Faculty Bibliography

BACKGROUND: Atypical claudication is a relatively uncommon problem within the general population. However, suspicion for the diagnosis is raised when young and athletic patients present with symptoms of claudication during exercise. The most common causes of atypical claudication are anatomical variants, including popliteal artery entrapment syndrome and tarsal tunnel syndrome. These variants result in impaired arterial flow and nerve compression, respectively. In this report, we present a seminal case of dorsalis pedis artery entrapment by the extensor hallucis brevis tendon during active dorsiflexion of the foot. METHODS: The patient was a 42-year-old male without significant past medical history, who presented with claudication in both feet upon active dorsiflexion. He underwent dynamic arterial duplex studies that first revealed normal flow in the neutral position and then revealed complete cessation of flow in both duplex and Doppler modes on dorsiflexion of the foot. He also underwent dynamic magnetic resonance angiography of bilateral lower extremities that revealed an incomplete pedal arch with early termination of the posterior tibial artery on static images and termination of the dorsalis pedis artery at notching on the dorsum of the foot during dorsiflexion. The patient was taken to the operating room for bilateral dorsalis pedis artery exploration. During exploration, the patient was found to have entrapment of the dorsalis pedis artery by the extensor hallucis brevis (EHB) tendon. This was documented by both direct visualization and intraoperative cessation of Doppler signal on dorsiflexion. Since the EHB tendon provides only secondary function to the extensor hallucis longus (EHL) tendon, the EHB was transected near its insertion and transposed directly to the EHL tendon. This allowed for normal extensor function of the great toe and restored triphasic Doppler signals during dorsiflexion. CONCLUSION: Dorsalis pedis arterial entrapment is a novel cause of atypical claudication. It is extremely uncommon as patients must have both abnormal anatomy and an incomplete pedal arch to display symptoms. Similar to other entrapment syndromes, if identified before permanent arterial scarring, the treatment does not require a bypass procedure. Removal of the tendon along with transposition will allow cessation of symptoms without impaired dorsiflexion of the great toe

This prospective study was designed to evaluate a nonoperative-based treatment protocol for patients with the clinical diagnosis of a degenerative medial meniscus tear and to determine if a significant percent of patients with degenerative medial meniscus tears improve with nonoperative treatment and do not elect operative treatment. Twenty-six patients were followed for 37 months and evaluated clinically, radiographically, and with standardized, validated Modified Lysholm Knee Scoring System (MLKS) and Standardized Activities of Daily Living Scale of the Knee (SADL) questionnaires. Patients were initially treated with 4 weeks of nonsteroidal anti-inflammatory drugs. After 4 weeks, they were offered arthroscopic partial meniscectomy or continued nonoperative treatment. Forty-six percent of patients (12 of 26) declined operative treatment. The mean length of time between enrollment and surgery was 3 months (range, 1-13 months). Both groups improved significantly over baseline (P<.05). The initial and final SADL and initial MLKS scores of the 2 groups were not significantly different (P>.05). The final MLKS score of the operative treatment group was significantly greater than the nonoperative group (P=.04). Both the nonoperative and operative treatment groups improved significantly at 3-year follow-up. Forty-six percent of the patients received nonoperative treatment and improved to a functional level that allowed them to avoid surgery. Therefore, we recommend an initial course of nonoperative treatment for all patients with a clinical diagnosis of degenerative medial meniscus tears prior to considering surgery.

The surgeon must determine the pathologic elements that need correction. Close observation for an increased HV angle, increased IM angle, pronation of the first toe, increased DMAA, enlarged medial eminence, and subluxation of the sesamoids must be performed. While there are a large number of procedures available for the management of HV, no one method sufficiently corrects all HV deformities. The upper limits of deformity correction for each procedure vary with the surgeon and their familiarity with each procedure. Ultimately, the surgeon must attempt to maintain a flexible first MTP joint and preserve the normal weightbearing pattern of the forefoot. Patient education also can be assistive in avoiding aggravating activities and making better choices in shoe wear. Tracings of the weightbearing foot and the shoe can be used to demonstrate to patients the size differences between the natural size and shape of the foot and that of the shoe, both pre- and postoperatively.

The current study evaluated a new pressure alarm and compared the ability of subjects to limit weightbearing to 20 lb with and without the alarm. The 28 subjects were divided into four groups (Group 1, n = 7, mean age, 33 years, with normal sensation; Group 2, n = 7, mean age, 59 years, with normal sensation; Group 3, n = 6, mean age, 56 years, without protective lower limb sensation, and Group 4, n = 8, mean age, 39 years, with transtibial amputation). All subjects were instructed in partial weightbearing ambulation and then practiced weight shifting onto a scale set at 20 lb for 2 minutes. Average peak force was measured using the F-scan in-shoe sensor while subjects ambulated in two trials: one with a deactivated pressure alarm and the other with an activated alarm. Data were analyzed using two-tailed t tests. In Groups 1, 2, and 4, significantly lower average peak force with the activated alarm versus deactivated alarm occurred in 43%, 86%, and 100% of subjects, respectively. Weightbearing was limited to less than 20 lb with the activated alarm in 86%, 57%, 33%, and 38% of subjects versus 71%, 14%, 0%, and 0% of subjects with the deactivated alarm, respectively.

A first metatarsophalangeal joint resection arthroplasty that combines a modest metatarsal cheilectomy with an oblique resection of the phalanx base (preserving the flexor hallucis brevis attachment) combined with interposition arthroplasty of the dorsal joint capsule sewn to the plantar soft tissues is presented. Numerous surgical procedures have been described for the treatment of hallux rigidus, including dorsal cheilectomy, resection arthroplasty, joint replacement, and arthrodesis. The Keller procedure has been abandoned by many because of shortening of the great toe and loss of push-off power. The modified oblique Keller technique described here allows for intraoperative transition from cheilectomy to resection arthroplasty with what appears to be a satisfactory outcome, maintaining plantarflexion power and hallux length

STUDY DESIGN. Computed tomography scans of the dens were performed on patients who had no atlantoaxial pathology. OBJECTIVES. To determine whether one or two screws is optimal for fracture fixation and whether two screws can always negotiate the intramedullary odontoid cavity. SUMMARY OF BACKGROUND DATA. Fixation of Type II dens fractures traditionally has used C1-C2 posterior wiring and fusion. Two screws placed across an odontoid fracture as a method of rigid internal fixation also has been described. However, it is not known whether two screws can always negotiate the odontoid canal. METHODS. Ninety-two consecutive computerized tomography scans of the dens were performed on adults who had no atlantoaxial pathology. Measurements were taken from the scan and compared with the cross-sectional diameter of two odontoid screws. RESULTS. The critical diameter for the placement of two 3.5-mm cortical screws with tapping was 9.0 mm. This dimension was present in 95% of the patients studied. CONCLUSIONS. Correct orientation of the computerized tomography scanner is critical for accurate measurements. Two 3.5-mm screws can be used in internal fixation of Type II dens fractures in 95% of the patients if the inner cortex is tapped