Marion C. Harper

Curvature of the femur and the proximal entry point for an intramedullary rod.

The degree of anterior curvature of 14 human femurs and four currently marketed intramedullary rods was analyzed with the use of an interactive graphic computer program. The radius of curvature of the femurs ranged from 188.5 to 68.9 cm (average, 114.4 cm). The radius of curvature of three of the four rods analyzed fell beyond the spectrum of radii found in the human femurs. A concomitant investigation of the most appropriate proximal entry site for an intramedullary rod was done based on the patterns of exit sites for both flexible guide wires and two intramedullary rods introduced in a retrograde fashion from the intercondylar notch in 14 matched pairs of human femora. The most appropriate area for proximal access into the medullary canal for these devices would appear to be at the junction of the femoral neck and the greater trochanter slightly anterior to or in the pyriformis recess.

The lateral ligamentous support of the subtalar joint.

A review of the ligamentous structures spanning the subtalar joint laterally, as well as within the sinus and canalis tarsi, is presented based on previous descriptions and a series of anatomic dissections. Defined supporting structures are categorized into superficial, intermediate, and deep layers. Of these, the inferior extensor retinaculum is seen to be a discrete, substantial structure readily accessible for ligament reconstructions involving both the ankle and subtalar joints.

Delayed reduction and stabilization of the tibiofibular syndesmosis.

Six patients with chronic widening and instability of the tibiofibular syndesmosis subsequent to pronation-external rotation ankle fractures were reviewed as regards diagnosis and treatment. An evaluation of the syndesmotic interval was best done by CT scans using axial cuts. Delayed reduction and stabilization using primarily large screw fixation resulted in maintenance of the reduction and satisfactory results in 5 of 6 cases. In one case, an arthrodesis of the tibiofibular interval was done because of significant incongruity.

Talonavicular arthrodesis for the acquired flatfoot in the adult.

The acquired painful flatfoot in the adult is a syndrome that commonly is disabling and progressive. Patients should benefit from a surgical technique that can provide correction of the major deformities and lasting stability with limited surgical morbidity. Twenty-nine patients treated with a talonavicular arthrodesis for this disorder were followed up a minimum of 12 months and an average of 26 months. Twenty-five patients (86%) were satisfied with no or minor reservations and achieved good or excellent results. A talonavicular arthrodesis, by addressing the instability at its focal point, appears to achieve these goals with one surgical procedure.

Primary iliopsoas bursography in the diagnosis of disorders of the hip.

The iliopsoas bursa is a well-defined anatomic structure that has been involved in various diseases about the hip, including osteoarthritis, rheumatoid arthritis, pigmented villonodular synovitis, and synovial chondromatosis. Demonstration of the iliopsoas bursa using contrast material has been reported during hip arthrography and inadvertently during angiography, but no direct or primary methods of iliopsoas bursography have been reported. A technique of primary bursography under fluoroscopy is described wherein filling of the bursa with contrast material allowed the observation of movement of the iliopsoas musculotendinous unit across the front of the pelvis during motion of the hip. This technique, which was of significant benefit in determining the etiology of two cases of the snapping hip syndrome of the internal variety, is simple, easily reproducible, and has clinical application.

The deltoid ligament. An evaluation of need for surgical repair.

Forty-two patients were treated surgically for ankle injuries, including complete disruption or incompetency of the deltoid ligament, without any surgical repair as part of the initial operation. In a retrospective study, 36 patients were followed for one year or longer. The functional results appeared satisfactory provided surgical reductions of the medial joint space and lateral malleolus were accurate and maintained until bone repair was complete. No evidence of ligamentous instability of the foot or ankle was noted.

An anatomic study of the short oblique fracture of the distal fibula and ankle stability.

The short oblique fracture of the distal fibula occurring as a stage 2 supination-external rotation injury was investigated in respect to its effect on ankle stability in a series of cadaver dissections. Approximately 25 and 20 degrees of external rotational displacement of the distal fibula and talus, respectively, as well as approximately 1 mm of direct lateral talar shift were noted to be possible with this injury. This degree of rotational or lateral talar displacement was seen to result in tibiotalar joint incongruity. The deltoid ligament effectively prevented talar eversion but not the initial 2 to 3 mm of lateral talar displacement. Ankle stability in respect to medial talar shift was not compromised by removal of the medial malleolus.

Positioning of the Hallux for First Metatarsophalangeal Joint Arthrodesis

Recommendations for positioning the hallux are usually given in ranges of degrees in the sagittal and axial planes (Le., 20-30° of extension and 15-20° of valgus) relative to the first metatarsal.1,2 Although helpful as approximations, these figures do not always allow for variability in terms of structure and flexibility of the human foot. For instance, because of differences in the declination angle of the first metatarsal and mobility of the first tarsometatarsal joint, optimum position in the flexible flat foot may differ greatly from that in the more rigid cavus foot. An alternative method of positioning the hallux is based on functional considerations. It emphasizes the fact that the great toe participates in weightbearing during the latter portion of the stance phase of the gait cycle. It must also seat comfortably alongside the second toe. Using this approach, angular measurements that are usually difficult to accurately determine intraoperatively become a secondary consideration. The position of the toe relative to the floor with simulated weightbearing is of primary importance.

Closed reduction and percutaneous stabilization of tibial plateau fractures.

Twenty-eight patients with tibial plateau fractures treated by closed reduction using forceful traction and percutaneous stabilization with pins or screws were reviewed. For six bicondylar fractures, transfixion pins with an external fixation device were used. In six cases, an arthroscopic exam was also done. For 21 patients, external support was used postoperatively. Twenty-one patients were followed an average of 26 months. All fractures healed. Functional ratings were: 14 excellent, 6 good, and 1 poor. Radiographic ratings were: 11 excellent, 9 good, and 1 fair. For fractures with large fragments without excessive comminution or severe central depression, this technique yields good results with minimal surgical morbidity.

Dorsal Closing Wedge Metatarsal Osteotomy: A Trigonometric Analysis

Dorsal closing wedge osteotomies are commonly done in order to elevate and shorten the metatarsals in the management of severe metatarsalgia with callus formation. A trigonometric analysis reveals that a proximal closing wedge with a small (i.e., 2-mm) base will significantly elevate (approximately 1 cm), and slightly shorten a typical lesser metatarsal. Larger proximal wedge osteotomies in a lesser metatarsal would appear to have the potential for excessive elevation of the metatarsal head. Because of differences in metatarsal width and length, a proximal wedge in the first metatarsal will elevate the metatarsal head approximately twice the width of the wedge base. A distal closing wedge osteotomy will elevate a lesser metatarsal head approximately the width of the wedge base.