Effect of Age and BMI on Sonographic Findings of Plantar Fascia.

Biomechanical dysfunction of the foot is most common cause of plantar fascia disorder and obesity and increasing age are well-known risk factors. Due to being inexpensive and quick, ultrasound imaging techniques are considered the modality of choice to assess plantar fascia. The aim of this study was to investigate the effect of age and body mass index (BMI) on sonographic findings of plantar fascia in normal population. Ultrasonography was used to measure the plantar fascia thickness of 148 healthy adults (54 males, 36.5% and 94 females, 63.5%) during a period of one year. The age, BMI, and walking distance of each participant were recorded and statistically analyzed. The mean plantar fascia thicknesses at 0.5, 1.0, and 2.0 cm distal to the insertion of the plantar fascia were 1.76 ± 0.32 mm, 2.50 ± 0.50 mm and 2.11 ± 0.41 mm respectively. The mean plantar fascia thickness for individuals ≥45 years and BMI ≥25 were significantly higher (p < .001) compared to individuals <45 years and BMI <25. In a normal population, the thickness of the plantar fascia determined by ultrasound measurement was less than 3 mm. We recommend using the position 1.0 cm distal to the calcaneal insertion of the plantar fascia as the reference point for diagnosing plantar fasciitis. The thickness of plantar fascia was significantly increased with age and BMI whereas gender, walking activity, exercise and running did not seem to affect the plantar fascia thickness.

How Adductor Hallucis Reattachment Affects Outcomes Following Scarf Osteotomy in Hallux Valgus Correction: A 4- to 8-Year Follow-Up Retrospective Comparative Study.

This study observed the differences between 2 adductor hallucis release techniques (nonreattachment vs reattachment) in 4- to 8-year follow-up outcomes of scarf osteotomy combined with distal soft tissue release (DSTR) in moderate to severe hallux valgus correction. A retrospective review of moderate to severe hallux valgus patients treated with scarf osteotomy with DSTR was conducted. The patients were divided into 2 groups based on adductor hallucis release techniques (without and with reattachment to the metatarsophalangeal joint capsule). The demographic-matching process divided the samples into 27 patients per group. A comparison of last follow-up of clinical foot ankle ability measure (FAAM) for activity of daily living (ADL) and numerical rating scale for pain during 2 hours of ADL and radiographic outcomes (hallux valgus angle (HVA) and intermetatarsal angle (IMA) was analyzed. A p < .05 was considered a statistically significant difference. The final follow-up of FAAM for ADL was statistically better in the reattachment group as the median was 79.0 (IQR = 4.00) versus 76.0 (IQR = 4.00), p = .047. However, this difference did not achieve minimal clinical importance difference (MCID). The last follow-up of IMA was also statistically better in the reattachment group as the mean was 7.67 (SD = 3.10) versus 10.5 (SD = 3.59), p = .003. DSTR with adductor hallucis reattachment has statistically better IMA correction and maintenance than nonreattachment for moderate to severe hallux valgus correction using scarf osteotomy at 4- to 8-years follow-up. However, the better clinical outcomes did not achieve MCID.

The talar body prosthesis treated end-stage ankle arthritis with talar body deficient: a 6-13 years of follow-up outcomes and 6-year survivorship.

