Paul J. Juliano

Single stage correction with external fixation of the ulcerated foot in individuals with Charcot neuroarthropathy.

The ulcerated foot in individuals with Charcot neuroarthropathy presents a complex problem when correction of the deformity is necessary but the presence of infection precludes the use of internal fixation. We reviewed 11 patients with midfoot Charcot neuroarthropathy, collapse, and ulceration who were at risk for amputation. These patients underwent operative debridement, corrective osteotomy, external skeletal fixation and culture-directed antibiotic therapy as a limb salvage procedure. Patients were transitioned from the external fixator (average 57 days) to total contact casting (average 131 days) and all subsequently progressed to therapeutic footwear in 12 to 49 months of follow-up (average 24 months), except one patient whose medical decline resulted in bedrest. We believe that when performed in properly selected patients, this procedure presents an alternative to amputation and, via corrective osteotomy, results in a shoe-able, functional foot that is potentially less prone to ulceration.

The Effects of Intratendinous and Retrocalcaneal Intrabursal Injections of Corticosteroid on the Biomechanical Properties of Rabbit Achilles Tendons

BACKGROUND The use of corticosteroid injections in the treatment of retrocalcaneal bursitis is controversial. We assessed the effects of corticosteroid injections, both within the tendon substance and into the retrocalcaneal bursa, on the biomechanical properties of rabbit Achilles tendons. The systemic effects of bilateral corticosteroid injections were also studied. METHODS The rabbits were divided into three treatment groups. The rabbits in Group I received injections of corticosteroid into the Achilles tendon on the left side and injections of normal saline solution into the Achilles tendon on the right, those in Group II received injections of corticosteroid into the retrocalcaneal bursa on the left side and injections of saline solution into the Achilles tendon on the right, and those in Group III received injections of corticosteroid into the Achilles tendon on the left side and injections of corticosteroid into the retrocalcaneal bursa on the right. These injections were given weekly for three weeks. At four weeks after the final injection, the tendons were harvested and were tested biomechanically to determine failure load, midsubstance strain and total strain, modulus of elasticity, failure stress, and total energy absorbed. The site of failure was also documented. The groups were compared according to the location of the injections, the type of injection (steroid or saline solution), and the total systemic load of steroid. RESULTS Specimens from limbs that had received intratendinous injections of corticosteroid showed significantly decreased failure stress compared with those from limbs that had received intratendinous injections of saline solution (p = 0.008). Specimens from limbs that had received intrabursal injections of corticosteroid demonstrated significantly decreased failure stress (p = 0.05), significantly decreased total energy absorbed (p = 0.017), and significantly increased total strain (p = 0.049) compared with specimens from limbs that had received intratendinous injections of saline solution. Specimens from limbs that had received intratendinous injections of corticosteroid were biomechanically equivalent to specimens from limbs that had received intrabursal injections of corticosteroid. Specimens from rabbits that had received bilateral injections of corticosteroid demonstrated significantly decreased failure load (p = 0.011), modulus of elasticity (p = 0.015), failure stress (p = 0.03), and total energy absorbed (p = 0.015) compared with those from rabbits that had received unilateral injections of steroid. CONCLUSIONS Local injections of corticosteroid, both within the tendon substance and into the retrocalcaneal bursa, adversely affected the biomechanical properties of rabbit Achilles tendons. Additionally, tendons from rabbits that had received bilateral injections of corticosteroid demonstrated an additive adverse effect, with significantly worse biomechanical properties compared with tendons from rabbits that had received unilateral injections of corticosteroid.

Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries.

Diagnosis of subtle Lisfranc injuries can be difficult for the examining clinician. Radiographs do not always reveal the full extent of tarsometatarsal injuries. We describe a clinical sign found in significant Lisfranc injuries that consists of a mid-foot ecchymotic area on the plantar aspect. This implies the potential for significant injury to the plantar tarsometatarsal ligaments. We call this the plantar ecchymosis sign. Patients with this injury and sign should be aggressively evaluated, with early consideration for stress radiographs and ORIF if indicated, as the prognosis of the undertreated Lisfranc injury is poor.

