Benedict F. DiGiovanni

Associated injuries found in chronic lateral ankle instability.

Sixty-one patients underwent a primary ankle lateral ligament reconstruction for chronic instability between 1989 and 1996. In addition to the ligament reconstruction, all patients had evaluation of the peroneal retinaculum, peroneal tendon inspection by routine opening of the tendon sheath, and ankle joint inspection by arthrotomy. A retrospective review of the clinical history, physical exam, MRI examination, and intraoperative findings was conducted on these 61 patients. The purpose was to determine the type and frequency of associated injuries found at surgery and during the preoperative evaluation. At surgery no patients were found to have isolated lateral ligament injury. Fifteen different associated injuries were noted. The injuries found most often by direct inspection included: peroneal tenosynovitis, 47/61 patients (77%); anterolateral impingement lesion, 41/61 (67%); attenuated peroneal retinaculum, 33/61 (54%); and ankle synovitis, 30/61 (49%). Other less common but significant associated injuries included: intra-articular loose body, 16/61 (26%); peroneus brevis tear, 15/61 (25%); talus osteochondral lesion, 14/61 (23%); medial ankle tendon tenosynovitis, 3/61 (5%). The findings of this study indicate there is a high frequency of associated injuries in patients with chronic lateral ankle instability. Peroneal tendon and retinacular pathology, as well as anterolateral impingement lesions, occur most often. A high index of suspicion for possible associated injuries may result in more consistent outcomes with nonoperative and operative treatment of patients with chronic lateral ankle instability.

Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study.

Background: Approximately 10% of patients with plantar fasciitis have development of persistent and often disabling symptoms. A poor response to treatment may be due, in part, to inappropriate and nonspecific stretching techniques. We hypothesized that patients with chronic plantar fasciitis who are managed with the structure-specific plantar fascia-stretching program for eight weeks have a better functional outcome than do patients managed with a standard Achilles tendon-stretching protocol. Methods: One hundred and one patients who had chronic proximal plantar fasciitis for a duration of at least ten months were randomized into one of two treatment groups. The mean age was forty-six years. All patients received prefabricated soft insoles and a three-week course of celecoxib, and they also viewed an educational video on plantar fasciitis. The patients received instructions for either a plantar fascia tissue-stretching program (Group A) or an Achilles tendon-stretching program (Group B). All patients completed the pain subscale of the Foot Function Index and a subject-relevant outcome survey that incorporated generic and condition-specific outcome measures related to pain, function, and satisfaction with treatment outcome. The patients were reevaluated after eight weeks. Results: Eighty-two patients returned for follow-up evaluation. With the exception of the duration of symptoms (p < 0.01), covariates for baseline measures revealed no significant differences between the groups. The pain subscale scores of the Foot Function Index showed significantly better results for the patients managed with the plantar fascia-stretching program with respect to item 1 (worst pain; p = 0.02) and item 2 (first steps in the morning; p = 0.006). Analysis of the response rates to the outcome measures also revealed significant differences with respect to pain, activity limitations, and patient satisfaction, with greater improvement seen in the group managed with the plantar fascia-stretching program. Conclusions: A program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis. These findings provide an alternative option to the present standard of care in the nonoperative treatment of patients with chronic, disabling plantar heel pain. Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up

BACKGROUND In a previous investigation, eighty-two patients with chronic proximal plantar fasciitis for a duration of more than ten months completed a randomized, prospective clinical trial. The patients received instructions for either a plantar fascia-stretching protocol or an Achilles tendon-stretching protocol and were evaluated after eight weeks. Substantial differences were noted in favor of the group managed with the plantar fascia-stretching program. The goal of this two-year follow-up study was to evaluate the long-term outcomes of the plantar fascia-stretching protocol in patients with chronic plantar fasciitis. METHODS Phase one of the clinical trial concluded at eight weeks. At the eight-week follow-up evaluation, all patients were instructed in the plantar fascia-stretching protocol. At the two-year follow-up evaluation, a questionnaire consisting of the pain subscale of the Foot Function Index and an outcome survey related to pain, function, and satisfaction with treatment was mailed to the eighty-two subjects who had completed the initial clinical trial. Data were analyzed with use of a mixed-model analysis of covariance for each outcome of interest. RESULTS Complete data sets were obtained from sixty-six patients. The two-year follow-up results showed marked improvement for all patients after implementation of the plantar fascia-stretching exercises, with an especially high rate of improvement for those in the original group treated with the Achilles tendon-stretching program. In contrast to the eight-week results, the two-year results showed no significant differences between the groups with regard to the worst pain or pain with first steps in the morning. Descriptive analysis of the data showed that 92% (sixty-one) of the sixty-six patients reported total satisfaction or satisfaction with minor reservations. Fifty-one patients (77%) reported no limitation in recreational activities, and sixty-two (94%) reported a decrease in pain. Only sixteen of the sixty-six patients reported the need to seek treatment by a clinician. CONCLUSIONS This study supports the use of the tissue-specific plantar fascia-stretching protocol as the key component of treatment for chronic plantar fasciitis. Long-term benefits of the stretch include a marked decrease in pain and functional limitations and a high rate of satisfaction. This approach can provide the health-care practitioner with an effective, inexpensive, and straightforward treatment protocol.

