bluuebunny/crossref_metadata_2025 huggingface dataset:
Recovery of the Posterior Tibial Muscle After Late Reconstruction Following Tendon Rupture
Authors: Valderrabano Victor , Hintermann Beat , Wischer Thorsten , Fuhr Peter , Dick Walter
Published: January 2017

The purpose of this study was to determine the recovery potential of the posterior tibial muscle after late reconstruction following tendon rupture in stage II of posterior tibial tendon dysfunction. Fourteen patients (18 women, 6 men; mean age 59.8 years) were investigated 47 months (range, 24–76 months) after surgical reconstruction of a completely ruptured posterior tibial tendon (end-to-end anastomosis, side-to-side augmentation with the flexor digitorum longus tendon) in combination with a distal calcaneal osteotomy with a tricortical iliac crest bone graft for lengthening of the lateral column. At follow-up, clinical and radiological investigations were performed, including strength measurement and qualitative and quantitative MRI investigation. The overall clinical results were graded excellent in 12 patients, good in one, fair in one, and poor in none. The average ankle-hindfoot score (American Orthopaedic Foot and Ankle Society) improved from preoperatively 49.1 (range, 32–60) to 93.1 (range, 76–100) at follow-up. The functional result correlated with patient's satisfaction and sports activities ( p < .05). All patients showed a significant strength of the posterior tibial muscle on the affected side, but it was smaller than on non-affected side ( p < .05). The mean posterior tibial muscle strength was 75.1 N on affected and 104.9 N on nonaffected side, corresponding to a ratio of 0.73 between the two legs. The mean area of the posterior tibial muscle was 1.89 cm2 on affected side, and 3.48 cm2 on nonaffected side, corresponding to a ratio of 0.55 between the two legs. While fatty degeneration for the posterior tibial muscle was found in all patients, it was found to decrease with increasing strength of the posterior tibial muscle ( p < .05) and muscular size ( p < .05). On postoperative MRI, the posterior tibial tendon could be found to be intact in all patients. The recovery potential of the posterior tibial muscle was shown to be significant even after delayed repair of its ruptured tendon. A ruptured and/or diseased posterior tibial tendon should not be transected as it excludes any recovery possibilities of the posterior tibial muscle.
Relationship Between Foot Angles and Hypermobility Scores and Assessment of Foot Types in Hypermobile Individuals
Authors: Kamanli Ayhan , Sahin Sezai , Ozgocmen Salih , Kavuncu Vural , Ardicoglu Ozge
Published: January 2017

This study proposed to assess foot types and radiological examination of feet of individuals with hypermobility syndrome in comparison to healthy matched controls for age, sex, and body mass index. The relationship between foot angles and hypermobility scores of subjects in both groups were also assessed. Twenty individuals having joint hypermobility syndrome previously diagnosed according to Beighton and Bulbena scores were compared to 20 healthy subjects. Standing anteroposterior (AP) and lateral weigthbearing radiographs of feet of the individuals were taken. Foot angles and foot types were evaluated on the AP and lateral views. The mean ± SD of Beighton and Bulbena scores were significantly higher in the hypermobile individuals ( p < .001) than in controls. In both groups, Egyptian and square types of feet were mostly encountered ( p > .05). Bilateral calcaneal pitch (CP) angles ( p < .001), bilateral talometatarsal (TM) angles ( p < .01), and right apex angles ( p < .05) were significantly low in hypermobile individuals, whereas first metatarsophalangeal (MTP) angles were significantly high (right foot, p < .01; left foot, p < .05) as compared to the control group. Hypermobility scores correlated negatively with bilateral CP and TM angles and positively with bilateral first MTP angles. No correlation was found for the other angles. These finding suggest that foot angles (especially CP, TM and first MTP angles) are in relation with severity of hypermobility. There was no difference between foot types in the hypermobile individuals and healthy controls. These angles may be useful for clinically monitoring the foot health in the hypermobile individuals
An Augmented Fixation Method for Distal Fibular Fractures in Elderly Patients: A Biomechanical Evaluation
Authors: Dunn Warren R. , Easley Mark E. , Parks Brent G. , Trnka Hans-Jörg , Schon Lew C.
Published: January 2017

This biomechanical investigation compared two fixation techniques for distal fibular fractures. Elderly cadaver lower extremities with simulated fibula fractures underwent fixation either with a plate and intramedullary Kirschner wires (K-wires) with or without the addition of three screws inserted through the four cortices of the fibula and the tibia. The specimens were axially loaded to body weight on a materials testing machine, and the supinated foot was externally rotated to failure. Displacement at the fracture site was monitored with an extensometer. Comparing the augmented technique with the technique without additional screws, mean stiffness was 460 ± 100 and 320 ± 200 N-mm/deg, strength at failure was 31 ± 10 and 19 ± 7 N-m, strength at 30° external rotation was 15 ± 5 and 10 ± 6 N-m, and axial deformation was 0.04 ± 0.06 mm and 0.10 ± 0.04 mm, respectively. All differences were statistically significant.
Mechanical Effect of Posterior Wire or Half-Pin Configuration on Stabilization Utilizing a Model of Circular External Fixation of the Foot
Authors: Rocchio Thomas M. , Younes Michael B. , Bronson Dwight G. , Birch John G. , Samchukov Mikhail L.
Published: January 2017

