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Study design: Biomechanical simulation of DVR and pure-moment testing on thoracic spines. Objectives: Characterize load-deformation response of thoracic spines under DVR maneuvers until failure, and compare to pure-moment testing of same spines. Summary of background data: Despite reports of surgical complications, few studies exist on increase in ROM under DVR torque. Biomechanical models predicting increases from surgical releases have consistently used “pure-moments”, a standard established for non-destructive measurement of ROM. Yet, DVR torque is not accurately modeled using pure moments and, moreover, magnitudes of torque applied during DVR maneuvers may be substantially higher than pure-moment testing. Methods: Cadaveric thoracic spines (N= 11) were imaged, then prepared. Polyaxial pedicle screws were implanted at T7–T10 after surgical releases. Bilateral facetectomies and Ponte osteotomies were completed at T10–T11. A custom apparatus, mounted into an 8-dofMTS load frame, was used to attach to pedicle screws, allowing simulation of surgical DVR maneuvers. Motions of vertebrae were measured using optical motion tracking. Torque was increased until rupture of the T10–T11 disc or fracture at the pedicle screw sites at any level. The torque-rotation behavior was compared to its behavior under pure-moment testing performed prior to the DVR maneuver. Results: Under DVR maneuvers, failure of the T10–T11 discs accompanied in most cases by pedicle screw loosening, occurred at 13.7–54.7 Nm torque, increasing axial rotation by 1.4°–8.9°. In contrast, pure-moment testing (4 Nm) increased axial rotation by only 0.0°–0.9°. Conclusions: DVR resulted in substantially greater correction potential increases compared to pure-moment testing even at the same torque. These results suggest increased flexibility obtained by osteotomies and facetectomies is underestimated using pure-moment testing, misrepresenting clinical expectations. The present study is an important and necessary step toward the establishment of a more accurate and ultimately surgically applied model. Level of evidence: III.

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Supplemental Digital Content is available in the text.Previous investigators have suggested a role for generalized joint hypermobility (GJH) in the etiology of clubfoot deformity, while others have suggested its presence may influence treatment outcomes. We sought to determine if GJH was associated with the demographics, treatment, or propensity to relapse of patients whose clubfeet were managed using the Ponseti method. Fifty-seven patients with Ponseti-treated clubfeet comprised the cohort; median age 61 months (range, 38–111 months). A physical therapist evaluated each patient using the nine-point Beighton scale to quantify hypermobility. The scores were then correlated with patient sex, laterality, Dimeglio severity score, treatment, relapse, and surgery. The median Beighton score was 5; 49 of 57 patients (86%) had Beighton scores ≥4. All feet were plantigrade without symptomatic overcorrection at the time of evaluation. Although there was a slightly lower probability of relapse in patients with higher Beighton scores, this was not statistically significant (P = 0.10). Accordingly, the sex, laterality, initial severity, number of pretenotomy casts, need for tenotomy, relapse, and need for tendon transfer surgery were not significantly influenced by the Beighton score. The outcome of Ponseti clubfoot treatment is not altered by the presence of GJH in young children. Joint hypermobility does not appear to influence the likelihood of relapse or surgery. Unlike clubfeet reportedly treated with release surgery, Ponseti-treated clubfeet were not prone to excessive overcorrection regardless of joint laxity. Last, the distribution of Beighton scores in the study’s cohort supports an association between GJH and clubfoot deformity.

