Long-term follow-up of flexor digitorum longus transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction.

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy is a well-recognised form of treatment for stage II posterior tibial tendon dysfunction. Although excellent short- and medium-term results have been reported, the long-term outcome is unknown. We reviewed the clinical outcome of 31 patients with a symptomatic flexible flat-foot deformity who underwent this procedure between 1994 and 1996. There were 21 women and ten men with a mean age of 54.3 years (42 to 70). The mean follow-up was 15.2 years (11.4 to 16.5). All scores improved significantly (p < 0.001). The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up. The mean pain component improved from 12.3 to 35.2 (20 to 40). The mean function score improved from 35.2 to 45.6 (30 to 50). The mean visual analogue score for pain improved from 7.3 to 1.3 (0 to 6). The mean Short Form-36 physical component score was 40.6 (sd 8.9), and this showed a significant correlation with the mean AOFAS score (r = 0.68, p = 0.005). A total of 27 patients (87%) were pain free and functioning well at the final follow-up. We believe that flexor digitorum longus transfer and calcaneal osteotomy provides long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

Intraoperative imaging in hallux valgus surgery.

BACKGROUND: This prospective study investigates the use of intraoperative fluoroscopy in hallux valgus surgery. To our knowledge there have been no studies questioning the benefit and reliability of intraoperative fluoroscopy in hallux valgus surgery. METHODS: We performed a prospective investigation of 28 consecutive cases undergoing hallux valgus surgery. Fluoroscopic images were examined intraoperatively and any significant findings documented. A comparison was made between these images and weight bearing films 6 weeks postoperatively to examine their reliability. We excluded those patients that went on to have an Akin osteotomy. RESULTS: There were no unforseen intraoperative events that were revealed by the use of fluoroscopy and no surgical modifications were made as a result of the intraoperative images. The intraoperative films were found to be a reliable representation of the postoperative weight bearing films but a small increase in the hallux valgus angle was noted at 6 weeks and this is thought to be due to stretching of the medial soft tissue repair. CONCLUSIONS: Intraoperative fluoroscopy is a reliable technique. This study was performed at a centre which performs approximately 100 hallux valgus operations per year and that should be taken into consideration when reviewing our findings. We conclude that there may be a role for fluoroscopy for surgeons in the early stages of the surgical learning curve and for those that infrequently perform hallux valgus surgery. We cannot, however, recommend that fluoroscopy be used routinely in hallux valgus surgery.

In situ arthrodesis with lateral-wall ostectomy for the sequelae of fracture of the os calcis.

Distraction bone-block arthrodesis has been advocated for the treatment of the late sequelae of fracture of the os calcis. Between 1997 and 2003 we studied a consecutive series of 17 patients who had in situ arthrodesis for subtalar arthritis after fracture of the os calcis with marked loss of talocalcaneal height. None had undergone any previous attempts at reconstruction. We assessed the range of dorsiflexion and plantar flexion and measured the talocalcaneal height, talocalcaneal angle and talar declination angle on standing lateral radiographs, comparing them with the normal foot. The mean follow-up was for 78.7 months (48 to 94). The mean American Orthopaedic Foot and Ankle Society hindfoot score improved from 29.8 (13 to 48) to 77.8 (48 to 94) (Student's t-test, p < 0.001). The mean loss of talocalcaneal height was 10.3 mm (2 to 17) and the mean talar declination angle was 6.7 degrees (0 degrees to 16 degrees) which was 36% of the normal side. One patient suffered anterior ankle pain but none had anterior impingement. Two patients complained of difficulty in ascending slopes and stairs and four in descending. The mean ankle dorsiflexion on the arthrodesed side was 11.6 degrees (0 degrees to 24 degrees) compared with 14.7 degrees (0 degrees to 24 degrees) on the normal side, representing a reduction of 21.1%. The mean plantar flexion on the arthrodesed side was 35.5 degrees (24 degrees to 60 degrees) compared with 44.6 degrees (30 degrees to 60 degrees ) on the normal side, a reduction of 20.4%. These results suggest that anterior impingement need not to be a significant problem after subtalar arthrodesis for fracture of the os calcis, even when the loss of talocalcaneal height is marked. We recommend in situ arthrodesis combined with lateral-wall ostectomy for all cases of subtalar arthritis following a fracture of the os calcis, without marked coronal deformity, regardless of the degree of talocalcaneal height loss.

