Alteration of the calf strength by heel cord lengthening, gastrocnemius recession through tenotomy or fasciotomy. A retrospective clinical force analysis before and after surgery.

BACKGROUND: Indications for surgical corrections about the Achilles tendon are increasing as additional measures in reconstructive interventions about the foot. These indications include shortened gastrocnemii, which cause a so-called 'functional pes equinus' and secondary forefoot imbalances, as well as corrections of pes planus and cavus. Surgery about the heel cord may also be indicated for achillodynia and diabetic pressure ulcers. However, there is a lack of evidence that quantifies the results of lengthening procedures about the heel cord. The aim of this study was to quantify the exact changes in calf strength one year after elongating the triceps surae, by measuring flexion forces in 90 degrees knee flexion and knee extension. METHODS: This study involves 69 patients who were examined for calf strength preoperatively and 1 year after gastrocnemius release. A new device, the Leonardo Mechanograph® (Novotec Medical) was used to measure calf strength. Measurements were performed with the knee flexed and extended. RESULTS: The operated leg had an overall statistically significant reduction in strength after surgery. Changes were similar on the contralateral leg. The difference in force reduction between the operated and non-operated leg was not statistically significant CONCLUSION: A correlation between measured plantar flexion forces of the foot after a reconstructive foot operation with or without a lengthening procedure about the calf musculature could not be established. LEVEL OF EVIDENCE: Level III: retrospective cohort study.

Longitudinal Plantar Approach for Excision of Morton's Neuroma: Long-Term Results.

Longitudinal plantar approaches are generally considered at risk for wound healing problems. Thus, we wanted to investigate long-term outcomes after a primary Morton's neuroma excision through a longitudinal plantar approach. A retrospective study of patients with primary neuroma excision was conducted. Twenty-four patients (28 feet) were evaluated at a mean 9-year follow-up (range, 6-14) by a single trained examiner using a specific postoperative evaluation protocol, including AOFAS Forefoot subjective and objective scores. Good-to-excellent outcomes were reported in 25 (89.3%) cases. A hypertrophic scar formation and keratosis occurred in only 2 cases (7.1%). All the patients, with a single exception, achieved full weightbearing with a postoperative shoe from the first day after the operation. A longitudinal plantar approach can lead to long-term, good-to-excellent outcomes with no case of recurrence or reoperation. Accurate wound closure and immediate weightbearing with a postoperative shoe can minimize the rate of complications. This approach should be considered for primary resection of Morton's neuromas.

The circular arc shaped nail for fixing the tibiotalocalcaneal arthrodesis. After clinical results.

BACKGROUND: Tibiotalocalcaneal arthrodesis is commonly considered a salvage option for a variety of hindfoot disorders involving the ankle and subtalar joint mostly with concomitant deformity. Retrograde interlocking nailing represents one of the biomechanically most stable fixation modes after reduction of hindfoot geometry. The considerable complications, non-union and revision rates at a moderate outcome reported even with modern retrograde nails underscore the idea that the development of an optimized retrograde nail may be warranted. METHODS: A novel circular shaped nail was designed with a perfect fit to the reamed canal and the implant geometry which respects physiologic hindfoot anatomy and alignment. The present clinical series reports the experience and the clinical and radiographic outcomes after application of the implant in the first 30 consecutive patients. Assessments included validated versions of the AOFAS Ankle/Hindfoot Score and the Foot Function Index. RESULTS: Anatomical alignment was achieved and maintained in 29/30 cases with a single case of later loss of reduction due to a technical error which led to surgical reintervention two months after the index procedure. The overall union rate reached 93%. Two non-unions (one ankle, one subtalar joint) were observed without necessitating further surgery. Three superficial surgical site infections were registered which made a local flap coverage necessary in two patients due to local skin break-down. No deep infection occurred. There were 2 implant removals, one was not related to hindfoot nailing. At the time of follow-up, the AOFAS Ankle/Hindfoot Score was 57 (median) from a maximum of 86 points. The self-assessment via the Foot Function Index improved from preoperative 155 points to 62.5 postoperatively (median values, p<0.001, Wilcoxon test). CONCLUSION: On the basis of our results, which saw a high rate of successful fusion and patient satisfaction and where the hindfoot reduction was maintained until definite healing in the vast majority of cases, the novel circular arc nail represents a viable and safe option for tibiotalocalcaneal arthrodesis with a low complication rate.