INTRODUCTION: Talar body deficient provides a unique challenge for ankle arthritis treatment. We studied the clinical-radiographic outcomes at 6 to 13 years and 6 year prosthesis survivorship of patients treated for ankle arthritis with poor talar body bone stock using a talar body prosthesis (TBP). MATERIALS AND METHODS: Between 2008 and 2015, we treated 32 consecutive end-stage ankle arthritis patients with talar body deficiency by TBP implantation and fascia interposition. One patient was excluded with a diagnosis of inflammatory arthritis. We assessed visual analogue scale (VAS) of ankle pain, sagittal range of motion, American Orthopaedics Foot and Ankle Society (AOFAS) ankle-hindfoot score, Foot Ankle Ability Measure (FAAM) of activity daily living (ADL), prosthesis tibiotalar surface angle, radiographic prosthesis loosening, adjacent joint arthritis and complication. Pre-operative to last follow-up outcomes (at 6-13 years) were compared. Prosthesis survivorship was analyzed at 6 year follow-up. p < 0.05 was considered a significant difference. RESULTS: There was statistically significant improvement of median VAS ankle pain, as 8.0 (IQR 1.0) to 1.0 (IQR 2.0), AOFAS ankle-hindfoot score from 48 (IQR 21) to 80 (IQR 7.0), FAAM of ADL from50.0 (28.0) to 88.0 (IQR 15.0), and sagittal ROM from 20o (IQR 19°) to 33° (IQR 14°), p < 0.05. The median tibiotalar surface angle was statistically significant improved from 85.0° (IQR 8.0°) to 89.0° (IQR 3.0°), p < 0.001. No radiographic prosthesis loosening or adjacent talonavicular-calcaneocuboid joint arthritis. The 6 year prosthesis survivorship was 93.5% (95% CI 84.9-100.0%). End of survivorship was observed in 2 patients due to progressive valgus tilting at 16° and 18°, respectively. No prosthesis was revised. CONCLUSIONS: TBP implantation with fascia replacing the articular end of distal tibia provided significant better pre- to post-operative clinical outcomes and had 6 year survivorship as 93.5% for the treatment of ankle arthritis with talar body deficient. LEVEL OF EVIDENCE: IV.

Müller-Weiss Disease: Three- to Eight-Year Follow-Up Outcomes of Isolated Talonavicular Arthrodesis.

Numerous surgical techniques for the treatment of Müller-Weiss disease (MWD) have been reported. However, no extensive clinical and radiographic studies of isolated talonavicular arthrodesis and MWD have been reported. The present retrospective cohort study examined the outcomes of isolated talonavicular arthrodesis at 3 to 8 years of follow-up in 16 MWD patients with a collapsed longitudinal arch and at least Maceira stage III. Demographic data, pre- and postoperative visual analog scale (VAS) scores for pain on walking and walking disability, foot and ankle outcome scores (FAOSs), and radiographic parameters were analyzed, with statistical significance at p < .05. A survival analysis was used to determine the median time to union. The mean ± standard deviation pre- and postoperative VAS scores for pain on walking were 7.69 ± 1.62 and 2.19 ± 1.52 and the walking disability scores were 7.06 ± 2.11 and 2.31 ± 1.92, respectively. The pre- and postoperative FAOSs were 48.07 ± 21.50 and 82.27 ± 13.86 for activities of daily living, 30.86 ± 19.70 and 76.17 ± 22.39 for quality of life, and 20.93 ± 22.89 and 51.88 ± 23.66 for sports/recreation, respectively. The median pre- and postoperative FAOSs for the symptoms subscale were 73.22 (range 42.88 to 100.00) and 87.50 (35.71 to 100.00) and for pain were 34.72 (range 8.33 to 72.22) and 88.89 (54.41 to 100.00), respectively. Significant improvements occurred from preoperatively to postoperatively for VAS scores and FAOSs (p < .05). The mean pre- and postoperative calcaneal pitch angles were 11.31° ± 4.35° and 13.81o ± 5.60o, significant improvement (p = .016). Improvement was also seen midfoot abduction, with a mean pre- and postoperative anteroposterior Meary's angle of 14.38° ± 10.07° and 9.38° ± 12.21°. The survival analysis showed union was achieved in all patients, with a median time to union of 2 (95% confidence interval 1.03 to 3.00) months. Our data indicate that talonavicular arthrodesis provides satisfactory functional outcomes for MWD patients with a collapsed longitudinal arch.

Is the Arthroscopic Transillumination Test Effective in Localizing the Superficial Peroneal Nerve?

PURPOSE: To evaluate the transillumination test in showing the position of the superficial peroneal nerve (SPN) to quantify the effectiveness of this test. METHODS: Prospectively, we selected 53 ankle arthroscopy patients (71 patients were excluded because of the invisible SPN). Demographic data including gender, weight, height, and body mass index were recorded. The intraoperative transillumination test was performed during portal establishment and recorded as positive if the SPN was visible via transillumination. The data were analyzed as mean, standard deviation, and percentage. Wilson's method was used as 95% confidence interval for proportion of the positive transillumination test. RESULTS: The intraoperative transillumination test was positive in 0 of 53 patients (0%) with 95% confidence interval ranging from 0% to 6.7%. CONCLUSIONS: The transillumination test has no value for showing the SPN. LEVEL OF EVIDENCE: Level II, prospective diagnostic study.

