Ian J. Alexander

Clinical Rating Systems for the Ankle-Hindfoot, Midfoot, Hallux, and Lesser Toes

Four rating systems were developed by the American Orthopaedic Foot and Ankle Society to provide a standard method of reporting clinical status of the ankle and foot. The systems incorporate both subjective and objective factors into numerical scales to describe function, alignment, and pain.

The Assessment of Dynamic Foot-to-Ground Contact Forces and Plantar Pressure Distribution: A Review of the Evolution of Current Techniques and Clinical Applications

The objective documentation of foot function before and after therapeutic intervention will be greatly enhanced by the utilization of devices capable of measuring dynamic foot pressure distribution. Efforts to develop this technology date back to the late 19th century, but only with recent advances in computers has it been possible to produce quantitatively accurate high resolution foot pressure distribution with high sampling rates and easily interpreted graphic displays. Over the years, a variety of methods have been employed to study foot pressure. Many of these techniques have already improved our understanding of the foot and its function, and have had an impact on the way we practice. Effective clinical utilization of these new investigative tools depends on an understanding of their scientific basis, capabilities and limitations.

Assessment and Management of Pes Cavus in Charcot–marie–tooth Disease

The sequential approach to evaluating the cavus foot is integrated with a description and assessment of the various treatment options. Decision making in the treatment of these cases is complicated by the progressive neurologic condition that underlies many of these deformities. An effort is made to recommend the most appropriate surgical intervention based on the nature of the deformity and its rigidity. Although these principles apply to all cavus feet, the deformity in Charcot-Marie-Tooth disease is the most difficult to treat and the most prone to recurrence because of the progressive nature of the muscular imbalance causing it.

Arthrodesis of the first metatarsophalangeal joint: a biomechanical study of internal fixation techniques.

This study compares the strength and rigidity of four methods of internal fixation for arthrodesis of the first metatarsophalangeal joint. Ten matched pairs of cadaveric first rays were harvested and arthrodesis performed by one of four techniques: (1) planar excision of joint surfaces and fixation with crossed Kirschner wires, (2) planar excision of joint surfaces and internal fixation with a dorsal plate and screws, (3) planar excision of joint surfaces and internal fixation with an interfragmentary screw, or (4) excision of the joint surfaces using powered conical reamers and fixation with an interfragmentary lag screw. Biomechanical testing with a Bionix 858 materials testing machine was carried out, applying a plantar force utilizing principles of cantilever loading. Force applied and displacement of the arthrodesis were recorded. Of the four methods tested, bony preparation with power conical reamers and supplementary interfragmentary screw fixation was the most stable.

Foot Function in Diabetic Patients after Partial Amputation

The function of partially amputated feet in 10 patients with diabetes mellitus was studied. First-step bilateral barefoot plantar pressure distribution and three-dimensional kinematic data were collected using a Novel EMED platform and three video cameras. Analysis of the plantar pressure data revealed a significantly greater mean peak plantar pressure in the feet with transmetatarsal amputation (TMA) than in the intact feet of the same patients. The heels of the amputated feet had significantly lower mean peak plantar pressures than all the forefoot regions. A significantly greater maximum dynamic dorsiflexion range of motion was seen in the intact compared with the TMA feet. However, no difference was noted in the static dorsiflexion range of motion between the two feet and there was, therefore, a trend for the TMA feet to use less of the available range of motion. Given the altered kinematics and elevated plantar pressures noted in this study, careful postsurgical footwear management of feet with TMA would appear to be essential if ulceration is to be prevented.

Stress Fracture of the Tibia after Arthrodesis of the Ankle or the Hindfoot

We studied twelve patients who had a stress fracture of the tibia and one patient who had a stress fracture of the fibula after arthrodesis of the ankle or the foot. A second stress fracture subsequently developed in two patients. All but two patients were managed non-operatively, and the fractures healed uneventfully. One patient who was managed operatively had a below-the-knee amputation to treat a painful non-union of a tibial fracture, and the other had interlocking intramedullary nailing for a displaced fracture. All but one of the arthrodesis sites had fused before the stress fracture occurred. All of the stress fractures that occurred after arthrodesis of the ankle were in the middle and distal aspects or the distal aspect of the tibia, while those that occurred after triple arthrodesis were in the distal aspect of the fibula or the medial malleolus. Although six of the thirteen patients still had uncorrected alignment and deformity after the arthrodesis, optimum alignment after the arthrodesis did not preclude the occurrence of a stress fracture. We conclude that stress fracture must be considered in the differential diagnosis of pain months or even years after solid fusion at the site of an ankle or triple arthrodesis.

Subtalar Arthrodesis with Interposition Tricortical Iliac Crest Graft for Late Pain and Deformity After Calcaneus Fracture

We are reporting our experience using tricortical interposition iliac crest grafting in the management of late pain and deformity after calcaneus fracture. Ten patients underwent this procedure, which was performed by the senior author. All but one were followed up with a questionnaire, physical examination, and repeat x-rays. The technique failed in one severely osteoporotic individual because of the graft sinking into the calcaneus. The experience led to two technique modifications that were evaluated in this study.

Morton's Neuroma: A Review of Recent Concepts

A number of new concepts in the pathology, diagnosis, and management of Mortons metatarsalgia have been presented in the recent literature. Probably as many questions as answers have been generated by these publications. The taut transverse metatarsal ligament appears to play a critical role compressing the interdigital nerve but the exact pathomechanics producing the neuroma and the role of the intermetatarsal bursa remain unclear. Electrodiagnostic techniques for this condition are in the early development stage and may be clinically applicable in the near future. Support for and recommendation against the preoperative injection of the intermetatarsal bursa and interdigital nerve area have been discussed. The necessity of interdigital neurectomy has been questioned but currently in North America, simple transverse metatarsal ligament division has not been widely utilized. Continued studies along these lines should improve our understanding of Mortons metatarsalgia, increase our diagnostic accuracy, and facilitate more effective management.

Step-Cut Osteotomy of the Medial Malleolus for Exposure of the Medial Ankle Joint Space

Osteochondral lesions of the medial talar dome, intraarticular fractures of the talar body, and malunited fractures of the tibial plafond, in some cases, necessitate medial malleolar osteotomy for adequate intraarticular exposure. Straight transverse and oblique osteotomies of the medial malleolus have been described prev io~s ly . ’~~*~ Nonunion or rotation of these osteotomies can result in significantly long morbidity. The stepcut medial malleolar osteotomy provides excellent inherent stability and a broad cancellous surface for rapid healing. With this technique, disruption of the weightbearing portion of the tibial plafond is minimal.

Bimalleolar Osteotomy for the Surgical Approach to a Talar Body Fracture: Case Report

Level of Evidence: V, Case Report