bluuebunny/crossref_metadata_2025 huggingface dataset:
Growth Disturbances After Distal Tibial Physeal Fractures
Authors: Berson Lawrence , Davidson Richard S. , Dormans John P. , Drummond Denis S. , Gregg John R.
Published: January 2017

Twenty-four patients with distal tibial growth disturbance were reviewed. Disturbances were classified as physeal bar (prior to deformity), angular, linear or combined deformities. Treatment consisted of osteotomy in fourteen, epiphyseodesis in seven, excision of bony bar in two, and observation in one patient. Follow up was an average 36.6 months (range 4–129 months) after treatment of growth disturbance. The age at time of injury was 10.4 years of age average (range 3–15 years). There were 12 SH2, 2 SH3, 7 SH4, and 3 SH5 distal tibial physeal fractures. Thirteen of 15 fractures considered high energy and only 1 of 9 fractures considered low energy resulted in angular deformity. Angular and linear deformities presented an average 46 months (range 12–120 months) and physeal bars at an average 14 months (range 6–25 months) after injury. Patients with a delay in presentation of growth disturbance greater than 24 months had angular deformities in 92% compared with 33% in children presenting less than or at 24 months. Treatment based on type of deformity, age at time of injury, and growth remaining was considered successful in 83%.

Patients with angular or linear deformities were more likely to present late, have high energy injuries, be male patients and have Salter-Harris types IV and V. Early diagnosis and treatment of growth disturbance can prevent severe deformity.
The Arterial Supply of the Lesser Metatarsal Heads: A Vascular Injection Study in Human Cadavers
Authors: Petersen W.J. , Lankes J.M. , Paulsen F. , Hassenpflug J.
Published: January 2017

The possibility of avascular changes of the metatarsal heads following forefoot surgery has been previously documented. The aim of this study was to investigate the arterial supply of the lesser metatarsal heads with regard to osteotomies of these bones.

We used epoxy resin injections and a modified Spalteholz technique in human cadaveric specimens to demonstrate the intraosseous and extraosseous blood supply of the lesser metatarsals.

The metatarsal heads had two arterial sources:

The dorsal metatarsal arteries, which arose from the dorsalis pedis artery, and The plantar metatarsal arteries, which are branches of the posterior tibial artery.

These two vessels typically anastomosed at two sites about the metatarsal heads, forming a vascular ring and provided an extensive extraosseous arterial network around the metatarsal heads. Small arterial branches of this network run distally on the metatarsal cortex to enter the bone of the metatarsal head. The nutrient arteries traversed the cortex of the metaphysis close to the capsular and ligamentous insertions to provide multiple branches for the supply of the subchondral bone.

Extensive capsular stripping during metatarsal head osteotomies results in damage to the medial and lateral head vessels.
Plantar Pressures in Fiberglass Total Contact Casts vs. a New Diabetic Walking Boot
Authors: Pollo Fabian E. , Brodsky James W. , Crenshaw Stephanie J. , Kirksey Chris
Published: January 2017

The objective of this study was to determine in healthy individuals whether the Bledsoe Diabetic Conformer Boot reduces plantar pressures as well as a fiberglass total contact cast. Eighteen normal subjects, without any prior foot or ankle problems, were recruited for this study. Plantar pressures were measured using the Novel Pedar™ in-shoe pressure measurement system. The results of this study demonstrate that in individuals without foot deformities, the Bledsoe Diabetic Conformer Boot™ performs as well as, and in many parameters, even better than a fiberglass total contact cast with respect to reducing the forces and pressures on the plantar surface of the foot.
Evaluation of the Validity of the AOFAS Clinical Rating Systems by Correlation to the SF-36
Authors: SooHoo Nelson Fong , Shuler Michael , Fleming Lamar L.
Published: January 2017

This study evaluates the validity of the AOFAS Clinical Rating Systems by examining their level of correlation to the Medical Outcomes Study Short Form-36 (SF-36) in patients with foot and ankle complaints. The SF-36 is an extensively validated outcomes tool that has been used as a benchmark in examining the validity of outcomes instruments designed for the upper extremity, knee, shoulder, and general orthopaedic conditions. The study sample was 91 patients seen at the foot and ankle clinic of a university-based orthopaedic practice. Patients were administered both the AOFAS Clinical Rating Systems and SF-36 instruments. Pearson correlation coefficients of the AOFAS scores to the SF-36 sub-scales ranged from 0.02 to 0.36 in the overall study population. Correlation was higher for the sub-set of patients with ankle-hindfoot disorders (0.11 to 0.53) than patients with forefoot disorders (−0.05 to 0.25). The low levels of correlation seen in this study suggest poor construct validity of the AOFAS Clinical Rating Systems.
Management of Large Soft-Tissue Defects in a Diabetic Patient
Authors: Öznur Ali
Published: January 2017

Amputation as the only option for treatment of large ulcers in a patient with diabetes is well known. This is a case presentation of a patient with large ulcers and osteomyelitis related to diabetes. He was treated with extensive debridement, segmental shortening, and wound closure.
Surgical Treatment of Insertional Achilles Tendinosis
Authors: Calder J.D.F. , Saxby T.S.
Published: January 2017

Most patients with insertional Achilles tendinosis can be managed nonoperatively but those who do not respond may require excision of the diseased tendon. Currently, there are no clinical studies indicating how much of the tendon may be excised without predisposing the patient to Achilles tendon rupture.