How to harvest the greatest length of tibialis posterior tendon for tendon transfer: A cadaveric study.

In anterior transfer of the tibialis posterior tendon, the tendon was harvested using two incisions, the first at its attachment point on the navicular bone and second on the medial side of the leg above the medial malleolus. To provide the maximum tendon length, the second incision needs to be as proximal as possible but injury to the muscle origin must be avoided. The purpose of this study is to establish the location of the second incision that yields the greatest tendon length. Forty-five unpaired embalmed cadaveric legs were dissected. Demographic data, gender, age, and side of specimen were recorded. The distance between the tip of the medial malleolus and the muscle origin was measured. Mobile tendon length, muscle origin, foot length, tibial length, and position of ankle were also noted. The mean mobile tendon length was 11.1 (range 10.7-11.4) cm and the distance between the tip of the medial malleolus and the muscle origin was 6.8 (range 6.5-7.0) cm. The mean foot length was 22.2 cm (range 21.7-22.7), tibial length was 31.5 cm (range 30.8-32.2), and muscle origin was 23.7 cm (range 21.0-26.3). The mean angle position was 46 degrees plantar flexion (range 43-49). In subgroup analysis by gender, the mobile tendon length, distance between the tip of the medial malleolus and the muscle origin, and tibial length, were significantly greater in males than females. In conclusion, for anterior transfer of the tibialis posterior tendon, an incision 7.1 cm above the medial malleolus in the male and 6.4 cm above it in the female provides the longest mobile tendon without injury to its origin. Clin. Anat. 30:1083-1086, 2017. © 2017 Wiley Periodicals, Inc. LEVEL OF EVIDENCE: V, Cadaveric descriptive study.

Benefit of Adding Fibular Osteotomy to Open-Wedge, Valgus, Distal Tibial Osteotomy for Correcting Varus Ankle Arthritis: An In Vitro Study.

Early-stage varus ankle arthritis can usually be treated with a medial, open-wedge, valgus, distal tibial osteotomy; however, the value of adding a fibular osteotomy has been debated. We sought to determine the increase in the maximum medial osteotomy gap and correction angle provided by fibular osteotomy. In 3 sequential experiments on 12 fresh cadaveric legs, we first performed a medial open-wedge, valgus, distal tibial osteotomy alone. Second, we added a transverse fibular osteotomy. Finally, we added a blocked fibular osteotomy. In each experiment, we measured the maximum corrected osteotomy gap and the maximum correction angle. Correction was defined as the absence of lateral cortex diastasis and talocrural joint incongruity. The mean ± standard deviation maximum osteotomy gaps and correction angles were 8.40 ± 1.6 mm and 10.70° ± 3.3° for the tibial osteotomy alone, 15.70 ± 4.6 mm and 20.20° ± 5.6° for the tibial plus transverse fibular osteotomy, and 16.67 ± 3.7 mm and 20.56° ± 4.6° for the tibial plus transverse plus blocked fibular osteotomies, respectively. The corresponding median maximum correction angles were 10° (range 8° to 18°), 19.5° (range 14° to 30°), and 20° (range 14° to 28°). The osteotomy gap and correction angle in the distal tibial and transverse fibular osteotomy were significantly greater than those in the distal tibial osteotomy alone (p < .001 for both) but not in the distal tibial and blocked fibular osteotomy (p = .62 for the gap and p = .88 for the correction angle). Our data support the clinical use of adjunct transverse fibular osteotomies. The blocked fibular osteotomy provided no additional benefit.

Frequency and Characteristics of Extensor Hallucis Capsularis: A Cadaveric Study.