Background: Numerous studies have addressed biomechanical characteristics of circular external fixation of long bones. The objective of the present study was to evaluate stabilization of a simulated foot model using external fixation with either calcaneal tensioned stopper wires or half-pins. Methods: Fixation configurations of the calcaneus included two parallel wires, two wires crossing at either 30° or 45°, a 4-mm- and 5-mm-diameter single half-pin, or two half-pins inserted at a cross-angle of either 45° or 90°. All frames were tested in axial compression, anteroposterior (AP) bending, and mediolateral (ML) bending. Results: An increase in wire cross-angle improved the axial and AP bending stabilization but had no influence on ML bending. Utilization of a single calcaneal half-pin instead of two cross-wires resulted in a considerable reduction in ML bending stabilization. Frame configurations with two half-pins substantially improved axial and ML bending stabilization. Due to the medial location of the metatarsal wire stopper, an increase in half-pin cross-angle significantly improved ML bending stiffness under lateral foot loading. Under the medial foot loading, however, the half-pin cross-angle had no effect on ML bending stabilization. Replacement of cross-wires with two half-pins significantly improved the AP bending stiffness only when the half-pin cross-angle was reduced to 45°. In all modes of two half-pin frame loading, the half-pin diameter had a substantial effect on foot stabilization. Conclusions: Although the wire cross-angle, half-pin cross-angle, and half-pin diameter affect the stability of foot circular external fixation, the influence of these mechanical parameters on foot stabilization is dependent on the mode and location of loading. Clinical Relevance: The results of the present mechanical testing can be utilized as a useful guideline for the optimization of circular external fixation of the foot.
Traumatic Lateral Dislocation of the Great Toe Fibular Sesamoid: Case Report
Authors: Cortés Zenia E. , Baumhauer Judith F.
Published: January 2017

Traumatic dislocation of the hallucal sesamoids is uncommon. This case involves a 17-year-old female driver involved in a head-on collision who sustained traumatic lateral dislocation of the fibular sesamoid associated with intersesamoidal ligament disruption, partial plantar plate avulsion, and impaction fracture of the metatarsal head. The diagnosis was delayed due to incorrect interpretation of initial radiographs. In addition, the severity of the soft-tissue injury was not appreciated, possibly further delaying the diagnosis. The patient was treated with open reduction of the fibular sesamoid and reconstruction of the intersesamoidal ligament. Eight months after surgery, she had mild persistent symptoms, decreased range of motion, and near full resumption of prior activities.
Associated Deformities and Hypermobility in Hallux Valgus: An Investigation with Weightbearing Radiographs
Authors: King David M. , Toolan Brian C.
Published: January 2017

Background:

Hallux valgus has been reported to recur after surgical correction in patients subsequently diagnosed with hypermobility of the first ray, pronation of the foot, and pes planovalgus. An objective means of assessing the foot for these deformities preoperatively may avert a poor outcome. This investigation evaluated the efficacy of full-length weightbearing radiographs to recognize associated deformities in patients with hallux valgus before surgery.

Methods:

This study compared five parameters from anteroposterior and four parameters from lateral weightbearing pedal radiographs of patients with moderate to severe hallux valgus to a control group to identify differences in the alignment of the midfoot and the first metatarsal-medial cuneiform joint. An examination for clinical evidence of hypermobility was also performed on both groups.

Results:

The hallux valgus group demonstrated increased abduction and dorsiflexion of the midfoot. The mean talonavicular coverage angle and lateral talo-first metatarsal angle of this group was greater than the mean values for the controls. Radiographic evaluation also revealed differences in the alignment of the first metatarsal-medial cuneiform joint in the sagittal plane. The hallux valgus group possessed a mean of 2 mm of dorsal translation and 2° of dorsiflexion at this joint compared to the controls.

Conclusions:

Weightbearing radiographs permit the recognition of associated malalignments of the foot in patients with hallux valgus. The comparisons performed in this study identified deformities consistent with pes planovalgus and hypermobility of the first ray in patients with moderate to severe hallux valgus. The results of our study support a recommendation for a thorough evaluation of full-length, biplanar weightbearing radiographs via the measurement of midfoot and first ray alignment for concomitant deformities of the foot in patients with hallux valgus.
Three-Dimensional and Two-Dimensional Computerized Tomographic Demonstration of Calcaneus Fractures
Authors: Prasartritha Thavat , Sethavanitch Chalama
Published: January 2017

The objective of the study was to illustrate the diagnostic quality of three-dimensional computed tomography (3DCT) and to document its usefulness for detecting gross changes in articular surfaces of the calcaneus and posterior articular facet (PAF). Superior view 3DCT images of 51 calcanei in 39 different patients were reviewed based on bony fragments produced by primary fracture lines and involvement of the PAF. Of 49 intraarticular fractures examined, there were two severely comminuted and 47 comminuted fractures. Main characteristics of both groups were described. Important findings best seen on 3DCT images were the number and configuration of displaced PAF fragments, fracture lines separating the anterior process and the middle facet, and the extension of fracture lines into the calcaneocuboid facet. The double density sign seen in plain x-rays was identified as a double articular sign in 3DCT images.
Technique Tip: Modification of DuVries's Lesser Metatarsophalangeal Joint Arthroplasty to Improve Joint Mobility
Authors: Myerson Mark S. , Redfern David J.
Published: January 2017

