Reduction of Posterior Malleolus Fractures With Open Fixation Compared to Percutaneous Treatment.

Background: Operative decision making between approaches to posterior malleolus reduction remains a challenge. The purpose of this study is to compare the quality of reduction between percutaneous and open reduction of posterior malleolus fractures and to identify factors associated with malreduction. Methods: Operatively managed ankle fractures that included posterior malleolus fixation were reviewed. Fracture characteristics were determined on preoperative CT scans. Initial postoperative radiographs were used to measure reduction of the posterior malleolus articular surface and graded as satisfactory (<2 mm step-off) or malreduced (≥2 mm step-off). Final postoperative PROMIS scores and 1-year complications were compared between percutaneous and open cohorts. A multivariate stepwise regression model was used to evaluate predictors for malreduction. Results: A total of 120 patients were included. Open reduction was performed in 91 (75.8%) compared with 29 (24.2%) who underwent percutaneous reduction. Malreduction (≥2-mm articular step-off) occurred in 11.7% of patients. Malreduction rates were significantly higher with percutaneous fixation than open fixation (24.1% vs 7.7%, P = .02). Multiple fragments and those with ≥5 mm of displacement demonstrated higher malreduction rates with percutaneous fixation (P < .05 for both), whereas single fragments and those with <5 mm of displacement experienced similar malreduction rates with percutaneous or open fixation. Initial displacement ≥5 mm (relative risk [RR] = 3.8, 95% CI = 1.2-11.5, P = .02) and percutaneous treatment (RR = 4.1, 95% CI = 1.6-10.5, P < .01) were identified as independent risk factors for malreduction. There were no significant differences in 1-year complication rates or final PROMIS scores between groups. Conclusion: Open reduction of the posterior malleolus may lead to improved fracture reduction compared to percutaneous reduction without significant increase in complications. Open fixation improves reduction among fractures with multiple fragments or ≥5 mm of displacement, whereas fractures with a single fragment or <5 mm of displacement achieve similar reductions regardless of approach. Initial displacement ≥5 mm and percutaneous reduction are independent risk factors for malreduction. Level of evidence: Level III, therapeutic.

Single Medial vs 2-Incision Approach for Double Hindfoot Arthrodesis: Is There a Difference in Joint Preparation?

BACKGROUND: Double hindfoot arthrodesis is a reliable treatment option in lower extremity deformity and arthritis. Single (medial) and 2-incision techniques have been described. The purpose of this study was to evaluate the extent of cartilage debrided in each approach and to evaluate the competency of the deltoid ligament. METHODS: Eight matched pairs of cadaveric specimens were acquired. One limb from each pair was randomly assigned to the single medial incision and the other to the 2-incision technique. Stress radiographs were obtained prior to dissection to evaluate for valgus tibiotalar tilt. The talonavicular and subtalar articular surfaces were denuded of cartilage and the joints disarticulated. The percentage of cartilage debrided was determined using ImageJ software. Postoperative tibiotalar tilt was measured with a technique and threshold previously described by our group. The intraclass correlation coefficient was calculated to determine inter- and intraobserver reliability. RESULTS: The single medial incision demonstrated significantly less cartilage denuded than the 2-incision technique at the talar head (61.1% ± 20.4% vs 88.1% ± 6.1%, P < .001), and the posterior facets of the talus (53.5% ± 7.6% vs 73.6% ± 7.0%, P < .001) and calcaneus (55.3% ± 16.5% vs 81.0% ± 7.4%, P = .001). Overall, 75% of specimens that underwent a single medial incision approach demonstrated increased valgus tibiotalar tilt postdissection, whereas none that underwent the 2-incision technique developed increased tibiotalar tilt (P < .01). The average tibiotalar tilt among these specimens was 4.6 ± 1.3 degrees (range 2.5-5.7 degrees). For all measurements, the intraclass correlation coefficient was greater than 0.8. CONCLUSION: The posterior facet of the subtalar joint and talar head are at risk of subtotal debridement, as well as increased tibiotalar tilt with the single medial incision technique. Adequate debridement may require greater soft tissue dissection, possibly at the expense of medial ankle stability. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Peritalar Kinematics With Combined Deltoid-Spring Ligament Reconstruction in Simulated Advanced Adult Acquired Flatfoot Deformity.

