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BACKGROUND: Wide variations in definitions of lesser toe deformities exist. In addition, a general consensus regarding treatment of lesser toe deformities is lacking. The objective of this study was to evaluate of the definitions, current concepts, and treatment protocols for lesser toe deformities among orthopaedic departments in The Netherlands. METHODS: A questionnaire with statements regarding lesser toe deformities was sent to all 101 Dutch departments of orthopaedic surgery. RESULTS: In total 76 (75%) completed forms were analyzed. A wide variation regarding definitions, concepts, and treatment strategies of lesser toe deformities was reported among the Dutch orthopaedic departments. Only half of all responding departments had a protocol or consensus in the treatment. CONCLUSIONS: The definitions of lesser toe deformities used in Dutch orthopaedic departments do not coincide. This might explain the variations in indications and the various performed interventions for different deformities. The differences of opinion among the Dutch orthopaedic departments may have important clinical consequences because an indication for surgery depends on the correct diagnosis. To correctly interpret and improve treatment results, a consensus on this topic should be introduced. [ABSTRACT FROM AUTHOR]

Background: It is recognized that different types of hallux valgus exist. Classification occurs with radiographic and clinical parameters. Severity of different parameters is used in algorithms to choose between different surgical procedures. Because there is no consensus about each parameter nor their cut-off point we conducted this study to analyze the influence of these variables on the postoperative hallux valgus angle.Methods: After informed consent 115 patients (136 feet) were included. Bunionectomy, osteotomy, lateralization of the distal fragment, lateral release and medial capsulorrhaphy were performed in all patients. Data were collected on preoperative and postoperative HVA, IMA and DMAA measurements. Forty cases were included since our findings in a previous article 1, therefore, current data concern an expanded study group with longer follow-up and were not published before. At least two-year follow-up data were evaluated with logistic regression and independent t-tests.Results: Preoperative HVA was significant for prediction of postoperative HVA in logistic regression. IMA and DMAA were not significant for prediction of postoperative HVA in logistic regression, although they were significantly increased in larger deformities. In patients with preoperative HVA of 37 degrees or more, satisfactory correction could be obtained in 65 percent. The other nine of these 26 patients developed subluxation.Conclusion: The preoperative HVA was the main radiological predictor for correction of hallux valgus, correction rate declined from preoperative HVA of 37. IMA and DMAA did have a minor role in patients with preoperative HVA lower than 37 degrees, however, likely contributed to preoperative HVA of 37 degrees or more. [ABSTRACT FROM AUTHOR]

Introduction: The population of people with a spinal cord injury (SCI) is changing to a diverse population with an increasing number of incomplete lesions. Often, these individuals have the capacity to walk, but experience disabling gait impairments., Case Presentation: The course of a 34-year-old male with a chronic incomplete traumatic cervical SCI who initially could walk no more than a few steps with supervision or a wheeled walker is described. He participated in a clinical trial with Targeted Epidural Spinal Stimulation (TESS). After this trial, he was able to walk with a wheeled walker and bilateral orthosis over a distance of 100 meters. Despite these improvements, his main complaints were (1) difficulty to correctly preposition the feet, and (2) pain in his toe and calf muscles. An interdisciplinary approach and the use of structured gait analysis formed the basis for shared decision-making with the team and the patient to perform ankle-foot surgery followed by 2-month gait training with a body weight support system. After this trajectory his walking distance increased to 250 meters, with a wheeled walker; but now without orthosis and with an increased walking speed compared to pre-surgery. Additionally, there was reduction of pain and he experienced no disturbances during sleeping, washing and clothing anymore., Discussion: This case shows that surgical interventions can improve the gait capacity even in case of chronic incomplete SCI. Furthermore, training with a body weight support system after medical-technical interventions is useful to utilize the full potential of these interventions., (© 2023. The Author(s), under exclusive licence to International Spinal Cord Society.)

Concomitant valgus deformities of the ankle joint are found in approximately 3% of patients with symptomatic flat foot deformities. Conservative treatment is mostly successful only in the short term or in low-demand patients. The operative treatment of flat foot deformities follows the standard algorithm for flat foot treatment. The ankle joint can be treated while retaining mobility or by arthrodesis depending on the degree and rigidity of the deformity, degenerative changes, patient factors and expectations. Achieving an orthograde hindfoot and midfoot is obligatory for successful treatment as well as in ankle reconstructive or arthrodesis procedures.

Background: A scientifically sound validated foot and ankle specific score validated ab initio for different languages is missing. The aim of a project of the European Foot and Ankle Society (EFAS) was to develop, validate, and publish a new score(the EFAS-Score) for different European languages., Methods: The EFAS Score was developed and validated in three stages: (1) item (question) identification, (2) item reduction and scale exploration, (3) confirmatory analyses and responsiveness. The following score specifications were chosen: scale/subscale (Likert 0-4), questionnaire based, outcome measure, patient related outcome measurement. For stage 3, data were collected pre-operatively and at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using analyses from classical test theory and item response theory., Results: Stage 1 resulted in 31 general and 7 sports related questions. In stage 2, a 6-item general EFAS Score was constructed using English, German, French and Swedish language data. In stage 3, internal consistency of the scale was confirmed in seven languages: the original four languages, plus Dutch, Italian and Polish (Cronbach's Alpha >0.86 in all language versions). Responsiveness was good, with moderate to large effect sizes in all languages, and significant positive association between the EFAS Score and patient-reported improvement. No sound EFAS Sports Score could be constructed., Conclusions: The multi-language EFAS Score was successfully validated in the orthopaedic ankle and foot surgery patient population, including a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co., (Copyright © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Total ankle arthroplasty is an accepted alternative to arthrodesis of the ankle. However, complication and failure rates remain high. Long-term results of the Scandinavian Total Ankle Replacement (STAR) are limited, with variable complication and failure rates observed. This prospective study presents the long-term survivorship and postoperative complications of the STAR prosthesis., Methods: Between May 1999 and June 2008, 134 primary total ankle arthroplasties were performed using the STAR prosthesis in 124 patients. The survivorship, postoperative complications, and reoperations were recorded, with a minimum follow-up period of 7.5 years. Clinical results were assessed using the Foot Function Index and the Kofoed score. The presence of component migration, cysts, and radiolucency surrounding the prosthesis components, heterotopic ossification, and progression of osteoarthritis in adjacent joints were determined., Results: The cumulative survival was 78% after the 10-year follow-up period. An ankle arthrodesis was performed in 20 ankles (14.9%) that failed. Fourteen polyethylene insert fractures occurred (10.4%). Other complications occurred in 29 ankles (21.6%), requiring secondary procedures in 21 ankles (15.7%). Nevertheless, the postoperative clinical results improved significantly. Osteolytic cysts were observed in 61 ankles (59.8%) and the surface area of these cysts increased during follow-up, without any association with the prosthesis alignment or clinical outcome. Heterotopic ossification at the medial malleolus was present in 58 cases (56.8%) and at the posterior tibia in 73 cases (71.6%), with no effect on clinical outcome. Osteoarthritis of the subtalar and talonavicular joint developed in 9 (8.8%) and 11 cases (10.8%), respectively., Conclusion: The long-term clinical outcomes for the STAR were found to be satisfactory. Although these results are consistent with previous studies, the survival and complication rates are disappointing compared to knee and hip arthroplasty. Higher rates of successful outcomes following ankle arthroplasty are important, and these results highlight the need for further research to clarify the origin and significance of the reported complications., Level of Evidence: Level II, prospective comparative study., (© The Author(s) 2016.)

