An equinus deformity of the ankle accounts for only a small amount of the increased forefoot plantar pressure in patients with diabetes.

Patients with diabetes mellitus may develop plantar flexion contractures (equinus) which may increase forefoot pressure during walking. In order to determine the relationship between equinus and forefoot pressure, we measured forefoot pressure during walking in 27 adult diabetics with a mean age of 66.3 years (sd 7.4) and a mean duration of the condition of 13.4 years (sd 12.6) using an Emed mat. Maximum dorsiflexion of the ankle was determined using a custom device which an examiner used to apply a dorsiflexing torque of 10 Nm (sd 1) for five seconds. Simple linear regression showed that the relationship between equinus and peak forefoot pressure was significant (p < 0.0471), but that only a small portion of the variance was accounted for (R(2) = 0.149). This indicates that equinus has only a limited role in causing high forefoot pressure. Our findings suggest caution in undertaking of tendon-lengthening procedures to reduce peak forefoot plantar pressures in diabetic subjects until clearer indications are established.

Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach.

This is a review of 183 patients with 218 displaced intraarticular fractures of the calcaneus treated by open reduction and internal fixation. One hundred and ninety four (89%) wounds underwent primary uneventful healing. Twenty-four wounds (11%) required local wound care. One deep infection occurred in a neuropathic foot that required below-knee amputation. No free-tissue transfers, local tissue flaps or skin grafts were needed in patients who presented initially with a closed fracture. Ninety-five fractures (43.5%) required subsequent surgical procedures (hardware removal-88/95 [93% of secondary procedures]). Six patients (2.8%) had postoperative sural nerve findings. Seventeen procedures other than hardware removal were performed. There were five subtalar fusions including two subtalar distraction bone-block arthrodeses. There were seven claw toe correction procedures, four calcaneal valgus osteotomies for varus malunions and one subtalar arthrolysis at the time of hardware removal. These results suggest internal fixation of displaced intra-articular calcaneus fractures using a single lateral approach is a safe, reliable method of treatment.

Fractures of the tarsal bones.

Fractures involving the midtarsal bones are relatively uncommon. The morbidity associated with these injuries can be significant, however. Accurate diagnosis and appropriate treatment can help restore midfoot function and decrease the incidence of chronic pain. Treatment should preserve the function of the talonavicular joint, maintain the relative length of the medial and lateral columns, and protect the ligaments and soft tissues until adequate healing has occurred.

Postoperative management of transtibial amputations in VA hospitals.

Rigid plaster dressings and immediate postoperative prostheses (IPOP) in patients undergoing transtibial amputations have been reported to reduce pain and healing time, prevent knee flexion contractures, and expedite early ambulation compared to soft dressings. Yet, despite the reported benefits, surgical adoption of (conventional) rigid dressings and IPOP has been inconsistent. The purpose of this study was to determine the current postoperative transtibial amputation dressing practices in VA hospitals. A six-item questionnaire was sent to 134 surgeons at the 117 VA hospitals where transtibial amputations were performed in fiscal year 1999. Responses were received from 83% of the surgeons. During the 1999 study year, surgeons performing transtibial amputations used soft dressings on 67% of patients, conventional rigid dressings with no intent to apply a foot attachment on 14% of patients, removable rigid dressings on 14% of patients, and IPOP (almost exclusively without a foot) on 5% of patients. The application of a rigid dressing or IPOP did not correlate well with the total number of transtibial amputations performed by the surgeon, hospital bed size, or academic affiliation.

Recreational activities of lower-limb amputees with prostheses.

Ninety-two (92) persons with lower-limb amputations who regularly used prostheses responded to a survey that included questions about preferred recreational activities. This article describes the variety of activities selected by these men and women aged 20 to 87 years. Of the activities that were of high importance, 74% to 88% could be performed. Those activities assigned moderate to low importance were less often reported as able to be performed. The activities that require high energy level were more problematic for performance. The diversity of identified activities (n= 166) underscores the value of learning about amputees' activity preferences when making prosthetic prescription decisions.

