William R. Post

Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome study.

Chronic plantar fasciitis frustrates patients and treating physicians. Our hypothesis was that use of a dorsiflexion night splint for 1 month would effectively treat patients with recalcitrant plantar fasciitis. A 6-month randomized crossover study included 37 patients with chronic plantar fasciitis. Patients were treated with dorsiflexion night splints for 1 month. Group A wore splints for the 1st month and group B for the 2nd month. No splints were used in either group for the final 4 months of the study. No other medications, stretching, or strengthening exercises were prescribed. Eighty-eight percent of patients who completed the study improved. Eighty percent of the involved feet improved subjectively. Results of the AOFAS Ankle-Hindfoot Rating System 17 and the Mayo Clinical Scoring System 7 demonstrated significant improvement for both groups during the period of splint wear. Improvements were maintained at study completion. Response to splinting did not correlate with foot type, degree of obesity, or the presence of heel spur on radiographs. We believe dorsiflexion splints provide relief from the symptoms of recalcitrant plantar fasciitis in the majority of patients.

Load to failure of common meniscal repair techniques : Effects of suture technique and suture material

Success of meniscal repair with early or immediate motion depends on the ability of the suture fixation to withstand the loads applied. Vertical and horizontal mattress suture techniques were tested using 2-0 Ethibond, and 0-PDS and 1-PDS sutures (Ethicon, Somerville, NJ). Mulberry knot technique was tested with 0-PDS and 1-PDS sutures. Twenty menisci (60 sutures) were tested for each suture material. Sutures were placed 3 to 4 mm from the peripheral edge of the meniscus with double barreled cannulas for vertical and horizontal mattress techniques or a spinal needle for the mulberry knot technique, reproducing clinical techniques of meniscal repair. Mechanical testing of suture fixation was performed to failure at a rate of 10 mm/min on a MTS material testing system (MTS Systems Corp, Minneapolis, MN). Suture pullouts were reported as the load displacement to failure from the inner fragment only, because clinical failure would ensue should a suture pull through the inner fragment of a tear. Vertical mattress technique with 1-PDS suture had significantly greater load to failure than any other combination (P < .05). Analysis of variance showed that the vertical mattress technique had statistically superior pullout strength (P < .0001) compared with the horizontal mattress and mulberry knot techniques, which were statistically similar. There were significant differences (P < .0001) between suture types, with 1-PDS proving best compared with 0-PDS, which was stronger than 2-0 Ethibond. Selection of suture material had the greatest impact on vertical mattress load to failure and was not important to the strength of the other techniques.

The Female Knee: Anatomic Variations and the Female-specific Total Knee Design

AbstractThe concept and need for a gender-specific or female-specific total knee prosthesis have generated interest and discussion in the orthopaedic community and the general public. This concept relies on the assumption of a need for such a design and the opinion that there are major anatomic differences between male and female knees. Most of the information regarding this subject has been disseminated through print and Internet advertisements, and through direct-to-patient television and magazine promotions. These sources and a recent article in a peer-reviewed journal, which support the need for a female-specific implant design, have proposed three gender-based anatomic differences: (1) an increased Q angle, (2) less prominence of the anterior medial and anterior lateral femoral condyles, and (3) reduced medial-lateral to anterior-posterior femoral condylar aspect ratio. We examined the peer-reviewed literature to determine whether women have had worse results than men after traditional TKAs. We found women have equal or better results than men. In addition, we reviewed the evidence presented to support these three anatomic differences. We conclude the first two proposed differences do not exist, and the third is so small that it likely has no clinical effect. Level of Evidence: Level IV, systematic review. See the Guidelines for Authors for a complete description of levels of evidence.

Knee pain diagrams: Correlation with physical examination findings in patients with anterior knee pain

All new patients who presented with knee problems were asked to fill out standard knee pain diagrams before being evaluated. Completed diagrams were not seen by the examining physicians. After obtaining the history and performing the physical examination, one of four physicians marked an identical diagram with the areas of tenderness. Ninety patients with a provisional diagnosis of patellofemoral pain completed 109 (19 bilateral) pain diagrams. Evaluation of the diagrams was quantitated by division of the diagrams into nine zones. The researcher grading the diagrams was blind to whether the diagrams were drawn by the patient or physician. Patients marked an average of 4.23 zones per knee compared with 2.66 zones for physicians. In 88% (96 of 109) of the knees, the physician diagram included all or some of the zones marked by the patients. Eighty-five percent of all zones marked by physicians were included in patient diagrams. Eighty-six percent of negative patient zones correctly predicted a negative examination. Overall frequency of positive findings in each of the nine zones was consistent between patient and physician diagrams. A physician can be confident that findings of tenderness will likely be within zones marked by a patient on a standard diagram of the knee. Pain diagrams facilitate proper diagnosis by correctly directing attention to areas of tenderness in a large percentage of cases and provide an inexpensive and highly useful prediction of areas of anterior knee tenderness in patients with patellofemoral pain.