Context: With the rise in sports participation and increased athleticism in the adolescent population, there is an ever-growing need to better understand adolescent meniscus pathology and treatment.Objective: To better understand the operative management of meniscus tears in the adolescent population.Data Sources: A systematic review of PubMed (MEDLINE) and Google Scholar was performed for all archived years.Study Selection: Studies that reported on isolated meniscus tears in adolescent patients (age, 10-19 years) were included.Study Design: Systematic review and meta-analysis.Level of Evidence: Level 4.Data Extraction: Two authors reviewed and extracted data from studies that fulfilled all inclusion criteria.Results: Nine studies on isolated meniscus tears in adolescent patients were found, with level of evidence ranging from 3 to 4. These studies evaluated a total of 373 patients (248 males, 125 females) and 390 knees. Seven studies were published between 1979 and 2000, all of which discuss meniscectomy as the primary treatment. Two studies were published after 2000 and report on meniscus repair surgery. The mean patient age was 14.4 years. A total of 308 meniscectomies and 64 meniscus repairs were performed. Follow-up ranged from 1.8 to 30 years (mean, 10.8 years). A 37% retear rate was reported for patients undergoing meniscus repair. Different outcome measures were used for meniscectomy versus meniscus repair. Three studies evaluating meniscectomy reported Tapper-Hoover scores, showing 54 patients with an excellent result, 58 with good, 57 with fair, and 23 with poor results.Conclusion: A shift in the management of isolated adolescent meniscal tears is reflected in the literature, with a recent increase in operative repair. This is likely secondary to poor outcomes after meniscectomy reflected in long-term follow-up studies. The current literature highlights the need for improved description of tear patterns, standardized reporting of outcome measures, and improved study methodologies to help guide orthopaedic surgeons on operative treatment of meniscal tears in adolescent patients.

Waterproof casting has been reported to increase patient comfort and satisfaction, and decrease skin irritation. There are no available data on the influence of waterproof casting materials on physical function in pediatric patients. Our aim was to determine whether the use of waterproof casting would result in faster recovery of physical function while maintaining similar clinical outcomes as those obtained with nonwaterproof materials. Twenty-six children with nonangulated or minimally angulated distal radius fractures were assigned randomly to initially receive a short-arm cast made of one of two optional materials: a hybrid mesh material with a waterproof lining or fiberglass with a nonwaterproof skin protector. Two weeks later, the initial cast was removed and replaced with a short-arm cast made of the alternative option. We compared the rate of fracture displacement, physical function, pain, skin changes, itchiness, and patient satisfaction. No evidence of displacement was found in either group. The mean Activities Scale for Kids – Performance (ASK-P) (physical function) score was 10% higher during the period of time when a waterproof cast was used (P=0.04). When a waterproof cast was used during the first 2 weeks of treatment, the mean total ASK-P scores were 23% higher than that when a nonwaterproof one was used during the same period of time (P=0.003). Patients who received a waterproof cast as the initial treatment reported lower functional scores overall and in almost every domain of the ASK-P once they were in a nonwaterproof one; similarly, those who received a nonwaterproof cast as the initial treatment reported higher functional scores overall and in every domain of the ASK-P once they were in a waterproof cast. Compared with a nonwaterproof cast, the use of waterproof casting resulted in comparable levels of pain, itchiness, skin irritability, and overall patient satisfaction. The results of this randomized, cross-over trial suggest that the use of waterproof casting material for the treatment of nondisplaced or minimally displaced distal radius fractures in children can result in a faster recovery of physical function, while providing comparable stability, pain, itchiness, skin irritability, and overall patient satisfaction. Level of Evidence: II.

With metal-on-metal (MoM) bearings, fluid film lubrication is disrupted when the contact patch area between the femoral head and the cup is close to the edge of the acetabular component, making the calculation of the contact patch to rim (CPR) distance a key variable in the study of the performance of MoM bearings. A few research centers have used models of varying complexity to calculate the CPR distance and determine its relationship with assessments of component wear. In this review, we aimed to summarise the current knowledge related to the application of CPR distance calculations in the study of in vivo performance of MoM bearings. Our systematic search of the US National Library of Medicine yielded 9 relevant publications in which 3 different models were used for the computation of the CPR distance. The 3 models show different levels of complexity and their use is mainly dependent upon the size of the subject sample and the nature of the data collected as a dependent variable. The studies reviewed consistently showed a strong inverse correlation between CPR distance and wear or metal ion levels suggesting that any study aiming to determine the risk factors for MoM hip devices needs to include an assessment of CPR distance. Cup anteversion can be measured reliably with various tools and should not be an obstacle to the use of this essential variable that is CPR distance.

