The Zadek calcaneal osteotomy in Haglund's syndrome of the heel: Clinical results and a radiographic analysis to explain its efficacy.

Local debridement or decompression of the posterior heel in Haglund's syndrome yields variable results. This condition is sometimes due to an excessively long calcaneus rather than simply a large posterosuperior bony prominence. Failure to address this abnormality may explain the poor results in some series. We recently published a new measurement (the X/Y ratio) which, combined with the calcaneal pitch angle, assesses the abnormality of the shape of the calcaneus. The Zadek osteotomy strongly modifies that shape. We retrospectively reviewed 50 patients treated by a Zadek osteotomy at a mean 7 years follow-up using the AOFAS ankle-hindfoot score, the VISA-A score and Tegner scale. We measured only the X/Y ratio and the calcaneal inclination angle, as the classically described radiographic measurements in Haglund's syndrome are unreliable. We then assessed the condition of the distal end of the Achilles tendon with an MRI. Our results demonstrate excellent outcomes(40/50, 80%) following Zadek osteotomy and correspond to the change in pre- and post-operative measurements, especially the X/Y ratio. An algorithm using those geometrical measurements of the calcaneus is proposed for decision making in Haglund's syndrome. Level of clinical evidence: Level 3.

The Zadek calcaneal osteotomy in Haglund's syndrome of the heel: Its effects on the dorsiflexion of the ankle and correlations to clinical and functional scores.

The Zadek osteotomy is a therapeutic option in Haglund' syndrome for patients with a X/Y ratio measurement of the calcaneus under 2.5. We hypothesized that Zadek osteotomy would lead to improvement in ankle dorsiflexion and functional scores. Twenty-two patients (mean age: 48.5 years) with Haglund's syndrome underwent a Zadek osteotomy and were enrolled in a prospective study investigating the proposed hypothesis. Radiological measurements included the X/Y ratio and the pitch angle. Measurements of the dorsiflexion of the ankle, using a hand-made frame, were performed twice by 2 independent observers. Inter and intra classes correlations were calculated. Functional results were assessed using AOFAS, EFAS and EFAS sport. Correlation between ankle dorsiflexion and functional scores were determined using linear regression curves. Our hypothesis was validated with a mean improvement of dorsiflexion of 7.27° (54.98% improvement from pre-operative measurement) (p < 0.0001). Ankle dorsiflexion measurements were highly reproducible with an interclass correlation coefficient(ICC)> 0.95 (0.98-0.99). All mean values of functional scores were significantly improved(p < 0.05) [AOFAS (61.95-94), EFAS (14-21.82), EFAS sport (7.68-13.69)] and were strongly correlated to the dorsiflexion values with a coefficient of determination of 0.82 for AOFAS and EFAS and of 0.86 for EFAS sport, respectively. The mean values of X/Y ratio and pitch angle improved from pre to postoperative conditions, 2.18-2.75 and 28.95-19.77° (p < 0.05), respectively. The angle correction obtained from modifiying the shape of the calcaneus, due to the Zadek osteotomy, confirms it as a safe and reliable treatment, with improvements of both ankle dorsiflexion and functional scores.

Assessment of Evertor Strength Following Inferior Extensor Retinaculum Flap Ligamentoplasty in Patients With Chronic Lateral Ankle Instability.

The primary aim of our study was to evaluate the strength of ankle evertor muscles in patients who have undergone a lateral ankle ligamentoplasty (which combined tensioning of the primary ligament group and reinforcing it with a pediculated extensor retinaculum flap), using 2 measurement systems (isokinetic and the functional weightbearing test [MyoLux). Our hypothesis was the strength of evertor muscles on the treated side was comparable to that of the contralateral healthy side. This prospective study included 23 patients who had chronic ankle instability and underwent an inferior extensor retinaculum flap ligamentoplasty. Clinical and functional results were assessed using the American Orthopaedic Foot & Ankle Society and Karlsson scores. The evertor muscle strength was analyzed, in both treated and healthy contralateral ankles, using isokinetic testing (gold standard) - an open kinetic chain test and a functional closed kinetic chain test (MyoLux). Data were interpreted using the Stata 14.0 software. The American Orthopaedic Foot & Ankle Society score was 88.1 ± 4.5, and the Karlsson score was 89.6 ± 4.0. Isokinetic tests did not show any significant difference between the treated ankles and the healthy one. Functional tests measuring inversion control at the ankle did not demonstrate any functional differences between the 2 ankles. As confirmed by good functional scores and the lack of difference in evertor muscle strength, this study reports that the inferior extensor retinaculum flap ligamentoplasty is a satisfactory treatment of chronic ankle instability. In addition, the MyoLux is a reliable and effective test to properly assess proprioception at the ankle.

Reliability of hindfoot alignment measurements from standard radiographs using the methods of Meary and Saltzman.

