Do corrective shoes improve the development of the medial longitudinal arch in children with flexible flat feet?

BACKGROUND: Flexible flatfoot, as the most prevalent foot deformity in pediatric population still has no standardized strategy for its management hence some orthopedic surgeons have the tendency to use orthotic devices. The objective of this study is to evaluate whether orthotic shoes effect the natural course of the developing medial longitudinal arch in children diagnosed with moderate flexible flatfoot. METHODS: Fourty-five children (33 boys and 12 girls) with moderate flexible flatfoot were enrolled in this study. They were followed up for 34.6 ± 10.9 months (24-57 months). Patients in group 1 were treated with corrective shoes whereas group 2 was left untreated. Patients were evaluated according to; general joint laxity, arch index, lateral talo-first metatarsal (TM), talo-horizontal (TH), calcaneal pitch (CP), lateral and anterior talocalcaneal (TC) angles. RESULTS: Although there was a significant decrease in general laxity in both groups, decrease of laxity percentage was not significant between groups (p = 0.812). TM, TH and anterior TC angles were found to be decreased in groups whereas there was no difference between group 1 and 2. The arch index was found to be correlated with TM and TH angles in both groups (p = 0.004, p = 0.013). CONCLUSIONS: Corrective shoes for flexible flatfoot was found not effective on development of foot arches. Therefore, they should be limited only for selected cases.

Bio-engineered synovial membrane to prevent tendon adhesions in rabbit flexor tendon model.

During tendon injuries, the tendon sheath is also damaged. This study aims to test effectiveness of engineered tendon synovial cell biomembrane on prevention of adhesions. Forty New Zealand Rabbits enrolled into four study groups. Engineered synovial sheath was produced by culturing cell suspension on fabricated collagen matrix membrane. Study groups were: tendon repair (group A), tendon repair zone covered with plane matrix (Group B), synovial suspension injection into the zone of repair over matrix (Group C), and biomembrane application (Group D). Biomechanical evaluations of tendon excursion, metacarpophalangeal and proximal interphalangeal joints range of motion, H&E and Alcian Blue with neutral red staining, and adhesion formation graded for histological assessments were studied. Ten non-operated extremities used as control. Tendon excursions and range of motions were significantly higher and close to control group for Group D, p < 0.05. Adhesion formation was not different among Groups C, D, and Control, p > 0.005. Hyaluronic acid synthesis was demonstrated at groups C and D at the zone of injury. Application of synovial cells into the tendon repair zone either by cell suspension or within a biomembrane significantly decreases the adhesion formation. Barrier effect of collagen matrix and restoration of hyaluronic acid synthesis can explain the possible mechanism of action.

The effect of pronation and inclination on the measurement of the hallucal distal metatarsal articular set angle.

OBJECTIVE: In this study, we tried to evaluate the effect of pronation and the inclination of the first metatarsal on the measurement of distal metatarsal articular angle (DMAA) in 10 cadaver first metatarsals. METHODS: Ten cadaver first metatarsals were fixed to a device. This device can change the inclination and pronation angles of the metatarsal. 15-30-45 degrees of inclination and 0-10-20 degrees of pronation were applied to the metatarsals. After applying radio-opaque putty to the medial and lateral articular edges and metatarsal dorsal diaphyseal ridge, the X-ray and digital images were taken at different degrees of inclination and pronation. A graphics software did the measurement of DMAA. The statistical analysis was done by paired sample t-test. RESULTS: The inclination had no effect on DMAA (p>0.1). The pronation of the first metatarsal was found to have a positive effect on DMAA (p<0.005). As the degree of pronation increased, the degree of DMAA was found to also increase. We found no difference between the measurements of the X-ray and the digital images. CONCLUSION: According to the current data, the measurement of DMAA is not suitable for making clinical and surgical decisions. The inclination of the first metatarsal can change, depending on the height of the medial longitudinal arch. By doing this study, we are trying to simulate the pes cavus and pes planus deformity on the radiologic measurement of pronation of the hallux. According to our results, inclination has no effect on the measurement of DMAA. However, the measurement of DMAA is expected to be dependent on the rotational deformity of the hallux.

The treatment of segmental bone defects in rabbit tibiae with vascular endothelial growth factor (VEGF)-loaded gelatin/hydroxyapatite "cryogel" scaffold.

