Morton neuroma: MR imaging after resection--postoperative MR and histologic findings in asymptomatic and symptomatic intermetatarsal spaces.

PURPOSE: To evaluate the prevalence of postoperative magnetic resonance (MR) imaging findings in asymptomatic and symptomatic patients after resection of Morton neuroma. MATERIALS AND METHODS: This study was approved by the institutional review board. Informed consent was obtained from each participant. Fifty-eight consecutive patients (46 women, 12 men) who had undergone resection of a painful Morton neuroma (90 Morton neuromas were removed in 66 feet), pre- and postoperative MR imaging, and clinical follow-up for a minimum of 2 years after surgery were identified. Two experienced musculoskeletal radiologists evaluated MR images with regard to the presence of presumed recurrent Morton neuroma, scar, or intermetatarsal bursitis. The prevalence of abnormalities in asymptomatic and symptomatic intermetatarsal spaces was determined. The results of the second radiologist were used only to determine interobserver reliability. The kappa statistics were obtained to assess interobserver agreement. Seven patients with presumed recurrent Morton neuroma underwent repeat surgery. RESULTS: Clinically speaking, 68 intermetatarsal spaces (44 of 58 patients [76%], 47 feet) were asymptomatic at follow-up and 22 (14 of 58 patients [24%], 19 feet) were symptomatic. A presumed Morton neuroma was found in 18 (26%) of the asymptomatic spaces and 11 (50%) of the symptomatic spaces. A presumed scar was found in six (9%) of the asymptomatic spaces and two (9%) of the symptomatic spaces. A presumed intermetatarsal bursitis was found in six (9%) of the asymptomatic spaces and six (27%) of the symptomatic spaces. Interobserver agreement for presumed recurrent Morton neuroma was substantial (kappa = 0.64). Histologic examination of presumed recurrent Morton neuroma revealed fibrous tissue but no sign of peripheral neural tissue. CONCLUSION: MR imaging after Morton neuroma resection commonly reveals Morton neuroma-like abnormalities in asymptomatic and symptomatic intermetatarsal spaces.

Treatment of hallux valgus deformity: preliminary results with a modified distal metatarsal osteotomy.

This study aimed to investigate the preliminary results achieved with a modified distal first metatarsal osteotomy (reversed L-shaped) for correction of moderate and severe hallux valgus deformities. This prospective study included 31 patients (39 feet) with a mean age of 56 years. All patients underwent a reversed L-shaped osteotomy of the first metatarsal. At follow-up all patients were reviewed clinically and radiologically. Patients were categorized into two groups (MTP angle A: < 20 degrees, and B: 20-40 degrees). The AOFAS score improved from 53 points to 91 points at follow-up (p < 0.0001). Group A showed an increase from 56 to 90 points (p = 0.003), group B from 52 to 92 points (p < 0.0001). The mean 1-2-inter-metarsal angle (IMA) decreased from 12.5 degrees preoperatively to 8 degrees at follow-up (p < 0.005): from from 11 degrees to 9 degrees in group A (p = 0.09) and from from 13 degrees to 7 degrees in Group B (p < 0.0001). No nonunion or avascular necrosis was observed. One diabetic patient developed a resistant postoperative infection. The L-shaped osteotomy provided good and excellent clinical as well as radiological results in the mild and moderate-to-severe hallux valgus deformities treated. The mid- and long-term effect of this type of osteotomy needs to be further investigated.

Treatment of chronic achilles tendinopathy and ruptures with flexor hallucis tendon transfer: clinical outcome and MRI findings.

