bluuebunny/crossref_metadata_2025 huggingface dataset:
Magnetic Resonance Diagnosis of an Occult Metastatic Colon Carcinoma of the Calcaneus
Authors: Schmidt Richard G. , Cecchini Albert J. , Mayer David P. , Kabbani Youssef
Published: March 2013

This is a case report which shows the potential benefit of magnetic resonance imaging in accurately visualizing occult metastatic lesions to bone. The case involves a relatively young patient with metastatic colon carcinoma to the calcaneus who ultimately required amputation.
Clinical Rating Systems for the Ankle-Hindfoot, Midfoot, Hallux, and Lesser Toes
Authors: Kitaoka Harold B. , Alexander Ian J. , Adelaar Robert S. , Nunley James A. , Myerson Mark S. , Sanders Melanie
Published: March 2013

Four rating systems were developed by the American Orthopaedic Foot and Ankle Society to provide a standard method of reporting clinical status of the ankle and foot. The systems incorporate both subjective and objective factors into numerical scales to describe function, alignment, and pain.
Clinical Results Following Revision Tibial Nerve Release
Authors: Skalley Thomas C. , Schon Lew C. , Hinton Richard Y. , Myerson Mark S.
Published: March 2013

The results following revision tarsal tunnel release in 12 patients (13 feet), including three men and nine women aged 28 to 66 years, are presented. The indication for surgery was incapacitating focal pain, associated with paresthesias and hyperesthesias, refractory to nonoperative treatment modalities. Electrodiagnostic studies were abnormal in nine and normal in four cases. Revision surgery was performed a mean 3.5 years (range 1–10 years) after the initial tarsal tunnel release. Epineurolysis was performed in nine of the 13 cases where the nerve was encased in a scar. An insufficient previous distal release was identified in nine of the 13 cases. Wound infection occurred in two patients, one of whom ultimately underwent a below the knee amputation. With the exception of this patient, all patients were evaluated a mean 31 months (range 12–59 months) after the revision surgery. Three groups of patients were identified based on similarities in presentation, intraoperative findings, and clinical outcome. The first group (four feet), characterized by encasement of the tibial nerve in scar and an adequate distal release at the previous tarsal tunnel surgery, did poorly. The second group (five feet), with both scarring of the tibial nerve and an inadequate prior distal release, had somewhat mixed results, but overall were improved. The final group (four feet), who had no significant tibial nerve scarring but had had an inadequate prior distal release, did well. Clinical history and physical examination were more helpful than electrodiagnostic studies in determining the extent and location of the tibial nerve irritation following previous tarsal tunnel release surgery.
Calcaneal Dome Osteotomy: A New Procedure for Revising Triple Arthrodesis
Authors: Stephens Michael , Saleh Jamal
Published: March 2013

A preliminary report of a new calcaneal osteotomy is presented. Five patients ranging in age from 18 to 35 years underwent a calcaneal dome osteotomy. They all had painful and significant foot deformity, recurrent tenosynovitis, callosities, and shoe wear problems. The osteotomy was developed to correct the deformity present in patients that had had a previous triple arthrodesis. The crescentic shape of the osteotomy allowed for the correction of various degrees and patterns of deformity with accuracy and provided a broad area of contact resulting in osteotomy union. The results achieved by this new technique showed that deformity was corrected, callosities had disappeared, and all the osteotomies were healed. All patients were satisfied by the procedure.
Surgical Repair of Achilles Tendon Ruptures Using Polypropylene Braid Augmentation
Authors: Sandro Giannini , Mauro Girolami , Francesco Ceccarelli , Fabio Catani , Stea Susanna
Published: March 2013

Surgical repair in fresh rupture of the Achilles tendon should be considered in active patients and athletes to restore their preinjury level of activity.

Fifteen cases of Achilles tendon rupture underwent surgical repair using interpositional augmentation. This technique provides an immediate mechanical strength of the repair, avoiding the need for a postoperative plaster cast and allowing immediate motion of the ankle. No wound infection, scar adherence of the skin to the tendon, or rerupture of the tendon is present in this series.

All patients were subjectively satisfied with the results and returned to their preinjury level of activity.

Objectively, isokinetic assessment revealed no significant difference, as per t-test evaluation ( P < .05), between the operated leg and the contralateral one.
Foot Movement and Tendon Excursion: An In Vitro Study
Authors: Hintermann Beat , Nigg Benno M. , Sommer Christian
Published: March 2013

The purpose of this study was to determine tendon excursions resulting from selected foot movement and to derive moment arms with respect to the eversion-inversion and flexion-extension axes of the foot. A lower legholding device with 6 degrees of freedom was used for the in vitro investigation of 15 fresh foot-leg specimens. Although high variation among the subjects existed, there was a pronounced uniformity of tendon excursion throughout a given foot eversion-inversion or flexion-extension range of motion. With reference to the tibialis posterior (1.00), average inverter moment arms with respect to the foot eversion-inversion axis were found to be as follows: flexor digitorum longus, 0.75; flexor hallucis longus, 0.62; tibialis anterior, 0.59; soleus, 0.24; extensor hallucis longus, 0.22; extensor digitorum longus, −0.26; peroneus longus, −0.82; and peroneus brevis, −0.85. A trend toward decreasing evertor/invertor moment arms was observed during the ranges of foot eversion, as well as when the foot was in flexion. Flexor and extensor moment arms were found to be substantially dependent on foot flexion-extension angle. Increasing flexor moment arms were observed when rotating the foot throughout the range from extension to flexion. The obtained results may have significant implications in foot surgery, muscle function analysis, and general considerations of foot function.
Operative Treatment of Syndesmotic Disruptions Without Use of a Syndesmotic Screw: A Prospective Clinical Study
Authors: Yamaguchi Ken , Martin Christopher H. , Boden Scott D. , Labropoulos Panos A.
Published: March 2013

