw tip violation of the superior two quadrants of the talar head when other views failed. Each screw tip violation of the inferior quadrants (medial and lateral) required a different view. A screw tip violation of the inferior medial quadrant required the lateral oblique view, whereas the inferior lateral quadrant required the medial oblique view for full appreciation. Here again, other views failed to demonstrate minor screw tip violations consistently. Using these views to assess screw placement could decrease the risk of developing posttraumatic arthritis caused by screw tip violation of the talonavicular joint.
Dorsiflexion Metatarsal Osteotomy for Treatment of Recalcitrant Diabetic Neuropathic Ulcers
Authors: Fleischli James E. , Anderson Robert B. , Davis W. Hodges
Published: March 2013

Twenty diabetic patients underwent 22 dorsiflexion metatarsal osteotomies for treatment of chronic persistent or recurrent neuropathic forefoot ulcers. Mean duration of nonoperative treatment was 13 months. The procedure consisted of irrigation and debridement of the ulcer followed by basilar closing wedge metatarsal osteotomy performed through a dorsal approach. At follow-up, complete ulcer healing was noted in 21 cases (95%) at an average of 40 days postoperatively. Complications occurred in 15 cases (68%). The main problems encountered postoperatively were acute Charcot disease (32%) and deep wound infections (14%). Transfer lesions under adjacent metatarsal heads developed in two cases (9%). One ulcer (5%) failed to heal secondary to vascular insufficiency and eventually required a below the knee amputation after a failed revascularization attempt. Loss of screw fixation occurred in one patient (5%) but acceptable metatarsal alignment was maintained and the ulcer healed uneventfully. There were no cases of ulcer recurrence. The results of this study suggest that dorsiflexion metatarsal osteotomy is a reliable salvage procedure for the treatment of recalcitrant neuropathic forefoot ulcers that have failed an adequate trial of nonoperative treatment. This procedure is associated with a high complication rate, as would be expected in this patient population.
Reconstruction of the Lateral Ankle Ligaments Using a Split Peroneus Brevis Tendon Graft
Authors: Sammarco G. James , Idusuyi Osaretin B.
Published: March 2013

Thirty-one consecutive ankles in 30 patients with chronic lateral ankle instability were reconstructed using a split peroneus brevis tendon graft. All patients had pain and instability despite adequate treatment and a rehabilitation program. Six patients had clinical and radiographic evidence of associated subtalar laxity. Four patients (four ankles) had prior Brostrom ligament reconstructions. The average time from the initial injury or treatment to surgery was 23 months. At a mean follow-up of 44 months (range, 24–64 months), the functional results included excellent in 20 ankles, good in 9, fair in 1, and poor in 1. Ankle stability, which did not deteriorate with time, was achieved in 30 of 31 ankles. This procedure is simple, safe, and reliable with a 94% good to excellent clinical result and 97% mechanical stability. It is an excellent reconstruction choice for those individuals with high demand ankles, with a longstanding ankle instability with or without subtalar instability, and for failed primary reconstruction.
Cartilage and Synovium of the Peroneocuboid Joint: An Anatomic and Histological Study
Authors: Ebraheim Nabil A. , Lu Jike , Haman Steve P. , Yang Hua , Yeasting Richard A.
Published: March 2013

The surface area, thickness, and composition of the articular cartilage of the peroneocuboid articulation and the location of the synovium were investigated in 15 cadaver foot specimens. The articulations of the medial side of the peroneus longus tendon and lateral side of the cuboid were covered with fibrous and hyaline cartilages, respectively. On the lateral tuberosity of the cuboid, there is a facet that has 79.37±20.24 mm2 articular cartilage area with an oval shape to conform to that of the articular surface of the peroneus longus tendon (articular cartilage area, 67.35±28.53 mm2) with which it articulates. The mean thickness of the articular cartilage of the peroneus longus tendon and cuboid was 0.34±0.08 and 0.52±0.07 mm, respectively. The peroneocuboid joint has its own joint capsule. The synovial cavity does not communicate with the sheath of the peroneus longus tendon. Synovial membranes were attached to the margins of the articular surfaces of the cuboid immediately peripheral to the cartilage region.
Intermediate to Long-term Follow-up of Medial-approach Dorsal Cheilectomy for Hallux Rigidus
Authors: Easley Mark E. , Davis W. Hodges , Anderson Robert B.
Published: March 2013