Safe aftercare following foot ankle surgery: Doing less is more: The Jones dressing cast, part 2.

BACKGROUND: There is no universal approach to surgery aftercare among foot and ankle surgeons. Although infections following foot and ankle surgery are rare, soft tissue healing can be jeopardized after extensive and multiple approaches. METHODS: We defined a precise fixation technique of the foot and ankle in the immediate post-operative phase using what we call "the Jones dressing cast". This technique is a modification of the Jones dressing bandage. In a previous study we compared two groups of patients (N=20/23) who underwent similar reconstructive surgery with the application of the described cast for one week and without. At the two-month follow-up we observed that the group treated with the cast required less pain relief, spent less time in hospital and achieved faster autonomy using crutches (Gottlieb and Klaue, 2013). In this study we considered a group of 45 patients who underwent similar reconstructive procedures to those in the first study and who were treated with the cast for two weeks post-operatively. There was no visual check of the soft tissues before removal of the cast. RESULTS: Unlike the earlier study, the results from this second study were more significant. Revision surgery occurred far less frequently in the group wearing the cast for two weeks. CONCLUSIONS: The reduced strain to the soft tissue around the foot due to the cast and less manipulation of the wound dressing decrease complications in the post-operative period.

[Internal circular arc osteosynthesis of tibiotalocalcaneal arthrodesis]. / Die innere Kreisbogen-Osteosynthese der tibio-talo-calcanealen Arthrodese.

Tibiotalocalcaneal arthrodesis has recently become more popular as a form of reconstructive surgery. The precise anatomical orientation and the functional extrinsic musculature of the hindfoot are essential for a satisfactory result. Fixation of the arthrodesis is a mechanical problem. Straight and angulated nails are not anatomically or mechanically ideal. A circular arc nail can fix the tibia, the talus and the calcaneus in anatomical alignment. This is a pure "bone nail", in contrast to the "intramedullary nail," which is driven through an existing opening in long bones. The nail is driven through a circular arc-shaped opening in the bone, which results in optimal form-fit between nail and bone. A corresponding aiming device permits the precise shaping of the bone tunnel, which follows the orientation of the bone trabeculae. The instrumentation was applied in 11 cases, with the following indications: post-traumatic conditions, congenital deformities, chronic polyarthritis and diabetic Charcot arthropathy. The desired alignment of the hindfoot is not affected while the nail is being introduced. The fixation achieves primary stability thus allowing for early functional treatment.

The Jones dressing cast for safe aftercare of foot and ankle surgery. A modification of the Jones dressing bandage.

Aftercare of surgical procedures is not consensual in the community of foot and ankle surgeons. Although the incidence of infections following foot and ankle surgery is rare, soft tissue healing might be jeopardized after extensive and multiple approaches. We define a precise fixation technique of the foot and ankle in the immediate post-operative phase by what we call "the Jones dressing cast". This technique is a modification of the Jones dressing bandage. We compared two groups of patients (20 and 23 patients) who underwent similar operative reconstructive procedures, with and without the application of the described cast, respectively, for one week. At the two-month follow-up, we observed that the group, which was treated with the cast required less analgetics, had a reduced hospitalization time and achieved faster autonomy using crutches. It may be assumed that reduced strain to the soft tissue around the foot due to the cast may reduce the complications in the post-operative period.

Reconstruction of Lisfranc joint dislocations secondary to Charcot neuroarthropathy using a plantar plate.

