bluuebunny/crossref_metadata_2025 huggingface dataset:
Monitoring Recovery Following Syndesmosis Sprain: A Case Report
Authors: Spaulding Sandi J.
Published: March 2013

A sprain to the tibial-fibular syndesmosis often results in prolonged rehabilitation or surgical intervention before recovery occurs. This paper documents gait recovery both before and after surgery for a syndesmosis sprain. Ground reaction force (GRF) data were available before injury and before surgery. Data were also collected every 3 days from 4 days to 4 months after syndesmosis screw removal (8 weeks after surgery). Weightbearing during the stance phase of gait did not approach normal values until approximately 4 months after syndesmosis screw removal. The push-off phase of gait also was slow to recover. When it was possible for the subject to use one or two crutches, differences in GRF were evident, such that walking with one crutch demonstrated increased force production at the ground. Bracing the ankle with a semirigid brace increased GRF, whereas a boot-type lace-up brace resulted in decreased GRF. In this case report of a combined ankle and syndesmosis sprain, results suggest the weightbearing and push-off force were seriously compromised. Decreasing the number of walking assistive devices and wearing a semirigid ankle brace increased the amount of weightbearing through the affected leg and may have merit in encouraging muscle function.
Therapeutic Footwear for Neuropathic Ulcers
Authors: Slavens Earl R. , Slavens Margie Linda
Published: March 2013

Current literature on the treatment of patients with neuropathic ulcers generally does not fully consider pedorthic treatment. To evaluate pedorthic treatment of patients with neuropathic ulcers, an ongoing treatment and tracking program was developed. This program consisted of regularly scheduled visits, footwear inspections, and orthosis replacement, repair, or adjustment. Our intent is not to suggest that therapeutic footwear be used as a primary treatment to close foot ulcers, but to highlight the place of education, proper shoes, and orthosis in the healing process.
Prognostic Factors in Bunion Surgery
Authors: Scranton Pierce E. , McDermott John E.
Published: March 2013

Between 1977 and 1992, 42 patients were seen who had 51 feet operated upon for bunions in which the surgery failed. A total of 105 procedures were done on these 51 feet until the patients either achieved satisfactory correction (N = 28) or they declined (N = 14) further surgery. An analysis of these failures and review of literature revealed 12 anatomic variations and 7 secondary factors that were seen in association with surgical failure. These findings were correlated with published criteria and our experience with various bunion procedures to advance general indications and contraindications for specific bunion procedures.
Bone Scintigraphy Findings in Lisfranc Joint Injury
Authors: Groshar D. , Alperson M. , Mendes D.G. , Barsky V. , Liberson A.
Published: March 2013

Three-phase bone scintigraphy diagnosis of Lisfranc injury in a patient after foot trauma is discussed. Early diagnosis of Lisfranc joint injury is frequently missed and radionuclide bone scintigraphy may show a specific pattern where the x-rays are inconclusive.
Tendon Transfer Combined with Calcaneal Osteotomy for Treatment of Posterior Tibial Tendon Insufficiency: A Radiological Investigation
Authors: Myerson Mark S. , Corrigan John , Thompson Francesca , Schon Lew C.
Published: March 2013

We present the radiographic results after flexor digitorum longus tendon transfer combined with a medial displacement calcaneal osteotomy for the treatment of posterior tibial tendon insufficiency. Eighteen patients with posterior tibial tendon insufficiency were reviewed from 12 to 26 months after surgery. The 15 women and 3 men had a mean age of 54 years (range, 38–72 years). The talar-first metatarsal and talonavicular coverage angles were measured before and after surgery on the anteroposterior weightbearing radiographs. The mean preoperative talar-first metatarsal and talonavicular coverage angles were 21° (range, 3–45°) and 34° (range, 0–55°), respectively. The mean postoperative values for these angles were 8.5° (range, 0–35°) and 21° (range, −30–45°), respectively. The mean talar-first metatarsal angle decreased from 21° to 8.5°, a mean improvement of 12.5°, and the mean talonavicular coverage angle decreased from 34° to 21°, a mean improvement of 13°. On the lateral weightbearing radiographs, the talar-first metatarsal angle and the distance from the medial cuneiform to the floor were measured before and after surgery. The mean preoperative values were −22° (range, −10 to −40°) and 9 mm (range, 1–19 mm), respectively. The mean postoperative values were −9° (range, +5 to −25°) and 16 mm (range, 10–28 mm), respectively. The mean talar-first metatarsal angle decreased from −22 to −9° (a mean improvement of 13°), and the distance from the medial cuneiform to the floor increased from 9 to 16 mm (a mean improvement of 7 mm). We conclude that the use of a combined medial displacement osteotomy of the calcaneus with a tendon transfer for treatment of posterior tibial tendon insufficiency may offset the inherent weakness of the flexor digitorum longus transfer by reducing the antagonistic deforming force of heel valgus.
Endoscopic Plantar Fascia Release: An Anatomical Study
Authors: Hofmeister Eric P. , Elliott Michael J. , Juliano Paul J.
Published: March 2013