Dorsal cheilectomy of the hallux metatarsophalangeal (MTP) joint through a medial approach can effectively provide long-term relief of pain and improve function in symptomatic mild-to-moderate hallux rigidus, despite progression of generalized first MTP joint arthritic degeneration and/or loss of motion. Fifty-seven patients (75 feet) with arthritis of the first MTP joint underwent dorsal cheilectomy through a medial approach for hallux rigidus failing nonoperative management. Excision of the dorsal articular surface of the first metatarsal head and dorsal osteophytes was performed through a medial approach that also allowed for plantar capsular release and removal of lateral osteophytes. Minimum follow-up was 3 years (average, 63 months; range, 37–92 months). Fifty-two patients (68 feet) returned for clinical and radio-graphic evaluation. American Orthopaedic Foot and Ankle Society Hallux Rating scores improved from a preoperative average of 45 to 85 points at follow-up. Average dorsiflexion improved from 19°, to 39°, and the average range of motion improved from 34° to 64°. Preoperative radiographic grade of arthritic degeneration was grade I in 17 feet, grade II in 39 feet, and grade III in 12 feet; at follow-up, the radiographic grade was grade I in 2 feet, grade II in 26 feet, and grade III in 40 feet. Thirty-two feet worsened one grade, 6 feet worsened two grades, and 28 feet demonstrated no change (12 of 28 were grade III, preoperatively). A dorsal spur recurred in 21 feet, 9 of which were symptomatic. Complications included two superficial wound infections and four transient paresthesias of the hallux, all of which resolved uneventfully.
Morton's Metatarsalgia: Sonographic Findings and Correlated Histopathology
Authors: Read John W. , Noakes Jennifer B. , Kerr David , Crichton Kenneth J. , Slater H. Kim , Bonar Fiona
Published: March 2013

The results of 79 high resolution ultrasound examinations of the forefoot that were performed for suspected Morton's metatarsalgia were retrospectively assessed. Scans were only obtained if the pain was poorly localized or if there were atypical features that made the clinical diagnosis uncertain. Ultrasound detected 92 hypoechoic intermetatarsal web space masses in 63 patients. Surgery was performed on 23 web spaces in 22 patients where the response to nonsurgical management had been poor. The surgical specimens were retrieved and reviewed by a pathologist in 21 cases. The histopathology in 20 of 21 operated cases was that of Morton's neuroma; however, prominent mucoid degeneration was also found to involve the adjacent loose fibroadipose tissues in 19 of 20 neuroma specimens. Ultrasound was sensitive in the detection of web space abnormality (sensitivity, 0.95), but could not clearly separate Morton's neuroma from associated mass-like mucoid degeneration in the adjacent loose connective tissues. The implications of these observations for both diagnosis and treatment are discussed.
Comparison of Open Isolated Subtalar Arthrodesis with Autogenous Bone Graft Versus Outpatient Arthroscopic Subtalar Arthrodesis Using Injectable Bone Morphogenic Protein-enhanced Graft
Authors: Scranton Pierce E.
Published: March 2013

Isolated subtalar joint arthrodesis is an established salvage procedure that can be performed in various ways for varying diagnoses. The purpose of this article is to report a new arthroscopic subtalar arthrodesis technique that has been developed. The results of this method versus an open technique were compared.

Length of hospital stay, tourniquet time, morbidity, and fusion rate were studied in 17 fusion patients between 1990 and 1997. Twelve patients had open arthrodesis with bone graft and 5 patients had arthroscopic arthrodesis with supplemental, injectable, osteoinductive enhanced-graft gel.

