bluuebunny/crossref_metadata_2025 huggingface dataset:
Biomechanical Testing of Cadaveric Specimens: Importance of Bone Mineral Density Assessment
Authors: Ambrose Catherine G. , Kiebzak Gary M. , Sabonghy E. Peter , Tabor Owen B. , Peindl Richard D. , Clanton Thomas O , Anderson Robert A. , Davis W. Hodges
Published: January 2017

The bone density of cadaveric specimens is highly variable and has a significant effect on the results of biomechanical testing but it is not often assessed before testing is performed in the lab. Bone mineral density (BMD) tests such as dual X-ray absorptiometry (DXA) are widely available, easy to perform and correlate highly and significantly with bone strength in many modes of failure. We present the results of two different studies performed on cadaveric foot and ankle specimens. In these studies the results vary significantly according to BMD, and this effect is not always eliminated with the use of matched pairs of cadaveric specimens.
The in Vivo Elastic Properties of the Plantar Fascia during the Contact Phase of Walking
Authors: Gefen Amit
Published: January 2017

The in vivo elastic properties of the plantar fascia during the contact phase of walking were determined experimentally by integrating a pressure-sensitive optical gait platform with a radiographic fluoroscopy system for recording skeletal motion. In order to calculate the fascia's tension-deformation relation, lateral images of the foot's skeleton that allowed evaluation of the fascia's transient length from the arch-contact to toe-off stages of walking were obtained simultaneously with the vertical foot-ground contact forces. The plantar fascia was shown to undergo continuous elongation from arch-contact to toe-off, reaching a deformation of 9 to 12% between these positions. Rapid elongation of the fascia, at a strain rate of about 0.9±0.1 Sec-1, was observed before and immediately after midstance, while a significantly slower elongation occurred at a strain rate of approximately 0.2±0.1 Sec-1 around push-off and toe-off. The average stiffness of the fascia at the slow-to-moderate walking velocities was 170±45 N/mm, which is similar to reported stiffness values for cadaver fascia specimens. The present technique may be useful for validation of computational models of the soft tissues of the foot as well as for testing the effectiveness of orthoses and shoe types for relieving excessive strain of the fascia in the treatment of plantar fasciitis.
The Effect of Plantar Fascia Release on Strain in the Spring and Long Plantar Ligaments
Authors: Crary Jay L. , Hollis J. Marcus , Manoli Arthur
Published: January 2017

The effect of plantar fascia release on strain in the spring and long plantar ligaments was investigated in 11 cadaveric feet. Strain gauges were placed in the spring and long plantar ligaments of each specimen, and cyclic axial loading was applied until reproducible hysteresis curves were observed in the ligaments before and after plantar fascia release. After release of the plantar fascia, the average strain observed in the spring ligaments at 920N of axial load increased by 52% (p<.001) and in the long plantar ligaments by 94% (p=.04). Longer resting lengths of the ligaments were also observed. Release of the plantar fascia significantly changed force distributions in the foot which may explain the development of deformities and symptoms observed clinically following this procedure.
Chondroblastoma of the Talus Treated with Osteochondral Autograft Transfer from the Lateral Femoral Condyle
Authors: Anderson Allen F. , Ramsey James R.
Published: January 2017

Chondroblastoma is a benign cartilaginous lesion of bone. When occurring in a position juxtaposed to articular cartilage, treatment is directed at removal of the tumor with preservation of the articular cartilage. In this case, a chondroblastoma of the talus with erosion into the articular cartilage was treated with transfer of an osteochondral autograft from the ipsilateral femoral condyle. At two-year follow-up, the patient was symptom free and magnetic resonance imaging revealed complete incorporation of the graft. This case is presented as a representative example of osteochondral autograft transfer surgery (OATS) for the treatment of chondroblastoma.
Muscular Imbalances Resulting in a Clawed Hallux
Authors: Olson Soren L. , Ledoux William R. , Ching Randal P. , Sangeorzan Bruce J.
Published: January 2017

A clawed hallux is a deformity of the great toe resulting from a muscular imbalance. Using a cadaveric foot-loading frame, we quantitatively assessed the role of the peroneus longus (PL), extensor hallucis longus (EHL), and flexor hallucis longus (FHL) on position and pressure distribution of the first ray by simulating muscle imbalances. The experimental protocol included applying seven different combinations of simulated disproportionate loads (“overpulls”) for these three muscles using midstance force values derived from the literature. This study quantified the angular change in the joints of the first ray and measured the plantar pressure beneath the head of the first metatarsal and the hallux. The results indicated that the peroneus longus was statistically the greatest contributor to the elevation of plantar pressure beneath the first metatarsal, while the EHL and FHL were primarily responsible for the angular changes resulting in the clawed hallux deformity.
Autogenous Graft Repair Using Semitendinous Tendon for a Chronic Multifocal Rupture of the Extensor Hallucis Longus Tendon: A Case Report
Authors: Park Hong Gi , Lee Beom Koo , Sim Jae Ang
Published: January 2017

Chronic multifocal closed rupture of the extensor hallucis longus tendon is an extremely rare injury. Previously, chronic multifocal partial rupture of the extensor hallucis longus tendon had not been reported. This case study reports one case of autogenous graft repair of a chronic multifocal rupture of the extensor hallucis longus tendon using a semitendinous tendon autograft.
Posterior Tibiotalar Ligament Injury Resulting in Posteromedial Impingement
Authors: Koulouris George , Connell David , Schneider Tim , Edwards William
Published: January 2017

Objective:

To describe the imaging features of the normal anatomy and injury of the posterior tibiotalar ligament (PTTL) of the ankle in a group of patients presenting with posteromedial impingement.