The anatomical relationship of neurovascular structures to the plantar fascia after endoscopic fasciotomy was studied in 13 adult fresh-frozen cadaver feet. Using a single portal technique, an endoscopic system was placed into the plantar compartment through a 1-cm medial incision. Under direct endoscopic visualization, the plantar fascia was released. The feet were then dissected and the anatomic relationship of the neurovascular structures to the area of release was studied. The average amount of plantar fascia released was 81%. The average distance of the release to the lateral plantar nerve, and the nerve to the abductor digiti minimi was 10.5 and 12.3 mm, respectively. The flexor digitorum brevis muscle was partially transected in 46% of the cases, and the average amount of muscle transected was 0.8 mm. The endoscopic approach to the release of the plantar fascia provides adequate release and does not appear to pose any danger to underlying neurovascular structures.
The Deep Peroneal Nerve in the Foot and Ankle: An Anatomic Study
Authors: Lawrence Steven J. , Botte Michael J.
Published: March 2013

Injury to the deep peroneal nerve in the foot and ankle may result from trauma, repetitive mechanical irritation, or iatrogenic harm. The nerve is most susceptible to injury along its more distal anatomic course. Dissection of 17 cadaver specimens was undertaken to describe the course of the deep peroneal nerve and quantify its branch patterns. In the distal one third of the leg, the nerve was located superficial to the anterior tibial artery between the tibialis anterior and extensor hallucis longus muscles. Typically, the nerve crossed deep to the extensor hallucis longus tendon to enter the interval between the extensor hallucis longus and extensor digitorum longus at an average distance of 12.5 mm proximal to the ankle. A proximal bifurcation was usually present at an average distance of 12.4 mm distal to the mortise. The lateral terminal branch penetrated the deep surface of the extensor digitorum brevis to provide motor innervation. The medial terminal branch passed over the talonavicular joint capsule, and coursed an average of 2.9 mm lateral to the first tarsometatarsal joint. Within the forefoot, it passed deep to the extensor hallucis brevis tendon, bifurcated in the midmetatarsal region, and then arborized, supplying sensibility to the first toe interspace and the adjacent sides of the first and second toes.
Lateral Column Lengthening with Calcaneocuboid Fusion: Range of Motion in the Triple Joint Complex
Authors: Deland Jonathan T. , Otis James C. , Lee Kyung-Tai , Kenneally Sharon M.
Published: March 2013

Lengthening the lateral column of the foot has been shown to correct flatfoot deformity. In adults, however, lengthening leads to calcaneocuboid arthritis. Lateral column lengthening with calcaneocuboid fusion, which lengthens the lateral column of the foot and prevents calcaneocuboid arthritis, was investigated in a cadaver model to determine the remaining range of motion in the talonavicular and subtalar joints. Inversion/eversion motion was produced by tendon pulls and the range of motion was measured in three dimensions using a magnetic space tracker. After lateral column lengthening with calcaneocuboid fusion, 48% of talonavicular and 70% of subtalar joint range of motion were preserved. Analysis of the inversion and eversion ranges of motion suggests that the lengthening fusion limits eversion more than inversion. These findings demonstrate the need for clinical investigation of this procedure, which could preserve motion in the talonavicular and subtalar joints, correct deformity, and obviate calcaneocuboid arthritis.
Surgical Revision after Failed Lateral Ankle Reconstruction
Authors: Sammarco G. James , Carrasquillo Hiram A.
Published: March 2013

Ten patients were treated with revision ankle ligament reconstruction from 1989 through 1994 for recurrent symptomatic instability of the ankle after failure of a primary reconstruction. There were seven female and three male patients with an average age of 28 years. In four patients, symptoms developed shortly after the first reconstruction and in six patients, symptoms developed 56.2 months (average) after the initial reconstruction surgery. The average follow-up was 14 months after revision surgery. All patients had significant functional impairment before surgery and all failed to respond to conservative treatment, which included physical therapy and bracing. Seven revision ligament reconstructions included the use of a tendon graft, including the pero-neus brevis, accessory peroneus, plantaris, and peroneus tertius. All revision procedures were modifications of the Elmslie procedure, (Sammarco-DiRaimondo). In addition, three Brostrom-Gould procedures were performed. The average follow-up was 31 months.

All patients had clinical stability of the ankle following revision reconstruction. Nine patients (90%) returned to their previous functional level. After surgery, two patients had minimal pain and mononeuritis multiplex developed in one patient. The outcome of revision ankle ligament reconstruction compares favorably with reports for primary ankle reconstruction. Revision ankle reconstruction is a good procedure for selected patients. It is an appropriate option when conservative therapy fails to relieve recurrent symptoms of ankle instability following primary reconstruction.
Split Posterior Tibial Tendon Transfer Through the Interosseus Membrane in Spastic Equinovarus Deformity
Authors: Mulier Thomas , Moens Pierre , Molenaers Guy , Spaepen Dominique , Dereymaeker Greta , Fabry Guy
Published: March 2013

The split posterior tibial tendon transfer procedure was first reported by Green for correction of equinovarus hindfoot deformity in patients with cerebral palsy. A modification of the split posterior tibial tendon transfer combined with an Achilles tendon lengthening is described in 17 children (21 procedures) with a minimum follow-up of 3 years.

This modified technique is indicated in young children with a continuously spastic posterior tibial tendon to correct a dynamic equinovarus. It restores active dorsiflexion when the anterior tibial and extensor muscles are weak.

