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Journal Cover   Foot & Ankle International
  [SJR: 1.202]   [H-I: 68]   [12 followers]  Follow
    
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 1071-1007
   Published by Sage Publications Homepage  [813 journals]
  • Inferior Results of Salvage Arthrodesis After Failed Ankle Replacement
           Compared to Primary Arthrodesis
    • Authors: Rahm, S; Klammer, G, Benninger, E, Gerber, F, Farshad, M, Espinosa, N.
      Pages: 349 - 359
      Abstract: Background: Up to now, there has been no evidence that salvage arthrodesis would perform inferior when compared with primary ankle arthrodesis. The purpose of this study was to compare their clinical and radiographic results. Methods: A retrospective analysis was performed using 2 validated scores and assessment of radiographic union by comparing 23 patients who underwent salvage ankle arthrodesis (group SA = salvage arthrodesis) after failed total ankle replacement with 23 matched patients who received primary ankle arthrodesis (group PA = primary arthrodesis). The mean follow-up period was 38 (range 16-92) months in group SA and 56 (23-94) months in group PA. Results: Complete union was achieved in 17 patients (74%) after a mean time of 50 (13- 114) weeks in group SA and in 16 patients (70%) after a mean time of 23 (10-115) weeks in group PA. The SF-36 score averaged 48 points (7-80) in SA and 66 points (14-94; P = .006) in group PA. In group SA the mean FFI was 57% (22-82) for pain and 71% (44-98) for function. In group PA significantly better results for pain with 34% (0-88; P = .002) and function with 48% (1-92; P = .002) were found. Conclusion: Salvage arthrodesis led to impaired life quality and reduced function combined with significantly higher pain when compared with primary ankle arthrodesis. These findings can be used to counsel our patients preoperatively. Level of Evidence: Level III, retrospective case series.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714559272
      Issue No: Vol. 36, No. 4 (2015)
       
  • Comparison of Perioperative Complications and Hospitalization Outcomes
           
    • Authors: Jiang, J. J; Schipper, O. N, Whyte, N, Koh, J. L, Toolan, B. C.
      Pages: 360 - 368
      Abstract: Background: The aim of this study was to analyze a validated, nationally representative admissions database in order to compare perioperative complications and hospitalization outcomes associated with ankle arthrodesis (AAD) versus ankle arthroplasty (TAA). Methods: Using the Nationwide Inpatient Sample (NIS) database from 2002 to 2011, 12 250 patients who underwent AAD and 3002 patients who underwent TAA were identified based on International Classification of Diseases, Ninth Revision (ICD-9) codes. The demographics, comorbidities, and perioperative outcomes during the index hospital stay were compared between patients who underwent AAD and TAA. Multivariate analysis was performed to adjust for differences in demographics and comorbidities between the 2 groups. Results: Multivariate analysis demonstrated that TAA was independently associated with a decreased risk of blood transfusion (relative risk [RR] = 0.53, P < .001), non–home discharge (RR = 0.70, P < .001), and overall complication (RR = 0.79, P = .03). There were similar rates of pneumonia, deep vein thrombosis, pulmonary embolus, cerebrovascular accident, myocardial infarction, and mortality. TAA was independently associated with a significantly higher hospital charge (difference = $24 431, P < .001). There was no significant difference in the adjusted length of stay between the 2 groups (P = .13). Conclusion: TAA was independently associated with a lower risk of blood transfusion, non–home discharge, and overall complication when compared to AAD during the index hospitalization period. TAA was also independently associated with a higher hospitalization charge, but length of stay was similar between the 2 groups. Until long-term comparative studies are performed, the optimal treatment for end-stage ankle arthritis remains controversial, this study provides greater clarity with regard to hospitalization outcomes after the 2 procedures and shows no significant difference in risk for the majority of medical perioperative complications. Level of Evidence: Level III, comparative series.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714558511
      Issue No: Vol. 36, No. 4 (2015)
       
