The Syme amputation in children.

Twenty-three children had proportionate growth of bone and soft tissue between two and eleven years after a Syme ankle disarticulation. All walked with permanent prostheses within three months after operation. Ischemic necrosis occurred twice after inadvertent ligation of the posterior tibial artery. Suture of the extensor tendons into the heel pad eliminated its posterior migration. Prosthetic realignment compensated for progressive genu valgum in ten of fourteen amputees with fibular hemimelia. On the basis of these gratifying results, the Syme ankle disarticulation is suggested as early treatment for certain congenital anomalies of the lower extremity.

Spontaneous osteonecrosis of the knee.

Spontaneous osteonecrosis was diagnosed in ninety knees in which a roentgenographically visible lesion had developed within six months after onset of symptoms. Scintimetry can be used to differentiate between osteonecrosis and other painful conditions of the knee. The prognosis of osteonecrosis is dependent on the size of the radiolucent lesion. In knees with a lesion that is larger than 2.3 square centimeters, osteoarthritis is likely to develop. For forty-two knees the patients were treated with analgesics, partial weight-bearing, and quadriceps exercises. Forty-eight knees were treated surgically. Indications for surgical treatment were persistent severe complaints in spite of conservative treatment and a large osteonecrotic lesion with collapse of the condyle resulting in a varus deformity. The best results were achieved with osteotomy together with arthrotomy, and by knee replacement arthroplasty. Arthrotomy and drilling alone were ineffective.

Spindle cell lipoma of the foot: a case report and literature review.

Lipomas are among the most commonly encountered soft tissue tumors in clinical practice, though they are rare in the foot. Although a presumptive diagnosis is typically made clinically, those tumors with atypical clinical features may require radiological consultation. Difficulty arises when radiographic features are not typical of lipoma. We present a fatty soft tissue tumor of the foot with nonadipose elements on magnetic resonance imaging evaluation. Differentiation of lipoma variants (e.g., spindle cell lipoma, atypical lipoma, pleomorphic lipoma, lipoblastoma, angiolipoma) from liposarcoma based on imaging features is not possible, necessitating surgical resection for definitive histological diagnosis.

Anatomy of the Achilles tendon and plantar fascia in relation to the calcaneus in various age groups.

Ten adult cadaver feet, three neonatal feet, and the feet of two fetuses were dissected to investigate whether an anatomical continuity exists between the fibers of the Achilles tendon and the plantar fascia. Histologic sections of the feet were done in three age groups: neonate, persons in their mid-20s, and the elderly. As the foot ages, there appears to be continued diminution of the number of fibers connecting the Achilles tendon and plantar fascia. The neonate has a thick continuation of fibers, while the middle-aged foot has only superficial periosteal fibers that continue from tendon to fascia. The elderly feet show simply an insertion of fibers of both structures into the calcaneus with periosteum in between.

Action of the peroneus longus tendon on the first metatarsal against metatarsus primus varus force.

A medially directed force was applied to the first metatarsal in 10 cadaver feet. The peroneus longus tendon was subjected to a pull of 5 pounds. The soft tissues between the first and second metatarsals were cut sequentially, starting with the skin on the dorsal and plantar aspect, followed by the intermetatarsal ligament and adductor hallucis tendon, and, finally, the peroneus longus tendon at its distal insertion. Dorsoplantar radiographs while weightbearing were taken after each sectioning. A statistically significant varus displacement of the first metatarsal was observed only after transection of the peroneus longus tendon. It was concluded that the peroneus longus tendon is a strong retaining mechanism of the first metatarsal.

The superior peroneal retinaculum: an anatomic study.

The superior peroneal retinaculum is thought to be the primary restraint to subluxation and/or dislocation of the peroneal tendons as they pass posterior to the distal fibula. The descriptions in anatomy texts vary widely. This anatomical study describes the different patterns of insertions for the superior peroneal retinaculum and its relationship to the peroneal tendons and the ligaments of the lateral ankle.

Ganglion cysts of the lower extremity: an analysis of 54 cases and review of the literature.

This article reviews 54 consecutive patients with lower extremity ganglion cysts that were surgically removed and histologically confirmed at the Hospital for Special Surgery from 1981 to 1993. Lower extremity ganglia were more common among women. Patients' ages ranged from 13 to 80 years, with the fifth and sixth decades being the most common. Size of the cysts ranged from 3 cm to 10 cm (average: 2.9 cm). Thirty-six (67%) patients had ganglion cysts of the foot and ankle, and 18 (33%) patients had ganglion cysts of the knee area. Four (7%) patients had intraosseous ganglia located in the proximal tibia, patella, and the first metatarsal head. Follow-up data of 40 (74%) patients at an average of 5.9 years (range: 1 to 12.5 years) were obtained. Satisfaction was reported by 83% of patients. Recurrence was seen in 10% of patients, and a report of no or mild pain was given by 86% of the group. Patients who underwent revision ganglion excision had inferior results. Only 25% reported satisfaction and 50% reported no or mild pain. Patients who underwent curettage of an intraosseous ganglion appeared to have superior results. All patients reported satisfaction and no or mild pain. The performance of a concomitant surgical procedure, the anatomic region of the ganglion, or type of postoperative immobilization did not appear to affect the outcome.

