bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Safety of the Esmarch Tourniquet
Authors: Biehl William C. , Morgan James M. , Wagner F. William , Gabriel Rodney A. 
Published: March 2013

The use of an Esmarch bandage as a tourniquet in surgery has been criticized. Many authors claim that the pressures under the Esmarch are inconsistent and may be extremely high. We have seen few, if any, problems from the use of an Esmarch in surgery of the foot and ankle. The purpose of this study was to evaluate the pressures generated under the Esmarch tourniquet in a situation that mimics its clinical application, and to determine whether pressures of appropriate magnitude and consistency are obtained in order to recommend its continued use in surgery. Ten volunteers performed numerous applications of the Esmarch. The number of wraps and the width of the Esmarch bandage used were varied. The Esmarch was applied as it would be for a surgical case. Pressures directly beneath the Esmarch were recorded 8 cm proximal to the distal tip of the medial malleolus. Considering all volunteers and all pressures generated, a 3-in Esmarch applied with three wraps gave a mean pressure (±SD) of 225 ± 46 mm Hg. A 3-in Esmarch applied with four wraps gave a mean pressure of 291 ± 53 mm Hg. A 4-in Esmarch applied with three wraps gave a mean pressure of 233 ± 35 mm Hg, and a 4-in Esmarch with four wraps gave a mean pressure of 284 ± 42 mm Hg. The maximum pressures generated by any individual were as follows: 3-in three wraps, 321 mm Hg; 3-in four wraps, 413 mm Hg; 4-in three wraps, 328 mm Hg; and 4-in four wraps, 380 mm Hg. There was no significant difference in the magnitude or consistency of pressures generated between the experienced and inexperienced wrappers. There did not appear to be a learning curve for the application of the Esmarch bandage. We conclude that an Esmarch bandage, used as a tourniquet, can generate safe and reliable pressures. Either a 3-in or 4-in Esmarch bandage applied above the ankle with three circumferential overlapping wraps consistently results in pressures that are in a safe range.
Concurrent Compartment Syndromes of the Foot and Leg
Authors: Manoli Arthur , Fakhouri Anton J. , Weber Timothy G. 
Published: March 2013

We reviewed the case summaries of eight patients who developed concurrent compartment syndromes of the foot and leg after trauma. Patients with multiple fractures of the lower extremities, particularly the tibia, femur, and foot, may develop this disorder. The obvious causes of the concurrent syndromes, concurrent fractures and generalized limb ischemia, were seen only in two patients. The communication between the compartments of the foot and leg may be an additional causative factor. Delayed fasciotomy resulted in muscle necrosis and/or tibial nerve dysfunction. Suspected cases should have the diagnosis established by catheterization of the involved compartments. Prompt fasciotomies of the foot and leg should be performed if the pressures are significantly elevated.
Treatment of Infected Pilon Nonunions with Small Pin Fixators
Authors: Stasikelis Peter J. , Calhoun Jason H. , Ledbetter Billy R. , Anger Diane M. , Mader Jon T. 
Published: March 2013

Six consecutive patients with infected intra-articular fractures of the distal tibia were studied. They were treated with resection of all infected or necrotic bone, systemic antibiotics, and instrumentation with a small pin fixator (llizarov external fixator). The fixator was used to perform an ankle arthrodesis and to fill the defect created by bone resection with distraction osteogenesis. In all cases, the infections were eradicated, and a solid arthrodesis was attained. The patients required from zero to two revision procedures (average 1.3), and their time in the fixator varied from 3 to 13 months (average 8 months). All of the patients experienced at least minor complications during treatment (superficial pin tract infections). At final follow-up, no patient demonstrated shortening of more than 1.5 cm. One patient has an internal rotation deformity of 15°; a second has a varus deformity of 10° and occasionally uses lateral support (a cane) secondary to unsteadiness on uneven ground; and one patient uses aspirin occasionally for subtalar pain. All are pleased with their results and would undergo the same procedure again without reservation.
Congenital Brachymetatarsia: Three Cases
Authors: Ferrández L. , Yubero J. , Usabiaga J. , Ramos L. 
Published: March 2013

