Biomedical subjects

Bruce J Sangeorzan

Publications and source records attributed to Bruce J Sangeorzan.

At least 19 recordsLinked to original sources

PubMed2006

Effect of foot shape on the three-dimensional position of foot bones.

To eliminate some of the ambiguity in describing foot shape, we developed three-dimensional (3D), objective measures of foot type based on computerized tomography (CT) scans. Feet were classified via clinical examination as pes cavus (high arch), neutrally aligned (normal arch), asymptomatic pes planus (flat arch with no pain), or symptomatic pes planus (flat arch with pain). We enrolled 10 subjects of each foot type; if both feet were of the same foot type, then each foot was scanned (n=65 total). Partial weightbearing (20% body weight) CT scans were performed. We generated embedded coordinate systems for each foot bone by assuming uniform density and calculating the inertial matrix. Cardan angles were used to describe five bone-to-bone relationships, resulting in 15 angular measurements. Significant differences were found among foot types for 12 of the angles. The angles were also used to develop a classification tree analysis, which determined the correct foot type for 64 of the 65 feet. Our measure provides insight into how foot bone architecture differs between foot types. The classification tree analysis demonstrated that objective measures can be used to discriminate between feet with high, normal, and low arches.

Biomechanical Phenomena↗

PubMed2006

Is the absence of an ipsilateral fibular fracture predictive of increased radiographic tibial pilon fracture severity?

OBJECTIVE: Despite their frequent occurrence, there is little clinical or biomechanical data associating the status of the fibula with any injury pattern of the tibial plafond. Similarly, the integrity of the fibula is not assessed in the commonly used tibial pilon fracture classification schemes. The purpose of this study was to determine whether there is a difference in the radiographic severity of tibial pilon injuries with fibular fractures compared with those without fibular fractures by using a rank-order method. DESIGN: Case-control, radiographic review. SETTING: Urban level-1, university trauma center. PATIENTS: During a 36-month period, 20 consecutive tibial pilon injuries without associated fibular fractures were retrospectively identified by using a prospectively gathered trauma database (group 1). During the same time period, an additional 197 tibial pilon injuries with fibula fractures were identified and classified according to the AO/OTA System. This included 48 AO/OTA 43B-type (24.4%) and 149 AO/OTA 43C-type (75.6%) fractures. From this larger group of patients, an age- (+/-5 years) and gender- matched cohort of 20 tibial pilon injuries with fibular fractures were randomly selected electronically (group 2). INTERVENTION: Digital concealment of the fibula on the anteroposterior and lateral injury radiographs. MAIN OUTCOME MEASURE: Before definitive fixation, 3 orthopaedic traumatologists independently ranked the digitized anteroposterior and lateral radiographs of all 40 patients according to severity with 40 representing the most severe injury. RESULTS: Interobserver agreement between the 3 evaluators showed a significant positive association (Kendall's concordance coefficient = 0.87; P = 0.0001). The overall mean rank score for tibial pilon injuries with fibula fractures was 24.4, whereas those without fibula fractures was 16.7 (t test = 0.02). When evaluated within the AO/OTA classification system, the mean rank score for C-type tibial pilon fracture patterns was 10.3 in group 1 and 8.7 in group 2 (P = 0.5). AO/OTA C-type tibial pilon fracture patterns were observed more commonly in group 2 than in group 1 (P = 0.006). CONCLUSIONS: This study demonstrates that, overall, tibial pilon injuries with fibular fractures were statistically ranked as more radiographically severe than those without fibular fractures. Fibular fractures are more commonly associated with C-type injuries than B-type injuries. There was no difference in severity in C-type injuries with or without fibular fractures; however, C-type injuries were ranked, as a group, significantly more radiographically severe than B-type injuries.

Adult↗

PubMed2006

Intramedullary nailing of proximal quarter tibial fractures.

