Ralph Lusskin

Correction of hypermobile flatfoot in children by molded insert.

One hundred feet in 50 children between the ages of 3 and 9 years with a diagnosis of idiopathic hypermobile flatfoot had a custom-molded insert ordered. A specific method of casting, correcting the various components of the deformity was utilized. An 1/8-inch polypropolene insert was fabricated from the positive cast. The insert was worn in leather shoes with a long counter, steel shank, and Thomas heel. The flatfoot was evaluated and classified by measurement of the talometatarsal angle on a standing lateral X-ray. The insert was fabricated so that the standing lateral talometatarsal angle was corrected to neutral with the insert on the foot and the foot in the shoe. The preliminary reports indicate that a correction can be obtained at the rate of 0.41° per month or approximately 5° per year. There was no significant loss of motion of the foot or the ankle. Perhaps this regimen may be utilized in those children with a hypermobile flatfoot for whom treatment is advised.

Post-traumatic lesions of the brachial plexus: treatment by transclavicular exploration and neurolysis or autograft reconstruction.

Between 1963 and 1970 twenty patients underwent exploration of the brachial plexus for post-traumatic neural deficits. Nineteen had paralysis and of these nineteen three had clinically significant pain as well. The remaining patient, previously treated by amputation, had exploratory surgery because of pain. Operation resulted in significant improvement in thirteen of the seventeen who had neurolysis and in both of the patients who had autografting. Pain referred to the peripheral distribution of the plexus was not relieved by silicone capping of the ends of the severed nerves emanating from the plexus in one patient or by neurolysis in two others. Subsequent rhizotomy was helpful in two of these three patients.

Squamous Cell Carcinoma Complicating Chronic Osteomyelitis in a Toe: A Case Report and Review of the Literature

Squamous cell carcinoma arising from chronic osteomyelitis is uncommon. Although the majority of cases occur in the lower extremity, incidence in the foot is relatively rare, and in the toe, exceptional. This report illustrates a particularly unusual incidence of squamous cell carcinoma complicating chronic osteomyelitis of the hallux. Guidelines for early diagnosis, recommendations for treatment, and prognostic data are included.

Ankle reconstruction for malunion by fibular osteotomy and lengthening with direct control of the distal fragment: a report of three cases and review of the literature.

Malunion of ankle fractures will lead to severe osteoarthritis when the architecture and mechanics of the talocrural joint are deranged. When fibular shortening is present, ankle reconstruction can be achieved by fibular lengthening and can provide an alternative to early arthrodesis for deformity and pain. Acceptable clinical and radiographic results can be achieved, provided that accurate reconstruction is achieved and intra-articular osteochondral injury is minimal. Restoration of fibular length, necessary for a good clinical result, can be estimated radiographically by the bimalleolar angle. We report three cases of ankle reconstruction by fibular lengthening with an average follow-up of 33 months.

Acute disruption of the posterior tibial tendon associated with open-fracture dislocation of the ankle.

A 27-year-old man with a high-energy, open-fracture dislocation of the ankle underwent debridement and open reduction of his injuries. During surgery a disruption-laceration of the posterior tibial tendon at the level of the fracture of the medial malleolus was found. Repair required location of the proximal muscle and tendon and controlled traction of the musculotendinous unit from its retracted position. Common aspects in the nine previously reported instances of this lesion include relatively high energy of the injury and the fracture type, a transverse fracture in the medial malleolus. Unique to this case was the open injury.

Evaluation and Therapy After Injury to Peripheral Nerves

Peripheral nerve injuries from whatever cause should be classified according to the degree of axon, fascicle, and main nerve trunk damage. This approach is useful in assessing the chances for spontaneous recovery and planning for surgery directed at improving neural recovery. Evaluation over time may be required to better classify the degree of injury. Once recovery slows or ceases, the surgical approaches available include neurolysis, nerve repair, nerve transposition, autograft reconstruction, and various procedures directed at painful neuromata. With proper mobilization and protection of neural and vascular structures, even extensive orthopaedic reconstructive procedures may be performed. Ischemic neuritis and myopathies may be improved by such combined approaches.

The Anatomy and Physiology of the Peripheral Nerve

The anatomy and physiology of nerve tissue and the peripheral nerve are reviewed. The importance of the anatomical and physiological understanding of nerve tissue in the surgical repair of nerve injuries is discussed. This includes an outline of the light and electron microscopic histology of nerve and a short review of axoplasmic flow. In addition, the nerve coverings, endoneurium, perineurium, and epineurium, are described. The relationship of these coverings to the surgical therapy of nerve injuries is outlined. By maintaining, where possible, nerve fascicle continuity and by restoring, where practical, the normal physiology of distorted but not disrupted fascicles, with the use of careful internal neurolysis, optimal clinical return of function should be achieved.

Malignant granular cell tumor mimicking herniated nucleus pulposus

Peripheral nerve tumors may arise in any nerve, large or small. Their presence is readily apparent when they are superficial, but when they are located in a deep nerve, symptoms can mimic+ the nerve root pain of herniated nucleus pulposus. This case of malignant granular cell tumor, probably of Schwann cell origin, involved the sciatic and tibial nerves in the popliteal fossa. Originally the pain was assumed to be produced by a herniated nucleus pulposus. The discovery of the mass thus +was delayed. The mass gave a heterogeneous signal on magnetic resonance imaging studies. A peripheral origin of nerve pain should be considered whenever pain radiates to a limb. A complete physical examination that includes palpation of the nerve to which pain is referred gives the best clue as to the true cause of pain when a peripheral nerve tumor is present.

Surgical management of late post-traumatic and ischemic neuropathies involving the lower extremities: classification and results of therapy.

Traumatic/ischemic events such as fractures, dislocations, lacerations, compression, vascular injuries, and embolus can result in several degrees of nerve injury with resultant sequelae of paralysis, sensory loss, and irritative phenomena (pain, hyperesthesia, and dysesthesia). Neuroma pain may prevent rehabilitation following amputation or nerve lacerations. Thirty-four patients with the late sequelae of traumatic/ischemic neuropathies underwent 36 neural operations using magnification techniques to define and repair neural lesions. Major bone and joint reconstruction could be performed at the same operation with protection of arterial and venous supply. A recovery score using defined criteria for motor, sensory, and irritative (pain) recovery has been developed to quantify the end results in compression/ischemia, contusion/stretch, laceration, idiopathic/irritative disorder, and painful neuroma. Excellent and good results were found in 39 of the 87 specific deficits analyzed (45%). Thus, there is the possibility of improved results in these late neuropathies with therapy before irrevocable muscle fibrosis occurs and intractable pain develops.

Upper Extremity Paralysis Consequent to Brachial Plexus Injury: Partial Alleviation Through Neurolysis or Autograft Reconstruction

While many brachial plexus injuries are irreversible, and others evidence spontaneous recovery, in a large group of patients spontaneous improvement is not seen but potential for nerve recovery can nevertheless be demonstrated. The authors present a plan of management in which those patients in whom surgical intervention might be justified are identified; the operation designed to effect improved function is described, and experience with a small group of patients so treated is summarized.