An interposition arthroplasty for the treatment of pain and stiffness in the second metatarsophalangeal joint (MTPJ) is presented. The procedure is a modification of DuVries's lesser MTPJ arthroplasty and is specifically intended to improve limited dorsiflexion not addressed by the original procedure.
Etiology of the Anterior Ankle Impingement Syndrome: A Descriptive Anatomical Study
Authors: Tol Johannes L. , van Dijk C. Niek
Published: January 2017

Background:

In the anterior ankle impingement syndrome, recurrent traction to the anterior joint capsule is stated to be the cause of formation of talotibial osteophytes. This hypothesis involves the assumption that the osteophytes originate at the site where a capsular attachment is located. A soft tissue component that can get squeezed between the distal tibia and talus is thought to be responsible for impingement complaints during dorsiflexion movements.

Methods:

In eight ankle specimens, the width of the nonweightbearing tibial cartilage rim and the distance of the tibial and talar cartilage to the capsular attachment were measured. The relationship of the soft tissue components to the anterior joint was studied. The average tibial cartilage rim width was 2.4 mm (1.5–3.0 mm). Tibial and talar cartilage-capsule distances were 4.3 mm (0.5–9.0 mm) and 2.4 mm (1.8–3.3 mm), respectively. In all specimens, the anterior joint space contained a triangular soft tissue component, overlying the joint capsule. The component consisted of a synovial membrane and subsynovial located fat and collagen tissue. It was observed that in 15° dorsiflexion the soft tissue component was squeezed between the tibia and talus.

Conclusions:

The anterior ankle joint capsule attaches proximal to the site where the anterior talotibial spurs originate. The hypothesis of formation of talotibial spurs due to repetitive capsule traction therefore does not seem plausible. The anatomic findings do support the hypothesis that an anteriorly located soft tissue component is present that can give impingement symptoms.
Relationship between Static Mobility of the First Ray and First Ray, Midfoot, and Hindfoot Motion during Gait
Authors: Allen Mary K. , Cuddeford Tyler J. , Glasoe Ward M. , DeKam Lisa M. , Lee Pamela J. , Wagner Kelli J. , Yack H. John
Published: January 2017

The relationship between a static measure of dorsal first ray mobility and dynamic motion of the first ray, midfoot, and hindfoot during the stance phase of walking was investigated in healthy, asymptomatic subjects who represented the spectrum of static flexibility. Static first ray mobility of 15 subjects was measured by a load cell device and ranged from stiff (3.1 mm) to lax (8.0 mm). Using three-dimensional motion analysis, mean first ray dorsiflexion/eversion and mid-/hindfoot eversion peak motion, time-to-peak, and eversion excursion were evaluated. Subjects with greater static dorsal mobility of the first ray demonstrated significantly greater time-to-peak hindfoot eversion and eversion excursion ( p >.01), and midfoot peak eversion and eversion excursion ( p > .01). No significant association was found between static first ray mobility and first ray motion during gait. This research provides evidence that the dynamic response of the foot may modulate the consequences of first ray mobility and that compensory strategies are most effective when static measures of dorsal mobility are most extreme.
The Efficacy of Two Methods of Ankle Immobilization in Reducing Gastrocnemius, Soleus, and Peroneal Muscle Activity during Stance Phase of Gait
Authors: Kadel Nancy J. , Segal Ava , Orendurff Michael , Shofer Jane , Sangeorzan Bruce
Published: January 2017

Background:

Immobilization to limit muscle activity is a common therapeutic and posttreatment event. There are potential time and resource savings if a prefabricated boot can replace a custom applied cast. The purpose of this study was to determine if muscle activity reduction is similar using a fiberglass cast versus a prefabricated (Aircast FoamWalker) boot.

Methods:

Surface EMG data were recorded from the gastrocnemius, soleus, and peroneals of 12 normal adults while walking barefoot, in a fiberglass cast with a cast shoe (cast), and while wearing an Aircast FoamWalker (boot). Subjects walked at their self-selected speed for 10 trials in each condition, and the order of barefoot, cast, and boot was randomly assigned. The data were rectified, integrated across stance phase and normalized to a percent of each subject's barefoot mean integrated EMG (iEMG) value. For each muscle, a linear mixed-effects statistical model (subject by trial by condition) was utilized to determine if iEMG activity levels were reduced by immobilization compared to barefoot walking.

Results:

Activity for all muscles was significantly lower in the boot compared with barefoot ( p <.05). The cast iEMG levels were significantly different from barefoot for the soleus and peroneals ( p <.05). Gastrocnemius activity was significantly decreased in the boot when compared with the cast ( p <.0001). The greater reduction in iEMG levels for the boot indicates that it is superior to a fiberglass cast in reducing gastrocnemius muscle activity during the stance phase of gait.

Conclusions:

The data show that a prefabricated boot is as effective as a custom applied cast in reducing soleus and peroneal muscle iEMG during stance phase. The boot was more effective in reducing gastrocnemius activity when compared to the cast.

