W. Hodges Davis

Painful os peroneum syndrome: a spectrum of conditions responsible for plantar lateral foot pain.

Plantar lateral foot pain may be caused by various entities and the painful os peroneum syndrome (a term coined by the authors) should be included in the differential diagnosis. Painful os peroneum syndrome results from a spectrum of conditions that includes one or more of the following: (1) an acute os peroneum fracture or a diastasis of a multipartite os peroneum, either of which may result in a discontinuity of the peroneus longus tendon; (2) chronic (healing or healed) os peroneum fracture or diastasis of a multipartite os peroneum with callus formation, either of which results in a stenosing peroneus longus tenosynovitis; (3) attrition or partial rupture of the peroneus longus tendon, proximal or distal to the os peroneum; (4) frank rupture of the peroneus longus tendon with discontinuity proximal or distal to the os peroneum; and/or (5) the presence of a gigantic peroneal tubercle on the lateral aspect of the calcaneus which entraps the peroneus longus tendon and/or the os peroneum during tendon excursion. Familiarity with the various clinical and radiographic findings and the spectrum of conditions represented by the painful os peroneum syndrome can prevent prolonged undiagnosed plantar lateral foot pain. Clinical diagnosis of the painful os peroneum syndrome can be facilitated by the single stance heel rise and varus inversion stress test as well as by resisted plantarflexion of the first ray, which can localize tenderness along the distal course of the peroneus longus tendon at the cuboid tunnel. Radiographic diagnosis should include an oblique radiograph of the foot for visualization of the os peroneum and, if indicated, other imaging studies. Recommended treatment ranges from conservative cast immobilization to surgical approaches including: (1) excision of the os peroneum and repair of the peroneus longus tendon, and (2) excision of the os peroneum and degenerated peroneus longus tendon with tenodesis of the remaining remnant of peroneus longus to the peroneus brevis tendon.

Intermediate to Long-term Follow-up of Medial-approach Dorsal Cheilectomy for Hallux Rigidus

Dorsal cheilectomy of the hallux metatarsophalangeal (MTP) joint through a medial approach can effectively provide long-term relief of pain and improve function in symptomatic mild-to-moderate hallux rigidus, despite progression of generalized first MTP joint arthritic degeneration and/or loss of motion. Fifty-seven patients (75 feet) with arthritis of the first MTP joint underwent dorsal cheilectomy through a medial approach for hallux rigidus failing nonoperative management. Excision of the dorsal articular surface of the first metatarsal head and dorsal osteophytes was performed through a medial approach that also allowed for plantar capsular release and removal of lateral osteophytes. Minimum follow-up was 3 years (average, 63 months; range, 37–92 months). Fifty-two patients (68 feet) returned for clinical and radio-graphic evaluation. American Orthopaedic Foot and Ankle Society Hallux Rating scores improved from a preoperative average of 45 to 85 points at follow-up. Average dorsiflexion improved from 19°, to 39°, and the average range of motion improved from 34° to 64°. Preoperative radiographic grade of arthritic degeneration was grade I in 17 feet, grade II in 39 feet, and grade III in 12 feet; at follow-up, the radiographic grade was grade I in 2 feet, grade II in 26 feet, and grade III in 40 feet. Thirty-two feet worsened one grade, 6 feet worsened two grades, and 28 feet demonstrated no change (12 of 28 were grade III, preoperatively). A dorsal spur recurred in 21 feet, 9 of which were symptomatic. Complications included two superficial wound infections and four transient paresthesias of the hallux, all of which resolved uneventfully.