The aim of this study was to investigate the effectiveness of a novel hydroxyapatite containing gelatin scaffold--with and without local vascular endothelial growth factor (VEGF) administration--as the synthetic graft material in treatment of critical-sized bone defects. An experimental nonunion model was established by creating critical-sized (10 mm. in length) bone defects in the proximal tibiae of 30 skeletally mature New Zealand white rabbits. Following tibial intramedullary fixation, the rabbits were grouped into three: The defects were left empty in the first (control) group, the defects were grafted with synthetic scaffolds in the second group, and synthetic scaffolds loaded with VEGF were administered at bone defects in the third group. Five rabbits in each group were killed on 6th and 12th weeks, and new bone growth was assessed radiologically, histologically and with dual-energy X-ray absorptiometry (DEXA). At 6 weeks, VEGF-administered group had significantly better scores than the other two groups. The second group also had significantly better scores than the control group. At 12 weeks, while no significant difference was noted between the second and third groups, these two groups both had significantly better scores in all criteria compared with the control group. There were no signs of complete fracture healing in the control group. The administration of hydroxyapatite containing gelatin scaffold yielded favorable results in grafting the critical-sized bone defects in this experimental model. The local administration of VEGF on the graft had a positive effect in the early phase of fracture healing.

Evaluation of the medial longitudinal arch: a comparison between the dynamic plantar pressure measurement system and radiographic analysis.

OBJECTIVES: The measurement of the medial longitudinal arch (MLA) of the foot is a controversial issue in orthopedics. Several methods have been developed to define and determine the MLA, but none of them are universally accepted. The purpose of this study was to compare some statically obtained radiographic angles with the dynamic plantar pressure distribution measurement system for the evaluation of the MLA in healthy individuals. METHODS: A total of 95 subjects (72 females, 23 males; mean age 37.8 years; range 11 to 85 years) were retrospectively evaluated. All the subjects were referred to the pedobarography laboratory for varying causes, had foot radiographies, and were evaluated as having normal feet. On standard lateral weight-bearing radiographs of the foot, the lateral talocalcaneal angle, talo-first metatarsal angle, talohorizontal angle, and calcaneal pitch angle were measured. The plantar pressure distribution was measured by the EMED-SF system. To evaluate the MLA, the arch index method was used. The arch index was calculated by the ratio of the pressure area of the midfoot to the sum of the forefoot, midfoot, and the hindfoot areas. Correlations between the radiographic angles and the arch index were analyzed by the Pearson correlation test. RESULTS: The mean values of the lateral talocalcaneal angle, talo-first metatarsal angle, talohorizontal angle, and calcaneal pitch angle were 43.2, 7.2, 29.5, and 41 degrees, respectively. The mean value of the arch index was 0.12 (range 0.04 to 0.17). There was no significant correlation between the arch index and gender (r=-0.10, p>0.05). The talo-first metatarsal (r=0.38) and talohorizontal (r=0.19) angles were found to be in significant correlation with the arch index (p<0.05), whereas the talocalcaneal (r=-0.16) and calcaneal pitch (r=-0.10) angles did not show correlation with the arch index (p>0.05). CONCLUSION: The arch index method is a simple and reproducible pedobarographic measurement for the evaluation of the MLA. However, the angles measured on statically obtained radiographs and showing correlations with the arch index may give similar results concerning the MLA. Both static and dynamic methods can be utilized in the evaluation of the MLA.

Results of triple arthrodesis: effect of primary etiology.

BACKGROUND: Severe disability originating from feet generally requires surgery. In addition to a number of other techniques, triple arthrodesis is still used to treat deformity and instability unresponsive to conservative measures. The aim of this study was to evaluate the results of the triple arthrodesis operation in two groups of patients with different primary etiologies and to identify the possible factors affecting the results. METHODS: During a 4-year period, triple arthrodesis was performed on 25 feet in 20 patients (average age 24.9 years). These patients were divided into two groups according to the primary etiology of the disability: neurogenic and nonneurogenic. Patients were evaluated with pre-and postoperative clinical examinations, American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot and Ankle Scale, radiography, pedobarography, and a general health questionnaire (Short Form 36, SF-36). The need for orthotics and the effect of previous treatments on the end results were also evaluated. RESULTS: The preoperative average AOFAS score improved from 24 to 71 postoperatively. Preoperative AOFAS values of neurogenic cases were significantly lower than those of nonneurogenic cases. Postoperative AOFAS values were found to be lower in neurogenic cases (64.0 vs. 77.6). Marked improvement was observed for all angular measurements. No relation was found between the AOFAS, changes in angular measurements, and pre-and postoperative plantar pressure analysis results. SF-36 results improved postoperatively in both groups. Triple arthrodesis decreased the use of orthotics postoperatively in both groups. Previous treatments were not found to affect the end results in this series. CONCLUSIONS: Triple arthrodesis operation is a surgical option with limited alternatives in patients with disabilities originating from feet. Both neurogenic and nonneurogenic patient groups improved significantly, and we were unable to show any significant differences in the results of these two groups.