A new protocol for the selected omission of transsyndesmotic fixation in Weber class C ankle fractures was prospectively evaluated in 21 consecutive patients. As proposed in a previous cadaveric study ( J. Bone Joint Surg., 71A:1548–1555, 1989), the protocol suggested that transsyndesmotic fixation was not required if (1) rigid bimalleolar fracture fixation was achieved or (2) lateral without medial fixation was obtained (i.e., with accompanying deltoid tears) if the fibular fracture was within 4.5 cm of the joint. According to this protocol, only 3 of 21 patients (14%) required transsyndesmotic fixation. Ten of the patients who did not receive transsyndesmotic fixation underwent pronation-external rotation stress radiographs in a fashion analogous to the previous cadaveric study. At 1- to 3-year follow-up, no stress (N = 10) or static view (N = 18) widening of the mortise or syndesmosis was seen in any patient, which supports (with the above guidelines) a limited, rather than routine, use of supplemental transsyndesmotic fixation.

Clinical results from this prospective study seem to substantiate previously proposed biomechanical guidelines for the selected omission of transsyndesmotic fixation. Given these guidelines, transsyndesmotic fixation was unnecessary in many cases and the need can be determined before surgery by assessing the integrity of the deltoid ligament and level of the fibular fracture.
Plantar Dislocation of the Metatarsophalangeal Joint: Case Report
Authors: Stephenson Kenneth A. , Beck Timothy L. , Richardson E. Greer
Published: March 2013

Dislocations of lesser metatarsophalangeal joints are rare and are almost always dorsal hyperextension injuries. The patient reported sustained plantar dislocations of the second and third metatarsophalangeal joints in a motor vehicle accident; the mechanism of injury was hyperflexion. Closed reduction was not possible, and at the time of open reduction, the extensor digitorum longus and brevis tendons to the third toe were trapped beneath the plantar aspect of the third metatarsal head. Once the tendons were retracted dorsomedially, the joint was easily reduced. Fixation with a Kirschner wire was necessary because of joint instability.
The Effect of Hallux Sesamoid Resection on the Effective Moment of the Flexor Hallucis Brevis
Authors: Aper Rhonda L. , Saltzman Charles L. , Brown Thomas D.
Published: March 2013

In this cadaver study, the functional significance of the hallux sesamoid bones was quantified by measuring the effective tendon moment arm (ETMA) of the flexor hallucis brevis (FHB) force. (The ETMA differs from the anatomic tendon moment arm in that ETMAs are determined by the experimentally measured moment of the tendon force, rather than by the actual location and orientation of the tendon pull in the joint.) The intact case was compared with three levels of progressive sesamoid resection: distal half of the medial sesamoid excised, entire medial sesamoid excised, and both the medial and lateral sesamoids excised. Five dorsiflexion angles of the metatarsophalangeal joint were tested, ranging from −10° to 50°. A known active load was applied to the FHB muscle of fresh frozen cadaver specimens while the corresponding resisting forces from three orthogonally mounted transducers were being recorded. Results showed that the ETMAs decreased significantly ( P < .05) only with the excision of both sesamoids. The percent decrease in ETMA was smallest at dorsiflexion angles of −10° and 15° (4.3% and 2.4%, respectively) and largest at dorsiflexion angles of 25°, 35°, and 50° (29.2%, 22.4%, and 26.7%, respectively). The clinical significance of the results is that distal hemiresection of the medial sesamoid or full medial sesamoid excision is unlikely to appreciably compromise the effective mechanical advantage of the FHB muscle. However, this mechanical advantage may be profoundly diminished by excision of both hallux sesamoids.
Gait Pattern Analysis after Ankle Ligament Reconstruction (Modified Evans Procedure)
Authors: Becker Horst Peter , Rosenbaum Dieter , Zeithammel Gerhard , Gerngross Heinz , Claes Lutz
Published: March 2013

We followed 38 patients with chronic ankle instability treated by a modified Evans procedure. Evaluation at an average of 68 months follow-up included a standard clinical questionnaire and examination, radiological procedures, and gait analysis. Plantar pressure distribution measurements were recorded during walking and were compared with data from a group of normal subjects (N = 100). The subjective patient questionnaire revealed 87% good or excellent results, but residual pain was reported by 40% of the patients. The gait analysis indicated a significant increase in midfoot loading (22%) consistent with an observed restriction of inversion after surgery. However, the plantar pressure changes were not associated with poor clinical outcome. We cannot say whether these increased pressures will be associated with long-term outcome.
The Influence of X-Ray Orientation on the First Metatarsocuneiform Joint Angle
Authors: Brage Michael E. , Holmes James R. , Sangeorzan Bruce J.
Published: March 2013

The purpose of this study was to determine whether the first metatarsocuneiform (MC) joint angle is affected by the orientation of the x-ray beam, whether it can be reliably measured, and, therefore, whether it is a valid indication of tarsometatarsal fusion as an adjunct to hallux valgus surgery. Each of seven cadaver feet were loaded to 350 newtons in a Plexiglas apparatus that maintained the foot in a plantigrade position. The loading apparatus was positioned to simulate a 10°, 20°, and 30° dorsal angulation of the x-ray beam. At each position, simulated weightbearing radiographs were obtained for each foot. Three observers independently measured the first MC angle and the first intermetatarsal (IM) angle on all the radiographs. The data collected were analyzed by the components of variance.

