Foot and Ankle Surgery - Articles in Press

How many joints does the 5th toe have? A review of 606 patients of 655 foot radiographs - Corrected Proof

Lawrence Stephen Moulton, Seema Prasad, Robert G. Lamb, Siva P. Sirikonda — 2012-05-21

Abstract: Background: It is a common understanding that the fifth toe has three bones with two interphalangeal joints. However, our experience shows that a significant number have only two phalanges with one interphalangeal joint.Methods: We identified 676 patients listed as having had a foot radiograph, during an eight week period, of which 606 radiographs were available for the assessment. The radiographs were then assessed counting the number of phalanges in the fifth toe.Results: The patients consisted of 344 females and 262 males. Bilateral radiographs had been performed in 49 patients. 362 radiographs (55.3%) were found to have 3 phalanges in their 5th toe, with 291 (44.4%) having only two phalanges.Conclusions: We have demonstrated the presence of two phalanges is a common anatomical variant. This finding has clinical implications with regard to the treatment of deformities of the fifth toe and the type of internal fixation device used.

A functional outcome study comparing total ankle arthroplasty (TAA) subjects with pain to subjects with absent level of pain by means of videofluoroscopy - Corrected Proof

R. List, H. Gerber, M. Foresti, P. Rippstein, J. Goldhahn — 2012-05-14

Abstract: Background: Total ankle arthroplasty (TAA) subjects often suffer pain on the anteromedial side of their ankle joint. Whether this prevalent pain is caused by a changed motion pattern of the TAA is unclear. Therefore, this study assessed the kinematic differences in the motion of the TAA components during gait, comparing TAA subjects with elevated versus absent levels of pain.Methods: Eleven TAA subjects (5 with pain vs. 6 without pain), all with unilateral Mobility™ TAA and at least two years post-operation, were recruited and stratified based on standard clinical assessed patient data. The 3D motion of the TAA was assessed by means of videofluoroscopy during level, uphill and downhill walking.Results: The hypothesis that the pain group shows a different kinematic motion pattern than the no pain group could not be confirmed.Conclusions: The same kinematic motion pattern causes pain in some patients, but not in others. Further investigation concerning ligament stresses is needed.

Midfoot arthritis: Diagnosis and treatment - Corrected Proof

N. Verhoeven, G. Vandeputte — 2012-05-14

Abstract: Background: Midfoot arthritis is a challenging problem causing chronic foot pain and impeding daily activity. There is not much written about this subject in literature and is often not well known by orthopaedic surgeons. The primary aim of treatment is to afford pain relief by enhancing midfoot stability and modifying loads sustained at the inflamed joints. The initial treatment is conservative with inserts and orthoses. Surgery, more specifically midfoot arthrodesis, is the next step when conservative management fails. The arthrodesis should be limited to the symptomatic joints but it is often difficult to determine which joints cause the symptoms. With this manuscript we would like to underline the importance of a precise anatomic preoperative diagnosis, review our surgical experience and discuss the different surgical fixation possibilities in midfoot arthrodesis.Methods: Between 2006 and 2011 24 patients (26 feet) with midfoot osteoarthritis underwent selective arthrodesis after conservative management had failed. Preoperative examinations, fixation method, complications and outcome were noted.Results: We achieved union in 25 feet. There was one delayed union and one non-union. There were no infections but 3 patients had chronic regional pain syndrome. Reoperation was required in one foot because of non-union and one for symptomatic hardware removal.Conclusion: Midfoot arthrodesis is an effective treatment for osteoarthritis of the joint. Identification of the affected joints is important to stipulate the extensiveness of the arthrodesis.

Resection of bilateral massive Achilles tendon xanthomata with reconstruction using a flexor hallucis longus tendon transfer and Bosworth turndown flap: A case report and literature review - Corrected Proof

P.J. Moroney, J.-L. Besse — 2012-05-14

Abstract: Tumours of the Achilles tendon are rare. Reconstruction of the large defect following excision, however, is often a challenge and is sometimes a factor in deciding against operative treatment of a benign lesion. We report a case of excision of bilateral Achilles tendon xanthomata, with reconstruction using a flexor hallucis longus tendon transfer and Bosworth turndown flap.