[Pressure distribution patterns under the metatarsal heads in healthy individuals]. / Saglikli kisilerde metatars baslarinda dinamik basnç dagilim sekilleri.

OBJECTIVES: Recognition of plantar pressure distribution patterns of healthy individuals would be helpful in the management of metatarsalgia. We investigated plantar pressure distribution patterns under metatarsal heads in healthy individuals using the EMED-SF plantar pressure analysis system. METHODS: Plantar pressure measurements were performed in 106 healthy volunteers (45 females, 61 males; mean age 24 years; range 20 to 35 years) during walking on the EMED-SF platform. Footprints were divided into three areas based on the three functional columns of the tarsometatarsal joint, that is, the first metatarsal head, the second and third metatarsal heads, and the fourth and fifth metatarsal heads. The mean and peak pressures obtained in these areas were recorded. RESULTS: Pressure distribution patterns did not differ significantly between the two sexes and the right and left soles (p>0.05). The mean and peak pressures of the middle column during the mid-stance phase of the gait cycle were significantly higher than those recorded for the medial and lateral columns (p=0.000). There were no significant differences between the medial and lateral columns in this respect. At the pre-swing phase, pressures were significantly greater in the medial column compared to the lateral column. Four different patterns were noted with respect to the distribution of pressures among the three columns. Body mass index (BMI) was below the limit for obesity (<30 kg/m(2)) in all the participants. Peak pressure values obtained from each column at the pre-swing phase were significantly correlated with BMI (p<0.05); however, no correlation existed between the plantar pressures and BMI at the mid-stance phase (p>0.05). CONCLUSION: Our data show that there are four distinct pressure distribution patterns, but the greatest plantar pressure occurs in the middle column of the foot in the majority of healthy individuals.

The relationship between the hindfoot angle and the medial longitudinal arch of the foot.

INTRODUCTION: The relationship of hindfoot valgus and the medial longitudinal arch (MLA) is a well-known parameter for the evaluation of the foot deformities. In this study, we evaluated the relationship between the hindfoot angle and the MLA and the effect of these parameters on the development and general joint laxity of the subjects. METHODS: Two-hundred-sixty-one volunteers who had no foot pain or major foot deformity were examined. The age range of the volunteers was 4 to 20 years. For each subject, the right foot was evaluated for the clinical hindfoot angle and footprint analysis. General ligamentous laxity also was recorded. Arch index and valgus index were used for the evaluation of the footprint analysis, and the valgus angle was measured clinically. RESULTS: The average heel valgus angle for all subjects was 5.2 (SD 3.3) degrees. The means of valgus index and arch index were 3.34 (SD, 5.6) and 0.7 (SD, 0.2), respectively. Although there was a positive correlation between the valgus angle and valgus index (p = 0.027), the arch index was not found to be correlated with these values. Positive correlation between joint laxity and arch height also was demonstrated (p < 0.05). CONCLUSIONS: We concluded that the hindfoot angle and MLA height must be considered separately in clinical practice, particularly in the management of childhood pes planus.

[Is there a correlation between severity of trauma and serum trace element levels?]. / Travma siddeti ile serum eser element düzeyi iliskili mi?

OBJECTIVES: Trace elements zinc and copper are effective in wound and fracture healing. In this prospective study, correlations between mangled extremity severity score (MESS) and mangled extremity syndrome index (MESI) and serum zinc and copper levels were investigated in trauma patients. METHODS: Seventeen trauma patients (11 females, 6 males; mean age 41.6 years; range 11 to 73 years) were evaluated with respect to MESS and MESI scores. On the seventh day of trauma, serum samples were obtained to determine zinc and copper levels by atomic absorption spectrophotometry. RESULTS: Serum levels of zinc and copper showed significant negative correlations with both MESS (r=-0.65 and r=-0.76, respectively) and MESI (r=-0.83 and r=-0.77, respectively) scores (p<0.05). CONCLUSION: The severity of trauma is associated with significant decreases in serum levels of trace elements. Thus, trace element supplementation may be an important aspect of treatment in trauma patients.