This chart review reports on 52 heels treated surgically for this condition and followed for a minimum of six months postoperatively. When less than 50% of the tendon was excised (49 heels) patients were immediately mobilized free of a cast.

There were two failures using this regimen - one patient with psoriatic arthropathy and another who underwent bilateral simultaneous procedures. We suggest that in selected patients it is safe to proceed with early active mobilization immediately postoperatively when less than 50% of the tendon is resected.
First Metatarsal-Phalangeal Joint Arthrodesis: A Biomechanical Assessment of Stability
Authors: Politi Joel , Hayes John , Njus Glen , Bennett Gordon L. , Kay David B.
Published: January 2017

Background:

First metatarsal phalangeal joint (MTP) arthrodesis is a commonly performed procedure for the treatment of hallux rigidus, severe and recurrent bunion deformities, rheumatoid arthritis and other less common disorders of the joint. There are different techniques of fixation of the joint to promote arthrodesis including oblique lag screw fixation, lag screw and dorsal plate fixation, crossed Kirschner wires, dorsal plate fixation alone and various types of external fixation. Ideally the fixation method should be reproducible, lead to a high rate of fusion, and have a low incidence of complications.

Methods:

In the present study, we compared the strength of fixation of five commonly utilized techniques of first MTP joint arthrodesis. These were: Surface excision with machined conical reaming and fixation with a 3.5 mm cortical interfragmentary lag screw. Surface excision with machined conical reaming and fixation with crossed 0.062 Kirschner wires. Surface excision with machined conical reaming and fixation with a 3.5 mm cortical lag screw and a four hole dorsal miniplate secured with 3.5 mm cortical screws. Surface excision with machined conical reaming and fixation with a four hole dorsal miniplate secured with 3.5 mm cortical screws and no lag screw. Planar surface excision and fixation with a single oblique 3.5 mm interfragmentary cortical lag screw. Testing was done on an Instron materials testing device loading the first MTP joint in dorsiflexion. Liquid metal strain gauges were placed over the joint and micromotion was detected with varying loads and cycles.

Results:

The most stable technique was the combination of machined conical reaming and an oblique interfragmentary lag screw and dorsal plate. This was greater than two times stronger than an oblique lag screw alone. Dorsal plate alone and Kirschner wire fixation were the weakest techniques.

Conclusions:

First MTP fusion is a commonly performed procedure for the treatment of a variety of disorders of the first MTP joint. The most stable technique for obtaining fusion in this study was the combination of an oblique lag screw and a dorsal plate. This should lead to higher rates of arthrodesis.
Soft-Tissue Arthroplasty for Hallux Rigidus
Authors: Coughlin Michael J. , Shurnas Paul J.
Published: January 2017

Seven patients (seven feet) were evaluated at an average follow-up of 42 months following soft-tissue interposition arthroplasty of the hallux metatarsophalangeal (MTP) joint for severe hallux rigidus. The technique involved reaming of the base of the proximal phalanx and metatarsal head to decompress the first MTP joint and placement of a soft-tissue tendon bundle as a biologic spacer. Six of seven patients had bilateral disease, and a positive family history of hallux rigidus. At final follow-up, all seven patients rated their result as good or excellent, the level of pain was substantially reduced, and the mean AOFAS score substantially improved from 46 to 86 points. Mild metatarsalgia was noted by four patients and characterized by mild plantar callosities in these cases. The mean MTP dorsiflexion improved from 9° to 34° and patients demonstrated good to excellent plantarflexion strength on manual muscle testing and with toe rise. Physical examination of the involved feet demonstrated no evidence of pes planus, metatarsus primus elevatus, Achilles tendon contracture, or metatarsocuneiform joint hypermobility in any of the seven. The technique of soft-tissue interposition arthroplasty as described gave excellent pain relief and reliable function of the hallux, and is an alternative treatment to MTP arthrodesis in select cases of severe hallux rigidus.
Surgical Treatment of Acquired Flatfoot Deformity: What is the State of Practice among Academic Foot and Ankle Surgeons in 2002?
Authors: Hiller Luke , Pinney Stephen J.
Published: January 2017

Purpose:

This study was performed to review the present approach to the surgical treatment of acquired flatfoot deformity among a cross section of academic foot and ankle surgeons in the United States.

Methods:

A typical case of stage II posterior tibial tendon dysfunction was developed. The hypothetical patient was a healthy 62-year-old male with a symptomatic acquired flatfoot deformity with posterior tibial tendon dysfunction. Nonoperative management had failed. A series of academic foot ankle surgeons were surveyed to identify their proposed operative treatment. Each surgeon surveyed was affiliated with an orthopaedic residency program and was directly responsible for teaching orthopaedic residents. Each surgeon had foot and ankle patients as the major component of their practice. The overall response rate was 81% (104/128).