Clinical Relevance:

This study suggests that a prefabricated boot may be used in place of a custom cast when the goal of treatment is to limit muscle activity of the leg.
Correlation of Hallux Valgus Surgical Outcome With AOFAS Forefoot Score and Radiological Parameters
Authors: Thordarson David , Ebramzadeh Edward , Moorthy Murali , Lee Jessica , Rudicel Sally
Published: January 2017

Background: The purpose of the study was to evaluate the effect of three different types of hallux valgus surgeries on patient function using validated questionnaires and to correlate the results with radiographic and physical examinations. This study presents the 2-year followup data of a previous prospective outcome study. Methods: One hundred and ninety-six patients were enrolled in this study and completed a baseline AAOS Lower Limb Outcomes Data Collection Questionnaire. They completed the same form at 6, 12, and 24 months after having one of three types of hallux valgus surgeries (106 chevron osteotomies, 72 modified McBride procedures, and 18 modified Lapidus procedures). This questionnaire included the Short Form-36 Health Survey (SF-36) as well as questions relating to lower extremity function. Additionally, physicians were asked to complete preoperative and postoperative questionnaires on each patient that included radiographic and physical examination data and the type of surgery done. Completed outcome surveys and radiographic data were available on 196 patients, and physical examination scores were available to assign an AOFAS score in 111 patients at 24-month followup. A one-way comparison was done after stratifying the results for the type of surgery, preoperative hallux valgus angle and 1-2 intermetatarsal angle, postoperative hallux valgus angle and 1-2 intermetatarsal angle, and the change in the angles. Results: Four of the 10 SF-36 scores (physical function, role-physical, bodily pain, and role-emotional) for the combined data improved by more than five points. For the AAOS lower extremity function scores, physical health and pain (68.5 to 81.6), satisfaction with symptoms (1.8 to 3.6), global foot and ankle (77.6 to 93.4), and shoe comfort (29.0 to 58.7) scores all increased significantly. The AOFAS score increased from 52.6 to 85.5 ( p < 0.001). Surprisingly, when comparing mild-to-moderate to severe deformities preoperatively and postoperatively using the absolute magnitude of the angular change in the hallux valgus or intermetatarsal angles, similar improvement was noted in AOFAS, SF-36, and AAOS lower extremity scores. The magnitude of preoperative deformity, postoperative residual deformity, and magnitude of correction also did not significantly change the amount of improvement in any of these scores. No significant differences were noted in the outcome scores among the three different surgeries. Conclusion: Patients who had hallux valgus surgery had significant improvements in four of their SF-36 scores, four of five of AAOS lower extremity scores, and AOFAS scores. The degree of deformity, amount of correction, or type of operation did not influence outcome.
Efficacy of Plantar Loading Parameters During Gait in Terms of Reliability, Variability, Effect of Gender and Relationship Between Contact Area and Plantar Pressure
Authors: Murphy Darlene F. , Beynnon Bruce D. , Michelson James D. , Vacek Pamela M.
Published: January 2017

Background: The purpose of this study was to determine plantar pressure and contact areas of the foot inside the athletic shoe during activity. The objectives were to determine if plantar pressure and contact area measurements collected on multiple trials from the same subject were reliable, to determine the variability of measurements between subjects as compared to that found between steps within a single subject, to determine the relationship between contact area and plantar pressure, and to ascertain whether there were any systematic gender differences in these measurements. Methods: Sixteen healthy adults volunteered for participation in the first part of the study that was designed to determine reliability and variability of the testing methodology. A separate group of fifty healthy high school and collegiate athletes participating in soccer, field hockey, basketball, and lacrosse comprised the second part of the study that was designed to investigate gender differences in terms of normalized midfoot plantar pressure and contact area, and the interrelationship between the two measurements. Data were collected during the midstance phase of gait, using the Pedar inshoe measurement system (Novel GMBH, St. Paul, MN). Athletes wore their own athletic shoes and performed walking trials on a surface similar to that used in their sport. The foot was divided into four regions based on radiographic measurements. Results: The midfoot region demonstrated excellent reliability across multiple trials of the same subject in contact area and plantar pressure, and the variability between steps within a single subject was small when compared to that between subjects. Normalized midfoot contact area and plantar pressure values were highly correlated with r values of 0.862 on the left foot and. 912 on the right foot. No significant differences were found in normalized midfoot contact area or plantar pressure values between males and females. Conclusions: The Pedar in-shoe pressure measurement system can be used reliably to quantify contact area and plantar pressure beneath the midfoot region during the midstance phase of gait. This measurement technique can now be used in risk factor studies designed to identify individuals at risk for injury to the foot, ankle, and other lower extremity structures.
Peroneal Tendon Lesions Caused by Antiglide Plates Used for Fixation of Lateral Malleolar Fractures: The Effect of Plate and Screw Position
Authors: Weber Martin , Krause Fabian
Published: January 2017