The anterior half of the split tibialis posterior is transferred through the interosseus membrane to the dorsum of the foot. Excellent or good results and two poor results were noted after a mean follow-up of 29 months. In the patients with an excellent or good result, marked improvement of their equinovarus foot deformity in stance and swing phase of gait was seen. In two patients, the procedure failed because of technical errors.
Morton's Interdigital Neuroma: A Comprehensive Treatment Protocol
Authors: Bennett Gordon L. , Graham Charles E. , Mauldin Donald M.
Published: March 2013

One hundred fifteen patients with signs and symptoms of Mortons' interdigital neuroma were studied in an attempt to evaluate the efficacy of a staged treatment program. The first stage consisted of patient education, footwear modifications, and metatarsal head relief. The second stage consisted of a steroid/local anesthetic injection into the affected interspace. The third stage was surgical excision of the inflamed interdigital nerve. Overall, 97 of 115 patients (85%) believed that they had improved with the treatment program. Twenty-four patients (21%) eventually required surgical excision of the nerve and 23 of 24 patients (96%) had satisfactory results. The results of the staged treatment protocol were very satisfactory and patient satisfaction was high.
Properties of Shoe Insert Materials Related to Shock Wave Transmission During Gait
Authors: Forner Arturo , García Ana-Cruz , Alcántara Enrique , Ramiro José , Hoyos Juan-Víctor , Vera Pedro
Published: March 2013

The influence of the mechanical characteristics of certain insole materials in the generation and transmission of heel strike impacts while walking was studied. Three insole materials were selected according to their mechanical characteristics under heel strike impacts. The selection of materials has made it possible to distinguish the effect of rigidity and loss tangent in the transmission of heel strike impacts. A lower rigidity and a high loss tangent have been shown to reduce the transmission of impacts to the tibia. A low rigidity was seen to significantly increase the transmission of impacts from tibia to forehead.
Paradoxical Transcutaneous Oxygen Response to Cutaneous Warming on the Plantar Foot Surface: A Caution for Interpretation of Plantar Foot TcPO2 Measurements
Authors: Smith Douglas G. , Boyko Edward J. , Ahroni Jessie H. , Stensel Victoria L. , Davignon Denise R. , Pecoraro Roger E.
Published: March 2013

We examined the effect of cutaneous warming on the transcutaneous oxygen measurement (TcPO2) at standard locations below the knee, on the dorsal foot, on the plantar right great toe, and on the plantar surface under the second metatarsal head of 656 diabetic and 16 nondiabetic subjects. All subjects underwent a directed medical history, physical examination, and neurovascular lower extremity evaluation and assessment of autonomic neuropathy. Associations between autonomic neuropathy and TcPO2 were tested using two-way analysis of variance and multiple linear regression.

An unexpected, statistically significant fall in TcPO2 occurred with cutaneous warming from 37°C to 44°C on the plantar great toe surface that did not differ by presence of autonomic neuropathy, or the presence of diabetes (mean change: −8.82 mmHg, 95% confidence interval [CI]: −7.70 to −9.93). The TcPO2 measured at the plantar metatarsal head site also fell with cutaneous warming from 37°C to 44°C (mean change: −9.67 mmHg, 95% CI: −7.75 to −11.59). As expected, the TcPO2 increased with cutaneous warming from 37°C to 44°C on the dorsal foot site (mean rise:= 35.61 mmHg, 95% CI: 34.18 to 37.04). The mean TcPO2 at any site did not differ by presence of autonomic neuropathy at either 37°C or 44°C.

We conclude that cutaneous warming leads to a paradoxical fall in TcPO2 on the plantar foot surface that does not depend on the presence of autonomic neuropathy or diabetes. Caution in interpretation of ambient versus warmed plantar TcPO2 values is recommended.
Calcification of the Tibialis Posterior Tendon: A Case Report and Literature Review
Authors: Delmi Marino , Kurt Anne-Marie , Meyer J.-M. , Hoffmeyer Pierre
Published: March 2013

The tibialis posterior muscle and tendon are subject to a number of pathological conditions and injuries that have recently received much attention in the literature. Because of its function as a main stabilizer of the subtalar complex against hindfoot valgus and forefoot pronation, the mechanical demand on the posterior tibial tendon is high. Problems with dislocation, tenosynovitis, rupture, and laceration have all been described with this tendon. In this report, we present a case of dysfunction of the posterior tibial tendon associated with chronic tendinitis and intratendinous calcifications. After removal of the calcifications, the patient became asymptomatic and returned to work. Proposed etiologies of these calcifications are discussed.
Extraskeletal Osteosarcoma: An Unusual Presentation as Tarsal Tunnel Syndrome
Authors: Jaffe Kenneth A. , Wade Jeffrey D. , Chivers F. Spencer , Siegal Gene P.
Published: March 2013

Tarsal tunnel syndrome is a compressive neuropathy caused by intrinsic or extrinsic pressure on the posterior tibial nerve or one of its terminal branches. A mass in association with tarsal tunnel syndrome is most likely a benign tumor or tumor-like condition, although a more malignant tumor must be in the differential diagnosis. We report an unusual case of an extraskeletal osteosarcoma causing tarsal tunnel syndrome.
Fracture of the Tarsal Navicular Associated with Calcaneonavicular Coalition: A Case Report
Authors: Tanaka Yasuhito , Takakura Yoshinori , Akiyama Kouichi , Kamei Shigeru , Nukata Masato , Tamai Susumu
Published: March 2013

Fracture of the navicular occurred in a 23-year-old male with unilateral cartilaginous calcaneonavicular coalition. Inversion sprain of the left foot caused the longitudinal navicular fracture next to the coalition. En bloc resection from the beak of the calcaneus to the fracture line of the navicular including the calcaneonavicular coalition was performed, and a short leg cast was applied for 10 days. Four weeks after surgery, he returned to his preinjury level of activity and job as a long-distance truck driver. Two years and 3 months after surgery, he was totally asymptomatic and had gained a full range of subtalar motion. He had no peroneal spasm or recurrence of the coalition.
Subtalar Joint Dislocations
Authors: Bohay Donald R. , Manoli Arthur
Published: March 2013

Dislocations of the subtalar joint are rare injuries. The anatomy, pathophysiology, treatment, and prognosis of subtalar joint dislocations have been well described in the literature. The purpose of this paper is to review the current literature on subtalar joint dislocations, as well as outline those aspects of the anatomy, pathomechanics, and treatment pertinent to care of the patient with subtalar joint dislocation. In addition, complications and obstacles to reduction are described.