Gross, Histological, and Microvascular Anatomy and Biomechanical Testing of the Spring Ligament Complex:

In recent years there has been an increased interest in the treatment of acquired pes planus. The breakdown of the medial longitudinal arch is most often seen at the talonaviculocalcaneal articulation. This suggests a relationship between the ligamentous complex at this articulation and acquired pes planus. This study was undertaken to gain a better understanding of the gross, histologic, and microvascular anatomy, as well as the biomechanics of the ligamentous structures surrounding the talonaviculocalcaneal articulation. Cadaver dissections of 38 fresh-frozen feet were performed. Detailed descriptions of the gross anatomy of the superomedial calcaneonavicular ligament, inferior calcaneonavicular ligament, and the superficial deltoid ligament were recorded. Their relationships to the posterior tibialis tendon and to the bones of the talonaviculocalcaneal articulation are described. The histology and microvascularity of these structures were also studied. Preliminary biomechanical testing was performed. It was found there are two definitive anatomic structures that are commonly called the spring ligament: the superomedial calcaneonavicular ligament (SMCN) and the inferior calcaneonavicular ligament (ICN). The SMCN ligament was found to have histologic properties that suggest significant load bearing. The histology of the ICN ligament suggests a pure tensile load function. The deltoid ligament and the posterior tibialis tendon had direct attachments to the SMCN ligament in all specimens. An articular facet composed of fibrocartilage was found in each SMCN ligament specimen. The microvascular structures showed an avascular articular facet present in the ligament. The biomechanical testing showed that the SMCN ligament and ICN ligament had strength similar to ankle ligaments. This study suggests this “spring ligament complex” has more of a “sling” function for the talar head. It is hoped that the better understanding of this region will add to our understanding of the etiology of pes planus and possible treatment alternatives.

Comparison of results of retrocalcaneal decompression for retrocalcaneal bursitis and insertional achilles tendinosis with calcific spur.

Sixteen feet with retrocalcaneal bursitis (RB) and twenty-two feet with calcific Achilles insertional tendinosis (IAT-CS) underwent retrocalcaneal decompression after failure of nonoperative treatment. Follow-up evaluation at least two years after surgery included AOFAS Ankle-Hindfoot subscale scores, satisfaction, time until maximum symptomatic improvement, and radiographs. Statistically significant differences between the groups include the following: IAT-CS patients were older, required nearly twice the time to reach maximum symptomatic improvement, had lower satisfaction rates, had a lower pain score, and more frequently had shoewear restrictions. Radiographic recurrence did not correlate with outcome or symptomatic recurrence.

Dorsiflexion metatarsal osteotomy for treatment of recalcitrant diabetic neuropathic ulcers.

Twenty diabetic patients underwent 22 dorsiflexion metatarsal osteotomies for treatment of chronic persistent or recurrent neuropathic forefoot ulcers. Mean duration of nonoperative treatment was 13 months. The procedure consisted of irrigation and debridement of the ulcer followed by basilar closing wedge metatarsal osteotomy performed through a dorsal approach. At follow-up, complete ulcer healing was noted in 21 cases (95%) at an average of 40 days postoperatively. Complications occurred in 15 cases (68%). The main problems encountered postoperatively were acute Charcot disease (32%) and deep wound infections (14%). Transfer lesions under adjacent metatarsal heads developed in two cases (9%). One ulcer (5%) failed to heal secondary to vascular insufficiency and eventually required a below the knee amputation after a failed revascularization attempt. Loss of screw fixation occurred in one patient (5%) but acceptable metatarsal alignment was maintained and the ulcer healed uneventfully. There were no cases of ulcer recurrence. The results of this study suggest that dorsiflexion metatarsal osteotomy is a reliable salvage procedure for the treatment of recalcitrant neuropathic forefoot ulcers that have failed an adequate trial of nonoperative treatment. This procedure is associated with a high complication rate, as would be expected in this patient population.

Clinical evaluation of the modified Brostrom-Evans procedure to restore ankle stability.