Arthroscopic resection of calcaneonavicular coalition/malunion via a modified sinus tarsi approach: An early case series - Corrected Proof

Ashok K. Singh, Stephen W. Parsons — 2012-05-11

Abstract: Background: Calcaneonavicular coalition represents abnormal coalescence between calcaneus and navicular bone. It is a congenital anomaly, sometimes becoming symptomatic in young adolescent. This is managed conservatively initially, failing which surgical excision, open or arthroscopic, is considered. We present our arthroscopic technique via a modified sinus tarsi approach, with early results in two adolescent and two young adult patients.Method: The patient is placed in a 45° “saggy” lateral position, and entry points for portals are marked around sinus tarsi area. The adequacy of resection is checked with image intensifier at the end of procedure. Patients complete subjective scoring forms, Manchester–Oxford Foot Questionnaire and Visual Analogue Scale, pre operatively and at follow-ups. Paired t test was performed to assess statistical significance.Results: The results of early follow-up of these patients have confirmed complete excision, non-recurrence and symptomatic improvement. The mean difference in MOXFQ scores pre and post surgery is 39.33, with a two-tailed p value of 0.0187. Similarly, the mean difference in VAS score is 5.67 with a two-tailed p value of 0.0034. These are statistically significant and confirm symptomatic improvement at an early follow-up.Conclusion: The arthroscopic technique provides better access allowing wide excision and causes minimal soft tissue trauma leading to early recovery and mobilisation.

Osteosarcoma of navicular bone. En bloc excision and salvage of the foot - Corrected Proof

2012-04-18

Abstract: Aim: To present foot salvage for osteosarcoma of the navicular bone with en bloc resection and reconstruction using bone allograft and talus-cuneiform arthrodesis.Patient and surgical technique: A 20year-old male with a history of osteosarcoma of the distal femur presented to our department 5years later with a metastatic lesion of the navicular bone of the contralateral foot. The patient received 4 cycles of neo-adjuvant chemotherapy with satisfactory response. Tumor shrinkage allowed en bloc excision of the navicular bone with clear margins. Reconstruction was done using a tricortical allograft and talus-allograft-cuneiform arthrodesis, secured with a mini-fracture plate (Synthes). Weight bearing protection was advised for 2months and partial weight bearing for another 4months. Patient received 4 cycles of adjuvant chemotherapy.Results: Three years postoperatively, the patient was free of local recurrence or distant metastasis. There were no signs of allograft resorption, fracture or non union. The patient was asymptomatic and full weight bearing. Ankle and subtalar joint motion was within normal limits.Conclusion: Foot salvage after excision of osteosarcoma of the navicular bone could be possible if en bloc resection of the lesion could be performed. Talus-cuneiform fusion with allograft interposition is a viable reconstructive option.

Soft tissue injury to the sole of the foot secondary to a retained AV impulse foot pump - Corrected Proof

Sean McIlhone, Heni Ukra, Amer Karim, Vesselin Vratchovski — 2012-04-05

A 17 year old gentleman was brought to the Emergency Department with a swollen left foot following an accident he had sustained that afternoon on his moped. X-rays of his foot demonstrated a minimally displaced fracture of the base of his 4th Metatarsal and the Cuboid which did not require surgical intervention. But, due to the high energy associated with the injury and the significant soft tissue swelling, he was immobilised in a below knee Plaster-of-Paris backslab and admitted for elevation and observation. Immediately prior to application of the backslab, a three layer, hypoallergenic, absorbent, orthopaedic padding bandage was applied to the foot and then a plastic, “in-cast” A-V Foot Pump was placed over the foot to assist in reducing the swelling []. A-V impulse “in-cast” systems have been shown to provide a significant benefit in the treatment of post-traumatic swelling following ankle fractures while providing effective thrombo prophylaxis .