BACKGROUND: Adult acquired flatfoot deformity (AAFD) is a complex and progressive deformity involving the ligamentous structures of the medial peritalar joints. Recent anatomic studies demonstrated that the spring and deltoid ligaments form a greater medial ligament complex, the tibiocalcaneonavicular ligament (TCNL), which provides medial stability to the talonavicular, subtalar, and tibiotalar joints. The aim of this study was to assess the biomechanical effect of a spring ligament tear on the peritalar stability. The secondary aim was to assess the effect of TCNL reconstruction in restoration of peritalar stability in comparison with other medial stabilization procedures, anatomic spring or deltoid ligament reconstructions, in a cadaveric flatfoot model. METHODS: Ten fresh-frozen cadaveric foot specimens were used. Reflective markers were mounted on the tibia, talus, navicular, calcaneus, and first metatarsal. Peritalar joint kinematics were captured by a multiple-camera motion capture system. Mild, moderate, and severe flatfoot models were created by sequential sectioning of medial capsuloligament complex followed by cyclic axial loading. Spring only, deltoid only, and combined deltoid-spring ligament (TCNL) reconstructions were performed. The relative kinematic changes were compared using 2-way analysis of variance (ANOVA). RESULTS: Compared with the initial condition, we noted significantly increased valgus alignment of the subtalar joint of 5.1 ± 2.3 degrees (P = .031) and 5.8 ± 2.7 degrees (P < .01) with increased size of the spring ligament tear to create moderate to severe flatfoot, respectively. We noted an increased tibiotalar valgus angle of 5.1 ± 2.0 degrees (P = .03) in the severe model. Although all medial ligament reconstruction methods were able to correct forefoot abduction, the TCNL reconstruction was able to correct both the subtalar and tibiotalar valgus deformity (P = .04 and P = .02, respectively). CONCLUSION: The TCNL complex provided stability to the talonavicular, subtalar, and tibiotalar joints. The combined deltoid-spring ligament (TCNL) reconstructions restored peritalar kinematics better than isolated spring or deltoid ligament reconstruction in the severe AAFD model. CLINICAL RELEVANCE: The combined deltoid-spring ligament (TCNL) reconstruction maybe considered in advanced AAFD with medial peritalar instability: stage IIB with a large spring ligament tear or stage IV.

Alterations in tibiotalar joint reaction force following syndesmotic injury are restored with static syndesmotic fixation.

INTRODUCTION: Syndesmotic injury alters joint mechanics, which may fail to be restored unless an anatomic reduction is obtained. METHODS: A minimally invasive method of measuring joint forces was utilized that does not require significant dissection or intraarticular placement of sensory instruments. Steinmann pins were placed in the tibia and talus of eight fresh-frozen human cadaveric lower extremities and a baseline joint reaction force was determined. A syndesmotic injury was created and reduction (anatomic and anterior malreduction) performed with one or two quadricortical screws and joint reaction forces were measured after the injury and subsequent repairs. FINDINGS: Baseline mean tibiotalar joint reaction force was 31.4 (SD 7.3 N) and syndesmotic injury resulted in a 35% decrease (mean 20.3, SD 8.4 N, p < 0.01). Fixation of the injury using one or two syndesmotic screws resulted in significant increase compared to the injury state (mean 28.7, SD3.9 N, and mean 28.3, SD 6.4 N, p < 0.05), however there was no significant difference between the two methods of fixation. Malreduction of the fibula also increased joint reaction force compared to the injury state (mean 31.5, SD 5.2 N, p < 0.01), however a significant difference was not detected between malreduction and anatomic reduction. INTERPRETATION: The present study demonstrates that syndesmotic injury decreases joint reaction force within the tibiotalar joint, suggesting ankle joint instability. Tibiotalar force was restored with anatomic reduction with either a 1 or 2 quadricortical syndesmotic screws. Furthermore, anterior malreduction restored joint reaction force to levels similar to those observed at baseline and with anatomic reduction. LEVEL OF EVIDENCE: Level V: biomechanical/cadaver study.