Can the presence of equinus contracture be established by physical exam alone?

The condition in which ankle dorsiflexion is restricted is known as equinus contracture (EC). Equinus contracture is purported to be associated with a number of clinical conditions. However, there are no data to support or refute a clinician's ability to diagnose EC by clinical exam. We prospectively evaluated the maximum ankle dorsiflexion with the knee fully extended in 68 people (34 patients with isolated fore- or midfoot pain and 34 asymptomatic subjects) both by clinical exam and by a custom-designed ankle goniometer. We compared the likelihood of agreement of the clinical impression (equinus, no equinus) to the maximum ankle dorsiflexion measured with the instrument at two different numerical definitions of EC (< or =5 degrees and < or =10 degrees of maximum dorsiflexion). When all subjects were included and equinus defined as < or =5 degrees of ankle dorsiflexion, a clinician's ability to detect the equinus when it is truly present is 77.8%. If equinus is defined as < or =10 degrees, this ability increases to 97.2%. Alternatively, if equinus is not present, as defined by < or =5 degrees, then a clinician's ability to correctly diagnose no equinus is 93.8%. If equinus is defined to < or =10 degrees, this ability decreases to 68.8%.

Trends in peripheral vascular procedures in the Veterans Health Administration, 1989-1998.

OBJECTIVE: To assess trends in peripheral vascular procedures performed in Veterans Health Administration (VHA) facilities. METHODS: All discharges with peripheral vascular procedures recorded for 1989-1998 were analyzed. The VHA user population was used to calculate age-specific rates. Trends were evaluated using frequency tables and Poisson regression. RESULTS: The VHA had 55,916 discharges with peripheral vascular procedures performed almost exclusively in men. Indications included peripheral vascular disease (53.7%), gangrene (19.3%), surgical complications (13.3%), and ulcers and infection (9.6%). The VHA age-specific rates were higher than US population rates for persons 45 to 64 years, similar for those 65 to 74 years, and lower for those 75 years and older. The age-specific rates declined slightly over the 10 years of observation, with the greatest decline noted in men age 45 to 65. CONCLUSION: The VHA provides almost 8% of all US peripheral vascular procedures in males. The VHA age-specific rates differ from the US rates with a shift to younger patients. The rates decreased for all age groups between 1989-1998.

Survival following lower-limb amputation in a veteran population.

GOAL: We sought to describe the common demographic and comorbid conditions that affect survival following nontraumatic amputation. METHODS: Veterans Administration hospital discharge records for 1992 were linked with death records. The most proximal level during the first hospitalization in 1992 was used for analysis. Demographic information (age, race) and comorbid diagnosis (cardiovascular, cerebrovascular, and renal disease) were used for Kaplan-Meier curves to describe survival following amputation. MAIN OUTCOME MEASURE: Death. RESULTS: Mortality risk increased with advanced age, more proximal amputation level, and renal and cardiovascular disease, and decreased for African Americans. No increased risk for persons with diabetes was noted in the first year following amputation but the risk increased thereafter. A higher risk of mortality in the first year was noted for renal disease, cardiovascular disease, and proximal amputation level. CONCLUSION: Survival following lower-limb amputation is impaired by advancing age, cardiovascular and renal disease, and proximal amputation level. Also, a small survival advantage is seen for African Americans and those with diabetes.

Biomechanics of procedures used in adult flatfoot deformity.

A flatfoot deformity can occur secondary to fairly obvious causes, or more subtle and less definable entities. Complicating the situation further, it is likely that the cause of an acquired flatfoot deformity in an adult is multifactorial. This likelihood makes the definition, diagnosis, and appropriate treatment of this condition a daunting task. More research is needed to define further the biomechanics of the foot and to understand the significance of the forces that combine to create flatfoot deformity.

