Foot and ankle research priority: report from the Research Council of the American Orthopaedic Foot and Ankle Society.
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Adult↗
Biomedical subjects
C L Saltzman
Publications and source records attributed to C L Saltzman.
Hallucal rotation: a method of measurement and relationship to bunion deformity.
A method for measuring hallucal rotation or weightbearing tangential radiographs is described. Under controlled conditions using cadaver specimens, 10 degree changes in hallucal rotation were associated with a mean change in radiographically measured rotation of 10.6 degrees (S.D. = 2.3 degrees). A clinical study of 30 control patients and 39 patients presenting with a chief complaint of a bunion deformity was undertaken to assess the reliability of the measurement method. The overall reliability was high for both groups (r = 0.98). A significant difference was found between mean values for hallucal rotation in the two groups (P < 0.005). There is a modest association between increasing valgus deviation and increasing rotation of the hallux (r = 0.43, P < 0.01). This study suggests that bunion deformities involve variable degrees of axial and coronal plane rotations of the first metatarsophalangeal joint and that the concept of a planar "hallux valgus" deformity may insufficiently describe this three-dimensional clinical condition.
Cadaver↗
Challenging fractures of the foot and ankle.
The foot and ankle is one of the most imaged parts of the body. Although most plain radiographs reveal no bony injury, subtle fractures can be overlooked. Because it is important to detect these fractures at the time of injury, a review of the most commonly missed foot and ankle fractures is presented.
Ankle Injuries↗
Long term follow-up of medial column fusion and tibialis anterior transposition for adolescent flatfoot deformity.
We report the results of three patients (four feet) who had surgical correction of adolescent flatfeet performed over fifty years ago. The surgery involved medial column stabilization with fusion procedures and tibialis anterior transposition into the navicular (Young's tenosuspension procedure). In this small sample, we found a high rate of painful arthrosis that developed over time in the contiguous joints of the foot.
Activities of Daily Living↗
Effects of medial and lateral displacement calcaneal osteotomies on tibiotalar joint contact stresses.
Translational calcaneal osteotomies are used clinically to realign the mechanical axis of the lower limb. In this study, the effects of medial and lateral displacements of the posteroinferior fragment on tibiotalar joint contact mechanics were assessed using pressure-sensitive film. Eight osteotomized fresh-frozen cadaver specimens were loaded in each of three testing positions: neutral position (no shift), 1 cm of lateral displacement of the inferior fragment with respect to the superior fragment, and 1 cm of medial displacement of the inferior fragment. For an applied load of 1,330 N, two times body weight, a 1 cm lateral displacement shifted the center of pressure an average of 1.06 mm laterally, whereas a 1 cm medial displacement shifted the center of pressure an average of 1.58 mm medially. While global contact parameters (contact area, spatial mean contact stress, and peak local contact stress) were not appreciably altered by osteotomy, regional contact parameters changed in a reproducible and statistically significant manner. Among four nominally equal-sized, parasagittally bounded cartilage zones, lateral displacements consistently unloaded the most medial zone and increased loading of the most lateral zone; medial calcaneal displacements had the converse effect. These cadaver results suggest that translational calcaneal osteotomies may be used clinically to partially offload focal areas of cartilage along the medial and lateral borders of the tibiotalar joint.
Ankle Joint↗
Relationship between foot flexibility and urinary incontinence in nulliparous varsity athletes.
OBJECTIVE: To explore the relationship between urinary incontinence in elite nulliparous athletes and force absorption on impact, as assessed by foot arch flexibility. METHODS: One investigator measured medial longitudinal arch height in two gait stances (neutral and maximally dorsiflexed ankle positions) in 47 female varsity athletes representing five sports. Each athlete completed a questionnaire about urinary incontinence prevalence. We compared the change in arch height between the two gait stances with the prevalence of urinary incontinence. RESULTS: There was a statistically significant association between decreased foot flexibility and urinary incontinence; the mean percent change in arch height was 8.94 +/- 0.08% (standard deviation) in incontinent women and 13.70 +/- 0.09% in continent women (P = .03). CONCLUSION: How impact forces are absorbed may be one potential etiology for stress incontinence. An improved understanding of how impact forces are transmitted to the pelvic floor could provide important information about potential preventive interventions for urinary incontinence and other pelvic floor disorders, such as genital prolapse.
Adolescent↗
In vivo validation of in vitro testing of hallucal flexor mechanics.
