bluuebunny/crossref_metadata_2025 huggingface dataset:
Intramedullary Screw Fixation of Lateral Malleolus Fractures
Authors: Bankston A. Brent , Anderson Lewis D. , Nimityongskul Prasit
Published: March 2013

A biomechanical evaluation of intramedullary versus buttress plate and lag screw fixation of lateral malleolus fractures is combined with a clinical evaluation of 44 patients with lateral malleolus fractures who underwent intramedullary screw fixation.

The biomechanical study was performed in experimentally produced, Weber B, supination-eversion ankle fractures. The fractures were fixed with one of the two above fixation methods and then placed under a torsional load to failure. Sixteen cadaver ankles were tested as compared with native bone. The intramedullary screw provided 66.5% the resistance of torsion, and the buttress plate and lag screw provided 61.5% the resistance to torsion. There was no statistical difference between these two groups.

The 44 fractures treated with an intramedullary screw were reviewed retrospectively. There was one failure of fixation, and one prominent hardware problem. Time to full weightbearing averaged 7.2 weeks.

These results suggest that intramedullary screw fixation of noncomminuted lateral malleolus fractures provides stable fixation with good clinical results. This technique has the advantages of providing dynamic intramedullary fixation with limited surgical dissection and no subcutaneous hardware.
Tibiotalocalcaneal Arthrodesis with an Intramedullary Device
Authors: Kile Todd A. , Donnelly Richard E. , Gehrke Jon C. , Werner Mark E. , Johnson Kenneth A.
Published: March 2013

An intramedullary fixation device was devised by the senior author (K.A.J.) to use in conjunction with a previously described method for tibiotalocalcaneal arthrodesis. Satisfactory results were obtained in approximately 87% of the initial 30 patients; union was radiographically or clinically evident in all but two patients. Many of these patients had been offered or were considering below the knee amputation; only two ultimately chose this reconstructive option at a follow-up that ranged from 4 to 27 months.
Pigmented Villonodular Synovitis of the Ankle: A Case Report and Review of the Literature
Authors: Friscia David A.
Published: March 2013

Pigmented villonodular synovitis is an unusual benign tumor of the joint lining. It is most common in the knee, but occasionally occurs in the ankle. It can present with pain and swelling of the joint. The appearance is characteristic on a magnetic resonance imaging scan. Complete excision and synovectomy is the usual treatment.
Mycobacterium phlei Infection of the Foot: A Case Report
Authors: Spiegl Paul V. , Feiner Clifford M.
Published: March 2013

A case of Mycobacterium phlei infection in the flexor digitorum longus and posterior tibialis tendon of an otherwise healthy adult male is reported. To our knowledge, this is the second reported case in the English literature of human infection by M. phlei. Diagnosis and treatment of nontuberculous mycobacterial infection are discussed. The clinician is encouraged to include this infection in the differential diagnosis of pain and swelling in the extremity.
Surgical Correction of Rheumatoid Forefoot Deformities
Authors: Mann Roger A. , Schakel Mark E.
Published: March 2013

Surgical correction of severe rheumatoid forefoot deformities with resection arthroplasties of the lesser metatarsal phalangeal joints and arthrodesis of the first metatarsal phalangeal joint resulted in a significant long-term improvement with respect to shoe wear, pain, and the ability to stand and walk in 95% of the patients. Ninety percent had a good or excellent functional result. There was minimal recurrence of deformity.

Modifications of the procedure with maintenance of the proximal phalangeal bases and K-wire fixation of the metatarsal phalangeal arthroplasty and interphalangeal joints resulted in an improved cosmetic result and simplified postoperative management with an equal functional result and no increase in recurrence of deformity or complications.
Local Anesthesia for Postoperative Pain Relief after Foot Surgery: A Prospective Clinical Trial
Authors: Needoff Maurice , Radford Philip , Costigan Patricia
Published: March 2013

A prospective, randomized, controlled clinical trial was set up to test whether the addition of ankle block to general anesthesia was useful in providing postoperative pain relief following forefoot surgery. Forty feet (20 treatment, 20 control) were entered into the trial and all underwent bony operations on the first ray. Pain was assessed at fixed times following the operation using pain analog scales. Analgesic consumption and wound healing were also assessed.

A significant difference was found between the pain scores in the two groups at the 6-hr stage, but there was no difference in any of the other assessments. It is concluded that ankle block is a useful addition to general anesthesia for this type of surgery.
Osteoid Osteoma of the Tarsal Cuboid Presenting with Recurrent Ankle Sprains in an Adolescent: A Case Report
Authors: Trettin David M. , Browne Jon E.
Published: March 2013

This case report illustrates an unusual cause of recurrent ankle sprains in a high school wrestler—osteoid osteoma of the cuboid bone in which the initial bone scan obtained was negative.
Modified Tension Band Wiring of Medial Malleolar Ankle Fractures
Authors: Georgiadis Gregory M. , White Drake B.
Published: March 2013

Twenty-two displaced medial malleolar ankle fractures that were treated surgically using the modified tension band method of Cleak and Dawson were retrospectively reviewed at an average follow-up of 25 months. The technique involves the use of a screw to anchor a figure-of-eight wire. There were no malreductions and all fractures healed. Problems with the technique included technical errors with hardware placement, medial ankle pain, and asymptomatic wire migration. Despite this, modified tension band wiring remains an acceptable method for fixation of selected displaced medial malleolar fractures. It is especially suited for small fracture fragments and osteoporotic bone.
Hallux Valgus in Ballet Dancers: A Myth?
Authors: Einarsdottir Hildur , Troell Staffan , Wykman Anders
Published: March 2013

