David R. Hootnick

Ipsilateral supracondylar femur fractures following knee arthroplasty.

A retrospective study was performed to evaluate the treatment of five patients with prosthetic knee arthroplasty who sustained a supracondylar femoral fracture of the ipsilateral side. Four of the patients were initially treated by plaster immobilization or traction. Two of the four showed no signs of healing at three months postfracture and had to have open reduction and internal fixation. The fifth patient had primary open reduction and internal fixation. The three patients who were treated surgically regained their prefracture knee rating score. The two who were treated nonoperatively for their fracture had a significant loss in limb function and failed to regain their prefracture knee rating score. Open reduction and internal fixation of these fractures achieves the best results despite the complicating factors of in situ prosthetic components.

Magnetic Resonance Angiography in Clubfoot and Vertical Talus: A Feasibility Study

AbstractCongenital vascular alterations of the normal adult arterial pattern have been associated with multiple congenital limb deformities including clubfoot and vertical talus. Investigators have observed absence of the anterior tibial artery and dorsalis pedis artery in most patients with clubfoot, and absence of the posterior tibial artery in all patients with vertical talus. We used magnetic resonance angiography to define the lower extremity vascular anatomy of two patients with left-sided vertical talus and right-sided clubfoot and one patient with bilateral vertical talus and cartilage-derived morphogenetic protein-1 (CDMP-1) gene mutation. Of the three patients, one had bilateral posterior tibial artery deficiencies while the other had bilateral anterior tibial artery deficiencies. The third patient with bilateral vertical talus and CDMP-1 mutation had normal arterial structure bilaterally. Though clubfoot and vertical talus have distinctly different clinical phenotypes, the association of each with arterial abnormalities suggests a common etiology during development. The presence of normal arterial structure in our patient with vertical talus and CDMP-1 mutation suggests that other nonvascular etiologies may be responsible for some cases of foot deformities. Level of Evidence: Level IV, prognostic case series. See the Guidelines for Authors for a complete description of levels of evidence.

Congenital arterial malformations associated with clubfoot. A report of two cases.

Arteriograms were examined in three limbs of two patients who had talipes equinovarus. An abnormal arterial pattern characterized by severe diminution in the size of the anterior tibial artery and diminution or absence of the dorsalis pedis artery was evident. Inasmuch as one of these patients was preambulatory, the arterial malformation is congenital and would not have been acquired in walking. The relationship between the abnormal arterial and bony pattern in talipes equinovarus is comparable to that previously described for congenital absence of the fibula. A possible etiologic relationship between TEV and embryonic arterial accidents is suggested.

Pulsed color-flow Doppler analysis of arterial deficiency in idiopathic clubfoot.

This prospective study used pulsed color-flow Doppler sonography to determine differences in the presence and direction of flow through the dorsalis pedis, posterior tibial, and peroneal arteries in a group of children with clubfoot and a comparison group of controls. There was a statistically significant difference in the prevalence of deficient (absent or retrograde flow) dorsalis pedis arteries in children with clubfoot (45%) compared with controls (8%). This indicates that there is an association between some clubfeet and deficiency of the dorsalis pedis artery. There was a trend toward difference in the prevalence of deficiency of the dorsalis pedis artery in the clubfeet that required surgery (54%) compared with those that did not (20%), suggesting that dorsalis pedis artery deficiency may be more prevalent among clubfeet with greater deformity.

Anatomy of a duplicated human foot from a limb with fibular dimelia.

