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.

Treatment of ankle arthrosis.

Patients with arthrosis of the ankle are seen routinely in the practice of orthopaedic surgery. Although the etiologies of the arthrosis may be varied, the treatment options are similar. These options vary with the severity of the symptoms, the findings on examination and radiographs, and the physical demands of the patients. Although there are many different conservative and surgical options available, it generally is accepted that arthrodesis of the ankle is the surgical treatment of choice for patients with significant symptoms that do not respond to conservative measures. Although ankle arthrodeses have been performed for more than 100 years, there is still little agreement as to the best method to achieve the best results. Various treatment options, conservative and surgical, available to treat patients with arthrosis of the ankle are reviewed.

Ultrasound in the diagnosis of posterior tibial tendon pathology.

We retrospectively evaluated the effectiveness of ultrasonography as a diagnostic tool for investigating pathology in the posterior tibial tendon by comparing the preoperative ultrasonograms for 17 patients with their recorded surgical findings. In all cases, the surgical findings confirmed the ultrasonographic diagnoses: 3 inflammations, 4 partial tears, and 10 ruptures. Interestingly, two ruptures had been undiagnosed by magnetic resonance imaging. Ultrasonography, which seems to be a reliable means of visualizing the extent of pathology of the symptomatic posterior tibial tendon, may be a valuable tool in surgical planning.

Kirschner wire breakage after surgery of the lesser toes.

A retrospective review was made of all patients operated on by the two senior authors from January 1985 to January 1993 for problems with Kirschner wire breakage following forefoot surgery. Thirty-three broken K-wires in 27 patients were encountered. All of these were 0.045-inch K-wires that had been placed across the metatarsophalangeal (MTP) joint of the lesser toes. In no case was there breakage of a K-wire that was larger than 0.045 inches or that did not cross the MTP joint. The medical records and radiographs of 565 consecutive patients having fixation with 0.045-inch K-wires that crossed the MTP joints of the lesser toes were then reviewed. A total of 1002 K-wires were used with an overall failure rate of 3.2% (4.8% of the patients). All of these K-wires failed just proximal to the point of entry into the metatarsal head. No intra-articular retained fragments were noted. Twenty-five of the retained fragments were completely within the metatarsal head and shaft, and eight of these fragments pierced the cortex of the metatarsal proximally. Twenty-three patients with retained fragments were examined in follow-up and in no case could the retained fragment be palpated or directly related to postoperative symptoms. Of the three patients who complained of persistent pain, two had mild pain with persistent MTP synovitis and one had severe pain due to lateral deviation of the toe after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Reliability of standard foot radiographic measurements.

Fifty standing dorsoplantar and lateral foot radiographs were obtained on a consecutive series of patients seen in an orthopaedic foot and ankle clinic. These radiographs were duplicated, and eight common foot measurements were made on each pair by six experienced examiners. Measurements were made in two ways: first by a subjective visual assessment, and second by quantitative evaluation made according to strictly defined criteria. All measurements were made under controlled, ideal conditions with similar high quality goniometers. The results demonstrated overall greater reliability in the quantitative methods than the non-quantitative methods. For each of the quantitative techniques, a cumulated frequency distribution of differences between examiners was calculated. The approximate 95% bounds for these measures were: hallux-metatarsophalangeal angle = 6 degrees, first intermetatarsal angle = 4 degrees, metatarsophalangeal-5 angle = 11 degrees, fourth intermetatarsal angle = 4 degrees, AP talocalcaneal angle = 20 degrees, lateral talocalcaneal angle = 12 degrees, sesamoid station = 2 grades, and forefoot width = 5 mm. Physicians using these parameters to make decisions regarding patient care and clinical outcomes need to keep in mind these potential errors in making foot radiographic measurements.

Treatment of Freiberg's disease.

Freiberg's disease is a relatively rare condition with a multifactorial cause in which trauma and circulation must play a major but not solitary role. Once the condition presents itself, early treatment is geared toward reducing its symptoms and preventing progression. If conservative measures fail, many surgical options are available. One of these, the dorsiflexion osteotomy of the metatarsal head is presented as a logical procedure that is simple, reliable, not destructive, and capable of good results regardless of the stage of the disease.

Relationship of metatarsophalangeal joint fusion on the intermetatarsal angle.

To evaluate the effect of fusion of the first metatarsophalangeal joint on the first intermetatarsal angle, a series of 62 consecutive first metatarsophalangeal fusions was reviewed. Of these, 47 had sufficient data to be included in this study. The results of this study showed that the change in the first intermetatarsal angle following a first metatarsophalangeal joint arthrodesis is directly proportional to the preoperative first intermetatarsal angle. Therefore, when a first metatarsophalangeal joint arthrodesis is performed on a patient with a wide intermetatarsal angle, a concomitant proximal first metatarsal osteotomy is usually not indicated.

Slotted acetabular augmentation in patients with neuromuscular disorders.

This study presents our results with a single graft modification of slotted acetabular augmentation in severely neuromuscularly compromised children from 1983 to 1986. Included in the study were 26 hips of 24 patients (13 males and 11 females) with an average age of 8 years 3 months at the time of surgery. Most of the patients had spastic cerebral palsy. The average followup was 29 months. We believe that our current results show that slotted acetabular augmentation in patients with neuromuscular conditions is a relatively simple and safe procedure with a high probability for a successful outcome.