  • Influence of Crosslinking on the Wear Performance of Polyethylene Within
           Total Ankle Arthroplasty
    • Authors: Bischoff, J. E; Fryman, J. C, Parcell, J, Orozco Villasenor, D. A.
      Pages: 369 - 376
      Abstract: Background: Wear debris of polyethylene within joint replacement systems can result in clinical complications including osteolysis and component loosening. Highly crosslinked polyethylene (HXPE) was introduced to improve these outcomes, and has been shown to result in improved wear performance in several joint replacement systems. However, bearing couples within total ankle replacement (TAR) systems have historically used conventional polyethylene (CPE) articulating on metal. The extent to which HXPE would result in a reduction of polyethylene wear compared to CPE in the ankle has not been studied. The hypothesis motivating this study was that use of HXPE within TAR will result in significantly lower wear rate than CPE. Methods: HXPE and CPE inserts within a semiconstrained, bicondylar TAR system were manufactured for this study. Samples were subjected to 5.0 million cycles of wear on an in vitro wear simulator. Testing was performed within a physiological environment, using kinematic and kinetic loading profiles characteristic of walking gait. Samples were weighed at regular intervals to determine gravimetric mass loss, and the morphology of wear particles was analyzed. Results: The wear rates for CPE and HXPE samples were 7.4 ± 1.3 and 1.9 ± 0.3 mg/Mc (mean ± SD), respectively. HXPE samples exhibited a significant (P < .01) wear rate reduction of 74% when compared with the CPE. Debris morphology trends between HXPE and CPE were consistent with what has been observed in other joint systems. Conclusion: Use of HXPE significantly reduces wear of TAR as compared to CPE, based on in vitro wear testing. Clinical Relevance: Highly crosslinked polyethylene may reduce clinical complications of total ankle replacement that are linked to polyethylene wear.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714558507
      Issue No: Vol. 36, No. 4 (2015)
       
  • Analysis of PITFL Injuries in Rotationally Unstable Ankle Fractures
    • Authors: Warner, S. J; Garner, M. R, Schottel, P. C, Hinds, R. M, Loftus, M. L, Lorich, D. G.
      Pages: 377 - 382
      Abstract: Background: Reduction and stabilization of the syndesmosis in unstable ankle fractures is important for ankle mortise congruity and restoration of normal tibiotalar contact forces. Of the syndesmotic ligaments, the posterior inferior tibiofibular ligament (PITFL) provides the most strength for maintaining syndesmotic stability, and previous work has demonstrated the significance of restoring PITFL function when it remains attached to a posterior malleolus fracture fragment. However, little is known regarding the nature of a PITFL injury in the absence of a posterior malleolus fracture. The goal of this study was to describe the PITFL injury pattern based on magnetic resonance imaging (MRI) and intraoperative observation. Methods: A prospective database of all operatively treated ankle fractures by a single surgeon was used to identify all supination-external rotation (SER) types III and IV ankle fracture patients with complete preoperative orthogonal ankle radiographs and MRI. All patients with a posterior malleolus fracture were excluded. Using a combination of preoperative imaging and intraoperative findings, we analyzed the nature of injuries to the PITFL. In total, 185 SER III and IV operatively treated ankle fractures with complete imaging were initially identified. Results: Analysis of the preoperative imaging and operative reports revealed 34% (63/185) had a posterior malleolus fracture and were excluded. From the remaining 122 ankle fractures, the PITFL was delaminated from the posterior malleolus in 97% (119/122) of cases. A smaller proportion (3%; 3/122) had an intrasubstance PITFL rupture. Conclusions: Accurate and stable syndesmotic reduction is a significant component of restoring the ankle mortise after unstable ankle fractures. In our large cohort of rotationally unstable ankle fractures without posterior malleolus fractures, we found that most PITFL injuries occur as a delamination off the posterior malleolus. This predictable PITFL injury pattern may be used to guide new methods for stabilizing the syndesmosis in these patients. Level of Evidence: Level IV, case series.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714558845
      Issue No: Vol. 36, No. 4 (2015)
       