The inclination of the first MC joint lessens significantly as the orientation of the x-ray beam changes from a 10° to a 20° tilt. The three examiners' mean MC angles and mean IM angles from the three sets of radiographs were not statistically different from each other, implying that there were minimal examiner-to-examiner differences in measuring these angles.

There were no significant differences in measurements between examiners, suggesting that the first MC and first IM angles can be measured reliably. There was a significant difference in the first MC angle, with different orientations of the foot with respect to the x-ray beam, suggesting that this angular measurement should not be used as an indication for tarsometatarsal arthrodesis.
A Disposable Fiberoptic Arthroscope: A Cadaver Study
Authors: Vangsness C. Thomas , Thordarson David B. , Park Kwan
Published: March 2013

Nine fresh cadaver ankle joints underwent arthroscopy to determine effectiveness of a small diameter, disposable, fiberoptic arthroscope. A sequential examination of the joint was performed through routine anteromedial and anterolateral portals.

The anterior aspect of the joint with all anatomical structures was well visualized via the two anterior portals. The posterior aspect of the joint was also well visualized via anterior portals without distraction due to the flexibility of the scope and its small diameter. The quality of the visualization of the posterior joint from the anterior portals alone was comparable to that from the posterior approach.

The results of this study indicate that diagnostic arthroscopy of the ankle joint with this disposable 1.6-mm arthroscope is comparable to the standard 2.7-mm to 5mm arthroscopes. The size, flexibility, and 30° viewing angle of this scope allow excellent and thorough joint visualization by routine anterior portals and minimize the need for joint distractors and posterior portals during routine diagnostic ankle arthroscopy.
Neglected Rupture of the Achilles Tendon
Authors: Gabel Steve , Manoli Arthur
Published: March 2013

Delayed treatment of a rupture of the Achilles tendon is a challenge. Operative treatment is generally recommended, with a variety of techniques being described to appose the tendinous ends and augment the repair.
Heel Cord Advancement in Children with Spastic Equinus Deformity
Authors: Walker Janet L. , Stevens David B. , Clark Nancy Stanley , Opfell Andrew R.
Published: March 2013

Heel cord advancement has been advocated for treatment of spastic equinus deformity. Transferring the gastrosoleus anteriorly weakens it by changing the lever arm rather than the resting length. A retrospective review of 90 children with 122 limbs undergoing heel cord advancement revealed 11% excellent, 53% good, and 35% poor results (average follow-up 9.7 years). The results were statistically better in diplegics and community walkers. The better results in previous studies may be due to procedure modifications and shorter follow-up. Since we obtain comparable results with simpler heel cord lengthenings, we no longer do heel cord advancement.
Validity and Reliability of the First Distal Metatarsal Articular Angle
Authors: Vittetoe David A. , Saltzman Charles L. , Krieg James C. , Brown Thomas D.
Published: March 2013

A laboratory study was undertaken to quantify the validity, the intra- and interobserver reliability, and the effect of first metatarsal orientation on the distal metatarsal articular angle (DMAA). First metatarsals from six cadavers were isolated by sharp dissection and attached to a custom-made triplanar protractor. This allowed controlled positioning of the first metatarsal in the three cardinal planes. Each specimen was moved through a stepwise sequence of first metatarsal orientation changes. Radiographs were taken at each position. The distal (metatarsophalangeal) articular surface of the first metatarsal was then circumscribed with metallic paint and the radiographic series was repeated. DMAA measurements were made on each radiograph multiple times by two measurers blinded to the parameters of variation. The difference between the standard (clinical) radiographic technique for estimating the DMAA and the metallic paint DMAA averaged −0.9° (SD = 2.4°). Longitudinal rotation ( P < .0001) and varus deviation (P < .02 at 10°) of the first metatarsal had a significant effect on the radiographic determination of the DMAA. Although intraobserver reliability for DMAA measurement was high, interobserver reliability for the clinical technique of measurement was poor (pooled intraclass correlation coefficient = 0.14).
Long-Term Results of Triple Arthrodesis: 42 Cases Followed for 25 Years
Authors: Haritidis John H. , Kirkos John M. , Provellegios Stefanos M. , Zachos Apostolos D.
Published: March 2013

We reviewed 42 patients who had had triple arthrodesis 25 years after surgery. The patients' age averaged 20 years. All patients had deformities due to poliomyelitis. They were satisfied with the operation, except for one patient. Good results were noted in 13, fair in 26, and poor in 3 cases. There was delayed wound healing in 8, superficial infection in 4, and avascular necrosis of the talus in 2 cases. There was no case of delayed union or nonunion. We found degenerative joint changes in 12 ankles and in 9 feet; fourteen patients experienced pain. In spite of these long-term changes, which appear acceptable, triple arthrodesis is a useful procedure for many deformities of the foot and can solve patients' problems for many years.
Osteoid Osteoma of the Lateral Cuneiform Bone
Authors: Catani Fabio , Sangiorgi Luca , Picci Piero , Giannini Sandro
Published: March 2013