Background: Debate exists regarding the effect of triple fusion on the development of osteoarthritis (OA) of the ankle joint. The midterm outcome after triple arthrodesis and the prevalence of OA following triple arthrodesis are reported in this study. The role of alignment in the development of OA was investigated., Methods: Seventy five patients (87 feet) were evaluated in 2003 and of these, 48 patients (55 feet) were available for second evaluation in 2008. X-rays of the ankles and feet were made prior to surgery, in 2003 and in 2008, and the level of osteoarthritis (OA) was graded with the Kellgren and Lawrence score. Of all postoperative X-rays, the AP and lateral talo first metatarsal angle X-rays were compared. Also, standardized digital photos were made to assess the geometry/alignment. The Foot Function Index (FFI) and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were completed. In order to investigate the role of the underlying alignment on the aggravation of ankle osteoarthritis, patients were divided into a 'varus' and a 'valgus' group based on the indication for surgery., Results: The outcome scores (AOFAS and FFI) after triple arthrodesis remained stable in the present 7.5-year follow-up study. An important increase of OA of the ankle was not established, 58% of the patients showed no aggravation, 31% one-grade and 2% two-grade increase of OA. A trend was found (P=.063) towards aggravation of OA of the ankle in patients of the varus group with the highest medial arches (persistent cavovarus deformity)., Conclusion: This study reports minor, not statistically significant, changes of the ankle joint following triple arthrodesis after 7.5 years. Clinical outcome remained stable in time. Clinical relevance It seems that triple arthrodesis as such does not lead to major osteoarthritis of the ankle, given that adequate alignment of the hindfoot is achieved., Level of Evidence: Level II, retrospective study., (Copyright © 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: It is unclear whether proximal interphalangeal joint (PIPJ) resection or fusion leads to superior clinical outcome in patients undergoing hammertoe surgery. The purpose of this study was to prospectively evaluate a series of patients undergoing this surgery., Methods: Patients with one or more toes with rigid PIP flexion deformity were prospectively enrolled. These patients were randomly assigned to undergo either PIPJ resection or PIPJ fusion. In addition to the PIPJ procedure, a metatarsophalangeal joint (MTPJ) release was performed if deemed necessary. Follow-up was up to 1 year postoperatively. Twenty-six patients (39 toes) were included in the PIPJ resection group and 29 (50 toes) in the PIPJ fusion group., Results: Thirty-four underwent an MTPJ release. No significant difference in foot outcome scores (American Orthopaedic Foot & Ankle Society scale, the Foot Function Index, and visual analog scale pain) could be detected after 1-year follow-up. A statistically significant difference was found regarding the toe alignment in the sagittal plane in favor of PIPJ fusion., Conclusions: Our randomized controlled study did not show any clinical outcome difference between PIPJ fusion and PIPJ resection. Both procedures resulted in good to excellent outcome in pain and activity scores., Level of Evidence: Level II, lesser quality RCT or prospective comparative study., (© The Author(s) 2016.)

Background: Duration of peripheral nerve blocks depends on multiple factors. Both technique and type of local anesthetic used, either with or without adjuncts, may result in different duration times of the block. The purpose of the present study was to compare the duration of postoperative analgesia of 30 mL ropivacaine 0.75 % with or without epinephrine for popliteal sciatic nerve block., Methods: Thirty-eight patients were included to receive ultrasound guided continuous popliteal nerve block with ropivacaine 0.75 % either without (ROPI) or with epinephrine 5 μg/mL (ROPI-EPI) for ankle fusion, subtalar fusion, or a combination of both. The primary outcome parameter was the duration of postoperative analgesia as reflected by the time to first request for postoperative analgesia (TTFR) through the popliteal nerve catheter. Secondary outcome measures included the onset of sensory and motor block and NRS score for pain at rest and during movement., Results: Thirty patients, 15 in each group, were studied. Eight patients were withdrawn because of specific withdrawal criteria described in the protocol and replaced according to their group allocation. Median [interquartile range] TTFR was 463 [300-1197] min and 830 [397-1128] min for the ROPI vs ROPI-EPI group respectively. Hodges Lehman median difference between groups was 71 min (95 % CI -415 - 473 min). There was no difference in any clinical outcome measure between the groups., Conclusion: The results of this study did not show any significant increase in the duration of postoperative analgesia by adding epinephrine to ropivacaine for popliteal nerve block. This may be due to the intrinsic vasoconstrictive properties of ropivacaine. The absence of a significant difference can also be the result of a type II error caused by a large variation in the individual TTFR., Trial Registration: Trial register.nl identifier: NTR3330 , keyword TTFR.

