Tendon transfer options in managing the adult flexible flatfoot.

Patients undergoing surgery for posterior tibial tendon dysfunction may require tendon transfer. The flexor digitorum longus is most commonly transferred, although the flexor hallucis longus and peroneus brevis have also been described in the literature. This article discusses the advantages and disadvantages of the different tendons, the surgical techniques used to perform them, and their results in the literature, concentrating principally on studies in which additional bone procedures were not performed. This article will also discuss the potential role for isolated soft tissue procedures in the treatment of stage 2 posterior tibial tendon dysfunction.

Porous tantalum stimulates the proliferation and osteogenesis of osteoblasts from elderly female patients.

Porous tantalum (Ta) implants have been successful in various orthopedic procedures for patients with compromised bone-forming abilities. Previous studies demonstrated that human osteoblast (HOB) cultures from older female patients produced less bone on implant materials in vitro compared to HOBs from age-matched male and younger female patients. In this study, the responses of HOBs from younger (< 45) and older (> 60 years old) female patients were compared on Ta, titanium fiber mesh (TFM) and tissue culture plastic. Adhesion, proliferation, and mineralization were greater in cells from younger patients than from older patients. Cell adhesion was slightly higher on Ta than TFM or plastic. However, Ta highly stimulated cell proliferation with a 4- and 6-fold increase compared to TFM for cells from younger and older patients, respectively, and 12- and 16-fold increase in proliferation compared to cells on plastic (p ≤ 0.001). At 3 weeks, mineralization was significantly higher on Ta compared to TFM for HOBs from older patients (p ≤ 0.05). Expression levels of bone matrix markers demonstrated differences dependent on age and substrate. Scanning electron micrographs revealed HOBs covering the surfaces and entering the pores of both Ta and TFM. In conclusion, tantalum greatly stimulates cell proliferation, and improves the ability of HOBs from older patients to form bone.

Foot and ankle experience in orthopedic residency: an update.

BACKGROUND: In 2003, a limited survey regarding the number of dedicated foot and ankle faculty and foot and ankle rotations at orthopaedic surgery residency programs was published. The purpose of this paper was to update the results of that previous survey and provide additional, more in-depth information. MATERIALS AND METHODS: A survey questionnaire was emailed to the program directors and chairpersons of the 150 ACGME-accredited orthopaedic residency training programs in the United States. RESULTS: Responses were obtained from all programs. One hundred thirty-seven (91.3%) programs had one or more orthopaedic surgeon faculty members with a predominantly foot and ankle practice (at least 50%), an increase of 5.5 percentage points from the survey performed 6 years previously. One hundred forty three (95.3%) programs had one or more orthopaedic surgeon faculty members with a practice consisting of at least 25% foot and ankle. One hundred twenty programs (80%) had one or more dedicated foot and ankle rotations, an increase of 15.1% from 6 years prior. Orthopaedic surgery residents were felt to spend a mean of 30.4% and a median of 20% of their time with board-certified/ board-eligible orthopaedic surgeons in rotations that include treatment of foot and ankle pathology but were not considered ;;dedicated'' foot and ankle rotations. CONCLUSIONS: The number of orthopaedic surgery residency programs with rotations and faculty members dedicated to foot and ankle education has increased over the 6 years between surveys. Orthopaedic surgery residents' experience and skill development in foot and ankle surgery during their 5 years of residency training are not limited to their time spent in dedicated foot and ankle rotations.

Implications for the anatomy of the flexor hallucis brevis insertion.

