An evaluation of intra and inter observer reliability of the five used classification systems of tibial plateau fractures.

We aimed to evaluate the intraobserver and inter- observer variations of the five primary classification systems for assessing tibial plateau fractures via standard X-Ray, biplanar and reconstructed 3D CT images. Using anteroposterior (AP) - lateral X-Ray, and CT images, one hundred tibial plateau fractures were evaluated and classified by four surgeons according to the AO, Moore, Schatzker, modified Duparc, and 3-column classification systems. Each observer evaluated the radiographs and CT images separately - listed each time randomly - on a total of 3 occasions: with an initial evaluation, and then subsequently in weeks 4 and 8. Intra- and interobserver variabilities were assessed using the Kappa statistics. Intra- and interobserver variabilities were 0.55 ± 0.03 and 0.50 ± 0.05 for AO, 0.58 ± 0.08 and 0.56 ± 0.02 for Schatzker, 0.52 ± 0.06 and 0.49 ± 0.04 for Moore, 0.58 ± 0.06 and 0.51± 0.06 for the modified Duparc, and 0.66 ± 0.03 and 0.68 ± 0.02 for the 3-column classification. Evaluation of tibial plateau fractures using 3-column classification in conjunction with radiographic classifications has higher levels of consistency compared to radiographic classifications alone.

How frequent should the radiographic examination be to monitor magnetically controlled growing rods? A retrospective look two to seven years postoperatively.

PURPOSE: Magnetically controlled growing rods (MCGR) allow more frequent outpatient lengthenings to better mimic the physiological growth. The assessment of distractions with radiographs raised concerns regarding ionizing radiation exposure in growing children. The aim was to assess the necessity of radiographs after every lengthening of MCGR. METHODS: A retrospective analysis of 30 consecutive patients (19F, 11 M) treated in a single institution between 2011 and 2017. Planned radiographs were taken based on a protocol, updated over the years to involve less frequent acquisitions. Unplanned radiographs were obtained after a patient complaint or a significant clinical examination finding. Outcome measures were preoperative and postoperative radiographic measurements, and complications such as proximal and distal junctional kyphosis and failure, rod or actuator breakage, collapse of previously achieved height or failure to lengthen and worsening of deformity. RESULTS: Mean age at surgery was 7.5 (4-11) years. Mean follow-up was 45 (24-84) months. Mean number of lengthenings and radiographs per patient were 14.4 (8-23), and 13.2 (5-46), respectively. Nine patients (30%) experienced a total of 13 mechanical complications. Almost all complications were detected in unplanned radiographs. The probability of detecting a mechanical complication was significantly lower (p < 0.00001) in planned radiographs. CONCLUSIONS: Radiographs taken after routine lengthenings of MCGR are not likely to reveal any significant finding, since only 0.9% of planned radiographs displayed a mechanical complication. Exposing growing children to radiation with an intention of checking the MCGR device after every lengthening could not be justified. Obtaining post-lengthening radiographs with a decreased frequency and after a significant complaint or clinical finding may be considered.

Relative lumbar lordosis and lordosis distribution index: individualized pelvic incidence-based proportional parameters that quantify lumbar lordosis more precisely than the concept of pelvic incidence minus lumbar lordosis.