  • Destructive Pseudo-neuroarthropathy Associated With Calcium Pyrophosphate
           Deposition
    • Authors: Lomax, A; Ferrero, A, Cullen, N, Goldberg, A, Singh, D.
      Pages: 383 - 390
      Abstract: Background: Calcium pyrophosphate deposition (CPPD) disease is a metabolic disorder characterized by soft tissue calcific deposits formed primarily in articular cartilage. What can result is a crystal-induced arthropathy often referred to as pseudogout, which is variable in both presentation and severity. A particularly destructive and deforming arthritis is an uncommon but well-recognized subtype of this disease. Radiologically resembling the neuroarthropathy described by Charcot, a pattern of joint fragmentation and structural collapse occurs in the absence of peripheral neuropathy. This pseudo-neuroarthropathy is rarely reported in the foot and ankle. Methods: A total of 15 cases of pseudo-neuroarthropathy involving some previously unreported joints within the foot and ankle are described in this case series of 9 patients. Results: All patients presented with disease involving multiple joints. Clinical deformity was apparent in each case, and extensive joint destruction was seen on plain radiographs. In 6 patients, histopathological CPPD disease was confirmed on tissue biopsy of the affected joints. In the remaining 3 patients a clinical diagnosis was made on the basis of the classic appearance of pseudo-neuroarthropathy in the foot, with additional recognized features of CPPD. Operative management with deformity correction using joint arthrodesis produced satisfactory clinical and radiological results. Conclusions: In the absence of peripheral neuropathy and systemic disease, the pseudo-neuroarthropathy of CPPD should be considered when a progressively deforming and destructive arthritis is seen in the foot and ankle. Level of Evidence: Level IV, case series.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714560399
      Issue No: Vol. 36, No. 4 (2015)
       
  • Radiographic Results After Hallux Metatarsophalangeal Joint Arthrodesis
           for Hallux Varus
    • Authors: Geaney, L. E; Myerson, M. S.
      Pages: 391 - 394
      Abstract: Background: Hallux metatarsophalangeal (MP) joint arthrodesis for hallux varus is generally reserved for severe deformity, failed surgery or the development of osteoarthritis. The purpose of this study was to determine the radiologic results of arthrodesis of the hallux MP joint following treatment for hallux varus. Our hypothesis was that in the process of correcting the hallux valgus angle, the 1-2 intermetatarsal angle (1-2 IMA) and hallux valgus angle (HVA) will be improved due to correction of the deforming forces. Methods: A retrospective review was performed on 26 patients with 29 feet that had symptomatic hallux varus deformities treated with arthrodesis of the hallux MP joint between September 1, 2002, and December 31, 2012. The 1-2 IMA and HVA were measured on the preoperative and most recent postoperative films and compared. Twenty-nine patients were followed with postoperative weight-bearing radiographs. Two were men and 24 were women. Twelve were performed on the right foot, 17 on the left, including 3 bilateral cases. Fourteen patients had concomitant procedures on the ipsilateral forefoot. Results: The average 1-2 IMA changed from 4.8 degrees to 8.4 degrees, a difference of 3.6 degrees (P < .05), and the average HVA changed from –20.7 degrees to 8.1 degrees (P < .05). Conclusion: Our study showed that a hallux MP joint arthrodesis in patients with hallux varus resulted in a predictable increase in the 1-2 IMA. Level of Evidence: Level IV, case series.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714560400
      Issue No: Vol. 36, No. 4 (2015)
       
  • Screw Size and Insertion Technique Compared With Removal Rates for
           Calcaneal Displacement Osteotomies
    • Authors: Lucas, D. E; Simpson, G. A, Berlet, G. C, Philbin, T. M, Smith, J. L.
      Pages: 395 - 399
      Abstract: Background: The calcaneal displacement osteotomy is frequently used by foot and ankle surgeons to correct hindfoot angular deformity. Headed compression screws are often used for this purpose, but a common complication is postoperative plantar heel pain from prominent hardware. We evaluated hardware removal rates after calcaneal displacement osteotomies and analyzed technical factors including screw size, position, and angle. We hypothesized that larger screws placed more plantarly would have been removed more frequently. We also believed that although 2 smaller screws cost more initially, when removal rates and cost are accounted for, savings would be demonstrated with this technique. Methods: We retrospectively collected data on type of fixation, cost of fixation, and frequency of removal. After exclusions we had 30 patients in our screw removal cohort and 119 in our screws retained cohort. A basic cost analysis and statistical analysis was performed. Results: The small screw group had a hardware removal rate of 9% (4/43) compared to 25% (26/104) of the larger screw group (P = .032). While the cost of 2 smaller screws is more than that of 1 larger screw, when the cost of removal and the rates of doing so are considered, the smaller screws resulted in substantial cost savings. Conclusion: Technical considerations for the medial displacement calcaneal osteotomy, including the use of multiple smaller screws, provided for a lower rate of hardware removal and likely decreased long-term costs. Level of Evidence: Level III, comparative series.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714559073
      Issue No: Vol. 36, No. 4 (2015)
       
