The Foot

Editorial Board

2009-12-01

The epidemiology of calcaneal fractures

M.J. Mitchell, J.C. McKinley, C.M. Robinson — 2009-12-01

Abstract: Background: Calcaneal fractures are rare, but debilitating injuries, which occur frequently in younger individuals. The economic impact of the residual long-term disability that may occur after these injuries is therefore disproportionate to their incidence. The aim of this study was to review the epidemiology and injury patterns of this injury.Methods: Data was extracted from a computer database, which prospectively coded all orthopaedic trauma events in a single unit between January 1995 and June 2005. Over this period 697 patients sustaining 752 fractures (55 bilateral) were treated in our unit. The patient's demographic details were prospectively recorded, together with details of their injury and primary treatment. The radiographs of a subgroup of patients were retrospectively examined in detail.Results: The annual incidence of fracture was 11.5 per 100,000, and occurred 2.4 times more frequently in males than females. In males, the incidence was 16.5/100,000/year, with a peak incidence in the age range 20–29 (21.6/100,000/year). In females, the overall incidence was 6.26/100,000/year, with a more even spread throughout the age cohorts and showing a gradual increase in incidence towards the post-menopausal years. The majority of fractures were sustained in falls from a height (71.5%), and 64.3% of these were from 6 feet and above. Only 18.8% of fractures occurred in the workplace, and although manual workers made up the largest occupational group, significant numbers occurred in both unemployed and the retired. Most injuries occurred in isolation but the most commonly seen concomitant injuries were lower limb (13.2%) or spinal injuries (6.3%).Conventional radiography in a subgroup of the patients showed an average Böhler's angle of 16.5° with no difference between the males and females. There was a strong association between the severity of the fracture, as assessed using the Sanders classification on computerised tomography, and the degree of depression of the Böhler's angle (p=0.002).

Trans-metatarsal amputation in patients with a diabetic foot: Reviewing 10 years experience

Israel Dudkiewicz, Oren Schwarz, Michael Heim, Amir Herman, Itzhak Siev-Ner — 2009-12-01

Abstract: Considerable disagreement exists whether trans-metatarsal amputations are indicated in persons with diabetes. A previous study reported that statistically the success rate of Syme's amputation in diabetic patients over 65 years of age resulted in a very poor results. The purpose of this study was to investigate the results of trans-metatarsal amputations, in patients with diabetes and to seek markers which could shed light upon the advantages/disadvantages of this procedure.The records of 46 patients covering a 10-year period (1996–2006) were used as a database.Twelve needed higher amputation level and another 10 needed a wound revision. All the patients that maintained the original amputation level walk without a need for a prosthesis and kept their previous abode.TMA in diabetic patients, although at a high risk for an extrasurgical procedure, once successful, the patient will regain his previous lifestyle.

The effect on neuromuscular stability, performance, multi-joint coordination and proprioception of barefoot, taping or preventative bracing

Derya Ozer, Gamze Senbursa, Gul Baltaci, Mutlu Hayran — 2009-12-01

Abstract: Objective: The objective of this study was to assess the effects of taping and preventive bracing on functional balance, jumping performance, multi-joint coordination and proprioception on comparison to barefoot and each other.Design: Controlled trial as an experiment with the independent variable testing in 3 trials: control (barefooted), preventive bracing, and taping.Setting: The sports physiotherapy research laboratory.Participants: Twenty physically active male university students aged between 20 and 28 who had been free from lower extremity pathology for 12 months and had no previous history of ankle sprain served as participants.Main outcome measures: Single leg balance (s), jumping performance (cm), coordination and proprioception assessments by the Functional Squat System. The software automatically calculated the absolute average error (cm) and the standard deviation (SD) of the average error. Average errors were independently quantified as a function of the action mode (concentric versus eccentric) and of the lower limb (dominant versus non-dominant).Results: There was no significant difference among the groups for balance tests (p>0.05). For vertical jump performance of bilateral and the dominant leg there were significant differences that the barefoot group had better results compared to the other groups (p=0.059; 0.017). According to the coordination results of Functional Squat System participants were better in brace and tape situations since the deviations were less for all concentric and eccentric positions. Deviation results for the proprioception test were different for first visual and non-visual deviations for dominant leg (p<0.05).Conclusion: In conclusion, bracing and taping may play an important role in preventing injury or rehabilitation of the injured ankle by improving concentric and eccentric coordination, proprioception with the ability of reproducing motion in closed kinetic chain while decreasing vertical jump performance. No superiority of brace over tape or vice versa was found in this study.