OBJECTIVE The subtraction of lumbar lordosis (LL) from the pelvic incidence (PI) offers an estimate of the LL required for a given PI value. Relative LL (RLL) and the lordosis distribution index (LDI) are PI-based individualized measures. RLL quantifies the magnitude of lordosis relative to the ideal lordosis as defined by the magnitude of PI. LDI defines the magnitude of lower arc lordosis in proportion to total lordosis. The aim of this study was to compare RLL and PI - LL for their ability to predict postoperative complications and their correlations with health-related quality of life (HRQOL) scores. METHODS Inclusion criteria were ≥ 4 levels of fusion and ≥ 2 years of follow-up. Mechanical complications were proximal junctional kyphosis/proximal junctional failure, distal junctional kyphosis/distal junctional failure, rod breakage, and implant-related complications. Correlations between PI - LL, RLL, PI, and HRQOL were analyzed using the Pearson correlation coefficient. Mechanical complication rates in PI - LL, RLL, LDI, RLL, and LDI interpreted together, and RLL subgroups for each PI - LL category were compared using chi-square tests and the exact test. Predictive models for mechanical complications with RLL and PI - LL were analyzed using binomial logistic regressions. RESULTS Two hundred twenty-two patients (168 women, 54 men) were included. The mean age was 52.2 ± 19.3 years (range 18-84 years). The mean follow-up was 28.8 ± 8.2 months (range 24-62 months). There was a significant correlation between PI - LL and PI (r = 0.441, p < 0.001), threatening the use of PI - LL to quantify spinopelvic mismatch for different PI values. RLL was not correlated with PI (r = -0.093, p > 0.05); therefore, it was able to quantify divergence from ideal lordosis for all PI values. Compared with PI - LL, RLL had stronger correlations with HRQOL scores (p < 0.05). Discrimination performance was better for the model with RLL than for PI - LL. The agreement between RLL and PI - LL was high (κ = 0.943, p < 0.001), moderate (κ = 0.455, p < 0.001), and poor (κ = -0.154, p = 0.343), respectively, for large, average, and small PI sizes. When analyzed by RLL, each PI - LL category was further divided into distinct groups of patients who had different mechanical complication rates (p < 0.001). CONCLUSIONS Using the formula of PI - LL may be insufficient to quantify normolordosis for the whole spectrum of PI values when applied as an absolute numeric value in conjunction with previously reported population-based average thresholds of 10° and 20°. Schwab PI - LL groups were found to constitute an inhomogeneous group of patients. RLL offers an individualized quantification of LL for all PI sizes. Compared with PI - LL, RLL showed a greater association with both mechanical complications and HRQOL. The use of RLL and LDI together, instead of PI - LL, for surgical planning may result in lower mechanical complication rates and better long-term HRQOL.

Late-Diagnosed Dislocation of the Proximal Interphalangeal Joint of the Fifth Toe in a 7-Year-Old Boy: A Case Report.

Dislocation of the proximal interphalangeal joint of the fifth toe is an uncommon injury. When it is diagnosed in the acute phase, closed reduction is commonly an adequate treatment option. We describe a rare case of a 7-year-old patient who presented with late-diagnosed isolated dislocation of the proximal interphalangeal joint of the fifth toe. Although there are a few reported cases of late-diagnosis combined fracture-dislocation of the toes in both adult and pediatric age groups in the literature, belatedly diagnosed dislocation of the fifth toe without accompanying fracture in the pediatric population, to our knowledge, has not yet been reported. This patient achieved good clinical outcomes after treatment via open reduction and internal fixation.

If you look this way, you will see it: cranial shift in adolescent idiopathic scoliosis.

INTRODUCTION: Anatomical variations in the spine can be seen in each transitional border, either toward the skull as 'cranial shifts' or away as caudal shifts. Cranial shifting (CS) occurs when there is presence of occipitalization, C7 cervical costae or prominent transverse processes, thoracolumbar transitional vertebrae (TLTV) at T12 level, L5 sacralization, and sacrococcygeal fusion. We termed the coexistence of sacralization of L5 and absence or remarkable reduction of T12 rib size in AIS as Abul cranial shift (ACS). In this descriptive clinical study, primary aim was to investigate the incidence of ACS in AIS. METHODS: Retrospective analysis of 187 surgically treated AIS cases was performed. Demographic data were recorded. The incidence of the specific set of anatomic variations including lumbosacral transitional vertebrae, TLTV, transverse process changes in C7 vertebrae, and posterior lumbosacral neural arch cleft formations (NACf) were evaluated in the radiological images. RESULTS: 36 (19%) of 187 cases had ACS. ACS was detected in only 1 of 19 male cases (5%), while in 35 of 168 female cases (21%). Forty-one cases had sacralization of L5 (22%). There were only eleven pair of ribs in 14 (7%) of 187 cases and 10 (28%) of 36 ACS cases. Forty cases had NACf (21%). ACS and NACf coexistence were observed in 8 (22%) of 36 ACS cases. CONCLUSION: Accurate spinal column assessment is critical in adolescent idiopathic scoliosis (AIS). ACS may be observed in up to one in five AIS cases and its presence should not be neglected to avoid wrong level surgery.

Implant-Related Complications Do Not Interfere with Corrections with the Shilla Technique in Early Onset Scoliosis: Preliminary Results.

