Anatomy and Physiology of the Lesser Metatarsophalangeal Joints
Knowledge and command of anatomy is paramount to effectively treating disorders of the lesser metatarsophalangeal (MTP) joints. The osseous structures consist of the proximal phalanx of the toe and the metatarsal head. The soft tissues on the dorsum of the MTP joint include the joint capsule and the tendons of extensor digitorum longus and extensor digitorum brevis. The proper and accessory collateral ligaments form the medial and lateral walls and contribute to stability in the coronal and sagittal planes. The plantar plate forms the plantar border of the MTP joint and stabilizes the MTP joint against hyperextension and d...
Source: Foot and Ankle Clinics - November 16, 2017 Category: Orthopaedics Authors: Fred T. Finney, Ezequiel Cata, James R. Holmes, Paul G. Talusan Source Type: research

Lesser Metatarsophalangeal Joint Instability
The plantar plate and associated collateral ligaments are the main stabilizers of each of the lesser metatarsophalangeal joints. Although clinical examination and plain radiographs are usually sufficient to establish the diagnosis of a plantar plate tear, MRI or fluoroscopic arthrograms may help in specific cases. Recent results with a dorsal approach to plantar plate repair are promising with respect to pain relief and patient satisfaction. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - November 16, 2017 Category: Orthopaedics Authors: Raymond Y. Hsu, Alexej Barg, Florian Nickisch Source Type: research

Conservative Management of Metatarsalgia and Lesser Toe Deformities
There are several forefoot conditions that can result in metatarsal head pain. Various points of the gait cycle can predispose the metatarsal heads to pain based on intrinsic and extrinsic imbalances. Metatarsalgia can further be classified according to primary, secondary, or iatrogenic etiologies. Within these groups, conservative management is the first line of treatment and can often obviate surgical intervention. Depending on the cause of pain, proper shoewear, orthoses, and inserts coupled with targeted physical therapy can alleviate most symptoms of metatarsalgia and lesser toe deformities. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - November 10, 2017 Category: Orthopaedics Authors: Andrew E. Federer, David M. Tainter, Samuel B. Adams, Karl M. Schweitzer Source Type: research

Presentation, Diagnosis, and Nonsurgical Treatment Options of the Anterior Tibial Tendon, Posterior Tibial Tendon, Peroneals, and Achilles
Disorders of the anterior tibial tendon (ATT) are rare, and relatively few series have been described in the literature. Ruptures of the ATT are more common than tendinopathies of the ATT. For those patients with a tendinopathy, initial treatment may include activity and shoe-wear modifications. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 25, 2017 Category: Orthopaedics Authors: David Pedowitz, David Beck Source Type: research

Acute Peroneal Injury
A high clinical suspicion and greater understanding of the anatomy and pathophysiology of lateral ankle injuries have enabled early diagnosis and treatment-improving outcomes of acute peroneal tendon tears. Multiple conditions can be the cause of lateral ankle pain attributed to the peroneal tendons: tenosynovitis, tendinosis, subluxation and dislocation, stenosing tenosynovitis, abnormality related to the os peroneum, as well as tears of the peroneal tendons. It is imperative for the clinician to maintain a high suspicion for peroneal tendon abnormality when evaluating patients with lateral ankle pain. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 25, 2017 Category: Orthopaedics Authors: James W. Brodsky, Jacob R. Zide, Justin M. Kane Source Type: research

All Those Worms
Dating back to the time of Homer, man has been intrigued by tendons. Achilles, the most popular and well known of the lot, has been a hot topic of debate for years. Treatment of acute to chronic issues, nonop versus surgical care, open versus percutaneous, the use of adjunctive treatments or not, and so much more have been argued. Many countries are not afforded the luxury of fancy tools that allow surgeons to help our patients. In this issue, we touch on the current state of many of these topics and have authors who discuss their implant-free methods of handling these issues in their own country. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 25, 2017 Category: Orthopaedics Authors: Selene G. Parekh Tags: Preface Source Type: research

Treatment of Acute and Chronic Tendon Rupture and Tendinopathy
FOOT AND ANKLE CLINICS (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 25, 2017 Category: Orthopaedics Authors: Selene G. Parekh Source Type: research

Copyright
ELSEVIER (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 25, 2017 Category: Orthopaedics Source Type: research

Contributors
MARK S. MYERSON, MD (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 25, 2017 Category: Orthopaedics Source Type: research

Editorial Advisory Board
J. Kent Ellington, MD, MS (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 25, 2017 Category: Orthopaedics Source Type: research