Intermediate Term Follow-up of Calcaneal Osteotomy and Flexor Digitorum Longus Transfer for Treatment of Posterior Tibial Tendon Dysfunction

Twenty-three patients with stage II posterior tibial tendon dysfunction who had failed non-surgical therapy were treated with flexor digitorum longus transfer and calcaneal osteotomy. At latest follow-up averaging 35±7 months (range, 24 to 51 months), 22 patients (96%) were subjectively “better” or “much better.” No patient had difficulty with shoe wear; however, four patients (17%) required routine orthotic use consisting of a molded shoe insert. AOFAS scores were available on 21 patients and improved from a preoperative mean of 50±14 (range, 27 to 85) to a postoperative mean of 89±10 (range, 70 to 100). Our experience, at an intermediate date follow-up is that calcaneal osteotomy and flexor digitorum longus transfer is a safe and effective form of treatment for stage II posterior tibial tendon dysfunction.

Fractures of the fourth metacarpal

OBJECTIVES To determine (a) the degree of shortening associated with isolated fourth metacarpal fractures and the functional outcome after operative or nonoperative (protocol of casting and outrigger) treatment (clinical portion), and (b) the role of the deep metacarpal ligament in minimizing shortening after isolated fourth metacarpal osteotomies simulating clinical fracture (cadaveric portion). STUDY DESIGN This two-part study included a retrospective clinical portion and a cadaveric investigation. METHODS First, the records of twenty-four patients with isolated displaced oblique or spiral fourth metacarpal fractures without adjacent metacarpal fractures were retrospectively reviewed. The amounts of shortening after nonoperative (seventeen patients) and operative (seven patients) intervention were compared. Second, seven hands were studied to compare the length of intact fourth metacarpals to that after oblique osteotomies and after deep metacarpal ligament sectioning. The differences in shortening measurements were statistically analyzed using a paired t test. RESULTS There was no significant difference in mean initial shortening (+/-SD) between operative and nonoperative patients (2.65 +/- 1.85 mm vs. 4.19 +/- 1.83 mm, respectively; p < 0.09; overall average shortening, 3.1 mm) or functional outcome. The cadaveric study documented the important role of the deep metacarpal ligament in minimizing fourth metacarpal shortening. Fourth metacarpals osteotomized with an intact deep metatarsal ligament had significantly less mean shortening (+/-SD) than those with a sectioned deep metacarpal ligament: 2.1 versus 5.8 mm, respectively (p < 0.001). CONCLUSIONS In the absence of unreducible rotational malalignment, fourth metacarpal fractures may be adequately treated nonoperatively with a protocol of casting and outrigger.

Endoscopic Plantar Fascia Release: An Anatomical Study

The anatomical relationship of neurovascular structures to the plantar fascia after endoscopic fasciotomy was studied in 13 adult fresh-frozen cadaver feet. Using a single portal technique, an endoscopic system was placed into the plantar compartment through a 1-cm medial incision. Under direct endoscopic visualization, the plantar fascia was released. The feet were then dissected and the anatomic relationship of the neurovascular structures to the area of release was studied. The average amount of plantar fascia released was 81%. The average distance of the release to the lateral plantar nerve, and the nerve to the abductor digiti minimi was 10.5 and 12.3 mm, respectively. The flexor digitorum brevis muscle was partially transected in 46% of the cases, and the average amount of muscle transected was 0.8 mm. The endoscopic approach to the release of the plantar fascia provides adequate release and does not appear to pose any danger to underlying neurovascular structures.

The superior gluteal artery in complex acetabular procedures. A cadaveric angiographic study.

A study of fresh cadavera was performed to assess the collateral circulation to the abductor muscle flap created by the various pelvic exposures in the presence of an occlusive injury to the ipsilateral superior gluteal artery. Through a bilateral extended iliofemoral, extended triradiate, modified extensile, or combined ilioinguinal and posterior approach, the right superior gluteal artery was occluded and an arteriogram was made. After use of the extended iliofemoral, the extended triradiate, and the modified extensile approaches, no angiographic evidence of circulation to the abductor muscles was demonstrated on the side of the occluded superior gluteal artery. There was circulation to the abductor muscles, despite occlusion of the superior gluteal artery, in cadavera in which the combined ilioinguinal and posterior approach had been used. After completion of the extended iliofemoral, extended triradiate, and modified extensile exposures, a Microfil injection study was performed on the cadavera to assess the presence of microcirculation. No evidence of Microfil circulation was observed in the abductor muscles macrosurgically or microsurgically. Preoperative assessment of the superior gluteal artery is recommended for a patient who is a candidate for an extensile exposure for an acetabular procedure. If the superior gluteal artery is occluded, a combined ilioinguinal and posterior operative approach should be considered.