Growth-preservation techniques are utilized in early onset scoliosis (EOS) cases requiring surgical intervention. The Shilla technique corrects the deformity by reducing additional surgeries with its growth-guidance effect. As with other techniques, various problems can be encountered following the administration of the Shilla technique. The aim of this study was to examine the effect of complications encountered with the Shilla treatment on correction and growth. Sixteen patients with a follow-up period of at least one year after receiving Shilla growth guidance for EOS were included in this retrospective study. No complications occurred, and no unplanned surgery was required in 50% of the cases. Of the remaining eight patients with postoperative implant-related complications (50%), six (37.5%) required unplanned surgery; this consequently caused implant failure in the proximal region in five cases (31.25%) and deep tissue infection around the implant in one case (6.25%). Deformity correction, spine length, and quality-of-life scores significantly improved in EOS through Shilla growth guidance. In terms of spinal growth and deformity correction, there were no significant differences between patients with implant-related problems and individuals without occurrences. Although implant-related problems were detected in our dataset and corresponding unexpected surgeries were necessary, these complications had no significant unfavorable influence on correction and spine growth.

Long-term opioid medication profile of European adult spinal deformity patients: minimum five years follow-up study.

BACKGROUND CONTEXT: There remains significant variability in the use of postoperative opioids. On one end, it is proven that appropriate pain control is a critical aspect of patient management; on the other end, past few decades have been associated with major increases in opioid-related overdoses and addiction treatment. We hypothesized that several pre- and postoperative risk factors affecting long-term opioid use could be identified. PURPOSE: Evaluation of factors associated with minimum 5-year postoperative opioid use following adult spinal deformity surgery. STUDY DESIGN/SETTING: Prospectively followed study group database. PATIENT SAMPLE: Adult spinal deformity patients who underwent elective spine surgery between 2009 and 2016 were included. OUTCOME MEASURES: Opioid usage or otherwise at minimum 5 years follow-up. Use of nonopioid analgesics, weak and strong opioids METHODS: Retrospective analysis of patients undergoing elective spinal deformity surgery. A total of 37 factors comprising patient characteristics, radiographic measurements, operative details, preoperative and early postoperative opioid use, and mechanical complications and revisions were analyzed. Details on identified factors were provided. RESULTS: A total of 265 patients (215F, 50M) from five sites were included. The mean follow-up duration was 68.4±11.7 (60-102) months. On average, 10.6±3.5 levels were fused. Preoperatively, 64 (24.2%) patients were using opioids. The rate of opioid users increased to 33.6% at 6 weeks and decreased to 21.5% at 6 months. During follow-up, there were patients who discontinued opioids, while others have started and/or restarted using opioids. As a result, 59 (22.3%) patients were still on opioids at the latest follow-up. Multivariate analyses showed that factors independently affecting opioid use at an average of 68 months postoperatively, in order of significance, were opioid use at sixth weeks, preoperative opioid use and opioid use at sixth months with the odds ratios of 2.88, 2.51, and 2.38 respectively. At these time points, factors such as age, number of comorbidities, tobacco use, the time of the last prior spine surgery and postoperative sagittal plane alignment affected opioid usage rates. CONCLUSIONS: Opioid usage at 6 weeks was found to be more predictive of long-term opioid use compared to preoperative use. Patients should be well informed to have realistic expectations regarding opioid use when considering adult spinal deformity surgery.

Adequacy of spine surgery fellowship training in Turkey: Results of a survey.

