In an attempt to prevent migration of the heel pad, 11 patients underwent a combined Syme's amputation and Achilles tendon tenodesis between December 1989 and April 1992. Ten patients healed the Syme's amputation, and one patient failed to heal the surgical wounds and required a below-knee amputation. In all 10 successful Syme's cases, the heel pad has remained stable with no migration, and no skin breakdown at an average follow-up of 18.5 months. Published series of Syme's amputations report that the incidence of heel pad migration is between 7.5% and 45%, and occurs primarily in the postoperative or early rehabilitation stage. We believe that tenodesis of the Achilles tendon is a technically easy addition to the Syme's amputation, that it keeps tension off of the incision during healing, and that it prevents migration of the heel pad.
The incidence of avascular necrosis of the metatarsal head following distal first metatarsal osteotomy combined with adductor tendon release has not been documented in a large series of patients. Of 82 consecutive procedures in 64 patients performed between 1986 and 1988, 42 patients (58 procedures) were available for clinical and radiographic examination. Average follow-up was 2.5 years (range 1.0-4.2 years). There were 35 L-shaped and 23 chevron osteotomies which were combined with a lateral soft tissue release that included adductor tenotomy. Preoperative hallux valgus angle averaged 25 degrees (range 15-40 degrees), and intermetatarsal angle averaged 12 degrees (range 5-24 degrees). Follow-up amount of correction averaged 13 degrees and 5 degrees, respectively. Eighty-four percent of patients were satisfied with their result. There was one case of avascular necrosis. The patient was asymptomatic at 4.2 years' follow-up, and the remaining patients included two with infections, one hallux varus, and no nonunions.
The purpose of this study was to determine whether tibialis anterior muscle activity influences the rate of rear-foot motion during walking. Two-dimensional rearfoot motion was recorded from 23 feet. The feet were assigned to one of two experimental groups. Muscle activity was recorded from the tibialis anterior muscle using surface electrodes. The early pronators (N = 12) reached maximal pronation within the first 20% of the stance phase. The late pronators (N = 11) reached maximal pronation only after 40% of the stance phase. The results of a t-test showed that there was a significant difference (P < .05) in the time to minimal tibialis anterior muscle activity between the two groups. These results indicate that tibialis anterior muscle activity can influence rearfoot motion during the stance phase of walking. A clinician should consider the muscular system when evaluating and designing a treatment program for patients with foot-related problems. The results of this study also indicate that static nonweightbearing evaluations alone may not provide an accurate picture of the foot during walking.
Foreign bodies in the foot can remain silent for years before presentation. We describe two foreign body infections in the feet of two patients more than 18 years after the initial insult. These cases emphasize the need for careful evaluation of patients with an unexplained infection in the foot, and thorough debridement, when surgical treatment is necessary.
Peak pressures and relative loads were determined under the feet of 125 children between 6 and 10 years of age. These results were compared with previously published data from 111 adults. A capacitive pressure distribution platform with a resolution of 2 sensors/cm2 was used for data collection during walking. As compared with the group of adults, the school children showed considerably lower peak pressures under all anatomical structures. Larger foot dimensions with respect to body weight result in reduced foot pressures for the children by distributing the ground reaction forces across larger contact areas. With increasing age, a medial load shift in the forefoot could be observed for the older children. Data analysis of the pressures under the midfoot revealed that the longitudinal foot arch development is almost complete before the age of 6. Contrary to the findings in adults, body weight was identified to be of major influence on the magnitude of the pressures under the feet of school children. No differences were found for the foot pressures between boys and girls.
Thirty cases of posterior ankle impingement in 28 patients were treated over a 10-year period (1982-1992). All conditions were caused by forced plantar flexion. An os trigonum or posterior process fracture was demonstrated radiographically in 63% of these cases, and an intact posterior process was demonstrated in 33%. Ten cases were lost to follow-up. Of the remaining 20 cases, in 18 patients 12 (60%) improved with nonoperative treatment; 8 (40%) required operative excision. The results were good to excellent in 7 patients and fair in 1 patient. Operative excision for the treatment of recalcitrant posterior ankle impingement can relieve symptoms and allow a return to full preinjury activities.