The modified Brostrom procedure has become the standard for anatomic repair of symptomatic chronic lateral instability. However, it was our perception that this local tissue repair may fail eventually, particularly in patients that are overweight, hyperflexible, or are involved in strenuous work or athletic activity. This is a retrospective review of 21 lateral ankle reconstructions (20 patients) in which the modified Brostrom technique was augmented with a portion of the peroneus brevis tendon. All patients were interviewed at an average of 29.5 months (range, 14–56 months postsurgery). Fourteen patients also agreed to be evaluated by a physical therapist. No surgical complications were identified. American Orthopaedic Foot and Ankle Society ankle-hindfoot scores averaged 98.2. There was no significant difference in passive or active range of motion of plantarflex-ion or dorsiflexion when compared to the contralateral ankle. However, a statistically significant loss of inversion (passive, P = 0.011; active, P = 0.018) and eversion (passive, P = 0.004; active, P = 0.007) was noted when compared to the contralateral ankle. Measurement of isometric eversion strength, using a Cybex 340 Isoki-netic device, and functional testing, using a lateral lunge test, revealed no significant loss of peroneal strength. The authors conclude that chronic lateral ankle instability in the general population can be successfully managed with a modified Brostrom procedure augmented with a portion of the peroneus brevis. The procedure remains technically simple and provides a greater static restraint for inversion stress without evidence of dramatic overtightening or loss of peroneal strength.

Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures.

Background: The optimal method for treating intra-articular fractures of the calcaneus remains controversial. Extensile approaches allow excellent fracture exposure, but high rates of wound complications are seen. Newer minimally invasive techniques for calcaneus fracture fixation offer a potentially lower wound complication rate, but long-term clinical results are not available. The aim of this study was to compare the outcomes of intra-articular calcaneus fractures treated with open reduction and internal fixation via an extensile approach versus those with a minimally invasive sinus tarsi approach. Methods: We performed a retrospective review of all intra-articular calcaneal fractures treated operatively between October 2005 and December 2008. A total of 112 fractures were found that met our inclusion criteria; 79 were treated with an extensile lateral approach and 33 via a minimally invasive approach based on surgeon preference. Chart and radiographic results were thoroughly reviewed on all 112 fractures, specifically for wound healing complications and the need for further surgeries within the study period. Additionally, all patients were contacted and asked to return for a research visit that included radiography, clinical examination, and quality of life questionnaires (Short Form 36 [SF-36], foot function index [FFI], visual analog scale [VAS] pain). A total of 47 of 112 (42%) patients returned for a research visit (31 extensile, 16 minimally invasive). Results: The 2 groups were comparable with regard to demographics (age, follow-up, male to female ratio, tobacco use, diabetes, workers’ compensation status). In the extensile group, 53% of fractures were Sanders II and 47% were Sanders III, whereas in the minimally invasive group 61% were Sanders II and 39% were Sanders III. The overall wound complication rate was 29% in the extensile group (9% required operative intervention) versus 6% in the minimally invasive group (P = .005) (none required operative intervention). Overall, 20% of the extensile group required a secondary surgery within the study period versus 2% in the minimally invasive group (P = .007). In the group of patients who returned for research visits, the average FFI total score was 31 in the extensile group versus 22 in the minimally invasive group (P = .21). The average VAS pain score with activity was 36 in the extensile group versus 31 in the minimally invasive group (P = .48). Overall, 84% of patients in the extensile group were satisfied with their result versus 94% in the minimally invasive group (P = .32). Both groups had 100% union rates, and no differences were noted in the final postoperative Bohler’s angle and angle of Gissane. Conclusion: Clinical results were similar between calcaneal fractures treated with an extensile approach and those treated with a minimally invasive approach. However, the minimally invasive approach had a significantly lower incidence of wound complications and secondary surgeries. The minimally invasive approach was a valuable method for the treatment of intra-articular calcaneal fractures, with low complication rates and results comparable to those treated with an extensile approach. Level of Evidence: Level III, retrospective comparative case series.

Injury Characteristics and the Clinical Outcome of Subtalar Dislocations: A Clinical and Radiographic Analysis of 25 Cases

