Tibiofibular syndesmosis in asymptomatic ankles: initial kinematic analysis using four-dimensional CT

AIM

To evaluate the reliability of ankle syndesmotic measurements and their changes during active motion using four-dimensional computed tomography (4DCT) examination in asymptomatic ankles.

MATERIALS AND METHODS

4DCT was performed on both ankles of patients with signs and symptoms of unilateral ankle instability. Ankles from the asymptomatic side of 10 consecutive patients were included in this analysis. Five ankle syndesmotic measurements were adopted from the available literature and performed by two fellowship-trained foot and ankle surgeons: (1) syndesmotic anterior distance (SAD); (2) syndesmotic posterior distance (SPD); (3) syndesmotic translation (ST); (4) syndesmotic tibiofibular angle (STFA); and (5) ankle tibiofibular angle (ATFA). A Monte Carlo simulation was also performed to obtain exact p-values with 99% confidence intervals.

RESULTS

Excellent interobserver reliability was observed among the two readers for four out of five measurements (intra-class correlation coefficients [ICC]: 0.767-0.995, p<0.001-0.020). The ICC values for SAD were not statistically significant (ICC=0.548 and 0.569 for dorsi and plantarflexion respectively, p=0.1). Among the five measurements, only ST measurements had significant changes during active motion (median [interquartile range] for change: -0.70 mm [-1.6-0.10]; p=0.012). Of the above measurements, only the ST measurements demonstrated a negative linear association with the tibiocalcaneal angle during active motion (beta=-2.5, p=0.04).

CONCLUSIONS

Reliable quantitative kinematic assessment of ankle syndesmosis can be performed using 4DCT examination. Syndesmotic measurements remain unchanged during ankle motion except for the syndesmotic translation, which tends to decrease during plantar flexion.

[Airlimb. Initial experiences with a new immediate early management prosthesis with individually adjustable air chambers]

Amputations of the lower extremity are still a common problem in diabetic feet and peripheral vasculopathies. The presented paper introduces a new device for an easier and faster mobilization of below-the-knee amputees. It is based on a new modular prostheses with individual inflatable air bladders. The compliance rate is higher with this device and it could be used from the day of surgery until the definitive prostheses is made. A biomechanical cadaver study with the prostheses will also be presented.

Complex salvage procedures for severe lower extremity nerve pain

From 1995 to 1999, the senior author did revision nerve release and vein wrapping (58 limbs in 58 patients) or peripheral nerve stimulation (62 limbs in 62 patients) to relieve intractable lower extremity nerve pain. Vein wrapping was done if the patient had temporary relief after a previous nerve release, if there was evidence of scarring around the nerve, and if nerve pain was triggered by mechanical stimulation. Peripheral nerve stimulation was done when previous nerve operations provided no relief or if the nerve pain was more constant and spontaneous without mechanical provocation. The duration of symptoms preoperatively averaged 52 months, and the number of previous peripheral neurosurgical interventions averaged 2.5. Postoperatively, the average pain improvement was rated as 60% for the patients who had vein wrapping and 41% for the patients who had peripheral nerve stimulation. Of the patients who had vein wrapping, 53% were satisfied, 14% were somewhat satisfied, and 33% were dissatisfied. Of the patients who had peripheral nerve stimulation, 61% were satisfied, 21% were somewhat satisfied, and 18% were dissatisfied. Most patients (78%) stated they would undergo the procedures again.

Subtalar distraction bone block arthrodesis

This retrospective study analyses the results of subtalar bone block distraction arthrodesis used in the treatment of late complications of calcaneal fractures, acute severely comminuted fractures, nonunion (and malunion) of attempted subtalar arthrodeses, avascular necrosis of the talus, and club-foot deformity. Of 39 patients (41 feet) who had this procedure, 35 (37 feet) returned for follow-up after a mean of 70 months (26 to 140). There were 24 men (25 feet) and 11 women (12 feet) with a mean age of 41 years (16 to 63). Each completed a standardised questionnaire, based on the hindfoot-scoring system of the American Orthopaedic Foot and Ankle Society and were reviewed both clinically and radiologically. Of the 37 operations, 32 (87%) achieved union. The mean hindfoot score (maximum of 94 points) increased from 21.1 points (8 to 46) preoperatively to 68.9 (14 to 82) at the final follow-up. The mean talocalcaneal and calcaneal pitch angles were 20.5° and 4.9° before operation, 25.9° and 8.3° immediately after, and 24.6° and 7.7° at the final follow-up, respectively. The mean talar declination angle improved from 6.5° (−10 to 22) before operation to 24.8° (14 to 32) at the final follow-up. The mean talocalcaneal height increased from 68.7 mm before operation to 74.5 mm immediately after and 73.5 mm at the final follow-up. Of the 37 arthrodeses available for review, 32 were successful; 29 patients (30 arthrodeses) were satisfied with the procedure. Minimal loss of hindfoot alignment occurred when comparing radiographs taken immediately after operation and at final follow-up.