We report on three cases with congenital brachymetatarsia, one with bilateral affectation, together with the results of a lengthening of the short metatarsal bones by progressive axial distraction using an external minifixator. The method proved to be easy to implement, permitting immediate functionality of the ankle and early load bearing. The immediate results (cosmetic) and later findings (functional) were excellent in all three cases.
A Comprehensive Study of Pressure Distribution in the Ankle Joint with Inversion and Eversion
Authors: Calhoun Jason H. , Li Fan , Ledbetter Billy R. , Viegas Steven F. 
Published: March 2013

The understanding of load transfer characteristics is the baseline for biomechanics of the ankle joint. Changes in contact patterns of the articular cartilage from the norm may indicate pathologic conditions. Measurement of the contact in human cadaver ankles provides a direct measurement for this understanding. The force transfer characteristics of the three facets of the ankle joint were investigated. Five fresh-frozen cadaver lower extremities were tested in 12 positions under three axial loads of 490, 686, and 980 N. Fuji film served as the pressure transducer and the prints were analyzed by a computerized video digitizer. The results demonstrated that as the foot was moved into inversion or eversion with the ankle in neutral flexion or dorsiflexion, there was a decrease in total contact area and an increase in the average high pressure. In plantarflexion, the contact area was lower and the average high pressure was higher, indicating a greater force per unit area as compared with dorsiflexion and neutral flexion. In plantarflexion, however, little change was noted with inversion or eversion. In dorsiflexion, the total contact area was higher and the average high pressure slightly lower as compared with neutral flexion. With inversion, the contact area of the medial facet of the ankle increased and with eversion it increased on the lateral facet, especially in dorsiflexion. With an increase in loading, the pressure did not significantly increase but the contact area did increase. The centroid of the contact moved anteriorly to posteriorly on the talus as the joint moved from dorsiflexion to plantarflexion. The talar dome facet sustained 77% to 90% of the load, while the medial facet was loaded more during inversion (up to 22%) and the lateral facet was loaded more during eversion (up to 10.5%). No previous study has examined the relative contributions of the three main talar joint surfaces in multiple positions. The new information in this study includes the fibular and medial facet contribution and the variation of the load with position changes and loading increase. This study also provides a comprehensive evaluation of the pressure, contact area, and centroid of the ankle joint in its normal ranges of motion.
Magnetic Resonance Imaging for the Diagnosis of Osteomyelitis in the Diabetic Patient with a Foot Ulcer
Authors: Levine Stuart Eric , Neagle Charles E. , Esterhai John L. , Wright Douglas Gregory , Dalinka Murray K. 
Published: March 2013

Twenty-seven diabetic patients (12 males and 15 females) with clinically suspected osteomyelitis complicating soft tissue infection of the foot underwent 29 magnetic resonance imaging studies of the suspected lesion. Of these patients, 26 had plain film radiographs, 11 had technetium bone scanning, and 12 had indium-labeled leukocyte scintigraphy performed within 2 weeks of the magnetic resonance imaging. Definitive diagnosis of the presence or absence of osteomyelitis was obtained on the basis of surgical findings, histological evidence, or resolution with nonoperative therapy. Magnetic resonance imaging was 90% accurate (sensitivity 77%, specificity 100%) in the diagnosis of osteomyelitis in this patient population. Technetium bone scan was 45% accurate (sensitivity 100%, specificity 25%); indium-labeled leukocyte scintigraphy was 50% accurate (80% sensitivity, 29% specificity); and plain film roentgenography was 73% accurate (60% sensitivity, 81% specificity). Magnetic resonance imaging is a powerful, noninvasive tool for determining the presence or absence of osteomyelitis in the patient with a diabetic foot ulcer.
Outcome after Free Flap Reconstruction of the Heel
Authors: Durham John W. , Saltzman Charles L. , Steyers Curtis M. , Miller Bruce A. 
Published: March 2013