Among dancers it is widely believed that ballet dancing induces hallux valgus. Revision of radiographs of 63 active and 38 retired dancers of both sexes showed no increase in the valgus angulation of the hallux compared with that of nondancers.
A Method to Facilitate Suture Removal
Authors: Trepman Elly , Mizel Mark S. , Mann Roger A.
Published: March 2013

Suture removal is facilitated when the strands are kept long and tied together. At removal, tension is applied to the long strands to pull the knot up from the skin surface, and the suture is cut with a scalpel. This method obviates the potential difficulty of finding a short suture tip with a forceps or passing the scissor tip under the knot of a tight suture, both potential causes of patient discomfort.
First Metatarsocuneiform Motion: A Radiographic and Statistical Analysis
Authors: Fritz Germaine R. , Prieskorn David
Published: March 2013

Fifty volunteers with 100 asymptomatic feet were evaluated by physical examination, radiographic analysis, and questionnaire. This investigation was used to evaluate first metatarsocuneiform motion and establish normal values at this joint. Normal first ray sagittal range of motion was 4.37° (SD, ±3.4°). The shape of the distal cuneiform was then categorized by three classification methods. Multiple independent variables were cross-referenced to determine their relationship with motion and shape at the distal cuneiform. Hyperflexibility of the thumb correlated with first ray hypermobility. No correlation was found between first ray motion and sex, age, intermetatarsal angle, side, skin stretch, hyperextension of the knee, hyperextension of the elbow, or shape of the distal cuneiform.
Syme Ankle Disarticulation in Peripheral Vascular Disease and Diabetic Foot Infection: The One-Stage versus Two-Stage Procedure
Authors: Pinzur Michael S. , Smith Douglas , Osterman Helen
Published: March 2013

A prospective randomized trial compared performing a Syme ankle disarticulation using a one-stage versus Wagner's two-stage technique. Surgery was performed at two University Medical Centers where patients underwent amputation surgery for gangrene or nonsalvageable diabetic foot infection. Those undergoing surgery subsequent to trauma or congenital anomaly were eliminated. Initially, 21 patients were randomized into one-stage and two-stage surgery. The randomization was stopped for ethical reasons when the results of both procedures appeared to be similar. The next 22 consecutive patients underwent 23 Syme ankle disarticulations in one-stage surgery. Selection of amputation level was based on clinical examination, transcutaneous oximetry as a measure of vascular inflow, serum albumin as a measure of tissue nutrition, and total lymphocyte count as a measure of immunocompetence.

As a total group, 31 of 44 amputations progressed to amputation wound healing and prosthetic limb fitting. In the randomized group, 9 of 13 one-stage and 5 of 8 two-stage surgeries healed. In the subsequent consecutive group, 17 of 23 healed. In all, 26 of 36 one-stage and 5 of 8 two-stage surgeries healed successfully.

We concluded from this study that Syme ankle disarticulation may be performed as safely in one stage as in two stages in properly selected patients and, therefore, recommend the one-stage Syme ankle disarticulation in those patients suitable for this level amputation.
Distraction Osteogenesis for Congenitally Short Lesser Metatarsals
Authors: Levine Stuart E. , Davidson Richard S. , Dormans John P. , Drummond Denis S.
Published: March 2013

Six lesser metatarsal lengthening procedures were performed in three patients using a miniature external fixator to perform distraction osteogenesis. The metatarsals were lengthened an average of 15.5 mm. The external fixator was left in place for an average of 15.5 weeks, with additional time in a cast or cast shoe.

Complications included five occurrences of infection, two cases of premature healing of the osteotomy, one nondisplaced fracture through the new bone formation, and hypertrophic granulation at a pin site. While all metatarsals were successfully lengthened, two rays (one patient) had symptomatic stiffness at the metatarsophalangeal joint with continued metatarsalgia.
Gait Analysis of the Donor Foot in Microsurgical Reconstruction of the Thumb
Authors: Barca Francesco , Santi Alessandro , Tartoni Pier Luigi , Landi Antonio
Published: March 2013

Clinical and step evaluations by a piezoelectric system board were performed in 54 patients who underwent microsurgical reconstruction of the thumb by great or second toe transfer. Forty-four patients were male and 10 were female. In 13 cases, the thumb was reconstructed by the Morrison wrap-around technique. In 27 cases, an extended variant of the Morrison technique was used in which the whole distal phalanx was harvested with skin and nail apparatus. Four patients were treated by great toe transfer and 10 were treated by second toe transfer. Follow-up ranged from 2 to 144 months.

The group of patients treated by the wrap-around technique presented hallux rigidus in 38.5% of cases. The group of patients treated by the extended variant of the Morrison technique presented a lesser tendency to hallux rigidus but a clear reduction of the pushing phase of hallux. The group of patients treated by second toe transfer presented a third and fourth metatarsal bone overload that was confirmed by a statistical Wilcoxon test: overload was linked to a plantar hyperkeratosis at the third metatarsal (20%), fourth metatarsal (10%), or fifth metatarsal bone (20%). A claw deformity of the third and fourth toes was observed in 20% of these patients. The four patients who underwent microsurgical reconstruction of the thumb by great toe transfer exhibited an overload of central and lateral metatarsal bones.