  • Treatment of Hypertrophic Distal Tibia Nonunion and Early Malunion With
           Callus Distraction
    • Authors: Schoenleber, S. J; Hutson, J. J.
      Pages: 400 - 407
      Abstract: Background: Hypertrophic nonunions and early malunions of pilon and distal tibia fractures result in complex, challenging to treat deformities. Callus distraction histiogenesis is an option for their management, allowing for the simultaneous correction of multiplanar deformity and limb length discrepancy. Methods: A single-surgeon, retrospective case series was performed. Eight patients (6 males and 2 females) who were treated with callus distraction from 1991 to 2011 were reviewed. Six of 8 patients had varus deformities (range, 8-19 degrees) and 2 patients had valgus deformities (both 16 degrees) of the distal tibia metaphysis. Six of 8 had apex anterior deformities (range, 2-21 degrees) and 2 had apex posterior deformity (range, 9-20 degrees). An Ilizarov fixator or Taylor Spatial Frame (Smith & Nephew, Memphis, TN) was used to distract the nonunion or early malunion to correct alignment and shortening. Preoperative and postoperative radiographic outcomes, limb alignment, and ankle-hindfoot scores were reviewed. Results: Union was achieved in all patients at a mean of 5.8 months (range, 4.1-7.6 months). The 3 patients treated with an Ilizarov-type fixator had deformity correction to within 5 degrees of neutral in 1 plane and to within 10 degrees in the other plane. All 5 patients treated with a Taylor Spatial Frame had correction to within 5 degrees of neutral alignment in both coronal and sagittal planes. There were 2 complications requiring reoperation and 1 persistent limb length discrepancy (2 cm) after treatment. Median AOFAS ankle-hindfoot score was 82.5 (range, 53-90) at an average follow-up of 30.4 months (range, 8-92). Conclusions: Callus distraction histiogenesis was a minimally invasive technique that can successfully treat patients with hypertrophic nonunion and early malunion of the distal tibia. We believe the application of a computer-assisted 6-axis frame to correct the deformity improved the correction of these multiplanar deformities. Level of Evidence: Level IV, case series.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714558509
      Issue No: Vol. 36, No. 4 (2015)
       
  • Predictors of Response to Physical Therapy Intervention for Plantar Heel
           Pain
    • Authors: McClinton, S. M; Cleland, J. A, Flynn, T. W.
      Pages: 408 - 416
      Abstract: Background: Age, weight, and duration of symptoms have been associated with a poor response to treatment for plantar heel pain (PHP), but no studies were identified that examined predictors of response to physical therapy intervention. The purpose of this investigation was to examine the influence of age, body mass index (BMI), and symptom duration on treatment response to physical therapy intervention. Methods: Sixty participants received 6 visits over 4 weeks of physical therapy intervention that included manual therapy and exercise or electrophysiological agents and exercise. Outcomes were assessed using the Foot and Ankle Ability Measure (FAAM), Numeric Pain Rating Scale (NPRS), and Global Rating of Change Scale (GRC). Logistic regression (P < .05) was used to analyze age, BMI, and symptom duration as potential predictors of a successful response based on the minimal clinically important difference of the outcome measures. Sensitivity analysis was used to assess the influence of success based on minimal clinically important changes in the FAAM, NPRS, and GRC or only the FAAM and NPRS. Receiver operating curves were used to determine the cut point for the significant predictor. Results: At the 6-month follow-up to physical therapy intervention, NPRS was improved by 3 points (95% CI, 2.4-3.6) and FAAM improved by 22.5 points (95% CI, 16.8-28.2). Individuals with symptoms less than 7.2 months were 4.2 (95% CI, 1.3-13.8; P = .016) and 8.5 (95% CI, 2.5-28.9; P = .001) times more likely to respond to treatment based on the NPRS/FAAM/GRC and NPRS/FAAM success criteria, respectively. Age and BMI were not significant predictors (P ≥ .455 and P ≥ .450, respectively). Conclusion: Age and BMI were not associated with outcomes and obese individuals did achieve a successful outcome with the physical therapy intervention used in the clinical trial. Individuals with PHP symptoms longer than 7 months require additional consideration and further investigation of effective strategies to improve treatment response. Level of Evidence: Prognosis, level 2b comparative study.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714558508
      Issue No: Vol. 36, No. 4 (2015)
       