BACKGROUND: Excessive hallux proximal phalangeal base removal during first MTP resection arthroplasty, implant arthroplasty, or amputation can compromise the flexor hallucis brevis (FHB) insertion leading to first MTP joint plantarflexion weakness, cock-up toe deformity, and altered forefoot loading. MATERIAL AND METHODS: The insertional anatomy of the FHB tendon was measured in 30 fresh frozen cadaver specimens. The FHB was then cyclically loaded and bone sequentially removed from the proximal phalangeal base until specimen failure occurred. RESULTS: The mean length of the lateral and medial FHB insertions measured 9.0 +/- 0.6 mm and 8.0 +/- 0.5 mm, respectively (p < 0.0001). The mean width of the lateral and medial FHB insertions measured 7.1 +/- 1.0 mm and 8.8 +/- 1.4 mm, respectively (p < 0.0001). FHB insertion length as a percentage of total proximal phalangeal length was 26% +/- 3% medially and 30% +/- 3% laterally. Twenty-two specimens failed at the FHB insertion site after an average of 7.8 +/- 1.0 mm or 24% +/- 3% of the total length of the proximal phalanx had been resected from the base. CONCLUSION: Six millimeters of bone or 20% of the proximal phalangeal length could be safely removed from the hallux proximal phalangeal base without compromising the integrity of the FHB insertion to a physiologic load. Retaining 10 mm of the hallux proximal phalangeal base during amputation would preserve the medial FHB insertion and sacrifice none to less than 0.4 mm of the lateral insertion in our specimens. CLINICAL RELEVANCE: This study demonstrates how much hallux proximal phalangeal base can be resected during first MTP arthroplasty or needs to be retained during amputation to preserve FHB function.

Therapeutic touch stimulates the proliferation of human cells in culture.

OBJECTIVES: Our objective was to assess the effect of Therapeutic Touch (TT) on the proliferation of normal human cells in culture compared to sham and no treatment. Several proliferation techniques were used to confirm the results, and the effect of multiple 10-minute TT treatments was studied. DESIGN: Fibroblasts, tendon cells (tenocytes), and bone cells (osteoblasts) were treated with TT, sham, or untreated for 2 weeks, and then assessed for [(3)H]-thymidine incorporation into the DNA, and immunocytochemical staining for proliferating cell nuclear antigen (PCNA). The number of PCNA-stained cells was also quantified. For 1 and 2 weeks, varying numbers of 10-minute TT treatments were administered to each cell type to determine whether there was a dose-dependent effect. RESULTS: TT administered twice a week for 2 weeks significantly stimulated proliferation of fibroblasts, tenocytes, and osteoblasts in culture (p = 0.04, 0.01, and 0.01, respectively) compared to untreated control. These data were confirmed by PCNA immunocytochemistry. In the same experiments, sham healer treatment was not significantly different from the untreated cultures in any group, and was significantly less than TT treatment in fibroblast and tenocyte cultures. In 1-week studies involving the administration of multiple 10-minute TT treatments, four and five applications significantly increased [(3)H]-thymidine incorporation in fibroblasts and tenocytes, respectively, but not in osteoblasts. With different doses of TT for 2 weeks, two 10-minute TT treatments per week significantly stimulated proliferation in all cell types. Osteoblasts also responded to four treatments per week with a significant increase in proliferation. Additional TT treatments (five per week for 2 weeks) were not effective in eliciting increased proliferation compared to control in any cell type. CONCLUSIONS: A specific pattern of TT treatment produced a significant increase in proliferation of fibro-blasts, osteoblasts, and tenocytes in culture. Therefore, TT may affect normal cells by stimulating cell proliferation.

The in vitro response of human osteoblasts to polyetheretherketone (PEEK) substrates compared to commercially pure titanium.

Polyetheretherketone (PEEK) is used as an alternative to titanium in medical devices. Previous in vitro studies examining PEEK have differed in their choice of polymer variant [PEEK or carbon-fiber reinforced PEEK (CFR-PEEK)], source of polymer (some of which are no longer available or for implantation) and cell type. While all studies demonstrated favorable cytocompatibility of the PEEK material, no studies are available which reflect the current state of the art of the material. Here, we use different forms of the only implantable grade PEEK available. These are compared with commercially pure titanium (cpTi) Grade 1 using a human primary osteoblast model. Sample materials were presented as industrially relevant surfaces. Machined or injection molded PEEK and CFR-PEEK were evaluated along with polished (Ra=0.200microm) and rough (Ra=0.554microm) cpTi. Osteoblast adhesion at 4h on injection molded variants of PEEK (Ra=0.095microm) and CFR-PEEK (Ra=0.350microm) material was comparable to titanium. Machined variants of PEEK (Ra=0.902microm) and CFR-PEEK (Ra=1.106microm) materials were significantly less. Proliferation at 48h determined by [(3)H]-thymidine incorporation was the greatest on the smoothest of all materials, the injection molded unfilled PEEK, which was significantly higher than the rough titanium control. The machined unfilled PEEK had the lowest DNA synthesis. RT-PCR for alkaline phosphatase, Type I collagen and osteocalcin normalized to glyceraldehyde-3-phosphate dehydrogenase revealed different patterns of mRNA levels. High mRNA levels for Type I collagen showed that CFR-PEEK stimulated osteoblast differentiation, whilst injection molded unfilled PEEK was less differentiated. Machined unfilled PEEK had comparable message levels of bone matrix proteins as rough titanium. All material variants permitted a degree of mineralization. Scanning electron microscopy at 3 days and 2 weeks in differentiation medium showed that human osteoblasts were well spread on all the different substrates. The varied response reported here at different time points during the study suggests that material formulation (unfilled PEEK or CFR-PEEK), subjection to industrial processing, surface roughness and topography may all influence the cellular response of osteoblasts to PEEK. Thus, differences in human osteoblast responses were found to the various samples of PEEK, but implantable grade PEEK, in general, was comparable in vitro to the bone forming capacity of rough titanium.

