John V. Marymont

Chronic Anterior Midtibial Stress Fractures in Athletes Treated With Reamed Intramedullary Nailing

Background A chronic anterior midtibial stress fracture is a serious, difficult-to-treat injury that can adversely affect an athletes career. Hypothesis The use of a reamed intramedullary nail for a chronic anterior tibial stress fracture is a safe and effective treatment for an athlete. Study Design Case series; Level of evidence, 4. Methods Seven collegiate-level athletes with 11 chronic anterior midtibial stress fractures were treated with reamed intramedullary nailing between 1997 and 2000. These patients were followed for a mean duration of 17 months. Results The mean age of the patients at the time of stress fracture diagnosis was 17 years. Seven of the fractures occurred in male athletes, whereas 4 occurred in female athletes. All patients had failed nonoperative treatment, including rest, activity modification, use of an orthosis, and low-intensity ultrasound stimulation, for a minimum of 4 months. Patients had experienced symptoms for a mean duration of 12 months. Clinical and radiological union occurred at a mean of 2.7 and 3 months, respectively. The mean duration for return to sports after surgery was 4 months. At last follow-up, all patients had full range of motion at the knee and ankle joints and were satisfied with the results. One patient developed bursitis at the tibial nail insertion site that was resolved with a steroid injection. Another patient sustained a traumatic fracture of the distal tibia 1 year after intramedullary nailing of the tibial stress fracture. This fracture healed with nonoperative treatment. No other complications were observed. Conclusion Intramedullary nailing of the tibia for chronic stress fracture has a high union rate, allows for a low complication rate, and allows for an early return to competitive sports. This procedure is an excellent alternative treatment for those fractures that have failed nonsurgical treatment.

Treatment of Plantar Fasciitis with a Night Splint and Shoe Modification Consisting of a Steel Shank and Anterior Rocker Bottom

Seventy-one feet in 57 patients with plantar fasciitis were treated with the combination of a night splint and a shoe modification consisting of a steel shank and anterior rocker bottom. At average follow-up of 16 months, symptoms were resolved in 42 (59%), improved in 13 (18%), not changed in 11 (15%), and worse in 5 (7%) of the feet. No relation was found between outcome and age, gender, duration of symptoms, and bilateral involvement. The method is effective for the treatment of plantar fasciitis.

Calcaneocuboid stability: a clinical and anatomic study.

Injuries to the midtarsal joints are relatively uncommon and often unrecognized entities. Acute and chronic instability patterns to the calcaneocuboid joint can occur from such injuries. No previous determinations of normal calcaneocuboid laxity have been reported. Utilizing a previously described technique, stress radiographs were performed in human cadaveric specimens following serial sectioning of the ligamentous supports of the calcaneocuboid joint. Significant differences in calcaneocuboid gap and angle occurred between unstressed and stressed conditions. Cadaveric specimen testing determined that the dorsal and plantar calcaneocuboid ligaments both provide significant contributions to joint stability. Prior to defining pathologic states of joint laxity, normal ranges of stability must be determined. By more clearly defining normal stability of the calcaneocuboid joint and its ligamentous contributions, greater insight into the diagnosis and treatment of calcaneocuboid instability can be obtained.

Evaluation and treatment of chronic ankle pain.

The evaluation and treatment of chronic ankle pain presents a challenge to the orthopaedic surgeon. A detailed history helps to determine causative factors resulting from earlier trauma or surgery. A careful physical examination and radiographic studies also are helpful in making an accurate diagnosis, which is the basis for choosing a specific and effective treatment regimen.

Variations on the insertion of the posterior tibialis tendon: a cadaveric study.

This cadaveric study specifically investigates the variations on the insertion of the posterior tibialis tendon (PTT) in the foot, a topic which is not well defined in anatomy discussions. The PTT insertion sites from 11 fresh-frozen cadaver feet (10 subjects) were evaluated. There were three distinct bands of the PTT seen in all specimens with variations on the insertion to the spring ligament (4/11), fifth metatarsal base (7/11), flexor hallucis brevis (9/11), and peroneus longus (4/11). This study also found a distinct slip to the abductor hallucis in five of the specimens.

Immediate, Full Weightbearing Cast Treatment of Acute Achilles Tendon Ruptures: A Long-Term Follow-up Study

Thirty-two patients with 33 ruptures were available for comprehensive evaluation, which included a questionnaire, physical examination, and manual as well as objective (Kin-Com) strength testing. Data excluding Kin-Com strength testing were available in an additional seven patients with seven ruptures; hence, the data are based on these 39 patients with 40 ruptures. Five patients with eight ruptures were excluded from strength testing but were included in our rerupture data, which totaled 44 patients with 48 ruptures. All patients were treated using a standard protocol by a single surgeon. All patients were treated within 11 days of injury, and the average follow-up was 55 months (range, 24–133). Ninety-five percent (38/39) of patients were completely satisfied with their treatment. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot scores were >80 in 97.4% of patients, and the rerupture rate was 6.25% (3/48). Calf circumference and ankle range of motion were not statistically different between the two legs. The injured leg tended to be slightly weaker than the uninjured leg, but the difference was not significant for most of the quantitative strength measurements. This study provides data for the Achilles rupture patient who asks, “Is there a treatment option other than surgery?” In addition, the standardized protocol can be utilized to obtain successful outcomes in those who choose nonoperative treatment or are poor surgical candidates.