The length of stay decreased 1.7 days with the arthroscopic procedure. Tourniquet time was not significantly different. One open procedure required refusion, whereas none did in the arthroscopic group. One patient in each group required AO screw removal. In selected patients with subtalar arthrosis without significant hind-foot deformity, arthroscopic arthrodesis can be an effective. It is too early to determine if there are specific advantages in this procedure compared with a conventional open arthrodesis.
Subtalar Arthrodesis for Late Sequelae of Calcaneal Fractures: Fusion In Situ Versus Fusion with Sliding Corrective Osteotomy
Authors: Huang Peng-Ju , Fu Yin-Chih , Cheng Yuh-Min , Lin Sen-Yuen
Published: March 2013

Primary subtalar arthritis is not common. In most cases, it is the late sequela of intra-articular calcaneal fracture. 7 Subtalar arthrodesis is mostly used for the treatment of traumatic subtalar arthritis in our clinics. We have compared our early cases of in-situ subtalar fusion with our recent cases of fusion with sliding corrective osteotomy in this clinical report.

From 1989 to 1992, 15 feet of 13 patients were treated with subtalar arthrodeses for subtalar arthritis caused by malunion of calcaneal fractures. Fusion in situ was done by Ollier's approach, and resection of bony protrusion was done if there was lateral entrapment syndrome. From 1992 to 1995, 13 feet of 12 patients also received subtalar arthrodeses to salvage their calcaneal fractures, but the subtalar fusion was done by wide lateral approach, calcaneal sliding corrective osteotomy, and sometimes (11 of 13 feet) with Achilles tendon lengthening to restore the calcaneal height and width.

Patients of both groups experienced obvious clinical improvement in subtalar pain relief, but there was no difference with walking distance, running, or jumping. The group undergoing fusion with sliding corrective osteotomy was more satisfied with regard to cosmetic results and shoe wear. The overall satisfactory rate in the group who underwent fusion with sliding corrective osteotomy (92%) was superior to the group who underwent fusion in situ (77%).

Though our method of sliding corrective osteotomy does not provide much improvement to the talus declination angle, it is suitable for those patients with a “banana”-shaped calcaneus malunion. If the patient has prominent anterior ankle pain caused by tibiotalar impingement, we believe that a distraction subtalar arthrodesis would be more appropriate.
Basal Closing Wedge Osteotomy for Correction of Hallux Valgus and Metatarsus Primus Varus: 10- to 22-Year Follow-up
Authors: Trnka Hans-Jörg , Mühlbauer Michaela , Zembsch Alexander , Hungerford Marc , Ritschl Peter , Salzer Martin
Published: March 2013

Between 1974 and 1985, 59 patients (83 feet) underwent basal closing wedge osteotomy in combination with a bunionectomy and a lateral soft tissue release for correction of hallux valgus and metatarsus primus varus at this institution. Of the original 59 patients, 42 patients (60 feet) with at least 10 years of follow-up (average, 194 months; range, 144–266 months) were available for this study. Results were analyzed by review of the medical records and plain radiographs, a standardized clinical questionnaire, and physical examination. Of the 60 feet, patients rated outcomes as excellent or good in 51 feet (85%) and rated cosmesis as excellent or good in 44 feet (73%). Radiographically at final follow-up, hallux valgus and intermetatarsal angles averaged 19.9° (range, 0–40°) and 6.7° (range, 0–18°), respectively. The sesam-oid position was corrected from an average preoperative grade of 2.6 to a grade of 0.9 at final follow-up. The average shortening of the first metatarsal was 5 mm. The disadvantages of the closing wedge osteotomy are that it is technically demanding and it entails the risk of shortening, dorsal malalignment, and metatarsalgia. In the current study, long-term complications included hallux varus deformity (16 feet), dorsal malalignment (15 feet), and metatarsalgia (14 feet). Despite good correction of the intermetatarsal angle and sesamoid position, the clinical results and the incidence of complications after basal closing wedge osteotomy were not as favorable as those reported for other procedures in the literature. Therefore, alternative procedures, such as the basal crescentic osteotomy or the basal chevron osteotomy, should be used.
Medial Arch Strain After Medial Displacement Calcaneal Osteotomy: An In Vitro Study
Authors: Otis James C. , Deland Jonathan T. , Kenneally Sharon , Chang Vivian
Published: March 2013