BACKGROUND: In patients with chronic Achilles tendinopathy, augmentation with flexor hallucis longus (FHL) tendon transfer can be performed to improve pain and functional limitations. There are no reports of postoperative imaging for evaluating tendon integration, inflammatory alterations or degeneration of the FHL muscle. The purpose of this study was to evaluate postoperative MR imaging based on clinical outcome and isokinetic strength. MATERIALS AND METHODS: 13 patients with chronic Achilles tendinopathy (10 ruptures) underwent augmentation with FHL transfer. Clinical parameters, isokinetic strength and outcome measurements (AOFAS, SF-36) were evaluated at an average followup of 46.5 months. Qualitative and quantitative analyses of postoperative MRI were conducted using the non-operated side for comparison. RESULTS: All patients had a significant reduction of pain. The operated side had a torque deficit of 35% for plantar flexion. Ten patients returned to their former level of activity. MRI showed a complete integration of the FHL tendon in six patients. Fatty atrophy in the triceps surae was found in ten patients. The FHL was free of degeneration in all patients. Hypertrophy of the FHL of more than 15% was observed in eight patients. CONCLUSION: Augmentation with FHL transfer is a valuable option in the treatment of chronic Achilles tendinopathy with and without rupture. Our results demonstrate high patient satisfaction without donor site morbidity. The FHL tendon is well integrated into the Achilles tendon. Hypertrophy of the FHL muscle suggests functional incorporation into plantar flexion. The primary benefit of the operation is pain relief and increased muscle strength.

Primary isolated subtalar arthrodesis: outcome after 2 to 5 years followup.

BACKGROUND: Favorable to excellent clinical results have been reported for isolated subtalar joint arthrodesis. Pedobarography after subtalar bone-block distraction arthrodesis have demonstrated a more laterally shifted gait line. However pedobarographic measurements after primary in-situ isolated subtalar arthrodesis have not been reported. This is the first study considering this. MATERIALS AND METHODS: Physical examination, AOFAS Hindfoot score, full weightbearing anterior/posterior and lateral radiographs were assessed in 15 feet. Peak pressures, ground reaction force and force distribution at foot-flat and push-off were measured. RESULTS: Average AOFAS-Score significantly improved. Subjective satisfaction was high. Non-union was found in 1 foot (7%), screws were removed in 4 of the 15 feet (27%). One new asymptomatic arthritic talonavicular joint was found. The pressure and force distributions under the operated and contralateral foot showed a different pattern compared to a normal foot. Ground reaction force under both the operated and contralateral feet were lower than a normal foot. DISCUSSION: This study found good clinical, subjective and radiographic results matching that of the reported literature. However, pedobarographic assessment suggests that great functional differences still remain when compared to a normal foot. Subtalar arthrodesis may induce an abnormal gait pattern by preventing compensation of axial rotation of the tibia. This is also reflected in the unaffected side, which may indicate an effort in the general locomotor control to keep a symmetrical gait pattern. This finally alters the pressure and force distribution under both feet. Nevertheless, subtalar arthrodesis is considered a valuable treatment for various isolated subtalar disorders.

Treatment of late recurring idiopathic clubfoot deformity in adults.

Late recurrence of idiopathic clubfoot deformity in adults after prior successful surgery in childhood remains a rarity and only case reports exist. No study has yet clarified the results of triple arthrodesis in such cases. Complete clinical and radiological review of 7 patients (7 feet) after a follow-up time of 43 months following triple arthrodesis was undertaken. The time interval between the last surgical intervention and the triple arthrodesis averaged 27 years. The American Orthopaedic Foot and Ankle Society (AOFAS) score was used as an outcome measure. Average age at time of review was 36 years (range 18-45). All patients were examined clinically and radiologically. The AOFAS-score improved from 43 points preoperatively to 61 points at follow-up (p = 0.004). If adjusted by excluding subtalar motion, the relative score improved by 19% (from 46% to 65%; p = 0.0043). Although not significantly altered (p = 0.1), pain scores remained fair (25 points) but were improved compared with the preoperative evaluation (13 points). Ankle motion was not changed. Although statistically not significant, there was an increase in degree of ankle arthritis in 67% of patients (one patient had ankle fusion) and mid- and forefoot degenerative changes in 57%. Hindfoot alignment remained fair after surgical intervention. Triple arthrodesis is a palliative means to correct recurrent deformity in patients with idiopathic clubfoot. Despite residual symptoms and degenerative changes at the ankle, 86% of all patients were satisfied with the postoperative result.

Comparative mechanical testing of different geometric designs of distal first metatarsal osteotomies.

