Jeffrey E. Johnson

Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial.

Background:Limited ankle dorsiflexion has been implicated as a contributing factor to plantar ulceration of the forefoot in diabetes mellitus. The purpose of this study was to compare outcomes for patients with diabetes mellitus and a neuropathic plantar ulcer treated with a total-contact cast with

A system for the analysis of foot and ankle kinematics during gait

A five-camera Vicon (Oxford Metrics, Oxford, England) motion analysis system was used to acquire foot and ankle motion data. Static resolution and accuracy were computed as 0.86 +/- 0.13 mm and 98.9%, while dynamic resolution and accuracy were 0.1 +/- 0.89 and 99.4% (sagittal plane). Spectral analysis revealed high frequency noise and the need for a filter (6 Hz Butterworth low-pass) as used in similar clinical situations. A four-segment rigid body model of the foot and ankle was developed. The four rigid body foot model segments were 1) tibia and fibula, 2) calcaneus, talus, and navicular, 3) cuneiforms, cuboid, and metatarsals, and 4) hallux. The Euler method for describing relative foot and ankle segment orientation was utilized in order to maintain accuracy and ease of clinical application. Kinematic data from a single test subject are presented.

Open Versus Arthroscopic Ankle Arthrodesis: A Comparative Study

A retrospective review was undertaken for 36 patients who underwent ankle arthrodesis. Nineteen patients underwent an arthroscopic ankle arthrodesis, and 17 patients underwent an open arthrodesis. Only patients with limited angular deformities were suitable candidates for an arthroscopic arthrodesis. The open arthrodesis group inclusion criteria were defined by the maximum coronal and sagittal plane deformity in the arthroscopic group. Perioperative parameters were compared and analyzed. Arthroscopic ankle arthrodesis yielded comparable fusion rates to open ankle arthrodesis, with significantly less morbidity, shorter operative times, shorter tourniquet times, less blood loss, and shorter hospital stays. Arthroscopic ankle arthrodesis is a valid alternative to traditional open arthrodesis of the ankle for selected patients with ankle arthritis.

Hindfoot Coronal Alignment: A Modified Radiographic Method

Accurate clinical evaluation of the alignment of the calcaneus relative to the tibia in the coronal plane is essential in the evaluation and treatment of hindfoot pathologic condition. Previously described radiographic views of the foot and ankle do not demonstrate the true coronal alignment of the calcaneus relative to the tibia. Some of these views impose on the patient an unnatural posture that itself changes hindfoot alignment, whereas other methods distort the coronal alignment by the angle of the x-ray beam. Our purpose was to develop a modified radiographic view and measurement method for determining an angular measurement of hindfoot coronal alignment based on a cadaver study of the radiographic characteristics of the calcaneus and motion analysis of standing subjects. The view was obtained by having the subject stand on a piece of cardboard to create a foot template. The template was then positioned so that each foot was x-rayed perpendicular to the cassette while still maintaining the natural base of support. A method using multiple ellipses was developed to determine more accurately the coronal axis of the posterior calcaneus. A study using cadavers was performed in which radio-opaque markers were placed on multiple bony landmarks on the calcaneus. The tibia was held fixed in a vertical position, and the foot was x-rayed using the above techniques in different degrees of rotation without changing the relation of the calcaneus to the tibia. The radiographs of the modified Cobey and our view were examined to verify which markers were visible at different angles of rotation and how the hindfoot alignment measurements changed with foot rotation. To define further the differences between the views, an analysis of postural stability was conducted while the subjects were standing with the feet in the positions for imaging both the Buck modification of the Cobey view and our hindfoot alignment view. The combined results of the cadaver, radiographic measurement, and postural stability segments of the study reveal that this coronal hindfoot alignment view and measurement method is reproducible, more closely measures “true” coronal hindfoot alignment, and is more clinically applicable because the alignment is measured while the patient is standing with a normal angle and base of stance. The modified radiographic measurement method relies on posterior calcaneal anatomic landmarks, is less affected by rotation of the foot and ankle, and is reproducible between observers.

Detection of osteomyelitis in the neuropathic foot: nuclear medicine, MRI and conventional radiography.

The diagnostic efficacy of (1) combined three-phase bone scintigraphy and In-111 labeled WBC scintigraphy (Bone/WBC), (2) MRI, and (3) conventional radiography in detecting osteomyelitis of the neuropathic foot was compared. Conventional radiography was comparable to MRI for detection of osteomyelitis. MRI best depicted the presence of osteomyelitis in the forefoot. Particularly in the setting of Charcot joints, Bone/WBC was more specific than conventional radiography or MRI.

Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis.