BACKGROUND: Few methods have been described for measuring hindfoot alignment from an anteroposterior view. The objective of this study was to compare two methods of angular measurement based on the views of Meary and Saltzman. METHODS: Thirty asymptomatic volunteers were included. Four radiographs were performed: the views of Meary and Saltzman with parallel feet and with the Fick correction. The reproducibility was determined by the inter- and intraobserver variability (ICC). RESULTS: Meary's method revealed a mean valgus angulation of 3.9° (SD 3.47°). The reliability was extremely variable with a mean ICC of 0.59. The best reproducibility was obtained with Meary's method with and without Fick correction. CONCLUSION: The results of this study show that the reliability of the angular measurements depends on the radiographic view and measurement method chosen. The lateral Fick correction did not counteract the influence of tibial rotation. The same method should be used consistently.

Contribution of a new radiologic calcaneal measurement to the treatment decision tree in Haglund syndrome.

INTRODUCTION: In Haglund syndrome, standard radiologic measurements lack specificity and reliability in assessing etiologic morphologic calcaneal abnormalities. We report a simple X/Y ratio to measure posterior calcaneal length, where X is calcaneal length on lateral weight-bearing view and Y is greater tuberosity length. OBJECTIVE: To compare this new parameter against the radiologic gold standard in a group of Haglund patients and a healthy control group. HYPOTHESIS: Measuring this ratio significantly distinguishes between Haglund patients and healthy subjects. MATERIAL AND METHODS: A retrospective study included 50 Haglund syndrome patients and 30 healthy controls. Standard measurements (Fowler-Philipangle, Chauveaux-Liet angle, Ruch pitch, Heneghan-Pavlov test) and X/Y ratio were calculated twice by 2 independent observers. Intra- and inter-observer correlations were calculated, as were the specificity and sensitivity of the various parameters, with a ROC curve to establish the X/Y threshold. RESULTS: All measurements were reproducible on intra- and inter-observer testing. There were no significant inter-group differences in standard measurement specificity or sensitivity. The Haglund group showed significantly lower X/Y ratio (2.07) than controls (2.70; p<0.0001), with a cut-off at 2.5. Threshold sensitivity in confirming Haglund syndrome was 100% (p<0.0001) and specificity 95% (p<0.0001). DISCUSSION: This new parameter measures the length of the calcaneus and its greater tuberosity. It is more reliable and reproducible in terms of sensitivity and specificity than standard measurements in Haglund syndrome. The 2.5 ratio threshold can guide surgical decision-making. LEVEL OF EVIDENCE: III.

Arthrodesis of the first metatarsophalangeal joint-A biomechanical comparison of four fixation techniques.

BACKGROUND: Arthrodesis of the first metatarsophalangeal joint is a commonly performed orthopaedic procedure. The optimum method of fixation and joint surface preparation has yet to be determined. METHODS: This study compared four fixation techniques: Biomechanical grade sawbones were used. The dorsal plate used was a titanium, anatomically contoured locked plate. Testing was performed using an Instron machine applying force from the plantar aspect of the fused joint. Each fused sample was tested to failure. Stiffness, as calculated from the force-displacement curve, and ultimate load tolerated were recorded for each sample. The method of failure of each sample was also documented. RESULTS: Constructs arthrodesed using dorsal plate with separate screw groups, regardless of method of joint preparation, were the stiffest (p<0.001). The weakest construct was dorsal plate alone without interfragmenary screw. There was no difference in stiffness between planar and cup-cone joint preparation (p=0.99). Maximum load tolerated was similar when comparing Crossed Screws with dorsal plate with screw with either cup-cone or planar reaming (p=0.93, p=0.89 respectively). Dorsal plating alone tolerated a significantly lower maximum load than Plate with Screw Groups or Crossed Screws (p<0.001). CONCLUSION: This study confirms that an IFS combined with a dorsally positioned locked-plate is the ideal construct, with the joint preparation technique of little consequence.

Bilateral distal tibial stress fractures in a healthy field-hockey goalkeeper.

Stress fractures occurring within the lower limbs are relatively common in athletes and military personnel. The specific bones affected are often predictable when the patient's activities are considered. We present an unusual case of bilateral distal tibial stress fractures sustained while playing as a goalkeeper in field hockey, in an otherwise healthy 46-year-old woman.

Atypical stress-avulsion fracture of the Lisfranc joint complex.

Antiphospholipid syndrome and systemic erythematosus have been associated with metatarsal stress fractures. Stress fractures of the Lisfranc joint complex are uncommon injuries but have been reported to occur most frequently in ballet dancers. We present a case of an avulsion fracture of the Lisfranc joint complex that occurred spontaneously. We have reviewed the association between systemic conditions and metatarsal fractures and proposed a series of hypothetical pathological events that may have contributed to this unusual injury.

The conundrum of calcaneal spurs: do they matter?

