Haluk Yetkin

Footprint and radiographic analysis of the feet.

There is controversy concerning the definition and measurement of the medial longitudinal arch of the foot. Various techniques are reported to assess the medial arch height, including radiographic measurements and footprint analysis, which are the most commonly used methods. Some authors define footprint analysis as unreliable for measuring the arch height. The purpose of this study was to investigate the relationship between radiologically measured angles and the arch index obtained from footprint analyses in 38 children with flexible pes planus. A positive correlation of arch index was found between lateral talo–horizontal and lateral talo–first metatarsal angles (p < 0.05). These angles have been used by some authors to describe the height of the medial longitudinal arch of the foot. This study demonstrated that footprint analysis could be used effectively for screening studies and at individual office examinations.

Evaluation of the medial longitudinal arch: a comparison between the dynamic plantar pressure measurement system and radiographic analysis

OBJECTIVES The measurement of the medial longitudinal arch (MLA) of the foot is a controversial issue in orthopedics. Several methods have been developed to define and determine the MLA, but none of them are universally accepted. The purpose of this study was to compare some statically obtained radiographic angles with the dynamic plantar pressure distribution measurement system for the evaluation of the MLA in healthy individuals. METHODS A total of 95 subjects (72 females, 23 males; mean age 37.8 years; range 11 to 85 years) were retrospectively evaluated. All the subjects were referred to the pedobarography laboratory for varying causes, had foot radiographies, and were evaluated as having normal feet. On standard lateral weight-bearing radiographs of the foot, the lateral talocalcaneal angle, talo-first metatarsal angle, talohorizontal angle, and calcaneal pitch angle were measured. The plantar pressure distribution was measured by the EMED-SF system. To evaluate the MLA, the arch index method was used. The arch index was calculated by the ratio of the pressure area of the midfoot to the sum of the forefoot, midfoot, and the hindfoot areas. Correlations between the radiographic angles and the arch index were analyzed by the Pearson correlation test. RESULTS The mean values of the lateral talocalcaneal angle, talo-first metatarsal angle, talohorizontal angle, and calcaneal pitch angle were 43.2, 7.2, 29.5, and 41 degrees, respectively. The mean value of the arch index was 0.12 (range 0.04 to 0.17). There was no significant correlation between the arch index and gender (r=-0.10, p>0.05). The talo-first metatarsal (r=0.38) and talohorizontal (r=0.19) angles were found to be in significant correlation with the arch index (p<0.05), whereas the talocalcaneal (r=-0.16) and calcaneal pitch (r=-0.10) angles did not show correlation with the arch index (p>0.05). CONCLUSION The arch index method is a simple and reproducible pedobarographic measurement for the evaluation of the MLA. However, the angles measured on statically obtained radiographs and showing correlations with the arch index may give similar results concerning the MLA. Both static and dynamic methods can be utilized in the evaluation of the MLA.

Demineralized bone matrix and hydroxyapatite/tri-calcium phosphate mixture for bone healing in rats

Purpose: Hydroxyapatite/tri-calcium phosphate (HA/TCP) mixture is an osteoconductive material used as a bone graft substitute, and demineralised bone matrix (DBM) is an osteoinductive material. A combination of DBM and HA/TCP mixture would probably create a composite with both osteoconductive and osteoinductive properties. The purpose of this study was to determine the effect of the combination of DBM and HA/TCP mixture on healing of rat radius segmental defects. Methods: Twenty-four adult male Wistar rats were used. Bilateral radial defects were created in each animal. Radial defects were implanted with DBM, HA/TCP mixture and a combination of both substances. Control defects were left unfilled. Ten weeks after implantation, the animals were sacrificed, and the radii were evaluated by radiograhic and histopathological studies. Results: The use of DBM alone demonstrated improved healing on radiographic and histological studies compared to other groups and the control group. There were no differences between the other two groups and the control group. Conclusion: The DBM group showed the best healing response. Combined use of DBM and HA/TCP mixture did not improve bone healing, and the osteoinductive properties of DBM were inhibited by HA/TCP mixture.RésuméLe mélange hydroxyapatite/phosphate tri-calcique (HA/TCP) est un matériel d’ostéo conduction utilisé comme greffe ou substitut osseux comme les matrices osseuses déminéralisées (DBM) utilisées en tant que matériel d’ostéo induction. La combinaison de DBM et HA/TCP devrait probablement avoir les deux propriétés d’ostéo induction et d’ostéo conduction. Le propos de cette étude est d’évaluer les effets d’un mélange de DBM et d’HA/TCP sur la consolidation de défauts osseux du radius chez le rat. Vingt quatre rats adultes Wistar ont été utilisés. Chaque animal était préparé avec un defect radial bilatéral. Les radius droits des rats ont été implantés soit avec DBM, soit avec HA/TCP isolée, soit avec une combinaison des deux substances, le radius gauche servant de contrôle. Dix semaines après l’implantation, les animaux ont été sacrifiés et les os ont été évalués sur la plan radiographique et histopathologique. L’utilisation de DBM isolée montre une amélioration de la guérison sur le plan radiographique et histologique. On ne retrouve pas de différence avec les autres groupes. En conclusion, le groupe DBM montre une bonne réponse sur le plan de la consolidation. L’utilisation d’une mixture DBM et HA/TCP n’entraîne pas une amélioration et une guérison, les propriétés d’ostéo induction du DBM étant inhibées par le mélange HA/TCP.

