bluuebunny/crossref_metadata_2025 huggingface dataset:
Salvage of Failed First Metatarsophalangeal Joint Implant Arthroplasty by Implant Removal and Synovectomy: Clinical and Biomechanical Evaluation
Authors: Kitaoka Harold B. , Holiday Allan D. , Chao Edmund Y. S. , Cahalan Thomas D.
Published: March 2013

Implant removal and synovectomy were used to treat the failure of 14 first metatarsophalangeal joint implant arthroplasties. Revision surgery was performed at an average of 3.1 years after arthroplasty. Follow-up (average 4.9 years) was possible in 10 patients, and clinical results were excellent in seven patients, good in one patient, fair in one patient, and poor in one patient. No significant changes in alignment occurred, although a trend toward toe extension was noted. Dynamic force plate studies in these patients demonstrated less pressure under the first metatarsal head and greater loading under the lateral forefoot. The great toe had less contact time during gait in the involved feet than in the control feet.
The Pneumatic Ankle Tourniquet with Ankle Block Anesthesia for Foot Surgery
Authors: Lichtenfeld Norman S.
Published: March 2013

The use of a pneumatic ankle tourniquet applied to the supramalleolar ankle region is a useful method of obtaining a bloodless field in surgery of the foot. The pneumatic ankle tourniquet allows for more accurate and reproducible control of circumferential compression than the standard Esmarch bandage, when used in conjunction with the regional ankle block. Between March 1987 and October 1990, 84 foot surgeries were performed using the pneumatic tourniquet and ankle block technique on 76 patients by one surgeon. Tourniquet ischemia lasted from 30 to 105 min. Tourniquet pressure was set to 100 to 150 mm of mercury above systolic blood pressure without exceeding 325 mm of mercury. Two patients reported mild pain directly beneath the tourniquet after 45 and 70 min, respectively. Neither patient required deflation of the tourniquet to complete the procedure. The clinical and electrophysiologic evidence showed that no neurologic or vascular damage occurs. The use of the pneumatic tourniquet in conjunction with regional ankle block anesthesia provides a reasonable alternative to the standard thigh tourniquet for surgery of the foot.
Ankle Arthroscopy: Review and Long-Term Results
Authors: Feder Keith S. , Schonholtz George J.
Published: March 2013

Ankle arthroscopy has evolved over the past decade as a diagnostic and an operative modality. Forty ankle arthroscopies were performed by the senior author (G.J.S.) for osteochondral fractures, chronic sprains unresponsive to conservative treatment, posttraumatic osteoarthritis, adhesions, locking, instability, synovitis, and ankle disability of undetermined cause. Thirty cases with at least 24 months of follow-up were reviewed. Complications occurred in two patients: reflex sympathetic dystrophy and a fibular fracture. Postoperatively, the patients were rated clinically as having 13% excellent, 60% good, 17% fair, and 10% poor results. However, 95% of the patients stated that they would undergo the same operation again if needed. Results were significantly better in those patients who had chondral or osteochondral defects as the diagnosis, and in noncompensation cases.
Ankle Fracture Classification Systems: A Case for Integration of the Lauge-Hansen and AO-Danis-Weber Schemes
Authors: Harper Marion C.
Published: March 2013

The two dominant classification systems for ankle fractures in use are the Lauge-Hansen and AO-Danis-Weber schemes. Each has certain advantages and disadvantages. Because of basic similarities, integration of these systems into one scheme involving three basic patterns with appropriate staging appears to be reasonable. This integration is based upon combining the pronation-abduction and pronation-external rotation injuries in Lauge-Hansen's scheme into one pronation-abduction-external rotation pattern. The resultant system would appear attractive in terms of combining relative simplicity with completeness.
Triple Arthrodesis through a Single Lateral Approach: A Cadaveric Experiment
Authors: Bono James V. , Jacobs Richard L.
Published: March 2013

Using a single lateral approach, triple arthrodesis was performed on six cadaveric feet. An attempt was made to obliterate the talocalcaneal, talonavicular, and calcaneocuboid joints. The limbs were subsequently disarticulated to allow for an inspection of the talonavicular, talocalcaneal, and calcaneocuboid joints. An estimate of cartilage and subchondral bone removed from each articular surface was made by a single observer (J.V.B.) by direct visual inspection. Results were as follows: calcaneocuboid joint, 90% of cartilage removed; talocalcaneal joint, 80% of cartilage removed; talonavicular joint, 38% of cartilage removed. Failures at the talonavicular joint were attributed to a poor appreciation of the anatomy of the talar head and poor observation. Complications involved in obliteration of the talonavicular joint from a single lateral approach included: inadvertent division of the talar neck; inadvertent division of the talar head; removal of excessive bone stock; medial skin punctures; and creation of an iatrogenic cut through the talar dome. Therefore, a triple arthrodesis through a single lateral approach, as described by Ryerson, 8 Hoke, 5 and Campbell, 2 cannot be recommended. The talonavicular joint should be approached through an auxiliary medial incision, as recommended by Cracchiolo. 3 This paper documents the experience of a beginner with this operation, and demonstrates the value of using the anatomy laboratory.
Traumatic Subluxation/Dislocation of the Peroneal Tendons
Authors: Brage Michael E. , Hansen Sigvard T.
Published: March 2013

Traumatic subluxation/dislocation of the peroneal tendons has been reported following a variety of sports-related activities. The peroneal musculature contracts reflexively during the injury and overcomes the restraining soft tissue. The tendons can then dislocate anteriorly from behind the distal fibula. Some patients have anatomical variations of the posterolateral ankle that predispose them to injury. If the physician is unaware of the injury, the diagnosis may be missed in the acute setting and can develop into a chronic, disabling condition.