Posterior tibial tendon dysfunction with concomitant progressive flatfoot deformity is associated with liga-mentous failure along the medial arch. Medial displacement calcaneal osteotomy is being used alone and in combination with other procedures, with the expectation that it contributes to maintaining the arch. The objective of this study was to examine the effect of osteotomy on reducing medial arch strain. Whole cadaver feet were subjected to vertical loads while plantigrade. Spring ligament length was monitored using liquid metal displacement gauges. Two outcomes were examined: the length of the ligament under one-half body weight and the change in length of the ligament per unit of applied load. The medial displacement calcaneal osteotomy allowed elongation of the ligament with weightbearing, but at a shorter ligament length. This afforded the spring ligament protection from the levels of force experienced in the intact and lateral column-lengthened conditions.
Clinical Outcome of Arthrodesis of the Ankle Using Rigid Internal Fixation with Cancellous Screws
Authors: Monroe Michael T. , Beals Timothy C. , Manoli Arthur
Published: March 2013

Thirty consecutive patients underwent arthrodesis of the ankle using rigid internal fixation with cancellous screws between 1992 and 1996. One patient died of causes unrelated to the surgery before bony union. Primary fusion occurred in 27 of the remaining 29 patients (93%). The average time to primary union was 9 weeks. Two patients developed a delayed union and were treated with an additional bone-grafting procedure. Ultimately, each of the 29 patients went on to fusion. Use of tobacco during the postoperative period had no apparent effect on the rate of fusion or time to fusion.

Twenty-five patients were available for clinical evaluation at an average of 24 months after surgery. Subjective evaluation using questionnaires revealed a high level of satisfaction. All patients stated that they would undergo the procedure again. The mean postoperative score on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale was 81 points, compared with 48 points preoperatively (of a possible 100). Constant pain was the reason given by all patients for seeking treatment. After the arthrodesis, pain was reported as absent in 13 and occasional in 12 patients. All patients noted less pain in the hindfoot after fusion of the ankle. Active litigation and Workers’ Compensation claims during the perioperative period had a significant negative effect on scores on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale and seemed to decrease patients’ perceived ability to return to work.
Cerclage Fibreux in the Treatment of Hallux Valgus
Authors: Franzreb Marco , Wimmer Cornelius , Stöckl Bernd
Published: March 2013

Resection arthroplasty was performed in 62 feet, with follow-up at an average of 36 months (range, 17–68 months). All cases were performed using a combined cerclage fibreux. The mean age at operation was 61 years (range, 49–77 years). The mean score according to the hallux metatarsophalangeal-interphalangeal scale of the American Orthopaedic Foot and Ankle Society was 81 points (range, 25–100 points). Correction of the hallux valgus angle at follow-up averaged 23° (range, 0–45°). The first intermetatarsal angle had been corrected an average of 3° (range, 0–14°). Transfer metatarsalgia was encountered in eight patients. No hallux varus or cock-up deformity was detected.
Unilateral Tibial Hemimelia with Leg Length Inequality and Varus Foot: External Fixator Treatment
Authors: Carranza-Bencano Andrés , González-Rodríguez Ernesto
Published: March 2013

A 15-year-old girl with type II unilateral hemimelia presented with a 13.5-cm shortening of her right leg, absence of the distal half of the tibia, tibiofibular synostosis, and medial dislocation of a cavus and varus foot. She was treated by means of an external fixator. The shortening was significantly corrected, and realignment of the foot with the limb was achieved. An arthrodesis of the talus and lower end of the fibula was carried out operatively and stabilized with an external fixator. In the same surgical procedure, we performed an osteotomy of the tibiofibular synostosis, and progressive distraction was done with another external fixator. We emphasize the advantages of progressive distraction for the correction of congenital deformities of the limbs.
Analysis of Function After Intra-articular Fracture of the Os Calcis
Authors: Catani Fabio , Benedetti Maria Grazia , Simoncini Laura , Leardini Alberto , Giannini Sandro
Published: March 2013

