Background
In the presence of a large gap where end-to-end repair of the torn Achilles tendon is difficult and V-Y advancement would likely be insufficient, augmentation is sometimes required. At our institute we have used primarily the hamstring autograft augmentation technique for the past two decades. The aim of this study was to analyze the complications after surgical treatment of Achilles tendon rupture with semitendinous tendon augmentation.
Methods
We retrospectively analyzed 58 consecutive patients treated with semitendinous tendon autograft augmentation at the Helsinki University Hospital between January 1, 2006, and January 1, 2016.
Results
During the study period, 58 patients were operated on by six different surgeons. Of 14 observed complications (24%), seven were major and seven were minor. Most of the complications were infections (n = 10 [71%]) The infections were noted within a mean of 62 days postoperatively (range, 22–180 days). Seven patients with a complication underwent repeated operation because of skin edge necrosis and deep infection (five patients), hematoma formation (one patient), and a repeated rupture (one patient).
Conclusions
In light of the experience we have had with autologous semitendinous tendon graft augmentation, we cannot recommend this technique, and, hence, we should abandon reconstruction of Achilles tendon ruptures with autologous semitendinous tendon grafts at our institute. Instead, other augmentation techniques, such as flexor hallucis longus tendon transfer, should be used.
Background
Altered foot loading during weightbearing is suggested to play a role in the development of patellofemoral pain (PFP). This study aimed to determine foot-loading characteristics associated with PFP by assessing center of pressure (COP) during single-limb loading in individuals with PFP compared with noninjured controls.
Methods
Thirty recreationally active patients with PFP and 30 noninjured control participants had barefoot plantar pressure assessed during single-limb squats (SLSs) from which COP parameters (COP velocity and COP index) were obtained. Groups were compared using independent t tests.
Results
Individuals with PFP demonstrated a greater COP index (P = .042), indicating a more lateral foot-loading pattern, and exhibited increased overall COP velocity (P = .013) and anteroposterior COP velocity during SLSs compared with control participants (P = .033).
Conclusions
Greater lateral foot loading and increased COP velocity during SLSs demonstrated by individuals with PFP may indicate reduced dynamic balance in this patient group, which may be implicated in the development of PFP.
Background
The purpose of this study was to compare the clinical and radiographic outcomes of stabilization of the lateral ligament combined with joint debridement in patients with ligamentous moderate neutral ankle osteoarthritis with those achieved for patients with varus ankle osteoarthritis.
Methods
We reviewed integrated data from 40 patients (40 ankles) with ligamentous moderate ankle osteoarthritis. Matched for age, gender, and follow-up duration, they were divided into two groups by preoperative coronal plane hindfoot moment arm values (HMAV): neutral (20 ankles, ≤15 mm) and varus (20 ankles, >15 mm) deformity. Stabilization of lateral ligament combined with joint debridement was performed. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot score, hindfood moment arm values, and classification of Takakura were used to compare clinical and radiographic outcomes after a mean follow-up period of 64.2 months (range, 60-84 months).
Results
Mean post-operative AOFAS was 86.0 and 72.6 in the neutral and varus groups, respectively. The post-operative AOFAS of both groups improved significantly, although the outcome improvement of the neutral group was better than that of the varus group (P = 0.0006). There was obvious improvement in HMAV of the neutral group (P = 0.0469) and less improvement in HMAV of the varus group (P = 0.8509). The mean postoperative HMAV was 4.60 mm (0–10 mm) and 17.85 mm (8–23 mm) in the neutral and varus groups, respectively. The radiographic classification of Takakura was unchanged in the neutral group, whereas four cases in the varus group had a worse classification.
Conclusions
Stabilization of the lateral ligament combined with joint debridement for ligamentous moderate ankle osteoarthritis showed better clinical and radiographic outcomes in patients with neutral alignment than that achieved for patients with varus malalignment.
Background
The windlass mechanism, first described by John Hicks in 1954, defines the anatomical and biomechanical relationship between the hallux and the plantar fascia. Hallux valgus (HV) and plantar fasciitis are the most common foot disorders, and, to date, no study has evaluated the relationship between these disorders. The purpose of this study was to determine the incidence of and factors associated with plantar fasciitis in patients with HV deformity.