Background: Extensor hallucis capsularis is an accessory extensor tendon that is sporadically observed at the medial side of the extensor hallucis longus tendon. Knowledge regarding frequency of occurrence and size of the tendon may help surgeons decide whether to use this tendon or not when tendon graft is needed during foot surgery. Conclusion: Extensor hallucis capsularis tendon was found in the vast majority of cadavers evaluated in this study. Most originated from the extensor hallucis longus tendon and inserted into the first metatarsophalangeal joint capsule. Application of this tendon as a tendon graft should be carefully considered due to variations of the length and the narrow width which may limited strength of this tendon graft. Objective: To evaluate the frequency, size, origin, and insertion of the extensor hallucis capsularis tendon in cadaveric study subjects. Material and Method: Extensor hallucis capsularis tendon was examined via dissection of 55 cadaveric feet. Thirty-six male and 19 female cadavers were included, with an age range of 33 to 90 years (mean 67.3±14.0). One foot from each study subject was dissected and evaluated (29 left feet and 26 right feet). Demographic data (gender, age, and height) and outcome data (frequency, origin, insertion, length, and width of the tendon) were recorded. Tendon measurement reliability was evaluated by intraclass correlation coefficient. Results: Extensor hallucis capsularis tendon was found in 90.9% of cadaveric subjects. Mean tendon length and width was 11.3±4.0 cm and 1.6±0.6 mm, respectively. Most tendons branched from the extensor hallucis longus tendon and attached to the first metatarsophalangeal joint capsule. Conclusion: Extensor hallucis capsularis tendon was found in the vast majority of cadavers evaluated in this study. Most originated from the extensor hallucis longus tendon and inserted into the first metatarsophalangeal joint capsule. Application of this tendon as a tendon graft should be carefully considered due to variations of the length and the narrow width which may limited strength of this tendon graft.

Relationship of the dorsalis pedis artery to the tarsal navicular.

When undertaking surgical maneuvers about the midfoot, caution must be used to avoid injury to the dorsalis pedis artery, which courses along the dorsum of the foot on the dorsolateral aspect of the tarsal navicular. In an effort to better understand the relationship of the course of the dorsalis pedis artery relative to the tarsal navicular, 128 embalmed feet (31 [48.4%] female and 33 [51.6%] male cadavers aged 15 to 91 years) were measured. The dorsalis pedis artery was dissected from its origin to its termination (i.e., the first dorsal metatarsal artery and the deep plantar perforating artery), and the distance from the medial cortex of the navicular tuberosity to the medial margin of the artery and the location of the artery as a percentage of the medial-to-lateral width of the navicular were measured. In the male cadaver specimens, the distance from the navicular tuberosity to the dorsalis pedis was 23.75 ± 3.1 mm, the width of the navicular was 37.41 ± 5.0 mm, and the location of the artery as a percentage of the width of the navicular was 64.34% ± 13.1%. In the female cadaver specimens, the distance from the navicular tuberosity to the dorsalis pedis was 22.81 ± 5.5 mm, the width of the navicular was 36.11 ± 4.0 mm, and the location of the artery as a percentage of the width of the navicular was 63.29% ± 9.9%. For the right foot specimens, the distance from the navicular tuberosity to the dorsalis pedis artery was 20.29 ± 3.3 mm, and the width of the navicular was 37.21 ± 4.4 mm. For the left foot specimens, the distance from the navicular tuberosity to the dorsalis pedis was 21.40 ± 2.5 mm, and the width of the navicular was 35.92 ± 4.4 mm. The statistical comparisons between the males and females showed no statistically significant differences. In contrast, those between the right and left feet showed significant differences in the distance from the navicular tuberosity to the dorsalis pedis artery and the location of the dorsalis pedis artery as a percentage of the width of the navicular. Knowledge of these distances and the location of the dorsalis pedis artery relative to the width of the tarsal navicular should aid surgeons in preparation for, and during, dissection of the midfoot.

Success rates of first-line antibiotics for culture-negative sub-acute and chronic septic arthritis.

A combination of surgical and medical treatment is normally required for patients with septic arthritis. Antibiotics selected for use on these patients are normally based on tissue culture results. However, in sub-acute and chronic septic arthritis cases, the results of the culture are usually negative as a result of prior treatment. The present study will investigate the incidence of culture-negative septic arthritis and the outcomes based on the use of first-line drug antibiotics for the treatment of sub-acute and chronic septic arthritis. For the present study, the authors retrospectively reviewed medical records of surgically treated septic arthritis cases over the past 10 years at Siriraj Hospital. The patient culture results, the antibiotics used, and the results of treatment were all recorded and analyzed. One hundredfifty-three septic arthritis patients were reviewed. Sixty-two patients were classified as having been diagnosed with either sub-acute or chronic septic arthritis. Thirty-six of 62 patients (58.1%) had a negative culture result. In the culture-positive patients, 42.3% had Streptococcus, 26.9% had Staphylococcus aureus, 11.5% had other gram positive bacteria, 15.4% had gram-negative bacteria, and 3.8% had tuberculus infection. In the culture-negative sub-acute and chronic group (36 of 62), 23 patients received Cefazolin, nine patients received Cloxacillin, and four patients received Clindamycin. Successful results were 69.9%, 66.7% and 75%, respectively. The present study reflects that the incidence ofculture-negative, sub-acute and chronic septic arthritis is approximately 58.1%. The first-line class of antibiotics remains the appropriate antibiotic choice for these patients because they are still effective for treatment of septic arthritis in up to 70% of all cases.