OBJECTIVE: The aim of this study was to determine the adequacy of spine surgery fellowship training (SSFT) in Turkey and what is needed for further development by interviewing current fellows. METHODS: Forty male orthopaedics and traumatology or neurosurgery specialists who had completed SSFT in three different spine centers in Turkey between 2010 and 2018 were asked to complete a survey with 29 questions about SSFT in Turkey. Thirty specialists responded, and the collected data were analyzed. RESULTS: Twenty-seven (90%) participants were orthopaedic and traumatology specialists and three (10%) were neurosurgery specialists, with a mean age of 39 (range = 35-53) years. Most participants received their residency training in the provinces where their fellowship training took place (11 (37%) in Istanbul and 7 (23%) in Ankara). The mean duration between residency training and the start of SSFT was 4 (range = 0-14) years, and the mean SSFT duration was 8 (range = 1-18) months. Seventy percent of participants had participated in spine surgery cases during their residency. Twenty-three (77%) participants reported that spine surgery training in their hospital during their residency was inadequate. Seventeen (57%) participants felt that they could not independently perform spine surgery cases before SSFT. All three centers (100%) participating in the study that offered SSFT were non-public institutions such as private hospitals and private university hospitals of medicine managed by a dedicated mentor with personal commitment, without any accreditation for SSFT. While 25 (83%) participants indicated that they felt competent enough to perform a standard spinal deformity surgery case independently at the end of SSFT, 5 (17%) indicated the opposite. This proportion, which was 43% at the end of residency, increased to 83% after SSFT. CONCLUSION: The results of this study have demonstrated the importance of SSFT in spine surgery as a specialty with a potentially high risk of complications that require prolonged case observation, challenging work-up, and adequate equipment. In this regard, there is a need for regulations on accreditation in government health facilities that provide ideal conditions. We propose to offer SSFT to all surgeons interested in spine surgery in Turkey by conducting further studies supported by an optimal health sector that ensures the appropriate requirements, in accordance with the declaration of TOTEK (The Turkish Orthopaedics and Traumatology Education Council), training workshops, and an accredited master's degree program in spine surgery or subspecialty.

Leg length discrepancy and adolescent idiopathic scoliosis: clinical and radiological characteristics.

PURPOSE: This retrospective study aimed to present the clinical and radiological features of functional scoliosis due to LLD and LLD concurrent with AIS; it also aimed to define their relationships for differentiating functional scoliosis due to LLD and LLD concurrent with AIS. METHODS: This study was conducted as a single-center retrospective comparative study on 47 scoliosis patients with diagnosed LLD, aged 10-18 years. Cases with a diagnosis of structural LLD were divided into two groups according to the presence or absence of concurrent AIS. Data on demographics and the angle of trunk rotation on a sacral basis (ATRsacrum) were recorded. Limb length was clinically measured with a tape measure and clinical LLD (C-LLD) scoliometer test. Cobb angle, axial rotation, pelvic obliquity, and radiological LLD (R-LLD) were obtained from standing spine radiographs and measured by two blinded orthopedic spine surgeons. RESULTS: The prevalence of LLD was 6.7% in scoliosis patients in our study population. Cobb angle and apical rotation were higher in the LLD concurrent with AIS group than in the LLD group (p ≤ 0.05). The C-LLDscoliometer test results were strongly correlated with both C-LLDtape measure (r = 0.651; p = 0.000) and ATRsacrum (r = 0.688; p = 0.000). CONCLUSION: LLD may develop as a result of adaptive changes due to scoliosis, or a concurrent condition to scoliosis. Cobb angle and apical rotation are the features that differentiate AIS from functional scoliosis in patients with LLD. The C-LLD scoliometer test can be an effective, practical, and useful method for measuring C-LLD, but its validity and reliability should be determined. TRIAL REGISTRATION: This study was retrospectively registered at ClinicalTrials.gov (number: NCT04713397, date of registration: 01/14/2021). LEVEL OF EVIDENCE: III.

Intramedullary nailing versus minimally invasive plating in the treatment of distal tibial extra-articular fractures: Comparison of cost analysis in Turkey.