Vertebral Alterations in Scheuermann's Kyphosis

In a cadaver-derived skeletal collection of 1,384 thoracolumbar spinal columns, 103 (7.4%) individuals with vertebral changes of Scheuermanns kyphosis were identified. Anterior extension of the vertebral specimens was noted in 94% of affected specimens. No evidence of osteoporosis was noted by single-photon absorptiometric analysis in the affected sample compared with a normal control group. Biopsy specimens from two immature patients obtained at surgery suggested disorganized endochondral ossification similar to that noted in Blounts disease. It was concluded that increased pressure on the anterior margin of the centrum is responsible for histologic and morphologic changes of Scheuermanns kyphosis.

Acute ankle injury and chronic lateral instability in the athlete.

Ankle injuries occur frequently in sports. The lateral ligamentous complex, specifically the anterior talofibular and calcaneofibular ligaments, are most commonly injured. In acute lateral ligament injuries, a functional ankle rehabilitation program is the mainstay of treatment. Chronic ankle instability develops in a minority of patients. Surgical procedures are broadly classified into anatomic ligament repairs versus reconstructive tenodeses. Commonly performed techniques include the Brostrom-Gould procedure,the modified Brostrum-Evans procedure, and the Chrisman-Snook procedure.

Subtalar Arthrodesis with Flexor Digitorum Longus Transfer and Spring Ligament Repair for Treatment of Posterior Tibial Tendon Insufficiency

The surgical treatment of flexible pes planovalgus deformities resulting from Stage 2 posterior tibial tendon insufficiency is controversial and many techniques have been proposed. We retrospectively reviewed the results of subtalar arthrodesis combined with spring ligament repair/reefing and flexor digitorum longus (FDL) transfer to the navicular. There were sixteen patients (seventeen feet) with an average follow-up of 27 months (9–52). All deformities were passively correctable. The average age was 56 yrs (39–78). All patients had failed conservative management, 88% had previously been treated with orthotics, and 53% had lateral pain from subfibular impingement. Two patients were noted to have degenerative changes of the subtalar joint. Successful subtalar joint fusion occurred in all patients with an average time to radiographic union of 10.1 weeks (5–24). The average AOFAS hindfoot score and Maryland foot score postoperatively was 82 and 86 respectively. Standing radiographic analysis demonstrated an average improvement in the AP talo-1st metatarsal angle of 6° (24° preoperative, 18° postoperative). The talonavicular coverage angle improved an average of 17° (34° preoperative, 17° postoperative). The lateral talo-1st metatarsal angle improved an average of 10° (18° preoperative, 8° postoperative). The lateral talocalcaneal angle decreased an average of 21 o (55° preoperative, 34° postoperative). The distance of the medial cuneiform to the floor on the lateral radiograph averaged 12mm preoperatively and 18mm postoperatively (avg. improvement 6mm). The combination of the flexor digitorum longus tendon transfer and spring ligament repair with subtalar arthrodesis is an effective and reliable procedure which provides excellent correction of hindfoot valgus as well as forefoot abduction and restoration of the height of the longitudinal arch. These results compare favorably with flexor transfer combined with either calcaneal osteotomy or lateral column lengthening.

Reliability and validity of the American Orthopaedic Foot and Ankle Society Clinical Rating Scale : A pilot study for the hallux and lesser toes

Background: The use of clinical outcomes instruments is essential for the effective interpretation of individual patient progress as well as the comparison of treatment groups. An outcomes instrument must be reliable and valid to obtain any meaningful data. The purpose of the present study was to examine the reliability and validity of the American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating scale for the hallux metatarsophalangeal-interphalangeal and lesser toes metatarsophalangeal-interphalangeal joints. Methods: Eleven patients (one man, 10 women) with an average age of 54 (range 40 to 72) years and with classic rheumatoid arthritis not currently treated for foot complaints were enrolled in the present study. The average duration of rheumatoid arthritis was 14 years. Each patient completed a set of two outcomes instruments and had a physical examination by a single clinician at the initial visit and returned at 1 week for completion of the same scales and examination. The outcomes scales used were the AOFAS clinical rating scale for the hallux, the AOFAS clinical rating scale for the lesser toes, and the previously validated Foot Function Index (FFI). Test-retest reliability was evaluated using intraclass correlation coefficients between week 1 and week 2 for the summary scores as well as for the subscales of pain and activity. Consistency between the two instruments was evaluated with Pearson correlation coefficients. Results: The AOFAS clinical rating scale for the hallux and lesser toes is repeatable between 1-week trials (ICC 0.95; p < 0.05; ICC 0.80; p < 0.05, respectively). Moderately strong correlations were found between the mean values for the AOFAS hallux and FFI (r = −0.81;p < 0.05). Weaker correlations were seen between the mean values for the AOFAS lesser toes and FFI scales (r = −0.69;p < 0.05). Conclusions: The hallux subscale for pain correlates strongly with the FFI subscale for pain, suggesting high content validity (r = −0.94;p < 0.001). Ceiling effects were seen with the AOFAS lesser toe subscale for activity, limiting its usefulness in a general patient population. The AOFAS lesser toe subscale for pain and the AOFAS hallux subscale for activity correlated weakly with the FFI values (r = −0.31;r = −0.37;p > 0.05, respectively). Conclusions: Although the AOFAS hallux and lesser toe scales were found to be reliable in a rheumatoid patient population, their validity remains in question. These findings must be confirmed with larger subject numbers, with the inclusion of symptomatic patients before recommended routine use of the hallux clinical rating and lesser toe clinical rating scales.