Management of hindfoot disease in rheumatoid arthritis.

There is a wide variety of hindfoot disease seen in patients with rheumatoid arthritis. Initial treatment is conservative including optimizing medical management to control the disease process. Should symptoms persist, surgical treatment may be performed, although there is an increased complication rate related to both the disease and the side effects of the medications used to treat it.

Cyclic loading of Achilles tendon repairs: a comparison of polyester and polyblend suture.

BACKGROUND: Early functional rehabilitation is widely used after open suture repair of the Achilles tendon. To our knowledge, no previous studies have assessed gap formation from cyclic loading and subsequent failure loads of simulated Achilles tendon repairs. A synthetic (polyblend) suture has been introduced for tendon repairs with reportedly greater strength than polyester suture. This stronger, stiffer suture material may provide stronger repairs with less elongation of the tendon repair. METHODS: Simulated Achilles tendon ruptures in bovine Achilles tendon were repaired with a four-strand Krackow suture technique using No. 2 polyester suture. Specimens were loaded for 3,000 cycles at maximal loads of 50, 75, 100, or 125 N, and gap formation at the repair site was continuously measured. After cyclic loading, each specimen was loaded to failure. Identical repairs were performed with number 2 polyblend suture and cyclically loaded to 75 N for 3,000 cycles. All specimens were loaded to failure. RESULTS: Cyclically loading polyester suture repairs to 50, 75, 100, or 125 N for 3,000 cycles resulted in mean gapping at the repair site of 3.0 +/- 0.8, 4.9 +/- 1.0, 7.2 +/- 0.9, and 7.9 +/- 0.8 mm, respectively. Cyclically loading the polyblend suture repairs for 3,000 cycles at 75 N, resulted in 3.3 +/- 0.3 mm of gap formation at the repair site, significantly less than polyester suture repairs (p < 0.001). The mean load to failure for polyester suture repair was 222 +/- 19 N and for polyblend suture repair was 582 +/- 49 N, a statistically significant difference (p < 0.001). Gap formation at 100, 1,000, and 2,000 cycles, as a percentage of total gap formation at 3,000 cycles, was 64.3%, 87.5%, and 95.4% for polyester suture and 45.8%, 78.5%, and 90.1% for polyblend repairs. All specimens in all groups failed at the knots during load-to-failure testing. CONCLUSIONS: Cyclic loading of simulated Achilles tendon repairs using a Krackow, four-core polyester suture technique showed progressive gap formation with increasing load. All repairs failed at the knot, and suture pull-out from tendon was not observed. Polyblend suture repair, when compared to identical repairs with braided polyester suture, resulted in a 260% higher load to failure and 33% less gap formation at the repair site after 3,000 cycles. CLINICAL RELEVANCE: The use of polyblend suture in a four-stranded Krackow configuration provides stronger repairs with less gap formation, which may provide increased security during early functional rehabilitation.

An in vitro study comparing the use of suture anchors and drill hole fixation for flexor digitorum longus transfer to the navicular.