An unusual case of osteoid osteoma is reported emphasizing the necessity of a careful history and physical examination combined with an adequate imaging supply. Treatment was surgical with an en bloc excision of the lesion.
Anatomic Study of Arthroscopic Debridement of the Ankle
Authors: Feiwell Lawrence A. , Frey Carol
Published: March 2013

To this date, there have been no published studies correlating gross intra-articular anatomy and the compartments of the ankle that can be instrumented under arthroscopic visualization. The purpose of this study was to demonstrate which areas of intra-articular surface were accessible to the standard portals using a technique that allows direct anatomic correlation.

Six fresh cadaver specimens and 12 fresh-frozen, below-knee amputations were used in this study. The 18 ankles were divided into six groups using only one arthroscopic portal site and one instrumentation site per group. Arthroscopic curettes were used to debride only the visualized talar, tibial, and fibular articular cartilage surfaces. After debridement, excision of the distal tibiofibular joint and the talus was performed. The total area of articular cartilage removed with each combination of arthroscope and instrument portal sites was noted, photographed, and recorded graphically.

Use of the various combinations of the anteromedial, anterolateral, and posterolateral portals allowed complete access to all surfaces of the tibial plafond, anterior and posterior rims, and the talar dome. Areas that were not accessible by any portal combination were the distal half of the anterior colliculus of medial malleolus, the majority of the lateral talar articular surface, and the inferior half of the lateral malleolar articular surface.
Chevron Osteotomy for Bunionette
Authors: Moran M. M. , Claridge Richard J.
Published: March 2013

Numerous procedures have been described for the surgical treatment of symptomatic bunionettes. We describe the technique, results, and follow-up of patients treated with a chevron osteotomy of the distal fifth metatarsal. This surgical approach to the treatment of bunionette is presented as a viable alternative to other surgical procedures.

Sixteen distal fifth metatarsal chevron osteotomies were performed on 12 patients. Follow-up was from 15 months to 6 years, with an average follow-up of 3.2 years.

A 100-point scoring system was devised and the average score improved from 44 points before surgery (range 20–65) to 91 points after surgery (range 65–100).

There was one complication of a transfer metatarsalgia. The overall results were good to excellent, except for the transfer metatarsalgia, which was rated as fair.

We have used the procedure in a laterally deviated, plantar metatarsal. There is concern that alternatives be used in a laterally deviated, plantarflexed fifth metatarsal. We have continued to use the chevron osteotomy with this condition.
Ossification Processes and Perichondral Ossification Groove of Ranvier: A Morphological Study in Developing Human Calcaneus and Talus
Authors: Cheng Xiaoguang , Wang Yunzhao , Qu Hui , Jiang Yebin
Published: March 2013

In this histologic-radiologic investigation of 32 feet of 16 fetuses and newborns ranging in age from 15 to 44 weeks, two types of ossification, i.e., endochondral ossification through primary ossification center and in-tramembraneous ossification through periosteal bone formation (PBF), were found to coexist in both calcaneus and talus. In addition, Ranvier's grooves (RG), or perichondral ossification groove, also was observed as a shallow, saucer-like or semicircular structure. As with PBFs, there are three and two RGs in the calcaneus and talus, respectively. RG and PBF appeared in time order and were located regularly in the concave areas of the adult calcaneus and talus. The findings support the hypothesis that one function of PBF and RG is to limit the growth of the calcaneus and talus. Thus, they are responsible for the irregular contour of the calcaneus and talus.
The Two-Boned Fifth Toe: Clinical Implications
Authors: Thompson Francesca M. , Chang Vivian K.
Published: March 2013

Eighty operations on the fifth toe in 59 patients were retrospectively reviewed to determine the effect of skeletal variation on the occurrence of pathological conditions requiring surgery. The two-boned fifth toe occurred in 60% of the operated group. This is statistically significant ( P < .05) as compared with 45% in our prospective control group. Our results support the theory that the stiffer two-boned fifth toe predisposes it to increased pathology, which includes hammertoes, interdigital and dorsal corns, and clawtoes.
Operative Treatment of Acute Displaced Intra-Articular Calcaneus Fractures
Authors: Monsey Robert D. , Levine Benjamin P. , Trevino Saul G. , Kristiansen Thomas K.
Published: March 2013

A retrospective study of 18 operatively treated calcaneal fractures was conducted. The fractures were all type II and type III fractures according to the classification system of Crosby et al. The average follow-up was 32 months and consisted of subjective and objective criteria.