Introduction Periprosthetic bone loss may lead to major complications in total hip arthroplasty (THA), including loosening, migration, and even fracture. This study analysed the influence of femoral implant designs on periprosthetic bone mineral density (BMD) after THA.Methods The results of all previous published studies reporting periprosthetic femoral BMD following THA were compiled. Using these results, we compared percent changes in bone loss as a function of: femoral stem fixation, material, and geometry.Results The greatest bone loss was in the calcar region (Gruen Zone 7). Overall, cemented stems had more bone loss distally than noncemented stems, while noncemented stems had more proximal bone loss than cemented stems. Within noncemented stems, cobalt-chromium (CoCr) stems had nearly double the proximal bone loss compared to titanium (Ti) alloy stems. Finally, within noncemented titanium alloy group, straight stems had less bone loss than anatomical, tapered, and press-fit designs.Discussion The findings from the present study quantified percent changes in periprosthetic BMD as a function of fixation method, alloy, and stem design. While no one stem type was identified as ideal, we now have a clearer understanding of the influence of stem design on load transfer to the surrounding bone.

Direct vertebral rotation (DVR) has gained increasing popularity for deformity correction surgery. Despite large moments applied intraoperatively during deformity correction and failure reports including screw plow, aortic abutment, and pedicle fracture, to our knowledge, the strength of thoracic spines has been unknown. Moreover, the rotational response of thoracic spines under such large torques has been unknown.

Background: Direct vertebral rotation (DVR) has gained increasing popularity for deformity correction surgery. Despite large moments applied intraoperatively during deformity correction and failure reports including screw plow, aortic abutment, and pedicle fracture, to our knowledge, the strength of thoracic spines has been unknown. Moreover, the rotational response of thoracic spines under such large torques has been unknown. Purpose: Simulate DVR surgical conditions to measure torsion to failure on thoracic spines and assess surgical forces. Study Design: Biomechanical simulation using cadaver spines. Methods: Fresh-frozen thoracic spines (n = 11) were evaluated using radiographs, magnetic resonance imaging (MRI) and dual-energy x-ray absorptiometry. An apparatus simulating DVR was attached to pedicle screws at T7–T10 and transmitted torsion to the spine. T11–T12 were potted and rigidly attached to the frame. Strain gages measured the simulated surgical forces to rotate spines. Torsional load was increased incrementally till failure at T10–T11. Torsion to failure at T10–T11 and corresponding forces were obtained. Results: The T10–T11 moment at failure was 33.3 ± 12.1 Nm (range = 13.7–54.7 Nm). The mean applied force to produce failure was 151.7 ± 33.1 N (range = 109.6–202.7 N), at a distance of approximately 22 cm where surgeons would typically apply direct vertebral rotation forces. Mean right rotation at T10–T11 was 11.6°±5.6°. The failure moment was significantly correlated with bone mineral density (Pearson coefficient 0.61, p =.047). Failure moment also positively correlated with radiographic degeneration grade (Spearman rho > 0.662, p <.04) and MRI degeneration grade (Spearman rho = 0.742, p =.01). Conclusion: The present study indicated that with the advantage of lever arms provided with DVR techniques, relatively small surgical forces, <200 N, can produce large moments that cause irreversible injury. Although further studies are required to establish the safety of surgical deformity correction surgeries, the present study provides a first step in the quantification of thoracic spine strength.

