Lamar L. Fleming

Evaluation of the validity of the AOFAS Clinical Rating Systems by correlation to the SF-36

This study evaluates the validity of the AOFAS Clinical Rating Systems by examining their level of correlation to the Medical Outcomes Study Short Form-36 (SF-36) in patients with foot and ankle complaints. The SF-36 is an extensively validated outcomes tool that has been used as a benchmark in examining the validity of outcomes instruments designed for the upper extremity, knee, shoulder, and general orthopaedic conditions. The study sample was 91 patients seen at the foot and ankle clinic of a university-based orthopaedic practice. Patients were administered both the AOFAS Clinical Rating Systems and SF-36 instruments. Pearson correlation coefficients of the AOFAS scores to the SF-36 sub-scales ranged from 0.02 to 0.36 in the overall study population. Correlation was higher for the sub-set of patients with ankle-hindfoot disorders (0.11 to 0.53) than patients with forefoot disorders (−0.05 to 0.25). The low levels of correlation seen in this study suggest poor construct validity of the AOFAS Clinical Rating Systems.

Traumatic dislocations of the peroneal tendons

Traumatic dislocation of the peroneal tendons is an often unrecognized injury which has been reported to occur most commonly during snow skiing. The strength of the peroneal retinaculum is exceeded during resist ance to violent passive dorsiflexion or to inversion stress. Pain, swelling, and ecchymosis may hinder early diagnosis; however, intense retromalleolar pain on ac tive eversion is a specific, highly suggestive finding. Fracture of a thin shell of the lateral malleolar cortex is diagnostic. In chronic cases, marked dislocation of the tendons is frequently demonstrable, with more than the usual degree of snapping. Surgical repair is advocated, using one of several procedures available. Most acute cases can be treated by simple repair of the torn or fractured structures. In chronic cases, or in acute cases with deficient structures predisposing to dislocation, it is necessary to reconstruct the peroneal retinaculum and/or deepen the peroneal groove. Longitudinal split ting of the peroneous brevis tendon was a new finding in this series.

The Biomechanical Relationship Between The Tendoachilles, Plantar Fascia and Metatarsophalangeal Joint Dorsiflexion Angle

We carried out an experiment to measure the relationship between tensile force in the tendoachilles and plantar fascia strain, and how this relationship is affected by the metatarsophalangeal joint dorsiflexion angle. Eight cadaver lower extremity specimens underwent biomechanical testing. Using a servo-hydraulic testing machine, a tensile force up to 500 N was applied to the tendoachilles while the strain on the plantar fascia was measured using an extensometer. The experiment was repeated at four different metatarsophalangeal joint dorsiflexion angles (0°, 5°, 30°, and 45°). Measurements and calculations showed that dorsiflexion of the toes tightens the plantar fascia (the windlass effect) and increases the effect that a tensile force in the tendoachilles has on the tensile strain and tensile force in the plantar fascia.

Extracorporeal Shock Wave Therapy for the Treatment of Plantar Fasciitis

One hundred fifty patients were enrolled in a multicenter, randomized, placebo-controlled, prospective, doubleblind study to assess the clinical safety and effectiveness of extracorporeal shock wave therapy (ESWT) using the Dornier Epos Ultra for the treatment of plantar fasciitis. The Active Group was treated with electromagnetically generated shocks using ultrasound guidance during a single therapy session. The Control Group received a sham treatment under similar clinical conditions. The groups were demographically similar with respect to age, height, and weight. The average duration of symptoms was nearly 2 years in both groups. All patients were evaluated by the visual analog scale for pain, American Orthopaedic Foot and Ankle Society scores, Roles and Maudsley Score, SF-12 health status questionnaire, and physical examination. The Active Group reported 56% success at 3 months and 94% success at 12 months posttreatment. The Control Group reported 47% success at 3 months posttreatment. Twelve-month data were not collected for the Control Group as they were unblinded at 3 months and offered treatment. ESWT represents a safe treatment option for chronic proximal plantar fasciitis.