We reviewed six free flap reconstructions of the weightbearing surface of the heel. Patients were seen for clinical evaluation at a mean follow-up of 4.7 years (range 2.7–6.0 years). Functional results using a modified Boston Children's Hospital Ankle Score were 33% excellent, 33% good, 17% fair, and 17% poor. The excellent functional results were related to the absence of chronic draining flap ulcers. All flaps lacked protective sensation by Semmes-Weinstein monofilament testing. Weightbearing plantar pressures in the flaps were elevated in all patients. Sequential radiographs from the time of flap coverage revealed the development of a bony protuberance (stalactite) projecting from the undersurface of the calcaneus in all patients with injuries to the plantar cortex of the calcaneus. In patients with flap ulceration, these stalactites projected into the ulcer at the site of maximum plantar pressure. A combination of loss of plantar calcaneal integrity, elevated pressure concentrations, and flap insensitivity appear causally related to the development of heel free flap ulceration and outcome.
Comparison of Stability of Proximal Crescentic Metatarsal Osteotomy and Proximal Horizontal “V” Osteotomy
Authors: McCluskey Leland C. , Johnson Jeffrey E. , Wynarsky George T. , Harris Gerald F. 
Published: March 2013

Proximal metatarsal osteotomies are often performed in patients with hallux valgus and significant metatarsus primus varus. The crescentic osteotomy is popular; however, some authors have reported malunion of the metatarsal shaft caused by dorsal angulation of the osteotomy in a significant number of cases. Recently, proximal transverse “V” osteotomies have been reported to have good results, with rapid healing and no dorsal malunions. We compared the stability of a transverse, proximal “V” osteotomy, using two 0.062-inch K-wires or a 3.5-mm cortical screw for fixation, with that of the proximal crescentic osteotomy, using a 3.5-mm cortical screw fixation. The three osteotomy/fixation techniques were performed on 30 fresh-frozen cadaver feet. The specimens were loaded to failure at the fixation site by applying a load through the plantar surface of the first metatarsal head. Force versus displacement curves were obtained to calculate the failure load and stiffness. Statistical differences among the three groups were determined by the nonparametric Mann-Whitney U-test and the standard t-test. The “V” osteotomy/screw group was more stable than either the “V” osteotomy/pin group or the crescentic osteotomy/screw group. Differences in failure strength between the “V”/screw group and the other two groups were significant at the P < .01 level and the differences in stiffness were significant at the P = .05 level. No statistical differences were found between the “V”/pins and the crescentic/screw groups.
The Plantar Plate of the Lesser Toes: An Anatomical Study in Human Cadavers
Authors: Johnston Richard B. , Smith Judith , Daniels Timothy 
Published: March 2013

The purpose of this study was to evaluate the anatomic structure and biochemical composition of the plantar plate of the lesser toes. Fresh frozen-human cadaveric feet were used to study 20 metatarsophalangeal and proximal interphalangeal plantar plates. The observations of foot dissections were compared with the finger volar plate. The plantar plate of the toe is a rectangular structure with a stout distal insertion and relatively flimsy proximal origin. The anatomic relationships to adjacent structures and composition are similar between the volar plates of the fingers and plantar plates of the toes. The plantar plate is known to experience extension forces that the volar plate does not experience. The weightbearing nature of the foot and forces imposed by toe-off may create chronic hyperextension of the metatarsophalangeal joint and predispose the plantar plate to attenuation or rupture, thus leading to instability of the metatarsophalangeal joint. These findings may explain in part the clinical condition of spontaneous metatarsophalangeal joint dislocation, most commonly found in the second toe.
A Biomechanical Comparative Analysis of Two Techniques for Tibiotalar Arthrodesis
Authors: Friedman Robert L. , Glisson Richard R. , Nunley James A. 
Published: March 2013