Materials and Methods:

Twenty-five consecutive patients underwent imaging for posteromedial ankle pain following injury. All 25 patients were investigated with MR imaging, 17 with ultrasound and 5 with radionuclide bone scanning. Clinical data and surgical findings were correlated with the results of radiological investigation.

Results:

The PTTL demonstrated scar formation and a hypertrophic response consistent with previous injury in all 25 patients. Displacement or encasement of the surrounding tendons and their sheaths was often encountered (12/25). Bony avulsion was demonstrated in 5/25 occasions with ultrasound and 2/25 with MR imaging. Twelve patients underwent surgery, confirming the radiological findings.

Conclusion:

Imaging can effectively evaluate the integrity of the PTTL in the context of ongoing posteromedial ankle pain.
In Vitro Simulation of Stance Phase Gait Part II: Simulated Anterior Tibial Tendon Dysfunction and Potential Compensation
Authors: Wülker Nikolaus , Hurschler Christof , Emmerich Judith
Published: January 2017

The diagnosis of anterior tibial tendon tear is often missed. The ability of the remaining ankle extensor muscles to compensate for lost anterior tibial force was thus investigated. The effect of tibialis anterior deficiency on tarsal bone motion and plantar pressure was measured during in vitro simulated stance phase gait on eight cadaver specimens. Increased internal rotation, plantarflexion, and inversion of the talus and calcaneus ( p ≤ .001), as well as significant reductions of plantar pressure on the heel ( p ≤ .04) were observed during the first half of the stance phase. The observed drop foot was partly compensated by increased extensor muscle force.
Fifth Metatarsal Tuberosity Fracture Fixation: A Biomechanical Study
Authors: Moshirfar Ali , Campbell John T. , Molloy Sean , Jasper Louis E. , Belkoff Stephen M.
Published: January 2017

This study tested the hypothesis that fixation of a fifth metatarsal tuberosity fracture with a lag screw that engages the intact medial cortex is biomechanically stronger than fixation with a long intramedullary screw (control). The right and left feet from 10 male cadavers were alternately assigned to the two fixation groups. After fracture reduction and fixation, each specimen was potted in acrylic cement and tested on a servohydraulic testing machine. The repairs were then distracted until failure by placing the peroneus brevis tendon under tension at a rate of 1 mm/s. The lag screw technique resulted in a significantly greater mean (± SD) load to failure (150 ± 90 N) than did intramedullary screw fixation (70 ± 60 N) ( p < .05) and may offer a useful method of internal fixation of fifth metatarsal tuberosity fractures when surgical stabilization is indicated.
Multiple Osseous Tarsal Coalitions: A Case Report and Review of the Literature
Authors: Kadambande Sujit S. , Hariharan Kartik
Published: January 2017

A patient with multiple tarsal coalitions presenting with symptoms at the age of 47 years is reported. The report highlights the presentation of symptomatic coalitions following trauma in adulthood. Coalitions can pose difficulties in diagnosis, particularly without previous history of pain or disability in childhood. A decrease or loss of subtalar movement, painful movement, and valgus deformity of the hindfoot are usually present in the adult patient but are not often pathognomonic and present a diagnostic conundrum, particularly with x-rays being misinterpreted. This report highlights the problem of diagnosing such a condition with the attendant difficulties in formulating treatment.
Investigation of Incidence of Superficial Peroneal Nerve Injury Following Ankle Fracture
Authors: Redfern David J. , Sauvé Phillip S. , Sakellariou Anthony
Published: January 2017

The aim of this study was to investigate the incidence of superficial peroneal nerve (SPN) injury following ankle fracture and to establish whether this differed between those treated by open reduction and internal fixation (ORIF) and those treated nonoperatively in a cast. Two hundred eighty patients who had been treated for an ankle fracture either surgically (ORIF group) or nonoperatively (cast group) were identified. Patients were invited for review, assessed using the AOFAS scoring system, and examined for any evidence of SPN injury. The surgical approach was documented and all fractures were classified according to the Weber classification. A total of 120 patients returned for review; 56 patients from the ORIF group and 64 patients from the cast group. The mean time from injury to review was 2 years (range, 12–36 months). Overall, 18 patients (15%) had a symptomatic SPN injury and these patients had a significantly lower AOFAS score. In the cast group, 9% of patients had painful symptoms from an SPN injury, compared to 21% of patients in the ORIF group ( p <.05). No evidence of SPN injury was found in those who had a posterolateral approach to the ankle. Surgeons should be aware that the SPN is at risk during lateral approach to the fibula and that injury to this nerve can frequently be identified as a cause of chronic ankle pain.
Impact of Demographic and Impairment-Related Variables on Disability Associated with Plantar Fasciitis
Authors: Riddle Daniel L. , Pulisic Matthew , Sparrow Karen
Published: January 2017

Background:

Plantar fasciitis is a common foot disorder that impacts many functional activities. Research that quantifies the impact that plantar fasciitis has on function is lacking. In addition, little is known about which variables are associated with disability in patients with plantar fasciitis. The first purpose of this study was to determine if age, gender, body mass index, pain intensity, chronicity of symptoms, or ankle dorsiflexion range of motion was associated with disability in patients with plantar fasciitis. The second purpose was to describe the impact that plantar fasciitis has on functional status in the context of five functional domains: household activities of daily living, usual work and hobbies, nonweightbearing activities, walking-related activities, and running-related activities.

