bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Significance of Magnetic Resonance Imaging in Preoperative Planning for Reconstruction of Posterior Tibial Tendon Ruptures
Authors: Conti Stephen , Michelson James , Jahss Melvin
Published: March 2013

A retrospective study of attenuated/ruptured posterior tibial tendons was conducted of all patients who underwent tendon reconstruction over a 4-year period. The study comprised 20 feet in 19 patients having an average age of 53.3 years, with an average follow-up of 2 years. Preoperative magnetic resonance images were taken and graded for assignment to one of three magnetic resonance imaging (MRI)-based groups. The surgical grade was determined intraoperatively based on a previously described classification scheme.

No medical or rheumatologic conditions predisposing to failure could be identified. Failure was defined as postoperative progression of pain and deformity which required subsequent triple arthrodesis. There were six failures at an average of 14.7 months. Surgical evaluation was not correlated to outcome following reconstruction. MRI grading, however, was predictive of outcome. The superior sensitivity of MRI for detecting intramural degeneration in the posterior tibial tendon that was not obvious at surgery may explain why MRI is better than intraoperative tendon inspection for predicting the outcome of reconstructive surgery. Therefore, it may be helpful to obtain preoperative MRI when this particular reconstruction of the posterior tibial tendon is contemplated, since this provides the best measure of tendon integrity and appears to be the best predictor of clinical success after such surgery.
Investigations into the Fat Pads of the Sole of the Foot: Heel Pressure Studies
Authors: Jahss Melvin H. , Kummer Frederick , Michelson James D.
Published: March 2013

The fat pads of the heel have a structure that is optimized for load bearing. In various diseases and aging, the load-carrying ability of the heel pad is clinically impaired. The loading pattern was examined in subjects having normal heel pads and those with atrophic heel pads, both with and without clinical symptoms. Normal heel pads showed a broad region of high pressure, which accounted for a high percentage of the total load transmission. In contrast, the atrophic heels showed a high but narrow peak pressure. However, most of the load was transmitted over a large area of low pressure. There was no difference between symptomatic and asymptomatic heels.

The mechanical behavior of the fat pad is discussed with particular reference to the anatomic structure of the pads. Pad thickness and septal integrity are both important to the mechanical characteristics of the fat pad. The load-bearing patterns observed are discussed in terms of the mechanical components influencing fat pad resilience. These results have direct relevance to understanding the pathophysiology of heel pain secondary to degeneration of the fat pad.
A Method for Measuring Foot Pressures Using a High Resolution, Computerized Insole Sensor: The Effect of Heel Wedges on Plantar Pressure Distribution and Center of Force
Authors: Rose Nicholas E. , Feiwell Lawrence A. , Cracchiolo Andrea
Published: March 2013

A new, high resolution, pressure-sensitive insole was tested and found to provide reproducible measurements of static and dynamic plantar pressures inside the shoe of normal test subjects under certain conditions. However, calibration between separate sensors was poor and the sensor pads showed significant wear with use.

This system was also used to investigate the effect of heel wedges on plantar foot pressure to determine whether this system was sensitive enough to detect the effect of a gross shoe modification on plantar foot pressure. Medial heel wedges decreased plantar pressures under the first and second metatarsals as well as under the first toe, and shifted the center of force laterally in all portions of the foot. Lateral heel wedges decreased pressures under the third, fourth, and fifth metatarsals, increased pressures under the first and second metatarsals, and shifted the center of force medially in all portions of the foot.

Our evaluations indicate that it is possible to measure static and dynamic plantar foot pressures within shoes and to study the possible effect of shoe modifications on plantar pressures in controlled gait trials.
Hallux Valgus Correction with Proximal Metatarsal Osteotomy: Two-year Follow-up
Authors: Thordarson David B. , Leventen Edward O.
Published: March 2013

We evaluated the results of 33 feet in 23 patients who underwent a basilar crescentic osteotomy with a modified McBride procedure with a minimum 24-month follow-up. The average hallux valgus improved from 37.5° to 13.8° and the intermetatarsal 1–2 angle from 14.9° to 4.7°. The angle of declination of the first metatarsal was found to have dorsiflexed an average of 6.2°. Unfortunately, osteotomies secured with staples dorsiflexed to a greater degree. Bilateral foot surgery produced results similar to those with unilateral procedures. Four of our patients developed a hallux varus (range 2–8°); however, none were dissatisfied at the time of evaluation. Although this bunion procedure resulted in more prolonged swelling and pain than a distal osteotomy, it should be considered for more complex deformities to avoid the failure that a distal metatarsal osteotomy might produce given a high 1–2 intermetatarsal angle or a high hallux valgus angle.
The Dynamics of Peroneus Brevis Tendon Splits: A Proposed Mechanism, Technique of Diagnosis, and Classification of Injury
Authors: Sobel Mark , Geppert Mark J. , Olson Eric J. , Bohne Walther H. O. , Arnoczky Steven P.
Published: March 2013

The etiology of peroneus brevis splits is unclear. 16 , 26 Because longitudinal splits in the peroneus brevis tendon do not necessarily effect the integrity or strength of the tendon, it is difficult to ascertain whether or not injury to the peroneus brevis tendon is present. Recent clinical, anatomic, and histologic reports have suggested that the split develops from prolonged mechanical attrition within the fibular groove as a result of ankle trauma with resultant lateral ankle instability and incompetency of the superior peroneal retinaculum with resultant subluxation of the peroneal tendons. 15 , 17 , 22 – 25 This cascade of events may result in splitting of the peroneus brevis tendon.