Subtalar distraction bone block arthrodesis

This retrospective study analyses the results of subtalar bone block distraction arthrodesis used in the treatment of late complications of calcaneal fractures, acute severely comminuted fractures, nonunion (and malunion) of attempted subtalar arthrodeses, avascular necrosis of the talus, and club-foot deformity. Of 39 patients (41 feet) who had this procedure, 35 (37 feet) returned for follow-up after a mean of 70 months (26 to 140). There were 24 men (25 feet) and 11 women (12 feet) with a mean age of 41 years (16 to 63). Each completed a standardised questionnaire, based on the hindfoot-scoring system of the American Orthopaedic Foot and Ankle Society and were reviewed both clinically and radiologically. Of the 37 operations, 32 (87%) achieved union. The mean hindfoot score (maximum of 94 points) increased from 21.1 points (8 to 46) preoperatively to 68.9 (14 to 82) at the final follow-up. The mean talocalcaneal and calcaneal pitch angles were 20.5 degrees and 4.9 degrees before operation, 25.9 degrees and 8.3 degrees immediately after, and 24.6 degrees and 7.7 degrees at the final follow-up, respectively. The mean talar declination angle improved from 6.5 degrees (-10 to 22) before operation to 24.8 degrees (14 to 32) at the final follow-up. The mean talocalcaneal height increased from 68.7 mm before operation to 74.5 mm immediately after and 73.5 mm at the final follow-up. Of the 37 arthrodeses available for review, 32 were successful; 29 patients (30 arthrodeses) were satisfied with the procedure. Minimal loss of hindfoot alignment occurred when comparing radiographs taken immediately after operation and at final follow-up.

Surgical treatment of chronic lower extremity neuropathic pain

The current authors retrospectively reviewed 147 lower extremity peripheral nerve procedures in 114 patients (average age, 42 years) with chronic lower extremity neuropathic pain to determine whether surgical treatment based on an empirically derived algorithm could reduce pain and improve function. This algorithm assigns crush, stretch, and chronic transection injuries to treatment with transection and containment. Peripheral nerve stimulation was used in conjunction with transection and containment for patients with more chronic presentations for whom previous transections had been unsuccessful. Patients with adhesive neuralgia underwent revision neurolysis with vein wrapping. Patients with repetitive nerve trauma (overuse) underwent primary or revision neurolysis. Duration of symptoms averaged 37 months, and mechanisms of nerve injury included chronic transection, crush, adhesive neuralgia, stretch, repetitive trauma, and idiopathic etiology. Time to followup averaged 38 months. Pain and dysfunction were ranked from 0 points (no pain or dysfunction) to 10 points (pain prompting request for amputation or functional deficit warranting wheelchair use); preoperative and followup work status were documented. Average pain and dysfunction scores improved: 8.8 to 5.6 points and 7.6 to 5.0 points, respectively. Of the 114 patients, 52 (46%) patients improved their work status, including 35 of 87 (40%) involved in workers' compensation. There were no statistically significant differences in outcome based on mechanism of nerve injury or type of procedure. The consistent average improvement suggests this algorithm assigns the appropriate procedure to a given mechanism of injury.

Biomechanical evaluation of the ability of casts and braces to immobilize the ankle and hindfoot

We evaluated the ability of seven devices to immobilize a prosthetic ankle-foot complex against plantarflexion, dorsiflexion, inversion, and eversion forces: two casts (plaster of Paris and Fiberglas) and five removable braces (molded ankle/foot orthosis, composite boot brace, pneumatic boot walker, nonarticulating fracture boot, and ankle stirrup). Each device was applied to a prosthetic ankle-foot complex and evaluated on a test frame for resistance to sagittal motion and coronal torque. Results showed that casts offered significantly (P < or = 0.05) more resistance to motion in all directions tested than did the braces. The resistance offered by the devices tested depends on the conformity of the device to the shape of the foot in that plane and the material properties of the device. Braces offer the advantage of being easily removed and reapplied. Different braces offer specific advantages and disadvantages in different planes tested, and immobilization selection should be individualized based on this information.

Six first metatarsal shaft osteotomies: mechanical and immobilization comparisons

Because malunion (usually with dorsal elevation of the first metatarsal) has been reported after the treatment of severe hallux valgus deformities by proximal osteotomies, the current study was designed to compare the sagittal stability of six different metatarsal shaft osteotomies: the proximal crescentic, proximal chevron, Mau, Scarf, Ludloff, and biplanar closing wedge osteotomies. A plate was used in the biplanar closing wedge osteotomy; all others used screws for fixation. Ten fresh-frozen, human anatomic lower extremity specimens were used for each osteotomy. Failure loads were measured as units of force (newtons) and converted to pressure (kilopascals). Then the F-Scan system, which uses a thin insole to measure plantar pressure, was used to evaluate the pressure under the first metatarsal of seven volunteers using four types of shoes. According to the results, in patients with normal bone stock who are compliant, any of the four shoe types tested may be used after a Ludloff, Scarf, biplanar wedge (plantar screw fixation), or Mau osteotomy, but the wedge-based shoe should be used after a proximal crescentic or chevron osteotomy or for patients with severe osteopenic bone.

Peripheral nerve vein wrapping for intractable lower extremity pain

HYPOTHESIS/PURPOSE

The purpose of this study was to determine the effectiveness of lower extremity peripheral nerve vein wrapping procedures in the management of patients with intractable lower extremity pain. The hypothesis was that nerve insulation through vein wrapping is effective in treating symptoms related to adhesive neuralgia, but not those secondary to intraneural damage.

METHODS

We retrospectively reviewed 25 consecutive patients whose intractable chronic lower extremity peripheral neuralgia had been treated with revision neurolysis and vein wrapping. The 14 women and 11 men had an average age of 39 years (range, 21 to 53 years). Vein wrapping was performed using a saphenous vein autograft in 19 patients and a fetal umbilical vein in six patients. The average length of follow-up after vein wrapping was 24 months (range, 12 to 63 months). Assessment of pain and dysfunction was on a scale of 0 (no pain/dysfunction) to 10 (severe enough to prompt request for amputation and required use of a wheelchair).

