A comparison of the monofilament with other testing modalities for foot ulcer susceptibility.

We studied the number of testing sites and the proportion needed to be insensate for the optimal assessment of foot ulcer risk with the 10 g monofilament. Also, we compared the sensitivity and specificity of the 10 g monofilament with other methodologies. Fifty-two individuals with either a current foot ulcer, a history of a foot ulcer or the presence of Charcot neuroarthopathy and 51 individuals with no history of any of these conditions were assessed with the 10 g monofilament at four sites on each foot, the 128 Hz tuning fork at the halluces, the Biothesiometer at the halluces and the modified neuropathy disability score. Sensitivities and specificities were calculated for the various modalities. The Biothesiometer and the neuropathy disability score had the highest sensitivities (0.92 for both). The 128 Hz tuning fork tested only at the halluces (criterion: >or=1 insensate site) had the same sensitivity (0.86) as the 10 g monofilament tested at eight sites (criterion: >or=1 insensate site) with similar specificities (0.56 and 0.58, respectively). The Biothesiometer and the modified neuropathy disability score tend to be more sensitive than the 10 g monofilament for the assessment of individuals at risk for foot ulcers. The 128 Hz tuning fork tested at only two sites is as sensitive as the 10 g monofilament tested at eight sites. These data suggest that the 10 g monofilament may not be the optimum methodology for identifying individuals at risk of foot ulcers.

Foot and ankle injuries in motor vehicle accidents.

BACKGROUND: We studied foot and ankle (F/A) injuries that occurred in motor vehicle accidents treated in a Level 1 trauma center. METHODS: The records of F/A injuries of 2248 consecutive orthopedic patients were reviewed to find foot and ankle injuries. RESULTS: Pilon fractures were common. Motor Vehicle Accident (MVA) occupants with F/A injuries had a higher injury Severity Score than those without (17.9 vs. 11.6, p <. 001). MVA F/A injury risk was higher without restraint [relative risk ratio (rrr) 1.68, p <. 0032] than with restraint except for air bagged drivers who were similar to unrestrained drivers (rrr 1.18, p > .05, NS). CONCLUSION: Patients with F/A injuries may have serious associated injuries. Air bags may not protect feet.

Results of operative fixation of unstable ankle fractures in geriatric patients.

It is widely accepted that operative fixation of unstable ankle fractures yields predictably good outcomes in the general population. The current literature, however reports less acceptable results in the geriatric population age 65 years and older. The current study analyzes the outcome of the surgical treatment of unstable ankle fractures in patients at least 65 years old. Twenty three patient over 65 years old were surgically treated after sustaining 21 (91%) closed and 2 (9%) open grade II unstable ankle fractures. Fractures were classified according to the Danis-Weber and Lauge-Hansen schemes. Fracture type was predominantly Weber B (21/23, 91%), or supination external rotation stage IV (21/23, 91%). Fracture union rate was 100%. There were three significant complications including a lateral wound dehiscence with delayed fibular union in an open fracture dislocation, and two below knee amputations, neither of which was directly related to the fracture treatment. There were three minor complications; one superficial wound infection and two cases of prolonged incision drainage, all of which resolved without further surgical intervention. Complications were associated with open fractures and preexisting systemic disease. These results indicate that open reduction and internal fixation of unstable ankle fractures in geriatric patients is an efficacious treatment regime that with results that are comparable to the general population.

Measurement of isolated subtalar range of motion: a cadaver study.

Fifteen fresh-frozen cadaveric lower extremities were studied to evaluate the reliability of measuring subtalar motion using a bubble inclinometer. There was high intra-observer reliability for manual inversion and eversion of the subtalar joint with the tibiotalar joint locked and unlocked. Poor correlation of radiographic and clinical measurements questioned the validity of bubble inclinometer measurements. The contribution of the tibiotalar joint to apparent subtalar motion, as measured clinically and radiographically, was found to be one-third of the arc of motion, as compared to motion measured clinically and radiographically with the tibiotalar joint locked.

Kinematics of a total arthroplasty of the ankle: comparison to normal ankle motion.