Methods:

Fifty consecutive patients diagnosed with unilateral plantar fasciitis were recruited. Demographic and impairment data were collected and all patients completed the Lower Extremity Functional Scale (LEFS), a validated self-report measure of disability. Multiple regression analysis was used to describe the association between the variables and disability. Graphs depicting five domains of function derived from the LEFS were generated to describe the extent of disability.

Results:

Body mass index (BMI) was the only variable that was significantly associated with disability (F = 9.87, p = .003). Measures of pain intensity, ankle dorsiflexion, age, gender, chronicity, and time spent weightbearing were not related to disability. Plantar fasciitis showed distinct patterns of disability depending on the functional domain that was assessed.

Conclusions:

With the exception of BMI, impairment and demographic variables do not predict the extent of functional loss in patients with plantar fasciitis. The most likely domains of function to be at least moderately affected in patients with plantar fasciitis are running-related activities and usual work or hobbies.
Infectious and Healing Complications after Elective Orthopaedic Foot and Ankle Surgery during Tumor Necrosis Factor-Alpha Inhibition Therapy
Authors: Bibbo Christopher , Goldberg Jerry W.
Published: January 2017

Background:

Biologic response modifiers are assuming a larger role in the management of patients with rheumatoid arthritis. The tumor necrosis factor-alpha (TNF-α) inhibitors etanercept and infliximab improve patient symptoms and function. However, these agents have been associated with a risk for healing and infectious complications due to systemic blockade of TNF-α, a ubiquitous mediator required in the normal inflammatory response in tissue healing and infection surveillance. This study analyzed the risk of healing/infectious complications in patients undergoing elective foot and ankle surgery while being treated with TNF-α inhibitors etanercept and infliximab.

Methods:

Patients with rheumatoid arthritis undergoing elective foot and ankle surgery over a 12-month period were prospectively followed for the development of complications in the postoperative period. All patients continued their antirheumatic medication schedule unaltered in the perioperative period. Data collected included sex, age, all medications used to treat rheumatoid arthritis, smoking history, and number of orthopaedic foot and ankle procedures performed. Patients were then stratified into two groups based on the use of immunomodulation via TNF-α inhibition (group 1) versus patients who did not receive TNF-α inhibition therapy (group 2). Groups 1 and 2 were followed and compared for the development of infectious/healing complications.

Results:

Thirty-one patients were enrolled in the study. Group 1 ( n = 16) and group 2 ( n = 15) patients were comparable for sex distribution, number of orthopaedic procedures performed, and use of steroids, methotrexate, leflunamide, and nonsteroidal anti-inflammatory drugs. Group 1 contained six times the number of smokers in group 2. At mean follow-up of 10.6 months (group 1) and 9.7 months (group 2), healing or infectious complications were similar in both groups. However, when total complications (healing + infection) were analyzed, group 1 (TNF-α inhibition, “higher risk”) patients demonstrated a lower complication rate ( p = .033).

Conclusions:

The data suggest that in patients with rheumatoid arthritis undergoing elective foot and ankle surgery, the use of TNF-α inhibition agents may be safely undertaken in the perioperative period without increasing the risk of healing or infectious complications.
Ankle and Subtalar Kinematics Measured with Intracortical Pins during the Stance Phase of Walking
Authors: Arndt Anton , Westblad Pär , Winson Ian , Hashimoto Takeshi , Lundberg Arne
Published: January 2017

Background:

The absence of external landmarks on the talus has rendered the description of ankle and subtalar joint kinematics difficult. Abnormal motion at these joints has, however, been implied in the etiology of an array of lower extremity overuse injuries.

Methods:

Intracortical pins were inserted under local anesthesia in the tibia, talus, and calcaneus with external marker clusters traced by a video motion analysis system. Kinematic data were collected during walking trials on a flat surface for three subjects. Gait pattern was monitored by comparison of ground reaction force curves during stance phase with and without the pins inserted.

Results:

Results were presented in terms of helical axis orientation for both joints and the component rotations about these axes. Large intersubject differences were seen in both ankle and subtalar joint helical axis orientation. Maximum rotations over the complete stance phase for the ankle and subtalar joints respectively were: eversion/inversion, 6.3° and 8.3°; dorsiflexion/plantarflexion, 18.7° and 3.7°; and abduction/adduction, 5.0° and 6.1°.

Conclusions:

The majority of ankle eversion/inversion occurred at the subtalar joint; however, the ankle component cannot be ignored. Abduction/adduction range of motion at the subtalar joint was surprisingly high, indicating that this component motion during walking is not purely attributable to the ankle joint. Future research should include greater subject numbers in order to present more universally applicable results.