BACKGROUND: The mechanical behavior of a newly described distal metatarsal osteotomy design in the shape of a reversed "L" was compared with the modified chevron and scarf osteotomies. METHODS: Experiments were performed using full-sized Sawbone models (Sawbones Europe AB, Malmö, Sweden) of the first ray. Three groups consisting of 10 scarf, 10 modified chevron, and 10 reversed L osteotomies were investigated. All distal fragments were displaced 5 mm laterally without angulation. The proximal fragment of each specimen was embedded in an epoxy resin cylinder and positioned at 15 degrees inclination to the ground. The distal fragment was loaded by a dorsally directed vertical force which was applied at the sesamoid location under the metatarsal head. Load and displacement at failure, work to failure, site of failure and contact areas were recorded for each osteotomy. RESULTS: Similar testing results were obtained in the reversed "L" and chevron osteotomies, while the scarf osteotomy needed almost 5 times less work to failure. In nine of 10 reversed "L" osteotomies and in all scarf osteotomies, the site of failure was at the proximal screw insertion site. The contact areas averaged 163 mm(2) for the reversed "L," 116 mm(2) for the chevron, and 270 mm(2) for the scarf osteotomy. CONCLUSIONS: The reversed L osteotomy is a promising design combining the advantages of both the chevron and scarf osteotomies. Further investigations need to be performed to confirm its clinical utility.

Medial collateral ligament complex of the ankle: MR appearance in asymptomatic subjects.

PURPOSE: To prospectively characterize the spin-echo magnetic resonance (MR) imaging appearance of the medial collateral ligament (MCL) complex of the ankle in asymptomatic volunteers. MATERIALS AND METHODS: The study was approved by institutional review board. Informed consent was obtained. MR images in 56 asymptomatic subjects (29 women, 27 men; mean age, 40.7 years; range, 23-60 years) were analyzed by two musculoskeletal radiologists. Visibility and signal intensity characteristics were analyzed for deep (anterior and posterior tibiotalar ligaments [TTLs]) and superficial (tibionavicular ligament [TNL], tibiospring ligament [TSL], and tibiocalcaneal ligament [TCL]) components of the MCL complex. Thickness of ligaments was compared between sexes (Mann-Whitney U test). Associations between age and variables of signal intensity characteristics and morphology were evaluated with Kruskal-Wallis test. RESULTS: Anterior and posterior TTLs, TNL, TSL, and TCL were visible in 31 (55%), 56 (100%), 31 (55%), 56 (100%), and 49 (88%) subjects, respectively. On T1-weighted images, anterior and posterior TTLs, TNL, TSL, and TCL were more commonly of intermediate signal intensity than hypointense (77%, 100%, 93%, 50%, and 73% of subjects, respectively); on T2-weighted images, they were commonly hypointense (55%, 52%, 42%, 75%, and 78% of subjects, respectively). On T2-weighted images, posterior TTL had a striated appearance that was significantly associated with age (P = .004) in 89% of subjects: In subjects younger than 45 years, this striated appearance was present. On T1-weighted images, striation was present in 48% of subjects. Striation was uncommon in remaining ligaments. Mean thickness and range were 1.5 mm and 1-4 mm (anterior TTL), 8.2 mm and 6-11 mm (posterior TTL), 1.6 mm and 1-2 mm (TNL), 2.0 mm and 1-4 mm (TSL), and 1.2 mm and 1-3 mm (TCL). TNL (P = .001) and TSL (P = .003) were significantly thicker in men than in women. CONCLUSION: In asymptomatic volunteers, posterior TTL and TSL were always visible, but anterior TTL and TNL are only seen in approximately half of subjects. Posterior TTL has a typically striated appearance.

Hindfoot instability in cavovarus deformity: static and dynamic balancing.