Contents
Selene G. Parekh (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 25, 2017 Category: Orthopaedics Source Type: research

Forthcoming Issues
Management of Metatarsalgia and Painful Lesser Toe Deformities (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 25, 2017 Category: Orthopaedics Source Type: research

Noninsertional Tendinopathy of the Achilles
Noninsertional Achilles tendinosis is differentiated from insertional Achilles tendinosis based on anatomic location. Tendinosis, as opposed to tendonitis, is primarily a degenerative process and the role of inflammation is believed limited. The etiology of Achilles tendinopathy may include overuse leading to repetitive microtrauma, poor vascularity of the tissue, mechanical imbalances of the extremity, or combination of these elements. There is evidence to support eccentric exercise nonoperative management for patients with noninsertional Achilles tendinopathy. Operative treatment options include percutaneous longitudinal...
Source: Foot and Ankle Clinics - September 26, 2017 Category: Orthopaedics Authors: Avreeta Singh, Arash Calafi, Chris Diefenbach, Chris Kreulen, Eric Giza Source Type: research

Using Arthroscopic Techniques for Achilles Pathology
Endoscopically assisted procedures have been established to provide the surgeon with minimally invasive techniques to address common Achilles conditions. Modifications to some of these techniques as well as improvements in instrumentation have allowed these procedures to provide similar clinical results to the traditional open surgeries while reducing wound complications and accelerating patient ’s recoveries. The available literature on these techniques reports consistently good outcomes with few complications, making them appealing for surgeons to adopt. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 26, 2017 Category: Orthopaedics Authors: Rebecca Cerrato, Paul Switaj Source Type: research

What Do You Do With The Achilles if You Have No Fancy Toys?
Surgical management of Achilles disorders warrants excision of the degenerated tendon and removal of impinging bone. Resulting defects can be bridged by various methods. Although FHL is the most commonly used tendon for transfer, large defects in cases of chronic Achilles ruptures may be bridged by use of a distant donor tendon. Bony anchorage of a lengthened or transferred tendon into the calcaneus can be done with suture anchors or with interference screws. In developing countries, such implants may not be available or affordable, necessitating the adoption of innovative ways to anchor tendons into the calcaneus. (Source...
Source: Foot and Ankle Clinics - September 26, 2017 Category: Orthopaedics Authors: Rajiv Shah, Sampat Dumbre Patil Source Type: research

Treatment of Acute and Chronic Tibialis Anterior Tendon Rupture and Tendinopathy
This article reviews the current literature on TA tendinosis and acute and chronic ruptures. It discusses the patient presentation, physical examination, nonoperative management, surgical treatment options, and outcomes. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 26, 2017 Category: Orthopaedics Authors: Elizabeth Harkin, Michael Pinzur, Adam Schiff Source Type: research

Treatment of Neglected Achilles Tendon Ruptures with Interpositional Allograft
Although most astute clinicians can diagnose Achilles tendon ruptures by physical examination alone, more than 20% are not accurately diagnosed in a timely fashion. The definition of a “chronic” Achilles tendon rupture in foot and ankle literature varies widely: from 4 to 10 weeks status after injury. Neglected or chronic Achilles tendon ruptures can be significantly disabling to patients if the muscle-tendon unit is stretched beyond its normal passive limit. There are a vari ety of treatment options that all have valid uses but have not been proven to be superior to one another. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 26, 2017 Category: Orthopaedics Authors: Christopher E. Gross, James A. Nunley Source Type: research

Chronic Rupture of the Peroneal Tendons
Chronic rupture of the peroneal tendons can be a functionally limiting condition with a multitude of causes. Conservative and operative interventions are heterogenous and tailored to the functional demands of the patient. Surgical plans are based on muscle viability, patient preference, and surgeon expertise. Clinical outcomes evidence remains limited in this domain, and further well-designed studies are warranted to guide treatment. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 26, 2017 Category: Orthopaedics Authors: Kamran S. Hamid, Annunziato Amendola Source Type: research

Tendonitis and Tendinopathy
The development of tendinitis and tendinopathy is often multifactorial and the result of both intrinsic and extrinsic factors. Intrinsic factors include anatomic factors, age-related factors, and systemic factors, whereas extrinsic factors include mechanical overload and improper form and equipment. Although tendinitis and tendinopathy are often incorrectly used interchangeably, they are in 2 distinct pathologies. Due to their chronicity and high prevalence in tendons about the ankle, including the Achilles tendon, the posterior tibialis tendon, and the peroneal tendons, tendinitis and tendinopathies cause significant morb...
Source: Foot and Ankle Clinics - September 25, 2017 Category: Orthopaedics Authors: Andrew E. Federer, John R. Steele, Travis J. Dekker, Jordan L. Liles, Samuel B. Adams Source Type: research