Highly cross-linked polyethylene (XLPE) has improved wear properties. This study reports the results of a small series of patients treated over 10 years ago with a metal-on-XLPE hip resurfacing.A total of 21 hips in 20 patients received a hip resurfacing with a cobalt-chromium metal femoral head and metal-backed acetabular cup lined with a XLPE insert and were retrospectively studied. Kaplan-Meier Survivorship was calculated.Five patients who had initial extreme cystic disease in the femoral head failed due to femoral loosening. Survivorship was 95.2% at 5 years and 81.0% at 10 years.We found that XLPE wear was not implicated in these failures, which were primarily attributed to poor bone quality of the femoral head, early bone preparation, cementing technique and excessive head reaming to near the neck diameter, necessitated for the implantation of a thick two-part socket.

We present a group of pediatric supracondylar humerus fractures in whom a medial pin was inserted, in addition to lateral-entry pins, and compared it with a group that was treated with lateral-only entry pins. We evaluated differences in the rate of complications related to the insertion of the medial pin.

Background:There is growing interest in suture-button devices for syndesmosis injury, which are intended to offer less rigid fixation than screw fixation.Methods:The fixation strength with 2 different suture-button devices, ZipTight and TightRope, were compared using 5 cadaveric leg pairs (n = 10). In an additional 5 pairs (n = 10), ZipTight was compared to 3.5 mm quadricortical screw fixation. Ankle motion was measured intact, then following simulated syndesmosis injury and fixation. Cyclic loads (peak 750 N, 7.5 Nm) were applied. Finally, external rotation to failure was measured and failure mode was documented.Results:Range of motion increased after simulated injury and fixation with all devices (max 14.5 degrees). In all groups, diastasis remained below 1.0 mm intact and below 2.0 mm during cyclic loading. Compared to intact, under load to failure, diastasis with ZipTight devices increased by 4.7 ± 1.3 mm and 7.6 ± 4.3 mm, with TightRope, 6.3 mm, and screw construct, 1.3 mm. ZipTight specimens rotated approximately 80 ± 22 degrees before failure, TightRope, 67 ± 13 degrees, screw constructs, 76 ± 27 degrees. Mean failure torque was between 22.2 ± 6.9 Nm and 28.1 ± 12.7 Nm for ZipTight, compared to 32.9 ± 8.0 Nm for TightRope (P = .07), and 30.1 ± 9.6 Nm for screw constructs (P = .03). The majority of suture-button constructs failed by fibular fracture (ZipTight = 6, TightRope = 4), the remaining by device pull-through (ZipTight = 3, TightRope = 1) and loosening (ZipTight = 1). Conversely, 3 of screw-fixed specimens failed by device failure, 2 from bone fracture.Conclusion:Suture-button devices provided torsional strength below that of screw fixation. However, all devices may provide failure torques well above 20 Nm, exceeding likely torques applied in casts during healing.1,2,4Clinical Relevance:Suture-button devices appear to have provided adequate fixation strength for syndesmosis injuries.

We measured biomechanical stability in simulated supracondylar humeral fractures fixed with each of 6 pin configurations, 2 with associated medial comminution, and developed a technique for reproducible pin placement and divergence.

Posterior-only procedures are becoming more popular for treatment of rigid adolescent idiopathic scoliosis, but little is known about the quantitative correction potential for Ponte osteotomies. The objective of this study was to quantify and compare the range of motion of intact multilevel thoracic spine segments with the same segments after each of 3 sequential Ponte osteotomies.

