An unusual exostosis presenting as a bunion deformity.

A large exostosis was the source of a bunion deformity in a 60-year-old woman. Its unusual clinical and radiographic features were suggestive of a bizarre parosteal osteochondromatous proliferation. However, histologic features were most consistent with a benign osteocartilaginous exostosis.

Early ankle motion after triple bundle technique repair vs. casting for acute Achilles tendon rupture.

The purpose of our study is to evaluate the triple bundle technique for acute Achilles tendon rupture repair followed by early (at 14 days) postoperative ankle range of motion compared to nonoperative treatment with delayed ankle range of motion. We retrospectively reviewed 73 patients with an acute Achilles tendon rupture treated with either a plantar flexed cast or surgical repair. We found operative treatment reduces immobilization time, allows safe early return to weight-bearing, and diminishes risk of rerupture compared to nonoperative treatment. However, at an average follow-up of greater than 3.5 years, there was no statistical difference in AOFAS hindfoot scores, strength, or patient satisfaction between the two groups. Significant complications were higher in the nonoperative group manifested by three reruptures (7.7%) vs. one deep wound dehiscence in the operative group (3%).

Achilles tendon rupture repair: biomechanical comparison of the triple bundle technique versus the Krakow locking loop technique.

This study was designed to compare the tensile strength of ruptured Achilles tendons repaired using either the triple bundle technique or the Krakow locking loop technique. Eight pairs of fresh frozen cadaveric Achilles tendons were harvested. A simulated "Achilles tendon rupture" was created 4 cm from the calcaneal insertion in all sixteen tendons by transversely cutting the tendon with a scalpel. One Achilles tendon "rupture" of a pair was repaired using the triple bundle technique, while the other tendon of the pair was repaired using the Krakow locking loop technique. Then, using a servohydraulic testing machine, each tendon was tested to failure in tension at a displacement rate of 2.54 cm/sec. The average rupture load for the triple bundle technique was 453 N (range 397 n 549 N), while the average rupture load for the Krakow locking loop technique was 161 N (range 121 n 216 N). This difference in averages represents a statistically significant superiority of 2.8 to 1 (p < 0.001) in favor of the triple bundle technique.

Complications of plantar fascia rupture associated with corticosteroid injection.

From 1992 to 1995, 765 patients with a clinical diagnosis of plantar fasciitis were evaluated by one of the authors. Fifty-one patients were diagnosed with plantar fascia rupture, and 44 of these ruptures were associated with corticosteroid injection. The authors injected 122 of the 765 patients, resulting in 12 of the 44 plantar fascia ruptures. Subjective and objective evaluations were conducted through chart and radiographic review. Thirty-nine of these patients were evaluated at an average 27-month follow-up. Thirty patients (68%) reported a sudden onset of tearing at the heel, and 14 (32%) had a gradual onset of symptoms. In most cases the original heel pain was relieved by rupture. However, these patients subsequently developed new problems including longitudinal arch strain, lateral and dorsal midfoot strain, lateral plantar nerve dysfunction, stress fracture, hammertoe deformity, swelling, and/or antalgia. All patients exhibited diminished tension of the plantar fascia upon examination by the stretch test. Comparison of calcaneal pitch angles in the affected and uninvolved foot showed a statistically significant difference of 3.7 degrees (P = 0.0001). Treatment included NSAIDs, rest or cross-training, stretching, orthotics, and boot-brace immobilization. At an average 27-month follow-up, 50% had good/excellent scores and 50% had fair/poor scores. Recovery time was varied. Ten feet were asymptomatic by 6 months post rupture, four feet by 12 months post rupture, and 26 feet remained symptomatic 1 year post rupture. Our findings demonstrate that plantar fascia rupture after corticosteroid injection may result in long-term sequelae that are difficult to resolve.

The effect of the CAT-CAM above-knee prosthesis on functional rehabilitation.

Five, rehabilitated, unilateral above-knee amputees (average age, 34.4 years) using quadrilateral sockets were converted to Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM) sockets to determine the effect on ambulatory function. Patients were evaluated before and after conversion for subjective acceptance, gait deviations, relative femoral shaft inclination, coronal-plane hip abduction torque, and ambulatory metabolic demands. The CAT-CAM socket was subjectively rated superior by four patients. Most gait deviations improved or disappeared. Femoral shaft inclination angles improved an average of 6.5 degrees toward adduction by roentgenographic measurements in four patients. Film records suggest that the compensatory lateral trunk lean, seen in patients with quadrilateral sockets, diminished after conversion. These four patients increased their customary gait velocities, and all showed a reduction in the quantity of oxygen consumed per meter traveled by up to 50%.

