Medial sliding calcaneal osteotomy with flexor hallucis longus transfer for the treatment of posterior tibial tendon insufficiency.

Medial sliding calcaneal osteotomy is a simple bone procedure to augment tendon transfer in treatment of stage 2 posterior tibial tendon dysfunction. This osteotomy moves the valgus heel under the weight-bearing axis of the leg, shifts the Achilles' insertion medially, and decreases strain on the spring ligament and deltoid ligaments. The osteotomy heals within 6 weeks. Consistently reproducible good-to-excellent results have been achieved using medial sliding calcaneal osteotomy in conjunction with FHL transfer.

Treatment of stage II posterior tibial tendon dysfunction with flexor hallucis longus transfer and medial displacement calcaneal osteotomy.

Nineteen consecutive patients underwent flexor hallucis longus (FHL) tendon transfer and medial displacement calcaneal osteotomy for the treatment of Stage 2 posterior tibial tendon dysfunction. The FHL tendon was utilized for transfer because it approximates the strength of the posterior tibialis muscle and is stronger than the peroneus brevis muscle. Seventeen patients returned for follow-up examination, follow-up time 18 months (ave.). The AOFAS hindfoot score improved from 62.4/100 to 83.6/100. The subjective portion of the AOFAS hindfoot score improved from 31.0/60.0 to 48.9/60. Weightbearing preoperative and postoperative radiographs revealed no statistically significant improvement for the medial longitudinal arch in measurements of lateral talo-first metatarsal angle, calcaneal pitch, vertical distance from the floor to the medial cuneiform, or talonavicular coverage angle. Three feet had a normal medial longitudinal arch and six feet had a longitudinal arch similar to the opposite side following the procedure. Patient satisfaction was high: 10 patients satisfied without reservations, 6 patients satisfied with minor reservations, and 1 dissatisfied. No patient complained of donor deficit from the harvested FHL tendon. Despite the inability of the procedure to improve the height of the medial longitudinal arch, FHL transfer combined with medial displacement calcaneal osteotomy yielded good to excellent clinical results and a high patient satisfaction rate.

Evaluation and treatment of ankle sprains: clinical recommendations for a positive outcome.

Ankle sprains usually involve damage to lateral ankle ligaments and syndesmotic ligaments. A detailed examination that focuses on physical examination techniques is important because other injuries may mimic ankle sprains, and hands-on grading of ankle sprains dictates treatment and forecasts recovery time. Most ankle sprains can be successfully treated nonsurgically with PRICE (protection, rest, ice, compression, and elevation). When patients experience chronic pain or instability from an ankle sprain, a directed approach will help physicians fine-tune nonsurgical treatments or suggest a surgical referral.

Fracture of an interphalangeal coalition: a report of two cases.

Congenital coalition of the middle and distal phalanges in the fifth toe are common. They have been reported to occur in up to 50% of American and European populations and in up to 73% of people of Japanese descent. Congenital interphalangeal coalition of the other toes is less common. We report two cases of fracture through an interphalangeal coalition following blunt trauma. Diagnosis was delayed in these fractures. One fracture healed only after prolonged immobilization and the other developed a delayed union. Patients with this fracture should be advised of the prolonged convalescence since this may delay their return to preinjury activities.

Forefoot problems in athletes.

Athletes who participate in high-impact sports involving running, jumping, or contact are at risk for forefoot injury. These injuries occur as a result of acute trauma or chronic overuse. Some athletes may be predisposed to injury because of preexisting foot deformity, such as cavus, hallux valgus, or Achilles contracture. This article reviews the common causes of forefoot pain in the athlete. The most common causes of forefoot pain in the athlete are metatarsal stress fracture, interdigital neuroma, sesamoid pathology, metatarsalgia, hallux rigidus, hallux valgus, and turf toe. The pathophysiology, clinical presentation, and treatment of these conditions are discussed.

Dislocation of the distal tibiofibular joint.

A case report of a patient with posterior dislocation of an intact fibula at the distal tibiofibular joint is presented. This rare injury is a variant of a Bosworth fracture, which is a posterior dislocation of the fibula usually accompanied by an oblique fibular fracture. The injury was initially treated by open reduction of the fibular dislocation, repair of avulsed lateral and deltoid ligaments, and placement of a syndesmotic screw. At one year postoperative, the patient has a poor result secondary to talar avascular necrosis and secondary degenerative ankle arthritis.

A biomechanical in vitro comparison of open versus percutaneous repair of tendon Achilles.

A study was undertaken to compare the in vitro strengths of percutaneous Achilles tendon repair to open Achilles tendon repair. Ten fresh frozen cadaver below-the-knee specimens underwent Achilles tenotomy. The specimens were divided into two groups of five specimens each. Group I specimens underwent open Achilles repair using a Bunnell suture technique. Group II specimens underwent percutaneous repair. Each specimen was placed on an apparatus which produced progressive ankle dorsiflexion. Measurements of anastomotic gap were correlated with angle of dorsiflexion. Group I anastomoses were able to resist almost twice the amount of ankle dorsiflexion compared to Group II anastomoses (P less than .05). Entrapment of the sural nerve occurred in three out of five specimens in Group II. Percutaneous anastomoses were malaligned in four out of five specimens. Based on this study, percutaneous repair of Achilles tendon ruptures provides approximately 50% of the initial strength afforded by open repair. Percutaneous repair places the sural nerve at risk for injury.