Comparison of Foot Kinematics Between Normal Arch and Flexible Flatfoot Using the Oxford Foot Model: A Matched Case-Control Study.

Background: Symptomatic flexible flatfoot causes alterations in gait, but exactly how this condition affects the intersegmental motion of the foot during the gait cycle remains unclear. Previous studies have examined the kinematics, yielding inconsistent findings. Therefore, the objective of this study was to investigate how flexible flatfoot deformity, defined as Johnson and Strom classification staging II, affects the intersegmental motion of the foot during fast walking based on a comparison with the matched control group. Methods: Eleven participants with symptomatic flexible flatfoot and 11 healthy matched control participants were recruited using a foot screening protocol incorporated through a foot physical examinations and radiographic measurements. All demographic characteristics exhibited comparable profiles between the groups. During controlled walking, kinematic outcomes pertaining to the hallux, hindfoot, forefoot, and tibia were collected using the multisegmental Oxford Foot Model. Results: All spatiotemporal parameters were comparable between the groups. In comparison to the control group, individuals with symptomatic flexible flatfoot demonstrated increased hallux valgus and plantarflexion, increased forefoot abduction, heightened hindfoot eversion, and internal rotation. Notably, no significant major differences were observed in the tibia motion segment. Further, significant correlations were identified between static foot measurements and the extent of the maximum deviation observed during dynamic kinematic assessments. Conclusion: Compared with age- and gender-matched controls, participants with symptomatic flexible flatfoot exhibited significant gait pattern deviations. A significant correlation also exists between static foot deformity measurements and dynamic kinematic deviations. Collectively, these findings have implications for developing targeted therapeutic interventions to address flexible flatfoot. Level of evidence: Level III, diagnostic study.

A Novel Update on the Management of Müller-Weiss Disease: Presentation of a Treatment Algorithm.

OBJECTIVE: Müller-Weiss disease (MWD) is a challenging condition involving the perinavicular region in the initial stages and subsequently the entire foot in the later stages. The goal of this article is to describe the pathomechanics, clinical evaluation, and nonoperative and operative treatment, including a treatment algorithm, based on current evidence and the combined authors' experience. DESIGN: We review the related articles and summarize the information about this condition. RESULTS: A number of related articles reveal that the treatments should focus on the management of degenerative regions and deformity correction to restore normal foot alignment and provide pain relief. CONCLUSION: This systematic review proposes a treatment algorithm that is comprehensive and practical to apply for the management of MWD.

Plantar Fascia Thickness and Stiffness in Healthy Individuals vs Patients With Plantar Fasciitis.

BACKGROUND: Plantar fasciitis is a major cause of heel pain, resulting from repetitive trauma to the plantar fascia and leading to structural changes within the fascia. It has been observed that plantar fascia thickness in plantar fasciitis patients exceeds that of normal individuals. However, the biomechanical properties of the plantar fascia in patients with plantar fasciitis remain unclear. Therefore, this study aimed to compare plantar fascia stiffness between healthy individuals and patients with plantar fasciitis across different areas. METHODS: Fifty-eight participants were divided into 2 groups: 29 healthy individuals and 29 individuals with plantar fasciitis. B-mode ultrasonography was used to assess plantar fascia thickness, whereas shear wave elastography was employed to measure plantar fascia stiffness. The study focused on 3 distinct areas: calcaneal insertion, 1-cm distal area, and 2-cm distal area. Additionally, the most painful area reported by patients was marked in the plantar fasciitis group. RESULTS: The findings showed that the plantar fasciitis group exhibited significantly greater plantar fascia stiffness in almost all areas compared to the healthy group (P < .05). Moreover, the stiffness of the plantar fascia in the most painful area demonstrated the highest value compared with other areas within the plantar fasciitis group (P < .05). CONCLUSION: This study suggests structural and mechanical changes in the plantar fascia in patients with plantar fasciitis.