Treatment of the acute injury is controversial because advocates exist for both conservative and surgical therapies. The chronic, painful lesion should be treated operatively. A tremendous number of surgical procedures have been described for the treatment of chronic tendon dislocations. Choice of a surgical procedure depends upon the anatomy of the peroneal groove and the retinaculum, and the nature of the damage to the area.
Anatomical Considerations of Posterior Tibialis Tendon Entrapment in Irreducible Lateral Subtalar Dislocation
Authors: Waldrop Jeffrey , Ebraheim Nabil A. , Shapiro Paul , Jackson W. Thomas
Published: March 2013

Irreducible lateral subtalar dislocation is associated with posterior tibialis tendon entrapment. Mulroy 7 and Leitner 6 have proposed conflicting theories regarding the exact mechanism of tendon entrapment.

Cadaveric analysis of lateral subtalar dislocation supported Leitner's 5 contention that tearing of the flexor retinaculum promotes posterior tibialis tendon entrapment. Retinacular disruption allowed tendon subluxation over the medial malleolus and talar head to the entrapped position.

Entrapment of the flexor digitorum longus only occurred in the Leitner model. When the flexor retinaculum and deep posterior compartment fascia were preserved, the muscle failed at the musculotendinous junction. Flexor hallucis longus entrapment could not be produced in either experimental model. Plantarflexion of the great and lesser toes, noted on clinical presentation, is caused by functional lengthening of the route coursed by the flexor digitorum longus and flexor hallucis longus.
Microvascular Anatomy of the Peroneal Tendons
Authors: Sobel Mark , Geppert Mark J. , Hannafin Jo A. , Bohne Walther H. O. , Arnoczky Steven P.
Published: March 2013

The etiology of longitudinal splitting of the peroneus brevis tendon is unclear. It has been hypothesized that compressive load applied to the tendon as it passes through the fibular groove may compromise the vascularity of the tendon with resultant inhibition of the repair response and degeneration of tendon structure.

To investigate this possibility, a study of the microvascularity of the peroneal tendons was undertaken. Twelve fresh, frozen cadaveric limbs were injected with India ink. The vascularity of the peroneal tendons was examined in situ and the tendons were harvested and cleared using a modified Spalteholz technique. The vascularity of the cleared tendons was evaluated utilizing a dissecting microscope.

The vascular supply of the peroneal tendons arises from two posterolateral vincula, one for the peroneus longus tendon and one for the peroneus brevis tendon. These vincula are supplied by branches of the posterior peroneal artery. A zone of hypovascularity within the peroneus brevis or peroneus longus tendon correlating with the site of peroneus brevis splits was not found. There was no relationship between increasing age of specimens and alteration in vascular supply.
Open Total Dislocation of the Talus with Extrusion (Missing Talus): Report of Two Cases
Authors: Hiraizumi Yutaka , Hara Tetsuya , Takahashi Masataru , Mayehiyo Susumu
Published: March 2013

Two different methods of treatment for open dislocation of the extruded talus without soft tissue attachments (missing talus) were examined. In case 1, a 20-year-old man sustained an open total dislocation of the talus due to a motorcycle accident. The missing talus was found within 3 hr and replaced after thorough washing and debridement. Weightbearing was permitted at 20 weeks; however, the density of the talar body increased in the x-ray and nonweightbearing status was resumed. Reexamination at 2 ½ years revealed that there was joint space narrowing on the x-ray and decreased pain with ambulation; the patient had returned to his job. In case 2, a 26-year-old man sustained an open total dislocation of the talus with a severe crush wound and impaired circulation to the foot. After thorough washing and debridement of the wound, the calcaneus and distal end of the tibia were aligned. The missing talus was found 3 days later, but not replaced. Weightbearing was allowed on the affected foot at 2 months; however, the patient felt pain at the joint surfaces and arthrodesis was consequently performed. At 2 ½ years, the patient had a 4.0-cm leg length discrepancy in the involved extremity, but felt no pain when walking. Although reduction of the talus is ideal to preserve function and length of the extremity, several complications can occur. A review of literature on open total dislocation of the talus with extrusion was performed.
Strength of Fixation Constructs for Basilar Osteotomies of the First Metatarsal
Authors: Lian George J. , Markolf Keith , Cracchiolo Andrea
Published: March 2013

Twenty-four pairs of fresh-frozen human feet had a proximal osteotomy of the first metatarsal that was fixed using either screws, staples, or K wires. Each metatarsal was excised and the specimen was loaded to failure in a cantilever beam configuration by applying a superiorly directed force to the metatarsal head using an MTS ser-vohydraulic test machine. Specimens with a crescentic osteotomy that were fixed using a single screw demonstrated higher mean failure moments than pairs that were fixed with four staples or two K wires; staples were the weakest construct. All specimens fixed with staples failed by bending of the staples without bony fracture; all K wire constructs but one failed by wire bending. Chevron and crescentic osteotomies fixed with a single screw demonstrated equal bending strengths; the bending strength of an oblique osteotomy fixed with two screws was 82% greater than for a crescentic osteotomy fixed with a single screw.

