David S. Caminear

Haglund's syndrome.

Haglunds syndrome is a painful condition of the heel caused by mechanically induced inflammation of the retrocalcaneal bursa, supracalcaneal bursa, and Achilles tendon. Surgical management has included calcaneal osteotomy, but results have been unpredictable because of the inability to measure accurately bone removal. A method was devised in this study to accurately determine radiographically the amount of bone removal necessary. Sixteen heels in 13 patients underwent surgery after failing 21 months of conservative treatment. The desired osteotomy angle (preop x-rays) was compared to the actual angle obtained at surgery. A patient questionnaire, developed by the Outcome Study Committee of the AOFAS, was used to assess results. There were 13 good results and 3 failures. The average actual angle of the good results was 49 degrees and that of the poor results was 61 degrees. These results were statistically significant to a p = .0012. The average score obtained by the good results was 87 points, while that of the failures was 25 points. Follow-up was 42 months. The authors recommend that the osteotomy be made in such a way as to remove not only the superolateral deformity, but also to decompress the retrocalcaneal bursa and to remove the calcaneal step. In order to do so, an osteotomy angle of 49 degrees should be achieved.

Mechanical Characteristics of an Absorbable Copolymer Internal Fixation Pin

Absorbable internal fixation is gaining acceptance among foot and ankle surgeons. While absorbable pins made of poly-L-lactic acid, polyglycolic acid, or poly-p-dioxanone are generally effective as applied in the foot, their strength loss profiles and degradation characteristics may not be optimally matched to the healing process. This study investigated a novel absorbable oriented copolymer pin, with unique absorption characteristics, made of 82% poly-L-lactic acid and 18% polyglycolic acid, to determine its suitability for use in fixation in the foot. The pins were incubated in a 37 degrees C buffer bath that simulated in vivo conditions and were mechanically tested in four-point bend and shear at time intervals up to 12 weeks. In vitro strength loss profiles demonstrated peak strength retention (flexural and shear) for about 8 weeks, with 50% of properties remaining by 12 weeks. The initial Youngs modulus of the pins was approximately 7 GPa. The mathematical relationship between pin strength and pin diameter was discussed, providing the surgeon with helpful criteria for making an implant selection. The degradation time course of these pins appears to compliment the known healing dynamics of bone, making them a suitable choice for use in foot surgery.

Clinically Relevant Effectiveness of Focused Extracorporeal Shock Wave Therapy in the Treatment of Chronic Plantar Fasciitis A Randomized, Controlled Multicenter Study

BACKGROUND The effectiveness of extracorporeal shock wave therapy in the treatment of plantar fasciitis is controversial. The objective of the present study was to test whether focused extracorporeal shock wave therapy is effective in relieving chronic heel pain diagnosed as plantar fasciitis. METHODS Two hundred and fifty subjects were enrolled in a prospective, multicenter, double-blind, randomized, and placebo-controlled U.S. Food and Drug Administration trial. Subjects were randomized to focused extracorporeal shock wave therapy (0.25 mJ/mm(2)) or placebo intervention, with three sessions of 2000 impulses in weekly intervals. Primary outcomes were both the percentage change of heel pain on the visual analog scale composite score (pain during first steps in the morning, pain with daily activities, and pain with a force meter) and the Roles and Maudsley score at twelve weeks after the last intervention compared with the scores at baseline. RESULTS Two hundred and forty-six patients (98.4%) were available for intention-to-treat analysis at the twelve-week follow-up. With regard to the first primary end point, the visual analog scale composite score, there was a significant difference (p = 0.0027, one-sided) in the reduction of heel pain in the extracorporeal shock wave therapy group (69.2%) compared with the placebo therapy group (34.5%). Extracorporeal shock wave therapy was also significantly superior to the placebo therapy for the Roles and Maudsley score (p = 0.0006, one-sided). Temporary pain and swelling during and after treatment were the only device-related adverse events observed. CONCLUSIONS The results of the present study provide proof of the clinically relevant effect size of focused extracorporeal shock wave therapy without local anesthesia in the treatment of recalcitrant plantar fasciitis, with success rates between 50% and 65%. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Granuloma formation after chevron osteotomy fixation with absorbable copolymer pin: A case report

After fixation of a chevron osteotomy for hallux valgus of the left foot with a bioabsorbable copolymer, a delayed onset of pain at the surgical site developed. Magnetic resonance imaging showed a cystic lesion that was unresponsive to conservative treatment. Surgical excision determined the lesion to be a giant-cell granuloma formed as a foreign body response to the degrading copolymer.