The purpose of this paper was to report the investigation of the mechanism by which peroneus brevis splits develop, to describe a technique of diagnosis, and to propose a classification of injury.

Peroneus brevis splits are the result of a dynamic mechanical insult at the fibular groove. Laxity of the superior peroneal retinaculum combined with peroneus longus mechanical compression causes the peroneus brevis to splay out and eventually split over the sharp posterior edge of the fibula. Anatomic factors, such as a shallow fibular groove (congenital convex groove) or the presence of an anomalous low-lying peroneus brevis muscle belly or peroneus quartus tendon, 4 , 7 , 25 may also play a role in this mechanism by interfering with the competence of the superior peroneal retinaculum.
Tbransverse Proximal Diaphysial Fracture of the Fifth Metatarsal: A Review of 12 Cases
Authors: Arangio George
Published: March 2013

A review of 12 cases of transverse proximal diaphysial fractures 3.0 cm distal from the fifth metatarsal tuberosity with a 2-year follow-up is presented. Six cases treated with percutaneous pinning, cast, and partial weightbearing with crutches and six cases treated with cast, partial weightbearing, and crutches are analyzed by classification, age, and average time to union. The healing times were the same in both groups.
Unilateral External Fixation for Severe Pilon Fractures
Authors: Bonar Susan K. , Marsh J. Lawrence
Published: March 2013

Twenty-one patients with severe tibial plafond fractures were treated by unilateral large screw external fixation. In 15 patients, this was combined with limited internal fixation. The fractures were classified according to the methods of Ovadia and Beals. 12 There were nine type lll, four type IV, and eight type V fractures, and according to the methods of Rüedi and Allgöwer, nine type II and 12 type III fractures. Seven fractures were open.

In five fractures, no attempt was made at articular reconstruction due to severe comminution. Four of these fractures required ankle arthrodeses and one type IIIB fracture received a late amputation. All other fractures healed. There were no cases of wound infection, skin slough, or osteomyelitis. Large screw external fixation in the talus and calcaneus was not associated with significant early or late complications. The less extensive tissue dissection in an area prone to wound complications may account for the low rates of infections, wound complications, and nonunion.
The Role of the Plantar First Metatarsal First Cuneiform Ligament in Weightbearing on the First Metatarsal
Authors: Mizel Mark S.
Published: March 2013

Twelve below the knee amputation specimens were examined while a dorsally directed force wasapplied to the first metatarsal. Seven specimens were tested with serial removal of soft tissues, followed by cutting the plantar first metatarsocuneiform ligament. Five specimens had only the plantar first metatarsocuneiform ligament cut, leaving the other structures intact. In both groups, dorsal displacement of the distal first metatarsal was noted to be more than 5 mm after sectioning of the ligament, with no marked change noted during removal of other soft tissues. This study demonstrates that the plantar first metatarsocuneiform ligament is the major component in the stabilization of the first metatarsal during weightbearing.
The Chevron Bunionectomy: A Trigonometric Analysis to Predict Correction
Authors: Graves Stanley C. , Dutkowsky Joseph P. , Richardson E. Greer
Published: March 2013

A trigonometric analysis was developed in an attempt to predict the postoperative hallux valgus angles and inter-metatarsal angles after Chevron bunionectomy. This analysis was used in 20 feet to predict postoperative angles, and these predicted values were compared with actual measured roentgenographic values. The postop erative intermetatarsal angles were evaluated to deter mine their correction to postoperative hallux valgus angles of 20° or less. Using the trigonometric analysis, the post operative intermetatarsal angles were highly predictable, but the hallux valgus angle could not be reliably predicted for individual patients. The intermetatarsal angle obtained at surgery, however, was indicative of the final hallux valgus angle: 75% of feet with intermetatarsal angles of more than 11° had postoperative hallux valgus angles of more than 20°. Thus, when an intermetatarsal angle of 11° or less can be obtained surgically, the hallux valgus angle can be corrected to 20° or less in most patients.
Metatarsal Shaft Fracture after First Metatarsophalangeal Joint Fusion: A Complication of Steinmann Pin Fixation
Authors: Albert Todd J. , Wapner Keith L.
Published: March 2013

First metatarsophalangeal joint fusion is a successful pro cedure for the treatment of rheumatoid forefoot problems, severe osteoarthritis of that joint, and failed first ray sur geries. We have identified three patients with fracture of the first metatarsal after fusion with Steinmann pins. Pen etration of the plantar and/or plantar medial cortex of these pins should be avoided. If penetration occurs, we recommend casting after pin removal.
Comparison of Talonavicular Dowel Arthrodesis Utilizing Autogenous Bone Versus Defatted Bank Bone
Authors: Thoren Klas , Ljung Peter , Pettersson Holger , Rydholm Urban , Aspenberg Per
Published: March 2013