Although the concept of a total ankle arthroplasty has been advanced as a method for treating severe ankle arthritis, the clinical experience with all of the models developed has been discouraging. Both the constrained designs, which maximize joint contact area by restricting the available motion, and the unconstrained designs, which allow more normal motion at the expense of higher contact stresses, uniformly result in implant loosening, pain, and clinical failure in 2 to 7 years. This has led to the recommendation against the use of a total ankle arthroplasty except in very low-demand patients. Failure of ankle implants can be ascribed to either anatomic considerations (e.g.--the talus is too small to accommodate the stress transfers of a prosthesis), or mechanical etiologies. Abnormal 3-dimensional motion of the ankle following arthroplasty would fall into the latter category. This study examined the motion that occurs after implantation of an unconstrained-type total ankle arthroplasty. Using previously validated methodology, axially loaded ankle specimens were cycled through an arc of plantarflex/dorsiflexion while measuring the resulting coupled internal/external and varus/valgus rotations. The average coupled motions in prosthetic ankles were not significantly different than their intact controls. There was, however, a significantly increased amount of hysteresis (defined as the difference between the upper and lower pathways of coupled motion at any given sagittal position) that occurred as the ankle was dorsiflexed and plantar flexed. The increased hysteresis was seen in both the axial and coronal planes. This indicates that there was a greater permitted envelop of motion in the prosthetic ankles compared to normal ankles. It is hypothesized that this subtle change in ankle kinematics caused by the arthroplasty leads to abnormal stress transfer at the prosthesis-bone interface, thereby promoting early implant failure.

Efficacy of three-phase bone scans in evaluating diabetic foot ulcers.

To evaluate the utility of bone scans in determining the treatment of diabetic patients with foot ulcers, a retrospective study was conducted. Medical records were reviewed for clinical signs of infection, laboratory data, and the radiologists' interpretations of imaging studies. During the study period, 34 bone scans were obtained by the treating physicians to evaluate diabetic foot ulcers. Among these, 22 of 34 bone scans were markedly confirmatory of being "consistent with osteomyelitis," 8 of 34 were moderately confirmatory ("indeterminate with regard to osteomyelitis"), and 4 of 34 were not confirmatory ("not consistent with osteomyelitis"). Of the 22 patients in the markedly confirmatory group, eight patients with clinical findings of uncontrolled infection or gangrene were treated with partial or complete amputation, whereas all others (14 patients) were treated with local wound care+/-intravenous antibiotics. Among the eight bone scans interpreted as indeterminate, three patients required partial or complete amputation, whereas the other five patients were managed with local wound care. Of the four patients with nonconfirmatory bone scans, two patients had evidence of dry gangrene and required amputation, whereas the other two patients did not have clinical evidence of infection or gangrene and were treated with local wound care. There was no significant difference in the amputation rate for patients with confirmatory, indeterminate, or nonconfirmatory bone scans for osteomyelitis (36%, 37%, and 50%, respectively) (P > 0.5). Therefore, the authors concluded that the ultimate treatment should be based on clinical indicators of the presence of uncontrolled infection or gangrene rather than on bone scan findings.

Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency.

Ten patients were identified with traumatic, complete common peroneal nerve palsy, with no previous foot or ankle surgery or trauma distal to the knee, who had undergone anterior transfer of the posterior tibial tendon to the midfoot. Six of these patients had a transfer to the midfoot and four had a Bridle procedure with tenodesis of half of the posterior tibial tendon to the peroneus longus tendon. Average follow-up was 74.9 months (range, 18-351 months). All patients' feet were compared assessing residual muscle strength, the longitudinal arch, and motion at the ankle, subtalar, and Chopart's joint. Weightbearing lateral X-rays and Harris mat studies were done on both feet. In no case was any valgus hindfoot deformity associated with posterior tibial tendon rupture found. It seems that the pathologic condition associated with a posterior tibial tendon deficient foot will not manifest itself if peroneus brevis function is absent.

Osteoblastoma of the foot and ankle.

A total of 329 patients with osteoblastoma were retrospectively reviewed from the archives of the Armed Forces Institute of Pathology, of which 41 (12.5%) presented with tumors in the foot and ankle. This was the third most common site of disease after the spine and femur. Overall, the mean age was 22.5 years, which was the same for the foot and ankle subset of patients; however, there was a significant male predominance in foot and ankle patients compared with the whole group. The majority of patients were skeletally mature (85.4%). Clinically, most patients presented with pain (97.2%), although one-third of the total related a history of antecedent trauma. The interval between the onset of symptoms and biopsy was 84 days (range, 0-572 days). Radiographically, the majority of lesions were in the hindfoot (N = 18; 44%) of which 16 of 18 tumors (89%) were in the talus. Of these, one-half were subperiosteal and dorsally based and were associated with osseous tumor matrix and a soft tissue mass. Two osteoblastomas, both in the metatarsals, transitioned into sarcomas; the rest were histologically benign. For diagnostic purposes, it was essential to obtain clinical, radiographic, and histologic correlation.