BACKGROUND: Chronic lateral ankle instability has been associated with varus deformity of the hindfoot, hyperactivity of the peroneus longus muscle, and insufficiency of the lateral ligaments. Many operative procedures have been described to correct this problem, but instability can recur if all contributing components are not treated. The purpose of this study was to offer an approach in the diagnosis and treatment of recurrent lateral ankle instability. METHODS: Eight consecutive patients (nine feet) were treated for recurrent chronic lateral ankle instability. The average age at surgery was 25 (range 8 to 37) years. All patients had prior operative procedures that failed and had persistent pain and functional instability of the ankle joint. After clinical and radiographic examination, lateralizing calcaneal osteotomy to correct the structured varus deformity and peroneus longus to peroneus brevis tendon transfer to add dynamic correction were done in all patients. A Broström ligament reconstruction was added in four feet. All patients were evaluated clinically and radiographically at an average followup of 37 months. Preoperatively and postoperatively patients were evaluated by means of the American Orthopaedic Foot and Ankle Society (AOFAS) Score. RESULTS: All patients were satisfied with the operation. The overall AOFAS-Score improved from 57 points preoperatively to 87 points postoperatively. Hindfoot alignment was restored to a valgus position at final evaluation. CONCLUSIONS: Recurrent chronic lateral ankle instability often is associated with chronic hindfoot malalignment and leads to functional impairment and patient discomfort. Clinical examination should determine the causes of instability. Varus malalignment of the hindfoot, hyperactivity of the peroneus longus muscle, and insufficiency of the lateral ligaments should be assessed and treated in a combined operative procedure to correct structured, static and dynamic components of the instability. The preliminary results of this particular approach are encouraging.

Anatomic variants associated with peroneal tendon disorders: MR imaging findings in volunteers with asymptomatic ankles.

PURPOSE: To evaluate prospectively, on magnetic resonance (MR) images in volunteers with asymptomatic ankles, various features of anatomic variants that are potentially associated with peroneal tendon disorders. MATERIALS AND METHODS: The study had institutional review board approval; informed consent was obtained from each volunteer. The prevalence of accessory peroneus quartus muscles, the location of the muscle-tendon junction of the peroneus brevis muscle, the prevalence and size of the peroneal tubercle and the retrotrochlear eminence, and the shape of the retromalleolar fibular groove were evaluated on MR images in 65 volunteers with asymptomatic ankles (35 women, 30 men; age range, 23-70 years; median age, 45 years). MR images were analyzed by two radiologists in consensus. The relationship between anatomic features and age and sex was analyzed by using Spearman rank correlation and the Wilcoxon rank sum test. RESULTS: A peroneus quartus muscle was identified in 11 (17%) ankles. Ninety percent of the musculotendinous junctions of the peroneus brevis muscle were located in a range between 27 mm proximal to and 13 mm distal to the fibular tip (median, 0 mm). A peroneal tubercle was identified in 36 (55%) ankles. Ninety percent of all peroneal tubercles were 4.6 mm or smaller (median height, 2.9 mm). A retrotrochlear eminence was seen in all ankles (median, 3.0 mm; 90% were 4.6 mm or smaller). The retromalleolar groove was concave in 18 (28%), flat in 28 (43%), convex in 12 (18%), and irregular in seven (11%) volunteers. A significant difference (P = .04) for the height of the retrotrochlear eminence was found between men (median, 3.4 mm) and women (median, 2.5 mm). All other P values were greater than .05. CONCLUSION: Anatomic variants thought to predispose individuals to peroneal tendon disorders can be seen in volunteers with asymptomatic ankles.

Simplified wound care and earlier wound recovery without closed suction drainage in elective total hip arthroplasty. A prospective randomized trial in 100 operations.

INTRODUCTION: Evidence to support or refute closed suction drainage (CSD) in primary total hip replacement (THR) is not conclusive. Our anecdotical experience was that persistent ooze from the drainage hole often delayed wound recovery. We hypothesized that, without CSD, wound care would be simplified without short or long term disadvantage. MATERIALS AND METHODS: Hundred patients scheduled for primary THR were randomly assigned for CSD or non-drainage. Drains were withdrawn at day 2. Pain, wound hematoma, number of dressing changes, time of persistent discharge from the operation site (skin incision and drain hole), total blood loss and number of blood transfusions were prospectively recorded. Hip function, presence of heterotopic ossifications (HTO) and complications were recorded at a follow visit 1 year after surgery. RESULTS: Wound sites managed without CSD needed significantly less wound dressings (P < 0.001) and were dry at an earlier time (P < 001). Despite a significant bigger subfascial hematoma in the non-drained group (P < 0.05), in terms of pain, thigh swelling, total blood loss, number of transfusions needed, hip function and HTO no difference was recorded between the groups (P = 0.2-0.82). CONCLUSION: To omit CSD in primary THR results in simplified and more rapid wound management without any disadvantage at short and long term.

Metatarsophalangeal joint arthrodesis after failed Keller-Brandes procedure.