At birth, a patient presented with a right lower limb featuring preaxial polydactyly and fibular dimelia with a complete absence of the tibia. Radiographic studies of the patients foot revealed a duplicated tarsus with eight metatarsals and toes. The three preaxial toes were surgically removed at 1 year of age. A hallux and four normal-appearing postaxial toes remained. The foot was amputated when the patient was 3 years old. Dissection of the amputated foot revealed that the muscles of the dorsum were normal, except that the tendon of the extensor hallucis brevis muscle inserted into both the hallux and toe 2, rather than only into the hallux. The few abnormalities observed among the muscles on the plantar surface of the foot included absence of the insertions of the tibialis posterior and the abductor hallucis muscles. In addition, the two heads of the adductor hallucis muscle inserted abnormally into the medial (tibial) side of metatarsal 1, rather than into the lateral side. These various muscular anomalies, in addition to the mirror duplication of the foot with the presence of only a single metatarsal 1, leads us to propose that this metatarsal probably represents two lateral (fibular) halves that form a laterally duplicated bone. Although the dorsalis pedis artery was present on the dorsal surface of the foot, most of its derivatives were absent. This artery did give rise to a supernumerary medial branch that ended abruptly in the connective tissue (presumably postsurgical scar) at the medial border of the foot. This branch may have represented a duplicated dorsalis pedis artery associated with the duplicated preaxial portion of the foot. The arteries on the plantar surface of the foot were normal. Even though some anomalies in the pattern of the cutaneous innervation were observed, the nerves of the foot were largely normal. The gross and radiographic anatomy of this specimen and the radiographic anatomy of the leg suggest that some teratogenic event occurred when developmental specification reached the level of the future knee. The teratogenic event, which probably occurred early in the fifth week of development, may have caused damage that led to a lateral duplication of both the leg and the foot with the absence of some of the most medial structures. Teratology 60:272-282, 1999.

Necrosis Leading to Amputation Following Clubfoot Surgery

Amputation after clubfoot surgery is a rare and catastrophic complication. This case report involves an amputation necessitated by postoperative necrosis on the medial side of the foot. To our knowledge, only one brief published report of necrosis following clubfoot surgery exists in the literature, and that report contains little clinical information. Although we know of several additional cases of necrosis following clubfoot surgery, the details of these cases remain unavailable to us for publication. The clubfoot deformity is almost always associated with vascular deficiencies involving the anterior tibial and dorsalis pedis arteries, as well as their derivatives. Since the area of necrosis in this case report coincided with the anatomic distribution of the derivatives of the congenitally reduced or absent dorsalis pedis artery, we suggest that insufficient blood flow to the dorsal and medial sides of the foot, and to the hallux contributed to the necrosis. In our opinion, the surgeon should assume that an abnormal vascular pattern, as described here, is present unless proven otherwise.

Midline Metatarsal Dysplasia Associated with Absent Fibula

In 5 patients with congenital deficiency of the fibula, the degree of fibular deficiency ranged from unilaterally short to bilaterally absent. The patients each had at least one missing metatarsal and, in addition, dysplasia of a midline metatarsal. In view of these findings, some missing metatarsals associated with congenital fibular deficiency could be midline metatarsals. The abnormality could represent a deficiency acquired after the development of the embryonic limb bud cartilage models.

The Nature of Foot Ray Deficiency in Congenital Fibular Deficiency.

Background: Absent lateral osseous structures in congenital fibular deficiency, including the distal femur and fibula, have led some authors to refer to the nature of foot ray deficiency as “lateral” as well. Others have suggested that the ray deficiency is in the central portion of the midfoot and forefoot. We sought to determine whether cuboid preservation and/or cuneiform deficiency in the feet of patients with congenital fibular deficiency implied that the ray deficiency is central rather than lateral in patients with congenital fibular deficiency. Methods: We identified all patients with a clinical morphologic diagnosis of congenital fibular deficiency at our institution over a 15-year period. We reviewed the records and radiographs of patients who had radiographs of the feet to allow determination of the number of metatarsals, the presence or absence of a cuboid or calcaneocuboid fusion, the number of cuneiforms present (if possible), and any other osseous abnormalities of the foot. We excluded patients with 5-rayed feet, those who had not had radiographs of the feet, or whose radiographs were not adequate to allow accurate assessment of these radiographic features. We defined the characteristic “lateral (fifth) ray present” if there was a well-developed cuboid or calcaneocuboid coalition with which the lateral-most preserved metatarsal articulated. Results: Twenty-six patients with 28 affected feet met radiographic criteria for inclusion in the study. All affected feet had a well-developed cuboid or calcaneocuboid coalition. The lateral-most ray of 25 patients with 26 affected feet articulated with the cuboid or calcaneocuboid coalition. One patient with bilateral fibular deficiency had bilateral partially deficient cuboids, and the lateral-most metatarsal articulated with the medial remnant of the deformed cuboids. Twenty-one of 28 feet with visible cuneiforms had 2 or 1 cuneiform. Conclusions: Although the embryology and pathogenesis of congenital fibular deficiency remain unknown, based on the radiographic features of the feet in this study, congenital fibular deficiency should not be viewed as a global “lateral lower-limb deficiency” nor the foot ray deficiency as “lateral.” Level of Evidence: Level IV—prognostic study.