A Review of Lateral Ankle Ligamentous Reconstructions

We have performed an ongoing retrospective and prospective multi-institutional review of 50 patients who underwent 53 lateral ligamentous reconstructive procedures of the ankle. The point grading system used for postoperative evaluation of our patients allowed for classification of functional activity. The grading system included evaluation of the patients return to preinjury activities and athletics, degree of pain, degree of swelling, number of recurrent sprains, and any disability that the patient incurred secondary to the tendon transfer. Preoperative and postoperative stress radiographs were obtained to evaluate the talar tilt angle. Of our 53 lateral ankle ligamentous reconstructions, we consider 45 to be excellent, with the patients returning to full activity and athletics. Our results show no statistically significant difference in long-term function among the five ligamentous repairs employed in this series (Pearson Chi-square test; χ2 = 2.30, df = 4, P = 0.68). No correlation could be made between the long-term clinical response of the various procedures and the postoperative talar tilt angle. We conclude that lateral ligamentous reconstructive repairs of the ankle are indicated, and that good or excellent clinical results, greater than 91 %, can be obtained with any of the five reconstructive procedures, performed correctly.

The Cybex II evaluation of lateral ankle ligamentous reconstructions.

Chronic lateral ankle instability is a costly disability to the athlete. The Chrisman-Snook and Evans lateral ligamentous reconstructions are two procedures fre quently performed to correct ligamentous instability. The entire peroneus brevis tendon is transected in the Evans procedure, thus sacrificing its eversion strength and power. The importance of preserving the eversion function of the peroneus brevis muscle is speculative, but may be of significance for good long-term results. The ankle eversion strength and power of 10 patients with Chrisman-Snook and 10 patients with Evans lat eral ligamentous reconstructions were objectively eval uated with the Cybex II Isokinetic Dynamometer. The mean postoperative time to testing was 4.2 years. The uninvolved ankle was also tested and used as the normal strength of the patient. Twenty normal controls matched for age, sex, and physical activity were tested to assure maximum test reproducibility. The eversion strength was tested at several speeds, but torque values at speeds of 30 and 120 deg/sec were selected for analysis. At slow speeds, 30 deg/sec, and ankles that had Evans and Chrisman-Snook reconstruction were 4% and 7% weaker, respectively, than the contralateral normal ankles. At 120 deg/second the ankles were 8% and 9% weaker with the Evans and Chrisman-Snook reconstructions, respectively. A three factor analysis of variance with repeated measures on two of the factors was used to analyze the data. The analysis indicated that the estimated mean difference in peak torque values between the control and surgical ankles for the Evans procedure at 30 deg/sec, the Chrisman-Snook procedure at 30 deg/sec, the Evans procedure at 120 deg/sec, and the Chrisman-Snook procedure at 120 deg/sec were not significantly different (F = 0.49, df = 1/18, P = 0.491). Thus, the surgical loss of the peroneus brevis muscle in the Evans lateral ligamentous reconstruction does not appear to result in a significant loss of eversion strength and power when compared to the contralateral normal ankle. Therefore, the authors contend that the loss of the peroneus brevis tendon should not be a factor in the selection of an operative procedure for lateral ankle instability.

Extrakorporale Stoßwellentherapie beim symptomatischen Fersensporn – eine Übersicht