Second toe transfer is not associated with the functional or cosmetic changes seen in great toe transfer and is therefore preferred.

The cosmetic and functional results from extended great toe transfer make this a much less desirable transfer than the wrap-around or modified wrap-around technique. The transfer with the least donor site problem is second toe to thumb.
Partial Rupture of the Flexor Hallucis Longus Tendon in a Tennis Player: A Case Report
Authors: Trepman Elly , Mizel Mark S. , Newberg Arthur H.
Published: March 2013

A 39-year-old woman sustained a forced dorsiflexion injury to the left great toe while pivoting to the right during tennis activity. Posteromedial ankle pain was reproduced with active plantarflexion and passive dorsiflexion of the great toe and, to a smaller extent, the lesser toes. Symptoms persisted for 9 months despite nonoperative treatment. Magnetic resonance imaging 5 months after injury revealed evidence of fluid surrounding the flexor hallucis longus (FHL) tendon. Operative findings 9 months after injury included scar tissue and tenosynovitis of the FHL and flexor digitorum longus tendon sheaths, with impingement of distal FHL muscle fibers and a longitudinal split tear (partial rupture) of the FHL tendon. Tenolysis, tenosynovectomy, excision of the distal muscle fibers, and repair of the partial tendon rupture were performed, resulting in resolution of symptoms. Partial rupture of the FHL tendon as a single-impact injury, or in activity other than ballet, has not been documented previously.
Aiming Guide for Accurate Placement of Subtalar Joint Screws
Authors: Gable Steve J. , Bohay Donald R. , Manoli Arthur
Published: March 2013

Accurate placement of rigid fixation of the subtalar joint in arthrodesing procedures (triple, subtalar, or pantalar arthrodesis) can be difficult. We have found that the “bottom-up” method simplifies this procedure and eliminates many potential problems. A technique is described incorporating the bottom-up method utilizing the combined aiming device (Synthes, Paoli, PA).
Histology and Histomorphometric Analysis of the Normal and Atrophic Heel Fat Pad
Authors: Buschmann William R. , Jahss Melvin H. , Kummer Frederick , Desai Panna , Gee Russell O. , Ricci John L.
Published: March 2013

Light and electron microscopy was used for a histologic examination of normal heel fat pads and atrophic heel fat pads from patients with peripheral neuropathies. Histomorphometric analysis revealed an average 30% smaller mean cell area and 16% smaller mean cell diameters in the atrophic pads compared with the normal heel fat pads. Septal walls in the atrophic fat pads were often fragmented and approximately 75% wider than normal. Perineural fibrosis was also found in the atrophic heel fat pads. The Verhoeff elastic staining technique was used to determine the relative percentage of collagen to elastic tissue within the septae. No significant differences were noted between the normal and atrophic heels.

The ultrastructure of the adipocytes from the normal and atrophic heel pads was similar to those found in abdominal subcutaneous fat. Lipid droplets of variable size and density within the center of the adipocyte were surrounded by a thin border of cytoplasm. The interphase between adipocytes contained fine collagen and elastic fibers.
First Ray Joint Limitation, Pressure, and Ulceration of the First Metatarsal Head in Diabetes Mellitus
Authors: Birke James A. , Franks B. Don , Foto James G.
Published: March 2013

Measurements of first ray mobility, pressure, and other variables were made on 19 diabetic patients with a history of ulceration at the first metatarsal head, 20 diabetic patients with a history of ulceration at other locations of the forefoot, 19 matched diabetic controls, and 19 matched nondiabetic controls.

Patients with a history of first metatarsal head ulceration had significantly less first ray mobility and significantly higher pressure at the first metatarsal head compared with the other groups. Regression analysis found a moderate inverse linear relationship between first ray dorsiflexion and peak pressure at the first metatarsal head (R2 = 0.46, P < .0001).

Results showed that sensory loss, duration of diabetes, and limited range of motion at the hip, ankle, and foot were related to ulcerations at all forefoot locations. Limited first ray mobility and high pressure at the first metatarsal head were related to ulcerations only at the first metatarsal head location.
Symptomatic Ossification of the Tibiofibular Syndesmosis in Professional Football Players: A Sequela of the Syndesmotic Ankle Sprain
Authors: Veltri Daniel M. , Pagnani Michael J. , O'Brien Steven J. , Warren Russell F. , Ryan Michael D. , Barnes Ronnie P.
Published: March 2013

Ankle syndesmosis sprains are common injuries in collegiate and professional football. Several reports have documented that patients with syndesmosis injuries require a longer time to return to full athletic participation than patients with lateral ankle sprains. Here we present the cases of two professional football players with ankle pain secondary to syndesmosis ossification following documented syndesmosis ankle sprains. Both patients eventually required resection of the heterotopic ossification to allow a pain-free return to football. We conclude that syndesmosis ossification may be symptomatic in some patients, and surgical excision of the ossification may be required to allow an asymptomatic return to sports.
Calcific Bursitis in a Three-Year-Old Boy: A Case Report
Authors: Hatori Masahito , Sakurai Minoru , Watanabe Nikichi , Oomamiuda Kouichi
Published: March 2013