Four-stage regimen for operative treatment of diabetic foot ulcer with deformity – Results of 300 patients - Corrected Proof

Martinus Richter, Stefan Zech — 2012-04-05

Abstract: Background: An operative four-stage regimen (stage 1, debridement; stage 2, closure; stage 3, unloading; stage 4, correction) for operative treatment of diabetic foot ulcer with deformity, and first clinical results are introduced.Methods and results: 335 patients entered stage 1 between 01/09/2006 and 31/08/2010.Stage 1: In 189 cases (56%), one debridement resulted in sterile postoperative specimens.Stage 2: 210 cases (63%) sustained secondary closure, 97 (29%) local shifted skin graft, and 20 (6%) functional amputation.Stage 3: 304 (90%) finished stage 3, 14 (4%) presented with recurrent ulcer.Stage 4: In 185 cases (55%), correction arthrodeses were performed successfully.Follow-up: 300 (90%) completed follow-up at 26months on average (12–48months). Recurrent ulcer was registered in 46 (15%). Overall amputation rate was 14%, the majority at digital or midfoot level. Four cases (1%) required a below-knee amputation.Conclusions: The management of diabetic foot ulcer combined with deformity with the introduced regimen showed low major amputation rate and low recurrent ulcer rate compared with the literature.

Talonavicular synostosis with lateral ankle instability—A case report and review of the literature - Corrected Proof

2012-03-09

Abstract: Talonavicular coalition is a rare autosomal recessive congenital anomaly that is usually asymptomatic and detected incidentally on radiographs. It is associated with symphalangism, clinodactyly, a great toe that is shorter than the second toe, clubfoot, calcaneonavicular coalition, talocalcaneal coalition and a ball-and-socket ankle joint.The authors present a review of the literature and case report of a patient with complete osseous talonavicular coalition, talocalcaneal coalition and lateral ankle instability which was successfully treated with subtalar fusion and lateral ligament reconstruction.

Controversies regarding radiological changes and variables predicting amputation in a surgical series of diabetic foot osteomyelitis - Corrected Proof

2012-03-05

Abstract: Background: To investigate if radiological changes have any influence on the outcomes of surgical treatment of diabetic foot osteomyelitis.Methods: Data of patients included in a prospective cohort who underwent surgical treatment for definitive osteomyelitis were analyzed. Cases were classified according to radiological changes as “early osteomyelitis” when no radiological changes were found or in cases showing periosteal elevation and/or subcortical demineralization and/or cortical disruption. Cases showing sequestra and/or gross bone destruction were classified as “advanced osteomyelitis”.Results: Early osteomyelitis was defined according to radiological findings in 37 cases (45.7%) and advanced in 44 (54.3%). Advanced osteomyelitis was not associated with the risk of undergoing amputation.Conclusions: The bone changes seen in simple X-rays in cases of osteomyelitis do not have any prognostic value when surgical treatment is undertaken. The outcomes are more related to soft tissue involvement than bone destruction seen in simple X-rays.

Touch pressure and sensory density after tarsal tunnel release in diabetic neuropathy - Corrected Proof

William H. Gondring, Prashant K. Tarun, Elly Trepman — 2012-03-05

Abstract: Background: Limited quantitative information is available about the improvement of protective sensation after tarsal tunnel release in patients with diabetic peripheral neuropathy.Methods: Prospective, non-blinded, non-randomized case series of 10 feet in 8 diabetic patients and 24 feet in 22 non-diabetic patients who had tarsal tunnel release. Preoperative and postoperative (average, 8–9 months) anatomic, quantitative sensory testing was done with touch pressure 1-point threshold (Semmes–Weinstein monofilaments) and 2-point discrimination.Results: There was marked, significant postoperative improvement of mean touch pressure 1-point threshold, compared with preoperative values, for medial calcaneal, medial plantar, and lateral plantar nerves in both non-diabetic and diabetic patients. There was minimal improvement in 2-point discrimination only for the medial calcaneal nerve in non-diabetic, but not in diabetic, patients.Conclusions: Nerve entrapment at the tarsal tunnel is an important component of diabetic peripheral neuropathy. Tarsal tunnel decompression may improve sensory impairment and restore protective sensation.