Arthrodesis of 1 or more joints of the hindfoot is performed to treat severe functional impairment due to pain, deformity, and/or instability. Evaluation of the results of hindfoot arthrodesis from the published data has been difficult owing to the great variety of pathologic entities and surgical techniques reported in the studies. A comprehensive search for relevant reports, reference lists, and citation tracking of the included studies was conducted using the PubMed(®), Embase(®), and CINAHL(®) databases. The studies had to have been prospective, included patients with hindfoot problems, evaluated arthrodesis of 1 or more tarsal joints, and had at least 1 of the following primary clinical outcome parameters: pain, function, or complications. Two of us independently selected the relevant studies using predefined criteria and graded the quality of evidence using a 0 to 9 star scale according to the Newcastle-Ottawa Scale. A total of 16 prospective case series were included; 5 studies scored 6 stars, 8 scored 5 stars, 2 scored 4 stars, and 1 scored 3 stars. A best evidence synthesis was performed, and improvement in function and pain was found for 3 combinations: talonavicular arthrodesis for rheumatoid arthritis, triple arthrodesis for rheumatoid arthritis, and subtalar arthrodesis for post-traumatic arthritis showed good results for pain and function, the last especially when performed arthroscopically. The best evidence syntheses revealed good results for pain and function for these disease-operative technique combinations., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Osteoarthritis, primary or secondary, of the fourth and/or fifth tarsometatarsal (TMT) joint is a rare condition. When conservative treatment fails or proves to be unacceptable for the patient, operative treatment is an option. In this article the technique of resection arthroplasty is described and a retrospective case series of 6 patients is presented. Three patients underwent tendon interposition arthroplasty after resection of the two joints and in the last three cases no interposition at all was performed. Results suggest that resection arthroplasty without interposition may be as effective as other operative treatment options for patients with fourth and fifth TMT pathology., (Copyright © 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Total ankle replacement (TAR) is presently considered to be an acceptable alternative to ankle fusion for patients with debilitating conditions of the ankle. The placing of a total ankle prosthesis is a technically demanding procedure. We hypothesized that the challenging conditions could cause a longer learning curve (>30 cases), and therefore the short-term results of the first and the last 50 cases in a consecutive series of 134 cases were compared., Methods: The first and last consecutive 50 cases by a single surgeon in a series of 134 Scandinavian Total Ankle Replacements (STAR; Waldemar Link, Hamburg, Germany), inserted between May 1999 and May 2008, were evaluated. Operation characteristics, clinical outcome (Foot Function Index [FFI], Kofoed score), complications, and the component alignment on X-rays were assessed. The outcome measures for both groups were compared using independent Student t tests, chi-square tests, and nonparametric alternatives (P < .05)., Results: Surgery time decreased from a median of 125 (83-160) to 100 (65-170) minutes (P < .001), and fewer perioperative complications were observed (12 vs 4, P = .04). The sagittal alignment of the tibial component was closer to normal in the last series (P < .001). The clinical outcome did not differ between the 2 series (median FFI: 32 [0-74] vs 25 [0-75], Kofoed score: median 71 [21-96] vs 80.5 [23-100]). The major underlying pathology did change from rheumatoid arthritis (60%) to osteoarthritis (44%; P = .002). No differences in type and number of complications were reported., Conclusion: The surgery time did decrease, there were fewer perioperative fractures, and the tibial component orientation improved, suggesting the presence of a learning curve. Operative experience and a shift in major underlying pathology did not influence clinical outcome. In view of this learning curve we suggest more restrictive patient selection for at least the first 50 TARs., Level of Evidence: Level III, comparative series.

Introduction: Based on the windlass mechanism theory of Hicks, the medial longitudinal arch (MLA) flattens during weight bearing. Simultaneously, foot lengthening is expected. However, changes in foot length during gait and the influence of walking speed has not been investigated yet., Methods: The foot length and MLA angle of 34 healthy subjects (18 males, 16 females) at 3 velocities (preferred, low (preferred -0.4 m/s) and fast (preferred +0.4 m/s) speed were investigated with a 3D motion analysis system (VICON(®)). The MLA angle was calculated as the angle between the second metatarsal head, the navicular tuberculum and the heel in the local sagittal plane. Foot length was calculated as the distance between the marker at the heel and the 2nd metatarsal head. A General Linear Model for repeated measures was used to indicate significant differences in MLA angle and foot length between different walking speeds., Results: The foot lengthened during the weight acceptance phase of gait and shortened during propulsion. With increased walking speed, the foot elongated less after heel strike and shortened more during push off. The MLA angle and foot length curve were similar, except between 50% and 80% of the stance phase in which the MLA increases whereas the foot length showed a slight decrease., Conclusion: Foot length seems to represent the Hicks mechanism in the foot and the ability of the foot to bear weight. At higher speeds, the foot becomes relatively stiffer, presumably to act as a lever arm to provide extra propulsion., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Background: Intra-articular anesthetic drug injections are claimed to confirm the localization of the pain in order to treat the pain. The aim of the present study was to evaluate whether a positive effect of injection could be indicative for a successful outcome of future arthrodesis., Methods: 74 Patients underwent fluoroscopically guided and contrast confirmed anesthetic joint injections for diagnostic reasons. Before and after injection, pain was measured by use of the Visual Analogue Scale (VAS) in rest and after exercise. Pain reduction was expressed as delta VAS (dVAS). Also, the Foot Function Index (FFI) was obtained. Based on the effect of the diagnostic injection and various clinical factors, patients were advised a conservative treatment (conservative group, n = 34) or an arthrodesis of the affected joint (operative group, n = 40). After a median follow-up period of 3.6 years (range 2.1 to 4.3 years) patients were again invited to complete the FFI and VAS in rest and after exercise. For data-analysis purposes the patients were assigned to four different groups, based on the result of injection and the occurrence of surgery. Wilcoxon signed rank tests and Mann Whitney U tests were used for statistical analysis., Results: Based on the analysis of the four groups we found that surgery, irrespective of the presence of pain reduction after injection, was related to improvement of VAS and FFI. Patients with conservative treatment always showed worse VAS and FFI scores, even when previous injections showed an improvement of VAS., Conclusions: Fluoroscopically-guided anesthetic injections of the supposed painful foot-ankle joint seem not to be indicative for a successful outcome of an arthrodesis of the affected joint. However, the sole occurrence of surgery shows a significant difference in VAS and FFI scores, where conservative treatment does not. The local hospital review board granted permission for this study. Ethical approval was not required for this study.

Despite recent advances in pharmacological management of rheumatoid arthritis, forefoot deformity, with its symptoms, remains a common problem, often requiring operative treatment. Typical deformities in these patients comprise hallux valgus and deformity of the lesser metatarsophalangeal (MTP) joints and toes. With regard to the lesser rays the standard operative procedure, advocated for the disabling forefoot pain in these patients, remains metatarsal head resection. It should be considered that with increasing success of pharmacological treatment the degree of forefoot deformity in these patients is becoming less and that resection of the lesser MTP joints is becoming more and more superfluous. This supports a trend towards metatarsal head-preserving surgery. The optimal treatment of the hallux deformity remains unclear. Fusion of the first MTP joint is, generally, recommended. This article will discuss the current surgical options in rheumatoid forefoot pathology.