The relationship between the hindfoot angle and the medial longitudinal arch of the foot

Introduction: The relationship of hindfoot valgus and the medial longitudinal arch (MLA) is a well-known parameter for the evaluation of the foot deformities. In this study, we evaluated the relationship between the hindfoot angle and the MLA and the effect of these parameters on the development and general joint laxity of the subjects. Methods: Two-hundred-sixty-one volunteers who had no foot pain or major foot deformity were examined. The age range of the volunteers was 4 to 20 years. For each subject, the right foot was evaluated for the clinical hindfoot angle and footprint analysis. General ligamentous laxity also was recorded. Arch index and valgus index were used for the evaluation of the footprint analysis, and the valgus angle was measured clinically. Results: The average heel valgus angle for all subjects was 5.2 (SD 3.3) degrees. The means of valgus index and arch index were 3.34 (SD, 5.6) and 0.7 (SD, 0.2), respectively. Although there was a positive correlation between the valgus angle and valgus index (p = 0.027), the arch index was not found to be correlated with these values. Positive correlation between joint laxity and arch height also was demonstrated (p < 0.05). Conclusions: We concluded that the hindfoot angle and MLA height must be considered separately in clinical practice, particularly in the management of childhood pes planus.

The Relationship of the Heel Pad Compressibility and Plantar Pressure Distribution

Loss of heel pad elasticity has been suggested as one of the possible explanations of heel pain. This study aimed to determine the effect of heel pad thickness and its compressibility to heel pressure distribution, in 47 (94 feet) normal subjects and 59 (94 feet) patients with heel pain, using radiological measurements and EMED-SF (Novel, Munich) plantar pressure distribution measurement system. Both heels of the patients and control group were radiographed with and without weight bearing. The ratio of the heel pad thickness in loading to unloading position was defined as “the heel pad compressibility index.” The plantar peak pressure of the heel was measured at heel strike phase of the gait cycle. The compressibility index for control and patient groups were found to be 0.60 and 0.69, respectively. The peak pressure under the heel pad was recorded to be 28.4 N/cm2 for patients and 31.7 N/cm2 for control group. No significant difference was found for heel pad compressibility index and heel pad pressures between patient and control groups (p>0.05). This study revealed that there is no relationship between heel pad compressibility and pressure distribution of the heel pad both in control and patient group. We feel the flexibility of the heel pad does not have any influence on heel pain syndromes.

Bio-engineered synovial membrane to prevent tendon adhesions in rabbit flexor tendon model.

