Foot & Ankle International

Fifty-four patients with congenital clubfoot (total: 82 club feet) were observed at the 2nd Department of Orthopaedic Surgery of Rome University from 1970 to 1980. The conclusions of this study were the following: The patients with congenital clubfoot who had a uniform treatment from the beginning at the same hospital obtained better results than those who received previous treatments at other hospitals. A relapse was considered as a recurrence of the initial deformity after complete recovery and not as an incompletely corrected congenital clubfoot. In many of the patients with clubfoot who were treated, no direct correlations existed between the radiographic and clinical results. Of the patients with clubfoot who received an early treatment by posterior release, 89% had excellent and good results. One- or two-stage posteromedial releases did not prevent relapses, even though those done in one stage obtained better results. The transfer of the anterior tibial tendon to the third cuneiform proved to be the most effective procedure to prevent and correct relapses.

This is a retrospective study of seven patients with 10 feet displaying nonparalytic congenital vertical talus treated at Riley Children's Hospital in Indianapolis by open reduction without naviculectomy. Each of the 10 feet underwent an operation for open reduction of congenital vertical talus. The procedure included a peritalar soft tissue release, posterior release of the hindfoot with Achilles tendon lengthening, and transfer of the tibialis anterior tendon into the talar neck. Length of follow-up ranged between 2 and 11 years. Average follow-up time was 6 years and 9 months. Age at time of open reduction ranged from 8 months to 3 years. The clinical follow-up evaluation revealed three excellent, three good, and four fair results. Only one patient underwent a subsequent surgical procedure.

Myotonic dystrophy is a progressive multisystem disorder that may be inherited from either parent, although only children with affected mothers usually show the more severe congenital form of the condition; others are classified as having adult myotonic dystrophy. Since 1940, 29 patients with myotonic dystrophy (10 adult, 17 congenital, two unclassifed) have been followed at the Alfred I. duPont Institute. Treatment protocols have been established for the treatment of talipes equinovarus deformity commonly seen in the congenital form of myotonic dystrophy, as well as the progressive dropfoot gait more commonly seen in the adult form.

The effect of angular deformities of the tibial shaft on the area, location, and shape of the ankle joint contact during the normal extremes in the gait cycle was studied with the use of a cadaveric model. Six lower limbs were first examined radiographically and found to be free of pathology. These specimens were then stripped of soft tissues proximal to the ankle joint and had a custom-designed universal joint-plate inserted into the tibia at the proximal, middle, or distal third level. An anterior ankle arthrotomy was performed, and pressure sensitive film was inserted into the tibiotalar joint. Load was then applied with the ankle set in dorsiflexion or plantarflexion via metal wedges, and tibial deformities of 5, 10, and 15° were simulated in varus, valgus, anterior bow, and posterior bow.

Contact area and location changes were noted to be of greater magnitude with proximal and distal third tibial deformities than with middle third deformities. Varus and valgus deformities showed smaller contact area changes than anterior or posterior bow deformities. Contact area changes tended to be larger in dorsiflexion compared to plantarflexion for each level and degree of tibial angulation. Posterior bow deformities at all levels resulted in greater changes in contact area and shape than other deformities. The role of subtalar compensation, stiffness of the foot-ankle complex, and geometric factors are all thought to influence the changes noted. On the basis of this experimental study it would appear that angular deformity of the tibia less than 10° would not significantly alter ankle joint contact.

Triaxial kinematics of ankle instability were studied in vitro by applying an inversion force to seven nonaxially loaded cadaveric ankle-foot specimens. In intact specimens, mean maximal adduction of the tibia with respect to the calcaneus was 38° and mean maximal external rotation was 24°; maximal displacement occurred near full plantar flexion. Increases after release of ligaments were as follows: calcaneofibular, maximal adduction 10%, external rotation 3% near 15° of plantar flexion; anterior talofibular, adduction 30%, external rotation 8% at 30° of plantar flexion; both, adduction 41%, external rotation 65% near 0° of flexion; all three lateral collateral, adduction 42%, external rotation 240% in slight dorsiflexion. Regardless of the status of the lateral collateral ligaments, the talus adducted and externally rotated 18° ± 1° with respect to the calcaneus. Hence, collateral ligament release had no effect on subtalar motion.

Microscopic evaluation of the interdigital neuroma is described in 24 nerves which were evaluated at six cross-section areas for size of the nerve and width of the perineural along with the fascicle diameter and the size and number of blood vessels inside each fascicle. A relationship was noted between the level of the distal edge of the intermetatarsal ligament. Cross-section that was taken at that area showed changes distally in nerve diameter, fascicle number and size, blood vessel number and size, and perineural width. These changes are consistent with the interdigital neuroma as an entrapment condition.