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.

Role of metatarsus primus elevatus in the pathogenesis of hallux rigidus.

Metatarsus primus elevatus has been suggested as a primary causative factor in the pathogenesis of hallux rigidus. The purpose of this investigation was to define the role of elevation of the first ray in the pathogenesis of hallux rigidus by comparing patients with known hallux rigidus with a control population. We reviewed 264 lateral weightbearing radiographs from 81 patients with hallux rigidus, 50 asymptomatic volunteers, and 64 patients diagnosed with isolated Morton's neuroma. Results revealed that the mean values for elevation of the first ray in patients with mild or moderate hallux rigidus were nearly identical to those in the control group. Patients with advanced radiographic hallux rigidus had a slightly higher mean value for metatarsus primus elevatus. An average of nearly 8 mm of metatarsus primus elevatus is a normal finding in patients with hallux rigidus as well as in normal subjects. This investigation did not address the clinical outcome or biomechanical effects of a plantarflexion osteotomy of the first ray. However, on the basis of the finding that first ray elevation is normal, it seems unlikely that a plantarflexion osteotomy would have a role in the treatment of hallux rigidus.

Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency.

Ten patients were identified with traumatic, complete common peroneal nerve palsy, with no previous foot or ankle surgery or trauma distal to the knee, who had undergone anterior transfer of the posterior tibial tendon to the midfoot. Six of these patients had a transfer to the midfoot and four had a Bridle procedure with tenodesis of half of the posterior tibial tendon to the peroneus longus tendon. Average follow-up was 74.9 months (range, 18-351 months). All patients' feet were compared assessing residual muscle strength, the longitudinal arch, and motion at the ankle, subtalar, and Chopart's joint. Weightbearing lateral X-rays and Harris mat studies were done on both feet. In no case was any valgus hindfoot deformity associated with posterior tibial tendon rupture found. It seems that the pathologic condition associated with a posterior tibial tendon deficient foot will not manifest itself if peroneus brevis function is absent.

Isolated subtalar arthrodesis.

Forty-eight isolated subtalar arthrodeses in 44 patients with an average follow-up of 59.5 months were retrospectively reviewed. Original diagnoses included talocalcaneal coalition, healed calcaneal fracture with subtalar arthrosis, acquired flatfoot because of posterior tibial tendon dysfunction, degenerative subtalar arthrosis, subtalar instability, and psoriatic arthritis. Ninety-three percent of patients were very satisfied or satisfied with their treatment. Pain and function improved significantly, and the American Orthopaedic Foot and Ankle Society ankle-hindfoot score at follow-up was 89. There were six unsatisfactory results: three feet had calcaneal fractures and three were malpositioned. Union was achieved in all cases. Transverse tarsal motion was diminished by 40%, dorsiflexion by 30%, and plantarflexion by 9%. There was a 36% and 41% incidence of mild radiographic progression of arthrosis in the ankle and transverse tarsal joint, respectively. Isolated subtalar arthrodesis provided a highly successful result in the disease presented, and this study provides support for the use of a selected hindfoot fusion procedure for specific indications.

Effect of calcaneal osteotomy and lateral column lengthening on the plantar fascia: a biomechanical investigation.

Medial calcaneal displacement osteotomy or lateral column lengthening fusion has been advocated to augment tendon transfer in planovalgus foot deformity associated with chronic posterior tibial tendon insufficiency. It is hypothesized that plantar fascia tightening occurs with these procedures, helping to restore a more normal longitudinal arch. To investigate this further, nine fresh-frozen cadaver below-knee specimens were used. A flatfoot model was created by sectioning of the posterior tibial tendon, spring ligament, talonavicular capsule, and deltoid ligament. A liquid-metal strain gauge, calibrated to measure fractional changes in length, was sutured proximally to the origin and distally into the thickest portion of the medial band of the plantar fascia. Specimens were axially loaded to 400 N and plantar fascia strain was measured. Fractional length changes in the plantar fascia were then measured after a medial displacement calcaneal osteotomy and after a lateral column lengthening through the calcaneocuboid joint. Tightening of the plantar fascia did not occur with either medial calcaneal displacement or lateral column lengthening. The plantar fascia became significantly less taut with both medial displacement and lateral column lengthening. We found that lateral column lengthening produced significantly looser plantar fascia than did medial displacement of the calcaneal tuberosity.

Radiographic and clinical classification of acquired midtarsus deformities.

To develop a classification of midtarsus deformities, clinical examination and weightbearing radiographs were used to evaluate 131 feet in 109 patients (average age, 59+/-11 years) with those deformities. Patients were classified into four types based on anatomic location of the maximum deformity. Type I (N=43) showed deformity at the metatarsocuneiform joints medially and the fourth and fifth metatarsocuboid joints laterally, with plantarmedial and/or medial prominence. Type II (N= 60) had deformity at the naviculocuneiform joint medially and the fourth and fifth metatarsocuboid joints laterally; plantarlateral prominence was characteristic, although one-third had isolated or additional medial prominences. Type III (N=17) had major deformity in the perinavicular region, with a prominence plantarcentrally or plantarlaterally. Type IV (N=11) had deformity at the transverse tarsal joints with variable prominences. Each type was further subdivided into stages A, B, and C based on the severity of the deformity. In stage B, the midtarsus was coplanar with the metatarsocalcaneal plane. In stage A, the midtarsus was above this plane. In stage C, the midtarsus was below this plane. We concluded that midtarsus deformities can be classified as one of four types and one of three stages. Additional study is warranted to correlate this system with prognosis and treatment for this pathologic process.