A simple dowel arthrodesis of the talonavicular joint in an early stage of destruction can reduce pain and prevent the development of valgus deformity in the rheumatoid hindfoot. Previously, we used autogenous dowels made from the iliac crest. In order to facilitate the operation and to get a better fitting dowel, we tried defatted cancellous allograft dowels from which marrow tissue had been removed. The dowels were prepared from femoral heads in our surgical bone bank. At operation, the dowels were embedded in fresh marrow aspirate from the iliac crest and the arthrodeses were stabilized with a staple. Results were evaluated by clinical examination and radiography. The results of four patients were compared with an earlier study of eight patients using autogenous dowels taken from the iliac crest. With both techniques, the patients were relieved of pain in the talonavicular joint, but some had pain from other hindfoot joints. With autogenous dowels, all eight patients healed with radiographic bony union, but with allogenous dowels, the four patients developed fibrotic nonunion. The results indicate that talonavicular arthrodesis should be made using only autologous dowels.
Magnetic Resonance Imaging and the Evaluation of Tarsal Tunnel Syndrome
Authors: Frey Carol , Kerr Roger
Published: March 2013

The bones, soft tissue contents, and boundaries of the tarsal tunnel can be imaged with sufficient detail to show all the major structures within it. Pathological conditions affecting these structures can also be identified. The purpose of this paper was to determine the ability of magnetic resonance imaging to help in the evaluation of tarsal tunnel syndrome. Thirty-three patients with 40 feet were used for this study. All patients presented with complaints of pain along the course of the posterior tibial nerve or its branches and a positive Tinel's sign. Nerve conduction studies were obtained on 29 feet. All feet were evaluated with a magnetic resonance imaging study of the tarsal tunnel. Twenty-one feet eventually required surgery.

Magnetic resonance imaging revealed an inflammatory or mass lesion in the tarsal tunnel in the majority of cases. The magnetic resonance imaging findings were confirmed at surgery in 19 patients. The information provided by magnetic resonance imaging can enhance surgical planning by indicating the extent of decompression required.
Digital Nerves of the Foot: Anatomic Variations and Implications Regarding the Pathogenesis of Interdigital Neuroma
Authors: Levitsky Kenneth A. , Alman Benjamin A. , Jevsevar David S. , Morehead James
Published: March 2013

Seventy-one cadaveric feet were dissected, with attention to communicating branches of the digital nerves, the diameters of the digital nerves, the distance between the metatarsal heads, and the presence or absence of interdigital neuromas. A communicating branch was absent in 52 feet (73.2%) and present in 19 specimens (26.8%). The communication was from the fourth to the third web space common digital nerve (i.e., from the lateral to the medial plantar nerve) in 11 specimens. A reverse communication, from the third to the fourth web space common digital nerve (i.e., from the medial to the lateral plantar nerve), was present in eight specimens.

Neuromas were identified in the second web space in 26 specimens and in the third web space in 32 feet. The common digital nerve to the third web space was not thicker in feet with a contribution from the fourth to the third web space nerve. Additionally, the incidence of third web space neuroma in feet with this type of communication was not significantly greater than in those feet without an internervous communication. However, the intermeta-tarsal head distances and the ratios of the intermetatarsal head distance to the digital nerve diameter in web spaces 2 and 3 were significantly smaller in comparison to spaces 1 and 4 ( P < .05).

The morphometric data lend support to theories that explain the propensity for neuroma formation in both the second and third web spaces on a mechanical basis. The data do not support those theories that explain an increased incidence of third web space neuroma formation based on a communication from the fourth to the third web space digital nerve.
Management of Metatarsus Adductovarus
Authors: Pentz Anthony S. , Weiner Dennis S.
Published: March 2013

A retrospective analysis of 795 patients treated for metatarsus adductovarus by a standardized outpatient approach by one of the authors (D.S.W.) from 1970 to 1983 was conducted to evaluate the efficacy of a straight metal bar and attached reverse last shoe protocol. Criteria for inclusion were developed excluding those milder cases in which spontaneous resolution was expected and indeed occurred. Nearly uniform excellent results were encountered, with a 99% likelihood of obtaining a fully corrected foot. Surgical intervention was deemed necessary in under 1% of cases seen.

The authors also examined birth weights and rank in relation to metatarsus adductovarus. Those children with the deformity had a mean birth weight of 7.6 pounds, without statistical variance from normal average birth weights. We were unable to establish any statistical association with birth rank.

In light of the results of this study, which compare favorably with serial casting, we recommend this approach as a more economical and less disruptive and cumbersome technique for parent, patient, and physician.
Transcutaneous Oxygen Tension in the Dysvascular Foot with Infection
Authors: Pinzur Michael S. , Stuck Rodney , Sage Ronald , Osterman Helen
Published: March 2013

Eight adult insulin-requiring diabetics with peripheral vascular disease were admitted with foot infection and signs of systemic sepsis. Transcutaneous oxygen tension was measured at the foot and ankle prior to surgery. None of the values were sufficient to support wound healing. Four of the patients underwent open ray resection and four open midfoot amputation. After resolution of the local infections, transcutaneous oxygen tensions were repeated. Seven of the eight patients exhibited an appreciable increase in the value following decompression of the foot infection, sufficient to support wound healing.
Microvasculature of the Tibialis Anterior Tendon
Authors: Geppert Mark J. , Sobel Mark , Hannafin Jo A.
Published: March 2013