Basilar osteotomies of the first metatarsal are useful in correcting metatarsus primus varus often associated with hallux valgus pathology. Fixation strength is an important consideration since weightbearing forces on the head of the first metatarsal acting at a distance from the osteotomy site subject the construct to a dorsiflexion bending moment, as simulated in our tests. Our results show that screw fixation is the strongest method for stabilizing a basilar osteotomy. Based upon the relatively low bending strengths of the staple and K wire constructs, we would not recommend these forms of fixation. If, for some reason, these are the only methods of fixation available, then use of a short leg cast and limited weightbearing for several weeks postoperatively should be considered.
The Modified Brostrom Procedure for Lateral Ankle Instability
Authors: Hamilton William G. , Thompson Francesca M. , Snow Stephen W.
Published: March 2013

Twenty-eight ankles in twenty-seven patients (average age 28) underwent the Gould modification of the Brostrom repair for symptomatic lateral ankle instability. Fifty-four percent were high level professional ballet dancers, 35% were recreational athletes, and 11% were nonathletes. Follow-up averaged 64.3 months (range 30–132 months). Of the 28 operations performed, there were 26 excellent results, one good result, and one fair result. All the professional dancers obtained excellent results. There were no failures, stretch-outs, re-dos, or complications. This operation is believed to be an excellent choice for the dancer, athlete, or nonathlete who needs a stable ankle with a full range of plantarflexion and dorsiflexion and normal peroneal function.
Occurrence of Two Interdigital Neuromas in One Foot
Authors: Thompson Francesca M. , Deland Jonathan T.
Published: March 2013

In a series of 89 neurectomies, the occurrence of a second primary interdigital neuroma was less than 4%. The clinical presentation and results of surgery were similar to those of a single interdigital neuroma. Two of five patients with a suspected second neuroma in the same foot did not have this entity, but instead had had the incorrect interspace operated on by the previous surgeon. The entity of a second neuroma is truly rare, especially if careful evaluation for correct diagnosis and interspace is done.
Stress Fracture of the Proximal Phalanx of the Great Toe
Authors: Shiraishi Minoru , Mizuta Hiroshi , Kubota Kenji , Sakuma Katsuhiko , Takagi Katsumasa
Published: March 2013

Three cases of stress fracture of the proximal phalanx of the great toe occurring in a 12-year-old female volleyball player, a 17-year-old female long distance runner, and a 12-year-old male soccer player are reported. This condition probably develops after repeated forced dorsiflexion of the first metatarsophalangeal joint with changing steps. When athletes who repeatedly run and jump complain of pain in the first metatarsophalangeal joint, and there is no history of trauma, this condition should also be considered.
Distal Tibiofibular Synostosis after Malleolar Fractures Treated Using Absorbable Implants
Authors: Böstman O.M.
Published: March 2013

Three patients (3.8%) of 80 with displaced malleolar fractures treated by open reduction and internal fixation using absorbable polyglycolide rods were found to have developed distal tibiofibular synostosis. To assess the general incidence of this complication, the serial radiographs of 150 patients with an identical distribution of the initial fracture severity treated with AO-ASIF implants were examined for comparison. Among these, no cases of tibiofibular synostosis were found. The difference ( P = .04) in incidence was postulated to be due to an osteogenic potential of the absorbable polymeric material, suggested previously in experimental studies. This study included fractures of the lateral malleolus and bimalleolar fractures, but patients with a disruption of the inferior tibiofibular syndesmosis causing tibiofibular diastasis on admission were excluded. The synostoses occurred in middle-aged, sedentary people, and no active measures were necessary because of the mild subjective symptoms of these patients. Previously, posttraumatic distal tibiofibular synostosis has been recorded as an uncommon late complication of severe ankle fractures with tibiofibular diastasis requiring transsyndesmotic fixation, but it has not been reported to occur after malleolar fractures of the kind surveyed in this study.
Syme Amputation in Patients with Severe Diabetes Mellitus
Authors: Laughlin Richard T. , Chambers Richard B.
Published: March 2013

Surgical results and functional outcome of 52 patients treated with Syme amputations for forefoot gangrene between 1986 and 1988 were retrospectively reviewed with reference to the predictive value of posterior tibial artery Doppler examination. Wound healing was correlated with the preoperative status of the posterior tibial artery. Functional outcome was assessed by the ability to wear a prosthesis, ambulatory capabilities, episodes of ulceration, and revision surgery. Follow-up averaged 27 months.

Twenty-nine patients had a posterior tibial artery with either a triphasic waveform (N = 23) or a normal pulse (6). Twenty-six (90%) of these achieved a healed wound suit able for prosthetic wear. Twenty-three patients had mon-ophasic flow in the posterior tibial artery. Thirteen (57%) of these achieved a healed wound.

Ninety percent of the patients who achieved healed wounds were fit with a prosthesis. Functional level of ambulation was assessed in 20 patients. Eighteen were community level ambulators, 11 could walk three or more blocks, and 16 could climb stairs. Eighteen wore their prosthesis all day.

