Treatment of chronic achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation.

Chronic disorders of the Achilles tendon are commonly seen by the orthopaedic surgeon. In cases that are resistant to conservative treatment, a variety of surgical procedures have been utilized in the past. The indications for a previously described technique of flexor hallucis longus tendon transfer for reconstruction of chronic Achilles tendon rupture have been expanded to include further subsets of chronic Achilles tendinopathy, including rupture and tendinosis. We evaluated 20 patients (mean age 61) who underwent flexor hallucis longus transfer for treatment of chronic Achilles tendinopathy at a mean of 14 months following surgery. Our results were measured with the SF-36 survey, AOFAS Ankle-Hindfoot Scale, and Cybex strength and range of motion testing. Wound complications, tip-toe stance, and calf circumference were also assessed. There were no postoperative reruptures, tendinopathy recurrences, or wound complications. Despite a small loss of calf circumference, range of motion, and plantarflexion strength, 90% of patients scored 70 or higher on the AOFAS scale. SF-36 testing revealed significantly lower scores in the physical function category when compared with United States norms. Flexor hallucis longus tendon transfer/augmentation is a reasonable option for treatment of chronic Achilles tendinosis and rupture.

The traumatic bunion.

In seven cases of Lisfranc joint injury after trauma, bunion deformity developed. This "traumatic bunion" occurs over a prolonged period of time after injury. A high index of suspicion is needed to identify the deformity as being traumatic in origin. Injury about the first metatarsophalangeal joint complex may also contribute to this deformity. When recognized, it may need to be treated with a first metatarsal-cuneiform fusion and distal soft tissue realignment.

Occult fractures following subtalar joint injuries.

Subtalar joint dislocations, although not common, have been increasing in frequency over the last decade. Generally, subtalar joint dislocation can be treated successfully with closed reduction and a short period of cast immobilization. The majority of patients will suffer minimal disability, with subtalar joint stiffness as the primary complaint. This report includes four cases of suspected joint dislocation or subluxation with occult intra-articular fractures identified only by CT scan following essentially normal radiographs. Evidence seems to indicate that CT scanning in patients with suspected subtalar joint subluxation or dislocation and normal radiographs is justified.

Subtalar joint dislocations.

Dislocations of the subtalar joint are rare injuries. The anatomy, pathophysiology, treatment, and prognosis of subtalar joint dislocations have been well described in the literature. The purpose of this paper is to review the current literature on subtalar joint dislocations, as well as outline those aspects of the anatomy, pathomechanics, and treatment pertinent to care of the patient with subtalar joint dislocation. In addition, complications and obstacles to reduction are described. Subtalar joint dislocations, although not common, have increased in frequency over the last decade. Generally, they can be treated successfully with closed reduction and a short period of cast immobilization. The majority of patients will suffer some disability with subtalar joint stiffness the primary complaint. Associated intra-articular fractures increase the risk of posttraumatic arthrosis.

Clawtoe deformity following vascularized fibula graft.

The free vascularized fibula graft has been an increasingly useful tool in orthopaedic surgery. In addition to its many applications, the reported low donor site morbidity has helped make this a popular treatment modality. Isolated flexor hallucis longus flexion contracture has been reported in the literature; however, multiple ipsilateral clawtoe deformity has not been reported. We describe two cases of multiple clawtoe deformity following ipsilateral harvest of a free vascularized fibula graft.

Treatment of ulnar shaft fractures: a prospective, randomized study.

The treatment of isolated ulnar shaft fractures is controversial. Previous studies comparing treatment options have been largely retrospective and nonrandomized. In this study, consecutive patients were randomized into treatment groups of long arm plaster immobilization, short arm plaster immobilization, or Ace Wrap bandage, based on the order of hospital admission. Thirty-one patients were followed until radiographic or clinical union, with no significant difference in time to union between groups. Age, sex, fracture pattern, and displacement did not significantly influence time to union or final angulation. Two patients in both the long arm cast group and the short arm cast group lost significant motion at final follow up. Seventy percent of patients in the Ace Wrap group failed treatment secondary to pain and were converted to plaster immobilization. Furthermore, patients in this group demonstrated significantly greater angulation than those treated in a long arm cast. Our results demonstrate that above-elbow plaster immobilization offers no advantage over below-elbow immobilization. We recommend short arm casting for a period of 8 weeks.

Aiming guide for accurate placement of subtalar joint screws.

Accurate placement of rigid fixation of the subtalar joint in arthrodesing procedures (triple, subtalar, or pantalar arthrodesis) can be difficult. We have found that the "bottom-up" method simplifies this procedure and eliminates many potential problems. A technique is described incorporating the bottom-up method utilizing the combined aiming device (Synthes, Paoli, PA).

Sacroiliac joint pyarthrosis.

Sacroiliac (SI) joint infection is rare, and symptoms are idiosyncratic and often confusing. This paper reviews six cases of SI joint infection with regard to their clinical manifestations, diagnostic imaging, and treatment. The six patients were seen over a 15-year period and had a mean age of 16.2 years and a mean follow-up of 44.2 months. The most common presenting symptom was fever (71.4%). The most common physical findings were elevated temperature and limited ipsilateral hip motion. In most cases the white blood cell count and erythrocyte sedimentation rate were elevated, and 71% of the cases had positive blood cultures. The most specific imaging study was the technetium bone scan. All patients were treated with 3 to 6 weeks of appropriate antibiotics and were asymptomatic and had a normal physical examination on follow-up. Routine anteroposterior roentgenograms of the pelvis demonstrated sclerosis of the affected SI joint in one third of the cases. There appeared to be no long-term sequelae in this group of patients.

The vertical axis fracture: a report on three cases.

We report on three cases of a rare fracture of the posterior body of C2. This is a variant of the classic traumatic spondylolisthesis and appears to respond to conservative management.