Steven D. K. Ross

Comparison of Custom and Prefabricated Orthoses in the Initial Treatment of Proximal Plantar Fasciitis

Fifteen centers for orthopaedic treatment of the foot and ankle participated in a prospective randomized trial to compare several nonoperative treatments for proximal plantar fasciitis (heel pain syndrome). Included were 236 patients (160 women and 76 men) who were 16 years of age or older. Most reported duration of symptoms of 6 months or less. Patients with systemic disease, significant musculoskeletal complaints, sciatica, or local nerve entrapment were excluded. We randomized patients prospectively into five different treatment groups. All groups performed Achilles tendon- and plantar fascia-stretching in a similar manner. One group was treated with stretching only. The other four groups stretched and used one of four different shoe inserts, including a silicone heel pad, a felt pad, a rubber heel cup, or a custom-made polypropylene orthotic device. Patients were reevaluated after 8 weeks of treatment. The percentages improved in each group were: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4)stretching only, 72%; and (5) custom orthosis, 68%. Combining all the patients who used a prefabricated insert, we found that their improvement rates were higher than those assigned to stretching only (P = 0.022) and those who stretched and used a custom orthosis (P = 0.0074). We conclude that, when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symp-toms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device.

The Operative Treatment of Fractures of the Os Calcis

Displaced intra-articular fractures of the body of the os calcis are notorious causes of significant and prolonged disability. Treatment recommendations for these injuries have varied widely. An understanding of the anatomy and pathomechanics of the injury is important in treatment selection. Tongue-type and joint depression-type calcaneal fractures are subdivided on the basis of relations of the primary fracture line to the posterior facet. Treatment regimens are also based upon these relations and fracture classification. Choice of surgical approach depends upon the fracture pattern, including secondary comminution. The goal of operative treatment is to reestablish articular congruency, calcaneal width, and early range of motion. Operative treatment can be recommended for fractures that can be accurately reduced and rigidly transfixed. Nonoperative treatment is recommended for those fractures where accurate reduction is unattainable.

Normal Human Synovial Fluid: Osmolality and Exercise-Induced Changes*

We measured the osmolality of human synovial fluid in the knees of healthy young adults following minimum activity and exercise. These results were compared with each subjects blood-serum osmolality. The synovial fluid was hyperosmolal with minimum activity, decreasing to blood-serum levels after exercise.

Internal Compression Arthrodesis of the Ankle

Eight patients with disabling tibiotalar arthritis (one patient with a supramalleolar nonunion) were treated by arthrodesis. The procedure in all of these patients consisted of internal compression obtained by bone plates and the application of a bilateral tension device. A bilateral surgical approach was used. No bone grafting was required. This study compares two groups immobilized for ten and three weeks, respectively. In both groups, the procedure invariably produced union with excellent cosmesis, few complications, and good function.

AMERICAN ORTHOPAEDIC FOOT AND ANKLE SOCIETY SHOE SURVEY OF DIABETIC PATIENTS

A one-page written survey was completed by 402 randomly selected patients with diabetes in five cities during a scheduled visit to their endocrinologist. Patients averaged 61.5 years of age and had been diagnosed with diabetes for 27.3 years. This study suggests that approximately 25% of adults with diabetes are at risk for developing foot ulcers, the precursor to deep infection leading to lower limb amputation. The goal at the inception of this project was to obtain benchmark data on the current level of prophylactic foot care being provided to adult patients with diabetes. The results of this survey suggest that most individuals with diabetes and their physicians are aware of potential diabetic foot morbidity, yet very few take advantage of prophylactic protective footware. Even fewer are presently taking advantage of benefits established through the Medicare Therapeutic Foot Bill. This survey highlights a substantial opportunity for improvement in the long-term care of individuals with diabetes.

FRACTURES OF THE TALUS AND CALCANEUS: EVALUATION BY COMPUTED TOMOGRAPHY

Fractures of the talus and calcaneus may be difficult to evaluate using conventional imaging modalities. Failure to recognize these fractures or to appreciate their extent may result in severe deformity or disability. Patients with talar and calcaneal fractures had computed tomography to assess its role in the management of these fractures. Computed tomography is superior to other imaging modalities in showing the position of the fracture fragments, the number of fragments, the relation of the fracture to the articular surfaces, residual articular changes, and evidence of healing.

Surgical Treatment of the Unstable Lesser Metatarsophalangeal Joint

Pain in a lesser metatarsophalangeal joint is a common presenting complaint and is often simply called metatarsalgia. There are multiple etiologies for metatarsalgia including inflammatory arthropathies such as rheumatoid arthritis, Freiberg infarction, interspace neuromas, pressure problems from overload, and degenerative instability. The focus of this article is on the surgical treatment of degenerative instability of the lesser metatarsophalangeals. The second metatarsophalangeal with its progression to overlapping toe syndrome is the most common example. When conservative measures fail to provide adequate comfort and function, then surgical intervention is indicated. A dorsal approach to the metatarsophalangeal joint through a Z-lengthening of the extensor allows appropriate rebalancing of the soft tissues about the metatarsal head. This is combined with shortening of the proximal phalanx and a long flexor tendon transfer. This approach consistently has provided good and excellent results in 96% of the authors’ patients with an average follow-up of 5 years.

Technical Tip: The Crescentic Shelf: A Modified Ludoff Osteotomy

Level of Evidence: V, Expert Opinion

Special report: Highlights of the Twenty-Fourth Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society, Denver, Colorado, June 26–28, 2008

The Twenty-Fourth Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society (AOFAS) was held 26-28 June 2008 at the Denver Marriott City Center in Denver, Colorado. There were 442 registrants in attendance, including 81 individuals from 21 countries outside the United States. There were 176 abstracts submitted, and 46 (26%) abstracts were accepted for podium presentation.

Special Report: Highlights of the 24th Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society, Denver, Colorado, June 26–28, 2008

I. Chronic Achilles tendon problems. Achilles tendinopathy may include non-insertional and insertional tendinosis28,60. Non-operative treatment may include anti-inflammatory medication, rest, and immobilization28,60. Operative treatment options include tendon debridement and repair, tendon augmentation with a flexor hallucis longus tendon transfer28, endoscopic debridement56, reconstruction using a central tendon splitting approach57, and tendon detachment and reconstruction84. II. Ankle instability. Ankle sprains may result in chronic instability and dysfunction42. Surgical treatment of chronic ankle instability may include the Brostrøm