Lisfranc joint dislocation secondary to Charcot arthropathy is a debilitating condition that often leads to ulceration and infection. After conservative treatment, such as bracing and appropriate shoe wear fail, the only option might be amputation. However, we have seen good clinical outcomes from applying a plate to the plantar (tension) side of the medial midfoot. In our retrospective study, 24 consecutive patients (25 feet) from April 1999 through July 2004 underwent Charcot reconstruction for Lisfranc dislocation. Clinical and radiographic follow-up examinations were performed every 3 weeks during the postoperative course. Union was achieved in 24 (96%) of the 25 feet. The average time to ambulation was 11.68 (range 7 to 20) weeks for the 24 patients. The average follow-up period was 38.0 (range 17 to 64) months. The union and interval to ambulation rates showed that a plate applied to the plantar aspect of the medial midfoot provides a strong, sturdy construct for arthrodesis and ambulation.

Central calcaneal osteotomy for correction of flexible pes planovalgus deformity.

BACKGROUND: Lateral column lengthening procedures have been extensively reported either as primary procedures or adjuncts to combined soft tissue procedures and osteotomies for the correction of the pes planovalgus deformity. There is also considerable debate as to the ideal procedure that is not followed by recurrence and obviates the need for revision surgeries and minimizes complications. We describe a technique and present the clinical results of lateral column lengthening that provides a powerful correction to restore normal foot alignment. METHODS: We retrospectively reviewed 26 feet in 21 patients with a mean age of 35.4 years (range, 12-75) over an average follow-up period of 71 months (range, 12-147) who underwent reconstructive surgery for flexible pes planovalgus foot. The reconstructive procedures included a central calcaneal osteotomy in all patients, a medial column stabilization procedure, flexor digitorium transfer (FDL), and a gastrocnemius or Achilles tendon lengthening. Clinical evaluation was carried out with the AOFAS ankle-hindfoot scores. Standard weight-bearing anterior posterior (AP) and lateral radiographs before surgery and at follow-up were analyzed for radiographic parameters of correction. RESULTS: The median AOFAS score increased from 50 to 90. Two patients reported dissatisfaction with the result. There were no nonunions nor complications related to hardware. Radiographic improvement of the talonavicular coverage angle was a 74% change from baseline value. All radiographic parameters improved (P < .001) except the lateral talocalcaneal angle (P = .48). No secondary subsidence of the arch was observed within the follow-up time. CONCLUSION: Correction of flexible pes planovalgus deformity with a central calcaneal osteotomy was an effective, reproducible method to restore normal foot alignment and good function. LEVEL OF EVIDENCE: Level IV, retrospective case series.

A complex forefoot malunion in a patient with Werner's syndrome: a case report.

Lower extremity surgical procedures in patients with Werner's syndrome are uncommon, and for this reason they are rarely reported in the literature. In this report, we present the case of a 39-year-old man with a history of Werner's syndrome, and a malunited right hallux varus and first ray insufficiency after previous bunionectomy performed 4 years earlier. Further reconstructive surgery involved forefoot osteotomy and arthrodesis with internal fixation, and the patient ultimately healed the soft tissues and bones, despite delayed wound healing.

Treatment of Chopart Fracture-Dislocations.

The Chopart articular space was used by François Chopart (1743-1795) as a practical space for amputation in cases of distal foot tumor. It corresponds to the center of the foot and allows for essential articulation by means of the talo-calcaneo-navicular joint (coxa pedis). Chopart fracture-dislocations may therefore include fractures of the navicular, the cuboid, the talus, and calcaneus. The treatment priorities should therefore include addressing all of the injured soft tissues by immediate joint reduction or restoring bony alignment, including the avoidance of threatening compartment syndromes. Subsequent anatomical bone and joint reconstruction, if possible, should first address the talar head and the navicular. The anterior process of the calcaneus and the cuboid should be aligned to preserve foot alignment in the sagittal and horizontal planes. In severe joint destructions, isolated fusion of the calcaneo-cuboidal joint may help preserve functional mobility of the foot. Isolated or associated talo-navicular fusion considerably limits functional mobility of the foot.

Bone regeneration in long-bone defects: tissue compartmentalisation? In vivo study on bone defects in sheep.