Spring ligament tear decreases static stability of the ankle joint.

BACKGROUND: Spring ligament tear is often found in advanced adult acquired flatfoot deformity and its reconstruction in conjunction with the deltoid ligament has been proposed to restore the tibiotalar and talonavicular joint stability. The aim of the present study is to determine the effect of spring ligament injury and subsequent reconstruction on static joint reactive force using a non-invasive method of measurement. METHODS: Ten fresh-frozen human cadaveric lower legs were disarticulated at the knee joint. Static joint reactive force of the tibiotalar and talonavicular joint were measured at baseline, after spring ligament injury, and after ligament reconstruction. Reconstruction consisted of a forked semitendinosis allograft with dual limbs to reconstruct the tibionavicular and tibiocalcaneal ligaments. FINDINGS: The mean baseline joint reactive force of the tibiotalar and talonavicular joints were 37.2 N + 8.1 N and 13.4 N + 4.2 N, respectively. The spring ligament injury model resulted in a significant 29% decrease in tibiotalar joint reactive force. Reconstruction of the tibionavicular limb resulted in a significant increase in tibiotalar and talonavicular joint reactive force compared to those seen in the injury state. Furthermore, the addition of the tibiocalcaneal limb significantly increased tibiotalar joint reactive force compared to those results obtained from the injury state and the tibionavicular limb alone. INTERPRETATION: This is the first study to demonstrate diminished tibiotalar static joint reactive force in a spring ligament injury model with subsequent joint reactive force restoration using two-limbed reconstruction of the deltoid and spring ligament. LEVEL OF EVIDENCE: Biomechanical Study.

Preoperative PROMIS Scores Predict Postoperative Success in Foot and Ankle Patients.

BACKGROUND: The use of patient-reported outcomes continues to expand beyond the scope of clinical research to involve standard of care assessments across orthopedic practices. It is currently unclear how to interpret and apply this information in the daily care of patients in a foot and ankle clinic. We prospectively examined the relationship between preoperative patient-reported outcomes (PROMIS Physical Function, Pain Interference and Depression scores), determined minimal clinical important differences for these values, and assessed if these preoperative values were predictors of improvement after operative intervention. METHODS: Prospective collection of all consecutive patient visits to a multisurgeon tertiary foot and ankle clinic was obtained between February 2015 and April 2016. This consisted of 16 023 unique visits across 7996 patients, with 3611 new patients. Patients undergoing elective operative intervention were identified by ICD-9 and CPT code. PROMIS physical function, pain interference, and depression scores were assessed at initial and follow-up visits. Minimum clinically important differences (MCIDs) were calculated using a distribution-based method. Receiver operating characteristic (ROC) curves were calculated to determine whether preoperative PROMIS scores were predictive of achieving MCID. Cutoff values for PROMIS scores that would predict achieving MCID and not achieving MCID with 95% specificity were determined. Prognostic pre- and posttest probabilities based off these cutoffs were calculated. Patients with a minimum of 7-month follow-up (mean 9.9) who completed all PROMIS domains were included, resulting in 61 patients. RESULTS: ROC curves demonstrated that preoperative physical function scores were predictive of postoperative improvement in physical function (area under the curve [AUC] 0.83). Similarly, preoperative pain interference scores were predictive of postoperative pain improvement (AUC 0.73) and preoperative depression scores were also predictive of postoperative depression improvement (AUC 0.74). Patients with preoperative physical function T score below 29.7 had an 83% probability of achieving a clinically meaningful improvement in function as defined by MCID. Patients with preoperative physical function T score above 42 had a 94% probability of failing to achieve MCID. Patients with preoperative pain above 67.2 had a 66% probability of achieving MCID, whereas patients with preoperative pain below 55 had a 95% probability of failing to achieve MCID. Patients with preoperative depression below 41.5 had a 90% probability of failing to achieve MCID. CONCLUSION: Patient-reported outcomes (PROMIS) scores obtained preoperatively predicted improvement in foot and ankle surgery. Threshold levels in physical function, pain interference, and depression can be shared with patients as they decide whether surgery is a good option and helps place a numerical value on patient expectations. Physical function scores below 29.7 were likely to improve with surgery, whereas those patients with scores above 42 were unlikely to make gains in function. Patients with pain scores less than 55 were similarly unlikely to improve, whereas those with scores above 67 had clinically significant pain reduction postoperatively. Reported prognostic cutoff values help to provide guidance to both the surgeon and the patient and can aid in shared decision making for treatment. LEVEL OF EVIDENCE: Level II, prognostic study.