Insertional Tendinopathy of the Achilles
Insertional Achilles tendinopathy is a degenerative enthesopathy associated with pain and dysfunction. Nonsurgical management is first attempted for a period of 3 to 6  months and may consist of physical therapy with eccentric training and other modalities. Surgical treatment can be successful with a variety of approaches. A thorough debridement through a midline tendon-splitting approach is associated with high satisfaction rates. Flexor hallucis longus transfer to augment the repair is considered in older, heavier patients or if more than 50% of the tendon was debrided. Early functional rehabilitation is associated ...
Source: Foot and Ankle Clinics - September 25, 2017 Category: Orthopaedics Authors: Rachel J. Shakked, Steven M. Raikin Source Type: research

The Acute Injury of the Achilles
Achilles tendon rupture is a common lower extremity injury seen in the active population. Although reruptures rates have improved with nonoperative functional management, surgical treatment is still preferred by the authors. Minimally invasive techniques allow optimal Achilles tendon rupture apposition and tensioning, with a reduced risk of soft tissue complications associated with the traditional open repair. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 20, 2017 Category: Orthopaedics Authors: Oliver Schipper, Bruce Cohen Source Type: research

The Missed Achilles Tear
This article reviews the principles of diagnosis, treatment options, and clinical outcomes, and outlines the authors’ preferred techniques. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 20, 2017 Category: Orthopaedics Authors: Brian D. Steginsky, Bryan Van Dyke, Gregory C. Berlet Source Type: research

Understanding the Anatomy and Biomechanics of Ankle Tendons
The tendons that cross the ankle are complex and sophisticated structures that enable standing and forward propulsion and the ability to accommodate uneven ground. Understanding the biomechanics and local anatomy of these tendons is essential to the treatment of disorders of the foot and ankle, whether it be in formulating an appropriate physical therapy regimen or planning a reconstructive surgical procedure. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 19, 2017 Category: Orthopaedics Authors: Christopher P. Chiodo Source Type: research

Is This My Ankle or My Foot?
This article poses the question, is there a subset of patients with “flatfoot” that has little to do with the foot and is all about the ankle? (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - August 3, 2017 Category: Orthopaedics Authors: William Hodges Davis Source Type: research

The Flatfoot: Even After Decades of Work, We Still Need Help Understanding It
The flatfoot condition is a very common problem, seen daily in the foot and ankle surgeon ’s office. Many patients can be treated nonoperatively. If conservative treatment fails, many surgical options exist. Choosing the correct procedure for the correct patient is not as easy as a textbook algorithm may suggest. The identical deformity in one patient may be treated in an entirely diff erent way in another patient. Following flatfoot correction, patients may still have ongoing issues. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - August 3, 2017 Category: Orthopaedics Authors: J. Kent Ellington Tags: Preface Source Type: research

The Flatfoot: Pearls and Pitfalls
FOOT AND ANKLE CLINICS (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - August 3, 2017 Category: Orthopaedics Authors: J. Kent Ellington Source Type: research

Copyright
ELSEVIER (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - August 3, 2017 Category: Orthopaedics Source Type: research

Contributors
MARK S. MYERSON, MD (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - August 3, 2017 Category: Orthopaedics Source Type: research

Editorial Advisory Board
J. Kent Ellington, MD, MS (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - August 3, 2017 Category: Orthopaedics Source Type: research

Contents
J. Kent Ellington (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - August 3, 2017 Category: Orthopaedics Source Type: research

Forthcoming Issues
Treatment of Acute and Chronic Tendon Rupture and Tendinopathy (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - August 3, 2017 Category: Orthopaedics Source Type: research

Evans Osteotomy Complications
In 1975, Evans published a paper describing surgical management of the “calcaneo-valgus deformity,” pointing out that the deformity was due to relative shortening of the lateral column of the foot. Correction involved “equalizing” both columns by performing an osteotomy in the neck of the calcaneus 1.5 cm from the calcaneocuboid joint, where a trapezoidal wedg e of tricortical bone was placed. Although it was considered a success, there were complications, including sural nerve injury, surgical wound dehiscence, undercorrection, and graft subsidence. The osteotomy grew in popularity. Indication...
Source: Foot and Ankle Clinics - June 13, 2017 Category: Orthopaedics Authors: Marcelo E. Jara Source Type: research