Clinical Relevance:

The in vivo kinematics of the talus during weightbearing activity are poorly understood. The description of this motion may assist in the structuring of clinical rehabilitation and in the design and insertion of ankle joint prostheses.
Arthrodesis of the First Metatarsophalangeal Joint Using a Dorsal Titanium Contoured Plate
Authors: Flavin Robert , Stephens Michael M.
Published: January 2017

Background:

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is used to treat a variety of foot pathologies. Numerous methods of internal fixation and bone end preparation have been reported. In an effort to bring together the best features of the various internal fixation devices, a low-profile contoured titanium plate (LPCT) using a compression screw was designed to be used with a ball-and-socket bone end preparation. A prospective study was carried out to determine the efficacy of this technique.

Methods:

First MTPJ arthrodesis using an LPCT was done in 12 patients (10 women and two men) either as an isolated procedure (seven patients) or in conjunction with other forefoot procedures (five patients). The changes in the level of pain and activities of daily living were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score and the Short-Form 36 (SF-36) score. Time to bone union also was assessed. Mean followup was 18 months (±6 months).

Results:

Statistically significant increases in the AOFAS hallux score and the SF-36 score were noted ( p = .002 and .001, respectively). All radiographs showed bone union at 6 weeks and an appropriate degree of hallux dorsiflexion in relation to the first metatarsal (20 to 25 degrees).

Conclusion:

The combination of the LPCT plate and a ball-and-socket bone-end preparation has both operative and biomechanical advantages over other fixation techniques. This combination ensures that the anatomical length of the first ray is only minimally shortened and the angle of plantarflexion of the first metatarsal is maintained, resulting in preservation of medial column stability and a better functional result.
Tibiocalcaneal Arthrodesis After Total Talectomy for Treatment of Osteomyelits of the Talus
Authors: Kolker Dov , Wilson Michael G.
Published: January 2017

Background: Outcomes after talectomy combined with tibiocalcaneal arthrodesis are variable, and there have been few reports of results for tibiocalcaneal arthrodesis after total talectomy using an external fixator as the sole stabilizing modality. Methods: Three adult patients with chronic talar infections secondary to complex fracture-dislocations of the talus are reported. Each patient was treated with staged radical debridement and total talectomy followed by tibiocalcaneal arthrodesis using interpositional autologous cancellous bone graft and multiplanar external fixation. Results: Solid union was achieved for all patients at an average of 14 weeks (range 10 to 16 weeks). Outcome results, standardized according to the AOFAS Ankle-Hindfoot Scale and the Modified Mazur Ankle Arthrodesis questionnaire, were good for all patients at a mean followup of 31 months (range 20 to 48 months). One patient had a leg-length discrepancy of 1.5 cm. Conclusion: The presented technique for tibiocalcaneal arthrodesis is an option for salvage of infection or complex injuries of the talus.
A Review of Rheumatoid Arthritis Affecting the Foot and Ankle
Authors: Jaakkola Juha I. , Mann Roger A.
Published: January 2017

Rheumatoid arthritis is a systemic disease that often affects the foot and ankle. Approximately 20% of patients with rheumatoid arthritis present initially with foot and ankle symptoms, and most patients will eventually develop foot and ankle symptoms. Although early intervention includes conservative measures, operative treatment often is needed to adequately treat rheumatoid patients. Treatment of foot and ankle problems in patients with rheumatoid arthritis is directed to maintaining ambulatory capacity. This article reviews the clinical presentation, evaluation, and treatment of rheumatoid arthritis affecting the foot and ankle.
Endoscopic Plantar Fascia Release
Authors: Hogan Kathleen A. , Webb Darby , Shereff Michael
Published: January 2017

Background: Endoscopic release of the plantar fascia is becoming an increasingly popular alternative to open procedures for the treatment of chronic plantar fasciitis. Although most patients can be successfully treated with Achilles tendon stretching, orthoses, physical therapy and corticosteroid injections, a small percentage of patients will have symptoms that are refractory to such treatments. Methods: This is a retrospective review, analyzing the clinical outcome of 22 consecutive patients treated for chronic plantar fasciitis with endoscopic plantar fascia release by a single orthopaedic foot and ankle surgeon. Results: These patients complained of symptoms for an average of 7.43 months before referral to the senior author (MS); 11 patients had chronic symptoms for 12 months or more. The ages at surgery ranged from 30 to 73 years. Followup averaged 8.48 (range 6 to 20) months. Satisfaction rate with this procedure was 97.7% and all patients reported at least a 50% improvement in pain after surgery. Twenty-two patients completed a modified Mayo Foot and Ankle Score: 15 of 22 (68%) were judged to have good or excellent results. Bilateral symptoms and prior ankle trauma or surgery were significantly correlated with less favorable results. Conclusions: Patients who had no previous foot trauma and had unilateral symptoms obtained the best results from this procedure. Even patients who had some residual pain in their foot were satisfied with the procedure and with the level of pain relief that had been achieved. Endoscopic plantar fascia release does appear to benefit selected patients who fail to respond to conservative therapy.
Soft Tissue Impingement Syndrome of the Ankle: Diagnostic Efficacy of MRI and Clinical Results after Arthroscopic Treatment
Authors: Lee Jin Woo , Suh Jin-Suck , Huh Yong-Min , Moon Eun-Su , Kim Sung Jae
Published: January 2017