OBJECTIVE: To report the results of intramedullary nailing of proximal quarter tibial fractures with special emphasis on techniques of reduction. DESIGN: Retrospective clinical study. SETTING: Level 1 trauma center. PATIENTS: During a 36-month period, 456 patients with fractures of the tibial shaft (OTA type 42) or proximal tibial metaphysis (OTA type 41A2, 41A3, and 41C2) were treated operatively at a level 1 trauma center. Thirty-five patients with 37 fractures were treated primarily with intramedullary nailing of their proximal quarter tibial fractures and formed the study group. Thirteen fractures (35.1%) were open and 22 fractures (59.5%) had segmental comminution. Three fractures had proximal intraarticular extensions. MAIN OUTCOME MEASUREMENTS: Alignment and reduction postoperatively and at healing. An angular malreduction was defined as greater than 5 degrees in any plane. RESULTS: Fractures extended proximally to an average of 17% of the tibial length (range, 4% to 25%). The average distance from the proximal articular surface to the fracture was 67.8 mm (range, 17 mm to 102 mm, not corrected for distance magnification, included for preoperative planning purposes only). Postoperative angulation was satisfactory (average coronal and sagittal plane deformity of less than 1 degree) as was the final angulation. Acceptable alignment was obtained in 34 of 37 fractures (91.9%). Two patients had 5-degree coronal plane deformities (one varus and one valgus), and 1 patient had a 7-degree varus deformity. Two patients with open fractures with associated bone loss underwent a planned, staged iliac crest autograft procedure postoperatively. Four patients were lost to follow-up. In the remaining 31 patients with 33 fractures, the proximal tibial fractures united without additional procedures. No patient had any change in alignment at final radiographic evaluation. Secondary procedures to obtain union at the distal fracture in segmental injuries included dynamizations (n = 3) and exchange nailing (n = 1). Complications included deep infections in 2 patients that were successfully treated. CONCLUSIONS: Multiple techniques were required to obtain and maintain reduction prior to nailing and included attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia. Simple articular fractures and extensions were not a contraindication to intramedullary fixation. The proximal tibial fracture healed despite open manipulations. Short plate fixations to maintain this difficult reduction, either temporary or permanent, were effective.

Adult↗

PubMed2006

The extruded talus: results of reimplantation.

BACKGROUND: There is considerable debate regarding the appropriate treatment of the extruded talus regardless of the presence of a fracture. The purpose of this study was to report the clinical results, complications, and functional outcome following reimplantation of the traumatically extruded talus. METHODS: A database of 119 patients with an open injury of the talus occurring between 1995 and 2003 at a level-I trauma center was reviewed to identify patients with a complete talar extrusion. Demographic, imaging, and treatment data were obtained from a review of the medical records. Follow-up was undertaken during clinic visits or by telephone. Preoperative and follow-up radiographs were reviewed to identify posttraumatic arthritis, osteonecrosis, or talar collapse, and the Musculoskeletal Functional Assessment was used to assess functional outcome. RESULTS: Twenty-seven patients were identified. A minimum follow-up of one year (average, forty-two months) was obtained for nineteen patients. Infection and the need for a secondary surgical procedure were the primary determinants of clinical outcome. Two of the nineteen patients had documented infections: one had developed at two weeks and one, after a calcaneal osteotomy at nineteen months. Twelve patients had no subsequent surgery, and seven had subsequent procedures (range, one to four procedures). No patient underwent a delayed amputation. The average Musculoskeletal Functional Assessment score at the time of follow-up was 29.8 (range, 5 to 59). With the numbers studied, no association was found between functional outcome and the following variables: ipsilateral lower-extremity injury, associated talar fracture, secondary procedures, osteonecrosis, or age. CONCLUSIONS: While functional outcome is difficult to assess, salvage of the extruded talus appears to be a relatively safe operation, with a minimal risk of infection, which allows maximal flexibility in aftercare by preserving the most normal ankle anatomy possible.

Adolescent↗

PubMed2005

Isolated medial column stabilization improves alignment in adult-acquired flatfoot.