Isolated dislocation of the posterior tibial tendon in an amateur snowboarder: a case report.

Isolated dislocation of the posterior tibial tendon is an uncommon pathologic entity that typically occurs in the setting of acute trauma. The diagnosis remains challenging and is often delayed second to the rarity of the injury and symptoms similar to that of medial ankle sprains and other routinely diagnosed injuries about the ankle. The factors that predispose this tendon to dislocation include a hypoplastic retromalleolar groove, flexor retinaculum insufficiency, chronic repetitive trauma, and a structural abnormality from a previous medial malleolar fracture, or a combination thereof. Dislocation has also been cited as a complication of multiple local steroid injections and tarsal tunnel release. The mechanism of injury appears to involve forced dorsiflexion and eversion of the ankle when the posterior tibial tendon is contracted. Most cases do not respond well to conservative treatment and will require surgery to restore function and eliminate symptoms. We report a case of posterior tibial tendon dislocation related to a snowboarding injury and offer our technique for surgical correction.

Cuboid-Navicular Tarsal Coalition: Report of a Small Case Series with Description of a Surgical Approach for Resection

Tarsal coalitions are an uncommon pathology, representing approximately a 1% occurrence in the general population, and most commonly diagnosed in the younger population. Coalitions between the cuboid and navicular are especially rare. In this case series, all patients were young (15-35 years of age), active patients with fibrous coalitions at the cuboid-navicular interface; 3 of the 4 patients related a past history of ankle sprains on the affected side. After conservative treatment was exhausted and a diagnostic injection was performed that eliminated the pain, surgical intervention was used that consisted of coalition resection and interposition of an adipose graft harvested from the lower leg. All patients were able to return to their previous level of activity and remain pain-free at the surgical site. Our series of 4 cases of this coalition suggests that, although rare, cuboid-navicular coalition should be included in the differential diagnosis when patients present with persistent foot pain and suspicion of tarsal coalition is high. We also demonstrate that surgical resection of this coalition with an interpositional adipose graft provides excellent results.

Revision Hallux Valgus Surgery

Foot and ankle surgeons routinely perform surgery of the first ray, such as correction of hallux valgus deformity. The complication rate in hallux valgus surgery ranges between 10% and 55%.1 Although hallux valgus surgery is common, several common complications can occur that necessitate revision.

Anatomic Repair of Plantar Plate With Flexor Tendon Sheath Reinforcement: Case Series.

Plantar plate pathology has gained considerable attention in recent time, and with this increased awareness multiple treatments have been proposed. There have been no comparison studies between these treatments. The authors feel a direct approach for anatomic repair allows for plantar plate repair and tightening to desired tension, without any plantar prominences or potentially irritating hardware. In addition if the plantar plate is found to be attenuated or there is a lack of residual tissue, the described imbrication utilizing the flexor digitorum longus sheath, which is not possible with hardware or newest instrumentation, allows for a robust repair. The presented case series provides results from consecutive patients treated with proposed concurrent plantar and dorsal incisions, providing proof of concept and viability of novel technique. Levels of Evidence: Level V: Case series

The Lapidus Procedure

In 1934, Dr. Paul Lapidus described a procedure for correcting hallux valgus. It was first described as a fusion of the base of the first and second metatarsal and the medial cuneiform combined with distal soft tissue alignment.1 As with surgical procedures, it has been modified over the years, particularly with the advent of internal fixation. There are numerous benefits to performing the Lapidus procedure. The Lapidus procedure addresses hallux valgus at the apex of the deformity, increases the efficacy of the peroneal longus tendon, and stabilizes the medial longitudinal arch.