Results:

Ninety-seven percent (101/104) of respondents reported that they would employ some type of bony procedure in their surgical treatment. Eighty-eight percent (89/104) described techniques that would preserve the subtalar and talonavicular joints. These included a medializing calcaneal osteotomy in 73% (76/104), a lateral column lengthening in 41% (43/104), and a medial column stabilization (first tarsometatarsal and/or navicular cuneiform arthrodesis) in 15% (16/104). Twelve percent (12/104) reported that they would perform an arthrodesis of one or more of the hindfoot joints. Ninety-eight percent (102/104) of respondents reported that they would employ some type of soft-tissue procedure. Ninety-four percent (98/104) would augment the posterior tibial tendon, 53% (55/104) would formally repair the spring ligament, and 70% (73/104) would address a presumed equinus contracture.

Conclusions:

There is a wide variation in the approach to surgical treatment of stage II acquired adult flatfoot deformity among academic foot and ankle surgeons. Most surgeons employed a combination of bony and soft-tissue procedures that preserved the subtalar and talonavicular joints.
Extracorporeal Shock Wave Therapy (ESWT) in Patients with Chronic Proximal Plantar Fasciitis: A 2-Year Follow-up
Authors: Hammer Dietrich S. , Adam Frank , Kreutz Andreas , Kohn Dieter , Seil Romain
Published: January 2017

The aim of this study was to compare the effect of extracorporeal shock wave therapy (ESWT) in patients with chronically painful proximal plantar fasciitis with a further conventional conservative treatment. Forty-seven patients (49 feet) with a previously unsuccessful nonsurgical treatment of at least 6 months were randomized to two groups. Heel cups had to be worn throughout the study. Group 1 (25 heels) was treated immediately with three sessions of ESWT (3000 shock waves/session of 0.2 mJ/mm 2 ) at weekly intervals. The patients of group 2 (24 heels) continued nonsurgical treatment (iontophoresis with diclofenac and an oral nonsteroidal anti-inflammatory drug) for 12 weeks. After this period they were treated using the protocol of group 1. No significant difference of pain and walking time after further nonsurgical treatment (3 months) was seen in group 2. At 12 weeks after ESWT, the pain estimation on the visual analogue scale (VAS) for activities of daily living diminished significantly by 62.9% in group 1 and by 63.0% in group 2. The comfortable walking time had increased significantly in both groups. Two years after ESWT, pain during activities of daily living decreased by 94% in group 1 and by 90% in group 2 on the VAS and the comfortable walking time had increased significantly in both groups.
Bunionette Deformity Correction with Distal Chevron Osteotomy and Single Absorbable Pin Fixation
Authors: Boyer Matison L. , DeOrio James K.
Published: January 2017

Between January 1997 and July 2000, 10 patients with symptomatic bunionette deformity underwent 12 distal fifth metatarsal chevron osteotomies in which an absorbable poly- p-dioxanone suture (PDS) pin was used for fixation. Of the 10 patients, nine were female. Average age at operation was 41 years (range, 23–70). Mean duration of follow-up was 48 months (range, 6–81). All patients obtained clinical and radiographic union by 6 weeks, and there was no radiographic evidence of osteolysis, displacement, or avascular necrosis of the metatarsal head at final follow-up. There were no serious complications. The average postoperative AOFAS score was 93 of 100 possible. All patients were satisfied with the procedure and would have it again. Distal chevron osteotomy with a single, nonpredrilled PDS absorbable pin for the correction of symptomatic bunionette deformity is a reliable and effective technique that provides adequate fixation without complications.
Optical Plantar Pressure Analysis Following Internal Fixation for Displaced Intra-articular Os Calcis Fractures
Authors: Davies Mark B. , Betts Roderic P. , Scott Ian R.
Published: January 2017

Using optical pedobarography, the outcome of open reduction and internal fixation of displaced os calcis fractures was assessed. In 12 patients, well reconstructed heel contact widths and no reduction in heel-ground contact times were found. In conjunction with this, patients showed lateral deviation of the plantar pressures and load bearing, indicating that subtalar and calcaneocuboid joint function remained altered despite reconstruction. These findings could not be linked to the initial fracture severity or clinical outcome score.
Fracture of the Polyethylene Component in an Ankle Arthroplasty: A Case Report
Authors: Assal Mathieu , Al-Shaikh Raad , Reiber Benjamin H. , Hansen Sigvard T.
Published: January 2017

A 57-year-old female underwent total ankle arthroplasty for post-traumatic arthrosis using the Agility™ Total Ankle System. The talar component was placed in varus malalignment. Her postoperative course was remarkable for 19 months of satisfactory function followed by the acute onset of intense pain and decreased range of motion. There was no history of trauma. After failing a short course of observation, revision surgery of the arthroplasty was performed. Operative findings revealed a complete fracture of the polyethylene. This report details the first case of such a complication and discusses the importance of component alignment in the prevention of polyethylene insert failure.
The Incisural Fracture
Authors: Cummings R. Jay , Hahn G. Alan
Published: January 2017

A case report is presented on two adolescent patients with fracture of the distal tibial articular surface that is different than the Tillaux, Wagstaffe–Le Fort, and Chaput fractures.
Bone Mineral Density, Gait Analysis, and Patient Satisfaction, before and after Ankle Arthroplasty
Authors: Zerahn Bo , Kofoed Hakon
Published: January 2017