Background: Soft-tissue impingement syndrome is now increasingly being recognized as a significant cause of chronic ankle pain. The aim of this study was to investigate the diagnostic accuracy of contrast-enhanced, fat-suppressed, three-dimensional (3D), fast-gradient-recalled acquisition in the steady state with radio-frequency-spoiling (CE 3D-FSPGR) magnetic resonance imaging (MRI), and to evaluate the clinical outcome of arthroscopic treatment of soft-tissue impingement associated with the ankle trauma. Methods: This study reviewed 38 patients who had preoperative MRI and arthroscopic treatment of chronic ankle pain after trauma. The CE 3D-FSPGR MRI was used to evaluate the chronic ankle pain, and the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score was used to evaluate the clinical results after arthroscopic treatment. Results: The CE 3D-FSPGR MRI showed a sensitivity of 91.9%, a specificity of 84.4%, and an accuracy of 87.5% in diagnosing synovitis and soft tissue impingement. All patients had excellent or good outcomes after arthroscopic debridement. Conclusion: The results of this study suggest that a preoperative fat-suppressed CE 3D-FSPGR MRI is highly beneficial in diagnosing synovitis and soft-tissue impingement and that arthroscopic debridement of the synovitis or soft-tissue impingement has a good clinical outcome.
Hindfoot Containment Orthosis for Management of Bone and Soft-Tissue Defects of the Heel
Authors: Johnson Jeffrey E. , Rudzki Jonas R. , Janisse Erick , Janisse Dennis J. , Valdez Ray R. , Hanel Douglas P. , Gould John S.
Published: January 2017

Background: Bone, soft-tissue, and nerve deficits of the weightbearing surface of the foot are frequent sequelae from foot trauma or diabetes mellitus and present challenging treatment issues. Injury to the specialized, shock-absorbing, heel-pad tissue containing spirally arranged fat chambers is particularly difficult to manage. Appropriate footwear modifications and shoe inserts for protection of this skin are essential to the long-term management of bone and soft-tissue defects of the heel. This study evaluated the performance of a new custom total contact foot orthosis (Hindfoot Containment Orthosis, HCO) which was designed to contain the soft tissues of the heel, reduce shear forces, redistribute weightbearing load, and accommodate bone or soft-tissue deformity of the heel. Methods: Twenty-two patients treated with HCO were retrospectively reviewed. Followup averaged 26 months. The effectiveness of the orthosis was assessed by how well the integrity of the soft tissue was maintained (e.g. the number of ulcerations since dispensing the orthosis), the number of refabrications of the orthosis that were required, and whether or not revision surgery was required. Results: Ten patients had superficial ulcerations. No patient required revision surgery. A total of 62 refabrications of the orthoses in 22 patients were required over a 2-year period. Overall results were good in 17 (77%) patients, fair in four (18%), and poor in one. Conclusions: The HCO is effective for preservation of soft-tissue integrity of the heel pad after bony or soft-tissue injury. Important factors in achieving success with the HCO are patient compliance and periodic monitoring for refabrication of the orthosis to accommodate skeletal growth, change in foot size or shape, and compression or wear of insert materials.
Arthroscopic Treatment of Soft-Tissue Impingement Lesions of the Ankle in Adolescents
Authors: Gulish Heather A. , Sullivan Raymond J. , Aronow Michael
Published: January 2017

Background: Ankle sprains are common injuries in adolescents. Most are treated conservatively with rest, ice, antiinflammatory medication, and rehabilitation. A small percentage of patients develop chronic pain and functional instability secondary to intraarticular soft-tissue impingement. This study evaluated the effectiveness of ankle arthroscopy for the treatment of functional instability of the ankle with pain specifically in adolescents between the ages of 13 and 19 years. Methods: We evaluated 11 patients at an average of 25 (range 15 to 38) months after arthroscopic debridement. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was used to evaluate outcomes. In addition, four questions were asked: 1) Are you satisfied with the outcome of your surgery? 2) Would you have the procedure again? 3) Would you recommend it to a friend? 4) Have you returned to your preinjury level of activity. Results: The average postoperative AOFAS score was 95 (range 75 to 100). We found that 10 of 11 patients had good to excellent results with arthroscopic debridement of soft-tissue, intraarticular impingement lesions. All but one patient was satisfied with the procedure and all stated that they would have the procedure again. Two patients had repeat injuries and one subsequently developed reflex sympathetic dystrophy. These two patients had not yet returned to their preinjury level of activity at last followup. Conclusions: We found ankle arthroscopy to be a safe and effective means of treatment in adolescents with functional instability from soft-tissue ankle impingement.
Plantar Fasciopathy and Orthotripsy®: The Effect of Prior Cortisone Injection
Authors: Ogden John , Alvarez Richard G. , Lee Cross G. , Jaakkola Juha L.
Published: January 2017

Background: Corticoid steroid injection into the heel is a popular treatment method for painful heel syndromes. However, the positive results usually are short term. Extracorporeal shock wave treatment (ESW) has been shown to have a more permanent effect. We evaluated 555 patients who received ESW using the device Ossa Tron Orthotripsy® (Health Tronics, Surgical Services, Marietta, GA) relative to antecedent cortisone heel injection. Methods: Before ESW, 312 patients (56%) received one or more cortisone injections into the heel, and 243 patients (44%) had never received a cortisone injection. Results: Two hundred and thirty-four patients (75%) who had antecedent injection or injections had positive outcomes after ESW. One hundred sixty-eight patients (69%) without prior heel injection had positive responses after ESW. Conclusion: The prior injection of cortisone did not affect the likelihood of a positive response to ESW. Similarly, the absence of prior injection of cortisone did not affect the outcome.
Mechanical Comparison of Two Types of Fixation for Proximal First Metatarsal Crescentic Osteotomy
Authors: Jones Carroll , Coughlin Michael , Petersen Wolf , Herbot Mirco , Paletta Jürgen
Published: January 2017