The findings were compared with the results of nonoperative treatment reported by Crosby et al. The findings suggests that type II fractures have a similar outcome when either operative or nonoperative treatment is used. Type III fractures, however, fared considerably better with operative intervention when compared with those treated with nonoperative techniques.
Clinical Characteristics in Relation to Final Amputation Level in Diabetic Patients with Foot Ulcers: A Prospective Study of Healing Below or Above the Ankle in 187 Patients
Authors: Larsson Jan , Agardh Carl-David , Apelqvist Jan , Stenström Anders
Published: March 2013

The aim of this study was to describe the clinical characteristics in relation to final amputation level in diabetic patients with foot ulcers. In a prospective series, 187 consecutively presenting patients were investigated. From admission until final outcome, the patients were treated by a multidisciplinary team both as in- and outpatients. All the patients had one or more signs of neuropathy and 171 had evidence of peripheral vascular disease. Healing with an amputation below the ankle occurred in 74 patients, 88 patients healed with an amputation above the ankle, and 25 patents died unhealed. Amputation above the ankle was associated with high age, living in an institution, a limited walking capacity, cerebrovascular disease, congestive heart failure, and a low hemoglobin level. Amputation below the ankle was associated with diabetes diagnosis before 30 years of age and diabetes duration.

In conclusion, older age, history of cerebrovascular disease and low hemoglobin level are associated with above ankle amputation level in diabetic patients with foot ulcers. However, level selection cannot be based upon these factors only, since some patients at high age, with cerebrovascular disease or with a low hemoglobin value, healed with an amputation below the ankle. None of these factors per se should be taken as a cause to choose a primary amputation above the ankle, unless amputation is supported by the total clinical picture, including local characteristics, such as type and localization of ulcer, and signs of peripheral vascular disease. More attention should be paid to biological than to chronological age.
Isolated Weakness of the Extensor Hallucis Longus in a Patient with Hereditary Spherocytosis
Authors: Spinner Robert J. , Orringer Eugene P. , Kaplan Jerry G. , Nibley Carleton T. , Hall Reginald L.
Published: March 2013

A 24-year-old woman with a history of hereditary spherocytosis and oral contraceptive use presented with a spontaneous, isolated loss of great toe extension. She had clinical and electrodiagnostic evidence of a localized lesion affecting the nerve supply to the extensor hallucis longus (EHL). Full clinical recovery was apparent within 6 months with nonoperative therapy. Isolated EHL weakness may occur as a rare neurologic complication of procedures such as high tibial osteotomies, but, to our knowledge, this has not been reported in the absence of trauma or surgery. While the coexistence of hereditary spherocytosis and a peripheral neuropathy may have been purely coincidental, it is plausible that the isolated lesion in this patient was due to ischemic changes from underlying rheologic conditions, possibly in association with a variation in the neural or nutrient vessel supply to the EHL.
Operative Repair of the Mallet Toe Deformity
Authors: Coughlin Michael J.
Published: March 2013

Over a 14-year period, 60 patients (86 toes) underwent resection arthroplasty of the proximal interphalangeal joint for a mallet toe deformity. During the same period, 788 hammertoe corrections were performed, for a ratio of 9:1 hammertoe to mallet toe corrections. Fifty patients (72 toes) were evaluated at an average 55-month follow-up. In 53 toes (73%), the involved toe was longer than the adjacent toes. The second, third, and fourth toes were almost equally involved with a mallet toe deformity.

With a resection arthroplasty technique, an arthrodesis of the PIP joint occurred in 52 toes (72%) and a fibrous union occurred in the remaining 20 toes (28%). Overall, 86% of the toes were rated as satisfactory by the patient ( P < .001). A slightly lower satisfaction rate (75%) was noted in those toes with a fibrous union. A flexor tenotomy was performed in 22 toes along with the mallet toe repair. Acceptable alignment was noted in 96% of toes without a flexor tenotomy, and in 90% where a mallet toe repair was performed with a flexor tenotomy.

Pain was relieved (97%), correction was well maintained (91%), and patient subjective satisfaction was high (86%) with this procedure. Minor complications occurred in 14% of cases; however, one fourth of these patients still noted a satisfactory result.
A Critical Analysis of the Anterior-Posterior Radiographic Anatomy of the Ankle Syndesmosis
Authors: Ostrum Robert F. , De Meo Patrick , Subramanian Revathi
Published: March 2013

To determine the normal anatomic radiographic landmarks of the ankle syndesmosis, standardized anterior-posterior radiographs of the right ankle were performed on 40 male and 40 female volunteers. The average tibiofibular clear space was 3.8 mm in females, 4.6 mm in males, and 4.2 mm overall. The tibiofibular overlap measured 6.0 mm in females, 9.6 mm in males, and 7.8 mm overall. Due to this variability and the gender differences, we investigated the anatomy of the syndesmosis as ratios of the potentially variable values to fixed landmarks. The ratio of the tibiofibular overlap to the fibular width averaged 54% and the ratio of the tibiofibular clear space to the fibular width averaged 30%, with no statistically significant difference due to gender.