Bone mineral density (BMD) and patient satisfaction were measured and gait analysis was performed in patients treated with unilateral dual-coated ankle arthroplasty. The study comprised 14 patients (eight women and six men) measured preoperatively and at a median of 15 (range, 12–26) months after surgery. BMD was measured bilaterally in the distal tibia and in the calcaneus. A plantar pressure analysis was performed, including foot contact duration and a new index for describing the ground reaction force curve called the Valley Index (VI). The patients also evaluated their level of pain, ability to cope with daily activities, adaptation of shoes, and walking ability before surgery and at follow-up on a visual analogue scale (VAS). Bone mass significantly increased adjacent to the tibial part of the prosthesis. The patients experienced less pain and improved walking and performance in daily activities. There was also a decrease in foot contact duration as well as an increase in VI and ankle range of motion. Change in bone mass was the variable that correlated best with the patients' evaluation of the general outcome of ankle arthroplasty. Correlations among other variables are described. The study concluded that a fairly simple analysis of the ground reaction force curve, bone mass measurements, and VAS can demonstrate that ankle arthroplasty is able to normalize gait, decrease foot contact duration, increase bone mass, and reduce pain.
Intramedullary Screw Fixation of the Fifth Metatarsal: An Anatomic Study and Improved Technique
Authors: Johnson Joseph T. , Labib Sameh A. , Fowler Rachel
Published: January 2017

Intramedullary screw fixation has been found to be a reliable treatment for certain fractures of the fifth metatarsal. Techniques for this treatment have been described relying largely on intraoperative fluoroscopy. Ten human cadaver specimens had their fifth metatarsals osteotomized and underwent retrograde intramedullary pin placement. Anatomic landmarks and the location of the sural nerve in relation to this starting point were measured. The trajectory of a pin reducing the osteotomy was analyzed. Using the resultant starting point and guide pin trajectory, intramedullary screw placement was performed reliably without the aid of fluoroscopy. This study demonstrates that intramedullary screw fixation of proximal fifth metatarsal fractures may be performed with the use of anatomic landmarks, which decreases the amount of intraoperative fluoroscopy needed.
Functional Evaluation of the Scandinavian Total Ankle Replacement
Authors: Dyrby Chris , Chou Loretta B. , Andriacchi Thomas P. , Mann Roger A.
Published: January 2017

The purpose of this study was to evaluate the function of the ankle joint during walking before and after Scandinavian Total Ankle Replacement (STAR). Nine patients (six males and three females) with an average age of 65 years, scheduled for unilateral total ankle replacement for osteoarthritis and rheumatoid arthritis, were evaluated both preoperatively and postoperatively in a gait analysis laboratory. Arthroplasty patients showed reduced range of motion at the ankle compared to normal controls. Postoperative arthroplasty subjects had significantly improved external ankle dorsiflexion moment, the moment that affects the plantarflexor muscles, when compared to their preoperative status. The moment in arthroplasty patients was increased, indicating improved function of the ankle joint.
The Accessory Extensor Tendon of the First Metatarsophalangeal Joint
Authors: Bibbo Christopher , Arangio George , Patel Dipak V.
Published: January 2017

The accessory extensor tendon of the first metatarsophalangeal joint (1st MTPJ) was evaluated in 32 cadaver feet. Eighty-one percent of feet possessed an accessory tendon to the 1st MTPJ. Of those feet possessing an accessory tendon to the 1st MTPJ, approximately 92% originated from the extensor hallucis longus muscle-tendon unit, while approximately 8% originated from the tibialis anterior muscle-tendon unit. All accessory tendons inserted onto the dorsal/dorsomedial capsule of the 1st MTPJ. Accessory tendons were found to be bilateral in the majority (87.5%) of specimens. Differences in sex distribution of the accessory tendon of the 1st MTPJ were not statistically significant. The difference in distribution of an accessory tendon to the 1st MTPJ in those feet that demonstrated clinical hallux valgus versus those that did not demonstrate hallux valgus was not statistically significant ( p = 1.0000, respectively, Fisher's exact test). This tendon is unique to the human foot (lacking in primates) and is a fairly constant structure (80%). The data presented do not lend support for the accessory tendon of the 1st MTPJ to play a role in the development of hallux valgus. At the present time, the role of this accessory tendon on the biomechanics of the 1st MTPJ remains unknown.
Functional Outcome of Arthrodesis of the First Metatarsophalangeal Joint Using Parallel Screw Fixation
Authors: Brodsky James W. , Passmore Roger N. , Pollo Fabian E. , Shabat Shay
Published: January 2017

Background: Arthrodesis of the first metatarsophalangeal (MTP) joint is a reliable procedure for a painful hallux. Most studies focus on the surgical results rather than the functional outcome for the patient. Therefore, we examined the effects of first MTP joint arthrodesis on activities of daily living and recreational activities. Methods: Fifty-three patients (60 feet) who had isolated arthrodesis of the first (MTP) joint using a parallel screw fixation technique were evaluated for the functional outcome after the surgery to determine the effect of the arthrodesis on the activities of daily living and on recreational sports and exercise. Results: Fusion was achieved in all patients; all but three stated that they would have the surgery again. Postoperative pain scores evaluated using the Visual Analogue Scale indicated effective pain relief. High levels of function were demonstrated in this group of patients. Conclusion: Arthrodesis of the first MTP joint is not only a successful surgical technique for relief of pain and correction of deformity but also allows a high level of function in everyday life and in recreational activities.
Calcaneal Lengthening: Investigation of Deformity Correction in a Cadaver Flatfoot Model
Authors: DuMontier Timothy A. , Falicov Alexis , Mosca Vincent , Sangeorzan Bruce
Published: January 2017