Independent evaluation of a recently described Achilles tendon repair technique.

BACKGROUND: We investigated a previously reported technique for the repair of acute Achilles tendon ruptures using the percutaneous Achillon suture system (Intega Life Sciences Corporation, Plainsboro, NJ). METHODS: Twenty-five patients with Achilles tendon ruptures were studied prospectively with a minimum of 12 months followup. A single 2- to 3-cm horizontal incision and the Achillon suture system were used. Early rehabilitation and an active range-of-motion brace were instituted. RESULTS: There were no wound problems, sural nerve injuries, or re-ruptures. All patients were able to return to their previous sporting activities by 6 months. CONCLUSIONS: This independent study confirms that the technique offers patients a safe operative procedure for repair of acute Achilles tendon ruptures that allows early active rehabilitation.

Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study.

OBJECTIVE: To assess the use of a supervised active rehabilitation program following repair of acute Achilles tendon ruptures using a minimally invasive suture system. METHODS: We performed a prospective study on 46 patients undergoing surgical repair of acute Achilles tendon ruptures using the Achillon suture system. All patients began a supervised active rehabilitation program from 2 weeks postoperatively. Patients were placed in a range of motion brace fixed at 20 degrees equinus for 2 weeks to allow wound healing followed by active movement from neutral to full plantar flexion for 4 weeks. RESULTS: At a minimum follow up of 12 months there were no re-ruptures. All patients were able to return to their previous sporting activities by 6 months post operation. The average American Orthopaedic Foot and Ankle Society (AOFAS) score at 6 months was 98, with 42 patients having excellent and four patients good Leppilahti scores. The average time to return to work was 22 days. One patient had a superficial wound infection which settled with 5 days of oral antibiotics. Two patients had altered sensation in the distribution of the sural nerve which settled spontaneously within 3 months. CONCLUSION: The Achillon suture system appears to allow a safe early active rehabilitation program and achieves a high rate of success. Further evaluation is necessary with regard to potential damage to the sural nerve.

Triple arthrodesis: is bone grafting necessary? The results in 100 consecutive cases.

Our aim was to evaluate the results of triple arthrodesis, performed without the use of supplementary bone graft. We carried out a retrospective review of 100 consecutive triple arthrodeses. All the operations had been performed by the senior author (TSS) using a standard technique. Only local bone graft from the excised joint surfaces had been used, thereby avoiding complications at the donor site. The mean age of the patients at surgery was 58 years (18 to 84). The mean time to union was 5.1 months (3 to 17). There were 75 good, 20 fair and five poor results. There were four cases of nonunion. Our study has shown that comparable rates of union are achieved without the need for supplementary bone graft from the iliac crest or other donor site.

Results of isolated Lisfranc injuries and the effect of compensation claims.

The results of treatment of Lisfranc injuries are often unsatisfactory. This retrospective study investigated 46 patients with isolated Lisfranc injuries at a minimum of two years after surgery. Thirteen patients had a poor outcome and had to change employment, or were unable to find work as a result of this injury. The presence of a compensation claim (p = 0.02) and a delay in diagnosis of more than six months were associated with a poor outcome (p = 0.01). There was no association between poor functional outcome and age, gender, mechanism of injury or previous occupation. This study may have medico-legal implications on reporting the prognosis for such injuries, and highlights the importance of prompt diagnosis and treatment.

The role of MRI and ultrasound imaging in Morton's neuroma and the effect of size of lesion on symptoms.