Altered tendon characteristics and mechanical properties associated with insertional achilles tendinopathy.

STUDY DESIGN: Case-control laboratory study. OBJECTIVES: To compare tendon characteristics (shape, composition) and mechanical properties (strain, stiffness) on the involved side of participants with insertional Achilles tendinopathy (IAT) to the uninvolved side and to controls, and to examine if severity of tendon pathology is associated with severity of symptoms during function. BACKGROUND: Despite the severity and chronicity of IAT, the quality of theoretical evidence available to guide the development of exercise interventions is low. While tendon pathology of midportion Achilles tendinopathy has been described, there are few studies specific to IAT. METHODS: Twenty individuals with unilateral IAT and 20 age- and sex-matched controls volunteered to participate. Ultrasound imaging was used to quantify changes in tendon shape (diameter) and composition (echogenicity). A combination of ultrasound and dynamometry was used to measure tendon mechanical properties (strain and stiffness) during passive ankle rotation toward dorsiflexion. Generalized estimating equations were used to examine the association between IAT, alterations in tendon properties, and participant demographics. Pearson correlation was used to examine the association between severity of tendon pathology and severity of symptoms (Victorian Institute of Sport Assessment-Achilles). RESULTS: The side with IAT had a larger tendon diameter (P<.001), lower echogenicity (P<.001), higher strain (P = .011), and lower stiffness (P = .007) compared to the side without IAT and the controls. On the involved side of participants with IAT, a lower echogenicity correlated with higher severity of symptoms (r = 0.603, P = .010). CONCLUSION: Ultrasound imaging combined with dynamometry can discriminate alterations in tendon shape, composition, and mechanics in participants with IAT. Future clinical trials for IAT may consider strategies to alter tendon characteristics and restore tendon mechanics.

Adult-acquired flatfoot deformity and age-related differences in foot and ankle kinematics during the single-limb heel-rise test.

STUDY DESIGN: Cross-sectional laboratory study. OBJECTIVE: To compare single-limb heel-rise performance and foot-ankle kinematics between persons with stage 2 adult-acquired flat foot deformity (AAFD) and healthy controls. BACKGROUND: The inability to perform a single-limb heel rise is considered a positive functional diagnostic test for AAFD. However, which foot motions contribute to poor performance of this task are not known. METHODS: Fifty individuals participated in this study, 20 with stage 2 AAFD (mean ± SD age, 57.6 ± 11.3 years), and 15 older participants (age, 56.8 ± 5.3 years) and 15 younger participants (age, 22.2 ± 2.4 years) without AAFD as control groups. Forefoot (sagittal plane) and rear foot (sagittal and frontal planes) kinematics were collected using a 3-D motion analysis system. Heel-rise performance (heel height) and kinematics (joint angles, excursions) were evaluated. One-way and 2-way analyses of variance were used to examine differences in heel-rise performance and kinematics between groups. RESULTS: Individuals with AAFD and older controls demonstrated lower heel-rise height than those in the younger control group (P<.001). Persons with AAFD demonstrated higher degrees of first metatarsal dorsiflexion (P<.001), lower ankle plantar flexion (P<.001), and higher subtalar eversion (P = .027) than those in the older control group. Persons with AAFD demonstrated lower ankle excursion (P<.001) and first metatarsal excursion (P<.001) than those in the older control group, but no difference in subtalar excursion (P = .771). CONCLUSION: Persons with stage 2 AAFD did not achieve sufficient heel height during a single-leg heel rise. Both forefoot and rear foot kinematics in the sagittal plane, as opposed to the frontal plane, contributed to the lower heel height in participants with stage 2 AAFD. Older controls demonstrated lower heel-rise height than younger controls, indicating that clinical expectations of heel-rise performance may need to be adjusted for age.