BACKGROUND: The surgical management of posterior tibial tendon dysfunction often includes transfer of the flexor digitorum longus (FDL) tendon through a tunnel in the navicular. Fixation often is obtained by sewing the tendon back onto itself. The purpose of this study was to compare this standard method of fixation with suture anchor fixation, a technique that may be associated with less surgical morbidity, because it requires the harvesting of less tendon length. METHODS: FDL tendon transfer to the navicular was done in 13 fresh-frozen cadaver specimens. In six feet comprising the standard group, the FDL tendon was transected distal to the master knot of Henry, placed through a drill hole into the navicular, and sutured back onto itself. In seven feet the FDL tendon was transected proximal to the master knot of Henry, placed into a drill hole into the navicular, and fixed with a suture anchor. Load was applied to the proximal FDL muscle and tendon using a materials testing system (MTS) machine and peak load to failure was measured. RESULTS: The mean load to failure was 142.48 N +/- 38.06 N for the standard group and 142.12 N +/- 59.26 N for the suture anchor group (p = 0.305 for the Student-t test and p = 0.945 for the Mann-Whitney test). CONCLUSION: Transfer of the FDL tendon to the navicular using suture anchor fixation requires less tendon length yet provides similar fixation strength as compared to sewing the tendon back onto itself. However, suture anchors are considerably more expensive than sutures. CLINICAL IMPLICATIONS: Suture anchors allow comparable fixation of FDL tendon transfer into a navicular without the need to disrupt the master knot of Henry. This technique may be associated with less morbidity including a shorter incision, decreased risk of medial plantar nerve injury, and decreased loss of lesser toe plantarflexion strength secondary to maintenance of the normal interconnections between the flexor hallucis longus (FHL) and FDL tendons.

Treatment of the missed Lisfranc injury.

Lisfranc joint injuries may be missed at the time of occurrence potentially leading to persistent instability, deformity, or arthritis. In the absence of significant residual arthritis or fixed deformity, delayed open reduction and internal fixation with or without reconstruction of the Lisfranc ligament may be performed. An alternative is reduction and primary arthrodesis of the relatively immobile medial tarsometatarsal (TMT) joints. In the presence of significant residual arthritis or fixed deformity that is recalcitrant to conservative treatment, arthrodesis, including correction of deformity, is the treatment of choice for the first, second, and third TMT joints. Resection arthroplasty of the fourth and fifth TMT joints may be preferable to arthrodesis in order to maintain physiologic motion.

The effect of triceps surae contracture force on plantar foot pressure distribution.

BACKGROUND: Triceps surae contractures have been associated with foot and ankle pathology. Achilles tendon contractures have been shown to shift plantar foot pressure from the heel to the forefoot. The purpose of this study was to determine whether isolated gastrocnemius contractures had similar effects and to assess the effects of gastrocnemius or soleus contracture on midfoot plantar pressure. METHODS: Ten fresh frozen cadaver below-knee specimens were loaded to 79 pounds (350 N) plantar force with the foot unconstrained on a 10-degree dorsiflexed plate. Combinations of static gastrocnemius or soleus forces were applied in 3-lb increments and plantar pressure recordings were obtained for the hindfoot, midfoot, and forefoot regions. RESULTS: The percentage of plantar force borne by the forefoot and midfoot increased with triceps surae force, while that borne by the hindfoot decreased (p

Transforming growth factor-beta 1 (TGF-beta1) prevents the age-dependent decrease in bone formation in human osteoblast/implant cultures.

Titanium implants have been extensively used in orthopedic surgery and dentistry. Most of the patients who receive such implants are elderly with a compromised ability to heal and form new bone. By using an in vitro osteoblast/implant culture system, the potency of TGF-beta1 in enhancing mineralization of human osteoblast cultures from elderly subjects was investigated in this study. Primary human osteoblast (HOB) cells obtained from different age group human subjects [Young (Y), Middle (M), and Old (O)] were cultured on Ti alloy (Ti-6Al-4V) disks with or without continuous administration of 0.2 ng/mL TGF-beta1 in the medium for 2 or 4 weeks. TGF-beta1 significantly (p < 0.05) increased calcium content and the size of calcified nodules on implant disks in the O group, but had no effect on the Y or M groups. The number of calcified nodules was not different with or without TGF-beta1 in all age groups. As measured by Northern blot analysis and RT-PCR, TGF-beta1 significantly increased the expression of bone-specific extracellular matrix proteins, including alkaline phosphatase, Type I collagen, bone sialoprotein and osteocalcin, after both 2 and 4 weeks in the O group but not in the Y group. In conclusion, TGF-beta1 enhances mineralization on implant materials of osteoblast cultures from elderly human subjects.

Ligamentous Lisfranc joint injuries: a biomechanical comparison of dorsal plate and transarticular screw fixation.