Background: Posterior-only procedures are becoming more popular for treatment of rigid adolescent idiopathic scoliosis, but little is known about the quantitative correction potential for Ponte osteotomies. The objective of this study was to quantify and compare the range of motion of intact multilevel thoracic spine segments with the same segments after each of 3 sequential Ponte osteotomies. Methods: We tested 5 human cadaveric thoracic spine segments, spanning T—T6, or 11—112, in an 8-degree-of-freedom servo-hydraulic load frame, monitoring motion of each vertebra with an optical motion tracker. We measured range of motion while we applied cyclic, pure moment loading to produce flexion-extension, lateral bending, and axial rotation at a rate of 0.5°/second, to a maximum of ± 6 Nm. Each specimen was tested intact and after each of 3 sequential Ponte osteotomies. Results: Total range of motion for the segments (either T2—T5 or T8—Til) increased by as much as 1.6° in flexion, 1.5° in extension, 0.5° in lateral bending, and 2.8° in axial rotation with each osteotomy. Because of the variation in initial specimen stiffness, we normalized motions to the intact values. In flexion, average range of motion increased after each osteotomy compared with intact, by 33%, 56%, and 69%. In extension, slightly smaller increases were seen, increasing by as much as 56% after the third osteotomy. In lateral bending, Ponte osteotomies had little effect on range of motion. In axial rotation, range of motion increased by 16%, 29%, and 65% after 3 osteotomies. Conclusions: Sequential Ponte osteotomies increased range of motion in flexion, extension, and axial rotation, but not in lateral bending. These results suggest that the Ponte osteotomy may be appropriate when using derotational correction maneuvers, or to improve apical lordosis at the apex of curvature during posterior spinal fusion procedures. Although these techniques are effective in gaining correction for kyphotic deformities and rigid curvatures, they add time and blood loss to the procedure.

To evaluate normative data on elbow range of motion (ROM) in the pediatric population. The passive ROM of 1361 healthy pediatric elbows was measured using a small goniometer calibrated in 1° increments, and recorded. The mean amount of flexion, extension, and arc of motion was 142°, −11°, and 153°, respectively. Our data indicated no meaningful correlation between patient sex, age, or weight and the amount of flexion, extension, or the total arc of motion. It appears that elbow ROM in this population is not affected by sex, age, or weight. Normative data are critical when setting the goals of a particular therapeutic approach.

To determine whether percutaneous tenotomy of the Achilles tendon in infants with idiopathic clubfeet can be safely performed under propofol sedation.

The Mitchell-Ponseti (MP) foot abduction orthosis was introduced to provide a more user-friendly alternative to the traditional Denis-Browne (DB) brace in the treatment of idiopathic clubfoot. We describe our experience with the effectiveness of the MP brace to maintain correction of clubfeet corrected using the Ponseti method.

The natural oxide layer on implantable alloys insulates the reactive underlying metal from the physiological environment, preventing substrate corrosion and device failure. This type of oxide film has had a major role in the minimization of functional failure and toxic response after implantation in the first generation biomaterials. Recent advances in theoretical, computational, and experimental surface engineering tools provide the foundation for the design of novel devices with improved performances in this regard based on conventional implantable metal alloys. An increasing number of technologies provide the possibility of tailoring chemico-physical and morphological parameters of the surface oxide layers. For some applications, such as dental implants, surface modifications result in substantial innovation and economic success. However, the selection of novel surfaces is in general based on experimental studies and has a limited theoretical and computational foundation.In this review, we offer a perspective analysis of the correlation between theoretical studies and chemical surface modification technologies, with a special emphasis on titanium oxide on Ti alloys. Theoretical approaches for the surface behavior at an atomistic level of description are presented, together with some adsorption studies on a rutile surface. The role of chemical and electrochemical surface modification technologies in modifying the TiO2structure, morphology, and chemistry to tailor in vivo biological response is then briefly reviewed. Finally, we discuss the role of surface modeling as a powerful design tool for a new generation of implantable devices in which metal oxide surface can be tuned to yield specific biological response.

In 2001, the members of the Pediatric Orthopaedic Society of North America (POSNA) were surveyed regarding their approach to treating idiopathic clubfoot deformity. Since that time, several studies have advocated a change in the approach to treating this deformity, moving away from surgical release and toward less invasive methods. The purpose of this study was to assess the recent approach to treating clubfoot among the POSNA membership.

This study describes five patients who had sustained a rare flexion-type fracture separation of the proximal tibial epiphysis and reviews the previous reports of this injury in the literature. The average age of our patients at injury was 15 years. All were male. The left side was involved in four patients; the right in one patient. Four of the injuries occurred during sports activities. All five of these fractures healed in satisfactory alignment after 6 weeks of immobilization without complication. We conclude that these injuries can be safely managed by closed reduction and cast immobilization in a position of full knee extension.