Subtalar joint dislocations, although not common, have increased in frequency over the last decade. Generally, they can be treated successfully with closed reduction and a short period of cast immobilization. The majority of patients will suffer some disability with subtalar joint stiffness the primary complaint. Associated intra-articular fractures increase the risk of posttraumatic arthrosis.
Biomechanical Assessment of a New Tenodesis for Correction of Hallux Varus
Authors: Juliano Paul J. , Myerson Mark S. , Cunningham Bryan W.
Published: March 2013

Each of six below-the-knee amputation specimens were transfixed to a wooden block and mounted to a jig on an amputee testing device preloaded with 5 N applied to the proximal phalanx and displaced at a constant rate of 2 mm/min. Load displacement curves were generated for the intact joint and after sequential incisions of the lateral capsule, the adductor hallucis, and the lateral slip of the flexor hallucis brevis tendon, which caused varus dislocation of the hallux. An extensor hallucis brevis tenodesis was performed after the varus dislocation. Division of the lateral capsule, the adductor, and the flexor brevis reduced the force required to displace the hallux by 42.2%, an additional 25.2%, and a further 14.2%, respectively. Use of the extensor hallucis brevis tenodesis restored the load displacement curves to that of the normal joint. We concluded that the extensor hallucis brevis tendon may be useful as a tenodesis for reconstructing the deformity of acquired hallux varus.
Results of Hallux Varus Correction Using an Extensor Hallucis Brevis Tenodesis
Authors: Myerson Mark S. , Komenda Gregory A.
Published: March 2013

We have used an extensor hallucis brevis tenodesis procedure to treat symptomatic hallux varus in six patients (five women and one man). Indications for this procedure include the presence of flexible metatarsophalangeal and interphalangeal joints and the absence of arthritis. In this group (mean age, 47 years; range, 18–65 years), hallux varus followed correction of hallux valgus deformity in five patients and traumatic dislocation of the hallux in one patient. Excellent correction was noted and maintained in all patients at a mean interval of 28 months (range, 24–32 months) after surgery. Despite a slight decrease in dorsiflexion following surgery (average, 10°), there were no additional complications noted, and the mean American Orthopaedic Foot and Ankle Society rating score improved from 61 to 85 after surgery.
A Reliability Study of the Universal Goniometer, Fluid Goniometer, and Electrogoniometer for the Measurement of Ankle Dorsiflexion
Authors: Rome Keith , Cowieson Fiona
Published: March 2013

This study investigated the reliability of three goniometers, the universal, fluid, and electro-goniometers, in the measurement of ankle dorsiflexion. Intra- and interobserver reliability were assessed using 10 healthy volunteers and five observers. A standardized ankle position was used to measure full range of active dorsiflexion. Intraobserver reliability was assessed using one observer over two successive occasions. Interobserver reliability was assessed among five observers over five separate occasions.

A one-factor analysis of variance to examine intraobserver reliability demonstrated no significant difference between each of the devices on the two occasions. A multifactorial analysis of variance demonstrated significant differences among observers and again among devices ( P < 0.001). Secondary analysis for interdevice reliability demonstrated significant differences among the three devices (p<0.1). The study suggests that each device cannot be used reliably among observers or be used interchangeably, and clinical judgment based on angular changes of less than 10° are invalid if rigid protocols are not followed.
Magnetic Resonance Imaging of Plantar Plate Rupture
Authors: Yao Lawrence , Cracchiolo Andrea , Farahani Keyvan , Seeger Leanne L.
Published: March 2013

Degenerative plantar plate failure is an under-recognized cause of lesser metatarsalgia. We performed magnetic resonance imaging (MRI) with a small receiver coil in 13 patients in whom plantar plate ruptures of the second or third metatarsophalangeal joint were clinically suspected. In eight patients, MRI showed focal hyperintensity in the plantar plate that was interpreted as a rupture of the plate. Ruptures were confirmed in all five patients who underwent an operative procedure to treat the unstable, painful metatarsophalangeal joint. MRI is a noninvasive technique that can visualize plantar plate abnormalities and aid the clinical evaluation of problematic lesser metatarsalgia.
Chronic Plantar Heel Pain: Treatment with a Short Leg Walking Cast
Authors: Tisdel Christopher L. , Harper Marion C.
Published: March 2013