Background: The proximal crescentic osteotomy is an effective technique for correcting a widened 1–2 intermetatarsal angle associated with moderate to severe hallux valgus deformities. However, postoperative dorsal malunion at the osteotomy site from loss of fixation has been reported. The purpose of this study was to evaluate the biomechanical characteristics of a new custom-designed plate and compare it to the traditional screw and Kirschner wire construct. Methods: Twenty identical Sawbone® (Pacific Research Laboratories, Vashon, WA) models were used for the study. A proximal crescentic osteotomy was done on each specimen, and 10 were secured with a dorsomedial plate (group I). The remaining 10 models were fixed with a screw and Kirschner wire combination (group II). Physiologic cyclical testing was done using a mechanical testing machine to evaluate dorsal displacement of the metatarsal. Load-to-failure testing was then done on each specimen to evaluate ultimate failure and stiffness of the constructs. Groups I and II were statistically compared using paired t-testing. Results: The mean dorsal displacement of the first metatarsal head after 1000 cycles was 0.19 mm (SD = 0.09 mm) for group I and 0.28 mm (SD = 0.15) for group II, and the difference was not statistically significant (p = 0.08). Group I demonstrated statistically superior ultimate failure strength (95.2 N) and stiffness (26.8 N/mm) compared to group II (73.7 N, 19.4 N/mm). Conclusions: Based on Sawbone® models, dorsal plate fixation of proximal crescentic osteotomy provides a stronger construct than the traditional screw and Kirschner wire construct. The clinical use of the specially-designed plate described in this study may lower the incidence of dorsal malunions that occur postoperatively and may decrease the occurrence of transfer metatarsalgia. Its application may be particularly helpful in patients with poor bone quality.
Are Displaced Talar Neck Fractures Surgical Emergencies? A Survey of Orthopaedic Trauma Experts
Authors: Patel Ravi , Van Bergeyk Anthony , Pinney Stephen
Published: January 2017

Background: Displaced talar neck fractures are relatively rare injuries with potentially serious long-term morbidity. Expedient treatment has long been held as a treatment principle. The purpose of this study was to assess the current state of practice of treating displaced talar neck fractures by recognized orthopaedic trauma experts working at level 1 trauma centers. Methods: A group of expert orthopaedic trauma surgeons were surveyed to determine what they considered “the maximal acceptable time delay from injury to the operating room representing the minimal standard of care at a level 1 trauma center for a displaced talar neck fracture?” Each survey recipient had been selected as a moderator at a national orthopaedic trauma meeting during the past 5 years. Eighty-nine of 109 (82%) responded to the survey. Results: For a displaced talar neck fracture, 60% of respondents stated that treatment after 8 hours is acceptable, with 46% percent of respondents stating that treatment at or after 24 hours is acceptable. Conclusion: These results indicate that most expert orthopedic trauma surgeons do not believe that an immediate operation is necessary to adequately treat a displaced talar neck fracture.
Stability of Lisfranc Joints in Ballet Pointe Position
Authors: Kadel Nancy , Boenisch Mark , Teitz Carol , Trepman Elly
Published: January 2017

Background: Ballerinas develop stress fractures at the second metatarsal base associated with dancing en pointe. The purpose of this study was to evaluate the relative importance of the pointe shoe and the tarsometatarsal ligaments in Lisfranc joint stability en pointe. Methods: Eleven cadaver feet were dressed with pointe shoes, loaded in foot flat with ligaments intact, and loaded en pointe before and after sequential sectioning of the dorsal, interosseous, and plantar ligaments between the first and second metatarsals and cuneiforms. Relative motion between the first and second metatarsals and cuneiforms was determined radiographically. Results: No significant displacement of the Lisfranc joints occurred when the shod foot with intact ligaments was loaded in the foot flat or en pointe positions. Serial sectioning of the ligaments from dorsal to plantar in the shod foot en pointe demonstrated no change in alignment after the dorsal and interosseous ligaments were cut, but a significant change in alignment between the second metatarsal and second cuneiform was noted after the plantar ligament was cut ( p < 0.0001). Removal of the pointe shoe after cutting the ligaments and applying a minimal (1 to 2 kg) load resulted in complete subluxation and diastasis through the first-second intermetatarsal and intercuneiform region. Replacing the shoe improved alignment en pointe with similar loading. Conclusions: Both the pointe shoe and Lisfranc ligaments are important for Lisfranc region stability in feet en pointe. The plantar ligaments are major stabilizers of the Lisfranc region in the loaded, shod foot en pointe. Selection of a pointe shoe with adequate support may limit susceptibility to stress fracture of the second metatarsal base in ballerinas.
A Prospective Randomized Comparison of the Zadik Procedure and Chemical Ablation in the Treatment of Ingrown Toenails
Authors: Shaath Nebal , Shea John , Whiteman Ian , Zarugh Adel
Published: January 2017