Subcutaneous rupture of the tibialis anterior tendon is an uncommon condition for which the etiology is unclear. The existence of a hypovascular zone has been proposed as an etiology for rupture of the tibialis anterior tendon. To investigate this possibility, the microvascular anatomy of the tibialis anterior tendon was studied using a modified Spalteholz technique. The vascular supply to the tibialis anterior tendon arises from proximal and distal ventral vinculae. Muscular branches of the anterior tibial artery, proximally, and the medial tarsal arteries, distally, form an intratendinous, longitudinal, competent blood supply. The tendon also receives a rich vascular blood supply from the synovial sheath. The blood supply appears adequate throughout the course of the tibialis anterior tendon, and no hypovascular region was noted at the common site of rupture 1 to 3 cm proximal to its insertion. No relationship was noted between increasing age and alteration in blood supply.
Bilateral Accessory Soleus: A Report on Four Patients with Partial Fasciectomy
Authors: Peterson David A. , Stinson Warren , Carter John
Published: March 2013

Four young adults (average age 24 years) presented with complaints of posterior ankle pain after running. Bilateral accessory soleus muscles were diagnosed using magnetic resonance imaging or CT scan. Symptoms were present an average of 3 years before diagnosis. Two patients had previous surgery (ankle arthroscopy, tarsal tunnel release, and leg compartment release) before diagnosis and treatment. Obliteration of Kager's triangle (posterior ankle fat pad) was present on six out of eight lateral ankle radiographs. Posteromedial prominence was present on four out of eight ankles. Operative exploration confirmed the presence of five muscles and fasciectomy was performed. Follow-up (17 to 29 months) showed good relief of symptoms in all patients and return to long-distance running for three patients.

Dissection of 47 preserved cadavers revealed three accessory soleus muscles in the 94 extremities (two muscles were bilateral in one cadaver).
SPLATT Combined with Tendo Achilles Lengthening for Spastic Equinovarus in Adults: Results and Predictors of Surgical Outcome
Authors: Edwards Peter , Hsu John
Published: March 2013

During a 4-year period, split anterior tibial tendon transfer (SPLATT) was performed on 42 adults with cerebrospastic equinovarus deformity. Twenty-one patients (24 feet) had a minimum 1-year follow-up, which included detailed documentation of foot appearance position and function as well as ambulatory status. Thirteen patients were male and 8 were female. Average age of the patients was 41 years. Seventeen patients were independent ambulators with orthoses, one was a maximally assisted ambulator. Three patients with spastic quadriparesis were nonambulatory. All patients had uniform surgical technique and postoperative management. This paper presents the results of SPLATT and identifies risk factors for poor surgical outcomes. After an average follow-up of 39 months, 83% of the feet were rated as having good or excellent results. All ambulatory patients had improved gait and 35% of them were able to discontinue their orthoses. Poor surgical outcomes were associated with nonambulatory status in brain injured patients ( P = .018). Salvage of failed SPLATT is discussed.
Jones' Fractures and Related Fractures of the Proximal Fifth Metatarsal
Authors: Lawrence Steven J. , Botte Michael J.
Published: March 2013

At least three fracture types occur in the proximal fifth metatarsal: the Jones' fracture, the proximal diaphysial stress fracture, and the tuberosity avulsion fracture. Each has distinct characteristics. The diaphysial stress fracture is commonly confused with the Jones' fracture, thereby obscuring vital differences in prognosis and treatment. Anatomical and biomechanical characteristics, as well as vascular studies of the proximal portion of the fifth metatarsal, are discussed in an attempt to better understand their diverse healing potentials.

Guidelines for treatment are controversial, and must frequently be individualized. Although surgical intervention for certain proximal fifth metatarsal fracture types may speed recovery time, most fractures heal with immobilization. Treatment of displaced, intra-articular fractures, delayed unions, and nonunions usually requires operative methods.
Flexor Tendon Transfer for Metatarsophalangeal Instability of the Second Toe
Authors: Thompson Francesca M. , Deland Jonathan T.
Published: March 2013

Flexor to extensor transfer was used to treat painful second metatarsophalangeal joint instability in thirteen feet in eleven patients. All patients had their pain reproduced with vertical stress motion of 50% to 100% at the metatarsophalangeal joint. Seven feet had concomitant hallux valgus correction, two feet had no hallux valgus, and four feet underwent no correction for asymptomatic hallux valgus. Results at an average of 33.4 months followup showed that all patients had substantial pain relief, with eight patients becoming pain-free, and five patients experiencing mild pain. All but one were satisfied with their result. Stiffness appeared to be the source of the mild residual pain. All toes, including six toes with preoperative medial crossover toe deformity, were corrected into valgus alignment with adjacent toes. All toes operated on for the first time were able to touch the ground with grasp postoperatively. Flexor to extensor transfer is successful in reducing the second toe and relieving pain caused by instability of the second metatarsophalangeal joint, but may require rapid postoperative mobilization to ensure passive dorsiflexion equal to that of the adjacent toes to reduce postoperative uncomfortable stiffness.
Arthrodesis of the First Metatarsophalangeal Joint: A Biomechanical Study of Internal Fixation Techniques
Authors: Curtis Mark J. , Myerson Mark , Jinnah Riyaz H. , Cox Quentin G.N. , Alexander Ian
Published: March 2013