Naviculocuneiform Sag in the Acquired Flatfoot
Sag at the naviculocuneiform (NC) joint represents an important aspect of the flatfoot deformity. Failure to address medial column instability could lead to continued deformity and poor patient outcomes. No single procedure is enough to address the complexity of the adult acquired flatfoot deformity. Whether in combination with other procedures or in isolation, NC fusion and Cotton osteotomy are important pieces of the armamentarium to address all aspects of the flatfoot deformity. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - June 8, 2017 Category: Orthopaedics Authors: Joshua A. Metzl Source Type: research

Calcaneal Osteotomies
This article reviews indications, techniques, complications, and outcomes for the medializing calcaneal osteotomy. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - June 8, 2017 Category: Orthopaedics Authors: Stephen Greenfield, Bruce Cohen Source Type: research

Did Failure Occur Because of Medial Column Instability That Was Not Recognized, or Did It Develop After Surgery?
Medial column instability is a primary deforming force in the setting of pes planovalgus deformity. Consideration for medial column stabilization only after correction of the hindfoot deformity may result in creating a rigid hindfoot, compromising clinical outcomes. Careful analysis of the lateral radiograph to determine whether the deformity is secondary to the medial column or true peritalar subluxation may allow superior outcomes. Iatrogenic creation of an excessively rigid medial column may lead to significant instability of the remaining joints in the short term and arthrosis in the long term. Medial column arthrodesi...
Source: Foot and Ankle Clinics - June 7, 2017 Category: Orthopaedics Authors: Anish R. Kadakia, Armen S. Kelikian, Mauricio Barbosa, Milap S. Patel Source Type: research

What to Do with the Spring Ligament
This article reviews the pathoanatomy of the spring ligament complex and the role of spring ligament reconstruction in acquired flatfoot deformity, and highlights current research. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - June 4, 2017 Category: Orthopaedics Authors: Brian Steginsky, Anand Vora Source Type: research

Deltoid Ligament Repair in Flatfoot Deformity
Deltoid ligament reconstruction allows for joint preservation of the ankle in the setting of patients a triple arthrodesis due to a flat foot deformity. Although the increased forces that may occur in the ankle joint after a triple arthrodesis cannot be eliminated, reconstruction of the ligament will delay and may prevent the onset arthritis, allowing the patient to maintain mobility of the ankle joint. The anatomy, surgery, and risks and benefits are discussed. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - June 2, 2017 Category: Orthopaedics Authors: Ezekiel Oburu, Mark S. Myerson Source Type: research

Deltoid Ligament Repair in Flat Foot Deformity
Deltoid ligament reconstruction allows for joint preservation of the ankle in the setting of patients a triple arthrodesis due to a flat foot deformity. Although the increased forces that may occur in the ankle joint after a triple arthrodesis cannot be eliminated, reconstruction of the ligament will delay and may prevent the onset arthritis, allowing the patient to maintain mobility of the ankle joint. The anatomy, surgery, and risks and benefits are discussed. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - June 2, 2017 Category: Orthopaedics Authors: Ezekiel Oburu, Mark Myerson Source Type: research

Severe Stage 2: Fuse or Reconstruct
This article examines when fusion verses reconstruction is the appropriate treatment of patients with severe stage II posterior tibial tendon dysfunction and its subclassifications. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - June 2, 2017 Category: Orthopaedics Authors: Scott B. Shawen, Theodora C. Dworak Source Type: research

The Undercorrected Flatfoot Reconstruction
This article discusses the typical deformities in adult flatfoot and indications for surgical intervention. Also presented are the surgical procedures for the correction of the typical deformity patterns with available outcome statistics and a stepwise algorithm for patient evaluation to assist in treatment and mitigate the risk of undercorrection of deformity. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - June 2, 2017 Category: Orthopaedics Authors: Kenneth J. Hunt, Ryan P. Farmer Source Type: research

Overcorrected Flatfoot Reconstruction
The overcorrected flatfoot reconstruction is a less common but often difficult sequelae of surgical treatment of the adult acquired flatfoot deformity. Understanding the patient ’s symptoms and how they correlate to the procedures performed during the index surgery are paramount to determining the appropriate course of treatment. Patients’ symptoms may resemble those seen in the cavovarus foot condition, often secondary to overlengthening of the lateral column or excess ive displacement of the calcaneal tuberosity. Osteotomies of the calcaneus, midfoot, and often the first metatarsal may be sufficient to revise...
Source: Foot and Ankle Clinics - June 2, 2017 Category: Orthopaedics Authors: Todd A. Irwin Source Type: research