The efficacy of a short leg walking cast in the treatment of chronic plantar heel pain was assessed for 32 patients with 37 involved extremities treated over a 2-year period. All patients had failed numerous other treatment modalities and had been symptomatic for an average of 1 year. Long-term follow-up for 24 patients with 28 involved extremities revealed complete resolution of pain for 7 extremities (25%), improvement for 17 (61%), and no improvement for 4 (14%). Ten (42%) patients were completely satisfied with cast treatment, 3 (12%) were satisfied with reservations, and 11 (46%) were dissatisfied. Casting appears to be a reasonable option for patients with recalcitrant heel pain and should be offered before surgical intervention.
Foot Function in Diabetic Patients after Partial Amputation
Authors: Garbalosa Juan Carlos , Cavanagh Peter R. , Wu Ge , Ulbrecht Jan S. , Becker Mary B. , Alexander Ian J. , Campbell James H.
Published: March 2013

The function of partially amputated feet in 10 patients with diabetes mellitus was studied. First-step bilateral barefoot plantar pressure distribution and three-dimensional kinematic data were collected using a Novel EMED platform and three video cameras. Analysis of the plantar pressure data revealed a significantly greater mean peak plantar pressure in the feet with transmetatarsal amputation (TMA) than in the intact feet of the same patients. The heels of the amputated feet had significantly lower mean peak plantar pressures than all the forefoot regions. A significantly greater maximum dynamic dorsiflexion range of motion was seen in the intact compared with the TMA feet. However, no difference was noted in the static dorsiflexion range of motion between the two feet and there was, therefore, a trend for the TMA feet to use less of the available range of motion. Given the altered kinematics and elevated plantar pressures noted in this study, careful postsurgical footwear management of feet with TMA would appear to be essential if ulceration is to be prevented.
Acute Calcification of the Peroneal Tendons in a Sheep Shearer
Authors: Williams C.R.P.
Published: March 2013

Acute calcification of periarticular tendons is known to occur at a variety of sites after subclinical trauma or after chronic overuse injuries. It can also be due to degeneration of the affected tendon. This problem is reported in the peroneal tendons of a sheep shearer.
Primary Subtalar Arthrodesis for the Treatment of Comminuted Calcaneal Fractures
Authors: Buch Barbara D. , Myerson Mark S. , Miller Stuart D.
Published: March 2013

We retrospectively evaluated the results of primary subtalar arthrodesis for the treatment of severely comminuted calcaneal fractures. Of 108 patients with 112 calcaneal fractures treated at our institution between 1989 and 1992, 16 (15%) underwent primary subtalar arthrodesis through an extensile lateral approach. The calcaneal height and width were restored with standard fixation techniques and then arthrodesis was performed with bone graft and fixation by 7.0-mm cannulated cancellous screws. Fourteen patients (12 males and 2 females; mean age, 40 years) were available for examination at a mean time of 26 months (range, 12–54 months) after surgery.

Arthrodesis, evidenced by radiographic bony bridging across the arthrodesis site, was present in all patients between 8 and 12 weeks. Minor wound complications occurred in three patients. Of the 12 patients employed before the injury, 11 returned to their original occupations at a mean time of 8.8 months after injury (range, 1 month to 3 years). The mean AOFAS 100-point clinical rating scale score, evaluating pain, function, and alignment, was 72.4 points (range, 48–88 points). We conclude that primary subtalar arthrodesis is indicated as part of the management of comminuted displaced articular calcaneal fractures, yielding results that allowed 11 of 12 formerly employed patients to return to work.
Stress Fractures at the Base of the Second Metatarsal in Ballet Dancers
Authors: O'Malley Martin J. , Hamilton William G. , Munyak John , DeFranco Michael J.
Published: March 2013

Stress fractures are a frequent injury in ballet companies and the most common location is at the base of the second metatarsal. While previous reports have focused on risk factors for this injury (overtraining, delayed menarche, poor nutrition), there is no published series describing the natural history and outcome following this fracture. We reviewed the office records of the senior author and identified 51 professional dancers (64 fractures) who sustained a stress fracture at the base of the second metatarsal. History of a previous stress fracture in the lower extremity was seen in 19 patients and delayed menarche in the women was common. The clinical presentation was insidious onset of midfoot pain an average of 2.5 weeks prior to seeking medical care. The initial radiographs of the foot were positive in 19 patients, questionable in 3 patients, and negative in 42 patients. The usual location of the fracture was at the proximal metaphyseal-diaphyseal junction (three fractures extended into the tarsometatarsal joint). Treatment consisted of a short leg walking cast for 6 patients, and a wooden shoe and symptomatic treatment for the remainder. At follow-up, 14% of patients still had occasional pain or stiffness in the midfoot with dancing. The patients returned to performance at an average of 6.2 weeks following diagnosis. No patients required bone grafting for persistent symptoms. There were eight refractures (at the same site) occurring an average of 4.3 years, all of which healed with conservative care.

Stress fractures at the base of the second metatarsal are common in ballet dancers and can usually be treated with symptomatically. The results of this study are discussed in terms of risk factors, the use of a posterior-anterior view of the foot to eliminate overlap at Lisfranc's joint, and our present treatment regimen.
Gross, Histological, and Microvascular Anatomy and Biomechanical Testing of the Spring Ligament Complex
Authors: Davis W. Hodges , Sobel Mark , DiCarlo Edward F. , Torzilli Peter A. , Deng Xianghua , Geppert Mark J. , Patel Manoj B. , Deland Jonathan
Published: March 2013

In recent years there has been an increased interest in the treatment of acquired pes planus. The breakdown of the medial longitudinal arch is most often seen at the talonaviculocalcaneal articulation. This suggests a relationship between the ligamentous complex at this articulation and acquired pes planus. This study was undertaken to gain a better understanding of the gross, histologic, and microvascular anatomy, as well as the biomechanics of the ligamentous structures surrounding the talonaviculocalcaneal articulation.

