Biomedical subjects
Justin Greisberg
Publications and source records attributed to Justin Greisberg.
Isolated medial column stabilization improves alignment in adult-acquired flatfoot.
UNLABELLED: In some patients with painful flatfoot, realignment and arthrodesis of the medial naviculocuneiform and first tarsometatarsal joints can be done to correct alignment and relieve symptoms. The primary purpose of this radiographic study was to assess the ability of isolated medial column arthrodesis to improve hindfoot alignment. We also assessed the ability of the procedure to correct radiographic parameters of overall foot structure in acquired flatfoot. Preoperative and postoperative radiographs of 19 patients who had naviculocuneiform and/or tarsometatarsal realignment and arthrodesis for adult-acquired flatfoot were examined by two reviewers. All parameters improved, with the lateral talometatarsal angle approaching normal. A decrease in talonavicular subluxation in the axial plane suggests passive improvement in hindfoot position without direct manipulation of any hindfoot bones or joints. These observations provide evidence for a link between stability of the midfoot and alignment of the hindfoot. In carefully selected patients, medial column realignment may restore normal anatomy without fusing essential joints. Modern clinical outcome studies are the next step in the objective evaluation of this procedure. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series-no, or historical, control group) See the Guidelines for Authors for a complete description of levels of evidence.
Recent innovations and future directions in external fixation of the foot and ankle.
Although the basic design of external fixators has changed little in the last 50 years, advances in pin engineering are decreasing rates of infection and loosening. Newer limb-specific frames are easier to apply to the ankle and novel designs in ring fixators are improving the field of deformity correction. Just as important as any technical improvement, though, is a more refined understanding of the merits and weaknesses of the technique. There are many applications in which external fixation is the best option and others in which it is the only surgical option. Because of this, external fixation will remain an essential tool for future orthopedic surgeons.
Takedown of ankle fusion and conversion to total ankle replacement.
The painful ankle arthrodesis is an unsolved clinical problem. In many cases, transtibial amputation may be the best option for functional recovery. Recent reports of early success with second generation ankle implants show takedown of the problematic ankle fusion and conversion to total ankle arthroplasty may be an alternative to amputation. This study is a retrospective review of 23 ankles in 22 patients scheduled to have this procedure. Four patients were lost to followup, leaving 19 ankles in 18 patients at an average followup of 39 months. Three patients chose to have an amputation because of continued pain. In the remaining 16 ankles, the mean AOFAS ankle-hind foot outcome score improved from 42-68. Patients who had a clear source of pain with the ankle arthrodesis (such as subtalar arthrosis) had a better result than patients without a clear source of pain. All the patients who had the lateral malleolus resected during previous arthrodesis had complicated courses after arthroplasty. For patients with a definable source of pain and who have not had previous malleolar resection, conversion of a failed ankle arthrodesis to total ankle arthroplasty may be a viable alternative to amputation.
Revision total ankle arthroplasty: conversion of New Jersey Low Contact Stress to Agility: surgical technique and case report.
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Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot.
Adult acquired flatfoot is generally characterized by loss of the longitudinal arch, hindfoot valgus, and forefoot abduction, but the precise deformity has not been adequately described at the level of individual joints. Simulated weightbearing CT scans and plain radiographs of 37 symptomatic flat feet were examined in this study. The degree of arthritic degeneration was assessed in the major hindfoot and midfoot joints, and the location of deformity was studied along the medial column of the arch. Moderate to severe degeneration was seen in about one-third of talonavicular, subtalar, and calcaneocuboid joints. The medial column of the arch collapsed through the talonavicular joint in some feet, through the medial naviculocuneiform joint in others, but rarely through both. First tarsometatarsal joint subluxation was a frequent finding as well. In this small series, neither the degree of degenerative arthritis nor the amount of joint deformity was seen to correlate with patient age. Furthermore, no correlation was observed between foot deformity and joint degeneration.
Ankle replacement: management of associated deformities.
Ankle arthroplasty is emerging as an alternative to arthrodesis. Restoring and maintaining proper bony alignment and muscle balance in the limb is essential if there is to be any chance for long-term survival. Deformity can arise above the ankle, in the joint itself, or in the foot. Secondary procedures in the foot and leg, including osteotomies, fusions and muscle balancing, are performed either before or simultaneously with ankle replacement.
The reliability of a new device designed to assess gastrocnemius contracture.
Gastrocnemius contracture may be a significant cause of many foot disorders. Gastrocnemius tension can be estimated clinically by measuring maximum ankle dorsiflexion during full knee extension. Such measurements, when made with currently available goniometric devices, are subject to high levels of intra- and inter-observer variability. We have designed a device to more consistently measure ankle dorsiflexion, using three dimensional tracking sensors on the leg and foot. The applied dorsiflexion torque is kept constant by a computer, and the computer also monitors hindfoot position to maintain a neutrally aligned foot during testing. Repeated measurements on 26 feet were taken to determine the consistency of the device. The correlation coefficient for the measurements was 0.96, indicating very low intra-observer variability. The standard deviation of the repeated measures was 2 degrees. Based on the 95% confidence interval, the device can be considered accurate to within 4 degrees. Given this accuracy, this instrument could be used to assess gastrocnemius tension, its role in foot pathology, and the effectiveness of surgical lengthening. Compared to other currently available measuring devices, this instrument is the most reliable in estimating ankle dorsiflexion, since it is capable of controlling hindfoot position and applied dorsiflexion torque, and it can be easily constructed by other laboratories.
Social and economic benefits of flexible intramedullary nails in the treatment of pediatric femoral shaft fractures.
All patients between the ages of 5 and 15 years with isolated femoral shaft fractures treated at our institution with flexible intramedullary nails between 1996 and 1998 were examined and compared to an age-matched group of patients treated with spica casting. All fractures healed well with no significant complications. Patients treated with flexible intramedullary nails achieved earlier independent ambulation, at an average of 19 days, compared to 106 in the control group (P<.0001). They also attained earlier independent bathroom use (21 versus 79 days, P<.0001). Hospital stays were significantly shorter as well (6 versus 29 days, P<.0001). These patients also returned to school earlier, at 28 days postinjury, compared to 120 days for patients in spica casts (P<.0001). The use of flexible intramedullaty nails allowed patients and their families to achieve independence months earlier than the spica cast patients. Earlier return to school, independent ambulation, and independent bathroom use are advantages of this treatment modality.