Outcomes of Tibiotalocalcaneal Arthrodesis vs Talar Body Prosthesis as Treatment of Collapsed Avascular Necrosis of the Talus: A 10- to 13-Year-Follow-up Retrospective Comparative Study.

BACKGROUND: Joint salvage surgeries such as tibiotalocalcaneal arthrodesis and talar prosthesis are commonly used in the surgical treatment of collapsed avascular necrosis of the talus (AVNT). However, differences in outcomes of these 2 surgical treatments are still inconclusive. This study compared the 10- to 13-year outcomes and 10-year survivorship rates of tibiotalocalcaneal arthrodesis and talar body prosthesis in the surgical treatment of collapsed AVNT. METHODS: A retrospective comparative study was conducted of patients who underwent either tibiotalocalcaneal arthrodesis or talar body prosthesis implantation between 2005 and 2012. The demographic matching process resulted in 24 patients per treatment group. Clinical outcomes were evaluated using a numeric rating scale (NRS) of 2 hours of activities of daily living (ADL) and Foot and Ankle Ability Measure (FAAM) for ADL. Radiographic assessments included the incidence of nonunion, adjacent joint arthritis, and prosthesis loosening. The 10-year survivorship of both surgical treatments was calculated. A P value of less than .05 was considered statistically significant. RESULTS: The median NRS of 2 hours of ADL and FAAM score for ADL were statistically significantly better in the talar body prosthesis group, with P values of .001 and <.001, respectively. The statistically significant differences in FAAM score for ADL exceeded the minimum clinically important difference. In the tibiotalocalcaneal arthrodesis group, nonunion was observed in 7 of 24 patients (29.2%). No prosthesis loosening was reported in the talar body prosthesis group. The 10-year survivorship was statistically significantly higher in talar body prosthesis than tibiotalocalcaneal arthrodesis (95.8% vs 70.8%), P = .023. CONCLUSION: Talar body prosthesis implantation in selected eligible patients demonstrated statistically significantly better 10- to 13-year clinical outcomes and higher 10-year survivorship compared with tibiotalocalcaneal arthrodesis in the surgical treatment of collapsed AVNT. LEVEL OF EVIDENCE: Level III, retrospective cohort comparative study.

Safety area for proximal metatarsal procedures.

BACKGROUND: Forefoot and tarsometatarsal surgery may be performed on the first and second metatarsal through the intermetatarsal space. However, no study has identified the safety area of the proximal metatarsal bone to avoid vascular injury. METHODS: One hundred and twenty-two uninjured embalmed feet of 31 female and 33 male cadavers aged 15 to 91 years (mean, 69.9 years) were studied. The dorsalis pedis artery was identified and dissected from its origin to the deep plantar artery. The distances from the artery to the dorsomedial aspect of first metatarsal bone, from the artery to the first tarsometatarsal joint, and from dorsalis pedis artery to the most plantar surface of second metatarsal bone were measured. RESULTS: The distance from the artery to the first tarsometatarsal joint averaged 23.1 mm (range, 12-31 mm) and the distance from the artery to the most plantar surface of the second metatarsal bone averaged 6.3 mm (range, 3-13 mm). CONCLUSIONS: The safety area for proximal metatarsal procedure is about a 69-mm(2) triangular area (23 mm from first tarsometatarsal joint and 6 mm from the most plantar surface of the second metatarsal bone). CLINICAL RELEVANCE: The study provides information of normal location and variation of deep plantar artery is which related to medial midfoot complex. This information may be used during proximal metatarsal procedures.

Sport and Exercise Activity After Isolated Ankle Arthrodesis for Advanced-Stage Ankle Osteoarthritis: A Single-Center Retrospective Analysis.