Pediatric Flatfoot
Pediatric flatfeet are common, usually asymptomatic, and typically improve over time as young children age. It is critical to differentiate flexible from rigid flatfeet and to assess for associated Achilles contracture with a careful history, physical examination, and initial radiographs. Although there are limited data, nonsurgical management of symptomatic flatfeet, both flexible and rigid, should be exhausted before considering surgical intervention. If patients fail conservative treatment, surgical management with joint preserving, deformity corrective techniques are typically used for pediatric flexible flatfeet in co...
Source: Foot and Ankle Clinics - June 2, 2017 Category: Orthopaedics Authors: Samuel E. Ford, Brian P. Scannell Source Type: research

Management of the Malunited Triple Arthrodesis
Malunion remains a common complication after triple arthrodesis, with rates as high as 6% in the reported literature. Careful patient evaluation is critical to determine the location and degree of bony deformity. A stepwise systematic approach to correct hindfoot and midfoot deformity is presented in this article. Few studies have been published to guide foot and ankle surgeons with this difficult clinical scenario but reports have demonstrated high success rates and low rates of complications after revision triple arthrodesis. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - June 2, 2017 Category: Orthopaedics Authors: Jeffrey D. Seybold Source Type: research

Kinematics and Function of Total Ankle Replacements Versus Normal Ankles
End-stage ankle arthritis produces severe functional disability, quantifiable by gait abnormalities. In all categories of gait parameters, total ankle arthroplasty (TAA) satistically significantly improves function, compared to patients ’ preoperative function. There are increases in step length, cadence and velocity; in sagittal plane motion of the ankle, as well has hip and knee motion, and in ankle power and moment. These functional gait improvements correspond to clinical improvements of pain relief and satisfaction. Although these improvements fail to reach the functional performance of healthy controls, the imp...
Source: Foot and Ankle Clinics - May 12, 2017 Category: Orthopaedics Authors: Justin M. Kane, Scott Coleman, James W. Brodsky Source Type: research

Soft Tissue Reconstruction After Total Ankle Arthroplasty
Wound complications following total ankle replacement are common. A team approach, including plastic surgeons, should be utilized to manage these wound issues. The handling of the wound, from the index procedure, to a variety of flaps, can be utilized to provide a successful outcome following an ankle replacement. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - May 12, 2017 Category: Orthopaedics Authors: Yash J. Avashia, Ronnie L. Shammas, Suhail K. Mithani, Selene G. Parekh Source Type: research

Ankle Arthrodesis Versus Total Ankle Arthroplasty
Reoperation rates are higher in total ankle arthroplasties (TAAs) compared with ankle arthrodesis. Infection rates for primary TAAs are 1.4% to 2.4%. The survival rate of TAA is approximately 75% to 90% at 10 years. Arc of motion is maintained with TAAs compared with ankle arthrodesis. Ankle arthrodesis increases arc of motion through the talonavicular joint. Several factors are strong reasons to favor ankle fusion rather than TAA. TAA and ankle arthrodesis are effective treatments of end-stage ankle arthritis but the choice must be tailored to individual patients. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - May 12, 2017 Category: Orthopaedics Authors: Joel Morash, David M. Walton, Mark Glazebrook Source Type: research

Current Update in Total Ankle Arthroplasty
Ankle replacement results may be compromised by malposition of the components. An anterior displacement can be measured on a lateral standing radiograph. The ankle may appear anteriorly translated because the ankle is overstuffed, the heel cord is tight, or the posterior capsule is tight. In ankle instability with degenerative arthritis, the talus may be anteriorly translated, internally rotated, and in varus. In an ankle replacement, this deformity may persist and will require correction. On occasion, the talus is inserted too anterior; revision to a flat cut talar component and posterior translation of the talar componen...
Source: Foot and Ankle Clinics - May 12, 2017 Category: Orthopaedics Authors: Alastair Younger, Andrea Veljkovic Source Type: research

Current Updates in Total Ankle Arthroplasty
FOOT AND ANKLE CLINICS (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - May 12, 2017 Category: Orthopaedics Authors: J. Chris Coetzee Source Type: research

Copyright
ELSEVIER (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - May 12, 2017 Category: Orthopaedics Source Type: research

Contributors
MARK S. MYERSON, MD (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - May 12, 2017 Category: Orthopaedics Source Type: research