Arthur Manoli

A New Operative Approach for Flatfoot Secondary to Posterior Tibial Tendon Insufficiency: A Preliminary Report

The treatment of Johnson stage 2 posterior tibial tendon insufficiency remains controversial. Because the deformities remain flexible in stage 2, bony osteotomies are preferable over fusion operations. It is our contention that operative intervention should address all of the components of the pes planovalgus deformity that exists in stage 2 disease. Seventeen patients with 20 cases of stage 2 posterior tibial tendon insufficiency were treated with heel cord lengthening, flexor digitorum longus to medial cuneiform tendon transfer, lateral column lengthening, and medial displacement calcaneal osteotomy. Preoperative, postoperative, and final radiographs while standing were analyzed to determine radiographic correction of the deformities. In addition, the American Orthopaedic Foot and Ankle Societys ankle/hindfoot rating scale was applied to all patients before surgery and at 6-month intervals after surgery. Currently, the average follow-up is 17.5 months. The average foot rating score preoperatively was 51.4 and has improved to 82.8. Radiograph measurements have demonstrated statistically significant correction of the pes planovalgus deformity, as well as maintenance of the correction to date. It is our conclusion that this combination of surgical procedures provides correction of the symptomatology and deformity associated with stage 2 posterior tibial tendon insufficiency. The long-term result of the procedure is unknown.

Subtalar Distraction Bone Block Fusion: An Assessment of Outcome:

Twenty-nine feet in 28 patients who underwent subtalar distraction bone block fusion for the treatment of subtalar deformities associated with symptomatic arthrosis were evaluated. All patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score. Eighteen men and 10 women with a mean age of 44 years were evaluated. The mean follow-up was 33 months. Subtalar arthrosis was secondary to trauma in 27 of 29 feet (93%) with os calcis fractures in 19, subtalar dislocations in 5, and talus fractures in 3. Eighteen of the 28 patients (64%) returned to either full- or part-time work. The change in the mean AOFAS Ankle-Hindfoot Scale score from 25 preoperatively to 75 postoperatively was statistically significant (P < 0.0001). The radiographic analysis of the pre- and postoperative standing lateral radiographs showed an average increase of 8 mm in hindfoot height, 9° in lateral talocalcaneal angle, and 11° in lateral talar declination angle that were statistically significant (P < 0.0001). All patients but one (96%) were satisfied. Complications included four nonunions, two varus malunions, one metatarsal stress fracture, and one medial plantar nerve paresthesia. Each nonunion occurred in patients who smoked.

Clinical outcome of arthrodesis of the ankle using rigid internal fixation with cancellous screws.

Thirty consecutive patients underwent arthrodesis of the ankle using rigid internal fixation with cancellous screws between 1992 and 1996. One patient died of causes unrelated to the surgery before bony union. Primary fusion occurred in 27 of the remaining 29 patients (93%). The average time to primary union was 9 weeks. Two patients developed a delayed union and were treated with an additional bone-grafting procedure. Ultimately, each of the 29 patients went on to fusion. Use of tobacco during the postoperative period had no apparent effect on the rate of fusion or time to fusion. Twenty-five patients were available for clinical evaluation at an average of 24 months after surgery. Subjective evaluation using questionnaires revealed a high level of satisfaction. All patients stated that they would undergo the procedure again. The mean postoperative score on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale was 81 points, compared with 48 points preoperatively (of a possible 100). Constant pain was the reason given by all patients for seeking treatment. After the arthrodesis, pain was reported as absent in 13 and occasional in 12 patients. All patients noted less pain in the hindfoot after fusion of the ankle. Active litigation and Workers’ Compensation claims during the perioperative period had a significant negative effect on scores on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale and seemed to decrease patients’ perceived ability to return to work.

Triple Arthrodesis in Adults Using Rigid Internal Fixation: An Assessment of Outcome

The intermediate outcome of patients who underwent a triple arthrodesis for the treatment of adult foot disorders was evaluated with an outcome tool to determine if their pain and functional status were improved. We evaluated 63 feet in 57 patients who underwent a triple arthrodesis using rigid internal fixation for the treatment of hindfoot deformities associated with symptomatic arthrosis. Twenty-four men and thirty-three women, with an average age of 54 years, were evaluated. The average follow-up was 30 months. Multiple diagnoses contributed to hindfoot deformities with secondary arthrosis. Iliac crest bone graft was used in 56 of 63 cases (89%). Percutaneous heel cord lengthening was done in 53 of 63 cases (84%). Twenty-four of the thirty patients (80%) returned to work. Twenty-five patients were retired and two were unemployed before surgery. All patients except two (97%) were satisfied with the surgery and would have the surgery again. The average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot preoperative score was 28 points, and the average postoperative score was 81 points (P < 0.0001). In the radiographic measurements, there was an average improvement of 12° in the lateral talometatarsal angle, 7° in the lateral talocalcaneal angle, and 10° in the AP talometatarsal angle (P < 0.0001). Complications experienced included two varus malunions, two valgus malunions, two nonunions, two deep vein thromboses, one distal fibula stress fracture, and one wound infection. Of the 26 feet in 22 patients with mortise views available, 10 feet (38%) had evidence of ankle arthrosis and 19 feet (73%) had some degree of talar tilt postoperatively.