Absence of the medial sesamoid bone associated with metatarsophalangeal pain.

Pain at the first metatarsophalangeal (MTP) joint can result from inflammation, chondromalacia, flexor hallucis brevis tendinitis, osteochondritis dessecans, fracture of a sesamoid bone, avascular necrosis of sesamoids, inflamed bursae, intractable keratoses, infection, sesamoiditis, gout arthropathy, and rheumatoid arthritis. Congenital absence of a sesamoid bone is extremely rare. We present a 17-year-old male patient with pain at the plantar aspect of the right MTP joint associated with congenital absence of the medial sesamoid. There was tenderness and the range of motion was minimally restricted. He described the pain as necessitating changes in his social life. On radiographs, the medial hallucial sesamoid was absent on the right side. The MTP joint was also evaluated using magnetic resonance imaging (MRI). A metatarsal pad was prescribed and the patient was satisfied with the treatment at the 2 months follow-up period. MRI revealed no pathological tissue at the medial sesamoid site. Hallucial sesamoids absorb pressure, reduce friction, protect the tendons, act like a fulcrum to increase the mechanical force of the tendons, and provide a dynamic function to the great toe by elevating first metatarsal head. Congenital absence of these bones is very rare but we must consider it in a patient with MTP joint pain.

Bilobed flaps for nonhealing ulcer treatment.

Healing of round ulcers may be difficult particularly in the plantar area. Rigidity and thickness of the plantar skin do not allow fusiform excision and primary suturing. The bilobed flap is a simple reconstructive technique principally used to repair substantial defects in the facial region. The authors' experience with this local flap in the foot is presented with good short-term results. Between 1995 and 1998, five female and seven male neuropathic foot patients with round plantar ulcers were treated with bilobed flaps. The average age of the patients was 50 (range, 15-76). The average size of the ulcers was 1.6 cm (1-3.2 cm). Debridement and orthotic insoles were used at least for 3 months before considering bilobed flaps. Seven patients were diagnosed as type II diabetes mellitus, four patients had cerebral palsy, and another patient had meningomyelocele. The minimal follow-up period was 1 year (average, 19.5 months). The only complication was wound dehiscence at the lateral side of the heel in a type II diabetic. Subsequently, this complicated ulcer was managed with a sliding flap and skin graft without further problem. The study concluded that nonhealing foot ulcers can be effectively treated with a bilobed skin flap of healthy tissues rotated from nonweightbearing parts of the sole.

The relationship between accessory navicular and medial longitudinal arch: evaluation with a plantar pressure distribution measurement system.

This study included 92 patients with an accessory navicular (AN) noted on an anteroposterior roentgenography. This group was selected from 860 patients admitted to the authors' gait analysis laboratory. The medial longitudinal arch was evaluated by using an "arch index" calculated from the pressure picture obtained from a pressure distribution measurement system. The average arch index was 0.15 and there was no significant correlation between AN types and arch index. The study concluded that the presence and type of AN are not correlated with the height of the medial longitudinal arch of the foot and that AN is not associated with pes planus.

Evaluation of the transverse metatarsal arch of the foot with gait analysis.

BACKGROUND: The existence of the transverse metatarsal arch (TMA) of the foot is a point of controversy. According to Kapandji, TMA of the foot elevates the 2(nd) to 4(th) metatarsal heads. Some authors suggest the existence of TMA, while others suggest that there is no functional metatarsal arch of the foot. In this study, we evaluated the existence of TMA of the foot and weight distribution on the metatarsal heads with the EMED-SF (Novel H, Munich, Germany) plantar pressure analysis system. METHODS: The test was performed with 16 volunteers. According to the three functional columns of the foot, the metatarsal region of pressure picture obtained from the EMED-SF system was divided into three regions called 'masks'. Mean pressures in the masks were calculated at the mid-stance phase. RESULTS: The highest mean pressure recorded was located at the 2nd to 3rd metatarsal heads (7.96 N/cm(2)), and the second highest pressure was at the heel (6.55 N/cm(2)). The pressures of the 1st metatarsal and 4th-5th metatarsal heads were 4.86 and 6.26 N/cm(2), respectively. The difference between the pressure distributions under metatarsal heads was statistically significant ( p=0.000). CONCLUSION: According to our results, TMA of the foot does not exist as described by Kapandji.