BACKGROUND: Chronic plantar heel pain is a common and potentially debilitating condition, often caused by plantar fasciitis. Plantar calcaneal spurs were originally considered the cause of plantar fasciitis but are now regarded as an incidental finding by most authors. We aimed to test this hypothesis and to investigate predisposing factors for the development of spurs. METHODS: We reviewed all lateral ankle X rays taken in our institution over a 6-month period and identified all X rays demonstrating calcaneal spurs. Then, we identified a similar number of age- and sex-matched controls without spurs. We contacted both groups by telephone and compared symptoms of heel pain, plantar fasciitis, associated comorbidities, and foot and ankle outcome scores (FAOSs). RESULTS: We reviewed the X rays of 1103 consecutive patients and found a spur prevalence of 12.4%, more common in women and older patients. Questioning of the spur group and control group found a higher body mass index in the spur group. Patients with spurs were 4 times more likely to have diabetes mellitus and 10 times more likely to have lower-limb osteoarthritis. Patients with spurs had more foot pain and poorer FAOS than the control group, even when patients with plantar fasciitis were excluded. CONCLUSION: Our results demonstrate that the presence of a plantar calcaneal spur may be an indicator of foot pain independent of plantar fasciitis. Although spurs may not cause foot pain themselves, they may be an indication of other associated conditions. CLINICAL RELEVANCE: We have demonstrated the relevance of a radiographic finding once considered irrelevant.

Long-term follow-up of lateral reconstruction with extensor retinaculum flap for chronic ankle instability.

BACKGROUND: Chronic instability is a common complication of lateral ankle sprains. Furthermore, patients often have unrecognized associated lesions affecting the ankle and subtalar joints. Many stabilizing surgical techniques have been described, each with variable results. This article reports the long-term results of ligamentous retensioning combined with reinforcement using an extensor retinaculum flap. PATIENTS AND METHODS: This is a retrospective, multicenter study. One hundred fifty cases were reviewed at a mean follow-up of 11 years. Functional results were assessed using the Karlsson score. Pre- and postoperative radiological assessment employed stress x-rays to measure varus tilt and anterior drawer and the Van Dijk classification to grade osteoarthrosis. The Stata 10 program was used for statistical analysis. RESULTS: A thorough preoperative workup identified ligamentous lesions of the subtalar joint in 30% of cases. At review, 93% of patients were satisfied. Residual instability was present in only 4.8%. Radiographic analysis of both ankles revealed a differential in varus tilt of only 0.12° and in anterior drawer of 0.17~mm. There was no deterioration of the articular surfaces after 11 years of follow-up. CONCLUSION: To the authors' knowledge, this is the largest series reported with such a follow-up. This technique addressed both lateral ankle and subtalar instability without sacrificing the peroneal tendons. It protected against progression of posttraumatic arthrosis and provided superior results to other reported techniques in terms of patient satisfaction and residual instability.

A single-center prospective evaluation of the Ponseti method in nonidiopathic congenital talipes equinovarus.

BACKGROUND: The Ponseti method has revolutionized the management of idiopathic congenital talipes equinovarus (CTEV). However, nonidiopathic CTEV is still often primarily treated by extensive surgical soft tissue release. We believe that nonoperative treatment of these patients using the Ponseti method may give very satisfactory results. METHODS: We examined the demographics of nonidiopathic CTEV and the success of the Ponseti method in this population over a 5-year period. We treated 29 patients with 43 nonidiopathic and 97 patients with 138 idiopathic CTEV feet. Patients with nonidiopathic CTEV made up 23% of all cases. The commonest etiologies were arthrogryposis (5 cases), trisomy 21 (4 cases), and spina bifida (3 cases). Average follow-up was 39 (nonidiopathic group) and 35 months (idiopathic group). RESULTS: The Ponseti method was initially successful in 91% of nonidiopathic and 98% of idiopathic feet. Recurrence of deformity occurred in 44% of nonidiopathic and 8% of idiopathic feet. Thirty-seven percent of nonidiopathic feet required extensive surgical release compared with 2% in the idiopathic group. CONCLUSIONS: Although the success rate of the Ponseti method in nonidiopathic CTEV is inferior to that in idiopathic CTEV, 63% of our nonidiopathic patients did not require extensive surgery. We believe that the Ponseti method should be used in all cases of nonidiopathic CTEV. LEVEL OF EVIDENCE: Level III--prospective cohort study.

The 90/90 pillow reduces blood loss after knee arthroplasty: a prospective randomized case control study.

Our goal was to evaluate the 90/90 pillow as an effective means of preventing blood loss after knee arthroplasty. We performed a prospective randomized case-control study on 40 patients undergoing knee arthroplasty. All patients were treated in a standard fashion, except for the use of the 90/90 pillow in one group. The 90/90 pillow flexes the knee to 90 degrees and is in situ for 24 hours after surgery. We measured blood loss at time points from 1 to 48 hours. Range of motion was assessed, as were analgesic requirements. Statistical analysis was performed on our results. We found a statistically significant reduction in blood loss without compromising range of motion. We advocate the 90/90 pillow after all knee arthroplasties.