Anatomic study of the medial neurovascular structures in relation to calcaneal osteotomy.

Medial displacement osteotomy of the calcaneous is commonly performed for stage II posterior tibial tendon insufficiency in an effort to improve the valgus deformity of the hindfoot. We performed an anatomic study examining the medial neurovascular anatomy and its relation to the osteotomy in an attempt to determine which structures may be at risk during the procedure. Calcaneal osteotomies were performed through a lateral approach on 22 fresh-frozen cadaver below-knee specimens. Dissection was then performed medially to identify the Medial Plantar Nerve (MPN), the Lateral Plantar Nerve (LPN), the Posterior Tibial Artery (PTA), and their respective branches. Measurements determined either 1) where the structure crossed the osteotomy or 2) if the structure did not cross, the closest perpendicular distance from the osteotomy and at which point along its length this occurred. Perpendicular distances were recorded in millimeters and position along the osteotomy as a percentage of the total length from the posterosuperior aspect. An average of four neurovascular structures crossed each osteotomy site (range 2 to 6), most of which were branches of the LPN or the PTA. The MPN did not cross in any of the specimens studied, the LPN crossed in one specimen, and the PTA crossed in two specimens. The MPN distributed no crossing branches. The calcaneal sensory branch of the LPN was identified and crossed in 86% of the cadavers at 19% (+/- 15%) along the osteotomy length. A more distal second branch of the LPN (Baxter's nerve) was identified and crossed in 95% of the specimens at 61% (+/ 20%) along the osteotomy length. A third crossing branch existed in one specimen. Each PTA distributed from zero to three branches which variably crossed the osteotomy at a point from 2% to 100% along its length. The PTA bifurcated in 77% of the specimens at 49% (+/- 9%) along the osteotomy length. A consistent finding in every specimen was the presence of two veins accompanying the PTA with one on either side. A number of medial neurovascular structures may be at risk when perfoming a calcaneal osteotomy through a lateral approach. A minimum of two structures crossed the osteotomy site at variable positions in this study, although most of these structures represented branches off of the LPN or the PTA, with the LPN and the PTA themselves crossing only infrequently. The authors recommend that the completion of the osteotomy through the medial calcaneal cortex be performed in a carefully controlled manner to reduce the risk of post-operative complications including pain, numbness, and hematoma formation.

Tibiotalocalcaneal arthrodesis.

The purpose of this multicenter retrospective study of 55 patients (56 ankles) who underwent simultaneous tibiotalocalcaneal arthrodesis with severe disease involving the ankle and subtalar joints was to determine improvement of pain and function. The surgical indications included osteoarthritis, posttraumatic injury, failed previous surgery, talar avascular necrosis, osteoarthritis, and rheumatoid arthritis involving the ankle and subtalar joints. The average age at the time of the operation was 53 years. The average time of follow-up was 26 months after the operation. Fusion was achieved in 48 ankles, with an average time of fusion of 19 weeks. Forty-eight of the 55 patients were satisfied with the procedure. The average leg length discrepancy was 1.4 cm. The average amount of dorsiflexion was 2 degrees and plantar flexion was 5 degrees. Following surgery, 42 patients complained of pain, 40 patients required shoe modification or an orthotic device, and 34 patients had a limp. Fourteen patients described their activity as unlimited. Based on the AOFAS evaluation, the patients scored an average of 66 on the ankle-hind foot scale following surgery. The most common complications were nonunion (8 ankles) and wound infection (6 ankles). This study demonstrates that tibiotalocalcaneal arthrodesis is an effective salvage procedure for patients with disease both involving the ankle and subtalar joints.

An anatomical basis for the degree of displacement of the distal chevron osteotomy in the treatment of hallux valgus.

The purpose of this study was to define the amount of lateral displacement of the chevron osteotomy to obtain a 50% displacement of the capital fragment. While mathematical analyses exist to predict the degree of correction of the intermetartarsal 1-2 angle with a distal metatarsal osteotomy, no guidelines exist regarding the degree of displacement (translation) that allows sufficient bone contact to enhance union and maintain stability of the osteotomy. We have addressed this concern based on anatomical parameters. The mean metatarsal width of the male specimens measured at 15 mm from the medial osteochondral junction was 15.3 mm (range, 13-18 mm; standard deviation, 1.6). The mean width among the female specimens was 14.5 mm (range, 11-18 mm; standard deviation, 1.6). This difference was statistically significant (P = 0.003). From the results of this study, we have concluded that when using a distal metatarsal osteotomy of the chevron type, in 97.5% of the cases the distal fragment can be translated laterally 6.0 mm in males and 5.0 mm in females to displace it 50% of its diameter.

