Transtibial amputation. Prosthetic use and functional outcome

Annually, roughly 80,000 to 100,000 amputations are performed with a total cost of greater than $50,000 per patient. Amputations in general and TTAs in particular are worthy of investigation to provide a cost-effective functional outcome that provides high patient satisfaction. The process of prosthetic selection, functional outcome, and avoidance of common complications begins with preoperative education of the patient and communication with the rehabilitation team. Determining an individual patient's perceptions of the process and his or her desired functional needs can help establish a baseline for prosthetic prescription and patient education. With the apparent difficulty in predicting who will be functional with a prosthesis, it seems prudent to initiate prosthetic training and fitting with all patients who have a moderate potential for use. Because many patients undergoing this operation have significant illness, as judged by the high mortality rate at follow-up, it is important to begin this process early to promote the highest recovery of functional independence. With the continual improvement in prosthetic components and postoperative management, it seems possible for the ill, elderly patient to regain near preoperative functional independence with the use of a prosthesis.

Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release

Between 1991 and 1995, 96 patients (114 feet) were treated with a proximal crescentic metatarsal osteotomy and distal soft-tissue procedure for moderate to severe hallux valgus deformity [intermetatarsal (IM) angle > 15 degrees, or hallux valgus (HV) angle > 30 degrees]. At an average follow-up of 26 months, 8 men and 62 women (86 feet) with a mean age of 53.2 years were retrospectively reviewed. The HV angle averaged 41.1 degrees preoperatively and 14.6 degrees postoperatively. The respective values for the IM angle were 17.8 degrees and 7.8 degrees. Neither the average metatarsal shortening of 3 mm nor the dorsal angulation at the osteotomy site seen in 9% of cases evidenced any clinical significance at follow-up. Patient satisfaction was excellent or good in 91%, and the mean Mayo Clinic Forefoot Score (total 75 points) improved from 37.2 to 61.1 points. Complications included 8 cases of hallux varus and 5 cases of hardware failure. Based on this first study exclusively focusing on moderate to severe hallux valgus deformity, we conclude that proximal first metatarsal osteotomy in combination with a lateral soft-tissue procedure is effective in correcting moderate to severe symptomatic hallux valgus deformity with metatarsus primus varus (IM angle > 15 degrees or HV angle > 30 degrees).

Effect of interposed periosteum in an animal physeal fracture model

To study the effect of interposed periosteum on physeal fracture healing, 52 skeletally immature female Harlan Sprague-Dawley rats, 4 to 5 weeks of age, were randomized to one of three cohort groups. All animals underwent surgical dissection of the left proximal medial tibia; dissection consisted of superficial exposure and incision of a standard periosteal flap. Animals in Group I (fracture alone) underwent physeal fracture; those in Group II (fracture and periosteum) underwent physeal fracture with interposition of periosteum in the fracture site, and those in Group III (positive control) underwent physeal fracture, excision of 1/2 of the growth plate, and interposition of periosteum in the defect. After histologic examination of serial sections, fracture alone resulted in physeal injury frequently associated with small bar formation without a reduction in leg length. With the addition of interposition of periosteum into the fracture site, a small, but statistically significant, increase in leg length discrepancy frequently associated with small histologic bar formation occurred when compared with fracture alone.

Stable bony integration with and without short-term indomethacin prophylaxis. A 5-year follow-up

We included in a prospective study of a standardized indomethacin protocol 134 consecutive patients undergoing primary cementless endoprosthetic hip replacement between January and June 1990. Periarticular heterotopic ossification (HO) was graded according to the Arcq classification (grades 0 to III). At final follow-up, all patients were analyzed clinically and radiographically for HO and aseptic loosening. A similar group of 44 patients (mean age of 64 years, range 38-82 years) undergoing total hip replacement (THR) with the same prosthesis and technique in 1987 did not receive HO prophylaxis and served as a control group. The average age of the 134 prophylaxis patients was 66.5 years (range 32-85 years), and the average follow-up was 65 months (range 60-71 months). Thirty patients (25%) were lost to final follow-up (19 died, 10 unknown, 1 amputation). In the study group, 77% had HO grade 0, while none had HO grade III, compared with 18% HO grade 0 and 16% HO grade III in the control group. These differences were statistically significant (P = < 0.001). At a minimum of 60 months follow-up, clinical and radiographic evaluation revealed no aseptic loosening in the study group: 4 cases of prosthesis subsidence during the first year did not progress. In the control group, there was a higher incidence of radiolucency around the femoral component, and one patient met all criteria for radiographic evidence of aseptic loosening. Statistical analysis revealed no significant difference between the two groups (P = 0.104). Based on our clinical and radiological results, indomethacin does not inhibit stable bony integration of the femoral component.

Posterior tibial tendon dysfunction in rheumatoid arthritis

Although hindfoot pathology in rheumatoid arthritis is a significant cause of disability for patients, the etiology of the planovalgus deformity is controversial. The present study surveys 99 patients with clinically proven rheumatoid arthritis for the presence and severity of hindfoot pathology. Specific attention was directed at the function of the posterior tibial tendon, as disruption of this structure has been implicated by some investigators as a cause of hindfoot deformity in rheumatoid arthritis. Assessment of posterior tibial function was by manual testing using two different grading scales, as well as by examination for several signs associated with posterior tibial tendon dysfunction. Between 13% and 64% of the study population could be considered to have posterior tibial tendon dysfunction, depending upon the specific diagnostic criteria used. Using the presence of all three of the most stringent criteria for diagnosis, 11% of patients were believed to have posterior tibial tendon dysfunction. These criteria were loss of the longitudinal arch, inability to perform a heel-rise, and lack of a palpable posterior tibial tendon. This study demonstrates that planovalgus deformity in rheumatoid arthritis can be due to clinically evident dysfunction of the posterior tibial muscle-tendon unit. There is a complex interplay between hindfoot joint disruption due to the inflammatory process and deformity due to tendinous dysfunction. If there is primary subtalar joint instability secondary to the inflammatory process, the posterior tibial tendon is rendered dysfunctional due to deranged hindfoot mechanics, as with primary posterior tibial tendon rupture. Since treatment of either condition (i.e., primary hindfoot instability or primary posterior tibial tendon rupture) is similar, the distinction is not important clinically.(ABSTRACT TRUNCATED AT 250 WORDS)

Foot and ankle problems in rheumatoid arthritis

The purpose of this study was to examine the prevalence of foot and ankle problems in 99 patients with clinically proven rheumatoid arthritis. Patients were recruited from outpatient rheumatology clinics; no attempt was made to select patients on the basis of the severity of their disease, duration of disease, or symptom constellation. Each patient was examined by an investigator utilizing a predesigned protocol to assess their functional status, functional capacity, and overall joint involvement. Ninety-three of 99 patients had complaints referable to the foot or ankle at some time since diagnosis of rheumatoid arthritis. Ankle problems were paramount in 42%, forefoot difficulties in 28%, and equal ankle and forefoot problems in another 14%. Only four patients had had any treatment involving foot orthotic devices or special shoe wear. The prevalence of foot and ankle symptoms was related to the duration of systemic illness, but was present in > 50% of patients at any time after diagnosis of rheumatoid arthritis. Patients with longstanding rheumatoid arthritis have a high prevalence of foot and ankle symptoms. Unlike previous reports, the present study found a high prevalence of ankle and hindfoot symptoms, as opposed to forefoot complaints. Despite this finding, the patients had been treated infrequently by either conservative nonoperative management directed at accommodating footwear or surgical intervention to favorably alter their foot and ankle mechanics.