These findings indicate that posterior tibial artery Dop pler examination is predictive of healing in the Syme amputation performed on diabetics. Furthermore, dia betics can attain a functional level of ambulation with a Syme amputation.
Changes in Gait and Maximum Ankle Torque in Patients with Ankle Arthritis
Authors: Shih Lih-Yuann , Wu Jiunn-Jer , Lo Wai-Hee
Published: March 2013

Findings from quantitative gait analysis and maximum ankle torque were used to assess the walking pattern of patients with ankle arthritis and to correlate the changes of gait parameters and muscle strength with severity of arthritis. Gait analysis and the isokinetic maximum ankle torque test were performed in 20 patients with first to fourth degree traumatic ankle arthritis. Six patients without evidence of traumatic arthritis were used as controls. Isokinetic maximum ankle plantarflexion and dorsiflexion torques were determined with Cybex instrumentation. Force plate and foot switch data were gathered during level walking. Maximum ankle plantarflexion and dorsi flexion torques were diminished in the injured ankles. Velocity, stride length, and cadence were decreased in arthritic patients compared with controls. The arthritic limbs had shorter single limb stance and longer double stance during free and fast walking speeds compared with the controls’ affected ankles. The patterns of ground reaction forces were similar in the injured and uninvolved limbs as well as the control subjects, except the magni tude of vertical forces during push-off were reduced in arthritic ankles. The gait parameters and muscle strength deteriorated as the arthritis became severe, but they showed significant changes only when the patients had third or fourth degree arthritis.
Use of Tissue Expansion in Clubfoot Surgery
Authors: Silver Lester , Grant Alfred D. , Atar Dan , Lehman Wallace B.
Published: March 2013

Tissue expansion was used successfully to prepare ade-quate soft tissue for closure following a difficult clubfoot correction. The gradual expansion was done weekly at the outpatient clinics (average 3–4 months). The procedure proved to be useful in severe cases of clubfoot.
Heel Pain Syndrome: Electrodiagnostic Support for Nerve Entrapment
Authors: Schon Lew C. , Glennon Terrence P. , Baxter Donald E.
Published: March 2013

A local entrapment neuropathy has been proposed as one of the etiologies of heel pain, but it has never been documented by electrodiagnostic studies. Primary symptoms in patients suspected of having a neurologic basis for their heel pain include neuritic medial heel pain and radiation either proximally or distally. On physical examination, all patients in our series had reproduction of their symptomatology with palpation over the proximal aspect of the abductor hallucis and/or the origin of the plantar fascia from the medial tubercle of the calcaneus. Twenty-seven patients (20 women and seven men; average age 49) with these clinical characteristics were examined by electromyography and motor/sensory/mixed nerve conduction studies. Bilateral heel signs and symptoms were present in 11 patients. Ten of the patients had a significant history of back pain with referral to the legs. In 23 of the 38 symptomatic heels, abnormalities were identified in the lateral and/or the medial plantar nerves. The number of abnormal values per heel ranged from one to four, with a mean of 2.1. The most common finding was involvement of the medial nerve (57%). Thirty percent of the heels had isolated findings in the lateral plantar nerve and 13% had abnormalities in both plantar nerves. Two patients had electrophysiologic evidence of active S1 radiculopathy, with ipsilateral evidence of plantar nerve entrapment suggesting a “double crush” syndrome. The results of this study support the presence of abnormalities of plantar nerve function in a selected group of patients with neuritic heel pain.
Tibiotalar Joint Dynamics: Indications for the Syndesmotic Screw—A Cadaver Study
Authors: Burns William C. , Prakash Karanvir , Adelaar Robert , Beaudoin Armaria , Krause William
Published: March 2013

Pronation-external rotation ankle injuries involve varying degrees of disruption of the syndesmotic ligaments. The loss of ligament support and alteration in the stability of the mortise have been postulated to lead to an increase in joint reactive forces and traumatic arthritis. The purpose of this study was to determine the changes in tibiotalar joint dynamics associated with syndesmotic diastasis as a result of the sequential sectioning of the syndesmotic ligaments to simulate a pronation-external rotation injury. Dissections were conducted on 10 fresh-frozen, knee-disarticulated cadaveric specimens which were then axi-ally loaded in an unconstrained manner. Tibiotalar joint forces were measured at each level of sequential sectioning of the syndesmotic ligaments, the interosseous membrane, and finally the deltoid ligament.

Complete disruption of the syndesmosis with the medial structures of the ankle intact resulted in an average syndesmotic widening of 0.24 mm and no significant change in the tibiotalar contact area or the peak pressure. However, deltoid ligament strain increases with sectioning of the syndesmosis. With the addition of deltoid ligament sectioning, there was an average syndesmotic diastasis of 0.73 mm, a 39% reduction in the tibiotalar contact area, and a 42% increase in the peak pressure.

In a simulated unconstrained cadaveric model of a pronation-external rotation ankle injury that results in complete disruption of the syndesmosis, if rigid anatomic medial and lateral joint fixation is obtained and the deltoid ligament complex is intact, syndesmotic screw fixation is not required to maintain the integrity of the tibiotalar joint.
First Metatarsal Head-Shaft Angle: A Method of Determination
Authors: Richardson E. Greer , Graves Stanley C. , McClure J. Thomas , Boone R. Tyler
Published: March 2013

The distal metatarsal angle (DMAA) is a measurement of the relationship between the longitudinal axis of the first metatarsal and the articular surface of the metatarsal head. We measured the DMAA on radiographs with and without markers on the articular edges and compared them with measurements of the anatomic specimens. Based on the studies, the significance of the radiographic measurements to the actual DMAA and the normal distribution of the measurement were determined.
A Treatment Algorithm for Neuropathic (Charcot) Midfoot Deformity
Authors: Pinzur Michael S. , Sage Ronald , Stuck Rodney , Kaminsky Shari , Zmuda Ann
Published: March 2013