Radiologic Signs of Unilateral Pes Planus

We used standard radiographs to evaluate the foot and ankle: AP and lateral views of the foot and the ankle, obtained with the patient standing. We include the same views of the opposite foot and ankle for comparison. Loss of the medial longitudinal arch occurs with pes planus. This can be seen on the lateral radiograph of the foot with the patient standing and can be quantified as the distance from the base of the medial cuneiform to the base of the fifth metatarsal (Fig. 1).1 As the arch collapses, this distance will decrease or actually become negative. In severe cases, the base of the medial cuneiform is actually below the level of the base of the fifth metatarsal (Fig. 2). Uncovering of the head of the talus occurs as the forefoot and hindfoot shift laterally. The exposure of the talar head is evident on the AP view of the foot and

Plantarflexion torque following reconstruction of Achilles tendinosis or rupture with flexor hallucis longus augmentation.

Nine patients treated surgically for Achilles tendon rupture (7 patients) or tendinosis (2 patients) with primary repair or debridement and augmentation with the flexor hallucis longus muscle-tendon unit were evaluated at a mean of 19 months postoperative. Subjective evaluation revealed a high level of satisfaction. All patients returned to work and only two patients reported limitation in their recreational activities. The mean post-operative AOFAS Ankle-Hindfoot Score was 90 points. Four patients reported mild occasional pain and one patient complained of moderate daily pain. Motion assessment showed a 20% increase in the hallux MTP dorsiflexion compared to the non-operative side (p = 0.045). No difference in ankle motion was noted. Cybex II+ dynamic evaluation of plantarflexion peak torque was complete on both extremities. The torque deficit on the reconstructed extremity was 20% (p = 0.01) at 120 degrees per second and 26% (p = 0.003) at 30 degrees per second. There is no significant difference between the torque deficit recorded for patients with Achilles rupture and those with Achilles tendinosis. A trend toward improved torque production with longer follow up was observed.

Osteotomy for Malunion of a Talar Neck Fracture: A Case Report:

A malunion of the talar neck after a Hawkins type II fracture/dislocation of the talar neck occurred in a 34-year-old man after nonoperative treatment. Rigid varus deformity of the forefoot was a source of severe pain and disability in this patient. We describe our surgical technique for osteotomy of the talar neck with insertion of a tricortical iliac crest bone graft to correct the deformity. At follow-up (56 months), the patient had consistent relief of pain and was employed at his preinjury job doing heavy labor. The score on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale improved from 11 points, preoperatively, to 85 points, postoperatively. Radiographs showed maintenance in the position of the osteotomy and no evidence of avascular necrosis in the talar body. Evidence of arthrosis of the talonavicular joint was apparent radiographically, but the patient did not complain of symptoms referable to this area.

Foot and Ankle Severity Scale (FASS)

Increasing use of air bags and seat belts has led to the saving of many lives. However, the orthopaedic surgeon is now left to manage increasing numbers of serious foot and ankle trauma. It is important to injury prevention programs to have an injury severity scale for these injuries. The Abbreviated Injury Scale is used widely; however, it is intended primarily to gauge possibility of death after accidents. It is not sensitive enough to give meaningful data about the foot and ankle trauma epidemic. The Trauma Committee of the American Orthopaedic Foot and Ankle Society has developed a rank order list of 91 foot and ankle injuries that commonly occur in vehicular crashes. The injuries are ranked according to severity (FASS-S). Estimated long-term impairment is also given for each injury (FASS-I). This scale is designed as a guideline to help rank importance and impairment of vehicular crash injuries. It is expected that the scale will be modified as future validity testing and other research dictates.

Osteoid Osteoma of the Lateral Talar Process Presenting as a Chronic Sprained Ankle

Pathologic conditions of the lateral talar process may be difficult to diagnose using physical examination and roentgenographs. A computed tomography scan of the hindfoot is often useful to define lesions of the lateral process. We report a case of osteoid osteoma of the lateral talar process that defied diagnosis for 4 years. The patient had an antecedent history of an inversion injury, which had been treated as a chronically painful sprained ankle without resolution of symptoms. The tumor was ultimately identified on a computed tomography scan, best seen on a coronal section through the talus. The patient had complete relief of pain after excisional biopsy of the tumor.

An Unusual Cause of Posterior Tibial Tendon Degeneration

A case demonstrating a mechanical cause of posterior tibial tendon degeneration is reported. The possible etiologies for degeneration of the posterior tibial tendon are discussed.