Michael Stephens

Flexor Hallucis Longus Tendon Transfer: Evaluation of Postoperative Morbidity

Clinical and pedobarograph evaluation was performed on 16 patients following flexor hallucis longus (FHL) tendon transfers to determine the resulting morbidity due to the loss of FHL function. All patients underwent FHL tendon transfer for either chronic tendon Achilles rupture or chronic Achilles tendinosis. Clinical evaluation of hallux function was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale, the SF-36 score, and a clinical questionnaire to assess alteration in the clinical function of the hallux during activities of daily living. Pedobarography was carried out using the Musgrave pedobarograph system to detect changes in forefoot loading in comparison to the contralateral normal foot. Fourteen of the 16 patients scored maximally on the hallux metatarsophalangeal-interphalangeal scale and none of the patients noticed functional weakness of the hallux during activities of daily living at a mean follow-up of 43.6 months (range, 5–120 months). Pedobarograph readings showed a trend toward reduction in peak pressure loading on the distal phalanx, but this was not significant for the numbers of patients studied. There was no significant increase in loading of the first or second metatarsophalangeal joints to suggest that transfer metatarsalgia may complicate FHL tendon transfer. According to the results of the study morbidity from FHL transfer should be clinically insignificant.

Arthrodesis of the first metatarsophalangeal joint using a dorsal titanium contoured plate.

Background: Arthrodesis of the first metatarsophalangeal joint (MTPJ) is used to treat a variety of foot pathologies. Numerous methods of internal fixation and bone end preparation have been reported. In an effort to bring together the best features of the various internal fixation devices, a low-profile contoured titanium plate (LPCT) using a compression screw was designed to be used with a ball-and-socket bone end preparation. A prospective study was carried out to determine the efficacy of this technique. Methods: First MTPJ arthrodesis using an LPCT was done in 12 patients (10 women and two men) either as an isolated procedure (seven patients) or in conjunction with other forefoot procedures (five patients). The changes in the level of pain and activities of daily living were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score and the Short-Form 36 (SF-36) score. Time to bone union also was assessed. Mean followup was 18 months (±6 months). Results: Statistically significant increases in the AOFAS hallux score and the SF-36 score were noted (p = .002 and .001, respectively). All radiographs showed bone union at 6 weeks and an appropriate degree of hallux dorsiflexion in relation to the first metatarsal (20 to 25 degrees). Conclusion: The combination of the LPCT plate and a ball-and-socket bone-end preparation has both operative and biomechanical advantages over other fixation techniques. This combination ensures that the anatomical length of the first ray is only minimally shortened and the angle of plantarflexion of the first metatarsal is maintained, resulting in preservation of medial column stability and a better functional result.

Birth-associated femoral fractures: Incidence and outcome

Femoral fractures resulting from birth injuries are rare. The authors undertook a study to assess their incidence and outcome. Seven patients from a total of 55,296 live births suffered 8 femoral fractures (incidence 0.13 per 1,000 live births). Twin pregnancies, breech presentations, prematurity, and disuse osteoporosis were associated with the occurrence of a fracture. The typical injury pattern was a spiral fracture of the proximal half of the femur, which was held in an extended position. A variety of treatment modalities were used, including gallows traction, spica cast, and Pavlik harness. All patients in this study, regardless of treatment, had a satisfactory clinical outcome, with no evidence of limb length discrepancy or angular deformity on follow-up.

Effect of Heel Height on Forefoot Loading

Sixty feet of 30 normal subjects were investigated to determine the effect of changing the heel height on forefoot loading. Subjects walked across footplates barefoot and with rigid polyurethane heels attached to the foot with a tubular bandage. The total load on the forefoot remained unchanged at all of the heel heights, but the distribution of the load changed as the heel was raised. The area of forefoot contact with the footplates decreased and there was a deviation of load toward the medial side of the forefoot with a resultant increase in pressure. These effects could contribute to overload of the distal forefoot and especially of the first ray.

Intermetatarsal Angle After First Metatarsophalangeal Joint Arthrodesis for Hallux Valgus