Hypermobility of the first ray in patients with planovalgus feet and tarsometatarsal osteoarthritis - Corrected Proof

S. Cowie, S. Parsons, B. Scammell, J. McKenzie — 2012-02-23

Abstract: Background: Hypermobility in the foot is a common observation but difficult to quantify. Primary tarsometatarsal arthritis is less common and its aetiology uncertain. This study introduces a novel means of clinical measurement for range of motion of the medial column and investigates the association between hypermobility, planovalgus foot shape and tarsometatarsal arthritis.Method: 32 planovalgus feet with symptomatic tarsometatarsal arthritis were compared with 36 controls. Radiographic angular measurements and arthritic grade were recorded from standing radiographs. Medial column flexion and extension was measured clinically using a validated electronic goniometer.Results: There was a significant difference in medial column range of motion between the patient and control groups (17±5° compared to 9±3° [P<0.001]).Conclusion: Patients with planovalgus feet and tarsometatarsal osteoarthritis have greater range of motion of the medial column than controls with normal feet when measured using this technique. Recognition of this association may lead to progress in prevention and treatment.

Percutaneous reduction and screw fixation of fracture neck talus - Corrected Proof

Sherif Mohamed Abdelgaid, Farid Fouad Ezzat — 2012-02-15

Abstract: Background: Fracture neck talus is a rare fracture represents about 1% of all fractures and usually due to high energy trauma. These fractures are usually associated with compromised soft tissues, concomitant skeletal fractures, or life threatening injuries. Talus has a tenuous blood supply which is affected by fracture displacement. Urgent fracture reduction±fracture fixation is mandatory. The associated injuries may make the conventional open reduction and internal fixation is impossible to be done in urgent base as it may impacts the already tenuous blood supply of talus increasing the risk of AVN and non union. Percutaneous fracture reduction and fixation can overcome this problem, and decrease complications associated with conventional open reduction and internal fixation.Materials and methods: Between 2006 and 2008, 16 patients with talar neck fractures were operated on by percutaneous reduction of fracture and percutaneous fixation with 3.5mm cannulated screws. Injuries were classified according to modified Hawkins classification system. Patients were followed up over an average of 48 months.Results: 87.5% of the patients were satisfied and resumed their preoperative activities. The mean AOFAS Hind Foot Scale was 89.25 points (range: 74–100) and no poor outcomes.Conclusion: Although the number of patients in this study is small, the results showed that, percutaneous reduction and fixation is a good treatment modality in treatment of fracture neck talus, especially in cases with increased risk of soft tissue complications and open reduction should be resort only when percutaneous reduction was failed.

Metatarsal extension osteotomy without plantar aponeurosis release in cavus feet. The effect on claw toe deformity a radiographic assessment - Corrected Proof

A.K. Singh, P.J. Briggs — 2012-01-13

Abstract: Background: This study reviewed patients undergoing correction of cavus foot deformity by metatarsal extension osteotomy with preservation of the plantar aponeurosis, and assessed the correction achieved of the claw deformity of the toe by radiographic assessment.Method: 15 patients (18feet) were reviewed clinically and radiographically. All feet required extension osteotomy of the first metatarsal and four patients (5feet) had extension osteotomy of the first to fourth metatarsals. Hallux extension angle in relation to the 1st metatarsal and in relation to the ground was measured in all feet to estimate the degree of clawing of the hallux.Results: 13 patients (15feet) were satisfied with the outcome of their surgery and also the appearance of their foot. The mean radiographic change in the hallux extension angle in relation to the 1st metatarsal was 16°, and in relation to the ground was 7°. These changes were statistically significant.Conclusion: Our results indicate an improvement in the claw toe deformity and we recommend preservation of the plantar aponeurosis in corrective surgery for cavus foot.