Methods
In this prospective observational study, 486 patients with HV were divided into three groups according to stage of HV deformity. Patient sex, age, and body mass index were recorded. Presence of accompanying plantar fasciitis and heel spur was investigated by physical and radiographic examination. First metatarsophalangeal joint dorsiflexion of the affected side was measured. Patients with or without plantar fasciitis were also compared to evaluate factors associated with plantar fasciitis.
Results
Mean age and body mass index of the patients were significantly different among the three HV groups. The incidence of plantar fasciitis and heel spur significantly increased in correlation with the severity of HV deformity. Increased age and HV stage and decreased first metatarsophalangeal joint dorsiflexion were significantly associated with presence of plantar fasciitis in HV.
Conclusions
In this study, the incidence of plantar fasciitis was significantly increased in correlation with the severity of HV deformity. Significant association was found between plantar fasciitis and HV, which are anatomically and biomechanically related to each other by the windlass mechanism.
Nonsurgical Treatment for Hallux Abducto Valgus with Botulinum Toxin Type A
An Improvement of the Injection Paradigm
Background
Hallux abducto valgus (HAV) is a frequently seen abnormality of the first metatarsophalangeal joint. Limited conservative treatment options exist, making surgery the only definitive treatment option for a mild to moderate deformity. Since initially published in 2008, treatment of HAV with botulinum toxin injection has evolved as a potentially effective modality as shown in several subsequent independent studies.
Methods
Botulinum injection of two intrinsic foot muscles (extensor halluces brevis and flexor hallucis brevis) in addition to adductor hallucis under electrical stimulation is presented as an improvement to the original method.
Results
The additional muscle injections of botulinum resulted in an further reduction of the HAV deformity and associated pain.
Conclusions
A significant improvement to the injection paradigm developed the author may prove to be more effective in reducing the HAV deformity and its associated pain.
Background
The Evans osteotomy is a widely used procedure for the correction of adult and pediatric flexible flatfoot deformity. Locking plates are commonly used to stabilize the osteotomy and the allograft. However, there have been incidences of soft-tissue irritation caused by the hardware, requiring subsequent hardware removal. Therefore, we sought to review whether age, sex, or laterality of the procedure had any correlation with the rate of hardware removal.
Methods
A retrospective review was performed of 47 consecutive patients who underwent an Evans calcaneal osteotomy between October 1, 2013, and October 1, 2016. Data were collected and analyzed based on age, sex, laterality, and the need for hardware removal.
Results
All of the 47 patients met the inclusion criteria. Seventy procedures were performed, and hardware removal was required in 16 patients and 21 feet (30%). The only statistically significant finding was that 11 females and only five males required either unilateral or bilateral hardware removal (P = .039). All 16 patients reported complete pain relief after hardware removal.
Conclusions
Females are twice as likely as males to develop symptoms after locking plate application over an Evans osteotomy and may require hardware removal. Despite the low-profile nature of the locking plate to fixate the Evans osteotomy, the hardware can be a source of significant pain. Patients, especially females, should be cautioned about potential hardware-related pain and a possible follow-up procedure to remove the hardware.
Background
Ankle dorsiflexion motion and plantarflexor stiffness measurement offer clinical insight into the assessment and treatment of musculoskeletal and neurologic disorders. We aimed to determine reliability and concurrent validity of an ankle arthrometer in quantifying dorsiflexion motion and plantarflexor stiffness.
Methods
Ten healthy individuals were assessed for dorsiflexion motion and plantarflexor stiffness using an ankle arthrometer with a 6 degree-of-freedom kinematic linkage system and external strain gauge to apply dorsiflexion torque. Two investigators each performed five loads to the ankle at different combinations of loads (10 or 20 Nm), rates (2.5 or 5 Nm/sec), and knee angles (10° or 20°). Anteroposterior displacement and inversion-eversion rotation were also assessed with arthrometry, and functional dorsiflexion motion was assessed with the weightbearing lunge (WBL) test.
Results
Good-to-excellent intrarater reliability was observed for peak dorsiflexion (intraclass correlation coefficient [ICC][2,k] = 0.949–0.988) and plantarflexor stiffness (ICC[2,k] = 0.761–0.984). Interrater reliability was good to excellent for peak dorsiflexion (ICC[2,1] = 0.766–0.910) and poor to excellent for plantarflexor stiffness (ICC[2,1] = 0.275–0.914). Reliability was best for 20-Nm loads at 5 Nm/sec. Strong correlations were observed between peak dorsiflexion and anteroposterior displacement (r = 0.666; P = 0.035) and WBL distance (r = -0.681; P = 0.036).