RESULTS

Pain scores improved from a preoperative average of 8.7 points (range, 6 to 10 points) to a postoperative average of 4.6 points (range, 0 to 10 points); dysfunction improved from a preoperative average of 7.3 points (range, 3 to 10 points) to a postoperative average of 4.4 points (range, 0 to 9 points). Although 17/25 patients were satisfied with the procedure, only 14/25 stated they would undergo the surgery again. All eight patients who exhibited no improvement had preoperative and intraoperative evidence of an idiopathic etiology and/or intraneural damage. Preoperatively, 18/25 patients could not work; postoperatively, that number improved to 8/25.

CONCLUSIONS

Vein wrapping of lower extremity peripheral nerves is most effective in relieving symptoms related to adhesive neuralgia and less beneficial in the presence of intraneural damage. Although symptoms are rarely relieved completely, vein wrapping typically results in a substantial improvement in symptoms related to scar entrapment of peripheral nerves.

Isolated subtalar arthrodesis

BACKGROUND

The purposes of this retrospective study were to review the results of isolated subtalar arthrodesis in adults and to identify factors influencing the union rate. The hypotheses were that (1) the overall outcome is acceptable but is not as favorable as previously reported, (2) complication rates, especially the nonunion rate, are higher than previously reported, and (3) factors contributing to a less favorable union rate can be identified.

METHODS

Between January 1988 and July 1995, 184 consecutive isolated subtalar arthrodeses were performed in 174 adults (115 men and fifty-nine women) whose average age was forty-three years (range, eighteen to seventy-nine years). Eighty patients (46 percent) were smokers. The indications for the procedure included posttraumatic arthritis after a fracture of the calcaneus (109 feet), a fracture of the talus (thirteen feet), or a subtalar dislocation (thirteen feet); primary subtalar arthritis (thirteen feet); failure of a previous subtalar arthrodesis (twenty-eight feet); and residual congenital deformity (eight feet). Rigid internal fixation with one or two screws was used for all feet. Bone graft was used in 145 feet; the types of graft material included cancellous autograft (ninety-four feet), structural autograft (twenty-nine feet), cancellous allograft (seventeen feet), and structural allograft (five feet). Bone graft was not used in the remaining thirty-nine feet.

RESULTS

Clinical and radiographic follow-up examinations were performed for 148 (80 percent) of the 184 feet at an average of fifty-one months (range, twenty-four to 130 months) postoperatively. The average ankle-hindfoot score according to the modified scale of the American Orthopaedic Foot and Ankle Society (maximum possible score, 94 points) improved from 24 points preoperatively to 70 points at follow-up. Thirty feet had clinical evidence of nonunion. The union rate was 84 percent (154 of 184) overall, 86 percent (134 of 156) after primary arthrodesis, and 71 percent (twenty of twenty-eight) after revision arthrodesis. The union rate was 92 percent (ninety-three of 101 feet) for nonsmokers and 73 percent (sixty-one of eighty-three feet) for smokers (p < 0.05). Intraoperative inspection revealed that 42 percent (seventy-eight) of the 184 feet had evidence of more than two millimeters of avascular bone at the subtalar joint; all thirty nonunions occurred in this group (p < 0.05). A nonunion occurred in three of the five feet that had been treated with structural allograft and in two of the six feet in which the subtalar arthrodesis had been performed adjacent to the site of a previous ankle arthrodesis. After elimination of the subgroups of feet in patients who smoked, those that had had a failure of a previous subtalar arthrodesis, those that had been treated with a structural graft, and those that had had the subtalar arthrodesis adjacent to the site of a previous ankle arthrodesis, the union rate improved to 96 percent (seventy-three of seventy-six). Complications other than nonunion included prominent hardware requiring screw removal (thirty-six of 184 feet; 20 percent), lateral impingement (fifteen of 148 feet; 10 percent), symptomatic valgus malalignment (five of 148 feet; 3 percent), symptomatic varus malalignment (four of 148 feet; 3 percent), and infection (five of 184 feet; 3 percent).

CONCLUSIONS

To the best of our knowledge, the present study includes the largest reported series of isolated subtalar arthrodeses in adults. Our results suggest that the outcome following isolated subtalar arthrodesis is not as favorable as has been reported in previous studies. The rate of union was significantly diminished by smoking, the presence of more than two millimeters of avascular bone at the arthrodesis site, and the failure of a previous subtalar arthrodesis (p < 0.05 for all). Other factors that probably affect the union rate include the use of structural allograft and performance of the arthrodesis adjac

Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length

We treated 24 patients (18 women, six men; average age, 46.4 years; (range, 28 to 66 years) with fusion of the hallux metatarsophalangeal (MTP) joint using bone graft for the restoration of the length of the first ray. This procedure was performed after bone loss subsequent to previous surgeries for the correction of hallux valgus and hallux rigidus with: silastic arthroplasty (11), bunionectomy and distal metatarsal osteotomy (six), Keller resection arthroplasty (five), and total joint replacement (two). The indication for performing the arthrodesis with bone graft was a short first metatarsal, and associated metatarsalgia of the lesser metatarsals in addition to a painful MTP joint with or without deformity. This bone loss was associated with avascular necrosis of the first metatarsal (nine patients) and with osteomyelitis (seven patients). Of the 24 patients, 14 underwent additional concurrent surgery for correction of hammer toes (10), excision of a Morton's neuroma (two), and lesser metatarsal osteotomy (two). All patients were examined clinically and radiographically at a mean interval of 62.7 months after surgery (range, 26 to 108 months). The patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux and MTP 100-point outcome scale. Arthrodesis occurred in 19/24 patients (79.1%) at a mean of 13.3 weeks (range, 11 to 16 weeks), and the first ray was lengthened by a mean of 13 mm (range, 0 to 29 mm). Of the five nonunions, two were asymptomatic, and three were subsequently revised successfully, with arthrodesis occurring at a mean of 10.7 weeks. Complications included one deep infection requiring intravenous antibiotics for treatment of osteomyelitis and two minor superficial wound infections. The mean AOFAS score improved from 39 points (range, 22 to 60 points) to 79 points (range, 64 to 90 points). All patients were satisfied with the final outcome of treatment and stated that they would undergo the surgical procedure again. We concluded that arthrodesis of the hallux MTP joint with bone graft to restore bone loss and length of the first ray may be a worthwhile procedure despite the technical difficulty and the high rate of nonunion.