Forty-nine feet in 47 patients with midfoot neuropathic foot deformity were referred for care to a comprehensive foot salvage clinic and followed for an average of 3.6 years. Twenty-three initially presented without open ulcers. Two underwent elective Syme's ankle disarticulation amputation, and the others were kept ambulatory with a combination of periods of nonweightbearing cast immobilization, accommodative extra-depth shoes with custom orthotics, and ankle-foot orthoses. Twenty-six of the feet initially presented for care with open ulcers and/or chronic osteomyelitis. Twenty-two of these patients underwent 32 surgical procedures. Sixteen underwent debridement of the infected bone and surrounding soft tissues. Excision of large, nonaccommodative boney prominence, termed ex-ostectomy, was performed in eight. Partial excision of the deformed midfoot combined with boney stabilization and attempted arthrodesis, termed partial tarsectomy, were performed in seven. All surgical patients were managed postoperatively with long-term custom accommodative bracing.

Follow-up at an average of 3.6 years revealed that all but one of the patients remained ambulatory. Six walk with accommodative shoe gear and persistent stable chronic open ulcers. None required below-knee amputation. Five amputations were performed, three at the Syme's ankle disarticulation level, one at the Chopart's hind-foot level, and one at the mid-foot level.

Neuropathic midfoot deformity is a disabling disorder that requires thorough patient education and compliance, prolonged palliative monitoring and care, accommodative orthotic shoe management, and selective surgery. It can markedly limit the patient's walking ability and independence. With careful monitoring and selective surgery to maintain a plantigrade foot, foot salvage and walking ability can be maintained. A treatment algorithm is presented to guide patient care.
Differences in Ankle Joint Complex Range of Motion as a Function of Age
Authors: Grimston Susan K. , Nigg Benno M. , Hanley David A. , Engsberg Jack R.
Published: March 2013

The purpose of this study was to determine whether gender- and age-related differences in ankle joint complex (AJC) range of motion (ROM) exist in children (range 9–13 years), adolescents (14–16 years), and young adults (17–20 years), and to compare these data with those published for older subjects (21–79 years) using the same protocol. 15 A total of 120 subjects (58 males and 62 females) ranging in age from 9 to 20 years were tested for AJC ROM using a specifically designed 6° of freedom fixture. 1 All measurements were made with respect to a laboratory coordinate system, and represented assessment of active AJC ROM. Angular displacements for plan-tarflexion, dorsiflexion, inversion, eversion, abduction, and adduction were digitally recorded and compared. AJC ROMs of females aged 9 to 20 years were generally greater than those for males about all three orthogonal axes. Within each gender, there was a consistent trend for AJC ROM to decrease from a maximum at 14 to 16 or 17 to 20 years to a minimum after age 60 years. The average decrement was greater for females than for males. This study provided evidence to support the contention that age-related and gender differences in AJC ROM do exist. The possibility of minimizing the decline in AJC ROM with age requires further investigation.
Protective Sensation of the Plantar Aspect of the Foot
Authors: Robbins Steven , Gouw Gerard J. , McClaran Jacqueline , Waked Edward
Published: March 2013

The scientific literature suggests that barefoot activity may be beneficial. There is a current trend in recreational barefoot activity in children and adults, and barefoot running among athletes. Although the type of skin over most of the body (hairy skin) seems to be easily injured by painful abrading loads, little is known about protection provided by plantar sensory feedback against damage from excessive wear during barefoot locomotion. To evaluate this, we administered a volley of 35 painful abrading loads to glabrous and hairy skin sites over a 5-min period, and examined its effects for signs of cutaneous injury in a sample of 12 normally shod healthy male subjects. Compared with hairy skin of the thigh, plantar skin required approximately 600% greater abrading loads to reach pain threshold. Furthermore, painful stimulation produced visible redness and hypersensitivity in all subjects at the hairy skin site 24 hr after stimulation, whereas only 8.3% reported hypersensitivity and none showed erythema at the plantar area 1 day later. We found that plantar skin possesses a higher pain threshold to abrading stimuli than hairy skin. In fact, loading of the plantar area was limited to innocuous levels due to intolerable pain. We conclude that plantar skin is well protected through sensory feedback from abrasive injuries when barefoot. This information combined with previous reports suggests that risk of injury when normally shod individuals perform barefoot locomotion should be low.
Comminuted Fracture of the Calcaneus Associated with Subluxation of the Talus
Authors: Ebraheim Nabil A. , Savolaine Edward R. , Paley Kevin , Jackson W. Thomas
Published: March 2013

Two cases of complex fracture dislocation of the calcaneus having an unusual pattern of injury are described. The cases exhibit the following special characteristics: (1) fracture dislocation of the calcaneus where the primary fracture line separates the calcaneus into an anteromedial fragment that maintains its normal relationship to the talus and a posterolateral fragment that is dislocated from the subtalar joint. This posterolateral fragment moves laterally and lies adjacent to the fibula; (2) a secondary fracture line separating the lateral portion of the posterior facet from the tuberosity of the calcaneus. Both fragments are dislocated from their normal anatomical position; (3) talar tilt as shown on AP view of the ankle caused by inversion of the talus due to rupture of the lateral collateral ligament. Also, the posterolateral fragments impinging on the fibula pushes the heel downward and contributes to the talar tilt; (4) involvement of the calcaneocuboid joint; (5) dislocation of the peroneal tendons.