The objective of this study was to determine the mechanisms of injury and pattern of associated foot and ankle injuries and systemic injuries associated with subtalar dislocations, and, correlate these data with the radiographic and clinical/functional outcome of patients after subtalar dislocation. Results: Twenty-five patients with a subtalar dislocation were identified over a seven year period. The mean patient age was 38 years. Males (n=19) comprised 76% of patients, with a mean age of 36 years. High energy mechanisms (motor vehicle accidents, falls) accounted for 68% of subtalar dislocations. Although high energy mechanisms showed a strong trend toward open subtalar dislocations, the association was not statistically significant (p=0.0573, Fishers exact test). Closed dislocations predominated (75%). Left and right-sided dislocations were nearly equally distributed, even among motor vehicle accidents. Medial dislocations predominated (65%): these were not influenced by mechanism of injury and did not result in statistically lower AOFAS ankle/hindfoot scores. Subtalar dislocation was irreducible (requiring open reduction) in 32%, with higher energy mechanisms of injury being statistically associated with an irreducible subtalar dislocation (p=0.0261, Fishers exact test). Block to reduction was evenly distributed among soft tissue elements (posterior tibial tendon, flexor hallucis longus tendon, capsule, extensor retinaculum) and osseous elements. Eighty-eight percent of patients incurred concomitant injuries to the foot and ankle (95% of which were closed injuries), namely, the ankle and talus. Systemic injuries occurred in 88% of patients. At a mean follow-up of five years, the mean AOFAS score of the subtalar dislocation side was significantly lower (mean=71 vs. 93, p=0.0007, unpaired Students t-test). No statistical relation was found between the number of associated extremity injuries and AOFAS score (Spearman correlation coefficient, r=(–)0.236, p=0.331). Radiographic follow-up demonstrated 89% of ankles with radiographic changes (31% symptomatic); however, the majority of these patients (61%) had an associated ankle injury. The subtalar joint demonstrated radiographic changes in 89% of patients, with 63% being symptomatic; 75% of patients with subtalar joint changes incurred a fracture about the subtalar joint at the time of dislocation. Four patients went on to subtalar fusion at an average of 8.8 months post-dislocation. The midfoot showed radiographic changes in 72% of patients, with only 15% of these patients being symptomatic. All patients with midfoot symptoms were well controlled by nonsurgical measures.

Results of in Situ Subtalar Arthrodesis for Late Sequelae of Calcaneus Fractures

A retrospective review was performed on all patients who had an in situ subtalar arthrodesis for painful sequelae of calcaneus fractures between 1989 and 1994. Nineteen feet were available for evaluation, with a mean follow-up of 27 months (range, 12–62 months). Lateral calcaneal wall decompression was performed in seven feet. Although loss of ankle dorsiflexion was associated with anterior ankle tenderness, loss of ankle dorsiflexion was not correlated with either talar declination angles or talar height differences. There was no correlation between American Orthopaedic Foot and Ankle Society hindfoot score and talar declination, talar height, or calcaneal width. Peroneal tendon/subfibular impingement, ankle tenderness, sural nerve injury and patient smoking were all statistically associated with lower scores. The calcaneocuboid joint was frequently involved in the fracture but was not painful at follow-up. Late pain after a calcaneal fracture is not caused by only subtalar arthrosis. Radiographic criteria alone cannot be relied upon for surgical decision making. Careful physical evaluation should be used to determine sources of pain. Distraction arthrodesis should be considered only if findings of anterior ankle impingement are present. If sural nerve symptoms are present, a sural neurectomy may be added to the procedure. Pain localized to the plantar fat pad should be managed nonoperatively. Radiographic changes in the calcaneocuboid joint rarely require surgical intervention. Based on these results, in situ subtalar arthrodesis with lateral wall decompression is the procedure of choice in most cases of subtalar traumatic arthritis with lateral wall impingement.

Complications of midfoot and hindfoot arthrodesis

Midfoot and hindfoot arthrodeses traditionally have been done to treat deformities resulting from paralytic disorders, residual clubfoot deformity, and posttraumatic arthritis. The surgical indications for midfoot and hindfoot arthrodeses more recently have been expanded to include painful arthritic deformities associated with neuroarthropathy, seropositive or seronegative arthropathies, and neurologic disorders. Regardless of the joint fused or the technique used, the goal of each remains similar: the creation of a painless, plantigrade foot capable of being fitted into, at the very least, a custom shoe. The aim of the current study is to describe the major complications associated with midfoot and hindfoot fusions in adults, and the prevention and the treatment of these complications.