Our data show that for 90% prediction intervals, the values are: (1) tibiofibular clear space less than 5.2 mm in women and 6.5 mm in men; (2) tibiofibular overlap of greater than 2.1 mm in females and 5.7 mm in males; (3) tibiofibular overlap:fibular width ratio greater than 24%; (4) tibiofibular clear space:fibular width ratio less than 44%. Additionally, using a linear regression model, a prediction of the tibiofibular overlap can be made when using the distance (in millimeters) from the incisura fibularis to the lateral tibial (LT) border: tibiofibular overlap = 0.862 × lateral tibia − 2.62 ( P = .0001). Utilization of these values will help in the determination of posttraumatic disruption of the syndesmosis and postoperative assessment of mortise reduction.
The Foot in Ballet Dancers: The Importance of Second Toe Length
Authors: Ogilvie-Harris D. J. , Carr M. M. , Fleming P. J.
Published: March 2013

Ballet dancers are prone to foot injuries. Our hypothesis was that the length of the second toe in relation to the big toe affected the distribution of stresses on the foot, correlating with calluses, injuries, and pain. Fifty-nine ballet dancers were examined for second toe length with respect to great toe, calluses, and metatarsophalangeal inflammation. Daily foot pain, limitation of work hours because of this, injuries, age, sex, and rank in the company were considered. The dancers’ feet had an incidence of shorter, equal, or longer second toes which was comparable to a non-ballet-dancing cohort (N = 60). In female dancers (N = 34), total callus counts and pain scores were significantly lower in the group with shorter second toes versus those with equal or longer second toes. Counts were unrelated to age or rank. Longer second toes were related to hallux rigidus. Limitation of practice hours, ankle sprains, and foot/ankle fractures and sprains were comparable across the groups. The male dancers (N = 25) had significantly fewer calluses than did the women, but had equal pain scores and number of injuries. There were no significant differences among the males in total callus counts, pain scores, limitation of practice hours, or injuries between groups based on toe length, age, or rank. We conclude that there is no significantly more ideal pattern of toe lengths for male ballet dancers, but females with shorter second toes have fewer calluses and less daily foot pain. Those with a longer second toe had a higher incidence of hallux rigidus and correspondingly increased pain scores.
Stress Radiography of the Talocrural and Subtalar Joints
Authors: Louwerens Jan Willem K. , Ginai Abida Z. , van Linge Bert , Snijders Chris J.
Published: March 2013

The object of this investigation was to determine a possible subtalar component in a group of 33 patients with chronic ankle instability. A group of 10 subjects without ankle/foot symptoms acted as controls. A standardized radiographic assessment of talar and simultaneous subtalar tilt was made. A hinge device to stress the joints and a specific subtalar stress view (Brodén view) were used under fluoroscopic control. Radiographs were made with the feet: (1) in neutral position, (2) after inversion with moderate force until the point of fair restraint (step 1), and (3) after inverting with more force as far as the conditions would allow (step 2).

An increase of talar tilt between step 1 and step 2 was only found in feet that were symptomatic. This suggests that this increase is only possible when lateral ligaments are damaged. Further research is necessary to determine whether this finding can serve as a parameter to discriminate between physiological and abnormal talar tilt.

A wide range of subtalar motion was found in both symptomatic and asymptomatic feet. With the present method, practically all subtalar joints showed some loss of congruity and medial shift of the calcaneus in relation to the talus. This could not be correlated with ankle instability at the talocrural joint. The consequence of the use of different subtalar stress methods has so far received little attention and is discussed.
Posterior Tibial Tendon Dysfunction in Rheumatoid Arthritis
Authors: Michelson James , Easley Mark , Wigley Fredrick M. , Hellmann David
Published: March 2013

Although hindfoot pathology in rheumatoid arthritis is a significant cause of disability for patients, the etiology of the planovalgus deformity is controversial. The present study surveys 99 patients with clinically proven rheumatoid arthritis for the presence and severity of hindfoot pathology. Specific attention was directed at the function of the posterior tibial tendon, as disruption of this structure has been implicated by some investigators as a cause of hindfoot deformity in rheumatoid arthritis. Assessment of posterior tibial function was by manual testing using two different grading scales, as well as by examination for several signs associated with posterior tibial tendon dysfunction.

Between 13% and 64% of the study population could be considered to have posterior tibial tendon dysfunction, depending upon the specific diagnostic criteria used. Using the presence of all three of the most stringent criteria for diagnosis, 11% of patients were believed to have posterior tibial tendon dysfunction. These criteria were loss of the longitudinal arch, inability to perform a heel-rise, and lack of a palpable posterior tibial tendon.

This study demonstrates that planovalgus deformity in rheumatoid arthritis can be due to clinically evident dysfunction of the posterior tibial muscle-tendon unit. There is a complex interplay between hindfoot joint disruption due to the inflammatory process and deformity due to tendinous dysfunction. If there is primary subtalar joint instability secondary to the inflammatory process, the posterior tibial tendon is rendered dysfunctional due to deranged hindfoot mechanics, as with primary posterior tibial tendon rupture. Since treatment of either condition (i.e., primary hindfoot instability or primary posterior tibial tendon rupture) is similar, the distinction is not important clinically. What is important is that attention to the specific cause of planovalgus would be expected to improve the overall treatment of rheumatoid feet.
The Short Oblique Fracture of the Distal Fibula Without Medial Injury: An Assessment of Displacement
Authors: Harper Marion C.
Published: March 2013

Eighteen patients with ankle injuries presenting as short oblique fractures of the distal fibula with no clinical or radiographic evidence of injury to the medial ankle were studied for fracture displacement. Plain radiographs and computed tomography were used for analysis. All fractures were clinically diagnosed as supination-external rotation stage 2 (SE-II) injuries under the Lauge-Hansen scheme. All exhibited slight displacement on plain radiographs and were treated nonoperatively.