BACKGROUND: Keller-Brandes resection arthroplasty for correction of symptomatic hallux valgus deformity can obtain early good results, but late complications, such as recurrence of the deformity and instability of the first ray, have been described. Arthrodesis of the first metatarsophalangeal, (MTP) joint can be done as a salvage procedure. The aim of this prospective study was to evaluate the clinical outcome of the arthrodesis and its effect on the biomechanics of the first ray. METHODS: Between October, 1999, and December, 2002, arthrodesis of the MTP joint was done after a failed Keller-Brandes procedure in 28 feet of 26 consecutive patients. Twenty patients (22 feet) with a minimum of 24 months followup were available for clinical and radiographic assessment. Pedobarographic measurements were obtained at latest followup in 16 patients (17 feet). RESULTS: Sixteen feet (72%) were pain-free and six feet (28%) had mild, occasional pain. The American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score increased from a preoperative 44 (range 29 to 67) points to 85 (range 73 to 90) points at longest clinical followup (average 34 months, range 23 to 48, p < 0.001). The average hallux valgus angle was corrected from 24.0 (range 7 to 47) degrees preoperatively to 16.0 (range 0 to 40) degrees postoperatively (p < 0.001). Two feet had pseudoarthroses. Biomechanically, the MTP joint arthrodesis could not fully restore the function of the hallux but produced a significant improvement, allowing a more physiologic loading pattern under the hallux and the metatarsal heads. CONCLUSIONS: First MTP joint arthrodesis after a failed Keller-Brandes procedure is a technically safe and reliable technique. It resulted in a marked reduction of pain and gain of function that produced high patient satisfaction.

Modified Coughlin procedure for surgical treatment of symptomatic tailor's bunion: a prospective followup study of 33 consecutive operations.

BACKGROUND: Symptomatic tailor's bunion is a painful osseous and soft-tissue prominence at the lateral aspect of the fifth metatarsal head. If conservative treatment fails, surgery is necessary to correct the deformity and to relieve the symptoms. The "Coughlin" procedure is an established corrective diaphyseal realignment osteotomy. The purpose of this study was to analyze the results of a modification of the Coughlin procedure in a series of 24 consecutive patients. METHODS: Between October, 1999, and August, 2002, we performed a modified Coughlin procedure for painful tailor bunions in 24 patients (33 feet). An additional bunionectomy was done only if the fifth metatarsal head remained prominent after the osteotomy (20 feet). The average age of the patients was 45 years. All patients were evaluated preoperatively and postoperatively using the AOFAS forefoot score, and the correction of the fourth-fifth intermetatarsal angle was assessed on full weightbearing dorsoplantar radiographs. The average followup was 24 months for objective and 39 months for the subjective results. RESULTS: There were no intraoperative and postoperative complications. The mean AOFAS score increased from 55 points preoperatively to 95 points at followup. At longest followup the subjective results were rated as good or excellent in 22 patients (97%). No difference in subjective patient satisfaction was seen whether bunionectomy was done or not. The mean fourth-fifth intermetatarsal angle improved from 10.4 degrees preoperatively to 1 degree at followup. Six patients (18%) required screw removal which was carried out on an outpatient basis under local anesthesia. CONCLUSION: The modified Coughlin procedure is a technically safe and reliable procedure for treatment of painful tailor's bunion. In our experience, it yields good or excellent results with high patient satisfaction and a low complication rate. Internal screw fixation leads to stable bony fusion with full weightbearing immediately postoperatively and is associated with a relatively low rate of implant removal.

The feasibility and complications of the continuous popliteal nerve block: a 1001-case survey.

Perineural catheters are increasingly used worldwide for the treatment of postoperative pain in orthopedics. Long-term complications associated with the placement of a perineural catheter remain largely unstudied. We investigated the efficacy and the acute and late complications associated with the continuous popliteal nerve block. One-thousand-one patients undergoing elective surgery of the ankle or foot and scheduled to have a continuous popliteal nerve block were prospectively evaluated. All patients received an initial bolus of 40 mL ropivacaine 0.5% through the catheter. A continuous infusion of ropivacaine 0.3% initiated 6 h after the initial bolus was administered for the first 24 h and then decreased to ropivacaine 0.2% until the end of the study period. The success rate and acute complications were recorded. The overall success rate was 97.5%. The highest success rate was associated with foot inversion. Acute complications consisted of paresthesias during nerve localization (0.5%), pain during local anesthetic application (0.8%), and blood aspiration (0.4%). No central nervous system toxicity or cardiotoxicity occurred. Late complications were checked at 10 days and 3 mo after surgery. These included two cases of inflammation at the puncture site. No infection or neuropathy was observed. The use of continuous popliteal nerve block for ankle or foot surgery is associated with frequent success and few acute and late complications.

