Management of acute and chronic lateral ligament injuries of the ankle.

Acute and chronic lateral ligament injuries of the ankle represent a common but persistent problem to orthopedic specialists. A comprehensive physical examination and classification system were proposed as an approach to this problem. Guidelines for both conservative and surgical management for acute and chronic injuries are described. A comparison of the most common lateral ligament repairs is provided, with emphasis on the benefits of the so-called anatomic repair.

Reconstruction of neglected Achilles tendon injury.

Chronic Achilles tendon injuries are debilitating injuries that are often difficult to treat. A review of previously reported procedures is presented. A new technique for repair is presented utilizing a transfer of the flexor hallicus longus muscle and tendon to provide a dynamic repair. A review of the clinical outcome from this procedure is provided.

Morphology of tibiotalar osteophytes in anterior ankle impingement.

The purpose of this study was to document radiographic trends in the size and location of osteophytes occurring in patients who have undergone surgical treatment of bony anterior ankle impingement. All patients over a period of 31 months who had undergone surgical excision of anterior ankle osteophytes were identified. 9 patients (10 ankles) in whom preoperative CT scans were available were selected as the study group. This group was retrospectively reviewed in terms of basic preoperative characteristics (age, sex, symptomatology, sports history, systemic disease, passive dorsiflexion). Osteophyte size was measured on plain lateral radiographs, and axial CT images were used to determine both tibial and talar osteophyte location by referencing them to the midline of the talar dome. 95% confidence intervals demonstrated that the talar spur peak lies medial to the midline, the tibial spur peak lies lateral to the midline, and the spurs typically do not overlap each other. Further, the tibial spur is wider than the talar spur, and the talar spur usually protrudes medially off the medial edge of the talar neck. Thus, there is evidence that anterior tibiotalar osteophytes may have a relatively consistent pattern of formation, with the talar spur occurring on the medial aspect of the talar neck, and the tibial spur peaking lateral to the midline.This information, if substantiated with additional patients, may provide insight into the pathophysiology of anterior ankle impingement, as well as facilitate the open and arthroscopic approaches toward resection of these lesions.

Heel anatomy for retrograde tibiotalocalcaneal roddings: a roentgenographic and anatomic analysis.

There is an increased interest in load-sharing devices for tibiotalocalcaneal arthrodesis. Although the neurovascular anatomy of the heel has been well described, the purpose of this study is to consider heel anatomy as it relates to plantar heel incisions and to well-defined fluoroscopic landmarks to prevent complications during these procedures. Twenty lateral radiographs of normal feet while standing were evaluated by two observers. The distance from the calcaneocuboid (CC) joint to a line parallel to the center of the intramedullary canal of the tibia was calculated. In the second part of the study, 14 dissections of the arterial and neural anatomy were performed. The distances from the CC joint to structures crossing the heel proximal to the CC joint were studied. In the 20 standing radiographs, the mean distance from the CC joint to the middle of the intramedullary canal of the tibia was 2.1 cm (standard deviation, 0.55 cm). In the dissections, the only artery or nerve found to cross the plantar surface proximal to the CC joint was the nerve to the abductor digiti quinti (NAbDQ). The mean distance from the CC joint to the NAbDQ was 3.1 cm (standard deviation, 1.36 cm). Assuming reaming to 12 mm, NAbDQ would be at risk 42% of the time. We recommend careful dissection of the heel during retrograde roddings to avoid damage to NAbDQ and subsequent neurogenic heel pain.

Computed tomographic demonstration of the vacuum phenomenon in the subtalar and tibiotalar joints.

Gas has been identified within diarthrodial joints for more than eight decades. From a radiologic standpoint, the so-called "vacuum phenomenon" is the most common demonstration of gas. We retrospectively reviewed computed tomographic scans of 495 feet and ankles performed over a 24-month period. We found 12 patients (2.4%) with clearly demonstrable gas within the tibiotalar or subtalar joints. This gas was not associated with the presence of fixation hardware or infection. Each patient with gas in the subtalar joint had plain radiographic changes consistent with subtalar arthritis. We conclude that gas in the subtalar joint can be effectively demonstrated by high-resolution CT techniques in the subtalar and tibiotalar joints in patients with advanced degenerative disease.

Anatomy of second muscular layer of the foot: considerations for tendon selection in transfer for Achilles and posterior tibial tendon reconstruction.

Controversy exists regarding tendon choice to substitute for a ruptured posterior tibial tendon. A similar debate about late Achilles tendon reconstruction also persists. To establish priorities and aid the surgeon's decision-making process, we studied 85 en bloc dissections of the second muscular layer of the sole. Muscular and tendinous interconnections were evaluated. Location and minimal donor deficit following harvest of the flexor digitorum longus make it the transfer of choice for posterior tibial tendon reconstruction. We suggest that relative strength, anatomic location, and available length of tendon make the flexor hallucis longus the superior choice for late Achilles tendon reconstruction.

Arthrodesis of the first metatarsophalangeal joint to salvage failed silicone implant arthroplasty.