Clinical outcomes and static and dynamic assessment of foot posture after lateral column lengthening procedure.

BACKGROUND: Lateral column lengthening (LCL) has been shown to radiographically restore the medial longitudinal arch. However, the impact of LCL on foot function during gait has not been reported using validated clinical outcomes and gait analysis. METHODS: Thirteen patients with a stage II flatfoot who had undergone unilateral LCL surgery and 13 matched control subjects completed self-reported pain and functional scales as well as a clinical examination. A custom force transducer was used to establish the maximum passive range of motion of first metatarsal dorsiflexion at 40 N of force. Foot kinematic data were collected during gait using 3-dimensional motion analysis techniques. RESULTS: Radiographic correction of the flatfoot was achieved in all cases. Despite this, most patients continued to report pain and dysfunction postoperatively. Participants post LCL demonstrated similar passive and active movement of the medial column when we compared the operated and the nonoperated sides. However, participants post LCL demonstrated significantly greater first metatarsal passive range of motion and first metatarsal dorsiflexion during gait than did controls (P < .01 for all pairwise comparisons). CONCLUSION: Patients undergoing LCL for correction of stage II adult-acquired flatfoot deformity experience mixed outcomes and similar foot kinematics as the uninvolved limb despite radiographic correction of deformity. These patients maintain a low arch posture similar to their uninvolved limb. The consequence is that first metatarsal movement operates at the end range of dorsiflexion and patients do not obtain full hindfoot inversion at push-off. Longitudinal data are necessary to make a more valid comparison of the effects of surgical correction measured using radiographs and dynamic foot posture during gait. LEVEL OF EVIDENCE: Level III, comparative series.

Prospective, randomized, multi-center feasibility trial of rhPDGF-BB versus autologous bone graft in a foot and ankle fusion model.

BACKGROUND: The increased morbidity and surgical time associated with harvesting autologous bone graft (ABG) have encouraged surgeons to develop synthetic orthobiologic alternatives. The recombinant form of platelet-derived growth factor (rhPDGF-BB), an angiogenic, mitogenic, and chemotactic cytokine, has been shown to significantly enhance bone formation in human periodontal osseous defects when combined with a tricalcium phosphate carrier (ß-TCP). The purpose of this prospective, controlled, randomized, multi-center feasibility clinical trial was to compare the safety and efficacy of this biosynthetic bone graft substitute (Augment™ Bone Graft) to ABG during ankle and hindfoot fusion. MATERIALS AND METHODS: Twenty adult subjects requiring ankle or hindfoot fusion from three U.S. centers were enrolled and randomized in a 2:1 ratio to receive Augment™ or ABG, respectively. Surgical approach and fixation techniques were standardized, and minimum followup was 9 months. The primary endpoint was radiographic osseous union, evaluated by a blinded independent radiologist. Secondary endpoints included assessment of clinical success, union rate by serial computed tomography (CT) examination, time to full weightbearing, AOFAS Ankle-Hindfoot Score (AOFAS), Foot Function Index (FFI), Short Form-12 (SF-12), and Visual Analog pain assessment Scale (Pain VAS). RESULTS: At 36 weeks, 77% (10/13) of the Augment™ and 50% (3/6) of the ABG patients were fused based on radiographic criteria. There were two nonunions in the Augment™ group (9%, 2/14). Healing rates based on 12 week CT scanning (50% osseous bridging) were 69% (9/13) in the Augment™ and 60% (3/5) in the ABG groups, respectively. All functional outcome measures (FFI, AOFAS, SF-12), as well as the VAS pain scores, improved in both groups over time. Surgical procedure times lasted an average 26 minutes longer for the ABG as compared to the Augment™ populations. There were no device related serious adverse events in this study. CONCLUSION: Based on the available data, the rate of radiographic union, time to full weightbearing, and outcomes scores between the Augment™ and ABG subjects appear comparable. Augment™ may represent a safe and efficacious treatment alternative to ABG during foot and ankle arthrodesis.

