Faculty Bibliography

BACKGROUND:It may be possible to avoid malleolar osteotomy for treatment of osteochondral talar lesions with chondrocyte transplantation techniques, where perpendicular approach to the talar surface is not required. We hypothesized that limited anterior distal tibial plafondplasty would allow access to most of the talar surface. We compared talar access with soft tissue exposure versus plafondplasty. METHODS:Two soft tissue exposures (anteromedial and anterolateral) and two limited anterior distal tibial plafondplasties (anteromedial and anterolateral) were used on 12 cadaver lower-extremity specimens. Digital analysis was used to assess the accessible area. RESULTS:Percentage of total talar dome surface area access increased significantly between soft tissue exposure and limited plafondplasty medially (22.3 +/- 6.3% versus 37.9 +/- 4.6%; p < 0.001) and laterally (22.4 +/- 7.7% versus 37.9 +/- 7.7%; p < 0.001). Percentage sagittal plane access also increased significantly between soft tissue exposure and limited plafondplasty medially 54.4 +/- 12.0% versus 81.3 +/- 9.7%; p < 0.001) and laterally (53.3 +/- 14.5% versus 80.9 +/- 12.8%; p < 0.001). Limited exposure to an additional 14.2 +/- 5% of the total talar surface area was possible. The posterior 10.6 +/- 8% was inaccessible. CONCLUSIONS:A soft tissue approach with limited plafondplasty provided adequate exposure for the majority of the medial and lateral talar surface. Only the central posterior 10% of the talus was not accessed by this method. CLINICAL RELEVANCE/CONCLUSIONS:It may be possible to avoid malleolar osteotomy by using limited plafondplasty to access the talar dome for treatment of osteochondral lesions if perpendicular access to the talus is not required.

BACKGROUND:We compared forefoot and calcaneocuboid pressure in isolated medial column fusion (1-3 tarsometatarsal fusion) versus medial and lateral column fusion (1-5 tarsometatarsal fusion) in a neutral, inversion, and eversion loading model in stance gait phase. METHODS:Twelve fresh-frozen cadaveric specimens were cyclically loaded to 720 N at 0.5 Hz for 30 cycles. Plantar and calcaneocuboid joint pressures were measured in neutral, inversion, and eversion in the intact foot, with isolated medial column fusion, and with medial and lateral column fusion. RESULTS:Lateral pressure was higher in the medial and lateral column fusion group than isolated medial column fusion and intact in neutral (55.8 +/- 14.8 versus 46.2 +/- 13.6 and 45.5 +/- 14.8 kPa, respectively) and eversion (80.7 +/- 18.4 versus 61.8 +/- 13.7 and 60.2 +/- 18.2 kPa, respectively) (p < or = 0.001). Calcaneocuboid pressure was higher in medial and lateral column fusion than isolated medial column fusion and intact in neutral (1436.7 +/- 210.6 versus 1073.7 +/- 282.5 and 1084.9 +/- 337.6, respectively; p = 0.001) and inversion (1518.3 +/- 270.5 versus 1310.5 +/- 298.8 and 1237.1 +/- 401.9, respectively; p = 0.02). Using combined position data, calcaneocuboid pressure was significantly higher in the medial and lateral column group than in both other groups. The isolated medial column fusion group did not differ significantly from the intact group in any measurement. CONCLUSION/CONCLUSIONS:Medial and lateral column fusion significantly increased lateral and calcaneocuboid pressures with loading compared with isolated medial column fusion and the intact state. No difference was observed between isolated medial column fusion and the intact state. CLINICAL RELEVANCE/CONCLUSIONS:It may be advisable to avoid fusing the lateral column in tarsometatarsal arthrodesis if possible to avoid pressure increase in the forefoot and hindfoot.

Interdigital neuralgia affects a significant number of individuals, with an average age of presentation in the sixth decade and a 4- to 15-fold increased prevalence in women. Historical descriptions date back to the 19th century. Nonoperative treatment with shoe modifications, metatarsal pads, and injections provides relief for most, but long term, 60% to 70% of patients eventually elect to have surgery. Although excision can be performed through a dorsal or plantar approach, we prefer the dorsal incision to prevent scar formation on the plantar aspect of the foot. Satisfactory results are common but not certain with reports of excellent or good ranging from 51% to 93%.

Recurrent or persistent symptoms following surgical neurectomy for an interdigital neuroma are quite common, because of incorrect initial diagnosis, true neuroma formation, nerve stump adhesions, accessory nerve branches, or an adjacent web space neuroma. The clinical presentation of a recurrent neuroma is similar to the initial presentation. Recurrent symptoms usually occur within the first 12 months after surgery. The physical examination coupled with diagnostic nerve blocks is critical for diagnosis. Conservative therapy, although not particularly effective in treating true recurrent neuromas, may help to alleviate pain. With proper isolation of the instigating neuroma, revision surgical excision can be effective.

The posterior tibial tendon (PTT) is the most important dynamic stabilizer of the medial ankle and longitudinal arch of the foot. PTT dysfunction is a degenerative disorder of the tendon, which secondarily involves multiple ligaments, joint capsules, fascia, articulations, and bony structures of the ankle, hindfoot, midfoot, and forefoot. When the tendon progressively attenuates, the patient develops a painful, progressive collapsed flatfoot or pes planovalgus deformity. This comprehensive review illustrates the 3-Tesla magnetic resonance imaging (3T MRI) features of PTT dysfunction. In addition, the reader will gain knowledge of the expected pathologic findings on MRI, as they are related to clinical staging of PTT dysfunction.