Clinical importance of the lateral branch of the deep peroneal nerve.

Persistent recalcitrant dorsolateral foot pain after ankle sprain cannot always be explained by known anatomic nerve pathways. To determine whether an impingement of a lateral branch of the deep peroneal nerve might be responsible for atypical pain, we conducted a cadaveric anatomic study to identify the anatomy and course of the nerve. Furthermore, using this information, we conducted a clinical study to determine if targeted treatment to a lateral branch of the deep peroneal nerve would resolve these symptoms. We dissected 22 cadaveric feet to identify a large lateral branch of the deep peroneal nerve. This nerve arborized into five main branches. We identified two areas of compression in the lateral branch of the deep peroneal nerve. We also performed a prospective clinical study including 11 consecutive patients with a 1-year minimum followup. Pain and clinical findings corresponded to the anatomic compression sites in all 11 patients. All patients responded to a local anesthetic injection or surgical release of the lateral branch of the deep peroneal nerve. We identified a previously unreported complex course of the lateral branch of the deep peroneal nerve that correlated with clinical impingement syndrome and responded to specifically targeted treatment.

Tarsal coalition.

Tarsal coalition is a common abnormality of the hindfoot skeleton that only rarely leads to symptoms. These symptoms occur most commonly in adolescence but rarely can be found also in adults. Although most coalitions are congenital, as the consequence of autosomal dominant inheritance, coalitions also can be acquired by degenerative joint disease, inflammatory arthritis, infection, and clubfoot deformities. Fifty percent of all coalitions are bilateral. Talocalcaneal and calcaneonavicular coalitions are most commonly found, and patients frequently have more than one coalition in the same foot. Clinical symptoms of the tarsal coalition frequently follow a sequence of sprains or other minor injuries to the involved foot. This leads to a rigid, painful foot. The pain is worsened by continued activities. The frequently cited peroneal spastic flatfoot is an uncommon means of identifying a tarsal coalition. The diagnosis of the tarsal coalition is made on the oblique radiograph of the foot, which demonstrates the calcaneonavicular coalition. Computed tomography (CT) and magnetic resonance imaging scans show the presence and extent of other coalitions. Secondary signs for the presence of a coalition are talar beaking, anteater nose sign, and C sign. These secondary signs can be demonstrated best on a lateral view of the involved foot. Local anesthetic blocks under image intensifier or CT guidance can identify areas of joint degeneration, which are caused by the altered biomechanics of the foot. Initial treatment should consist of conservative therapy in the form of support or immobilization of the involved foot, change in the activities of the patient, and nonsteroidal anti-inflammatory medication. Surgical treatment in the form of a resection of the coalition should be reserved for those patients for whom conservative therapy has failed. Subtalar or triple arthrodesis should be reserved for those patients for whom all other therapy has failed.

Gait analysis in surgically treated clubfoot.

Clubfoot, a congenital foot abnormality, has been successfully managed with surgical treatment. To assess gait in individuals with surgically treated clubfeet, the patterns of electromyographic activity for the medical gastrocnemius and tibialis anterior muscles and the stride characteristics during gait were measured and compared with normal values. The duration of medial gastrocnemius activity was significantly greater than normal, whereas tibialis anterior activity, stride length, and single limb support times were not different. No correlation was found between the results of the gait analysis and the quality of the surgical result.

Hypoplasia of the fibula.

Fibular hypoplasia occurs in differing degrees of severity with fibular hemimelia as its most severe form. Normally the distal epiphyseal plate of the fibula is at the same level as the distal end of the distal tibial epiphysis, whereas the tip of the proximal fibular epiphysis is level with the proximal tibial epiphyseal plate. Varying degrees of shortening of the fibula in relation to the tibia were found in 14 children, 6 of them boys. Shortening at the distal end of the tibia leads to instability of the ankle. Shortening at the proximal end of the fibula leads to hypoplasia of the lateral tibial plateau and valgus deformity of the knee. Syme type ankle disarticulation became necessary in five cases of fibular hemimelia because of leg length discrepancies or ankle instability.

A radiographic study of the ligamentous anatomy of the ankle.