Background: Plantar pressure is widely used to evaluate foot complaints. However, most plantar pressure studies focus on the symptomatic foot with foot deformities. The purposes of this study were to investigate subjects without clear foot deformities and to identify differences in plantar pressure pattern between subjects with and without forefoot pain. The second aim was to discriminate between subjects with and without forefoot pain based on plantar pressure measurements using neural networks., Methods: In total, 297 subjects without foot deformities of whom almost 50% had forefoot pain walked barefoot over a pressure plate. Foot complaints and subject characteristics were assessed with a questionnaire and a clinical evaluation. Plantar pressure was analyzed using a recently developed method, which produced pressure images of the time integral, peak pressure, mean pressure, time of activation and deactivation, and total contact time per pixel. After pre-processing the pressure images with principal component analysis, a forward selection procedure with neural networks was used to classify forefoot pain., Findings: The pressure-time integral and mean pressure were significantly larger under the metatarsals II and III for subjects with forefoot pain. A neural network with 14 input parameters correctly classified forefoot pain in 70.4% of the test feet., Interpretation: The differences in plantar pressure parameters between subjects with and without forefoot pain were small. The reasonable performance of forefoot pain classification by neural networks suggests that forefoot pain is related more to the distribution of the pressure under the foot than to the absolute values of the pressure at fixed locations., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

In contrast to western countries, foot complaints are rare in Africa. This is remarkable, as many African adults walk many hours each day, often barefoot or with worn-out shoes. The reason why Africans can withstand such loading without developing foot complaints might be related to the way the foot is loaded. Therefore, static foot geometry and dynamic plantar pressure distribution of 77 adults from Malawi were compared to 77 adults from the Netherlands. None of the subjects had a history of foot complaints. The plantar pressure pattern as well as the Arch Index (AI) and the trajectory of the center of pressure during the stance phase were calculated and compared between both groups. Standardized pictures were taken from the feet to assess the height of the Medial Longitudinal Arch (MLA). We found that Malawian adults: (1) loaded the midfoot for a longer and the forefoot for a shorter period during roll off, (2) had significantly lower plantar pressures under the heel and a part of the forefoot, and (3) had a larger AI and a lower MLA compared to the Dutch. These findings demonstrate that differences in static foot geometry, foot loading, and roll off technique exist between the two groups. The advantage of the foot loading pattern as shown by the Malawian group is that the plantar pressure is distributed more equally over the foot. This might prevent foot complaints.

Background: Lateral column lengthening (LCL) has become an accepted procedure for the operative treatment of the flexible flatfoot deformity. Hindfoot arthrodesis via a calcaneocuboid distraction arthrodesis (CCDA) has been considered a less favourable surgical option than the anterior open wedge calcaneal distraction osteotomy (ACDO), as CCDA has been associated with reduced hindfoot joint motion postoperatively. The ankle and subtalar joint ranges of motion were measured in patients who underwent an ACDO or CCDA procedure for flatfoot deformity., Methods: CT scanning was performed with the foot in extreme positions in five ACDO and five CCDA patients. A bone segmentation and registration technique for the tibia, talus and calcaneus was applied to the CT images. Finite helical axis (FHA) rotations representing the range of motion of the joints were calculated for the motion between opposite extreme foot positions of the tibia and the calcaneus relative to the talus., Results: The maximum mean FHA rotation of the ankle joint (for extreme dorsiflexion to extreme plantarflexion) after ACDO was 52.2 degrees ± 12.4 degrees and after CCDA 49.0 degrees ± 12.0 degrees. Subtalar joint maximum mean FHA rotation (for extreme eversion to extreme inversion) following ACDO was 22.8 degrees ± 8.6 degrees, and following CCDA 24.4 degrees ± 7.6 degrees., Conclusion: An accurate CT-based technique was used to assess the range of motion of the ankle and subtalar joints following two lateral column lengthening procedures for flatfoot deformity. Comparable results with a considerable amount of variance were found for the range of motion following the ACDO and CCDA procedures.

Background: Ultrasound is a non-invasive method to quantitatively measure various muscle parameters. Purpose of this study was to assess the feasibility of ultrasound of lower leg and foot muscles and to obtain reference values for muscle thickness (MT) and echo intensity (EI)., Methods: Ultrasound measurements of leg and foot muscles were performed in 60 healthy adults. MT and EI were quantitatively determined for the abductor hallucis (AH), extensor digitorum brevis (EDB), extensor hallucis longus (EHL) and peroneus longus (PER) muscles. Influence of age, height, weight and sex was determined using a multiple linear regression analysis., Results: All muscles except the AH could easily be visualized with ultrasound. EI tended to be increased above 60 years and MT was significantly higher in men compared to women, necessitating age- and sex-dependent reference values., Conclusions: This study shows that muscle ultrasound is capable of visualizing lower leg and foot muscles and reference values for MT and EI can be obtained. Future research will focus on the use of these reference values to evaluate muscle abnormalities caused by neuromuscular disorders like hereditary motor and sensory neuropathy., (Copyright © 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background and Purpose: In the present study a classification system for the rheumatoid forefoot is reported with its intra- and interobserver reliability and clinical relevance. The classification is based on the sequence of anatomical changes resulting from the loss of integrity of the MTP joints, loss of motion and changes regarding the quality and position of the plantar soft tissues. It is hypothesized that with progression of the amount of deformity of the MTP joint(s), patients have more pain and functional loss., Patients and Methods: In total 94 patients were included in the study following precise inclusion criteria. The forefeet of the patients were classified according to the introduced classification system by two observers in order to determine the intra- and interobserver reliability. The relation of the suggested classification between pain, function scores, and plantar foot pressure measurements was examined., Results and Conclusion: According to the Cohen's kappa and the ICC, the intra- and inter-observer reliability were high. Despite the large variation between subjects in a certain grade, a clear trend was found between increase in classification and VAS for pain, FFI difficulty with activities, and plantar peak pressure under the metatarsals. The suggested classification is of clinical relevance and can be used to develop therapeutical algorithms and to test interventions., (Copyright © 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Although many patients with foot complaints receive customized insoles, the choice for an insole design can vary largely among foot experts. To investigate the variety of insole designs used in daily practice, the insole design and its effect on plantar pressure distribution were investigated in a large group of patients., Materials and Methods: Mean, peak, and pressure-time-integral per sensor for 204 subjects with common foot complaints for walking with and without insoles was measured with the footscan® insole system (RSscan International). Each insole was scanned twice (precision3D), after which the insole height along the longitudinal and transversal cross section was calculated. Subjects were assigned to subgroups based on complaint and medial arch height. Data were analyzed for the total group and for the separate subgroups (forefoot or heel pain group and flat, normal or high medial arch group)., Results: The mean pressure significantly decreased under the metatarsal heads II-V and the calcaneus and significantly increased under the metatarsal bones and the lateral foot (p<0.0045) due to the insoles. However, similar redistribution patterns were found for the different foot complaints and arch heights. There was a slight difference in insole design between the subgroups; the heel cup was significantly higher and the midfoot support lower for the heel pain group compared to the forefoot pain group. The midfoot support was lowest in the flat arch group compared to the high and normal arch group (p<0.05)., Conclusion: Although the insole shape was specific for the kind of foot complaint and arch height, the differences in shape were very small and the plantar pressure redistribution was similar for all groups., Clinical Relevance: This study indicates that it might be sufficient to create basic insoles for particular patient groups.