UNLABELLED: In some patients with painful flatfoot, realignment and arthrodesis of the medial naviculocuneiform and first tarsometatarsal joints can be done to correct alignment and relieve symptoms. The primary purpose of this radiographic study was to assess the ability of isolated medial column arthrodesis to improve hindfoot alignment. We also assessed the ability of the procedure to correct radiographic parameters of overall foot structure in acquired flatfoot. Preoperative and postoperative radiographs of 19 patients who had naviculocuneiform and/or tarsometatarsal realignment and arthrodesis for adult-acquired flatfoot were examined by two reviewers. All parameters improved, with the lateral talometatarsal angle approaching normal. A decrease in talonavicular subluxation in the axial plane suggests passive improvement in hindfoot position without direct manipulation of any hindfoot bones or joints. These observations provide evidence for a link between stability of the midfoot and alignment of the hindfoot. In carefully selected patients, medial column realignment may restore normal anatomy without fusing essential joints. Modern clinical outcome studies are the next step in the objective evaluation of this procedure. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series-no, or historical, control group) See the Guidelines for Authors for a complete description of levels of evidence.

Adult↗

PubMed2005

Functional limitations of patients with end-stage ankle arthrosis.

BACKGROUND: Arthritis and other rheumatic conditions are the leading causes of disability among adults in the United States. The purpose of this report was to describe the self-reported functional limitations of a group of patients with end-stage ankle arthrosis. METHOD: Patients who presented for operative management of end-stage ankle arthrosis at the University of Minnesota and Harborview Medical Center completed a Musculoskeletal Functional Assessment (MFA) as part of their preoperative clinical evaluation. Data from patients evaluated during the time period April, 1995, through May, 2004, were used for this project. RESULTS: Four hundred and twenty-six patients with the diagnosis of end-stage ankle arthrosis completed baseline questionnaires. Six of the 426 patients received care on both ankles during the time of this project. The average age of patients at the time of completion of the questionnaire was 56.7 years. There were 241 men and 185 women. The primary underlying causes identified by the treating surgeon at the time of surgery were primary osteoarthritis with no known prior trauma (66), previous trauma (tibial fracture, foot fractures, or ankle ligamentous disruption) (296), rheumatoid arthritis (24), no known cause (21), and a variety of diseases or infections (19). In all domains, the patients with end-stage ankle arthrosis showed statistically significant differences from a general population sample. CONCLUSIONS: The effects of ankle arthritis as demonstrated by this data are severe. Most of these patients were severely limited in function. Without a data-driven understanding of the limitations the patients have, it is difficult to make an effective argument for focused research to solve the problems. Without understanding the patients' needs, it is impossible to assess the effect of treatment. The information in this paper provides a baseline understanding of effect of the current functional limitations of patients with end-stage ankle arthrosis.

Activities of Daily Living↗

PubMed2005

Issues of importance to patients seeking care from members of the AOFAS: a preliminary report of the outcomes committee of the AOFAS.

BACKGROUND: The purpose of this multi-center study was to examine the outcomes of importance for patients seeking treatment for foot and ankle disorders. An improved understanding of patient outcome preferences will assist surgeons in improving patient satisfaction. METHODS: An open-ended priority function questionnaire was administered to 235 patients presenting as new patients to five different outpatient locations. The questionnaire was designed to identify activities of importance to patients and was based on the McMaster Toronto Arthritis (MACTAR) patient preference disability questionnaire. Subjects were asked to list the specific activities that were limited by their condition. Open-ended answers were written on five blank spaces and then ranked as to their importance. The visual analog pain scale was recorded as a measure of the severity of the patient's symptoms at the time the response was made. The outpatient settings were two university hospitals, two private offices with academic affiliation, and one private office. Two hundred thirty-five surveys were collected between September and November of 2000; 227 surveys were acceptable for analysis. The respondents included 132 females (58.1%), 94 males (41.4%) and one patient who did not specify his gender (0.4%). The mean age was 45.8 (range 18 to 83) years. RESULTS: Average pain at the time of assessment was 2.7 on a scale of 0 to 9 and was reported to increase to 4.8 in a typical day. The most frequently ranked limitations were difficulty with walking (159), running (73), standing (55), and exercise (54). Walking also was the issue ranked as the highest priority (77 of 159), while running (11 of 73), standing (10 of 55) and exercise (3 of 54) were assigned lesser priority values. Only 68 of 227 respondents failed to list walking as an issue. Work, sleep, and social activities were not commonly cited as issues of importance. CONCLUSION: Patients presenting to office practices identified as specializing in foot and ankle disorders are predominantly middle-aged women in mild to moderate pain. Walking is the function most frequently identified as a problem and ranked as the highest priority for improvement. Social limitations were unlikely to be named as a limitation in this population.