This fracture pattern is unusual and has not been described before. Recognition of this unusual injury with subsequent and proper management may prevent major disability to the patient. Conservative treatment by casting or early range of motion is contraindicated. Closed reduction should be attempted immediately, and if not successful, a lateral approach with open reduction and internal fixation is the treatment of choice for this complex injury.
The Treatment of Rigid Metatarsus Adductovarus with the Use of a New Hinged Adjustable Shoe Orthosis
Authors: Allen William D. , Weiner Dennis S. , Riley Patrick M.
Published: March 2013

A retrospective review of the early results of treatment of metatarsus adductovarus with a new hinged adjustable shoe orthosis, the Bēbax shoe, is presented. The results in 120 cases (210 feet) are included in the study. Criteria for severity of the initial deformity were developed, and all cases of true clubfoot and those cases with prior treatment were excluded.

The average age at institution of treatment was 4.5 months, and treatment time averaged 2.7 months (range 1–7 months). Overall, 96% of the cases were completely resolved with the use of the orthotic alone, 3% required additional casting, and 1% required a bar and shoes for complete correction of the deformity. No treatment complications were encountered except some minor problems with hinge loosening, particularly in the child of walking age.

We believe that the Bēbax shoe is a lightweight, convenient, safe, and both cost- and treatment-effective device in the management of metatarsus adductovarus.
Ultrasound Diagnosis of Plantar Fasciitis
Authors: Wall Janet Rae , Harkness Margo Amy , Crawford Alan
Published: March 2013

There is currently no objective reliable diagnostic test for plantar fasciitis inasmuch as diagnosis cannot be made on the basis of finding a heel spur on radiography (x-ray). In this single-blind observational study, ultrasonography was used to measure plantar fascia thickness in subjects with clinically suspected plantar fasciitis and in control subjects. It was concluded that the population mean plantar fascia thickness is greater for people with plantar fasciitis than for people without heel pain (P < .0005) and that the difference is clinically significant. The ultrasonic appearance of the plantar fascia in plantar fasciitis indicated inflammatory changes.
A Comparison of Two Studies of the Pressure Distribution under the Feet of Normal Subjects Using Different Equipment
Authors: Hughes Janet , Clark Peter , Linge Keith , Klenerman Leslie
Published: March 2013

There is growing interest in the use of foot pressure measurement both clinically and in the study of normal subjects. A number of systems are now commercially available, but comparison of the results is complicated by the different techniques employed. This paper compares the results of two studies. The first examined a large group of normal subjects using the dynamic pedobarograph. The second was identical to the first except that the EMED F system was used. The second study was carried out in order to verify existing results and to assess the clinical significance of the expected differences.

Comparison of the results from the two studies showed that the median peak pressures demonstrated similar patterns with the highest pressure in the forefoot under the second/third metatarsal heads and the toes taking gradually reduced pressure from the first to the fifth toe. The EMED F showed higher peak pressures than the dynamic pedobarograph under the heel, the medial four metatarsal heads, and the great toe and showed lower peak pressures and shorter contact times under the lateral four toes.

The pattern of loading across the metatarsal heads was further analyzed using an objective method of splitting the subjects into groups. Four groups were isolated from both sets of results, and this has confirmed that only a proportion of normal subjects demonstrate highest loading under the first metatarsal head whereas the remainder show highest loading centrally within the forefoot.
Acute Compartment Syndrome of the Lower Extremity Secondary to Noncontact Injury
Authors: Moyer Ray A. , Boden Barry P. , Marchetto Paul A. , Kleinbart Frederick , Kelly John D.
Published: March 2013

We retrospectively reviewed the cases of three patients with injuries similar to the mechanism of an ankle sprain which resulted in compartment syndrome of the lower extremity. All three patients presented with sharp, proximal, anterolateral pain in the leg after an indirect, twisting injury. None of the injuries involved direct contact. Two of the three athletes initially presented to local hospitals, where the injury was misdiagnosed as an ankle sprain. The mechanism appears to be a muscle strain or tear with resultant hemorrhage in the compartment. All three patients returned to high-level athletics after prolonged recovery periods.
Clinical, Quantitative Assessment of First Tarsometatarsal Mobility in the Sagittal Plane and Its Relation to Hallux Valgus Deformity
Authors: Klaue Kaj , Hansen Sigvard T. , Masquelet Alain C.
Published: March 2013

Today, bunion surgery is still controversial. Considering that a bunion deformity in fact may be a result of multiple causes, the rationale of the currently applied techniques of surgical treatment has not been conclusively demonstrated. In view of the known hypermobility syndrome of the first ray that results in insufficient weightbearing beneath the first metatarsal head, the relationship between this syndrome and hallux valgus deformity has been investigated. The results suggest a direct relationship between painful hallux valgus deformity and hypermobility in extension of the first tarsometatarsal joint. A pathological mechanism of symptomatic hallux valgus is proposed that relates this pathology with primary weightbearing disturbances in the forefoot where angulation of the first metatarsophalangeal joint is one of the consequences. The alignment of the metatarsal heads within the sagittal plane seems to be a main concern in many hallux valgus deformities. As a consequence, treatment includes reestablishing stable sagittal alignment in addition to the horizontal reposition of the metatarsal over the sesamoid complex. As an example, first tarsometatarsal reorientation arthrodesis regulates the elasticity of the multiarticular first ray within the sagittal plane and may be the treatment of choice in many hallux valgus deformities.
Achilles Tendon Tenodesis to Prevent Heel Pad Migration in the Syme's Amputation
Authors: Smith Douglas G. , Sangeorzan Bruce J. , Hansen Sigvard T. , Burgess Ernest M.
Published: March 2013