This study compares the strength and rigidity of four methods of internal fixation for arthrodesis of the first metatarsophalangeal joint. Ten matched pairs of cadaveric first rays were harvested and arthrodesis performed by one of four techniques: (1) planar excision of joint surfaces and fixation with crossed Kirschner wires, (2) planar excision of joint surfaces and internal fixation with a dorsal plate and screws, (3) planar excision of joint surfaces and internal fixation with an interfragmentary screw, or (4) excision of the joint surfaces using powered conical reamers and fixation with an interfragmentary lag screw. Biomechanical testing with a Bionix 858 materials testing machine was carried out, applying a plantar force utilizing principles of cantilever loading. Force applied and displacement of the arthrodesis were recorded. Of the four methods tested, bony preparation with power conical reamers and supplementary interfragmentary screw fixation was the most stable.
Achilles Tendon Injuries: A Comparison of Surgical Repair Versus No Repair in a Rat Model
Authors: Murrell George A.C. , Lilly Edward G. , Collins Alison , Seaber Anthony V. , Goldner Richard D. , Best Thomas M.
Published: March 2013

Controversy exists regarding the treatment of Achilles tendon ruptures. The aim of this study was to determine whether surgical repair of the rat Achilles tendon offered any biomechanical, functional, or morphological advantage over no repair. Thirty-two male Sprague-Dawley rats were randomly allocated into four groups: (1) sham operated (skin incision only), (2) no repair (complete division of the Achilles tendon and plantaris tendon without repair), (3) internal splint (plantaris left intact), and (4) Achilles repair (with a modified Kessler-type suture). Functional performance was determined from the measurements of hindpaw prints utilizing the Achilles Functional Index. On day 15, the animals were killed, and biomechanical and histological evaluations were performed on both the injured and uninjured Achilles tendon constructs.

All groups subjected to Achilles tendon division had a significant initial functional impairment that gradually improved so that by day 15 there were no functional or failure load impairments in any group. The injured tendons in all three groups subjected to Achilles tendon division had a 13-fold increase in the cross-sectional area and were less stiff and more deformable than uninjured and sham-operated tendons on day 15 ( P < .001). The magnitude of the biomechanical and morphological changes at postoperative day 15 and the initial impairment and rate of functional recovery were similar for no repair, internal splint, and Achilles repair groups. In summary, this study demonstrates that surgical repair of the Achilles tendon in the rat does not offer any advantage over nonoperative management.
Calcaneal Fracture-Dislocation with Entrapment of the Medial Neurovascular Bundle: A Case Report
Authors: Mallik Arati R. , Chase Mark D. , Lee Paul C. , Whitelaw George P.
Published: March 2013

The calcaneus is the most commonly fractured of all the tarsal bones. Soft-tissue interposition, usually involving the peroneal tendons, has been reported to block reduction of calcaneal fractures and subtalar dislocations. 3 , 4 , 10 To our knowledge, no case of entrapment of the neurovascular bundle has been reported. This is the subject of our report.
Spontaneous Atraumatic Rupture of the Flexor Hallucis Longus Tendon Under the Sustentaculum Tali: Case Report, Review of the Literature, and Treatment Options
Authors: Thompson Francesca M. , Snow Steven W. , Hershon Stuart J.
Published: March 2013

A case of spontaneous rupture of the flexor hallucis longus tendon within the hind part of the foot is reported in a middle-aged woman who had no trauma or systemic disease. Repair was effected by tenodesis to the flexor digitorum longus tendon above and below the fibro-osseous tunnel. Hyperextension of the interphalangeal joint which most troubled the patient was corrected postoperatively. Active range of motion was equal in extension. Flexion at the IP joint was present, but significantly less than the unaffected side.
The Blood Supply to the Great Toe Sesamoids
Authors: Chamberland Patricia D. C. , Smith Judith W. , Fleming Lamar L.
Published: March 2013

The purpose of this study was to define the intraosseous and extraosseous blood supply of the hallucal sesamoids by studying a total of 10 fresh-frozen, below-knee specimens with no evidence of vascular disease. Most specimens were injected with high grade India ink, cleared using a standard Spalteholz technique, and processed to delineate the extraosseous and intraosseous blood supply to include soft tissue dissection and coronal sectioning. Two additional specimens were injected with blue Mercox acrylic solution to further define the extraosseous vasculature.

The major extraosseous blood supply to the sesamoids is via the posterior tibial artery. This vessel then branches into the medial plantar artery which further divides upon entering the medial and lateral sesamoids in their proximal poles. Vessels in the peripheral soft tissues, although abundant, do not seem to penetrate the cortex of the sesamoids.

The intraosseous blood supply to the sesamoids seems to be threefold. Mainly, sesamoid arteries enter the lateral and medial sesamoids from the proximal aspect via a single vessel. This proximal vessel proceeds distally with a network of branching. Plantar, nonarticular vessels enter the sesamoids, constituting a second source of vascularity. Finally, small vessels also enter the sesamoids through medial and lateral capsular attachments.