Deep posterior compartment strength and foot kinematics in subjects with stage II posterior tibial tendon dysfunction.

BACKGROUND: Tibialis posterior muscle weakness has been documented in subjects with Stage II posterior tibial tendon dysfunction (PTTD) but the effect of weakness on foot structure remains unclear. The association between strength and flatfoot kinematics may guide treatment such as the use of strengthening programs targeting the tibialis posterior muscle. MATERIALS AND METHODS: Thirty Stage II PTTD subjects (age; 58.1 +/- 10.5 years, BMI 30.6 +/- 5.4) and 15 matched controls (age; 56.5 +/- 7.7 years, BMI 30.6 +/- 3.6) volunteered for this study. Deep Posterior Compartment strength was measured from both legs of each subject and the strength ratio was used to compare each subject's involved side to their uninvolved side. A 20% deficit was defined, a priori, to define two groups of subjects with PTTD. The strength ratio for each group averaged; 1.06 +/- 0.1 (range 0.87 to 1.36) for controls, 1.06 +/- 0.1 (range, 0.89 to 1.25), for the PTTD strong group, and 0.64 +/- 0.2 (range 0.42 to 0.76) for the PTTD weak group. Across four phases of stance, kinematic measures of flatfoot were compared between the three groups using a two-way mixed effect ANOVA model repeated for each kinematic variable. RESULTS: Subjects with PTTD regardless of group demonstrated significantly greater hindfoot eversion compared to controls. Subjects with PTTD who were weak demonstrated greater hindfoot eversion compared to subjects with PTTD who were strong. For forefoot abduction and MLA angles the differences between groups depended on the phase of stance with significant differences between each group observed at the pre-swing phase of stance. CONCLUSION: Strength was associated with the degree of flatfoot deformity observed during walking, however, flatfoot deformity may also occur without strength deficits. CLINICAL RELEVANCE: Strengthening programs may only partially correct flatfoot kinematics while other clinical interventions such as bracing or surgery may also be indicated.

Ankle and foot kinematics associated with stage II PTTD during stance.

BACKGROUND: Subjects with stage II posterior tibial tendon dysfunction (PTTD) exhibit abnormal foot kinematics; however, how individual segment kinematics (hindfoot (HF) or first metatarsal (first MET) segments) influence global foot kinematics is unclear. The purpose of this study was to compare foot and ankle kinematics and sagittal plane HF and first MET segment kinematics between stage II PTTD and controls. MATERIALS AND METHODS: Thirty patients with stage II PTTD and 15 healthy controls were evaluated. Kinematic data from the tibia, calcaneus, and first MET were collected during walking using three dimensional motion analysis techniques. A three-segment foot model (HF, calcaneus; first MET, first metatarsal, and tibia) was used to calculate relative angles (ankle, HF relative to tibia; midfoot, first MET relative to HF) and segment angles (HF and first MET relative to the global). A mixed effect ANOVA model was utilized to compare angles between groups for each variable. RESULTS: Patients with PTTD showed greater ankle plantarflexion (p = 0.02) by 6.8 degrees to 8.4 degrees prior to or at 74% of stance; greater HF eversion (p < 0.01) across stance (mean difference = 4.5 degrees); and greater first MET dorsiflexion (p < 0.01) across stance (mean difference = 8.8 degrees). HF and first MET segment angles revealed greater HF dorsiflexion (p = 0.01) during early stance and greater first MET dorsiflexion (p = 0.001) across stance. CONCLUSION: Abnormal HF and first MET segment kinematics separately influence both ankle and midfoot movement during walking in subjects with stage II PTTD. CLINICAL RELEVANCE: These abnormal kinematics may serve as another measure of response to clinical treatment and/or guide for clinical strategies (exercise, orthotics, and surgery) seeking to improve foot kinematics.