Late results of subtalar distraction fusion.

Between 1990 and 1994, 15 subtalar distraction fusions were performed on 14 patients for sequelae of calcaneus fractures. Twelve patients (13 feet) were available for a minimum 2-year follow-up and constituted the composition of this study. All patients complained of lateral ankle pain and had CT evidence of calcaneofibular abutment and radiographic evidence of loss of heel height preoperatively. The average age at time of surgery was 56 years (range, 23-81 years), and the average follow-up was 47 months (range, 25-75 months). The only change in surgical technique from that previously described was the use of a bone spreader rather than a femoral distractor for distraction of the subtalar joint. The average preoperative talocalcaneal angle improved from 27 degrees range, 19-37 degrees) to 33 degrees (range, 23-45 degrees) postoperatively (P < 0.003). The mean talar declination angle improved from 11 degrees (range, 6-18 degrees) to 16 degrees (range, 7-27 degrees) postoperatively (P < 0.003). The mean heel height increased from 71 mm (range, 60-83 mm) to 76 mm (range, 63-91 mm) postoperatively (P < 0.0001). All patients completed the AOFAS Ankle-Hindfoot scale at latest follow-up, and the average score was 76.1 (range, 57-94). Eleven of 13 outcomes were rated as very satisfactory or satisfactory. Twelve of 13 said they would 'definitely yes" do surgery again. We have found that subtalar distraction fusion for late complications of calcaneus fracture in a carefully selected population can provide a consistent and satisfactory outcome.

Management of the foot and ankle in rheumatoid arthritis.

Rheumatoid arthritis frequently involves the foot and ankle, resulting in pain, deformity, and difficulty with ambulation. This article outlines clinical, radiographic, and gait evaluation in the management of foot and ankle problems in rheumatoid arthritis. Conservative nonsurgical management of foot deformities is presented including available shoewear and orthotic options. Surgical considerations including indications, biomechanic implications, and specific operative procedures are discussed.

Epiphysiodesis of the lower extremity: results of the percutaneous technique.

The results of 42 percutaneous epiphysiodeses of the lower extremity in 26 patients are reported. All patients achieved physeal arrest radiographically and clinically. No patient developed angular deformity from incomplete arrest. No neurovascular complications or fractures occurred. The average hospital stay for patients undergoing epiphysiodesis alone was 1 day. Percutaneous epiphysiodesis of the lower extremity provides a reliable and safe technique for growth plate arrest. The advantages of this technique include a cosmetic scar, short hospital stay, low incidence of complications, and reliable physeal arrest.

Femoral pulse as a guide to the mechanical axis in total knee arthroplasty.

The anatomic relationship of the center of the femoral head to the femoral artery was studied in 140 hips in 70 patients. The coronal plane distance between the femoral artery 2.5 cm below the inguinal ligament and the center of the femoral head was measured on pelvic arteriograms. The femoral artery was found an average of 7.7 +/- 5 mm medial (range, -3-22 mm) to the center of the femoral head. The femoral artery was within 15 mm of the center of the femoral head in 93% of cases reviewed. A 76-cm theoretical mechanical axis was used in estimating clinical angular changes in the axis for a given coronal plane difference. By use of this model, the range of variability translates into a maximum change in the mechanical axis of 1.66 degrees and up to only 1.2 degrees in 95% of the cases reviewed. A marker placed just lateral to the palpable femoral pulse approximately 2 to 3 cm below the inguinal ligament is suitable as a guide to locate the center of the femoral head when determining the mechanical axis during total knee arthroplasty.

Triple arthrodesis with lateral column lengthening for treatment of severe planovalgus deformity.

Triple arthrodesis with lateral column lengthening through the calcaneocuboid joint was performed on 22 feet in 14 patients. The primary indication for surgery was severe symptomatic planovalgus deformity unresponsive to conservative measures. All patients achieved solid fusion within 12 weeks. No patient had no decline in ambulatory status. Excellent correction of deformity was achieved and maintained with an average correction of the talus first metatarsal angle of 25 degrees in both the AP and lateral planes. Triple arthrodesis with lateral column lengthening provides for reliable arthrodesis and allows correction of severe planovalgus deformity while maintaining foot length.

Deformity correction and arthrodesis of the midfoot with a medial plate.

Nine feet in eight patients undergoing tarsometatarsal (Lisfranc) or other midfoot arthrodeses for posttraumatic or degenerative arthritis were reviewed retrospectively. All patients were treated using a medial one-third tubular plate spanning the midfoot joints to be fused. Three feet underwent fusion in situ while six feet underwent correction of residual planus, planovalgus, or cavovarus deformity at the time of fusion. All patients achieved fusion within 12 weeks. A good or excellent result was achieved in seven of nine feet. There was no radiographic or clinical evidence of pseudarthrosis or medial hardware failure in any patient. No patient to date has required hardware removal for a painful or prominent implant. The talus first metatarsal angle was improved an average of 15.5 degrees in the lateral plane and 10 degrees in the AP plane in patients undergoing deformity correction. The technique of using a medial plate for midfoot arthrodesis allows for reliable fusion in patients who require salvage for midfoot arthritis. This technique also allows for correction of deformity in patients with residual midfoot deformity.