Foot & Ankle International

To determine whether definitive radiographic criteria could be elucidated tor the Grice-Green extra-articular subtalar arthrodesis, all 70 cases performed at the Shri-ner's Hospital for Crippled Children, Erie, Pennsylvania, from 1972 to 1980 were reviewed. Patients were followed both clinically and radiographically an average of 4 years and 11 months. Major conclusions were as follows: 1) the standing lateral talocalcaneal angle is the most reliable measurement for operative selection and assessment of postoperative success; and 2) by using strict operative techniques and proper patient selection, a 90% success rate can be expected.

The extraosseous and intraosseous vascularity of the talus was studied in 26 fresh cadaver limbs. The specimens were injected with latex or Batson's compound, debrided by a nondissection technique, and cleared by a modified Spalteholz method. The extraosseous vascularity was through the branches of the three major regional arteries which entered the five nonarticulating surfaces of the bone. The major blood supply to the body was provided by the artery of the tarsal canal. The deltoid and sinus tarsi vessels provided significant minor sources of vascularity. The superior neck and posterior tubercle vessels supplied small areas of the body, but did have anastomoses with the other arteries in some specimens. These vascular patterns correlated well with the reported incidence of avascular necrosis of the body of the talus following injury.

The calcaneotibial and posterior talotibial ligaments slacken and the naviculotibial ligament tightens as the nakle plantarflexes; the reverse occurs in ankle extension. The naviculotibial ligament increases its length and the posterior talotibial ligament relaxes in abduction. The cutting of the posterior talotibial ligament repercutes on other parts of the medial collateral ligament. The cutting of other parts of the medial collateral ligament produces very little change on the posterior talotibial ligament. When the whole medial collateral ligament is severed, there is a lateral displacement of the talus. This may be important in the diagnosis and surgical treatment of a torn medial collateral ligament.

Cadaveric anterior talofibular ligaments, with their associated bone attachments, were tensile tested to destruction. The ligament ruptured by either bone avulsion from the talus or midsubstance failure. The values of tensile strength varied from 58 to 556 newtons with a mean strength of 206 newtons.

A simplified, predictable method of peripheral nerve block at the ankle and foot with a long acting anesthetic agent bupivacaine (Marcaine) 0.5% is presented. Combined with the use of a pneumatic tourniquet it allows the performance of mid and forefoot surgery on an inpatient or outpatient basis. It alleviates the risks of general or spinal anesthesia and avoids the use of analgesics for a period of 10 to 25 hours. The posterior tibial nerve is blocked at the level of the neurovascular tunnel on the posterior aspect of the distal tibia. The deep peroneal nerve is blocked at the level of the midtarsus in the fourth fascial compartment. The intermediate and medial dorsal cutaneous branches of the superficial peroneal nerve and the saphenous nerve are blocked subcutaneously on the dorsum of the foot. The sural nerve is blocked subcutaneously at one fingerbreadth distal to the tip of the lateral malleolus. The results have been excellent to good. No adverse reactions occurred affecting the central nervous system or the myocardium.

Fourteen displaced intra-articular fractures of the os calcis are reviewed following open reduction and internal fixation using a lateral approach with an average follow-up of 22 months (range, 12 to 44 months). Postoperative management consisted of early subtalar motion with delayed weightbearing. Twelve of 14 fractures were considered good results on the basis of no pain, 50% normal subtalar motion, and near-normal anatomy. Pain correlated with incomplete reduction of the superomedial fragment and, thus, incongruent reduction of the posterior facet in two cases. The importance of effecting a reduction of the superomedial border of the os calcis is emphasized.

In 20 years through 1981, the author performed 1841 clean foot and ankle operations without any prophylactic antibiotics. Excluded from this study group are patients with compound fractures or open wounds, prior infection, toenail procedures, and other superficial operations. All postoperative wound infections were recorded in a timely manner and healing was documented. Infections occurred in 41 cases (gross infection rate, 2.2%). Thirty-seven cases healed without further surgery and without sequellae from the infection. Three cases required further surgery. One patient developed narrowing of the ankle joint (permanent damage rate, 0.05%). These four patients represent 0.22% of the study group.

All Americans, and most likely all individuals in all societies, have mismated feet; that is, the two feet of probably no individual are exactly alike in size, shape, or proportions. This conclusion was based on the findings of a demographic foot-measurement survey embracing 6800 adults (4000 females, 2800 males), conducted in 1981–1982 by the Prescription Footwear Association. The findings may explain why the ideal or expectation of “perfect” shoe fit is virtually impossible, although they do not suggest that adequate or satisfactory shoe fit is not attainable in most instances involving so-called “normal” feet. They also indicate that a mild degree of “breaking in” is required with most new footwear, although never necessitating any distress.

This article presents the methodology of the survey and foot measurements, along with the found data and their significance regarding the traditional processes of search of “proper” shoe fit and the obvious need for higher levels of professional shoe-fitting skills and service. The article also analyzes and discusses some little known or seldom considered complexities of shoe fit and the foot-shoe relationship that surfaces from this study, for example, the role of shoe design, shoe-sizing systems, consumer shoe-buying attitudes, and shoe materials, the four variable phases of shoe fit (static, weightbearing, functional, and thermal), and the availability of shoe sizes in stores.