The Effects of Bone Plug Length and Screw Diameter on the Holding Strength of Bone-Tendon-Bone Grafts

The effect of bone plug length and Kurosaka screw (DePuy, Warsaw, IN) diameter on graft holding strength of the bone-tendon-bone construct was determined. Random length porcine bone plugs were assigned to fixation with 7 or 9 mm Kurosaka screws. Peak load to failure was determined. There was a significant decrease in peak load to failure of the 5-mm long bone plugs compared with longer bone plugs. No difference was found between longer lengths of bone plug in either the 7- or 9-mm screw diameter groups. The 9-mm diameter screws significantly increased peak load to failure for both 1- and 2-cm bone plug lengths.

Open or arthroscopic lateral release. Indications, techniques, and rehabilitation.

Careful patient selection, accurate surgical technique, and careful postoperative rehabilitation are all equally important to success in lateral release surgery. Whether the surgery is performed by open or arthroscopic technique, one must release all layers of the retinaculum, spare the vastus lateralis, extend the release far enough distally, check intraoperative patellar mobility, and obtain absolute hemostasis. Postoperative rehabilitation must stress pain control, early quadriceps contraction, patellar mobility, and knee motion. With attention to these details, successful lateral release surgery is likely in most patients with pathologic lateral patellar tilt and minimal patellofemoral arthrosis.

The intra- and inter-observer reliability of the physical examination methods used to assess patients with patellofemoral joint instability

BACKGROUND An accurate physical examination of patients with patellar instability is an important aspect of the diagnosis and treatment. While previous studies have assessed the diagnostic accuracy of such physical examination tests, little has been undertaken to assess the inter- and intra-tester reliability of such techniques. The purpose of this study was to determine the inter- and intra-tester reliability of the physical examination tests used for patients with patellar instability. METHODS Five patients (10 knees) with bilateral recurrent patellar instability were assessed by five members of the International Patellofemoral Study Group. Each surgeon assessed each patient twice using 18 reported physical examination tests. The inter- and intra-observer reliability was assessed using weighted Kappa statistics with 95% confidence intervals. RESULTS The findings of the study suggested that there were very poor inter-observer reliability for the majority of the physical tests, with only the assessments of patellofemoral crepitus, foot arch position and the J-sign presenting with fair to moderate agreement respectively. The intra-observer reliability indicated largely moderate to substantial agreement between the first and second tests performed by each assessor, with the greatest agreement seen for the assessment of tibial torsion, popliteal angle and the Bassetts sign. CONCLUSIONS For the common physical examination tests used in the management of patients with patellar instability inter-observer reliability is poor, while intra-observer reliability is moderate. Standardization of physical exam assessments and further study of these results among different clinicians and more divergent patient groups is indicated.

The effects of cyclic loading on tensile properties of a rabbit femur–anterior cruciate ligament–tibia complex (FATC)

Abstract The purpose of this study was to investigate the effect of cyclic loading on tensile properties of femur–ACL–tibia complexes (FATCs). Paired FATCs of New Zealand white rabbits were tested. One specimen of each pair was designated as a control and loaded until failure. The contralateral specimen was cyclically loaded and then loaded until failure. In specimens cyclically loaded with 40% of control ultimate tensile strength (UTS), UTS decreased significantly compared to controls. Half the specimens of the 50% group were ruptured during cyclic loading. Load-to-failure of FATCs can be decreased by cyclic loading in the range of 40∼50% of their UTS. Cycled specimens had a significantly higher incidence of intrasubstance failure pattern as compared to controls. This result correlates well with clinical experience.

Patellofemoral Instability: A Consensus Statement From the AOSSM/PFF Patellofemoral Instability Workshop:

To come to some consensus on the state of knowledge and opinion regarding the definitions of patellofemoral stability and instability, the clinical evaluation of patients with suspected patellar instability, treatment recommendations, and future directions of study on this subject, a workshop was jointly funded by the American Orthopedic Society for Sports Medicine (AOSSM) and the Patellofemoral Foundation (PFF), a nonprofit corporation with a mission to improve the care of patients with anterior knee problems through targeted research and education. Sixteen individuals with recognized expertise and experience from the fields of orthopaedic surgery, physical therapy, and basic science were invited to participate.

Percutaneous tensioning of the glenohumeral ligaments during arthroscopic bankart repair

Tensioning of the inferior glenohumeral ligament complex (IGLC) before arthroscopic repair is a critical step in restoring stability. This article describes a simple surgical technique to tension the IGLC percutaneously before arthroscopic fixation. This technique eliminates the need for grasping instruments and a second anterior portal.