Conclusions
Using an ankle arthrometer to assess peak dorsiflexion and plantarflexor stiffness seems reliable when performed to greater torques with faster speeds; and offers consistency with functional measures. Use of this readily available tool may benefit clinicians attempting to quantify equinus and dorsiflexion deficits in pathological populations.
Background:
The increasing resistance of bacteria to antibiotics and the frequency of comorbid conditions of patients make the treatment of diabetic foot infections problematic. In this context, photodynamic therapy could be a useful tool to treat infected wounds. The aim of this study was to evaluate the effect of repeated applications of a phthalocyanine derivative (RLP068) on the bacterial load and on the healing process.
Methods:
The present analysis was performed on patients with clinically infected ulcers who had been treated with RLP068. A sample for microbiological culture was collected at the first visit before and immediately after the application of RLP068 on the ulcer surface, and the area was illuminated for 8 minutes with a red light. The whole procedure was repeated three times per week at two centers (Florence and Arezzo, Italy) (sample A), and two times per week at the third center (Stuttgart, Germany) (sample B) for 2 weeks.
Results:
Sample A and sample B were composed of 55 and nine patients, respectively. In sample A, bacterial load decreased significantly after a single treatment, and the benefit persisted for 2 weeks. Similar effects of the first treatment were observed in sample B. In both samples, the ulcer area showed a significant reduction during follow-up, even in patients with ulcers infected with gram-negative germs or with exposed bone.
Conclusions:
RLP068 seems to be a promising topical wound management procedure for the treatment of infected diabetic foot ulcers.
Artificial Dermis Composite Tissue Flaps versus Traditional Prefabricated Flaps
Comparison of Repair Characteristics
Objective
We compared the application of artificial dermis composite tissue flaps and traditional prefabricated flaps in a rat model of exposed bone and tendon injury.
Methods
Sprague Dawley rats were randomly divided into two groups (n = 40 per group). Group A rats received artificial dermis composite tissue flaps and group B rats received traditional prefabricated flaps. Flap appearance, range of motion, degree of swelling, tissue histologic results, and imaging findings were compared between groups at 7, 14, 21, and 28 days.
Results
There was no difference in flap appearance, range of motion, or degree of swelling between groups. However, blood perfusion of the artificial dermis composite tissue flap was better than that of the traditional prefabricated flap; the artificial dermis was also found to be thicker than the traditional prefabricated flap.
Conclusions
The artificial dermis composite tissue flap is an ideal method for repairing exposed bone and tendon, and it displays repair effects comparable with those of the traditional prefabricated flap and may be a better alternative.
Dynamic and Stabilometric Analysis After Syndesmosis Injuries
A Comparative Study
Background
Distal tibiofibular syndesmosis contributes to dynamic stability of the ankle joint and thereby affects gait cycle. The purpose of this study was to evaluate the grade of syndesmosis injury on plantar pressure distribution and dynamic parameters of the foot.
Methods
Grade of syndesmosis injury was determined by preoperative plain radiographic evaluation, intraoperative hook test, or external rotation stress test under fluoroscopic examination, and two groups were created: group 1, patients with grade III syndesmosis injury (n = 17); and group 2, patients with grade II syndesmosis injury (n = 10). At the last visit, radiologic and clinical assessment using the Foot and Ankle Outcome Score was performed. Dynamic and stabilometric analysis was carried out at least 1 year after surgery.
Results
The mean age of the patients was 48.9 years (range, 17–80 years), and the mean follow-up was 16 months (range, 12–24 months). No statistically significant difference was noted between two groups regarding Foot and Ankle Outcome Score. The comparison of stabilometric and dynamic analysis revealed no significant difference between grade II and grade III injuries (P > .05). However, comparison of the data of patients with grade III syndesmosis injury between injured and healthy feet showed a significant difference for dynamic maximum and mean pressures (P = .035 and P = .49, respectively).
Conclusions
Syndesmosis injury does not affect stance phase but affects the gait cycle by generating increased pressures on the uninjured foot and decreased pressures on the injured foot. With the help of pedobarography, processing suitable orthopedic insoles for the injured foot and interceptive measures for overloading of the normal foot may prevent later consequences of ankle trauma.
