Carol Frey

Comparison of Custom and Prefabricated Orthoses in the Initial Treatment of Proximal Plantar Fasciitis

Fifteen centers for orthopaedic treatment of the foot and ankle participated in a prospective randomized trial to compare several nonoperative treatments for proximal plantar fasciitis (heel pain syndrome). Included were 236 patients (160 women and 76 men) who were 16 years of age or older. Most reported duration of symptoms of 6 months or less. Patients with systemic disease, significant musculoskeletal complaints, sciatica, or local nerve entrapment were excluded. We randomized patients prospectively into five different treatment groups. All groups performed Achilles tendon- and plantar fascia-stretching in a similar manner. One group was treated with stretching only. The other four groups stretched and used one of four different shoe inserts, including a silicone heel pad, a felt pad, a rubber heel cup, or a custom-made polypropylene orthotic device. Patients were reevaluated after 8 weeks of treatment. The percentages improved in each group were: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4)stretching only, 72%; and (5) custom orthosis, 68%. Combining all the patients who used a prefabricated insert, we found that their improvement rates were higher than those assigned to stretching only (P = 0.022) and those who stretched and used a custom orthosis (P = 0.0074). We conclude that, when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symp-toms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device.

A Review of Ankle Arthrodesis: Predisposing Factors to Nonunion

The purpose of this study was to review 15 years of experience with ankle fusions, specifically addressing the underlying etiology of ankle pathology, incidence of nonunion, and associated predisposing conditions that can lead to nonunion. Seventy-eight ankle fusions, performed between 1975 and 1990, were reviewed for this study. The average follow-up was 4 years. Patients with nonunion were evaluated separately to look at the predisposing factors that may have lead to nonunion. Factors associated with nonunion included fracture type, evidence of avascular necrosis, infection, major medical problems, and open injuries. Factors that were not associated with nonunion included age, past history of subtalar or triple arthrodesis, and technique.

Vascularity of the posterior tibial tendon.

Operative exploration of ruptures of the posterior tibial tendon has revealed a relatively constant site of damage just posterior and distal to the medial malleolus. It has been hypothesized that the stress that is applied to the tendon as it passes under the medial malleolus may compromise the vascularity of the tendon in this area, a process that is similar to that described for the supraspinatus tendon. In order to evaluate this possibility, we studied the vascularity of the posterior tibial tendon. We injected twenty-eight cadaveric limbs with an India ink-gelatin mixture and cleared them using a modified Spalteholz technique. The gross external and internal vascularity were drawn, and the specimens were photographed. The vascularity of the tendons was noted to be abundant at the osseous insertion and the musculotendinous function of the tendon. There was a zone of hypovascularity posterior and distal to the medial malleolus in all specimens. The results of this study suggest that relative avascularity and resulting degenerative changes may be predisposing factors in rupture of the posterior tibial tendon, and that they have important implications in terms of the operative management of the rupture.

Vascular Anatomy of the Fifth Metatarsal

The extraosseous and intraosseous vascular anatomy to the fifth metatarsal as visualized in a group of below-the- knee amputation specimens has been described. The extrinsic circulation to the area is provided by the dorsal metatarsal artery, the plantar metatarsal arteries, and the fibular plantar marginal artery. These three source arteries supply branches to the metatarsal and adjacent joints. The intraosseous vascularity consists of a periosteal plexus, a nutrient artery, and a system of metaphyseal and capital vessels.

American Orthopaedic Foot and Ankle Society Women's Shoe Survey:

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 womens 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.

The effects of obesity on orthopaedic foot and ankle pathology

Background: It is believed that obese individuals may have an increased number of foot and ankle problems. The World Health Organization recommends a standard classification of adult overweight and obesity using the following body mass index (BMI) calculations: a BMI of 25.0 to 29.9 kg per m 2 is defined as overweight; a BMI of 30.0 kg per m 2 or more is defined as obesity. The purpose of this paper was to report a survey of 1411 patients in an orthopaedic foot and ankle practice and compare the incidence of orthopaedic foot and ankle complaints with the BMI. Method: One thousand four hundred and eleven adults, including 887(62.4%) women and 535(37.6%) men, were evaluated in this study. The BMI was calculated for each subject using the standards of the World Health Organization. The subjects were divided into two groups: normal and overweight. The normal weight subjects had a BMI of 18.5 to 24.9 (n = 684; 48.1%) and the overweight or obese group had a BMI greater than or equal to 25 (n = 738; 51.9%). Results: In this study, being overweight or obese significantly increased the chances of having tendinitis in general. If the subjects were overweight or obese, there was an increased likelihood, although not significant, of plantar fasciitis and osteoarthritis. If the individuals were of normal weight, there was an increased likelihood of hallux valgus. Conclusions: Tendinitis, plantar fasciitis, and osteoarthritis usually are secondary to overuse and increased stress on the soft tissues and joints, which may be directly related to increased weight on these structures.