We investigated 29 cases, diagnosed clinically as having Morton's neuroma, who had undergone MRI and ultrasound before a neurectomy. The accuracy with which pre-operative clinical assessment, ultrasound and MRI had correctly diagnosed the presence of a neuroma were compared with one another based on the histology and the clinical outcome. Clinical assessment was the most sensitive and specific modality. The accuracy of the ultrasound and MRI was similar and dependent on size. Ultrasound was especially inaccurate for small lesions. There was no correlation between the size of the lesion and either the pre-operative pain score or the change in pain score following surgery. Reliance on single modality imaging would have led to inaccurate diagnosis in 18 cases and would have only benefited one patient. Even imaging with both modalities failed to meet the predictive values attained by clinical assessment. There is no requirement for ultrasound or MRI in patients who are thought to have a Morton's neuroma. Small lesions, < 6 mm in size, are equally able to cause symptoms as larger lesions. Neurectomy provides an excellent clinical outcome in most cases.

Surgical treatment of insertional Achilles tendinosis.

Most patients with insertional Achilles tendinosis can be managed nonoperatively but those who do not respond may require excision of the diseased tendon. Currently, there are no clinical studies indicating how much of the tendon may be excised without predisposing the patient to Achilles tendon rupture. This chart review reports on 52 heels treated surgically for this condition and followed for a minimum of six months postoperatively. When less than 50% of the tendon was excised (49 heels) patients were immediately mobilized free of a cast. There were two failures using this regimen--one patient with psoriatic arthropathy and another who underwent bilateral simultaneous procedures. We suggest that in selected patients it is safe to proceed with early active mobilization immediately postoperatively when less than 50% of the tendon is resected.

Calcaneal osteotomy and transfer of the tendon of flexor digitorum longus for stage-II dysfunction of tibialis posterior. Three- to five-year results.

The treatment of acquired flat foot secondary to dysfunction of the posterior tibial tendon (PTT) of stage II, as classified by Johnson and Strom, remains controversial. Joint sparing and soft-tissue reconstructive procedures give good early results, but few studies describe those in the medium-term. We studied prospectively the outcome of surgery in 51 patients with classical stage-II dysfunction of the PTT treated by a medial displacement calcaneal osteotomy and transfer of the tendon of flexor digitorum longus. We reviewed 44 patients with a mean follow-up of 51 months (38 to 62). The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot rating scale improved from 48.8 before operation to 88.5 at follow-up. The operation failed in two patients who later had a calcaneocuboid fusion. The outcome in 43 patients was rated as good to excellent for pain and function, and in 36 good to excellent for alignment. There were no poor results.

Traumatic 'mallet toe' of the hallux: a case report.

We describe a case of a traumatic avulsion fracture of the distal phalanx of the hallux. In the upper limb this fracture leads to a "mallet" deformity. Such an injury in the great toe has not been reported previously in the English orthopaedic literature to our knowledge. The injury was treated in a dorsal extension splint for eight weeks. At six months follow-up, a satisfactory clinical outcome was achieved.

Arthroscopy of the hallux metatarsophalangeal joint.

Despite the paucity of literature on the subject of first MTP joint arthroscopy, the literature that does exist suggests that it is a worthwhile procedure in certain well-selected patients. These patients are usually young to middle-aged and have persistent pain and swelling of the first MTP joint that has failed to respond to conservative measures. These patients in general are too good for arthrodesis or arthroplasty, and certainly in the authors' experience, the results have been highly satisfactory.

Metatarsal neck osteotomy with rigid internal fixation for the treatment of lesser toe metatarsophalangeal joint pathology.

Metatarsalgia associated with metatarsophalangeal (MTP) joint instability and/or plantar callosity formation is a difficult problem to treat. During a 15-month period, we performed 50 osteotomies of the metatarsal neck with rigid internal fixation in 47 feet of 42 patients. Three patients were excluded from the study, leaving 47 osteotomies in 44 feet of 39 patients for review. There were 6 men and 33 women, with a mean age of 57 years. In addition to lesser MTP joint pain with or without instability, the majority of patients had first ray pathologic condition, which was also addressed at the time of surgery. All but one of the osteotomies were united radiologically at 6 weeks. The mean shortening was 4.1 mm (range, 2-12 mm), and the mean follow-up was 9 months. There were no cases of malunion, nonunion, or avascular necrosis. At follow-up, 33 patients were asymptomatic. Eight patients (nine feet) had a degree of persisting pain at follow-up (seven mild and two moderate), but the source of this pain was only the metatarsal or MTP joint that was operated on in three cases. In this article, we describe the indications, the technique, and the results of the osteotomy.