Forty-seven patients (58 feet) underwent first metatarsophalangeal joint fusion with a small Vitallium plate (Howmedica, Inc., Rutherford, NJ). Congruous joint surfaces were prepared with either cone-shaped or cup-shaped reamers. At an average follow-up of 19.2 months, 98% (57 feet) were successfully fused. Ninety-three percent (54 feet) noted good or excellent results. Plate removal was necessary in only 7% (4 feet) of cases. Complications included nonunion with plate breakage in 2% (1 foot) and delayed union in 2% (1 foot) of cases. This technique was useful and predictable in achieving successful fusion of the first metatarsophalangeal joint.
A 75-year-old woman presented with a ganglion-like nodule on the dorsal aspect of the right foot. A 2.5 x 1.5 cm, saccular and malleable tumor, that was in continuity with the dorsal venous arch, was completely resected. It was characterized by a diffuse intramural and circumferential, low grade, malignant, smooth muscle proliferation with an aneurysmal-like luminal space. No endoluminal or periadventitial invasive neoplastic component was present. The patient had no evidence of disease at 58-month follow-up. This is the first reported case of venous leiomyosarcoma in the foot. Furthermore, the intramural confinement of neoplastic growth is a unique observation.
Ossification of the Achilles tendon is a rare condition. We recently treated a patient with ossification of bilateral Achilles tendons. The patient was a 50 year old male whose chief complaint was discomfort around the Achilles tendon. He had a previous history of treatment of bilateral club feet On the roentgenograms, the length of the bony mass in the Achilles tendon was 5.5 cm on the right side and 1.5 cm on the left side. The left side was treated by surgical removal of a bony mass and suture of the tendon. Microscopic examination of the extirpated specimen revealed bone formation through enchondral and intramembranous ossification in the Achilles tendon.
All patients operated upon for Morton's neuroma during 1991 who were examined with both magnetic resonance imaging and ultrasonography were included in this prospective study. The object of the study was to evaluate the diagnostic value of these two modalities. The preoperative diagnosis was purely clinical. Histology confirmed surgical findings. A 0.3 T scanner was used for the magnetic resonnance imaging, and a 7.5 MHz linear transducer was used for the ultrasonography. The study includes ninepatients. Eight neuromas were found at surgery. This indicicates that false negative diagnoses are common. At present we find these modalities of little or no value, but, with improved these modalities of little or no value, but, with improved equipment and experience, they may become valuable.
The use of magnetic resonance imaging (MRI) in pigmented villonodular synovitis (PVS) has been well described in the literature. MRI has been used predominantly with diffuse PVS lesions. We recently had a patient with an unusual case of localized PVS of the ankle with bone and cartilage destruction. Preoperative MRI was useful in the diagnosis of localized PVS and in the planning for surgery. MRI in a patient with this lesion had not been documented previously, but should be considered whenever PVS, either diffuse or localized PVS, is suspected.
The purpose of our study was to determine the effects of severe obesity on the foot mechanics of adult females. Twenty-nine adult females between the ages of 20 and 48 years volunteered as subjects for this investigation. The subjects were separated into a severely obese (O) group (body mass index = 41.14 ± 2.61; N = 16) and a normal weight control group (body mass index = 20.84 ± 0.47; N = 13). A Locam camera (100 Hz) positioned perpendicular to the subjects’ posterior aspect was used to film the rearfoot movement of the subjects during the final 15 sec of a 10 min treadmill walk. The O group had a significantly greater touchdown angle ( P = .05), more total eversion range of motion ( P = .001), and a faster maximum eversion velocity ( P < .001). Moreover, analysis of dynamic foot angles indicated that the O group had significantly ( P = .003) more forefoot abduction. Finally, anthropometric data revealed statistically different ( P < .001) Q angle measurements between the O and control groups. The results of this study suggest that severely obese females have significantly greater rearfoot motion, foot angle, and Q angle values than normal weight females.
A 35-year-old female patient presented to us with a lesion in the talus that on AP-roentgenographic view simulated an osteoid osteoma. Final pathology revealed it to be an intraosseous hemangioma. An intraosseous hemangioma at this site is extremely uncommon and has not been previously reported.