Purpose. To assess the anatomic association of acromioclavicular joint degeneration to supraspinatus outlet impingement and the acromion shape.Methods. Sagittal oblique magnetic resonance images of 49 shoulders in 49 patients were reviewed. 29 of them (mean age, 59 years) underwent surgery for impingement with or without rotator cuff tear (group 1), whereas the 20 controls (mean age, 27 years) were treated for shoulder instability without rotator cuff disease or acromioclavicular joint derangement (group 2). The supraspinatus outlet and the acromion shape of the 2 groups were compared. Results. The difference in the mean supraspinatus outlet between groups 1 and 2 was 11% (514 vs 577 mm2, p=0.095) and between the subgroup (of group 1) with full thickness rotator cuff tears and group 2 was 17% (481 vs 577 mm2, p=0.036). Six of the acromions in group 1 were type III (hooked) compared to none in group 2.Conclusion. In severe acromioclavicular degeneration, distal clavicular excision is recommended, even in cases with an asymptomatic acromioclavicular joint, so as to prevent further osteophyte formation.

Background: The purpose of the study was to evaluate the effect of three different types of hallux valgus surgeries on patient function using validated questionnaires and to correlate the results with radiographic and physical examinations. This study presents the 2-year followup data of a previous prospective outcome study. Methods: One hundred and ninety-six patients were enrolled in this study and completed a baseline AAOS Lower Limb Outcomes Data Collection Questionnaire. They completed the same form at 6, 12, and 24 months after having one of three types of hallux valgus surgeries (106 chevron osteotomies, 72 modified McBride procedures, and 18 modified Lapidus procedures). This questionnaire included the Short Form-36 Health Survey (SF-36) as well as questions relating to lower extremity function. Additionally, physicians were asked to complete preoperative and postoperative questionnaires on each patient that included radiographic and physical examination data and the type of surgery done. Completed outcome surveys and radiographic data were available on 196 patients, and physical examination scores were available to assign an AOFAS score in 111 patients at 24-month followup. A one-way comparison was done after stratifying the results for the type of surgery, preoperative hallux valgus angle and 1-2 intermetatarsal angle, postoperative hallux valgus angle and 1-2 intermetatarsal angle, and the change in the angles. Results: Four of the 10 SF-36 scores (physical function, role-physical, bodily pain, and role-emotional) for the combined data improved by more than five points. For the AAOS lower extremity function scores, physical health and pain (68.5 to 81.6), satisfaction with symptoms (1.8 to 3.6), global foot and ankle (77.6 to 93.4), and shoe comfort (29.0 to 58.7) scores all increased significantly. The AOFAS score increased from 52.6 to 85.5 (p< 0.001). Surprisingly, when comparing mild-to-moderate to severe deformities preoperatively and postoperatively using the absolute magnitude of the angular change in the hallux valgus or intermetatarsal angles, similar improvement was noted in AOFAS, SF-36, and AAOS lower extremity scores. The magnitude of preoperative deformity, postoperative residual deformity, and magnitude of correction also did not significantly change the amount of improvement in any of these scores. No significant differences were noted in the outcome scores among the three different surgeries. Conclusion: Patients who had hallux valgus surgery had significant improvements in four of their SF-36 scores, four of five of AAOS lower extremity scores, and AOFAS scores. The degree of deformity, amount of correction, or type of operation did not influence outcome.

The incidence of orthopaedic surgery for young people with childhood onset of orthopaedic disabilities is not well documented. This study tabulated that incidence in the past two decades in California. Trauma, tumors, and hand surgery were not included in the study. Common pediatric orthopaedic diagnoses by ICD-9 code requiring CPT orthopaedic surgical procedures were tabulated in three years: 1983, 1990, and 1999. The most common procedures in each of these years studied were, in order of incidence, scoliosis, congenital hip problems, slipped femoral capital epiphyses, and clubfeet. The incidence of surgery for scoliosis and slipped femoral capital epiphyses increased over the past two decades. These data should be helpful in planning for future inpatient services for orthopaedically handicapped children.