Ankle trauma commonly results in significant injury. Knowledge of the anatomy of the normally nonopaque major supportive ligaments, and their relationships to the osseous structures seen on standard roentgenograms, facilitates interpretation of both plain films and ankle arthrograms. A group of normal, non-preserved ankles was dissected. The laterally located anterior talofibular calcaneofibular, posterior talofibular, distal anterior tibiofibular ligaments, and the medially located deltoid ligament were carefully defined. They were coated with a mixture of powdered tantalum, photographed, and then radiographed in standard projections. The normal gross anatomy of these major supportive ligaments of the ankle and their relationship to the osseous structures about the ankle are remarkably constant.

Cadaver correlation of peroneal tendon changes with magnetic resonance imaging.

Magnetic resonance imaging (MRI) is used to show the soft tissues of the body. The presence of anomalous tendons and muscles can be detected. Chronic lateral ankle pain and instability can be associated with peroneal tendon pathology and MRI may be used to assess both longitudinal attrition of the peroneus brevis tendon, as well as the presence of the peroneus quartus which may be useful in lateral ankle reconstruction. Tenography can occasionally present technical difficulties and can lead to patient dissatisfaction.

Lateral ankle instability as a cause of superior peroneal retinacular laxity: an anatomic and biomechanical study of cadaveric feet.

The role of the competent superior peroneal retinaculum (SPR) as a primary restraint to peroneal tendon subluxation and mechanical attritional wear is clear. Injury to the SPR has classically been described as a dorsiflexion eversion movement of the ankle coupled with a forceful peroneal tendon reflex contraction. This mechanism, however, does not cause injury to the lateral collateral ligaments of the ankle and does not explain the coexistent findings of lateral ankle instability, laxity of the SPR, and concurrent peroneal tendon pathology. Anatomic studies reveal a parallel alignment of the calcaneal band of the SPR and the calcaneofibular ligament. A cadaveric model of ankle instability created by serial sectioning of the lateral collateral ligaments revealed increasing visual strain on the SPR with increasing degrees of ankle instability. These findings suggest the SPR serves as a secondary restraint to ankle inversion stress and that the force or forces that result in chronic ankle instability can also injure and attenuate the superior peroneal retinaculum.

Peroneal tendon subluxation in a case of anomalous peroneus brevis muscle.

We report a case of peroneal tendon subluxation as a result of an anomalous extension of the peroneus brevis muscle into the fibular groove, causing an encroachment phenomenon, stretching-out of the superior peroneal retinaculum, longitudinal splitting of the peroneus brevis tendon, subluxation of the peroneal tendons, and peroneal tenosynovitis. We describe a simple surgical technique for tendon stabilization, after decompression of the fibular groove.

Neuropathic injuries to the lower extremities in children.

Neuropathic injuries of the lower extremities in children due to meningomyelocele, congenital indifference to pain, and peripheral nerve damage were studied in 10 patients. The injuries fell into four categories: (a) fractures of the metaphysis and diaphysis of long bones, (b) epiphyseal separation, (c) Charcot joints, and (d) soft-tissue ulceration. These injuries are often unrecognized; untreated, they can lead to severe disability. For patients with impaired sensation, radiographs should be obtained at any sign of localized soft-tissue swelling, warmth, or hyperemia, especially near a joint. Following diagnosis, immobilization of the limb will lead to prompt healing of fractures and epiphyseal separation.

Scintimetric evaluation of complications after femoral neck fractures.

The primary surgical approach to the femoral neck fracture should be one with the lowest mortality and morbidity. Internal fixation appears to be the safe and logical approach for most of the reducible intracapsular fractures. Careful follow-up of these patients then is important. 85Sr scintimetry is a simple and accurate method in the early detection and evaluation of secondary complications in these patients. The 85Sr scintimetric pattern in the normal healing process was defined in relation to time interval after the fracture. At any time after 4 months following fracture, those hips destined for osteonecrosis, with or without non-union, showed significantly more radionuclide uptake over the femoral head than those hips which healed normally. In non-union there was a trend toward increased counts over the fracture site during 6 to 18 months after fracture, but no such tendency was noted in other periods.

18-F scintimetric diagnosis of osteoid osteoma of the carpal scaphoid bone.

In a patient with symptoms suggestive of osteoid osteoma of the carpal scaphoid, 18-F scintimetry supported the diagnosis in the absence of clear cut roentgenographic signs. High concentration of 18-F in the area of the lesion allowed direct surgical approach and extirpation. The diagnosis was proven by histology.

Bone scanning for the evaluation of knee prosthesis.

Twenty-six knees were scanned after total replacement to evaluate the relationship between bone scan, pain, the presence of a radiolucent line at the bone-cement interface and loosening. A radiolucent line was often accompanied by an increased uptake over the affected condyle, but there was no significant relationship with pain or loosening.