Activities of Daily Living↗

PubMed2005

Reliability of the Foot Function Index:: A report of the AOFAS Outcomes Committee..

BACKGROUND: There currently is no widely used, validated, self-administered instrument for measuring musculoskeletal functional status in individuals with nonsystemic foot disorders. The purpose of this paper was to report on the assessment of reliability of one of these instruments. We wanted to determine if the Foot Function Index (FFI), which has been validated in rheumatoid patients without fixed foot deformity or prior foot surgery, would be reliable for a population of patients with foot complaints without systemic disease. METHODS: Patients were recruited from five orthopaedic offices where the physicians were members of the American Orthopaedic Foot and Ankle Society. Patients were asked to complete the FFI at the time of their initial office visit and then were given a second copy to complete and return by mail 1 week after their visit. RESULTS: Ninety-six patients completed the first questionnaire, and 54 patients completed the second. Reliability in this population was acceptable with an average of 23.5% of the patients providing retest values within one point of the initial response and an average of 45.3% of the patients providing the same response, for a total of 68.8% of all respondents answering within one point between their initial and second questionnaire. In two of the three categories, there were frequent nonresponses or no applicable responses. Four questions, two in the pain section and two in the activity limitation section, generated 20% or more of the nonapplicable answers. CONCLUSIONS: The FFI appears to be a reasonable tool for low functioning individuals with foot disorders. It may not be appropriate for individuals who function at or above the level of independent activities of daily living.

Activities of Daily Living↗

PubMed2005

Alternative to the modified jones procedure: outcomes of the flexor hallucis longus (FHL) tendon transfer procedure for correction of clawed hallux.

BACKGROUND: The modified Jones procedure is the traditional operative procedure for correction of a clawed hallux, although the deformity may be caused by overpull of one of three different muscles. In this study we present the radiographic and functional outcomes of flexor hallucis longus (FHL) tendon transfer as treatment for clawed hallux. The transfer is performed by drawing two thirds of the FHL tendon up through a drill hole in the proximal phalanx and then suturing it medially back to the remaining third. METHODS: We retrospectively identified 19 patients (22 feet) who had FHL tendon transfer for correction of clawed hallux over a period of 5 years. Followup was an average of 51.0 (range 6 to 74; +/- 3.8) months after the procedure. Outcome and patient satisfaction were determined using the Long-Form Musculoskeletal Function Assessment (MFA) score. Patients were asked whether they were satisfied, somewhat satisfied, or dissatisfied with the overall outcome and were asked about shoewear limitations. Preoperative and postoperative radiographs were evaluated in 15 patients (17 feet). We measured the hallux valgus and interphalangeal (IP) angles on the anteroposterior (AP) radiographs. On the lateral view we measured the angle of the IP joint, the metatarsophalangeal (MTP) joint, and the talometatarsal angle. Statistical analysis was done using a repeated measures ANOVA (p < 0.05). RESULTS: On the lateral radiographs, the hallux IP joint angle (p < 0.0012; n = 15) and hallux MTP joint angle (p < 0.0265; n = 15) were significantly reduced postoperatively. On AP radiographs, the hallux valgus angle (p < 0.0334) was significantly reduced; however, the IP angle and the talometatarsal angle were not significantly different after surgery. Patients had an average MFA score of 14.6 (+/-3.8 standard error, range 1 to 35; n = 19). Thirteen patients were fully satisfied and six were somewhat satisfied with the overall result of the surgery. Four patients thought that their hallux limited the types of shoes they could wear, while 15 did not. CONCLUSION: It has been shown that clawed hallux can result from excessive motor function in one of three muscles: FHL tendon, peroneus longus (PL), and extensor hallucis longus (EHL). This study suggests that transfer of part of the tendon of the FHL is an effective alternative operative procedure for correction of clawed hallux.

Adolescent↗

PubMed2005

The midtarsal joint locking mechanism.