Clinical outcome after primary triple arthrodesis

BACKGROUND

To analyze the effects of multiple preoperative, intraoperative, and postoperative factors on the intermediate results of triple arthrodesis, we focused on preoperative deformity, preoperative diagnosis, degree of clinical and radiographic correction, and arthritis of the ankle.

METHODS

Between 1987 and 1995, 160 patients were managed with a total of 183 triple arthrodeses. Patients who had an infection or neuroarthropathy or who were managed with a revision arthrodesis were excluded from our study. Of the 160 patients, 111 (132 feet) who had been followed for a minimum of two years formed our study group. Each patient had an arthrodesis with rigid screw fixation and realignment of the joint surfaces without resection of wedges. The average duration of follow-up was 5.7 years (range, 2.0 to 10.8 years).

RESULTS

As seen radiographically, arthritis of the ankle was significantly more severe postoperatively than preoperatively (p<0.01), although patient satisfaction was not associated with the presence of arthritis. On a scale (not a visual analog) of 0 (not satisfied) to 10 (completely satisfied), overall satisfaction averaged 8.3 points (range, 0 to 10 points). The postoperative modified ankle-hindfoot score of the American Orthopaedic Foot and Ankle Society averaged 60.7 points (range, 0 to 94 points). There was a significant association (p = 0.001) between satisfaction of the patient and postoperative alignment. Ten patients had a total of eleven complications: four superficial wound problems, three nonunions, one case of superficial peroneal neuritis, one case of Charcot-like neuroarthropathy of the foot (in a patient in whom diabetes developed during the follow-up period), one rupture of the Achilles tendon, and one case of peroneal tenosynovitis. Of the 111 patients, 101 (91 percent) stated that they would have the procedure again under similar circumstances, and this response was independent of the preoperative diagnostic or deformity group.

CONCLUSIONS

Triple arthrodesis for the treatment of various deformities and etiologies is effective in relieving pain and improving functional deficits. Although a high prevalence of subsequent arthritis of the ankle was noted clinically and radiographically, we could detect no association between satisfaction of the patient and arthritis.

Biomechanical evaluation of two different screw positions for fusion of the calcaneocuboid joint

In triple arthrodesis performed for severe deformity and neuroarthropathy in poorly compliant patients with osteoporotic bone, fixation of the arthrodesis is critical. We biomechanically tested an alternative means of stabilization for calcaneocuboid fusions. In seven matched pairs of fresh-frozen cadaver feet, we removed the soft tissue from around the calcaneocuboid joint, except for the capsule, and we did not resect the articular cartilage. One joint of each pair was fixed with an oblique standard screw, and the contralateral joint was stabilized with an axial screw placed perpendicularly to the joint surface. Testing on an MTS Mini Bionix Test Frame (MTS Systems Corp., Eden Prairie, MN) demonstrated that the axial screw provided significantly higher initial stiffness and maximum load to failure. We concluded that an axial screw provided better fixation of the calcaneocuboid joint.

Histopathologic findings in autogenous saphenous vein graft wrapping for recurrent tarsal tunnel syndrome: a case report

Autogenous saphenous vein graft wrapping of the tibial nerve has been described as an effective treatment option for failed tarsal tunnel decompression. Various theories have been proposed to explain how this method works, with little histologic evidence to date. A pathologic investigation of a sectioned nerve that had been previously wrapped provides some insight into these proposals.

Midfoot fusion technique for neuroarthropathic feet: biomechanical analysis and rationale

To test the hypothesis that a plate applied to the plantar (tension) side of the medial midfoot provides stronger fixation than midfoot fusion with screw fixation, we biomechanically compared the two constructs for midfoot fusion. We created a model of midfoot instability in eight matched pairs of cadaver legs by section of joint capsule, ligaments, and tendons about Lisfranc's joints, and then performed a load-to-failure study to compare the fixation provided by a plantarly applied third tubular plate with that by cortical screws. After an initial load deformation curve to 1000 N was obtained, specimens were cyclically loaded at 200 to 750 N for 3000 cycles and then loaded to failure (screw pullout, fracture, or deformation >3 mm). Comparing the plantar plate and midfoot fusion with screw fixation constructs, a plate applied to the plantar (tension) aspect of the medial midfoot provides a stronger, sturdier construct than does midfoot fusion with screw fixation.

A comparative mechanical analysis of the pointe shoe toe box. An in vitro study

Dancing en pointe requires the ballerina to stand on her toes, which are protected only by the pointe shoe toe box. This protection diminishes when the toe box loses its structural integrity. The objectives of this study were 1) to quantify the comparative structural static and fatigue properties of the pointe shoe toe box, and 2) to evaluate the preferred shoe characteristics as determined by a survey of local dancers. Five different pointe shoes (Capezio, Freed, Gaynor Minden, Leo's, and Grishko) were evaluated to quantify the static stiffness, static strength, and fatigue properties (cycles to failure) of the shoes. Under axial loading conditions, the Leo's shoe demonstrated the highest stiffness level, and the Freed shoe exhibited the least strength. Under vertical loading conditions, the Leo's and Freed shoes demonstrated the highest stiffness levels, and the Gaynor Minden and Freed shoes exhibited the highest strength. Fatigue testing highlighted the greatest differences among the five shoes, with the Gaynor Minden demonstrating the highest fatigue life. Dancers rated the top five shoe characteristics, in order of importance, as fit, comfort, box/platform shape, vamp shape, and durability and indicated that the "best" shoe is one that "feels right" and permits artistic maneuvers, not necessarily the strongest or most durable shoe.