Fractures of the os calcis with intra-articular involvement can cause difficulty in treatment and can result in abnormal function throughout the ankle-foot complex. We evaluated the function of the ankle-foot complex and the overall gait pattern after fracture of the os calcis, and we compared the results of surgical and nonsurgical treatment. Those in whom the geometry of the os calcis and joint was restored by reconstructive surgery had better compensation of gait and a better clinical-functional score. Complex disturbances in gait were found in the group of patients that did not undergo open reduction or internal fixation.
Forefoot Reconstruction in Rheumatoid Arthritis Patients: Keller-Lelièvre-Hoffmann Versus Arthrodesis MTP1-Hoffmann
Authors: Vandeputte Geoffroy , Steenwerckx Annie , Mulier Tom , Peeraer Louis , Dereymaeker Greta
Published: March 2013

The aim of this study was to compare the subjective, clinical and pedodynographic results of two large groups of patients operated on in our department.

From January 1987 to December 1992, 38 rheumatoid patients (59 feet) underwent a Keller-Lelièvre arthroplasty of the first metatarsophalangeal (MTP1) joint and a Hoffmann resection of the lesser metatarsal heads. The mean follow-up was 35 months.

From June 1992 to August 1997 48 patients (62 feet) with rheumatoid arthritis underwent an arthrodesis of the MTP1 joint and Hoffmann resection of the lesser metatarsal heads. The mean follow-up was 25 months. In 10 feet the arthrodesis was performed as a revision procedure of a failed Keller-Lelièvre arthroplasty.

The patients of both series were assessed in the same way: personal interview, clinical examination, radiographs, bilateral footprints, and pedodynographic measurements. Static and dynamic pedodynographic measurements were taken with a 64-sensor matrix insole in a standard shoe. Six of our patients had an arthrodesis-Hoffmann procedure performed on one foot and a Keller-Lelièvre-Hoffmann procedure on the contralateral side.

Although there is better loadbearing of the first ray with relative unloading of the central metatarsal heads in the arthrodesis MTP1-Hoffmann group, subjective evaluation of the procedure was slightly better in the Keller-Lelièvre-Hoffmann group. Ninety-three percent of the patients in the Keller group were satisfied or satisfied with minor reservations versus 87 percent in the arthrodesis group. This difference is not statistically significant.

Recurrent deformity was not more prominent in the Keller-Lelièvre-Hoffmann group; however, it may be that with a longer follow-up, the feet in the arthrodesis-Hoffmann group hold up better over time.

The arthrodesis MTP1-Hoffmann procedure can be used as a revision procedure for a failed Keller-Hoffmann operation, although these procedures were more difficult and needed a longer recovery time than the primary MTP1 arthrodesis.
Defining Flatfoot
Authors: Tareco Jennifer M. , Miller Nancy H. , MacWilliams Bruce A. , Michelson James D.
Published: March 2013

Pes planus is a term frequently used in describing flatfoot; however, no study has objectively defined flatfoot. We evaluated the single leg stance footprint of 40 feet in 21 people with no history of foot problems, using pressure-sensitive film and a Harris mat. The medial and lateral aspects of the forefoot, midfoot, and hindfoot were assessed. The midfoot was further analyzed by dividing the medial midfoot force by the total midfoot force. The mean medial midfoot force/total midfoot force was 11.1 % (SD = 6.5%). Pes planus was defined as the medial midfoot force/total midfoot force > 24.0% (mean + 2 SD).

A population associated with pes planus (124 feet in 63 patients with Marfan syndrome) was then evaluated in the same fashion. Although the mean medial midfoot force/total midfoot force was not statistically different (16.0%), a distinct group of patients (25%) had forces that were outside the range of normal midfoot forces.
Ankle Arthroplasty in Patients Younger and Older than 50 Years: A Prospective Series with Long-term Follow-up
Authors: Kofoed Hakon , Lundberg-Jensen Allan
Published: March 2013

One hundred consecutive cases treated with ankle arthroplasty for osteoarthritis (OA) or rheumatoid arthritis were followed prospectively and annually for up to 15 years. Survivorship analysis was performed, with the endpoint being prosthesis revision or change to arthrodesis. Patients who were younger than 50 years at the first implantation constituted one group (group A, 30 ankles). The other group (group B, 70 ankles) consisted of patients aged 50 years or older at the first implantation. All patients were assessed clinically according to the Kofoed Ankle Score.

