Citations

Intramedullary tibiotalocalcaneal arthrodesis (IMTCA) is an increasingly used procedure for salvage of complex hindfoot and ankle disorders. 1 , 2 To avoid injury to vital plantar neurovascular structures, it is important to begin with an appropriate insertion site during retrograde IMTCA. We use a simple, reproducible method to determine this site based on anatomic landmarks.

We studied 15 cadaver feet to determine three-dimensional motion of selected tarsal bones under axial loading at three different loading levels. We determined the motion of individual joints and also the rotation of the tarsal bones in relation to the tibia. Joint rotations increased consistently with higher loads. The navicular-talar joint had the greatest total screw axis rotation, which averaged 9.4° ± 2.2° at 667 N of load, followed by the first metatarsal-navicular (mean, 7.2° ± 1.5°), talar-tibial (mean, 5.2° ± 1.6°), and calcaneal-talar (mean, 4.4° ± 1.7°) joints. The observed changes indicate the need for assessment of foot and ankle alignment clinically and radiologically while the patient is weightbearing.

An intramedullary fixation device was devised by the senior author (K.A.J.) to use in conjunction with a previously described method for tibiotalocalcaneal arthrodesis. Satisfactory results were obtained in approximately 87% of the initial 30 patients; union was radiographically or clinically evident in all but two patients. Many of these patients had been offered or were considering below the knee amputation; only two ultimately chose this reconstructive option at a follow-up that ranged from 4 to 27 months.

Nineteen patients underwent surgical synovectomy and debridement for the clinical diagnosis of stage I posterior tibial tendon (PTT) dysfunction. Stage I PTT dysfunction is characterized by pain and swelling along the medial aspect of the ankle. Fourteen patients (74%) reported complete relief of pain, 3 patients (16%) reported minor pain, and 1 patient (5%) had moderate pain, and 1 (5%) had continued severe pain. Sixteen (84%) of the patients subjectively reported being “much better” and had a return of function of the PTT, as evidenced by their ability to perform a single limb-heel-rise test. Two patients (10%) underwent subtalar arthrodesis for progressive foot deformity and continued pain. Based on these results, surgical release, tenosynovectomy, and debridement are recommended for the treatment of stage I PTT dysfunction.

The chevron osteotomy for hallux valgus was modified by addition of screw fixation and change of the osteotomy angle. Thirty-six patients underwent this modified osteotomy. All had mild to moderate symptomatic hallux valgus deformities. No other forefoot procedures were performed. Standing radiographs were taken before surgery, at 1 month after surgery, and, for the 15 patients who returned for long-term follow-up, at 1 year or more after surgery. Overall, 35/42 procedures were rated as satisfactory without reservations and 7 were rated as satisfactory with mild reservations. All patients stated that they had some improvement in their preoperative symptoms, which included pain, cosmetic concerns, and shoe wear difficulties. Radiographically, none of the capital fragments displaced and there were no malunions, nonunions, nor evidence of avascular necrosis. The average metatarsophalangeal-1 angle improved 8° and the average intermetatarsal 1–2 angle improved 4°. This modification is relatively simple, increases stability, and allows early weightbearing. In our experience, the modified chevron osteotomy has been a very reliable procedure for mild to moderate symptomatic hallux valgus deformity.

Material properties of the plantar aponeurosis were determined by a two-dimensional video tracking method to simultaneously measure the aponeurosis deformation. Failure loads averaged 1189 ± 244 N and were higher in men. Average stiffness of the intact fascia was 203.7 ± 50.5 N/mm at a loading rate of 11.12 N/sec and it did not vary significantly for the loading rates of 11.12 to 1112 N/sec. The high tensile loads required for failure were consistent with clinical and biomechanical studies and indicated the importance of the aponeurosis in foot function and arch stability.

Four rating systems were developed by the American Orthopaedic Foot and Ankle Society to provide a standard method of reporting clinical status of the ankle and foot. The systems incorporate both subjective and objective factors into numerical scales to describe function, alignment, and pain.

The relative risk of nonunion in smokers versus nonsmokers after ankle arthrodesis was determined in a case control study. Twenty-two patients were matched to 22 controls by age, sex, surgeon, surgical technique, and preoperative diagnosis. Information on duration, amount, and past history of smoking was obtained for these 44 patients. Ten of the patients were actively smoking at the time of surgery compared with four of the controls. Six of the patients had no history of smoking and six had stopped smoking before surgery. Eleven of the controls had no history of cigarette smoking and 7 had stopped smoking before surgery. The relative risk of nonunion was increased 3.75 times for active smokers. When patients did not have any known risk factors for nonunion, the risk of nonunion for smokers was 16 times the risk of nonunion for nonsmokers

The Rochester bone trephine is a useful instrument for performing small joint arthrodesis in the foot. The technique involves harvesting a dowel graft from the iliac crest and then inserting the graft into a recipient bed across the small joints in the foot. Minimal surgical trauma and patient discomfort result from this technique. Three cases are presented to illustrate the usefulness and diversity of this system.

In spite of the common occurrence of pes planus and multiple operations that have been reported to relieve the associated symptoms, there is little published on the relative contribution of various structures to stabilization of the arch of the foot. Twelve fresh-frozen human cadaveric feet were loaded along the tibial axis with compressive loads of 230, 460, and 690 newtons with the specimens intact and after sequential sectioning of plantar fascia, plantar ligaments, and spring ligament. Structures were sectioned in six different sequences and changes in vertical and horizontal dimensions of the medial arch were measured. The highest relative contribution to arch stability was provided by the plantar fascia, followed by plantar ligaments and spring ligament. Plantar fascia was a major factor in maintenance of the medial longitudinal arch. Its division in the cadaveric feet decreased arch stiffness by 25%.