Background: Posterolateral antiglide plating of unstable AO-type B lateral malleolar fractures is biomechanically stronger than lateral plating and causes less wound healing problems and less frequent hardware removal. However, the distal end of the plate or the screws may cause peroneal tendinitis. The limits of safe hardware placement have not been established. Method: A retrospective analysis of 70 patients was done to determine hardware position and identify peroneal tendon lesions. An adjunct study involved dissection of the retromalleolar region in 10 embalmed cadaver specimens to study the anatomy of the osteosynovial peroneal groove. Results: Thirty of 70 (43%) patients had the plate removed because of discomfort or signs of peroneal tendinitis. Peroneal tendon lesions were identified intraoperatively in nine of the 30 (30%) patients. Only two of these nine patients had felt symptoms preoperatively. Placement of the distal end of the plate distal to the proximal third of the lateral malleolus did not correlate with a peroneal tendon lesion. However, this placement combined with a screw in the most distal hole of the plate and a prominent screw head was strongly correlated with peroneal tendon lesions. In the anatomic specimens the shape of the osteosynovial part of the peroneal groove was uniform, but its length showed greater variation than the length of the foot. Conclusions: Antiglide plating of lateral malleolar fractures led to high rates of hardware removal and peroneal tendon lesions. Correlations were found to low placement of the plate together with a protruding screw head in the most distal hole of the plate. Distal screw placement should therefore be avoided or the hardware should be removed early. Absence of subjective signs of peroneal tendon irritation does not exclude even a major tendon lesion.
Tibiotalocalcaneal Arthrodesis With a Retrograde Intramedullary Nail: A Biomechanical Analysis of the Effect of Nail Length
Authors: Noonan Timothy , Pinzur Michael , Paxinos Odysseas , Havey Robert , Patwardhin Avinash
Published: January 2017

Background: Fatigue fractures of the tibia have been observed at the level of the proximal end of the nail after successful tibiocalcaneal arthrodesis with a retrograde intramedullary device. Materials: To study the effect of nail length, five matched pairs of cadaver tibiae were instrumented with strain gauges and potted in methyl-methacrylate from a level 3 cm proximal to the distal medial malleolus to simulate a successful tibiocalcaneal arthrodesis. A standard length (15 cm) ankle arthrodesis nail and an identical longer device terminating in the proximal tibial metaphysis were inserted in each paired tibia using appropriate technique. The strain of the posterior cortex of the tibia was recorded under bending moments of up to 50 Nm for each intact specimen after nail insertion and after proximal locking of the nail. The nails were then exchanged between the specimens of the same pairs and the experiment was repeated to insure uniformity. Results: The standard length locked nail increased the principal strain of the posterior cortex of the tibia at the level of the proximal screw holes 5.3 times more than the locked long nail (353 and 67 microstrains), respectively. This stress concentration was not observed when the proximal extent of the nail terminated within the proximal tibial metaphysis. Conclusion: A successful tibiocalcaneal arthrodesis with a standard length locked intramedullary nail creates stress concentration around the proximal screw holes that may be responsible for the fractures observed clinically. This study supports the use of a “long” retrograde locked intramedullary nail for tibiocalcaneal arthrodesis in patients with systemic or localized osteopenia.
Radiographic Indicators of Ankle Instability: Changes with Plantarflexion
Authors: Kragh John F. , Ward John A.
Published: January 2017

Background: The effect of plantarflexion on radiographic indicators of instability was investigated in matched pairs of stable ankles and unstable ankle fractures with complete deltoid ligament tears to test the hypothesis that differences exist in indicators as a function of either stability or position. The purpose of this study was to determine whether plantarflexion increases radiographic indicators of ankle fracture instability. Methods: Measurements from 34 patients scheduled for operative treatment of unstable ankle fractures were collected prospectively from normal, stable ankles and the injured, unstable ankles. Instability was defined as a positive fluoroscopic stress examination under anesthesia. Stability and instability and neutral position and plantarflexion were associated with eight radiographic indicators of which five were distances in millimeters and three were binomial (either stable or unstable). Results: Measurements were larger in the unstable ankles than in the normal stable ankles. Plantarflexion was associated with increased distances in stable ankles, and a trend was seen in unstable ankles. Plantarflexion was associated with increased binomial indicators in unstable ankles but not in stable ankles. Discussion: Joint positioning affected measurement of ankle stability: plantarflexion increased the sensitivity of radiographic indicators.
Evaluation of the Validity of the Foot Function Index in Measuring Outcomes in Patients with Foot and Ankle Disorders
Authors: SooHoo Nelson F. , Samimi David B. , Vyas Raj M. , Botzler Tin
Published: January 2017

Background: There is uncertainty regarding which outcomes tools should be used to report the results of treatment for patients with foot and ankle disorders. This study evaluates the validity of the Foot Function Index (FFI) by examining its level of correlation to the Medical Outcomes Study Short Form-36 (SF-36). The SF-36 is an extensively validated outcomes tool that has been used as a benchmark in examining the validity of several orthopaedic outcomes tools. Methods: Seventy-three patients were recruited at a tertiary referral foot and ankle practice. Patients completed packets which included informed consent forms, the FFI, and the SF-36 questionnaires. The questionnaires were scored and Pearson correlation coefficients were determined between the three domains of the FFI and the eight SF-36 sub-scales, as well as the two SF-36 summary scales. Results: Sixty-nine patients completed an adequate number of items to be included in the study. The mean age of the patient sample was 46 (range 16 to 82) years and 44 were women (64%). Twenty-one patients (30%) had conditions affecting the forefoot, while 48 patients (70%) had conditions affecting the ankle or hindfoot. All three FFI domains had moderate to high levels of correlation to many of the SF-36 scales. The Disability domain of the FFI had the most consistent level of correlation to the SF-36 with Pearson coefficients in the range of −0.23 to −0.69. The Activity Limitation ( r = −0.28 to −0.64) and Pain domains ( r = −0.10 to −0.61) also demonstrated moderate levels of correlation to several of the SF-36 scales. Conclusions: The consistently moderate to high levels of correlation of the FFI to the SF-36 seen in this study support the FFI as a valid measure of health status. This suggests that the FFI is a reasonable method to monitor patient outcomes. Future studies should focus on determining if the FFI improves responsiveness to clinical change when used in combination with generic instruments like the SF-36.
Differentiating Clinical and Radiographic Features of Enchondroma and Secondary Chondrosarcoma in the Foot
Authors: Gajewski Donald A. , Burnette Jeffery B. , Murphey Mark D. , Temple H. Thomas
Published: January 2017