A clinical guideline for the conservative management of tibialis posterior tendon dysfunction

Beverly Bowring, Nachiappan Chockalingam — 2009-12-01

Abstract: Background: Early and appropriate conservative treatment is considered essential to prevent progression of tibialis posterior tendon dysfunction (TPTD), with its potential long term disabling consequences and the need for surgical intervention. However, there is no consensus in the literature regarding the treatment of the disorder. This investigation aimed at developing a local clinical guideline for the conservative management of TPTD by a consensus development group.Methodology: An action research methodology utilising the RAND modified Delphi approach was employed involving seven multidisciplinary consensus group participants. The guideline developed from this process was then sent for national evaluation via postal questionnaire.Results: Although a difference in opinion regarding certain aspects of the conservative management of TPTD was initially present, a local consensus was achieved following extensive discussion. 86% of survey respondents from other localities found the guideline useful but their comments, which were sometimes at odds with each other, revealed a lack of national consensus regarding the management of the condition.Conclusion: This research project has provided empirical evidence that a local clinical guideline can be developed by a consensus group for the management of TPTD. However, the lack of national consensus regarding TPTD treatment found in this research study and as reflected in the published literature, would limit the transferability of this guideline to other localities. While, the guideline reported in this study could be used to inform the development of other national and international guidelines, different areas of expertise that emerged between professions highlighted the importance of employing a multidisciplinary group in the development of guidelines for the management of musculoskeletal conditions of the foot and ankle.

Arthroscopic release of flexor hallucis longus tendon using modified posteromedial and posterolateral portals in the supine position

John S. Theodoropoulos, Preston M. Wolin, Drew W. Taylor — 2009-12-01

Abstract: Background: The flexor hallucis longus (FHL) is a known site of pathological conditions. FHL stenosing tenosynovitis presents as posterior medial ankle pain or great toe discomfort and is often associated with a catching sensation of the great toe. There are a wide variety of open procedures for the treatment of FHL stenosing tenosynovitis.Objective: Arthroscopic treatment may circumvent some of the complications associated with open surgical treatment of the hindfoot.Methods: Arthroscopic surgery was completed in the supine position using modified posteromedial and posterolateral portals. A 70° arthroscope allowed for circumferential evaluation of the ankle through the posterolateral portal including the subtalar areas and the entire FHL tendon for release using basket forceps and a 3.5mm shaver.Results: This method allows for decompression of the FHL from the entrance of the fibro-osseous tunnel to the knot of Henry. Active and passive range of motion of both the ankle and toes was encouraged postoperatively. The patient returned to sporting activity 6 weeks after surgery.Conclusions: Endoscopic treatment of the FHL stenosing tenosynovitis is presented as an alternative to an open surgical procedure; it may reduce wound complications and may allow for an earlier return to sport.

Treatment of gun-shot defect of the foot with bovine collagen matrix application

Yusuf Kenan Coban, Ali Murat Kalender — 2009-12-01

Abstract: Nonoperative therapy might be chosen for patients with small wounds or defects around the foot and ankle region. Lyophilized bovine collagen matrix is one of ideal biological dressings used in wound treatment. We present an example of type 1 bovine collagen (Gelfix, Euroresearch, Inc., Milano, Italy) usage in a complex gun-shot wound of the foot and relevant literature is discussed.