This is a case report of calcific bursitis adjacent to the first metatarsophalangeal (MP) joint in a 3-year-old boy. The patient had two attacks of pain on the medial side of the first MP joint, resembling an acute gouty attack. Roentgenograms showed calcified opacity adjacent to the medial side of the first MP joint. Surgical removal of the calcified bursa was performed. X-ray analyses revealed that this calcified deposit was hydroxyapatite.
Fixation of the Chevron Osteotomy Utilizing Absorbable Polydioxanon Pins
Authors: Small Henry N. , Braly W. Grant , Tullos Hugh S.
Published: March 2013

The Chevron osteotomy has become popular for the treatment of hallux valgus deformity. Displacement of the osteotomy is a known complication. Many methods of internal fixation have previously been reported to prevent the displacement and each has inherent advantages and disadvantages. An alternative method of fixation, utilizing absorbable polydioxanon pins, is presented in this article. Between April 1989 and April 1990, 71 procedures were performed on 50 patients. At 1-year follow-up, there were no complications or infections. Review of the osteotomy after surgery and at 1 year revealed no fractures or displacements, and no pins required removal. Internal fixation utilizing absorbable polydioxanon pins appears to have significant benefits when compared with metallic fixation.
Integrity of the First Metatarsophalangeal Joint: A Biomechanical Analysis
Authors: Prieskorn David , Graves Stan , Yen Michael , John Ray , Randy Schultz
Published: March 2013

Five fresh-frozen cadaver feet obtained from traumatic amputations were tested during hyperdorsiflexion stress of the first metatarsophalangeal joint. Three different types of injury were observed: (1) rupture of the capsule proximal to the sesamoids, (2) rupture of the plantar plate distal to the sesamoids, and (3) rupture of the capsular structures medially, allowing a lateral swing of the sesamoids around the metatarsal head. Incomplete dislocation can be associated with significant damage to the plantar plate and other soft tissues of the foot.
Long-Term Costs for Foot Ulcers in Diabetic Patients in a Multidisciplinary Setting
Authors: Apelqvist Jan , Ragnarson-Tennvall Gunnel , Larsson Jan , Persson Ulf
Published: March 2013

The purpose of this study was to analyze long-term costs for foot ulcers in diabetic patients. Patients were treated and followed prospectively by a foot care team. A retrospective economic analysis was performed of costs for 274 patients during 3 years from healing of an initial foot ulcer, with or without amputation. Costs were estimated for inpatient care, outpatient care, home care, and social service. The cost calculations include costs due to complications and disability related to the initial ulcer, costs related to recurrence of ulcer, and costs for prevention of new ulcers.

Expected total present value cost per patient during 3 years of observation was $26,700 (U.S. dollars) for primary healed patients with critical ischemia and $16,100 for primary healed patients without critical ischemia. For patients who healed with an amputation, the corresponding costs were $43,100 after a minor amputation and $63,100 after a major amputation.

When estimating the costs for diabetic foot ulcers, it is not sufficient to calculate short-term costs. Long-term costs are high, mainly due to the need for increased home care and social service, but also due to costs for recurrent ulcers and new amputations.
Tibiocalcaneal Arthrodesis
Authors: Mann Roger A. , Chou Loretta B.
Published: March 2013

A review of eight patients who underwent nine tibiocalcaneal arthrodeses was performed. The surgical indications were failed previous surgery, posttraumatic talar avascular necrosis, and rheumatoid arthritis. The average age at the time of operation was 54 years. The average time of follow-up was 40 months after the operation. Fusion was achieved in all nine feet, with an average time of fusion of 5 months. Results were excellent in three feet, good in four feet, fair in one foot, and poor in one foot. The average leg length discrepancy was 2 cm. The average position of fusion was 6° of valgus and 2° of plantarflexion. All patients stated that they had improvement of pain and function. Seven of the eight patients stated that they would have the procedure done again. Complications were local infection in two patients, malunion in two patients, wound slough in one patient, and a prominent fibula in one patient. Tibiocalcaneal arthrodesis should be reserved as a salvage procedure because it is technically difficult and has a significant risk of complications.
Irreducible Dorsal Dislocation of the Great Toe Interphalangeal Joint: Case Report and Literature Review
Authors: Crosby Lynn A. , McClellan John W. , Prochaska Vern J.
Published: March 2013

Irreducible dorsal dislocation of the interphalangeal joint of the great toe is rare. Few case reports can be found in the literature. Most cases have been treated with operative exploration of the joint and reduction through a dorsal midline incision. We present a case where a medial approach was used under local block anesthesia to treat an irreducible complex dislocation of the interphalangeal joint of the great toe.
The Long Accessory Flexor Muscle: An Anatomical Study
Authors: Peterson David Alan , Stinson Warren , Lairmore James R.
Published: March 2013