The distribution of OA/rheumatoid arthritis in group A was 18/12, and in group B it was 43/27 (not significant). The median age in group A was 46 years (range, 22–49 years), and in group B it was 63 years (range, 51–83 years). In group A, one case was revised, and three cases were converted to arthrodesis after a median of 5 years (range, 5–9 years). In group B, four cases were revised, and four cases were converted to arthrodesis after a median of 5.5 years (range, 2–8 years). The results of cases with traumatic OA did not differ between groups A and B. It was concluded that the results of ankle arthroplasty were of equal quality in patients younger than 50 years and those who were older.
Relative Movement of the Navicular Bone During Normal Walking
Authors: Cornwall Mark W. , McPoil Thomas G.
Published: March 2013

The purpose of this study was to determine the pattern and magnitude of navicular bone (NB) movement during walking as well as the relationship between dynamic NB and rearfoot movement. The angle of rearfoot and displacement of the NB was recorded in 106 subjects using the 6D Research electromagnetic tracking system. The relative change in the height of the NB between foot flat and heel-off was 7.9 mm. The NB seems to undergo significant vertical as well as medial displacement during the stance phase of normal walking. This motion is also correlated with rearfoot motion during walking.
Elevated Plantar Pressure and Ulceration in Diabetic Patients After Panmetatarsal Head Resection: Two Case Reports
Authors: Cavanagh Peter R. , Ulbrecht Jan S. , Caputo Gregory M.
Published: March 2013

Panmetatarsal head resection (variously called forefoot arthroplasty, forefoot resection arthroplasty, the Hoffman procedure, and the Fowler procedure) was developed for the relief of pain and deformity in rheumatoid arthritis. Although there are successful retrospective series reported in the literature, such an approach is not supported by carefully designed controlled trials. This procedure has also been advocated by some for the relief of plantar pressure in diabetic patients who are at risk for plantar ulceration. The efficacy of the procedure in this context is not supported by existing pressure measurements on rheumatoid arthritis patients in the literature, which has tended to show that although pain relief is obtained, the procedure results in elevation of forefoot pressure. Case reports are described of two patients (three feet) with sensory neuropathy who presented to our clinic 1 to 2 years after panmetatarsal head resections had been performed. Peak plantar pressures in these feet during first step gait were above the 99th percentile and outside the measuring range of the device used (EMED SF platform; NOVEL Electronics Inc., St. Paul, MN). Both patients had also experienced plantar ulcers subsequent to the surgery. Combining the information on patients with rheumatoid arthritis (RA) with that from our two case studies, we conclude that panmetatarsal head resection does not necessarily eliminate focal regions of elevated plantar pressure.
Fibular Nonunion and Equinovarus Deformity Secondary to Posterior Tibial Tendon Incarceration in the Syndesmosis: A Case Report After a Bimalleolar Fracture-Dislocation
Authors: Curry Eugene E. , O'Brien Timothy S. , Johnson Jeffrey E.
Published: March 2013

A 39-year-old woman sustained a grade II open bimalleolar fracture-dislocation of the left ankle. Six months after an ORIF of these fractures was performed, she presented with a nonunion of the distal fibula fracture and with a fixed hindfoot equinovarus and forefoot adduction deformity. At surgery for repair of the fibular nonunion, the posterior tibial tendon (PTT) was found to be entrapped in the posterior tibiotalar joint, with a portion of the tendon interposed between the tibia and the fibula in the area of the posterior syndesmosis. After extrication of the PTT, the hindfoot varus and forefoot adduction deformity were corrected. To our knowledge, this is the first case report in the English literature of a missed PTT syndesmotic entrapment that resulted in a fibular nonunion and in a fixed foot deformity after an open bimalleolar ankle fracture dislocation.
Lengthening of the Lateral Column and Reconstruction of the Medial Soft Tissue for Treatment of Acquired Flatfoot Deformity Associated with Insufficiency of the Posterior Tibial Tendon
Authors: Hintermann Beat , Valderrabano Victor , Kundert Hans-Peter
Published: March 2013