Background: Ankle arthrodesis, a recognized operative treatment for advanced-stage ankle osteoarthritis (OA), is recommended when conservative treatment proves unsuccessful. This single-center retrospective analysis examined the change in functional outcomes and the type of sport/exercise activity performed by advanced-stage ankle OA patients after ankle arthrodesis treatment. Methods: A total of 61 advanced-stage ankle OA patients (age, 63.1 ± 12.6 years) who had undergone ankle arthrodesis were included in this single-center retrospective study. The patients had functional outcomes evaluated via American Orthopaedic Foot & Ankle Society Score (AOFAS), Foot Function Index (FFI), Tegner Activity Level Scale (TAS), and High-Activity Arthroplasty Score (HAAS) questionnaires. Clinical status was compared across prearthritic, arthritic, and postarthrodesis periods, and satisfaction with return to sport/exercise activity was recorded. Results: Patients' tarsal sagittal ROM (mean [95% CI]: 22.7 degrees [21.4-24.0]); time to union (15.7 weeks [11.8-19.6]); time to walk without gait aid (14.4 weeks [11.0-17.7]); time to return to work (17.9 weeks [15.1-20.8]); and time to exercise activity (20.6 weeks [17.9-23.4]) were recorded postarthrodesis. Hindfoot alignment angle toward a neutral position (difference: 11.4 degrees [9.2-13.6], P < .001) and functional outcomes (P < .001) significantly improved after arthrodesis surgery; however, only the TAS questionnaire indicated patients returned to their prearthritic activity level (P > .99). Patients generally reported "good" satisfaction with their recovery from ankle arthrodesis surgery, with 64% of patients returning to high-impact-type activity. Conclusion: Advanced-stage ankle OA patients had improved functional outcomes at ~1 year postarthrodesis surgery, enabling the majority of patients to return to high-impact-type activity. Level of Evidence: Level III, retrospective cohort study.

Biomechanical Comparison of Nonlocked Minimally Invasive and Locked Open Achilles Tendon Simulated Rupture Repairs.

BACKGROUND: Open repair of Achilles tendon ruptures is associated with a risk of infection and other wound complications. Although percutaneous repairs reduce these complications, they may increase the risk of nerve injury. This study was designed to determine whether a percutaneous nonlocking repair can approach the gapping resistance offered by a standard open repair under conditions approximating typical postoperative physiotherapy. METHODS: Ten pairs of cadavers Achilles tendons were transected in situ 5 cm above the insertion. One tendon from each pair was repaired using an open 4-strand Krackow locking loop, and the contralateral tendon was repaired with the Achillon system using the same suture material. Displacement transducers were attached to the medial, lateral, anterior, and posterior aspects of the tendon, spanning the repair. Each tendon underwent 1000 tensile loading cycles to 86.5 N, simulating passive ankle range-of-motion physiotherapy. Gapping was documented on the 1st, 50th, 100th, 500th, and 1000th cycles. The ultimate tensile strength of each repaired tendon was then measured by distracting until gross failure occurred. RESULTS: Gapping of the percutaneous repairs exceeded that of conventional open repairs on the first, 500th, and 1000th load cycles. All 10 conventionally repaired tendons withstood 1000 load cycles without gross failure, but 4 of 10 percutaneous minimally invasive repairs failed, one on the 9th load cycle and the others between the 100th and 500th cycles. On average, tendons repaired with the open technique withstood 66% greater tensile load in failure testing than those repaired with the percutaneous technique. CONCLUSION: Open Krackow Achilles tendon repairs may better withstand more aggressive postoperative physiotherapy than nonlocked percutaneous repairs. CLINICAL RELEVANCE: The study suggests that surgeons should consider locking suture approaches to avoid loss of repair integrity with early motion.

Comparing proximal and distal metatarsal osteotomy for moderate to severe hallux valgus.

PURPOSE: This study compared results of distal and proximal metatarsal osteotomy for moderate to severe hallux valgus in terms of radiographic correction and functional outcome. METHODS: We analyzed 125 moderate to severe hallux valgus surgeries. Patients were divided into two groups. Group 1 underwent distal metatarsal osteotomy, and group 2 underwent proximal metatarsal osteotomy. Patients were interviewed for functional scores before and one year after surgery. The anteroposterior (AP) weight-bearing radiography of the foot was taken before and one year after surgery. RESULTS: There were no significant differences in pain and function after one year in either group. Both groups experienced significant pain reduction and increase in all functional scores. There was significant improvement of hallux valgus and intermetatarsal angle corrections in group 2. There was less improvement in radiographic correction in group 1. CONCLUSION: Either distal or proximal metatarsal osteotomy is an appropriate pain-relieving procedure and can increase functional outcome in moderate to severe hallux valgus. However, distal metatarsal osteotomy provides lower correction power.