Background: Enchondroma is the most common benign tumor of the bones of the foot. Chondrosarcoma in this area is relatively rare with malignant transformation from enchondroma occurring rarely. In contrast to similar tumors in the appendicular skeleton, it is difficult to distinguish between these two tumors when they occur in the foot. Methods: We reviewed the medical records and radiographs of all patients with enchondroma and chondrosarcoma arising from enchondroma (secondary chondrosarcoma) from the radiologic archives at the Armed Forces Institute of Pathology (AFIP) and identified those patients with tumors involving the bones of the foot. There were 755 patients with enchondroma of which 34 (4.8%) involved the foot; there were 340 patients with secondary chondrosarcoma and 14 (4.1%) involved the foot. We compared clinical and radiographic features of both these lesions. We also compared interobserver differences not only for diagnosis but also for the presence of scalloping, fracture, cortical destruction, and mineralized matrix. Results: Size and location were statistically significant variables differentiating the two tumors ( p = 0.03). Enchondromas had a mean size of 2.7 cm2. Lesions that occurred in the hindfoot and midfoot were more likely to be malignant compared to those in the forefoot. In comparing interobserver reliability, most disagreement occurred regarding the presence or absence of matrix with the examiners concurring only 51% of the time. With regard to diagnosis, the examiners' accuracy was 71% and 80%. Their accuracy increased only to 83% when they agreed. Conclusion: Our findings suggest that it is difficult to differentiate enchondroma from secondary chondrosarcoma in the foot. Concern for malignant change is warranted for cartilage bone tumors of the foot if they exceed 5 cm2, or if they arise in the midfoot or hindfoot. In these cases, we recommend either biopsy or close clinical followup.
Correction of Neglected Clubfoot Using the Ilizarov External Fixator
Authors: Ferreira Ricardo Cardenuto , Costo Marco Túlio , Frizzo Gastão Guilherme , da Fonseca Filho Fernando Ferreira
Published: January 2017

Background: This study was conducted to evaluate the corrective capability of the Ilizarov external fixator in the treatment of neglected clubfoot. Methods: Thirty patients (38 feet) with a mean age of 19 (5 to 39) years with severe deformities and stiff feet associated with neglected clubfoot were studied. A limited soft-tissue dissection, Achilles tenotomy, and plantar fasciotomy were done. Progressive correction of the deformities was achieved through a standard setting of the Ilizarov external fixator. The device was used for 16 weeks, on average, and after removal a short-leg walking cast was used for an additional 6 weeks, followed by an ankle-foot orthosis (AFO) for 6 months. Results: The final outcome was scored as good (complete correction and no pain); fair (partial correction with plantigrade foot and occasional pain); or poor (nonplantigrade foot and continuous pain during walking). After a mean followup of 58 (range 12 to 107) months, the results were good in 30 feet (78.9%); fair in three feet (7.9%); and poor in five feet (13.2%). Early complications were a distal tibial fracture in one foot, dislocation of the first metatarsophalangeal joint in one foot, and arterial damage that resulted in amputation of the toes in one foot. Recurrence of the deformity was found in 19 feet (50%): 11 minor, three mild, and five severe. Spontaneous ankylosis developed in 28 feet (73.7%). Nine feet (23.7%) required arthrodesis for symptomatic arthritis of the ankle or midfoot and deformity that could not be treated with orthoses. Conclusion: The Ilizarov external fixator allows simultaneous correction of all the severe foot deformities associated with neglected clubfoot with minimal surgery, reducing risks of cutaneous or neurovascular complications and avoiding excessive shortening of the foot. Even in those patients in whom final corrective arthrodesis is necessary, this may be carried out with minimal bone resection, since the severe deformities of the foot and ankle have been corrected.
The Use of a Working Model for Teaching Functional and Applied Surgical Anatomy of the Subtalar Joint
Authors: Joseph Benjamin , Rebello Gleeson , Mayya Sreemathi
Published: January 2017