Background: We present the results of a prospective randomized trial of the Zadik procedure versus chemical ablation by sodium hydroxide for the treatment of ingrowing toenails. Methods: Thirty-eight patients had the Zadik procedure, and 45 patients had chemical ablation by sodium hydroxide. Mean followup was 12.45 months for the Zadik group and 11.69 months for the chemical ablation group. Results: In the Zadik group, the average return to normal shoewear was 2.13 weeks and in the chemical ablation group 3.73 weeks. Average return to normal activity was 2.18 weeks for the Zadik group and 3.89 weeks for the chemical ablation group. The median number of dressings were 3 and 8 for the Zadik and chemical ablation groups, respectively. The pain score, using the visual analogue scale were not statistically significant between the two groups. The recurrence rates were 23 recurrences in the Zadik group (60.5%) and seven recurrences in the chemical ablation group (15.6%). Conclusion: The use of chemical ablation by sodium hydroxide in the treatment of ingrowing toenails shows statistically significant ( p < 0.05) reduction in recurrence rates of ingrowing toenails compared to the Zadik procedure.
Posterior Tibial Tendon Insufficiency: Which Ligaments are Involved?
Authors: Deland Jonathan T. , de Asla Richard J. , Sung Il-Hoon , Ernberg Lauren A. , Potter Hollis G.
Published: January 2017

Background: The pathology manifested in posterior tibial tendon insufficiency (PTTI) is not limited to the posterior tibial tendon. The association of ligament failure with deformity has been discussed in numerous publications, but extensive documentation of the structures involved has not been performed. The purpose of this observational study was to identify the pattern of ligament involvement using standarized, high-resolution magnetic resonance imaging (MRI) in a series of 31 consecutive patients diagnosed with PTTI compared to an age matched control group without PTTI. Method: The structures evaluated by MRI were the posterior tibial tendon, superomedial and inferomedial components of the spring ligament complex, talocalcaneal interosseous ligament, long and short plantar ligaments, plantar fascia, deltoid ligament, plantar naviculocuneiform ligament, and tarsometatarsal ligaments. Structural derangement was graded on a five-part scale (0 to IV) with level 0 being normal and level IV indicating a tear of more than 50% of the cross-sectional area of the ligament. Standard flatfoot measurements taken from preoperative plain standing radiographs were correlated with the MRI grading system. Results: Statistically significant differences in frequency of pathology in the PTTI group and controls were found for the superomedial calcaneonavicular ligament ( p < 0.0001), inferomedial calcaneonavicular ligament ( p < 0.0001), interosseous ligament ( p = 0.0009), anterior component of the superficial deltoid ( p < 0.0001), plantar metatarsal ligaments ( p = 0.0002) and plantar naviculocuneiform ligament ( p = 0.0006). The ligaments with the most severe involvement were the spring ligament complex (superomedial and inferomedial calcaneonavicular ligaments) and the talocalcaneal interosseous ligament. Conclusion: Ligament involvement is extensive in PTTI, and the spring ligament complex is the most frequently affected. Because ligament pathology in PTTI is nearly as common as posterior tibial tendinopathy, treatment should seek to protect or prevent progressive failure of these ligaments.
Peroneal Tendon Subluxation in Athletes: Fibular Groove Deepening and Retinacular Reconstruction
Authors: Porter David , McCarroll John , Knapp Erin , Torma Jennifer
Published: January 2017

Background: The purpose of this study was to evaluate the results of operative treatment of recurrent peroneal tendon dislocations followed by accelerated rehabilitation incorporating early range of motion and intermittent immobilization. Methods: Four female and nine male athletes with an average age of 24 years had objective clinical evidence of peroneal tendon dislocation (14 ankles). Operative treatment involved removing a bone flap from the distal posterior fibula, deepening the posterior fibular groove, and reattaching the bone flap within the deepened groove. The superior peroneal retinaculum also was reconstructed. Postoperatively, a removable boot was worn for approximately 4 weeks, when it was replaced with a stirrup brace. Results: At an average followup of 35 months, no recurrent subluxation or dislocation of the peroneal tendons had occurred. All patients were able to return to sports by 3 months after surgery. Nine of the 14 ankles regained normal range of motion, and the remaining five were within 5 degrees of the opposite side. Four patients were completely pain free, and nine patients had mild occasional pain that did not limit their activities. Eight patients returned to preinjury sports participation, and five patients elected to participate in sports at a level lower than they had before surgery for reasons not related to their ankle injury. Conclusions: This procedure was reliable for preventing recurrent peroneal tendon instability. Range of motion was nearly normal, immobilization time was minimal, and all patients returned to daily activities and sports within 3 months of surgery.
Recurrence Potential of Diffuse-Type Giant Cell Tumor in the Foot: Radiologic and Pathologic Features
Authors: Shimizu Tominaga , Uehara Takeshi , Akahane Tsutomu , Isobe Kenichi , Arai Hideki
Published: January 2017

