Marco Corradin

Plantar fascia anatomy and its relationship with Achilles tendon and paratenon

Although the plantar fascia (PF) has been studied quite well from a biomechanical viewpoint, its microscopic properties have been overlooked: nothing is known about its content of elastic fibers, the features of the extracellular matrix or the extent of innervation. From a functional and clinical standpoint, the PF is often correlated with the triceps surae muscle, but the anatomical grounds for this link are not clear. The aim of this work was to focus on the PF macroscopic and microscopic properties and study how Achilles tendon diseases might affect it. Twelve feet from unembalmed human cadavers were dissected to isolate the PF. Specimens from each PF were tested with various histological and immunohistochemical stains. In a second stage, 52 magnetic resonance images (MRI) obtained from patients complaining of aspecific ankle or foot pain were analyzed, dividing the cases into two groups based on the presence or absence of signs of degeneration and/or inflammation of the Achilles tendon. The thickness of PF and paratenon was assessed in the two groups and statistical analyses were conducted. The PF is a tissue firmly joined to plantar muscles and skin. Analyzing its possible connections to the sural structures showed that this fascia is more closely connected to the paratenon of Achilles tendon than to the Achilles tendon, through the periosteum of the heel. The PF extended medially and laterally, continuing into the deep fasciae enveloping the abductor hallucis and abductor digiti minimi muscles, respectively. The PF was rich in hyaluronan, probably produced by fibroblastic‐like cells described as ‘fasciacytes’. Nerve endings and Pacini and Ruffini corpuscles were present, particularly in the medial and lateral portions, and on the surface of the muscles, suggesting a role for the PF in the proprioception of foot. In the radiological study, 27 of the 52 MRI showed signs of Achilles tendon inflammation and/or degeneration, and the PF was 3.43 ± 0.48 mm thick (99%CI and SD = 0.95), as opposed to 2.09 ± 0.24 mm (99%CI, SD = 0.47) in the patients in which the MRI revealed no Achilles tendon diseases; this difference in thickness of 1.29 ± 0.57 mm (99%CI) was statistically significant (P < 0.001). In the group of 27/52 patients with tendinopathies, the PF was more than 4.5 mm thick in 5, i.e. they exceeded the threshold for a diagnosis of plantar fasciitis. None of the other 25/52 paitents had a PF more than 4 mm thick. There was a statistically significant correlation between the thicknesses of the PF and the paratenon. These findings suggest that the plantar fascia has a role not only in supporting the longitudinal arch of the foot, but also in its proprioception and peripheral motor coordination. Its relationship with the paratenon of the Achilles tendon is consistent with the idea of triceps surae structures being involved in the PF pathology, so their rehabilitation can be considered appropriate. Finally, the high concentration of hyaluronan in the PF points to the feasibility of using hyaluronan injections in the fascia to treat plantar fasciitis.

Comparison of dorsal and dorsomedial displacement in evaluation of first ray hypermobility in feet with and without hallux valgus

BACKGROUND Hypermobility of the first ray, a probable primary cause of hallux valgus, has traditionally been evaluated in the dorsal direction only although the first tarso-metatarsal joint allows movement in a dorso-medial direction. MATERIALS AND METHODS 600 feet, divided according to the presence or absence of hallux valgus, were evaluated for both dorsal and dorso-medial displacement using a Klaue device. RESULTS In the control group, the mean first ray displacement was 7.2mm (4.2-11.3) in the dorsal direction (sagittal plane) and 8.3mm (4.0-12.6) in the 45° dorso-medial direction. In the hallux valgus group, the mean first ray mobility was 9.8mm (5.2-14.1) in the dorsal direction compared to a mean of 11.0mm (5.9-16.2) in the 45° dorso-medial direction. CONCLUSION It is a paradox that hypermobility of the first ray is measured in only a dorsal (vertical) direction whereas a hallux valgus angle and an intermetatarsal angle are only measured in a transverse plane. Furthermore, the weightbearing foot pronates during gait and the first metatarsal is displaced in a dorsomedial direction rather than a pure dorsal direction. It is suggested that measurement hypermobility of the first ray at a 45° dorso-medial direction is more appropriate.