Cadaver dissections of 38 fresh-frozen feet were performed. Detailed descriptions of the gross anatomy of the superomedial calcaneonavicular ligament, inferior calcaneonavicular ligament, and the superficial deltoid ligament were recorded. Their relationships to the posterior tibialis tendon and to the bones of the talonaviculocalcaneal articulation are described. The histology and microvascularity of these structures were also studied. Preliminary biomechanical testing was performed.

It was found there are two definitive anatomic structures that are commonly called the spring ligament: the superomedial calcaneonavicular ligament (SMCN) and the inferior calcaneonavicular ligament (ICN). The SMCN ligament was found to have histologic properties that suggest significant load bearing. The histology of the ICN ligament suggests a pure tensile load function. The deltoid ligament and the posterior tibialis tendon had direct attachments to the SMCN ligament in all specimens. An articular facet composed of fibrocartilage was found in each SMCN ligament specimen. The microvascular structures showed an avascular articular facet present in the ligament. The biomechanical testing showed that the SMCN ligament and ICN ligament had strength similar to ankle ligaments. This study suggests this “spring ligament complex” has more of a “sling” function for the talar head. It is hoped that the better understanding of this region will add to our understanding of the etiology of pes planus and possible treatment alternatives.
Anatomical Considerations of Irreducible Medial Subtalar Dislocation
Authors: Heck Bruce E. , Ebraheim Nabil A. , Jackson W. Thomas
Published: March 2013

Irreducible medial subtalar dislocation has been associated with the talar head “buttonholing” through the extensor digitorum brevis (EDB) muscle, entrapment of the talar head in the extensor retinaculum, talonavicular impaction, interpositioning of the EDB muscle between the talus and navicular, and buttonholing of the talar head through the talonavicular ligament and joint capsule.

Cadaver analysis of the medial subtalar dislocation in this study supported entrapment of the talar head in the extensor retinaculum and talonavicular impaction as well as impingement of the deep peroneal nerve and associated dorsalis pedis arterial branches between the talus and navicular as causes of irreducible subtalar dislocation. In this study, the talar head was not noted to buttonhole through or entrap the EDB muscle.

This is the first report of the deep peroneal nerve implicated as a possible cause of irreducible medial subtalar dislocation.
Abstracts
Authors: Trepman Elly
Published: March 2013

This section will bring to the readership of Foot & Ankle International articles of potential interest that have appeared in other peer review journals. Recently published articles are selected on the basis of quality and relevance, and reviewed in abstract form with comments. Authors are invited to submit reprints for consideration to the Foot & Ankle International Editorial Office. Articles in languages other than English, French, German, Hebrew, or Yiddish should be accompanied with a brief (150 word) abstract in any of these languages. Articles submitted without clear identification of journal name, issue, inclusive page numbers, year of publication, and corresponding author cannot be considered. Submission does not guarantee selection. Reprints will not be returned.
Advanced Hallux Valgus Deformity: Long-Term Results Utilizing the Distal Soft Tissue Procedure and Proximal Metatarsal Osteotomy
Authors: Dreeben Sharon , Mann Roger A.
Published: March 2013

A series of 28 cases with a moderate to severe hallux valgus deformity and intermetatarsal angle of 14° or greater was followed an average of 5½ years to determine whether any significant loss of correction occurred. All feet were treated with a distal soft tissue procedure and proximal metatarsal osteotomy. The average correction of the intermetatarsal angle was 13.2° (7–20°), and the average loss of correction was 1.4°; the average correction of the hallux valgus angle was 26.7° (−2° to 48°), and the average loss of correction was 3.8°. In three cases, a recurrent deformity developed; in three other cases, a hallux varus deformity developed, two of which were symptomatic. Patient satisfaction was 85%. This study indicates that in most patients with a hallux valgus deformity and an intermetatarsal angle of 14° or greater, there is sufficient inherent stability of the first metatarsocuneiform joint that it does not require stabilization to obtain a satisfactory long-term result.
Use of Titanium Grommets in Silicone Implant Arthroplasty of the Hallux Metatarsophalangeal Joint
Authors: Sebold E. James , Cracchiolo Andrea
Published: March 2013

Double-stem silicone implants protected by titanium grommets were placed in the hallux metatarsophalangeal joints of 32 patients (47 feet). All patients had a painful destroyed joint and most were women. Three patients (six feet) were lost to follow-up. Nineteen patients had a diagnosis of rheumatoid arthritis (25 feet) and 10 had degenerative joint disease (16 feet). The average age for the group was 57 years and the average follow-up was 51 months (range, 34–76 months). Twenty patients (30 feet) were completely satisfied with their result. Eight patients (10 feet), all with rheumatoid arthritis, had some minor postoperative complaints, usually involving the lateral toes. Two patients (three feet) in this group had no pain, but would have preferred more hallux motion. One patient with rheumatoid arthritis (one foot) had a poor result due to implant removal for deep sepsis.

Radiographic analysis of these patients showed no evidence of implant fracture and the implant composite appeared to be well tolerated by the surrounding bone in which it was placed. When compared with another, similar group of patients in whom grommets were not used, this implant appeared to be much more stable, as there was significantly less evidence of radiolucency seen around those implants protected by the grommets.