  • New Radiographic Parameter Assessing Hindfoot Alignment in Stage II
           Adult-Acquired Flatfoot Deformity
    • Authors: Williamson, E. R. C; Chan, J. Y, Burket, J. C, Deland, J. T, Ellis, S. J.
      Pages: 417 - 423
      Abstract: Background: The hindfoot moment arm is a reliable measurement of hindfoot valgus deformity in stage II adult-acquired flatfoot deformity (AAFD) and can be used to guide intraoperative correction of the hindfoot. There is currently little understanding of how the hindfoot moment arm relates to angular measurements of hindfoot alignment. The purpose of this study was to develop a new hindfoot alignment angle that can reliably quantify hindfoot valgus in patients with AAFD and to establish the relationship of this angle with the hindfoot moment arm. Methods: Preoperative hindfoot alignment radiographs were reviewed for 10 consecutive patients (10 feet) who were indicated for reconstruction for stage II AAFD. A second group of 10 patients (10 feet) without flatfoot were identified to serve as normal controls. The hindfoot moment arm and the new hindfoot alignment angle were measured in blinded fashion by 2 readers. Reliability was assessed using intraclass correlation coefficients (ICCs). The difference in angle between normal and flatfoot patients was assessed with a Mann-Whitney U test. A linear regression model was used to assess the relationship between hindfoot moment arm and the new hindfoot alignment angle. Results: Intra- and interrater reliability for the hindfoot alignment angle was excellent (ICC = 0.979 and 0.965, respectively). Flatfoot patients had greater mean angles than did normal patients (22.5 ± 4.9 vs 5.6 ± 5.4 degrees, P < .001). The hindfoot moment arm was correlated significantly with the hindfoot alignment angle (P < .001), increasing by 0.81 mm for every degree increase in angle (adjusted R 2 = 0.9046). Conclusion: These results indicate that the new hindfoot alignment angle is a reliable measure of hindfoot valgus and can differentiate between flatfoot and normal patients. In addition, the strong linear relationship between the hindfoot alignment angle and moment arm may allow for the use of this angle in the intraoperative correction of hindfoot valgus. Level of Evidence: Level III, retrospective case control study.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714558846
      Issue No: Vol. 36, No. 4 (2015)
       
  • Reconstruction of the Medial Talonavicular Joint in Simulated Flatfoot
           Deformity
    • Authors: Baxter, J. R; LaMothe, J. M, Walls, R. J, Prado, M. P, Gilbert, S. L, Deland, J. T.
      Pages: 424 - 429
      Abstract: Background: Reconstructing the ligamentous constraints of the medial arch associated with adult acquired flatfoot deformity remains a challenge. The purpose of this study was to test the efficacy of several reconstruction techniques of the medial arch. We hypothesized that an anatomic reconstruction of the spring ligament complex would correct the deformity better than other techniques tested. Methods: Three reconstructions of the medial support structures were performed on each specimen to recreate the different lines of action and insertions of the medial ligamentous complex in 12 specimens with a simulated flatfoot deformity. Talonavicular and tibiocalcaneal (hindfoot) orientations were measured in the axial, sagittal, and coronal planes in the intact, flatfoot, and reconstructed conditions. Results: While each reconstruction technique corrected the deformity (P < .05), proximal fixation of the graft corrected the greatest amount of talonavicular deformity while also correcting hindfoot valgus (P < .05). Conclusion: The fixation points and lines of action of a medial arch reconstruction have important implications on deformity correction in a flatfoot model. Despite its fidelity to the native structure, the anatomic spring ligament reconstruction provided the least amount of correction. These findings suggest that other ligamentous structures of the medial arch are critical in supporting the midfoot. Clinical Relevance: Reconstruction of the ligamentous supports of the medial arch might be able to correct substantial amounts of deformity without osseous procedures like calcaneal osteotomies or midfoot fusions.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714558512
      Issue No: Vol. 36, No. 4 (2015)
       