A total of 136 lower limbs from 68 human cadavers were dissected to determine the incidence of the long accessory flexor muscle and its origins and insertions. The muscle was present in 11 of 136 lower extremities (8%) and 9 of 68 cadavers (13%). Five long accessory flexor muscles originated from the tibia and fascia of the deep posterior compartment and six began on the fibula. All of the tendons were deep to the laciniate ligament and coursed within the tarsal tunnel. All five of the tendons originating from the tibia inserted on the quadratus plantae, with two of the tendons having an additional insertion on the flexor digitorum longus. Three of the tendons with fibular origin inserted on the quadratus plantae and three inserted on the flexor digitorum longus. The importance of the long accessory flexor muscle relates as a cause or association with tarsal tunnel.
Juvenile Hallux Valgus: Etiology and Treatment
Authors: Coughlin Michael J.
Published: March 2013

In an 11-year retrospective study of 45 patients (60 feet) with juvenile hallux valgus, a multiprocedural approach was used to surgically correct the deformity. A Chevron osteotomy or McBride procedure was used for mild deformities, a distal soft tissue procedure with proximal first metatarsal osteotomy was used for moderate and severe deformities with MTP subluxation, and a double osteotomy (extra-articular correction) was used for moderate and severe deformities with an increased distal metatarsal articular angle (DMAA).

The average hallux valgus correction was 17.2° and the average correction of the 1–2 intermetatarsal angle was 5.3°. Good and excellent results were obtained in 92% of cases using a multiprocedural approach. Eighty-eight percent of patients were female and 40% of deformities occurred at age 10 or younger.

Early onset was characterized by increased deformity and an increased DMAA. Maternal transmission was noted in 72% of patients. An increased distal metatarsal articular angle was noted in 48% of cases. With subluxation of the first MTP joint, the average DMAA was 7.9°. With a congruent joint, the average DMAA was 15.3°. In patients where hallux valgus occurred at age 10 or younger, the DMAA was increased.

First metatarsal length was compared with second metatarsal length. While the incidence of a long first metatarsal was similar to that in the normal population (30%), the DMAA was 15.8° for a long first metatarsal and 6.0° for a short first metatarsal. An increased DMAA may be the defining characteristic of juvenile hallux valgus. The success of surgical correction of a juvenile hallux valgus deformity is intimately associated with the magnitude of the DMAA.

Moderate and severe pes planus occurred in 17% of cases, which was no different than the incidence in the normal population. No recurrences occurred in the presence of pes planus. Pes planus was not thought to have an affect on occurrence or recurrence of deformity.

Moderate and severe metatarsus adductus was noted in 22% of cases, a rate much higher than that in the normal population. The presence of metatarsus adductus did not affect the preoperative hallux valgus angle or the average surgical correction of the hallux valgus angle.

Constricting footwear was noted by only 24% of patients as playing a role in the development of juvenile hallux valgus.

There were six recurrences of the deformities and eight complications (six cases of postoperative hallux varus, one case of wire breakage, and one case of undercorrection).
Early Motion After Repair of Achilles Tendon Ruptures
Authors: Troop Randal L. , Losse Gary M. , Lane John G. , Robertson Daniel B. , Hastings Pamela S. , Howard Mark E.
Published: March 2013

The purpose of this study was to evaluate the clinical outcome of patients treated with limited immobilization and early motion after repair of acute Achilles tendon ruptures. Thirteen consecutive patients with complete ruptures of the Achilles tendon were identified, repaired, and rehabilitated with early motion starting an average of 10 days after surgery. Active range of motion was begun at an average of 23 days and weightbearing in a walking boot was started at an average of 3.5 weeks after surgery. The average length of follow-up was 27 months. Twelve of 13 patients returned to running activities in an average of 3 months. All 12 patients who participated in lateral motion activities before their injury returned to similar activities in an average of 7 months. The patients rated their overall status at an average of 93% of their preinjury level. Follow-up Cybex testing demonstrated plantarflexion strength averaging 92%, plantarflexion power averaging 88%, and plantarflexion endurance averaging 88% of the nonindexed extremity. Early range of motion after Achilles repair is safe and there is no increased risk of rerupture in compliant patients. The patients achieved good return of plantarflexion strength, power, and endurance.
Posteromedial Process Fractures of the Talus
Authors: Ebraheim Nabil A. , Padanilam Thomas G. , Wong Fook Y.
Published: March 2013

In this report, we present the diagnosis and clinical outcome of four patients with fractures of the posteromedial process of the talus. In two patients, the posteromedial process fracture was missed initially, which led to painful nonunions. One patient was treated with excision of a nonunion, and the other patient with a nonunion refused further surgery. Two patients underwent ORIF through a posteromedial approach. CT scans were useful in defining the fracture in all four patients. Cast treatment was recommended for nondisplaced fractures or fractures without significant subtalar joint involvement. ORIF was recommended for displaced fractures with significant subtalar joint involvement.
Nonunion of a Fracture of the Sustentaculum Tali Causing a Tarsal Tunnel Syndrome: A Case Report
Authors: Myerson Mark S. , Berger Barry I.
Published: March 2013

A middle-aged man sustained an isolated sustentaculum tali fracture that formed a stable nonunion. Subsequently, tarsal tunnel syndrome developed when this sustentacular fragment migrated superiorly to cause tibial nerve impingement. The patient presented with a history of longstanding foot and ankle pain. He was pain-free 2 weeks after excision of the bony mass encased in fibrous tissue.
A Technique to Evaluate Foot Function During the Stance Phase of Gait
Authors: Siegel Karen Lohmann , Kepple Thomas M. , O'Connell Paul G. , Gerber Lynn H. , Stanhope Steven J.
Published: March 2013