In an attempt to prevent migration of the heel pad, 11 patients underwent a combined Syme's amputation and Achilles tendon tenodesis between December 1989 and April 1992. Ten patients healed the Syme's amputation, and one patient failed to heal the surgical wounds and required a below-knee amputation. In all 10 successful Syme's cases, the heel pad has remained stable with no migration, and no skin breakdown at an average follow-up of 18.5 months. Published series of Syme's amputations report that the incidence of heel pad migration is between 7.5% and 45%, and occurs primarily in the postoperative or early rehabilitation stage. We believe that tenodesis of the Achilles tendon is a technically easy addition to the Syme's amputation, that it keeps tension off of the incision during healing, and that it prevents migration of the heel pad.
Late Infections of the Foot Due to Incomplete Removal of Foreign Bodies: A Report of Two Cases
Authors: Markiewitz Andrew D. , Karns Daniel J. , Brooks Peter J.
Published: March 2013

Foreign bodies in the foot can remain silent for years before presentation. We describe two foreign body infections in the feet of two patients more than 18 years after the initial insult. These cases emphasize the need for careful evaluation of patients with an unexplained infection in the foot, and thorough debridement, when surgical treatment is necessary.
Avascular Necrosis of the First Metatarsal Head: Incidence in Distal Osteotomy Combined with Lateral Soft Tissue Release
Authors: Peterson Drew A. , Zilberfarb Jeffrey L. , Greene Marie A. , Colgrove Robert C.
Published: March 2013

The incidence of avascular necrosis of the metatarsal head following distal first metatarsal osteotomy combined with adductor tendon release has not been documented in a large series of patients. Of 82 consecutive procedures in 64 patients performed between 1986 and 1988, 42 patients (58 procedures) were available for clinical and radiographic examination. Average follow-up was 2.5 years (range 1.0–4.2 years). There were 35 L-shaped and 23 chevron osteotomies which were combined with a lateral soft tissue release that included adductor tenotomy. preoperative hallux valgus angle averaged 25° (range 15–40°), and intermetatarsal angle averaged 12° (range 5–24°). Follow-up amount of correction averaged 13° and 5°, respectively. Eighty-four percent of patients were satisfied with their result. There was one case of avascular necrosis. The patient was asymptomatic at 4.2 years' follow-up, and the remaining patients included two with infections, one hallux varus, and no nonunions.
Treatment of Peroneal Tendon Dislocation by Transposition Under the Calcaneofibular Ligament
Authors: Steinböck Gunther , Pinsger Martin
Published: March 2013

Of the many different surgical techniques to treat peroneal tendon dislocations, transposition of the peroneal tendons under the calcaneofibular ligament has been used at the Orthopädisches Spital of Vienna/Austria since 1975. The method was first described by Platzgummer in 1967. After dividing the calcaneofibular ligament and removing the fatty tissue in the space between this ligament, the posterior talofibular ligament, and the lateral capsule of the subtalar joint, the peroneal tendons are placed behind the lateral malleolus and under the calcaneofibular ligament, which is reconstructed by suture to create an efficient retainment.

Of 17 feet operated on, 13 were available for follow-up in 12 patients. Dislocation was idiopathic in three and traumatic in 10 feet. Criteria for evaluation were patient's satisfaction, absence of pain and swelling, and stability of tendon retention and of ankle and subtalar joints. Of the 13 operated feet, 11 showed an excellent result and two showed a good result.

In the results graded as “good,” occasional pain and swelling occurred in both feet of a patient belonging to the idiopathic group.
Painful Os Peroneum Syndrome: A Spectrum of Conditions Responsible for Plantar Lateral Foot Pain
Authors: Sobel Mark , Pavlov Helene , Geppert Mark J. , Thompson Francesca M. , DiCarlo Edward F. , Davis W. Hodges
Published: March 2013

Plantar lateral foot pain may be caused by various entities and the painful os peroneum syndrome (a term coined by the authors) should be included in the differential diagnosis. Painful os peroneum syndrome results from a spectrum of conditions that includes one or more of the following: (1) an acute os peroneum fracture or a diastasis of a multipartite os peroneum, either of which may result in a discontinuity of the peroneus longus tendon; (2) chronic (healing or healed) os peroneum fracture or diastasis of a multipartite os peroneum with callus formation, either of which results in a stenosing peroneus longus tenosynovitis; (3) attrition or partial rupture of the peroneus longus tendon, proximal or distal to the os peroneum; (4) frank rupture of the peroneus longus tendon with discontinuity proximal or distal to the os peroneum; and/or (5) the presence of a gigantic peroneal tubercle on the lateral aspect of the calcaneus which entraps the peroneus longus tendon and/or the os peroneum during tendon excursion.