It appears that the titanium grommets may protect the silicone implant and may help provide a longer life for the silicone implant.
Coronal Plane Rotation of the First Metatarsal
Authors: Saltzman Charles L. , Brandser Eric A. , Anderson Chris M. , Berbaum Kevin S. , Brown Thomas D.
Published: March 2013

A method for measuring first metatarsal rotation on weightbearing tangential radiographs is described. Under controlled conditions using cadaver specimens, 5° changes in first metatarsal rotation were associated with a mean change in radiographically measured rotation of 5.4° (SD = 1.7°). A clinical study of 30 hallux valgus and 30 control patients was undertaken to assess the reliability of the method of measurement. The overall reliability was high for both hallux valgus and control patients ( r = 0.93 and 0.95, respectively). In these two groups, no significant difference was found between the mean values for first metatarsal rotation. Likewise, we found no correlation between first metatarsal rotation measured on tangential standing (“sesamoid” view) radiographs and the first metatarsophalangeal angle or the intermetatarsal 1–2 angle measured on anteroposterior standing radiographs.
Occult Fractures Following Subtalar Joint Injuries
Authors: Bohay Donald R. , Manoli Arthur
Published: March 2013

Subtalar joint dislocations, although not common, have been increasing in frequency over the last decade. Generally, subtalar joint dislocation can be treated successfully with closed reduction and a short period of cast immobilization. The majority of patients will suffer minimal disability, with subtalar joint stiffness as the primary complaint.

This report includes four cases of suspected joint dislocation or subluxation with occult intra-articular fractures identified only by CT scan following essentially normal radiographs. Evidence seems to indicate that CT scanning in patients with suspected subtalar joint subluxation or dislocation and normal radiographs is justified.
The Bicycle Spoke Injury: An Avoidable Accident?
Authors: D'Souza L. G. , Hynes D. E. , McManus F. , O'Brien T. M. , Stephens M. M. , Waide V.
Published: March 2013

A prospective study of the bicycle spoke injury over a 1-year period included a total of 71 spoke injuries. Of these, 67 injuries occurred on an adult bicycle and four occurred on a child's bicycle. All children sustained ankle and foot injuries, which consisted of contusion and superficial abrasion (N = 45), skin loss (N = 10), skin laceration (N = 4), and undisplaced fractures (N = 12).

A biomechanical study was conducted to investigate the use of a protective cover over the wheel to prevent the foot from slipping between the spokes. Wind resistance studies showed that a cover with a mesh size of 10 mm hexagonal could prevent this and at the same time stop the cover from acting as a sail if a flat cover without holes was used instead. The mesh cover, however, will prevent the toes from entering between the spokes but will not prevent the foot from becoming jammed between the wheel and the fork. To prevent this, a plastic shield to bridge the gap between the fork and the horizontal upright has been designed. With these modifications, the bicycle spoke injury can become an injury of the past.
Surgical Correction of a Simian Foot
Authors: Kelly Ian Peter , O'Byrne John Martin , Mulcahy David , Stephens Michael
Published: March 2013

Congenital varus deformity of the first metatarsal can be secondary to the abnormal insertion of abductor hallucis, a space-occupying lesion of the first web space, or hypoplasia of the metatarsal. We report a unique case where all three factors were present in one foot. This was combined with talipes equinovarus, which gave the appearance of a simian or hand-like foot.
Clinical Examination and Magnetic Resonance Imaging in the Assessment of Ankle Sprains Treated with an Orthosis
Authors: De Simoni C. , Wetz H. H. , Zanetti M. , Hodler J. , Jacob H. , Zollinger H.
Published: March 2013

This is a prospective clinical study of treatment of ankle sprains with an ankle brace that permits ankle dorsiflexion and plantarflexion of 20°, but limits inversion and eversion for 6 weeks. The ankle brace is followed by physiotherapy for another 6 weeks.

Thirty patients were evaluated with clinical examination and magnetic resonance (MR) imaging before treatment and after 12 weeks of treatment. MR imaging revealed acute tears in the anterior talofibular ligament in all 30 ankles (100%) and tears in the calcaneofibular ligament in 25 of 30 ankles (83%). At 12 weeks after injury, MR evidence of healing was present for the anterior talofibular ligament in 22 of 30 ankles (73%) and for the calcaneofibular ligament in 23 of 25 ankles (92%).

Postural sway analysis after therapy was used to quantify functional stability of the ankle. There was no correlation with MR findings, but there was a correlation with the subjective impression of functional instability. Twenty-eight of 30 patients (93%) had a functionally stable ankle after 12 weeks of treatment. MR findings after ankle sprain could not predict clinical outcome.
Isolated Medial Compartment Syndrome of the Foot: A Case Report
Authors: Myerson Mark S. , Berger Barry I.
Published: March 2013

Compartment syndrome, which results from increased pressure within a closed osseofascial compartment, compromises the viability of tissues and requires prompt fasciotomy for successful outcome. The vast majority of published series on compartment syndrome emphasizes the substantial amount of soft tissue and/or bony trauma that accompanies the condition. This report describes an isolated medial compartment syndrome without evidence of specific injury.
Fracture of the Medial Tubercle of the Posterior Process of the Talus: A Case Report and Literature Review
Authors: Kim David H. , Hrutkay Jeffrey M. , Samson Mary M.
Published: March 2013

A 32-year-old man experienced pain behind the medial malleolus and an inability to bear full weight after jumping approximately 3 feet during a basketball game. A diagnosis of fracture of the medial tubercle of the posterior process of the talus was made, and the patient was treated for 7 weeks in a nonweightbearing cast. Twenty-four-month follow-up demonstrated no limitation of activity. To our knowledge, this is the first reported case of fracture of the posterior process of the talus that was treated nonoperatively with a successful outcome.
Fractures of the Central Metatarsal
Authors: Alepuz E. Sánchez , Carsi V. Vicent , Alcántara P. , Llabrés A. J.
Published: March 2013

We reviewed the evolution and final results of 57 patients with central metatarsal fractures treated in Hospital “La Fe” in Valencia between 1982 and 1993. The treatments were nonsurgical in 36 cases and surgical in 21 cases. The most frequent etiologies were traffic accidents, followed by work-related accidents.