Background: First metatarsophalangeal (MTP) joint arthrodesis is commonly done for hallux valgus with an arthritic joint. In patients with a wide preoperative first intermetatarsal (IM) angle an important question is whether the metatarsus varus will be corrected by the first MTP joint fusion alone or whether an additional basal osteotomy is necessary. Methods: The charts and radiographs of 20 patients who had arthrodesis of the first MTP joint were retrospectively reviewed. All 20 patients were female with a mean age of 54.2 (range 42 to 78) years. Either a Hallu-S® plate (Integra Life Sciences, Nudeal, France) or two crossed screws were used to stabilize the arthrodesis. The IM angles were measured independently by two individuals on weightbearing preoperative, 6-week postoperative, and final followup films. The final followup radiographs were taken at an average of 13.7 (range 6 to 30) months after surgery. A Student t-test was used to evaluate the changes in the IM angle and interobserver variations. Results: The mean preoperative IM angle was 16.65 (range 12 to 26) degrees. The mean postoperative IM angle was 10.35 (range 6 to 15) degrees. The mean IM angle at final followup was 8.67 (range 5 to 12) degrees. The mean change between preoperative IM angle and IM angle at final followup was 8.22 (range 4 to 14) degrees. This change of the IM angle was statistically significant (p < 0.0001). Conclusions: These results indicate that in patients with severe hallux valgus and first MTP joint degeneration arthrodesis can significantly correct the IM angle without the addition of a basal osteotomy.

Foot deformities in children with cerebral palsy.

Clinical observation suggests that deformities of the foot and ankle are common in children with cerebral palsy. Two hundred children with cerebral palsy attending the Central Remedial Clinic were examined and photographed. The children had no previous surgical intervention and were between 1.5 and 19 years of age. Deformities were assessed and related to the type of cerebral palsy and mobility status.

The Role of Hamstring Tightness in Plantar Fasciitis

Background: Plantar fasciitis is a repetitive microtrauma overload injury of the attachment of the plantar fascia at the inferior aspect of the calcaneus. Several etiological factors have been implicated in the development of plantar fasciitis; however, the role of hamstring tightness has not been evaluated. Methods: Fifteen volunteers (mean age 32.6 ± 4.7 years) were prospectively analyzed for differences in forefoot loading using a Don-Joy brace (dj Orthopedics, Vista, CA) applied to each knee simultaneously. The brace was locked at varying degrees of knee flexion (0 degrees, 20 degrees, and 40 degrees). Their mean popliteal angle was 6.5 degrees. Fifteen patients (mean age 40 ± 16.5 years) with a diagnosis of chronic plantar fasciitis were similarly analyzed on the pedobarograph. These patients also had their hamstring tightness evaluated by measuring the popliteal angle. The mean popliteal angle was 23 degrees. Results: Increasing the angle of flexion from 0 to 20 degrees at the knee joint led to a statistically significant increase in pressure in the forefoot phase by an average of 0.08 K/cm2s (p < 0.05). An increase from 20 to 40 degrees led to increased forefoot phase pressure of 0.08 kg/cm2s (p < 0.05). The percentage of time spent in contact phase decreased from 35.37% to 30.87% to 26.37% with increasing flexion (p < 0.05). However there was an inverse increase in the time spent in the forefoot phase 46.6% to 55.6 to 61.25% with increasing degrees of flexion (p < 0.05). Conclusion: The results indicate that an increase in hamstring tightness may induce prolonged forefoot loading and through the windlass mechanism be a factor that increases repetitive injury to the plantar fascia.

Irreducible Dislocation of the Fifth Metatarsophalangeal Joint: A Case Report

Metatarsophalangeal joint dislocations are unusual in children and usually occur in the hallux. We are reporting a case of irreducible traumatic dislocation of the fifth metatarsophalangeal joint. At open reduction, the metatarsal head was incarcerated under the flexor digitorum longus. After returning the flexor digitorum longus tendon to its anatomical position, the metatarsophalangeal joint reduced and was stable.

Foot deformities in children with hereditary motor and sensory neuropathy.

The authors reviewed 104 feet from 52 consecutive children with hereditary motor and sensory neuropathy (HMSN) seen for the first time in clinics in two pediatric institutions between 1996 and 2003. Sixty-nine feet had a cavovarus deformity, 23 feet had a planovalgus deformity, and 12 feet had no significant deformity. All cases with deformity had bilateral involvement, and of those with deformity, only 45% had symmetric involvement. In HMSN I, III, IV, V, and X-linked HMSN, cavovarus was the most common deformity. However, in HMSN II, 55% of feet had a planovalgus deformity, 36% had a cavovarus deformity, and 9% had no deformity. In all, 43 feet underwent surgery of some type. Surgery, and in particularly combined bony and soft tissue procedures, was performed much more frequently on feet with cavovarus than planovalgus deformities. Soft tissue surgery alone was performed at an earlier age than combined bony and soft tissue surgery.

“Os Post Peronei” and the Posterolateral Nutcracker Impingement Syndrome

Impingement syndromes have been described in relation to accessory or anomalous bony additions to the foot skeleton. We describe a hitherto undescribed accessory bone in the hindfoot causing posterolateral impingement in a 28-year-old woman.