BACKGROUND Plantar fasciitis is a common foot disorder that may be resistant to nonoperative treatment. This study evaluated the use of electrohydraulic high-energy shock waves in patients who failed to respond to a minimum of six months of antecedent nonoperative treatment. METHODS A randomized, placebo-controlled, multiply blinded, crossover study was conducted. Phase 1 consisted of twenty patients who were nonrandomized to treatment with extracorporeal shock waves to assess the phase-2 study protocol. In phase 2, 293 patients were randomized and an additional seventy-one patients were nonrandomized. Following ankle-block anesthesia, each patient received 100 graded shocks starting at 0.12 to 0.22 mJ/mm(2), followed by 1400 shocks at 0.22 mJ/mm(2) with use of a high-energy electrohydraulic shock-wave device. Patients in the placebo group received minimal subcutaneous anesthetic injections and nontransmitted shock waves by the same protocol. Three months later, patients were given the opportunity to continue without further treatment or have an additional treatment. This allowed a patient in the active treatment arm to receive a second treatment and a patient who received the placebo to cross over to the active treatment arm. Patients were followed at least one year after the final treatment. RESULTS Treatment was successful in seventeen of the twenty phase-1 patients at three months. This improved to nineteen (95%) of twenty patients at one year and was maintained at five years. In phase 2, three months after treatment, sixty-seven (47%) of the 144 actively treated patients had a completely successful result compared with forty-two (30%) of the 141 placebo-treated patients (p = 0.008). At one year, sixty-five of the sixty-seven actively treated, randomized patients maintained a successful result. Thirty-six (71%) of the remaining fifty-one nonrandomized patients had a successful result at three months. For all 289 patients who had one or more actual treatments, 222 (76.8%) had a good or excellent result. No patient was made worse by the procedure. CONCLUSIONS The application of electrohydraulic high-energy shock waves to the heel is a safe and effective noninvasive method to treat chronic plantar fasciitis, lasting up to and beyond one year.

Plantarflexion Opening Wedge Medial Cuneiform Osteotomy for Correction of Fixed Forefoot Varus Associated with Flatfoot Deformity

Background: Flatfoot presents as a wide spectrum of foot deformities that include varying degrees of hindfoot valgus, forefoot abduction, and forefoot varus. Medial displacement calcaneal osteotomy, lateral column lengthening, and subtalar fusion can correct heel valgus, but may not adequately correct the fixed forefoot varus component. The purpose of this study was to determine the effectiveness of plantarflexion opening wedge medial cuneiform (Cotton) osteotomy in the correction of forefoot varus. Methods: Sixteen feet (15 patients) had plantarflexion opening wedge medial cuneiform osteotomies to correct forefoot varus associated with flatfoot deformities from several etiologies, including congenital flatfoot (six feet, average age 37 years), tarsal coalition (five feet, average age 15 years), overcorrected clubfoot deformity (two feet, ages 17 years and 18 years), skewfoot (one foot, age 15 years), chronic posterior tibial tendon insufficiency (one foot, 41 years), and rheumatoid arthritis (one foot, age 56 years). Results: Standing radiographs showed an average improvement in the anterior-posterior talo-first metatarsal angle of 7 degrees (9 degrees preoperative, 2 degrees postoperative). The talonavicular coverage angle improved an average of 15 degrees (20 degrees preoperative, 5 degrees postoperative). The lateral talo-first metatarsal angle improved an average of 14 degrees (−13 degrees preoperative, 1 degree postoperative). Correcting for radiographic magnification, the distance from the mid-medial cuneiform to the floor on the lateral radiograph averaged 40 mm preoperatively and 47 mm postoperatively (average improvement 7 mm). All patients at followup described mild to no pain with ambulation. There were no nonunions or malunions. Conclusions: Opening wedge medial cuneiform osteotomy is an important adjunctive procedure to correct the forefoot varus component of a flatfoot deformity. Advantages of this technique in comparison to first tarsometatarsal arthrodesis include predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Because of the variety of hindfoot procedures done in these patients, the degree of hindfoot correction contributed by the cuneiform osteotomy alone could not be determined. We have had excellent results without major complications using this technique.