A technique to measure foot function during the stance phase of gait is described. Advantages of the method include its three-dimensional approach with anatomically based segment coordinate systems. This allows variables such as ground reaction forces and center of pressure location to be expressed in a local foot coordinate system, which gives more anatomical meaning to the interpretation of results. Application of the measurement technique to case examples of patients with rheumatoid arthritis demonstrated its ability to discriminate normal from various levels of pathological function. Future studies will utilize this technique to study the impact of pathology and treatment on foot function.
Operative vs. Nonoperative Treatment of Intra-Articular Fractures of the Calcaneus: A Prospective Randomized Trial
Authors: Thordarson David B. , Krieger Lauren Eric
Published: March 2013

Thirty patients with displaced, intra-articular calcaneus fractures were randomized to operative or nonoperative treatment. All patients had two or three major articular fragments of the posterior facet (Sanders type II or III). Nonoperative treatment included early mobilization and delayed weightbearing. Operative treatment involved open reduction and rigid internal fixation with a plate and screws through an extensile, L-shaped lateral approach followed by early mobilization and delayed weightbearing. Fifteen operative patients were evaluated at an average of 17 months follow-up and 11 nonoperative patients were seen at 14 months average follow-up. In the operative group, there were 7 excellent results, 5 good results, 2 fair results, and 1 poor result, and in the nonoperative group there was 1 excellent result, 3 good results, 1 fair result, and 6 poor results (difference significant at P < 0.01). A functional scoring system of 0–100 points was developed based upon the responses to an outcome assessment questionnaire. The average functional score for the operative group was far superior at 86.7, compared with 55.0 for the nonoperative group ( P < 0.0001). Subtalar range of motion averaged 20° for the operative group and 17° for the nonoperative group with pain on extremes of motion of 25% of the operative patients compared with 100% of the nonoperative patients. This study is the first prospective, randomized trial to demonstrate the superior results of current operative treatment with early mobilization compared with nonoperative treatment.
Analysis of Cryotherapy Penetration: A Comparison of the Plaster Cast, Synthetic Cast, Ace® Wrap Dressing, and Robert-Jones Dressing
Authors: Weresh Matthew J. , Bennett Gordon L. , Njus Glen
Published: March 2013

Four groups were studied to determine the cooling effect at skin level of ice application over common ankle bandages and casts. The plaster cast, synthetic cast, and Ace® wrap dressing groups had 18 participants and the Robert-Jones dressing group had four participants. In a standardized fashion, ice bags were applied over each bandage or cast and skin temperatures were measured with a thermocouple over a 90-min period. The average final skin temperature was 16.5° in the plaster cast, 18.8° in the synthetic cast, 21.2° in the Ace wrap dressing, and 28.7° in the Robert-Jones dressing. The temperature curves showed that ice application effectively decreased skin temperatures through the plaster cast, synthetic cast, and Ace wrap dressing. The cooler temperature did not adequately penetrate the Robert-Jones dressing.
Influence of Ankle Ligaments on Tibial Rotation: An In Vitro Study
Authors: Sommer Christian , Hintermann Beat , Nigg Benno M. , van den Bogert Anton J.
Published: March 2013

The purpose of this study was to clarify the role of the ankle ligaments in controlling the tibial rotation for different foot positions. A 6 degrees of freedom device was constructed for in vitro simulation of this movement transfer during the support phase of gait. Tibia rotation angle was measured for different foot positions and vertical loads, while the ligament integrity was modified. Data were collected from eight legs of four different cadavers. The results showed that vertical loading is unimportant to influence tibial rotation, while the lateral ankle ligaments have significant influence, especially during eversion. It was concluded that chronic partial or total lateral ankle instability may contribute to knee and foot injuries through abnormal tibial rotation.
Centrocentral Anastomosis with Autologous Nerve Graft Treatment of Foot and Ankle Neuromas
Authors: Lidor Cobi , Hall Reginald L. , Nunley James A.
Published: March 2013

Painful neuromatas in the foot and around the ankle can be difficult to treat. Five patients of clinically and histologically proven neuromas underwent centrocentral union with autologous transplantation. Three patients had previous toe amputations involving multiple operations. One patient had failed multiple operative treatments for Morton's neuroma in his 3rd web space. One patient had a neuroma in his superficial peroneal nerve caused by a gun shot wound. All patients but one showed definitive subjective and objective improvement after centrocentral union with the interposed autologous nerve graft. The patient with “recurrent” Morton's neuroma had the least improvement. This technique can be recommended as an alternative for the prevention of painful stump neuromata.
Acute Midtarsal Sprains: Frequency and Course of Recovery
Authors: Søndergaard Lars , Konradsen Lars , Hølmer Per , Jørgensen Lars N. , Nielsen Poul T.
Published: March 2013

In a prospective consecutive registration of 711 ankle inversion sprains, the dorsal ligaments and capsule of the midtarsal joints were involved in 237 of the cases (33%), and in 172 cases (24%) only these joints seemed to be injured.

