Faculty Bibliography

The tibial nerve trunk and its branches were dissected in 20 embalmed cadaver legs and the relative topographic anatomy was defined at 3-cm intervals up to 15 cm proximal to the medial malleolar-calcaneal (MMC) axis. Each nerve branch was found in various locations. The calcaneal nerve was found to descend from medial to posteromedial. It was never found anterolaterally and only rarely laterally. The lateral plantar nerve was found to rotate externally from lateral and posterolateral to lateral and posteromedial as it descends. This nerve was not found medially or anteromedially. The first branch of the lateral plantar nerve was indistinguishable from the trunk of the tibial nerve descending medially to between the lateral plantar and calcaneal nerves. The overall pattern of the medial plantar nerve was an internal rotation from anteromedial (proximal) to anterior (distally). It was not found posteriorly. The flexor hallucis longus motor branch was located an average of 17.9 cm (range, 10-24 cm) proximal to the MMC axis. Preliminary application of these data has facilitated surgical dissection and afforded an understanding of how tibial nerve trunk pathology correlates with clinical manifestations.

Maintaining mobility of the fourth and fifth tarsometatarsal joints has been reported to be important in arthrodesis of the midfoot. A review of the records at a tertiary care center of 23 patients (28 feet) with arthrodesis of these joints and a minimum 2-year follow-up showed that 22 complete midfoot arthrodeses were performed as part of the correction for a neuroarthropathic rocker-bottom deformity. Six arthrodeses of the fourth and fifth metatarsal joints were performed on normosensate feet with painful arthritis involving the lateral joints. Clinical and radiographic fusion occurred in 26 of 28 feet. Comparing average preoperative and postoperative scores, functional incapacity from lateral midfoot pathology decreased (8.4/10 to 2.2/10), overall pain scores improved (5.1/10 to 1.3/10), pain scores in the arthritic subgroup decreased (8.2/10 to 2.4/10), and the modified overall AOFAS midfoot score improved (35/100 to 78/100).

Amputation surgery should be the first step in the rehabilitation of a patient with a nonfunctional limb, rather than the final step in treatment. When faced with a difficult decision regarding lower extremity amputation compared with attempted limb reconstruction, expectations for a reasonable outcome must be determined. After reasonable goals have been set, the surgery should be directed toward interfacing with a prosthetic limb. Current surgical techniques of lower extremity amputation, paying special attention to transosseous versus disarticulation amputation, help to optimize prosthetic limb fitting and functional rehabilitation. With the evolution of end-bearing amputation levels, there is resurgent interest in the bone bridging technique of Johann Ertl and interest in a new pneumatic immediate postoperative prosthetic limb fitting system.

The purposes of the current study were: 1. to analyze the relative fatigue endurance of five different first metatarsal shaft osteotomies (proximal crescentic, proximal chevron, Ludloff, Mau, and Scarf), as performed on sawbone models using the most common fixation techniques (part I); and 2. to compare the two more commonly used techniques (per part I results) in matched-pair cadaver specimens (part II). In part I, the proximal chevron and Mau osteotomies were significantly more stable (P < or = 0.005) than all other osteotomies except the Ludloff. In part II, there was no significant difference in fatigue endurance between the proximal chevron and Ludloff osteotomies.

Twenty-one collegiate ballet pupils were evaluated via history/questionnaire, musculoskeletal assessment, and pedobarographs, focusing on factors (e.g., alignment of hip, knee, and foot) thought to affect the important and common second-position relevé in dance. In a blinded manner, three observers classified the pedobarographs (obtained by an independent examiner) according to force distribution through the foot. Most dancers bore weight through the toes and transmitted force on both the medial and central metatarsal heads, and some transmitted force through only one of these rays, but none transmitted force through the lateral ray alone. This analysis provides a baseline for future assessment of normal or abnormal dance maneuvers.

To evaluate the use of an immediate postoperative prosthesis (IPOP) for transtibial amputees, we compared patient outcomes from a prospective clinical study of 19 patients managed with an IPOP with those of a retrospective review of a matched historic control group of 23 patients managed with standard soft dressings. Data were analyzed with the Student's t-test, and significance was set at P = 0.05. The IPOP patients had no surgical revisions, whereas the patients with standard soft dressings had 11. This was a significant difference. IPOP patients also had significantly fewer postoperative complications and shorter times to custom prosthesis than did controls.

We evaluated an adjustable pneumatic prefabricated prosthesis and a rigid custom-molded prosthesis for immediate postoperative use. Twelve transtibial amputations were performed on cadaver limbs. Differential variable reluctance transducers were placed subcutaneously across the wound edge medially and laterally. The limbs were then placed in either the pneumatic prosthesis (five limbs) or the rigid prosthesis (seven limbs). The specimens underwent static and cyclic loading to simulate weight bearing. The strain readings for static and cyclic loading were greater in the rigid prosthetic group. Only the mean medial strain measurement after cyclic loading was statistically significant. The results demonstrate that the pneumatic prosthesis places less strain across the wound than a rigid prosthesis.

Second metatarsal osteotomies (30 degrees angle to shaft) were performed in 40 sawbones with: 1. head shifted proximally 5 mm; 2. head shifted proximally 10 mm; 3. 5-mm slice resected and head shifted proximally 5 mm; or 4. 5-mm dorsally based wedge resected and head shifted proximally 5 mm. Bone slice resection resulted in shortening (16.4+/-1.7 mm) and mild plantar displacement of the head (3.5+/-0.8 mm). Bone wedge excision resulted in moderate shortening (7.8+/-0.9 mm) and essentially no plantar displacement of the head (0.8+/-1.4 mm).

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.