Recurrent pain following interdigital neurectomy--a plantar approach.

Thirty patients with 39 recurrent interdigital neuromas were evaluated to determine the success of subsequent surgery. Two surgical techniques were used to resect the nerve over a 2.5-year period and their results were compared. One consisted of exposure through the previous dorsal incision and the other of exposure through a transverse plantar incision proximal to the metatarsal heads. Overall results revealed significant improvement for greater than 80% of patients after their final operation. Less than 50% gained complete relief, however, and 58% experienced persistent discomfort in certain types of shoes. The plantar approach offers a simplified, less traumatic exposure of the nerve in a more proximal location. No healing problems were encountered with the proximal plantar incision.

Surgical repair of Achilles tendon ruptures.

We evaluated the surgical results of 42 consecutive patients with spontaneous rupture of the Achilles tendon treated from 1973 to 1984 to determine the causes of rupture and to evaluate our treatment methods. Patients were divided into early and late repair groups and their charts reviewed to determine common clinical features. A new method of repair with early functional range of motion exercises before casting was used and compared to other techniques in common use. Thirty-one patients were contacted for long-term followup (average, 4.7 years). Twenty-three of these patients returned for intensive reevaluation and Cybex testing. We found a high incidence of gout (14.3%) and previous steroid injections (7.1%) in our patients. Good results were obtained from the four surgical methods used. There were no reruptures and only 7% of the patients experienced minor wound problems. Patients treated with early functional range of motion exercises averaged 12.5 degrees more dorsiflexion at the time of cast removal and did not require adjunctive protective devices. Long-term results, however, revealed equilibration of range of motion and near normal function in all repair techniques with 88% of all patients returning to preinjury activity levels.

Regional anesthesia for ambulatory foot and ankle surgery.

Regional anesthesia provides significant advantages for the patient and practitioner involved in ambulatory foot and ankle surgery. Reliable techniques for administering regional ankle blocks emphasizing their importance in the practice of ambulatory surgery are presented.

Clinical basis for a mechanical etiology in adolescent Blount's disease.

The exact etiology and treatment of adolescent Blount's disease remains uncertain. In this study, the clinical and radiographic characteristics of eight consecutive patients (ten knees) with late onset tibia vara are reviewed to identify common features suggestive of aberrant mechanical forces causing their deformity. Consistent clinical features include progressive varus during the adolescent growth spurt and gross obesity. All patients were black, most were males with unilateral disease, and the only female patient had bilateral involvement. All were symptomatic cases, but in no case was trauma the cause of their disease. In addition, measurements of the physeal widths of the proximal tibia and distal femur on preoperative x-rays demonstrate consistent characteristics compatible with aberrant forces predicted by Heuter-Volkman and Delpech's laws. The clinical findings along with our surgical results confirm that these patients are best treated by corrective osteotomy to neutral mechanical axis and that over-correction is unwarranted.

Desmoplastic fibroma of the first metatarsal. A case report.

Desmoplastic fibroma is a benign but frequently aggressive tumor of bone. A 27-year-old man was treated for this lesion in the first metatarsal. The lesion recurred, extending into the medial cuneiform necessitating ray resection. The similar clinical and histologic findings of this tumor and other tumors, both benign and malignant, makes familiarity with the character of desmoplastic fibroma essential for proper treatment.

Aztreonam in the treatment of serious orthopedic infections.

Aztreozam was evaluated in the treatment of a variety of orthopedic infections. Included were 17 patients with osteomyelitis, three with purulent arthropathy with prostheses, and 16 with superficial infections secondary to trauma or surgical procedure. Pathogens were gram-negative bacilli sensitive to aztreonam. Concomitant antibiotics were administered for gram-positive cocci that were present initially or by superinfection. Infecting organisms included Pseudomonas aeruginosa (minimal inhibitory concentration 4 to 16 micrograms/ml), Serratia marcescens, Enterobacter cloacae, Enterobacter sakazakii, Morganella morganii, Citrobacter freundii, Proteus vulgaris, Proteus rettgeri, Acinetobacter calcoaceticus and others (all with minimal inhibitory concentrations less than 1.0 microgram/ml). Dosage of aztreonam was 2 to 8 g per day administered intravenously or intramuscularly for five to 52 days. Clinical and bacteriologic responses were adequate in all instances. Recurrences were observed in two individuals with osteomyelitis and one with purulent arthropathy. Adverse clinical or laboratory observations were infrequent and inconsequential.