The use of surgeon-performed ultrasound assessment in a foot and ankle clinic - Corrected Proof

K. Thomason, P.H. Cooke — 2012-01-11

Abstract: Background: We describe the first reported use of ultrasound examination performed by an orthopaedic surgeon in the setting of a foot and ankle clinic.Methods: The senior author attended a course in musculoskeletal ultrasound and performed 100 examinations each checked against the results from a consultant radiologist. Records were kept of all examinations performed in the clinic over a 6-month period with results.Results: Of the 622 patients seen, 91 had an ultrasound scan and 36 had guided injections. All patients had one hospital attendance spared, for most two. Time saved on the treatment pathway per patient was on average 6 weeks.Conclusion: Ultrasound assessment performed by a clinician during an outpatient clinic appointment reduces delay in treatment and cuts costs by reducing patient episodes.

Tarsal tunnel syndrome: A literature review - Corrected Proof

M. Ahmad, K. Tsang, P.J. Mackenney, A.O. Adedapo — 2011-12-23

Abstract: Background: Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the posterior tibial nerve or its branches within its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. It is a rare but important condition which is regularly under diagnosed leading to a range of symptoms affecting the plantar aspect of the foot. Management of this entrapment neuropathy remains a challenge and we have therefore reviewed the published literature in an attempt to clarify aspects of initial presentation, investigation and definitive treatment including surgical decompression. We also assessed the continuing controversial role of electrodiagnostic techniques in its diagnosis.Conclusion: Recommendations from literature:

A comparative study of bone shortening and bone loss with use of saw blades versus burr in hallux valgus surgery - Corrected Proof

Muhammad Saleem Shahid, Paul Lee, Sam Evans, Rhys Thomas — 2011-12-16

Abstract: Background: The aim of this study was to assess bone loss and thickness of the cut with the use of a burr in percutaneous hallux valgus surgery.Methods: Twelve blocks of saw bone were used. Cuts of same depth were made in each block with two different saw blades and a burr. Each block was assessed for bone loss and thickness of the cut.Results: There was statistically significant (p<0.05) increased bone loss and thickness of the cuts with the use of a burr as compared to use of two different saw blades. The use of a burr resulted in threefold increased loss of bone material and fourfold increase in the thickness of the cut as compare to use of two different saw blades.Conclusion: The metatarsal shortening is a risk factor in percutaneous hallux valgus surgery with the use of a burr.

Motion of the fibula relative to the tibia and its alterations with syndesmosis screws: A cadaver study - Corrected Proof

Thomas Huber, Werner Schmoelz, Andreas Bölderl — 2011-12-09

Abstract: Background: The motion of the fibula in relation to the tibia is coupled on the motion of the talus in the ankle joint. Several authors investigated this motion with different methods. An injury of the elastic fixation of the fibula to the tibia and its treatment with the syndesmotic set screw has an impact on this motion.Methods: The motion of the fibula relative to the tibia was measured in eight embalmed human above the knee amputated cadaver specimens using a 3D-motion analysis system. The relative motion was measured from 50° of plantar flexion to 30° of dorsiflexion. Experiments were performed in the following conditions: without fixation and intact ligaments, after sectioning of the four syndesmotic ligaments and the interosseous membrane, and application of either a tricortical screw, or a quadricortical screw or two quadricortical screws.Results: Concordant movements of the lateral malleolus were a medial translation during plantar flexion, external rotation around the sagittal axis during plantar and dorsiflexion. The motion of the proximal fibula was smaller and more variable than in the distal part. After sectioning of the syndesmosis the range of motion, compared to the intact state increased, particularly in translation along the transversal (118%), sagittal (160%) and the longitudinal (136%) axis and in axial rotation (145%). Syndesmotic screws reduced the range of motion in transversal (p<0.006) and sagittal translation (p<0.011) and axial rotation.Conclusion: The small relative motion of the tibia and fibula is increased by syndesmotic injuries. Syndesmosis screws significantly limit this increased relative motion below physiologic values, which makes it necessary to remove the screws before flexion in the ankle joint is performed.