The effect of posterior tibial tendon dysfunction on hindfoot kinematics.

This biomechanical study investigated the functional role of the posterior tibial tendon (PTT) in acquired flatfoot mechanics. Acquired flatfoot deformity has been attributed to PTT dysfunction; however, the progression from acute dysfunction to end-stage deformity has not been fully demonstrated. Eight human cadaver lower leg and foot specimens were used in two phases of experimental testing. In Phase 1, intact (normal) specimens were loaded to simulate (a) heel strike, (b) stance, and (c) heel rise both with and without PTT function. Then, each specimen was subjected to a procedure designed to create a simulated flatfoot deformity. The resulting flattened feet were used in Phase 2 to examine the effect of restoring PTT function to a flatfoot model. During both phases of testing, the 3-D kinematic orientation of the hindfoot complex was recorded. Small but statistically significant changes in the angular orientation of the hindfoot complex were observed, during both Phase 1 and 2 testing, when comparing the effects of a functional and dysfunctional PTT. The greatest angular changes were recorded during heel rise. For the normal foot, the small changes observed in the orientation of the hindfoot complex following release of the PTT load suggest that the intact osteo-ligamentous structure of the hindfoot is initially able to maintain normal alignment following acute PTT dysfunction. Once the soft tissues have been weakened, as in our flatfoot model, the PTT had little effect in overcoming the soft tissue laxity to correct the position of the foot.

Outcome after open reduction and internal fixation of Lisfranc joint injuries.

BACKGROUND: Open reduction and internal fixation has been recommended as the treatment for most unstable injuries of the Lisfranc (tarsometatarsal) joint. It has been thought that purely ligamentous injuries have a poor outcome despite such surgical management. METHODS: We performed a retrospective study of patients who underwent open reduction and screw fixation of a Lisfranc injury in a seven-year period. Among ninety-two adults treated for that injury, forty-eight patients with forty-eight injuries were followed for an average of fifty-two months (range, thirteen to 114 months). Fifteen injuries were purely ligamentous, and thirty-three were combined ligamentous and osseous. Patient outcome was assessed with use of the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and the long-form Musculoskeletal Function Assessment (MFA) score. RESULTS: The average AOFAS midfoot score was 77 points (on a scale of 0 to 100 points, with 100 points indicating an excellent outcome), with patients losing points for mild pain, decreased recreational function, and orthotic requirements. The average MFA score was 19 points (on a scale of 0 to 100 points, with 0 points indicating an excellent outcome), with patients losing points because of problems with "leisure activities" and difficulties with "life changes and feelings due to the injury." Twelve patients (25 percent) had posttraumatic osteoarthritis of the tarsometatarsal joints, and six of them required arthrodesis. The major determinant of a good result was anatomical reduction (p = 0.05). The subgroup of patients with purely ligamentous injury showed a trend toward poorer outcomes despite anatomical reduction and screw fixation. CONCLUSIONS: Our results support the concept that stable anatomical reduction of fracture-dislocations of the Lisfranc joint leads to the best long-term outcomes as patients so treated have less arthritis as well as better AOFAS midfoot scores.

Trends in lower limb amputation in the Veterans Health Administration, 1989-1998.

OBJECTIVE: To assess trends in lower limb amputation performed in Veterans Health Administration (VHA) facilities. METHODS: All lower limb amputations recorded in the Patient Treatment File for 1989-1998 were analyzed using the hospital discharge as the unit of analysis. Age-specific rates were calculated using the VHA user-population as the denominator. Frequency tables and linear, logistic, and Poisson regression were used respectively to assess trends in amputation numbers, reoperation rates, and age-specific amputation rates. RESULTS: Between 1989-1998, there were 60,324 discharges with amputation in VHA facilities. Over 99.9% of these were in men and constitute 10 percent of all US male amputations. The major indications were diabetes (62.9%) and peripheral vascular disease alone (23.6%). The age-specific rates of major amputation in the VHA are higher than US rates of major amputation. VHA rates of major and minor amputation declined an average of 5% each year, while the number of diabetes-associated amputations remained the same. CONCLUSION: The number and age-specific rates of amputations decreased over 10 years despite an increase in the number of veterans using VHA care.

Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot. Early results after distraction arthrodesis of the calcaneocuboid joint in conjunction with stabilization of, and transfer of the flexor digitorum longus tendon to, the midfoot to treat acquired pes planovalgus in adults.

BACKGROUND: The successful correction of flatfoot in children through lengthening of the lateral column, osteotomy of the medial cuneiform, and advancement of the posterior tibial tendon led to the introduction of similar procedures to treat acquired pes planovalgus secondary to attrition or rupture of the posterior tibial tendon in adults. However, to our knowledge, no study has been published documenting whether these procedures are effective treatment for acquired flatfoot in adults. METHODS: The functional and radiographic results of complex reconstruction of a painful, flexible flatfoot associated with attrition or rupture of the posterior tibial tendon were evaluated in thirty-six patients (forty-one feet) with use of a detailed questionnaire, a comprehensive physical examination, and a review of the radiographs and the medical record. RESULTS: At a mean of thirty-four months (range, twenty-four to fifty months) postoperatively, thirty-six feet (88 percent) were less painful compared with the preoperative status or were pain-free and five of the six parameters that had been used to assess correction of the deformity radiographically had improved significantly (p<0.0001). Eight feet (20 percent) had a non-union at the calcaneocuboid joint, and thirteen feet (32 percent) had anesthesia or paresthesia of the sural nerve. Twenty-nine feet (71 percent) had had additional operations, including removal of hardware from twenty feet; bone-grafting to treat a nonunion at the site of the calcaneocuboid arthrodesis and revision of the internal fixation in four feet; a medial displacement calcaneal osteotomy because of recurrent valgus angulation of the hindfoot in two feet; and a Lapidus procedure because of a hypermobile tarsometatarsal joint with hallux valgus, a triple arthrodesis because of a nonunion at the site of the calcaneocuboid arthrodesis associated with loss of correction, and a dorsiflexion-abduction wedge osteotomy through the site of the calcaneocuboid arthrodesis (which had healed) for alignment of an overcorrected foot in one foot each. The outcomes of the procedures in thirty-five feet (85 percent) were rated by the patients as satisfactory, and thirty-three (92 percent) of the thirty-six patients (thirty-eight [93 percent] of the forty-one feet) stated that they would have the procedure again if the circumstances were similar. CONCLUSIONS: Despite the high prevalence of postoperative complications, most of our patients were satisfied with the result of the procedure after the short duration of follow-up. We believe that the relief of pain and the restoration of function achieved through effective correction of the severe pes planovalgus deformity account for the satisfactory outcomes in our patients.

Subluxation of the talocalcaneal joint in adults who have symptomatic flatfoot.

BACKGROUND: When flatfoot is acquired during adulthood, the shape of the foot changes. In addition to a decreased arch, there may be valgus angulation of the hindfoot or abduction of the forefoot, or both. However, there is little objective information to provide a better understanding of the anatomical or morphological changes that occur in acquired adult flatfoot. We wondered if such an understanding of the three-dimensional anatomy might shed light on the pathway by which these changes occur. We designed this study to measure the three-dimensional position of the talocalcaneal joint in patients who have painful flatfoot. METHODS: Computed tomography scans of the feet of eight patients who had symptomatic flatfoot were used to construct a model of the talocalcaneal articulation. The scans were performed on a custom loading frame developed to simulate weight-bearing with the foot in a neutral position while a seventy-five-newton axial compressive load was applied. The digital data from the scans were used to make three-dimensional computer models of the articular surfaces of the talus and calcaneus of each foot. These models then were used to calculate the percentage of the articular surface that was in contact and, conversely, the percentage that was subluxated. Two surfaces were modeled for each bone; the posterior facet formed one surface, and the anterior and middle facets were combined to form the second surface. The data were compared, with use of Mann-Whitney nonparametric U analysis, with those derived from scans of the feet of four patients without a deformity of the hindfoot who served as controls. RESULTS: A mean (and standard deviation) of 68+/-9 percent of the posterior facet of the calcaneus was in contact with the talus in the patients who had flatfoot compared with 92+/-2 percent in the controls, and a mean of 51+/-23 percent of the anterior and middle facets of the calcaneus was in contact with the talus in the patients who had flatfoot compared with 95+/-6 percent in the controls. These differences were significant (p = 0.0066 for both). CONCLUSIONS: Marked subluxation of the talocalcaneal joint occurs in some patients who have symptomatic planoabductovalgus deformity.