A total of 162 isolated midtarsal injuries and 161 cases of isolated lateral talocrural lesions selected at random were followed using questionnaires 1, 3, 6, 9, and 12 months after injury. The frequencies of pain after 1 month and swelling after 1 and 3 months were significantly lower in isolated dorsal midtarsal sprains compared with isolated lateral talocrural sprains. At the following controls, frequencies of both pain and swelling were the same for both groups. Functional instability appeared with the same frequency in both groups during the 12 months of follow-up. Regarding the social impact of the sprains, absence from work and sports did not differ between groups. When avulsions were present in midtarsal injuries recovery was slow, with two thirds of the patients experiencing pain after 6 months.

We conclude that the dorsal midtarsal sprain is a common entity with a course of recovery and a frequency of residual symptoms very like the lateral talocrural lesions.
Reliability of an In-Shoe Pressure Measurement System During Treadmill Walking
Authors: Kernozek T. W. , LaMott E. E. , Dancisak M. J.
Published: March 2013

We examined the reliability of in-shoe foot pressure measurement using the Pedar in-shoe pressure measurement system for 25 participants walking at treadmill speeds of 0.89, 1.12, and 1.34 meters/sec. The measurement system uses EMED insoles, which consist of 99 capacitive sensors, sampled at 50 Hz. Data were collected for 20 seconds at two separate times while participants walked at each gait speed. Differences in some of the loading variables across speed relative to the total foot and across the different anatomical regions were detected. Different anatomical regions of the foot were loaded differently with variations in walking speed. The results indicated the need to control speed when evaluating loading parameters using in-shoe pressure measurement techniques. Coefficients of reliability were calculated. Variables such as peak force for the total foot required two steps to achieve a coefficient of reliability of 0.98. To achieve excellent reliability (>0.90) in the peak force, force time integral, peak pressure, and pressure time integral across the total foot and the seven regions, a maximum of eight steps was needed. In general, timing variables, such as the instant of peak force and the instant of peak pressure, tended to be the least reliable measures.
A Method for Combined Percutaneous and Open Surgical Repair of Achilles Tendon Ruptures: A Report of Three Cases
Authors: Esemenli Behiç Tanil , Gündeş Hakan , Mecikoğlu Mete
Published: March 2013

Surgical treatment of Achilles tendon ruptures provides excellent functional results in active individuals, although it carries an incidence of wound complications. After experiencing a 25% wound complication rate with the traditional techniques in Achilles tendon ruptures, we modified the Bosworth technique by passing the gastrocsoleus flap percutaneously through the distal stump. This modification eliminated one third of the distal incision, which appears to be the most vulnerable part. We performed the operation in three consecutive cases. At 2-year follow-up there were no wound complications and no reruptures.
Fractures of the Calcaneus Part I: Anatomy, Injury Mechanism, and Classification
Authors: Lowery Robert B. W. , Calhoun Jason H.
Published: March 2013

Calcaneal fractures have been treated by closed methods since the time of Hippocrates. The understanding of the anatomy, injury mechanism, and classification of these fractures has advanced since surgical treatment was introduced in 1850. Despite 145 years of different treatment techniques, no consensus has been reached. Investigation into the injury patterns, anatomy, and outcomes has lead to the advances reviewed in this article.
The First Metatarsal Rise Sign: A Simple, Sensitive Sign of Tibialis Posterior Tendon Dysfunction
Authors: Hintermann Beat , Gächter André
Published: March 2013

Although foot deformation starts in the early stage of tibialis posterior (TP) tendon dysfunction, this condition is often overlooked or misdiagnosed. We observed consistently a clinical sign of TP tendon dysfunction that, to our knowledge, has not yet been described. Patients were tested while they were standing and fully weightbearing with both feet. When the shank of the affected foot was taken with one hand and externally rotated, or when the heel of the affected foot was taken with one hand and brought passively into a varus position, the head of the first metatarsal raised in the case of TP dysfunction and remained on the ground in normal TP function. The purpose of this prospective study was to validate this clinical finding by surgical exploration, and to compare its sensitivity with other common clinical signs. Our series included 21 consecutive feet with TP tendon dysfunction (19 patients). The deformity was supple in 12 feet and fixed in 9 feet. Radiographs and magnetic resonance imaging were found to be unreliable in diagnosing dysfunction of the TP tendon. While other clinical signs (too many toes, the single-heel rise, and the double-heel rise) were noted to be negative in 20% to 35%, we found our first metatarsal rise sign to be positive in all cases of TP tendon dysfunction. This simple clinical test enables us to recognize and treat a dysfunction of the TP tendon at an early stage, when the foot is still supple. As the foot deformation progresses, early treatment may be the most effective measure in preventing long-term functional impairment.
Magnetic Resonance Imaging of Acute Maisonneuve Fractures
Authors: Morris John R. , Lee Jackson , Thordarson David , Terk Michael R. , Brustein Marshall
Published: March 2013

Magnetic resonance imaging (MRI) studies were performed on five patients with acute Maisonneuve fractures. All patients had sustained a twisting injury to their ankles and complained of ankle pain and pain over their proximal fibula.

High quality images with excellent visualization of all the ankle ligamentous structures were obtained. MRI showed that the anterior inferior tibiofibular ligament was disrupted in ail patients and the posterior inferior tibiofibular ligament was intact in three of five patients. Also, the anterior talofibular ligament was disrupted in all patients and the calcaneofibular ligament was ruptured in two of five patients. This raises the question of whether patients with Maisonneuve fractures have lateral ankle instability at long-term follow-up.