Displaced articular calcaneus fractures: classification and fracture scores: a preliminary study.

OBJECTIVE: To review and group configurations of displaced articular calcaneal fracture advantaged for classification and radiographic fracture scores. MATERIAL AND METHOD: Between 2002 and 2011, medical records and radiographs of patients who sustained acute displaced articular calcaneal fractures were reviewed. The calcanealfracture configurations were grouped as avulsion, bending, burst, or combination. Radiographic displaced articular calcaneal fracture score was designed to include Bohler and Gissane angles, degrees of posterior subtalar joint line parallel, degrees of varus, and burst. The calcaneal fracture score was modified as power of the fracture response to treatment (PFRT). Prevalence of the fracture types, pre- and post-reduction fracture scores including PFRT were studied and statistically analyzed. RESULTS: Sixty-four patients had 77 acute displaced articular calcaneal fractures. The classification consisted of type I avulsion, type II compression bending, type III compression burst, type IV avulsion burst, and type V bending burst. Type IV is the most common. The radiographic calcaneal fracture scores were 10 points. Pre-, post-reduction calcaneal fracture scores and PFRTof type I, II, III, IV, and V were 4.17 (0.41), 0 and 1 (0), 4.63 (2.13), 0.50 (0.93) and 0.84 (0.35), 6.94 (2.05), 3.18 (1.38) and 0.50 (0.27), 8.03 (1.12), 3.03 (2.42) and 0.62 (0.30), and 7.22 (2.11), 3.00 (2.50) and 0.59 (0.29) respectively. Statistical analysis showed significant difference (p < 0.05). PFRT for screw and pin fixation of type I plus II, IV and V were 1.00 (0) and 1.00 (0), 0.64 (0.27) and 0.60 (0.36), and 0.54 (0.28) and 0.51 (0.45) respectively. PFRT for plate of type III was 0.54 (0.16). PFRT for casting of type I plus II, III, and IV were 0.50 (0.71), 0.27 (0.46), and 0.35 (0.33) respectively. CONCLUSION: The classification consisted of five types, which were based on injury mechanisms as avulsion, bending, and burst. The radiographic calcaneal fracture scores contained 10 points and were used for determining complexity of the fractures. PFRT was used for evaluating efficacy of fracture treatment.

Local Ketorolac Injection vs Popliteal Sciatic Nerve Blockade as an Adjuvant to a Spinal Block in Hindfoot Arthrodesis.

BACKGROUND: Popliteal nerve blocks reduce pain and markedly improve postoperative outcomes during foot and ankle surgery; however, several potential complications may arise from nerve block procedures. The purpose of this study was to investigate local infiltration analgesia with ketorolac as a convenient alternative for pain relief. METHODS: A total of 80 patients scheduled for hindfoot arthrodesis were randomly allocated to one of 2 anesthetic groups: a spinal block augmented with either a popliteal nerve block (n = 40) or local ketorolac and Marcaine infiltration (n = 40). Clinical assessment included postoperative visual analog scale (VAS) pain scores at 4, 8, 12, 24, and 48 hours, total morphine consumption, time to incision (time in operating room to incision), operative time, length of hospital stay, and complications. RESULTS: Despite similar morphine consumption between groups (P = .28), VAS scores were significantly lower at 24 hours (1.6 ± 2.2 cm vs 2.7 ± 3.0 cm, P = .01) and 48 hours (0.2 ± 0.7 cm vs 1.0 ± 1.5 cm, P < .01) after surgery using local ketorolac injection. Although time from entry into the operating room to incision was also reduced after local ketorolac injection (19.0 ± 5.3 minutes vs 31.4 ± 14.6 minutes, P < .001), the length of operative time (P = .38), hospital stay (P = .43), and number of complications (P = .24) were similar between groups. CONCLUSION: Ketorolac local injection provided effective pain control in hindfoot arthrodesis and markedly reduced VAS pain scores up to 48 hours after surgery compared with popliteal nerve block. In addition, ketorolac local injection also reduced time in the operating room compared with popliteal nerve blockade. LEVEL OF EVIDENCE: Level 1, randomized controlled trial.