Biomedical subjects
Publications and source records attributed to Alan R Catanzariti.
This article describes a basic model for clinical research in a 3-year residency training program. Obstacles to research along with practical solutions are presented. Performing clinical research should be an integral part of residency training with publication being the ultimate goal for every resident research project.
The use of sciatic popliteal nerve blocks in conjunction with common peroneal and saphenous nerve blocks can provide prolonged hours of analgesia after foot and ankle surgery. This adjunct to analgesia allows for reduced amounts of postoperative opioids and the undesirable and adverse effects associated with these drugs. The peripheral blocks are technically easy to perform and offer the surgical patient many hours of pain relief. Furthermore, when utilized preoperatively, a lighter depth of anesthesia can be maintained with little demand for opioids so that the postoperative recovery will be accelerated with fewer complications.
Tears of the peroneal tendons are not uncommon but remain an underappreciated source of chronic lateral ankle pain. The purpose of this study was to identify the typical patient profile and nature of the injury, to analyze the course of treatment, and to determine the prevalence of complications seen with surgical repair. Forty patients with chronic pain over the peroneal tendons from the Foot and Ankle Institute at the Western Pennsylvania Hospital underwent peroneal tendon repair. During a 3-year period, a retrospective review was performed by evaluating medical records, surgical reports, and radiographs. The average patient age was 42 years (range, 13 to 64 years). The most common cause was an ankle sprain or other traumatic injury (58%). Peroneus brevis tears (35 patients; 88%), peroneus longus tears (5 patients; 13%), combined peroneus brevis and longus tears (15 patients; 37%), low-lying peroneus muscle belly (13 patients; 33%), lateral ankle ligamentous disruptions (13 patients; 33%), and peroneal subluxation (8 patients; 20%) were identified during surgery. The average follow-up was 13 months (range, 9 to 40 months). Ninety-eight percent of the patients were able to return to full activities without pain at final follow-up. The minor complication rate (transient symptoms) was 20%. Clinically significant (major) complications (continued symptoms or revisionary surgery) occurred in 10% of patients. This study indicates that lateral ankle ligamentous incompetence, combined peroneal brevis and longus tears, and low-lying peroneus muscle belly commonly coexist in patients with peroneal tendon injuries. Appropriate surgical intervention of peroneal tendon tears and their coexisting pathology yields successful and predictable results with few clinically significant complications.
This study reviewed retrospectively preoperative magnetic resonance imaging (MRI) and intraoperative findings of 32 patients who underwent surgical treatment of longstanding peroneus brevis tendon pathology. The purpose of this study was 3-fold: 1) to determine the sensitivity and specificity of MRI diagnosis of peroneus brevis tendon tears as confirmed by surgical findings, 2) to define the prevalence of osseous and soft-tissue pathologies that coexist with peroneus brevis injuries, and 3) to compare the occurrence rates of other associated pathologies found on MRI to that of the surgical findings. MRI diagnosis of a peroneus brevis tendon tear showed 83% sensitivity and 75% specificity to intraoperative findings. Four false positive and 2 false negative cases were identified. Coexisting conditions identified by MRI included a low-lying muscle belly/peroneus quartus (44%), anterior talofibular ligament rupture (50%), flattened/hypertrophy peroneus longus tendon (56%), increased signal intensity within peroneus longus tendon (53%), and a flat/convex fibular groove (78%). These results show that peroneus brevis tears rarely present as isolated injuries and support the need for a comprehensive preoperative clinical evaluation and MRI assessment of the entire lateral ankle complex.