BACKGROUND: The midtarsal joint, consisting of the talo-navicular and the calcaneocuboid joints, is presumed to be responsible for the foot being both flexible and rigid during different parts of the stance phase of gait. However, this mechanism has never been well quantified. This study explores the midtarsal joint locking mechanism by comparing the effect of hindfoot inversion and eversion on midfoot and forefoot mobility. METHODS: Motion of the tibia, talus, calcaneus, navicular, cuboid and the first, second, and fifth metatarsals were measured in nine cadaver feet using Polhemus Fastrak electromagnetic sensors (EST GmbH and Co. KG, Kaiserslautern, Germany). The talus was fixed to the tibia, and then the forefoot was maximally dorsiflexed, plantarflexed, inverted, and everted, with the hindfoot in maximal eversion and inversion, for a total of eight test positions. The range of motion of the individual bones between maximal forefoot dorsiflexion and plantarflexion and between maximal forefoot inversion and eversion was calculated for the hindfoot in maximal eversion and inversion. RESULTS: For the range of motion from maximal dorsiflexion to maximal plantarflexion there was significantly increased movement of the first, second, and fifth metatarsals in the sagittal plane (p-value = 0.003, 0.007, and 0.002, respectively) when the calcaneus was maximally everted compared to when the calcaneus was maximally inverted. No significant differences were detected for the range of motion from forefoot inversion to eversion for the two hindfoot positions. CONCLUSIONS: This study demonstrated that motion in the forefoot is influenced by hindfoot position through the midtarsal joint. Specifically, the sagittal plane range of motion of the metatarsals is increased when the hindfoot is in valgus.

Aged, 80 and over↗

PubMed2005

An association between functional second metatarsal length and midfoot arthrosis.

BACKGROUND: Primary tarsometatarsal arthrosis is relatively uncommon. The etiology of osteoarthritis in the foot is poorly understood, and it is possible that mechanical or anatomic factors play a role. METHODS: We compared the relative length of the metatarsals in patients with idiopathic arthrosis of the midfoot with that in a group of controls without arthrosis. We analyzed the radiographs of all patients who had had an arthrodesis of the first, second, and third tarsometatarsal joints to treat arthrosis during a three-year period at a tertiary teaching hospital. We excluded patients with a history of inflammatory arthritis, trauma, or Charcot arthropathy. Nine patients (fifteen feet), seven women and two men with an average age of 64.2 years, met the inclusion criteria. We compared them with a control group consisting of the uninjured feet of patients with an acute traumatic injury to the hindfoot and the feet of volunteers with no foot problems. We measured the first, second, and fourth metatarsal lengths and the intermetatarsal angles on weight-bearing anteroposterior radiographs. We also measured the length of the first metatarsal relative to the long axis of the second metatarsal to define the functional first metatarsal length. The ratios of metatarsal lengths and the ratios of functional lengths were used for analysis to minimize differences in foot size and differences caused by radiographic magnification. Statistical comparisons between groups were then carried out. RESULTS: In the study group, the length of the first metatarsal was, on the average, 77.0% of the length of the second metatarsal, whereas, in the control group, the first metatarsal length was an average of 82.0% of the second metatarsal length. The functional length of the second metatarsal was, on the average, 18.6% greater than that of the first metatarsal in the study group and only an average of 4.1% greater than that of the first metatarsal in the control group. Both differences were significant (p < 0.0004 and p < 0.0001, respectively). CONCLUSIONS: Patients with midfoot arthrosis had a different ratio of the first to the second metatarsal length than did a similarly aged cohort without midfoot arthrosis. The patients had a relatively short first metatarsal or a relatively long second metatarsal, or both. Midfoot arthrosis may have a mechanical etiology. Recognition of risk factors is the first step in developing prevention strategies.

Adult↗

PubMed2004

Clinical biomechanics of the peritalar joint.

The peritalar joint includes the articulations between the talus and calcaneus and the talus and navicular. Motion between the talus and calcaneus is described most often as rotation about an axis that points medially, anteriorly, and superiorly. This motion is considered to be triplanar, with inversion, plantar flexion, and adduction occurring together, whereas eversion, dorsiflexion, and abduction are associated. Similar motions have been described between the talus and navicular. Foot deformity, such as a pes planus or a pes cavus foot type, and hindfoot or midfoot joint fusion can alter the biomechanics of the peritalar joint.