Computerized tomography using axial cuts across the fracture site and ankle mortise revealed normal positioning of the talus beneath the tibial plafond, as evidenced by no abnormality of the medial joint space in all patients. In the majority of patients, the relationship between the talus and distal fibula also appeared undisturbed, with fracture displacement being confined to a change in position of the proximal fibular fragment relative to the tibia as compared with the contralateral ankle. In a minority of cases, in addition to the above-described displacement of the proximal fibular fragment, the distal fibular fragment was noted to shift slightly laterally relative to the talus, with mild widening of the lateral joint space. Occult-associated avulsion fractures off the distal tibia were present in 39% of the cases.
Spindle Cell Lipoma of the Foot: A Case Report and Literature Review
Authors: Math Kevin R. , Pavlov Helene , DiCarlo Edward , Bohne Walther H. O.
Published: March 2013

Lipomas are among the most commonly encountered soft tissue tumors in clinical practice, though they are rare in the foot. Although a presumptive diagnosis is typically made clinically, those tumors with atypical clinical features may require radiological consultation. Difficulty arises when radiographic features are not typical of lipoma. We present a fatty soft tissue tumor of the foot with nonadipose elements on magnetic resonance imaging evaluation. Differentiation of lipoma variants (e.g., spindle cell lipoma, atypical lipoma, pleomorphic lipoma, lipoblastoma, angiolipoma) from liposarcoma based on imaging features is not possible, necessitating surgical resection for definitive histological diagnosis.
Peroneus Longus Tendon Tears: Acute and Chronic
Authors: Sammarco G. James
Published: March 2013

Tear of the peroneus longus tendon can be difficult to diagnose and treat. Fourteen cases of clinically proven tears are reported. Patients ranged in age from 31 to 63 years. There were 10 men and four women. The onset of symptoms was acute in eight cases. Chronic onset with slowly increasing pain occurred in six cases. Despite acute onset of symptoms, only one patient was diagnosed within 2 weeks of his injury. The others had symptom duration ranging from 7 to 48 months.

Twelve tears were located distally as the tendon turned into the cuboid groove. An os peroneum visible on x-ray was present in six cases, absent in seven cases, and cartilaginous in one case. The os peroneum was involved in the tear in three cases. Excision of part or all of the os peroneum was performed in four cases with a bridging tendon graft required in one case. A plantaris tendon graft was required in one case in which an os peroneum was absent.

Patients with acute onset of symptoms tended to fare better than those with chronic onset of symptoms, regardless of the length of time from onset to time of surgery. Associated pathology in the peroneus brevis tendon was common, occurring in nine cases. These patients seemed to have a better surgical outcome than those with only a tear of the peroneus longus tendon.

Associated findings affected diagnosis by masking symptoms but did not alter the outcome of treatment. The presence or absence of an os peroneum did not affect symptoms or treatment, but its presence on x-rays may aid in the diagnosis if migration of part or all of the sesamoid occurs.
Measurement of the Forefoot with Roentgen Stereophotogrammetry in Hallux Valgus Surgery
Authors: Resch Sylvia , Ryd Leif , Stenström Anders , Yuan Xunhua
Published: March 2013

Eight hallux valgus patients were marked with tantalum markers in conjunction with hallux valgus surgery (seven proximal osteotomies and one chevron osteotomy). Changes on weightbearing before surgery as well as corrective changes after surgery were analyzed with roentgen stereophotogrammetry (RSA) and with standard x-rays. RSA is accurate to 0.6° in rotational changes and 0.3 mm in translation. Weightbearing changes were inconsistent, and minimal with both standard x-rays and RSA. It was possible to analyze the correction at the osteotomy site with RSA. In half the cases, the correction measured by RSA corresponded with that measured with standard x-rays, within measurement error; in the other cases, RSA showed that the correction was of a different size or direction than that measured on standard x-rays. Corrective changes in hallux valgus surgery are complex, including angular and translational changes at several levels and in several joints in order to produce a clinical resultant. Rotational changes can be evaluated with RSA. Although RSA in an optimal situation is very accurate, it is still limited to a laboratory setting.
The Ball-and-Socket Ankle: A Case History and Literature Review
Authors: Steingard Michael , Percy Edward
Published: March 2013

The ball-and-socket ankle is a rare clinical condition that has a deformity of the talotibial articulation. Assorted anomalies frequently exist. Treatment is usually based on clinical presentation of a foot problem.
Traumatic Focal Posterior Tibialis Muscle Denervation
Authors: Rolle William A. , Herbison Gerald J. , Wapner Keith L. , Schweitzer Mark E.
Published: March 2013

The purpose of this case presentation is to demonstrate posterior tibialis muscle (PTM) denervation as a cause of traumatic plantarflexion inversion weakness. In a 42-year-old woman, severe pain, swelling, and ecchymosis over the medial aspect of her left ankle developed after she twisted it while playing tennis. Plantarflexion inversion weakness developed (grade 3/5). The strength of all other muscle groups of the lower extremity was normal. Her pin and light touch sensation were normal in the left lower extremity. Deep tendon reflexes were equal and active at both knees and ankles. A magnetic resonance image of the left leg, ankle, and foot performed 1 month after injury demonstrated an intact posterior tibialis tendon behind the medial malleolus and edema-like increased signal intensity in the PTM on the T1-weighted image consistent with denervation. On electromyographic testing, there were continuous fibrillation and positive sharp wave potentials in every site tested in the PTM without any voluntary motor unit activity. The left extensor hallucis, left gastrocnemius, and lumbar paraspinal muscles were normal. In conclusion, combined magnetic resonance imaging and electromyographic studies supported denervation of the PTM as the cause of plantarflexion inversion weakness, rather than posterior tibialis tendon rupture in this patient.
Triple Arthrodesis with Lateral Column Lengthening for Treatment of Severe Planovalgus Deformity
Authors: Horton Greg A. , Olney Brad W.
Published: March 2013