Between 1987 and 1992, all patients presenting to the senior author with a symptomatic failed silicone implant arthroplasty refractory to conservative treatment were converted to a metatarsophalangeal joint arthrodesis. Internal fixation was achieved with either dual intrameduilary threaded Steinmann pins or an obliquely placed AO compression screw and a three- or four-hole one-third tubular dorsal neutralization plate. Bone grafting was used to maintain hallux length. Successful arthrodesis was achieved in all five feet in patients with rheumatoid arthritis. Subjectively, patients improved from an average of 0.69 before arthrodesis to 4.89 after arthrodesis. The average walking tolerance improved from 1.11 to 4.80, and the overall level of satisfaction improved from 0.0 to 4.79. The patient's ability to wear shoes improved from 0.87 to 3.1. Successful arthrodesis produces a foot that is more functional and durable than excisional arthroplasty. Subjectively, these patients stated that their level of pain, walking tolerance, and overall satisfaction improved significantly after the arthrodesis. Clinically, there was no evidence of transfer lesions, tenderness, or hallux subluxation. Hallux length was well maintained after surgery with bone grafting, but it was more difficult to obtain the alignment goals. The average postoperative metatarsophalangeal dorsiflexion angle was 15.6 degrees and the first metatarsophalangeal angle was 3.1 degrees. Despite this, patient satisfaction was high. Arthrodesis of the first metatarsophalangeal joint using a bone graft to salvage failed silicone implant arthroplasty produces acceptable subjective and radiographic results. Although technically demanding, it provides long-term stability to the hallux, restores weightbearing, and allows for maintenance of a propulsive gait. We recommend this procedure instead of an excisional arthroplasty to maintain high level of function and overall patient satisfaction.

Nonoperative management of posterior tibial tendon dysfunction.

Forty-nine patients with posterior tibial tendon dysfunction (4 patients had bilateral involvement) were treated with orthoses. Forty feet were treated with molded ankle-foot orthoses, and 13 feet were treated with University of California Biomechanics Laboratory shoe inserts with medial posting. A total of 37 women and 12 men were included in the study. The mean follow-up period was 20.3 months (range, 8-60 months). The average age of the patients was 66 years (range, 42-89 years). Sixty-seven percent of patients had good to excellent results, according to a functional scoring system based on pain, function, use of assistive device, distance of ambulation, and patient satisfaction. The average period of orthosis use was 14.9 months (range, 1.5-29 months), with an average length of daily orthosis wear of 12.3 hours. One patient elected to undergo surgical treatment rather than continuing with long-term orthosis use. Thirty-three percent of patients had discontinued using the orthosis at the time of follow-up evaluation. Three patients were unable to wear the orthosis because of concurrent medical conditions. Nine patients stopped wearing the orthosis after experiencing discomfort and inconvenience. Although these patients continued to exhibit signs and symptoms of posterior tibial tendon dysfunction, they were not disabled enough to consider further treatment. Four patients tolerated orthosis treatment poorly and were treated surgically. Patients with posterior tibial tendon dysfunction can be treated by aggressive nonoperative management using molded ankle-foot orthoses or University of California Biomechanics Laboratory shoe inserts with medial posting. Surgical treatment can be reserved for patients who fail to respond to an adequate trial of brace treatment. Nonoperative management using an orthosis is particularly useful for elderly patients with a sedentary lifestyle or for patients at high risk because of medical problems.

Posterior tibial tendon dysfunction: secondary MR signs.

We evaluated four potential secondary magnetic resonance imaging signs to aid in clinical diagnosis of posterior tibial tendon (PTT) tears. Seventy-one ankles (25 PTT tears and 46 controls) were evaluated for the following secondary signs: (1) PTT sheath fluid, (2) a distal tibial spur located just anterior to the PTT, (3) unroofing of the talus, and (4) "bone bruise"--like medullary lesions. Two musculoskeletal radiologists rated their confidence using a scale and were compared for level of agreement. The presence of PTT sheath fluid had modest specificity and fair to moderate sensitivity. Tibial spurring and unroofing of the talus had excellent specificity and fair sensitivity. Bone bruise-like lesions were commonly seen in cases and controls. Examination of divergence of opinion between the two radiologists revealed pitfalls in interpretation of PTT sheath fluid and bone bruise-like lesions, which were commonly the result of adjacent vessels and inhomogeneous fat saturation, respectively. We conclude that secondary signs of PTT tears with high specificities include unroofing of the talus, tibial spurring, and PTT sheath fluid.

Plantar fibromatosis: a review of primary and recurrent surgical treatment.

Plantar fibromatosis can be quite disabling to the patient, as well as a technical challenge to the surgeon. Patients who undergo previous local excisions and in whom aggressive recurrences develop are difficult to manage successfully. We present a consecutive series of five primary procedures on patients with painful plantar fibroma and seven revision operations on patients with recurrent plantar fibroma. The average follow-up was 47 months (range, 22-66 months) in the primary group and 40 months (range, 21-78 months) in the revision group. The overall results were satisfactory in four of the five primary operations, with only one recurrence. In the revision group, five of seven results were satisfactory with no recurrences. The major complication that led to unsatisfactory results was the development of a postoperative neuroma. In this article, we outline our present surgical techniques of wide primary excision and a staged revision procedure with delayed split-thickness skin graft closure. These techniques can be used successfully to manage this disabling, progressive disease.

Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency.

Ten patients were identified with traumatic, complete common peroneal nerve palsy, with no previous foot or ankle surgery or trauma distal to the knee, who had undergone anterior transfer of the posterior tibial tendon to the midfoot. Six of these patients had a transfer to the midfoot and four had a Bridle procedure with tenodesis of half of the posterior tibial tendon to the peroneus longus tendon. Average follow-up was 74.9 months (range, 18-351 months). All patients' feet were compared assessing residual muscle strength, the longitudinal arch, and motion at the ankle, subtalar, and Chopart's joint. Weightbearing lateral X-rays and Harris mat studies were done on both feet. In no case was any valgus hindfoot deformity associated with posterior tibial tendon rupture found. It seems that the pathologic condition associated with a posterior tibial tendon deficient foot will not manifest itself if peroneus brevis function is absent.

Regional anesthesia in foot and ankle surgery.

A method of regional anesthesia use in forefoot and midfoot surgery is described. Careful identification of the peripheral sensory nerves allows for effective anesthesia using bupivacaine and lidocaine in addition to sedation for comfort. A review of 355 patients showed that 98% received an effective surgical block of the sensory nerves. Complications were found to be minimal and patient satisfaction was high. This method provides a safe and effective anesthesia alternative for foot and ankle surgery.

Complications of achilles and posterior tibial tendon surgeries.

Surgery of the Achilles and posterior tibial tendons requires finesse to achieve optimal function. Although superficial in anatomic location, various critical neurovascular structures exist in close proximity. The superficial blood supply is fragile, requiring a delicate touch to prevent problems with wound healing. Damaged tendon tissue often is friable, making it difficult to sew or anchor. Adjusting the tendon length to the appropriate tension requires good judgment and affects long-term outcome through power and range of motion. Finally, surgery on these two tendons significantly affects function of the ankle and longitudinal arch, where small changes are magnified into large changes in maintaining normal gait. The current authors review the complications encountered in various common surgeries of the Achilles and posterior tibial tendons.

Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer.

A new technique is described for reconstruction of chronic Achilles tendon rupture using the flexor hallucis longus tendon. Follow-up on seven patients (mean age 52 years) is provided (average follow-up 17 months, range 3-30 months). All patients were re-examined to assess postoperative range of motion, scar healing, and sensation. Motor strength was assessed by Cybex testing. Subjective satisfaction was examined by completion of a questionnaire. There were no postoperative infections, skin losses, or re-ruptures. Each patient developed a small but functionally insignificant loss in range of motion in the involved ankle and great toe. All patients had a satisfactory return of function. One patient required a molded foot-ankle orthosis for extended ambulation but was able to play golf.

Effects of thermal therapy on rehabilitation after total knee arthroplasty. A prospective randomized study.

The role of local heat or cold therapy used in conjunction with exercise in the rehabilitation of total knee arthroplasty patients was investigated. Thirty-six osteoarthritic patients were analyzed. Parameters evaluated were range of motion, swelling about the knee, and pain. All patients received the total condylar knee prosthesis and began range of motion rehabilitation fourteen days after operation. Results showed that temperature alteration does not augment passive range of motion after total knee arthroplasty. It was also shown that cold application decreases swelling as compared with heat. Additionally, the application of cold partially alleviates the discomfort of the rehabilitation process in certain patients.

MR imaging findings of entrapment of the flexor hallucis longus tendon.

OBJECTIVE: In this retrospective study, we describe the MR imaging patterns of various causes of flexor hallucis longus tendon entrapment. CONCLUSION: Entrapment of the flexor hallucis longus tendon may be due to an enlarged os trigonumtarsitarsi, calcaneal fracture, and soft-tissue scar. These disorders have characteristic imaging findings that may be revealed on MR imaging.

Osteomyelitis in feet of diabetics: clinical accuracy, surgical utility, and cost-effectiveness of MR imaging.

PURPOSE: To evaluate sensitivity, specificity, clinical utility, and cost-effectiveness of magnetic resonance (MR) imaging in the diagnosis of osteomyelitis of the foot in diabetics. MATERIALS AND METHODS: MR studies of 62 feet (diabetics [n = 27], nondiabetics [n = 35]) in 59 patients were prospectively evaluated to detect the presence and extent of osteomyelitis. Biopsy (n = 41 feet) and clinical follow-up (n = 62 feet) were used to establish the diagnosis, select treatment, and determine outcome; sensitivity and specificity of MR imaging were calculated. A cost analysis was performed. RESULTS: Sensitivity and specificity of MR imaging in the diagnosis of osteomyelitis were 82% and 80%, respectively, in diabetics and 89% and 94%, respectively, in nondiabetics. There was no recurrent infection at the surgical margin in 13 feet in which the area of limited resection had been delineated at MR imaging. CONCLUSION: MR imaging shows good sensitivity and specificity for diagnosing osteomyelitis in diabetic feet, and it is competitively priced compared with other imaging modalities. Accurate delineation of extent allows limited surgical resection, making MR imaging clinically useful and cost-effective.