Stress fractures result when bone is subjected to repeated loading which causes fatigue, cracking of the bone, and, eventually, a complete fracture. Stress fractures of the foot and ankle are common injuries affecting a broad range of the population, from the young to the elderly, the fitness enthusiast to the chronically debilitated. The diagnosis of stress fracture is not always obvious because radiographs are often negative, especially on initial presentation. In this report, we present four cases in which, after appropriate initial studies proved inconclusive, magnetic resonance imaging (MRI) was used to establish the diagnosis of stress fracture. We propose that MRI is a useful diagnostic modality in a select group of patients with suspected stress fractures of the foot and ankle.
The epidemiology of sprains in the lateral ankle and foot was investigated in a prospective study at the casualty ward at Hillerad County Hospital. During one year, 766 patients were registered. The overall sprain incidence was 7/1000 person-years. The incidence was highest for young males. After the age of 40 years, the incidence was higher for women than for men. Most sprains were sustained during sport, but, with increasing age, other activities became dominant. Sixty-one percent of the lesions were located around the lateral ankle, and 24% were located on the lateral midfoot.
The relative risk of nonunion in smokers versus nonsmokers after ankle arthrodesis was determined in a case control study. Twenty-two patients were matched to 22 controls by age, sex, surgeon, surgical technique, and preoperative diagnosis. Information on duration, amount, and past history of smoking was obtained for these 44 patients. Ten of the patients were actively smoking at the time of surgery compared with four of the controls. Six of the patients had no history of smoking and six had stopped smoking before surgery. Eleven of the controls had no history of cigarette smoking and 7 had stopped smoking before surgery. The relative risk of nonunion was increased 3.75 times for active smokers. When patients did not have any known risk factors for nonunion, the risk of nonunion for smokers was 16 times the risk of nonunion for nonsmokers.
Today, bunion surgery is still controversial. Considering that a bunion deformity in fact may be a result of multiple causes, the rationale of the currently applied techniques of surgical treatment has not been conclusively demonstrated. In view of the known hypermobility syndrome of the first ray that results in insufficient weightbearing beneath the first metatarsal head, the relationship between this syndrome and hallux valgus deformity has been investigated. The results suggest a direct relationship between painful hallux valgus deformity and hypermobility in extension of the first tarsometatarsal joint. A pathological mechanism of symptomatic hallux valgus is proposed that relates this pathology with primary weightbearing disturbances in the forefoot where angulation of the first metatarsophalangeal joint is one of the consequences. The alignment of the metatarsal heads within the sagittal plane seems to be a main concern in many hallux valgus deformities. As a consequence, treatment includes reestablishing stable sagittal alignment in addition to the horizontal reposition of the metatarsal over the sesamoid complex. As an example, first tarsometatarsal reorientation arthrodesis regulates the elasticity of the multiarticular first ray within the sagittal plane and may be the treatment of choice in many hallux valgus deformities.
This is a retrospective study of the modified Robert Jones tendon transfer in 24 patients and 28 feet. The main indication for the procedure was to correct symptoms related to clawing of the hallux in seven patients, relieve pressure under the head of the first metatarsal in 13 patients, and treat for both symptoms in three patients. One patient had diffuse ache in the arch. Fifteen patients had idiopathic cavus feet, of whom five had associated spina bifida occulta. The remainder had a variety of different etiologies including cerebral palsy, head injury, brain abscess, and spinal cord tethering. Postoperative follow-up ranged from 7 months to 33 years with an average of 5 years and 6 months. The modified Robert Jones tendon transfer was shown to be effective in relieving symptoms related to clawing of the hallux in 90% of patients but was not reliable in curing pain under the first metatarsal head, with success in only 43% of patients. In three patients, pain under the metatarsal head was relieved initially but recurred by 18 months. Complications were frequent. Six patients developed pain under the tip of the hallux postoperatively.
Shoes have been implicated as being responsible for the majority of foot deformities and problems that physicians encounter in women. A total of 356 women were studied in this investigation to evaluate trends in women's shoe wear and their effect on the development of foot deformities and pain. The majority of women in this study wore shoes that were too small for their feet, had foot pain and deformity, and had increased shoe size since the age of 20. Few women had their feet measured in over 5 years. The women without foot pain or deformities also wore shoes that were smaller than their feet but to a lesser degree.