The fractures were classified according to their anatomic localization and whether they were closed (44 cases) or open (13 cases). Poor functional results manifested by metatarsalgia were present most often when one or two of the following were present: comminution, sagittal plane displacement, open fracture, or severe soft tissue injury. The mean follow-up was 5 years.
Two Case Reports of a Technique of Medial External Fixation in Calcaneal Fractures: Indirect Control of the Sustentacular Fragment
Authors: Borowsky Keith Adrian
Published: March 2013

In attempted open reduction and internal fixation of displaced calcaneal fractures, comminution of the sustentacular fragment can pose major problems. Two cases of a form of external fixation are presented. The method takes advantage of the strong superomedial and plantar calcaneonavicular ligaments, which link the sustentaculum to the navicular. Traction along these structures (by pins placed in the first metatarsal) indirectly controls the sustentacular fragment, while countertraction from medially placed pins in the tuberosity allows derotation of the fragment and correct repositioning in relation to the sustentaculum. The essential deformities of a calcaneal fracture are corrected by this technique. In addition, distortion of the middle facet appears to correct as well.
Recurring Desmoid Tumor of the Foot: A Case Study
Authors: Barbella Ronald , Fox Ira M.
Published: March 2013

The desmoid tumor is benign, uncommon, and frequently recurs after excision. It can be confusing in terms of diagnosis and treatment due to its ability to achieve large size, causing functional limitation and/or pain. Its overall clinical characteristics can mimic those of its malignant counterparts. Because of its high rate of recurrence, surgical treatment should include a wide excision around the margins.
Fracture of the Entire Posterior Process of Talus Associated with Subtalar Dislocation: A Case Report
Authors: Chen Yeung-Jen , Hsu Robert Wen-Wei , Shih Hsin-Nung , Huang Tsung-Jen
Published: March 2013

This is a case report of a 52-year-old woman who sustained a medial subtalar dislocation with fracture of the posterior process of the talus in a traffic accident. After closed reduction of the subtalar dislocation, tomography demonstrated that the talus fracture involved the entire posterior process and the posterior portion of the talar body. The fracture of the talus was treated with an open reduction and miniscrew fixation. At follow-up examination 32 months later, the functional and radiographic results were graded as good. The proposed mechanism of this case was a forced plantarflexion and inversion acting simultaneously on the subtalar joint. This was different from an isolated medial subtalar dislocation, which was caused by an inversion.
Ankle Arthrodesis: Results after the Miniarthrotomy Technique
Authors: Paremain Guy D. , Miller Stuart D. , Myerson Mark S.
Published: March 2013

Of 34 ankle fusions (34 patients) performed at our institution between June 1992 and June 1993, 15 utilized a miniarthrotomy technique. This technique involves two 1.5-cm incisions, one medial and one anterolateral, through which the ankle joint cartilage and synovium are debrided. Subchondral bone resection is completed with a high-speed cutting tool, creating a “slurry” that is saved for local bone graft. The ankle is then appropriately positioned (5° of valgus, 0° of dorsiflexion, and neutral rotation), cannulated screws are inserted, the position is checked fluoroscopically, and the wound is closed. The patient receives a short leg cast at 2 weeks and a walking cast at 3 to 5 weeks until there is radiographic and clinical evidence of solid arthrodesis. In our 15 patients, follow-up ranged from 12 to 19 months after surgery and arthrodesis was radiographically evident at a mean of 6.0 weeks (range, 3–15 weeks). Complications were limited to a transient synovitis in 7/15 patients, which lasted approximately 3 weeks and was possibly related to the bone slurry.

Although ankle joints with marked malalignment require a more extensive open arthrodesis procedure, this miniarthrotomy technique offers decreased soft-tissue insult, decreased bone stripping, easy application, and rapid healing time for the treatment of severe degenerative changes of the ankle with minimal deformity.
Open Reduction and Internal Fixation of Type II Intra-Articular Calcaneus Fractures
Authors: Crosby Lynn A. , Fitzgibbons Timothy C.
Published: March 2013

Open reduction and internal fixation of 23 type II calcaneus fractures in 21 patients was performed using a standard extended lateral approach. Average follow-up was 26 months (range, 12–47 months). The Creighton-Nebraska Health Foundation Assessment Score for Fractures of the Calcaneus was used to evaluate fractures. The average score was 91.4 (range, 80–100), which represented an excellent result. A series of 10 type II fractures treated with closed methods was also evaluated using the same evaluation methods. The average score was 70 (range, 60–84), which represented a fair result. There was a clear statistically significant superiority with type II calcaneus fractures treated with open reduction and internal fixation ( P < 0.0001). We recommend type I calcaneus fractures (nondisplaced) be treated with closed methods, and type II calcaneus fractures (displaced) be treated with open reduction and internal fixation.