Based on this study, a possible explanation for avascular necrosis and nonunion of sesamoids is proposed, and an optimal surgical approach is discussed. A medial operative approach avoiding the proximal pole of the sesamoids will preserve the main arterial source. The plantar surface of the sesamoids should also be avoided. Minimal dissection through the circumferential soft tissue vascular sleeve is recommended.
Repair of Chronic Achilles Tendon Rupture with Flexor Hallucis Longus Tendon Transfer
Authors: Wapner Keith L. , Pavlock Gail S. , Hecht Paul J. , Naselli Francis , Walther Robyn
Published: March 2013

A new technique is described for reconstruction of chronic Achilles tendon rupture using the flexor hallucis longus tendon. Follow-up on seven patients (mean age 52 years) is provided (average follow-up 17 months, range 3–30 months). All patients were re-examined to assess postoperative range of motion, scar healing, and sensation. Motor strength was assessed by Cybex testing. Subjective satisfaction was examined by completion of a questionnaire. There were no postoperative infections, skin losses, or re-ruptures. Each patient developed a small but functionally insignificant loss in range of motion in the involved ankle and great toe. All patients had a satisfactory return of function. One patient required a molded foot-ankle orthosis for extended ambulation but was able to play golf.
Foot and Ankle Manifestations of Charcot-Marie-Tooth Disease
Authors: Holmes James R. , Hansen Sigvard T.
Published: March 2013

The term Charcot-Marie-Tooth disease represents a spectrum of neurological dysfunction more recently described as hereditary motor-sensory neuropathies. An abnormality of myelination is thought to be responsible for the clinical manifestations. While histological findings have been well described, the exact biochemical basis for this disorder remains unknown.

Over one half of patients with Charcot-Marie-Tooth disease manifest foot and ankle problems, including pain, weakness, deformity, and, rarely, paresthesias. Characteristic patterns of neuromuscular weakness have been identified. Bilateral pes cavovarus is the most common pathologic foot deformity seen. The specific components include hindfoot varus, anterior or forefoot cavus, and, often, clawtoes. The etiology of this abnormal foot posture usually results from tibialis posterior overpowering peroneus brevis coupled with peroneus longus overpowering tibialis anterior.

Multiple treatment options have been described. Rationale for specific tendon transfers, soft tissue release, osteotomies, and arthrodesis is discussed. Results of surgical intervention are difficult to interpret and compare because of the wide spectrum of both neurological dysfunction and described operative procedures. In the presence of flexible deformity, early soft tissue release and tendon transfers may help prevent or delay more extensive bony procedures. The clinical results of triple arthrodesis in the Charcot-Marie-Tooth disease patient appear to deteriorate with time.

Genetic transmission, progression of the neurological dysfunction, flexibility of the deformity, distribution of muscular weakness, and anticipated foot demands vary a great deal within this patient population. Treatment decisions, therefore, must be individualized and based upon a clear history, careful examination, and well-defined patient goals.
Tuberculosis of Bones and Joints of the Foot: An Analysis of 22 Cases
Authors: Dhillon Mandeep S. , Sharma Suresh , Gill S.S. , Nagi O.N.
Published: March 2013

Skeletal tuberculosis constitutes 1% to 3% of extrapulmonary cases and involvement of foot bones is rare. Lack of awareness and a confusing clinical and radiological picture often lead to a delay in diagnosis. We reviewed 23 feet seen over a 3.5-year period. Most cases were children or young adults less than 40 years of age; isolated bony involvement was seen in 10 feet, with the calcaneus being involved in five cases. Articular involvement at presentation was seen in 13 cases and these cases had significantly higher delays in diagnosis. Twenty cases responded to antitubercular therapy alone while one case had to be operated (there was one fatal outcome). Complete resolution of sequestra was seen with antitubercular therapy alone. The results were better in cases with isolated bony involvement, while cases with joint involvement had residual sequelae in the form of stiffness or pain. Two patients were advised arthrodesis. Early diagnosis and antitubercular therapy is essential to prevent joint involvement from periarticular bony lesions; surgical intervention is rarely needed. A high index of suspicion has to be maintained in high risk groups like Asian immigrants. Concomitant extraskeletal lesions may not always be present.
The Influence of Tibialis Anterior Muscle Activity on Rearfoot Motion during Walking
Authors: Cornwall Mark W. , Mcpoil Thomas G.
Published: March 2013

The purpose of this study was to determine whether tibialis anterior muscle activity influences the rate of rearfoot motion during walking. Two-dimensional rearfoot motion was recorded from 23 feet. The feet were assigned to one of two experimental groups. Muscle activity was recorded from the tibialis anterior muscle using surface electrodes. The early pronators (N = 12) reached maximal pronation within the first 20K of the stance phase. The late pronators (N = 11) reached maximal pronation only after 40% of the stance phase. The results of a C-test showed that there was a significant difference (P < .05) in the time to minimal tibialis anterior muscle activity between the two groups. These results indicate that tibialis anterior muscle activity can influence rearfoot motion during the stance phase of walking. A clinician should consider the muscular system when evaluating and designing a treatment program for patients with foot-related problems. The results of this study also indicate that static nonweightbearing evaluations alone may not provide an accurate picture of the foot during walking.
Magnetic Resonance Imaging in the Diagnosis of Localized Pigmented Villonodular Synovitis of the Ankle: A Case Report
Authors: Konrath Gregory A. , Shifrin Louis Z. , Nahigian Kevin
Published: March 2013