Background: Some aspects of functional and applied anatomy may be difficult to conceptualize if taught by conventional methods. In such situations, alternative methods of teaching may need to be adopted. This study was undertaken to evaluate whether a working model can facilitate understanding of the functional and applied surgical anatomy of the subtalar joint. Methods: A working model of the articulated talus and calcaneus was constructed and used to explain the mechanics of motion of the subtalar joint, the rationale of release of structures to correct hindfoot deformity in clubfoot, principles of tendon transfers, and the rationale of extra-articular subtalar joint arthrodesis. Twenty-four orthopedic residents were divided into two groups (A and B). Group A was taught these specific concepts of functional and applied anatomy with the help of the model, while Group B was taught the same concepts with a written text and diagrams. The level of knowledge of both groups was evaluated by a test with multiple-choice questions. A week later, Group A was given the text while Group B was shown the model. Both groups then answered a questionnaire assessing the value of the model in enhancing their understanding of the subject. Results: In the test, the performance of students in Group A was better than those in Group B. Students of both groups felt that the model gave them a much clearer understanding of the functional anatomy of the subtalar joint. Conclusions: We conclude that this simple, inexpensive model is a valuable teaching aid that helps students to understand the surgical anatomy of the subtalar joint. Clinical relevance: Surgeons can use this model to effectively teach trainees in this field about the mechanics and anatomy of the subtalar joint and other relevant applications.
Mid-Term Results of Titanium Hemi-Great Toe Implants
Authors: Konkel Kurt Frederick , Menger Andrea Gayle
Published: January 2017

Background:

We reviewed the mid-term results of metatarsophalangeal hemiarthroplasty with titanium hemi-great toe implants. This study may help with future prosthetic design and evaluation leading to improved management and patient satisfaction.

Methods:

Ten of 12 patients were contacted more than 2.5 years after surgery. Their charts were reviewed, and they were evaluated clinically and radiographically.

Results:

All patients were improved and satisfied in the first 5 years after surgery, but subsidence and lucency in all patients and a painful fracture in one patient bring long-term implant survival into question. The ultimate longevity of the implant and its long-term functionality should be questioned.

Conclusions:

Metallic hemi-great toe implants have satisfactory mid-term results. Improved prosthetic design may lead to less implant subsidence and stem lucency.
Location Modalities for Focused Extracorporeal Shock Wave Application in the Treatment of Chronic Plantar Fasciitis
Authors: Dorotka Ronald , Sabeti Manuel , Jimenez-Boj Esther , Goll Alexandra , Schubert Simone , Trieb Klemens
Published: January 2017

Background:

Focused extracorporeal shock waves (ESWT) has been used in the treatment of plantar fasciitis with heel spurs. The optimal location for administering treatment, however, has not been determined. The purpose of this study was to determine whether fluoroscopy-guided location of a heel spur or patient location of the maximal point of tenderness is more effective in administering ESWT.

Methods:

In a prospective, examiner-blinded trial, 41 patients were randomized into two groups for treatment by ESWT: group 1, location of the heel spur for ESWT by fluoroscopy, and group 2, patient location for ESWT by maximal point of tenderness. Each group had three session of ESWT at 1-week intervals. The success rates between the two groups were assessed at 6 and 12 weeks.

Results:

No significant differences were noted between the groups.

Conclusions:

Despite the small number of patients in the study, patient location for positioning the focus in ESWT in treatment of plantar fasciitis with a heel spur is recommended.
Biphalangeal Fifth Toe
Authors: Dereymaeker Greta , van der Broek Chris
Published: January 2017

Background:

A biphalangeal fifth toe is a common variant in the European population. The frequency is higher in the Japanese population. It is considered an anatomical variant of the normal triphalangeal fifth toe.

Methods:

Patients divided into three study groups were retrospectively reviewed to determine the effect of a biphalangeal fifth toe on the occurrence of clinically symptomatic pathology of the fifth ray.

Results:

The prevalence of a biphalangeal fifth toe in patients with hammer or claw toes was 65%, bunionettes 47%, and overriding fifth toe 37%. Only for the group with hammer or claw toes was prevalence significantly higher than that in the control group (39%).

Conclusion:

The stiffness and rigidity of the biphalangeal fifth toe may predispose it for symptomatic hammer or claw toe.
Etiologic Factors Associated with Symptomatic Achilles Tendinopathy
Authors: Holmes George B. , Lin Johnny
Published: January 2017

Background:

The purpose of this study was to determine if a statistical association exists between Achilles tendinopathy (also referred to as tendinosis) and obesity, diabetes mellitus, hypertension, the supplemental use of estrogen, and exposure to local or systemic steroids.

Methods:

From July, 1997, to February, 2003, 82 patients with a diagnosis of Achilles tendinopathy were identified. The diagnosis of Achilles tendinopathy was confirmed by a review of medical records, radiographs, and MRI. There were 44 women and 38 men with an average age of 50 (range 27 to 77) years. For the parameters of obesity, hypertension, diabetes, steroid exposure, and the use of estrogen compounds, all patients were analyzed both cumulatively and stratified into subgroups by gender and age. Chi-square 2 times 2 tables were used to compare the observed prevalence of the parameters in patients with Achilles tendinopathy to the expected prevalence of these disorders and exposures in the population at large.