Estimating the insertion site during retrograde intramedullary tibiotalocalcaneal arthrodesis.

Intramedullary tibiotalocalcaneal arthrodesis (IMTCA) is an increasingly used procedure for salvage of complex hindfoot and ankle disorders. To avoid injury to vital plantar neurovascular structures, it is important to begin with an appropriate insertion site during retrograde IMTCA. We use a simple, reproducible method to determine this site based on anatomic landmarks.

Osteoporosis of pregnancy: long-term follow-up of patients and their offspring.

BACKGROUND: The usual course of osteoporosis of pregnancy is complete resolution without recurrence. We report the 10-year follow-up of two patients with osteoporosis of pregnancy and their offspring. CASES: A 30-year-old woman presented with right hip pain at 30 weeks' gestation. Single-photon absorptiometry of the distal radius showed osteopenia, which persisted on 10-year follow-up. A dual-energy x-ray absorptiometry performed on the 11-year-old daughter of this pregnancy showed osteopenia. A 26-year-old woman presented with left hip pain at 16 weeks' gestation. Single-photon absorptiometry of the distal radius showed osteopenia, which persisted on 10-year follow-up. Dual-energy x-ray absorptiometry performed on the 13-year-old daughter of this pregnancy showed osteopenia. CONCLUSION: Osteoporosis of the hip discovered during pregnancy may not be a transient process and should prompt a search for osteopenia in both mother and offspring.

The plantar incision for procedures involving the forefoot. An evaluation of one hundred and fifty incisions in one hundred and fifteen patients.

Between 1984 and 1990, 172 plantar incisions were used in 137 patients. Eighty-nine of these patients returned for a personal interview and examination, twenty-six were interviewed by telephone, and twenty-two were lost to follow-up. Of the eighty-nine patients (124 incisions) who returned for follow-up examination at an average of twenty-five months (range, six to seventy-seven months), eighty-five (96 per cent) were pleased with the result of the plantar incision. None of these patients had altered their activities, and only three had modified their selection of footwear. Of the twenty-six patients who were interviewed by telephone, twenty-five (96 per cent) were pleased with the result. Thus, 110 (96 per cent) of 115 patients (150 plantar incisions) were satisfied with the result. The plantar incision may be used for resection of an interdigital neuroma (primary or recurrent); drainage of an abscess; removal of a foreign body; sesamoidectomy; lateral release of the first metatarsophalangeal joint; or excision of an invaginated keratotic plug (intractable plantar keratosis), a metatarsal head, the plantar aspect of a metatarsal head, or an intermetatarsal bursa.

First metatarsal head-shaft angle: a method of determination.

The distal metatarsal angle (DMAA) is a measurement of the relationship between the longitudinal axis of the first metatarsal and the articular surface of the metatarsal head. We measured the DMAA on radiographs with and without markers on the articular edges and compared them with measurements of the anatomic specimens. Based on the studies, the significance of the radiographic measurements to the actual DMAA and the normal distribution of the measurement were determined.

Morphometric analysis of the plantar plate apparatus of the first metatarsophalangeal joint.

Reliable and reproducible radiographic assessment of plantar plate integrity of the great toe is possible with standard radiographic techniques. Normal values in 100 pairs of feet (200 feet) are defined for comparison of one foot to the other and absolute values emerge if comparison is not possible. Bipartite sesamoids occurred in 13.5% of 200 feet with a 37% bilaterality.

Fractures of the olecranon in children: long-term follow-up.

Olecranon fractures are relatively uncommon in children, and most are nondisplaced or minimally displaced fractures that can be treated by closed methods. During a 30-year period, 44 olecranon fractures were treated. Of 41 fractures with adequate follow-up, 37 (90%) had satisfactory results. Of 30 undisplaced or minimally displaced (< 5 mm) fractures, 28 (93%) had satisfactory results. Seven of 9 (78%) displaced fractures had satisfactory results. The most common cause of unsatisfactory results was loss of motion, although this usually did not prevent good function.

Triple arthrodesis in older adults. Results after long-term follow-up.