Tibiotalocalcaneal arthrodesis: anatomic and technical considerations

In the first of this two-part cadaver investigation, we inserted a specially designed, pointed device (simulating a 12-mm nail) in an antegrade fashion in each of eight fresh-frozen cadaver tibial specimens; the tibial isthmus was used as a centralizing guide. The exit point was noted, and the specimen was dissected to identify the structures at risk. In all specimens, we found that the device placed the lateral plantar artery and nerve at risk (average minimal distance from device to structure, 0 mm) and that damage to the flexor hallucis brevis and plantar fascia occurred. In addition, in six of the eight specimens, the device skewered or skived the flexor hallucis longus tendon. We also noted that in each specimen the exit point was the sustentaculum tali, not the body of the calcaneus as expected. Thus, there was less calcaneal bone-to-rod interface for stability, and distal locking would be less effective in the lateral-to-medial direction because of the lack of medial bone stock. On the basis of the results of the first portion of the study, we investigated an alternative approach to retrograde tibial nailing to reduce the risk of injury to the plantar and medial structures of the foot. We performed a medial malleolar resection, medially displaced the talus, inserted the device in an antegrade fashion, and dissected the specimens to analyze the structures at risk. We found that malleolar resection and medial translation of the distal extremity an average of 9.3 mm (range, 7-11 mm) increased the average minimal distance from the tip of the device to the neurovascular bundle to 18.4 mm (range, 14-32 mm). We also found that there was no damage to the flexor hallucis longus and that all eight specimens demonstrated bony contact completely surrounding the nail device within the tuberosity portion of the calcaneus (assessed by postoperative radiographs). The results of this study suggest that malleolar resection and medial translation of the distal extremity before retrograde nailing of the tibia may reduce the risk of vital structure injury and enhance the rigidity of the fixation.

Radiographic and clinical classification of acquired midtarsus deformities

To develop a classification of midtarsus deformities, clinical examination and weightbearing radiographs were used to evaluate 131 feet in 109 patients (average age, 59+/-11 years) with those deformities. Patients were classified into four types based on anatomic location of the maximum deformity. Type I (N=43) showed deformity at the metatarsocuneiform joints medially and the fourth and fifth metatarsocuboid joints laterally, with plantarmedial and/or medial prominence. Type II (N= 60) had deformity at the naviculocuneiform joint medially and the fourth and fifth metatarsocuboid joints laterally; plantarlateral prominence was characteristic, although one-third had isolated or additional medial prominences. Type III (N=17) had major deformity in the perinavicular region, with a prominence plantarcentrally or plantarlaterally. Type IV (N=11) had deformity at the transverse tarsal joints with variable prominences. Each type was further subdivided into stages A, B, and C based on the severity of the deformity. In stage B, the midtarsus was coplanar with the metatarsocalcaneal plane. In stage A, the midtarsus was above this plane. In stage C, the midtarsus was below this plane. We concluded that midtarsus deformities can be classified as one of four types and one of three stages. Additional study is warranted to correlate this system with prognosis and treatment for this pathologic process.

Mechanical comparison of biplanar proximal closing wedge osteotomy with plantar plate fixation versus crescentic osteotomy with screw fixation for the correction of metatarsus primus varus

Proximal crescentic metatarsal osteotomy is a clinically successful technique for correcting metatarsus primus varus in hallux valgus surgery. However, there have been instances of dorsal elevation of the metatarsal head with this technique. Mechanical testing on 10 matched pairs of cadaver feet was performed to evaluate a new technique combining a biplanar closing wedge osteotomy and plantar plate fixation versus crescentic metatarsal osteotomy. The specimens were tested in cantilever-bending mode on an MTS Mini Bionix test frame. The mean load-to-failure values were 127.2 +/- 81.9 N (SD) for biplanar osteotomy with plate fixation and 44.9 +/- 43.3 N for crescentic osteotomy (P = 0.019); the mean stiffness values at the initial portion of the load-deflection curve were 83.11 +/- 73.76 N/mm and 31.95 +/- 43.00 N/mm, respectively (P = 0.012). The biplanar wedge osteotomy with plantar plate fixation demonstrated significantly stronger fixation than the crescentic osteotomy, with higher mean load-to-failure and stiffness values. This newly described technique may provide an acceptable alternative for patients at risk for dorsal elevation of the metatarsal, particularly those who are noncompliant or have osteopenia. Clinical study will determine whether this new technique offers satisfactory long-term results.

A new modified technique for harvest of calcaneal bone grafts in surgery on the foot and ankle

Reported sites for retrieval of cancellous bone for grafts include the iliac crest, greater trochanter, proximal tibia, and distal tibia. A new lateral technique for retrieval of cancellous bone from the calcaneus is evaluated through anatomic review, quantitative analysis, and retrospective clinical assessment. Of 22 patients managed with this technique over a 2-year period, 17 returned for an evaluation by questionnaire, physical examination, and radiographic follow-up at an average of 7 months after surgery (range, 4-16 months). Complaints/complications were minor: three had minor incisional symptoms, five had medial heel pain (3 caused by plantar fasciitis), and one had unchanged preoperative heel pain secondary to clubfoot deformity. Compared with more extensive bone-grafting procedures, this procedure offers the advantages of bone harvested under local anesthesia using a readily accessible ipsilateral extremity and producing minor complications.