Congenital absence of the hallux fibular sesamoid: a case report and review of the literature.

Congenital absence of the fibular sesamoid of the hallux is an extremely rare condition. We could find only one previously reported case in the literature. The authors present a second case of congenital absence of the fibular sesamoid and a review of the literature regarding the clinical significance of this anomaly.

Management of heel pain in the inflammatory arthritides.

Subcalcaneal pain is a common complaint presented to the orthopaedist. Excessive attention to mechanical or traumatic causes may result in an improper diagnosis if rheumatologic or systemic conditions are not considered in the differential diagnosis. Systemic conditions associated with heel pain are reviewed and a conservative treatment protocol is presented that should help to obtain a correct diagnosis and to lead to effective management of this common condition.

Thromboembolism after foot and ankle surgery. A multicenter study.

Thromboembolic disease presents a potentially fatal complication to patients undergoing orthopaedic surgery. Although the incidence after hip and knee surgery has been studied and documented, its incidence after surgery of the foot and ankle is unknown. For this reason, a prospective multicenter study was undertaken to identify patients with clinically evident thromboembolic disease to evaluate potential risk factors. Two thousand seven hundred thirty-three patients were evaluated for preoperative risk factors and postoperative thromboembolic events. There were six clinically significant thromboembolic events, including four nonfatal pulmonary emboli, after foot and ankle surgery. The incidence of deep vein thrombosis was six of 2733 (0.22%) and that of nonfatal pulmonary emboli was four of 2733 (0.15%). Factors found to correlate with an increased incidence of deep vein thrombosis were nonweightbearing status and immobilization after surgery. On the basis of these results, routine prophylaxis for thromboembolic disease after foot and ankle surgery probably is not warranted.

Nonsurgical treatment of monarticular nontraumatic synovitis of the second metatarsophalangeal joint.

Thirteen patients with second metatarsophalangeal joint synovitis in 14 feet were seen during 4.5 years for monarticular nontraumatic synovitis of the metatarsophalangeal joint. They were treated with a nonsurgical regimen of intra-articular corticosteroids, along with the modification of a regular laced shoe to provide a rockerbottom effect. Nine feet of 8 patients were available for follow-up at an average of 75 months. Seven feet were asymptomatic, with no recurrence. One patient with bilateral involvement continued with symptoms unchanged. There were no recurrences. The treatment was unsuccessful for one patient who underwent surgical synovectomy. The above regimen seems to satisfactorily resolve the symptoms in 70% of the patients treated.

Chondroblastoma of the foot.

A total of 322 cases of chondroblastoma were referred to the Armed Forces Institute of Pathology between 1960 and 1990. Ten additional cases of chondroblastoma were treated at Walter Reed Army Medical Center between 1985 and 1993. Forty-two of these involved the foot, two of which were treated at Walter Reed Army Medical Center. Patients with chondroblastoma of the foot were male in 35 (81%) cases, with a mean age of 25.5 years, which was significantly different from the mean age of 17.3 years in patients with chondroblastoma of the long bones (P < 0.0001). Chondroblastoma of the foot is most commonly found in the posterior subchondral areas of the talus and calcaneus as well as in the calcaneal apophysis. Radiographically, the lesion was associated with an articular surface or apophyseal area in all cases and appeared radiolucent, with little to no matrix production. The margins were generally well defined. Cystic features were noted grossly and histologically in 24 (57%) specimens, a feature seen in only 21% of all chondroblastomas overall. Treatment consists of thorough curetting and bone grafting with good oncologic and functional results.

Treatment of plantar fasciitis with a night splint and shoe modification consisting of a steel shank and anterior rocker bottom.

Seventy-one feet in 57 patients with plantar fasciitis were treated with the combination of a night splint and a shoe modification consisting of a steel shank and anterior rocker bottom. At average follow-up of 16 months, symptoms were resolved in 42 (59%), improved in 13 (18%), not changed in 11 (15%), and worse in 5 (7%) of the feet. No relation was found between outcome and age, gender, duration of symptoms, and bilateral involvement. The method is effective for the treatment of plantar fasciitis.