BACKGROUND: Minimally invasive percutaneous plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are the two most commonly used methods for distal tibial extra-articular fractures; however, the ideal treatment is still on debate. The aim of this study was to compare MIPO and IMN in the treatment of distal tibial extra-articular fractures in terms of cost analysis according to health insurance records in Turkey. METHODS: The data of patients who underwent either MIPO or IMN for the treatment of distal tibial extra-articular fractures between 2013 and 2018 were analyzed in this retrospective study. Patients' clinical data, as well as the overall expenses from the first admission until return to work including hospitalization, and all outpatient controls had been reviewed from the hospital's billing department. The total amount of money paid per month by Turkish National Social Security Institution to the patient until the patient's returns to work were also recorded. RESULTS: 118 consecutive patients (35 female-83 male) with the mean age of 37.2±13.4 were participated to the study. IMN group consisted of 57 patients with a mean age of 36.7±12.8 years, and MIPO group consisted of 61 patients with a mean age of 37.8±13.6 years. No significant differences were observed between study groups in terms patients' age, gender, fracture classification (AO/OTA: Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association), soft-tissue injury (Tscherne classification), presence of type 1 open fracture, and presence of accompanying fibula fracture. There was no statistical difference between two groups in terms of pre-operative hospital stay (p=0.713). However, the mean length of hospital stay was significantly higher in the MIPO group (p=<0.001). The means of number of total outpatient controls, time to union, and return to work were also significantly higher in the MIPO group (p=0.005, p<0.001 and p<0.001, respectively). The mean hospital cost until discharge and the mean total cost until return to work were significantly higher in the MIPO group (p=0.001 and 0.001, respectively). The mean total costs of hospital stay and outpatient controls were also significantly higher in the MIPO group (p=0.001 and 0.004, respectively). The mean implant costs did not significantly differ between groups (p=0.179). CONCLUSION: According to the results acquired from the present study, IMN is a better option compared to MIPO for the treatment of extra-articular distal tibial fractures in terms of costs paid by the national health insurance in Turkey.

Thoracoscopic Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: Follow-up Curve Behavior According to Sanders Skeletal Maturity Staging.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To report the follow-up curve behaviors in different Sanders staging groups. SUMMARY OF BACKGROUND DATA: Vertebral body tethering (VBT) is a growth modulation technique that allows gradual spontaneous follow-up curve correction as the patient grows. There is a lack of scientific evidence regarding appropriate patient selection and timing of implantation. METHODS: Patients were grouped into five as: Sanders 1, 2, 3, 4-5, and 6-7. Data were collected preoperatively, at the day before discharge, and at each follow-up. Outcome measures were pulmonary and mechanical complications, readmission, and reoperation rates. Demographic, perioperative, clinical, radiographic, and complication data were compared using Fisher-Freeman-Halton exact tests for categorical variables and Kruskal-Wallis tests for the continuous variables. RESULTS: Thirty-one (29 F, 2 M) consecutive patients with a minimum of 12 months of follow-up were included. The mean age at surgery was 12.1 (10-14). The mean follow-up was 27.1 (12-62) months. The mean preoperative main thoracic curve magnitude was 47°â€Š±â€Š7.6°. For all curves, preoperative and first erect curve magnitudes, bending flexibility, and operative correction percentages were similar between groups (for all comparisons, P > 0.05). The median height gained during follow-up was different between groups (P < 0.001), which was reflected into median curve correction during follow-up. Total curve correction percentage was different between groups (P = 0.009). Four (12.9%) patients had pulmonary and six (19.4%) had mechanical complications. One (3.2%) patient required readmission and two (6.5%) required reoperation. Occurrence of pulmonary complications was similar in Sanders groups (P = 0.804), while mechanical complications and overcorrection was significantly higher in Sanders 2 patients (P = 0.002 and P = 0.018). CONCLUSION: Follow-up curve behavior after VBT is different in patients having different Sanders stages. Sanders 2 patients experienced more overcorrection, thus timing and/or correction should be adjusted, since Sanders 3, 4, and 5 patients displayed a lesser risk of mechanical complications. LEVEL OF EVIDENCE: 3.

Relative pelvic version: an individualized pelvic incidence-based proportional parameter that quantifies pelvic version more precisely than pelvic tilt.