Arthrodesis↗

PubMed2004

Surgical anatomy of the gastrocnemius recession (Strayer procedure).

BACKGROUND: The Strayer procedure (gastrocnemius recession) is a treatment option for patients with clinically relevant gastrocnemius equinus contracture. The purpose of this study was to review the surgical anatomy of the Strayer procedure with specific reference to 1) the location of the sural nerve, and 2) the gastrocnemius tendon release point. METHODS: Forty consecutive Strayer procedures in 33 patients (15 males, 18 females) served as the study group. Recorded measurements included: 1) the location of the sural nerve relative to the deep fascia, 2) the distance from the medial border of the gastrocnemius tendon to the sural nerve, and 3) the distance from the distal end of the gastrocnemius muscle belly (identified by surface landmarks) to the actual release site. RESULTS: At the point of the gastrocnemius release, the sural nerve was located superficial to the fascia in 17/40 legs (42.5%) and deep to the fascia in 23/40 legs (57.5%). In five legs (12.5%), the nerve was directly applied to the gastrocnemius tendon and needed to be gently dissected off the tendon. The gastrocnemius release point was located an average of 18 mm distal (range, 20 mm proximal to 57 mm distal) to the surface landmark created by the distal extent of the gastrocnemius muscle belly. CONCLUSION: Knowledge of the relevant anatomy associated with the gastrocnemius recession should allow surgeons to minimize the rate of sural nerve injuries and improve cosmesis by decreasing the length of the surgical incision. A posteromedial incision that begins 2 cm distal to the gastrocnemius indentation and extends proximally will minimize the length of the incision required.

Achilles Tendon↗

PubMed2004

Surgical treatment of talar body fractures.

BACKGROUND: Fractures of the body of the talus are uncommon and poorly described. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment. METHODS: Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Twenty-three patients had a concomitant talar neck fracture. Eleven of the fifty-seven fractures were open. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Foot Function Index and Musculoskeletal Function Assessment questionnaires were completed. RESULTS: Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Early complications occurred in eight patients. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of both the talar body and neck led to development of advanced arthritis more frequently than did fractures of the talar body only (p = 0.04). All patients with open fractures had end-stage posttraumatic arthritis (p = 0.053). Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Worse outcomes were noted in association with comminuted and open fractures. Osteonecrosis and posttraumatic arthritis adversely affected outcome scores. CONCLUSIONS: Open reduction and internal fixation of talar body fractures may restore congruity of the adjacent joints. However, early complications are not infrequent, and most patients have development of radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Worse functional outcomes are seen in association with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications.

Ankle Joint↗

PubMed2004

Talar neck fractures: results and outcomes.

BACKGROUND: Talar neck fractures occur infrequently and have been associated with high complication rates. The purposes of the present study were to evaluate the rates of early and late complications after operative treatment of talar neck fractures, to ascertain the effect of surgical delay on the development of osteonecrosis, and to determine the functional outcomes after operative treatment of such fractures. METHODS: We retrospectively reviewed the records of 100 patients with 102 fractures of the talar neck who had been managed at a level-1 trauma center. All fractures had been treated with open reduction and internal fixation. Sixty fractures were evaluated at an average of thirty-six months (range, twelve to seventy-four months) after surgery. Complications and secondary procedures were reviewed, and radiographic evidence of osteonecrosis and posttraumatic arthritis was evaluated. The Foot Function Index and Musculoskeletal Function Assessment questionnaires were administered. RESULTS: Radiographic evidence of osteonecrosis was seen in nineteen (49%) of the thirty-nine patients with complete radiographic data. However, seven (37%) of these nineteen patients demonstrated revascularization of the talar dome without collapse. Overall, osteonecrosis with collapse of the dome occurred in twelve (31%) of thirty-nine patients. Osteonecrosis was seen in association with nine (39%) of twenty-three Hawkins group-II fractures and nine (64%) of fourteen Hawkins group-III fractures. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5.0 days for patients who did not have development of osteonecrosis. With the numbers available, no correlation could be identified between surgical delay and the development of osteonecrosis. Osteonecrosis was associated with comminution of the talar neck (p < 0.03) and open fracture (p < 0.05). Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09). Patients with comminuted fractures also had worse functional outcome scores. CONCLUSIONS: Fractures of the talar neck are associated with high rates of morbidity and complications. Although the numbers in the present series were small, no correlation was found between the timing of fixation and the development of osteonecrosis. Osteonecrosis was associated with talar neck comminution and open fractures, confirming that higher-energy injuries are associated with more complications and a worse prognosis. This finding was strengthened by the poor Foot Function Index and Musculoskeletal Function Assessment scores in these patients. We recommend urgent reduction of dislocations and treatment of open injuries. Proceeding with definitive rigid internal fixation of talar neck fractures after soft-tissue swelling has subsided may minimize soft-tissue complications.