Background: Evans showed that lengthening the lateral column by inserting structural bone graft into the anterior calcaneus could correct abduction and valgus deformity in flatfoot. To better understand the mechanism of correction and the three-dimensional effect of this procedure a cadaver study was done. Methods: Three cadaver flatfoot models were used. Computed tomographic (CT) scans were made of each specimen before and after lengthening. Data from these scans were used to determine the center of volume of the talus, navicular, cuboid, and calcaneus. The angular and translational motions for each bone were determined. Results: On average, relative to the talus, the navicular moved 18.6 degrees of rotation in adduction, 2.6 degrees of rotation in pronation, and 3.4 degrees in plantarflexion. The average translation was 5.6 mm medial, 0.4 mm posterior, and 1.8 mm plantar. The cuboid moved an average of 24.2 degrees of rotation in adduction and lengthening, 13.9 degrees in pronation, and 1.9 degrees in plantarflexion. The average translation was 9.4 mm medial, 2.6 mm distal, and 1.5 mm plantar. The calcaneus moved an average of 4.4 degrees of rotation in adduction, 0.1 degrees of rotation in eversion, and 1.3 degrees of plantarflexion. The average translation was 3 mm medial and 0.7 mm posterior with no plantar translation. Conclusions: The mechanism of Evans calcaneal lengthening involves adduction and plantarflexion of the midfoot relative to the hindfoot. The cuboid and navicular appear to move as a unit. The shape of the talar head, axis of the subtalar joint, degree of initial deformity, competence of plantar soft tissues, such as the long plantar ligament, and adequate length of the Achilles tendon are important. Knowing what qualitative three-dimensional changes take place allows a better understanding of the mechanics of the procedure and its possible applications.
The Medial Longitudinal Arch as a Possible Risk Factor for Ankle Sprains: A Prospective Study in 83 Female Infantry Recruits
Authors: Mei-Dan Omer , Kahn Gadi , Zeev Aviva , Rubin Amir , Constantini Naama , Even Adi , Nyska Meir , Mann Gideon
Published: January 2017

Background: Ankle sprains are frequent, especially in athletes, soldiers, or others who perform high levels of physical activity. Although prevention is a primary goal, little is known about the risk factors. We evaluated the association of the structure of the medial arch of the foot to the occurrence of acute and recurrent ankle sprains in 83 female infantry recruits. We found no previous studies on ankle sprains in women in the English literature. Methods: Arch height was quantified using the Chippaux-Smirak index, and each arch was classified as high, normal, or low. Retrospective data were obtained from questionnaires in which the soldiers noted whether or not they had had ankle sprains in the past, the grade of the sprain, and recurrence. Prospective data were accumulated in the 4 months of basic training, during which time every ankle sprain was documented and classified according to its grade and cause. Results: The retrospective data showed more frequent ankle sprains in the low arch group than in the normal arch group, mainly in the right foot (RR of 2.9, p < 0.05). Recurrent sprains studied retrospectively also showed that more sprains occurred in the low arch group than in the normal arch and high arch groups (RR of 10.3, p < 0.05). The prospective data suggested a pattern toward the same outcome (50% in the low arch as opposed to 36% in the normal arch group, RR, 1.3), but with no statistical significance. Conclusions: We concluded that a low arch of the foot might be a risk factor for ankle sprains. However, our study consisted of a relatively small population, and further studies are needed.
A Comparison of Plates With and Without Locking Screws in a Calcaneal Fracture Model
Authors: Richter Martinus , Gosling Thomas , Zech Stefan , Allami Mohamad , Geerling Jens , Droste Patricia , Krettek Christian
Published: January 2017

Background: We compared different plates in an experimental calcaneal fracture model under biocompatible loading. Methods: Four plates were tested: a plate without locked screws (Synthes), and three different plates with locked screws (Newdeal, Darco, Synthes). Synthetic calcanei (Sawbone) were osteotomized to create a fracture model, and the plates were fixed onto them. Seven specimens for each plate model were subjected to cyclic loading (preload 20 N, 1,000 cycles with 800 N, 0.75 mm/s), and load to failure (0.75 mm/s). Motion, forces, plastic deformation of the plate, and consequent depression of the posterior joint facet were analyzed. Results: During cyclic loading, all plates with locked screws showed statistically significant lower displacement in the primary loading direction than the plates without locked screws. Mean values (mm) of maximal displacements for each plate during cyclic loading were as follows: Synthes, 3.5; Darco, 4.5; Newdeal, 5.0; Synthes without locked screws, 7.5; ( p < 0.001). No statistically significant differences between the plates were found in relation to loads to failure and corresponding displacement. Conclusion: This is the first biomechanical study to assess the stability of different plates currently in use in our practice for the fixation of calcaneal fractures. Our results showed that plates with locked screws provided greater stability during cyclic loading than the plate without locked screws.
The Effect of Triceps Surae Contracture Force on Plantar Foot Pressure Distribution
Authors: Aronow Michael S. , Diaz-Doran Vilmaris , Sullivan Raymond J. , Adams Douglas J.
Published: January 2017