Identification of a flexor digitorum accessorius longus muscle with unique distal attachments

2009-12-01

Abstract: During a cadaver dissection in a gross anatomy course, a flexor digitorum accessorius longus (FDAL) muscle was identified. The FDAL was a unilateral, two-headed, multipennate muscle originating from the flexor retinaculum, deep fascia, and calcaneus. The muscle bodies fused into one tendon and coursed distally where slips were observed inserting into the flexor digitorum longus tendon and the flexor hallicus longus tendon. A survey of the literature revealed that an FDAL may be present in approximately 15% of the general population. Our results concerning the FDAL suggest the need for clinicians to recognize the occurrence and variability of accessory leg and ankle muscles, and to use available technology such as MRI to assist with the diagnosis and treatment of compressive neuropathies of the foot.

Interdigital pilonidal sinus of the foot

Anne C. O’Neill, Elizabeth M. Purcell, Padraic J. Regan — 2009-12-01

Abstract: Pilonidal sinus of the interdigital spaces is a common condition among barbers. The condition results from a foreign body reaction to clients’ hairs. It is thought that the short sharp hairs penetrate the skin when hands are rubbed through freshly cut hair. We present an unusual case of a pilonidal sinus arising in the interdigital spaces of the foot in a female hairdresser. This is to our knowledge only the second such case reported in the literature.

Complete rupture of the peroneus longus tendon secondary to injection

Steven Borland, Stanislaw Jung, Ivan Anthony Hugh — 2009-12-01

Abstract: Rupture of the peroneal tendons is rare, particularly rupture of peroneus longus. We report a case of a peroneus longus rupture following repeated steroid injection for chronic pain.

Painful and tender toe, osteoid osteoma of the distal phalanx of toe, a diagnostic dilemma

Mohamed H. Ebrahimzadeh, F. Omidi-Kashani, M.R. Hoseini — 2009-12-01

Abstract: Osteoid osteoma rarely involves the phalanges of the toes. Basically osteoid osteoma is often a diagnostic dilemma in musculoskeletal practice especially in the foot and ankle. Its presentation is confusing and this may result in delayed diagnosis. We have reported a case of osteoid osteoma of the distal phalanx of the second toe which was treated successfully with surgical excision and reviewed the literature.

An anomalous hindfoot insertion of the posterior tibialis tendon

Thomas W. Barwick, Paul J. Mackenney — 2009-12-01

Abstract: The posterior tibialis tendon has numerous insertions but none into the hindfoot has ever been reported in the literature. We present the operative and histological findings of an anomalous insertion slip into the sustentaculum tali in an adult patient with flatfoot deformity.

Diary of events

2009-12-01

Characteristics of the ischemic lower extremity wound: Interim results of the Southern Arizona Limb Salvage Alliance (SALSA) patient registry

Janice Clark, Manish Bharara, Joseph Mills, David Armstrong — 2009-12-01

Goals/purpose: This study evaluated patients admitted for lower extremity wounds at a southwestern United States hospital to determine the prevalence and most common locations of ischemic ulcerations and the most common infecting organisms in these wounds.

Load effect on Metatarsus Adductus Angle

Adam Lang, T. Nguyen, John Bennett, Vassilios Vardaxis — 2009-12-01

Goal/purpose: The Metatarsus Adductus Angle (MAA) is used often for pre and post surgical evaluation (hallux abducto valgus, pes plano-valgus) and anatomical alignment considerations in podiatric surgery. It provides a measurement for the long axis of the 2nd metatarsal to the mid-foot. Considering Hansen's well accepted theory (regarding essential joints), the MAA should not change with load.