A retrospective review of 158 type 3 supracondylar humerus fractures was undertaken to determine whether any correlation exists between an increased time from injury to surgery and four unfavorable results a longer operative time, an increase in hospital stay, an increase in the need to open the fracture, or an increase in unsatisfactory outcomes. The average age of the patients was 5.0 years. Five children had nerve injury on initial examination, and no arm was poorly perfused. The average time from injury to evaluation in the emergency department was 9.8 hours and the average time from the emergency department to surgery was 11.5 hours. The average total time from injury to surgical treatment was 21.3 hours. The patients were in the hospital between 1 to 6 days. The average operative time was 53 minutes. Thirty patients had unsatisfactory results, defined as a pin infection, more than 15° loss of motion in any plane, loss of normal carrying angle, neuropraxia, or retained hardware. There was no correlation between an increase in time to surgical intervention and longer operative time or need to open the fracture site, nor was there an indication that the delay to surgical treatment resulted in a longer hospital stay or an increase in unsatisfactory results.

Three hundred and eleven patients have been enrolled in a multi-center prospective study evaluating the outcome of hallux valgus surgery by the members of the American Orthopaedic Foot and Ankle Society. One hundred seventy-nine of these patients have completed six-month follow-up questionnaires, and 195 have completed 12-month questionnaires. The AAOS Lower Limb Outcomes Data Collection Questionnaire and the Foot and Ankle Outcomes Data Collection Questionnaire were used to assess patients' perceptions of their results. Both of these instruments are validated lower extremity instruments. They contain the SF-36 instrument as well as questions relating to lower extremity function. At six- and 12-month follow-up, significant improvement has been noted in the patients' SF-36 physical function scores, role physical scores, and bodily pain scores. Role emotional scores were increased at six months but returned to baseline at 12 months. The scores for physical health and pain and satisfaction with symptoms for the lower extremity have significantly improved. The global foot and ankle score and shoe comfort score from the foot and ankle module have also significantly improved. This outcome study is the first to focus on the patient's perception of results of hallux valgus surgery and demonstrates a significant improvement in pain, function, and satisfaction after bunion surgery performed by members of the American Orthopaedic Foot and Ankle Society.

To describe the epidemiology, early results of treatment, and complications associated with open fractures of the forearm in children.

Eight adult below-knee cadaver specimens were placed in a testing machine and loaded to 350 newtons according to a strict protocol. Arch height and length measurements were obtained in each specimen with the toes resting on the foot plate, dorsiflexed to 30°, and maximally dorsiflexed manually. The plantar fascia was then divided from medial to lateral in one-quarter increments, and the effect on arch height and length measurements was assessed using the same loading protocol. A consistent decrease in the arch-supporting function on sequential sectioning of the plantar fascia was encountered. A less consistent decrease in the arch-supporting function was reflected by the increase in the height of the arch with sequential sectioning of the plantar fascia. The study demonstrates that partial plantar fasciotomy decreases the arch-supporting function of the plantar fascia in addition to weakening the structure. Strict surgical indications for this type of procedure should be maintained.

The purpose of this study was to review 15 years of experience with ankle fusions, specifically addressing the underlying etiology of ankle pathology, incidence of nonunion, and associated predisposing conditions that can lead to nonunion. Seventy-eight ankle fusions, performed between 1975 and 1990, were reviewed for this study. The average follow-up was 4 years. Patients with nonunion were evaluated separately to look at the predisposing factors that may have lead to nonunion. Factors associated with nonunion included fracture type, evidence of avascular necrosis, infection, major medical problems, and open injuries. Factors that were not associated with nonunion included age, past history of subtalar or triple arthrodesis, and technique.