OBJECTIVE: The purpose of this study was to validate an in vitro method of testing first metatarsophalangeal joint mechanics. DESIGN: We compared the orientation of the resultant moment of hallucal plantarflexion in cadaveric specimens undergoing loading of the flexor hallucis longus to the plane of the active great toe plantarflexion moment in normal volunteers. BACKGROUND: Frontal plane deviation of hallucal plantarflexion is a fundamental component of the altered biomechanics in hallux valgus. METHODS: The cadaveric model utilized dynamic loading of the flexor hallucis longus and static loading of the remaining muscles of the great toe. The in vivo method involved measurement of force output with isometric hallucal plantarflexion in the standing position. The medial-lateral and superior-inferior forces as well as the angle of the resultant moment in the clinically relevant frontal plane for both groups were quantified. RESULTS: We found no significant difference between the frontal plane forces of each group. The directional orientations in the frontal plane also displayed a marked similarity, with an average lateral deviation of 0.63 degrees (P = 0.99) for each group. CONCLUSIONS: The lack of a significant difference between the cadaveric and clinical methods of finding the resultant hallucal moment indicates that the cadaveric method accurately simulates in vivo internal flexor muscular loading of the great toe.
Journal Article↗
The effect of hallux sesamoid excision on the flexor hallucis longus moment arm.
Surgical treatments for chronic, painful hallux sesamoid disorders typically involve partial or complete resection of 1 or both sesamoids. Although these approaches generally result in satisfactory symptom relief, their effect on biomechanical function of the major hallux flexors is not completely understood. The effects of selective sesamoid resections on the effective tendon moment arm of the flexor hallucis longus tendon were evaluated. Twelve fresh frozen cadaver first rays were each mounted in a device that held rigid the metatarsal. A ramp-controlled displacement of an MTS ram supplied a functional load input force to the flexor hallucis longus. The components of the resultant output force necessary to resist the input flexor hallucis longus force were transduced simultaneously by a multicomponent load cell. Subsequently, 3 progressively more extensive seasamoid resections were done: (1) distal hemiresection, (2) complete resection, and (3) resection of both sesamoids. Six specimens were tested with the medial sesamoid removed first and 6 with the lateral sesamoid removed first. Statistical analysis showed that significant decreases in the effective tendon moment arms occurred with full medial sesamoid resection, full lateral sesamoid resection, and resection of both the medial and lateral sesamoids.
Biomechanical Phenomena↗
Peroneus longus and brevis tendon tears: MR imaging evaluation.
PURPOSE: To evaluate magnetic resonance (MR) findings of surgically proved peroneal tendon tears. MATERIALS AND METHODS: MR images, medical records, and surgical findings were retrospectively reviewed in the cases of 12 patients who underwent surgery because of suspected peroneal tendon tear (14 tendons). Sagittal and oblique axial T1-weighted spin-echo and T2-weighted fast spin-echo images were obtained in all patients. RESULTS: At surgery, isolated peroneus longus tendon tears were seen in four patients, isolated peroneus brevis tendon tears in five, and both peroneus brevis and peroneus longus tendon tears in two. When correlated with surgical findings, findings at MR imaging were correct in 12 tendons. Findings were false-positive in two patients and false-negative in one, who underwent surgery anyway because unrelated abnormal MR findings were present. The most common MR finding was increased intra-substance signal intensity on T1- and T2-weighted images (11 tendons), in linear or rounded areas on oblique axial images (n = 11) and in linear areas along the longitudinal axis of the tendons on sagittal images (n = 7). Tendon distortion was noted in severe cases (five tendons). The most frequent surgical finding was a longitudinal tendon tear (split) (10 tendons). CONCLUSION: MR imaging enabled detection of peroneus brevis and peroneus longus tendon tears.
Adolescent↗
Coronal plane rotation of the first metatarsal.
A method for measuring first metatarsal rotation on weightbearing tangential radiographs is described. Under controlled conditions using cadaver specimens, 5 degree changes in first metatarsal rotation were associated with a mean change in radiographically measured rotation of 5.4 degrees (SD = 1.7 degrees). A clinical study of 30 hallux valgus and 30 control patients was undertaken to assess the reliability of the method of measurement. The overall reliability was high for both hallux valgus and control patients (r = 0.93 and 0.95, respectively). In these two groups, no significant difference was found between the mean values for first metatarsal rotation. Likewise, we found no correlation between first metatarsal rotation measured on tangential standing ("sesamoid" view) radiographs and the first metatarsophalangeal angle or the intermetatarsal 1-2 angle measured on anteroposterior standing radiographs.