Results:

Cumulatively, 98% percent (43 of 44 women; 29 of 38 men) had hypertension, diabetes, obesity, and steroid or estrogen exposure. Seventy-six percent of men (29) had hypertension, diabetes, and obesity, or steroid exposure. Sixty-eight percent of women (15 of 22) had a history of hormone replacement therapy and 44% (8 of 15) had a positive history for use of oral contraceptives. When compared with published national data using Chi-square analysis, the association between tendinopathy and hormone replacement therapy and oral contraceptives was found to be statistically significant with p-values of 0.01 and 0.001, respectively. For both women and men, obesity was statistically associated with Achilles tendinopathy with p-values of 0.025 and. 001, respectively. Hypertension was statistically associated with Achilles tendinopathy only for women. Diabetes mellitus and Achilles tendinopathy were found to have a statistical association only for men younger than 44 years old

Conclusions:

Obesity, hypertension, and steroids have as their end-organ effect a diminution of local microvascularity. The significant correlation of these factors with Achilles tendinopathy suggests the importance of their effect on microvascularity in the development of Achilles tendinopathy.
Effectiveness of Custom-Made Orthopaedic Shoes in the Reduction of Foot Pain and Pressure in Patients with Degenerative Disorders of the Foot
Authors: Jannink Michiel , van Dijk Henk , Ijzerman Maarten , Groothuis-Oudshoorn Karen , Groothoff Johan , Lankhurst Gustaf
Published: January 2017

Background:

Degenerative disorders of the foot often are painful during standing and walking. It is assumed that, because of bone deformity, callus, and deformity of the plantar pads, the plantar pressure distribution changes. Prescription of orthopaedic shoes for patients with degenerative disorders of the foot is based on the hypothesis that excessive pressure under the foot causes pain. The goal of this study was to evaluate the effectiveness of custom-made orthopaedic shoes, in terms of pressure and pain, in patients with degenerative disorders of the foot. Additionally, the relationship between plantar pressure parameters and foot pain was studied, with special emphasis on second and third metatarsal heads.

Methods:

Seventy-seven consecutive patients with degenerative disorders of the foot were recruited from the outpatient clinics of seven rehabilitation centers and rehabilitation departments of university hospitals in the Netherlands. The study was prospective. The Questionnaire for Usability Evaluation for Orthopaedic Shoes was used to measure perceived foot pain. To measure plantar pressures, the Pedar in-shoe pressure measurement system (Novel GmbH, Munich) was used. The effectiveness of custom-made orthopaedic shoes, in terms of pressure and pain in patients with degenerative disorders of the foot, was analyzed by means of a paired sample t-test. To select the pressure parameter (Pmax, PTI, and Pav) most closely associated with walking pain, within-subject correlation coefficients were calculated.

Results:

Custom-made orthopaedic shoes significantly decreased perceived foot pain by at least 23%, and significantly reduced plantar pressure under all foot regions by at least 9%. A significant correlation ( r = 0.521) was found between walking pain and the average pressure beneath the second and third metatarsal heads.

Conclusions:

Based on these results, it can be concluded that custom-made orthopaedic shoes are effective in reducing foot pain and foot pressure. The moderate (significant) relationship between average pressure and walking pain can be used as a tool for evaluating custom-made orthopaedic shoes prescribed for patients with degenerative disorders of the foot.
First Ray Instability in Hallux Valgus Deformity
Authors: Dietze Albrecht , Bahlke Ulf , Martin Heiner , Mittlmeier Thomas
Published: January 2017

Background:

Hallux valgus remains a common forefoot condition where different causes may contribute to the pathology. The extent of first ray mobility and, in particular, instability of the first tarsometatarsal joint represents a key argument in the debate on the selection of an appropriate operative treatment. Until now, assessment of first ray instability has relied on clinical examination or static assessment only. For dynamic evaluation in our study, pedobarographic, clinical, and standard weightbearing radiographic findings were correlated with the radiokinematically determined first ray instability in the sagittal plane in hallux valgus patients.

Methods:

Eight patients with hallux valgus deformity and a clinically unstable first tarsometatarsal joint were enrolled. Seven patients were females; 1 was male. Mean age was 44 years (range, 15-65). Clinical symptoms, American Orthopaedic Foot and Ankle Society forefoot scores, and standard parameters of weightbearing radiographs in 2 planes of the forefoot were recorded. A mobile C-arm fluoroscope with a novel distortion-free flat-screen detector and a pedobarographic platform were synchronized during the rollover process. Fluoroscopic image analysis was performed employing a specific CAD model. Pedobarographic parameters were determined within 8 defined areas of the forefoot contact zone.

Results:

The mean dorsiflexion distance and angle of the first ray was 13.9 ± 9.4 mm (range, 6.3 to 34.5) and 5.9 ± 4.0 degrees (range, 2.4 to 14.5). At the first tarsometatarsal joint, the mean maximum dorsiflexion angle was 2.6 ± 1.3 degrees (range, 0.1 to 4.0). The intermetatarsal angle correlated significantly ( P = .013) with the radiokinematically determined maximum dorsiflexion. Furthermore, a significant correlation between maximum force transfer to the central ( P = .021) and lateral forefoot (fourth metatarsal; P = .032) and first tarsometatarsal joint instability was detected with an unloading of the first metatarsal.

Conclusion:

Although our analysis was limited to the sagittal plane only, we can support the notion that an enlarged intermetatarsal angle was associated with increased maximum dorsiflexion of the first ray during gait in hallux valgus patients. Gross instability of the first tarsometatarsal joint during weightbearing was not detectable in our patients, while first tarsometatarsal joint instability increased maximum force transfer to the central forefoot with the potential risk of metatarsalgia.

Clinical Relevance:

The results here may shed further light on the role of hypermobility of the first ray on hallux valgus deformity which could have implications for its surgical management.