Nineteen patients (20 feet) with severe hindfoot and ankle deformity underwent tibiotalocalcaneal fusion with a retrograde locked intramedullary nail as a limb-salvage procedure. The purpose of this study was to compare the complication rates of this procedure in diabetic versus nondiabetic patients. There were 8 men and 11 women with preoperative diagnoses including Charcot neuroarthropathy, primary osteoarthritis, rheumatoid arthritis, equinocavovarus, posttraumatic osteoarthritis, gouty arthritis, and ankle malunion. Ten of 20 procedures were performed in patients with diabetes. The average patient age was 56 years, and the average postoperative follow-up was 19.8 months. Nineteen of 20 ankles (95%) achieved successful fusion with an average time of 4.1 months. Four patients (21%) required either a fracture brace or an ankle foot orthosis at final follow-up. Five patients (25%) had major complications and 11 patients had minor complications. Major complications included osteomyelitis (n = 2), Charcot arthropathy (n = 2), failure of fixation (n =1), soft-tissue necrosis (n = 1), cardiac arrest (n = 1), cerebral vascular accident (n = 1), and fatal pulmonary embolus (n = 1). All patients with major complications were diabetic, and 14 of 20 combined major and minor complications occurred in patients with diabetes. The complication rate was found to be high in diabetic patients with end-stage deformity undergoing a limb salvage
This article presents the results of a retrospective chart and radiographic review of 11 feet (8 patients) that underwent a Cole midfoot osteotomy from February 1998 through October 2000 at the Western Pennsylvania Hospital. The average time to follow-up was 23 months (range, 11 to 29.5 months). A 100% bony union rate was achieved, with an average time to radiographic union of 2.3 months (range, 1.2 to 4.5 months). The average time until full weightbearing was 3.3 months (range, 2 to 4.25 months). The average preoperative talo-first metatarsal angle on an anteroposterior radiograph was 8.60 degrees and 8.64 degrees on the lateral radiograph. The average postoperative change was 3.50 degrees (P =.03) on the anteroposterior radiograph and 16.82 degrees (P =.003) on the lateral radiograph. At the final follow-up visit, all patients were independently active and were able to wear conventional shoe gear. A postoperative questionnaire was completed by 5 of 8 patients (8 of 11 feet) at a mean 21 months (range, 13 to 29.5 months) postoperatively. Of these patients, 4 of 5 patients (7 of 8 feet) would recommend this surgery to others. No major complications were reported in this study. These results suggest that the Cole midfoot osteotomy is a reasonable procedure to consider for correcting pes cavus deformities with the apex in the midfoot.
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The current literature shows that proper alignment of the lower extremity allows for greater function throughout the gait cycle. Therefore, realignment should be one of the primary goals in the surgical management of lower-extremity deformities and pathology. Multiplanar radiographic angular relationships should be critically evaluated to appropriately identify the level and extent of the deformity before performing realignment procedures. This article describes a systematic approach to deformity evaluation through a comprehensive radiographic assessment of the rearfoot, ankle, and lower leg.
Triple arthrodesis is indicated for pain, deformity, and instability of the tritarsal complex. Although osseous consolidation is important to outcome, success depends primarily on appropriate realignment. A poorly positioned triple arthrodesis may result in continued pain and disability, gait disturbances, excessive stress in adjacent joints, and footwear problems. We present a protocol for intraoperative realignment of the triple arthrodesis guided by image intensification. This protocol for alignment evaluation was followed in nine patients who underwent triple arthrodesis for a variety of pathologies.
Foot structure is typically evaluated using static clinical and radiographic measures. To date, the literature is devoid of a correlation between rearfoot frontal plane radiographic parameters and clinical measures of alignment. In a repeated-measures study comparing radiographic and clinical rearfoot alignment in 24 healthy subjects, radiographic angular measurements were made from standard weightbearing anteroposterior, lateral, long leg calcaneal axial, and rearfoot alignment views. Clinical measurements were made using a jig and scanner to assess the malleolar valgus index and a goniometer to evaluate the resting and neutral calcaneal stance positions. There was a significant correlation between frontal plane radiographic angles (long leg calcaneal axial and rearfoot alignment views) (r = 0.814). Similarly, there was a significant correlation between clinical measures (resting calcaneal stance position and malleolar valgus index) (r = 0.714). A multivariate stepwise regression showed that resting calcaneal stance position can be accurately predicted from 3 of the 15 clinical and radiographic measurements collected: malleolar valgus index, rearfoot alignment view, and long leg calcaneal axial view (r = 0.829). In summary, a commonly used clinical measure of static rearfoot alignment, resting calcaneal stance position, was correlated closely with the malleolar valgus index and both frontal plane radiographic parameters.