Background: Triceps surae contractures have been associated with foot and ankle pathology. Achilles tendon contractures have been shown to shift plantar foot pressure from the heel to the forefoot. The purpose of this study was to determine whether isolated gastrocnemius contractures had similar effects and to assess the effects of gastrocnemius or soleus contracture on midfoot plantar pressure. Methods: Ten fresh frozen cadaver below-knee specimens were loaded to 79 pounds (350N) plantar force with the foot unconstrained on a 10-degree dorsiflexed plate. Combinations of static gastrocnemius or soleus forces were applied in 3-lb increments and plantar pressure recordings were obtained for the hindfoot, midfoot, and forefoot regions. Results: The percentage of plantar force borne by the forefoot and midfoot increased with triceps surae force, while that borne by the hindfoot decreased (p ≤ 0.005). Increasing gastrocnemius force had similar results. Increasing triceps surae force from 0 to 21 lbs (93 N) increased average percent forefoot and midfoot force 59% and 38%, respectively, and reduced average percent hindfoot force 18%. Increasing gastrocnemius force from 0 to 18 lbs increased average percent forefoot and midfoot force 50% and 32%, respectively, and reduced average percent hindfoot force 16%. For a given triceps surae force, there was no statistical difference in pressure distribution noted between different combinations of gastrocnemius and soleus force. Conclusions: In a static model, increased triceps surae or isolated gastrocnemius force shifted weightbearing plantar pressure from the hindfoot to the midfoot and forefoot. Similar results were noted whether the triceps surae force was applied through the gastrocnemius or soleus or both. The results of this study are consistent with the clinical association of triceps surae contracture with foot and ankle disorders including diabetic foot ulcers and metatarsalgia. The similar effects with triceps surae force application through the gastrocnemius or soleus suggest that patients with isolated gastrocnemius contractures may obtain similar clinical benefits with potentially less morbidity after gastrocnemius aponeurosis lengthening as compared to Achilles tendon lengthening.
Results and Outcomes After Operative Treatment of High-Energy Tibial Plafond Fractures
Authors: Harris A. Michael , Patterson Brendan M. , Sontich John K. , Vallier Heather A.
Published: January 2017

Background: The purposes of this study were to evaluate the clinical and radiographic results and the functional outcomes after operative treatment of tibial plafond fractures treated with internal or external fixation. Methods: A retrospective review identified 76 patients with 79 fractures (OTA 43-B or 43-C) of the tibial plafond. Their average age was 45 years. Twenty-one fractures (27%) were open, and 43 (54%) were type 43-C3. Five were type 43-B1, four were 43-B2, two were 43-B3, 15 were 43-C1, and 10 were 43-C2. Patients were treated with open reduction and internal fixation (ORIF) ( n = 63) or limited open articular reduction and wire ring external fixation (EF) ( n = 16). Tibial fixation was performed at a mean of 7.6 days after injury, with staged reconstruction in 56 fractures (71%). Bone graft was used initially in 32 fractures (41%). Early and late complications, secondary procedures, and radiographic evidence of post-traumatic arthritis were evaluated. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were administered. Results: Seventy-nine fractures were followed clinically and radiographically for a mean of 26 (range 24 to 38) months, and 33 patients completed outcomes questionnaires at a mean of 98 months after surgery. Early complications included two superficial wound problems and three deep infections. Late complications included two nonunions and four malunions. Thirty-one fractures (39%) developed post-traumatic arthritis. Complications occurred after six of 21 open fractures and after 11 of 43 type C3 fractures ( p = 0.007). Patients treated with EF more frequently had type C3 fractures (88% versus 46%, p = 0.004) compared with patients treated with ORIF. The EF patients developed more complications (six of 16, p = 0.007) and post-traumatic arthritis (11 of 16, p = 0.01) when compared with ORIF. Patients treated with EF (88% were type C3 fractures) had lower FFI and MFA scores. The greatest impairment in outcome was noted after type C3 fractures, regardless of the method of treatment. Conclusions: Tibial plafond fractures are difficult to manage and may have serious complications. We identified more complications, more secondary procedures, and worse outcomes in patients with articular and metaphyseal comminution (type C3). ORIF was associated with fewer complications and less post-traumatic arthritis when compared to EF, possibly reflecting a selection bias for open injuries and more severely comminuted fractures to be managed with EF. ORIF with appropriate soft tissue handling resulted in acceptable results in most patients. Severely damaged soft tissues and highly comminuted C3 fractures may be safely treated with EF. Loss of function and progression to post-traumatic arthritis are common after tibial plafond fractures. Assessment of long-term results and the efficacy of additional reconstructive procedures will refine the treatment algorithms for these fractures.
Unloading Mechanism in the Total Contact Cast
Authors: Leibner Efraim D. , Brodsky James W. , Pollo Fabian E. , Baum Brian S. , Edmonds Bentley W.
Published: January 2017