Although the superficial deltoid ligament was disrupted in all patients, the deep deltoid ligament was intact in one patient, partially disrupted in one patient, and completely disrupted in three patients. The interosseous ligament was disrupted at the ankle in all patients, while the interosseous membrane was disrupted in the leg in all patients except one. This patient had an intact interosseous membrane despite rupture of the interosseous ligament at the ankle, and the presence of a proximal one third fibula fracture.
Tarsal Coalition
Authors: Kulik Steven A. , Clanton Thomas O.
Published: March 2013

Tarsal coalition is a bridging between the tarsal bones of the foot. The bridge may be composed of bone, cartilage, fibrous tissue, or a combination of these. When symptomatic, patients usually present with hindfoot pain and frequent sprains as children, adolescents, or young adults. The classical appearance is a rigid flatfoot with heel valgus and abduction of the forefoot. Flexible cavus feet have been reported. The incidence in the general population is less than 1%, and the most common types are talocalcaneal and calcaneonavicular coalitions. The cause is attributed to failure of segmentation and differentiation of the primitive mesenchyme. Calcaneonavicular coalitions can be diagnosed with an oblique radiograph of the hindfoot. Most talocalcaneal coalitions require computerized tomography for diagnostic confirmation. Magnetic resonance imaging may be useful for cartilaginous and fibrous coalitions. Casting is the usual initial treatment for the symptomatic individual. With treatment failure, in the absence of degenerative changes, resection of the coalition can be performed with good results. Isolated subtalar fusion may be performed for failed talocalcaneal resections. Failed subtalar fusions and failed calcaneonavicular resection may be treated with triple arthrodesis.
Contribution of the Deltoid Ligament to Ankle Joint Contact Characteristics: A Cadaver Study
Authors: Earll Mark , Wayne Jennifer , Brodrick Christopher , Vokshoor Amir , Adelaar Robert
Published: March 2013

Changes in ankle biomechanics lead to altered load transmission through the ankle joint, possibly predisposing it to osteoarthritis. Contributions of the different bands of the deltoid ligament to the contact characteristics in the ankle were examined. Fifteen normal cadaveric lower extremities were axially loaded to 445 N after intra-articular Fuji film placement. Ankles were tested in neutral, 10° dorsiflexion, and 10° plantarflexion. Repeated testing was done following sequential sectioning of the deltoid ligament, and the contact characteristics were analyzed.

The greatest significant tibiotalar changes ( P < 0.0001) occurred after sectioning of the tibiocalcaneal fibers of the superficial deltoid ligament complex. Contact areas decreased up to 43%, peak pressures increased up to 30%, and centroids moved 4 mm laterally, on average. In contrast, sectioning of the other bands led to insignificant changes in joint contact characteristics. The data indicate that significant changes in contact characteristics occur before radiographic evidence of deltoid ligament damage is evident, and may indicate that greater attention to the medial side of the ankle is indicated to restore normal biomechanics to this joint.
Surgical Reconstruction of the Diabetic Foot: A Salvage Approach for Midfoot Collapse
Authors: Early John S. , Hansen Sigvard T.
Published: March 2013

Between 1985 and 1993, 18 patients representing 21 feet underwent surgical reconstruction for diabetic neuroarthropathy with collapse of the midfoot. Forty-seven percent (10/21) of these feet presented with plantar pressure ulcers. Reconstruction involved reduction and fusion of collapsed joints, using internal fixation to restore foot shape and improve weightbearing alignment. The average follow-up in these patients was 28 months (range, 6–84 months).

Limb salvage was obtained in 18 of 21 feet. Average time to radiographic union was 5 months (range, 3–9 months). Improvement in shoe fit and ambulatory status was noted for 13 of the 15 patients who had successful reconstruction. Forty-seven percent of the reviewed cases were without any complication throughout their postoperative course. Seventy percent of the presenting ulcers healed without incident. There were no recurrent midfoot ulcers.
Distally Based Flaps for Skin Coverage of the Foot and Ankle
Authors: Hallock Geoffrey G.
Published: March 2013

Skin loss about the foot and ankle is notorious for creating a difficult challenge for limb salvage. Local tissue rearrangements rarely prove satisfactory, so a free flap as a solution can be readily justified. Distally based flaps utilizing unviolated ipsilateral proximal lower limb donor territories offer new possibilities in lieu of the complexity of microsurgery. Yet some unique disadvantages must be acknowledged particularly for island flaps, depending on retrograde circulation via major collateral source vessels, where venous congestion can occur and risk of limb devascularization may be unacceptable. Antegrade perfused, distally based flaps nourished by a single septocutaneous perforator or communicating branches may be more reliable options. This introduction to these three potential types of distally based lower extremity flaps is intended to promote this concept with appropriate reservations as another relatively simple alternative for wound coverage in the lower extremity.
Intraoperative Peroneus Brevis Tendon Rupture: A Technique to Salvage the Graft During Ankle Ligament Reconstruction
Authors: Berg Eugene E.
Published: March 2013

The peroneus brevis tendon is frequently used in lateral ankle ligament reconstruction for chronic instability. Intraoperative tendon rupture at the exit of the interosseous transfibular tunnel occurred in two cases. A technique is described to salvage this situation. At 2-year follow-up, both cases had successful restoration of ankle joint stability.