Triple arthrodesis with lateral column lengthening through the calcaneocuboid joint was performed on 22 feet in 14 patients. The primary indication for surgery was severe symptomatic planovalgus deformity unresponsive to conservative measures. All patients achieved solid fusion within 12 weeks. No patient had a decline in ambulatory status. Excellent correction of deformity was achieved and maintained with an average correction of the talus first metatarsal angle of 25° in both the AP and lateral planes. Triple arthrodesis with lateral column lengthening provides for reliable arthrodesis and allows correction of severe planovalgus deformity while maintaining foot length.
Selective Hindfoot Arthrodesis for the Treatment of Adult Acquired Flatfoot Deformity: An In Vitro Study
Authors: O'Malley Martin J. , Deland Jonathan T. , Lee Kyung-Tai
Published: March 2013

An acquired flatfoot deformity with significant laxity at the transverse tarsal joint was created experimentally and the amount of correction that was obtained with selective hindfoot fusions was measured radiographically. Results showed that the talonavicular, double (talonavicular and calcaneocuboid), and triple arthrodeses were able to fully correct the deformity, including correction of hindfoot valgus with just a talonavicular fusion. Subtalar and calcaneocuboid fusions failed to completely correct the deformity. This study provides experimental evidence that although the triple joints are interconnected, they differ with respect to their ability to correct malalignment. We conclude that talonavicular or double arthrodesis will correct deformity in a flatfoot with considerable laxity through the transverse tarsal joint, but that a subtalar fusion will not provide consistent correction.
Anatomy of the Achilles Tendon and Plantar Fascia in Relation to the Calcaneus in Various Age Groups
Authors: Snow Stephen W. , Bohne Walther H.O. , DiCarlo Edward , Chang Vivian K.
Published: March 2013

Ten adult cadaver feet, three neonatal feet, and the feet of two fetuses were dissected to investigate whether an anatomical continuity exists between the fibers of the Achilles tendon and the plantar fascia. Histologic sections of the feet were done in three age groups: neonate, persons in their mid-20s, and the elderly.

As the foot ages, there appears to be continued diminution of the number of fibers connecting the Achilles tendon and plantar fascia. The neonate has a thick continuation of fibers, while the middle-aged foot has only superficial periosteal fibers that continue from tendon to fascia. The elderly feet show simply an insertion of fibers of both structures into the calcaneus with periosteum in between.
Dynamic Orthopaedic Brace in the Treatment of Ankle Sprains
Authors: Regis Dario , Montanari Michele , Magnan Bruno , Spagnol Stefano , Bragantini Alberto
Published: March 2013

Ankle sprains may lead to disabling sequelae such as joint instability and persistent pain. Immobilization with plaster cast may give rise to joint stiffness and muscle atrophy.

Twenty patients with acute inversion sprains of the ankle were treated with a “dynamic” orthopaedic brace after a 10-day plaster immobilization. A control group, consisting of 10 subjects, received a weight-bearing short-leg plaster cast for 25 days.

A clinical evaluation and an instrumental isokinetic investigation (Cybex) were performed as scheduled.

The clinical findings suggest an earlier and more comprehensive functional recovery in the group receiving the “dynamic” brace compared to the casted group. The isokinetic test revealed a statistically significantly better performance for most parameters in the brace group especially regarding the ankle joint invertors.
Correction of Fixed Hammertoe Deformity with Resection of the Head of the Proximal Phalanx and Extensor Tendon Tenodesis
Authors: Sarrafian Shahan K.
Published: March 2013

A method of surgical correction of a fixed hammertoe deformity is presented. It incorporates the resection of the head of the proximal phalanx with an extensor tendon tenodesis to the dorsum of the proximal phalanx. The controlled tension in the extensor tendon provides the necessary stability. It alleviates the use of K-wire fixation.
Iatrogenic Hallux Varus Surgical Procedure: A Study of 14 Cases
Authors: Tourné Y. , Saragaglia D. , Picard F. , De Sousa B. , Montbarbon E. , Charbel A.
Published: March 2013

Hallux varus occurs most frequently as result of excessive surgical correction of musculoligamentous imbalance around the metatarsophalangeal (MTP) joint of the great toe (lateral release and medial capsuloligamentous tensioning). If untreated, the condition may lead to motion loss and degenerative arthritis. In this series, 14 cases of hallux varus were treated. Medial arthrolysis was done in each case. In five cases, reconstruction of the lateral ligament (with a 1.5-mm Ligapro suture), using a new technique, accompanied the medial release. Arthrodesis of the MTP was done in nine cases treated when there was already stiffness and arthrosis. According to a 100-point scoring system, the results were excellent in 56% and good in 44% of the MTP joint arthrodesis cases. Results were excellent in 100% of the mobilizing technique cases using Ligapro suture.