Purpose: The popularity of long-distance walking (LDW) has increased in the last decades. However, the effects of LDW on plantar pressure distribution and foot complaints, in particular, after several days of walking, have not been studied., Methods: We obtained the plantar pressure data of 62 subjects who had no history of foot complaints and who walked a total distance of 199.8 km for men (n = 30) and 161.5 km for women (n = 32) during four consecutive days. Plantar pressure was measured each day after the finish (posttests I–IV) and compared with the baseline plantar pressure data, which was obtained 1 or 2 d before the march (pretest). Mean, peak, and pressure–time integral per pixel as well as the center of pressure (COP) trajectory of each foot per measurement day were calculated using the normalization method of Keijsers et al. A paired t-test with an adjusted P value was used to detect significant differences between pretest and posttest., Results: Short-term adjustment to LDW resulted in a significant decreased loading on the toes accompanied with an increased loading on the metatarsal head III–V (P < 0.001). At all stages, particularly at later stages, there was significantly more heel loading (P < 0.001). Furthermore, the COP significantly displaced in the posterior direction but not in the mediolateral direction after marching. Contact time increased slightly from 638.5 +/- 24.2 to 675.4 +/- 22.5 ms (P < 0.001)., Conclusions: The increased heel loading and decreased function of the toes found after marching indicate a change of walking pattern with less roll-off. It is argued that these changes reflect the effect of fatigue of the lower leg muscles and to avoid loading of the most vulnerable parts of the foot.

Introduction: The standard procedure when operating on the rheumatoid forefoot is resection arthroplasty of the metatarsophalangeal joints of the lesser rays. Good clinical results (with a follow-up of over 10 years) have been reported when this technique is used. Another technique is repositioning of the metatarsophalangeal subluxation or dislocation of the lesser rays., Aim: To assess the results of forefoot reconstruction using the repositioning technique performed in 54 feet (39 patients) by one surgeon using this technique., Methods: 39 RA patients (15 bilateral, 54 feet) were treated with the technique of repositioning the metatarsophalangeal subluxation or dislocation. All surgery was performed by one orthopaedic surgeon. In case of severe deformity or degeneration of the metatarsophalangeal joint of the hallux, an arthrodesis was performed. All patients were reviewed after a mean follow-up of 40 months (range 12-72 months) and an American Orthopaedic Foot and Ankle Society (AOFAS) foot score, and Foot Function Index (FFI) were obtained., Results: When, in addition to repositioning the metatarsophalangeal joints, an arthrodesis of the hallux was performed, the mean AOFAS-forefoot score was 69.80 (SD=11.8) at a mean of 40 months (SD=15.6 months) postoperatively. In cases with no operation on the hallux, the AOFAS score was 42.2 (SD=18.8) (p=0.001). The postoperative FFI-scores were 23.0 (SD=17.5) and 43.9 (SD=14.6) respectively (p=0.026). When comparing the patients who were satisfied (satisfaction VAS>7) and those who were not, the most important factor was also fusion of the first metatarsophalangeal (MPJ) joint, without a fusion only 50% was satisfied, with a fusion the satisfaction rate was 93%. In four patients a recurrence of the deformity of one of the lesser rays developed, for which a re-operation has been performed., Conclusions: Reconstruction of the rheumatoid forefoot by repositioning the metatarsophalangeal joints of the lesser rays, thereby preserving the joints, can be considered as a procedure that provides improvement in the clinical outcome. Best results were seen in patients in whom, in addition to reconstruction of the lesser rays, an arthrodesis of the hallux was performed., (Copyright (c) 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Objectives: The purpose of this paper was to retrospectively evaluate the short-term to mid-term results of combined first ray proximal dorsiflexion osteotomy and soft tissue surgery in treatment of pes cavovarus with a fixed plantar flexed first ray and a passively correctable tarsus due to Charcot-Marie-Tooth disease., Patients and Methods: Between January 1995 and July 2005, thirty-three patients with pes cavovarus deformity due to Charcot-Marie-Tooth disease were included. All patients had in common that prior to surgery the hindfoot was passively still adequate correctable at the talonavicular joint. The Coleman block test was performed to establish with certainty that hindfoot varus was a secondary deformity. Fourteen patients were male (21 feet) and nineteen were female (31 feet). Mean age at surgery was 28.1 years (range 13-59 years). Mean follow-up time was 56.9 months (range 13-153 months). Evaluation consisted of physical examination of all patients with assessment of early and late complications. The validated Foot Function Index (FFI) was used to measure pain and impairment. Patients' satisfaction was assessed by a Quality of Care Through the Patients' Eyes (QUOTE) questionnaire., Intervention: Surgical correction of cavovarus foot deformity consisted of dorsiflexion osteotomy at the base of the first metatarsal combined with tendon transfers. Secondary calcaneal osteotomy was performed in case of persistent varus of the calcaneus., Results: No major complications were seen. Recurrence of cavovarus deformity in two feet resulted in triple arthrodesis 37 and 64 months postoperatively. The FFI 5-point score for pain improved from a mean 29.3% to a mean 14.8% (p=0.005). The score for disability improved from a mean 37.8% to a mean 23.5% (p<0.001). Patients' satisfaction was assessed by the QUOTE questionnaire. Seventy percent of the patients could walk barefoot after the operation and 77% of the patients had less pain after surgery. Pressure callosities diminished in 81%. Foot function was considered better after surgery by 84%. Ninety percent was satisfied with the correction of the deformity., Conclusions: First ray dorsiflexion osteotomy combined with tendon transfers is a good and consistent solution to realign the foot and provides short-term to mid-term satisfactory results in 90% of patients with a rigid forefoot cavus deformity due to plantar flexion of the first ray and with a still passively reducible tarsus., (Copyright (c) 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: We measured with a validated score the operative outcome in patients without concomitant foot surgery who underwent fusion of the first metatarsophalangeal (MTP) joint for hallux rigidus (HR) and hallux valgus (HV). We also examined whether there is a correlation between foot function and hallux position to try to formulate an optimum fusion angle., Materials and Methods: Between 2002 and 2005, a consecutive series of 62 patients underwent crossed screw fusion of the first MTP joint (27 HR and 35 HV) without concomitant surgery of the same or contralateral foot or had previous surgery of the same foot. Foot function was measured by the Dutch Foot Function Index (FFI) pre- and postoperatively. Hallux valgus and dorsiflexion angles were measured on standing radiographs before operation and at followup., Results: Postoperatively the median hallux valgus angle was 14 (range, -2 to 33) degrees and the median dorsiflexion angle was 23 (range, 7 to 45) degrees. The median FFI score improved from 38 (range, 0 to 80) to 8 (range, 0 to 59) (p < 0.001). The FFI score was not different between the HV and HR groups. There was no correlation between postoperative foot function, dorsiflexion angles and hallux valgus angles., Conclusion: Fusion of the first MTP joint in HR and HV results in improved function according to the validated FFI. There was no significant correlation between foot function and hallux position. This could be due to the fact that the desired position of the hallux was most often achieved.