Charcot neuroarthropathy of the foot and ankle

The goal of this study was to characterize Charcot neuroarthropathy of the foot and ankle by specific sites of involvement (ankle, hindfoot, midfoot, and forefoot), modes of presentation, methods of management, and outcome. A summary of treatment and results for 50 ankles, 22 hindfeet, 131 midfeet, and 18 forefeet is presented. Nondisplaced neuropathic ankle fractures typically healed uneventfully with casting and bracing. For displaced ankle fractures, closed reduction and casting generally resulted in loss of reduction and progressive deterioration; better results were obtained with open reduction and internal fixation, using supplemental Kirschner wires and screws. Ankles with Charcot neuroarthropathy and preexisting arthritis typically required arthrodesis. Of the ankles with neuropathic avascular talar necrosis, approximately 1/3 did well with nonoperative intervention and 2/3 required surgery. Chronic, unstable, malaligned Charcot ankles often required arthrodesis. Neuropathic calcaneal fractures were managed successfully nonoperatively. For feet with transverse tarsal joint involvement (Schon Type IV), management was more complex. Nonoperative treatment was successful for less than 1/2. Two thirds of the feet with midtarsus involvement (Schon Types I, II, and III) were managed successfully nonoperatively; 1/3 required surgery for recurrent ulceration, instability, or osteomyelitis. Half of the feet with forefoot neuroarthropathy required surgery for malalignment, ulceration, and/or difficulty with shoewear or braces. This review has established patterns of Charcot involvement of the foot and ankle with corresponding methods of treatment and subsequent responses. From this extensive clinical experience with 221 neuropathic fractures or Charcot joints, recommendations were derived to assist in selecting appropriate management options.

Hallux metatarsophalangeal arthritis

Arthritis of the hallux metatarsophalangeal joint is a common disorder that affects shoewear, ambulation, and other activities of daily living. Etiologies include degenerative arthritis (hallux rigidus), crystal induced arthropathy (gout, pseudogout), rheumatoid arthritis, the seronegative spondyloathropathies, posttraumatic degeneration, and advanced hallux valgus. Accurate diagnosis and selection of the appropriate intervention depends on recognition of pertinent clinical and radiographic features. This study presents a synopsis of the senior author's (LCS) experience with 439 surgically treated patients with hallux metatarsophalangeal arthritis, focusing on origin and treatment.

Posttraumatic posterior tibialis tendon insertional elongation with functional incompetency: a case report

We present a case report and literature review of distal intrasubstance rupture of the posterior tibial tendon with progressive pes planovalgus secondary to tendon incompetence. Three months after a severe ankle sprain, a 25-year-old basketball player presented with ankle weakness and pain. Treatment by advancement of the posterior tibial tendon to the navicular and medial displacement osteotomy of the calcaneal tuberosity restored alignment, strength, and full function.

Thromboembolism after foot and ankle surgery. A multicenter study

Thromboembolic disease presents a potentially fatal complication to patients undergoing orthopaedic surgery. Although the incidence after hip and knee surgery has been studied and documented, its incidence after surgery of the foot and ankle is unknown. For this reason, a prospective multicenter study was undertaken to identify patients with clinically evident thromboembolic disease to evaluate potential risk factors. Two thousand seven hundred thirty-three patients were evaluated for preoperative risk factors and postoperative thromboembolic events. There were six clinically significant thromboembolic events, including four nonfatal pulmonary emboli, after foot and ankle surgery. The incidence of deep vein thrombosis was six of 2733 (0.22%) and that of nonfatal pulmonary emboli was four of 2733 (0.15%). Factors found to correlate with an increased incidence of deep vein thrombosis were nonweightbearing status and immobilization after surgery. On the basis of these results, routine prophylaxis for thromboembolic disease after foot and ankle surgery probably is not warranted.

Salvage of pseudoarthrosis after tibiotalar arthrodesis

We retrospectively reviewed the treatment of a selected group of 23 patients with pseudoarthrosis after ankle arthrodesis who underwent revision arthrodesis at an average of 1.7 years (range, 0.3-17.0 years) after the initial, unsuccessful procedure. Fourteen patients underwent isolated revision tibiotalar arthrodesis, and 9 had an additional hindfoot arthrodesis (7 tibiotalocalcaneal, 2 pantalar) performed at the time of the procedure. Rigid internal fixation with screws was performed when possible, and, in patients with poor bone quality, an external fixator was used. Autogenous bone grafting was used in 14 patients where bone loss was present. Twenty-one of 23 patients had successful union (average, 14 weeks; range, 6-48 weeks). Two patients underwent successful arthrodesis but had persistent pain from reflex sympathetic dystrophy. Overall, 19 of 23 patients were satisfied with the surgery. We conclude that revision arthrodesis for tibiotalar pseudoarthrosis is a worthwhile procedure.