We analyzed our results of surgery for acquired flatfoot deformity after dysfunction of the posterior tibial tendon. This included lengthening the proximal lateral column by calcaneal osteotomy and reconstructing the medial soft tissue. Nineteen patients (9 women and 10 men; average age, 52.9 years [range, 24–72 years]) were treated for stage II and stage II–III insufficiency of the posterior tibial tendon. The medial soft tissue surgery included 18 reconstructions of the tendon, 11 transfers of the flexor digitorum longus tendon, 13 repairs of the deltoid ligament, and 3 repairs of the spring ligament. At follow-up (mean, 23.4 months), all patients had satisfactory restoration of their medial longitudinal arch, reduction of abduction in the forefoot, and restored height in the arch. All patients were able to bear weight fully on the foot that underwent surgery, and all but one were satisfied with the result achieved. The clinical result was rated as excellent in 6, good in 11, and fair in 2 cases. In all but one case, no loss of achieved correction in the foot was found. In one case, the calcaneocuboid joint had to undergo arthrodesis after 5 months because of painful degenerative joint disease. In the pes planovalgus and abductus deformities occurring in stage II disease, calcaneal osteotomy and reconstruction of the medial tendon and ligament seem to play a significant role in operative management. This was the case only when degenerative joint disease and significant subluxation of the subtalar or talonavicular joint or both had not already occurred. They seem to function by restoring more normal biomechanics, which allows reconstructed or transferred tendon to function successfully.
Peroneus Quartus Muscle: A Case Report and Review of the Literature
Authors: Trono Marco , Tueche Serge , Quintart Christian , Libotte Mark , Baillon JeanMarie
Published: March 2013

The peroneus quartus is a supernumerary muscle of the lateral compartment of the lower leg. There are several variations of this accessory muscle, and its terminology is very confusing.

The peroneus quartus is found with a frequency varying from 10 to 21.7% of observed individuals. 4 , 17 It is rarely involved in pathologic processes of the foot and ankle. Only a few reports exist in the literature involving peroneus quartus in a “retromalleolar conflict” (lateral ankle stenosis 17 ), sometimes in association with longitudinal attrition and tears of the peroneus brevis. We present a novel case, together with a review of the clinical, anatomic, and radiologic references about this muscle, and we try to make order in classification and terminology of its different forms.
Acute Complications in the Operative Treatment of Isolated Ankle Fractures in Patients with Diabetes Mellitus
Authors: Blotter Robert H. , Connolly Edward , Wasan Ajay , Chapman Michael W.
Published: March 2013

Using a computer database, we conducted a retrospective review of all ankle fractures treated at our institution from March 1985 to October 1996. Twenty-one patients with diabetes mellitus and isolated ankle fractures that were treated operatively met all inclusion criteria. Seven had insulin-dependent diabetes, and 14 had non–insulin-dependent diabetes. A randomly selected control group of 46 patients without diabetes who also underwent operative treatment of ankle fractures during this same time period were matched for age, sex, and fracture severity. The complication rate was 43% with 13 complications in nine patients with diabetes. There were seven (15.5%) complications in the control group. Complications in the diabetic group included seven infections (five deep, two superficial) and three losses of fixation. The complications were more severe in our diabetic population, requiring seven additional procedures including two below-knee amputations; a third patient refused an amputation. No additional procedures were required in our control group. All complications in our control group resolved with treatment. The relative risk for postoperative complications in patients with diabetes who sustained ankle fractures that were treated operatively was 2.76 times greater than the control group's (95% confidence interval, 1.57–3.97).
Arthroscopy of the Ankle: Analysis of Results and Indications on a Series of 75 Cases
Authors: Bonnin Michel , Bouysset Maurice
Published: March 2013

The purpose of this study was to evaluate the results of arthroscopy of the ankle. Of the 114 arthroscopies of the ankle that we performed between 1991 and 1996, 13 were for diagnosis, 6 were associated with open surgery, and 10 were ankle arthrodeses. We report the results of the remaining 85 therapeutic arthroscopies.