We studied the results for seventeen patients (eighteen feet) who had had a triple arthrodesis at an average age of sixty-six years (range, fifty-two to eighty years). There were twelve women and five men. The procedures had been performed to correct deformities of the hindfoot and midfoot caused by an untreated rupture of the posterior tibial tendon in ten patients; by rheumatoid arthritis in three patients (four feet); and by neuropathic arthropathy (associated with diabetes mellitus), trauma, old poliomyelitis, and a stroke in one patient each. The average duration of follow-up was forty-two months (range, twenty-seven to 156 months). At the most recent follow-up examination, three patients had a non-union (one, of the talonavicular joint and two, of the calcaneocuboid joint), six patients (seven feet) had progressive degenerative joint disease involving the ankle, seven had progressive degenerative changes in the mobile joints of the feet, two had had an infection but both infections had healed, and one had had postoperative collapse of the foot because of premature, unauthorized weight-bearing. In one patient, a staple across the subtalar joint had been removed because of pain caused by impingement of the staple on the tip of the fibula. Over-all, fourteen of the seventeen patients were satisfied with the result of the operation. All seventeen had less pain postoperatively, but eleven still had some discomfort.(ABSTRACT TRUNCATED AT 250 WORDS)

The Chevron bunionectomy: a trigonometric analysis to predict correction.

A trigonometric analysis was developed in an attempt to predict the postoperative hallux valgus angles and intermetatarsal angles after Chevron bunionectomy. This analysis was used in 20 feet to predict postoperative angles, and these predicted values were compared with actual measured roentgenographic values. The postoperative intermetatarsal angles were evaluated to determine their correction to postoperative hallux valgus angles of 20 degrees or less. Using the trigonometric analysis, the postoperative intermetatarsal angles were highly predictable, but the hallux valgus angle could not be reliably predicted for individual patients. The intermetatarsal angle obtained at surgery, however, was indicative of the final hallux valgus angle: 75% of feet with intermetatarsal angles of more than 11 degrees had postoperative hallux valgus angles of more than 20 degrees. Thus, when an intermetatarsal angle of 11 degrees or less can be obtained surgically, the hallux valgus angle can be corrected to 20 degrees or less in most patients.

Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up.

We retrospectively reviewed the results for seventy-five patients (109 feet) in whom a hallux valgus deformity had been corrected with the release of the distal soft tissues, excision of the medial eminence, plication of the medial part of the capsule, and proximal crescentic osteotomy of the first metatarsal. The patients were followed for an average of thirty-four months (range, twenty-four to fifty-six months). The preoperative hallux valgus angle averaged 31 degrees, and the postoperative angle averaged 9 degrees. The preoperative intermetatarsal angle averaged 14 degrees and the postoperative angle, 6 degrees. Ninety-three per cent of the patients were satisfied with the result of the procedure. They stated that, given the same circumstances, they would have the operation again. The most common complication was hallux varus, which occurred in thirteen feet (nine patients). The other complications included recurrence of the hallux valgus in two feet, pain under a fibular sesamoid in one foot, and a tailor's bunion that was unrelated to the operation in one foot. Only five of forty-eight feet that had had a symptomatic plantar keratosis beneath the second metatarsal head preoperatively remained symptomatic postoperatively.

Posttraumatic proximal migration of the first metatarsophalangeal joint sesamoids: a report of four cases.

Four cases are presented with plantar plate injury to the first metatarsophalangeal (MTP) joint and proximal retraction of the sesamoids by the flexor hallucis brevis. No history of dislocation occurred in any patient, although two had associated fractures of a sesamoid bone. Clinical and radiographic aids to the diagnosis are discussed. Clinical findings included diffuse pain beneath the first MTP joint and pain with extremes of joint motion in all patients. The anterior-posterior (AP) radiographic technique was the most helpful in determining the proximal migration of the sesamoids. By taking the AP view with both feet on the cassette and by centering the beam perpendicular to it, the diagnosis of plantar plate disruption can easily be made. Initial treatment of this disorder was nonoperative using a stiff soled shoe. With conservative treatment, two of the patients returned to preinjury activities. One patient required sesamoidectomy for resistant pain, and the final patient is still unable to return to his preinjury job requiring standing and heavy lifting.

Dysplasia epiphysealis hemimelica (Trevor disease) presenting as peroneal spastic flatfoot deformity: a case report.

Trevor disease (dysplasia epiphysealis hemimelica) involving the foot and ankle is not uncommon, but its presentation as a progressive spastic flatfoot deformity is unusual. The patient reported had an isolated lesion in the medial facet of the subtalar joint. In addition to the unusual presentation and location, the lesion recurred 1 year after surgical excision.