The lateral column lengthening and medial column stabilization procedures.

The results of medial column stabilization, lateral column lengthening, and combined medial and lateral procedures were reviewed in the treatment of adult acquired flatfoot secondary to posterior tibialis tendon insufficiency. All bony procedures were accompanied by transfer of the flexor digitorum longus tendon to the medial cuneiform or stump of the posterior tibialis tendon and tendoachilles lengthening or gastrocnemius recession. Medial column fusion was performed for naviculocuneiform and cuneiform first metatarsal sag; lateral column lengthening was performed for calcaneovalgus deformity with a flat pitch angle; and combined procedures were performed for complex combined deformities. At 1 to 4 year followup of 65 feet, 88% of the feet that had lateral column lengthening, 80% that had medial column stabilization, and 88% of the feet that had medial and lateral procedures had a decrease in pain or were pain free. The lateral talar first metatarsal angle improved by 16 degrees in the patients in the lateral column lengthening group, 20 degrees in the patients in the medial column stabilization group, and 24 degrees in the patients in the combined medial and lateral procedures group. The anteroposterior talonavicular coverage angle improved by 14 degrees in the patients in the lateral column lengthening group, 10 degrees in the patients in the medial column stabilization group, and 14 degrees in the patients in the combined medial and lateral procedures group. These techniques effectively correct deformity without disrupting the essential joints of the hindfoot and midfoot.

Support of the talus: a biomechanical investigation of the contributions of the talonavicular and talocalcaneal joints, and the superomedial calcaneonavicular ligament.

The goal of this study was to determine the magnitude of force transmission to the talus by its inferior articulations to provide insight into mechanisms involving acquired deformities of the hindfoot. Cadaver feet were mounted in a loading apparatus that applied axial force through the tibia and fibula as well as tensile loading of the tendons of extrinsic musculature. This also permitted positioning of the tibia in the sagittal plane. Eighteen specimens were tested in three selected positions of the gait cycle. In one series, pressure-sensitive film was inserted into the posterior and anteromedial facets of the talocalcaneal joint as well as into the talonavicular joint. In a second series, film was inserted between the talar head and the superomedial calcaneonavicular ligament. In stance position, the specimens were also tested without posterior tibial tendon (PTT) tension. Contact areas and force transmitted across the articulations were greatest in near toe-off position, in the posterior facet of the talocalcaneal joint. The talonavicular joint, the anteromedial facet of the talocalcaneal joint, and the calcaneonavicular ligament articulation showed sequentially decreasing amounts of contact area and force transmission. Mean pressures were similar across all articulations, except in the posterior facet in near toe-off position. From heel-strike to stance, to near toe-off, a trend to increasing contact area and force was noted. No difference in contact characteristics was found in the calcaneonavicular ligament articulation after PTT release. The contact force of the calcaneonavicular ligament against the talus was found to be much smaller than those of other talar articulations; however, its medially oriented direction must contribute to stabilization of the head of the talus against medial displacement. Loss of PTT tension was not found to alter the contact forces acting at the talar head in this model, which might indicate that it shares its talar stabilizing function with other structures.