Arthrodesis of the ankle joint after a failed ankle prosthesis is most often demanding because of bone loss. The bone loss is also responsible for limb length discrepancy. Intramedullary nail fixation has been described to be successful for arthrodesis of the arthritic ankle joint. We report the use of the nail technique in combination with a morsellized bone graft in and around a cage to convert failed ankle prosthesis with bone loss into an arthrodesis. The advantages which were strived for include developing a more practical operative method with lower morbidity (no autograft), early mobilization and weight-bearing provided by the stability of the internal fixation and restoration of limb length., (Copyright 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background and Purpose: The first generations of total ankle replacements (TARs) showed a high rate of early failure. In the last decades, much progress has been made in the development of TARs, with the newer generation showing better results. We evaluated TARs implanted with rheumatoid arthritis (RA) or juvenile inflammatory arthritis (JIA) as indication., Patients and Methods: 58 total ankle prostheses (Buechel-Pappas and STAR type) were implanted in patients with RA (n = 53) or JIA (n = 5) in 54 patients (4 bilateral). After a mean followup of 2.7 (1-9) years, all patients were reviewed by two orthopedic surgeons who were not the surgeons who performed the operation. Standard AP and lateral radiographs were taken and a Kofoed ankle score was obtained; this is a clinical score ranging from 0-100 and consists of sub-scores for pain, disability, and range of motion., Results: 2 patients died of unrelated causes. Of the 52 patients who were alive (56 prostheses), 51 implants were still in place and showed no signs of loosening on the most recent radiographs. The mean Kofoed score at follow-up was 73 points (SD 16, range 21-92). 4 patients showed a poor result (score < 50) with persistent pain for which no obvious reason could be found. 5 implants were removed, 4 because of infection and 1 because of aseptic loosening., Interpretation: Medium-term results of the STAR and BP types of TAR in RA were satisfactory. The main reason for failure of the implant was infection.

Background: Lesser toe surgery is among the most conducted interventions in general orthopedic practice. However, the definitions of hammer toe and claw toe are not uniform. The objective of this literature study is to propose clear definitions for these deformities to establish unambiguous communication., Methods: A literature search was performed in the PubMed database (May 2006). Of 81 eligible articles, 42 that stated a clear definition of hammer toe or claw toe were selected., Results: In all 35 articles in which hammer toe was clearly defined, flexion in the proximal interphalangeal joint was part of the definition. Seventeen articles (49%) defined hammer toe as a combination of metatarsophalangeal extension and proximal interphalangeal flexion. Thirteen articles showed flexion of the proximal interphalangeal joint as the single criterion. Twenty-three articles with a clear definition of claw toe were selected. Twenty-one articles (91%) showed metatarsophalangeal extension as part of the claw toe deformity. Twelve articles (52%) regarded metatarsophalangeal extension and flexion of the proximal interphalangeal and distal interphalangeal joints as the essential characteristics. Seven articles described a claw toe as metatarsophalangeal extension with flexion in the proximal interphalangeal joint., Conclusions: There are variations in the definitions of lesser toe deformities in the literature. We propose that extension of the metatarsophalangeal joint is the discriminating factor and essential characteristic for claw toe. Claw toe and hammer toe should be characterized by flexion in the proximal interphalangeal joint, which is the single criterion for a hammer toe. The flexibility of these joints could be a basic factor in discriminating between these deformities. The development of these deformities should be regarded as a continuum in the same pathophysiologic process.

Background: To follow the weight bearing foot posture in subjects, a measurement tool using digital photography was developed, Foot Build Registration System (FBRS) (Fig. 1) [M. Van der Cruijsen, Voetvorm registratie systeem, Boxmeer (1999).]. This study's objective was to investigate the reproducibility of FBRS measurements in healthy feet and feet of patients with Charcot-Marie-Tooth disease (CMT)., Methods: Reproducibility and reliability studies were performed in several foot views in healthy and CMT patients., Results: These studies showed that the variability of the 95% prediction limit depended upon the foot view being studied and whether markers had been drawn. Some individuals had a higher intra-individual variability than others. Limiting data collection to those individuals with a SD<3.5 degrees for a series of five or more photographs per view improved the 95% prediction limits. These varied between 2.8 degrees and 7.7 degrees., Conclusions: If the differences found between registration are greater than the abovementioned, values can be attributed to time or operative management for healthy and CMT patients and not to measurement error.

Background: Forty-seven consecutive patients treated for ankle arthritis with a Scandinavian total ankle replacement (STAR) by one surgeon were investigated retrospectively., Materials and Methods: A modification of the Foot Function Index (FFI), which scores pain and task difficulties, was followed prospectively. Patients were assessed clinically and radiologically. Failure was defined as revision of the prosthesis or arthrodesis for any reason., Results: In 47 patients (16 male, 31 female) 49 total ankle replacements were carried out between May 1999 and June 2004. Indication for surgery was end stage arthritis for rheumatoid arthritis in 29 cases, post-traumatic arthritis in 12, osteoarthritis in five and arthritis secondary to degenerative flatfoot in three. Mean followup time was 28 (12 to 67) months. The modified FFI (range, 0 to 100, a high score meaning more pain and disability) improved significantly from 59 before to 35 after surgery. The mean postoperative Kofoed ankle score was 68. Sixteen procedures were complicated by fractures or temporary neurological damage. At the time of followup, 45 prostheses survived, while four replacements had failed. Radiological examination at followup showed radiolucent lines, osteolysis, and malposition of the components in 31 cases., Conclusion: Our results are comparable with those reported in the literature. The clinical outcome improved significantly. Due to aseptic and septic loosening, 8.2% of the prosthesis failed.

