Faculty Bibliography

Although dancers put a great deal of stress through the first metatarsophalangeal joint (MTPJ), it is unlikely that dancing causes bunions; however, such forces may produce an environment in which bunions may develop. It is best to employ conservative measures rather than surgical intervention in dancers who have a painful bunion. Any surgery on the first MTPJ will adversely affect dorsiflexion of this joint, which is a critical motion for dancers. Two types of bunions (slowly progressive and rapidly progressive) are commonly seen; arthritic bunions occur in dancers who have mild arthrosis and loss of cartilage on the head of the first MTPJ. Secondary problems arising from bunions include metatarsalgia, stress fractures, sesamoiditis, and flexor hallucis longus tendonitis.

Dancers are required to perform at the extreme of physiologic and functional limits. Under such conditions, peripheral nerves are prone to compression. Entrapment neuropathies in dance can be related to the sciatic nerve or from a radiculopathy related to posture or a hyperlordosis. The most reproducible and reliable method of diagnosis is a careful history and clinical examination. This article reviews several nerve disorders encountered in dancers, including interdigital neuromas, tarsal tunnel syndrome, medial hallucal nerve compression, anterior tarsal tunnel syndrome, superficial and deep peroneal nerve entrapment, and sural nerve entrapment.

Cycling is an increasingly popular recreational and competitive activity, and cycling-related injuries are becoming more common. Many common cycling injuries of the lower extremity are preventable. These include knee pain, patellar quadriceps tendinitis, iliotibial band syndrome, hip pain, medial tibial stress syndrome, stress fracture, compartment syndrome, numbness of the foot, and metatarsalgia. Injury is caused by a combination of inadequate preparation, inappropriate equipment, poor technique, and overuse. Nonsurgical management may include rest, nonsteroidal anti-inflammatory drugs, corticosteroid injection, ice, a reduction in training intensity, orthotics, night splints, and physical therapy. Injury prevention should be the focus, with particular attention to bicycle fit and alignment, appropriate equipment, proper rider position and pedaling mechanics, and appropriate training.

Persistent recalcitrant dorsolateral foot pain after ankle sprain cannot always be explained by known anatomic nerve pathways. To determine whether an impingement of a lateral branch of the deep peroneal nerve might be responsible for atypical pain, we conducted a cadaveric anatomic study to identify the anatomy and course of the nerve. Furthermore, using this information, we conducted a clinical study to determine if targeted treatment to a lateral branch of the deep peroneal nerve would resolve these symptoms. We dissected 22 cadaveric feet to identify a large lateral branch of the deep peroneal nerve. This nerve arborized into five main branches. We identified two areas of compression in the lateral branch of the deep peroneal nerve. We also performed a prospective clinical study including 11 consecutive patients with a 1-year minimum followup. Pain and clinical findings corresponded to the anatomic compression sites in all 11 patients. All patients responded to a local anesthetic injection or surgical release of the lateral branch of the deep peroneal nerve. We identified a previously unreported complex course of the lateral branch of the deep peroneal nerve that correlated with clinical impingement syndrome and responded to specifically targeted treatment.

Metatarsalgia of the central ray is a major surgical challenge. Without precise correction, transfer lesions may occur at an adjacent metatarsal or patients may have inadequate pain relief. Current surgical treatment strategies do not facilitate precise positioning in different planes, resulting in disappointing outcomes. To achieve better outcomes we used an oblique sliding osteotomy to facilitate precise correction. We hypothesized the procedure would reduce pain in patients with prominent second and/or third metatarsal heads, with few complications. We retrospectively reviewed 32 consecutive patients with 42 osteotomies of the lesser metatarsal bones. The mean and median ages at the time of surgery were 49 and 54 years, respectively, with a minimum followup of 26 months. Thirty-one patients (97%) had relief of plantar pain. The mean American Orthopaedic Foot and Ankle Society score was 82.4 points. We identified no transfer lesions. The median time to radiographic union was 10 weeks. Although time to bony union can be extended, the oblique sliding osteotomy facilitates intraoperative adjustment to provide the precise positioning critical to eliminating plantar pain.

BACKGROUND:Patellar complications following endoprosthetic reconstruction can occur as a result of anatomic, physiologic, and surgical reasons. Patellar impingement on tibial polyethylene is a complication of distal femoral replacement, and it is frequently related to inaccurate restoration of the joint line and to soft-tissue contracture. The purpose of our study was to determine the prevalence and type of patellar complications following distal femoral replacements after excisions of bone tumors. METHODS:The results of reconstruction with use of a rotating-hinge endoprosthesis following excision of a distal femoral tumor in forty-three patients were retrospectively reviewed. Patients were followed clinically and radiographically for a minimum of forty-eight months or until death. Pain status, functional scores, and the range of motion were determined from a prospectively maintained database. The ratio of the patellar tendon length to the height of the patellar tendon insertion, as described by Insall and Salvati, was calculated. In addition, we attempted to determine whether the position of the patella was associated with anterior knee pain or with the functional scores derived with use of the International Society of Limb Salvage (ISOLS) scoring system. RESULTS:Thirty-five patellar complications, including eleven cases of impingement, occurred in twenty-seven patients (63%). We found no difference, on the basis of our sample size, with regard to the presence of patellar pain, the range of motion, or the Insall-Salvati ratio between the patients with and those without impingement. The ratio of the patellar tendon length to the height of the patellar tendon insertion averaged 0.9 in the group with impingement and 1.4 in the group without impingement (p = 0.07). The ISOLS score averaged 21.2 points in the group with impingement compared with 24.2 points in the group without impingement (p = 0.01). Patella baja occurred in nine patients. The average ISOLS score (and standard deviation) was 20.1 +/- 4.4 points for the patients with patella baja compared with 24.8 +/- 3.9 points in the group with a normal patellar position (p = 0.004). Patellar fracture occurred in two patients, and osteonecrosis occurred in two patients. These patients were treated nonoperatively. CONCLUSIONS:Patellar complications are common after distal femoral resection and endoprosthetic reconstruction. Patellar impingement on the polyethylene tibial bearing surface is a more common and important complication of distal femoral replacement than has been reported to date. Patella baja is also a relatively common complication, which has a negative impact on knee function.

BACKGROUND:Operative strategies used in resecting the digital nerve in Morton neuroma emphasize retaining the digital artery. Concern over inadvertent resection of the digital vessel has prompted many surgeons to avoid adjacent interdigital neurectomies when more than one nerve is affected. METHODS:The current study examined 674 consecutive pathologic specimens obtained after neurectomy. RESULTS:The digital vessel was identified along with the resected nerve in 39% of specimens. No adverse effect was recorded from these arterial resections. CONCLUSION/CONCLUSIONS:Extensive collateralization of digital vessels is hypothesized to account for the lack of adverse sequelae.

Isolated carpal scaphoid dislocations are rare. Because of this, treatment strategies can be conflicting and vague. The current authors present a case of isolated scaphoid dislocation that was treated initially with closed reduction and percutaneous pinning. Failure of this index treatment necessitated open reduction and internal fixation providing an adequate short-term outcome. Current treatment strategies now advocate ligament reconstruction as a first-line treatment to restore normal anatomy and preserve function.