A mechanical equinometer to measure the range of motion of the ankle joint: interobserver and intraobserver reliability.

BACKGROUND: Clinical measurement of passive dorsiflexion of the ankle joint is essential for the diagnosis of various pathologic conditions of the foot and ankle but is of unreliable precision with high interobserver variability in nonweightbearing tests. This work was designed to develop and test a precise, standardized, and reliable technique for measurement of passive and active ankle range of motion. METHODS: The proposed measurement tool is composed of two mobile parallelograms, one attached to the tibia, the second one to the plantar surface of the foot. The parallelograms are connected with a hinge with an angular scale to measure the angle between the foot and tibia. RESULTS: Interobserver correlation between clinical measurements for maximal passive foot dorsiflexion were 0.03 with knee extension and 0.38 with knee flexion, while for measurements with the proposed tool they reached 0.89 and 0.97, respectively, with a mean measurement error of 0.9 degrees. Intraobserver correlations reached values of r = 0.98 and 0.99. CONCLUSIONS: The proposed tool allows measurement of the ankle range of motion with very high precision and reproducibility far superior to clinical measurements. CLINICAL RELEVANCE: Precise measurement of ankle range of motion is clinically challenging. With the use of the proposed tool, measurement precision and reliability are decisively improved.

Magic angle effect in MR imaging of ankle tendons: influence of foot positioning on prevalence and site in asymptomatic subjects and cadaveric tendons.

The influence of foot positioning on prevalence of the magic angle effect (MAE) in ankle tendons was investigated. In 30 asymptomatic volunteers and five cadaveric feet, MR imaging of the ankle was performed in the supine (neutral position of the foot) and prone (plantar-flexed foot) position. MAE was considered if increased T1-weighted signal at a certain site was seen in one position only. Histological correlation was obtained at 25 sites of the cadaveric posterior tibialis tendons (PTT). MAE occurred in 6/30 vs 1/30 (supine vs prone) anterior tibialis tendons (ATT), 30/30 vs 0/30 extensor hallucis longus and 27/30 vs 0/30 extensor digitorum longus tendons, 29/30 vs 0/30 PTTs, 30/30 vs 0/30 flexor digitorum and flexor hallucis longus tendons, 30/30 vs 1/30 peroneus brevis and 23/30 vs 1/30 peroneus longus tendons. At 12/25 cadaveric PTT sites where MAE was exclusively responsible for the increased signal, histology revealed normal tissue (11/12) or minimal degeneration (1/12). In conclusion, the supine body position with neutral position of the foot, a high prevalence (77-100%) of MAE in ankle tendons except for the ATT (20%) is seen. MAE is almost absent in the prone body position with plantar flexion of the foot.

[Interposition arthrodesis of the ankle].

OBJECTIVE: Bony fusion of the ankle in a functionally favorable position for restitution of a painless weight bearing while avoiding a leg length discrepancy. INDICATIONS: Disabling, painful osteoarthritis of the ankle with extensive bone defect secondary to trauma, infection, or serious deformities such as congenital malformations or diabetic osteoarthropathies. CONTRAINDICATIONS: Acute joint infection. Severe arterial occlusive disease of the involved limb. SURGICAL TECHNIQUE: Lateral approach to the distal fibula. Fibular osteotomy 7 cm proximal to the tip of the lateral malleolus and posterior flipping of the distal fibula. Exposure of the ankle. Removal of all articular cartilage and debridement of the bone defect. Determination of the size of the defect and harvesting of a corresponding tricortical bone graft from the iliac crest. Also harvesting of autogenous cancellous bone either from the iliac crest or from the lateral part of the proximal tibia. Insertion of the tricortical bone graft and filling of the remaining defect with cancellous bone. Fixation with three 6.5-mm titanium lag screws. Depending on the extent of the defect additional stabilization of the bone graft with a titanium plate. Fixation of the lateral fibula on talus and tibia with two 3.5-mm titanium screws for additional support. Wound closure in layers. Split below-knee cast with the ankle in neutral position. RESULTS: Between January 2002 and January 2004 this technique was used in five patients with extensive bone defects (four women, one man, average age 57 years [42-77 years]). No intra- or early postoperative complications. The AOFAS (American Orthopedic Foot and Ankle Society) Score was improved from 23 points preoperatively to 76 points postoperatively (average follow-up time of 25 months). Two patients developed a nonunion and underwent a revision with an ankle arthrodesis nail. A valgus malposition after arthrodesis in one patient was corrected with a supramalleolar osteotomy.