The use of magnetic resonance imaging (MRI) in pigmented villonodular synovitis (PVS) has been well described in the literature. MRI has been used predominantly with diffuse PVS lesions. We recently had a patient with an unusual case of localized PVS of the ankle with bone and cartilage destruction. Preoperative MRI was useful in the diagnosis of localized PVS and in the planning for surgery. MRI in a patient with this lesion had not been documented previously, but should be considered whenever PVS, either diffuse or localized PVS, is suspected.
The Diagnostic Efficacy of Magnetic Resonance Imaging and Ultrasonography in Morton's Neuroma: A Radiological-Surgical Correlation
Authors: Resch Sylvia , Stenstrom Anders , Jonsson Asbjorn , Jonsson Kjell
Published: March 2013

All patients operated upon for Morton's neuroma during 1991 who were examined with both magnetic resonance imaging and ultrasonography were included in this prospective study. The object of the study was to evaluate the diagnostic value of these two modalities. The preoperative diagnosis was purely clinical. Histology confirmed surgical findings. A 0.3 T scanner was used for the magnetic resonnance imaging, and a 7.5 MHz linear transducer was used for the ultrasonography. The study includes ninepatients. Eight neuromas were found at surgery. This indicicates that false negative diagnoses are common. At present we find these modalities of little or no value, but, with improved these modalities of little or no value, but, with improved equipment and experience, they may become valuable.
The Extra-Depth Toe Box: A Rational Approach
Authors: Kaye Robert A.
Published: March 2013

The conservative management of foot deformities often requires the use of a modified shoe. A higher toe box is one of the most common variations required when the abnormality is located in region of the forefoot. High toe boxes are available in a variety of footgear, including athletic sneakers, comfort shoes, and prescription footwear. A rational approach to accommodating a deformed forefoot would be to first measure the maximum height of the abnormal toes in a weightbearing position. Then, by referring to a table listing shoes and available toe box space, the physician could match the foot with a shoe. The purpose of this study was to collect and tabulate measurements of toe box height for a variety of shoes.

Impressions were taken from various shoes using a moldable plastic material. Toe box height was then measured and recorded. Results were tabulated for various types of men's and women's shoes. The depth of shoes at the point 5 cm from the tip of the toe was about 44 mm for most styles. The sagittal profile (i.e., vertical height available) of extra-depth shoes, comfort shoes, and athletic shoes was similar.
Removal of Internal Fixation—The Effect on Patients’ Complaints: A Study of 66 Cases of Removal of Internal Fixation after Malleolar Fractures
Authors: Jacobsen Steffen , Lichtenberg Mette Honnens de , Jensen Claus Munk , Tørholm Carsten
Published: March 2013

To estimate the effect of removal of internal fixation after treatment of malleolar fractures on postoperatively presented complaints, we retrospectively evaluated 66 patients by their records and by personal questionnaires. Of all the patients, 89.4% had one or more complaints. These were typically soreness over implant and cicatrix, reduced movement of the ankle joint, and strain-related pain. About 75% of these patients reported improvement after removal. The AO mode of fixation, i.e., typically by lateral semitubular plating and transsyndesmotic screw and a medial screw or pins, and the Wiberg-Cedell mode, i.e., typically consisting of lateral single or double cerclage and staple and medial pinning, constituted the principal groupings of the patients. The two groups were comparable. In this series, we found significantly more complaints associated with the AO mode in the postoperative period. We conclude that removal of internal fixation after malleolar fractures is indicated when common types of complaints are presented.
Analysis of Surgical Treatment of 33 Foot and Ankle Tumors
Authors: Chou Loretta B. , Malawer Martin M.
Published: March 2013

Thirty-three patients treated for tumors of the foot and ankle at one cancer institution over a 14-year period were reviewed. There were 15 females and 18 males, with an age range of 1 to 64 years (average 22.6 years). Twenty-one tumors were benign, 11 were malignant, and 1 tumor had metastasized. The most common diagnoses were: fibromatosis (10), aneurysmal bone cyst (4), synovial sarcoma (4), chondrosarcoma (3), and other (12). Surgical procedures included: wide resection (14), local resection (8), curettage and cryosurgery (7), and below-knee amputation (4). Follow-up from surgery was 1 to 13 years (average 7.2 years). There were no local recurrences. Functional results were good-to-excellent in 82% (27/33) of patients. Fifty-five percent (18/33) of the patients were full weightbearing and enjoyed unlimited activity.
Radiographic Changes in the First Metatarsal Head after Distal Chevron Osteotomy Combined with Lateral Release Through a Plantar Approach
Authors: Thomas Ruth Lourdes , Espinosa Francisco J. , Richardson E. Greer
Published: March 2013

The purpose of this study was to evaluate the development of clinically significant avascular necrosis of the head of the first metatarsal after: (1) distal metatarsal osteotomy of the chevron configuration beginning apically at the center of the metatarsal head and extending into the head metatarsal neck junction and (2) release of the adductor hallucis muscle, the lateral capsulosesamoid ligament, and the lateral head of the flexor hallucis brevis via fibular sesamoidectomy in the majority of procedures (71/77).