Minimally Invasive Distal Metatarsal Diaphyseal Osteotomy (DMDO) for Chronic Plantar Diabetic Foot Ulcers

Background: The aims of this prospective study were first to evaluate the safety and effectiveness of minimally invasive distal metatarsal diaphyseal osteotomies (DMDOs) for treating a consecutive series of diabetic patients with chronic plantar diabetic foot ulcers (CPDFUs) and second to assess their clinical-functional and radiographic outcomes. Methods: A consecutive series of patients affected by diabetes mellitus with CPDFUs, not responsive to previous nonoperative management, underwent DMDO. The CPDFUs were evaluated using the University of Texas Diabetic Wound Classification System (UTDWC). Demographic parameters, Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores, healing times, and complications were recorded. Maestro et al criteria and bone callus formation were analyzed radiologically. Statistical analysis was carried out (P < .05). Thirty consecutive enrolled patients with a mean age of 66.7 (range, 53-75) years presented 35 CPDFUs with a mean diameter of 16.3 mm and a mean duration of 10.3 months. The most frequent grade of the UTDWC was IIIB (42.9%). Results: All ulcers recovered with a mean healing time of 7.9 ± 4.0 (range, 4-17) weeks. AOFAS scores improved significantly from 55.3 to 81.4 points (P < .001). At a mean follow-up of 25.3 months (range, 18-71), no cases of ulcer recurrence were recorded, while a major complication or a wound infection required longer healing time. Conclusion: Minimally invasive DMDO was a safe and effective method in promoting CPDFU healing, regardless of the grade of severity, by the reduction of the high plantar pressure under the metatarsal heads. This technique improved functional and radiographic outcomes with few complications. Level of Evidence: IV, case series.

Anatomical study of the paratendinous tissues and their role in the pathogenesis of the tendinopathy

According with the recent Literature, the paratendineous tissues have an important role in the pathogenesis of the so-called tendinitis, but their anatomical and histological features are not clear. This research has the aim to analyze the paratendinous tissues from a macroscopic, histological and imaging point of view. Samples were taken from the Achilles tendon and the tendon of the flexor hallucis longus muscle of thirteen fresh non-embalmed cadaver’s feet. All samples were stained with hematoxylin-eosin, Azan-Mallory, van Gieson and Alcian Blue stains and antiS100 and PGP 9.5 antibodies. Measurement were also performed on 60 foot- RMN, both in healthy people and in patients with Achilles tendinopathy. The paratendinous tissues are made of three different layers: the paratenon, the epitenon and the endotenon. The dissections have demonstrated that the paratenon is in continuity with the crural fascia. It is a layered sheath of collagen fibres densely packaged. It envelopes the tendon and isolates it from the surrounding tissues, guarantying its free sliding. The elastic fibres are less than 1%. The epitenon is a dense connective tissue sheath covering the tendons over their entire length. It is rich in elastic fibers, distribute fairly uniformly in the whole thickness. Both paratenon and epitenon contain blood and lymphatic vessels and many free nerve endings. Between the two structures, loose connective tissue rich in hyaluronic acid is present. In some samples, some fibroblast-like cells that stained very well at the Alcian Blue stain were observed. It was postulated that these were specialized cells for the biosynthesis of the HA-rich matrix, that we have called “fasciacytes”. The innermost layer of the three is the endotenon, it surrounds the tertiary fascicles of the tendon. It is formed by collagen fibers and it is rich of elastic fibers. It reacts intensively to the Alcian Blu, having an important component of ialuronic acid. At the RMN, the Achilles paratenon in the healthy patient appears as a homogenous line that surrounds the tendon and the loose tissue near the tendon; it presents a mean thickness of 1.04 mm. The crural fascia appears like a line with a signal slightly increase, localized laterally to the tendon that give the origin to the paratenon with a splitting, it has a mean thickness of 1.19 mm. In the patients affected by tendinopathy a statistically significant (p<0,0001) variation of the thickness of the paratenon is present. Besides, also an increased intensity of signal is evident. Our findings support the idea that the paratendineous tissues could have a role in the etiology of the so-called tendinitis, in particular thanks to the rich vascularization and innervations. Consequently we suggest that the term “tendinitis” in some cases could be replaced with the term “paratendinitis”.

La prognosi dei distacchi epifisari dell’arto inferiore

Physeal fractures, which represent almost 25% of all the fractures in children, are generally classified according to the Salter Harris (S-H) classification, which is accepted worldwide thanks to its simplicity and reproducibility. However, during the last two decades several reports have questioned its prognostic value. In this review, the main prognostic factors of lower limb physeal injuries were identified on the basis of our personal experience and of the most recent literature. Although a bad prognosis may be still recognised as S-H type III and type IV, particularly when anatomic reduction of the articular fracture is not obtained, type I and type II lesions may also have a poor outcome especially in case of high-energy trauma.