Internet information quality for ten common foot and ankle diagnoses - Corrected Proof

2011-12-07

Abstract: Background: Patients use the Internet regularly to access health-related information. This study's goal was to assess the quality and content of Internet-based information for common foot and ankle diagnoses.Methods: We identified the ten most common foot and ankle diagnoses in our academic foot and ankle practice. Ten websites for each diagnosis were identified using two large Internet search engines. A custom grading form was used to determine website quality, based upon the Health On the Net Foundation (HON) principles, and information content. Four independent reviewers graded each website.Results: One hundred thirty-six unique websites were reviewed. Average HON score was 62.4 (range, 52.3–68.8) and content score was 49.7 (range, 33.8–62.1) out of a maximum of 100. Interobserver variability was low.Conclusions: The overall quality of Internet information for common foot and ankle diagnoses is variable, raising concerns about what information is currently available to patients.

A new limb-salvaging technique for the treatment of late stage complicated Charcot foot deformity: Two-staged Boyd's operation - Corrected Proof

Muzaffer Altindas, Ali Kilic, Mehmet Ceber — 2011-11-21

Abstract: Background: Depending on the stage of disease, several operative and non-operative treatment options exist for diabetic patients with Charcot foot deformity. In the early stages of the disease, the most effective treatment is total-contact cast application. In patients with multiple bone fractures and deformations, surgical interventions are generally required for the reconstruction of foot architecture. Exostectomy, osteotomy, arthrodesis, and internal–external fixation are some of these operative methods. However, recurrence of ulcer and infection is very likely following these surgical procedures. If the lesion and infection reach to midfoot and hindfoot region, a major amputation is usually required for treatment.Methods: We have been performing Boyd's operation for the last 10 years in diabetic foot patients who had complicated lesions in midfoot and hindfoot regions. Furthermore, since 2004, we have been doing the same operation for complicated Charcot foot deformities. So far, we have treated 11 patients.Results: The mean age of the patients was 53.4±10.2 years, and the mean duration of diabetes mellitus (DM) was 17.5±7.2 years. All patients had chronic infections with fractures of the tarsal bones for at least 2 years. Durable wound coverage and ankylosis were achieved in all patients with two-staged Boyd's operation. No recurrence is detected in any of the patients during mean post-operative follow-up period of 2.1±0.8 years.Conclusion: Boyd's operation is a reliable option for the treatment of patients with late stage Chatcot foot deformity.

Reliability of metatarsus adductus angle and correlation with hallux valgus - Corrected Proof

Aryan I.S. Dawoodi, Anthony Perera — 2011-11-14

Abstract: Background: Metatarsus adductus is a common congenital foot deformity. Variable prevalence values were reported using different techniques in different populations.Numerous radiological measurements have been proposed to assess this deformity with a paucity of studies reporting the reliability of these methods.The metatarsus adductus angle was shown to correlate with the severity of hallux abductovalgus in normal feet and preselected populations of juvenile hallux valgus.Materials and methods: Weight bearing dorsoplantar radiographs of 150 feet were examined for 5 angles commonly used in assessing metatarsus adductus: angle between the second metatarsus and the longitudinal axis of the lesser tarsus (using the 4th or 5th metatarso-cuboid joint as a reference), Engel's angle and modified Engle's angle. The prevalence of metatarsus adductus was assessed according to published criteria for different techniques. Inter and intra-observer reliabilities of these angles were evaluated on 50 X-rays. Linear regression tests were used to assess the correlation between hallux valgus and different angles used in assessing metatarsus adductus.Results: Intraclass correlation coefficients were high for intra- as well as inter-observer reliability for the 5 angles tested. Prevalence of metatarsus adductus ranged (45–70%) depending on the angle used in the same population. Only the metatarsus adductus angle using the 4th metatarso-cuboid joint as a reference demonstrated significant correlation between metatarsus adductus and hallux abductovalgus angles.Conclusion: Five techniques commonly used in assessing metatarsus adductus demonstrated high inter and intra-observer reliability values. Prevalence of metatarsus adductus and the correlation between the severity of this deformity and hallux valgus angle is sensitive to the assessment method.