Spring ligament complex: MR imaging-anatomic correlation and findings in asymptomatic subjects.

PURPOSE: To use magnetic resonance (MR) imaging to assess the anatomy of the spring ligament complex (SLC) in cadaveric feet and to prospectively evaluate the MR imaging depiction of this complex in asymptomatic subjects. MATERIALS AND METHODS: Cadaveric feet were obtained and used according to institutional guidelines and with institutional approval and consent from the donors (before death) or the appropriate family members. Healthy volunteers were examined, with institutional review board approval and informed consent from each volunteer. MR imaging findings of the SLC in five cadaveric feet were analyzed and correlated with the findings in dissected foot specimens. Then, the MR imaging findings in the feet of 78 asymptomatic subjects were analyzed. For all three parts of the SLC, visibility, optimal imaging plane, and signal intensity characteristics were analyzed. The thicknesses of all SLC parts were measured. The measurements obtained in men and women were compared by using the Mann-Whitney U test, and Pearson correlation coefficients for associations between ligament thickness and subject age and sex were calculated. RESULTS: In the cadaveric feet, MR imaging enabled differentiation of all three parts of the SLC. The superomedial calcaneonavicular ligament (CNL) was visible in all; the medioplantar oblique CNL, in 60; and the inferoplantar longitudinal CNL, in 71 volunteers. The superomedial CNL had a mean thickness of 3.2 mm, was best seen on transverse oblique or coronal MR images, and had mainly intermediate signal intensity on T1-weighted images and low signal intensity on T2-weighted images. The medioplantar oblique CNL had a mean thickness of 2.8 mm, was best seen on transverse oblique MR images, and had mainly a typical striated appearance on T1- and T2-weighted images. The inferoplantar longitudinal CNL was the thickest (mean thickness, 4.0 mm), was best seen on coronal MR images, and had mainly intermediate signal intensity on T1-weighted images and variable signal intensity on T2-weighted images. Women had significantly thinner superomedial (mean thickness, 3.3 vs 3.5 mm; P = .015, Mann-Whitney U test) and inferoplantar longitudinal (mean thickness, 3.8 vs 4.2 mm; P = .02) CNLs than men. There was no significant correlation between ligament thickness and subject age. CONCLUSION: The superomedial and inferoplantar longitudinal CNLs are consistently visible portions of the SLC. The medioplantar oblique ligament is thinner, is seen less consistently, and has mainly a characteristic striated MR imaging appearance.

Anterior tibial tendon abnormalities: MR imaging findings.