Analysis of Variance↗
The Foot Function Index for measuring rheumatoid arthritis pain: evaluating side-to-side reliability.
The Foot Function Index is a validated and reliable instrument for measuring foot pain, disability, and activity restriction in patients with rheumatoid arthritis. For the purposes of orthopaedic studies in which one foot serves as an internal control, we assessed the side-to-side reliability of the seven-question Foot Function Index pain subscale. Thirty patients with rheumatoid arthritis completed visual analog scale pain questionnaires for both feet on two occasions 8 days apart. Internal reliability of the scale was high, with Cronbach's alphas ranging from 0.94 to 0.96, suggesting good left versus right discriminatory abilities. Principal component factor analysis segregated the questions into two large clusters containing predominantly either left or right foot items. Intraclass correlation coefficients were examined for test-retest reliability (separated by side) and for side-to-side reliability (separated by the day of test). The resultant intraclass correlation coefficients were nearly equivalent, ranging from 0.79 to 0.89. Generalizability analysis yielded similar results. Intraclass correlation coefficients and generalizability analysis demonstrate that the majority of variation is best explained by the differences within subjects or between subjects rather than by test-retest or side-to-side differences. We recommend the Foot Function Index as a reliable measurement scale for use in orthopaedic interventional trials.
Adult↗
Rupture of the anterior tibial tendon: diagnosis by MR imaging.
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Adolescent↗
Intraarticular foot and ankle injections to identify source of pain before arthrodesis.
OBJECTIVE: The purpose of our study was to evaluate the usefulness of diagnostic joint injections in patients with foot and ankle pain when the radiologist attempts to identify the source of pain. This study also correlated the results of injection with outcome after arthrodesis. MATERIAL AND METHODS: We retrospectively reviewed the records of 22 patients who had a foot or ankle joint injected to identify a source of pain and who later underwent arthrodesis of the painful joint. All patients had long-term foot and ankle symptoms of variable causes. Twenty-four joints were assessed: 13 subtalar, five talonavicular, four ankle, one calcaneocuboid, and one metatarsocuneiform. All patients had plain radiographs, 11 had CT studies, and five had bone scans. Contrast material was used to assess adequate positioning of the needle inside the joint before injection. All joints were injected under fluoroscopic control. Steroid was added in eight joints. After injection, patients were assessed for relief of symptoms. Patients subsequently underwent arthrodesis on the basis of the results of the injection. RESULTS: In 20 patients (22 joints), long-term follow-up showed that injections allowed us to correctly identify the source of pain and successfully guide arthrodesis. Of these 20 patients, 17 had significant pain relief after injection and fusion, whereas three patients had mild or no response. With one of these patients, we injected other joints and changed surgical plans. One of the two remaining patients had more pain relief after injection than after arthrodesis. The other patient had no relief after injection, but subsequent fusion because of persistent pain was successful. We found imaging studies to be less useful than diagnostic injections when we were attempting to identify the source of pain. CONCLUSION: Intraarticular injection of anesthetic in painful foot and ankle joints helped us confirm the source of pain in 20 of 22 patients, which in turn led to successful arthrodesis and good outcomes for these patients.
Adult↗
MR imaging of posterior tibial tendon dysfunction.