Regeneration of living tissue varies with species, age and type of tissue, and undoubtedly with the biological and mechanical environment of the precise tissue. Autologous cancellous bone grafting is a well-known technique that provides bony regeneration. We investigated the efficiency of autologous bone grafting in a well-vascularised muscle environment, and additionally when isolated from the muscle and connected only to the bony environment. We designed a reproducible animal model producing a stable 3cm middiaphyseal bone and periosteal defect on sheep femurs and created a foreign-body membrane with a temporary poly-methylmethacrylate spacer. The foreign-body membrane had the outer dimension of the removed bone segment. We then ascertained the bony regeneration potential within the bone defect using autologous cancellous bone graft. Regeneration of bone is enhanced considerably by an autologous foreign-body membrane that separates the interfragmentary space from the muscular environment. This effect is independent of the autologous bone graft. The results suggest that bone behaves like a compartment that protects its specific humoral or its cellular environment, or both. Regeneration of bone can be enhanced by compartmentalisation of the bone defect.

Hindfoot issues in the treatment of the cavovarus foot.

Cavovarus foot deformity is a result of a dysbalance of the extrinsic musculature about the foot. Because of the multi-articular bony structure of the foot and ankle, the slightest imbalance of muscular forces causes osteo-articular malalignment and consequent gross deformities. This article discusses hindfoot issues involved in the treatment of cavovarus foot.

Tubular Remodeling of Massive Cancellous Bone Graft in the Treatment of Long Bone Defects.

BACKGROUND: This case report describes the clinical and radiological result at the 4.5-year follow-up after an extensive reconstruction of the femoral diaphysis using autologous cancellous bone graft. The radiological study including axial tomography demonstrates secondary remodelling to form tubular diaphyseal bone. METHODS: A patient with an existing hip fusion, who sustained a fracture of the proximal femur 12 years later, was treated by open internal fixation using a plate and screws. Infection followed which became chronic, causing bone resorption and necrosis and producing a septic non-union. Reconstruction in two stages was performed: open radical debridement which ended with a 14.5 cm diaphyseal defect of the femur, temporary alloplastic spacer interposition and secondary de-arthrodesis of the hip with massive autologous cancellous grafts into the induced foreign body membrane left by the spacer. Fixation was provided by a plate and screws. RESULTS: The femur was free of infectious recurrence at 4.5 years. The patient walks without crutches with a shortened lower limb using a leg length compensation shoe and a painfree sine-sine hip arthroplasty. The former bone defect is fully remodelled into new cortical bone. X-ray and CT-scan demonstrate the tubular form of the reconstructed bone. CONCLUSION: This clinical case demonstrates the restoration of a medullar cavity after massive cancellous bone grafting of a diaphyseal defect of the femur. The question remains open as to whether the foreign body membrane has only a simple passive protective function against extraosseous bone resorbing factors or whether it functions actively by producing growth factors or other beneficial bone inducing factors.

Detection of fibular torsional deformities after surgery for ankle fractures with a novel CT method.

BACKGROUND: Substantial fibular torsional deformities were detected after surgery for ankle fractures combined with a lesion of the syndesmotic complex using a novel CT analyzing method. METHODS: In a prospective study, 61 patients with ankle fracture dislocations were treated with trans-syndesmotic screw fixation of the distal tibiofibular joint. Postoperative axial CT scans of both lower legs under standardized leg positioning conditions were made and analyzed with three different methods. Method 1 (M1) used proximal and distal CT planes of the lower leg for detection of the fibular torsional angle, method 2 (M2) considered only the angle at the distal tibiofibular joint, and method 3 (M3) measured the angles between the fibular and tibial tangents at the distal tibiofibular joint. Twenty patients with fibular torsional asymmetries of more than 10 degrees were evaluated clinically 6 to 34 months postoperatively with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score. RESULTS: Thirty-five of the 61 patients had torsional side-to-side differences of more than 10 degrees. M1 and M2 showed statistically significant differences compared to M3 (p = 0.001). Validity was controlled by interobserver data, variation coefficients were low for M1 and M2. Clinically, six of 20 patients with torsional differences of more than 10 degrees had excellent results, while seven had good results and seven had moderately functional results. Six of the seven with moderate results had fibular torsional differences of more than 15 degrees, two of the seven patients with good outcomes. Torsional results of M1 and M2 correlated with the AOFAS score (r = -0.506). CONCLUSIONS: Of the 61 ankle fractures with ruptures of the syndesmotic complex, 25% showed torsional side-to-side differences of more than 10 degrees on proximal and distal CT planes. This CT technique correlated with the AOFAS score and could help determine when early operative revision is indicated.