PURPOSE: To retrospectively evaluate the magnetic resonance (MR) imaging findings of anterior tibial tendon (ATT) abnormalities. MATERIALS AND METHODS: Institutional review board approval was not necessary for review of patient images and was granted for examination of the volunteers; informed consent was obtained. MR imaging findings in 28 consecutive patients (20 women, eight men; mean age, 63.2 years) clinically suspected of having an ATT abnormality were compared with those in an age- and sex-matched control group of 28 asymptomatic volunteers (20 women, eight men; mean age, 62.9 years). Surgical correlation was available for 11 patients. The short-axis diameter of the ATT and the longitudinal extent of signal intensity abnormalities were measured (Mann-Whitney U test). Signal intensity abnormalities of the ATT and irregularities of the underlying tarsal bones were analyzed in consensus by two blinded radiologists (chi2 test). RESULTS: In the symptomatic group, three cases of tendinosis and 13 partial and 12 complete ATT tears were diagnosed. In 11 cases (one case of tendinosis and two cases of partial and eight cases of complete ATT tear), surgical correlation was available and the MR imaging diagnosis was confirmed. In the asymptomatic group, four cases of tendinosis of the ATT were seen. The ATT diameter was significantly thicker in symptomatic patients at 1 cm (5.1 vs 3.1 mm in control group, P < .001), 3 cm (5.8 vs 3.4 mm, P < .001), and 6 cm (5.4 vs 4.3 mm, P = .006) proximal to the distal point of insertion. Most ATT abnormalities (in 23 [82%] of 28 patients) were located within the first 3 cm proximal to the insertion. Signal intensity abnormalities were seen in the anterior portion of the ATT in two (7%) of the 28 symptomatic patients and in the posterior portion in 11 (39%); diffuse involvement was seen in 15 (54%). Bone spurs on the navicular surface (nine [32%] patients vs no [0%] control subjects, P = .001), a ridged shape of the medial surface of the medial cuneiform bone (13 [46%] vs one [4%], P < .001), and osteophyte formation at the first tarsometasarsal joint (eight [29%] vs two [7%], P = .036) were significantly more common in the symptomatic patient group. CONCLUSION: Characteristic findings of ATT abnormalities include tendon thickening (> or =5 mm) and diffuse or posterior signal intensity abnormalities of the tendon within 3 cm from the distal point of insertion.

Clinical evaluation of a modified posterior anatomical approach to performing the popliteal block.

BACKGROUND: Tibial and common peroneal nerves can be blocked by the posterior approach to the popliteal fossa. Techniques using fixed measured distances between knee skin crease and puncture point have been described. We report on an approach that is based on manual identification of the apex of the popliteal fossa. METHODS: Five-hundred patients undergoing surgery of ankle or foot were prospectively included. The apex of the popliteal fossa (determined by the crossing point of the biceps femoris and the semitendinosus and semimembranosus muscles) was assessed by manual palpation. The puncture point was 0.5 cm below the apex, on the medial side of the biceps femoris muscle. When indicated for postoperative analgesia, a perineural catheter was placed. We assessed success rate, number of attempts, the distance between knee skin crease and the apex of the popliteal fossa, nerve depth, and acute and late complications. RESULTS: Block success rate was 94% and 92% when the block was performed through the needle and the catheter, respectively. Inversion was the motor response with the highest success rate. The first attempt was successful in 97.5% of the patients. Mean depth of the nerve was 4.5 cm (range, 2.0 to 7.0 cm) and mean knee skin crease to apex of popliteal fossa distance was 9 cm (range, 7.0 to 12.0 cm). Nine patients (2%) had acute complications. There were no technical problems associated with the perineural nerve catheter. After 12 weeks, no late complications were observed. CONCLUSIONS: The modified posterior anatomical approach for popliteal sciatic nerve block is easy to perform, has a high success rate, and has a low complication rate. The location of the needle insertion point is assessed without any measurement, thus avoiding inaccuracies caused by repeated skin-distance measurements.

Effect of manual lymph drainage after hindfoot operations.

BACKGROUND AND PURPOSE: Manual lymph drainage therapy is often prescribed following hindfoot operations. However, the relative efficacy of this treatment component has not yet been determined. METHOD: A two-group pre-test-post-test study design was used in this preliminary randomized clinical trial of 23 subjects who underwent hindfoot surgery. Patients were randomly assigned into two groups: an intervention group of 11 patients who received standard physiotherapy plus manual lymph drainage; and a control group of 12 patients who received standard physiotherapy but no lymph drainage. The main outcome measure was the percentage reduction in excess limb volume, measured by the water displacement method at the second post-operative day (t1) and at the day of discharge (t2). RESULTS: Compared to the control group, a significant reduction in post-operative swelling was measured in the intervention group only (p = 0.011). CONCLUSIONS: Application of lymph drainage techniques after hindfoot operations, in combination with standard physiotherapy exercises, achieves greater limb volume reduction than exercise alone. The present study offers an insight into a treatment that may shorten rehabilitation and thereby control the cost of caring for post-operative treatment complicated by post-operative swelling.