The relationship between ankle, hindfoot, and forefoot position and posterior tibial muscle excursion.

BACKGROUND: The purpose of this study was to examine the relationship of forefoot position in the transverse plane (abduction/adduction), hindfoot position in the frontal plane (eversion/inversion), and ankle position in the sagittal plane (plantarflexion/dorsiflexion) with posterior tibialis (PT) muscle excursion using an in vitro cadaver model. METHODS: Seven fresh-frozen cadaver specimens were potted and mounted on a frame. The PT tendon was dissected 15 cm proximal to the medial malleolus, and a 5-kg weight was sutured to the tendon. A six-camera motion analysis system (Optotrak, Northern Digital, Inc.) was used to track three-dimensional (3-D) motion of the tibia, calcaneus (hindfoot) and first metatarsal (forefoot) using bone pins. The ankle, hindfoot, and forefoot were manually placed in 24 different ankle and foot positions. A stepwise regression analysis was used to examine the relationship among ankle, hindfoot, and forefoot kinematics and PT muscle excursion. RESULTS: Hindfoot eversion/inversion and forefoot abduction/adduction accounted for 77% of the variance in PT muscle excursion, with small contributions from ankle plantarflexion/dorsiflexion (5.7%) and forefoot plantarflexion/dorsiflexion (1.9%). A combined regression equation applied to individual specimens resulted in average errors of less than 2.5 mm. CONCLUSIONS: This study supports the hypothesis that PT muscle excursion can be estimated using specific foot and ankle kinematic variables. Further, these data suggest that hindfoot eversion and forefoot abduction account for most of the variance in PT muscle excursion and are theorized to be important to control clinically altering the length of the posterior tibial muscle.

Using resident input to identify and integrate essential components of a foot and ankle rotation.

BACKGROUND: Foot and ankle surgery is one of the orthopaedic subspecialties to which residents not uncommonly receive limited exposure. Therefore, it is important to identify what both faculty and residents regard as fundamental to a foot and ankle rotation. The purposes of this study were to identify the essential components of a foot and ankle rotation and to correlate these with the American Orthopaedic Foot and Society (AOFAS) core curriculum, and to discuss how to integrate resident input and AOFAS guidelines into a valued foot and ankle rotation. METHODS: Over a 5-year period, each orthopaedic resident beginning a 10-week postgraduate year (PGY) 3 foot and ankle rotation was asked to choose topics to be covered during weekly 45-minute discussion conferences. Each resident also identified personal goals for the rotation. Data were collected in this prospective nature, and the responses of the 24 PGY 3 residents from our program who completed the rotation between February, 2000, and April, 2005, were analyzed. The discussion conference topics were compared to the AOFAS guidelines, and the top 10 personal goals were determined. Prerotation and postrotation Orthopaedic Inservice Training Examination (OITE) foot and ankle scores for the residents also were analyzed. RESULTS: Among the nine AOFAS core curriculum categories, residents most frequently chose chronic soft-tissue foot and ankle problems, followed in frequency by foot and ankle arthritis, foot and ankle trauma, and diabetic foot. Individually, posterior tibial tendon insufficiency, hallux valgus, diabetic foot, and calcaneal fracture were the most frequently chosen discussion conference topics. In regards to personal goals for the rotation, residents most commonly wanted to improve their physical examination skills (88%) and increase their orthotic knowledge (71%). The OITE scores improved by a mean of 12% after the rotation. CONCLUSIONS: This study provides new and detailed information about resident expectations for a valued foot and ankle rotation. These results should be integrated with existing AOFAS guidelines to further refine the essential components of a core foot and ankle curriculum.

The role of extracorporeal shock wave on plantar fasciitis.

Extracorporeal shock wave therapy for chronic plantar fasciitis has been under investigation since its advent in the early 1990s. Its use has been approved by the U.S. Food and Drug Administration; however, much controversy exists surrounding its mechanism of action, treatment protocols, and clinical efficacy. This article reviews some of the existing theories, opinions, and data in an attempt to summarize the current role that shock wave therapy plays in the treatment of plantar fasciitis.