[The dorsolateral approach to the ankle for arthrodesis].

OBJECTIVE: Bony fusion of the ankle in functional position. Restitution of a pain-free use of the limb. INDICATIONS: Joint destruction not amenable anymore to conservative treatment modalities. Chronic instabilities of diverse causes. CONTRAINDICATIONS: Severe general and metabolic diseases. Extensive scarring at the posterior aspect of the ankle. SURGICAL TECHNIQUE: Posterolateral approach to the ankle. Fibular osteotomy and resection of a 1 cm long bone block from its diaphysis. Removal of articular cartilage of tibia, talus, and lateral malleolus. Plantigrade positioning of the talus under the tibia in slight external rotation. Internal tibiotalar screw fixation. Fixation of the lateral malleolus to tibia and talus with screws. POSTOPERATIVE MANAGEMENT: Plaster cast for 2 weeks without weight bearing followed by partial weight bearing in an ankle-foot orthesis with a rocker-bottom sole until radiologic evidence of bony fusion. RESULTS: 26 patients (21 men, five women, average age 55 years (21-83 years) underwent a total of 29 ankle arthrodeses. Minimum clinical and radiologic follow-up of 1 year. All patients were able to bear full weight between the 2nd and 3rd postoperative month. All patients could be reached by telephone 1-14 years after surgery. Screws had been removed in six of the patients. The activities of daily living were assessed on a visual analog scale (0-10 points); they had improved from 2.5 points preoperatively to 8.3 points postoperatively. All patients stated they would undergo this operation again. 16 patients were physically active and participated in sports such as bicycling, hiking and swimming.

Integral classification of injuries (ICI) to the bones, joints, and ligaments--application to injuries of the foot.

The integral classification of injuries (ICI) is a very logical, descriptive classification of fractures and dislocations of the human skeleton. By enumerating all 28 foot bones in relation to the three anatomical and functional regions of the foot, ie, hindfoot (81), midfoot (82), forefoot (83), from proximal to distal, and by introducing lowercase letters for the joints of the foot skeleton,the localization of the injury can be described precisely. The uppercase A defines extra-articular, B describes intra-articular and C is for fracture dislocations. By introducing the uppercase D, different dislocations can be described. By using additional lowercase Greek letters, the direction of a dislocation can be coded. For simple 'everyday' use, a fracture of the calcaneus(81.2) involving three joints can be described as a B3-fracture. For scientific or database coding purposes, one can describe in square brackets which joints or segments are involved and how they are injured in relation to three different subgroups representing first the tissue (bone, cartilage, capsule, and ligaments),second the kind of injury (three graduations of fracture, cartilage, or ligament damage), and third (three graduations) the extent of the dislocation or displacement. Following ten conventions, a complex foot trauma can be coded as precisely as a simple dislocation of the big toe.

Chopart fractures.

The Chopart articular space was described by François Chopart (1743-1795) as a practical space for amputations in cases of distal foot necrosis. It corresponds to the limit between the anatomical hind-foot and the mid-foot. The bones involved are the talus and the calcaneus proximally, and the navicular and the cuboid distally. This space thus holds two functionally distinct entities, the anterior part of the coxa pedis (an essential functional joint) and the calcaneo-cuboidal joint,which can be considered to be an "adaptive joint" within a normal foot. Trauma to this region may cause fractures and/or dislocations and, in high energy trauma,compartment syndromes. Principles of treatment are immediate reduction of dislocations and realignment of the medial and lateral column of the foot in length and orientation. Open reduction and internal fixation of talus and navicular fractures are often indicated to restore the "coxa pedis". Open reconstruction or fusion in correct length of the calcaneo-cuboidal joint is occasionally indicated. Salvage procedures in malunions include navicular osteotomies and calcaneo-cuboidal bone block fusions. Treatment of joint destructions, especially involving the talo-navicular joint, include triple arthrodesis.