Exposure to Direct and Scatter Radiation with Use of Mini-C-Arm Fluoroscopy

BACKGROUND Mini-c-arm fluoroscopy has become an important resource to the orthopaedic surgeon. Exposure of the orthopaedic surgical team to radiation during standard large-c-arm fluoroscopy has been well studied; however, little is known about the amount of exposure to which a surgical team is subjected with the use of mini-c-arm fluoroscopy. Moreover, there is controversy regarding the use of protective measures with mini-c-arm fluoroscopy. METHODS We evaluated the use of mini-c-arm fluoroscopy during a simulated surgical procedure to quantify the relative radiation doses at various locations in the operative field. A standard calibrated mini-c-arm fluoroscope was used to image a phantom upper extremity with thirteen radiation dosimeters placed at various distances and angulations to detect radiation exposure. RESULTS After 155 sequential fluoroscopy exposures, totaling 300.2 seconds of imaging time, only the sensor placed in a direct line with the imaging beam recorded a substantial amount of measurable radiation exposure. CONCLUSIONS The surgical team is exposed to minimal radiation during routine use of mini-c-arm fluoroscopy, except when they are in the direct path of the radiation beam.

Association between plantar fasciitis and isolated contracture of the gastrocnemius.

Background: Current evidence suggests that limited ankle dorsiflexion is an etiologic factor for plantar fasciitis. This limitation can arise from either an isolated contracture of the gastrocnemius or from a contracture of the gastrocnemius-soleus complex. This studys aim was to determine the proportion of patients with plantar fasciitis that have an associated isolated gastrocnemius contracture. Materials and Methods: This investigation was a prospective evaluation of patients with either acute or chronic plantar fasciitis. Two hundred fifty-four patients with plantar fasciitis were included. Patients were assessed for the existence of limited ankle dorsiflexion which was further characterized by noting the presence of an isolated gastrocnemius contracture or contracture of the gastrocnemius-soleus complex. The patients duration of symptoms, type of occupation, and body mass index were also documented. Patients with acute plantar fasciitis were defifined as having symptom duration of 9 months or less while those with chronic plantar fasciitis were those with over 9 months of symptoms. The Wilcoxon rank sum and chi square tests were used to compare characteristics between the acute and chronic populations. Results: Eighty-three percent (211 of 254 patients) had limited ankle dorsiflexion. Fifty-seven percent (145 of 254) had an isolated contracture of the gastrocnemius, 26% (66 of 254) had a contracture of the gastrocnemius-soleus complex, and 17% (43 of 254) did not have a dorsiflexion limitation. Patients were further stratified into acute versus chronic symptom duration at the time of presentation. Equinus contracture was noted in 83% (129 of 155) of acute cases, and 82% (82 of 99) of chronic cases. An isolated contracture of the gastrocnemius was found in 60% (93 of 155) of acute, and 52% (52 of 99) of chronic cases. A gastrocnemius-soleus complex contracture was noted in 23% (36 of 155) of acute cases, and 30% (30 of 99) of chronic cases. Patients with chronic plantar fasciitis had a significantly higher number (p < 0.05) of medical comorbidities than those with acute plantar fasciitis. Conclusion: Limited ankle dorsiflexion is commonly associated with plantar fasciitis and more than half of these patients had evidence of an isolated gastrocnemius contracture. These findings can be utilized to develop and further refine non-operative and operative treatment strategies for those with recalcitrant plantar fasciitis. Level of Evidence: IV, Case Series

A Guide to Improving the Care of Patients With Fragility Fractures

This monograph is written as a guide for physicians, nurses, therapists, and students interested in ideal care for their patients with fragility fractures. The scope of fragility fractures in the United States is large and will grow over the next 20 years as the population ages. There is much that can be done currently to idealize the outcomes of these patients. Additional research in many areas is needed to further improve the quality of care for these patients. We plan to update this monograph as new information concerning the care of seniors with fragility fractures develops.