OBJECTIVE: The purpose of this study was to describe the MR findings of posterior tibial tendon dysfunction. MATERIALS AND METHODS: MR images and medical records were reviewed for 11 patients with surgically proven posterior tibial tendon abnormalities (i.e., tears or tenosynovitis) and for six patients with clinical evidence of posterior tibial tendon dysfunction. Our study group included 16 women and one man from 37 to 70 years old (mean, 53.5 years old). MR examinations used T1-weighted and T2-weighted spin-echo sequences in the oblique axial and sagittal planes. RESULTS: Abnormal MR findings were observed in all 17 patients. The spectrum of MR abnormalities included fluid in the tendon sheath of a normal tendon interpreted as isolated paratenonitis (tenosynovitis, n = 3); tendon thickening and surrounding fluid with normal tendon signal interpreted as tendinosis (degeneration, n = 1); tendon thickening with increased linear or heterogeneous intrasubstance signal interpreted as partial tear (n = 11); tendon discontinuity with fluid-filled tendon sheath interpreted as complete rupture (n = 2). In 11 patients, the posterior tibial tendon was explored at surgery. In these patients, MR imaging accurately showed two cases of isolated paratenonitis, one case of tendinosis, four partial tears, and two complete ruptures. In the remaining two patients, the presumed MR diagnosis did not correlate very closely with the surgical findings: one patient with isolated paratenonitis shown by MR imaging had tendinosis found at surgery; however, the surgery in this patient followed the MR examination by 10 months, a time during which degeneration might have occurred. The other patient had an MR diagnosis of partial tear, which was not found at surgery; however, tendon degeneration was severe and a small tear not reaching the tendon surface could have been missed at inspection. MR imaging characteristics of severe tendinosis and partial tear may overlap. CONCLUSION: MR imaging is effective for detecting abnormalities related to posterior tibial tendon dysfunction. Familiarity with the appearance of these changes facilitates accurate characterization.
Ankle↗
Measurement of the medial longitudinal arch.
Although clinical evidence suggests a causal relationship between arch structure and musculoskeletal injury patterns, biological variations in soft-tissue structures effect the accuracy of arch-height measurements. Medial longitudinal arch (MLA) structure was assessed clinically and radiographically in 100 consecutive patients with foot problems. Intraclass correlation coefficients were calculated for three radiographic parameters and three anthropometric parameters of the MLA. Intrarater and interrater reliability estimates for the radiographic measurements were uniformly excellent. Intrarater reliability coefficients were higher than interrater coefficients for the three tested anthropometric parameters. The strengths of associations between anthropometric and radiographic data were assessed with Pearson correlation coefficients. The clinically determined ratio of navicular height-to-foot length correlated most closely with the radiographic indices of MLA structure.
Adult↗
Major open injuries of the talus.
Seventeen patients with 18 open talar fracture-dislocations or total dislocations of the talus were reviewed to determine the functional outcome and incidence of infection. Seven of 18 feet (38%) developed infection. Infection was associated with extrusion of the talar body through the open wound (p < 0.025). Final follow-up was achieved in 13 of 17 patients (14 of 18 feet) at an average of 7 years and 4 months after injury. According to the Boston Children's Hospital ankle grading system, the overall results were considered excellent in one, good in five, fair in two, and failures in six feet. The data suggest a greater proportion of failures in the infected group compared with the non-infected group (p = 0.05).
Adolescent↗
The hindfoot alignment view.
A modification of Cobey's method for radiographically imaging the coronal plane alignment of the hindfoot is described. Using this view, we estimated the moment arm between the weightbearing axis of the leg and the contact point of the heel. Normative data on 57 asymptomatic adult subjects are presented. The weightbearing line of the tibia falls within 8 mm of the lowest calcaneal point in 80% of subjects and within 15 mm of the lowest calcaneal point in 95% of subjects. The technique for measuring coronal plane hindfoot alignment is reliable, with an interobserver correlation coefficient of 0.97. This radiographic technique should help in the evaluation of complex hindfoot malalignments.
Adult↗
The effect of foot orthotics on three-dimensional kinematics of the leg and rearfoot during running.
Foot orthotics have been used successfully in the treatment of musculoskeletal symptoms associated with structural variations of the foot. Their effectiveness has been primarily addressed through two-dimensional, frontal plane motion studies of the subtalar joint in individuals considered "clinical pronators." Recent evidence suggests that assessment of tibial axial rotation in combination with frontal plane analysis of calcaneal inversion/eversion may provide improved understanding of subtalar joint function. The purpose of this study was to examine the effects of semi-rigid foot orthotics on three-dimensional lower limb kinematics in 20 recreational runners presenting with distinct structural foot characteristics. Radiographic measurements were used to classify subjects into a low or high rearfoot profile group. The results of the kinematic analysis showed a significant orthotic effect for rotations occurring from heel contact to peak tibial internal rotation, as well as in the coupling relationship between tibial axial rotation and calcaneal inversion/eversion. Both groups responded similarly with a mean reduction of 2 degrees in tibial internal rotation. No differences were found for the frontal plane rotations for either group when orthotics were worn. The findings suggest that the maximum effect of orthotics may be realized in the first 50% of stance and related to the changes in tibial axial rotation.
Biomechanical Phenomena↗