  • Sagittal Subtalar and Talocrural Joint Assessment With Weight-Bearing
           Fluoroscopy During Barefoot Ambulation
    • Authors: McHenry, B. D; Exten, E. L, Long, J, Law, B, Marks, R. M, Harris, G.
      Pages: 430 - 435
      Abstract: Background: Identifying talar position during ambulation has proved difficult as the talus lacks palpable landmarks for skin marker placement and more invasive methodologies such as bone pins are not practical for most clinical subjects. A fluoroscopic motion system was used to track the talus and calcaneus, allowing kinematic analysis of the talocrural and subtalar joints. Methods: Thirteen male subjects (mean age 22.9 ± 3.0 years) previously screened for normal gait were tested. A fluoroscopy unit was used to collect images at 120 fps during stance. Sagittal motion of the talocrural and subtalar joints were analyzed. Results: The intersubject mean and standard deviation values for all 58 trials of 13 subjects are reported. Maximum talocrural joint plantarflexion of 11.2 degrees (4.3 degrees of standard deviation) occurred at 11% stance and maximum dorsiflexion of –6.9 degrees (5.6 degrees of standard deviation) occurred at 85%. Maximum subtalar joint plantarflexion of 4.8 degrees (1.0 degrees of standard deviation) occurred at 96% stance and maximum dorsiflexion of –3.6 degrees (2.3 degrees of standard deviation) occurred at 30%. Talocrural and subtalar range of motion values during stance were 18.1 and 8.4 degrees, respectively. Conclusion: Existing fluoroscopic technology was capable of defining sagittal plane talocrural and subtalar motion during gait. These kinematic results compare favorably with more invasive techniques. This type of assessment could support more routine analysis of in vivo bony motion during gait. Clinical Relevance: Fluoroscopic technology offers improved sagittal plane motion evaluation during weight-bearing with potential application in patients with end-stage ankle arthritis, postoperative ankle replacements and fusions, and orthotics and braces.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714559540
      Issue No: Vol. 36, No. 4 (2015)
       
  • Arterial Anatomy of the Tibialis Posterior Tendon
    • Authors: Manske, M. C; McKeon, K. E, Johnson, J. E, McCormick, J. J, Klein, S. E.
      Pages: 436 - 443
      Abstract: Background: Tibialis posterior tendon dysfunction is a common disorder leading to pain, deformity, and disability, although its pathogenesis is unclear. A vascular etiology has been proposed, but there is controversy regarding the existence of a hypovascular region that may render the tendon vulnerable. The purpose of this study was to provide a description of the arterial anatomy supplying the tibialis posterior tendon. Methods: Sixty adult cadaveric lower extremities were obtained from a university-affiliated body donation program. Thirty specimens obtained within 72 hours of death were used for microscopic analysis. Thirty specimens were previously frozen and used for macroscopic analysis. The tibialis anterior, tibialis posterior, and peroneal arteries were injected with India Ink and Ward’s Blue Latex. The specimens used for macroscopic analysis were debrided with sodium hypochlorite to expose the extratendinous anatomy. For the microscopic analysis, the tendon was cleared using a modified Spälteholz technique to expose the intratendinous vascular anatomy. Results: Macroscopically, an average of 2.5 ± 0.7 vessels entered the tendon proximal to the navicular insertion. In all, 28/30 (93.3%) specimens had a vessel entering 4.1 ± 0.6 cm proximal to the medial malleolus and 24/30 (80.0%) specimens had a vessel entering 1.7 ± 0.9 cm distal to the medial malleolus. Microscopically, an average of 1.9 ± 0.3 vessels entered each tendon proximal to the navicular insertion. In total, 27/30 (90%) specimens had a vessel entering the tendon 4.8 ± 0.8 cm proximal to the medial malleolus and 30/30 (100%) specimens had a vessel entering the tendon 1.9 ± 0.8 cm distal to the medial malleolus. In all specimens, a hypovascular region was observed, starting 2.2 ± 0.8 cm proximal to the medial malleolus and ending 0.6 ± 0.6 cm proximal to the medial malleolus with an average length of 1.5 ± 1.0 cm. The insertion of the tendon was well vascularized both on microscopic and macroscopic specimens. Conclusion: The tibialis posterior tendon was supplied by 2 vessels entering the tendon approximately 4.5 cm proximal and 2.0 cm distal to the medial malleolus. A retromalleolar hypovascular region was observed. Clinical Relevance: Improved understanding of the vascularity of the tibialis posterior tendon may be helpful in clinical practice and potentially provides a basis for further evaluation of the causative factors of tibialis posterior tendinopathy.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714559271
      Issue No: Vol. 36, No. 4 (2015)
       
