Faculty Bibliography

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.

Arthrodesis of the first metatarsophalangeal joint of 21 matched pairs of cadaver toes was performed in order to compare the strength of three methods of internal fixation: 1. two crossed cannulated screws, 2. a dorsal plate with an oblique 0.062 K-wire, and 3. two compression staples with an oblique 0.062 K-wire. Biomechanical testing with plantar force was carried out, and gapping across the fusion site was measured. Stiffness, load to 1-mm displacement, and force to failure was determined for each specimen. Both the plate and screw constructs were statistically stronger in force to failure and initial stiffness than the compression construct. Compression staples have an advantage in their ease of insertion and theoretical continuous compressive force across an arthrodesis site, but should be supplemented with a cast or other external immobilization until union is achieved.

A radiographic classification (Schon's) divides Charcot midtarsus deformities into four types identified by Roman numerals (I to IV), according to the anatomical location of the pathological process,11 and an objective method of severity staging using radiographic criteria is introduced and tested. A beta stage is assigned if one of the following criteria is met: 1. a dislocation is present; 2. the lateral talar-first metatarsal angle is > or = 30 degrees; 3. the lateral calcaneal-fifth metatarsal angle > or = 0; or 4. the AP talar-first metatarsal angle is > or = 35 degrees. An alpha stage can be assigned when all four features are absent. Clinical features useful in assessing and managing these deformities have been associated with the various types and stages. To determine whether the classification system is valid, a study was performed. Two examination booklets and an instructional booklet designed to teach the method were distributed to 75 orthopaedic surgeons at the AOFAS summer meeting to test for intraobserver reproducibility and interobserver reliability. Information about the participants was recorded, and the tests were scored. The highest scores for correct responses were achieved by foot and ankle fellows, followed by orthopaedic residents. Attending orthopaedic surgeons achieved the lowest scores. The most common error was a type I deformity misidentified as a type II. The interobserver reliability for correctly classifying the deformities was 81%, and the intraobserver reproducibility was 97%. We concluded that this classification system, intended to clarify the patterns of acquired midfoot collapse, permits assignment of both anatomic type (I to IV) and degree of severity (alpha-beta) with high reliability and reproducibility. It can therefore be used as a tool for diagnosis, planning treatment, and assessing the prognosis.

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.

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.