Two commonly used techniques for tibiotalar fusion were quantitatively compared using instrumented testing of the strength of the construct. The tibiae and tali from 10 pairs of fresh-frozen cadaveric limbs were used. One joint of each pair was fused using two 6.5-mm crossed cancellous screws from proximal to distal while the contralateral joint was fused using two 6.5-mm parallel cancellous screws from distal to proximal. Each specimen was subjected to cantilever bending and torsional testing by servohydraulic actuators. The bending tests included plantarflexion, dorsiflexion, inversion, and eversion, and measured the load during deflection applied 10 cm distal to the fusion site. The rigidity was expressed as newtons per millimeter of deflection. The torsional tests measured construct stiffness in external and internal rotation, and were expressed as newton-meters per degree of rotation. For the bending tests, the crossed screw construct was more rigid in eversion (23.1 N/mm, P = .0004) and dorsiflexion (16.9 N/mm, P = .02), while the parallel screw construct was more rigid in inversion (22.8 N/mm, P = .02) and plantarflexion (22.3 N/mm, P = .0007). In torsional testing, the crossed screw construct was at least 1.5 times stiffer than the parallel screw construct in resisting internal (1.7 N-m/deg versus 0.9 N-m/deg, P = .0001) and external (1.4 N-m/deg versus 0.9 N-m/deg, P = .02) rotation. In laboratory testing, the crossed screw technique is more rigid than the parallel screws, especially in resisting torsional stresses. Assuming that a stronger construct is desirable, and given that short leg casts commonly used after such fusions do not completely restrict torsional motion, this biomechanical analysis suggests that the crossed screw technique improves the likelihood of a successful arthrodesis.
Anatomy of Second Muscular Layer of the Foot: Considerations for Tendon Selection in Transfer for Achilles and Posterior Tibial Tendon Reconstruction
Authors: Wapner Keith L. , Hecht Paul J. , Shea John R. , Allardyce Thomas J. 
Published: March 2013

Controversy exists regarding tendon choice to substitute for a ruptured posterior tibial tendon. A similar debate about late Achilles tendon reconstruction also persists. To establish priorities and aid the surgeon's decision-making process, we studied 85 en bloc dissections of the second muscular layer of the sole. Muscular and tendinous interconnections were evaluated. Location and minimal donor deficit following harvest of the flexor digitorum longus make it the transfer of choice for posterior tibial tendon reconstruction. We suggest that relative strength, anatomic location, and available length of tendon make the flexor hallucis longus the superior choice for late Achilles tendon reconstruction.
Arthroscopy of the Subtalar Joint
Authors: Frey Carol , Gasser Seth , Feder Keith 
Published: March 2013

The purpose of this study was to determine the position and relative safety of the anterior, posterior, and newly defined middle portals by measuring their distance from the neurovascular structures and tendons on the lateral side of the foot and ankle. Furthermore, this study demonstrates specific components of the posterior subtalar joint and arthroscopic access to each utilizing a technique that allows direct anatomic correlation. The 15 specimens were divided into three groups of five feet each, with one arthroscopic portal site and one instrumentation portal site per group. Group I used the anterior portal for the arthroscope and the posterior portal for the curette. Group II used the posterior portal for the arthroscope and the anterior portal for the curette. In group III, the arthroscope was inserted through the anterior portal and the curette through the middle portal. The sural nerve and small saphenous vein were at risk with posterior portal placement. The anterior portal presented a minor risk of injury to the dorsal intermediate cutaneous branch of the superficial peroneal nerve. The middle portal was without risk to surrounding structures. Group I provided the best access to the posterior facet of the subtalar joint. Group II provided excellent arthroscopic visualization of the posterior facet, but poor access for instrumentation via the anterior portal. Group III provided the best access to the sinus tarsi. No combination of portals allowed visualization or instrumentation of the middle or anterior facets.
Distal Chevron Osteotomy with Lateral Release for Treatment of Hallux Valgus Deformity
Authors: Pochatko David J. , Schlehr Frank J. , Murphey Mark D. , Hamilton James J. 
Published: March 2013