Thromboembolism after foot and ankle surgery : A multicenter study

Thromboembolic disease presents a potentially fatal complication to patients undergoing orthopaedic surgery. Although the incidence after hip and knee surgery has been studied and documented, its incidence after surgery of the foot and ankle is unknown. For this reason, a prospective multicenter study was undertaken to identify patients with clinically evident thromboembolic disease to evaluate potential risk factors. Two thousand seven hundred thirty-three patients were evaluated for preoperative risk factors and postoperative thromboembolic events. There were six clinically significant thromboembolic events, including four nonfatal pulmonary emboli, after foot and ankle surgery. The incidence of deep vein thrombosis was six of 2733 (0.22%) and that of nonfatal pulmonary emboli was four of 2733 (0.15%). Factors found to correlate with an increased incidence of deep vein thrombosis were nonweightbearing status and immobilization after surgery. On the basis of these results, routine prophylaxis for thromboembolic disease after foot and ankle surgery probably is not warranted.

Anatomic Study of Arthroscopic Portal Sites of the Ankle

Numerous anatomic structures are at risk when performing ankle arthroscopy through the more commonly utilized portals. The purpose of this paper was to demonstrate the relative safety of each of the arthroscopic portal and Acufex external ankle distractor pin sites by measuring their proximity to the neurovascular structures surrounding the ankle joint. Six fresh cadaver specimens and 12 fresh-frozen, be-low-knee amputations were utilized for this study. An Acufex ankle distractor was applied using the standard technique. Anteromedial, anterolateral, anterocentral, posterolateral, and posteromedial portals were placed using an 11-blade scalpel to make 5-mm longitudinal incisions. The joint capsule was penetrated and a 3-mm arthroscope was placed into the ankle joint. The skin surrounding each of the portals was carefully removed and the proximity of any nerves or vessels was measured with respect to the arthroscope. At least one incidence of contact or penetration of a nerve or vessel was noted for each site. The anterocentral portal was at greatest risk for nerve or vessel damage. The anterolateral, anteromedial, and posterolateral portals were the safest areas for portal placement, with no penetration of neurovascular structures in any case.

Foot health and shoewear for women.

Females are different from males in structure and biomechanics. The foot in the female tends to have a narrower heel in relationship to the forefoot and overall is narrower than a mans foot relative to length. Females tend to pronate their feet more and have smaller Achilles tendons than males, both factors having implications for shoe fit. Although shoes have been worn for thousands of years for the main purpose of protecting feet from the environment, recent studies have implicated shoes as the principal cause of forefoot disorders seen in females. Several authors have reported the harmful effects of shoewear and the greatest factor is a shoe that is improperly fit. With respect to foot disorders in the female, the current study will explore anatomy, biomechanics, common forefoot disorders, and shoewear through the ages, athletic shoewear, and a toe strengthening program.

Arthroscopy of the subtalar joint.

The purpose of this study was to determine the position and relative safety of the anterior, posterior, and newly defined middle portals by measuring their distance from the neurovascular structures and tendons on the lateral side of the foot and ankle. Furthermore, this study demonstrates specific components of the posterior subtalar joint and arthroscopic access to each utilizing a technique that allows direct anatomic correlation. The 15 specimens were divided into three groups of five feet each, with one arthroscopic portal site and one instrumentation portal site per group. Group I used the anterior portal for the arthroscope and the posterior portal for the curette. Group II used the posterior portal for the arthroscope and the anterior portal for the curette. In group III, the arthroscope was inserted through the anterior portal and the curette through the middle portal. The sural nerve and small saphenous vein were at risk with posterior portal placement. The anterior portal presented a minor risk of injury to the dorsal intermediate cutaneous branch of the superficial peroneal nerve. The middle portal was without risk to surrounding structures. Group I provided the best access to the posterior facet of the subtalar joint. Group II provided excellent arthroscopic visualization of the posterior facet, but poor access for instrumentation via the anterior portal. Group III provided the best access to the sinus tarsi. No combination of portals allowed visualization or instrumentation of the middle or anterior facets.