Böhler's angle – What is normal in the uninjured British population? - Corrected Proof

H. Willmott, J. Stanton, C. Southgate — 2011-11-11

Abstract: Böhler's angle is a radiographic parameter widely used in the detection and assessment of fractures of the os calcis. The normal range in the uninjured British adult population has not previously been established. We analysed 128 lateral radiographs without fracture in order to establish the true value of Böhler's angle. Analysis was performed with respect to age, sex and laterality. Interobserver reliability was also assessed. The mean angle was 36.4° (SD 4.2°, range 24.7–48.9°). The normal range was 28.2–44.5°, which incorporates 95% of subjects. There was no difference with respect to age, sex or laterality. Agreement between independent observers was good (interobserver correlation coefficient=0.72), although there was disagreement of >5° in 40.9% of cases. Given the wide range of normal values we recommend a comparative radiograph of the contralateral side if the presence of fracture is ambiguous.

Owens et al. “Morton's neuroma: Clinical testing and imaging in 76 feet, compared to a control group” [Foot and Ankle Surgery 17 (September (3)) 2011] - Corrected Proof

Magdi E. Greiss — 2011-10-05

We read the above article with interest. We note that the PLP Plantar Percussion test described as one of four clinical tests is in fact a version of the DNS Digital Nerve Stretch test we described in Foot and Ankle Surgery, Vol. 12, Issue 4, January 2006.

Response to Letter to the Editor - Corrected Proof

Anthony Sakellariou — 2011-10-03

I thank Mr. Greiss for his interest in our article and for his valuable comments. We were, in fact, not aware of the DNS (Digital Nerve Stretch) test as described in FAS Vol. 12, Issue 4, January 2006. I first became aware of the PLP (Plantar Percussion) test when it was described to me, many years ago, by Ian Anderson, a North American foot and ankle surgeon. I have since successfully incorporated it into my clinical practice. Although I accept that, as the DNS test appears to be more sensitive than the PLP test (97% positive vs. 62% positive), it could be incorporated into our practice as well, what I am unsure about, is how sensitive it is with regard to identifying the pathological web space. It may be, as Mr. Greiss states in his letter, that the PLP (and DNS) tests may be very sensitive in ‘identifying’ inflammatory changes surrounding an inflamed nerve; however, I have found that the percussion component helps me (in combination with the squeeze test), to identify the actual pathological web space.

Closed reduction and percutaneous cannulated screws fixation of displaced intra-articular calcaneus fractures - Corrected Proof

Sherif Mohamed Abdelgaid — 2011-08-26

Abstract: Background: Displaced intra-articular calcaneal fractures remain a therapeutic challenge due to fracture complexity and different treatment options. One of the adverse effects of operative treatment is secondary damage to soft tissues. To avoid soft tissue complications, several less invasive procedures have been introduced. The most frequently used minimally invasive technique is closed reduction of fracture and percutaneous cannulated screws fixation.Method: This study evaluates the medium-term outcome of a new technique of percutaneous treatment in 60 cases operated in Al-Razi orthopedic hospital in Kuwait in the period from 2007 to 2009. The described technique applies the principle of closed manipulation with new reduction method using a medial subperiosteal tunnel to manipulate the fragments. The technique involves new method of distribution of screws required to fix the fracture.Results: According to the American Orthopedic Foot and Ankle Society Hind foot Score, 38.3% of all cases (22 cases) had excellent results, 41% good (25 cases), fair results in 15% (9 cases), and poor results in 5% (4 cases). The overall satisfactory results (excellent and good) were 79.3%.Conclusion: The technique is suitable for most types of intra-articular fractures especially in patients with compromised soft tissues in which open reduction and internal fixation is contraindicated.