Background: Most techniques for posterior tibial tendon transfer attach the posterior tibial tendon somewhere at the dorsum of the foot. Inadequate tendon length and difficulties in securing the tendon to bone or tendon can complicate these procedures. Performing the tenodesis proximal to the ankle joint can prevent these problems. The present study is the first to describe the results of posterior tibial tendon transfer through the interosseous membrane attaching only the posterior tibial tendon to the extensor tendons proximal to the ankle joint., Methods: We examined 13 feet in 12 patients with a foot-drop, equinovarus deformity, or both. The median (range) followup was 3.7 years (9 to 81 months) and the median age at surgery as 30 (13 to 59) years. Evaluation included recording patient satisfaction, use of ankle-foot orthoses (AFO), video-assisted gait analysis, physical examination, the Stanmore system, modified Ninković method, and complications., Results: At followup, patient satisfaction was excellent to good in nine feet. Ten of the 11 feet that needed an AFO preoperatively did not need one after surgery. Gait analysis demonstrated a good to fair gait in 10 patients. Median dorsiflexion was 0 (-25 to 12) degrees, with dorsiflexion to a neutral position or beyond in nine feet. The Stanmore system and modified Ninković method showed excellent to good results in 10 feet. Three complications were recorded including one failed tendon transfer., Conclusions: Attachment of a split posterior tibial tendon to the extensor tendons proximal to the ankle joint provides results equivalent to other procedures and can be considered a viable operative alternative because it is less difficult and more straightforward than other techniques.

Background: Several methods for the treatment of acquired flexible flatfoot have been described., Patients and Methods: We followed the outcome of calcaneocuboid distraction arthrodesis with lengthening of the lateral column prospectively in 20 patients (20 feet). The mean age of the patients was 55 (30-66) years and 16 were women. The lateral column lengthening was combined with percutaneous lengthening of the Achilles tendon and augmentation of the posterior tibial tendon in all patients. Fixed forefoot supination, hallux valgus, and/or symptomatic arthrosis, were corrected with arthrodesis of the first cuneiform-metatarsal joint (n = 8) and arthrodesis of the naviculocuneiform joint (n = 2). The Foot Function Index (FFI) and American Orthopedic Foot and Ankle Society (AOFAS) Clinical Rating Index hindfoot score (CRI) were completed preoperatively and at follow-up. Follow-up time was 25 (13-39) months. All patients were physically examined at follow-up at the outpatient clinic, and the overall satisfaction rate was registered. Standardized weight-bearing radiographs were taken preoperatively and at follow-up. The lateral and dorsoplantar talometatarsal angle was measured, together with the ground-navicular distance., Results: At follow-up, 17/20 feet had complete relief of pain or only minor symptoms. The overall patient satisfaction rate was excellent or good in 15 patients and 17 patients reported an increase in daily and/or recreational activities. 3 patients complained of pain at the distraction site and/or cuboid-MT5 joint, without signs of arthrosis. All but 1 patient would have chosen to undergo the same procedure given the same circumstances. The improvement in both the FFI and CRI was statistically significant. On radiographic examination, the lateral and dorsoplantar talometatarsal angle and the ground-navicular distance improved significantly. Nonunion developed in 2 patients and united after bone grafting. 3 patients had either paresthesia or anesthesia in the distribution area of the sural nerve., Interpretation: We found good short-term results after calcaneocuboid distraction arthrodesis, percutaneous tendon Achilles lengthening, and medial soft tissue augmentation for the treatment of degenerative/acquired flexible flatfoot. Pain or discomfort along the lateral aspect of the foot is the most common and worrying postoperative complaint.

Objective: The aim of this study was to investigate the effect of shoe design on the plantar pressure dynamics of patients with diabetic neuropathy during walking., Research Design and Methods: Three shoe design categories were tested. Total contact area and biomechanical variables in multiple areas under the foot were measured., Results: Shoes with a rocker bottom principle reduced pressure 35-65% underneath the heel and the central metatarsal heads. Increased contact area did not result in significant pressure reductions underneath the forefoot. Pressure dynamics underneath the heel and medial forefoot (first metatarsal head and hallux) on average showed no significant differences among the different shoes with a cushioning insole., Conclusions: The most effective way to offload the forefoot of patients with neuropathic feet is through the use of the rocker sole principle. In general, the effect of an insole depends on the design characteristics of a shoe. Predicting the effect of therapeutic footwear on an individual scale, however, remains difficult. Therefore, in-shoe pressure measurements seem to be necessary to evaluate a therapeutic shoe prescription in certain individual cases.

We prospectively evaluated subtalar inversion stress views (Brodén view) with inversion stress views on helical CT in a group of 10 patients with unilateral instability. The contralateral, asymptomatic ankle was used as control. All patients were examined with inversion stress views on plain stress radiography and helical CT. Subtalar tilt was demonstrated in all cases on conventional stress radiography. Helical CT didn't show tilting in any of the patients except in the subluxated posteromedial part of the subtalar joint. Our data do not support prior reports that the Brodén view is useful for screening patients with subtalar instability.

Objective: The objective of this study was to determine the presence and location of subchondral bone contusions, fractures, and "kissing" lesions of the talotibial joint after a sprain of the ankle shown on MR imaging., Materials and Methods: We retrospectively reviewed the images of all consecutive patients who underwent MR imaging of the ankle after acute or recurrent sprain occurring between January and December 1997. The number and location of subchondral contusions or fractures revealed on MR imaging were recorded, and a comparison was made with the radiographs obtained for each patient., Results: Of the 146 ankles, 42 osteochondral lesions were revealed on MR imaging in 26 ankles (18%) involving 23 patients. Twenty-three lesions were localized in the dome of the talus and 19, in the tibiofibular plafond. In 16 (11%) of the 146 ankles, the lesions were present in the opposing bones of the joint ("kissing" lesions). Only six of the 12 talar fractures and none of the tibial fractures involving the 26 ankles were seen on conventional radiography., Conclusion: Subchondral lesions in the talus and tibia are relatively common after ankle trauma, occurring in 18% of patients in our series. Kissing lesions were present in more than half of the lesions in these patients.

The primary objective of this study was to compare the objective and subjective effects of amisulpride with those of a classic antipsychotic, haloperidol, when both were given to healthy volunteers in representative therapeutic doses over 5 days. The secondary objective was to compare the effects of relatively low and high doses of amisulpride to confirm the suspected duality of its pharmacologic activity. Twenty-one subjects participated in the four-way, randomized, double-blind, crossover study with repeated daily doses of amisulpride 50 mg, amisulpride 400 mg, haloperidol 4 mg, and placebo. Subjects were institutionalized during treatment periods and were under 24-hour medical supervision. They underwent a series of psychomotor and cognitive tests 1 hour before and 3 and 6 hours after dosing on days 1 and 5. Their extrapyramidal disturbances and drug-related feelings were assessed at the end of each replication. Psychiatric interviews and ratings of depression, subjective well-being, and negative symptoms occurred on day 4. Amisulpride 50 mg had no significant effect on any parameter. Amisulpride 400 mg had several adverse effects on psychomotor and, although less severe, on cognitive performance on the fifth day only. Amisulpride 400 mg produced no significant extrapyramidal disturbances in the group as a whole, although it may have in some individual subjects. Also, it produced no signs of mental disturbances on clinical rating scales or during a structured psychiatric interview. Haloperidol ubiquitously impaired psychomotor and cognitive performance in a similar fashion after the first and the final doses. It produced extrapyramidal disturbances in nearly every subject, the most common being akathisia and the most severe, in the case of one individual, being acute dystonia. Unlike amisulpride, haloperidol produced a number of mental disturbances, the most noteworthy being negative symptoms. Amisulpride seems to be a well-tolerated drug. Its side effects should be much less troublesome to patients using the drug on a long-term basis than those of classic antipsychotics, like haloperidol.