BACKGROUND CONTEXT: Pelvic tilt (PT) is used as an indicator of pelvic version with increased values indicating retroversion and disability. The concept of using PT solely as an absolute numerical value can be misleading, especially for the patients with pelvic incidence (PI) values near the upper and lower normal limits. Relative pelvic version (RPV) is a PI-based individualized measure of the pelvic version. Relative pelvic version indicates the individualized spatial orientation of the pelvis relative to the ideal sacral slope as defined by the magnitude of PI. PURPOSE: The aim of this study was to compare RPV and PT for their ability to predict mechanical complications and their correlations with health-related quality of Life (HRQoL) scores. STUDY DESIGN: A retrospective analysis of a prospectively collected data of adult spinal deformity patients was carried out. Mechanical complications (proximal junctional kyphosis or proximal junctional failure, distal junctional kyphosis or distal junctional failure, rod breakage, and implant-related complications) and HRQoL scores (Oswestry Disability Index [ODI], Core Outcome Measures Index [COMI], Short Form-36 Physical Component Summary [SF-36 PCS], and Scoliosis Research Society 22 Spinal Deformity Questionnaire [SRS-22]) were used as outcome measures. METHODS: Inclusion criteria were ≥4 levels fusion, and ≥2-year follow-up. Correlations between PT, RPV, PI, and HRQoL were analyzed using Pearson correlation coefficient. Pelvic incidence values and mechanical complication rates in RPV subgroups for each PT category were compared using one-way analysis of variance, Student t test, and chi-squared tests. Predictive models for mechanical complications with RPV and PT were analyzed using binomial logistic regressions. RESULTS: A total of 222 patients (168 women, 54 men) met the inclusion criteria. Mean age was 52.2±19.3 (18-84) years. Mean follow-up was 28.8±8.2 (24-62) months. There was a significant correlation between PT and PI (r=0.613, p<.001), threatening the use of PT to quantify pelvic version for different PI values. Relative pelvic version was not correlated with PI (r=-0.108, p>.05), being able to quantify pelvic version for all PI values. Compared with PT, RPV had stronger partial correlations with ODI, COMI, SF-36 PCS, and SRS-22 scores (p<.05). Discrimination performance assessed by area under the curve, percentage accuracy in classification, true positive rate, true negative rate, and positive and negative predictive values was better for the model with RPV than for PT. For average PI sizes, the agreement between RPV and PT were moderate (0.609, p<.001), whereas the agreement in small and large PI sizes were poor (0.189, p>.05; -0.098, p>.496, respectively). When analyzed by RPV, each PT "0," "+," and "++" category was further divided into two or three distinct subgroups of patients having different PI values (p=.000, p=.000, and p=.029, respectively). Relative pelvic version subgroups within the same PT category displayed different mechanical complication rates (p=.000, p=.020, and p=.019, respectively). CONCLUSIONS: Pelvic tilt may be insufficient or misleading in quantifying normoversion for the whole spectrum of PI values when used as an absolute numeric value in conjunction with previously reported population-based average thresholds of 20 and 30 degrees. Relative pelvic version offers an individualized quantification of ante-, normo-, and retroversion for all PI sizes. Schwab PT groups were found to constitute inhomogeneous subgroup of patients with different mean PI values and mechanical complication rates. Compared with PT, RPV showed a greater association with both mechanical complications and HRQoL.

Detection of normal plantar fascia thickness in adults via the ultrasonographic method.

BACKGROUND: Heel pain is a prevalent concern in orthopedic clinics, and there are numerous pathologic abnormalities that can cause heel pain. Plantar fasciitis is the most common cause of heel pain, and the plantar fascia thickens in this process. It has been found that thickening to greater than 4 mm in ultrasonographic measurements can be accepted as meaningful in diagnoses. Herein, we aimed to measure normal plantar fascia thickness in adults using ultrasonography. METHODS: We used ultrasonography to measure the plantar fascia thickness of 156 healthy adults in both feet between April 1, 2011, and June 30, 2011. These adults had no previous heel pain. The 156 participants comprised 88 women (56.4%) and 68 men (43.6%) (mean age, 37.9 years; range, 18-65 years). The weight, height, and body mass index of the participants were recorded, and statistical analyses were conducted. RESULTS: The mean ± SD (range) plantar fascia thickness measurements for subgroups of the sample were as follows: 3.284 ± 0.56 mm (2.4-5.1 mm) for male right feet, 3.3 ± 0.55 mm (2.5-5.0 mm) for male left feet, 2.842 ± 0.42 mm (1.8-4.1 mm) for female right feet, and 2.8 ± 0.44 mm (1.8-4.3 mm) for female left feet. The overall mean ± SD (range) thickness for the right foot was 3.035 ± 0.53 mm (1.8-5.1 mm) and for the left foot was 3.053 ± 0.54 mm (1.8-5.0 mm). There was a statistically significant and positive correlation between plantar fascia thickness and participant age, weight, height, and body mass index. CONCLUSIONS: The plantar fascia thickness of adults without heel pain was measured to be less than 4 mm in most participants (~92%). There was no statistically significant difference between the thickness of the right and left foot plantar fascia.