During tendon injuries, the tendon sheath is also damaged. This study aims to test effectiveness of engineered tendon synovial cell biomembrane on prevention of adhesions. Forty New Zealand Rabbits enrolled into four study groups. Engineered synovial sheath was produced by culturing cell suspension on fabricated collagen matrix membrane. Study groups were: tendon repair (group A), tendon repair zone covered with plane matrix (Group B), synovial suspension injection into the zone of repair over matrix (Group C), and biomembrane application (Group D). Biomechanical evaluations of tendon excursion, metacarpophalangeal and proximal interphalangeal joints range of motion, H&E and Alcian Blue with neutral red staining, and adhesion formation graded for histological assessments were studied. Ten non-operated extremities used as control. Tendon excursions and range of motions were significantly higher and close to control group for Group D, p < 0.05. Adhesion formation was not different among Groups C, D, and Control, p > 0.005. Hyaluronic acid synthesis was demonstrated at groups C and D at the zone of injury. Application of synovial cells into the tendon repair zone either by cell suspension or within a biomembrane significantly decreases the adhesion formation. Barrier effect of collagen matrix and restoration of hyaluronic acid synthesis can explain the possible mechanism of action.

Results of triple arthrodesis: effect of primary etiology

BackgroundSevere disability originating from feet generally requires surgery. In addition to a number of other techniques, triple arthrodesis is still used to treat deformity and instability unresponsive to conservative measures. The aim of this study was to evaluate the results of the triple arthrodesis operation in two groups of patients with different primary etiologies and to identify the possible factors affecting the results.MethodsDuring a 4-year period, triple arthrodesis was performed on 25 feet in 20 patients (average age 24.9 years). These patients were divided into two groups according to the primary etiology of the disability: neurogenic and nonneurogenic. Patients were evaluated with pre-and postoperative clinical examinations, American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot and Ankle Scale, radiography, pedobarography, and a general health questionnaire (Short Form 36, SF-36). The need for orthotics and the effect of previous treatments on the end results were also evaluated.ResultsThe preoperative average AOFAS score improved from 24 to 71 postoperatively. Preoperative AOFAS values of neurogenic cases were significantly lower than those of nonneurogenic cases. Postoperative AOFAS values were found to be lower in neurogenic cases (64.0 vs. 77.6). Marked improvement was observed for all angular measurements. No relation was found between the AOFAS, changes in angular measurements, and pre-and postoperative plantar pressure analysis results. SF-36 results improved postoperatively in both groups. Triple arthrodesis decreased the use of orthotics postoperatively in both groups. Previous treatments were not found to affect the end results in this series.ConclusionsTriple arthrodesis operation is a surgical option with limited alternatives in patients with disabilities originating from feet. Both neurogenic and nonneurogenic patient groups improved significantly, and we were unable to show any significant differences in the results of these two groups.

The effect of pronation and inclination on the measurement of the hallucal distal metatarsal articular set angle

OBJECTIVE In this study, we tried to evaluate the effect of pronation and the inclination of the first metatarsal on the measurement of distal metatarsal articular angle (DMAA) in 10 cadaver first metatarsals. METHODS Ten cadaver first metatarsals were fixed to a device. This device can change the inclination and pronation angles of the metatarsal. 15-30-45 degrees of inclination and 0-10-20 degrees of pronation were applied to the metatarsals. After applying radio-opaque putty to the medial and lateral articular edges and metatarsal dorsal diaphyseal ridge, the X-ray and digital images were taken at different degrees of inclination and pronation. A graphics software did the measurement of DMAA. The statistical analysis was done by paired sample t-test. RESULTS The inclination had no effect on DMAA (p>0.1). The pronation of the first metatarsal was found to have a positive effect on DMAA (p<0.005). As the degree of pronation increased, the degree of DMAA was found to also increase. We found no difference between the measurements of the X-ray and the digital images. CONCLUSION According to the current data, the measurement of DMAA is not suitable for making clinical and surgical decisions. The inclination of the first metatarsal can change, depending on the height of the medial longitudinal arch. By doing this study, we are trying to simulate the pes cavus and pes planus deformity on the radiologic measurement of pronation of the hallux. According to our results, inclination has no effect on the measurement of DMAA. However, the measurement of DMAA is expected to be dependent on the rotational deformity of the hallux.

Multiple hemangiomas of the foot: a case report.

Although hemangiomas are common soft tissue tumors, it rarely involves the feet. We are reporting a forty-seven-year-old female with multiple hemangiomas of her left foot without pain. During surgery there were seven well-defined masses that were totally excised after ligation of penetrating vessels. The microscopic investigation revealed mixed-type (capillary and cavernous) hemangioma. We had not experienced any recurrence after two years follow up period.