ZusammenfassungExtrakorporale Stoßwellen werden seit Jahren in Europa zur Behandlung von Insertionstendinopathien wie der plantaren Fasziitis mit klinischem Erfolg eingesetzt. Bislang existierte jedoch kein Wirksamkeitsnachweis anhand placebokontrollierter Studien.Der Beitrag gibt eine Übersicht über konservative und operative Behandlungsmethoden und beleuchtet den Wirksamkeitsnachweis dieser bisher gängigen Therapiemethoden.Zusätzlich werden die Ergebnisse einer prospektiven randomisierten placebokontrollierten multizentrischen Studie zum Nachweis der Effektivität und Sicherheit der ESWA beim Fersensporn dargestellt. Die Resultate der Untersuchung zeigen, dass bei zuvor konservativ erfolglos behandelten Patienten durch eine einmalige Stoßwellenanwendung eine statistisch signifikante Verbesserung (p=0,0149) des morgendlichen Anlaufschmerzes als Hauptzielkriterium eintritt [Therapiegruppe: Reduktion von 7,7 auf 3,4 Punkte auf der visuellen Analogskala (VAS); Placebogruppe: Reduktion von 7,7 auf 4,1 Punkte auf der VAS]. Die Analyse der Daten des Scores nach Roles u. Maudsley mit dem exakten Test nach Fisher zeigte mit 61,6% vs. 39,7% sehr guter und guter Einschätzungen ein signifikant besseres Ergebnis der Therapiegruppe (p=0,0128). Therapiebedingte Nebenwirkungen (lokale Schwellung, Petechien) waren selten. Aufgrund der Daten wurde im Januar 2002 die FDA-Zulassung für das verwendete Stoßwellengerät erteilt.AbstractExtracorporeal shock wave application (ESWA) has been successfully used for years in routine clinical management of plantar fasciitis. So far no clinical trails have shown the efficiency in placebo-controlled protocols.This paper presents an overview of conservative and operative treatment modalities with respect to their efficacy.Results of a prospective randomized placebo-controlled double-blind multicenter trial to show efficiency and safety of ESWT are presented. In patients treated conservatively without success, a single shock wave application can improve the condition significantly compared with placebo treatment (p=0.0149). The Roles and Maudsley score also showed a significant improvement between the groups, with 61.6% good or excellent results in the verum group and 39.7% in the placebo group (p=0.0128). Therapy-related side effects (local swelling, petechia) are rare. The data presented in this study led to FDA approval in January 2002 of the shock wave device used.

Silicone rubber distal ulnar replacement arthroplasty

We retrospectively reviewed 42 patients who underwent resection of the distal ulna with implantation of a silicone rubber ulnar head prosthesis (45 wrists). Two prostheses were used: the original Swanson prosthesis, and a prosthesis of our own design. Follow-up X-rays showed migration or breakage of 63% of the prostheses. No statistically significant correlation existed between the quality of functional outcome and the integrity of the prostheses. There was no significant difference between pre-operative and post-operative range of motion for the entire group or between patients with broken or intact prostheses. Histological confirmation of silicone synovitis was documented in one patient who required implant removal. We suggest that destabilization and breakage of prostheses result from fatigue failure secondary to the torque generated at the distal radio-ulnar joint during repeated pronation and supination. Use of a silicone rubber ulnar head prosthesis following distal ulna resection is not recommended.

Treatment of acquired adult planovalgus deformities with subtalar fusion.

A retrospective review was conducted of isolated subtalar arthrodeses performed on 32 adults (34 fusions) between August 1990 and September 1993. Each fusion was performed using a single large cannulated lag screw through the talar neck. The American Orthopaedic Foot and Ankle Society standard clinical rating system for the ankle and hindfoot was used to assess outcome. Patients answered subjective questions based on the scale. Followup examination was done to evaluate clinically and radiographically each patients foot and ankle according to the scale. Average patient age was 53 years (range, 27–80 years). Average followup was 30.8 months (range, 16–55 months). Twenty-four patients answered the subjective questions, and the average subjective score was 47 of a maximum 60 points (range, 9–60 points). Clinical data from 17 patients showed an average objective score of 30 of a maximum 34 points (range, 25–34 points). The average total score was 77 of a maximum 94 possible points (range, 34–94 points). Forty-two percent of the patients indicated a 100% improvement, 42% a 75% improvement, and 16% a 50% improvement. Eighty-three percent stated they definitely would have the procedure again. Results indicate that subtalar arthrodesis is an effective treatment for adult patients with pain and disability secondary to acquired planovalgus, posttraumatic, and inflammatory conditions of the hindfoot. In addition, the American Orthopaedic Foot and Ankle Society standard rating system of the ankle and hind-foot corresponds to clinical outcome.

The Tensile Strength of the Anterior Talofibular Ligament

Cadaveric anterior talofibular ligaments, with their associated bone attachments, were tensile tested to destruction. The ligament ruptured by either bone avulsion from the talus or midsubstance failure. The values of tensile strength varied from 58 to 556 newtons with a mean strength of 206 newtons.