Familiarity with the various clinical and radiographic findings and the spectrum of conditions represented by the painful os peroneum syndrome can prevent prolonged undiagnosed plantar lateral foot pain. Clinical diagnosis of the painful os peroneum syndrome can be facilitated by the single stance heel rise and varus inversion stress test as well as by resisted plantarflexion of the first ray, which can localize tenderness along the distal course of the peroneus longus tendon at the cuboid tunnel. Radiographic diagnosis should include an oblique radiograph of the foot for visualization of the os peroneum and, if indicated, other imaging studies.

Recommended treatment ranges from conservative cast immobilization to surgical approaches including: (1) excision of the os peroneum and repair of the peroneus longus tendon, and (2) excision of the os peroneum and degenerated peroneus longus tendon with tenodesis of the remaining remnant of peroneus longus to the peroneus brevis tendon.
The Outcome of Nonoperated Patients with Chronic Lateral Instability of the Ankle: A 20-Year Follow-up Study
Authors: Löfvenberg Richard , Kärrholm Johan , Lund Björn
Published: March 2013

Thirty-seven patients conservatively treated because of chronic lateral instability of the ankle were studied 18 to 23 years after their index visit. Twenty-two patients, 12 with unilateral and 10 with bilateral symptoms (32 of 49 ankles), still suffered from instability, but only three considered further treatment Degenerative changes were observed in six of 46 radiographically examined ankles, with no correlation to age or persistent instability.
Fractures and Dislocations of the Foot and Ankle in Diabetics Associated with Charcot Joint Changes
Authors: Holmes George B. , Hill Nathan
Published: March 2013

This study was undertaken to evaluate the occurrence of Charcot joint changes in diabetic patients after fractures and/or dislocations of the foot and ankle. There were 20 fracture/dislocations of the foot and ankle in 18 patients, with an average follow-up of 27 months (range 14–70 months). There were eight fractures of the midfoot, six fractures of the ankle, four fractures of the hindfoot, and two fractures of the forefoot. Eight fractures were followed by the development of Charcot changes: five in the midfoot and one each in the forefoot, hindfoot, and ankle. Of nine fractures recognized early and initially treated by early immobilization or ORIF, seven healed uneventfully. Two fractures, both open injuries, developed soft tissue infection and osteomyelitis, respectively. Of the 11 fractures in which there was a delay in diagnosis and treatment, eight developed Charcot changes. The early recognition and appropriate treatment of fractures in diabetic patients appears to be important in the prevention of Charcot joint changes.
Ankle Arthroplasty by Excision of the Talar Body: Subtotal Talectomy
Authors: Itokazu Mansho , Matsunaga Takanobu , Tanaka Seisuke
Published: March 2013

We carried out the ankle arthroplasty by excision of the talar body (subtotal talectomy) on 10 ankles of nine patients with talar body tumor, paralytic talipes equinovarus, talipes varus due to spinal injury, or comminuted fracture of the talar body. Talar body excision was initiated by lateral incision and subsequent osteotomy of the fibula. The fibula was everted, leaving the lateral ligament (calcaneofibular ligament) intact. After the talus was exposed, the talar body was excised, leaving about 1.5 cm of head unresected. Subsequently, the fibula was shortened slightly, and the tibia was pulled down to the level of the calcaneus to form a joint, instead of arthrodesis being performed. After surgery, the joint formed by the tibia and calcaneus was mobile in seven of the 10 feet and immobile (arthrodesis) in the remaining three feet. The average follow-up period was 6 years. Although postoperative x-ray revealed slight osteoarthritic changes of Chopart's joint and the tibiocalcaneal joint, none of the patients showed ankle pain that impaired activities of daily living. Subtotal talectomy allows correction of talipes equinus without Achilles tendon lengthening.
Idiopathic Adult Hallux Varus
Authors: Granberry William Malcolm , Hickey C. Hugh
Published: March 2013

Adult hallux varus is an uncommon clinical entity usually caused by an inflammatory arthropathy or overcorrection during bunion reconstruction. We present five cases of unexplained spontaneous hallux varus. Clinically, all patients initially were found to have flexible deformities, and no evidence of underlying inflammatory disease or history of trauma. Symptoms were easily relieved with shoe wear modifications. Two of the patients developed more rigid deformities and subsequent medial callusing of the first toe and varus deformities of the lesser toes. These two patients eventually required surgical intervention. A Keller arthroplasty was performed on the first metatarsophalangeal joint and valgus proximal phalangeal osteotomies were done on the lateral toes when indicated. The outcome for these patients was good. Possible etiologic mechanisms are discussed. It is postulated that in these cases, the abductor hallucis tendon inserts more medially on the phalanx and overpowers the adductor. This produces a medially directed moment and, with time, a varus deformity.
Effect of Pronation and Supination Orthosis on Morton's Neuroma and Lower Extremity Function
Authors: Kilmartin Timothy Edward , Wallace W. Angus
Published: March 2013

Twenty-three adult patients with Morton's neuroma of one foot were randomized to receive in-shoe orthoses made from a hard, compressed, felt material that would either pronate or supinate both feet. The response of the neuroma pain was measured using subjective visual analogue scales, an objective examination, and the MACTAR patient-specific measure of maximal function. The development of any other lower limb symptoms was also recorded. The pain associated with Morton's neuroma was not significantly altered by changing the position of the foot with the compressed felt orthosis. Forcibly pronating the foot did not produce a significant incidence of lower limb symptoms in the short term.