Plantar fasciitis: how successful is surgical intervention?

Forty-three patients (47 heels) underwent decompression of the nerve to abductor digiti minimi with partial plantar fascia release for intractable plantar fasciitis over a 4-year period. Forty-one patients (45 heels) were available for follow-up. All of the patients had failed to respond to nonoperative treatment. The mean duration of symptoms before surgery was 34.8 months (range, 12-132 months), and the mean follow-up was 31.4 months (range, 11-66 months). Seventy percent of the patients in the study were overweight or obese. Before surgery, 39 patients (43 heels) rated their heel pain as severe. At follow-up, 34 of 45 (75.6%) of the heels were pain-free or only mildly painful. The mean visual analogue pain score dropped from 8.5 of 10 preoperatively to 2.5 of 10 postoperatively. Only four patients failed to report an improvement in their activity restrictions, and only one patient had a walking distance of under 100 m after surgery; this patient had been affected by a reflex sympathetic dystrophy. Overall, however, only 20 of 41 patients were totally satisfied with the outcome (48.8%). We recommend that the small group of patients who fail to respond to nonoperative treatment be considered for surgical intervention. The results in terms of symptomatic relief are generally good but in terms of patient satisfaction can only be rated as moderate. The patients should be counseled about the likely outcome of surgery.

Intercuneiform instability and the "gap" sign.

We describe three cases of low-energy injuries to the midfoot resulting in rupture of Lisfranc's ligament without tarsometatarsal injury. Examination of the feet revealed an obvious physical sign only on weightbearing, and all three patients were noted at surgery to have intercuneiform instability in association with a rupture of Lisfranc's ligament.

Arthroscopy of the first metatarsophalangeal joint.

We carried out 12 arthroscopies of the first metatarsophalangeal (MTP) joint in 11 patients over a five-year period. Their mean age was 30 years (15 to 58) and the mean duration of symptoms before surgery was eight months (1 to 24). Six patients had an injury to the joint; all had swelling and tenderness with a reduced range of movement. In six patients, radiographs revealed no abnormality. Under general anaesthesia with a tourniquet the hallux is suspended by a large Chinese finger trap to distract the joint. Using a 1.9 mm 30 degree oblique arthroscope the MTP joint is inspected through dorsomedial and dorsolateral portals with a medial portal if necessary. All patients were found to have intra-articular pathology, which was treated using small instruments. The mean follow-up was 19.3 months (6 to 62) and all patients had no or minimal pain, decreased swelling and an increased range of movement of the affected joint.

Pigmented villonodular synovitis in the first metatarsophalangeal joint: arthroscopic treatment of an unusual condition.

Pigmented nodular synovitis is an uncommon condition of the foot. In this case history, we report a case of pigmented nodular synovitis in the first metatarsophalangeal joint, treated by arthroscopic synovectomy. Pigmented nodular synovitis to our knowledge has not been described in the first metatarsophalangeal joint. We report successful treatment of the condition by arthroscopic removal of the tissue, with the patient being asymptomatic 2 years after surgery.

Tear of the plantar calcaneonavicular (spring) ligament causing flatfoot. A case report.

Acquired flatfoot deformity after injury is usually due to partial or complete tearing of the tendon of tibialis posterior, with secondary failure of the other structures which maintain the medial longitudinal arch. We describe a patient in whom the rupture of the plantar calcaneonavicular (spring) ligament resulted in a clinical picture similar to that of rupture of the tendon of tibialis posterior. Operative repair of the ligament and transfer of the tendon of flexor digitorum gave an excellent result at four years with the patient returning to full sporting activities.

Feet and systemic disease.

Diabetes mellitus and rheumatoid arthritis often affect the foot. Indeed in either of these, the foot is commonly the initial site of symptoms. Early diagnosis appropriate treatment can prevent or at least slow the progression of the disease in the foot. Extra depth shoes and moulded inserts are the keystone of non operative treatment. Surgery is indicated when the deformity is severe. Surgery does have good results in rheumatoid arthritis but in diabetes mellitus it is usually reserved as a salvage procedure.