From 1986 to 1990, 42 feet in 30 patients had a combined chevron osteotomy and lateral release to correct their painful bunion deformity. Seventeen patients, 23 feet, were available for follow-up. The purpose of this study was to evaluate the outcome of this procedure and to determine the incidence of avascular necrosis. The patients were examined by an independent examiner, radiographs obtained, and questionnaires filled out. Avascular necrosis was determined using plain films read by a musculoskeletal radiologist who did not know the outcomes. The average age was 45 years at the time of the procedure. Average follow-up was 50 months. The preoperative intermetatarsal angle averaged 13° and the hallux valgus angle averaged 31°. At study follow-up, the intermetatarsal angle averaged 8° and the hallux valgus angle averaged 17.5°. The results were graded by the Mayo Clinic Forefoot Scoring System (75-point scale) and a subjective scoring system. Average postoperative Mayo Clinic score was 67. Fifteen feet were subjectively rated as excellent, six as good, and two as fair. Complications occurred in four feet. Hallux varus occurred in two feet, extension contracture in one foot, and an infection in one foot. None of the feet developed definite radiographic evidence of avascular necrosis. Distal chevron osteotomy combined with a lateral release for corrective bunion surgery has come under scrutiny, because of the risk of avascular necrosis of the first metatarsal head. However, our study showed no evidence of avascular necrosis on radiographs. In addition, 91% of patients had good to excellent results at an average 50-month follow-up.
Outpatient Foot Care: Correlation to Amputation Level
Authors: Weaver Frances M. , Burdi Michael D. , Pinzur Michael S. 
Published: March 2013

A retrospective analysis of Department of Veterans Affairs automated inpatient and outpatient records was performed for 3945 patients who underwent lower extremity amputation surgery due to peripheral vascular disease during fiscal year 1991. Demographic and clinical data were collected from reviewing patient database information for all Department of Veterans Affairs Hospitals nationwide. Patients were identified from the Physicians' Current Procedural Terminology codes for lower extremity amputations, and then divided into three groups (above the knee, below the knee, and foot and ankle) based on the most proximal level of amputation performed. Results indicate that increased use of designated foot care clinics was significantly associated with more distal level amputation surgery. Patients with above-the-knee amputations averaged 1.0 foot care clinic visit in the 2 years prior to amputation, whereas below-the-knee and foot and ankle amputees averaged 2.8 and 5.3 foot care clinic visits, respectively ( F [ df = 2,3939] = 94.20, P < .05). The same finding was noted when only users of foot care clinics were examined. Patients with a codiagnosis of diabetes were more likely to undergo distal amputation than those with other diagnoses ( P < .05). The results of this study suggest the potential effectiveness of designated foot care clinics in preserving limb length in individuals with peripheral vascular disease and diabetes.
Jones Transfer to the Lesser Rays in Metatarsalgia: Technique and Long-Term Follow-Up
Authors: Mulier Tom , Dereymaeker Greta , Fabry Guy 
Published: March 2013

Thirty-three feet in 29 patients with metatarsalgia were reviewed after Jones transfer to the lesser rays to evaluate the long-term results and the indications for these procedures. Transfer of the long extensor tendons to their respective metatarsal necks and fusion of the interphalangeal joints with shortening of the toe were performed. The procedures were performed in patients with symptoms of metatarsalgia, secondary to anterior pes cavus deformity (clawfeet, 16 patients), and in patients with mild or severe spreadfoot deformity with fall of the central metatarsals (12 patients). In all of our patients, the striking clinical sign was the long toes. Rating of the results was based on (1) the presence of pain or calluses and (2) residual deformity of the forefoot and toes. Symptoms of metatarsalgia were relieved in 25 feet, occasionally present in 6 feet, and unchanged in 2 patients. Complete correction of the deformity was achieved in 26 patients, 6 patients had slight residual deformities, and in the 1 poor result, overcorrection was present after the procedure. This operation is believed to be an excellent choice for patients with metatarsalgia due to (simple) pes cavus deformity and in patients with clawing and metatarsalgia secondary to excessively long toes.
Treatment of Delayed Unions and Nonunions of the Proximal Fifth Metatarsal with Pulsed Electromagnetic Fields
Authors: Holmes George B. 
Published: March 2013

Nine delayed unions and nonunion of the proximal fifth metatarsal were treated with pulsed electromagnetic fields (PEMF). All fractures healed in a mean time of 4 months (range 2–8 months). Those fractures treated with both pulsed electromagnetic fields and a nonweightbearing cast healed in a mean time of 3 months (range 2–4 months). The average duration of follow-up was 39 months (range 24–60 months). There were no refractures. When compared with reported healing times and morbidity for conventional casting, medullary curettage with inlay bone, and closed axial intramedullary screw fixation, pulsed electromagnetic fields provided an effective alternative for the treatment of delayed unions and nonunion of the proximal fifth metatarsal.