Faculty Bibliography

BACKGROUND:The goal of this study was to identify pressure changes throughout the peroneal groove after a groove deepening procedure. We hypothesized that pressures would decrease. METHODS:Twelve fresh-frozen foot and ankle specimens were used. A thin pressure strip containing four sensor pads was secured within the peroneal groove with pads 1 through 4 positioned at the calcaneofibular ligament (CFL) and at the distal, middle, and proximal groove, respectively. The midstance phase of gait was simulated with loads applied to the plantar foot and posterior tibial tendon and to the peroneus longus and brevis tendons. Pressures were recorded with the ankle in neutral, plantarflexion, dorsiflexion, inversion, and eversion. Groove deepening was done by osteotomizing the posterior fibular wall. Pressure readings were then recorded. Average pressures for each of the four sensor pads after the procedure were compared to those obtained before the procedure. RESULTS:The mean pressure overlying the CFL increased at all five ankle positions; however, these changes were not significant. Significant decreases in pressure were noted within the distal and middle groove at all ankle positions after the peroneal groove deepening procedure. Pressure within the proximal groove increased at all but one position, with a significant difference noted in neutral and plantarflexion. CONCLUSION/CONCLUSIONS:Pressures within the middle and distal peroneal groove significantly decreased after a groove deepening procedure. Combining this technique with peroneal tendon debridement may be advantageous for treatment of partial peroneal tendon tears or recalcitrant peroneal tendinitis.

BACKGROUND:With technological advances in ankle arthroplasty, there has been parallel development in the outcome instruments used to assess the results of surgery. The literature recommends the use of valid, reliable, and responsive ankle scores, but the ankle scores commonly used in clinical practice remain undefined. METHODS:An internet survey of members of the American Orthopaedic Foot and Ankle Society (AOFAS) was conducted to determine which three ankle scores they perceived as most commonly used in the literature, which ones they believe are validated, which ones they prefer, and which they use in practice. RESULTS:According to respondents, the three most commonly used scores were the AOFAS Ankle score, the Foot Function Index (FFI), and the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS). The respondents believed that the AOFAS Ankle score, FFI, and MODEMS were validated. The FFI and MODEMS are validated, but the AOFAS ankle score is not validated. CONCLUSIONS:Most respondents preferred using the AOFAS Ankle score. The use of the empirical AOFAS Ankle score continues among AOFAS members.

By using three-dimensional magnetic resonance image reconstruction, lateral displacement of the flexor hallucis longus tendon and sesamoid bones was made clearly visible in a living patient. This finding supports a biomechanical model related to disturbed muscle balance at the first metatarsophalangeal joint, which could play an important role in the pathogenesis of hallux valgus and metatarsus primus varus.

BACKGROUND:Biomechanically, the Ludloff osteotomy fixed with lag screw compression has been shown to be more rigid than proximal crescentic and other proximal first metatarsal osteotomies for correction of symptomatic hallux valgus with a moderate to severe increase in the first intermetatarsal angle. The Ludloff osteotomy may, therefore, have a lower incidence of dorsal malunion and transfer metatarsalgia than other proximal first metatarsal osteotomies, such as the crescentic or chevron. METHODS:We reviewed the results of 82 consecutive cases of moderate to severe hallux valgus deformities corrected with the Ludloff oblique metaphyseal-diaphyseal osteotomy of the first metatarsal combined with a distal soft-tissue procedure and medial eminence resection. RESULTS:Follow-up was possible in 70 cases (85%) at an average of 30 months (range, 18 to 42 months). Preoperatively, the mean hallux valgus and first intermetatarsal angles were 31 degrees and 16 degrees, respectively. Postoperatively, these values improved to an average of 11 degrees and 7 degrees. In the sagittal plane, the first metatarsal was plantarflexed by an average of 1 mm, and there were no symptomatic transfer lesions of the second metatarsal. The mean AOFAS hindfoot score improved from 54 to 91 points. Complications included prominent hardware requiring removal (5), hallux varus (4), delayed union (3), superficial infection (3), and neuralgia (3). CONCLUSIONS:The use of the Ludloff oblique first metatarsal osteotomy resulted in excellent correction of the first intermetatarsal angle in patients with moderate to severe hallux valgus. With the plane of the osteotomy and rigidity of fixation, immediate ambulation was possible with minimal risk of dorsiflexion malunion of the first metatarsal.

BACKGROUND:To assess the efficacy of surgical correction of stage II tibial tendon deficiency with medial translational calcaneus osteotomy and flexor digitorum longus tendon transfer to the navicular, the authors retrospectively reviewed results of treatment of stage II posterior tibial tendon deficiency in 129 patients for whom surgery was performed between 1990 and 1997. METHODS:The indication for surgery included tendon weakness, flexible deformity, and foot pain refractory to nonsurgical treatment. All patients had a painful flexible flatfoot without fixed forefoot supination deformity (stage II). A medial translational osteotomy of the calcaneus and transfer of the flexor digitorum longus tendon into the navicular were done. The patients were examined, radiographs were obtained, and isokinetic evaluation of both feet was performed at a mean of 5.2 years postoperatively. The American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Scale and Short Form Health Surgery (SF-36) were used to evaluate patients postoperatively. RESULTS:The mean AOFAS score at follow-up was 79 points (range, 54-93). There were seven significant complications in six patients. Isokinetic inversion and plantarflexion power and strength were symmetric with the contralateral limb in 95 patients, mildly weak in 18 patients, and moderately weak in eight patients. Subtalar joint motion was normal in 56 (44%), slightly decreased in 66 (51%), and moderately decreased in seven patients (5%). Correction was significant (p < .05) in all four radiographic parameters evaluated. Patients were entirely satisfied (118 patients), partially satisfied (seven patients), or dissatisfied (four patients). Further, 125 (97%) experienced pain relief, 121 (94%) showed improvement of function, 112 (87%) experienced improvement in the arch of the foot, and 108 (84%) were able to wear shoes comfortably without shoe modifications or orthotic arch support. CONCLUSIONS:The surgical correction of stage II posterior tibial tendon deficiency with medial translational calcaneus osteotomy and flexor digitorum longus tendon transfer to the navicular yielded excellent results with minimal complications and a high patient satisfaction rate.

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.

The treatment of chronic neuropathic pain with revision surgical procedures can be beneficial. A thorough evaluation can help to guide treatment to optimize outcome. With an increasing understanding of the pain-generating mechanisms and the appropriate application of surgical interventions, quality of life and function continues to be improved in patients who have otherwise significant disability.

Previous studies have shown that increasing angulation of the Weil osteotomy produces greater plantar translation of the metatarsal head. Modifications have been proposed to reduce plantar translation. However, there is no evidence that the increased plantar translation with a Weil osteotomy is clinically significant or that these modifications are required. Ten lower extremities consisting of five matched pairs were used to evaluate whether different configurations of the Weil osteotomy altered plantar pressure in a dynamic cadaver model. For each pair, an oblique Weil osteotomy with a 5-mm shift was done on one side and a standard (parallel) Weil osteotomy with a 5-mm shift was done on the matched foot. A 4-mm slice resection and a metatarsal head resection then were done sequentially. Plantar pressures were measured with cyclic loading to 700 N at a frequency of 1 Hz with an F-scan in-shoe sensor on the intact specimens and after each intervention. Increased plantar translation of the metatarsal head with a more oblique Weil osteotomy did not significantly increase plantar pressure, and the 4-mm slice resection did not significantly unload the metatarsal head. Only complete metatarsal head resection significantly unloaded the metatarsal head.

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 degrees 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.