BACKGROUND: The current treatment of displaced ligamentous injuries of the tarsometatarsal (TMT) joints is open reduction and rigid fixation using transarticular screws. This technique causes further articular surface damage that theoretically may increase the risk of arthritis. Should the screws break, hardware removal is difficult. An alternative method that avoids these potential complications is rigid fixation using dorsal plates. METHODS: The displacement between the first metatarsal and medial cuneiform, the second metatarsal and intermediate cuneiform, the first and second metatarsal bases, and the medial cuneiform and second metatarsal base were measured in 10 matched pairs of fresh-frozen cadaver lower extremities in the unloaded and loaded condition. After sectioning the Lisfranc and TMT joint ligaments, measurements were repeated in the loaded condition. The first and second TMT joints of the right feet were fixed with transarticular 3.5-mm cortical screws while those of the left feet with were fixed with dorsal 2.7-mm 1/4 tubular plates. Measurements were then repeated in the unloaded and loaded condition. RESULTS: After ligament sectioning, significantly increased first and second TMT joint subluxation with loading was seen. No significant difference was noted with direct comparison between plates and screws with respect to ability to realign the first and second TMT joints and to maintain TMT joint alignment during loading. The amount of articular surface destruction caused by one 3.5-mm screw was 2.0 +/- 0.7% for the medial cuneiform, 2.6 +/- 0.5% for the first metatarsal, 3.6 +/- 1.2% for the intermediate cuneiform, and 3.6 +/- 1.0% for the second metatarsal. CONCLUSIONS: The model reliably produced displacement of the first and second TMT joints consistent with a ligamentous Lisfranc injury. Transarticular screws and dorsal plates showed similar ability to reduce the first and second TMT joints after TMT and Lisfranc ligament transection and to resist TMT joint displacement with weightbearing load. CLINICAL RELEVANCE: Dorsal plating may be an alternative to transarticular screws in the treatment of displaced Lisfranc injuries.

Posterior heel pain (retrocalcaneal bursitis, insertional and noninsertional Achilles tendinopathy).

The majority of patients with Achilles tendinopathy respond to nonoperative treatment. In patients with refractory symptoms, surgery can be considered. If paratenonitis is present, the paratenon is partially excised, and adhesions are released. Areas of symptomatic tendinosis are excised with repair of the residual defect in the Achilles tendon. An alternative for patients with tendinosis who are at increased risk for wound problems or who do not want a large open incision is percutaneous or endoscopic tenotomy. A symptomatic Haglund's deformity or inflamed retrocalcaneal bursa is excised. Augmentation of the Achilles tendon may be considered if debridement threatens the structural integrity of the tendon, in older patients, and in revision surgery.

The effects of patient age on human osteoblasts' response to Ti-6Al-4V implants in vitro.

Osseointegrated implants are a common therapy for the elderly population as lifespan increases. Understanding the effects of age and sex on osseointegration is important for successful implant therapy. Therefore, the response of primary human osteoblasts (HOB) to implant materials was studied. HOBs were obtained by outgrowth of cells from bone from orthopaedic procedures and categorized as Young (Y), <15; Middle (M), 30-50; and Old (O), >60 years old. Initially the HOB phenotype was determined on tissue culture plastic. Alkaline phosphatase (ALP) staining and activity were significantly increased in HOBs from older patients. Message levels of type I collagen (COL), bone sialoprotein (BSP) and ALP were significantly higher (from 2.3- to 3.8-fold) in Y subjects compared to M and O patients at 2 weeks. Studies of the response of HOBs to implant materials were undertaken using Ti-6Al-4V disks prepared in a manner similar to orthopaedic implants. A 1.4-fold (p<0.05) increase in cell attachment was found in HOBs from Y compared with O in female subjects but not in male subjects. Cell proliferation at 24 h was not significantly different by age or sex, nor was DNA content different at 2 and 4 weeks. Mineralization in HOB-implant cultures was 2.3-fold higher in Y than in O, and 1.7-fold higher in Y compared to M HOBs from female but not male subjects at 4 weeks. Northern blot and RT-PCR analysis at 2 weeks of culture showed significantly higher levels (1.6-2.3-fold) of COL, BSP, and osteocalcin (OC) mRNAs in Y HOBs compared to M and O HOBs from female subjects. We conclude that human osteoblasts from older female patients have a decreased ability to form bone on implants.