Although there were initial radiographic findings suspicious of avascular necrosis, subchondral lucencies (28 feet), mottling (40 feet), and focal lucencies (29 feet) in 76% of the feet, at final follow-up (12–43 months, average 25 months) this figure had fallen to 25%. The range of motion of the first metatarsophalangeal joint and articular symptoms were important in this study because of the assumption that these two parameters of evaluation would correspond to the severity of radiographic evidence of avascular necrosis. Only those patients (8 feet) with persistent mottling at final follow-up had a statistically significant decrease in the average range of motion ( P = .013), with 51° total arc of motion compared with 64° total arc of motion for the remainder.

There were no patients with persistent radiographic changes suggesting avascular necrosis who complained of pain. We concluded from the radiographic and clinical data that if the primary blood supply to the capsule and head of the metatarsal (the first dorsal intermetatarsal artery) is preserved, an extensive lateral release combined with a distal metatarsal osteotomy of the chevron configuration are unlikely to cause clinically significant avascular necrosis of the first metatarsal head. By clinically significant, we refer to range of motion and articular pain.
Redefining the Anatomy of the Anterior Tibialis Tendon
Authors: Fennell Colin W. , Phillips P.
Published: March 2013

The observation that, when performing a split anterior tibialis tendon transfer, a twist develops as the distal segment is brought into position on the lateral side of the foot led to our hypothesis that, as a consequence of foot rotation during embryologic development, rotation of the tendon of the anterior tibialis muscle also occurs and can be seen in the adult.
Vertical Shear Fractures of the Medial Malleolus: A Biomechanical Study of Five Internal Fixation Techniques
Authors: Toolan Brian C. , Koval Kenneth J. , Kummer Frederick J. , Sanders Roy , Zuckerman Joseph D.
Published: March 2013

Fifty embalmed human tibias were osteotomized to create a simulated vertical shear (supination-adduction) fracture of the medial malleolus and were stabilized using one of five internal fixation techniques.

In offset axial testing, which simulated supination-adduction loading, the fixation strength of tibias stabilized with either cortical or cancellous lag screws placed perpendicular to the osteotomy was over five times greater than the strength of those treated with an antiglide plate and nearly two and a half times greater than those treated with cancellous lag screws placed oblique to the osteotomy. The tibias stabilized with cancellous lag screws placed perpendicular to the osteotomy exhibited twice the fixation strength of the tibias stabilized with an antiglide plate and distal lag screw. The tibias stabilized with an antiglide plate and distal lag screw and perpendicularly placed cortical or cancellous lag screws demonstrated three times greater resistance to displacement to the applied supination-adduction load than those stabilized with an antiglide plate alone.

In offset transverse testing, to simulate loading in external rotation, the mean failure load of the tibias stabilized with cancellous lag screws placed perpendicular to the osteotomy was over two and a half times greater than those stabilized with an antiglide plate and distal lag screw. No significant differences were observed in the resistance to displacement for these tests.

These results support the use of lag screws placed perpendicular to the fracture surface for stabilization of vertical shear fractures of the medial malleolus and indicate that the use of an antiglide plate, with or without a distal lag screw, does not offer any advantage over lag screw fixation.
Combined Rupture of the Anterior Tibial and Posterior Tibial Tendons: A New Clinical Entity
Authors: Ouzounian Tye J.
Published: March 2013

Two patients with combined rupture of the anterior tibial tendon and posterior tibial tendon are described. Both were elderly women with a gradually progressive valgus deformity of the ankle/hindfoot and severe pain. Arthrodesis procedures were performed in both patients; however, postoperative complications prevented significant clinical improvement. This combined tendon rupture is presented to document a new clinical entity.
Treatment of the Atypical Lesser Toe Deformity with Basal Hemiphalangectomy
Authors: Conklin Mark J. , Smith Ronald W.
Published: March 2013

Eighty-six lesser toe basal hemiphalangectomies were performed in 52 patients. The surgical technique included an oblique dorsal incision, resection of 8 mm of bone, and an extensor tenotomy. Minimum follow-up was 2 years (range 2–6/1/2 years). Sixty percent of the patients had total relief of pain. Twenty-nine percent stated that they would not have the surgery again, and we categorized these patients as dissatisfied.

An extensor tenotomy increased the satisfaction rate and was found to decrease the radiographic sagittal angulation of the toe.

The preoperative diagnosis was significant to the outcome of the surgery. Patients with metatarsophalangeal joint synovitis and rheumatoid toe deformities had high rates of satisfaction; those with transverse deviation, metatarsalgia, and hammertoes with metatarsophalangeal joint subluxation/dislocation had lower rates of satisfaction. Seventy percent of the dissatisfied patients were dissatisfied because of persistent flexion deformity of the PIP joint or pain under the metatarsal head. We now add a PIP fusion if any flexion deformity, even a mild deformity, is present at the PIP joint and a plantar metatarsal condylectomy for metatarsalgia.