Screw versus plate fixation of proximal first metatarsal crescentic osteotomy

BACKGROUND Hallux valgus associated with metatarus primus varus is a deformity that disrupts normal foot function. Standard treatment has often included distal or proximal metatarsal osteotomy with or without a distal soft tissue procedure. The intrinsically unstable proximal crescentic osteotomy relies on operative fixation for stability. This study examined the strength of fixation of a single screw versus a plate for stabilization of proximal first metatarsal crescentic osteotomies for correction of hallux valgus. MATERIALS AND METHODS A crescentic osteotomy was performed on nine pairs of fresh/frozen cadaveric feet. The distal fragment was rotated laterally and the osteotomy was temporarily stabilized with a Kirschner wire. The osteotomized metatarsal fragments were fixed with a cancellous screw on one side and single plate on the contralateral side. Each specimen was loaded in a mechanical testing machine, and its response was measured by monitoring the opening of the osteotomy and change in alignment of the fragments. Position and alignment of the proximal and distal fragments were calculated. RESULTS All of the measures of fixation strength were statistically greater in specimens treated with a plate rather than with screw fixation. Plate fixation provided approximately twice the resistance to disruption of the osteotomy under cyclic loading conditions. CONCLUSION The dorsal plate is biomechanically more stable than a single cancellous screw when applied to proximal crescentic osteotomies. CLINICAL RELEVANCE The greater stability of the plate construct may be helpful in selecting the fixation device for these osteotomies.

Axial load weightbearing radiography in determining lateral malleolus fracture stability: a cadaveric study.

Background: Ankle fractures are the most common fracture treated by orthopaedic surgeons in the United States. Isolated lateral malleolus fractures are treated nonoperatively, while associated deltoid disruption injuries are unstable and usually treated by fixation of the fracture. Various stress radiographs and MRI have been used to determine deltoid competency and the subsequent need for operative stabilization of lateral malleolus fractures. To date, no standardization of stress radiography has been performed. The aim of this study was to evaluate the ability of weightbearing ankle X-rays to determine stability and their reliability. Methods: This study sought to utilize simulated weightbearing radiography as a potential method to determine the need for lateral malleolus fixation. Twelve cadaveric ankle specimens were tested by obtaining ankle mortise radiographs for interpretation of medial clear space. Each ankle was tested with 0, 25, 36, and 50 kg of axially applied weight. The groups of measurements obtained were: intact ankles (Group A), ankles with an isolated oblique fibular osteotomy (Group B), and osteotomized ankles after complete deltoid ligament transaction (Group C). Three authors measured the medial clear space for every ankle using PACSR software. Instability of the ankle mortise was defined as medial clear space widening of greater than 2 mm from the intact ankle. Results: An isolated lateral malleolus fracture (Group B) and a lateral malleolus fracture with an incompetent deltoid ligament (Group C) showed no statistical medial clear space widening with simulated axial weightbearing radiography when compared to intact ankles (Group A). ANOVAs between Group A and B had p < 0.001, and between Group A and C of p < 0.001. Conclusion: Our model did not find instability with an osteotomized fibula and a disrupted deltoid. Clinical Relevance: This study suggests a weightbearing radiograph of an isolated lateral malleolus fracture cannot determine deltoid ligament integrity and thus need for fibular operative fixation.

Mechanical Strain Promotes Fibroblast Gene Expression in Presence of Corticosteroid

Posterior tibial tendon (PTT) dysfunction has commonly been treated with local corticosteroid injections to reduce inflammation. However, a concern with this treatment is potential degeneration and spontaneous rupture of the PTT. This study set out to determine whether mechanical strain may counteract the potentially deleterious effect of corticosteroid treatment on fibroblasts and therefore improve outcomes during recovery from tendinitis. In this study, PTT fibroblasts in vitro were treated with 0 M, 10−7 M, 10−6 M, and 10−5 M triamcinolone acetonide (TA) while incubated under cyclic strains of 0% or 5% for 24 hr. Type I collagen and decorin mRNA expressions were determined by RT-PCR. The results indicated that mechanical strain significantly increased type I collagen and decorin gene expression in the PTT fibroblasts and TA decreased type I collagen and decorin gene expression. Therefore, mechanical strain might be beneficial to PTT after corticosteroid treatment by direct stimulation of fibroblast synthesis.

Computerized Matching of Autologous Femoral Grafts for the Treatment of Medial Talar Osteochondral Defects

Background: Cored autologous graft from the distal ipsilateral femur has been used to fill osteochondral defects in the talus. There are no studies that compare the articular morphology of potential donor sites on the distal femur with recipient sites on the talus. Methods: Using coronal MRI of the talus and distal femur of five matched cadaver, computer reconstructions of the articular surfaces were prepared. From these, six 10-mm in diameter donor sites from the nonweightbearing surfaces of the medial and lateral aspects of the femoral condyles were matched to three recipient sites on the anterior, middle, and posterior aspects of the corresponding medial talus using customized computer software that minimized differences between the articular surfaces of the graft and the talus. After matching the femoral to the talar graft, the average and maximal distances between the surfaces (surface contour) and the average and maximal distances of the offset at the outer 1 mm of the graft periphery (step-off) were determined. Results: For all graft combinations, the average step-off was 0.24 +/−0.03 mm and the maximum 0.60 mm. The average surface contour was 0.32 +/−0.04 mm and the maximum was 1.16 mm. In all cases, the best donor site was from the superolateral femur for any medial talar lesion. Conclusion: In this study of grafts from the femoral condyles, the superolateral femur was the optimal location for an osteochondral graft for any medial talar lesion.