Clinical and radiographic outcome of revision surgery for failed triple arthrodesis

Between 1987 and 1994, we treated 33 patients with surgical revision for failed triple arthrodesis, 28 (29 feet) of whom returned for final examination (mean, 4.4 years; range, 2-7 years). The average age of these 16 women and 12 men was 46 years (range, 14-69 years). Before the revision procedure, patients had undergone nonoperative therapies for an average of 3.7 years (range, 0.5-12 years) and an average of three foot operations (range, 1-6 operations) after the primary triple arthrodesis. All patients were managed with rigid internal fixation via cannulated screws and power staples. Calcaneal osteotomy and/or revision of the transverse tarsal arthrodesis via appropriate saw cuts and bone wedges were used. Iliac crest bone graft was added, when a bone block arthrodesis was required, for those patients with nonunion or ankle impingement. Arthrodesis was achieved in all 29 feet, although 4 patients (4 feet) (14%) required additional procedures for malunion (2 patients), deformity recurrence (1 patient), deep infection (1 patient), and skin graft (1 patient). Comparison of the average pre- (retrospective) and postoperative American Orthopaedic Foot and Ankle Society 94-point hindfoot and ankle scores showed a significant improvement: 31 points (range, 13-61 points) versus 59 points (range, 24-91 points), respectively (P < 0.05). On a scale of 0 to 10 points, average patient satisfaction was 7.8 points (range, 2-10 points). This study demonstrated a satisfactory improvement in patient outcome after surgical correction of failed triple arthrodesis. We conclude that such a revision, although complex, may be attempted to establish a plantigrade foot free of infection and able to wear shoes without and orthosis or brace.

Avascular necrosis of the talus treated by core decompression

We reviewed 11 patients (17 ankles) who had had core decompression for symptomatic avascular necrosis of the talus before collapse. The Mazur grading system was used to assess function preoperatively and at final follow-up, and radiographs were graded according to the Ficat and Arlet (1980) classification modified for the ankle. At a mean follow-up of seven years (2 to 14) 14 ankles (82%) had an excellent or good outcome (Mazur scores > 80 points; pain scores > 40 points (41 to 50). The other three ankles required tibiotalar fusion at a mean of 13 months (5 to 20) after core decompression. We conclude that core decompression is a viable method of treatment for symptomatic avascular necrosis of the talus before collapse.

AVASCULAR NECROSIS OF THE TALUS TREATED BY CORE DECOMPRESSION

We reviewed 11 patients (17 ankles) who had had core decompression for symptomatic avascular necrosis of the talus before collapse. The Mazur grading system was used to assess function preoperatively and at final follow-up, and radiographs were graded according to the Ficat and Arlet (1980) classification modified for the ankle.

At a mean follow-up of seven years (2 to 14) 14 ankles (82%) had an excellent or good outcome (Mazur scores > 80 points; pain scores > 40 points (41 to 50)). The other three ankles required tibiotalar fusion at a mean of 13 months (5 to 20) after core decompression.

We conclude that core decompression is a viable method of treatment for symptomatic avascular necrosis of the talus before collapse.

Lower extremity musculoskeletal problems in dancers

Ankle and foot problems are extremely common in the high-performance dance population. To adequately evaluate and treat these problems, the physician must possess knowledge of how the physical demands of dance affect the performer's body. A routine evaluation of the dancer, involving a team of orthopedists, dance instructors, and physical therapists familiar with dance mechanics, has been developed to facilitate recognition of the abnormal mechanics responsible for injury. This technique can be useful in prevention and early diagnosis of injury, thus minimizing lost performance time.

Tendon transfer combined with calcaneal osteotomy for treatment of posterior tibial tendon insufficiency: a radiological investigation

We present the radiographic results after flexor digitorum longus tendon transfer combined with a medial displacement calcaneal osteotomy for the treatment of posterior tibial tendon insufficiency. Eighteen patients with posterior tibial tendon insufficiency were reviewed from 12 to 26 months after surgery. The 15 women and 3 men had a mean age of 54 years (range, 38-72 years). The talar-first metatarsal and talonavicular coverage angles were measured before and after surgery on the anteroposterior weightbearing radiographs. The mean preoperative talar-first metatarsal and talonavicular coverage angles were 21 degrees (range, 3-45 degrees) and 34 degrees (range, 0-55 degrees), respectively. The mean postoperative values for these angles were 8.5 degrees (range, 0-35 degrees) and 21 degrees (range, -30-45 degrees), respectively. The mean talar-first metatarsal angle decreased from 21 degrees to 8.5 degrees, a mean improvement of 12.5 degrees, and the mean talonavicular coverage angle decreased from 34 degrees to 21 degrees, a mean improvement of 13 degrees. On the lateral weightbearing radiographs, the talar-first metatarsal angle and the distance from the medial cuneiform to the floor were measured before and after surgery. The mean preoperative values were -22 degrees (range, -10 to -40 degrees) and 9 mm (range, 1-19 mm), respectively. The mean postoperative values were -9 degrees (range, +5 to -25 degrees) and 16 mm (range, 10-28 mm), respectively. The mean talar-first metatarsal angle decreased from -22 to -9 degrees (a mean improvement of 13 degrees), and the distance from the medial cuneiform to the floor increased from 9 to 16 mm (a mean improvement of 7 mm). We conclude that the use of a combined medial displacement osteotomy of the calcaneus with a tendon transfer for treatment of posterior tibial tendon insufficiency may offset the inherent weakness of the flexor digitorum longus transfer by reducing the antagonistic deforming force of heel valgus.

The management of neuroarthropathic fracture-dislocations in the diabetic patient

Appropriate management for the diabetic patient with a fracture or sprain depends on recognition of "at-risk" factors. For patients with stable, minimally displaced injuries, conservative modalities (prolonged immobilization and non-weight-bearing) are sufficient. For patients with unstable or displaced fracture-dislocations, and whose general condition does not contraindicate surgery, open reduction and internal fixation, at times combined with external fixation, is recommended. Initial aggressive management can avoid or minimize the disastrous sequelae of a destructive neuroarthropathic process and can effect a biomechanically sound plantigrade, braceable, and shoeable lower extremity.