Clinical practice and nursing management of pre-operative skin or skeletal traction for hip fractures in elderly patients: A cross-sectional three-institution study

BACKGROUND Femoral fractures are a major healthcare problem worldwide. One of the most difficult issues is their preoperative care, which is still managed by either skeletal or skin traction in some countries, including Italy. These issues are discussed and compared with the contemporary literature. OBJECTIVE This study aims to analyse the distribution of these treatment options within the orthopaedic community and the reasons for their use, as well as to identify how this may impact nursing care in terms of pain management, hygiene care, venous thromboembolism (VTE)prophylaxis and prevention of pressure ulcers. DESIGN For this cross-sectional study, a 12-item survey was administered to the nursing staff, consultants and residents of the Orthopaedic Units in three different hospitals in NorthEastern Italy. The questionnaire investigated the routine use of skeletal or skin traction for the preoperative management of hip fractures in those settings. FINDINGS 136 surveys were completed, providing a response rate of 87.74%. Preoperative traction for hip fractures was still in use in the three hospitals, mainly applied by experienced surgeons for subtrochanteric fractures. Pain management, VTE and pressure ulcer prevention were perceived as worse only with skeletal traction, while hygiene was described as more difficult with both skeletal and skin traction. CONCLUSIONS AND RECOMMENDATIONS Based on the data and the literature revision, skin or skeletal traction for patients with proximal femoral fractures should be discouraged as standard practice. This is supported widely in the international literature, and consideration of knowledge translation strategies should be made to refine current practice in these settings.

Deep postoperative spine infection treated by negative pressure therapy in patients with progressive spinal deformities

BackgroundThe aim of the study is to review the outcome of using the VAC system in children and adolescents who have developed postoperative spinal infection after posterior instrumented spinal fusion, and to evaluate whether this technique is also feasible in patients treated with posterior instrumented fusion with polyester sublaminar bands.MethodsA total of 11 out of 118 consecutive children and adolescents (5 males) with deep postoperative spinal infection were identified; infections were categorised as early (acute), delayed (subacute) or late (chronic) according to time of onset. Irrespective of the etiology and the onset, all the deep infections were managed with the reported technique. All the patients had regular clinical and radiological follow-up.ResultsEight out of 11 patients developed an early (72.7%), 2 a delayed (18.2%) and 1 a late deep postoperative infection (9.1%); 7 out of 11 (63.6%) showed severe mental compromise. No statistically significant differences were observed for mean number of VAC dressing changes (p = 0.81) and mean length of hospitalisation comparing patients with early infection versus patients with delayed or late infections (p = 0.32). Mean number of VAC dressing changes (p = 0.02) and mean number of hospitalisation days (p = 0.05) were higher in patients with underlying neurological disorders than in those without, while mean length of hospitalisation was longer in neuromuscular patients.ConclusionsThe application of the VAC system, as an adjunct to surgical debridement and adequate antibiotic therapy, is a reliable method for the treatment of postoperative infection in children and adolescents undergoing spinal instrumentation and fusion. It can reduce the need for further complex soft-tissue procedure, removal of hardware with consequent loss of correction, and pseudoarthrosis. Finally, the use of VAC therapy is not contraindicated in patients treated with hybrid constructs with sublaminar bands.Level of evidenceIII.

Anatomical-radiological study of the plantar fascia and its correlation with Achilles tendon pathologies

Although the plantar fascia (PF) has been studied quite well from a biomechanical viewpoint [1], nothing is known about its content of elastic fibers, the features of the extracellular matrix or the extent of innervation. From a functional and clinical standpoint, the PF is often correlated with the triceps surae muscle, but the anatomical grounds for this link are not clear. Twelve feet from frozen human cadavers were dissected to isolate the PF. Specimens from each PF were tested with various histological and immunohistochemical stains. 52 MRI obtained in patients complaining of non-specific ankle or foot pain were analyzed. The thickness of PF and paratenon was assessed and statistical analyses were conducted. The PF is a tissue firmly joined to plantar muscles and is closely connected to the paratenon of Achilles tendon through the periosteum of the heel. The PF was rich in hyaluronan, probably produced by fibroblastic-like cells described as “fasciacytes” [2]. Nerve endings and Pacini and Ruffini corpuscles were present, particularly in the medial and lateral portions, and on the surface of the muscles, suggesting a role for the PF in the proprioception of foot. In the radiological study, 27 of the 52 MRI showed signs of Achilles tendon inflammation and/or degeneration, and the PF was 3.43 ± 0.48 mm thick, as opposed to 2.09 ± 0.24 mm in the cases in which the MRI revealed no Achilles tendon diseases (p<0.001). In the group of 27/52 cases with tendinopathies, the PF was more than 4.5 mm thick in 5, i.e. they exceeded the threshold for a diagnosis of plantar fasciitis. None of the other 25/52 cases had a PF more than 4 mm thick. There was a statistically significant correlation between the thicknesses of the PF and the paratenon. These findings suggests that the plantar fascia has a role not only in supporting the longitudinal arch of the foot, but also in its proprioception and peripheral motor coordination. Its relationship with the paratenon of the Achilles tendon is consistent with the idea of triceps surae structures being involved in the PF pathology, so their rehabilitation can be considered appropriate. Finally, the high concentration of hyaluronan in the PF points to the feasibility of using hyaluronan injections in the fascia to treat plantar fasciitis.