Background: The effectiveness of total contact casts is postulated to be due to the reduction of plantar pressure. We investigated plantar loads to evaluate the mechanism by which total contact casts off-load the plantar surface of the foot to determine if it is the intimate molding of the weightbearing plantar surface or if a below-knee cast is necessary. Methods: Plantar pressures and forces in a total contact cast (TCC) were recorded in 12 healthy subjects, using the Pedar® (Novel GmbH, Munich, Germany) pedobarographic system. The measurements were repeated after removal of the ‘shank’ portion of the cast (proximal to malleoli), leaving in effect, a well-molded shoe-cast (SC). Measurements included average force and peak pressure. All parameters were measured under two different loading conditions: single-leg standing balanced on the casted limb and over-ground walking. To assess the contribution of calf geometry, the ‘calf ratio’ was calculated by dividing the largest by the smallest circumferences of the calf. All parameters were compared between TCC and SC for each subject in each of the two conditions. Paired t-tests were used to evaluate significance, which was set at a level of p < 0.006 due to the Bonferroni Correction. Results: Removal of the shank portion of the TCC significantly increased the average plantar force by 31% during walking. The force only increased 9% during standing, which was not significant. Peak pressure increased 53% after removal of the shank portion of the TCC during walking. Peak pressure was not significantly different during standing on one limb. No correlation was found between the calf ratio and the magnitude of change in the measured values. Conclusions: These results help to partially explain the widely recognized clinical observation that molded insoles and shoes, no matter how well conformed to the foot, do not reduce plantar loads as effectively as a total contact cast. The mechanism appears to be a critical unloading function of the proximal, ‘shank’ portion of the cast, presumably due to reduction in ankle motion.
Navicular Stress Fractures: A Prospective Study on Athletes
Authors: Saxena Amol , Fullem Brian
Published: January 2017

Background:

Navicular stress fractures of the foot often are difficult to diagnose and treat.

Methods:

Nineteen athletic patients seen from 1999 to 2003, were compared to a previously treated group of 22 athletes with similar injuries treated from 1994 to 1998. Based on the frontal plane CT images, a previously described classification system was used to assess the injury: type I dorsal cortical break; type II fracture extending into the navicular body; and type III fracture breaches two cortices. Nonoperative treatment was recommended for patients with type I injuries and open reduction and internal fixation (ORIF) were recommended for those with type II and III injuries. The time to return to activity and ability to return to competition were assessed, along with differences between fracture type and gender.

Results:

Return to activity (RTA) was 4.0 months for the entire group. RTA for type I (four injuries), type II (eight injuries), and type III (seven injuries) was 3.8, 3.7, and 4.2 months, respectively. Fifteen of 16 competitive athletes returned to full competition, including all who had ORIF.

Conclusions:

Navicular stress fractures can take 4 months to heal with nonoperative or operative treatment. Surgery should be considered for more severe injuries, which can be assessed by CT scan.
Kinematic MRI of the Normal Ankle Ligaments Using a Specially Designed Passive Device
Authors: Tokuda Osamu , Awaya Hitomi , Taguchi Kotaro , Matsunga Naofumi
Published: January 2017

Background:

Knowledge of the normal MRI appearances of the ankle ligaments and tendons is particularly important in the diagnosis of ankle sprains. In most clinical practices, the ankle is imaged in a neutral position with standard imaging planes and sequences. The purpose of our study was to investigate whether passive positioning influences the MRI appearances of the ligaments of the ankle.

Methods:

The axial and coronal T1- weighted MR images obtained from 10 subjects were reviewed by two musculoskeletal radiologists. The following imaging planes were used: dorsiflexion with inversion, dorsiflexion with neutral, dorsiflexion with eversion, neutral with inversion, neutral, neutral with eversion, plantarflexion with inversion, plantarflexion with neutral, and plantarflexion with eversion. A subjective rating system was used to determine the optimal imaging plane and position for individual ligaments in each volunteer. Each ligament was rated on a scale (of 1 to 6).

Results:

There were significant differences in the appearances of the anterior talofibular ( p = 0.0002), calcaneofibular ( p < 0.0001), and posterior talofibular ( p 0.0001) ligaments between the optimal and least optimal ankle positions in the axial plane, and in those of the (plantar calcaneonavicular) spring ( p 0.0001), tibiocalcaneal ( p 0.0001), posterior tibiotalar ( p = 0.0087) and posterior talofibular ( p = 0.0213) ligaments in the coronal plane.

Conclusions:

Kinematic MRI of the ankle is feasible and appears to improve visualization of ankle ligaments compared to MRI.
Antibiotic-Coated Nail for Fusion of Infected Charcot Ankles
Authors: Pawar Abhijit , Dikmen Goksel , Fragomen Austin , Rozbruch S. Robert
Published: January 2017

Background:

Treating infected ankles in patients with neuropathy is difficult, and complications are frequently encountered. Eradication of infection and effective arthrodesis are required for a successful outcome. The purpose of this study was to evaluate the outcomes of patients with Charcot neuropathy whose infected ankles were treated with a retrograde, antibiotic-coated, locked intramedullary nail.

Methods:

We analyzed 5 patients with infected neuroarthropathy of the ankle joint. Three patients had failed treatment with the circular external fixator for infected neuroarthropathy of the ankle. The other 2 were treated primarily by this technique. All patients were treated with surgical nonunion repair, arthrodesis, and insertion of an antibiotic-coated, locked intramedullary nail. The average age was 59 years (range, 46 to 82 years). The average follow up period was 18 months (range, 12-24 months).

Results:

The average time taken for radiological healing was 4.1 months (range, 4-4.5 months). In all patients, bony union was achieved and infection was eradicated. There were no cases of hardware failure.

Conclusion:

Antibiotic-coated nails were used to treat infected ankle nonunions and infected distal tibial fractures in Charcot patients with successful bony union, fusion, and eradication of infection.

