Foot & Ankle International

Nineteen patients with 28 feet with congenital vertical talus were reviewed. The male to female ratio was equal, and associated congenital abnormalities were found in 15 of the 19 patients. No genetic pattern was established. Fifteen of the 16 surgically corrected feet were reevaluated, with an average follow-up of 60 months. Ten of the 15 feet were found to be in the good to excellent category, and five were rated poor. Twelve of 12 feet treated by cast correction were poor. Poor prognostic signs include late age of surgical correction, associated arthrogryposis and cerebral palsy, and an increased space between the calcaneus and cuboid. Best results occurred in those patients who had early surgical correction, after 4 to 6 months of serial casting, using magnification. Surgical technique which yielded the best results involved total release of the talus from the posterior, medial, and lateral approach, with reduction of the talocalcaneal as well as the talonavicular joints with multiple pin fixation. Lengthening of the Achilles tendon, extensor tendons, and peroneal tendons and transfer of the anterior tibialis to the navicular are recommended. Navicular excision was not found to be necessary. Surgical results in those patients over 3½ years of age were found to be poor, and these individuals were considered for salvage procedures using a subtalar extra articular arthrodesis, excision of the navicular, or triple arthrodesis, depending on age.

A review of children with talar injuries treated at the Winnipeg Children's Hospital yielded 12 patients that had been treated for fractures of the neck of the talus between 1960 and 1978, inclusive. Three developed avascular necrosis of the body of the talus; two of these had their fractures recognized only after avascular necrosis had become radiologically evident. The children ranged in age from 1 year 7 months to 13 years 11 months at the time of the injury. Fracture of the neck of the talus does occur in children and may be associated with avascular necrosis of the body. This injury should be considered and the talus should be examined in all children sustaining trauma secondary to falls from a height or motor vehicle trauma.

Preoperative and postoperative dynamic gait electromyography (EMG) was performed on 15 patients 8 to 13 years of age with Duchenne's muscular dystrophy who underwent Achilles tendon lengthening and posterior tibial tendon transfer anteriorly through the interosseous ligament for correction of equinus and equinovarus foot deformities.

The muscles tested preoperatively (anterior tibial, soleus, gastrocnemius, posterior tibial, peroneal longus, and peroneal brevis) showed phase changes. It is believed that patients with weakened leg muscles fire multiple muscle groups out of phase in an attempt to overcome the action of the stronger muscles, thus stabilizing the limb for ambulation. Postoperative EMGs, performed with the patients walking in long leg braces after the deformity had been corrected, showed litte activity in the muscles tested. As the patients became dependent on the brace, the need for the muscles to be active out of phase was eliminated. The transferred posterior tibial muscle appeared to be active both clinically and electromyographically.

Utilizing an apparatus for separately testing the status of the anterior talofibular and the calaneofibular ligaments of the ankle in 25 healthy, 15 to 30-year-old adults, it became apparent that the stability of the ankle depends primarily upon the integrity of the anterior talofibular ligament. When the “fore n' aft” stress measurement exceeds 4 mm, a positive anterior drawer test is elicited, and the ankle ligament needs surgical repair. Tibial talar tilt normals ranged up to 18°.

Repair (early and late) is accomplished by suturing what one finds (there is always some ligament present) and reinforcing the anterior talofibular ligament repair with overlap of the nearby lateral talocalcaneal ligament plus the marginal ankle retinaculum. Four weeks in a plaster of paris walking cast are followed by use of Ace bandages for 2 weeks. Light activity is begun 6 weeks after repair, and activity of choice is begun 8 weeks after repair. Repeat stress testing is performed at 3 months postsurgery, and a questionnaire is completed at the same time. On a point system (1 to 10) reviewing pain, stability, and swelling, the results in 50 cases rate from 8 to 10, with a lower rating improving with more time. Surgical time is approximately 30 minutes.

There seems to be no need for more radical surgery utilizing other muscles. The senior author has employed this surgery for the past 19 years with approximately 165 cases. Only 50 patients with proper 3-month postoperative stress testing and questionnaire follow-up, who were operated upon 1 or more years ago, are recorded here.

The clawtoe or hammertoe deformity is frequently encountered in office practice. The etiology of this condition remains obscure, although intrinsic atrophy or imbalance was suspected as early as 1863 by Duchenne. Arthrodesing the proximal interphalangeal joint converts the more powerful flexor tendon to a flexor of the metatarsophalangeal joint, thereby alleviating pressure on the metatarsal head and distributing the weight more evenly on the forefoot. Arthrodesing is accomplished by the peg and dowel method, with the fourth toe presenting the most technical difficulties. An extensor tenotomy or dorsal capsulotomy of the metatarsophalangeal joint is frequently necessary to realign the toe with the corresponding metatarsal ray. A collodian dressing is used to immobilize the toe for a period of 4 to 6 weeks, with a fusion rate of 97% in 73 toes. All patients were contacted, with 87% responding favorably and stating that they had relief of their pain and were able to resume wearing normal footwear.

A long-term follow-up was evaluated on silastic implant arthroplasty performed on five patients (seven feet) for pathology of the metatarsophalangeal joint of the hallux. Four patients (five feet) displayed an inflammatory reaction in the immediate postoperative period with considerable swelling about the operative site. Subsequently, these patients developed either delayed wound healing of mild skin necrosis with secondary superficial infection. Three patients (five feet) ultimately developed implant failure via fracture of the prosthesis and/or erosion through the articulating surface of the prosthesis. All patients had late roentgenographic findings of resorption of bone around the implants. These complications necessitated removal of implants in three patients (five feet). Implant removal was recommended but refused in two patients (two feet).

For over 100 years, many different types of external fixation have been used to immobilize fracture fragments. The greatest aceptance of external fixation has been with open fractures of the tibia.

Three ankle fusions, all complex cases, were performed using the double-framed Hoffmann external fixation device. The deformities treated were a severe posttraumatic equinus deformity of the ankle and forefoot, a painful nonunion of a previous ankle fusion, and an equinus deformity secondary to a transmetatarsal amputation.

One-hundred sixty-four knee injuries in runners with abnormal foot configuration were reviewed and followed. Definite injury patterns related to pronation and cavus configuration of the foot are seen, and specific treatment can be made.

This study presents a common finding in the first metatarsal bone of a distal epiphyseal cartilage which is considered as a physis. This growth center is omitted in the classic anatomical descriptions of the bone.

Analyses of the growth of this physis relates to the metatarsal formula of the adult foot. It may result in a first metatarsal “index-plus,” where the first metatarsal is longer than the second, depending upon the duration of the activity of the physis.

The presence of this physis may be related, in some cases, to:Hallux rigidus. The conformation of index-plus anatomically predisposes the development of such degeneration.Kohler's metatarsal disease. Disturbance in the arterial vascularity of the epiphyseal-metaphyseal type may, in theory, cause osteonecrosis of the first metatarsal head, although no cases have been reported in the literature.Osteochondritis dissecans. Our finding that disorders of epiphyseal ossification may lead to the development of osteochondritis dissecans.