The main objective of this study was to compare subtalar inversion stress views using the Brodén view with inversion stress views on helical computed tomography (CT). One of the drawbacks of routine radiography is the imaging of three-dimensional structures in a two-dimensional plane. We investigated whether the use of helical CT would lead to a more objective and clearer measurable method to determine the amount of tilt in the subtalar joint. A group of 15 patients with unilateral chronic instability complaints and clinically suspected subtalar instability was examined. The contralateral asymptomatic foot was used as control. A variable amount of subtalar tilt (range, 4 degrees to 18 degrees) was demonstrated in all cases on stress radiographs, without finding significant difference between the symptomatic and asymptomatic feet. However, contrary to the findings at the talocrural level, subtalar tilt was found in none of the patients using helical CT. Thus, we now doubt that the tilt seen during stress examination using the Brodén view is the true amount of tilt. It may be that the lateral opening, seen on these radiographs, largely results from imaging two planes that have made a translatory and rotary movement relative to each other in an oblique direction. It is concluded that the Brodén stress examination might not be useful for screening patients with subtalar instability. Associated anomalies not visible on the radiographs were detected by helical CT. In four cases, narrowing of the articular cartilage and irregular and hypertrophic bone formation at the middle facet joint of the subtalar joints were found. It is likely that these changes cause disturbance of function of this joint and it is suggested that the subjective complaint of instability with "giving way" is not only caused by hypermobility, but can be caused by other disturbance of normal motion.

The electromyographic activity of the peroneus longus and anterior tibial muscles of 25 patients with chronic ankle instability (18 patients with bilateral symptoms and 7 patients with unilateral complaints) and 10 controls was registered during the stance phase under different walking conditions. With balance secured by external support, there was a variable amount of peroneal activity, most of which was found in the third quarter of stance. A high increase in peroneus longus activity starting after foot-flat was found when subjects had to maintain balance in a natural way. No difference in peroneal activity was found in relation to instability complaints. It is thought that the peroneus longus serves to maintain balance, that this function decreases with increase of speed and that one cannot rely on this muscle to prevent an inversion injury during normal walking. The anterior tibial muscle was predominantly active in the first quarter after heel contact. An increase in activity in the second quarter as an effect of loss of secured balance suggests that this muscle plays some part in balance control, but this is not its main function. A significant increase in tibialis anterior activity was found in patients with bilateral instability. No significant difference was found between the symptomatic and asymptomatic leg of patients with unilateral instability under the same walking conditions. These findings suggest changes in central control.

In the present open study the effects of the D1-dopamine antagonist SCH 39166 on positive and negative symptoms of schizophrenia (DSM-IIIR) were investigated. SCH 39166 was given orally according to a fixed dosage schedule (day 1: 25 mg b.i.d; day 4: 50 mg b.i.d.; day 7: 100 mg b.i.d.; day 18: 200 mg b.i.d.; day 21: 225 mg b.i.d.). Seven patients completed 2 weeks, and five patients completed the study. The reason for premature withdrawal was lack of efficacy or refusal to take SCH 39166. In none of the patients a reduction of the BPRS or CGI score was found. As measured with the PANSS, a significant reduction was observed in the score of the negative subscale, whereas the positive symptoms scale and general psychopathology score remained unaffected. Akathisia, rigidity and hypokinesia were reported occasionally, although only mild in severity. The results of the present study do not support the hypothesis that D1-dopamine antagonists are clinically effective antipsychotics in schizophrenia, considering the fact that SCH 39166 had no effect on positive symptoms. The present study provides circumstantial evidence for an effect of SCH 39166 on negative symptoms.

The object of this investigation was to determine a possible subtalar component in a group of 33 patients with chronic ankle instability. A group of 10 subjects without ankle/foot symptoms acted as controls. A standardized radiographic assessment of talar and simultaneous subtalar tilt was made. A hinge device to stress the joints and a specific subtalar stress view (Brodén view) were used under fluoroscopic control. Radiographs were made with the feet: (1) in neutral position, (2) after inversion with moderate force until the point of fair restraint (step 1), and (3) after inverting with more force as far as the conditions would allow (step 2). An increase of talar tilt between step 1 and step 2 was only found in feet that were symptomatic. This suggests that this increase is only possible when lateral ligaments are damaged. Further research is necessary to determine whether this finding can serve as a parameter to discriminate between physiological and abnormal talar tilt. A wide range of subtalar motion was found in both symptomatic and asymptomatic feet. With the present method, practically all subtalar joints showed some loss of congruity and medial shift of the calcaneus in relation to the talus. This could not be correlated with ankle instability at the talocrural joint. The consequence of the use of different subtalar stress methods has so far received little attention and is discussed.

The two benzodiazapines used in this experiment, namely midazolam and flunitrazepam, have both been shown to have effects on memory processing in laboratory studies. In spite of the potential hazards involved in real life testing, it should be possible to replicate such findings in everyday environments and it is argued that a successful replication would be a very meaningful extension to the existing laboratory data. The present study was successful in producing significant "hangover" effects in healthy volunteers using a novel "user-friendly" telephone testing technique. Compared to placebo, the two hypnotics reduced speed of processing in tasks which required retrieval from long-term semantic memory (semantic verification) and the manipulation of material in working memory (syntactic reasoning). We suggest that this new method offers the potential for carrying out large-scale psychopharmacological studies with real patients and achieves a meaningful step forward in the search for ecological validity.

Generalization of skills is a major problem in social skills training for schizophrenic patients. Assessment of skills is mostly not based on objective indices of specific skill deficits. The results of this study show that global competence of schizophrenics can be differentiated from specific competence. Global competence was found to be related to symptoms, whereas specific competence was not. No support was found for the assumption that social dysfunctions are caused by negative symptoms. Social perception and positive symptoms did explain a substantial part of the variance of global competence. It is therefore concluded that neither global incompetence nor negative symptoms should be used as an indication for social skills training.