Treatment of chronic plantar fasciitis with pulsed radio frequency energy therapy

Rosemay Michel — 2009-12-01

Goal/purpose: To evaluate the effectiveness of Pulsed Radio Frequency Energy (PRFE) as an adjunctive treatment modality for chronic plantar fasciitis. PRFE is indicated for adjunctive, palliative treatment of postoperative pain and edema in superficial soft tissue. Mechanisms of action include edema reduction, angiogenesis stimulation, and alteration of inflammatory responses. This modality has been investigated in the management of shoulder and knee pathology however evidence to support its use in the management of chronic plantar fasciitis is limited.

Can plantar temperature be used to assess tri-axial loading under the foot?

2009-12-01

Goal/purpose: Previously, investigators suggested using plantar temperature increase as an indicator of plantar loading. However this idea has not been validated. The purpose of this study is to explore whether there is a direct linear relationship between plantar stresses and post-exercise temperature increase under the foot. If confirmed, thermographs can be used to assess plantar tri-axial and/or shear loading, which may lead to significant advancements in diabetic foot biomechanics.

Radiofrequency coblation for tendinosis and fasciosis

2009-12-01

Purpose: To evaluate a new method of treating tendinosis and fasciosis utilizing Topaz coblation. Methods: The authors retrospectively evaluated 100 patients after surgical treatment with Topaz coblation. Tendinosis and fasciosis were clinically diagnosed, and confirmed by MRI and ultrasound, respectively. Anatomic dissection was utilized to the particular site of pathology, followed by micro-debridement in a grid-like pattern. All patients underwent phone interview and data was collected on 13 outcome variables. Pre- and post-operative responses were compared by Chi-square test and one-sample t-test.

Cuboid/cuneiform and calcaneal osteotomy for correction of cavoadductus varus deformity secondary to post-polio syndrome

Maggie U. Solimeo, Renato J. Giorgini — 2009-12-01

Purpose: The purpose of this surgical case study is to evaluate the effectiveness of a Calcaneal Dwyer osteotomy with closing cuboid/open cuneiform osteotomy using autologous bone graft from the cuboid and calcaneus for the correction of a cavoadductus varus deformity secondary to post-polio syndrome.

Utilizing the benefits of combination therapy of topical O2 and DERMAClose™ RC in the treatment and healing of a diabetic foot ulceration in a patient with multiple comorbidities

Bradley J. Hart, Kurt Rode, Anthony R. Iorio — 2009-12-01

Topical Oxygen Therapy TO2™ has been indicated for chronic non-healing wounds. These wounds are deficient in sufficient oxygen levels to promote proper healing. Oxygen therapy (HBO) has been used to promote proper healing of chronic wounds but it has generally been performed in a hyperbaric chamber in a hospital setting with the oxygen taken in systemically. Topical Oxygen Therapy TO2™, with its FDA approved O2Boot® and O2Sacral® devices gives the oxygen therapy directly to the wound site as this will increase the amount of O2 perfusion and essentially enhance the healing of a chronic wound as this will allow by-products to assist in wound closure.

Case study: ACeLL™ Matristem™ wound sheet used in conjunction with Medline® Puracol Plus™ as a multi-modality approach to wound closure in an immune compromised patient

Richard T. Bauer, Anthony R. Iorio — 2009-12-01

Treatment methods and experience using a novel aggregating powder dressing over a living single layer skin equivalent (LSLSE)

James Stavosky, Shawn Cazzel — 2009-12-01

Goal/purpose: We report on clinical experience treating diabetic foot ulcers (DFU's) using a novel powder dressing, as a primary dressing over a LSLSE. The purpose of this presentation is to show clinical experience in the application and performance of a novel aggregating powder dressing over a LSLSE. Because this dressing is unique both in application and behavior on a wound surface, it is important to convey experience gained so that “best clinical practice” with this material can be defined as a primary dressing over a LSLSE.

ACFAOM Clinical Conference 2009

2009-12-01

An abstract session will be a part of the 2010 ACFAOM Clinical Conference, August 26–29 in Orlando, Florida, at the Buena Vista Palace Hotel. A call for abstracts will be announced in early 2010. For more information about ACFAOM 2010 at Disney World go to www.ACFAOM.org.