  • Biomechanical Evaluation of Varying the Number of Loops in a Repair of a
           Physiological Model of Achilles Tendon Rupture
    • Authors: Grieco, P. W; Frumberg, D. B, Weinberg, M, Pivec, R, Naziri, Q, Uribe, J. A.
      Pages: 444 - 449
      Abstract: Background: Numerous suturing techniques have been described to treat Achilles tendon ruptures. No prior studies have evaluated frayed tendon ends on construct strength and whether this allows for less extensile exposure. Methods: Forty bovine Achilles tendons were divided into groups: 1 control and 4 experimental. Experimental groups were sectioned with ends frayed longitudinally in 2 mm intervals for 2 cm with no fraying for the control group. Four-stand Krackow sutures were used for repairs with 3 loops in the control group, 2 loops in frayed section for experimental groups, and varying numbers of loops (1-4) in healthy tendon. Samples were tested in loading cells at 100 N and 190 N for 1000 cycles. Gap width and maximum load failure were measured. Results: Gapping was
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714559270
      Issue No: Vol. 36, No. 4 (2015)
       
  • Contribution of the Sural Nerve to Postural Stability and Cutaneous
           Sensation of the Lower Limb
    • Authors: Mazzella, N. L; McMillan, A. M.
      Pages: 450 - 456
      Abstract: Background: The sural nerve is a cutaneous nerve of the lower limb that innervates the posterolateral aspect of the lower leg, ankle, and foot. Considering this pattern, it is plausible that it contributes to the maintenance of postural stability. However, the implications of sensory loss following sural nerve injury have yet to be thoroughly investigated. Therefore, the aim of this study was to investigate the immediate effect of sural nerve sensory loss on postural stability and its variability of innervation to the lower limb. Methods: Twenty-five healthy adult subjects participated in an observational study with a repeated-measures design. Each participant underwent a postural stability assessment using the Neurocom Balance Master under 2 conditions: 1) with the sural nerve functioning normally and 2) following a bilateral ultrasound-guided sural nerve block. The cutaneous distribution of the sural nerve was mapped for descriptive purposes. Results: There were no statistically significant differences between conditions for the primary outcome measure (unilateral stance on the dominant leg with eyes closed). A statistically significant reduction in postural stability was detected during unilateral stance on the nondominant leg (with eyes closed) following the nerve block (mean increase, 2.25 deg/s; 95% confidence interval, –0.48 to 2.91; t = 2.75; df = 24; P = .01). The mean area of plantar skin innervated by the sural nerve was 17% ± 11%, and the mean area of lateral skin was 50% ± 6%. Conclusion: Our findings demonstrate that a loss in sural nerve function is unlikely to reduce postural stability during daily activities. The sural nerve has a variable innervation pattern that can involve the third digit and the plantar medial border of the heel. Clinical Relevance: Practitioners should consider this variability when assessing for potential sensory deficits and when planning procedures requiring anesthesia to the plantar surface of the foot.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714560398
      Issue No: Vol. 36, No. 4 (2015)
       