Adolescent↗

PubMed2003

Biomechanics and pathophysiology of flat foot.

When the foot works properly it is an amazing, adaptive, powerful aid during walking, running, jumping, and in locomotion up or down hill and over uneven ground. Dysfunction of the foot can often arise from the foot losing its normal structural support, thus altering is shape. An imbalance in the forces that tend to flatten the arch and those that support the arch can lead to loss of the medial longitudinal arch. An increase in the arch-flattening effects of the triceps surae or an increase in the weight of the body will tend to flatten the arch. Weakness of the muscular, ligamentous, or bony arch supporting structures will lead to collapse of the arch. The main factors that contribute to an acquired flat foot deformity are excessive tension in the triceps surae, obesity, PTT dysfunction, or ligamentous laxity in the spring ligament, plantar fascia, or other supporting plantar ligaments. Too little support for the arch or too much arch flattening effect will lead to collapse of the arch. Acquired flat foot most often arises from a combination of too much force flattening the arch in the face of too little support for the arch. Treatment of the adult acquired flat foot is often difficult. The clinician should remember the biomechanics of the normal arch and respond with a treatment that strengthens the supporting structures of the arch or weakens the arch-flattening effects on the arch. After osteotomies or certain hindfoot fusions, the role of the supporting muscles of the arch, in particular the PTT, play less of a role in supporting the arch. Rebalancing the forces that act on the arch can improve function and lessen the chance for further or subsequent development of deformity.

Aged↗

PubMed2003

Temporary bridge plating of the medial column in severe midfoot injuries.

Severe crush injuries to the midfoot often involve comminuted cuneiform or tarsal navicular fractures. Treatment principles for the bony injury of the crushed midfoot include maintenance of the medial column length and alignment, as well as appropriate stable fixation after open or closed fracture reductions. This is especially important because outcomes after midfoot injuries are related to the stability of the medial longitudinal arch of the foot. Treatment options include closed reduction and isolated K-wire fixation, limited open reduction and internal fixation with K-wires, screw fixation directed from the navicular to the cuneiforms, spanning external fixation between the talus and the first metatarsal, or combinations of these techniques. Limited internal fixation combined with external fixation may be difficult or impossible in comminuted fractures secondary to the small size and large number of bony fragments. Also, the external fixator is a potential source of pin tract infections. We propose a temporary internal bridge plating technique of the medial column of the foot using an 8- to 10-hole, 2.7-mm reconstruction plate between the talar neck and the first metatarsal, which may provide adequate temporary internal stabilization until bony healing occurs.

Adult↗

PubMed2003

Muscular imbalances resulting in a clawed hallux.

A clawed hallux is a deformity of the great toe resulting from a muscular imbalance. Using a cadaveric foot-loading frame, we quantitatively assessed the role of the peroneus longus (PL), extensor hallucis longus (EHL), and flexor hallucis longus (FHL) on position and pressure distribution of the first ray by simulating muscle imbalances. The experimental protocol included applying seven different combinations of simulated disproportionate loads ("overpulls") for these three muscles using midstance force values derived from the literature. This study quantified the angular change in the joints of the first ray and measured the plantar pressure beneath the head of the first metatarsal and the hallux. The results indicated that the peroneus longus was statistically the greatest contributor to the elevation of plantar pressure beneath the first metatarsal, while the EHL and FHL were primarily responsible for the angular changes resulting in the clawed hallux deformity.

Aged↗