Talocalcaneal coalition. Diagnosis with the C-sign on lateral radiographs of the ankle.

We analysed 42 weight-bearing lateral radiographs of the ankle, 20 of which were from patients with a clinical and plain radiological diagnosis of talocalcaneal coalition (TCC) who subsequently had CT. The remainder were from 22 healthy volunteers with no clinical findings suggestive of hindfoot pathology. Four observers, blinded to the CT findings, independently evaluated the radiographs on two separate occasions. With the 95% confidence interval and using the CT findings as the comparison we calculated the sensitivity, specificity, accuracy, and positive and negative predictive values for the C-sign, and for other signs known to be associated with TCC. Similarly, we also calculated the interobserver and intraobserver reliability for these signs using the kappa statistic. Our results suggest that the C-sign is highly sensitive and specific for TCC. It is an accurate indicator and significantly more reliable than other previously recognised radiological signs of TCC. Features of the C-sign, however, cannot be relied upon to indicate whether the TCC is fibrous or bony.

The role of diagnostic block in the management of Morton's neuroma.

OBJECTIVE: To determine the outcome of surgical excision of Morton's neuroma after a local anesthetic diagnostic block into the neuroma has relieved symptoms. DESIGN: A cohort study. SETTING: A university affiliated hospital. PATIENTS: A sequential series of 37 patients who underwent 41 excisions with at least 2 years' follow-up. Seven patients had undergone repeat excision of a neuroma, and 34 primary excisions were performed. Surgery was performed by a specialist in orthopedic surgery of the foot and ankle. INTERVENTION: Excision of the Morton's neuroma after a positive diagnostic block. MAIN OUTCOME MEASURES: Grade of symptoms at follow-up done by independent review on a 4-point scale. RESULTS: Of 41 procedures, 11 had an unfavourable outcome: 4 procedures were graded 3, and 7 procedures were graded 4. Eight (24%) of the 34 primary procedures were reported as failures, and 3 (43%) of the 7 revision procedures were reported as failures. Most patients reported poor results owing to persistent pain. CONCLUSIONS: Diagnostic blocks do not improve the results of surgery for excision of Morton's neuroma and are not recommended. Because failure rates are greater than 20%, surgery for Morton's neuroma should only be offered after a full course of nonoperative management.

Lateral popliteal sciatic nerve block compared with ankle block for analgesia following foot surgery.

The purpose of this study was to compare postoperative analgesia after foot surgery in patients anaesthetised either with popliteal sciatic nerve block or ankle block. In a prospective study, 40 patients scheduled for foot surgery involving osteotomies were allocated randomly into one of two groups. Following induction of general anaesthesia, Group PS (n = 21) received a lateral popliteal sciatic nerve block and Group AB (n = 19) received an ankle block. Both groups received 20 ml bupivacaine 0.5% plain. In group PS 43% required morphine analgesia in the Post Anaesthetic Recovery Room (PAR) compared with 16% in group AB. Postoperative analgesia was assessed using VAS and a pain scale in the PAR and a questionnaire by telephone follow-up on the day after surgery. The ankle block appeared to be more reliable, providing more consistent analgesia in the PAR. Postoperative analgesia in Group PS lasted a median of 18.0 hr and in Group AB lasted 11.5 hr (P < 0.05). Both techniques provided effective analgesia after discharge home and high levels of patient satisfaction.

Chevron osteotomy for bunionette.

Numerous procedures have been described for the surgical treatment of symptomatic bunionettes. We describe the technique, results, and follow-up of patients treated with a chevron osteotomy of the distal fifth metatarsal. This surgical approach to the treatment of bunionette is presented as a viable alternative to other surgical procedures. Sixteen distal fifth metatarsal chevron osteotomies were performed on 12 patients. Follow-up was from 15 months to 6 years, with an average follow-up of 3.2 years. A 100-point scoring system was devised and the average score improved from 44 points before surgery (range 20-65) to 91 points after surgery (range 65-100). There was one complication of a transfer metatarsalgia. The overall results were good to excellent, except for the transfer metatarsalgia, which was rated as fair. We have used the procedure in a laterally deviated, plantar metatarsal. There is concern that alternatives be used in a laterally deviated, plantarflexed fifth metatarsal. We have continued to use the chevron osteotomy with this condition.

Lateral popliteal sciatic nerve block compared with subcutaneous infiltration for analgesia following foot surgery.

A new lateral approach to blocking the sciatic nerve in the popliteal fossa is described. In a prospective study, 40 patients scheduled for foot surgery involving osteotomies were allocated randomly into one of two groups following induction of general anaesthesia: group PS (n = 21) received a lateral popliteal sciatic nerve block and group SC (n = 19) received subcutaneous infiltration of the wound. Both groups received 20 ml bupivacaine 0.5% plain. The lateral approach to the popliteal sciatic nerve was found to be an effective, quick, and easy to perform, block. Postoperative analgesia in groups PS lasted a median of 18.0 hr and in group SC lasted 6.3 hr (P < 0.05). The lateral popliteal sciatic nerve block provided effective analgesia following foot surgery and had a high level of patient satisfaction.

Reconstructive surgery of the lower extremity.

Non-operative treatments for degenerative arthritis, such as physiotherapy, anti-inflammatory medication, and occupational therapy, can help reduce the impact of the disease on the joint and hence on the mobility of the patient. Once the joint has become so diseased that non-operative modalities are inadequate, it is the task of the orthopedic surgeon to evaluate these individuals and determine which ones would benefit from a reconstructive procedure. The author explores the indications for arthrotomies, resection arthroplasties, arthrodeses, osteotomies, and total joint replacements. Total joint arthroplasty has revolutionized the treatment of degenerative arthritis of the lower extremity, although it is not a panacea for arthritis in the lower extremity.