Effect of Achilles Tendon Lengthening on Neuropathic Plantar Ulcers

BACKGROUND Limited ankle dorsiflexion has been implicated as a contributing factor to plantar ulceration of the forefoot in diabetes mellitus. The purpose of this study was to compare outcomes for patients with diabetes mellitus and a neuropathic plantar ulcer treated with a total-contact cast with and without an Achilles tendon lengthening. Our primary hypothesis was that the Achilles tendon lengthening would lead to a lower rate of ulcer recurrence. METHODS Sixty-four subjects were randomized into two treatment groups, immobilization in a total-contact cast alone or combined with percutaneous Achilles tendon lengthening, with measurements made before and after treatment, at the seven-month follow-up examination, and at the final follow-up evaluation (a mean [and standard deviation] of 2.1 +/- 0.7 years after initial healing). There were thirty-three subjects in the total-contact cast group and thirty-one subjects in the Achilles tendon lengthening group. There were no significant differences in age, body-mass index, or duration of diabetes between the groups. Outcome measures were time to healing of the ulcer, ulcer recurrence rate, range of dorsiflexion of the ankle, peak torque (strength) of the plantar flexor muscles, and peak plantar pressures on the forefoot. RESULTS Twenty-nine (88%) of thirty-three ulcers in the total-contact cast group and all thirty ulcers (100%) in the Achilles tendon lengthening group healed after a mean duration (and standard deviation) of 41 +/- 28 days and 58 +/- 47 days, respectively (p > 0.05). (One patient in the Achilles tendon lengthening group died before treatment was completed.) In the first seven months of follow-up, sixteen (59%) of the twenty-seven patients in the total-contact cast group who were available for follow-up and four (15%) of the twenty-seven patients in the Achilles tendon lengthening group who were available for follow-up had an ulcer recurrence (p = 0.001). At the time of the two-year follow-up, twenty-one (81%) of the twenty-six patients in the total-contact cast group and ten (38%) of the twenty-six patients in the Achilles tendon lengthening group had ulcer recurrence (p = 0.002). Compared with the group treated with the total-contact cast, the group treated with Achilles tendon lengthening had increased dorsiflexion and it remained increased at seven months (p < 0.001). Plantar flexor peak torque also decreased after Achilles tendon lengthening (p < 0.004), but it returned to baseline after seven months. Peak plantar pressures on the forefoot during barefoot walking were reduced (p < 0.0002) following Achilles tendon lengthening yet returned to baseline values within seven months after treatment. CONCLUSIONS All ulcers healed in the Achilles tendon lengthening group, and the risk for ulcer recurrence was 75% less at seven months and 52% less at two years than that in the total-contact cast group. Achilles tendon lengthening should be considered an effective strategy to reduce recurrence of neuropathic ulceration of the plantar aspect of the forefoot in patients with diabetes mellitus and limited ankle dorsiflexion (</=5 degrees ).

Nonoperative treatment of adult acquired flat foot with the Arizona brace

Nonoperative treatment of posterior tibial tendon dysfunction can be successful with the Arizona AFO brace, particularly when treatment is initiated in the early stages of the disease. This mandates that the orthopedist has a high index of suspicion when evaluating patients to make an accurate diagnosis. Although there is a role for surgical management of acquired flat feet, a well-fitted, custom-molded leather and polypropylene orthosis can be effective at relieving symptoms and either obviating or delaying any surgical intervention. In todays climate of patient satisfaction directed health care, a less invasive treatment modality that relieves pain may prove to be more valuable than similar pain relief that is obtained after surgery. Questions regarding the long-term results of bracing remain unanswered. Future studies are needed to determine if disease progression and arthrosis occur despite symptomatic relief with a brace. Furthermore, age- and disease stage-matched control groups who are randomized to undergo surgery or bracing are necessary to compare these different treatment modalities. At this time, the Arizona AFO brace can be a useful weapon in the orthopedists armamentarium for treating acquired flat foot deformity.

A protocol for treatment of unstable ankle fractures using transarticular fixation in patients with diabetes mellitus and loss of protective sensibility.

Background: Surgical treatment of ankle fractures in patients with diabetes mellitus is associated with a high complication rate. Diabetic patients with peripheral neuropathy are a particularly difficult group to treat because of their inability to sense deep infection, repeat trauma, and wound complications. The purpose of this study was to evaluate a protocol that included transarticular fixation and prolonged, protected weightbearing in the treatment of unstable ankle fractures in diabetic patients with peripheral neuropathy and loss of protective sensibility. Methods: The authors retrospectively reviewed the records of 15 patients with diabetes mellitus, unstable ankle fractures (AO classification 44B), and loss of protective sensibility confirmed via testing with a 5.07 Semmes-Weinstein monofilament. Retrograde trans-calcaneal-talar-tibial fixation using large Steinmann pins or screws in conjunction with standard techniques of open reduction and internal fixation was used. The postoperative treatment protocol included: 1) short leg, total contact casting and nonweightbearing status for 12 weeks; 2) removal of the intramedullary implants between 12 and 16 weeks; 3) application of a walker boot or short leg cast with partial weightbearing for an additional 12 weeks; and 4) transition to a custom-molded ankle-foot orthosis (AFO) or custom total-contact inserts in appropriate diabetic footwear. Results: The major complication rate for all fractures was 25% (4/16) and for closed fractures was 23% (3/13). These are lower than previously reported rates between 30% (3/10) and 43% (9/21) for diabetic patients with and without neuropathy. The amputation rate for all fractures was 13% (2/16) and for closed fractures alone was 8% (1/13). These are similar to previously reported rates of 10% (2/10) to 20% (2/21). There were no deaths or Charcot malunions in this series. The combination of transarticular fixation and prolonged, protected weightbearing provided 13 of 15 patients with a stable ankle for weightbearing. Conclusion: Although these fractures remain a treatment challenge, this study presents a successful, multidisciplinary protocol for treatment of unstable ankle fractures in the most challenging group of diabetic patients – those with loss of protective sensibility.