Preliminary results of 97 percutaneous gastrocnemius muscular lengthening operations in neurologically healthy children with an equinus contracture - Corrected Proof

2011-08-22

Abstract: Background: We report a gastrocnemius lengthening in neurologically healthy children, whose gastrocnemius equinus could not be corrected non-operatively.Methods: Fifty-five children with an equinus contracture were included in this study. Ninety-seven operations were performed in these patients. The mean age was 11.5 years and sixty percent of the patients were male. After 12 weeks we measured dorsiflexion post-surgery and after one year all parents of patients were telephoned and asked about their satisfaction with the result of the surgical treatment. Persistence of pre-operative complaints and complications were evaluated.Results: Ankle dorsiflexion significantly improved by more than 11° post-surgery compared with preoperative (p=0.01). The mean satisfaction was 8.0 on a 10-point VAS scale. Except one complication of ankle fracture during surgery, no other clinically relevant complications were observed. At follow up 50% of the patients have no complaints, 47% reported an improvement but some persisting complaints and 3% of the patients report no improvement.Conclusion: Percutaneous muscular gastrocnemius lengthening can be used to correct gastrocnemius equinus in otherwise healthy children, who have not benefited from prior nonsurgical treatment.

UK national survey of venous thromboembolism prophylaxis in ankle fracture patients treated with plaster casts - Corrected Proof

Hafiz Javaid Iqbal, Raef Dahab, Simon Barnes — 2011-06-13

Abstract: Background: Ankle fractures are one of the commonest orthopaedic injuries. A substantial proportion of these are treated non-operatively at outpatient clinics with cast immobilization. We conducted this survey to assess the current practice in UK regarding thromboembolism prophylaxis in these patients.Methods: A telephonic survey was carried out on junior doctors within orthopaedic departments of 56 hospitals across the UK. A questionnaire was completed regarding venous thromboembolism risk assessment, prophylaxis, hospital guidelines, etc.Results: 84% (n=47) hospitals did not routinely use any prophylaxis for these patients, while 7% (n=4) hospitals used chemo-prophylaxis. Only 5.3% (n=3) hospitals had DVT prophylaxis guidelines regarding these patients while other 9% (n=5) hospitals were in process of developing such guidelines. In 64% (n=36) hospitals, no formal DVT risk assessment was carried out.Conclusion: A large variation exists across NHS hospitals and a poor risk assessment is being carried out in these patients. Development of local guidelines and extension of national guidelines to include high risk outpatients may improve the situation.

Functional outcome of ankle fracture patients treated with biodegradable implants - Corrected Proof

Sushil Rangdal, Daljit Singh, Narendra Joshi, Ashwani Soni, Radheshyam Sament — 2011-06-06

Abstract: Background: Biodegradable devices have been developed to overcome the disadvantages of metallic implants especially the need for their subsequent removal, though they have their own drawbacks like poor mechanical properties and tissue reactions. Aim of this prospective study was to access the outcome of bimalleolar fractures fixed with biodegradable plates and screws.Methods: A prospective study was conducted between July 2006 and November 2008 comprising of sixteen patients with unilateral bimalleolar fractures. Fibula fractures were fixed with biodegradable plates and medial malleoli with screws. Patients were followed at two weeks, six weeks, three months, six months, twelve months and eighteen months. Final evaluation was done using Olerud Molander ankle score.Results: Six patients had excellent results; four patients had good results and six patients had fair performance. No patient in this series had a poor outcome. One patient had both pain and swelling at 14 weeks postoperatively which settled down with debridement and antibiotics. None of the patients needed implant removal.Conclusion: Biodegradable plates and screws when used to fix bimalleolar fracture along with restricted weight bearing, provide satisfactory fracture healing, good functional results and reduce the need of implant removal.