Branches of the tibial nerve: anatomic variations

Anatomic variations in tibial nerve branches may help explain discrepancies between clinical examination and electrophysiologic tests as to the location of neuronal lesions. Dissection of 20 cadaveric feet (10 pair) along the course of the tibial nerve and its branches confirmed that it bifurcates within 2 cm of the medio-malleolar-calcaneal axis in 90% (18/20) and that it gives off frequent small branches with its accompanying vascular structures. Unlike other studies, however, we found that 60% had multiple calcaneal branches off the tibial nerve and that 20% evidenced previously undescribed accessory innervation to the abductor hallucis muscle from other than the medial plantar nerve.

Dance screen programs and development of dance clinics

Dance movements can be stressful to the body, and the required extreme positions may place physiologic structures at risk for acute, subacute, or chronic injury. The authors designed a screening program, conducted by a team of physical therapists, orthopedists, and dance instructors, to evaluate dancers for musculoskeletal problems and to make recommendations that would improve movement compensation, strength, endurance, and mobility.

Clinical results following revision tibial nerve release

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

Nerve entrapment, neuropathy, and nerve dysfunction in athletes

Nerve entrapment, neuropathy, and nerve dysfunction in the legs, ankles, and feet of athletes are not uncommon conditions. Frequently, the conditions are overlooked as the more obvious musculoskeletal injury draws the physician's attention. Typically, with conservative treatment, including an occasional injection of local anesthetic with and without corticosteroid, resolution is achieved. Rarely, symptoms are severe and diffuse enough to require administration of a tricyclic antidepressant medication to decrease the nerve irritability. In cases that fail to respond to conservative treatment and have well-localized neurologic findings, surgery may be indicated. During surgery, the nerve should be minimally manipulated. The surrounding veins, arteries, and fat should be relatively undisturbed. Critical to understanding and treating these problems is a thorough knowledge of the peripheral neuroanatomy.

Heel pain syndrome: electrodiagnostic support for nerve entrapment

A local entrapment neuropathy has been proposed as one of the etiologies of heel pain, but it has never been documented by electrodiagnostic studies. Primary symptoms in patients suspected of having a neurologic basis for their heel pain include neuritic medial heel pain and radiation either proximally or distally. On physical examination, all patients in our series had reproduction of their symptomatology with palpation over the proximal aspect of the abductor hallucis and/or the origin of the plantar fascia from the medial tubercle of the calcaneus. Twenty-seven patients (20 women and seven men; average age 49) with these clinical characteristics were examined by electromyography and motor/sensory/mixed nerve conduction studies. Bilateral heel signs and symptoms were present in 11 patients. Ten of the patients had a significant history of back pain with referral to the legs. In 23 of the 38 symptomatic heels, abnormalities were identified in the lateral and/or the medial plantar nerves. The number of abnormal values per heel ranged from one to four, with a mean of 2.1. The most common finding was involvement of the medial nerve (57%). Thirty percent of the heels had isolated findings in the lateral plantar nerve and 13% had abnormalities in both plantar nerves. Two patients had electrophysiologic evidence of active S1 radiculopathy, with ipsilateral evidence of plantar nerve entrapment suggesting a "double crush" syndrome. The results of this study support the presence of abnormalities of plantar nerve function in a selected group of patients with neuritic heel pain.

Foot and ankle problems in dancers

Lower extremity problems, specifically in the feet and ankles, are common in dancers. This is not surprising considering the repetitive and acute stresses applied to lower limbs during this rigorous performing arts activity. When evaluating a dancer with lower extremity complaints, the nature of these demands must be appreciated. In addition to routine physical examination, static and dynamic biomechanical evaluation is paramount to analysis and treatment of leg, foot, and ankle conditions. Although a particular problem, such as painful bunion, may seem localized, it is often related to other factors, such as weak posterior tibial tendon, tight heel cords, or inadequate or forced turnout. It is incumbent on the physician to treat the specific area and, more importantly, to discover contributing factors that may be corrected by changes in technique or training. The physician caring for dancers should communicate with the instructor, physical therapist, or choreographer to facilitate the process. An overview of some common maladies and their characteristics findings are presented.

Chronic Exercise-Induced Leg Pain in Active People

In brief "Shin splints" is a catchall term for any kind persistent exercise-related lower leg pain with no obvious cause. Such pain can originate from a number of conditions, such as medial tibial stress syndrome, stress fracture, compartment syndrome, vascular pathology, nerve entrapment, and others. A methodical work-up designed to detect problems in all anatomic structures from bone to skin will narrow the possibilities and lay the basis for appropriate treatment.

Reconstruction for subtalar instability: a review

Instability of the subtalar joint has become a more well-defined clinical entity in recent years. While there have been several articles which have discussed diagnosis of this condition, there has been little written on the surgical treatment. Reconstructive techniques with which we have had experience are presented. Technical aspects of these methods are described in detail.

Neuropathies of the foot and ankle in athletes

Although neuropathies in the athlete's foot and ankle are uncommon, they are often underdiagnosed. This is primarily due to the complex interplay of factors that are required for their presentation. The most frequently encountered entrapment syndromes (in decreasing order) involve the interdigital nerves, first branch of the lateral plantar nerve, isolated medial or lateral plantar nerves, posterior tibial nerve, deep peroneal nerve, superficial peroneal nerve, sural nerve, and saphenous nerve. A thorough knowledge of peripheral nerve anatomy is essential in establishing the diagnosis. Roentgenograms may reveal bony abnormalities that are the diagnosis. Roentgenograms may reveal bony abnormalities that are commonly contributory. Electrodiagnostic tests may be normal because these dynamic syndromes often resolve at rest. In most cases, correction of underlying etiologies combined with rest, NSAIDs, and occasionally injections will allow resolution of the syndrome. Recalcitrant cases may require surgical decompression, which frequently provides satisfactory results.