Meagan M. Jennings

The Effects of Sectioning the Spring Ligament on Rearfoot Stability and Posterior Tibial Tendon Efficiency

UNLABELLED Posterior tibial tendon insufficiency has been implicated as a cause of adult acquired flatfoot. Multiple theories are debated as to whether or not a flatfoot deformity develops secondary to insufficiency of the posterior tibial tendon or of the ligamentous structures such as the spring ligament complex. This cadaveric study was undertaken in an attempt to determine the effect that sectioning the spring ligament complex has on foot stability, and whether engagement of the posterior tibial tendon would be able to compensate for the loss of the spring ligament complex. A 3-dimensional kinematic system and a custom-loading frame were used to quantify rotation about the talus, navicular, and calcaneus in 5 cadaveric specimens, before and after sectioning the spring ligament complex, while incremental tension was applied to the posterior tibial tendon. This study demonstrated that sectioning the spring ligament complex created instability in the foot for which the posterior tibial tendon was unable to compensate. Sectioning the spring ligament complex also produced significant changes in talar, navicular, and calcaneal rotations. During simulated midstance, the navicular plantarflexed, adducted, and everted; the talar head plantarflexed, adducted, and inverted; and the calcaneus plantarflexed, abducted, and everted, after sectioning the spring ligament complex. The results of this study indicate that the spring ligament complex is the major stabilizer of the arch during midstance and that the posterior tibial tendon is incapable of fully accommodating for its insufficiency, suggesting that the spring ligament complex should be evaluated and, if indicated, repaired in flatfoot reconstruction. LEVEL OF CLINICAL EVIDENCE 5.

Normal and abnormal function of the first ray.

The first ray is the most important structure of the forefoot in its contribution to normal locomotion. Because first ray dysfunction is encountered in clinical practice with the development of hallux valgus, metatarsus primus varus, and hallux rigidus, there has been a belief that there is a mechanical basis for these conditions. Since publications in the 1930s, there has been significant research focused on the first ray. This article discusses the subtleties of normal and abnormal mechanics of the first ray to promote a better understanding for foot and ankle practitioners when treating these various disorders.

Reconstruction of the Extruded Talus with Large Allograft Interfaces: A Report of 3 Cases

UNLABELLED Although replant of the extruded talus would be preferable at the time of initial management, some patients present with a talus that had not been recovered. A series of 3 cases of the extruded talus that were reconstructed with large allograft interfaces are presented. Two of the cases had femoral head allografts and the other used morcellized cancellous allograft. Several orthobiologic substances were used in various proportions for each case. All 3 resulted in a solid union with minimal shortening of the extremity. LEVEL OF CLINICAL EVIDENCE 4.

Fixation of the Medial Malleolar Fracture: A Simplified Technique

A technique for fixation of the medial malleolar fracture is presented as an alternative to cannulated screws or conventional screw fixation. Two partially threaded screws are inserted in to the same corridors created by the temporary fixation after anatomic reduction. The procedure minimizes soft tissue stripping of the fracture fragments and facilitates expedient delivery of the hardware. In addition to the simplicity of the technique, there is substantial cost savings and better thread purchase compared to cannulated screws.

An Anatomic and Autologous Lateral Ankle Stabilization

A new technique for stabilization of the lateral ankle ligaments is presented. The procedure uses a split peroneus longus tendon to recreate the calcaneofibular and anterior talofibular ligaments. The new ligaments follow a precise anatomic course that replicates the pathway of the original ligaments. The procedure also capitalizes on interference screw technology so that accurate ligament tension can be obtained. This technique is most useful for severe ligamentous insufficiency involving both the calcaneofibular and anterior talofibular ligaments. Biomechanical rationale for the use of peroneus longus is also discussed.

Talus Fractures: Surgical Principles

Surgical treatment of talus fractures can challenge even the most skilled foot and ankle surgeon. Complicated fracture patterns combined with joint dislocation of variable degrees require accurate assessment, sound understanding of principles of fracture care, and broad command of internal fixation techniques needed for successful surgical care. Elimination of unnecessary soft tissue dissection, a low threshold for surgical reduction, liberal use of malleolar osteotomy to expose body fracture, and detailed attention to fracture reduction and joint alignment are critical to the success of treatment. Even with the best surgical care complications are common and seem to correlate with injury severity and open injuries.

Modified Blair tibiotalar arthrodesis for post-traumatic avascular necrosis of the talus: a case report.

Surgical treatment of post-traumatic avascular necrosis of the talus coupled with collapse often results in limited treatment options. Of those options, the Blair tibiotalar arthrodesis has been beneficial in preserving limb length and subtalar motion. The complications associated with Blair tibiotalar arthrodesis have led to modifications to improve stability and functional outcomes with rigid internal fixation. We present the case of a 29-year-old female with a history of an open fracture dislocation of the talus 10 years previously, with subsequent development of avascular necrosis of the talus. The purpose of the present case report was to describe the surgical approach and use of an anterior compression plate to augment the modified Blair tibiotalar arthrodesis.

Practical Aspects of Foot and Ankle Arthroscopy

Arthroscopy of the foot and ankle, although sometimes technically challenging, is a useful tool for the foot and ankle surgeon. Burman in 1931 was the first to attempt arthoscopy of the ankle joint and surmised that it was not a suitable joint for arthroscopy because of its narrow intra-articular space. With the development of smaller-diameter arthroscopes and improvements in joint distraction techniques, Watanabe was the first to present a series of 28 ankle arthroscopes in 1972. At present, arthroscopy is used not only to evaluate and treat intra-articular abnormalities but also for endoscopic and tendoscopic procedures.

Management of Incision Complications

As surgeons, our incision is one of the most important steps during the surgical procedure. Not only does it allow us access to the anatomy below, but it is a representation to the patient of our work. Although much of incision healing is based on patient factors such as underlying medical comorbidities and a patient’s collagen, we as surgeons can optimize many factors of incision wound healing. Taking care not to skive our incision, minimizing tension with retraction, ensuring adequate return of vascularity, and appropriate hemostasis are a few examples of ways we can contribute to optimal incision healing. However, when incisions have complications and do not heal optimally, we, too, are responsible again for managing the wound and optimizing its healing potential.

Closure of Deep Fascia in Ankle Fracture Surgery

Closure of the deep fracture after open reduction and internal fixation of the ankle is often difficult due to the damage from the injury or from the intraoperative exposure. The technique described herein provides a consistent method for coverage of the hardware. The specific maneuver capitalizes on the unique arrangement of the fascial overlying the anterior compartment of the leg.