Background: Aggressive musculoskeletal tumors in the foot, such as diffuse-type giant cell tumors or extra-abdominal desmoid tumors, are difficult to treat because the foot does not have enough soft tissue to allow wide tumor resection. We reviewed the clinical behavior of diffuse-type giant cell tumor in the foot and evaluated the recurrence potential of these tumors from radiologic and pathologic perspectives. Methods: Six patients with a mean age of 37.6 years were included in this study. Radiologic studies, including sonography, computed tomography (CT), magnetic resonance imaging (MRI), and bone and gallium citrate scintigraphy, were obtained followed by surgical treatment and histologic evaluation of the tumor. Results: Recurrence occurred in three patients. Although CT and MRI findings were similar in the recurrent and nonrecurrent tumors, marked differences were found between the two by scintigraphy; positive radiotracer uptake to the affected foot with gallium citrate scintigraphy was noted only in recurrent tumors, although positive accumulation was seen in all patients with bone scintigraphy. Histologically, the necrotic area and mitotic activity were more apparent in recurrent than in the nonrecurrent tumors, and tumor cell dyscohesion was noted in the former, (the intercellular space was increased). Conclusions: Repeated recurrence with tumor invasion into tarsal bone resulted in breakage of the tarsal arch that supports the body's weight. Amputation would be necessary for patients in whom the disease had progressed to obtain local cure and relief of pain. In the present study, we found two features of the recurrence potential of diffuse-type giant cell tumors: sparse cell to cell contact on pathologic examination and positive accumulation in the tumor on gallium citrate scintigraphy. We concluded that giant cell tumors with these two features have a strong potential for local recurrence, and thus require intensive followup.
Plantar Pressures in the Forefoot After Lateral Column Lengthening: A Cadaver Study Comparing the Evans Osteotomy and Calcaneocuboid Fusion
Authors: Tien Tudor R. , Parks Brent G. , Guyton Gregory P.
Published: January 2017

Background: Excessive varus alignment of the forefoot after lateral column lengthening has been reported to lead to overloading of the lateral foot. The purpose of this study was to investigate whether there is a difference between the Evans opening wedge calcaneal osteotomy (Evans) and the calcaneocuboid distraction arthrodesis (CCDA) with respect to lateral forefoot loading. Methods: In each of 12 matched pairs of cadaver feet, plantar pressure measurements of the intact specimens were obtained during simulated foot-flat and early heel-rise phases of gait and again after randomly performing the Evans procedure on one foot and the CCDA on the other foot. Cervical plate fixation was used for immediate stability. Results: Both procedures resulted in statistically significant increased loading of the lateral forefoot and decreased loading of the medial forefoot compared with the preoperative status. The relative increase in lateral pressures was statistically greater with the CCDA than with the Evans. The average increase in pressure under the fifth metatarsal head in the foot-flat phase was 46% ± 42% (range − 4% to 141%) with the Evans and 104% ± 58% (range 9% to 216%) with the CCDA ( p = 0.003). In the early heel-rise phase, the increase in pressure was 50% ± 43% (range 2% to 108%) and 96% ± 65% (range 12% to 263%), respectively ( p = 0.02). Conclusion: The experimental data suggest that lateral column overload may be more likely with the CCDA than with the Evans. Physicians should be aware of the likelihood of increasing lateral column loads with both the CCDA and the Evans procedure. It may be possible to avoid this problem by using less lateral column lengthening than the 1 cm used in this study or by considering a medial column arthrodesis or plantarflexion osteotomy to balance forefoot loading.
Blood Flow to the Metatarsal Head After Chevron Bunionectomy
Authors: Kuhn Michael A. , Lippert Frederick G. , Phipps Michael J. , Williams Craig
Published: January 2017

Background: Avascular necrosis (AVN) of the metatarsal head is a known, but infrequent, complication of a chevron bunionectomy. An increased incidence of AVN has been reported with the addition of an adductor tenotomy and lateral release. The purpose of this study was to document the vascular insult to the metatarsal head during a chevron bunionectomy with adductor tenotomy and lateral release through direct blood flow measurements during the procedure. Methods: A prospective study of 20 patients was performed. A chevron bunionectomy was performed under regional anesthesia without tourniquet control by two surgeons. Blood flow recordings were documented during key portions of the procedure: baseline, medial capsulotomy, adductor tenotomy and lateral release, and chevron osteotomy. The Periflux PF3 laser Doppler probe (Perimed, Inc., North Royalton, OH) was used to record blood flow. Mauchly's test of Sphericity and a pairwise comparison were performed with significance defined as p < 0.05. All patients had radiographs 3 months postoperatively to assess AVN. Results: There was a statistically significant decrease in blood flow to the metatarsal head at each portion of the procedure. The greatest insult occurred with the medial capsulotomy (45% decrease). The lateral release and adductor tenotomy caused a 13% decrease and the chevron osteotomy caused a 13% decrease, totaling 71% decrease from the baseline. There was no evidence of AVN at 3 months, and all patients had radiographic evidence of union without recurrence or over-correction. Conclusion: The addition of the adductor tenotomy with lateral release often is crucial to obtain the desired correction and avoid the complication of recurrence. The disruption of microvascular blood flow to the metatarsal head after a chevron bunionectomy with adductor tenotomy and lateral release was not complete, totaling 71% in the study population. The greatest insult occurred with the medial capsulotomy. There were no occurrences of AN. Despite the fear of AN, this study demonstrated that an adductor tenotomy and lateral release could be done safely completed with a chevron bunionectomy.