Estrogen Receptor Expression in Posterior Tibial Tendon Dysfunction: A Pilot Study:

Background: The pathophysiology of posterior tibial tendon dysfunction (PTTD) is poorly understood. It has been theorized that changes in hormone physiology may be a factor influencing tendon health. Estrogens influence on the fibroblast has been studied in other musculoskeletal tissues. Gender differences in anterior cruciate ligament (ACL) injuries have been studied and it has been discovered that the Estrogen receptor (ER) as well as Progesterone receptor (PR) are expressed in the ACL. Material and Methods: Eight patients with PTTD requiring surgery were enrolled in our pilot study. The mean patient age was 52.4 (range, 18 to 73) years. There were five female and three male patients. Tendon samples were harvested from diseased PTT. Tendon samples harvested from healthy PTT and healthy flexor digitorum longus (FDL) tendon were used as controls. Tendon samples were processed using specific protocols for total RNA isolation from hypocellular, dense connective tissues. ERα and ERβ transcripts were quantified using real time RT-PCR. Quantitative values were obtained from the threshold cycle (Ct) number at which the increase in fluorescent signal associated with an exponential increase of PCR products can be detected. Results: Transcripts of both ERα and ERβ were reproducibly detected in RNA samples isolated from our tendon samples. There was no difference in receptor expression between diseased and control tendon samples. There was no difference in receptor expression between male and female patients. Conclusion: We found that the tenocyte of the PTT and FDL tendons express ERα and ERβ. Normal and diseased tendons of both male and female patients expressed both estrogen receptors. Clinical Relevance: Identifying ERα and ERβ gene expression in the fibroblast was an initial step in discovering whether tenocytes are targets for estrogen function. Estrogen receptors were identified indirectly by measuring receptor gene expression but we were unable to show a significant difference between diseased and control tendons.

Biomechanical Assessment of a New Tenodesis for Correction of Hallux Varus

Each of six below-the-knee amputation specimens were transfixed to a wooden block and mounted to a jig on an amputee testing device preloaded with 5 N applied to the proximal phalanx and displaced at a constant rate of 2 mm/min. Load displacement curves were generated for the intact joint and after sequential incisions of the lateral capsule, the adductor hallucis, and the lateral slip of the flexor hallucis brevis tendon, which caused varus dislocation of the hallux. An extensor hallucis brevis tenodesis was performed after the varus dislocation. Division of the lateral capsule, the adductor, and the flexor brevis reduced the force required to displace the hallux by 42.2%, an additional 25.2%, and a further 14.2%, respectively. Use of the extensor hallucis brevis tenodesis restored the load displacement curves to that of the normal joint. We concluded that the extensor hallucis brevis tendon may be useful as a tenodesis for reconstructing the deformity of acquired hallux varus.

Effectiveness of Composite Bone Graft Substitute Plugs in the Treatment of Chondral and Osteochondral Lesions of the Talus

A review of outcomes in 13 patients with talar dome osteochondral or chondral lesions treated with a bone graft substitute plug was undertaken in an effort to evaluate its effectiveness in comparison with other reported surgical techniques. Mean patient age was 36.4 (range 16 to 57) years. Mean follow-up was 30.1 (range 7 to 43) months. Medial malleolar osteotomy was performed in 9 (69.23%) cases. Average defect diameter was 9.8 (range 5 to 20) mm. Pain decreased significantly from 6.2 (range 3 to 9) to 4.0 (range 0 to 9) (P = .009). Postoperative American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores averaged 67.3 (range 26 to 100). Younger age, smaller defect size, and avoidance of medial malleolar osteotomy resulted in better outcomes. Mean Short Form-36 scores for the study group fell below US norms in all categories, and 12 (92.31%) ankles demonstrated persistent lesions radiographically. Postoperative magnetic resonance imaging in 2 (15.39%) patients demonstrated enlarged lesions, and 4 (30.77%) patients underwent revision surgery that revealed abnormal cartilage around the implant site. Complications included 1 (7.69%) deep venous thrombosis, 1 (7.69%) arthrofibrosis, and 1 (7.69%) superficial neuritis. Despite some improvement in pain, comparison of functional outcome showed bone graft substitute plug implantation to be less effective overall than other operative interventions. Future investigations with more specific selection criteria are warranted to gain further insight into the efficacy of these bone graft substitute plugs.