We identified five groups according to preoperative indications: (1) anterolateral synovitis after a sprained ankle (33 cases), (2) sequelae of fractured ankles (17 cases), (3) anterior impingement as a result of osteophytes (12 cases), (4) loose foreign bodies as a result of avulsion of fragments of bone (6 cases), and (5) osteochondral lesions of the talar dome (17 cases). In anterolateral synovitis, results were better when the pain followed a single sprain than when after chronic instability. In osteochondral lesions of the talar dome, results were better in anterolateral lesions than in posteromedial lesions.
Treatment of Hallux Valgus with an Increased Distal Metatarsal Articular Angle: Evaluation of Double and Triple First Ray Osteotomies
Authors: Coughlin Michael J. , Carlson Robert E.
Published: March 2013

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a “triple osteotomy.” The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23° and the average 1–2 intermetatarsal angle correction was 9°. The DMAA averaged 23° preoperatively and was corrected to an average of 9° postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.
Effect of Increasing Distal Medial Closing Wedge Metatarsal Osteotomies on the Distal Metatarsal Articular Angle
Authors: Lau Johnny T.C. , Daniels Timothy R.
Published: March 2013

The recognition, definition, and management of the congruent hallux valgus deformity continue to evolve. To correct the skeletal deformity and maintain joint congruity, many authors have emphasized the importance of extra-articular procedures. One such procedure is a distal medial closing wedge osteotomy of the first metatarsal. Unfortunately, there are few guidelines to help determine the pre- and intraoperative size of the medial wedge to obtain the desired correction of the distal metatarsal articular angle (DMAA). The purpose of this study was to quantify the effects of increasing distal medial closing wedge osteotomies on the DMAA in an in vitro cadaver model.

In this study, a closing wedge osteotomy was performed 2 cm proximal to the articular surface, removing wedges measuring 2 mm, 4 mm, and 6 mm in width. The mean preoperative DMAA was 8.5°, and the mean postoperative DMAAs after 2-mm, 4-mm, and 6-mm closing wedge osteotomies were −2.6°, −10.2°, and −20.2°, respectively. The data showed that for every 1 mm of closing wedge osteotomy, the DMAA decreased by 4.7° ± 0.6°. These results can be used for pre- and intraoperative planning when surgically correcting a congruent hallux valgus deformity with a distal medial closing wedge osteotomy of the first metatarsal.

Additional information obtained from this cadaver study includes (1) increased shortening of the first metatarsal and (2) incongruity produced at the joint after the medial-based osteotomy. The amount of shortening of the first metatarsal correlated directly with the size of the medial-based wedge. The second point indicates that a lateral soft-tissue release may still be required when using this method of reorienting the DMAA.
Role of Metatarsus Primus Elevatus in the Pathogenesis of Hallux Rigidus
Authors: Horton Greg A. , Park Yong-Wook , Myerson Mark S.
Published: March 2013

Metatarsus primus elevatus has been suggested as a primary causative factor in the pathogenesis of hallux rigidus. The purpose of this investigation was to define the role of elevation of the first ray in the pathogenesis of hallux rigidus by comparing patients with known hallux rigidus with a control population. We reviewed 264 lateral weightbearing radiographs from 81 patients with hallux rigidus, 50 asymptomatic volunteers, and 64 patients diagnosed with isolated Morton's neuroma. Results revealed that the mean values for elevation of the first ray in patients with mild or moderate hallux rigidus were nearly identical to those in the control group. Patients with advanced radiographic hallux rigidus had a slightly higher mean value for metatarsus primus elevatus. An average of nearly 8 mm of metatarsus primus elevatus is a normal finding in patients with hallux rigidus as well as in normal subjects. This investigation did not address the clinical outcome or biomechanical effects of a plantarflexion osteotomy of the first ray. However, on the basis of the finding that first ray elevation is normal, it seems unlikely that a plantarflexion osteotomy would have a role in the treatment of hallux rigidus.