Forty patients (12 men and 28 women) treated with isolated subtalar joint arthrodesis were retrospectively reviewed. The average patient age was 50 years (range, 21-76 years). Preoperative diagnoses included posterior tibial tendon dysfunction, post-traumatic arthritis, nontraumatic arthritis, and subtalar joint middle facet coalition. The average follow-up was 15 months (range, 12-74 months). Subjective postoperative questionnaire results were classified as satisfied (n = 32), satisfied but with reservations (n = 4), or dissatisfied (n = 4). Eighty-three percent of the patients (n = 33) stated that they would undergo the procedure again. Minor complications (those that resolved with nonoperative treatment) occurred in 55% of the patients. However, the major complication rate was only 12.5%. This study showed no statistical correlation between the preoperative diagnosis and the postoperative outcome. Our results also suggested that the prevalence of complications is slightly higher than in previous reports. Isolated subtalar joint arthrodesis is an effective treatment for pain and deformity of the rearfoot.
Posterior calcaneal displacement and anterior calcaneal distraction osteotomies have been recommended for surgical management of flexible flatfoot deformity. We combined these procedures for surgical management of adolescent flatfoot and late stage II posterior tibial tendon dysfunction in the adult. Lateral column distraction has been shown to reduce rearfoot valgus and forefoot abduction by stabilizing the midtarsal joint. Posterior calcaneal displacement osteotomy, which results in medial translation of the tuberosity, converts the posterior muscle group from an everter to an inverter. A supinatory moment, therefore, is created about the subtalar joint axis, which results in supination during the midstance phase of gait. These procedures may be considered when calcaneal valgus, forefoot abduction, and midtarsal joint instability are clinically significant. We also include rearfoot alignment radiographs, long leg calcaneal axial radiographs, and malleolar valgus indices to further evaluate alignment of the foot, ankle, and leg. Ideal realignment is achieved when the heel is vertical in resting calcaneal stance position, the forefoot is parallel to the rearfoot in the frontal plane, and the medial column is stabilized, with elimination of forefoot abduction.
Ankle and tibiotalocalcaneal arthrodeses are performed for the treatment of painful, arthritic, unstable, and deformed rearfoot and ankle joints. Surgical complications are not uncommon (approximately 30%); some can be attributed to poor preoperative planning and inadequate intraoperative position. Several authors have attempted to define the optimal position for ankle arthrodesis without objective multiplanar radiographic analysis and consistent reference points. This investigation explored the effects of ankle and tibiotalocalcaneal realignment arthrodeses on static lower-extremity position in 20 patients. The most common preoperative diagnosis was severe degenerative joint disease following ankle fractures and ankle instability. Seven tibiotalocalcaneal arthrodeses and 13 isolated ankle arthrodeses were performed (mean follow-up, 22 months). Average time to radiographic osseous union of the isolated ankle and tibiotalocalcaneal arthrodeses was 11 and 7 weeks, respectively. Medical complications occurred in 2 patients (10%). There were no statistically significant differences between preoperative and postoperative angular relationships. This study objectively quantifies multiplanar foot-to-leg realignment and defines the optimal clinical and radiographic positions for ankle and tibiotalocalcaneal realignment arthrodeses.
Supramalleolar osteotomies are performed to realign the distal tibia and to improve foot and ankle function. This procedure requires a thorough preoperative and intraoperative understanding of limb-deformity parameters and of the center of rotation of angulation method of surgical planning. Radiographic, gait, and clinical analyses along with intraoperative fluoroscopic images are paramount to deformity correction. This article describes the radiographic and clinical analyses and technical considerations in performing a focal dome supramalleolar osteotomy.
Tarsometatarsal arthrodesis is indicated for degenerative joint disease after trauma. Deformity is often associated with post-traumatic arthropathy. Outcomes after surgical management are directly related to realignment. This article reviews the indications, preoperative evaluation, technical execution, and postoperative management of tarsometatarsal arthrodesis. Special emphasis is placed on realignment and restoration of normal foot architecture.