  • Staple Fixation for Akin Proximal Phalangeal Osteotomy in the Treatment of
           Hallux Valgus Interphalangeus
    • Authors: Neumann, J. A; Reay, K. D, Bradley, K. E, Parekh, S. G.
      Pages: 457 - 464
      Abstract: Background: The Akin proximal phalangeal osteotomy is commonly used in conjunction with metatarsal osteotomies to treat hallux valgus. Multiple fixation methods including suture, wire, screw, and staple fixation have been described. The aims of this study were to assess the intraoperative and postoperative complications and to evaluate short-term postoperative outcomes in patients who underwent Akin osteotomy with staple fixation. Methods: Forty-four patients (51 feet) with painful hallux valgus were retrospectively reviewed at an average of 40.4 ± 15.8 (range, 25.9 to 79.9) weeks following an Akin osteotomy with staple fixation. Patient reported preoperative and postoperative Visual Analog Score (VAS) (0 to 10, 0 = no pain) was recorded. Level of activity was reported postoperatively. Hallux valgus angles (HVAs), intermetatarsal angles (IMAs), and hallux valgus interphalangeus angles (IPAs) were evaluated on preoperative as well as final postoperative radiographs. Postoperative clinical and radiographic examinations were used to evaluate for complications. Results: Mean VAS improved from 4.4 ± 2.6 to 1.0 ± 1.2 (P < .001). Activity level was classified as ability to bear weight as tolerated 3/51 (5.9%), ambulate 1 to 4 blocks 2/51 (3.9%), ambulate a minimum of 6 blocks 18/51 (35.3%), and ambulate an unlimited distance 28/51 (59.4%). Average HVA, IMA, and IPA improved from 25.6 ± 10.0 degrees to 14.1 ± 8.1 degrees (P < .001), 13.1 ± 4.6 degrees to 8.0 ± 3.0 degrees (P < .001), and 7.9 ± 3.4 degrees to –3.1 ± 6.4 degrees (P < .001), respectively. No major postoperative complications, including infections, nonunions, or recurrent deformities, were recorded. Two patients sustained breaches of the lateral cortex, but this was without appreciable complication. Three patients (5.9%) reported unilateral proximal-medial great phalanx tenderness. There was 1 revision for persistent deformity, specifically in the HVA and IPA angles. Conclusion: Akin osteotomy with staple fixation was a safe and effective procedure as part of a hallux valgus correction with improvement in pain and hallux valgus deformity with a low risk for complications. Level of Evidence: Level IV, case series.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100714559072
      Issue No: Vol. 36, No. 4 (2015)
       
  • Arthroscopic Brostrom Technique
    • Authors: Acevedo, J. I; Mangone, P.
      Pages: 465 - 473
      Abstract: Surgical strategy regarding chronic lateral ankle instability is undergoing an evolution from traditional open procedures to minimally invasive and arthroscopic techniques. The development of arthroscopic techniques for the ankle mirrors the processes witnessed for the shoulder and knee over the last 30 years. The arthroscopic Brostrom is a novel technique that allows the surgeon to use an arthroscope to perform a lateral ankle ligament reconstruction that was previously thought possible only through open surgical technique. Indications and contraindications for the arthroscopic technique are essentially the same as those for an open Brostrom type of procedure. The arthroscopic Brostrom procedure is easy to remember and relatively simple to perform for the surgeon who has mastered basic ankle arthroscopy. The authors’ results discussed in this article reveal that the arthroscopic Brostrom is a safe and effective procedure with outcomes at least equal to published results for traditional open techniques. Level of Evidence: Level V, expert opinion.
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100715576107
      Issue No: Vol. 36, No. 4 (2015)
       
  • Education Calendar
    • Pages: 474 - 474
      PubDate: 2015-04-02T15:58:08-07:00
      DOI: 10.1177/1071100715580127
      Issue No: Vol. 36, No. 4 (2015)
       
 
 
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