Level of Evidence:

Level IV, therapeutic study.
The Intraosseous and Extraosseous Vascular Supply of the Fifth Metatarsal
Authors: McKeon Kathleen E. , Johnson Jeffrey E. , McCormick Jeremy J. , Klein Sandra E.
Published: January 2017

Background:

Osteotomies of the fifth metatarsal may disrupt the nutrient artery and result in nonunion. The location of the nutrient artery foramen relative to the location of common osteotomies has not been described. The goal of this study was to describe the vascular supply of the proximal fifth metatarsal, including the artery of origin of the nutrient artery and the location of the nutrient artery foramen.

Methods:

Fifty-six adult cadaver specimens were amputated below the knee. The anterior tibial, posterior tibial, and peroneal arteries were injected with India ink and Ward’s Blue Latex. The specimens were frozen for 48 hours and then thawed to room temperature. The soft tissues were débrided with sodium hypochlorite, and the extraosseous vascularity was recorded. The fifth metatarsal was then removed and the intraosseous vascular anatomy elucidated using a modified Spälteholz technique.

Results:

The dorsalis pedis, posterior tibial, and peroneal arteries branch in predictable patterns to supply the fifth metatarsal. The nutrient artery arose from the fourth plantar metatarsal artery in 100% of specimens and inserted into the plantar medial diaphysis in 83% of specimens. The nutrient artery foramen was an average of 26.8 mm (range, 19-40) from the medial aspect of the base of the fifth metatarsal.

Conclusions:

When an operative approach to the fifth metatarsal is planned, care should be taken to avoid stripping the bone on the plantar and medial aspects.

Clinical Relevance:

Osteotomies placed within the proximal 40 mm of the bone carry a risk of disrupting the nutrient artery, resulting in possible nonunion.
The Ability of Outcome Questionnaires to Capture Patient Concerns Following Ankle Reconstruction
Authors: Pinsker Ellie , Daniels Timothy R. , Inrig Taucha , Warmington Kelly , Beaton Dorcas E.
Published: January 2017

Background:

The objective of this study was to compare questions from outcome questionnaires with items generated by preoperative and postoperative ankle reconstruction patients (using the open-ended questions of self-reported Patient-Specific Index [PASI]) to determine whether existing questionnaires address patients’ concerns.

Methods:

Patients (n = 142) completed the PASI. Questions from 6 standardized questionnaires (American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire [AAOS], patient-reported portion of the American Orthopaedic Foot and Ankle Society Clinical Rating System Ankle-Hindfoot Scale [AOFAS], Foot Function Index [FFI], Lower Extremity Functional Scale [LEFS], Short Musculoskeletal Function Assessment [SMFA], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) and PASI were matched by 3 reviewers to corresponding categories in the International Classification of Functioning, Disability and Health (ICF). Standardized questionnaires were then compared with the patient responses produced by the PASI.

Results:

Patients identified 690 items corresponding to 45 ICF categories. Most PASI concepts fell into Activities and Participation (60.3%) and Body Functions (29.0%) components, including the categories “walking” (19.1%), “pain” (16.5%), and “recreation and leisure” (15.4%); 237 items were identified in questionnaires and linked to 39 ICF categories. Core issues in questionnaires (“pain,” “walking,” “stairs”) were important concerns for patients, but other key patient concerns (“swelling,” “recreation and leisure,” “sports”) were seldom included in questionnaires.

Conclusion:

No single questionnaire captured all patient concerns, and standardized questionnaires differed largely in content. This analysis may help guide development of a more comprehensive instrument for evaluating outcomes following ankle reconstruction.

Clinical Relevance:

When choosing an outcome questionnaire, clinicians and researchers should consider the targeted outcome because no one questionnaire captures the full patient experience.
An Experimental Comparison of Two Perspectives on the Concept of Need for Orientation in Agenda-Setting Theory
Authors: Chernov Gennadiy , Valenzuela Sebastián , McCombs Maxwell
Published: January 2017

Need for orientation (NFO) is a key contingent condition for agenda-setting effects. Traditionally, this concept has been measured by two lower-order components, but a recent reconceptualization expanded it to three dimensions. The current experimental study tested how comparable the traditional and new NFO scales are, and how strongly they predict agenda setting. Findings indicate that both NFO scales are (1) reliable tools for predicting first-level agenda-setting effects, and (2) significantly correlated with each other. The question whether or not the new NFO scale predicts second-level agenda-setting effects, however, needs further exploration.
The FunOASIS: An Easy Tool for Increasing Clinician Consistency in Answering OASIS Functional Assessment Questions
Authors: Neal Leslie Jean , Elrod Cathy
Published: January 2017

Consistency in answering the questions on the Outcomes Assessment Information Set (OASIS) remains a challenge to home health care professionals. It is a high stakes challenge because reimbursement under the prospective payment system rests largely on how the OASIS questions are answered. Answers to OASIS questions that pertain to activities of daily living (ADL) and instrumental activities of daily living (IADL) appear to be a particular source of inconsistency among health care professionals. The authors designed a tool to be used to assist the home care professional to answer the ADL and IADL questions with enhanced consistency. This article will discuss the importance of accurate functional assessment and implications for the use of a measurement tool by home health care professionals, describe the process of designing the tool, and propose a method for testing it.