Melvin H. Jahss

Spontaneous Rupture of the Tibialis Posterior Tendon: Clinical Findings, Tenographic Studies, and a New Technique of Repair

Ten patients with spontaneous rupture of the tibialis posterior tendon were evaluated in regards to clinical and roentgenographic diagnostic criteria, tenographic findings, conservative treatment, and surgical repair. It was concluded that while tenography was a significant diagnostic adjuvant, the diagnosis and decision for surgical intervention must be based primarily upon the clinical findings. Previously described surgical repairs either gave less than optimum results or were impossible to achieve due to the extent of tendon damage. A new surgical technique, consisting of a side to side anastamosis of both the normal proximal and distal portions of the tibialis posterior tendon to the adjacent flexor digitorum longus tendon, proved a simple procedure and gave consistently excellent results.

Investigations into the Fat Pads of the Sole of the Foot: Anatomy and Histology

Anatomical, histological, and histochemical studies were performed on normal and abnormal fat pads of the sole of cadaver feet. The fat pads were found to contain a significant nerve and blood supply separate from that to the surrounding musculature and skin. Pacinian corpuscles and free nerve endings within the fat were identified. Histological analysis indicated a meshwork of fibroelastic septae arranged in a closed-cell configuration. The mechanical consequences of this organization are discussed in the context of the weightbearing role of the fat pads of the feet. Alterations seen in dysvascular or senescent feet are consistent with the hypothesis that the septal anatomy of the fat pads is central to their cushioning function.

Traumatic Dislocations of the First Metatarsophalangeal Joint

The mechanics, anatomy, and pathomechanics of traumatic dorsal dislocation of the first metatarsophalangeal joint are discussed. There are two basic types of dislocations. In Type I, dislocation of the hallux with the sesamoids occurs without disrupting the sesamoid mass. Such cases are usually irreducible on closed reduction, the metatarsal head being incarcerated by the conjoined tendons with their intact sesamoids. In Type II, there is either associated disruption of the intersesamoid ligament (Type IIA) or a transverse fracture of one of the sesamoids (Type IIB). In Type II, the sesamoid disruption usually permits closed reduction.

Magnetic Resonance Imaging of Anomalous Leg Muscles: Accessory Soleus, Peroneus Quartus and the Flexor Digitorum Longus Accessorius

Since the availability of magnetic resonance imaging (MRI), the suspected diagnosis of an accessory muscle of the lower extremity can now be confirmed without the need for invasive procedures. The accessory soleus, peroneus quartus, and flexor digitorum longus accessorius are anomalous muscles of the lower extremity that can be diagnosed by MRI. These accessory muscles are probably more common than once thought and can now be easily distinguished from other space occupying lesions that can occur around the ankle. MRI of these anomalous muscles enables one to make a definitive diagnosis without a biopsy. In those symptomatic patients, the origins and insertions of these accessory muscles can be accurately evaluated by MRI prior to any anticipated surgical intervention.

Deltoid Ligament Forces after Tibialis Posterior Tendon Rupture: Effects of Triple Arthrodesis and Calcaneal Displacement Osteotomies

Deltoid ligament forces were studied after observing deltoid ligament insufficiency in several post-triple arthrodesis patients. Six fresh-frozen, below-knee amputation specimens were axially loaded. The results demonstrate that a properly positioned triple arthrodesis produced deltoid ligament forces that were similar to those seen with an intact tibialis posterior tendon. A triple arthrodesis in combination with a lateral displacement calcaneal osteotomy produced deltoid ligament forces that were 76% greater than those seen with the intact tibialis posterior tendon (P < .05). A triple arthrodesis in combination with a medial displacement calcaneal osteotomy produced deltoid ligament forces that were 56% less than those seen with the lateral displacement calcaneal osteotomy (P < .01). Patients with longstanding ruptures of the tibialis posterior tendon and associated peritalar subluxation/dislocation may have less than optimal clinical results after triple arthrodesis, unless the hindfoot can be properly reduced, due to persistent elevated forces in the deltoid ligament and resulting ligament laxity. This study suggests that a medial displacement calcaneal osteotomy in combination with a triple arthrodesis may be a viable treatment when the hindfoot cannot be positioned properly.

Investigations into the fat pads of the sole of the foot: heel pressure studies.

The fat pads of the heel have a structure that is optimized for load bearing. In various diseases and aging, the load-carrying ability of the heel pad is clinically impaired. The loading pattern was examined in subjects having normal heel pads and those with atrophic heel pads, both with and without clinical symptoms. Normal heel pads showed a broad region of high pressure, which accounted for a high percentage of the total load transmission. In contrast, the atrophic heels showed a high but narrow peak pressure. However, most of the load was transmitted over a large area of low pressure. There was no difference between symptomatic and asymptomatic heels. The mechanical behavior of the fat pad is discussed with particular reference to the anatomic structure of the pads. Pad thickness and septal integrity are both important to the mechanical characteristics of the fat pad. The load-bearing patterns observed are discussed in terms of the mechanical components influencing fat pad resilience. These results have direct relevance to understanding the pathophysiology of heel pain secondary to degeneration of the fat pad.

Histology and Histomorphometric Analysis of the Normal and Atrophic Heel Fat Pad

Light and electron microscopy was used for a histologic examination of normal heel fat pads and atrophic heel fat pads from patients with peripheral neuropathies. Histomorphometric analysis revealed an average 30% smaller mean cell area and 16% smaller mean cell diameters in the atrophic pads compared with the normal heel fat pads. Septal walls in the atrophic fat pads were often fragmented and approximately 75% wider than normal. Perineural fibrosis was also found in the atrophic heel fat pads. The Verhoeff elastic staining technique was used to determine the relative percentage of collagen to elastic tissue within the septae. No significant differences were noted between the normal and atrophic heels. The ultrastructure of the adipocytes from the normal and atrophic heel pads was similar to those found in abdominal subcutaneous fat. Lipid droplets of variable size and density within the center of the adipocyte were surrounded by a thin border of cytoplasm. The interphase between adipocytes contained fine collagen and elastic fibers.

The Foot and Ankle in Multiple Hereditary Exostoses

Twenty-two cases of multiple hereditary exostoses revealed pathological changes in two areas: the first group caused by epiphyseal disturbances, and the second group due to mechanical problems created by the exostoses. The epiphyseal disturbances resulted in ankle valgus, shortened metatarsals, and angular deformities of the necks of the metatarsals. The exostoses produced local tenderness, synostosis of the medial subtalar facet resulting in loss of subtalar motion, and asymptomatic synostosis of the lower tibial fibular syndesmosis.

Myxoid Chondrosarcoma of the Os Calcis: A Case Report

This case report of a myxoid chondrosarcoma of the oscalcis is presented because of its rarity. The clinical, roentgenographic, and pathological features are discussed, and the difficulty in diagnosis is elaborated

Chronic and recurrent dislocations of the fifth toe.

Ten cases of chronic and recurrent dislocations of the fifth toe were reviewed. The history consisted of forceful abduction by catching the toe on a piece of furniture while walking barefoot. In every case the pathology was overlooked by the treating physician or the patient failed to seek medical care. All of the patients were seen years after the initial injury. The clinical patterns revealed a relatively fixed abduction deformity at the proximal interphalangeal level or a recurrent dislocation occurring on weightbearing at either the proximal interphalangeal or metatarsophalangeal level. Treatment consisted of resection of the head and neck of the proximal phalanx and/or syndactyly to the fourth toe. Results were uniformly excellent.